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 LUKE'S CORNWALL HOSPITAL||70 DUBOIS STREET NEWBURGH, NY 12550||May 9, 2019|
|VIOLATION: MEDICAL RECORD SERVICES||Tag No: A0450|
Based on medical record (MR) review, document review and interview, the Emergency Department (ED) staff did not ensure signed Discharge Instructions were included in the MR, in 1 (one) of 3 (three) MRs reviewed.
Patient #1's MR identified the Patient Signature Page from the patient's Discharge Instructions was missing.
During interview of Staff A (Senior Vice President) on 5/9/19 at 12:10PM, Staff A confirmed the Patient Signature Page was missing from Patient #1's MR. Even after an extensive search of other MRs processed on the same discharge date as that of Patient #1, no signed Patient Signature Page was found for Patient #1.
A facility letter from Staff A to the surveillance team dated 5/9/19 stated, "...we agree that the signature sheet was not locatable in this situation..."