HospitalInspections.org

Based on document review, medical record review and staff interview, the hospital failed to ensure the medical staff enforces its bylaws relative to completion of medical records in three (3) of six (6) closed medical records (Patient #1, 2 and 3) reviewed. This has the potential to negatively impact all patient care by not promoting continuity of care. Findings include:

1. A review of the hospital's "2010 Medical Staff Rules and Regulations" states, in part, on page #4 "A discharge summary (clinical resume) shall be written, dictated and completed on all patients no later than 30 days after discharge. All discharge summaries shall be authenticated by the responsible practitioner. If the summary is not complete within 30 days after discharge the record will be considered delinquent."

2. Review of the medical record for Patient #1 revealed the patient was discharged on 2/12/11 and as of 3/31/11 there was no documented evidence of a dictated Discharge Summary.

3. Review of medical record for Patient #2 revealed the patient was discharged on 2/23/11 and as of 3/31/11 there was no documented evidence the discharge summary had been authenticated.

4. Review of medical record for Patient #3 revealed the patient was discharged on 2/19/11 and as of 3/31/11 there was no documented evidence the discharge summary had been authenticated.

5. The Chief Nursing Officer (CNO) was interviewed in the afternoon of 3/30/11 and agreed with the above findings.