HospitalInspections.org

Based on document review and interview, it was determined that the facility failed to maintain an accurate medical record for one (1) of three (3) Patients (Patient # 1).

The findings include:

On July 12, 2022, the clinical record review for Patient # 1 revealed the following:

On June 5, 2021 at 1:05 p.m., a Pulmonary Care Note by the Physician reads in part "History of C5-7 paraplegia related to accident in 2018 when fell at home and fractured neck. Just before that time was diagnosed with severe dementia, the patient is unresponsive."

On June 6, 2021 at 12:46 a.m., Care Plan documentation by Staff Member # 9 reads in part "Plan of Care reviewed with Patient. Patient verbalized understanding in concurrence with plan of care. Questions encouraged."
Patient was diagnosed with severe dementia, and unresponsive per Physician documentation.

On June 6, 2021 at 4:21 p.m., Care Plan documentation by Staff Member # 10 reads in part "Plan of Care reviewed with Patient. Patient states understanding of care provided.
Patient made no attempts out of bed without assistance. Patient used call bell appropriately."
Patient was diagnosed with severe dementia, and unresponsive per Physician documentation.

On June 8, 2021 at 12:31 p.m., Nutritionist note by Staff Member # 12 reads in part "Patient remains essentially non-verbal - SLP (speech-language pathologist) has not been able to complete evaluation d/t (due to) drowsy."

On June 8, 2021 at 6:47 p.m., Progress noted by Staff Member # 16 reads in part "Patient arrived to room, oriented to room, call bell in reach."
Patient was diagnosed with severe dementia, and unresponsive per Physician documentation.

On June 10, 2021 at 6:35 p.m., Speech therapy note by Staff Member # 13 reads in part "Cognitive - communication deficits. Patient was history of paraplegia from injury now bed bound and minimally communicative. Past Medical History of Dementia."

On June 10, 2021 at 6:45 p.m., Care Plan documentation by Staff Member # 10 reads in part "Plan of Care reviewed with Patient. Patient states understanding of care provided."
Patient was diagnosed with severe dementia, and unresponsive per Physician documentation.

On June 11, 2021 at 11:44 a.m., Care Coordination note by Staff Member # 11 reads in part "Received call from [Name] with Richmond VA (Veterans Administration) (757-XXX-XXXX) inquiring into this patients condition and to assist with placement if needed."
The phone number provided is to the Hampton VA not Richmond.

On June 11, 2021 at 4:33 p.m., Care Coordination note by Staff Member # 11 reads in part "placed call to [Name] with the Richmond VA."
The phone number provided is to the Hampton VA not Richmond.

On June 14, 2021 at 5:31 p.m., Wound Care note by Staff Member # 15 reads in part "Patient awake/alert in bed. Present at visit: Patient, family with patient permission and NCP (Nurse Care Practitioner)"
Patient was diagnosed with severe dementia, and unresponsive per Physician documentation.

On July 12, 2022 at 1:30 p.m. Staff Member # 1 stated "I see what you are saying." In response to the inaccurate documentation.

A review of the facility policy titled "Records Management Policy" reads in part "It is [Name of Company]'s policy to apply effective and cost efficient techniques (a) to manage and maintain complete, accurate and high quality Records."

The findings were discussed on July 12, 2022 with Staff Members # 1, # 2 and # 14 during the exit interview.