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Based on document review and interview, the hospital failed to ensure their polices for medical record retention were consistent. Also, their policy on abbreviations was not consistent with the Medical Staff Rules and Regulations which were approved by the medical staff and reflective of current practice. This failure could result in staff using unapproved abbreviations.

Findings:

1. Review of the Medical Staff Rules and Regulations approved 6/23/14, Section C. 7. showed "Symbols and abbreviations may be used only when they have been approved by the Medical Staff. An official record of approved abbreviations is kept on file in the Health Information Management Department's record room."

Review of the hospital's policy 739721 titled Abbreviations for use in the Medical Record approved 5/2014, Section III. A. showed "Reference [a website] for a list of medical abbreviations ...." There was no documentation to show the medical staff had approved this policy.

During the interview on 5/14/15 at 1200 hours, the DHIM acknowledged the Medical Staff Rules and Regulations and hospital policy were not consistent. The DHIM was unable to provide evidence the medical staff had approved the above policy.

2. Review of the hospital's policy 317732 titled General Administrative Policy: Document Retention approved 7/2012 regarding medical records and x-ray films showed the records/films of a minor are to be retained no less than seven years after being discharge.

Review of the hospital's policy 127195 tiled HIM: Medical Record Retention approved 1/2015, Section III. A. showed the medical records of a minor shall be retained no less than 10 years following the patient's last encounter.

During the interview on 5/14/15 at 1200 hours, the DHIM acknowledged the retention timeframe of the medical records of a minor were not consistent in the above two policies.

Based on document review and interview, the hospital failed to ensure the confidentiality of patient medical records by not having a temporary employee signing the Confidentiality Agreement prior to working in the Medical Records Department. This failure had the potential of breaching of patient confidential health information.

Findings:

Review of the hospital's policy 377726 titled Computer Access Codes revised 2/2013, showed the Department/Head/Director/Supervisor/Coordinator must include a signed copy of the hospital's Confidentiality Agreement in order to process the request computer access code to staff.

A copy of the personnel file of an employee from the hospital's temporary staffing agency was reviewed on 5/13/15. There was no Confidentiality Agreement found, which was confirmed by DRRA after further research on 5/14/15 at 1215 hours.

During the interview on 5/14/15 at 1200 hours, the DHIM stated the above employee had worked in the Medical Records Department for one month, from April to May 2015, to scan paper portions of patient medical records into the electronic medical record system. She stated it was her understanding that all employees, including those from the temporary agency were required to sign a Confidentiality Agreement upon hire and prior to being granted access to the hospital's information system.

Based on interview and medical record review, the hospital failed to ensure the medical staff completed, dated, timed, signed, authenticated, co-signed medical entries for 10 of 32 sampled patients (Patients 32, 17, 4, 5, 19, 21, 26, 25, 22, and 27) and used appropriate abbreviations for one of 32 sampled patients (Patient 30). These failures had the potential to result in insufficient and inaccurate information to identify these patients' medical conditions, develop the course of care, and promote continuity of care.

Findings:

Review of the hospital's Medical Staff Rules and Regulations dated 6/23/14, showed the following:

* Review of the hospital's Medical Staff Rules and Regulations dated 6/23/14, showed the H&P should include examinations of at least nine elements from the seven body areas or thirteen organ systems. The seven body areas listed the following: head including face; neck; chest including breasts and axillae (armpits); abdomen; genitalia including groin and buttock; back including spine and extremities. The thirteen organ systems listed the following: ophthalmologic (eyes), musculoskeletal (muscle and bone), allergy/immunologic, otolaryngologic (ear, nose, and throat), integumentary (skin), gastrointestinal (stomach and intestine), cardiovascular (heart and blood vessel), neurologic (brain, spinal cord, and nervers), genitourinary (reproductive organ and urinary system), respiratory (lung), psychiatric (mental), hematologic/lymphatic, and endocrine (glands) systems.

* All clinical entries in the patient's medical record shall be dated, timed, and authenticated by a house staff, medical staff member, or authorized allied health professional. Medical students and allied health students may document clinical entries. All these entries must be co-signed by their appropriate supervising practitioner.

On 5/12 and 5/13/15, medical record review showed the following medical entries/records were not completed, signed, dated, authenticated, and co-signed as evidenced by:

1. On 5/12/15, medical record review for Patient 32 was initiated. The H&P Evaluation conducted on 5/8/15, was written and signed by the MD Resident on the same day but was not co-signed by the supervising physician.

2. On 5/12/15, medical record review for Patient 17 was initiated. The H&P was signed by the MD Resident on 4/24/15, but was not co-signed by the supervising physician yet.

