HospitalInspections.org

Based on medical record review and staff interview, in 1 of 20 medical records reviewed, the facility failed to ensure that entries in the medical records were accurately written to reflect the patient's treatment, and disposition in the Emergency Department (Patient #1).

Findings include:

Review of medical record for Patient #1 identified that the patient was evaluated in the Emergency Room (ED) on 9/13/18 at 7:30 PM and was discharged in stable condition on 9/14/18 at 3:10 AM. The patient exited the ED on 9/14/18 at 7:15AM.

On 9/14/18 at 11:06 PM, approximately 16 hours post patient discharge, Staff D, a Registered Nurse (RN) documented in the patient's medical record that the patient was maintained on a one to one (1 to 1) observation.

On 9/15/18 at 8:19 AM another RN Staff E, documented that patient was discharged home in no apparent distress and the patient exited the ER". A second note by Staff E on 9/15/18 at 8:30AM indicated that the patient is waiting to go home at 6:30AM.

There was no documented evidence that these nurses notes written 16 to 24 hours after the patient's departure from the ED were identified as delayed entries.

During interview with Staff A, Risk Manager, it was verified that the nurses created the notes at the time noted in the electronic medical record but failed to identify the notes as addendum or late entries.