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Based on records reviewed and interviews the Hospital failed to ensure the right to personal privacy (release or disclosure of patient information, such as name, or information on the patient's medical condition) for 3 of 10 patients (Patients #1, #7, #8) in a total sample of 15, identified with a patient identification concern.

Findings included:

1.) The Surveyor interviewed the Regulatory Manager at 9:30 A.M. on 6/22/16. The Regulatory Manager said Patient #1 presented to the Emergency Department (ED) on 3/4/16 with pain and the Hospital performed a Computed Tomography (CT) scan. The Regulatory Manager said the Hospital sent the results of Patient #1's CT scan to Patient #2's Primary Care Provider because the Emergency Department registered Patient #1 as Patient #2. The Regulatory Manager said Patient #2's Primary Care Provider ordered an ultrasound-guided biopsy based on Patient #1's CT scan which indicated cancer. The Regulatory Manager said Patient #2 had the ultrasound-guided biopsy on 4/25/16, the biopsy results did not indicate cancer and Patient #2's Primary Care Provider ordered Patient #2 to have a CT scan and another biopsy. The Regulatory Manager said the Radiology Department discovered the patient identification error at the time of Patient #2's CT scan on 5/10/16.

Hospital policy titled Uses and Disclosures of Protected Health Information, dated 8/6/15, indicated Protected Health Information was confidential and shall not be used or disclosed except as set forth in the policy or as required by law.

The Surveyor interviewed the Regulatory Manager, at 2:30 P.M. on 6/27/16. The Regulatory Manager said the Hospital sent a letter of results of Patient #1's CT scan to Patient #2's Primary Care Provider in error and as a result, Patient #2 underwent a biopsy and CT scan for evaluation of cancer. The Regulatory Manager said that the Hospital did not have a copy of the letter of the results of Patient #1's CT scan that the Hospital sent to Patient #2's Primary Care Provider (Patient #1's Protected Health Information that the Hospital disclosed to Patient #2's Primary Care Provider).

2.) A Hospital Report, dated 3/21/16, indicated there was a patient identification error. The Hospital Report indicated Patient #7 received a certified letter from the Hospital regarding microbiology (laboratory test) with Patient #13's name.

The Surveyor interviewed the Regulatory Manager, at 10:40 on 6/24/16. The Regulatory Manager said that the Hospital did not have documentation that Patient #13's Protected Health Information was disclosed to Patient #7.

3.) The Surveyor interviewed the Risk Management Manager, at 3:00 P.M. on 6/24/16. The Risk Management Manager said the Hospital sent Patient #13's abnormal test results to Patient #7 on 12/7/15 in error. The Risk Management Manager said the person sending out the abnormal laboratory results selected Patient #7, instead of the Patient #13.

The Regulatory Manager said that the Hospital did not have documentation that Un-sampled Patient #1's Protected Health Information was disclosed to Patient #8.

Based on observations, records reviewed and interviews the Quality Assessment and Performance Improvement Program Condition of Participation was not met.

Findings included:

The Hospital failed to ensure it had an effective Quality Assessment and Performance Improvement Program that analyzed performance of Hospital processes, operations and Hospital reports about patient identification errors that involved the Emergency Department (ED) and Radiology Department; and monitor the effectiveness and safety of the Hospital's patient identification and medical record reconciliation processes.

Refer to TAG: A-0273

The Hospital failed to ensure it had effective Quality Assessment and Performance Improvement activities considering the incidence and severity of patient identification errors, involving the Emergency, Radiology, Laboratory and Medical Records Departments. The Hospital failed to develop appropriate corrective action(s), which measured the effectiveness and sustainability of the corrective action(s).

Refer to TAG: A-0283

Based on records reviewed and interview for 10 of 10 (Patients #1, #2, #7, #8, #11, #12, #13, #14 #15, and Un-sampled patient #1) in a total sample of 15 medical records the Hospital failed to ensure an effective Quality Assessment and Performance Improvement (QAPI) Program that analyzed performance of Hospital processes, operations and Hospital reports of 5 cases concerning patient identification errors or patient identification issues that occurred in the Emergency Department (ED), Radiology Department and Medical Records Department.

Findings included:

1.) For Patients #11 & #14 the Hospital failed to Conduct a timely, complete and accurate investigation.

A Hospital Report, dated 6/15/16, indicated that the Hospital ordered an x-ray for Patient #14 and the Radiology Department performed the X-ray on Patient #11 on 5/27/16.

