HospitalInspections.org

Based on observation, staff interview and policy review the Hospital failed to ensure the confidentiality of patient electronic records for one of one portable ultrasound machine (imaging method that uses high-frequency sound waves to produce images of structures within your body) observed. The hospital's failure to ensure the confidentiality of patient records has the potential for unauthorized individuals to gain access to or alter patient records.

Findings include:

- Document review of the Hospital's policy titled, "HIPAA (health insurance portability and accountability act provides data privacy and security provision for safeguarding medical information).GEN.001, Compliance Program Requirements" dated Review: 3/31/2016, showed, To establish the authority and guidance provisions for the HIPAA Compliance Program in order to protect individual rights to privacy and confidentiality of protected health information (PHI) as required by the Health Insurance Portability and Accountability Act.

Observation on 06/18/19 at 12:25 PM revealed a portable ultrasound machine, in the hallway between heart catheterization laboratory (Cath lab) and the six-bed pre-post procedure area, unattended, and the screen was logged on displaying an unsampled patient's medical record information.

During an interview on 06/18/19 at 12:25 PM, Staff T, quality and risk manager, stated that it is a locked area and "I'll get someone to take care of that."

Based on interview and record review the Hospital failed to ensure all patients' medical record entries were complete; timed, dated, noted, and authenticated by the responsible person evaluating or providing patient service. One of ten medical records failed to have a nurse note standing orders (Patient #10) and one of ten medical records has an electronic order entered by a nurse but failed to have a physician's order for the laboratory test (Patient #8). The Hospital's failure to ensure all patients' medical record entries were complete has the potential to disrupt the continuity of care among providers and fails to ensure the providers comply with the Hospital's policies and procedures.

Findings include:

- Document review of the Hospital's Medical Staff Rules and Regulations "General Conduct of Care," dated 12/2015 showed that all clinical entries in the patient's medical record, shall be accurately dated, timed, authenticated, and legible.

1. Review of Patient #10's record on 06/18/18 at 3:30 PM showed that she arrived from the ER (emergency room) to the OB (obstetrical) department on 03/29/17 at 5:32 PM saying that she can't stand up, she has not been eating well for more than one week and that her family has been carrying her to and from the bed. Last menstrual period (LMP) 10/20/16, 22 weeks gestation.

Triage Labor Medical Screen Examination was initiated and was not noted by the OB registered nurse, Staff Y, or signed by the physician Staff U. The Hospital failed to ensure nursing staff noted and that physician staff signed the standing orders within 72 hours.


2. Review of Patient #8's record on 06/18/18 at 3:00 PM showed that the patient presented to the OB department from the ER on 03/02/17 at 7:29 PM with complaints of decreased fetal movement and leaking fluid. LMP 06/14/16. External fetal monitor was applied, Fetal Heart Tones (FHT) 140 and vital signs were stable. Patient denied burning or pain with urination. Ferning (confirms the rupture of membranes) test done.

Patient #8's record showed there was not a physician's or a practitioner's verbal order or any standing order for the Ferning test Staff ?, OB nurse ordered in the electronic health record system on 03/02/17 at 7:38 PM. The Hospital failed to ensure nursing staff had an order for a lab test from a practitioner and that a practitioner authenticated the order.


During an interview on 06/20/19 at 9:00 AM, Staff S, OB director stated that "there's not a physician order for the Ferning test" and it's not on the Triage Labor Medical Screen Examination OB standing orders.

Based on record review, staff interview, and policy review the Hospital failed to ensure all verbal orders were accurate, signed, and dated as required by the Medical Staff Rules and Regulations within 72 hours for five of ten patients (Patient #'s 1,3,7,9, and 10) This deficient practice has the potential to cause patients to receive unauthorized treatments and/or medications which could lead to patient harm.

Findings include:

Review of the Hospital's Medical Staff Rules and Regulations dated 12/15, showed that the recipient shall indicate that he/she has written for or otherwise recorded the order, and shall read the verbal order back to the physician and indicate that the individual has confirmed the order. The physician who gave the verbal order or another practitioner (Controlled and granted privileges to write orders) who is responsible for the care of the patient shall authenticate, time, and date of any order including but not limited to medication orders within 72 hours of the patient's discharge or 30 days whichever comes first.


1. Review of Patient #1's record on 06/18/18 showed she arrived at the hospital on 04/07/18 at approximately 7:00 PM with a complaint of right flank pain.

a. At 7:00 PM, Staff D, Registered Nurse documented a verbal order stating, "Transfer to OB (obstetrical unit) and monitor for Fetal Heart Tones (FHT) and contractions then return to emergency department (ED) if no complications. The documentation showed it as a Verbal Order Repeated Back (VORB) to Staff A, Physician from Staff C, Registered Nurse who then told Staff D, Registered Nurse to carry out the order. The Hospital staff inappropriately documented an order they failed to properly obtain which remained in the record unsigned as of 06/19/18 (73 days after the patient was discharged).

