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Based on interview and record review, the hospital failed to ensure one of one sampled Certified Physician Assistant (PA-C) 1 followed the hospital's approved Policy and Procedure (P&P) titled, "Documentation, Corrections, Edit Functionality in the Electronic Health Record" for documenting the condition and care of 12 of 12 sampled patients (Patient 20, Patient 10, Patient 16, Patient 17, Patient 18, Patient 19, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25 and Patient 26) at the time of care. This failure had the potential to affect patients' continuity of care, due to incomplete, and inaccurate information for subsequent emergency department (ED) visits resulting in negative patient outcomes.




Findings:

During a concurrent interview and record review on 5/1/24 at 2:25 p.m. with Quality Patient Safety Program Manager (QPSPM) 1, Patient 20's electronic medical records (EMR) were reviewed. Patient 5's registration document (RD) dated 4/30/24 was reviewed. The RD indicated Patient 20 arrived at the ED on 4/30/24 at 8:52 a.m. and discharged on 4/30/24. Patient 20's "Orders" dated 4/30/24 were reviewed. The "Orders" indicated PA-C 1 entered discharge orders on 4/30/24 at 11:53 a.m. Patient 20's "ED check out" dated 4/30/24 was reviewed. The "ED check out" indicated Order start Date/Time 4/30/24 12:20 p.m. QMPS was unable to provide documentation by a health care provider for Patient 20's 4/30/24 ED encounter. QPMS stated, the PA-C 1 was the health care provider for Patient 20's ED visit on 4/30/24 and PA-C 1 should have documented the care provided in the EMR.

Patient 10's registration document (RD) dated 4/30/24 was reviewed. The RD indicated Patient 10 arrived at the ED on 4/30/24 at 8:13 a.m. and discharged on 4/30/24 at 10:59 a.m. Patient 10's "EDN" dated 4/30/24 (date of ED visit) was reviewed. The EDN indicated Patient 10's chief complaint was cough, congestion, and fever which started "yesterday 4/30/24 8:30 a.m." The EDN indicated PA-C 1 documented Patient 10's patient's condition and the care provided during the 4/30/24 ED encounter on 5/1/24 at 4:13 p.m. (29 hours 14 minutes after discharge)

Patient 16's registration document (RD) dated 4/30/24 was reviewed. The RD indicated Patient 16 arrived at the ED on 4/30/24 at 8:06 a.m. and discharged on 4/30/24 at 10:58 a.m. Patient 16's "EDN" dated 4/30/24 (date of ED visit) was reviewed. The EDN indicated Patient 16's chief complaint was cough, pulling at ears, wheezing. The EDN indicated PA-C 1 documented Patient 16's patient's condition and the care provided during the 4/30/24 ED encounter on 5/1/24 at 4:07 p.m. (29 hours 8 minutes after discharge)

Patient 17's registration document (RD) dated 4/30/24 was reviewed. The RD indicated Patient 17 arrived at the ED on 4/30/24 at 8:22 a.m. and discharged on 4/30/24 at 11:18 a.m. Patient 17's "EDN" dated 4/30/24 (date of ED visit) was reviewed. The EDN indicated Patient 17's chief complaint was shortness of breath. The EDN indicated PA-C 1 documented Patient 17's patient's condition and the care provided during the 4/30/24 ED encounter on 5/1/24 at 4:17 p.m. (28 hours 59 minutes after discharge)

Patient 18's registration document (RD) dated 4/30/24 was reviewed. The RD indicated Patient 18 arrived at the ED on 4/30/24 at 8:24 a.m. and discharged on 4/30/24. Patient 18's "Orders" dated 4/30/24 were reviewed. Patient 18's orders indicated, "ED check out" 4/30/24 9:24 a.m. Patient 18's "EDN" dated 4/30/24 (date of ED visit) was reviewed. The EDN indicated Patient 18's chief complaint indicated Patient 18 came to the ED for scalp suture removal. The EDN indicated PA-C 1 documented Patient 18's patient's condition and the care provided during the 4/30/24 ED encounter on 5/1/24 at 4:05 p.m. (30 hours 41 minutes after discharge)

During an interview with on 5/2/24 at 10:15 a.m. with PA-C 1 and Medical Director of Emergency Services (MDEDS), MDEDS, stated all patient seen in the ED should have, at the minimum, the medical screening examination (MSE - assessment to determine if the individual has an Emergency Medical Condition) documented in "real time" by the health care provider. MDEDS stated "something" should be entered into the patient's EMR to provide information as to what happened during the visit, the care given, the plan, in the event the patient returns for care before the medical provider has documented the prior visit. MDEDS stated it is not a "best practice" to take up to 48 hours to document in the EMR.

