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Based on records reviewed and interviews, for four (4) of 10 patients (Patients #16, #17, #18 & #19), the Hospital failed to conduct thorough internal investigations and analyze patient identification occurrences.

Findings included:

The Hospital policy titled Occurrence Reporting, dated 1/14/15, indicated that the policy was applicable for all workforce members at all campuses of the Hospital and other sites operating under the Hospital's provider number. The policy indicated workforce members included all employees and members of the medical staff. The policy indicated that an occurrence was an event that resulted in an actual or potential patient adverse outcome (harm).

The Surveyor interviewed the Senior Director of Health Information Management, 10:45 A.M. on 10/4/16. Senior Director of Health Information Management said the Hospital corrected four (4) medical records (Patients #16, #17, #18 & #19) due to patient identification occurrences.

The following refers to Patients #16 & #17.

The Surveyor interviewed Regulatory Manager #1 at 9:00 A.M. on 10/5/16. Regulatory Manager #1 said the Hospital did not have an Occurrence Report regarding Patient #16 and #17's patient identification occurrence.

Patient #16's medical record indicated Patient #16 received Hospital services on 9/21/16.

The Surveyor interviewed the Associate Vice President of Regulatory Compliance and the Regulatory Manager at 10:00 A.M. on 10/5/16. The Associate Vice President of Regulatory Compliance and the Regulatory Manager said the Hospital used the SharePoint System for documentation and communication of occurrence follow-up information.

The document titled SharePoint, dated 10/7/16, did not indicate a thorough Hospital internal investigation regarding Patient #16's patient identification occurrence.

The Surveyor interviewed the Senior Director for Patient Access Services at 10:20 A.M. on 10/5/16. The Senior Director for Patient Access Services said that the patient identification occurrence happened on 9/9/16 when a Hospital workforce member incorrectly scheduled Patient #16 for a 9/21/16 appointment. The Senior Director for Patient Access Services said the Hospital did not update the SharePoint System (electronic system for documentation and communication of occurrence investigation) to correctly instruct workforce members to submit the Occurrence Report on the correct electronic reporting system. The Senior Director for Patient Access Services said that, on 9/25/16, she notified the Pediatric Orthopedic Outpatient Service Director of the patient identification occurrence and the Pediatric Orthopedic Outpatient Service Director did not submit investigation information regarding the patient identification occurrence. The Senior Director for Patient Access said that the SharePoint System did not indicate specifics or details of the patient identification occurrence.


The following refers to Patients #18 & #19: Women's Health Services.

The document titled Report, dated 9/12/16, indicated the Hospital discovered a patient identification occurrence on 9/7/16. The report indicated the Hospital incorrectly registered Patient #18 as Patient #19
on 8/3/16 for an 8/17/16 obstetric ultrasound appointment. The Report indicated a notification went out in SharePoint on 9/12/16. The Report did not indicate progress notes or manager notes.

Patient #18's medical record indicated a date of service appointment for 8/17/16.

The document titled SharePoint, dated 10/7/16, did not indicate communication regarding a Hospital internal investigation and did not indicate a thorough Hospital internal investigation regarding Patient #18's patient identification occurrence.

The Associate Vice President of Regulatory Compliance and the Regulatory Manager said the narrative report of Patient #18's obstetric ultrasound was not corrected in Patient #18's medical record.

The document titled Timeline Chart Reconciliation OB Ultrasound, dated 10/7/16 at 8:30 A.M., indicated the interpreting physician finalized and amended, with the correct medical record, Patient #18's obstetric ultrasound report on 10/5/16 (during Survey).

The following refers to the Hospital Health Center.



The Surveyor interviewed the Associate Vice President of Regulatory Compliance at 2:15 P.M. on 10/5/15. The Associate Vice President of Regulatory Compliance said that a Risk Manager/Manager communication (Email) was an action to confirm communication regarding a patient identification occurrence.

The Email, dated 10/4/16, indicated a Risk Manager/Manager communication of high importance concerning a medical records patient identification occurrence on 9/21/16. The Email indicated instructions to the Manager for review and follow-up information.

The document titled Report, dated 9/30/16, indicated a medical records patient identification occurrence on 9/21/16. The Report did not indicate review and did not indicate follow-up investigation information.

The following refers to a Patient Identification Physician Allegation.

The Surveyor interviewed the Associate Vice President of Regulatory Compliance at 1:00 P.M. on 10/7/16. The Associate Vice President of Regulatory Compliance said that she did not know of an occurrence where a Hospital physician selected the incorrect patient from a Hospital computer system. The Associate Vice President of Regulatory Compliance said that the Surveyor would need to speak with the Chief Medical Officer.

The Surveyor interviewed the Chief Medical Officer at 2:20 P.M. on 10/7/16. The Chief Medical Officer said that he was aware of an occurrence where a Hospital physician incorrectly selected a patient from a Hospital computer system. The Chief Medical Officer said that the patient outcome had nothing to do with the Hospital. The Chief Medical Officer said that he sent an email to the Medical Staff. The Chief Medical Officer said that he did not know if someone had notified anyone else in the Hospital of the occurrence.

An email, dated 8/24/16 from the Chief Medical Officer to Hospital Medical Staff, indicated a reminder regarding patient identification.

The Surveyor interviewed the Senior Director of Risk Management at 6:30 P.M. on 10/11/16. The Senior Director of Risk Management said that she was aware of the misidentification and investigated the occurrence. The Senior Director of Risk Management said the notification was not regarding Hospital patient care quality and that it was not necessary to notify the Hospital Quality Department.

Based on records reviewed and interview, for 4 (Patients #16, #17, #18 & #19) of 10 patients, the Hospital failed to measure compliance of performance improvement activities

Findings included:

The Surveyor interviewed the Senior Director of Health Information Management (Medical Records) and the Health Information Management Manager at 10:45 A.M. on 10/4/16. The Senior Director of Health Information Management and the Health Information Management Manager said the Hospital's plan was to weekly reconcile (correct) late entries to the medical record.

The document titled, Health Information Management Department Patient Correction Worksheet Incorrect Medical Record Number Assignment Form, dated 9/12/16, did not indicate the Hospital weekly reconciled Patients #16 & #17's medical records for late entries.

The document titled, Health Information Management Department Patient Correction Worksheet Incorrect Medical Record Number Assignment Form, dated 9/10/16, did not indicate the Hospital weekly reconciled Patients #18 & #19's medical records for late entries.