HospitalInspections.org

Based on a review of documentation and interview the facility failed to ensure the patient's right to access information contained in his or her clinical records within a reasonable time frame.

Findings included:

Facility based policy entitled, "Release of Patient Information" stated in part,
"J. ACCESS TO HEALTH CARE INFORMATION (PHI):
A patient (or legally authorized representative) has the right to access and/or obtain a copy of his/her Health Care Information (PHI) from The Hospitals of Providence Memorial Campus (or to request that a copy be provided to a third party) within a reasonable time and to examine the record during regular business hours. The patient may review his/her medical record in the presence of a Medical Record Staff Member, Medical Record Managers or Nursing Director. Arrangements for the meeting time and date will be made when the request is initiated.

In accordance with HCF A guidelines, The Hospitals of Providence Memorial Campus will comply with the request or notify the patient that the requested information does not exist or cannot be found within 15 days from the date of request. Patients are informed of this right upon admission."

Review of the Authorization to Use and Disclose Health Information Forms related to Patient #2 revealed the following:
* Patient #2 requested records in person on 07/10/18 per Patient #2's spouse's signature, Patient #2 dated the form 07/12/19 (most likely in error). The form requested, "July 4-present all". The patient was provided the following documents: Radiology/Laboratory, Consultation. ED Note Physician, and H&P.
* On 07/31/18 [a medical provider for Patient #] faxed a request for "Cardiac/syncope/atrial fibulation/Cons/H&P/Testing Procedure/Discharge/ Meds". The following documents were provided: Radiology & Laboratory, EKG, ED Note, H&P, Echocardiogram. Discharge Summary, and EKG.
* On 08/02/18 [a medical provider for Patient #] made a request for "7/5/18-All Records". A fax communication result indicated that the facility faxed 31 pages on 08/02/18 to this provider in response. The following documents were sent to the physician office: Radiology & Labs, Echocardiogram, ED Note; Discharge Summary, and H&P.
* On 08/08/18 [a medical provider for Patient #] faxed a request for HP; DS; Lab; XRAY; ER; Immunizations; Psychology Evaluations; Operative Reports; Consultations; Specialty Clinic Notes; Audio/PT/OT speech Evals). The following documents were provided: Radiology & Laboratory; Physician Progress Note; Echocardiogram; Discharge Summary; Consultation; EKG; ED Note Physician; H&P; Consultation Reports;
* On 10/02/18 [a medical provider for Patient #] faxed a "Request for Release of Medical records". This did not specify what from the record. A fax communication result indicated that the facility faxed 64 pages on 01/02/18 and 65 pages on 10/03/18 to the provider in response. The following was provided: Laboratory, Consultation, H&P, EKG, Echocardiogram, Discharge Summary, ED Note, and Discharge Summary.
* On 12/05/19 [a medical provider for Patient #] requested, "Entire Medical Record including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records received from other health care providers." A fax communication result indicated that the facility faxed 64 pages on 12/06/18 to [a medical provider for Patient #] in response. The following documents were provided to the physician office: Discharge Summary, Echocardiogram, Consultation, ED Note, Discharge Summary, and H&P.
* On 03/19/19 a request by Patient #2 was faxed in requesting "Complete medical records, including but not limited to heart monitor/EKG recordings of events, nurses records, physician records, medication records, occupational therapy and physical therapy records." A letter included with this request dated 03/07/19 stated in part, "I am writing to request my complete medical records from my admission, July 4 through July 16, 2018. It is importation to include the records of Occupational Therapy, Nurse's notes, Medication records, and the heat monitor tracings. It is critical to have all these records ..." The following documents were provided: Physician Orders, Physician reports; Consultation, Nursing Documentation, Physician Progress Notes, Echocardiogram, ED Note, EKG, H&P, Heart Monitoring Tracing, Discharge Summary, Laboratory, Rad, Medication Administration, Emergency, and Cardiovascular documents. A postal tracking record indicated documents were sent to Patient #2 on April 1, 2019.
* On 04/29/19 Patient # 2 called the facility requesting Occupational/Therapy/Physician Notes, Medication records, and Heart Monitoring tracing. The facility was planning to overnight the complete medical record to the requestors. The surveyor was provided a Fed EX receipt on 05/01/19 that the complete medical record was provided to Patient #2 via overnight shipping.

