HospitalInspections.org

Based on medical record review, interview, and review of the facility's policy and procedures revealed that the physician failed to promptly complete documentation of a disharge summary for 2 of 10 sample patients (#7, and #8) after discharge.

Findings:

1.) Review of the facility's Policy and Procedure for Medical Staff Rules and Regulations revealed the following:

COMPLETION OF MEDICAL RECORDS

All discharged summaries and other medical record documentation shall be completed within 15 days for SIPP clients and 30 days following the patients discharge for all other programs. Incomplete records exceeding 15 or 30 days following discharge will be considered delinquent.

2.) Medical record review on 06/26/2014 at 2:00 PM revealed patient #7 was admitted on 05/05/2014 and discharged on 05/09/2014. Review of the record with the Director of Nursing (DON) revealed that there was not a discharge summary document from the physician. The DON stated the physician had not met the requirement of the Discharge summary, and she was unable to provide one.

3.) Medical record review on 06/26/2014 at 2:00 PM revealed patient #8 was admitted on 05/28/2014 and discharged on 06/19/2014. Review of the record with the Director of Nursing (DON) revealed that there was not a discharge summary document from the physician. The DON stated the physician had not met the requirement of the Discharge summary, and she was unable to provide one.