HospitalInspections.org

11835

Based on record review, policy review, and interview, the provider failed to ensure all patient medical record entries were verified with signatures, dates, and times on the written or electronic forms. A sample of 242 surgical and emergency/outpatient record entries revealed 233 instances where either the signature, date, or time of the entry was not recorded. Findings include:

1. Review of 54 written physicians' orders revealed 21surgical patient records were not dated and 39 were not timed.

2. Review of 22 telephone, voice, or standing orders revealed 4 sampled surgical patient records and emergency/outpatient records were not signed, 21 were not dated, and 22 were not timed.

3. Review of 31 physicians' progress notes revealed 6 were not signed, 19 were not dated, and 23 were not timed.

4. Review of 2 consultant reports revealed 1 was not dated and 2 were not timed.

5. Review of 22 history and physicals revealed 1 was not signed and 13 were not dated or timed.

6. Review of 23 surgical reports revealed 3 were not signed, 8 were not dated, and 15 were not timed.

7. Review of 22 anesthesia consents revealed 4 were not timed.

8. Review of 17 discharge summaries revealed 1 was not signed and 9 were not dated or timed.

9. Review of 22 admission and treatment consents revealed 22 were not timed.

10. Review of 23 surgical consents revealed 3 were not timed.

11. Interview on 7/21/10 at 11:15 a.m. with the medical records director revealed:
*She was not aware all medical record entries were to be dated and timed.
*She monitored to be sure all entries were signed, but not if they were dated and timed.
*She knew the medical staff had been informed to date signatures,but they did not always do it.
*Only a couple of physicians used the electronic signature capability of their computer system.

Interview on 7/21/10 at 11:30 a.m. with the director of nursing revealed record entries were usually signed but not dated or timed. Not many physicians used the electronic signature process that would automatically put in the date and time the physician had signed the entry.

Review of section V, paragraph 5.15 of the medical records policy revealed:
*"A practitioner's routine orders, when applicable to a given patient, shall be reproduced in detail on the order sheet of the patient's record, dated and signed by the practitioner."
*There was no mention of timing the medical record entries.

Based on record review and interview, the provider failed to ensure a consent form for treatment was completed for four of five sampled emergency/outpatient patients (10, 11, 13, and 14) reviewed. Findings include:

1. Review of emergency room-out patient records for patients 10, 11, 13, and 14 revealed those patients had been treated as emergency/outpatients at the hospital without a consent for treatment completed.

Interview with the administrator on 7/21/10 at 8:20 a.m. revealed the consent form for treatment was not completed for the above patients. She stated the consent form was blank, and it should have been completed. She thought it was not completed because the above patients were seen after business hours.

Interview with the director of nursing on 7/21/10 at 9:10 a.m. confirmed the consent for treatment for the above patients was not completed. She stated the consent was on the back of the emergency room-out patient record and had been overlooked by the staff when completing the form.

Interview with registered nurse 3 on 7/21/10 at 10:15 a.m. revealed she had completed the emergency room-out patient record for patients in the past. She was not aware the consent for treatment needed to be completed. She was not aware of the consent on the back of the form.

Review of the informed consent policy last reviewed on 1/14/10 revealed:
*"The physician performing a medical or surgical procedure/treatment is responsible for obtaining the patient's informed consent prior to the procedure/treatment."
*"The individual performing the procedure/treatment may be a physician, registered nurse or other healthcare provider approved and qualified to perform the procedure."

Based on record review and interview, the provider failed to ensure utilization reviews for 13 of 13 sampled patients were completed by physicians who did not have a financial interest in the hospital. Findings include:

1. Review of 13 utilization review cases for April 2010 revealed all the cases were reviewed by physicians who were listed as owners of the hospital.

Interview on 7/21/10 at 9:05 a.m. with the hospital administrator confirmed the above physicians had an ownership interest in the hospital. The administrator stated she was not aware physicians with an ownership interest in the hospital should not have been performing the utilization reviews.