|Survey Date: 5/25/2010|
Regulation Title: MR-COMPLETE RECORDS PROMPTLY
Regulation Description: (1) Current medical records and those of discharged patients must be completed promptly.
Based on review of medical records, the facility failed to appropriately complete medical records in six (#1 through #6) of six medical records reviewed. 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. 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. The telephone and/or verbal orders written by the nurses in the nurses' progress notes were not timed either. 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.