The Surveyor interviewed the Risk Manager, at 3:15 P.M. on 6/24/16. Risk Manager #1 said that a Radiology Technician made the error by putting 2 x-ray plates into the x-ray machine and crossed them. The Risk Manager said that the corrective action was that the medical record was reconciled with the correct report and x-ray image that evening (5/27/16). The Risk Manager said she did was not sure if the practice of patient and x-ray identification was monitored by the Radiology Department.

The Surveyor interviewed the Radiology Director at 10:10 A.M. on 6/27/16. The Radiology Director said she started to further investigate this incident on 6/24/16. The Radiology Director said the Radiology Department did an x-ray on Patient #11 on 5/27/16 and Patient #11 did not have an indwelling intravenous catheter. The Radiology Director said that Patient #14 had an indwelling intravenous catheter and the Radiology Department did the x-ray on 5/27/16. The Radiology Director said that a Radiology Technician went to the Emergency Department with a copy of Patient #11's physician order for the x-ray. The Radiology Director said the Radiology Technician returned to the Radiology Department with Patient #14 because an Emergency Department nurse said Patient #11 was not ready for the x-ray and an Emergency Department nurse said Patient #14 was ready for his/her x-ray. The Radiology Director said Radiology Technicians were required to verify the patient identification bracelet with the physician order. The Radiology Director said she did not know if the Radiology Technicians verified patient identification because she had not interviewed the Radiology Technician(s) about the x-ray patient identification error regarding Patients #11 & #14. The Radiology Director said that the Radiology Department did not use an official policy for patient identification, the Radiology Department used the National Patient Safety Goals of verifying the physician order with the patient's name and birth date.

The Hospital policy titled Patient Identification, dated 7/24/14, indicated that patient identifiers were patient name and birth date, and name and medical record number.

2.) For Patients #1 & #2 the Hospital failed to conduct a complete investigation and interview the ED Patient Access Representative who made the patient identification error that resulted in Patient #2 having tests for cancer when Patient #2 did not have cancer. For Patients #1 and #2 the Hospital failed to completely reconcile Patients #1 & #2's medical records.

The Surveyor interviewed the Regulatory Manager at 9:30 on 6/22/16. The Regulatory Manager said Patient #1 presented to the ED on 3/4/16 with pain and the Hospital performed a Computed Tomography (CT) scan. The Regulatory Manager said the Hospital sent the results of Patient #1's CT scan to Patient #2's Primary Care Provider because the ED registered Patient #1 as Patient #2. The Regulatory Manager said Patients #1 & #2 had the same name, similar birth dates and Patient #1 did not speak English. The Regulatory Manager said Patient #2's Primary Care Provider ordered an ultrasound-guided biopsy based on Patient #1's CT scan, which indicated cancer. The Regulatory Manager said Patient #2 had the ultrasound-guided biopsy on 4/25/16, the biopsy results did not indicate cancer and Patient #2's Primary Care Provider ordered Patient #2 to have a CT scan and another biopsy. The Regulatory Manager said the Radiology Department discovered the patient identification error at the time of Patient #2's CT scan on 5/10/16. The Regulatory Manager said that the Radiology Department conducted the Hospital Internal Investigation.

The Surveyor interviewed the Radiology Director at 11:00 A.M. on 6/22/16. The Radiology Director said the Hospital scheduled Patient #2's CT scan and a second biopsy on 5/10/16. The Radiology Director said the physician performing Patient #2's CT scan evaluated the CT scan as normal (no cancer) and there was a "mix-up" somewhere and they did not know where. The Radiology Director said she discovered that Patients #1 & #2 had the same first and last name with similar birth dates. The Radiology Director said she did not know what Patient #1 presented to the ED as identification. The Radiology Director said the Hospital corrected Patients #1 & #2's medical records and she was not aware of any other corrective actions.

The Surveyor interviewed the Patient Access Services Senior Director at 12:00 P.M. on 6/22/16. The Patient Access Services Senior Director said that the Emergency Department Senior Registration Representative made the patient identification error by registering Patient #1 as Patient #2.

The Surveyor interviewed the Patient Access Services Supervisor at 12:20 P.M. on 6/22/16. The Patient Access Services Supervisor said Patient Access Services Representative received re-education of patient identification by an electronic email she distributed. The Patient Access Services Supervisor said the Hospital did not re-educate all the Patient Access Services Representatives because the Hospital canceled the staff meeting due to staffing. The Patient Access Services Supervisor said that the Patient Access Services Manager was responsible for addressing the patient identification, registration error with the Patient Access Services Representative that made the error and that the Hospital had not asked her to address the error with the Patient Access Services Representative who made the error.

