HospitalInspections.org

Based on review of hospital documents, surveyors' observations, and interviews with hospital staff, the governing body failed to ensure:

a. adhere to the policies and procedures for medical records; See Tag C-301

b. the medical records were complete, accurately documented and readily accessible; See Tag C-302

c. patient reports completed by the mid-level practitioner were signed by the physician; See Tag C-0305

d. medical records was complete with all the documentation, including all practitioners' orders properly authenticated; See Tag C-306

e. all entries in the medical record were dated, timed and authenticated by the practitioner; See Tag C-307

f. clinical/medical records were safeguarded against loss, destruction or unauthorized use. See Tag C-308.

Based on review of hospital documents and medical record review, surveyor observations and staff interview, the hospital failed to ensure:

a. adhere to the policies and procedures for medical records; See Tag C-301

b. medical records were complete, accurately documented and readily accessible; See Tag C-302

c. patient reports completed by the mid-level practitioner were signed by the physician; See Tag C-0305

d. medical records was complete with all the documentation, including all practitioners' orders properly authenticated; See Tag C-306

e. all entries in the medical record were dated, timed and authenticated by the practitioner; See Tag C-307

f. clinical/medical records were safeguarded against loss, destruction or unauthorized use. See Tag C-308.

Based on surveyor observations, review of hospital documents and interviews with hospital staff, the hospital failed adhere to the policies and procedures for medical records.

Findings:

1. A hospital policy titled, "Information Security", revised 08/20/2014, documented, "... It is the responsibility of the organization to safeguard the record and its contents against, loss, destruction, tampering and unauthorized access or use..."

A different hospital policy titled, "General Overview", revised 08/20/2014 documented, "... The Health Information Service Department is responsible for protecting patient and confidentiality in accordance with state and federal law..."

On 04/02/2015 at 11:00 a.m., the surveyors accompanied Staff M to a metal storage building located on the hospital campus. At that time the surveyors observed the following;

~ The door was unlocked.

~ Equipment such as hospital beds, mattresses, metal infant cribs, laboratory (lab) processing equipment and lab supplies; metal shelving and metal cabinets, a riding lawn mower. and covered cardboard boxes. The boxes were reviewed by the surveyors in the presence of hospital Staff M and Q.

~ The cardboard boxes contained patient information such as: name, date of birth, medical records numbers, dates of services, insurance carrier, results and specific type of laboratory exams completed. This was verified by Staff M and Q.

~ A metal shelf that contained radiological film jackets. The writing on the outside of the film jackets contained the patient name and date of birth. The film jackets also contained the actual films from the radiological procedure(s). This was also verified by Staff M during the tour of the storage building on 04/02/2015.

~ Staff M and Q told the surveyor that the patient records were stored in the building after storage space in the hospital was no longer available.


2. The hospital's emergency department (ED) policy titled, "Triage", effective date of 05/01/2000, documented. ..." The Registered Nurse will evaluate and categorize each patient upon arrival to the Emergency Department into either Emergent, Urgent or Non-Urgent categories..."

~Review of the triage levels for the ED's electronic medical records documents five (5) triage options. The options were as follows: 1-resuscitation, 2-emergent, 3-urgent, 4-semi-urgent and 5-non-urgent.

~Six (Patients # 2, 4, 9, 10, 12 and 15) of fifteen medical records documented patient triage levels as 4- Semi-Urgent.

~The above information was confirmed by Staff M on the afternoon of 04/02/2015. Staff M told the surveyors that the triage options for the electronic medical records were not controlled by the hospital staff and would have to be changed at the corporate level.

Based on review of medical records and interviews with hospital staff, the hospital failed to ensure medical records were complete, accurately documented and readily accessible for 15 of 15 emergency department (ED) medical records reviewed.

Findings:

1. The surveyors requested and review 15 ED medical records on 04/02/2015.

2. During medical record review with Staff F on 04/02/2015 at 2:00 p.m., the surveyors observed missing documents from the records.

3. Review of the medical records provided to the surveyors by Staff F did not contain:
a. the title of the person creating the entry in the medical record,
b. the date, time and signature of the mid-level practitioner on the verbal orders,
c. the signature of the mid-level practitioner,
d. the date and time (authentication) the physician counter-signed the report(s). The documentation of physician authentication is not included in the written or electronic medical record. This was confirmed with Staff F at the time of review.

4. On 04/02/2015 at 4:00 p.m., Staff F stated that the only way to show the date and time of authentication was to access another program.

Based on medical record review and interviews with hospital staff, the hospital failed to ensure reports of physical examinations were signed by the physician. This occurred in 15 of 15 medical records reviewed.

Findings:

Written emergency department (ED) medical records were reviewed on the afternoon of 04/02/2015.

Review of Patient's #1 through 15 ED medical records documented all the patients were evaluated by a mid-level practitioner.

Staff F was asked for documentation in the ED medical records of where the physician counter signed the report(s) completed by the mid-level practitioner.

