|Survey Date: 2/3/2010|
Regulation Title: MR-COMPLETE RECORDS PROMPTLY
Regulation Description: (1) Current medical records and those of discharged patients must be completed promptly.
Based on staff interviews, review of medical records and facility policies and procedures, the facility failed to appropriately document written/verbal/protocol orders in 10 of (#1 through #10) ten medical records reviewed. This failure created the potential for patient care to be compromised.
The findings were:
The facility's policy and procedure entitled, "Orders for Patient Care" revised on September 2009, stated the following in pertinent part: "All verbal/telephone orders will be transcribed upon receipt into the patient's medical record and will include all of the following:
-Date order was given.
-New order or change in existing order.
-Name and credentials of physician giving order.
-Name and credentials of licensed teammate receiving the order."
The medical records of ten patients were reviewed throughout the survey. The following areas were noted that did not follow the standards of practice for nursing and physician documentation of orders:
1. Orders written by nursing staff that did not indicate if the orders were voice/telephone/protocol orders.
2. Orders written by nursing staff that did not indicate who the prescribing physician was.
3. Nursing and physician orders were not timed.
4. Orders noted by nursing staff with just a signature and not dated and timed.
5. Orders not documented as being noted by nursing at all.
An interview was conducted with several facility nursing directors on 2/3/10 at approximately 8:00 a.m. The directors stated physician orders are also entered into their electronic system; however, manual orders are still being written and they should be documented according to professional standards of practice.
Facility Plan of Correction:
The facility plan of correction (POC) for this survey was not sent to the Health Facilities and Emergency Medical Services Division in electronic format. Therefore, the POC does not appear on this web site along with the survey statement of deficiencies. The facilities are given an opportunity to submit their plan of correction electronically over the Internet in order to have it published with their survey results on this web site. The paper version of this statement of deficiency along with this facility's POC may be viewed during business hours without charge and copied for $0.25 per page at the Colorado Department of Public Health and Environment offices located at: Health Facilities and Emergency Medical Services Division, Second Floor, 4300 Cherry Creek Drive South, Denver, CO 80246, (303) 692-2800.