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Based on record reviews and interviews, the hospital failed to ensure all patient records included documentation of the disposition of care, provisions for follow-up care and timely completion of the medical record for 2 (#3 and #5) of the 5 (#1, #2, #3, #4, #5) records reviewed.
Findings:

Review of the policy and procedure titled, "General Documentation Guidelines" last reviewed and revised on 03/01/21 revealed, in part, the purpose of the policy was to establish guidelines for the initiation and maintenance of patient care information. Further review revealed the policy which stated, in part, the provider was to ensure the following: 1. The hospital initiates and maintains a medical record for every individual assessed, cared for, or treated, to ensure an adequate, accurate, timely, and complete medical record; 2. Documentation in the medical record is detailed, organized, and contains sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers; and, 14. Discharge Summary: A discharge summary must be written or dictated and authenticated by the responsible medical provider on the medical record within 30 days post discharge.

In interview on 05/18/2022 at 9:15 a.m., S1Director of Quality Management (S1DQM) indicated the medical records department reviews the discharge summary for specific components as per the Discharge Summary Template.

Review of the Discharge Summary Template revealed the discharge summary should contain the following elements: admitting diagnosis, discharge diagnosis, procedures, consultants, hospital course, discharge disposition, discharge medications, information provided to the patient and family and discharge follow-up.

Review of the discharge summary for Patient #3 revealed no documentation of the discharge disposition or discharge follow-up. Further review revealed the discharge summary was dictated beyond 30 days as evidence by Patient #3 was discharged on 07/12/2021 and the discharge summary was dictated on 08/17/2021 or 36 days following discharge.

Review of the Discharge Summary for Patient #5 revealed no documentation of the discharge disposition or discharge follow-up. Further review revealed the discharge summary was dictated beyond 30 days as evidenced by Patient #5 was discharged on 07/12/2022 and the discharge summary was dictated on 8/17/2021 or 36 days following discharge.

In interview on 05/18/22 at 11:28 a.m., S1DQM verified, after review of the discharge summaries for Patients #3 and #5, the discharge summaries were not timely and required items on the discharge summaries were not completed.