Observations
Based on the review of patient records, the facility failed to document discharge summaries that included all of the required information in nine of nine patient records reviewed.
The findings include:
Twenty four patient records were reviewed on August 28-30, 2012. Nine patient records were reviewed for complete discharge summaries. Nine patient records failed to document a discharge summary with all required components, # 12, 13, 16, 17, 18, 20, 21, 22 and 23.
Patient # 12 was admitted on May 16, 2011 and discharged on January 20, 2012 . The record failed to identify services offered in the discharge summary.
Patient # 13 was admitted on March 16, 2012 and discharged on August 5, 2012. The record failed to identify services offered in the discharge summary.
Patient # 16 was admitted on August 10, 2011 and discharged on June 21, 2012. The record failed to identify services offered in the discharge summary.
Patient # 17 was admitted on January 31, 2012 and discharged on June 27, 2012. The record failed to identify services offered in the discharge summary.
Patient # 18 was admitted on September 26, 2010 and discharged on March 30, 2012. The record failed to identify services offered in the discharge summary.
Patient # 20 was admitted on July 19, 2011 and discharged on March 22, 2012. The record failed to identify services offered in the discharge summary.
Patient # 21 was admitted on November 4, 2009 and discharged on August 17, 2012. The record failed to identify services offered in the discharge summary.
Patient # 22 was admitted on March 15, 2011 and discharged on August 27, 2012. The record failed to identify services offered in the discharge summary.
Patient # 23 was admitted on August 9, 2011 and discharged on October 13, 2011. The record failed to identify services offered in the discharge summary.
The Facility Director was interviewed on August 30, 2012 and confirmed the findings.
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Plan of Correction
715.23(b)(23) Patient Records: Citation for failure to identify services offered in the discharge summary was reviewed with clinical staff on 9-4-12, examples of a correct discharge summary were reviewed and discussion held with staff. Education and discussion was again held on 10-31-12. An audit was conducted by the Clinical Supervisor on patient records on 10-31-12 which found compliance at 100% in the sample. The Clinical Supervisor is responsible for implementing this corrective plan. |