|Survey Date: 5/25/2010|
Regulation Title: MR-COMPLETE, ACCURATE, ACCESSIBLE
Regulation Description: The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility.
Based on review of Sample #1's medical record and staff interview, it was determined that a physician's order was not completed. Specifically, on 3/1/10 sample #1's Nephrologist wrote an order for "check Hepatitis C viral DNA". The order was signed off by the RN, however, the correct test was not completed.
A telephone interview was conducted on 6/2/10 at 11:15 a.m. with the Facility's Administrator. S/he stated that the nurse who noted the order was not aware of this test and only had a Hepatitis C test without the DNA drawn on the patient. S/he stated the test was drawn as ordered on 6/2/10 and the results would be sent to the patient's Nephrologist.
Based on medical record review and staff interviews, it was determined that the facility failed to maintain a complete, accurate and accessible patient record on all patients. This failure created the potential for patient care to be compromised.
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. The facility was unable to provide the absent physician progress notes and written physician orders from October 2009.
An interview with the medical director was conducted on 5/19/10 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 (physicians and allied health personnel) against the facility's policies.
An interview with the Facility Administrator for the Acute Care Hospital Dialysis 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.
On 5/19/10 at approximately 5:00 p.m., when the documents listed above were provided, the Facility Administrator stated that the documents were obtained from one of the treating physician's office.
In summary, the facility allowed original documents to leave the premises and the documents were not available to all members of the interdisciplinary team at all times. This failure created the potential for patient care to be compromised.
Facility Plan of Correction:
The Governing Body will ensure the facility
maintains an effective, data driven, quality
assessment and performance improvement
program (QIFMM) that includes a monthly
medical record review. Policy
#3-02-01Medical Record Maintenance and
#3-02-03 “Orders for Patient Care” has been
reviewed with the facility team with
emphasis on the importance of following
orders as written and 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 6/21/10followed by monthly audits of
10% of the charts.
These medical records audits will be
documented on the QIFMM form and
reviewed in QIFMM meeting with 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