The documentation provided to the surveyors by Staff F did not contain, a signature for the mid-level practitioner; or the time and date the mid-level practitioner signed the report(s). The documents did not contain the title of the person authenticating the report(s). This was verified by Staff F on the afternoon of 04/02/15.

Based on review of medical records and hospital policies and procedures, and interviews with hospital staff, the hospital failed ensure every medical record was complete with all the documentation, including all practitioner's orders properly authenticated. This occurred in 15 of 15 emergency room records review.

Findings:

1. In Records #1 through 15, the medical records initially provided to the surveyors for review - identified at the time as complete medical records - contained verbal orders given to nursing staff by the mid-level practitioner. The records did not contain:
i. The signature of the mid-level practitioner who gave the verbal order, with time and date of the signature.
ii. The signature of the supervising physician, with time and date of the signature.
iii. The findings were reviewed and confirmed Staff F on 04/02/2015 at 2:00 p.m.

2. On 04/02/2015 at 4:00 p.m., Staff F and M brought the surveyors additional pages for each patient. The additional information still did not contain the titles of nursing staff or physician entries. See Tag C-302 for further details.

3. Policies and procedures for the Health Information Management Department did not contain a policy and procedure that specified the steps in order to obtain a complete record for patients requesting their complete records.

Based on review of medical records and policies and procedures, and interviews with hospital staff, the hospital failed to ensure that all entries in the medical records were authenticated with:

a. Signature, hand-written or electronic, of the individual who responsible for the entry;
b. Counter signature by the supervising medical staff member, when entries were made by mid-level practitioners;
c. Title of each individual; and
d. Date and time of the each entry and/or signature.

This occurred in 15 of 15 emergency room patient medical records reviewed.

Findings:

The hospital's medical records contained both electronic entered data/documents and hand-written documents that were scanned into the electronic medical record.

1. Records #1 through 15 did not contain the titles of the staff making the nursing entries.

2. Record #2 contained a hand-written nursing form. The form contained two different hand-writings.
i. The first entry did not contain the name of the individual, title, or time the entry was made. On 04/02/2015 at 2:00 p.m., Staff F identified the entry was made by Staff N, a registered nurse.
ii. The second entry contained the name and title of the staff, but did not contain the time the entry was made.

3. In Records #1 through 15, the medical records initially provided to the surveyors for review - identified at the time as complete medical records - contained verbal orders given to nursing staff by the mid-level practitioner. The records did not contain:
i. The signature of the mid-level practitioner who gave the verbal order, with time and date of the signature.
ii. The signature of the supervising physician, with time and date of the signature.
iii. The findings were reviewed and confirmed Staff F on 04/02/2015 at 2:00 p.m.

4. Policies and procedures for the Health Information Management Department did not contain a policy and procedure that specified how entries would be authenticated. This findings was review with Staff F on 04/02/2017 at 2:00 p.m.

5. On 04/02/2015 at 4:00 p.m., Staff F and M brought the surveyors additional pages for each patient. The additional information still did not contain the titles of nursing staff or physician entries. See Tag C-302 for further details.

6. The additional papers did not contain documentation that the supervising physician had co-signed the mid-level practitioner's emergency room report. This was confirmed with Staff K on 04/02/2015 at 4:00 p.m. She stated that on inpatient medical records, staff had to print History and Physical( H and P) reports that had been written or dictated by the mid-level practitioner, but they had not done this one emergency room records. The H and P reports were printed in order for the supervising physician to counter-sign the report.

Based on surveyors' observations, review of medical records and hospital documents and interviews with hospital staff, the hospital failed to ensure all confidential records, containing patient identifying information, were kept/maintained in secure locations to ensure the information was only accessed by those authorized to have access to the information.

Findings:

1. On 04/02/2015, shortly after arrival at the hospital at 10:00 am , the surveyors toured the facility with Staff M, including the medical records department.

2. Medical records staff (Staff F) told the surveyors that the hospital had electronic medical records and after the paper records were scanned, they were sent to an off-site company storage.

3. On 04/03/2015 at 11:00 a.m. , the surveyors and Staff M went into an unlocked detached metal building. The building contained equipment, supplies, large manilla folders and boxes, including, but not limited to:
a. Storage of hospital equipment and supplies, including beds, metal shelving and mowing equipment.

b. The boxes contained patient names and patient identifying information, including billing and laboratory records.
i. On top of two of the hospital beds, there were seven boxes of business office pages that contain patient names and confidential identifying information. The dates on these boxes were from January 2011 to December 28, 2011.
ii. In the corner closest to the door were shelving units containing 39 white covered boxes. Inside the boxes were laboratory records that contain patient names and confidential identifying information. The dates on the boxes were marked on the outside with dates ranging from January 2012 through May 2014.
iii. These findings were reviewed and confirmed with Staff M at the time of observation.

c. On the opposite side of the door, was a shelving unit that contained two and one-half shelves of large manilla folders. The folders were radiology film jackets and each folder contained x-ray films with patient names and confidential identifying information.