During an interview on 06/19/18 at 12:30 PM Staff D, Registered Nurse, stated, "I never heard a transfer order from Staff A. Staff C is the one that called me that night and she said she had gotten an order from Staff A. No, I didn't actually hear from Staff A at all that night." Staff D confirmed management staff had not interviewed her regarding the medical record or potential error.

During an interview on 06/19/18 at 9:00 AM Staff C, Registered Nurse, stated, "Staff A, Physician, had not told me to transfer the patient or collect any labs."

During an interview on 06/19/18 at 9:30 AM Staff J, Registered Nurse, stated that Staff A's standard practice was if the patient was 20 weeks or greater gestation then she needed to be seen in OB first. Staff J confirmed he was in triage that day but does not remember a specific conversation with Staff A.

b. Staff D, Registered Nurse, documented a Telephone order from Staff V, Physician, directing staff to Transfer to emergency room (ER) for treatment and evaluation. Staff V signed the order on 05/10/18. (33 days after the patient was discharged)


2. Review of Patient #3's record on 06/18/18 showed she arrived at the hospital on 04/19/18 at 10:13 AM and was sent to OB for FHT and monitoring.

a. Staff O, Registered Nurse, documented telephone orders received directing staff initiate the "Labor Medical Screen Examination" standing orders. Staff X, Physician, signed the orders on 05/01/18 (12 days after the patients discharge).

b. Staff O, Registered Nurse, documented telephone orders received directing staff to transfer the patient to the ER on 04/19/18 at 11:45 AM. Staff X, Physician, signed the orders on 05/01/18 (12 days after the patients discharge).


3. Review of Patient #7's record on 06/18/18 at 3:00 PM showed that the patient was seen in the OB department and on 02/22/17 at 8:38 AM. The patient wanted to know how pregnant she was. Last menstrual period (LMP) 06/01/16 gestational age by dates 37 weeks 4 days.

Staff Q, Registered Nurse documented verbal order received directing staff to dismiss the patient to home on 02/22/17 at 12:50 PM. Staff U, Physician, signed the orders on 03/02/17 at 9:22 AM (5 days late).


4. Review of Patient #9's record on 06/18/18 at 3:30 PM showed that the patient presented to the ER for vomiting and was seen in the OB department on 03/14/17 at 10:38 AM. LMP 06/22/16, 37.5 weeks.
At 10:56 AM, Staff P, Registered Nurse, documented verbal orders received directing staff to transfer the patient to the ER for further treatment. Staff U, Physician signed the orders on 03/23/17 at 10:00 AM (six days late). The Hospital failed to ensure physician staff signed the verbal orders within 72 hours.


5. Review of Patient #10's record on 06/18/18 at 3:30 PM showed that she arrived from the ER to the OB department on 03/29/17 at 5:32 PM saying that she can't stand up, she has not been eating well for more than one week and that her family has been carrying her to and from the bed. LMP 10/20/16, 22 weeks gestation. Staff U, Physician orders for consult with Staff B, Physician.

a. Staff Z, Registered Nurse, documented verbal order received on 03/29/17 at 7:45 PM directing staff to Admit to the patient to Observation in the OB department. Staff U, Physician, signed the orders on 04/06/17 at 12:00 AM (5 days late).

b. Staff Z, Registered Nurse, documented verbal order received on 03/29/17 at 9:25 PM directing staff to transfer the patient to medical /surgical floor. Staff B, Physician signed the orders on 04/20/17 at 7:37 AM (19 days late).

c. Staff Z, Registered Nurse, documented verbal order received on 03/29/17 at 9:28 directing staff to Doppler FHT every shift. Staff U, Physician signed the orders on 04/06/17 at 9:25 AM (5 days late).


During an interview on 06/18/18 at 11:30 AM Staff K, Director of Health Information, stated that a chart analysis is done daily and all orders are to be signed and dated. If not, they are supposed to be flagged for the physician to sign.

During an interview on 06/19/18 at 3:05 PM Staff E, Chief Executive Officer, stated that we see now that we have some problems in medical records. Some things are on paper, some are electronic. We need to do a better job of making sure all orders are signed.

Based on record review, staff interview, and policy review the Hospital failed to ensure standing order sets were dated, timed, and authenticated within 24-hours per the hospital's policy for eight of ten patient's (Patient #'s 1, 3, 4, and 6-10) record. This deficient practice has the potential to cause a lack of physician oversight for each patient receiving care directed under standing orders which could lead to patient harm.


Findings include:


Review of the Hospital's Medical Staff Rules and Regulations dated 12/15, showed that standing orders shall be dated and signed by the practitioner and reproduced in detail on the order sheet of the patient's record.

