|Survey Date: 3/30/2010|
Regulation Title: MR-COMPLETE RECORDS PROMPTLY
Regulation Description: (1) Current medical records and those of discharged patients must be completed promptly.
Based on staff interview and review of medical records, the facility failed to appropriately complete medical records in 8 of (#1 through #8) eight medical records reviewed. This failure created the potential for patient care to be compromised.
The findings were:
The medical records of eight patients were reviewed throughout the survey from 3/29/10 through 3/30/10. The "Physician Orders and Progress Notes" were reviewed for approximately the previous six months to one year. It was noted that all physician orders and progress notes were not timed. The telephone and/or verbal orders written by nurses were not timed as well. The physician orders that were noted by nurses were not timed when orders were taken off except when the nurse used a stamp which stated: "Noted and Entered into Snappy." This stamp prompted the nurse to date, time and sign the order being noted.
The above findings were brought to the attention of the facility educator on 3/30/10 at approximately 7:45 a.m. The educator stated that education regarding the necessity of timing all orders in all the associated dialysis facilities has been done several months ago.
Facility Plan of Correction:
On Tuesday April 13th, the Facility Administrator held an in-service with the dietitian, social worker and all nurses working at the dialysis center on required documentation for physician orders. This in-service covered the following items that are needed to appropriately document written/verbal orders:
1. Date and time the order was given
2. Proper notation on the type of order, whether it be a verbal order, telephone order, or following protocol.
3. Name and credentials of physician giving the order
4. First initial, last name and the title of the teammate receiving the order
5. Nurses will “note” all orders they take off going forward, new licensed teammate training will include review of the related documentation policies
a. Medical record preparation and charting 3-02-02
b. Orders for patient care 3-02-03
c. Physician’s order policy 3-02-10
d. Allied health professionals order policy 3-02-11
On an annual basis all teammates will review the above policies
FA/designee will audit 10% of records monthly x3 then do random audits quarterly to ensure compliance. Results of audits will be reviewed in CQI with Medical Director and addressed as necessary. FA is responsible for ongoing compliance with POC.