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Based on interviews and record reviews, the hospital failed to accurately track medication errors and near misses as evidenced by having 143,714 medications dispensed from the pharmacy in 2013 and one documented medication error.
Findings:
Review of the Hospital Daily Charge Report from S7Pharmacist revealed she had dispensed 143,714 medications at the hospital in 2013.

Review of the 2013 Occurrence Reports revealed the only medication error listed was a delay in medication administration on 1/22/13 at 1500.

An interview was conducted with S7Pharmacist on 12/9/13 at 1:30 p.m. When asked what the hospital's medication error rate had been for the last several months she replied she was not sure. She was asked the number of medication errors for the last 6 months and she replied zero. S7Pharmacist said she was only tracking adverse drug reactions. She confirmed she had not been tracking near misses. She said an occurrence report would have been generated if a medication error had occurred.

In an interview on 12/9/13 at 2:30 p.m. with S2DirQuality, she said medical error reporting had been a problem. S2DirQuality acknowledged there was a significant lack of data collection related to medication errors and the numbers were not representative of the true number of errors. She verified there was only one medication error documented for the year. She also said self-reporting was the main source of reporting, but it was ineffective. S2DirQuality said because the facility is so small, and the pharmacist works so closely with the nurses on the floor, she (the pharmacist) is uncomfortable about confronting them with medication errors. She said S7Pharmacist had not wanted to hurt the nurses' feelings.

Based on record review and interview the facility failed to ensure the medical staff was composed of physicians and practitioners appointed by the governing body as evidenced by 1 (S18NP) Nurse Practitioner not approved and appointed by the governing body out of 8 (S6MD, S9MedicalDirector, S11MD, S17MD, S18NP,S19PA, S20PA, S21MD)staff member files reviewed for credentialing and appointment by the governing body.
Findings:

Review of the Medical Staff ByLaws revealed, in part, the following:
Article VI. Procedure for Appointment and Reappointment, Section 6.01 Pre-Screening...The applicant will be asked to supply documentation of the following threshold requirements...2. Current, unrestricted DEA registration...5. A completed delineation of privileges form.
Section 6.02 General Procedure.... The Medical Staff shall consider each application for appointment,...and specific Clinical Privileges... The Governing Board shall be ultimately responsible for granting Membership and specific Clinical Privileges.
Article VII. Clinical Privileges, Section 7.01 Exercise of Privileges- Every Practitioner providing clinical services within this Hospital, by virtue of Medical Staff Memberships or otherwise, shall in connection with such practice, be entitled to exercise only those Clinical Privileges specifically granted to him by the Governing Board, except as provided in Sections 7.03 and 7.04 of this Article.
Section 7.03 Temporary Clinical Privileges-...B. Authority to Grant Temporary Privileges/Conditions. The Administrator, with the written concurrence of the MEC (Medical Executive Committee), may grant Temporary Privileges under the circumstances noted below. In all case, Temporary Privileges shall be granted for a specific period, not to exceed thirty (30) days. After that period the Practitioner may request a renewal of Temporary Privileges for another specific period of time...E. Pending Appointment to the Medical Staff:... Except pursuant to appropriate Governing Board action, under no circumstances shall Temporary Privileges be extended under this paragraph for more than a total of one hundred twenty (120) days...

Review of the Credentialing file for S18NP (Nurse Practitioner) revealed a credentialing application dated 9/1/13. Further review of S18NP's credentialing application packet revealed no requested privileges, no DEA number, a Prescriptive Authority License from the State Board of Nursing, or a collaborative practice agreement with a physician (as required by the State Board of Nursing). Review of a recommendation and approval form for Medical Staff appointment and clinical privileges revealed a top section titled Credentials Committee Recommendation that recommended privileges be granted for S18NP, was signed by S9MedicalDirector, and dated 9/1/13. The MEC Recommendation and Governing Body Approvals/Action Taken sections were blank.

Review of the medical record for Patient #3 revealed that S18NP wrote progress notes on 12/7/13 and 12/8/13 that included an assessment of the patient and a medical plan. Further review of the record revealed S18NP had written an order 12/8/13 to discontinue accuchecks (blood glucose checks) and sliding scale (administration of Insulin), and verbal orders from S18NP, documented by nurses on 12/7/13, 12/8/13, and a verbal order for the patient's discharge on 12/9/13.

