HospitalInspections.org

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure that patient records were completed within 30 days following discharge for 57 of 98 applicable medical records reviewed (MR41, MR42, MR43, MR44, MR45, MR46, MR47, MR48, MR49, MR50, MR51, MR52, MR53, MR54, MR55, MR56, MR57, MR58, MR59, MR60, MR61, MR62, MR63, MR64, MR65, MR66, MR67, MR68, MR69, MR70, MR71, MR72, MR73, MR74, MR75, MR76, MR77, MR78, MR79, MR80, MR81, MR82, MR83, MR84, MR85, MR86, MR87, MR88, MR89, MR90, MR91, MR92, MR93, MR94, MR95, MR96, MR97 and MR98).

Findings include:

Review on November 8, 2011, of the facility's "GMC Rules and Regulations For Use of the Medical Record," last reviewed September 7, 2011, revealed "... VII. Delinquent Medical Records - Completion of the medical record is the responsibility of the attending physician and must be done promptly at the time of discharge but in any event must be completed within 30 days of discharge. Failure of the staff physician to complete a medical record 30 days following discharge, in the absence of extenuating circumstances, may lead to suspension of privileges. Resident and mid-level providers are to complete electronic signatures within 10 days of discharge/service. The electronic signature may be considered delinquent if not completed by that time. The Health Information Management Department will generate physician-specific, distribution by age, post-discharge reports of the number of incomplete medical records. ..."

Review on November 8, 2011, of the facility's "Professional Bylaws of the Medical Staff of Geisinger Medical Center," effective March 2011, revealed "... 3.3 Basic Responsibilities Each members shall ... 3.3-5 Prepare and complete accurately, timely and legibly, and as otherwise required by these Bylaws and Rules and Regulations and Medical Center Policies, the medical and other required records for all patients the Member admits or in any way provides care to in the Medical Center. ..."

1) Review on November 8, 2011, of the facility provided "Allocation Report - Detailed Report" identified by the facility as the medical record delinquent report, dated Tuesday, November 8, 2011, revealed OTH1 had 12 delinquent medical records that were greater than 30 days from the patient's date of discharge. OTH1's delinquent medical record list included the following: MR41 was discharged on September 13, 2011; MR42 was discharged on September 27, 2911; MR43 was discharged on July 25, 2011; MR44 was discharged on August 29, 2011; MR45 was discharged on September 9 , 2011; MR46 was discharged on July 31, 2011; MR47 was discharged October 5, 2011; MR48 was discharged on July 29, 2011; MR49 and MR50 were discharged on August 5, 2011; MR51 was discharged on August 30, 2011; and MR52 was discharged on July 1, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:00 PM confirmed that OTH1 did not complete MR41, MR42, MR43, MR44, MR45, MR46, MR47, MR48, MR49, MR50, MR51 and MR52's within 30 days of discharge and that these patients' medical records were considered delinquent medical records.

2) Review on November 8, 2011, of the facility's delinquent medical record list revealed that OTH2 had two delinquent medical records that were greater than 30 days from the patients' date of discharge. OTH2's delinquent medical records include the following: MR53 was discharged on September 8, 2011, and MR54 was discharged on August 12, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:00 PM confirmed that OTH2 did not complete MR53 and MR54 within 30 days of discharge and that these patients' medical records were considered delinquent medical records.

3) Review on November 8, 2011, of the facility's delinquent medical record list revealed that OTH3 did not complete MR55's medical record within 30 days from this patient's date of discharge. MR55 was discharged on July 3, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:00 PM confirmed that OTH3 did not complete MR55's medical record within 30 days of discharge and that this patient's medical record was considered a delinquent medical record.

4) Review on November 8, 2011, of the facility's delinquent medical record list revealed that OTH4 did not complete MR56's medical record within 30 days from this patient's date of discharge. MR56 was discharged on October 1, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:05 PM confirmed that OTH4 did not complete MR56's medical record within 30 days of discharge and that this patient's medical record was considered a delinquent medical record.

