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KENTUCKIANA MEDICAL CENTER LLC
MEDICAL STAFF BYLAWS
Tag No.: A0353
Based on document review and interview, the Medical Staff failed to ensure 2 of 5 medical records (P#1 and P#4) contained discharge/death summaries as required by the Medical Staff Bylaws/Rules and Regulations.
Findings included:
1. Review of the Medical Staff Rules and Regulations (last reviewed/adopted 9-4-12) on 2-27-13 indicated the following: Discharge Summary Report and Diagnosis: A discharge summary should be written or dictated upon dismissal...All expired patients require a death summary regardless of the length of stay...Medical Staff members shall be given thirty days to complete medical records of discharged patients from the date of discharge.
2. Review of patient medical records on 2-27-13 lacked evidence that P#1's medical record contained a discharge summary/death summary as required by the Medical Staff ByLaws/Rules and Regulations; P#1's death is documented as 12-25-12.
3. Review of patient medical records on 2-27-13 lacked evidence that P#4's medical record contained a discharge summary as required by the Medical Staff ByLaws/Rules and Regulations; P#4's medical record indicated P#4 was transferred to a hospice on 12-24-12.
4. An interview was conducted with B#2 on 2-27-13 at 1445 hours who confirmed that physicians must write or dictate a discharge or death summary within 30 days of the patients death or discharge; B#2 confirmed the medical record of P#1 lacked a death summary and the medical record of P#4 lacked a discharge summary; B#2 confirmed P#1's death occurred 12-25-12 and P#4 was transferred to a hospice on 12-24-12.
CONTENT OF RECORD: FINAL DIAGNOSIS
Tag No.: A0469
Based on document review and interview, the Medical Staff failed to ensure 2 of 5 medical records (P#1 and P#4) contained discharge/death summaries as required by the Medical Staff Bylaws/Rules and Regulations.
Findings included:
1. Review of the Medical Staff Rules and Regulations (last reviewed/adopted 9-4-12) on 2-27-13 indicated the following: Discharge Summary Report and Diagnosis: A discharge summary should be written or dictated upon dismissal...All expired patients require a death summary regardless of the length of stay...Medical Staff members shall be given thirty days to complete medical records of discharged patients from the date of discharge.
2. Review of patient medical records on 2-27-13 lacked evidence that P#1's medical record contained a discharge summary/death summary as required by the Medical Staff ByLaws/Rules and Regulations; P#1's death is documented as 12-25-12.
3. Review of patient medical records on 2-27-13 lacked evidence that P#4's medical record contained a discharge summary as required by the Medical Staff ByLaws/Rules and Regulations; P#4's medical record indicated P#4 was transferred to a hospice on 12-24-12.
4. An interview was conducted with B#2 on 2-27-13 at 1445 hours who confirmed that physicians must write or dictate a discharge or death summary within 30 days of the patients death or discharge; B#2 confirmed the medical record of P#1 lacked a death summary and the medical record of P#4 lacked a discharge summary; B#2 confirmed P#1's death occurred 12-25-12 and P#4 was transferred to a hospice on 12-24-12.