Review of the medical record for Patient #14 revealed she was admitted to the hospital 12/10/13 for a surgical procedure. Further review revealed 2 verbal orders by S18NP on 12/11/13 which included administration of packed red blood cells.

On 12/11/13 at 10:32 a.m., an interview was conducted with S16HR. She explained staff applying for credentialing had to be nominated, appointed by the Medical Executive Committee, and approved through the Governing Body. She explained S18NP had been given temporary privileges, verbally, by S9Medical Director. S16HR said she (S18NP) was not credentialed and did not have privileges at the hospital. She said she had not presented S18NP at the last credentialing meeting. S16HR confirmed S18NP had been rounding (seeing patients and writing progress notes) in the hospital. S16HR also confirmed the collaborative agreement for S18NP had just been filled out last week. S16HR said S18NP had no DEA# (Drug Enforcement Administration) and did not have prescriptive authority.

Based on interviews and record reviews, the hospital failed to ensure the medical staff enforced bylaws as evidenced by 6 physicians having discharged patients' medical records delinquent greater than 45 days without having their privileges suspended.

Findings:
Review of Medical Staff Bylaws and Rules & Regulations, revised 11/12/09, revealed in part:
Section 1.03: Medical Records
25. Medical records will be deemed delinquent if the discharge summary is not completed within thirty days (30) days of the discharge or if H&P ( History and Physical) is not completed within 24 hours of Admission. The practitioner will be notified of all delinquencies in writing by the Medical Records Department on the day the practitioner becomes delinquent. As specified herein.
26. The Practitioner's admitting privileges will be suspended if the practitioner fails to cure the medical record delinquency contained in written notice in fifteen (15) days from the date of notice. Upon the request of the suspended practitioner, however, the President may temporarily lift the automatic suspension if it determined that an emergency exists in which the health and safety of any patient will be jeopardized by failure to allow Practitioner to treat that patient. Otherwise, Practitioners whose clinical privileges are suspended shall not be permitted to admit any patients, or perform consults or other procedures, assist or otherwise treat any patients unless such patients were admitted to the hospital prior to the imposition of the automatic suspension.

In an interview on 12/10/13 at 8:45 a.m. with S8HIM, she stated when medical records were delinquent from 7-30 days post discharge, she notified the physician by letter or fax of their deficiencies. S8HIM said after 30 days, she notified the CEO of the delinquencies. After 45 days, she said she believed the privileges were suspended. S8HIM said she continued to send delinquency letters twice per month, but is not involved in the suspension of privileges process.

Review of a Medical Record Deficiency Report provided by S8HIM revealed the following:
Delinquent records greater than 45 days:
S9MedicalDirector-3 records
S14MD-2 records
S10MD-19 records
S15MD-1 record
Delinquent records greater than 60 days:
S17MD-1 record
S9MedicalDirector-4 records
S6MD-2 records
S10MD-15 records
In an interview on 12/10/13 at 9:03 a.m. with S1Administrator, she said the Medical Staff Bylaws stated medical records should not be delinquent greater than 30 days. S1Administrator said a letter was generated that the physician's privileges would be suspended 15 days after the discharge record was 30 days delinquent, but the letters were never sent. S1Administrator said the Medical Director was aware of the problem. S1Administrator also said the physicians are the owners, so they are not going to suspend themselves. S1Administrator said the records eventually get done, but not in a timely manner.

In an interview on 12/10/13 at 9:26 a.m. with S16HR, she said HIM was responsible for sending suspension letters to physicians. She said no physicians have ever been suspended for delinquent medical records. S16HR said it was an ongoing problem.

Interview attempts on 12/10/13 and 12/11/13 with the Medical Director were unsuccessful due to his surgery schedule.

Based on interviews and record reviews, the hospital failed to ensure patient medical records were promptly completed within 30 days of discharge as evidenced by 25 medical records delinquent greater than 45 days and 22 medical records delinquent greater than 60 days with no physicians having suspension of hospital privileges as per the Medical Staff Rules and Regulations.

