HospitalInspections.org

Based on medical record review and interview, the facility failed to maintain a complete medical record for one patient (#2) of five sampled patients.

The findings included:

Patient #2 was admitted to the facility on August 9, 2011, with diagnoses including Altered Mental Status and Hyperglycemia.

Medical record review of an Hourly Rounding Log dated August 11, 2011, revealed no documentation regarding hourly repositioning of the patient from 7:10 a.m. through 6:00 p.m.

Interview with the facility's Chief Quality Officer on September 6, 2011, at 10:45 a.m., in a conference room, revealed nurses were responsible for completion of the Hourly Rounding Log and confirmed the facility failed to maintain a complete medical record for Patient #2.