5) Review on November 8, 2011, of the facility's delinquent medical record list revealed that OTH5 did not complete MR57's medical record within 30 days from this patient's date of discharge. MR57 was discharged on September 4, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:05 PM confirmed that OTH5 did not complete MR57's medical record within 30 days of discharge and that this patient's medical record was considered a delinquent medical record.

6) Review on November 8, 2011, of the facility's delinquent medical record list revealed that OTH6 had three delinquent medical records that were greater than 30 days from the patients' date of discharge. OTH6's delinquent medical records include the following: MR58 and MR59 were discharged on October 5, 2011, and MR60 was discharged on October 6, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:05 PM confirmed that OTH6 did not complete MR58, MR59 and MR60's medical records within 30 days of discharge and that these patients' medical records were considered delinquent medical records.

7) Review on November 8, 2011, of the facility's delinquent medical record list revealed that OTH7 had two delinquent medical records that were greater than 30 days from the patients' date of discharge. OTH7's delinquent medical records include the following: MR61 was discharged on October 6, 2011, and MR62 was discharged on October 9, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:05 PM confirmed that OTH7 did not complete MR61 and MR62's medical records within 30 days of discharge and that these patients' medical records were considered delinquent medical records.

8) Review on November 8, 2011, of the facility's delinquent medical record list revealed that OTH8 did not complete MR63's medical record within 30 days from this patient's date of discharge. MR63 was discharged on September 27, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:10 PM confirmed that OTH8 did not complete MR63's medical record within 30 days of discharge and that this patient's medical record was considered a delinquent medical record.

9) Review on November 8, 2011, of the facility's delinquent medical record list revealed that OTH9 had two delinquent medical records that were greater than 30 days from the patients' date of discharge. OTH9's delinquent medical records include the following: MR64 was discharged on October 4, 2011, and MR65 was discharged on October 3, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:10 PM confirmed that OTH9 did not complete MR64 and MR65's medical records within 30 days of discharge and that these patients' medical records were considered delinquent medical records.

10) Review on November 8, 2011, of the facility's delinquent medical record list revealed that OTH10 had three delinquent medical records that were greater than 30 days from the patients' date of discharge. OTH10's delinquent medical records include the following: MR66 and MR67 were discharged on October 6, 2011, and MR68 was discharged on September 10, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:10 PM confirmed that OTH10 did not complete MR66, MR67 and MR69's medical records within 30 days of discharge and that these patients' medical records were considered delinquent medical records.

11) Review on November 8, 2011, of the facility's delinquent medical record list revealed that OTH11 did not complete MR69's medical record within 30 days from this patient's date of discharge. MR69 was discharged on September 7, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:10 PM confirmed that OTH11 did not complete MR69's medical record within 30 days of discharge and that this patient's medical record was considered delinquent medical records.

12) Review on November 8, 2011, of the facility's delinquent medical record list revealed that OTH12 had two delinquent medical records that were greater than 30 days from the patients' date of discharge. OTH12's delinquent medical records include the following: MR70 was discharged on September 27, 2011, and MR71 was discharged on September 28, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:10 PM confirmed that OTH12 did not complete MR70 and MR71's medical records within 30 days of discharge and that these patients' medical records were considered delinquent medical records.

13) Review on November 8, 2011, of the facility's delinquent medical record list revealed that OTH13 had two delinquent medical records that were greater than 30 days from the patients' date of discharge. OTH13's delinquent medical records include the following: MR72 was discharged on September 27, 2011, and MR73 was discharged on October 7, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:10 PM confirmed that OTH13 did not complete MR72 and MR73's medical records within 30 days of discharge and that these patients' medical records were considered delinquent medical records.

14) Review on November 8, 2011, of the facility's delinquent medical record list revealed that OTH14 had two delinquent medical records that were greater than 30 days from the patients' date of discharge. OTH14's delinquent medical records include the following: MR74 was discharged on September 27, 2011, and MR75 was discharged on September 28, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:10 PM confirmed that OTH14 did not complete MR74 and MR75's medical records within 30 days of discharge and that these patients' medical records were considered delinquent medical records.