The Surveyor interviewed the Patient Access Services Manager at 1:30 P.M. on 6/22/16. The Patient Access Services Manager said she did not know who interviewed the Patient Access Services Representative and to her knowledge, the Hospital did not interview the Patient Access Services Representative who made the error.

The Surveyor interviewed the Patient Access Services Representative at 11:40 A.M. on 6/22/16. The Patient Access Services Representative said the Hospital did not interview her about Patient #1's patient identification error and she did not remember registering Patient #1.

The Surveyor interviewed RN #1 at 11:00 A.M. on 6/27/16. RN #1 said that although he was the nurse that greeted Patient #1 on 3/4/16 and would have placed the patient identification bracelet on Patient #1 as part of the greeter nurse role, he did not remember triaging (first ED evaluation) and did not remember registering Patient #1 to the ED. RN #1 said that he had probably triaged and registered about 1000 patients since 3/4/16 (the date of the error). RN #1 said that the Hospital did not interview him regarding Patient #1's identification error.

The Surveyor interviewed Patient #1's Oncology Surgeon at 10:50 A.M. on 6/24/16. The Oncology Surgeon said that the biopsy report in Patient #1's medical record (reviewed at 10:50 A.M. on 6/24/16) indicated Patient #1 did not have cancer. The Oncology Surgeon said that he would expect the biopsy report to indicate Patient #1 had cancer according to his evaluation of Patient #1's CT scan. The Oncology Surgeon said that he was not aware of a patient identification error of Patient #1 & Patient #2.

Review of Patient #1's medical record on 6/24/16 indicated it contained medical information of Patient #2.

Review of Patient #2's medical record on 6/24/16 indicated it contained medical information of Patient #1, who had a diagnosis of cancer.

The Surveyor interviewed the Regulatory Manager at 11:10 A.M. on 6/24/16. The Regulatory Manager said that the biopsy report in Patient #1's medical record was Patient #2's biopsy report and the biopsy report in Patient #2's medical record was Patient #1's biopsy report.

The Surveyor interviewed the Regulatory Associate Vice President at 1:00 P.M. on 6/28/16. The Regulatory Associate Vice President said that the Hospital did not conduct a formal root case analysis (formal investigation) because the Hospital already knew how Patients #1 & #2's identification error happened.

3.) For Patients #12 & #15 the Hospital failed to conduct a complete investigation of patient identification processes.

A Hospital Report, dated 3/28/16, indicated there was a patient identification issue. The Hospital Report indicated that upon placing the Hospital patient identification bracelet on Patient #12, staff noted that the patient had another hospital bracelet on with a different name on it.

Patient #12's medical record did not indicate documentation of an Emergency Department visit.

The Surveyor interviewed the Regulatory Manager at 1:00 P.M. on 6/24/16. The Regulatory Manager said she did not know why the medical record did not contain the Emergency Department visit and that the Risk Management Department would know. The Regulatory Manager said that Patient #15 identified himself/herself as Patient #12 during patient registration in the Emergency Department on 3/28/16. The Regulatory Manager said the informed consent form, signed by Patient #15, (in Patient #12's medical record on 6/24/16) needed to come out of Patient #12's medical record.

The Surveyor interviewed the Risk Management Manager at 3:00 P.M. on 6/24/16. The Risk Management Manager said that the corrective action included correcting the medical records and the Patients #12 & Patient #15's medical records were corrected. The Risk Management Manager did not provide information or documentation to indicate that the investigation included staff interview or observation that staff followed Hospital policy of patient identification processes.

4.) For Patients #7 & #13 the Hospital failed to conduct a complete investigation and identify who, in the Emergency Department, made the error and circumstances contributing to the error.

A Hospital Report, dated 3/21/16, indicated there was a patient identification issue in the Emergency Department. The Hospital Report indicated (Patient #7) received a certified letter from the Hospital regarding microbiology (laboratory test) with another person's name (Patient #13).

The Surveyor interviewed the Risk Management Manager, at 3:00 P.M. on 6/24/16. The Risk Management Manager said the Hospital sent Patient #13's abnormal test results to Patient #7 on 12/7/15 in error. The Risk Management Manager said the Hospital provided Patient #7 care on 1/23/12 and was therefore a patient in the Hospital medical record computer system. The Risk Management Manager said the person sending out the abnormal laboratory results selected Patient #7, instead of the correct patient (Patient #13), because the person identified the patient by name and not medical record number. The Risk Management Manager said that the Hospital was "unclear" who made the error.

