|Survey Date: 5/24/2010|
Regulation Title: MR-CENTRALIZE ALL INFO;IDT HAS ACCESS
Regulation Description: (2) All clinical information pertaining to a patient must be centralized in the patient's record, including whether the patient has executed an advance directive. These records must be maintained in a manner such that each member of the interdisciplinary team has access to current information regarding the patient's condition and prescribed treatment.
Based on medical record review and staff interviews, it was determined that the facility failed to maintain a centralized patient record. 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. In three (#5, #6, and #7) of eight records original physician progress notes and written physician orders were absent from the chart for the month of April, 2010. The facility was unable to provide the absent physician progress notes and written physician orders.
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 (which 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.
In summary, the facility allowed original documents to leave the premises. 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:
V730 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 has been reviewed with the facility team with emphasis on 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 6/21/10, followed 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 POC.