HospitalInspections.org

Based on the systematic nature of the standard level deficient practices related to the implementation of policies and procedures and auditing practices regarding Clinical Record Requirements as cited in:
485.638 (a) (3) ---- 0303
485.638 (a) (4) (i) -- 0304
485-638 (a) (4) (iii)--0306
485.638 (a) (4) (iv)--0307

Deficient practice was found in 22 of 27 clinical records reviewed.

A review of the Medical Staff Bylaws revealed the following: 5E. Performance Improvement: (1) (q) " Accurate, timely, and legible completion of medical records. "

Based on staff interview and clinical record review, it was determined the facility staff failed to ensure complete and accurate clinical records were maintained for 22 of 27 patient records reviewed.

The findings include:

During the survey, the team reviewed 27 patient records. Of the 27 records, 22 had missing or incomplete documentation. Patient #'s 1, 2, 3, 4, 6, 8, 9, 10, 11, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 25, and 27.

In an interview with Staff # 7 on 8/19/14, the survey team discussed the patient records and incomplete documentation. Staff #7 stated he/she would "talk" to the doctors and "remind" them they needed to complete their records. Staff #7 also stated ""We are developing a better auditing tool that meets the standards and is not repetitive, also that will include the electronic record and issues with that..."

On 8/19/14 at 3:40 p.m., and again on 8/20/14 at 12:15 p.m., the survey team discussed the clinical record findings with the facility Administrative staff.

The survey team reviewed the 'Emergency Medical Treatment and Patient Transfer' Policy and Procedure (P&P), related to discharge and transfer documentation. The policy had a creation date of 7/1/99 with the most recent review and effective date of 11/1/13. The policy and preocedure included a component related to chart reviews for emergency department patients who were transferred.
1. Each hospital shall periodically review its transfers to identify opportunities for improvements. The review shall include, but not be limited to, a determination of whether the following requirements for transfer are being satisfied:
a. Documentation reflects patient's condition on transfer (refer to Transfer Authorization Form for stable/unstable).
b. The physician has signed a certification stating that based on the assessed needs of the patient at the time of transfer, the medial benefits reasonably outweigh the increased risks to the patient...
c. The receiving facility has available space and qualified personnel and has agreed to accept the patient (refer to Transfer Authorization Form).
d. Documentation reflects all medical records related to the emergency condition are sent to the receiving facility (refer to Transfer Authorization Form).
e. The transfer is affected through qualified personnel and transportation equipment (refer to Transfer Authorization Form).
f. Results of the reviews shall be reported to the Medical Staff and to the Administration.

