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REID HEALTH
MEDICAL RECORD SERVICES
Tag No.: A0450
Based on document review and interview, the facility failed to ensure medical records were complete in 1 of 10 medical records reviewed (Patient 1).
Findings Include:
1. Review of policy titled: Reporting Care Concerns of Nursing Home (ECF), Policy #: PRS-001, last approved on 01/26/22, indicated that if concerns exist to call the Ombudsman and the State if instructed and document in the patient's record.
2. Review of Patient 1's medical record had documentation of possible sexual assault, but lacked documentation of call to the Ombudsman and/or IDOH if so instructed.
3. Interview on 11/17/22 at 2:35 pm with P59 (Social Worker), confirmed that Ombudsman was called on 08/10/22 after realizing that the Ombudsman had never been called; told to notify the state; called the state on 08/10/22, 08/11/22, 08/15/22 and received no answer or left message; upon return to work P59 called on 08/18/22 and stated complaint. P59 confirmed that none of this information was documented in the patient's MR.