HospitalInspections.org

Based on record review and the interview, the facility failed to document the neurological examination in such a way as to verify the specific cranial nerve testing performed for 1 of 8 active sample patients (A5). This failure to document complete cranial nerves examination potentially compromises the identification of pathology and future comparative re-examination.

Findings include:

A. Record review

1- Since the last survey, the facility designed a new form for neurological examinations; it includes the detailed description of all cranial nerves.

2. Patient A5: medical history and physical examination (6/11/10) stated, "other cranial nerves intact and symmetric." The detailed form was not used, and the details of the exam were not present.

B. Interview

In an interview on 7/7/10 at 1 p.m. the Medical Director agreed with the finding and stated that the facility had removed all old forms.