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Based on a review of facility documents and interviews with staff (EMP), it was determined the facility failed to ensure the Perinatal Evaluation Center (PEC) maintained an accurate and complete log entry for each patient seen in the center for three of three entries reviewed (MR7, MR8, MR9).

Findings include:

A review conducted on March 9, 2010, of the e PEC patient log revealed that the log contained areas for the following entries for each patient: NO (number), NAME, GEST. (Gestational) AGE, ADMISSION TIME, FROM, Chief Complaint/ Reason Sent, Ante-Partum, Post-Partum, Room, Chair, D/C or Trans (Transfer) TIME, TO (where the patient went).

1) A review of the PEC log revealed an entry for MR7 that included a sticker with the patient name entered under the name column on the page dated March 6, 2010, as NO 15. Further review of the log for MR7 revealed no documentation related to whether the patient refused treatment, was refused treatment, or whether the patient was transferred, admitted and treated, stabilized and transferred, or discharged.

2) A review of the PEC log revealed an entry for MR8 that included a sticker with the patient name entered under the name column on the page dated March 6, 2010, as NO 9. Further review of the log revealed no documentation related to whether the patient refused treatment, was refused treatment, or whether the patient was transferred, admitted and treated, stabilized and transferred, or discharged.

3) A review of the PEC log revealed an entry for MR9 that included a sticker with the patient name entered under the name column on the page dated March 5, 2010, as NO 7. Further review revealed no documentation related to whether the patient refused treatment, was refused treatment, or whether the patient was transferred, admitted and treated, stabilized and transferred, or discharged.

4) An interview conducted on March 9, 2010, at 1500 with EMP40 confirmed that the PEC log was not complete for MR7, MR8 and MR9.