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Based on clinical record review and staff interviews, it was determined that the hospital failed to ensure that all patient medical records are complete and authenticated by the person responsible for providing the service for relevant sample patient ID #1.

Findings are as follows:

During an interview on 4/7/10 at 1:00 PM with the Blood Bank Supervisor, it was determined that patient ID # 1 had a Type and Screen done on 1/19/10, 2/1/10 and 2/5/10. Electronic requisitions to the Blood Bank were produced for these dates. A review of the clinical record revealed no evidence of a physician's order corresponding to the Type and Screen that had been requested and performed on this patient on 1/19/10 and 2/1/10.

During an interview on 4/7/10 at 1:30 PM with the Nurse Manager of the Tomorrow Fund Clinic, it was determined that the physician writes the order in the medical record for the Type and Screen, as the Ambulatory Patient Services are not currently utilizing the POM (Physician Order Management) electronic record. The Clinic Unit Secretary transcribes the order into the electronic Blood Bank requisition. The Nurse Manager could not produce the written physician order for the Type and Screen for 1/19/10 and 2/1/10.

Based on clinical record review and staff interview, it was determined that the hospital failed to authenticate verbal orders, related to a Type and Screen, within 48 hours, for relevant sample patient ID #1.

During an interview with the Blood Bank Supervisor on 4/7/10 at 1:00 PM and review of the Blood Bank electronic requisitions, it was determined that the physician had requested a Type and Screen on 1/19/10 and 2/1/10 for patient ID #1. However, a review of the medical record for patient ID #1 failed to reveal evidence of a physician's order that was written and authenticated by the ordering physician within 48 hours for either of the two Type and Screens requested.

Based on clinical record review and staff interview, it was determined that the hospital failed to ensure that all practitioner's orders and other information necessary to monitor the patient's condition are available in the medical record for relevant patient ID #1.

Findings are as follows:

Refer to A-0450.

Additionally, during interview with the Blood Bank Supervisor on 4/7/10 at 1:00 PM and review of the Blood Bank requisitions for 1/19/10 and 2/1/10, there was no evidence found indicating that the required Bone Marrow Transplant Field, on this electronic laboratory requisition, was appropriately completed for patient ID #1, who had a history of a stem cell transplant in August of 2009. Based on clinical record documentation, it was determined that the information regarding the patient's history of a bone marrow transplant, that had not been communicated on the Blood Bank requisition by the Clinic Unit Secretary, could have impacted on the patient's care.