HospitalInspections.org

Based on record review and interview, the facility failed to have accurate entries and/or promptly completed 1 of 10 medical records (Patient #1) from 6/17/14 through 1/12/16.

Findings included:

Patient #1 was admitted on 6/17/14 for "acute on chronic respiratory failure."

- On 6/20/14 Patient #1 completed and signed a durable power of attorney and advanced directives. These documents were acknowledged by a notary public (Personnel #4) by affixing her signature and date. The date that was entered was 9/20/14.

In an interview on 1/29/16 at 9:00 AM, Personnel #4 was informed of the above findings. Personnel #4 was asked why she entered a date of 9/20/14 when Patient #1 completed and signed the documents on 6/20/14. Personnel #4 replied that she reviewed her logbook and the date she entered it in the book was 6/20/14. She confirmed that it was an error on her part.

- Patient #1 was discharged on 6/24/14. The physician dictated and signed Patient #1's discharge summary on 8/15/14 and 8/22/14 respectively, 52 days after Patient #1's discharge.

In an interview on 1/26/16 at approximately 11:00 PM, Personnel #3 was informed of the above findings and she confirmed the findings. Personnel #3 stated the physicians have 30 days to complete a discharge summary after patients' discharge.

Policy #RC.01.04 "Discharge Summary Documentation" dated 12/2013 revised 2/20/15 required "...a discharge summary will be completed by a physician or nurse practitioner on all discharged patients within 30 days."

Policy # RC.01.06 "Medical Record Content and Documentation" dated 12/2013 revised 2/20/15 required "...maintain a complete and accurate medical record for every patient..."