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.

LAREDO MEDICAL CENTER 1700 EAST SAUNDERS LAREDO, TX 78044 Nov. 6, 2013
VIOLATION: CONTENT OF RECORD - DISCHARGE DIAGNOSIS Tag No: A0469
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of patient #1 medical record and interview with staff it was observed that this requirement was not met as followed:

Findings:

A. In review of medical record it was observed on November 6, 2013 that patient #1, 86y/o was discharged on [DATE]. The patients discharge summary was not completed and included in the medical record withing 30 days following discharge. There were several entries through out the record tagged by the medical record staff for the physician to complete which were not completed within 30 days of the patients discharge.

B. In an interview with Staff # 1, Director of Quality at 2:20pm on November 6, 2013 who also reviewed the medical record and observed that a note was made for the attending physician of the patient to complete the discharge summary and other tagged entries in the medical record for his signature, date and time. As of November 6, 2013 , 83 days after the patient was discharged from the medical unit and discharged and transferred to a skilled nursing unit, a discharge summary with outcome of hospitalization , disposition of care and provisions for follow-up was not completed. Staff #1 could not show evidence that this requirement was met.
VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY Tag No: A0468
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of patient #1 medical record and interview with staff it was observed that this requirement was not met as followed:

Findings:

A. In review of medical record it was observed on November 6, 2013 that patient #1, 86y/o was discharged on [DATE]. The patients discharge summary was not completed and included in the medical record.

B. In an interview with Staff # 1, Director of Quality at 2:20pm on November 6, 2013 who also reviewed the medical record and observed that a note was made for the attending physician of the patient to complete the discharge summary. As of November 6, 2013 , 83 days after the patient was discharged from the medical unit and discharged and transferred to a skilled nursing unit, a discharge summary with outcome of hospitalization , disposition of care and provisions for follow-up was not completed. Staff #1 could not show evidence that this requirement was met.