HospitalInspections.org

Based on document review and interviews Medical Records failed to ensure patient medical records were promptly completed in 1 of 1(Patient #1) patient medical records.Patient #1's medical record failed to have a written physician order for readmission on 11/26/24.

A review of patient #1's medical record revealed patient #1 was discharged from the facility to home on 11/26/24. The facility took the patient home via the facility van. The patient was left at the residence in the care of her daughter. A few hours later the daughter called the facility and stated the patient was out of control, fighting and slapping the daughter. The facility went back to pick up the patient at her residence and brought her back to the facility.

A review of the medical record revealed the physician was aware of this and instructed the facility to bring the patient back to the facility for continued care. The nurse failed to write a verbal physician order to readmit the patient.

An interview was conducted with Staff #2 and #12. Staff #12 stated there was no order to readmit the patient. Staff #2 stated that she was unaware that a physician order was not written. Staff #2 reviewed the chart with the surveyor and confirmed there was no order to readmit the patient.