HospitalInspections.org

Based on review of Hope Harbor policies, medical records and staff interviews the facility failed to ensure all Physician orders and Physician handwritten progress notes in the patient's medical record were timed for 8 of 8 open records (Patient # 1, #2, #3, #4, #5, #6, #7, #8) and 6 of 16 closed records, (Patients #9, #10, #11, #12, #13, #14 #15 and #16). The Hope Harbor unit identified a census of 8 patients.

Failure to document time could potentially interrupt continuity of care and transferability of changes in procedures or treatments.

Findings included:

1. Review of Patient Records/Charting revised 2/02 noted:
S. Complete chart entries using these guidelines: 4. all entries are dated, timed and signed with the writer's credentials

2. Review of open medical records noted:
a. Patient #1, 5 of 9 Physician's orders lacked documentation of time
b. Patient #2, 10 of 17 Physician's orders lacked documentation of time
c. Patient #3, 5 of 5 Physician's orders lacked documentation of time
d. Patient #4, 15 of 23 Physician's orders lacked documentation of time
e. Patient #5, 5 of 6 Physician's orders lacked documentation of time
f. Patient #6, 6 of 10 Physician's orders lacked documentation of time
g. Patient #7, 12 of 20 Physician's orders lacked documentation of time
h. Patient #8, 8 of 12 Physician's orders lacked documentation of time

3. Review of closed medical records noted:
i. Patient #9, 15 of 28 Physician's orders lacked documentation of time
j. Patient #10, 4 of 6 Physician's orders lacked documentation of time
k. Patient #11, 14 of 23 Physician's orders lacked documentation of time
l. Patient #12, 11 of 20 Physician's orders lacked documentation of time
m. Patient #13, 17 of 20 Physician's orders lacked documentation of time
n. Patient #14, 12 of 17 Physician's orders lacked documentation of time

3. On 4/6/19 at 2:50 PM the Director of Hope Harbor unit verified the lack of documentation of time for the Patients' Physician orders, "The Physicians know it is policy for all entries to be dated, timed and signed".