HospitalInspections.org
Bringing transparency to federal inspections
AUSTIN OAKS HOSPITAL
FORM AND RETENTION OF RECORDS
Tag No.: A0438
Based on a review of documentation and interview the facility failed to ensure that medical records were accurate and complete, containing information to describe the patient's progress.
Findings included:
A review of the facility policy Documentation Guidelines, Review Date 1/16/2019 stated, in part:
"Mental Health Technicians ...
b. A progress note is documented on the back of the Patient Observation form in the designated section on each shift"
Review of documentation for Patient #1 revealed the following:
* Patient #1 was found in a shower with another patient on 01/25/19.
* A review of the Q15 Patient Observation/MHT Progress Notes on 01/25/19 revealed this incident and discovery of Patient #1in the shower was not documented by the mental health technician per policy.
In an interview on 02/13/19 staff member #6 confirmed that there was no progress note documented by the mental health technician regarding this incident. Per facility policy a progress note is to be made on each shift.