HospitalInspections.org

Based on review of facility policies, review of medical records, and interviews, the facility failed to maintain an accurate medical record for 1 patient (#1) of 6 patients reviewed for accurate medical records.

The findings included:

Review of the facility's policy titled "NURSING DOCUMENTATION," effective date 8/1/2012 revealed "...All contacts with a patient and/or family will be documented in the patient's medical record by the staff member making the contact...Documentation will be entered at the time of or as soon as possible after the contact...Pre-charting is not allowed..."

Review of the medical record showed Patient #1 was admitted to the facility on 9/21/2020 with diagnoses of Bipolar Disorder, Asthma, Bell's Palsy (facial paralysis), and Urinary Tract Infection.

Review of a Physician's Progress Note dated 9/22/2020 revealed the patient was to be observed by staff every 15 minutes (safety checks).

Review of the documentation of the Safety Checks for Patient #1 dated 9/23/2020 revealed staff documented safety checks were completed at 6:00 AM, 6:08 AM, 6:17 AM, 6:30 AM, and 6:55 AM.

During a telephone interview on 9/27/2020 at 1:25 PM, Patient Care Tech (PCT) #1 stated she was sitting with another patient (one on one) the morning of 9/23/2020 and she could see Patient #1's room and no staff checked on Patient #1 from 6:00 AM to 7:00 AM.

During an interview on 9/28/2020 at 2:00 PM, the Administrator stated the facility viewed a security video of Patient #1's room and was able to determine no staff checked on Patient #1 between 6:00 AM and 7:00 AM on 9/23/2020. The Administrator confirmed Patient #1's safety checks were not done on 9/23/2020 between 6:00 AM and 7:00 AM.