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RIVERSIDE BEHAVIORAL HEALTH CENTER
FORM AND RETENTION OF RECORDS
Tag No.: A0438
Based on document review and staff interview the facility staff failed to ensure the medical records for 6 of 13 patients, Patients #5-8, #11 and #13, had accurately documented demographic information.
The findings include:
The medical records for Patients #5-8, 11 and 13 were reviewed on 6/26 and 27/12. The demographic information on the electronic medical record of the summary diagnoses page for each of these patients indicated the diagnoses, date of birth, allergies, height and weight of these 6 patients. The weight of these 6 patients and was as follows:
Patient #5; 135000
Patient #6; 181000
Patient #7; 160000
Patient #8; 174500
Patient #11; 159000.01
Patient #13; 135799.99
Interviews were conducted on 6/26 and 27/12 with Employee #8 and #6 neither of which was aware the electronic medical record documented the weight of patients as noted above. Employee #8 indicated they believed it was a "glitch" in the documentation program. It was pointed out that the other 7 medical records reviewed did not contain the errors of weight. Employee #8 stated, "I don't have an answer as to why that happens."
Employee #1 was interviewed on 6/27/12 and stated, "I don't know why that is happening but we will be contacting (Name of company) who assist us with programing and find out why."
MEDICAL RECORD SERVICES
Tag No.: A0450
Based on document (electronic and paper) review and interviews the facility staff failed to ensure the physician to authenticate admission orders for 12 of 13 patients, Patients #1-9 and 11-13.
The findings include:
A review of the medical record for Patients #1-9 and 11-13 was conducted on 6/26 and 27, 2012. The reviews were by electronic records and paper records. For each of these patients, Patient 1-9 and 11-13, physician orders did not indicate the orders were acknowledged by the nurse or authenticated by the physician.
Employee #1 was interviewed on 6/26 and 27/12. Employee #1 stated, "We were not aware the physician's were not authenticating their orders for admission. We will have that corrected immediately."