HospitalInspections.org

Based on document review and interview, the facility failed to document patient skin assessment in the medical record with an intra-facility transfer per policy (for patient P # 1).

Findings include:

1. Review of hospital policy titled "Patient Transfers", policy number 6667791: Sending unit responsibilities to complete hand off communication with the receiving unit to include appropriate documentation. This policy was last revised 12/09/2019.

2. Review of hospital policy titled, "Content of Medical Records", policy number 9971171. The medical record shall contain pertinent, factual, meaningful observations and facilitate continuity of care among health care providers. This policy was last revised 06/23/2021.

3. On 10/31/2022, MR for P # 1 indicates he/she was transferred from the PCU to Unit B 7. Medical record (MR) lacked documentation of P #1's skin assessment at the time of transfer.

4. In interview on 12/13/22 at approximately 2:00 pm with A 1 (Director of Operations for the Chief Medical Officer and Chief Operations Officer) confirms P # 1's skin issue was not properly documented for continuity of patient care in the medical record with an inter-facility transfer.