HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 10 (Pt #1), clinical records reviewed for discharge planning, the Hospital failed to complete a discharge summary with all necessary medical information pertaining to the patient's course of treatment to notify the appropriate specialists and practitioners responsible for the patient's follow-up care.

Findings include:

1. On 04/17/2024 the policy titled "Assessment Timeframes for Chart Completion" (revised 03/2024) was reviewed. The policy states, "Discharge Summary ...Attending Psychiatrist ...Within 30 days of discharge."

2. The clinical record for Pt #1 was reviewed on 4/16/2024. Pt #1 was admitted to the Hospital on 2/11/2024 with the diagnosis of bipolar disorder and Schizophrenia. Pt #1 was discharged from the Hospital on 2/28/2024. Pt #1's clinical record was reviewed, and it was noted Pt #1's chart lacked a completed discharge summary.

3. During an interview on 4/16/2024 at approximately 3:30PM, E #1 (Facility Risk Manager) reviewed Pt #1's record and verbally agreed that the record lacked a completed discharge summary.