HospitalInspections.org

Based on record review and interview, the facility failed to document a discharge summary per policy for 1 of 10 closed patient records reviewed (Patient #1).

Findings:

Patient #1 was admitted to the facility on 8/7/2015 for a transmetatarsal amputation of left ischemic foot. Patient #1 underwent surgery on 8/7/2015. Patient #1 was discharged to home on 8/9/2015.

Review of facility policy "Medical Record--Regulations" #MR-009 states in part: "5.6 Discharge Summary/Discharge Progress Note: a. A discharge summary is required for patient hospitalized more than 2 days...b. Patients hospitalized under 2 days require a final discharge progress note. See 5.6 g. for content...g. The discharge summary/discharge progress note shall contain the following information: 1. The reason for hospitalization; 2. Care, treatment, and services provided; 3. Procedures performed; 4. The condition of the patient on discharge; 5. Instructions to the patient and/or family, if any. 6. The principal diagnosis, together with secondary diagnoses."

Patient #1's medical record does not contain a discharge summary for the inpatient stay on 8/7/2015 through 8/9/2015. During an interview on 5/2/2016 at 10:35 AM, Director A stated the facility does not require discharge summaries for stays "less than 2 days." Patient #1's medical record includes a progress note from the admitting MD dated 8/9/2015 at 8:19 AM. The note in its entirety states: "Doing well. Flap is cool and turning dusky. Will watch and see. DC home." Director A stated the note would be considered the patient's discharge progress note. Per A, "no, the note does not have all the information we would expect."