HospitalInspections.org

25892

Based on record review and interview, the hospital failed to ensure that all entries entered into the medical record were timed for 2 of 5 patients (#2, #8) whose medical record was reviewed for the dating and timing of entries out of a total sample of 10 patients. Findings:

Patient #2: Review of the medical record revealed progress noted dated 8/28/10 & 8/29/10 that were not timed and physician orders dated 8/28/10 that were not timed. In an interview on 8/30/10 at 12:45 p.m., the Quality Data Coordinator confirmed that the entries were not timed.

Patient #8: Review of the medical record revealed progress notes dated 8/28/10, 8/29/10 & 8/30/10 that were not timed. In interview on 8/30/10 at 12:40 p.m., the Chief Nursing Officer confirmed that the entries were not timed.