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ST FRANCIS HOSPITAL
FORM AND RETENTION OF RECORDS
Tag No.: A0438
Intakes: TN00029715
Based on medical record review and interview, it was determined the facility failed to maintain accurate medical records for 1 of 7 (Patient #3) sampled patients.
The findings included:
Review of the "Physician Documentation" record for Patient #3 revealed a physician's order dated 7/8/11 at 1:49 AM for a portable chest x-ray. Review of the results of the portable chest x-ray revealed, "Radiology Reason: Injury; Post Tube Placement/Patient in Room one ..."
Upon surveyor request, on 6/6/12 at 9:15 AM, the Emergency Department (ED) Nurse Manager reviewed the results of the portable chest x-ray report dated 7/8/11 at 2:20 AM for Patient #3. The chest x-ray report documented, "FINDINGS: Endotracheal tube is demonstrated with tip 1 cm [centimeter] above the carina. This should be retracted 1 to 2 cm ..."
During an interview in the ED on 6/6/12 at 9:20 AM, the ED Nurse Manager stated, "That's not her [Patient #3] x-ray. She [the patient] was on her way out the door when it [that chest x-ray] was done... she [the patient] was in room 4 not room 1...She [the patient] did not have an ET [endotracheal] tube..."
CONTENT OF RECORD: ORDERS DATED & SIGNED
Tag No.: A0454
Based on the facility's Medical Staff Rules and Regulations, medical record review, and interview, it was determined the facility failed to have verbal orders signed by the physician for 1 of 7 (Patient #3) patients reviewed.
The findings included:
Review of the facility's Medical Staff Rules and Regulations documented, "...Prescription for Treatment...All orders of treatment shall be in writing with date and time being indicated. Orders for restraints and Schedule II medications must be signed by the physician within 24 hours; the signature must be dated and timed...All telephone orders must be authenticated within 48 hours. The timed and dated authentication indicates that the orders is accurate, complete and final..."
Review of the "BEHAVIOR (VIOLENT OR AGGRESSIVE BEHAVIOR) RESTRAINT/SECLUSION ORDERS & SUPPORTING DOCUMENTATION" form dated 7/7/11 at 1740 documented a verbal order had been received from the physician for restraints for Patient #3. The ordering physician had not signed the form.
During an interview in the Emergency Department on 6/6/12 at 9:00 AM, the Nurse Manager verified the verbal order had not been signed by the physician.