HospitalInspections.org

Based on interview and record review the Critical Access Hospital (CAH) failed to ensure that medical records were complete and accurately documented for 4 of 7 patients in the applicable sample (Patient #1, Patient #2, Patient #5 and Patient #7). Findings include:

1.) Per record review Patient #1 presented to the Emergency Department (ED) on 4/9/19 with suicidal ideations. S/he was evaluated by the ED physician and transferred to an outside hospital on 4/10/19. Per review of the nursing notes from 4/10/19 at 8:15 AM, a crisis counselor had come to the ED to assess Patient #1. There was no evidence in the medical record that the crisis consult was done. Per interview on 5/21/19 at approximately 11:30 AM with the Director of Quality, s/he confirmed that this information was not in Patient #1's medical record and should have been.

Per review of the policy, Components of Hospital Chart-Emergency Room Record-effective 2/13/18, "The components of a hospital chart for the Emergency Room Record should include the items listed below, "Clara Martin Consultation Notes". (Crisis Center)

2.) Per record review, Patient #2 presented to the ED on 4/19/19 at 11:46 AM with complaints of intermittent chest pain which radiated to the back and shoulders. The EKG heart tracing (electrocardiogram) demonstrated Patient #2 was experiencing a myocardial infarction (MI). After initial treatment and further testing, it was determined that Patient #2 required a higher level of care for further cardiology intervention. The decision was made to transfer Patient #2 to Dartmouth Hitchcock Medical Center (DHMC). Per review of the Transfer Form and Consent it was noted that the document was incomplete. It failed to designate whether the patient consented to transfer or requested transfer; and lacked a date and time of consent. The form also states "Patient unable to sign" and "verbal consent received from patient" however, the person who signed the form does not designate their relationship with the patient or provide a title of a hospital employee. Per interview on 5/21/19 at 11:45 AM, a Chart Analyzer for the Health Information Systems, who reviews medical record documentation for completeness, acknowledged that although the Transfer Form for Patient #2 was incomplete, s/he had considered the record to be complete, failing to recognize necessary components of the Transfer form were left incomplete.

3.) Per record review, Patient #5 presented to the ED on 3/22/19 after being bitten by a dog. The injury sustained involved the patient's right hand and was considered significant enough to require a hand specialist to perform the repair and treatment. As a result, it was determined the patient should be transferred to DHMC for a higher level of care. A transfer was arranged for Patient #5 from the CAH. Review of the Transfer Form and Consent noted a failure to complete necessary components ".... I acknowledge that I have been fully informed of the hospital's obligation under law and the risks involved in the transfer and that I have given my consent to the transfer....". The lack of completeness was noted by the Health Information Systems Manager on 5/21/19 at 11:47 AM.

4.) Per record review Patient #7 presented to the ED on 4/11/19 with back pain. S/he was evaluated by the ED physician; X-rays and a CT scan were done. The patient was diagnosed with an unstable fracture of his/her back. The ED physician in consultation with a neurosurgeon from another hospital determined that the patient needed a higher level of care; therefore, Patient #7 was transferred to an outside hospital. There was no evidence in the record that Patient #7 received and/or signed consent to transfer to another facility for a higher level of care. Per interview on 5/21/19 at 11:41 AM with the Manager of Health Information Systems, s/he confirmed that the medical record did not contain a documented/signed consent to transfer the patient to a higher level of care.

Per review of the policy, Transfer from the Emergency Department-effective 9/17/18, it read, "A. The ED Physician will: 6. Obtain signed transfer consent, whenever reasonably possible, after explaining the risks and benefits of transfer to the patient and/or persons acting on the patient's behalf. B. The ED Nurse will: 5. Compile records to accompany patient: 1. All pertinent physician documentation, nursing documentation, and ancillary reports. 2. Signed permission for transfer. 3. Pre-hospital care record if applicable".