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ASCENSION SE WISCONSIN HOSPITAL - ST JOSEPH CAMPUS
CONTENT OF RECORD
Tag No.: A0449
Based on record review and interview, the facility failed to complete care management documentation regarding patient care needs in 7 of 10 records reviewed (Patient 1,2,3, 4, 5, 9, 10). Failure to complete documentation has the potential to affect all patients receiving care in the Neonatal Intensive Care Unit during this survey.
On 11/08/16 review of hospital policy titled Care Management Documentation reviewed/revised August 2016 revealed under Procedure: A. Initial Assessment Documentation 1. Within 24 business hours of admission to an inpatient unit, patients will be evaluated for appropriateness of admission... B.Concurrent Documentation 1. In NICU, care management staff will document a minimum of every 7 days.
During record reviews on 11/07/16 at 11:15 AM through 11:50 AM and 11/08/16 at 10:35 AM through 12:05 PM, Quality Manager E confirmed that all care management documentation was reviewed in closed charts.
Closed record review was conducted on patient #1 on 11/07/16 at 11:50 AM. Patient #1 was admitted 8/26/16 at 9:38 PM, Social Worker (SW) G evaluation completed 8/30/16 at 1:50 PM. There was no documentation between 8/30/16 - 9/12/16 and 9/19/16 -10/03/16.
Closed record review was conducted on patient #2 on 11/07/16 at 11:35 AM. Patient #2 was admitted 9/16/16 at 10:14 AM. There was no documenation between 10/10/16 - 10/18/16 and 10/24/16 prior to discharge on 10/31/16.
Closed record review was conducted on patient #3 on 11/07/16 at 11:15 AM. Patient #3 was admitted 9/01/16 at 5:40 PM. There was no documentation between 9/12/16 - 9/22/16.
Closed record review was conducted on patient #4 on 11/08/16 at 10:50 AM. Patient #4 was admitted on 7/29/16 at 9:34 PM, admission evaluation was done 8/10/16 at 1:03 PM.
Closed record review was conducted on patient #5 on 11/08/16 at 12:05 PM. Patient #5 was admitted on 5/17/16 at 2:16 AM. There was no documentation between 6/27/16 - 7/07/16, 8/05/16 - 8/15/15 and 8/31/16 - 9/12/16.
Closed record review was conducted on patient #9 on 11/08/16 at 11:35 AM. Patient was admitted on 10/22/16 at 5:43 PM. SW evaluation completed on 10/31/16 at 3:22 PM.
Closed record review was conducted on patient #10 on 11/08/16 at 11:18 AM. Patient 10 was admitted on 06/10/16 at 4:37 AM. SW evaluation was not documented.