Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 531310 (X3) Date Survey Completed 05/03/2012
Name of Provider or Supplier Powell Valley Hospital Street Address, City, State 777 Avenue H, Powell, WY
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
C0302 RECORDS SYSTEMS
CFR(s): 485.638(a)(2)

The records are legible, complete, accurately documented, readily accessible, and systematically organized.


This STANDARD is not met as evidenced by:
Based observation, staff interview and medical record review, the hospital failed to ensure the accuracy of the allergy history for 1 of 21 sample patients (#20). The findings were: Review of the medical record for patient #20 showed a bright red allergy sticker was placed on the outside cover. Observation of this sticker showed it was blank; indicating no allergies. However, review of the record on 5/1/12 at 9:48 AM revealed the physician's history and physical noted the patient was allergic to penicillin "causes hives" and "valium turns the patient red." Interview with RN #1 on 5/1/12 at 9:48 AM confirmed the patient had allergies and the cover sticker needed to be changed. Review of the medical record on 5/2/12 at 10:48 AM revealed the allergy sticker on the cover of the medical record had been changed but NKDA (no known drug allergies) was written on it. Interview with RN #2 at that time revealed the sticker was still incorrect.