Findings:
Review of Medical Staff Bylaws and Rules & Regulations, revised 11/12/09, revealed in part:
Section 1.03: Medical Records
25. Medical records will be deemed delinquent if the discharge summary is not completed within thirty days (30) days of the discharge or if H&P (History and Physical) is not completed within 24 hours of admission. The Practitioner will be notified of all delinquencies in writing by the Medical Records department on the day the Practitioner becomes delinquent. As specified herein.
26. The Practitioner's admitting privileges will be suspended if the practitioner fails to cure the medical record delinquency contained in written notice in fifteen (15) days from the date of notice. Upon the request of the suspended Practitioner, however, the President may temporarily lift the automatic suspension if it determined that an emergency exists in which the health and safety of any patient will be jeopardized by failure to allow practitioner to treat that patient. Otherwise, Practitioners whose clinical privileges are suspended shall not be permitted to admit any patients, or perform consults, or other procedures, assist or otherwise treat any patients unless such patients were admitted to the hospital prior to the imposition of the automatic suspension.

In an interview on 12/10/13 at 8:45 a.m. with S8HIM, she stated when medical records were delinquent from 7-30 days post discharge, she notified the physician by letter or fax of their deficiencies. S8HIM said after 30 days, she notified the CEO of the delinquencies. After 45 days, she said she believed the privileges were suspended. S8HIM said she continued to send delinquency letters twice per month, but is not involved in the suspension of privileges process.

Review of a Medical Record Deficiency Report provided by S8HIM revealed the following:
Delinquent records greater than 45 days:
S9MedicalDirector-3 records
S14MD-2 records
S10MD-19 records
S15MD-1 record
Delinquent records greater than 60 days:
S17MD-1 record
S9MedicalDirector-4 records
S6MD-2 records
S10MD-15 records
In an interview on 12/10/13 at 9:03 a.m. with S1Administrator, she said the Medical Staff Bylaws stated medical records should not be delinquent greater than 30 days. S1Administrator said a letter was generated that the physician ' s privileges would be suspended 15 days after the discharge record was 30 days delinquent, but the letters were never sent. S1Administrator said the records eventually get done, but not in a timely manner.

In an interview on 12/10/13 at 9:26 a.m. with S16HR, she said HIM was responsible for sending suspension letters to physicians. She said no physicians have ever been suspended for delinquent medical records. S16HR said it was an ongoing problem.

Based on interview and record review, the hospital: 1) failed to ensure all patients' medical record entries that had physician authentication were timed for 3 (#2, #3, #14) of 5 (#2, #3, #6, #7, #14) patient records reviewed ; 2) failed to ensure electric authentication by the physician was consistent with hospital policy and procedures.
Findings:
1) Failed to ensure all patient medical record entries that had physician authentication were timed.

Review of the Hospital policy titled Physician's Orders, Policy Number: 74, Revision Date 8/22/11, revealed in part:
B. All physician orders will be authenticated by responsible physician to include date, time and signature.
Review of the Hospital Medical Staff Rules and Regulations revealed in part:
Section 1.03 Medical Records
2. All clinical entries in the patient's medical record shall be accurately authenticated with date and time by persons authorized to assess, write orders, and treat patients.

Patient #2
Review of the Anesthesia Consent Form for Patient #2 dated 12/6/13 revealed the physician had authenticated the consent but had not timed his signature.

Review of the Post-Operative Progress Note for Patient #2 dated 12/7/13 revealed he had authenticated the note but had not timed his signature.
Review of the Post-Operative Progress Note for Patient #2 dated 12/6/13 revealed he had authenticated the note but had not timed his signature.

In an interview on 12/9/13 at 3:40 p.m. with S4CPC, she verified the above mentioned notes for Patient #2 had physician signatures, but they had not been timed. S4CPC said the signatures should have been timed.

Patient #3
Review of the medical record for Patient #3 revealed she was admitted 12/5/13. Review of physician order sheets revealed an order, dated 12/5/13 at 2:54 p.m., that read " Hold Metformin 48 hours after CTA (Computed tomography angiography) done. Further review revealed there was no ordering practitioner's signature or a nurse's notation of the receipt of a verbal/phone order. The order was noted/signed off by a RN on 12/5/13 at 3:00 p.m. Review of Anesthesia Preop Orders revealed orders signed , but without a date or time. The Anesthesia Preop orders were signed off/noted by the nurse on 12/5/13 at 2:13 p.m. Review of Anesthesia PACU (Post Anesthesia Care Unit) orders dated 12/5/13 revealed an authentication signature, but no time.

