HospitalInspections.org

Based on record review and staff interview, the hospital staff failed to ensure medical records for 1 (#2) of 2 were complete. Findings include:

On 9/4/14 at 10:15 a.m., staff member B, Outpatient Therapy Department Manager, stated a treatment plan was required for all therapy services. The treatment plan directed the plan of care and kept the medical doctor informed of what services were being provided. The treatment plan was the medical script for services to be provided.

On 9/4/14 at 11:00 a.m., patient #2's medical record was not complete. Patient #2 was approved to receive occupational therapy services starting 7/23/13 because of a stroke. The medical record was missing the treatment plan for occupational therapy services received.

Based on staff interview the hospital staff failed to develop policies and procedures for the outpatient therapy department. The hospital staff could not verify the outpatient services were integrated with the inpatient services. Findings include:


On 9/4/14 at 12:30 p.m., staff member A, Quality Director, stated there were no departmental policies and procedures for the outpatient therapy department.