HospitalInspections.org

.
Based on record review and interview the facility failed to abide by the provider's agreement that required a hospital to comply with 42 CFR §482.24 and ensure medical records were accurately and promptly completed when the facility failed to provide a discharge summary that included radiological findings of an identified suspicion for a nondisplaced fracture to his clavicle or further provisions for follow-up care. The facility failed to provide instructions, and provisions for follow up care, disposition of care and provisions for follow-up care for 1 of 20 patients whose records was reviewed (Patient #1).
.
Based on record review and interview, the hospital failed to include a discharge summary with the complete outcome of hospitalization, disposition of care, and provisions for follow-up care for 1 of 20 patients whose records were reviewed (Patient #1) reviewed with a complaint regarding the discharge summary findings, instructions, and provisions for follow up care; and in accordance with the facility's By Laws. Specifically, Patient #1's discharge summary did not include the radiology findings for an identified suspicion for a nondisplaced fracture to his clavicle or further provisions for follow-up care.
.
Cross reference A0468.
.

.
Based on record review and interview, the hospital failed to include a discharge summary with the complete outcome of hospitalization, disposition of care, and provisions for follow-up care for 1 of 20 patients whose records were reviewed (Patient #1) reviewed with a complaint regarding the discharge summary findings, instructions, and provisions for follow up care; and in accordance with the facility's By Laws. Specifically, Patient #1's discharge summary did not include the radiology findings for an identified suspicion for a nondisplaced fracture to his clavicle or further provisions for follow-up care.
.
Findings:
Complaint Review:
Review of the Complaint intake summary dated 02/22/2025 indicated that on 02/05/2025 Patient #1 was in the Emergency Department (ED) bathroom, after checking in when he felt faint, lightheaded, and grabbed the emergency cord by the toilet. Patient #1 then reportedly lost consciousness and woke up on a table with an oxygen mask on, surrounded by people. Patient #1 had a sharp pain in his left shoulder and asked the facility staff what happened to him. The next day, Patient #1 reported to the Director of the ED what happened in the ED bathroom. Patient #1 then had an x-ray done for his shoulder where he alleged the provider told him his x-ray results, when asked were "nothing, probably arthritis." Patient #1 did not believe him because he had a sharp burning pain in his shoulder and his T-shirt had a hole in it where the pain was coming from. Patient #1 reported that he went to his primary care physician (PCP) on 02/10/2025 and asked his doctor to review the x-ray. Patient #1's PCP called Patient #1 on 02/17/2025 and told him he had a fracture on his clavicle. Patient #1 felt the hospital did not take appropriate actions. Patient #1 was provided with a discharge report that stated the reason for his visit was a GI Bleed and Syncope. There were not any medications prescribed or no further instructions. Patient continues to have pain in his shoulder and just recently completed a CT scan on 02/28/2025.
.
Medical Records were reviewed for Patient #1 and included:
02/05/2025:
7:33 PM
Additional Text by Staff #7 (the admitting ED physician):
" ...Patient with reassuring labs and imaging and vitals. However, he had a syncopal event. During his ED course, feel he warrants admission for trending of H&H (hemoglobin and hematocrit), GI consultation, and continued monitoring. Discussed the case with GI (gastroenterology) and hospitalist who accept consult/admission and agrees with plan ..."
.
02/06/2025:
10:16 AM - X-ray, 2 view, of the left shoulder ordered by Staff #13.
.
11:20 AM - Left shoulder - 2 view x-ray:
"IMPRESSION:
1. Cortical irregularity in the distal clavicle suspicious for a nondisplaced fracture.
2. Mild soft tissue swelling/thickening along the superior AC joint capsule.
3. Hydroxyapatite deposition/calcifying tendinopathy in the posterior rotator cuff."
"FINDINGS:
Left glenohumeral joint grossly aligned. No acute fracture at the glenohumeral joint. There is cortical irregularity in the distal clavicle suspicious for a nondisplaced fracture. Left AC joint remains aligned/intact. There is mild soft tissue swelling/thickening along superior AC joint capsule. Hydroxyapatite deposition/calcifying tendinopathy in the posterior rotator cuff along the posterior humeral head margin."
