HospitalInspections.org

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Based on document review, Medical Record review and staff interview, in one (1) out of ten (10) Medical Records, the facility failed to ensure that the patient's Medical Records consistently and accurately documented the care provided to a patient. Specifically, the Post-Operative Report incorrectly documented the patient's condition at the end of surgery.

The lack of accurate Medical Record documentation may place patients at risk for adverse outcomes.

Findings:

Review of Patient #1's Medical Record identified the following information: The patient is a 74-year-old male admitted on 07/03/17 with acute congestive heart failure and renal failure. The Medical Record documents at 2:52PM on 07/08/17 that the patient had bilateral ureteral obstruction and that the patient's last option was cystourethroscopy with ureteral stent placement as a peri-renal hematoma precluded nephrostomy placement in intervention radiology.

The Post-Operative Report dictated by the Physician at 2:21PM on 07/08/17 documents that the patient underwent a cystourethroscopy (a procedure allowing viewing the urinary tract, particularly the bladder, the urethra, and the openings to the ureters) with bilateral stent placement. The report describes the procedure and finding then incorrectly states "urinary catheter [was] placed and the patient was sent to recovery in good condition".

The brief Operative Note signed by the Physician at 2:47PM on 07/08/17 documents that the "patient coded while recovering in the OR post procedure and Foley [urinary catheter] placement".

Review of the "Code Blue Flow Sheet" dated 07/08/17 and timed at 2:20PM documents that resuscitation was started in Operating Room #5 at 2:20PM and the efforts [were] terminated at 3:02PM. The outcome documents [the patient] was dead. The is no documentation indicating the patient was moved out of the Operating Room.

Review of the "Adult Critical Care Attending Progress Note" dated 07/08/17 and signed by the Critical Care Physician at 5:30PM documents "called Code Blue in the operating room [at] approximately 2:25PM. On arrival CPR (Cardio-Pulmonary Resuscitation) per ACLS (Advanced Cardiac Life Support) protocol in progress. The Note documents the measures taken during the resuscitation then states the "patient pronounced" at 3:02PM on 07/08/17. There is no indication that the patient left the OR.

The facility "Medical Staff Bylaws" and "Physician Responsibilities Related to Medical Record Documentation..." dated 09/27/16 contains the following statements: "the content of the medical record shall be pertinent, accurate, legible timely and current. It shall include ... (h) special reports when applicable, such as operative [reports]". ... "[The} Operative and Special Procedure reports must contain ... a detailed account of the findings, technical procedures used, ..." and ... "post-operative diagnosis".

Per interview with Staff H on the morning of 01/23/18, the staff member responded that the Operative Report was dictated in the Operating Room, after placement of the stents before there was a change in the patient's condition.