HospitalInspections.org

Based on review of records and interview the hospital failed to document 1 of 1 patient's (Patient #8)
medical records.

Findings Include

1. The hospital nursing notes failed to include dates and times of all dressing, and bandage changes. Medical Records reflected the bandages and dressing changes should be completed in the record every other day. Nursing notes notated a dressing change on 10/06/16 at 1700 hours. The next dressing change was noted on 10/17/16 at 0900.

2. During an Interview with Hospital staff #2 the medical records were reviewed. Staff #2 verified the medical records for Patient #8 did not reflect times of all dressing, and bandage changes. Nursing Notes reflected, Staff #2 indicated that they have failed to document all times of all dressing, and bandage changes.