HospitalInspections.org

Based on document review, medical record review and staff interview, the medical staff failed to ensure its members follow its own bylaws when dictating patient Discharge Summaries in one (1) of ten (10) medical records (Patient #1) reviewed. This has the potential to negatively impact all patient care by not providing accurate information for continuity of care. The findings include:

1. Raleigh General Hospital (RGH) Medical Staff Bylaws, Rules and Regulations, last revised May 2010, state on page 6, in part "...Discharge Summary ...The discharge summary should include the reason for hospitalization, the significant findings, the procedures performed and treatment, the condition of the patient on discharge and instructions given relating to physical activity, medication, diet and follow-up care..." and on page 26 Section 4: Physician Supervision of the AHP A. It shall be clearly understood that any activities permitted by the Trustees to be done in the Hospital by AHP (Allied Health Professional) shall be under the direct and immediate supervision of the supervising physician, but that "direct and immediate supervision" shall not require the physical presence of the supervising physician unless the policies of the Clinical Department to which the AHP is assigned and require it in certain circumstances..."

2. Review of the medical record for Patient #1 revealed the Discharge Summary was dictated by the Physician Assistant (PA)on 9/27/10 and electronically signed by the attending Physician on 9/29/10. The dictation stated in part "...Course of Hospitalization ...Patient was typed and cross matched and transfused 2 units of packed red blood cells...Patient was started on Procrit and received IV iron and was eventually placed on oral Iron. NSAID therapy was discontinued...Due to the fact that the patient is a Jehovah's Witness, it is against the patient's religion to receive transfusions. As a result further treatment of anemia through transfusion was not able to be performed. The medical power of attorney is DHHR, who did not give permission for transfusion. As a result the patient was treated conservatively..."

3. During an interview in the morning of 10/6/10 with the PA, with the Regulatory Compliance Officer present, the PA acknowledged dictating the Discharge Summary. The PA further stated the patient absolutely did not receive any blood product transfusions during the hospitalization, that it was a "clerical error" during dictation. The PA further stated getting in a hurry with the dictation, saw the order for the type and crossmatch from the Emergency Department (ED) and must have assumed the patient was transfused in the ED. The surveyor then asked the PA if the patients' records are available during dictation and the PA stated yes, as well as the computer. The surveyor also asked, since the attending physician signed the Discharge Summary, would it be fair to say the attending physician should have read the report to make sure it was true and accurate. The PA stated yes.