HospitalInspections.org

Based on medical record review and staff interview, it was determined the facility failed to ensure medical record entries were accurately timed for 1 of 5 patients (Patient #4) whose records were reviewed. This resulted in a failure to establish a timeline of events on which to base future action, assessment, and intervention, potentially impacting patient safety and quality of care. Findings include:

Patient #4 was an 85 year old man who was admitted on 7/01/19 for a left total shoulder arthroplasty revision.

His record included a "PT Initial Eval Form," dated 7/02/19, signed by the PT. It noted the PT visit was performed at 9:20 AM.

Patient #4's record also included a Nursing progress note, dated 7/02/19, signed by an RN. The note stated, "Unwitnessed fall, patient found down at 0910 [9:10 AM]."

An incident report for Patient #4's fall on 7/02/19, was provided to surveyors. It noted the hospital's staff tracker system recorded the PT's visit in Patient #4's room from 8:52 AM to 9:07 AM on 7/02/19.

During an interview on 8/06/19 at 1:10 PM, the Director of Patient safety and the Director of Acute Care were interviewed at the same time. They reviewed Patient #4's medical record and the report of his fall and confirmed the PT documented the incorrect time for the Patient #4's PT visit.

The hospital failed to ensure medical record entries were accurately timed.