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5/25/2010 Survey Tag 0715 Detail for:
PRINTERS PLACE DIALYSIS CENTER
Wednesday, October 23, 2019 12:18 AM

Survey Date: 5/25/2010

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 that all policies and procedures were adhered to by all individuals that treat patients in the facility.

The findings were:

The medical records of six patients were reviewed throughout the survey. In four (#1, #2, #3, #5) of six records original physician progress notes and written physician orders were absent from the chart for the months of March and April 2010. In two (#2 and #6) of six records original physician progress notes and written physician orders were absent from the chart for the month of October 2009. In one (#2) of six records original physician progress notes and written physician orders were absent from the chart for the month of February 2010.

On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for April 2010 on four (#1, #2, #3 & # 5) of the five patients. On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for March 2010 on two (#1 and #2) of the four patients. On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for February 2010 on the one (#2) patient. However, the facility was unable to provide the absent physician progress notes and written physician orders for the two patients (#2 and #6) from October 2009.

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.

An interview with the Facility Administrator for the Acute Care Program was conducted on 5/19/2010 at approximately 8:30 a.m. When asked where the physician rounding reports were for Sample patient #3, S/he stated that they may be in the patient's treating physician's office.


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 06/21/2010, followed by
monthly audits of 10% of the charts. These
medical records audits will be documented
on the QIFMM form and 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. 6/21/10
The Clinical Services Specialist ( CSS) to
have pre QAPI and QIFMM meetings with
the FA's X 6 months to ensure all plans of
correction are documented correctly.
Clinical Services Specialist (CSS) to attend
QAPI meetings X 6 months to ensure
Medical Director participation. AA's will
attend QAPI meetings to record the meeting
minutes and POC's developed by the IDT
during the meetings.


Back to Survey Tag Summary for:PRINTERS PLACE DIALYSIS CENTER

Colorado Department of Public Health and Environment
Health Facilities and Emergency Medical Services Division
4300 Cherry Creek Drive South
Denver CO 80246-1530
Email us or phone 303.692.2800 main

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