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5/25/2010 Survey Tag 0730 Detail for:
PRINTERS PLACE DIALYSIS CENTER
Wednesday, October 23, 2019 12:20 AM

Survey Date: 5/25/2010

Regulation Number:0730

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.

Surveyor Findings:


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 six patients were reviewed throughout the survey. In four (#1, #2, #3, #5) of six records, original physician progress notes and written physician orders were absent from the chart for the months of March and April 2010. In two (#2 and #6) of six records, original physician progress notes and written physician orders were absent from the chart for the month of October 2009. In one (#2) of six records, original physician progress notes and written physician orders were absent from the chart for the month of February 2010. On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for April 2010 on four (#1, #2, #3 & # 5) of the five patients. On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for March 2010 on two (#1 and #2) of the four patients. On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for February 2010 on the one (#2) patient. The facility was unable to provide the absent physician progress notes and written physician orders from October 2009.

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.

An interview with the Facility Administrator for the Acute Care Hospital Dialysis Program was conducted on 5/19/2010 at approximately 8:30 a.m. When asked where the physician rounding reports were for sample patient #3, s/he stated that they may be in the patient's treating physician's office.

On 5/19/10 at approximately 5:00 p.m., when the documents listed above were provided, the Facility Administrator stated that the documents were obtained from one of the treating physician's office.

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.


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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

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