In an interview on 05/01/19 staff members #2 and 3 verified that the facility failed to provided Patient #2 and Patient #2's medical providers all the requested medical records within 15 days of the requests per facility policy.

Based on a review of documentation and an interview with staff, the hospital failed to maintain an accurately written medical record for each patient.

Findings were:

A review of the clinical record for patient #1 revealed that the patient, a 5-year-old male, was admitted to PMH (Providence Memorial Hospital) on 2-28-19 at 8:46 pm with a 1-week history of worsening cough and a 4-day history of fever. Patient #1 had been treated a week prior for croup and had not been eating. He had been seen earlier in the day at his pediatrician's office and had been sent to the ER (of PMH) with hand-written admission orders, which included:
* Admit to pediatric unit (diagnosis: flu-like illness & pneumonia)
* Regular diet
* NS [normal saline] bolus 450 mg IV [intravenous] now
* Dextrose 5 ½ NS + 2 mEq [milliequivalents] KCl [potassium], 100ml at 60ml/hour
* CBC, BMP, NP swab for respiratory panel
* Continuous pulse oximetry
* Rocephin 1000mg IV x 1
* Albuterol nebulizer 2.5 mg [milligrams] q 4 hr PRN [as needed] wheezing only
A chest x-ray showed lingular pneumonia and the patient received Rocephin 1000mg IV (per physician's order) shortly after midnight.

On 3-1-19 at 8:51 am, the treating physician ordered Rocephin 1,140 mg IV to be given to patient #1 every 12 hours, beginning at 10:00 am the same morning. A review of the MAR [medication administration record] revealed that the medication was not given until 9:21 pm. A note in the MAR stated only "late from pharmacy". The clinical record for patient #1 contained no documentation to indicate that the ordering physician had been notified of the missed dose or that the pharmacy had been contacted regarding the whereabouts of the medication. In an interview with staff #1 [clinical informaticist], staff #1 confirmed that the clinical record contained no documentation to indicate that the ordering physician had been notified of the missed dose or that the pharmacy had been contacted regarding the whereabouts of the medication.

A review of facility incident reports revealed that staff #7 [the assigned nurse] completed an electronic incident report during the shift in which the Rocephin dose for patient #1 was missed. Staff #7 stated in the report "Resident [physician] entered order Rocephin to be given at 1200 [12:00 pm], RN [registered nurse] called pharmacy at 1300 [1:00 pm], 1600 [4:00 pm], 1800 [6:00 pm], still no receipt. Parents [of patient #1] upset." The incident report also indicated that patient #1's physician had been contacted. The report indicated that the incident had been reviewed by staff #3 [safety officer] on 3-1-19 and routed to staff #9 [director of pharmacy], who had stated "Nursing needs to speak to a pharmacist after 2 failed attempts to obtain needed medication."

Facility policy titled "Event Reporting" states, in part:
"III. Definitions:
...
F. 'Event Report' means a confidential, internal electronic, telephonic, or paper submission used for reporting of events for identification of patient safety issues and performance initiatives. This submission is not a part of the medical record.
...
V. Procedure:
...
B. Information to Provide in the Event Report
...
f. Do not reference the Event Report of investigative process in the medical record.
(1) The patient's chart must:
(a) Reflect all pertinent medical facts relating to the Reportable Event:
(b) Be accurate, legible, and completed timely; and
(c) Properly dated and timed"

Facility policy titled "eMar Process (Medication Administration)" states, in part:
"III. Policy:
The Electronic Medication Administration Record (eMAR) will be used for the documentation of medications.
...
5. When prescribed medication is not given, a reason must be documented.
...
IV. Procedure:
...
3. General Medication Administration Guidelines:
...
h. If a scheduled medication is not administered document as not given, including a reason as to why medication was not given.
9. Timing of Medication Administration:
...
b. Medications eligible for scheduled dosing times are those prescribed on a repeated cycle of frequency such as once a day, BID [twice daily], TID [three times daily], or at hourly intervals (every 1, 2, 3 or more hours) etc.
1. Non-time critical scheduled medications which include frequencies greater than daily, but no more frequent than every 4 hours:
" These medications should be administered 1 hour prior or 1 hour after when medication due, for a total window of 2 hours.
Notes:
a. Drug Administration errors/events, adverse drug reactions and incompatibilities must be immediately reported to the attending physician and reported through the internal incident reporting system."

The above was confirmed in an interview with the CEO and other administrative staff the afternoon of 5-1-19.