.
The following discharge notes for Patient #1 were reviewed:
02/07/2025:
1:56 PM - Discharge Notes by Staff #13:
"Discharge diagnosis:
1.Lower GI bleed possibly secondary to diverticular bleed
2. Acute blood loss anemia secondary #1
3.Diabetes mellitus type 2
4.History of abdominal aneurysm 3.1 cm"
.
"Hospital course:
69-year-old gentleman with past medical history of diet-controlled diabetes mellitus type 2, hyperlipidemia, general anxiety disorder admitted with lower GI bleed."
.
"GI: Admitted with lower GI bleed possibly secondary to diverticular bleed which was self-limiting. GI was on consult no plans for scopes and patient recently had one in October 2023. No further bleeding during this hospital course hemoglobin hematocrit remained stable. Patient tolerating a soft diet has been has been cleared for discharge by GI. Patient
to follow-up with GI as an outpatient"
.
"Heme: Acute blood loss anemia secondary #1
-Globin has remained stable was 9.5 upon discharge
3. Diabetes mellitus type 2
-Diet control
4. History of abdominal aneurysm 3.1 cm
-Monitor as an outpatient
Discharge Time spent 38 minutes."
.
Discharge instructions included: Follow up with PCP and GI in 2-3 weeks.
.
There was no evidence in Patient #1's record of a physician's interpretation of any of the imaging of the left shoulder or reporting the results/findings to Patient #1 found within any of the attending physician's notes. There were no instructions to follow-up with any outside practitioner related to the radiological findings.
.
Rules and Regulations Review:
The facility's "Medical Staff Rules and Regulations", last reviewed and implemented on 11/13/2023, contained 17 pages that were reviewed. The "Medical Staff Rules and Regulations" stated on page 6 of 17:
" ...B. MEDICAL RECORDS:
The attending practitioner shall be responsible for the preparation of a complete and legible medical record lor each patient. Its contents shall be pertinent and current. This record shall include identification data, complaint, personal history, including social history, medications, allergies and family history, history of present illness, physical examination, special reports such as consultations, clinical laboratory and radiology services, and others, provisional diagnosis, medical or surgical treatment, operative report, pathological findings, progress notes, final diagnosis, condition on discharge, summary or discharge notes, clinical resume, and autopsy report when performed ..."
.
And on page 8 of 17:
" ...15. A discharge clinical summary shall be written or dictated on all medical records of patients hospitalized over forty-eight (48) hours. The discharge summary shall include: the reason for hospitalization, significant findings, procedures performed and treatment rendered,
patient's condition at discharge, and instruction to the patient and family, if any. A final
progress note may be substituted only for those patients with problems and interventions of a minor nature and expected results as defined by the Executive Committee of the Medical Staff and normal obstetrical deliveries and normal newborns. For these patients, the final note must include at least: condition of the patient at discharge, discharge instructions, instructions for follow up care. In all instances, the content of the medical record shall be sufficient to justify the diagnosis and warrant the treatment and end result. All summaries shall be authenticated by the responsible practitioner ..."
.
Interviews:
On 05/05/2025 at 4:01 PM Staff #1, the Vice President of Quality, was interviewed. Staff #1 was asked for a hospital (not ED) policy for documenting discussions on test result by the facility physicians. Staff #1 indicated that the facility did not have a policy for documenting discussions of test results. Staff #1 indicated that anything regarding physician documentation would be in our bylaws or rules and regs.
.
Staff #1 was asked if the facility had a hospital (not ED) discharge policy, and to provide a copy if so. Staff #1 indicated that the facility did not have an overall inpatient discharge policy and the Medical Staff Bylaws contained, "The content of the discharge summary shall contain the reason for Hospitalization, significant findings, instructions to the patient and family, as appropriate, be sufficient to justify the diagnosis and treatment, include follow-up instructions and shall state the condition of the patient, outcome of the hospitalization, disposition of care, final diagnosis, complications and procedures performed at the time of discharge..." The facility's "Medical Staff Bylaws", last reviewed and implemented on 11/14/2022, contained 55 pages that were reviewed. No section regarding the "discharge summary" could be located.
.