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Based on review of documentation and interviews with facility staff, the facility failed to ensure that medical record discharge summaries were completed within 30 days as required by facility policy in 3 of 10 medical records reviewed causing a delay in completing records.

The findings were:

Patient records were reviewed on 10/16/18 and the patient records of patient # 8, and 9 did not contain a discharge summary as follows. The record of patient #8 reflected the patient had been discharged on 8/21/18 and did not contain a discharge summary. The record of patient #9 reflected the patient had been discharged on 8/27/18 and did not contain a discharge summary. The record of patient #1 reflected the patient was discharged on 12/6/17 and contained a discharge summary that was dictated on 2/26/18.

The facility policy entitled "General Documentation Guidelines" #H-IM01-001 dated 6/17 reflected in part "21b. The time period for completion of the medical record is specified in the Medical Staff Rules and Regulations and cannot exceed 30 days after discharge. The Medical Staff Rules and Regulations dated 11/16 reflected in part "14. A medical record must be completed within thirty (30) days after discharge ..."

In an interview with the quality director, staff #1 on the morning of 10/16/18 in an office, staff #1 agreed that records of patients #8 and 9 did not contain discharge summaries and in the record of patient #1, the discharge summary was completed more than 30 days after discharge as outlined above.

Based on review of documentation and interviews with facility staff, the facility failed to have the physician sign the memorandum of transfer forms as required by facility policy in 2 of 10 patient records reviewed which resulted in an incomplete record.

The findings were:

Patient records were reviewed on 10/16/18 and the patient records of patient # 8, and 9 contained memorandum of transfer forms that had not been signed by the transferring physician as follows. The medical record of patient #8 contained a memorandum of transfer dated 8/20/18 that had not been signed by the physician, staff #10. The medical record of patient #9 contained a memorandum of transfer dated 8/27/18 that had not been signed by the physician, staff #11.

The facility policy entitled "Discharge/Transfer of Patients" #PC.290 dated 2/08 reflected in part "The hospital will provide a memorandum of transfer (MOT) to be completed for each patient who is transferred. The MOT will be signed by the transferring physician, or if not present, a hospital staff member acting under the physician's orders if a delay in transferring has been determined to be detrimental to the patient ...The physician shall countersign the certification as soon as possible if initially completed by hospital personnel."

The facility policy entitled "General Documentation Guidelines" #H-IM01-001 dated 6/17 reflected in part "21b. The time period for completion of the medical record is specified in the Medical Staff Rules and Regulations and cannot exceed 30 days after discharge. The Medical Staff Rules and Regulations dated 11/16 reflected in part "14. A medical record must be completed within thirty (30) days after discharge ..."

In an interview with the quality director, staff #1 on the morning of 10/16/18 in an office, staff #1 agreed that the memorandums of transfer of patients #8, and 9 had not been signed by the transferring physician.