15) Review on November 8, 2011, of the facility's delinquent medical record list revealed that OTH15 did not complete MR76's medical record within 30 days from this patient's date of discharge. MR76 was discharged on October 9, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:10 PM confirmed that OTH15 did not complete MR76's medical record within 30 days of discharge and that this patient's medical record was considered a delinquent medical record.

16) Review on November 8, 2011, of the facility's delinquent medical record list revealed that OTH16 did not complete MR77's medical record within 30 days from this patient's date of discharge. MR77 was discharged on October 8, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:10 PM confirmed that OTH16 did not complete MR77's medical record within 30 days of discharge and that this patient's medical record was considered a delinquent medical record.

17) Review on November 8, 2011, of the facility's delinquent medical record list revealed that OTH17 did not complete MR78's medical record within 30 days from this patient's date of discharge. MR78 was discharged on September 28, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:10 PM confirmed that OTH17 did not complete MR78's medical record within 30 days of discharge and that this patient's medical record was considered a delinquent medical record.

18) Review on November 8, 2011, of the facility's delinquent medical record list revealed that OTH18 did not complete MR79's medical record within 30 days from this patient's date of discharge. MR79 was discharged on August 24, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:10 PM confirmed that OTH18 did not complete MR79's medical record within 30 days of discharge and that this patient's medical record was considered a delinquent medical record.

19) Review on November 8, 2011, of the facility's delinquent medical record list revealed that OTH19 did not complete MR80's medical record within 30 days from this patient's date of discharge. MR80 was discharged on October 8, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:15 PM confirmed that OTH19 did not complete MR80's medical record within 30 days of discharge and that this patient's medical record was considered a delinquent medical record.

20) Review on November 8, 2011, of the facility's delinquent medical record list revealed that OTH20 did not complete MR81's medical record within 30 days from this patient's date of discharge. MR81 was discharged on October 1, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:15 PM confirmed that OTH20 did not complete MR81's medical record within 30 days of discharge and that this patient's medical record was considered a delinquent medical record.

21) Review on November 8, 2011, of the facility's delinquent medical record list revealed that OTH21 had six delinquent medical records that were greater than 30 days from the patients' date of discharge. OTH20's delinquent medical records include the following: MR82 was discharged on October 5, 2011; MR83 was discharged on September 7, 2100; MR84 was discharged on September 9, 2011; MR85 was discharged on September 5, 2011; MR86 was discharged on September 2, 2011, and MR87 was discharged on September 4, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:15 PM confirmed that OTH21 did not complete MR86, MR84, MR85, MR86 and MR87's medical records within 30 days of discharge and that these patients' medical records were considered delinquent medical records.

22) Review on November 8, 2011, of the facility's delinquent medical record list revealed that OTH22 did not complete MR88's medical record within 30 days from this patient's date of discharge. MR88 was discharged on October 7, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:15 PM confirmed that OTH22 did not complete MR88's medical record within 30 days of discharge and that this patient's medical record was considered a delinquent medical record.

23) Review on November 8, 2011, of the facility's delinquent medical record list revealed that OTH23 did not complete MR89's medical record within 30 days from this patient's date of discharge. MR89 was discharged on October 1, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:20 PM confirmed that OTH23 did not complete MR89's medical record within 30 days of discharge and that this patient's medical record was considered a delinquent medical record.

24) Review on November 8, 2011, of the facility's delinquent medical record list revealed that OTH24 had two delinquent medical records that were greater than 30 days from the patients' date of discharge. OTH24's delinquent medical records include the following: MR90 was discharged on October 3, 2011, and MR91 was discharged on October 4, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:20 PM confirmed that OTH24 did not complete MR90 and MR91's medical records within 30 days of discharge and that these patients' medical records were considered delinquent medical records.

25) Review on November 8, 2011, of the facility's delinquent medical record list revealed that OTH25 had three delinquent medical records that were greater than 30 days from the patients' date of discharge. OTH25's delinquent medical records include the following: MR92 was discharged on August 28, 2011; MR93 was discharged on September 10, 2011, and MR94 was discharged on October 4, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:20 PM confirmed that OTH25 did not complete MR92, MR93 and MR94's medical records within 30 days of discharge and that these patients' medical records were considered delinquent medical records.

