HospitalInspections.org

Based on review of medical records, review of information provided and interviews with key staff on June 7, 2013, it was determined that the facility failed to ensure that medical records were complete and all documentation was readily accessible.

Findings include:

1. During an intake interview with the complainant on June 6, 2013, she stated that she had tried and tried to get the results of tests that her mother had. She was concerned because her mother was not feeling well.

2. During a review of Patient A's medical record on June 7, 2013, there was no documentation of the EKG [electrocardiogram] portion of the stress test that was completed May 22, 2013.

3. During an interview with the Chief Nursing Officer on June 7, 2013, at approximately 10:15 a.m. , she stated that she found the missing report of the EKG portion of the stress test in the Radiology folder rather than in the Respiratory folder. She further stated that there was no one who could explain how the report got to the wrong place. Additionally, she stated that a RCA [root cause analysis] needed to be done to coordinate all the steps that occur between Radiology and Respiratory from the moment of the order to the final report to the provider and scanned into the electronic medical record [CPSI].

4. During a telephone interview with Physician A on June 7, 2013, at approximately 11:30 a.m., he stated that he knew the report of the EKG portion of the stress test was somewhere. He stated that he called Radiology and asked if someone could find it and they did. He stated that he reviewed the results with Patient A and the family member. He further stated that he didn't knew where the report went once he reviewed it.

5. The Chief Nursing Officer and the Chief Executive Officer confirmed on June 7, 2013, at approximately 3:30 p.m., that Patient A's medical record was not complete and the test results were not readily accessible.