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5/24/2010 Survey Tag 0715 Detail for:
PIKES PEAK DIALYSIS CENTER
Wednesday, October 23, 2019 12:16 AM

Survey Date: 5/24/2010

Regulation Number:0715

Regulation Title: MD RESP-ENSURE ALL ADHERE TO P&P

Regulation Description: The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers;

Surveyor Findings:


Based on review of medical record reviews and staff interviews it was determined that the medical director failed to ensure all policies and procedures were adhered to by all individuals that treat patients in the facility. This practice of removing physician progress notes and written orders had the potential for causing negative patient outcomes.

The findings were:

The medical records of eight in-center hemodialysis patients were reviewed throughout the survey from 5/20/10 through 5/24/10. In three (#5, #6, and #7) of eight records original physician progress notes and written physician orders were absent from the chart for the month of April, 2010. The facility was unable to provide the absent physician progress notes and written physician orders.
An interview with the medical director was conducted on 5/19/2010 at approximately 3:30 p.m. S/he stated that the physician rounding sheets that contained physician progress notes and written orders were part of the patients' medical records and were being removed by providers against the facility's policies.

Facility Plan of Correction:

V715
The Medical Director is accountable to the GB and will ensure the security of medical records, be involved in the quality improvement process in evaluation and prevention of medical errors, and ensure teammates adhere to policies and procedures.

Policy #3-02-01Medical Record Maintenance has been reviewed with the facility team with emphasis on the need for a monthly review of 10% of the medical records and that medical records are to remain in the facility at all times, until such time they are archived in an approved medical records storage company. AA’s are to complete all filing and audit 100% of the patient charts by 07/15/2010, followed by monthly audits of 10% of the charts. These medical records audits will be documented on the QIFMM form m reviewed in QIFMM meeting and any action plans developed and implemented as needed. A letter was written to XXX Nephrology Associates on May 20, 2010 by the Medical Director, stating that no documents are to be removed from the facility from that date forward. FA and Medical Director are responsible for ongoing compliance with POC.
CSS to have pre QAPI and QIFMM meetings with the FA’s X 6 months to ensure all plans of correction are documented correctly. CSS to attend QAPI meetings X 6 months to ensure Medical Director participation. AA’s will attend QAPI meetings to record the meeting meetings and POC’s developed by the IDT during the meetings.


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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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