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.
|CYPRESS CREEK HOSPITAL||17750 CALI DRIVE HOUSTON, TX 77090||April 12, 2012|
|VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY||Tag No: A0468|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to ensure that 4 of 8 sampled patients (ID # s 1, 2, 3 and 5) medical records contained appropriate documentation:
Four (4) medical records of discharged patients (ID # s 1, 2, 3 and 5) failed to contain a documented Discharge Summary.
On 04-12-12, review of the 8 sampled patients ' medical records revealed the following:
Patient ID # 6: admitted on [DATE]; discharged on [DATE]. A Discharge Summary for the wrong patient was observed in his record; no summary for Patient # 6.
Patient ID # 3: admitted on [DATE]; discharged on [DATE]. Review revealed a blank History & Physical Form that had the word " dictated " handwritten on the front of the form. There was no typed copy located in the record. Interview at the time of review with the Health Information Management (HIM) Director (ID # 54); she stated the dictated H & P should have been typed and present in the chart by this time.
Patient ID # 1: admitted on [DATE]; discharged on [DATE]. Review failed to reveal a documented Discharge Summary in the record.
Patient ID # 2: admitted on [DATE]; discharged on [DATE]. Review failed to reveal a documented Discharge Summary in the record.
Interview on 04-12-12 at 3:10 PM with HIM Director/ ID # 54, she stated the expected competition time for a Discharge Summary was within 30 days after discharge from the facility. She went on to say the facility had experienced some problems with transcription and changed transcription companies in February 2012.
Review of facility policy titled: " Guidelines for Documentation Timeliness " revised 01/2012, read: " 1. Discharge Summary (in-patient): complete within 30 days of discharge.