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.
|SAINT ALPHONSUS REGIONAL MEDICAL CENTER||1055 NORTH CURTIS ROAD BOISE, ID 83706||Aug. 7, 2019|
|VIOLATION: MEDICAL RECORD SERVICES||Tag No: A0450|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
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 [AGE] year old man who was admitted on [DATE] 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.