HospitalInspections.org

Based on record reviews and interviews with hospital staff, the hospital does not ensure that medical records are complete, retained, and properly filed for prompt retrieval.

Findings:

1. On the morning of 7/2/2012, administrative staff told the surveyors that all patient medical records were maintained on computer/electronic medical records. In the afternoon, surveyors were provided hard copy closed medical records. Review of the medical records indicated the hard copy documents did not include physician orders for treatment, date and time of procedures, physician/mid-level authentication. On the afternoon of 7/2/2012 Staff E told surveyors the charts provided to surveyors in the morning were the same records that would be provided to patients requesting a copy of their complete medical record.

2. On the afternoon of 7/2/2012 and the morning of 7/3/2012, surveyors reviewed medical records policies. There was no policy indicating what a complete medical record included. On the morning of 7/3/2012 Staff E provided surveyors a hard copy "Training Workflow: Release of Information Printing Cheat Sheet", and stated the document was the policy on complete medical records. There document was not on the intranet with the other policies. There was no documentation this document is a policy. The policy does not match the form and content of the other policies. There is no header with policy name, date written, date revised, date reviewed and approved.

3. On the morning of 7/3/2012 surveyors reviewed medical records policy and procedures. According to Staff B and D the physician emergency documentation is completed in a separate electronic system and is merged into the patient emergency room record. There was no policies, procedures, or processes in the medical records policies stipulating the physician utilized a separate system and how the information could be retrieved. . The policy and procedures do not reflect all the current electronic medical records practice.

4. The facility did not have policy and procedures addressing all components of the electronic documentation in outpatient and inpatient medical records.

5. The above findings were reviewed with administration at the exit conference. No further documentation was provided.

Based on a review of medical records and interviews with hospital staff, the hospital failed the ensure the medical records were complete and contained all pertinent information such as complete nursing assessments, reports of treatments, and documentation of care provided.

Findings:

1. On 7/2 and 7/3/2012 surveyors reviewed seven emergency room records. Seven of seven (Pt#1,2,3,4,5.6.7) records did not contain dated, timed, and authenticated physician orders. This finding was confirmed with staff E

2. Patient #1's medical record stipulated in the physician assistant documentation "(patient miscarried in WR bathroom and fetus sent to pathology)". There was no documentation of the incident by personnel assisting the patient. On the morning of 7/3/2012 Staff B confirmed this finding.

3. Patient #1 presented with a chief complaint of threatened miscarriage and vaginal bleeding. Documentation at the time of triage indicates "threatened miscarriage X (times) one day"; vaginal bleeding X 1 hour". There is no documentation to quantify the amount of bleeding. The initial nursing assessment indicates vaginal bleeding with characteristics "continuous; painful" and "pad count 'retired' with the number 3 and in parenthesis "number of pads saturated/hr). There is no other documentation in the medical record regarding amount or pad changes, quantifying the bleeding included in any nursing assessments or triage assessments.. On the morning of 7/3/2012 Staff B told surveyors there was no other documentation by nursing of amount of bleeding.
The ED (emergency department) provider note stipulates "large amount of tissue and clotting removed from the vaginal vault. Os slightly patent with bleeding coming from it." The provider note does not indicate the time of the assessment, the amount of tissue and clotting, and the amount of bleeding.

4. The above findings were reviewed at the exit conference 7/3/2012. No further documentation was provided.

Based on medical record review and interviews with hospital staff, the hospital failed to ensure the emergency services department (ED) required staff to be trained to provide complete triage assessments for patients presenting to the ED with complaints of vaginal bleeding.
Findings:

1. Patients # 1 presented to the ED on 1/6/2012 at 1705 with a complaint of vaginal bleeding and possible miscarriage. Triage documentation at 17:26 does not include vital signs to determine orthostatic hypotension, no documentation of the amount, type of bleeding, or frequency of pad changes. Triage assessment indicates the patients pain level was an "8" "threatened miscarriage X (times) one day"; vaginal bleeding X 1 hour". Triage documentation the patient was classified as "urgent".

According to interviews, hospital documents, and documents received at the Department, patient #1 had a miscarriage in the waiting room bathroom. There is no documentation of this event in the patient's medical record by personnel caring for the patient during the event. This finding was verified with Staff B on 7/3/2012

According to the next documentation in the record an initial nursing assessment was performed at 2000. At that time documentation reflected the patient's pain level was a "7". One set of supine vital signs are documented. There is no documentation of the amount or type of vaginal bleeding. A sanitary pad count indicated "3/retired". The assessment did not include any information regarding the miscarriage in the waiting room bathroom. At 2100 the nurse documents intravenous pain medication was given. Nursing documentation "note time 2118-patient informed of need for pelvic exam....assistance provided to physician." The provider note does not have a date and time the pelvic exam was performed.

2. On 7/2 and 7/3/2012 surveyors reviewed the emergency room log for January 2012. All patient's with a chief complaint of "vaginal bleeding were triaged level 3 "urgent". Staff B told surveyors triage classification was based on the number of resources (intravenous lines, lab, x-ray) utilized by the patients. There was no documentation, policy or procedure differentiating the type and amount of bleeding that indicates a patient has a "life threatening" amount of bleeding or should be triaged to a higher level. There was no policy, procedure or process indicating who or how frequent patient's would be checked on while waiting to be seen. There is no policy, procedure, or process in place to ensure triaged patient's who's conditions deteriorate or change while waiting are reassessed and the information documented to ensure continuity of care.

3. On 7/2/2012 surveyors reviewed the emergency room triage and assessment educational packet. According to Staff B any nursing personnel assigned to the triage position must go through this training. There was no documentation the amount, type, frequency of dressing/pad changes were included in the triage education. These findings were reviewed with administration at the time of the exit and no further documentation was provided.