3. On 5/12/15, medical record review for Patient 4 was initiated.

a. The primary surgical Progress Notes were dated and signed by the MD Resident on 5/8, 5/9, 5/10, and 5/11/15, but were not co-signed by the supervising physician.

b. The H&P Evaluation was dated and signed by the MD Resident on 4/1/15, but was not co-signed by the supervising physician.

4. On 5/13/15, medical record review for Patient 5 was initiated.

a. The Progress Note-Primary Orthopaedics was dated and signed by the MD Resident on 4/29/15, but was not co-signed by the supervising physician.

b. The Progress Note-Primary Orthopaedics was dated and signed by the MD Resident on 5/2, 5/3, and 5/7/15, but was not co-signed by the supervising physician.

5. On 5/13/15, medical record review for Patient 19 was initiated. The Medical Student Progress Note-Primary was dated and signed by the Medical Student on 4/29/15, but was not co-signed by the supervising physician.

During the interview on 5/14/15 at 1200 hours, the DHIM stated the hospital's policy required supervision and co-signature for all medical students' medical record entries. She reviewed and confirmed the above findings.


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6. Review of Patient 21's medical record was initiated on 5/13/15. The patient was admitted to the hospital on 2/7/15, had a surgery on 2/8/15, and was discharged on 2/10/15.

a. The H&P-Primary-Neurosurgery (a surgery is performed on the brain or spinal cord) showed the Physical Exam section did not include at least nine elements from the seven body areas or thirteen organ systems as per the Medical Staff Rules and Regulations. Cross reference to A458.

Further medical record review showed the above H&P was signed by the MD Resident on 2/8/15, but was not co-signed by the supervising physician.

b. The H&P: Interval Perioperative was signed by the MD Resident on 2/8/15, but was not co-signed by the supervising physician.

c. The Discharge Note was signed by the PA on 2/10/15, but was not co-signed by the supervising physician.

During an interview and concurrent medical record review with the Senior Risk Administrative Analyst on 5/13/15 at 1435 hours, she confirmed the above findings.

d. The Consent for Operative/Procedures or Rendering of other Medical Services showed the section for witness or interpreter was signed and dated on 2/7/15; however, the section for time was left blank.

During an interview and concurrent medical record review with the DHIM on 5/14/15 at 1200 hours, the DHIM acknowledged the findings.

7. Review of Patient 26's medical record was initiated on 5/13/15. The patient admitted to the hospital on 4/21/15, and discharged from the hospital on 4/21/15.

The H&P: Interval Perioperative-Ophthalmology was signed by the MD Resident on 4/21/15, but was not co-signed by the supervising physician.

During an interview and concurrent medical record review with the Senior Risk Administrative Analyst on 5/13/15 at 1435 hours, she confirmed the finding.

8. Review of Patient 25's medical record was initiated on 5/13/15. The patient admitted to the hospital on 3/30/15, and discharged to other facility on 4/6/15. The patient had a surgery on 4/2/15.

a. The Consent for Operation/Procedures Or Rendering of other Medical Services was signed on 4/1/15 at 1100 hours. The attending physician had signed the Consent; however, the section of date and time was left blank.

During an interview and concurrent medical record review with the Senior Risk Administrative Analyst on 5/13/15 at 1435 hours, she confirmed the finding.

b. The H&P: Interval Perioperative-Surg: Cardiothoracic (heart and chest) was signed by the MD Resident on 4/1/15, but was not co-signed by the supervising physician.


During an interview and concurrent medical record review with the Senior Risk Administrative Analyst on 5/13/15 at 1435 hours, she confirmed the finding.

c. The Patient Transfer form was signed by the attending physician on 4/6/15 at 1500 hours, and was initialed by the patient on 4/6/15 at 1718 hours; however, the sections for "Physician accepting transfer" and "Receiving hospital" were left blank.

During an interview and concurrent medical record review the Risk Manager Affairs on 5/14/15 at 1045 hours, she confirmed the Patient Transfer form was not complete.

9. Review of Patient 22's medical record was initiated on 5/13/15. The patient was admitted to the hospital on 3/6/15 and was discharged on 3/11/15.

The Discharge Note was signed by the MD Resident on 3/11/15 at 1306 hours, but was not co-signed by the supervising physician.

During an interview and concurrent medical record review with the the Senior Risk Administrative Analyst on 5/13/15 at 1435 hours, she confirmed the finding.

10. Review of Patient 27's medical record was initiated on 5/13/15. The patient was admitted to the hospital on 5/5/15.

a. The H&P: Interval Perioperative-Surg was signed by the MD Resident on 5/5/15, but was not co-signed by the supervising physician.

b. The Sedation/Analgesia/Procedure Record was signed by the attending physician; however, the sections of date and time were left blank.

During an interview and concurrent medical record review with DRRA on 5/14/15 at 1140 hours, the DRRA confirmed the above findings.


