Poplar Springs Hospital cited for incomplete medical records and patient assessments

The Virginia Department of Behavioral Health and Developmental Services (DBHDS) cited Poplar Springs Hospital for noncompliance with medical record and human rights regulations after finding that vital information was missing from seven patient records. During a records review, the DBHDS found many instances of improper record authentication. For example, individual #1’s suicide risk assessment was not dated or signed by the RN or clinician completing the assessment. In addition, individual #1’s fall risk assessment did not include a date, time, or an area on the form for a signature. The DBHDS also found other fall risk assessments for individual #3 and placement agreements for individuals #3, #4, #5, and #7 that were not signed by the RN or filled in correctly. Upon another records review, the DBHDS found documents of other individuals filed within patients’ records. For example, individual #2 had master treatment plans that contained another individual’s name and one of the master treatment plans included several sections of another individual’s treatment plan. To correct these deficiencies, the facility agreed to remove all of the old forms from all of the units that did not have a place for signatures and to re-train staff on completing forms.