HospitalInspections.org
Bringing transparency to federal inspections
SELECT SPECIALTY HOSPITAL SOUTH DALLAS
MEDICAL RECORD SERVICES
Tag No.: A0450
Based on record review and interview the facility failed to ensure that the documentation written by staff # 2 on 06/01/12 and 06/21/12 in patient medical records were legible.
Findings were:
Review of patient medical records dated 06/01/12 and 06/21/12 revealed that staff # 2's documentation on sections of the progress notes were not legible. After assistance from facility staff and the assistance of the surveyor the information documented could not be read or understood by the facility staff.
Review of Rules and Regulations of Medical Staff, C. Medical Records 1. Stated, " The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient. "
The above findings were confirmed in an in-person interview with Director of Quality/Risk Management on the afternoon of 10/01/12 at the facility.
CONTENT OF RECORD: ORDERS,NOTES,REPORTS
Tag No.: A0467
Based on interview and record review the facility failed to ensure that orders were written for oxygen by the physician for patient # 1.
Findings were:
Review of medical record revealed that patient # 1 was on oxygen at 2 liters by nasal cannula. Physician orders in the medical record for patient # 1 to have oxygen were not available for review at the time of the investigation.
Review of clinical services policy and procedure Oxygen Administration, issue date: 12/01/98, revised date 03/10/06 stated, " 1. No oxygen can be initiated without a physician ' s order or without the documented judgment of the Nurse in charge of the respiratory therapist that oxygen was required. 2. If oxygen is ordered by either of the two caregivers listed above, the order must be written in the chart following all necessary criteria for any other valid order. 3. The responsible physician should be contacted as soon as possible to advise that oxygen was needed and the order must be re-enforced by the physician at their next time on the unit. "
The above findings were confirmed in an interview at the facility on the afternoon of 10/01/12 with the Director of Quality/Risk Management.