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Based on review of documentation and interview with staff, the facility failed to ensure that patient records contained a final diagnosis and were completed within 30 days following discharge for 3 of 5 patients whose records were reviewed.

Findings were:

The facility Medical Staff Bylaws state that all medical records must be completed with a discharge summary contiaining a discharge diagnosis within 30 days following the patient's discharge. Review of the records of patients #1-5 revealed that the records of patients #1, #4, and #5 were not completed with a discharge diagnosis within 30 days of the patients' discharge dates. Patient #1 was discharged 3/9/13; however, the medical record did not contain a discharge summary as of the date of the survey 5/15/13. The record of patient #4 contained a discharge summary dictated 33 days after discharge, and patient #5's record contained a discharge summary dictated almost 2 months following discharge. This patient was discharged 3/6/13; however, the summary was not dictated until 5/2/13.

These findings were acknowledged by the Chief Nursing Officer the afternoon of 5/14/2013.