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EDGERTON HOSPITAL AND HEALTH SERVICES
No Description Available
Tag No.: C0307
Based on medical record review and interview with staff, in 10 of 10 Emergency Department (ED) records (#1 through #10) the facility failed to ensure documentation of the MD notification time or the MD exam time.
Findings include:
Pt #1's medical record review revealed there is no documentation of when the MD was notified the patient arrived in the ED on 10/6/11 and there is no documentation of the exam time.
Pt #2's medical record review revealed there is no documentation of when the MD was notified the patient arrived in the ED on 10/2/11.
Pt #3's medical record review revealed there is no documentation of when the MD was notified the patient arrived in the ED on 10/5/11 and there is no documentation of the exam time.
Pt #4's medical record review revealed there is no documentation of when the MD was notified the patient arrived in the ED on 10/11/11 and there is no documentation of the exam time.
Pt #5's medical record review revealed there is no documentation of when the MD was notified the patient arrived in the ED on 10/23/11 and there is no documentation of the exam time.
Pt #6's medical record review revealed there is no documentation of when the MD was notified the patient arrived in the ED on 11/4/11 and there is no documentation of the exam time.
Pt #7's medical record review revealed there is no documentation of when the MD was notified the patient arrived in the ED on 10/31/11 and there is no documentation of the exam time.
Pt #8's medical record review revealed there is no documentation of when the MD was notified the patient arrived in the ED on 10/7/11.
Pt #9's medical record review revealed there is no documentation of when the MD was notified the patient arrived in the ED on 10/19/11.
Pt #10's medical record review revealed there is no documentation of when the MD was notified the patient arrived in the ED on 10/19/11.
The preceding deficiencies were confirmed per interview with staff A and B on 11/08/11 at 2:00 PM.