HospitalInspections.org

Based on document review and staff interview, the facility failed to ensure physicians completed a discharge summary for 3 of 16 medical records (patients #N2, N3, and N20).

Findings include:

1. Review of patient #N2 medical record indicated the following:
(A) The patient was admitted on 10/6/11 and discharged 10/11/11.
(B) The medical record lacked a discharge summary.

2. Review of patient #N3 medical record indicated the following:
(A) The patient was admitted on 10/12/11 and discharged 10/25/11.
(B) The medical record lacked a discharge summary.

3. Review of patient #N20 medical record indicated the following:
(A) The patient was admitted on 2/7/12 and discharged 2/15/12.
(B) The medical record lacked a discharge summary.

4. Staff member #4 verified the above medical record information at 3:00 p.m. on 4/3/12.

Based on document review and staff interview, the facility failed to ensure physicians completed the medical record within 30 days of discharge for 4 of 16 medical records (patients #N2, N3, N14, and N20).

Findings include:

1. Review of patient #N2 medical record indicated the following:
(A) The patient was admitted on 10/6/11 and discharged 10/11/11.
(B) The medical record lacked a discharge summary.

2. Review of patient #N3 medical record indicated the following:
(A) The patient was admitted on 10/12/11 and discharged 10/25/11.
(B) The medical record lacked a discharge summary.

3. Review of patient #N14 medical record indicated the following:
(A) The patient was admitted on 1/5/12 and discharged 1/12/12.
(B) The discharge summary was not dictated until 4/2/12.

4. Review of patient #N20 medical record indicated the following:
(A) The patient was admitted on 2/7/12 and discharged 2/15/12.
(B) The medical record lacked a discharge summary.

5. Staff member #4 verified the above medical record information at 3:00 p.m. on 4/3/12.