During a concurrent interview and record review on 5/2/24 at 10:30 a.m. with QPSPM 1 the following patient's electronic medical records (EMR) were reviewed.

Patient 19's registration document (RD) dated 4/30/24 was reviewed. The RD indicated Patient 19 arrived at the ED on 4/30/24 at 8:27 a.m. and discharged on 4/30/24 at 10:24 a.m. Patient 19's "EDN" dated 4/30/24 (date of ED visit) was reviewed. The EDN indicated Patient 19's chief complaint was left eye pain. The EDN indicated PA-C 1 documented Patient 19's patient's condition and the care provided during the 4/30/24 ED encounter on 5/1/24 at 4:05 p.m. (29 hours 41 minutes after discharge)


Patient 20's registration document (RD) dated 4/30/24 was reviewed. The RD indicated Patient 20 arrived at the ED on 4/30/24 at 8:52 a.m. and discharged on 4/30/24 at 12:21 p.m. Patient 20's "EDN" dated 4/30/24 (date of ED visit) was reviewed. The EDN indicated Patient 20's chief complaint was abdominal pain. The EDN indicated PA-C 1 documented Patient 20's patient's condition and the care provided during the 4/30/24 ED encounter on 5/1/24 at 4:44 p.m. (28 hours 13 minutes after discharge)

Patient 21's registration document (RD) dated 4/30/24 was reviewed. The RD indicated Patient 21 arrived to the 4/30/24 at 9:44 a.m. and discharged on 4/30/24 at 12:10 p.m. Patient 21's "EDN" dated 4/30/24 (date of ED visit) was reviewed. The EDN indicated Patient 21's chief complaint was cough, shortness of breath and asthma (lung condition which causes difficulty breathing). The EDN indicated PA-C 1 documented Patient 21's patient's condition and the care provided during the 4/30/24 ED encounter on 5/1/24 at 5:05 p.m. (28 hours 59 minutes after discharge)


Patient 22's registration document (RD) dated 4/30/24 was reviewed. The RD indicated Patient 22 arrived at the ED on 4/30/24 at 10:21 a.m. and discharged on 4/30/24. Patient 22's "Orders" dated 4/30/24 were reviewed. Patient 22's orders indicated, "ED check out" 4/30/24 3:22 p.m. Patient 22's "EDN" dated 4/30/24 (date of ED visit) was reviewed. The EDN indicated Patient 22's chief complaint was epigastric pain. The EDN indicated PA-C 1 documented Patient 22's patient's condition and the care provided during the 4/30/24 ED encounter on 5/1/24 at 5:09 p.m. (25 hours 47 minutes after discharge)


Patient 23's registration document (RD) dated 4/30/24 was reviewed. The RD indicated Patient 23 arrived at the ED on 4/30/24 at 11:33 a.m. and discharged on 4/30/24. Patient 23's "Orders" dated 4/30/24 were reviewed. Patient 23's orders indicated, "ED check out" 4/30/24 3:01 p.m. Patient 23's "EDN" dated 4/30/24 (date of ED visit) was reviewed. The EDN indicated Patient 23's chief complaint was back pain. The EDN indicated PA-C 1 documented Patient 23's patient's condition and the care provided during the 4/30/24 ED encounter on 5/1/24 at 5:07 p.m. (27 hours after discharge)

Patient 24's registration document (RD) dated 4/30/24 was reviewed. The RD indicated Patient 24 arrived at the ED on 4/30/24 at 12:19 p.m. and discharged on 4/30/24. Patient 24's "Orders" dated 4/30/24 were reviewed. Patient 24's orders indicated, "ED check out" 4/30/24 4:24 p.m. Patient 24's "EDN" dated 4/30/24 (date of ED visit) was reviewed. The EDN indicated Patient 24's chief complaint was nausea and vomiting. The EDN indicated PA-C 1 documented Patient 24's patient's condition and the care provided during the 4/30/24 ED encounter on 5/1/24 at 5:07 p.m. (24 hours after discharge)

Patient 25's registration document (RD) dated 4/30/24 was reviewed. The RD indicated Patient 25 arrived at the ED on 4/30/24 at 12:40 p.m. and discharged on 4/30/24. Patient 25's "Orders" dated 4/30/24 were reviewed. Patient 25's orders indicated, "ED check out" 4/30/24 3:28 p.m. Patient 25's "EDN" dated 4/30/24 (date of ED visit) was reviewed. The EDN indicated Patient 25's chief complaint was fever. The EDN indicated PA-C 1 documented Patient 25's patient's condition and the care provided during the 4/30/24 ED encounter on 5/1/24 at 5:03 p.m.

