Observations
Based on a review of client records the facility failed to document the physician's impressions in physical examinations for residential clients.
The findings include:
Six inpatient client records were reviewed for a physical examination on November 7, 2013. The facility neglected to include the physician's impressions in the physical examination in five inpatient client records specifically, # 1, 2, 3, 4, and 6.
Client # 1 was admitted on August 28, 2013. The physical examination was completed on August 29, 2013 and did not include documentation of the physician's impressions.
Client # 2 was admitted on September 10, 2013. The physical examination was completed on September 13, 2013 and did not include documentation of the physician's impressions.
Client # 3 was admitted on September 17, 2013. The physical examination was completed on September 20, 2013 and did not include documentation of the physician's impressions.
Client # 4 was admitted on March 29, 2013. The physical examination was completed on March 29, 2013 and did not include documentation of the physician's impressions.
Client # 6 was admitted on June 7, 2013. The physical examination was completed on June 14, 2013 and did not include documentation of the physician's impressions.
The findings were discussed with the director of residential treatment.
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Plan of Correction
This is a Residential Program Citation:
POC: The Residential Program Director met with the physician to review, educate and discuss the proper completion of the physical evaluation. The Physician will include treatment recommendations and/or impressions for each client on the physical evaluations.
COMPLIANCE: The Residential Program Director will monitor on going physican compliance with documentation and timeliness during the weekly chart review process
EFFECTIVE DATE POC: 11/21/2013 |