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11. The Medical Staff Rules and Regulations approved 6/23/14, Section C. 14. showed "Final diagnosis shall be recorded in full, without the use of symbols or abbreviations ...."

Patient 30's medical record was reviewed on 5/13/15. In the Discharge Diagnoses section, the Discharge Note contained abbreviations (RLTCS+BTL) which were the procedures performed, not the diagnoses. The Discharge Note also referenced the HPI (History of Present Illness)/Hospital Course section which contained abbreviations (IUP, A1DM, A2GDM, NIPT,VSD, PTD, OHP, and LSC).

The above finding was confirmed by the DHIM during the interview on 5/14/15 at 1200 hours.

Based on interview and medical record review, the hospital failed to ensure the medical staff completed the medical H&P examination for one of 31 sampled patients (Patient 21). This had the potential for not providing appropriate care to this patient.

Findings:

Review of the hospital's Medical Staff Rules and Regulations dated 6/23/14, showed the H&P should include examinations of at least nine elements from the seven body areas or thirteen organ systems. The seven body areas listed the following: head including face; neck; chest including breasts and axillae (armpits); abdomen; genitalia including groin and buttock; back including spine and extremities. The thirteen organ systems listed the following: ophthalmologic (eyes), musculoskeletal (muscle and bone), allergy/immunologic, otolaryngologic (ear, nose, and throat), integumentary (skin), gastrointestinal (stomach and intestine), cardiovascular (heart and blood vessel), neurologic (brain, spinal cord, and nervers), genitourinary (reproductive organ and urinary system), respiratory (lung), psychiatric (mental), hematologic/lymphatic, and endocrine (glands) systems.

Review of Patient 21's medical record was initiated on 5/13/15. The patient was admitted to the hospital on 2/7/15, had a surgery on 2/8/15, and was discharged on 2/10/15.

Review of the H&P-Primary-Neurosurgery dated 2/8/15, under the Physical Exam section showed the physician documented the following:

"at neuro baseline per patients, aphasic (loss of ability to understand or express speech, caused by brain damage), R (right) pupil small, L (left) cataract, moves all extremities spont (spontaneously), does not follow commands

shunt reservoir does not pump/refill well

abd (abdomen) with no pseudocyst (fluid-filled cavity but lacking a wall or lining)

chest no palpable fx (fracture)

skin warm

prior abd (abdominal) scars"

The Physical Exam section of the above H&P did not include at least nine elements from the seven body areas or thirteen organ systems as per the hospital's Rules and Regulations.

During an interview and concurrent medical record review with the DHIM on 5/14/15 at 1200 hours, the DHIM confirmed the physical H&P examination was not complete for Patient 21.

Based on interview and medical record review, the hospital failed to ensure the Terms and Conditions of Services: Admission, Medical Services and Financial Agreement form, a patient consent to hospitalization and routine services, financial responsibility for payment of hospital charges for services rendered, and authorization to release patient-identifiable information was properly executed per the the hospital's P&P for two of 32 sampled patients (Patients 26 and 31) as evidenced by the section of the Signature of Witness being left blank. This failure had the potential for the patients not being fully informed of their rights to the services provided.


Findings:

1. The hospital's policy titled Admissions & ED Registration revised 5/2015, Section III. A. showed for the ambulance arrivals, in the event where the patient could not sign, two physicians would sign on the "Signature of Witness" line.

Patient 31's medical record was reviewed on 5/13/15. The patient was brought in by the ambulance, seen in the ED, admitted to the hospital, and then expired two days after. There was no Terms and Conditions of Service form found.

On 5/14/15 at 1215 hours, the DRRA produced a copy of a comment made by the registration staff in the electronic financial/billing system, stating no (patient or family) signatures were obtained.


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2. Review of the hospital's P&P titled Terms and Conditions of Service revised 5/15 showed staff should present the Terms and Conditions of Services: Admission, Medical Services and Financial Agreement to the patient/legal representative and obtain the appropriate signatures for each visit and inpatient admission. The patient would sign on the "signature of Patient" line, and the PAW would sign on the "Signature of Witness" line.

Review of Patient 26's medical record was initiated on 5/13/15. The patient was admitted to on 4/21/15, and discharged on 4/21/15.

Review of Patient 26's Terms and Conditions of Services: Admission, Medical Services and Financial Agreement form showed the patient signed on 4/21/15. The section of Signature of Witness (required if patient is unable to sign) was left blank.

During an interview and concurrent medical record review with the DRRA on 5/14/15 at 1400 hours, the DRRA stated the Signature of Witness was not needed when the patient was able to sign. However, the hospital's P&P showed the PAW was to sign on the "Signature of Witness" line.