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.
|CROSS CREEK HOSPITAL||8402 CROSS PARK DRIVE AUSTIN, TX 78754||April 5, 2016|
|VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY||Tag No: A0468|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of documentation and interview it was determined that the facility failed to ensure that the discharge summary for patient #1 was completed.
There was no discharge summary found in the medical record of patient #1. Patient #1 was admitted on [DATE] and discharged on [DATE]. On 4/05/2016, (the second day of the survey and 45 days after discharge) the facility was unable to produce a copy of the discharge summary when requested by the surveyor. Review of facility policy entitled; "HIM POLICY 011 DELINQUENT MEDICAL RECORDS" stated under the POLICY section: "It is the policy of the facility to maintain an information management process that supports timely, accurate and complete documentation of medical record data and information for all patients." Under the PROCEDURE section of the policy, the following comment was found: "3.0 A medical record is deemed "DELINQUENT" if it is deficient due to failure to document and authenticate a History and Physical Examination, Psychiatric Evaluation, and/or Discharge Summary 30 days after discharge." In the telephonic exit interview with Chief Executive Officer on 4/05/2016 it was confirmed that the discharge summary for patient #1 was delinquent.