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5/24/2010 Survey Tag 0725 Detail for:
PIKES PEAK DIALYSIS CENTER
Wednesday, October 23, 2019 12:16 AM

Survey Date: 5/24/2010

Regulation Number:0725

Regulation Title: CFC-MEDICAL RECORDS

Regulation Description:

Surveyor Findings:


Based on the number and nature of deficiencies cited, the facility failed to comply with the Condition for Coverage of Medical Records. The facility failed to maintain complete and accurate records and protect them against loss and unauthorized use.
The facility failed to meet the following standards under the condition of Medical Records:
V 0726 Maintenance of a complete, accurate, and accessible record on all patients.
The facility failed to maintain a complete, accurate, and accessible patient record on all patients. Original physician progress notes and physician orders left the premises of the facility and were absent from the patient's record during review of the patients' records. This failure created the potential for patient care to be compromised.
V 0727 Protection of patient's record.
The facility failed to ensure the patients' medical records were protected from loss, destruction, or unauthorized use. Original physician orders and progress notes left the premises and were not available during review of the patients' records during the survey.
V 0729 Completion of patient records promptly.
The facility failed to appropriately complete medical records in eight of eight in-center hemodialysis patients' medical records reviewed. Entries were lacking documentation of the time of the entries. This failure created the potential for patient care to be compromised.
V 0730 Centralization of clinical information.
The facility failed to maintain a centralized patient record that was accessible to all members of the interdisciplinary team. This failure created the potential for patient care to be compromised.

Facility Plan of Correction:

V725 Members of the Governing Body (GB) have reviewed the Statement of Deficiencies (SOD) and formulated the Plan of Correction (POC). The standards under Condition: Medical Records (V725) that is not met as well as other standards contains specifics of corrective plans. 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. Policy #3-02-02 Medical Record Preparation Charting Guidelines has been reviewed with the teammates with the emphasis on that all entries are to be dated and signed at the time of entry.
AA’s are to complete all filing and audit 100% of the patient charts by 6/21/10followed by monthly audits of 10% of the charts. In addition compliance will be evidenced by random audits conducted by the FA of monthly physician Rounding Reports X 3 months. Results of audits will be reported in QIFMM and addressed as necessary. FA and Medical Director are responsible for ongoing compliance with POC.

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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
Email us or phone 303.692.2800 main

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