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Based on review of medical record and interview with staff this requirement was not met. Medical record was not complete within 30 calendar days following discharge and had incomplete entries.

Findings:

A. Review of medical record.

1. The documentation in different areas in the medical record provided conflicting evidence that rounds were made. It was noticed that all of the certified nursing assistant (CNA) rounds were not documented on July 30, 2014 12 am - 6 am time period. The rounds were captured on the nursing notes as a delayed entry on July 30 2014 that the CNA did make rounds at 2:00 am on July 30, 2014 and the patient was fine at that time with no problems.

2. Documentation met very minimal requirements and was not detailed enough.

3. The discharge summary was included in the medical record. The patient's date of death was July 30, 2014. It was observed that the discharge summary was dictated by a secondary DO provider on September 20, 2014 at 2:45pm, transcribed on September 23, 2014 at 12:20 pm and reviewed by primary MD provider,authenticated dated, and timed on September 29, 2014 at 10 am. Which is greater than 30 days after the patients death. There was no addendum or any information regarding the patient ' s heart attack on morning of July 30, 2014 included in the discharge summary.

4. Illegible physician entries documented at 5:50 pm on July 20, 2015.

B. Interviewed and reviewed medical record with staff #4, Director of Nursing on September 11, 2015 at 12:30 pm, several phone interviews between September 11, 2015 to February 2016 and interviewed again onsite February 18, 2016 at 10:20 am in the administration conference room. The staff member agreed with the medical record documentation issues found did not meet requirements of completeness.

Based on review of medical record and interview with staff this requirement was not met. Medical record was not complete within 30 calendar days following discharge and had incomplete entries.

Findings:

A. Review of medical record.

1. The discharge summary was included in the medical record. The patient's date of death was July 30, 2014. It was observed that the discharge summary was dictated by a secondary DO provider on September 20, 2014 at 2:45pm, transcribed on September 23, 2014 at 12:20 pm and reviewed by primary MD provider,authenticated dated, and timed on September 29, 2014 at 10 am. Which is greater than 30 days after the patients death. There was no addendum or any information regarding the patient ' s heart attack on morning of July 30, 2014 included in the discharge summary.


B. Interviewed and reviewed medical record with staff #4, Director of Nursing on September 11, 2015 at 12:30 pm, several phone interviews between September 11, 2015 to February 2016 and interviewed again onsite February 18, 2016 at 10:20 am in the administration conference room. The staff member agreed with the medical record documentation issues found did not meet requirements of completeness.