HospitalInspections.org

Based on medical record review, staff interview, and review of the Medical Staff Rules and Regulations it was determined the facility failed to ensure discharge summaries were completed for each patient. This affected five ( Patient's #9, #10, #11, #14, #17 ) of eighteen medical records reviewed. The active census was 26.



Findings include:

Review of the Madison Health Medical Staff Rules and Regulations states a final progress note may be substituted for the discharge summary for those patients with problems and interventions of a minor nature who require less than a 48-hour stay, including normal newborns and uncomplicated obstetric deliveries. The final progress note must clearly summarize the patient's hospital course, outcome of hospitalization, disposition of the case, and include relevant discharge instructions/provisions for follow up care.


1. Review of the medical record for Patient #9 (G1P0) revealed the patient presented to the labor and delivery unit with a complaint of leaking vaginal fluid. The medical record noted the patient was admitted on 09/15/18 at 5:10 PM for premature rupture of membranes. The patient required augmentation of labor with pitocin and a spontaneous vaginal delivery occurred without complication. The medical record included a physician final progress note dated 09/17/18 at 8:27 AM which lacked the components for a final progress note according to the medical staff rules and regulations. The medical record confirmed the patient was not discharged until 09/17/18 at 10:50 PM which requires a discharge summary to be completed as the hospital stay was greater than forty-eight hours.


2. Review of the medical record for Patient #10 (G2P1) revealed the patient presented to the labor and delivery unit at 40w1d for a scheduled term induction. The medical record noted the patient was admitted on 10/14/18 at 5:05 PM with a plan for augmentation of labor with pitocin. It was noted the patient had a spontaneous vaginal delivery without complication. The medical record included a physician final progress note dated 10/16/18 at 12:52 PM which lacked the components for a final progress note according to the medical staff rules and regulations. The medical record confirmed the patient was not discharged until 10/16/18 at 6:24 PM which requires a discharge summary to be completed as the hospital stay was greater than forty-eight hours.


3. Review of the medical record for Patient #11 (G1P0) revealed the patient presented to the labor and delivery unit at 39w4d for a scheduled term induction. The medical record noted the patient was admitted on 09/18/18 at 7:45 AM with a plan for augmentation of labor with pitocin. The medical record noted the patient made cervical changes from 1 to 3 cm without further advancement and a low transverse c-section was required. The medical record included a physician final progress note dated 09/22/18 at 9:55 AM which lacked the components for a final progress note according to the medical staff rules and regulations. The medical record confirmed the patient was not discharged until 09/22/18 at 11:30 AM which requires a discharge summary to be completed as the hospital stay was greater than forty-eight hours.


4. Review of the medical record for Patient #14 (G2P1) revealed the patient presented to the labor and delivery unit 40+ weeks gestation for a post date induction. The medical record noted the patient was admitted on 09/17/18 at 5:50 PM with a plan for augmentation of labor with pitocin and a spontaneous vaginal delivery occurred without complication. The medical record included a physician final progress note dated 09/19/18 at 9:44 AM which lacked the components for a final progress note according to the medical staff rules and regulations. Further, the medical record did not have a completed discharge summary.


5. Review of the medical record for Patient #17 (G5P3) revealed the patient presented to the labor and delivery unit with complaints of contractions every four to ten minutes. The patient made cervical change from 3 to 4 cm and then progressed to 9 cm dilated within one half hours which resulted in a spontaneous vaginal delivery. The medical record included a physician final progress note dated 10/07/18 at 12:23 PM which lacked the components for a final progress note according to the medical staff rules and regulations. The medical record confirmed the patient was not discharged until 10/07/18 at 6:37 PM which requires a discharge summary to be completed as the hospital stay was greater than forty-eight hours.

Staff C stated in an interview on 10/31/18 at 2:23 PM the obstetric physician reported only completing a progress note for normal vaginal deliveries as the patient(s) are admitted less than forty-eight hours.

The facility also reported no delinquent records for September and October 2018. This data was found to be inaccurate as five medical records were determined to be incomplete from 09/14/18 through 10/14/18.

These findings were confirmed with Staff B on 10/31/18 at 12:15 PM.