HospitalInspections.org

Based on record review, interview, and observation the hospital failed to ensure medical records were accurately written as evidenced by 2 (#1, #4) Emergency Department (ED) medical records with incorrectly documented entries of 7 (#1, #2, #3, #4, #5, #6, #7) sampled medical records. The hospital failed to ensure a complete medical record contained all documents associated with the care provided to the patient, as evidenced by providing incomplete medical records as complete medical records, when the provided medical records did not contain physician orders or electronically generated vital signs/monitoring for the patient.
Findings:


Review of hospital policy #600-1.32, titled "General Documentation Guidelines", effective 12/12 and provided by S1CNO as current, revealed in part, the following:
Purpose: to establish a policy regarding the documentation of patient care. Documentation should provide a patient centered, comprehensive, consecutive, complete, current, and accurate record of care in the patient's electronic and paper medical record.
Policy: 1) All components of the patient care process, plan of care, evaluation, and outcomes will be documented in the patient's medical record ...2) The nursing process would be used in the delivery of patient care and would be evidenced in the following documentation: * Initial assessments and evaluation performed by the RN and appropriate reassessments ...*Documented nursing interventions which were related to the patient problems identified ...*Documented aspects of nursing care provided to the patient or significant other(s), * The effectiveness or outcomes of nursing interventions and the patient's response ...4) Documentation should be a record of first hand (direct) knowledge, observation, actions, decisions and outcomes ...5) All components of nursing care related to the patient are permanently integrated into the medical record or clinical information system and can be identified and retrieved.
Procedure: 1. All entries are prefaced with date and time of care or event by initiating a new charting session and providing the appropriate date and time of patient encounter and charting session date and time.


Review of hospital policy (no #) titled "Defining the Legal Health Record", effective date 6/26/14, provided by S11MedicalRecords as current, revealed the following, in part:
" ...Scope: The legal health record is a subset of the entire patient database which serves as the legal business record and applies to all uses and disclosures of the health record for the organization ...
The Legal Hybrid Health Record: ...The paper record will contain all documents associated with the care provide(d) to the patient with the exception of the following documents which will be maintained on the MedHost, Computerized Provider Order Entry (CPOE), Physician Documentation (Phys Doc), Electronic Medication Administration Record (EMAR), and the Clinical Documentation (Clin Doc) System in an electronic format.
Corrections or Addendums in the Electronic Record: ...2. ... 'late entry' should be documented clearly as close to chronological sequence as possible using "Late Entry, date, time" and indicate the date/time being referenced when the documentation should have been recorded. 3. In the EMR, recorded documentation will be corrected if in error and indicated with a dropdown showing the reason, whether modified (M) or revised (R), and the author performing the task. Patient Care Notes reveal specifics of any removal or deletion of data such as if documentation occurred for the wrong patient.
Further review revealed Physician Orders, as a part of the medical record could be in paper or electronic form (MedHost Patient Care), and was considered a part of the LHR (Legal Health Record).


Review of Medical Staff Rules and Regulations revealed, under section 2.8, Clinical Entries/Authentications, the following, in part: "All clinical entries in the patient's medical record, including written and verbal orders, shall be accurately dated, timed, and authenticated. "

Review of a MedHost Superuser Training Manual revealed, in part, Free-Text Notes documentation that read, " Additional information aside from the charting choices can be entered about a patient in free-text entry style. Each choice level had the 'Other' or 'Note' button, depending on the section and documentation choice selected ... " Further review revealed a heading titled "Changing Observation Times", with the following information provided: "All new charting entries are recorded with the current time. However, the time can be edited to reflect the actual time the observation, examination, procedure, or entry occurred, if necessary, before closing a section. " Further review revealed instructions on accomplishing editing of the time.


