HospitalInspections.org

Based on medical record review and staff interview, the hospital failed to ensure the medical staff appropriately dated and timed the authentication signatures in nine (9) of ten (10) medical records reviewed (patients # 1, 2, 3, 4, 5, 6, 7, 8, 9). This has the potential to negatively impact all patient care by not allowing the QA/PI process to function properly. The findings include:

1. Review of the medical record for Patient #1 revealed the History and Physical (H&P) was dictated 11/23/09 at 1635, a Consult report dictated 11/25/09 at 2042, a Consult report dictated 12/2/09 at 0823 and the Discharge (D/C) Summary was dictated 12/2/09 at 1636. All were authenticated by the appropriate medical staff members but without documented evidence of the date and time of the signatures.

2. Review of the medical record for Patient #2 revealed the H&P was dictated 11/5/09 at 1630 and the D/C Summary 11/30/09 at 1443. Both were authenticated by the appropriate medical staff members but without documented evidence of the date and time of the signatures.

3. Review of the medical record for Patient #3 revealed the H&P was dictated 11/11/09 at 1628 and the D/C Summary 11/13/09 at 0831. Both were authenticated by the appropriate medical staff members but without documented evidence of the date and time of the signatures.

4. Review of the medical record for Patient #4 revealed the H&P was dictated 11/19/09 at 1038 and the D/C Summary 11/20/09 at 1403. Both were authenticated by the appropriate medical staff members but without documented evidence of the date and time of the signatures.

5. Review of the medical record for Patient #5 revealed the H&P was dictated 12/16/09 at 1430 and the D/C Summary 12/18/09 at 1058. Both were authenticated by the appropriate medical staff members but without documented evidence of the date and time of the signatures.

6. Review of the medical record for Patient #6 revealed the H&P was dictated 12/9/09 at 0728 and the D/C Summary 1/15/10 at 0851. Both were authenticated by the appropriate medical staff member but without documented evidence of the date and time of the signatures.

7. Review of the medical record for Patient #7 revealed the H&P was dictated 11/6/09 at 1505 and the D/C Summary 3/18/10 at 1456. Both were authenticated by the appropriate medical staff member but without documented evidence of the date and time of the signatures.

8. Review of the medical record for Patient #8 revealed the H&P was dictated 11/17/09 at 1324 and the D/C Summary 11/19/09 at 0957. Both were authenticated by the appropriate medical staff member but without documented evidence of the date and time of the signatures.

9. Review of the medical record for Patient #9 revealed the H&P was dictated 12/10/09 at 1608 and the D/C Summary 12/14/09 at 1257. Both were authenticated by the appropriate medical staff member but without documented evidence of the date and time of the signatures.

10. During an interview, in the afternoon of 1/5/11, with the 6th Floor Oncology Unit Manager (NM) and the Director of Support Services (DSS) the above medical records were reviewed and both agreed with the findings.