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SPRING GROVE HOSPITAL CENTER
CONTENT OF RECORD: ORDERS DATED & SIGNED
Tag No.: A0454
All patient medical record entries must be legible, complete, dated, timed and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures
This standard is not met as evidenced by:
Based on a review of ten (10) open and nine (9) closed records, it is revealed that in four of the 10 open records, the hospital failed to date, time and authenticate in written or electronic form the services provided. The time of each entry was not accurately documented. The hospital failed to require each author takes a specific action to verify that the entry being authenticated is accurate and timely.
The time at which the Medication Administration Record was checked by this surveyor was 1:30 PM on 12/29/2016. PT #16's Risperidone 1 mg PO ( by mouth) BID ( twice a day) that was to be administered for 5 PM was initialed and circled. There was no documented reasons the medication was given/not given; no nurse initials beside reason. PT #17's Quetiapine 700 mg PO and Chlorpromazine 75 mg IM (n Intramuscular) that were to be administered for 9 PM were initialed and circled. There were no documented reasons the medications were given/not given, no nurse initials beside reasons. PT #18's Olanzapine 10 mg PO BID that was to be administered for 5 PM was initialed and circled. There was no documented reasons the medication was given/not given. In these four occasions, the time of each entry was not accurately documented. Timing establishes when an activity happened.
Furthermore, PT, #16's last entry of the reason medication given/not given was on 12/24/16 even though medications were initiated and circled from 12/15/2016 to 12/29/2016. Pt #17's last entry for the reason the medication was given/not given was on 12/17/2016, even though some medications were initialed and circled from 12/18/16 to 12/29/16. Pt #19's last entry for the reason the medication was given/not given was on 12/14/2016 even though medication was initialed and circled from 12/15/16 to 12/29/16.