26) Review on November 8, 2011, of the facility's delinquent medical record list revealed that OTH26 had two delinquent medical records that were greater than 30 days from the patients' date of discharge. OTH26's delinquent medical records include the following: MR95 and MR96 were discharged on October 6, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:20 PM confirmed that OTH26 did not complete MR95 and MR96's medical records within 30 days of discharge and that these patients' medical records were considered delinquent medical records.

27) Review on November 8, 2011, of the facility's delinquent medical record list revealed that OTH27 had two delinquent medical records that were greater than 30 days from the patients' date of discharge. OTH27's delinquent medical records include the following: MR97 was discharged on October 5, 2011, and MR98 was discharged on September 26, 2011.

Interview with EMP7 on November 8, 2011, at approximately 3:20 PM confirmed that OTH27 did not complete MR97 and MR98's medical records within 30 days of discharge and that these patients' medical records were considered delinquent medical records.

Interview with EMP1, EMP2, EMP6 and EMP7 on November 9, 2011, at approximately 10:30 AM confirmed that OTH1, OTH2, OTH3, OTH4, OTH5, OTH6, OTH7, OTH8, OTH9, OTH10, OTH11, OTH12, OTH13, OTH14, OTH15, OTH16, OTH17, OTH18, OTH19, OTH20, OTH21, OTH22, OTH23, OTH24, OTH25, OTH26, OTH27 and OTH27 had medical records that were not completed within 30 days of the patients' discharge date. Further interview with EMP1, EMP2, EMP6 and EMP7 revealed that the medical records department compiles a list of delinquent medical records for review at the Medical Executive Committee and that the department chairs attending this meeting were responsible for following up with the specific physician or physicians who have delinquent medical records.

Based on review of facility documents, observation and staff interview (EMP), it was determined that staff working in the facility laboratory areas failed to ensure that personal clothing was protected when working with potentially contaminated blood and body fluids.

Findings include:

Review on November 9, 2011, of the facility's "Laboratory Safety Infection Control" policy, last reviewed May 2, 2011, revealed "... Policy: Defines infection prevention and control practices that pertain to all lab sections that ensure the safety of patients and employees by minimizing the risk of acquisition and transmission of infections. ... Complies with regulatory and accreditation requirements to prevent and control infections related to laboratory services. I. Standard Precautions A. All blood, body fluids, or other potentially infectious materials are considered infectious regardless of possible disease status of the source individual. B. Standardized practices are followed to prevent contact with blood, body fluids, or other potentially infectious materials. ... II. Engineering Controls - Engineering controls isolate or remove the bloodborne pathogen from the workplace. Appropriate barrier precautions should be taken to prevent exposure to blood and body fluids and other potentially infectious materials from any patient. ... IV. Personal Protective Equipment - Personal Protective Equipment (PPE) refers to clothing or equipment worn by employees for protection against a hazard. ... A. Employees must use personal protective equipment such as lab coats ... or similar outer garments as appropriate based on the anticipated exposure to blood or other potentially infectious materials. ... B. The PPE should not permit blood or potentially infectious materials to pass through or reach the employee's clothing ... under normal conditions of use and for the duration of time which the PPE will be used. ..."

Observation on November 9, 2011, at approximately 10:00 AM revealed EMP8, EMP9, EMP10 EMP11, EMP12 and EMP13 working in areas of the facility laboratory with potentially contaminated blood and body fluids. Further observation revealed these employees did not have their laboratory coats buttoned to protect their clothing.

Interview with EMP3, EMP4, EMP5 on November 9, 2011, at approximately 10:45 AM confirmed that EMP8, EMP9, EMP10 EMP11, EMP12 and EMP13 were working in areas of the facility laboratory with potentially contaminated blood and body fluids and these employees did not have their laboratory coats buttoned to protect their clothing.