HospitalInspections.org

Based on record review and interview, it was determined the facility failed to ensure accurate identification data for 2 of 4 medical record reviewed (sampled patients #2 and #3).

The findings include:

The facility Chief Nursing Officer (CNO) was contacted by telephone on 12/20/10 and additional information was requested from the facility: i.e. the original birth certificate worksheets filled out by the mother and the last version of the face sheet prior to each infants discharge.

The face sheets were received on 12/20/10 and listed the twin infants correctly as Baby A (dated 10/23/07) and Baby B (dated 10/15/07). Per the CNO, these were the last versions of the face sheets prior to the infants' discharges.

Per the telephone interview with the CNO, Admitting Director and Health Information Management (HIM) Director on 12/20/10 at approximately 2:15 pm, it was stated that the date in the upper left corner of the face sheets provided by the facility at the time of the complaint survey (12/7/10) attached to the medical records of patient #2 (Twin A - time of birth 02:49 with stated name EC) and patient #3 (Twin B-time of birth 02:50 with stated
name AC) indicated the date the face sheet was generated. The face sheets were dated for Twin A (EC) 5/2/08 and for Twin B (AC) 10/28/08, significantly later than the respective discharge dates of 11/16 and 11/13/07.

Interview with the CNO, HIM Director and admitting director on 12/20/10 via telephone at 2:15 pm revealed that the Birth Certificate Worksheets are completed by the mother prior to discharge. Review of the Birth Certificate Worksheets on 12/21/10 revealed the twin born at 02:49 (Twin A) was named AC and the twin born 02:50 (Twin B) was named EC, the opposite of the names on the face sheets given to the surveyor at the time of the survey on 12/7/10.

Further review of the records revealed 2 privacy forms for the patient named AC (Twin A per the Birth Certificate Worksheets) were found on the record labeled Twin B. The forms were dated 4/8/08 and 10/27/10 and contained the medical record number for Twin B.

In addition, 2 privacy forms for patient named EC (Twin B per the Birth Certificate worksheets) were found on the record labeled Twin A. The forms were dated 4/8/08 and 11/8/10 and contained the medical record number for Twin A.
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Interview with the CNO, Admissions Director and HIM Director on 12/21/10 at 3:00 pm revealed that both babies returned to the hospital on 4/8/08 and at that time the mother was asked to identify the babies. The names were assigned incorrectly to the medical records as per that identification.