Observations
Based on a review of client records, the facility failed to document a physical examination completed by a physician, physician assistant or certified registered nurse practicioner in 9 of 9 client records.
The findings include:
Ten client records were reviewed on October 14, 2014. All ten client records were required to include documentation of a physical examination completed by a physician, physician assistant or certified registered nurse practioner. Client records #1, 2, 3, 4, 5, 6, 8, 9 and 10 contained physical examinations conducted by a registered nurse.
Client #1 was admitted on April 25, 2014 and the physical examination was completed by the registered nurse (RN) on April 25, 2014. The physican co-signed the physical examination form on April 30, 2014.
Client #2 was admitted on April 14, 2014 and the physical examination was completed by the registered nurse (RN) on April 14, 2014. The physican co-signed the physical examination form on April 23, 2014.
Client #3 was admitted on April 18, 2014 and the physical examination was completed by the registered nurse (RN) on April 18, 2014. The physican co-signed the physical examination form on April 23, 2014.
Client #4 was admitted on June 4, 2014 and the physical examination was completed by the registered nurse (RN) on June 4, 2014. The physican co-signed the physical examination form on June 4, 2014.
Client #5 was admitted on July 8, 2014 and the physical examination was completed by the registered nurse (RN) on July 8, 2014. The physican co-signed the physical examination form on July 9, 2014.
Client #6 was admitted on April 16, 2014 and the physical examination was completed by the registered nurse (RN) on April 16, 2014. The physican co-signed the physical examination form on April 23, 2014.
Client #8 was admitted on July 21, 2014 and the physical examination was completed by the registered nurse (RN) on July 21, 2014. The physican co-signed the physical examination form on October 8, 2014.
Client #9 was admitted on April 29, 2014 and the physical examination was completed by the registered nurse (RN) on April 29, 2014. The physican co-signed the physical examination form on April 30, 2014.
Client #10 was admitted on May 15, 2014 and the physical examination was completed by the registered nurse (RN) on May 15, 2014. The physican co-signed the physical examination form on May 16, 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
Observations
Based on a review of client records, the facility failed to document verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan in 6 of 9 client records.
The findings include:
Ten client records were reviewed on October 14, 2014. Nine of the client records reviewed included documentation of a treatment and rehabilitation plan. All nine client records were required to include verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan. This verification was not documented in client records #1, 2, 4, 5, 8 and 10.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |