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Tag No.: A0450
Based on record review and interview, the facility failed to ensure that all patient medical records were complete.
Findings include:
Review of documentation on 1/27/10 titled "Deficiency Aging by Document Report" presented by the Director of Health Information Management (Medical Records), it was noted that the facility has 113 medical records that have been incomplete for more than 30 days. Per document, records are missing Consultation Reports, History and Physicals, Operative Reports and Discharge Summarys.
During interview on 1/27/10 at 1:00 PM with the Director of Health Information Management (Medical Records), it was confirmed that records have been incomplete and missing documents for more than 30 days.
Tag No.: A0700
The facility failed to provide and maintain a safe environment for patients and staff.
This is evidenced by the Life Safety Code deficiencies identified. See A-710.
Tag No.: A0710
Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on January 25, 2010, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.
See the K-tags on the CMS-2567 dated January 25, 2010 for Life Safety Code.