HospitalInspections.org

Based on review of medical staff rules and regulations, medical record review, and interviews, the facility failed to document a discharge summary in the medical record for one (#10) patient of five discharged patients reviewed.

The findings included:

Review of facility "...Medical Staff Rules and Regulations..." effective date 3/16/17 revealed "...Within 14 days of discharge, a discharge summary shall be written, entered directly into the patient's medical records...A delinquent medical record is any medical record not completed within 30 days post discharge..."

Medical record review revealed Patient #10 was admitted to the facility on 7/24/18 for diagnoses including Heart Failure, Pneumonia, and Unresponsiveness and was discharged on 8/8/18. Review of the medical record on 10/16/18 revealed there was no discharge summary documented in Patient #10's medical record (69 days after discharge).

Interview with the Risk Manager on 10/16/18 at 10:00 AM, in the administration conference room, confirmed Patient #10 was discharged on 8/8/18 and there was no discharge summary documented in Patient #10's medical record on 10/16/18. Further interview confirmed the medical record was incomplete and the facility failed to follow facility policy.