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Based on interview and record review, the facility failed to ensure that the medical staff was accountable to the governing body for the quality of care provided to patients through compliance with the rules and regulations of the medical staff for 1 of 10 sampled patients (#1).

Findings:

A review of the medical record of patient #1 was performed. A physician note of 11/29/11 at 6:36 AM read, "Preliminary diagnosis are Chest Pain, Unstable Angina." The attending physician stated in a progress note of 11/30/11 at 9:22 AM, "Dry cough, heavy chest . . . A/P (assessment plan) Probable bronchitis, r/o (rule out) cardiac r/o (rule out) PE (pulmonary emboli). If negative, then D/C (discharge). The Discharge Summary by the attending physician (dictated on 11/30/11 at 9:43 AM) read, "The patient was hospitalized for chest pain, atypical for angina, and probable bronchitis. She was seen in consultation with cardiology and at time of this dictation stat CT (computed tomography) angiogram of the chest is pending. If the above evaluations are okay, the patient will be discharged to home later today." This document did not include any statements along the lines of a discharge diagnosis or final diagnosis. Physician orders by the attending physician at 7:30 PM on 11/30/11 read, "OK to DC (discharge) home. No further test."

A review of facility Rules and Regulations of the Medical Staff revealed the following: "At the time of the patient's discharge, the attending/covering physician shall see that the record is complete, state his/her final diagnosis and procedures if possible, and sign and date the record." Also, "The attending physician shall be held responsible for the preparation of a complete medical record for each patient. This record shall include. . . . final diagnosis. . . ."

A review of Medical Staff By-Laws revealed the following: "The responsibilities of the medical staff are to . . . implement and conduct the following specific activities . . . . through the following measures ... seek compliance with these Bylaws, the Rules and Regulations of the Staff and other hospital policies."

As indicated above, the record did not include any statements along the lines of a discharge diagnosis or final diagnosis. This was not in compliance with the Rules and Regulations of the Medical Staff.

The preceding was confirmed in an interview with the Quality Director and Risk Manager on 1/17/12 at approximately 2 PM.

Based on interview and record review, the facility failed to ensure that the medical staff was accountable to the governing body for the quality of care provided to patients through compliance with the rules and regulations of the medical staff for 1 of 10 sampled patients (#1).

Findings:

A review of the medical record of patient #1 was performed. A physician note of 11/29/11 at 6:36 AM read, "Preliminary diagnosis are Chest Pain, Unstable Angina." The attending physician stated in a progress note of 11/30/11 at 9:22 AM, "Dry cough, heavy chest . . . A/P (assessment plan) Probable bronchitis, r/o (rule out) cardiac r/o (rule out) PE (pulmonary emboli). If negative, then D/C (discharge). The Discharge Summary by the attending physician (dictated on 11/30/11 at 9:43 AM) read, "The patient was hospitalized for chest pain, atypical for angina, and probable bronchitis. She was seen in consultation with cardiology and at time of this dictation stat CT (computed tomography) angiogram of the chest is pending. If the above evaluations are okay, the patient will be discharged to home later today." This document did not include any statements along the lines of a discharge diagnosis or final diagnosis. Physician orders by the attending physician at 7:30 PM on 11/30/11 read, "OK to DC (discharge) home. No further test."

A review of facility Rules and Regulations of the Medical Staff revealed the following: "At the time of the patient's discharge, the attending/covering physician shall see that the record is complete, state his/her final diagnosis and procedures if possible, and sign and date the record." Also, "The attending physician shall be held responsible for the preparation of a complete medical record for each patient. This record shall include. . . . final diagnosis. . . ."

A review of Medical Staff By-Laws revealed the following: "The responsibilities of the medical staff are to . . . implement and conduct the following specific activities . . . . through the following measures ... seek compliance with these Bylaws, the Rules and Regulations of the Staff and other hospital policies."

As indicated above, the record did not include any statements along the lines of a discharge diagnosis or final diagnosis. This was not in compliance with the Rules and Regulations of the Medical Staff.

The preceding was confirmed in an interview with the Quality Director and Risk Manager on 1/17/12 at approximately 2 PM.