Observations
The facility failed to document physical examinations in four of eight client records reviewed on January 27, 2017. Eight records were reviewed. All required documentation of a physical examination. Client records # 1, 2, 4 and 5 did not document a complete physical examination. Client # 1 - The physical examination documented was completed by a registered nurse. Client # 2- There was no physical examination documented. Client # 4- The physical examination form did not document who had completed the exam.Client # 5- The physical examination documented was completed by a registered nurse. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Prior to the client's admission, the Administrative Assistant will review the physical provided by the referral source, and ensure that it has been completed according to DDAP regulations, which includes a medical doctor's signature. In the event that the documentation of the client's physical is inadequate, a call will be made to the referring source and a request for adequate documentation of the client's physical be faxed to LRH. If the documentation provided remains unacceptable, the client will be taken to Med Express or another walk-in outpatient medical facility to have a physical completed and documented, within three days of admission to LRH. Otherwise, if an office appointment with a General Practitioner can be obtained in five days maximum, a client may opt to be seen and have their physical exam performed by a local PCP. The client will obtain documentation of the physical at the time of the office visit and provide it to LRH upon their return from the appointment. The document will be filed in the client's chart immediately. |