HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the physician completed the discharge summaries according to medical staff rules and regulation for two of 22 (patient # 11 & 13) records reviewed.

This failed practice resulted in delinquent patient records for patient # 11 & 13.

Findings:

A policy titled "Medical Staff Rules and Regulations 2018" says all discharge shall be completed within 30 days following the patient's discharge...Incomplete records exceeding 30 days following discharge will be considered delinquent.

Patient # 11

Patient was admitted 04/10/18 and discharged 04/19/18.

A review of document titled "Discharge Summary" shows document was dictated by Staff H on 05/20/18 (1 day late).

Patient # 12

Patient was admitted on 05/31/18 and discharged on 06/12/18.
A review of document titles "Discharge Summary" show document was dictated by Staff H on 07/17/18 (5 days late).

Patient # 13

Patient was admitted on 04/26/18 and discharged 05/08/18.

A review of document titled "Discharge Summary" shows document was dictated by Staff I on 07/02/18 (55 days late).

On 07/19/18 at 11:30 am, Staff C stated discharge summaries should be completed within 30 days.