HospitalInspections.org

Based on review of facility documents and medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure that requirements of the Medical Staff Rules and Regulations were followed for five of 10 medical records. (MR1, MR4, MR8, MR9 and MR10)

Findings include:

Review of Select Speciality Medical Staff Rules and Regulations, reviewed February 2011 revealed, " ... 9. The discharge summary shall include. a. Primary and secondary diagnosis. b. Complications and infections (if any). c. Procedures performed during admisssion. d. a summary of pertinent history , physical findings, laboratory and x-ray results. e. Reason for hospitalization. f. Function at time of discharge. h. Special instructions, equipment, diet, etc. i. List of medications. j. Rehabilitation potential. k. Follow up plan and physician for follow up.

1. Review of MR1, November 8, 2011, at approximately 10:15 AM revealed a discharge summary that did not contain a report of laboratory or radiology findings or a list of medications.

2. Review of MR4, November 8, 2011, at approximately 11:00 AM revealed a discharge summary that did not contain a summary of laboratory or radiology findings, a medication list and rehabilitation potential

3. Review of MR8, November 8, 2011, at approximately 11:10 AM revealed a discharge summary that did not contain a medication list.

4. Review of MR9, November 8, 2011, at approximately 11:20 AM revealed a discharge summary that did not contain a diet and medication list.

5. Review of MR10, November 8, 2011, at approximately 11:30 AM revealed a discharge summary that did not contain a medication list, diet, rehabilitation potential and laboratory or radiology findings

6. During an interview with EMP4, November 8, 2011, at approximately 12:00 PM, all the above findings were verified.