HospitalInspections.org

Based on record review and interview, the facility failed to ensure that the information provided in the patient's clinical records are complete and accurately written in 4 (#1, #2, #3 and #9) of 13 sample patients.

The findings include:

Clinical record review of Sample Patient (SP)#1 conducted from 9-17-12 to 9-20-12 revealed an admission on "3-8-12 for a cadaveric donor kidney transplant" and a second admission on "4-18-12 due to nausea, vomiting, diarrhea and dehydration."

Documentation showed that SP#1 signed all consents related to his hospital care during his first admission on 3-8-12.
Documentation on SP#1's second admission on 4-18-12 showed: [Name of SP#1's mother] "name of authorized representative acting on behalf of patient" and showed her signature on all consents.

Documentation on the Operative Report showed "Date of Operation: 03-09-2012."
Documentation on the Autopsy Report showed "Status post renal re-transplant on 6 Mar 12."

Documentation on all the consents during SP#1's second admission showed his mother's name and signature.
Documentation on the Autopsy Report showed: "Authorized by: [SP#1's mother's name] Relationship to patient: wife. "

Interview with the Transplant Unit Associate Director of Patient Care Services conducted on 9-19-12 at 1120am confirmed the inaccurate information on the Autopsy Report mentioned above. She stated that "the Senior Chief Medical Officer addressed inaccurate entries with the Head of Pathology."


Review of SP#2's Request for Amendment/Correction of Protected Health Information conducted from 9-17-12 to 9-19-12 revealed that information entered in the Clinic Visit dated 8-26-12 showed: "There he was given a Prednisone taper together with full dose of Asacol." Corrected statement dated 9-19-12 showed: "When the patient was given steroids, he was given Prednisone without taper 40mg for 21 days in addition to half of the full Mesalamime (Asacol) dose."

Interview with the HIM Department Director conducted on 9-19-12 at 1215pm confirmed that SP#2's request for amendment of health information was accepted and corrected.


Clinical record review of SP#3 conducted from 9-17-12 to 9-19-12 revealed no documented evidence that he was transported to and dropped off at the designated Assisted Living Facility [ALF] upon discharge.

Interview with the Mental Health Associate Director of Quality conducted on 9-20-12 at 3pm confirmed that there is no documented evidence that SP#3 was dropped off at the designated ALF on 6-18-12. She confirmed that SP#3 was transported by the Hospital van/transport. She confirmed that there is no copy of SP#3's Transportation Referral Form - a proof that SP#3 was dropped off at the right facility.


Review of SP#9's Request for Amendment/Correction of Protected Health Information conducted from 9-17-12 to 9-19-12 revealed that information entered in the Gastroenterology Diagnostic Procedure form dated 4-24-12 showed: "She states her last colonoscopy was while she was living in Tampa 5 years ago and had a polyp removed." Corrected statement dated 6-20-12 showed: "She states her last colonoscopy was while she was living in Tampla 5 years ago and had two polyps removed."

Interview with the HIM Department Director conducted on 9-19-12 at 1215pm confirmed that SP#9's request for amendment of health information was accepted and corrected.