HospitalInspections.org

Based on document review, medical record review and interview it was revealed the medical staff failed to follow their bylaws, rules, and regulations by not documenting a change in condition on one (1) of ten (10) patients (patient #1) after the patient fell and failed to document a discharge summary on one (1) of ten (10) patients (patient #10). These failures have the potential to adversely affect all patients who experience a change in condition or are discharged from the facility.

Findings include:

1. A review of the facility document entitled 'Rules and Regulations of the Medical Staff of: Encompass Health Rehabilitation Hospital of Morgantown & Bridgeport,' effective date 5/27/21, revealed in part: "Pertinent progress notes should provide a chronological report of a patient's course of treatment in the Hospital, reflect any change in condition, and reflect the results of treatment ..."

2. A review of the facility document entitled 'Rules and Regulations of the Medical Staff of: Encompass Health Rehabilitation Hospital of Morgantown & Bridgeport,' effective date 5/27/21, revealed in part:
"The Attending Practitioner shall prepare a written or dictated discharge summary for all inpatients within thirty (30) days of discharge ..."

3. A review of the facility document entitled 'Medical Staff Bylaws of Encompass Health Rehabilitation Hospital of Morgantown & Bridgeport,' effective date 5/27/21, revealed in part: "to complete accurate and legible Medical Records or Electronic Medical Records within thirty (30) days of the date of a patient's discharge ..."

4. A review of patient #1's medical record revealed the physician had not documented a progress note after notification of the patient falling and experiencing increased confusion and prior to the patient's discharge to home.

5. A review of patient #10's medical record on 9/14/21 revealed he had been discharged on 8/5/21 and there was no discharge summary in the medical record.

6. An interview with patient #1's physician conducted on 9/14/21 at approximately 11:45 a.m. revealed he had not seen the patent after he was notified of the fall and prior to the patient discharge and had not documented a progress note in the medical record.

7. An interview was conducted with the Director of Quality on 9/13/21 at approximately 2:00 p.m. and she agreed there was no physician progress note documented in patient #1's medical record after the patient fall and notification of change in condition and the patient discharge.

8. An interview was conducted with the Director of Quality on 9/14/21 at approximately 1:00 p.m. and she agreed there was no discharge summary in patient #10's medical record.