HospitalInspections.org
Bringing transparency to federal inspections
ERIE COUNTY MEDICAL CENTER
CONTENT OF RECORD: ORDERS,NOTES,REPORTS
Tag No.: A0467
Based on medical record review, policy review and interview, staff did not document an incident involving Patient #1 in the medical record in accordance with facility policy.
Findings Include:
Review on 03/16/16 of policy " Occurrence Reporting: ADM-033 " last facility revision 03/2015 revealed occurrences should be documented as to the objective specific details of the occurrence in the medical record (if involves a patient).
Review on 03/16/16 of policy " Sexual Assault: Evidence Collection Policy: ED-012 " last facility revision 10/2013 revealed for staff to make note and/or document the facts, comments/statements made by patient/victims and/or offender.
Review of Nursing Notes dated 03/07/16 revealed no documentation of the statements made by the patient or mother, description of the incident/allegations and actions taken.
On 03/17/16 at 01:30 PM, this finding was confirmed by Staff #1.