The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|ST. MARY'S HEALTH, INC.||3700 WASHINGTON AVE EVANSVILLE, IN 47750||Dec. 18, 2012|
|VIOLATION: MEDICAL STAFF BYLAWS||Tag No: A0353|
|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).
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."