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Based on interview and record review on 4/12/21 at 1530, the hospital failed to ensure that the medical record was complete for treatment consents. 2 of 21 patients reviewed had incomplete consents in the record.

Finding:

Patients 14 and 5 had consents that were incomplete or missing from the record. On 4/12/21 at 1532, staff A was questioned about when the consents should be placed into the chart of a patient admitted on 4/1/21. On 4/12/21 at 1532 Staff A responded, "The documents should have been put in at admission or or soon after". Staff B reviewed the EMR chart for patient's 14 and 5 and stated, " they were not in the chart". The documentation of consent was not completed as required by§482.24(c)(4)(v).

Based on interview and record review the hospital failed to ensure that the medical record was complete for 1 of 21 patients.

Finding:

Patient 17, who discharged more than 50 days ago, did not have a discharge summary in the record as required by§ 482.24 (c)(4) (vii)(viii). On 4/12/21 at 1540, Staff A was asked to show the discharge summary for patient 17 in the medical record. On 4/12/21 at 1541, Staff A stated, " the discharge summary was not present in the record".