HospitalInspections.org

Based on document review and interviews, it was determined the facility failed to maintain accurate medical records by having incorrect discharge information for one (1) out of seven (7) patients reviewed.

The findings include:

Following entrance conference, the surveyor reviewed the medical record of Patient #1 with the assistance of Staff Member #6 (Director of Clinical Informatics) in the afternoon of 05/31/23. The surveyor identified documentation within the medical record of Patient #1, including the "Patient Abstract" section, indicating that Patient #1 was present in facility between 12/13/22 through 12/15/22. The medical record indicated that Patient #1 had a discharge date and time of 12/15/22 at 3:09 am.

The surveyor confirmed with order set information that the surgeon had placed an order for the patient's discharge home on 12/14/22 at 6:23 pm. The surveyor reviewed the discharge medication reconciliation, discharge education, and discharge instruction information which was documented and signed on 12/14/22 at 7:00 pm.

The surveyor met with Staff Member #5 (Nursing Director of "5 Front" Medical/Surgical, Orthopedic and "6 Front" Telemetry Trauma units) for interview on 05/30/23 at 2:08 pm. Staff Member #5 confirmed that the patient was discharged in the evening of 12/14/22, and not on 12/15/22 as indicated in the medical record.

The surveyor communicated the discrepancy with Staff Member #1 (Vice President of Quality) on 05/31/22 at 9:31 am, who stated that the facility Coders within the Health Information Management (HIM) Department-contracted with the facility through the Parallon agency-were primarily responsible for reviewing the medical records for accuracy and completion pertaining to discharge dates and diagnoses.

At approximately 1:00 pm on 05/31/22, the surveyor was provided the facility's "Inpatient Coding and Abstracting" policy (with last effective date of 03/07/23) from Staff Member #1. As outlined on the final page of said policy, the Coders of the HIM department are to "verify the discharge date documented in the medical record" matches appropriately.

Staff Member #1 speculated the erroneous discharge date documentation was most likely attributed to the overnight supervisory staff checking the inpatient census and reconciliating for patient discharges. Staff Member #1 added that the error most likely occurred as a result of Patient #1 not being identified as having been discharged in "real-time" on 12/14/22.

Staff Members # (1-4) were made aware of the identified concern during exit conference on 05/31/23 at 2:15 pm without further questions.