HospitalInspections.org

Based on document review and interview, the facility failed to enforce medical staff by laws/policy & procedures related to documentation of a discharge summary for 1 of 5 patients (patient #1).

Findings include:

1. Review of patient #1 medical record indicated the following:
(A) The patient presented to the emergency department (ED) on 10/22/12 after a fall and was diagnosed with fractured left hip.
(B) The patient was discharged to longterm care facility #3 on 11/1/12.
(C) The discharge summary lacked information required by medical staff by laws/policy & procedures. The summary did not include the recommended medications at the time of discharge nor the discharge diagnoses.

2. Staff member #1 verified the lack of information in the discharge summary for patient #1 at 2:45 p.m. on 12/18/12.

3. Review of medical staff by laws/policy & procedures approved on 5/27/11 states on page 56-57: "9) Discharge summaries will address, at a minimum, the following: A) summarization of the hospital clinical course of the patient B) dietary instructions, if any C) recommended medications D) disposition and follow-up recommendations (E) documentation of pertinent diagnostic findings during the course of the patient's admission (F) condition of the patient at the time of discharge (G) discharge diagnoses."