| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 531311 | (X3) Date Survey Completed 09/29/2016 |
| Name of Provider or Supplier Crook County Hospital | Street Address, City, State 713 Oak Street, Sundance, 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) |
| C0305 | RECORDS SYSTEMS CFR(s): 485.638(a)(4)(ii) [For each patient receiving health care services, the CAH maintains a record that includes, as applicable--] reports of physical examinations, diagnostic and laboratory test results, including clinical laboratory services, and consultative findings; This STANDARD is not met as evidenced by: Based on medical record review and staff interview, the facility failed to ensure history and physical exam (H&P) information was included in 2 of 20 sample patient records (#13, #18). The findings were: 1. Review of the clinical record showed patient #13 was admitted to inpatient status on 1/12/16. Review of the electronic clinical record and the paper documentation showed there was no H&P completed. Interview with HIM employee #1 on 9/28/16 at 1:45 PM verified the document was unable to be located and it may have been lost when there was a server problem with the electronic system. 2. Medical record review showed patient #18 was admitted to the facility on 11/13/15 with diagnoses which included essential hypertension. The review showed the patient was discharged on 11/18/15. Review of the entire medical record showed no evidence that a history and physical was completed. Interview with HIM employee #1 on 9/29/16 at 10 AM confirmed the facility was unable to locate a history and physical for patient #18. |