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Based on record review and interview, the facility failed to ensure that 4 of 8 sampled patients (ID # s 1, 2, 3 and 5) medical records contained appropriate documentation:

Four (4) medical records of discharged patients (ID # s 1, 2, 3 and 5) failed to contain a documented Discharge Summary.

Findings include:

On 04-12-12, review of the 8 sampled patients ' medical records revealed the following:

Patient ID # 6: admitted on 02-08-12; discharged on 02-22-12. A Discharge Summary for the wrong patient was observed in his record; no summary for Patient # 6.

Patient ID # 3: admitted on 02-01-12; discharged on 02-09-12. Review revealed a blank History & Physical Form that had the word " dictated " handwritten on the front of the form. There was no typed copy located in the record. Interview at the time of review with the Health Information Management (HIM) Director (ID # 54); she stated the dictated H & P should have been typed and present in the chart by this time.

Patient ID # 1: admitted on 02-27-12; discharged on 03-06-12. Review failed to reveal a documented Discharge Summary in the record.

Patient ID # 2: admitted on 02-29-12; discharged on 03-06-12. Review failed to reveal a documented Discharge Summary in the record.

Interview on 04-12-12 at 3:10 PM with HIM Director/ ID # 54, she stated the expected competition time for a Discharge Summary was within 30 days after discharge from the facility. She went on to say the facility had experienced some problems with transcription and changed transcription companies in February 2012.

Review of facility policy titled: " Guidelines for Documentation Timeliness " revised 01/2012, read: " 1. Discharge Summary (in-patient): complete within 30 days of discharge.