HospitalInspections.org

Based on observation and staff interview, the hospital failed to ensure all parts of patients' medical records are kept secure at all times. This has the potential to negatively impact all patient care by unauthorized individuals gaining access to and altering patient records or removing them from the facility. Findings include:

1. During observations on 1-East Nursing Unit, it was observed the facility uses chart boxes in the hallway outside each patient room. Inside the boxes were patient medical records. Included in the records were the patient's demographics sheet (name, address, date of birth, social security number, insurance, etc.), all physician orders, physician progress notes, information sent from nursing homes, medication administration record (MAR), vital signs flowsheet and pain assessment/management sheet. Locks were noted at the top of each box. The boxes were unlocked. They were also unattended.

2. Upon interview on 3/24/10 in the morning, when asked about the lock noted at the top of each box and why they weren't kept locked, the CNM stated "We just never have." The CNM stated the chart boxes aren't used in the entire facility, but the majority.

3. The Clinical Nurse Manager (CNM) and Team Leader (TL) were present during the above observation and findings. They agreed the medical reccords were not secure from unauthorized use.

Based on document review and staff interview, it was determined the medical staff failed to follow its Bylaws, Rules & Regulations in six (6) of ten (10) medical records reviewed (record #1, 2, 3, 4, 7 and 10). This has the potential to adversely affect patient care if the hospital is not enforcing its bylaws.
Findings include:

1. Review of the Bylaws, Rules & Regulations (revised 3/08) reveals (in part): "All entries in the record shall be legible, dated, timed and authenticated."

2. Review of medical record #1 (patient discharged 1/7/10) revealed the History and Physical had not been authenticated. Review of this record also revealed an operation report had not been authenticated.

3. Review of medical record #2 (patient discharged 1/28/10) and #3 (patient discharged 1/31/10) revealed their consultation reports had not been authenticated.

4. Review of medical record #7 (patient is an inpatient) revealed the consultation report was dictated 3/21/10 at 1704 and had yet to be authenticated.

5. Review of medical record #10 (patient is an inpatient) revealed the consultation report was dictated 3/22/10 at 2002 and had yet to be authenticated.

6. Further review of the Bylaws, Rules & Regulations reveals (in part):
"23. Incomplete records will be considered delinquent if not completed within fifteen (15) days following the patient's discharge, this includes the Transitional Care Unit. Temporary suspension of admitting and surgical privileges will occur in accordance with the Medical Record Suspension Policy. The following parts that shall constitute an incomplete medical record are:
c. Discharge Summary"

7. A review of medical record #3 (patient discharged 1/31/10) and #4 (patient discharged 1/8/10) revealed neither medical record contained a Discharge Summary.

8. The Clinical Nurse Manager of 1 East and the Registered Nurse Team Leader of 1 East were jointly interviewed in the afternoon of 3/24/10. Both concurred with the above findings.

Based on medical record review and staff interview, the hospital failed to ensure the nursing staff provided documented evidence of adequate care to one (1) of one (1) patients (Patient #3) as evidenced by insufficient nursing documentation. This has the potential to negatively impact all patient care by not providing adequate information to caregivers in order to monitor the patients' condition and provide appropriate care. Findings include:

1. Review of the medical record for Patient #3 revealed the patient was admitted 1/29/10 at 2100. The admission assessment was completed and a received note was documented at the time of arrival (2100) to the floor (1-East) by the night shift Registered Nurse (RN). There was an assessment documented by the RN at midnight. No other documentation was noted until a nurses' patient note at 0700 by the night shift nurse. At 0745 and 1600 on 1/30/10, the day shift RN documented an assessment with no evidence of documentation between. There were two (2) nurse's patient notes documented by the day shift RN on 1/30/10, the first at 1846 and the last at 1854 when the patient returned from surgery. The night shift RN documented a nurse's patient note at 2000, an assessment at 2321, a nurse's patient note at 2343 and not again until 0614. On 1/31/10, the day shift RN documented an assessment at 0730. There is no evidence in the medical record of documentation by the nurse until two (2) different notes documented at 1651 and the final nurse's patient note documented at 1654.

2. During an interview in the afternoon of 3/24/10 with the Clinical Nurse Manager (CNM) and Team Leader (TL) of 1-East, the medical record was reviewed and the CNM and TL both agreed with the above findings.

Based on medical record review and staff interview, the hospital failed to ensure the nursing staff properly signed-off physician orders in three (3) of five (5) medical records (Patients #6, 8, 9) reviewed. This has the potential to negatively impact all patient care by not providing an accurate timeline of when orders were received and care provided. Findings include:

1. In the morning of 3/24/10, the open records were reviewed on the 1East nursing unit. Review of the medical record for Patient #6 revealed all physician orders written since admission on 3/22/10 were signed-off (noted-off) by the nursing staff with the nurse's name only - no date and/or time.

2. Review of the medical record for Patient #8 revealed all physician orders written since admission on 3/23/10 were sign-off by the nursing staff with the nurse's name only - no date and/or time.

3. Review of the medical record for Patient #9 revealed no documented evidence of the admission orders dated 3/22/10 being signed-off by a nurse at all.

4. The Clinical Nurse Manager (CNM) and Team Leader (TL) reviewed the medical records at the same time with the surveyor (the morning of 3/24/10) and agreed with the above findings.