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SOUTHERN HILLS HOSPITAL AND MEDICAL CENTER
CONTENT OF RECORD: ORDERS,NOTES,REPORTS
Tag No.: A0467
Based on record review and interview, the facility failed to ensure 1 of 32 medical records reviewed (Patient 22) documented a physician order and contained an accompanying lab result for a specimen removed for pathology.
Findings include:
On 12/11/2024, the facility admitted Patient 22 and Patient 21 with rectal polyp for transanal excision of rectal polyp.
On 12/11/2024 at 8:57 AM, informed consent was obtained from Patient 22 for transanal excision of rectal mass via flexible sigmoidoscopy.
On 12/11/2024, Patient 22's operative report revealed a dissection, and excision was completed on the rectal mass, and a low rectal polyp, right posterior specimen was removed. Patient 22's specimen was later mislabeled with Patient 21 when two specimen orders were entered for Patient 21, instead of one for each patient (Patient 21 and 22).
On 5/23/2024 in the morning, Patient 22's medical record lacked documented evidence of a physician order and pathology report for the specimen removed. The Director of Regulatory Compliance indicated the medical record was not corrected because there was no order to remove a specimen.
On 6/10/2025 at 8:30 AM, the Surgeon indicated nursing was supposed to enter the specimen order correctly in order to process the respective specimens. Patients were notified as soon as the surgeon was notified of the specimen mix-up.