HospitalInspections.org

Based upon document review and interview, the facility failed to follow its policy/procedure to ensure that the medical record (MR) was accurately written for 1 of 5 MR (patient 27) reviewed.

Findings:

1. The policy/procedure Medical Records Administration - General (reviewed 12-09) indicated the following: "An accurate, complete medical record will be maintained for all patients treated at Parkview Hospital."

2. On 4-11-13 at 1030 hours, staff A2 indicated patient 27 was transferred to 7 medical from the cardiac medical unit late in the day on 1-07-13.

3. Review of patient 27's MR lacked documentation to indicate a reason for the MR medication entries of 'not given' at 0730, 0800, 0900, 0933, 1000 and 1045 hours and lacked documentation regarding the transfer of patient 27 from the 4th floor cardiac medical unit to the 7th floor medical unit on 1-07-13.

4. During an interview on 4-11-13 at 1405 hours, staff A4 confirmed that the MR medication entries dated 1-07-13 for patient 27 failed to indicate a reason why the morning medications were not given as scheduled.

5. During an interview on 4-11-13 at 1530 hours, staff A10 confirmed that the MR failed to indicate a physician order or nursing entry for patient 27 departing the cardiac medical unit or arriving on the 7 medical unit on 1-07-13.