The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|QUEENS HOSPITAL CENTER||82-68 164TH STREET JAMAICA, NY 11432||Oct. 19, 2018|
|VIOLATION: FORM AND RETENTION OF RECORDS||Tag No: A0438|
|Based on medical record review and staff interview, in 1 of 20 medical records reviewed, the facility failed to ensure that entries in the medical records were accurately written to reflect the patient's treatment, and disposition in the Emergency Department (Patient #1).
Review of medical record for Patient #1 identified that the patient was evaluated in the emergency room (ED) on 9/13/18 at 7:30 PM and was discharged in stable condition on 9/14/18 at 3:10 AM. The patient exited the ED on 9/14/18 at 7:15AM.
On 9/14/18 at 11:06 PM, approximately 16 hours post patient discharge, Staff D, a Registered Nurse (RN) documented in the patient's medical record that the patient was maintained on a one to one (1 to 1) observation.
On 9/15/18 at 8:19 AM another RN Staff E, documented that patient was discharged home in no apparent distress and the patient exited the ER". A second note by Staff E on 9/15/18 at 8:30AM indicated that the patient is waiting to go home at 6:30AM.
There was no documented evidence that these nurses notes written 16 to 24 hours after the patient's departure from the ED were identified as delayed entries.
During interview with Staff A, Risk Manager, it was verified that the nurses created the notes at the time noted in the electronic medical record but failed to identify the notes as addendum or late entries.