HospitalInspections.org

Based on policy review, medical record review and staff interview it was determined the medical staff failed to enforce their own medical staff bylaws, rules and regulations, by not ensuring complete documentation for one (1) of ten (10) medical records reviewed (patient #1). The patient was transferred from the facility without complete documentation in the discharge summary. This failure has the potential to adversely impact the care and condition of all patients.

Findings include:

1. The Medical Staff Bylaws, Rules and Regulations, last reviewed 11/12, was provided for review. Article VIII. Medical Records states: Discharge Summaries (c)," The discharge summary shall include the reason for hospitalization, the significant findings, the procedures performed and treatment rendered, the condition of the patient on discharge, and any specific instructions given to the patient or family, as pertinent. The condition of the patient on discharge should be stated in terms that permit a specific measurable comparison with the condition on admission. When preprinted instructions are given to the patient or family, the record should so indicate and a copy of the instruction sheet used should be on file in the Health Information Management Department." "The attending practitioner shall authenticate all summaries."

2. Review of the medical record revealed the discharge summary failed to address the temporary Via Vac (wound vac) that was placed on the patient's chest after excision of skin lesion masses that were malignant. The patient was transferred from the facility with the wound vac and no orders were present for the care and maintenance of the temporary wound vac.

3. An interview was conducted with the Dayshift Registered Nurse (RN) on 02/20/13 at 0830. This RN transferred the patient from the facility to the nursing home facility. He stated, "Report was given to the receiving nurse at the other facility and the wound vac was not documented on the discharge summary." He stated, "I knew the patient had a wound vac so I verbally told the receiving RN about the vac and how to care for it". He stated, "The wound vac is temporary and should stay on the patient for seven (7) days until his follow-up appointment with the physician". He stated, "The discharge summary always states what the course of treatment was with the patient during their stay in the hospital and he doesn't know why it wasn't documented on the discharge summary." He concurred with the findings.