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.

THE VINES HOSPITAL 3130 SW 27TH AVE OCALA, FL 34474 June 26, 2014
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, interview, and review of the facility's policy and procedures revealed that the physician failed to promptly complete documentation of a disharge summary for 2 of 10 sample patients (#7, and #8) after discharge.

Findings:

1.) Review of the facility's Policy and Procedure for Medical Staff Rules and Regulations revealed the following:

COMPLETION OF MEDICAL RECORDS

All discharged summaries and other medical record documentation shall be completed within 15 days for SIPP clients and 30 days following the patients discharge for all other programs. Incomplete records exceeding 15 or 30 days following discharge will be considered delinquent.

2.) Medical record review on 06/26/2014 at 2:00 PM revealed patient #7 was admitted on [DATE] and discharged on [DATE]. Review of the record with the Director of Nursing (DON) revealed that there was not a discharge summary document from the physician. The DON stated the physician had not met the requirement of the Discharge summary, and she was unable to provide one.

3.) Medical record review on 06/26/2014 at 2:00 PM revealed patient #8 was admitted on [DATE] and discharged on [DATE]. Review of the record with the Director of Nursing (DON) revealed that there was not a discharge summary document from the physician. The DON stated the physician had not met the requirement of the Discharge summary, and she was unable to provide one.