HospitalInspections.org

Based on a review of facility documents, and interview with staff it was determined that Holy Spirit Hospital failed to ensure that medical records are retrievable for two of two medical records requested. (MR7 and MR8).

Findings include:

A review of Holy Spirit Hospital Administrative policy, Health Record, Access and Security, reviewed, April 2012, revealed, " ... To insure all protected health information necessary to assist in patient care will be provided ... It is the policy of Holy Spirit Health System to assure legal integrity of the patient's protected health information through adequate access control of patient's health records ... ."

MR7 and MR8 were requested for review on May 8, 2012, by the surveyor. The records were not able to be produced while onsite. The surveyor requested the records be scanned to the Field Office for offsite review on May 9, 2012. The records were not received to date.

A telephone interview was conducted with EMP6 on May 10, 2012, at 10:30 AM. EMP6 confirmed that MR7 and MR8 had not been located.

Based on a review of facility policy, medical records (MR) and interview with staff (EMP) it was determined that Holy Spirit Hospital failed to ensure that Pharmacy services were provided within accepted professional principles for one of eight MR reviewed (MR1).

Findings include:

A review of the Holy Spirit Hospital Pharmacy Practice entitled, "Medication Administration" last reviewed May 2012 revealed, " ... Purpose To ensure ... consistent distribution and administration of medications throughout the hospital. ..."

A tour of the Occupational Health area revealed that the department does not stock Varivax or Zostavax.
A review on May 8, 2012, of MR1 revealed the patient presented with a prescription for Zostavax on April 17, 2012. MR1 received Varivax instead of Zostvax.
A review of a Note that EMP10 had written after the patient was discharged on April 17, 2012 at 3:15 PM revealed, " ... pt presented with script for Zostavax vaccine ... Called for Varicella Vaccine. ... Vaccine information obtained/ Varivax - pt's history and allergies, temp checked, obtained vaccine/given to pt - Reviewed with EMP12. ... Notified patient's physician office of substitution and awaiting return phone call ... Pt physician notified of substitution by message ... Pt refused Zostavax ... ."


An interview was conducted with EMP8 on May 8, 2012, at 9:50 AM, EMP8 confirmed that the Pharmacy had not received a copy of the prescription for Zostavax for MR1. " We can release med to Occupation Health because a Licensed Independent.Practitioner was on duty ... we did not need the prescription. We filled it without verifying the order on the prescription."