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Based on record review and interview, the medical staff failed to enforce bylaws to carry out it's responsibilities for 3 of 10 patients reviewed (Patient #1, #8, and #10), in that, Patient #1's, #8's, and #10's record did not document a physician discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care for their respective admissions.

Findings Included


Patient #1's, #8's, and #10's record did not document a physician discharge summary within 30 days of discharge.


During an interview on 5/07/2015 starting at 8:15 AM, Personnel #1 navigated the electronic medical records review and confirmed the physician discharge summary was not in the record and not completed within 30 days of the discharge.


The 1/28/2015 "Rules and regulations of the Medical Staff" required, "a written or dictated discharge summary within 30 days of discharge...Medical records must be completed within the time frames specified..."

Based on record review and interview, the hospital failed to ensure a registrered nurse supervise and evaluated the nursing care for 1 of 10 patients reviewed, in that, Patient #1 was not medicated for pain on 2/10/2015 for a phyical therapist assessment of the patient having 6 out of 10 pain pre-physical therapy treatment.

Findings Included

The 2/10/2015 9:00 AM "PT (Physical Therapy) documentation" for Patient #1 of a pretreatment numeric pain (1-10) rating scale was 6 and post was 5, to the lower right leg.

Although Patient #1's pain improved from pre to post physical therapy, there was no documentation of pain medication given at this time.

There was no indication of nursing being notified for Patient #1's pain management needs.

During an interview and records review, Personnel #1 confirmed the above documentation and stated, "I see what you are saying."

The April 2014 last reviewed, "Pain Management" policy required, "pain management is to provide for a pro-active interdisciplinary approach that ensures the highest level of comfort...Promoting an optimal level of function and maximize the patient's ability to participate in the rehabilitation program...Uncontrolled pain is pain that is rated greater than four (4) on the 1-10 pain scale..."

Based on record review and interview, the hospital failed to document a physician discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care for 3 of 10 patients reviewed (Patient #1, #8, and #10), in that, Patient #1's, #8's, and #10's record did not document a physician discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care for their respective admissions.

Findings Included


Patient #1's, #8's, and #10's record did not document a physician discharge summary within 30 days of discharge.


During an interview on 5/07/2015 starting at 8:15 AM, Personnel #1 navigated the electronic medical records review and confirmed the physician discharge summary was not in the record and not completed within 30 days of the discharge.


The 1/28/2015 "Rules and regulations of the Medical Staff" required, "a written or dictated discharge summary within 30 days of discharge...Medical records must be completed within the time frames specified..."