In an interview 12/10/13 at 3:45 p.m. S4CPC reviewed the record of Patient #3 and verified the lack of a signature on an order dated 12/5/13 at 2:54 p.m. S4CPC further verified the Anesthesia Preop orders and Anesthesia PACU orders both dated 12/5/13 had no documented time of the authentication signature.

Patient #14
Review of the medical record for Patient #14 revealed a post-operative progress note dated 12/10/13 and signed by S6MD. Further review revealed no time was documented. Further review revealed an Anesthesia Consult-IV (Intravenous) PCA (Patient Controlled Analgesia) signed by the consulting MD, dated 12/10/13, but contained no documented time.

In an interview 12/11/13 at 1:35 p.m. S2DirQuality verified the post-operative note for the patient's second surgery 12/10/13 and an anesthesia consultation for an IV PCA did not contain a time.

2) Failed to ensure electric authentication by the physician was consistent with hospital policy and procedures.
Review of the hospital policy titled Electronic Signature pen, Number: 9.1, Revised: 10/11/11, revealed in part:
Physicians will only have access to their designated RESP (Reiner Electronic Scan Pen) after making arrangements with Health Information department.
The RESP will be checked out by scanning the designated RESP on the sign out log and initialing the Health Information staff checking the RESP out.
The RESP will be checked in by scanning the RESP on the sign in log, verifying that the correct RESP is being received, initialing of the Health Information staff checking in the RESP and locking it in the designated area.

Review of the medical record for Patient #20 revealed the Operative Report dated 11/1/13 was authenticated by S10MD using the RESP.

In an interview on 12/11/13 at 10:12 a.m. with S2DirQuality, she said she or another member of HIM (Health Information Management) have access to the electronic pens used by the physicians to time, date, and sign entries. S2DirQuality said when the physician needs the RESP to sign charts, she loads his information onto the pen with the computer, he uses it to sign his charts, then returns the pen to the HIM department. She said according to the hospital policy, the pens are supposed to be logged when they are issued to the physicians and when they are returned. She verified the log had not been completed in at least a year.


30420

Based on record reviews and interviews the hospital failed to ensure all orders were dated, timed, and authenticated by the ordering practitioner for 3 (#3, #4, #5) of 20
(#1-#20) sampled patients.
Findings:

Review of the Hospital policy titled Physician's Orders, Policy Number: 74, Revision Date 8/22/11, revealed in part:
B. All physician orders will be authenticated by responsible physician to include date, time and signature.
Review of the Hospital Medical Staff Rules and Regulations revealed in part:
Section 1.03 Medical Records
2. All clinical entries in the patient's medical record shall be accurately authenticated with date and time by persons authorized to assess, write orders, and treat patient.


Patient #3
Review of the medical record for Patient #3 revealed she was admitted 12/5/13. Review of physician order sheets revealed an order dated 12/5/13 at 2:54 p.m. that read " Hold Metformin 48 hours after CTA (Computed tomography angiography) done. Further review revealed there was no ordering practitioner's signature or a nurse's notation of the receipt of a verbal/phone order. The order was noted/signed off by and RN 12/5/13 at 3:00 p.m. Review of Anesthesia Preop Orders revealed orders signed , but without a date or time. The Anesthesia Preop orders were signed off/noted by the nurse 12/5/13 at 2:13 p.m. Review of Anesthesia PACU (Post Anesthesia Care Unit) orders dated 12/5/13 revealed an authentication signature, but no time.

In an interview 12/10/13 at 3:45 p.m. S4CPC reviewed the record of Patient #3 and verified the lack of a signature on an order dated 12/5/13 at 2:54 p.m. S4CPC further verified the Anesthesia Preop orders and Anesthesia PACU orders both dated 12/5/13 had no documented time of the authentication signature.


Patient #4:
Review of the medical record revealed the patient was a 56 year-old female admitted to the hospital 11/14/13.

Review of the Physician's Orders revealed an order to: Register to Observation Patient level of care on 11/14/13 at 7:36 a.m. Further review revealed no documented evidence the physician signed, dated, and timed this order.

Review of the Physician's Orders revealed telephone orders on 11/15/13 at 1055 for Demerol 100 mg(milligram) IM (intramuscular) every 4 hours prn (as needed) pain, Clonazepam 1 mg by mouth every 6 hours as needed for anxiety, Ok to give Lortab 7.5/500 mg 2 tabs by mouth every 4-6 hours also. Continue PCA (Patient Controlled Analgesia) at this time as well. Further review revealed no documented evidence the physician signed, dated, and timed this order.

