HospitalInspections.org

Based on interviews, record reviews, and document reviews, it was determined the facility staff failed to ensure electronic medical record documentation was protected from alteration for 1 of 21 patients sampled for review (Patient #1).

The findings include:

During the review to ensure medical records were accessible for the required time frame, and that integrity and security of the record was maintained, the following was noted.

Patient #1's clinical documentation from 2011 related to admission education was altered when the facility's electronic documentation software was updated.

On 9/15/15 at 1:05PM, Patient #1's clinical record was reviewed with the facility's Clinical Informatics Specialist (CIS) #1. No evidence was found in Patient #1's clinical record to indicate the patient had been provided information about his/her patient rights.

On 9/15/15 at 3:05PM, CIS #1 and the facility's Patient Access Supervisor (PAS) were interviewed about Patient #1's patient rights education/information. The PAS reported that documentation indicating Patient #1 was provided patient rights education / information was not found in the patient's clinical record. The PAS stated the patient rights education/information should have been provided by the pre-operative nursing staff. CIS #1 stated it should have been documented as 'room orientation' education; but it might have been affected by a software update.

On 9/16/15 at 10:05AM, CIS #1 provided the survey team with a screen shot of the section of a spreadsheet which included the electronic documentation software item information that was updated. CIS #1 explained that the spreadsheet should have been reviewed to make certain that the information linked to the item remained the same after the update.

On 9/16/15 at 10:15AM, a screenshot of Patient #1's electronic clinical record was provided to the surveyor to show that only the words 'Room/Orientation' was documented as the 'Description' under the 'Education ... Title: Generic Teaching Goals / Outcomes ... Room / Orientation' section electronic medical record. (Shortly after receiving the printed screenshot, the surveyor was provided a copy of the aforementioned information printed from the patient's electronic medical record.) This documentation was dated as being completed on 11/22/11 at 4:58PM.

On 9/16/15 at 10:20AM, the CIS #1 stated the update can be corrected to include the planned documentation under the Room / Orientation description. The surveyor requested a copy of the documentation after the update was corrected.

On 9/16/15 at 11:33AM, the survey team was provided with a copy of Patient #1's 'Education ... Title: Generic Teaching Goals / Outcomes ... Room / Orientation' section dated 11/22/11 at 4:58PM; this documentation now included the following documentation as the 'Description': "Call light, bed control, visiting hours, patient rights, communicating safety concerns, phone, television, expected meal tray delivery, bathroom call light, electrical and safety concerns, no tobacco use policy, cell phones, Admission [sic] information reviewed."

On 9/16/15 at 3:55PM, (a) the Manager of (software name) Input Team, (b) Input Clinical Documentation Team Lead, and (c) the Vice President of Quality & Patient Safety were interviewed related to information contained in Patient #1's electronic clinical record being changed as a result of a software update. The Manager of (software name) Input Team acknowledged that at the time of the software update a change occurred which altered the wording of Patient #1's aforementioned documentation; he/she also reported this was being discussed with the software vender. The VP of Quality & Patient Safety reported the change in the aforementioned documentation occurred at the end of June, 2015.