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.
|SPRING GROVE HOSPITAL CENTER||55 WADE AVENUE CATONSVILLE, MD 21228||Dec. 29, 2016|
|VIOLATION: ORDERS DATED AND SIGNED||Tag No: A0454|
|All patient medical record entries must be legible, complete, dated, timed and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures
This standard is not met as evidenced by:
Based on a review of ten (10) open and nine (9) closed records, it is revealed that in four of the 10 open records, the hospital failed to date, time and authenticate in written or electronic form the services provided. The time of each entry was not accurately documented. The hospital failed to require each author takes a specific action to verify that the entry being authenticated is accurate and timely.
The time at which the Medication Administration Record was checked by this surveyor was 1:30 PM on 12/29/2016. PT #16's Risperidone 1 mg PO ( by mouth) BID ( twice a day) that was to be administered for 5 PM was initialed and circled. There was no documented reasons the medication was given/not given; no nurse initials beside reason. PT #17's Quetiapine 700 mg PO and Chlorpromazine 75 mg IM (n Intramuscular) that were to be administered for 9 PM were initialed and circled. There were no documented reasons the medications were given/not given, no nurse initials beside reasons. PT #18's Olanzapine 10 mg PO BID that was to be administered for 5 PM was initialed and circled. There was no documented reasons the medication was given/not given. In these four occasions, the time of each entry was not accurately documented. Timing establishes when an activity happened.
Furthermore, PT, #16's last entry of the reason medication given/not given was on 12/24/16 even though medications were initiated and circled from 12/15/2016 to 12/29/2016. Pt #17's last entry for the reason the medication was given/not given was on 12/17/2016, even though some medications were initialed and circled from 12/18/16 to 12/29/16. Pt #19's last entry for the reason the medication was given/not given was on 12/14/2016 even though medication was initialed and circled from 12/15/16 to 12/29/16.