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INDIANHEAD MEDICAL CENTER SHELL LAKE
No Description Available
Tag No.: C0307
Based on record review and interview the facility failed to assure all entries in the medical record are authenticated by a Registered Nurse in 2 Patient's (#5, 9) in a total sample of 10.
Findings:
Review of Patient #5's medical record on 11/25/2019 revealed an Emergency Department (ED) record dated 11/24/2019. There was an "ER (Emergency Room) Pediatric Assessment" completed at 9:15PM without a signature on the form from the Registered Nurse (RN). This was confirmed with ED Manager B on 11/25/2019 at 12:50PM.
Review of Patient # 9's medical record on 11/25/2019 revealed an Emergency Department record dated 11/3/2019. There was an "Emergency Room Nursing Assessment" completed at 3:25AM without a signature on the form from the Registered Nurse. This was confirmed with ED Manager B on 11/25/2019 at 1:40PM.
In interview on 11/25/2019 at 1:10PM with ED Manager B, when asked about expectations for RN signatures in the ED medical record stated, "all nurses notes need to have the nurses signature."