Based on staff interview and clinical record review, it was determined the facility staff failed to ensure the disposition at discharge was documented for 9 of 27 patients of the survey sample (Patient #'s 2, 6, 15, 16, 18, 19, 21, 22 and 27), and for 4 (four) of 27, (Patient #'s 4, 9, 10 and 16) the facility staff failed to ensure the transfer record was completed. The facility also failed to ensure the "Patient Rights and Responsibilities" document (containing how and where to file a grievance or complaint and a listing of the Patients Rights) and "Policy on Advance Directives" was signed by the patient acknowledging receipt of this information.
Upon discharge, the physician documentation of disposition, was not documented or was unclear in the clinical record for Patient #'s 2, 6, 15 16, 18, 19, 21, 22 and 27.
The transfer record was not completed for Patient #4, 9, 10 and 16.
"Patient Rights and Responsibilities" and "Policy on Medical Advance Directives" document was not signed for Patient #'s 6, 13, 17, and 25.
The findings included:
(A) Review of the clinical records for Patient #'s 2, 6, 16, 18, 21, and 27 revealed no disposition documentation on the emergency room record by the physician. On the second page (Page 2) of the emergency room document was an area designated for the physician to document "Disposition: Disposition Decision Time" and "Discharge" with choices for the physician to circle as to the disposition of the patient (ex: home, work, Nursing Home, Deceased, AMA). For the Patient charts listed above, there was no documentation by the physician of the patient's disposition at discharge.
Review of the clinical records for Patient 4, 9, and 16 revealed the patients were transferred to another facility for a higher level of care or speciality service. Patient #4 had a "Transfer Authorization Form" which, on page 2, failed to document" "VI: Patient Consent to Transfer- (check one) I hereby Consent to Transfer...I hereby refuse to be transferred...I hereby request transfer..." None were checked. Also the document was signed in the area for "responsible person" however there was no indication who the "Responsible Person" was in relation to Patient #4. At the bottom of the form, there was no documentation as to what additional records were sent with the patient ( VII: Accompanying Documentation) and the date and time of transfer were not documented.
For Patient # 16 the "Transfer Authorization Form" did not document "IV. Mode/Support/Treatment During Transport".
For Patient #16, the "Transfer Authorization Form" did not document: "III. Risks and Benefits of Transfer", or "VIII. Accompanying Documentation".
Further review of the clinical records revealed "Patient Rights and Responsibilities" and "Policy on Medical Advance Directives" document was not signed for Patient #'s 6, 13, 17, and 25. The document contained a signature area on the second page which had a computer printed date and time but no patient signature.
(B) Review of the clinical record for Patient #10 revealed that on page 1 of 1 of the Medical screening Exam under the heading "DISPOSITION:" there was no documentation as to where Patient #10 was discharged. However, further reviewed revealed Patient # 10 had documentation that the patient was transferred to another facility. Patient # 10's record lacked a transfer record.
The clinical record for Patient 15 revealed that on page 2 of the physician's physical assessment, under the heading "DISPOSITION: Disposition Decision Time" there was no documentation of the time, where the patient was discharged, whether the patient was transferred, what condition the patient was in at the time of discharge, or with whom the discharge was discussed with at the time of discharge.
Review of the clinical record for Patient # 19 revealed that on the second page of the physician's assessment emergency room record under the heading "DISPOSITION: Disposition Decision Time" there was documentation by the physician that Patient # 19 was discharged home and also that a transfer form was completed. Subsequent documentation in Patient # 19's record was a physician order sheet dated 7/24/2014 with an order to "transfer to "another facility" DQ drug O.D./Tylenol O.D. "name of accepting MD" notify resident on call on arrival". The record also included a transfer form dated 7/24/2014 which named the receiving facility and name and title of hospital personnel accepting transfer of Patient # 22.
The clinical record for Patient # 22 had documentation on the physical examination by the physician that Patient # 22 was to be "discharged to behavioral health" for acceptance in another facility. There was documentation by the emergency room nurse in the Clinical Notes Report that "Behavioral Health "staff" has been here and advised the patient was going voluntarily to "a facility" to be admitted there. He/she "is being discharged to his/her family". Patient # 22's record lacked a transfer order, and based on documentation in the record, it was unclear as to where the patient was discharged.
On 8/19/14 at 12:50 p.m., the surveyors discussed the findings with Staff # 7. Staff #7 stated that when the audits are done of the medical records the physicians are reminded to sign and complete their charts. "We are developing a better auditing tool that meets the standards and is not repetitive, also that will include the electronic record and issues with that..."
On 8/19/14 at 3:40 p.m., and again on 8/20/14 at 12:15 p.m., the survey team discussed the findings with the facility Administrative staff.
The survey team reviewed the 'Emergency Medical Treatment and Patient Transfer' Policy and Procedure (P&P), related to discharge and transfer documentation. The policy had a creation date of 7/1/99 with the most recent review and effective date of 11/1/13.
The procedure included the following, in part, "The physician must also complete, or confirm the information contained in, the physician-required sections of the Transfer Authorization Form".
Prior to transfer, the RN (registered nurse), Case Manager, or Social Worker must confirm positive acceptance by the receiving facility, including bed availability and qualified staff awaiting patient ' s arrival. The date and time of confirmation must be documented in the Transfer Form.
In order to verify and document appropriate transfer the following forms must be completed and the following records must be kept (unless noted to be inapplicable to the patient, as described in the P&P: Transfer Authorization Form; Pertinent Medical Information; Physician Order; Emergency Commitment Form; Certificate of Medical Necessity for Ambulance Transportation.

Based on staff interview and clinical record review, it was determined the facility staff failed to ensure all treatment orders were documented in the clinical records for 7 (seven) of 27 patient records in the survey sample (Patient #'s 2, 6, 8, 17, 20, 22 and 23).

Patient #'s 2, 6, 8, 17, 20, 22 and 23 were evaluated by Behavioral Health in the Emergency Department. There was no order from the physician on the clinical record for the Behavioral Health Evaluation.

