Observations
The facility failed to properly document physical examinations in one of four records. The physical examination in client record number 4 did not include a date, therefore compliance with regard to the agency's policy on time frames could not be determined for this examination.
|
Plan of Correction
Maple Manor Staff will date the form as the client is taken to the physicians office for the inital physical this will ensure that the form is dated. The physician will also be contacted and informed that the physical form must be completed in it's entirety to include date and signature. This will be monitored by the Inpatient Director. |