HospitalInspections.org

Based on document review and interview, the facility failed to ensure complete medical record in one of 10 records reviewed (patient 1).

Findings include:

1. Review of patient 1's medical record (MR) indicated the following, Orders, Nursing Communication:12/18/17, 16:47:00, On pt's (patient's) day of d/c (discharge) (12/19), please only allow pt (patient) up in w/c (wheel chair) for one hour prior to d/c. Should be in bed the remainder of the time due to pressure wounds. Will transfer to next facility via stretcher.... MR indicated pt in w/c @ 11:36 am. MR lacked documentation of when patient moved to bed.

2. Interview on 1/9/1018, at approximately 4:20 pm, with N6 (Nursing Program Director) confirmed the following, unable to determine in MR, how long patient was in wheel chair.