In an interview on 12/10/13 at 10:52 a.m. S4CPC indicated the hospital had an issue with orders being signed, dated, and timed by physicians in a timely manner.


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Patient #5
Review of Patient #5's medical record revealed an Admission date of 11/26/13 and a Diagnosis of Breast Cancer.
Review of Patient #5's medical record revealed the following MD orders authenticated, but not dated and timed:
Intra-Operative orders, dated (by the nurse) 11/26/13, 10:18 a.m.: signature authenticated but not dated or timed.
Medicines and Treatment: Anesthesia Pre-Op (Pre-Operative) Orders, dated (by the nurse) 11/26/13, 11:55 a.m.: signature authenticated but not dated or timed.
Medicines and Treatment: Anesthesia PACU orders, dated (by the nurse) 11/26/13, 11:55 a.m.: signature authenticated but not dated or timed.
In an interview on 12/9/13 at 3:35 p.m., S4CPC verified the above mentioned orders for Patient #5 had not been dated or timed.


30420

Based on interview and record review, the hospital failed to ensure patients who had a History and Physical within 30 days of admission had an updated History and Physical (H&P) placed in their medical records prior to surgery for 3 (#2, #3, #7) of 20 (#1-#20) patients reviewed.

Findings:
Review of the Medical Staff Rules and Regulations revealed in part:
Section 1.03 Medical Records:
13.2 When the History and Physical is completed within 30 days prior to admission or registration, an updated medical record entry documenting an examination for any changes in the patient's condition must be completed and documented in the patient's medical record within 24 hours after admission or registration, but prior to surgery or procedure requiring anesthesia services.
13.3 An H&P completed thirty (30) days prior to admission does not meet the requirement for a current H&P and cannot be updated. A new H&P is therefore required.
13.4 All H&P's not created on the calendar day of the surgery or procedure utilizing anesthesia will require an interim note signed/dated/timed by the attending physician prior to the procedure. An interim note or update indicates that an H&P had been reviewed and that:
13.4.1 There are not significant changes to the findings contained in the H&P since the time the H&P was performed.
13.4.2 There are significant changes and such changes are subsequently documented in the medical record.

Patient #2
Review of the medical record for Patient #2 revealed she was admitted to the hospital on 11/24/13 with diagnosis which included an open area to the right breast. Her planned surgical procedure was listed as right breast revision for wound separation. Further review revealed she had a History and Physical completed on 11/5/13 at Clinic " A " .
Review of the Anesthesia Records for Patient #2 revealed she had surgery on 11/25/13 at 2:11 p.m. and 11/27/13 at 7:49 a.m.
Review of documents for Patient #2 titled History and Physical Update/Addition dated 11/25/13 at 12:22 p.m. and 11/27/13 at 8:30 a.m. revealed she had a History and Physical performed on 11/5/13 before admission on 11/24/13. The form listed in Part: Complete this update if the H and P less than 30 days old, but without interim note or, H and P not created on calendar day of surgery/procedure requiring anesthesia. The physician had two boxes to check indicating either " Review of the patient indicates no changes to previous H and P exam or status " or " Review of patient revealed the following additions or revisions since last exam " with blanks for an explanation following the choices. Neither of the choices had been chosen and no written explanation or update was provided.

In an interview on 12/9/13 at 3:40 p.m. with S4CPC, she verified the History and Physical for Patient #2 had not been updated since admission and prior to surgery on 11/25/13 and
11/27/13.


Patient #3

Review of the medical record for Patient #3 revealed she was admitted 12/5/13 with a diagnosis of Cancer of the Left Breast. Further review revealed Patient #3 had Bilateral Mastectomies with Left Sentinel Node Biopsy and Immediate Breast Reconstruction with Abdominal Free Flaps performed the day of admission. Further review revealed the patient had an H&P dated 12/4/13. Review of a History and Physical Update/Addition dated 12/5/13 revealed no documentation of a change, addition, or no change to the patients previous H&P or status.



