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12/5/2007 Survey Tag 0238 Detail for:
RELIANT RENAL CARE RRC TRINIDAD
Wednesday, October 23, 2019 12:19 AM

Survey Date: 12/5/2007

Regulation Number:0238

Regulation Title: MEDICAL RECORD: MEDICAL & NURSING HISTORY

Regulation Description: All medical records contain medical and nursing history of patient.

Surveyor Findings:


Based on medical record review and staff interview, the facility failed to ensure patients received an initial nursing assessment upon admission for three (#2, #3 and #4) of 5 medical records reviewed. The failure to ensure pertinent medical history was obtained and a physical assessment performed by the registered nurse prior to initiation of dialysis treatment has the potential to result in inadequate clinical information in which to develop an adequate plan of care. The findings were:

The medical record for sample patient #2 was reviewed on 12/5/07. The patient was admitted on 8/31/07 for the first hemodialysis treatment. There was no initial nursing assessment performed for this patient. As of 12/5/07 there was no nursing assessment performed.

The medical record for sample patient #3 was reviewed on 12/5/07. The patient was admitted on 6/15/07 for the first hemodialysis treatment. There was no initial nursing assessment performed for this patient. As of 12/5/07 there was no nursing assessment performed.

The medical record for sample patient #4 was reviewed on 12/5/07. The patient was admitted on 3/22/06 for the first hemodialysis treatment. There was an initial nursing assessment started on the patient; however, there was no date and the assessment had not been completed. As of 12/5/07 there was no nursing assessment performed.

The clinical supervisor was interviewed on 12/5/07 at 8:50 a.m. The supervisor was asked about an assessment on sample patient #2 and the supervisor stated that it had not been done. The supervisor further stated that s/he works on the dialysis floor with patients as well as doing charge duties and it is difficult to get nursing assessments completed.

Facility Plan of Correction:

A new policy was implemented regarding nursing history and physicals. All new patients will have a nursing history and physical upon first dialysis treatment in the clinic and yearly there after. See attachment.

Patients #2, #3 and #4 nursing history and physicals were completed 12/19/07. see attachments.

The Clinical Supervisor will come in on the first Tuesday (non dialysis day) of each month to review and update all charts.



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Colorado Department of Public Health and Environment
Health Facilities and Emergency Medical Services Division
4300 Cherry Creek Drive South
Denver CO 80246-1530
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