HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the medical record for 1 (#3) of 5 sampled patients included documentation relative to all treatment reported to have been provided to a patient during their hospitalization. This was evidenced by the hospital's failure to ensure documentation for the use of a CPM (Continuous Passive Motion) machine was included in the medical record of Patient #3. Findings:

Patient #3: Medical record review revealed Admit Physicians orders dated 8/28/2014 that included the PRN (as needed) use of a CPM (Continuous Passive Motion) machine. Review of the PT (physical therapy) Daily Note dated 9/4/2014 reflected Patient #3 was fitted and set up for 0 to 60 degrees for new CPM machine, and the patient's nurse was informed of status. Review of the medical record revealed no documentation to indicate the dates and times the CPM machine was used on the patient.

S2Rehab Director was interviewed on 10/14/2014 at 3:25 p.m. S2Rehab Director reported that the nursing staff applied the CPM to the patients at bedtime. S2Rehab Director was unable to provide documentation relative to the dates and times the CPM machine was used on Patient #3 and indicated there was nowhere currently to document the usage of the CPM machine.