HospitalInspections.org

Based on medical record review, policy and procedure review and staff interview, the CAH (Critical Access Hospital) failed to provide a discharge summary that included a recapitulation of the resident's stay for 2 of 4 discharged Swing Bed records reviewed (Medical Records 34 and 35). A total of 5 Swing Bed records were reviewed. Swing Bed census was 1 on the first day survey. Findings are:

A. Review of Swing Bed Record 34 revealed the resident was admitted to Swing Bed on 5/14/10 and was discharged on 6/1/10. Review of Patient Care Notes dated 6/1/10 revealed Resident 34 was being discharged to a nursing home. Review of the paper medical record and the electronic medical record with the Chief Quality Officer on 2/7 and 8/2011 revealed no discharge summary that included a recapitulation of the resident's stay.

B. Review of Swing Bed Record 35 revealed the resident was admitted to Swing Bed on 12/27/10 and was discharged on 12/30/10. Review of Admission, Dismissal, and Status Changes Notes dated 12/30/10 revealed Resident 35 was discharged to a nursing home on 12/30/10. Review of the paper medical record and the electronic medical record with the Chief Quality Officer on 2/7 and 8/2011 revealed no discharge summary that included a recapitulation of the resident's stay.

C. Review of the Swing Bed Policy and Procedure Manual on 2/8/11 revealed a lack of a policy regarding discharge summaries or recapitulation of patients' stay.

D. Interview with the CNE (Chief Nurse Executive) on 2/8/11 from 12:45 PM to 12:55 PM revealed the following:
- Confirmed there was no policy and procedure regarding Discharge Summary;
- Indicated they used to have a form that said Recapitulation that they completed but stopped using that form as they thought it was redundant; and
- Indicated the record probably had all of the information but was not put in a summary; and
- Agreed they were not completing a recapitulation of the residents' stay.