Patient #7

Review of the medical record for Patient #7 revealed he was admitted to the hospital 12/2/13 with a diagnosis of Erectile Dysfunction. Further review revealed he had a Inflatable Penile Prosthesis surgically implanted. Review of a History and Physical Update/Addition dated 12/5/13 revealed an H&P documented as performed 11/5/13. Further review of the update revealed that neither of the boxes to indicate no changes, or additions/revisions since last exam were checked and no documentation related to an H&P or patient status was noted.


In an interview 12/10/13 at 3:45 p.m. S2DirQuality, after review of the medical records for Patients #3 and #7, verified that the H&Ps on the records did not document any findings of change or no change in either patient's H&P or status.

Based on interview and record review, the hospital failed to ensure a physician or other qualified practitioner developed and entered the Discharge Summary in the patient's medical record for 3 (#3, #7, #16) of 20 records reviewed.
Findings:

Review of the Medical Staff Rules and Regulations revealed, in part, Section 1.03: Medical Records, 24. The attending Practitioner shall complete the medical record..., to include... final diagnosis and discharge summary.

Patient #3
Review of the medical record for Patient #3 revealed she was admitted 12/5/13 with a diagnosis of Cancer of the Left Breast and had surgical procedures 12/5/13 of Bilateral Mastectomies with Left Breast Sentinel Node Biopsy with Immediate Breast Reconstruction with Abdominal Free Flaps performed. Further review revealed Patient #3 was discharged 12/9/13. Review of a Discharge Summary was partially completed with the admitting/pre-op Diagnosis documented as Breast Cancer. Further review revealed, in part, the following boxes marked with a check mark: (1). " Discharge/Post-Op Diagnosis: same as Admitting and/or Pre-Operative Diagnosis, and (2). Surgical Procedure: See Dictated Operative Report for Procedure in Detail. No signature, date, or time was documented on the Discharge Summary.

Patient #7
Review of the medical record for Patient #7 revealed he was admitted and discharged 12/2/13 with a diagnosis of Erectile Dysfunction and underwent a surgical insertion of an Inflatable Penile Prosthesis. Further review revealed a discharge summary that documented, in part, an admitting/pre-op diagnosis of Erectile Dysfunction, admission and discharge date of 12/2/13, a summary of stay that read "IPP" (Inflatable Penile Prosthesis), discharged meds: "given to pt (patient) @ (at) pre-op by Dr___(S12MD)." No signature, date, or time was noted on the discharge summary.

Patient #8
Review of the medical record for Patient #8 revealed she was admitted and discharged 12/9/13. Review of the Post-Operative Progress Note revealed the patient's diagnosis pre- and post-operatively was Cancer of the Left Breast and the surgical procedure performed 12/9/13, documented by S11MD, was "L Lumpectomy, SN Bx" (Left Breast Lumpectomy with Sentinel Node Biopsy). Further review of a Discharge Summary was partially completed with, in part, an admitting diagnosis of Left Breast Mass. No signature, date, or time was noted.

Patient #16
Review of the medical record for Patient #16 revealed she was admitted on 11/19/13 at 5:00 a.m. with diagnosis which included absence of breast and a personal history of breast cancer.

Review of the preprinted Discharge Summary for Patient #16 revealed it had been completed, but not timed, dated, or signed by the physician. No indication was written as to who had completed the Discharge Summary.

In an interview on 12/10/13 at 1:40 p.m. with S1Administrator, she said she could not verify who had hand written the discharge summary information on the preprinted Discharge Summary sheet for Patients #3, #7, and #16, but she could tell it was not the MD's handwriting. She said she did not know who had completed the discharge sheets, but she said the physicians would sign the forms.

In an interview 12/10/13 at 2:45 p.m. S19RN reported that she was the charge nurse on the inpatient care unit. S19RN reported that the nurses usually completed the preprinted Discharge Summary in a patient's medical record. She reported that she would fill in the information from the patient's medical record, and the physician would later sign it.

In an interview on 12/11/13 at 2:30 p.m. with S6MD, he said he was not sure who filled out the Discharge Summary for Patient #16, he just signed the form. S6MD said he was not aware he had to actually complete the Discharge Summary himself since the information was gathered from the patient's medical record.