5.) For Patients #8 & Un-sampled Patient #1 the Hospital failed to conduct a complete investigation.

A Hospital Report, dated 3/15/16, indicated the Emergency Department gave Patient #8 a "work note", on 3/8/16; however, it was for a different patient (Un-sampled Patient #1).

The Surveyor interviewed the Regulatory Manager at 1:40 P.M. on 6/23/16. The Regulatory Manager said that the Hospital did not know why Patient #1 received the wrong patient note.

Based on records reviewed and interview for 10 of 10 (Patients #1, #2, #7, #8, #11, #12, #13, #14, #15 and #Un-sampled Patient #1, in a total sample of 15 medical records, the Hospital failed to ensure effective Quality Assessment and Performance Improvement (QAPI) activities considering the incidence and severity of patient identification errors and patient identification issuse of 5 cases that occurred in the Emergency Department (ED), Radiology Department and Medical Records Department with appropriate corrective action(s) and measure effectiveness and sustainability of the corrective actions.

Findings included:

1.) For Patients #11 & #14 the Hospital failed to implement QAPI activity(s) and monitor the effectiveness of those QAPI activity(s) in the Emergency & Radiology Departments.

A Hospital Report, dated 6/15/16, indicated that the Radiology Department performed an x-ray on Patient #14 that an ED physician ordered for Patient #11, on 5/27/16, in error.

The Surveyor interviewed the Radiology Director at 10:10 A.M. on 6/27/16. The Radiology Director said the Hospital had no corrective action(s) or monitoring plan because she started to further investigate the error on 6/24/16.

2.) For Patients #1 & #2 the Hospital failed to implement corrective actions and correct Patients #1 & #2's medical records.

The Surveyor interviewed the Regulatory Manager at 9:30 on 6/22/16. The Regulatory Manager said corrective actions included developing an Identification Reference Tool and language interpreters would now identify patients by name and birth-date. The Regulatory Manager said that the Hospital had not implemented the Identification Reference Tool.

The Surveyor interviewed the Patient Access Services Senior Director at 12:00 P.M. on 6/22/16. The Patient Access Services Senior Director said the Hospital conducted a conference-call meeting on 5/20/16 (patient identification error discovery date, 5/10/16) and discussed corrective actions that included the physical space of the ED patient registration area and that some patients present to the ED patient registration without identification. The Patient Access Services Senior Director said she believed that the Patient Access Services Supervisor sent a communication by electronic mail to Patient Access Services Representatives about patient identification. Patient Access Services Senior Director said that the Patient Access Services Manager developed an Identification Reference Tool and that she (the Director) did not know if the Patient Access Services Representatives had read the email or were educated on the Identification Reference Tool. The Patient Access Services Senior Director said that Patient Access Services Representatives hear the patient identification information the patient says to the Greeter Nurse (Registered Nurse that greets the patient and asked the patient for identification) and then registered the patient with the identification. The Patient Access Services Senior Director said that she wanted to change the patient registration process from the Greeter Nurse taking patient identification information and applying the name bracelet to the patient, to having the Patient Access Services Representatives take the patient identification and the Patient Access Service Representative would applying the name bracelet to the patient, but the process was not changed.

The Surveyor observed at 10:20 A.M. on 6/22/16 the registration of Patients #3, #4, #5 and #6. The Surveyor observed Patients #3, #4, #5 and #6 present (at individual times) to the Emergency Department registration window staffed by a Greeter Nurse. The Surveyor observed the Greeter Nurse ask the Patient for name and identification. The Surveyor observed the Greeter Nurse hand-off to the Patient Access Services Representative the patient identification information. The Surveyor observed the Patient Access Services Representative conduct a computer search for the patient, registered the patient and printed a patient name bracelet. The Surveyor observed the Patient Access Services Representative hand-off to the Greeter Nurse the name bracelet. The Surveyor observed the Greeter Nurse ask the patient their name and birth date and then applied the name bracelet to the patient's wrist.

The email document, dated 5/20/16 (10 days after the patient identification error discover date of 5/10/16) indicated that 6 of 17 Patient Access Service Representatives read the email. The email document indicated instructions to Patient Access Services Representative about patient registration and that some patients have similar or same names and similar or same birth dates.

The document titled Driver's License/Identification Card, Hospital Blue Card, Immigration - Identification Documents (undated, a Patient Identification Reference Tool) indicated pictures of a Driver's License, Identification Card, Hospital Blue Card, Immigration and Identification Documents.

