HospitalInspections.org

A. Based on review of documents, medical record review and staff interview it was determined the medical staff failed to enforce bylaws/rules and regulations for completion of medical records. The medical staff failed to ensure pertinent information regarding clinical observations and test results were included for one (1) of one (1) inpatients (patient #3) reviewed who had an elevated white blood count (WBC). This failure creates the potential for the care and condition of all patients with abnormal test results to be adversely impacted.

Findings include:

1. The "Rules and Regulations of the Medical Staff and Allied Health Professional Staff," effective 3/4/12, were provided for review with the Medical Staff Bylaws. These rules state in part: "The attending physician/dentist shall be responsible for a complete medical record for each patient. The record shall include...the report of a relevant physical examination, all diagnostic and therapeutic orders...clinical observations including results of therapy, reports of procedures, tests and the results and conclusions at termination of hospitalization or evaluation/treatment....Pertinent progress notes shall be recorded at the time of the observation, sufficient to permit continuity of care and transferability and give a pertinent chronological report of the patient's course in the hospital reflecting change of condition and results of treatment."

2. Review of the medical record for patient #3 revealed she was hospitalized 7/10/12 through 7/12/12. Review of the 7/10/12 blood work test results revealed the patient's WBC was classified as high. The result was 22.8 with 4.8 - 10.8 referenced by the laboratory as normal range. Review of the patient's 7/11/12 blood work results revealed the WBC was classified as high. The result was 23.9 with 4.8 - 10.8 referenced by the laboratory as normal range. The patient was discharged on 7/12/12 with no further check of the WBC. There was no documentation by the physician to reflect the elevated WBC were noted, reviewed or treated prior to discharge.

3. The record was reviewed and discussed with the Director of Women's and Children's Services at 1145 on 5/7/13. She agreed the record lacked any documentation by medical staff to reflect the elevated WBC was noted, reviewed or treated.

4. The record was discussed by phone with the Attending Physician at approximately 1300 on 5/7/13. She stated she could not remember if she was aware of the elevated WBC. She also acknowledged she may not have included any documentation in the medical record which reflected awareness of the elevated WBC.


B. Based on review of documents, medical record review and staff interview it was determined the medical staff failed to enforce bylaws/rules and regulations for completion of medical records. The medical staff failed to ensure consultation reports were completed with the signature of the provider in a timely fashion for two (2) of three (3) patients (patients #1 and #2) reviewed who had a consultation ordered. This failure creates the potential for the care of all patients who require consultation evaluations to be adversely impacted.

Findings include:

1. The "Rules and Regulations of the Medical Staff and Allied Health Professional Staff," effective 3/4/12, were provided for review with the Medical Staff Bylaws. These rules state in part: "Incomplete records will be considered delinquent if not completed within fifteen (15) days following the patient's discharge."

2. Review of the medical record for patient #1 revealed a specialty consultation by medical staff which was dictated and transcribed on 8/4/12. This consultation was signed by the provider on 11/5/12. This signature was ninety-three (93) days after discharge.

3. Review of the medical record for patient #2 revealed a specialty consultation by medical staff which was dictated and transcribed on 7/30/12. This consultation was signed by the provider on 11/5/12. This signature was ninety-four (94) days after discharge.

4. These records were reviewed and discussed with Women's and Children's Quality Nurse Specialist on 5/7/13 at 1318 and she agreed with these findings.