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KINGWOOD PINES HOSPITAL
MEDICAL RECORD SERVICES
Tag No.: A0450
Based on record review and interview the facility failed to assure medical record entries were completed for 1 of 3 patients with assessments provided by NP #25.
Nurse Practioner (NP) #25 failed to complete documentation of assessments. There was no date, time, signature or credentials for 1 of 3 patients trviewed with assessments provided by NP #25.
Patient #S had a Medical Consultation Note filed in the chart between 11/1/25 and 11/3/25. The consultation was filled out but lacked a date, time, signature and credentials.
The handwriting on the form matched documentation made 11/1/25 by NP #25. Physician #29 was called 12/4/25 at 4:10 PM and questioned regarding who did consultations for her. She confirmed NP #25 was the sole agent who assisted her at this facility.
When interviewed 12/4/25 at 4:20 PM administrative staff #19 confirmed the Medical Consultation Note filed in the chart between 11/1/25 and 11/3/25. The consultation was filled out but lacked a signature, credentials, time and date and was filled out but lacked a signature, credentials, time and date.