Patient #1:
Review of Patient #1's ED record revealed he was a 51 year old male who presented to the ED on 12/28/14 at 6:13 p.m. with complaints of Low Blood Pressure.
Review of Patient #1's "ED (Emergency Department) Physician Documentation " for 12/28/14 revealed the following documentation, in part, by S8MD:
6:26 p.m. - Patient #1 presents to ED...; patient medically screened;
6:29 p.m. - On Oxycontin, Fentanyl patch; past medical history of hip fracture and Hypertension; past surgical history of multiple orthopedic surgeries;
9:00 p.m. - call placed to Hospital A transfer center - patient request;
9:35 p.m. - Exam: ... Neuro: Awake and alert, GCS (Glascow Coma Scale) 15, oriented to person, place, time, and situation.
Psych: Awake, alert, with orientation to person, place, and time. Behavior, mood, and affect are within normal limits...
9:36 p.m. - Differential diagnosis: Hypotension due to overmedication/Pneumonia;
...Data reviewed: vital signs, nurse ' s notes;
ED course: initially thought to have Hypotension due to medication - taking Oxycontin and Fentanyl patch - patient had two patches on (although one was old and thought to be inert) - had spouse remove patch and gave Narcan 2 mg (milligrams) - after this patient convulsed briefly and was combative for about 20 to 30 minutes.
9:38 p.m. - Discussed with hospitalist at Hospital A who accepts patient.
9:39 p.m. - Data interpreted: pulse oximetry: on room air.

Review of Patient #1 ' s " Order Sheet " revealed the following, in part:
6:30 p.m. - Saline lock;
6:33 p.m. - Narcan 2 mg IVP (intravenous push);
6:59 p.m. - ETOH (Ethanol) stat;
6:59 p.m. - Ativan 2 mg IVP;
7:02 p.m. - cardiac monitor, blood pressure monitoring, continuous pulse oximetry; oxygen
9:06 p.m. - Consult S10Physician;
10:50 p.m. - Zofran 4 mg IVP over 2 minutes;
12/29/14 at 12:37 a.m. - Demerol 25 mg IVP.
Review of S8MD's disposition of Patient #1 documented on 12/28/14 at 9:39 p.m. revealed " Transfer ordered to Other Acute Facility. Diagnoses are Pneumonia, Acute Renal/Kidney Failure, Nontraumatic, Hypotension. Reason for transfer: Patient request. ... Condition is Stable for transfer. Problem is new. Symptoms have improved."

Review of Patient #1 ' s " ED Nurse Documentation " revealed, in part, he was a 51 year old male who arrived on 12/28/14 at 6:13 p.m. At 6:23 p.m., S9RN documented Patient #1 reported that he went to the urgent care center to be evaluated for flu, and his blood pressure was too low. Further review revealed he arrived ambulatory and was triaged at Acuity Level # 3. His blood pressure was 82/45, pulse 98, respirations 18, temperature 97.7 degrees, oxygen saturation 100%, weight 88.45 kilograms. Further review revealed the following documentation:
6:15 p.m. - 22 gauge saline lock inserted to left wrist;
6:40 p.m. - decline in condition after Narcan administration; S8MD at bedside, moved to trauma room;
6:45 p.m. - portable x-ray done;
7:01 p.m. - ETOH sent; 7:03 p.m. by - cardiac monitor on; NIBP (non-invasive blood pressure) on; oxygen applied at 15 liters (no documented evidence of route of administration)...
7:31 - EKG done;
10:29 p.m. - transfer report called to nurse at Hospital A;
12/29/14 at 12:33 a.m. - patient awake, alert, and oriented times 3. No cognitive and/or functional deficits noted. Patient verbalized understanding of disposition instructions.
1:04 a.m. - patient left the ED.
Review of the documented vital signs contained in the ED record revealed the following:
6:15 p.m. - blood pressure 92/46;
6:24 p.m. - blood pressure 82/45, pulse 98, respirations 18, temperature 97.7 degrees, oxygen saturation 100%;
6:30 p.m. - blood pressure 85/47, pulse 123, oxygen saturation 80%;
Review of Patient #1's Transfer Consent revealed the mode of transfer selected was " ambulance with Paramedic (Advanced Life support) and was signed by the transferring nurse and S8MD on 12/28/14 at 9:38 p.m. Further review revealed Patient #1's step-son signed the consent on 12/28/14 at 9:48 p.m. Further review revealed the following statement was selected as evidenced by an " x" in the box before the statement: "The patient is being transferred to a hospital that provides a different level of care and/or services which this hospital does not provide, for the purpose of stabilizing and/or treating the patient's Emergency Medical Condition, including psychiatric emergencies." S8MD signed the Physician Certification, and in the space for " Expected Benefits of Transfer " S8MD wrote " Pt. (patient) has MD known to them - request."
Review of Administered Medications revealed the following, in part:
6:20 p.m. Narcan 2 mg (Note 1: Administered by S5RN) IVP right hand -S4RN staff
6:20 p.m. Follow up: Response: Adverse Reaction, Physician notified- S14RN staff
7:00 p.m. Ativan 2mg (Note 2: Administered by S7RN) IVP right hand -S4RN staff
7:30 p.m. Follow up: Response: No adverse Reaction; Symptoms improved- S14RN staff
12:41 a.m. Zofran 4 mg IVP right antecubital- S6RN staff
12:41 a.m. Follow up: Response: No adverse response-S6RN staff
12:42 a.m. Demerol 25 mg IVP right antecubital- S6RN staff
12:42 a.m. Follow up: response: No adverse reaction- S6RN staff
Further review of the medical record revealed no documentation of nausea or vomiting, pain assessment, or indication for the Zofran and Demerol ordered and administered at 12:41 a.m. and 12:42 a.m.