30420

Based on record review and interview the facility failed to ensure an operative report was written or dictated immediately following each surgery and signed by the surgeon as evidenced by post-operative reports timed by the surgeon before or during the time of the surgical procedure for 4 (#6, #7, #8, #14) and no post-operative surgical report for 1 (#3) of 5 (#3, #6, #7, #8, #14) medical records reviewed for operative reports of a total sample of 20.
Findings:

Review of hospital policy titled Medical Record Standard, Section: ADM-MS, Number 1.0, Revision Date 10/28/11 and Review Date 9/2/12, provided by S2DirQuality (Director of Quality) as current, revealed, in part that a post procedure progress note must be completed immediately after all procedures. Further review revealed all operative reports would include, in part, the signature/date/time.

Review of the Medical Staff Rules and Regulations revealed, in part, the following:
Section 1.03 Medical Records... " 2. All clinical entries in the patient's medical record shall be accurately authenticated with date and time by persons authorized to assess, write orders, and treat patient(s). The medical record must be clear, concise, complete, and accurate.
17. An operative note by the operating Practitioner (or his assistant) will be written out or dictated as soon as possible following the procedure."

Patient #3
Review of the medical record for Patient #3 revealed she was admitted to the hospital 12/5/13, had a surgical procedure performed by S10MD (Medical Doctor) the same day. Further review revealed Patient #3 was discharged 12/9/13. Review of the Anesthesia Record revealed that the surgical procedure started at 7:47 a.m. and ended at 1:52 p.m. Review of the Post-Operative Progress Note revealed it to be blank and without a signature.

In an interview 12/10/13 at 2:35 p.m. S2DirQuality reported, after searching computer records, there was no dictated operative report for Patient #3's surgery on 12/5/13. S2DirQuality further verified that the Post-Operative Progress Note on the patient's medical record was blank.

Patient # 6
Review of the medical record for Patient #6 revealed she was admitted 12/9/13 and had a surgical procedure performed by S10MD the same day. Further review revealed a Post-Operative Progress note signed by S10MD dated 12/9/13 and timed for 8:30 a.m. Review of the Anesthesia Record revealed Patient #3's surgery began at 11:18 a.m. 12/9/13.

Patient #7
Review of the medical record for Patient #7 revealed he was admitted 12/2/13 and had surgery performed by S12MD the same day. Further review revealed a Post-Operative Progress Note signed by S12MD, dated 12/2/13 and timed 8:30 a.m. Review of the Anesthesia Record revealed Patient #7's surgery started at 8:00 a.m. and ended at 8:53 a.m.

Patient #8
Review of the medical record for Patient #8 revealed she was admitted 12/09/13, had surgery performed by S11MD, and was discharged 12/9/13. Further review revealed a Post-Operative Progress Note signed by S11MD, dated 12/29/13, and timed 10:15 a.m. The documented surgery date was 12/9/13. Review of Patient #8's Anesthesia Record revealed her surgery procedure began at 10:06 a.m. and ended at 11:25 a.m.

Patient #14
Review of the medical record for Patient #14 revealed she was admitted 12/10/13 and had surgical procedures by S13MD and S6MD, with S6MD documented as the primary surgeon. Review of a Post-Operative Progress Note revealed it was signed by S6MD, dated 12/10/13, and timed 6:00 a.m. Review of an anesthesia record documented the start of the surgical procedure as 6:56 a.m. and the end of the procedure as 1:09 p.m.
Further review of Patient #14's medical record revealed she had a second surgical procedure performed by S6MD the same day (12/10/13) because of postoperative bleeding. A post-operative progress note was completed for the second surgical procedure, signed and dated 12/10/13 with no time documented. Review of the anesthesia record for Patient #14's second surgery on 12/9/13 revealed a surgical procedure start time of 2:16 p.m. and an ending time of 3:51 p.m.

In an interview 12/10/13 at 2:35 p.m. S2DirQuality and S4CPC (Clinical Program Coordinator), after review of medical records of Patients #3, #6, #7, #8, and #14, verified the above findings.
In an interview on 12/10/13 at 4:10 p.m. S1Administrator verified that it was not an appropriate practice to complete Post-Operative Progress Notes prior to performing the operation.

In an interview on 12/11/13 at 2:30 p.m., with S6MD, he said he completes and signs the Post-Operative Report before surgery because he performs the same procedures repeatedly and knows the usual outcome of the surgery. He also said he filled out the Post-Operative progress note before the surgery to cut down on his delinquencies related to not timing and dating orders. He explained he was usually busy performing one surgery after another so he completed the Post-Operative progress note prior to surgery.


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