HospitalInspections.org

Based on medical record review, policy review, and staff interview the facility failed to ensure staff documented all unusual events in the patient medical record as per their own policy.

Findings were:

Review of medical record for patient #1 on 10/26/15 in an office in the facility revealed a conversation between the patient's mother and the nurse on duty regarding discharge against medical advice was not documented in the medical record as to the entire contents of the discussion.

Facility policy titled "Clinical Services Documentation" states in part "The Registered Nurse will document in the Medical Record: Upon unusual circumstances. All staff are responsible to make entries about any other information, which is pertinent to the patient's treatment."

In an interview with staff #1 on 10/26/15 in an office in the facility he acknowledged key elements in the conversation between the mother and the nurse were not documented in the patient medical record as per hospital policy.