In an interview 3/4/15 at 9:40 a.m. S4RN reported that she was one of the nurses that provided care to Patient #1 during his ED admission on 12/28/14. S4RN reported the assessment and intervention times documented are sometimes later than when the actual assessment or intervention was performed. After review of Patient #1's medical record for his 12/28/14 visit to the ED, S4RN reported there should have been a print-out of the patient's vital signs, produced by the Phillips monitor, which merged with the patient ' s record. The RN reported that is why the ED nurses did not document vital signs very often. S4RN confirmed there was not a vital sign monitor print out included in Patient #1's medical record. S4RN reported that Patient #1 had 2 (transdermal medication) patches on his body when she entered his room at 6:15 p.m. S4RN reported that she could not remember what kind (medication patches), and verified that there was no documentation of the presence of the medication patches, or when a patch was removed and by whom. S4RN confirmed that nursing documentation included an entry at 6:40 p.m., which read " Pt is Decline in condition after Narcan administration ...moved to trauma room." S4RN further reported she witnessed the patient have what looked like a seizure. The RN further described the patient as having a " white " tongue, decorticate posturing, and being on a non-rebreather. The RN reported the patient was of " grayish " color when he presented to the ED. S4RN verified there was no documentation of these assessments or what the decline in the patient ' s condition had been. S4RN stated this was the trouble with team nursing; one person is documenting while the other person is performing skills. When reviewing Patient #1's medical record, S4RN reported that the MD's sheet of " Dispensed Medications were the physician's orders. After being unable to locate physician orders with time ordered and authentication by the provider, staff name taking a verbal order, or a time for either, S4RN reported that there was a separate sheet of physician orders not included with the chart. S4RN verified that the section of medical record titled, "Orders" did not include medication orders, and did not document the actual provider order for interventions listed. After review of a section of the medical record titled, " Administered Medications " , S4RN verified a documented entry (at 6:20 p.m.) of Narcan 2 mg. IVP, administered by another RN and documented by her (S4RN). A follow-up entry for the Narcan administration was documented at 7:00 p.m. as " Response: Adverse Reaction; Physician Notified." S4RN verified that the type or nature of the patient's adverse reaction was not documented. When reviewing the ED Nurse Documentation section of Patient #1's medical record, S4RN couldn't explain why the patient ' s General assessment was documented as occurring at 11:00 p.m. when the patient arrived at the ED at 6:13 p.m. S4RN reported that there should be a physician order record, an event record, and a vital sign record included in the chart, which there were not.


In an interview 3/4/15 at 11:00 a.m. S1CNO (Chief Nursing Officer) and S2Quality confirmed physician orders, an event record, and the Trend Review Sheet of Vital signs were not included in the medical records provided as Complete medical records of Patient #1 and Patient #4, as requested. S2Quality reported that physician's orders, the Event record, and Vital sign records (from the automated monitor machines) were not a part of a patient's complete chart (medical record). S1CNO reported that the above listed documents should be in the record and she would obtain the omitted portions of the patients ' medical records. S2Quality provided the omitted copies of the physician orders, event report, and vital sign sheet generated from the vital sign monitoring machine. S2Quality reported that there was a mistake and these documents were actually part of the medical record, after all.