Review of the Hospital's policy titled, "Triage procedure as outlined in P&P- Labor Medical Screen Examination (MSE) Approved by medical staff on 07/26/11," dated 04/18, showed the obstetrical screening tool documenting the MSE is part of the patient's medical record. The record and one-hour fetal heart monitoring strips will be retained on the unit for review by the physician. A physician will conduct a review within 24 hours of the visit.


1. Review of Patient #1's record on 06/18/18 showed she arrived at the hospital on 04/07/18 at approximately 7:00 PM with a complaint of right sided flank pain.

At 8:00 PM Staff D, Registered Nurse, documented the initiation of the "Labor Medical Screen Examination" standing orders on 04/07/18 at 8:00 PM. Staff V, Physician, signed the standing orders and Obstetrical (OB) Medical Screening Exam Record on 05/10/18 (32 days late).


2. Review of Patient #3's record on 06/18/18 showed she arrived at the hospital on 04/19/18 at 10:13 AM and was sent to the Obstetrical department (OB) for Fetal Heart Tones and monitoring.

Staff O, Registered Nurse, documented the initiation of the "Labor Medical Screening Examination" standing orders without documenting a time or date and initiation. Staff X, Physician, signed the document on 05/01/18 (11 days late).



3. Review of Patient #4's record on 06/18/18 showed she arrived at the hospital on 02/20/18 at 12:08 PM.

Staff AA, Registered Nurse, failed to sign the initiation of the "Labor Medical Screening Examination" on 02/20/18 at 12:25 PM. Staff U, Physician, failed to sign the document as of 06/19/18 (118 days late).


4. Review of Patient #6's record on 06/18/18 at 3:00 PM showed that she was seen in the OB department on 09/16/17 at 11:35 PM for abdominal pain.
Registered Nurse documented the initiation of the "Labor Medical Screen Examination" standing orders on 09/16/17 at 11:57 PM. Staff U, Physician signed them on 09/19/17 at 7:00 PM (48 hours late).


5. Review of Patient #7's record on 06/18/18 at 3:00 PM showed that the patient was seen in the OB department and on 02/22/17 at 8:38 AM. The patient wanted to know how pregnant she was. Last Menstrual Period (LMP) 06/01/16 gestational age by dates 37 weeks 4 days.
Staff Q, Registered Nurse, failed to document the initiation of the "Labor Medical Screen Examination". Staff U, Physician failed to sign the standing orders as of survey date 06/19/18 (greater than 14 months late)


6. Review of Patient #8's record on 06/18/18 at 3:00 PM showed that the patient presented to the OB department from the ER (emergency room) on 03/02/17 at 7:29 PM with complaints of decrease fetal movement and leaking fluid. LMP 06/14/16. External fetal monitor was applied, fetal heart tones (FHT) 140 and vital signs were stable. Patient denied burning or pain with urination. Ferning (confirms the rupture of membranes) test done.
Staff R, Registered Nurse, documented the initiation of the "Labor Medical Screen Examination" standing orders on 03/02/17. Physician Staff failed to sign the document as of survey date 06/19/18 (greater than 15 months late).


7. Review of Patient #9's record on 06/18/18 at 3:30 PM showed that the patient presented to the ER for vomiting and was seen in the OB department on 03/14/17 at 10:38 AM. LMP 06/22/16, 37.5 weeks.
Staff P, Registered Nurse, documented the initiation of the "Labor Medical Screen Examination" standing orders on 03/14/17 at 10:30 AM. Physician Staff failed to sign the document as of survey date 06/19/18 (greater than 15 months late).


8. Review of Patient #10's record on 06/18/18 at 3:30 PM showed that she arrived from the ER to the OB department on 03/29/17 at 5:32 PM says that she can't stand up, she has not been eating well for more than one week and that her family has been carrying her to and from the bed. LMP 10/20/16, 22 weeks gestation.
Staff Y, Registered Nurse failed to document the initiation of the "Labor Medical Screen Examination" standing orders. Physician Staff U failed to sign the document as of survey date 06/19/18 (greater than 15 months late).

During an interview on 06/19/18 at 1:30 PM Staff T, Quality Director, stated the providers should have signed all the standing orders titled "Labor Medical Screening Examination" within 24-hours. Staff T confirmed that is what the hospital's policy states.

During an interview on 06/18/18 at 11:30 AM Staff K, Director of Health Information, stated that a chart analysis is done daily and all orders are to be signed and dated. If not, they are supposed to be flagged for the physician to sign.

During an interview on 06/19/18 at 3:05 PM Staff E, Chief Executive Officer, stated that we see now that we have some problems in medical records. Some things are on paper, some are electronic. We need to do a better job of making sure all orders are signed.