The findings included:

(A) Patient #'s 2, 6, 17, 20, and 23 clinical records were reviewed and revealed each of the patients were seen in the emergency department by personnel from Behavioral Health for a mental health screening. The surveyors were unable to locate in the clinical record an order from the physician for the mental health consult/evaluation.

According to Staff # 9 on 8/19/14 at 2:00 p.m., any physician's orders were located on the electronic print out in the patient's record. The surveyors were unable to locate any consult/evaluation orders on the electronic print out for the Behavioral Health.

(B) Patient #'s 8 and 22 were evaluated by Behavioral Health in the emergency Department. There was no order from the physician on the clinical record for the Behavioral Health Evaluation.

On 8/19/14 at 12:50 p.m., the surveyors discussed the findings with Staff # 7. Staff #7 stated that when medical record audits are done, the physicians are reminded to sign and complete their charts. "We are developing a better auditing tool that meets the standards and is not repetitive, also that will include the electronic record and issues with that..."

On 8/19/14 at 3:40 p.m., and again on 8/20/14 at 12:15 p.m., the survey team discussed the findings with the facility Administrative staff.

Based on staff interview and clinical record review, it was determined the facility staff failed to ensure clinical records contained complete documentation of dates and times of orders and disposition of the patient for 15 of 27 charts reviewed. Patient #'s 1, 3, 4, 8, 9,10, 11, 13, 16, 17, 18, 19, 21, 22 and 27.

Patient # 3, 4, 8, 10, 11, 13, 16, 18, 19, 22 and 27 did not have the time of disposition decision documented by the physician on the clinical record.

Patient # 9, and 27 did not have the date of the disposition documented by the physician on the clinical record.

Patient # 1, 3, 8, 9, 10, 15, 16, 17, 18, 19, 21 and 22 did not have the time of the initial orders documented on the clinical record by the physician.

The findings included:

(A) Review of the clinical records for Patient # 4, 13,16, 18, and 27 revealed no documentation of the time of the patient's disposition decision at discharge on the physician's physical assessment emergency room record. On the second page of the documents, under the heading "DISPOSITION: Disposition Decision Time" there was no documentation of the time of the disposition decision.

For Patient # 9 and 27, on the second page of the physician's physical assessment emergency room record, at the bottom left of the document was an area for the physician's signature and a box containing "Disposition time and Disposition Date". There was no documentation of the date of disposition for Patient #9 and #27.

The clinical records for Patient #'s 9, 16, 17, 18, and 21 evidenced on the physicians "Order Sheet" in the bottom left area for "Time of Initial Orders", no time documented on the clinical record.

(B) Review of the clinical records for Patients # 3, 8, 10, 11, 19, and 22 revealed that on page 2 of the physician's physical assessment, under the heading "DISPOSITION: Disposition Decision Time" there was no documentation of the time of the disposition decision.

Review of the clinical records for Patients # 1, 10, revealed no documentation of the time of disposition on page 1 of 1 on the Medical Screening Exam under the heading "DISPOSITION: Disposition Decision Time".

For Patient # 8, on the second page of the physician's physical assessment emergency room record, at the bottom left of the document was an area for the physician's signature and a box containing "Disposition time and Disposition Date". There was no documentation of the date of disposition for Patient # 8.

Review of the clinical record for Patient #10 revealed that on page 1 of 1 of the Medical screening Exam under the heading "DISPOSITION:" there was no documentation as to the time that Patient #10 was discharged.

Review of the clinical record for Patient # 19 revealed that on the second page of the physician's assessment emergency room record under the heading "DISPOSITION: Disposition Decision Time" there was documentation by the physician that Patient # 19 was discharged home and also that a transfer form was completed. Documentation in Patient # 19's record was that he/she was transferred from the emergency room to another hospital.

On 8/19/14 at 12:50 p.m., the surveyors discussed the findings with Staff # 7. Staff #7 stated that when the audits are done of the medical records, the physicians are reminded to sign and complete their charts. "We are developing a better auditing tool that meets the standards and is not repetitive, also that will include the electronic record and issues with that..."

On 8/19/14 at 3:40 p.m., and again on 8/20/14 at 12:15 p.m., the survey team discussed the findings with the facility Administrative staff.