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Based upon review of documents, medical records and staff interview it was determined the medical staff failed to ensure the physician documented a complete discharge summary in one (1) of one (1) medical records reviewed for completeness of a discharge summary (patient #1 on identifier list). This has the potential to negatively affect all patients by leaving them with an incomplete medical record without a final diagnosis.

Findings include:

1. The Rules and Regulations of the medical staff, last reviewed 11/13, states in part: "Should a patient leave the hospital against the advice of the Attending Physician or without proper discharge, a notation of the incident shall be made in the patient's medical record by the Attending Physician. The discharge process and corresponding documentation shall provide for continuing care based on the patient's assessed needs at the time of discharge."

2. Patient #1 was admitted to the hospital on 11/10/13. Review of the medical record for patient #1 revealed the discharge summary dictated on 12/9/13 stated in full: "The patient signed out AMA on 11/15/2013. For details, please refer to the progress note dated 11/15/13 and other dictation."

3. Review of the progress note for 11/15/13 revealed it did not contain the information required for a discharge summary.

4. This record was reviewed with the Director of Quality on 1/28/14 at approximately 1400 and she agreed with these findings.

Based on review of documents, medical records and staff interview it was determined the hospital failed to ensure nursing documented in the medical record per hospital policy in one (1) or one (1) medical records reviewed for documentation following a patient leaving against medical advice (patient #1 on identifier list). This has the potential to negatively affect all patient's by leaving them with an incomplete medical record.

Findings include:

1. Hospital policy titled "Patient Leaving Hospital Against Medical Advice/Elopements," last reviewed 2/12, states in part: "1. If the patient desires to leave against medical advice, notify the attending physician." "8. Document in nurses' notes, the reason the patient/legal guardian gives for leaving and the instructions he was given. Note the condition of the patient/legal guardian and his objective mental and physical status."

2. Review of the patient's medical record revealed there was no documentation of physician notification, nor were there any notes describing the events leading up to leaving against medical advice, nor the reason given by the legal guardian for taking the patient against medical advice.

3. This lack of documentation was reviewed with the executive nurse director of the Medical Surgical floor on 1/28/14 at approximately 1400 and she agreed with these findings.