HospitalInspections.org

Based on document review, medical record review and interview, the facility failed to ensure medical records were completed for one of fourteen (Patient #4) sampled patients.

The findings included:

1. Review of the facility's "MEDICAL STAFF OF [NAMED FACILITY] RULES AND REGULATIONS" revealed, "...B. DOCUMENTATION OF RECORDS AND TIMING REQUIREMENTS...1. All entries in the medical record must be dated, timed, and authenticated, in written or electronic form, by the person responsible for providing or evaluating the service provided..."

2. Medical record review for Patient #4 revealed an admission date of 3/11/2020 with diagnoses that included Stage 4 Metastatic Colon Cancer, Diabetes, Pulmonary Embolism and High Cholesterol. Review of a 3/14/2020 progress note revealed a physician signature, with no date or time documented.

In an interview on 5/13/2021 at 12:00 PM, Attending Physician #1 verified physician progress notes should be dated, timed and signed as soon as possible, within 24 hours.

Based on document review, medical record review and interview, the hospital failed to ensure operative reports were signed timely for 1 of 14 (Patient #6) sampled patients.

The findings included:

1. Review of the Hospital Medical Staff Rules and Regulations revealed, " ...Operative Reports ...Timing: The Attending Physician of his/her Supervisee must dictate the operative report no later than the end of the surgical day ..."

2. Medical record review for Patient #6 revealed an admission date of 4/26/2021 with diagnoses that included Constipation, Lower Abdominal Pain, and Colon Cancer. Review of an operative report dated 5/10/2021 for Exploratory Laparoscopy, biopsies, sigmoidoscopy, and bowel resection with a colostomy, revealed the surgeon had not signed the operative report.

In an interview on 5/17/2021 at 10:00 AM, the Senior Director of Quality verified the report had not been signed timely.