Go to the State of Colorado Web
5/24/2010 Survey Tag 0729 Detail for:
Tuesday, May 26, 2020 1:28 AM

Survey Date: 5/24/2010

Regulation Number:0729


Regulation Description: (1) Current medical records and those of discharged patients must be completed promptly.

Surveyor Findings:

Based on review of medical records, the facility failed to appropriately complete medical records in eight (#1, #3, and #5 through #10) of eight in-center hemodialysis patient medical records reviewed. This failure created the potential for patient care to be compromised.
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. The "Physician Orders and Progress Notes" were reviewed for the previous six months to approximately one year. It was noted that all physician orders and progress notes were not timed. Also, the physician orders that were noted by nurses were not timed when orders were taken off, only dated.

Facility Plan of Correction:

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 timed dated and signed at the time of entry.
AA’s are to complete all filing and audit 100% of the patient charts by 6/21/10 followed 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.

Back to Survey Tag Summary for:PIKES PEAK 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

Return to Health Facilities Main Page