Patient 26's registration document (RD) dated 4/30/24 was reviewed. The RD indicated Patient 26 arrived at the ED on 4/30/24 at 12:42 p.m. and discharged on 4/30/24. Patient 26's "Orders" dated 4/30/24 were reviewed. Patient 26's orders indicated, "ED check out" 4/30/24 3:36 p.m. Patient 26's "EDN" dated 4/30/24 (date of ED visit) was reviewed. The EDN indicated Patient 26's chief complaint was vomiting and diarrhea. The EDN indicated PA-C 1 documented Patient 26's patient's condition and the care provided during the 4/30/24 ED encounter on 5/1/24 at 7:28 p.m. (almost 28 hours after discharge)

During a review of the facility's "Rules and Regulations of the Medical Staff [R&R]," dated 12/2023, the R&R indicated, "The attending physician shall maintain the primary responsibility for the discharge of the patient. At the time of discharge, the attending physician shall see that the record is complete, state his final diagnosis and sign the record."

During a review of the facility's Policy and Procedures (P&P) titled, "Documentation, Corrections, Edit Functionality in the Electronic Health Record," dated 8/8/23, the P&P indicated, "PURPOSE The purpose of this Standard is to establish parameters. . .and to address the accuracy, timeliness and correction of documentation errors. . .STANDARD. . .The health record shall. . .facilitate the continuity of patient care. Documentation must be accurate, timely, objective, and concise.

Based on interview and record review, the hospital failed to one of one sampled Certified Physician Assistant (PA-C) 1 protected and ensured the confidentiality for 12 of 12 sampled patient's (Patient 20, Patient 10, Patient 16, Patient 17, Patient 18, Patient 19, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25 and Patient 26) protected healthcare information (PHI). This failure had to potential for loss of patients' medical records and unauthorized access to Patients protected healthcare information (PHI).

Findings:

During a concurrent interview and record review on 5/1/24 at 2:25 p.m. with Quality Patient Safety Program Manager (QPSPM) 1, Patient 20's electronic medical records (EMR) were reviewed. Patient 5's registration document (RD) dated 4/30/24 was reviewed. The RD indicated Patient 20 arrived at the ED on 4/30/24 at 8:52 a.m. and discharged on 4/30/24. Patient 20's "Orders" dated 4/30/24 were reviewed. The "Orders" indicated PA-C 1 entered discharge orders on 4/30/24 at 11:53 a.m. Patient 20's "ED check out" dated 4/30/24 was reviewed. The "ED check out" indicated Order start Date/Time 4/30/24 12:20 p.m. QMPS was unable to provide documentation by a health care provider for Patient 20's 4/30/24 ED encounter. QPMS stated, the PA-C 1 was the health care provider for Patient 20's ED visit on 4/30/24 and PA-C 1 should have documented the care provided in the EMR.

During a concurrent interview and record review on 5/1/24 at 2:50 p.m. with Quality Patient Safety and Program Manager (QPSPM) and Physician Assistant - Certified (PA-C) 1. Patient 20's electronic medical record (EMR) was reviewed. PA-C 1 was unable to provide documentation by a medical provider in Patient 20's emergency room (ED) EMR on 4/30/24. PA-C 1 stated she did not document any provider notes in the EMR regarding Patient 20's ED visit on 4/30/24. PA-C 1 stated she kept handwritten notes in her pocket on all the patients she saw during her shift on 4/30/24. PA-C 1 stated she took the handwritten papers home, with PHI, from most patient's ED encounters, and would refer to the notes when she documented in the patients' EMR as a late entry (documentation within the health record entered after the point of care).

During an interview with on 5/2/24 at 9:25 a.m. with PA-C 1 and Medical Director of Emergency services (MDEDS), PA-C 1 stated she wrote notes on each patient on a "sheet of computer paper" during her 4/30/24 ED shift. PA-C 1 stated the Patient's name, chief complaint, care provided, physical examination and other pertinent information from the ED visit was written on the paper. PA-C 1 stated the papers with the patient PHI were placed in her backpack and taken home. PA-C 1 stated the only other person in the home is PA-C 1's significant other. PA-C 1 stated she did not know or ask what the process was to transport and store PHI.

During a review of the facility's Policy and Procedures (P&P) titled, "Privacy Safeguards for Protected Health Information," dated 6/1/21, the P&P indicated, "Examples of appropriate Privacy Rule safeguards for PHI [Protected Health information] include (but not limited to) the following: Access and Storage Maintain paper PHI in areas that are not accessible to unauthorized individuals. This includes securing paper PHI in locked cabinets, bins, etc., and ensuring physical access to rooms containing cabinets, bins, etc., is restricted from the general public.

During a review of the facility's "Rules and Regulations of the Medical Staff [R&R]," dated 12/2023, the R&R indicated, All records are the property of the hospital and shall not be removed from the hospital except upon a court order, subpoena, or statute. In case of readmission of a patient, all previous records shall be available for the use of the attending physician.