HospitalInspections.org

Based on record review and interview, the facility failed to ensure timely completion of the Discharge Summary per facility policy for 2 of 7 discharged patient medical records (Patient's #1 & #6) in a sample of 10 records.

Findings include:

A review of the facility policy, titled "Medical Records-Completion of the Medical Record" last revised 2019, revealed: "In accordance with all applicable state and federal laws, regulatory agencies, and the Medical Staff Rules and Regulations, all records must be complete within 15 days post discharge."

A review of Patient #1's medical record revealed: Admitted on 4/5/2023 for a tonsillectomy/adenoidectomy (surgery to remove tonsils and adenoids). Discharged on 4/6/2023. As of 4/25/2023 at 1:00 PM there is no discharge summary, 19 days after discharge.

A review of Patient #6's medical record revealed: Admitted on 2/23/2023 for a tonsillectomy/adenoidectomy. Discharged on 2/24/2023. As of 4/25/2023 at 2:30 PM there is no discharge summary, 60 days after discharge.

During an interview on 4/25/2023 at 2:50 PM, Registered Nurse Clinical Educator M stated, I don't see a discharge summary for Patient #1 or #6.

During an interview on 4/25/2023 at 2:55 PM, Executive Director of Critical Care B stated, the discharge summary should be completed within 15 days of discharge.