Discharge Documentation Missing or Incorrect

The Centers for Medicare and Medicaid Services (CMS) cited Cypress Creek Hospital following a complaint investigation survey. CMS found that the facility failed to ensure patient medical records contained appropriate documentation. It was determined that four out of eight sampled records did not contain appropriate discharge summaries. A discharge summary for the wrong patient was observed in one record. Another record had the word “dictated” on the front of the discharge form (with no typed copy in the file), while two others did not contain proper forms. As a result, the facility had to submit a plan of correction to address its cited deficiencies.