The Surveyor interviewed the Patient Access Services Supervisor at 12:20 P.M. on 6/22/16. The Patient Access Services Supervisor said that she had never seen the Patent Identification Reference Tool and that the Patient Access Services Representative staff was not educated on the Patent Identification Reference Tool.

The electronic email document, dated 6/16/16, indicated instructions to Interpreter Services staff about patient identification and to ask the patient for his/her name, date of birth, and compare it to the patient's electronic medical record and to report discrepancies immediately.

The electronic email document, dated 6/23/16, indicated the Hospital would conduct monitoring about the new protocol by random checks and direct observation of interpreters within the next 30 day.

The Surveyor interviewed the Patient Access Services Manager at 1:30 P.M. on 6/22/16. The Patient Access Services Manager said the Hospital had not implemented the Patient Identification Reference Tool. The Patient Access Services Manager said the Hospital had not re-educated staff about patient identification because the Hospital canceled the staff meeting due to staffing. The Patient Access Services Manager said that the Hospital scheduled a meeting for 6/28/16 to plan staff education.

The Surveyor Interviewed the Risk Management Manager and Risk Manager #2, at 9:15 A.M. on 6/23/16. The Risk Management Manager and Risk Manager #2 said that they did not interview the Patient Access Services Representative about the patient registration processes. The Risk Management Manager and Risk Manager #2 said that they did not know if the Patient Access Services Representative staff read the email (dated 5/20/16) about patient identification and patient registration. The Risk Management Manager and Risk Manager #2 said staff did not use an interpreter when the Patient Access Services Representative registered Patient #1 as Patient #2. The Risk Management Manager and Risk Manager #2 said that they did not know if a monitoring process was in place to make certain the Patient Access Services Representatives used interpreter services. The Risk Management Manager and Risk Manager #2 said that the Hospital had not implemented the Patient Identification Reference Tool because of conversation about printing and laminating. The Risk Management Manager and Risk Manager #2 said they did not know where the process was about changing the registration process or changing the space of the Emergency Department registration area.

3.) For Patients #12 & #15 the Hospital failed to monitor the effectiveness of the QAPI activity(s) regarding patient identification errors, and correct the medical records.

A Hospital Report, dated 3/28/16, indicated a patient identification issue. The Hospital Report indicated that upon placing the Hospital patient identification bracelet on Patient #12, staff noted the patient had another hospital bracelet on with a different name on the bracelet.

Patient #12's medical record indicated, on the 6/24/16 medical record review, an advanced directive and consent for treatment signed on 3/28/16, (signed by Patient #15) without documentation of an Emergency Department visit.

The Surveyor interviewed the Regulatory Manager at 9:30 on 6/22/16. The Regulatory Manager said that Patient #15 identified himself/herself as Patient #12 during patient registration in the Emergency Department on 3/28/16. The Risk Manager said that the consent needed to come out of Patient #12's medical record. The Regulatory Manager said she did not know why the medical record did not document the Emergency Department visit and that the Risk Management Department would know.

4.) For Patients #7 & #13 the Hospital failed to implement QAPI activity(s) and monitor the effectiveness of the QAPI activity(s).

The Surveyor interviewed the Risk Management Manager, at 3:00 P.M. on 6/24/16. The Risk Management Manager said the Hospital sent Patient #13's abnormal test results to Patient #7 on 12/7/15. The Risk Management Manager said the Hospital provided Patient #7 care on 1/23/12 and Patient #7 was in the Hospital medical record system. The Risk Management Manager said the person sending out the abnormal laboratory results selected Patient #7, intending Patient #13, because the person identified the patient by name and did not identify the patient by medical record number. The Risk Management Manager said that the Hospital was "unclear" who made the error, corrective actions include only managers and clinical coordinators would send the certified letters of test results to patients. The Risk Management Manager said she was not sure if a copy of the letter sent to Patient #7 with Patient #13's laboratory results was in the medical record. The Risk Management Manager said that she was not sure who in the Emergency Department monitored the performance improvement effectiveness and sustainability of the identified corrective action.

5.) For Patients #8 & Un-sampled Patient #1 the Hospital failed to implement QAPI activity(s) and monitor the effectiveness of the QAPI activity(s).

A Hospital Report, dated 3/15/16, indicated a patient identification error and that the Emergency Department gave Patient #8 a "work note", on 3/8/16, however it was for a different patient (Un-sampled Patient #1).

