HospitalInspections.org

Based on clinical record review, review of the Hospital's policies and procedures and staff interviews, for 3 of 4 patients (Patient #2, #3 and #5) in a total sample of 10 patients, the Hospital failed to follow their policy and procedure to document an immediately apparent unanticipated outcome in the clinical record.

The Hospital policy titled "Communication of Unanticipated Outcomes and Medical Errors", indicated factual, non-accusatory documentation is entered into a patient's medical record by the attending physician after the disclosure to the patient is made and retained as a permanent part of the patients medical record.

For Patient #2, a peripherally inserted central catheter (PICC) line was inserted on 12/3/14 into the right arm. The physician order indicated the line be placed into the left arm. Patient #2 had the right PICC line discontinued and re-inserted into the left arm. Patient #2's medical record lacked any documentation of a disclosure to Patient #1 as required by the hospital policy.

For Patient #3, a right kidney lithotripsy (a medical procedure that uses sound waves to destroy kidney stones) was planned for 2/11/14. The left kidney received the lithotripsy procedure. Although the Urologist said he immediately informed Patient #3, the medical record lacked any documentation of a disclosure to Patient #3 as required by the hospital policy.

For Patient #5, a kyphoplasty (a medical procedure used to treat painful fractures in the spine) at the Lumbar 3 level was performed on 4/17/14. At the completion of the procedure, the physician mistakenly re-read the imaging studies and incorrectly performed a second kyphoplasty at the Lumbar 4 level. Patient #5's medical record lacked any documentation of a disclosure to Patient # 5 as required by the hospital policy.