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Based on record review, staff interview and review of the General Rules and Regulations of the Medical Staff, the facility failed to ensure an amended entry to a clinical record was accurately and timely completed; and failed to ensure the time of each entry was accurately documented for 2 of 17 records in the case sample.

Findings include:

1. Patient #4 was a trauma activation and seen by Physician #1 on 7/12/14. The patient was transferred to an Oahu hospital for higher level of care on 7/12/14. Review of the Emergency Physician Record however, noted "Ammended 08/15/2014" written on it, more than a month after the patient was discharged from the facility.

During a concurrent record review with the Director of Health Information Management (HIM) on 11/19/14, she stated her staff wrote the amended date as Physician #1 had not completed the record. The Director of HIM verified Physician #1 was to have initialed the change(s) made to the original record, but this was not found. She also verified the record was delinquent when it was shown that under 9.2 of the Medical Staff Rules and Regulations, a record is incomplete and/or delinquent when a patient is discharged with information missing and when it is incomplete 21 days after discharge of a patient.

2. Timing establishes when an order was given, when an activity happened or when an activity is to take place and establishes a timeline of events. For Patient #1, who was admitted to the emergency room on 7/5/14 at 4:26 A.M., the Trauma Resuscitation Record noted the patient was transported for a CT scan at "0430" with a return time of "0510." Yet, on page 4 of the trauma record, a licensed nurse's entries noted it the patient's initial presentation/assessment was at "0620", and at "0630" the patient was transported for the CT scan. The next entry by the same licensed nurse was for "0510" indicating the patient returned from CT.

During an interview with licensed nurse #1 (LN #1) on 11/19/14, she verified the record contained incorrect time entries by the licensed nurse who attended to Patient #1 on 7/5/14. LN #1 stated the licensed nurse failed to correct the trauma record, resulting in an inaccurate time sequence of events.

Based on record review, staff interview and review of the General Rules and Regulations of the Medical Staff, the facility failed to ensure physician orders were verified and signed by a practitioner for 1 of 17 records in the case sample.

Finding includes:

Patient #17 was admitted to the hospital on 12/11/13 from the emergency room. A 12/11/13 telephone order with read back found in the clinical record noted the patient was to be admitted to the medical surgical unit with a diagnoses of genital herpes. Physician #2, the ordering practitioner, however, electronically signed the telephone order on 12/31/14. Review of the Medical Staff Rules and Regulations found at 8.3.2 that all telephone and verbal orders "...shall be countersigned within 48 hours of the order." Concurrent review with the Director of HIM on the morning of 11/21/14 verified Physician #2 did not sign the telephone order within 48 hours as required.

Based on record review and staff interview, the facility failed to ensure the medical records contained all necessary and accurate documentation of the patient's care for 1 of 17 records in the case sample.

Finding includes:

1. Patient #5 was admitted to the emergency room on 8/21/14 at 5:14 P.M. for jaundice, increased confusion and fall at home. The emergency physician's clinical impression was acute cholecystitis, common bile duct stone obstruction, jaundice secondary to the patient's acute condition and pancreatitis. The patient was accepted for transfer to another Hawaii island hospital that night. The reason for transfer, for an ERCP procedure, was only found in the ED nursing disposition notes because the transfer documents were not found in the patient's legal health record. The missing documentation included the Physician's Authorization for Transfer form, AMR transfer form and the Physician's Certification Statement. On 11/19/14 at 9:40 A.M., the Director of HIM confirmed the transfer request documents were missing from this patient's legal record.

On 11/20/14, the ED Nurse Manager (ED NM) verified the transfer documents were missing from the patient's record and may have been sent with the patient. In addition, the Director of HIM and the ED NM Patient #5 both confirmed the patient's discharge instruction sheet was incomplete and the licensed staff assigned to the patient should have completed it.