HospitalInspections.org

Based on document review and interview, it was determined that the Medical Records Department did not have a written policy governing the prompt retrieval of medical records which are sequestered for legal reasons.


Findings include:

At a joint interview with Staff #7 (Medical Records Director, Management (HIM), and Informative Technology (IT) and Nursing Informatics and Medical Record staff on 9/17/15, it was stated that medical records which are deemed "sequestered" as a result of ongoing or pending litigation involving the hospital are not available for review under any circumstances, including emergencies. The survey team requested the policy that governed such practice.

On 9/18/15, Staff #7 submitted to the surveyor, a new policy titled "Sequestered Medical Record," with an effective 9/18/15 and no superseding date. The policy stated; only Risk Management, the Information Security Officer, the Administrator on Duty or the SUNY ( State University of New York ) Vice President or above can unlock a record under a sequestered hold status.
This was contradictory to what was stated by hospital staff on 9/17/15 .
The date on the policy was brought to the attention of Staff #1, who acknowledged this was a new policy.

Based on document review and interview, it was determined that the hospital failed to ensure that staff is familiar with all aspects of the Electronic Medical Records system and know how to access information from the Electronic Medical Records system.

Findings include:


Review patient MR#A and the facility Quality Assessment (QA) reports, identified that a dialysis patient who was Hepatitis B surface antigen (HBsAG) positive was improperly documented as Hepatitis B surface antigen (HBsAG) negative by nursing staff. This resulted in the patient being dialyzed 6 times in the general acute dialysis unit from 5/26/15 through 6/4/15 on machine # 28330 and this machine was subsquently used by 26 other patients, 9 of those patients had no immunity.

Review of the Quality Assessment (QA) data identified the performance review documentation stated; "clinical staff failed to check and document the patient's hepatitis B status on the Dialysis Flow Sheet prior to initiating hemodialysis. Nurses were reported as being not familiar with the "Health Bridge" function that allows staff to filter for pertinent lab test results."
At interview on 7/18/15 with a nursing staff member involved in the incident, it was verified that there was a problem with accessing laboratory reports in the system. The nurse stated, "it was in a difficult place."

During interview Nursing Informatics staff on 9/17/15, it was identified that the Medical Records Department uses multiple systems for access to information contained in the medical record. Specifically, there is Health Bridge for lab reports, Trace View for Labor and Delivery, Fuji RIS for Radiology, T-system for ED ( Emergency Department ) documentation, Cerner for Laboratory, Alpha for Imaging, and Eagle for Registration.

Based on review of document and interview, it was determined that the medical records did not include all pertinent clinical information.

Findings include:

Review of MR#A on 9/18/15, identified that patient information documented on the SBAR (situation, background, assessment, recommendation) tool is not retained in any form or record. This tool contains a record of communication to transfer patient care information (Hand off flow sheet) between nursing staff and was not considered part of the medical record.

At interview with nursing administration and Nursing Informatics on 9/18/15 it was stated that SBAR is not part of the medical record and is not retained in any form or record.

Based on review of document and interview, it was determined that the facility did not comply with the policy to ensure safe infection control practices for patients on hemodialysis.

Findings include:

Review of patient MR#A on 9/17/15, identified this patient who was Hepatitis B surface antigen (HBsAG) positive, was dialyzed 6 times in the general acute dialysis unit from
5/26/15 to 6/4 /15 on machine # 28330. This machine was subsequently used by 26 other patients, 9 of those patients had no immunity.

Review of the lab reports for patient MR#A showed, on 05/21/15 ,05/27/15 and 06/02/15, the patient was Hepatitis B antigen positive(HBsAG) but nursing flow sheets documented that the patient was HBsAG negative for those dates.

Between 5/27/15 to 5/30/15, nursing staff continued to document Hepatitis B status as
"negative." From 6/2/15 to 6/4/15, the patient's hepatitis status was not not recorded by the nursing staff on the flow sheet.

At interview with Staff #2, (Infection Control Director) on 09/18/15 at approximately 10.30 AM, it was stated that the incident was discovered on 06/04/15 during the social worker discussion on outpatient placement for continued dialysis treatment, that the clinical staff failed to document on the dialysis flow sheet the patient Hepatitis B antigen positive status. She stated that nurses were unfamiliar with the function that allows staff to filter for pertinent test results in the Health Bridge system.

The facility's policy, "Infection Control Guidelines Hemodialysis Units," Issued May 2005 and Approved June 2013, stated; "HBsAG positive patient are to be identified, and shall be cared for in a designated area using a designated machine and isolation techniques......" The policy also stated; "The designated HBsAG positive machine should only be used for a HBsAG positive patients."
The surveyor identifed the policy did not specify a process for identifying patient HBsAG status and the facility did not have designated HBsAG positive machine. This was acknowledged by Staff #2.