The Surveyor interviewed the Regulatory Manager at 1:40 on 6/23/16. The Regulatory Manager said that the Emergency Department corrected the error and gave Patient #8 a work note with Patient #8's name. The Regulatory Manager said that the Hospital did not know why Patient #8 received a work note with Un-sampled Patient #1's name.

Based on records reviewed and interviews the Hospital failed to ensure maintenance, accuracy, completeness and filing for 6 of 6 patients (Patients #1, #2, #7, #12, #13 and #15) in a total sample of 15 medical records and maintain a medical record for each patient treated in the Hospital.

Findings included:

1.) For Patients #1 & #2 the Hospital failed to correct the medical records.

The Surveyor interviewed Patient #1's Oncology Surgeon at 10:50 A.M. on 6/24/16. The Oncology Surgeon said that the biopsy report in Patient #1's medical record (reviewed at 10:50 A.M. on 6/24/16) indicated Patient #1 did not have cancer. The Oncology Surgeon said that he would expect the biopsy report to indicate Patient #1 had cancer according to his evaluation of Patient #1's Computerized Tomography (CT) scan. The Oncology Surgeon said that he was not aware of a patient identification error about Patient #1 & Patient #2.

Patient #1's medical record, reviewed on 6/24/16, indicated a biopsy report of no cancer and Patient #2's medical record, reviewed on 6/24/16, indicated a biopsy report of cancer.

The Surveyor interviewed the Regulatory Manager at 11:10 A.M. on 6/24/16. The Regulatory Manager said that the biopsy report in Patient #1's medical record belonged to Patient #2 and the biopsy report in Patient #2's medical record belonged to Patient #1.

The Surveyor interviewed the Health Information's Management Manager, at 12:30 P.M. on 6/24/15. The Health Information's Management Manager said she was not aware that the biopsy reports were in the wrong medical records. The Health Information's Management Manager said the biopsy reports went into Patients #1 & #2's medical records after the Health Information's Management Department corrected Patients #1 & #2's medical records. The Health Information's Management Manager said the Health Information's Management Department was not sure when the biopsy reports were entered into Patients #1 & #2's medical records. The Health Information's Management Manager said that the Health Information's Management Department reconciled medical records again after an error a few weeks later and reconciliation depended on the circumstance.

The document titled, HIM Department Patient Correction Worksheet, dated 5/24/16, indicated the Health Information Management (HIM) Department corrected Patients #1 & #2's medical records. The HIM Department Patient Correction Worksheet did not indicated correction dates after 5/24/16.

Patient #2's medical record, on 6/24/16, did not contain consent for the scheduled biopsy procedure on 5/10/16.

Hospital policy titled Informed Consent, dated 4/24/2014, indicated treatments, including surgical procedures and anesthesia, including biopsy of any tissue or any site, as described on the Treatment and Procedure Consent Form, required a specific informed consent.
The Surveyor interviewed the Regulatory Manager, at 8:50 A.M. on 6/24/16. The Regulatory Manager said that the Hospital could not retrieve a copy of the letter sent to Patient #2's Primary Care Provider, which contained Patient #1's information, from the Hospital electronic system(s).
2.) For Patients #7 & #13 the Hospital failed to maintain Patient #7's medical record.
The Surveyor interviewed the Risk Management Manager, at 3:00 P.M. on 6/24/16. The Risk Management Manager said that she was not sure if a copy of the letter sent to Patient #7 with Patient #13's laboratory results was in the medical record.

The Surveyor interviewed the Risk Manager, at 11:45 A.M. on 6/28/16. The Risk Manager said that the Hospital deleted Patient #7's medical record from the system.

3.) For Patients #12 & #15 the Hospital failed to correct the medical records.

A Hospital Report, dated 3/28/16, indicated a patient identification issue. The Hospital Report indicated that upon placing the Hospital patient identification bracelet on Patient #12, staff noted that the patient had another hospital bracelet on with a different name on the bracelet and some of the Emergency Department staff knew the patient.

Patient #12's medical record indicated, on the 6/24/16 medical record review, an advanced directive and consent for treatment signed on 3/28/16, without documentation of an Emergency Department visit.

The Regulatory Manager said she did not know why the medical record did not document the Emergency Department visit and that the Risk Management Department would know. The Regulatory Manager said that Patient #15 identified himself/herself as Patient #12 during patient registration in the Emergency Department on 3/28/16. The Risk Manager said Patient #15 presented himself/herself as Patient #12 and that the consent needed to come out of Patient #12's medical record.