HospitalInspections.org

Based on document review and interview, it was determined that the facility failed to maintain an accurate clinical record for two (2) of eight (8) patients (Patient # 1 and # 4).

The findings include:

1. On June 24, 2019 at 11:30 a.m., the clinical record review for Patient # 4 revealed the following:
The facility document titled "LD Labor Notes" read in part "04/01/2019 10:39 a.m. Baby A Assessment Note. Vigorous female after tactile stim. Pinked up quickly on RA and placed skin to skin with mom. 04/01/2019 12:52 p.m. Intrapartum Comments. SVD (spontaneous vaginal delivery) LFC (live female child) over intact perineum."
The facility document titled "Anesthesiology Perioperative Evaluation" reads in part "Procedure: TOLAC (Trail of labor after cesarean) Diagnosis: Twins Labor. Date 04/01/2019."

An interview with Staff Member # 3 on June 24, 2019 at 1:50 p.m. revealed "This patient had a previous delivery with twins but this delivery was a single birth. The entry at 10:39 a.m. was entered on the wrong patient and it wasn't caught and corrected."

There was no facility policy available for review related to the accuracy of the clinical record.


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2. During the review of Patient #1's medical record on 9/5/18 at 6:07 P.M., documentation stated, "Live vigorously crying male infant born via SVD, placed directly to mother's abdomen following delivery." Patient #1 did not deliver until 9/7/18 at 6:27 A.M.

Documentation on 9/6/18 at 7:13 A.M. stated, "Assumed care of one 30YO..." Patient #1 was a 20YO (Year Old).

On 9/7/18 at 6:27 A.M. Patient #1 gave birth to a male infant. Patient #1 sustained a laceration during the birth. The Hospitalist present during the delivery noted in their documentation on 9/7/18 at 7:39 A.M. that the laceration was a 1st degree laceration. The attending physician noted in their discharge summary on 9/9/18 at 10:24 A.M. that the laceration as a 3rd degree laceration.