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Based on record review and interview, the hospital failed to ensure each patient's discharge summary included all hospital outcomes of the hospitalization, in that, 1 of 10 (Patient #4) patient's discharge summary did not contain all hospital outcomes of the hospitalization.

Findings included

Patient #4's discharge summary failed to reflect the patient's acquired Vancomycin Resistant Enterococcus and an unstageable wound to his coccyx during his hospitalization.

During an interview on 7/12/16 at 1:25 PM, Personnel #2 was asked to confirm the above findings. Personnel #2 agreed the Vancomycin Resistant Enterococcus and an unstageable wound to his coccyx were not noted in the discharge summary.

Based on record review and interview, the hospital failed to complete a discharge summary within 30 days of the patient's discharge, in that, 3 of 10 (Patient #1, #2, and #4) patient's discharge summaries were not completed within 30 days following discharge.

Findings included

Patient #1's medical record reflected the discharge date of 6/09/16. The discharge summary reflected a dictated date of 7/12/16.

Patient #2's medical record reflected the discharge date of 6/06/16. The discharge summary reflected a dictated date of 7/12/16.

Patient #4's medical record reflected the discharge date of 2/12/15. The discharge summary reflected a dictated date as 4/06/15.

During an interview on 7/12/16 at 1:25 PM, Personnel #3 was asked to verify the above findings. Personnel #3 agreed, the discharge summaries were completed more than 30 days after the patient's discharged from the hospital.

The facility's May 2013 "Medical Staff Rules and Regulations" reflected, "...Discharge summary...within 30 days of discharge..."

Based on record review and interview, the facility failed to identify, investigate, and report health care associated infections and communicable diseases between patients and personnel, in that, 1 of 10 patients (Patient #4) had a hospital acquired VRE (Vancomyocin Resistant Enterococcus) that was not documented as identified, investigated and reported by the facility.

Findings included

Patient #4's electronic record contained a respiratory Culture & Gram Stain collected on 2/06/15 from the tracheostomy that reflected Enterococcus Faecalis, heavy growth, resistant to Ciprofloxin, Gent synergy, Levofloxacin, Tetracycline, and Vancomycin. Patient #4 had 2 previous respiratory cultures that were negative during the 1/02/15 admission.

During electronic record review and interview on 7/11/16 ending at 3:30 PM, Personnel #3 was asked if Patient #4 had VRE. Personnel #3 reviewed the trach culture results and stated, "Yes, it says resistant to Vancomycin."

During an interview on 7/12/16 at 11:50 AM, Personnel #10 was asked for the investigation and reporting of Patient #4's VRE. Personnel #10 stated, "There isn't one that I can find."