In an interview 3/4/15 at 11:25 a.m. S7RN reviewed the medical record of Patient #1, and confirmed the documentation showed he administered Ativan 2mg at 7:00 p.m. to Patient #1. S7RN reported that the documentation should indicate that he "pulled" (removed from the automated medication dispensing(ADM) machine) the Ativan, because he did not recall administering it, but then said, "I really don't recall if I pulled it (the medication) or gave it. " S7RN agreed that the charting did not document what actually happened.

In an interview 3/4/15 at 12:00 noon, S8MD confirmed he was the ED physician on duty 12/28/14 and provided care to Patient #1. S8MD confirmed the medical record documented an exam at 9:35 p.m. S8MD stated when documenting an exam later (after the exam had been performed) there was no way for him to " back time" it, and he could not change the time until after the patient had been discharged. S8MD could not locate or provide any documentation that he had evaluated Patient #1 after the Narcan was given. "(I) Can't be sure if the exam documented was at 9:35 p.m.(time documented) or earlier." S8MD stated, "This, I guess, didn't paint an accurate betrayal of him (Patient #1)." S8MD reported the patient was transferred to another hospital because of patient and family request. After reviewing the Patient Transform Form (Emergency Services ER-3401-2CER 02/05 (Rev. 12/11) page 2 of 2) S8MD confirmed he signed the transform form as the Transferring Physician, but checked the wrong reason for transfer box. He (S8MD) confirmed he checked the box indicating the patient was being transferred to a hospital that provided a higher level of care, but reported that was incorrect and a mistake. S8MD reported that it was checked (incorrectly) out of habit.

In an interview 3/4/15 at 2:10 p.m. S9RN reported he doesn't necessarily do an assessment on each patient. S9RN reported that in the ED team nursing is done so you may take care of a patient who was assessed by another nurse. When asked if he assessed a patient at the time of providing an intervention, he responded, "Any good nurse would do a focused assessment at the time of providing an intervention, like med(ication) administration." S9RN reported that when documenting after an assessment or intervention was provided, MedDoc (the ED electronic documentation system) had a drop down list, providing the ability to put in a narrative note. S9RN stated the system (electronic charting system) allowed the staff documenting to enter a late entry into the system, as there was an icon in every section where you had the ability to enter the actual time of the assessment or intervention, and the actual time of documentation would be noted, as well,

In an interview 3/4/15 at 2:30 p.m., S4RN reported that if she assessed a patient, 9 times out of 10 she would document it. S4RN reported that she does not always document on a patient if another nurse says he or she has documented on the patient. The RN reported that when a narcotic is given, she had to document who pulled it and who administered it. S4RN stated, "You should always be able to tell who pulled it (a narcotic) and who gave it." In reference to her documentation of the "adverse reaction" response of Patient #1 to the administration of Narcan, S4RN reported that this was the only option (from drop down box of choices) that fit. S4RN reported that MedHost trainers told staff, during training, to try not to free document (narrative documentation) any more than possible because it would not capture charges, as charges were built in. After review of documented response (at 7:30 p.m.) of Patient #1 to Ativan administered at 7:00 p.m., S4RN confirmed the response was documented as "No adverse reaction; Symptoms improved ". S4RN reported that she always assessed her patients, but another nurse usually documented if she performed the skills (interventions). She (S4RN) confirmed there was not documentation of what symptoms were improved, and to what degree. S4RN stated that was all the system would allow them (staff) to document. S4RN was asked if there was a system for documenting a late entry, or documenting after an intervention. S4RN reported that there was an option in the computer charting to change the time on a late entry. She reported it was easier and quicker to click "now" tab, instead of having to go in and take the extra steps to enter the actual time something was done. S4RN reported that this was not an option with a verbal order. The computer system did not give you an option to enter the actual time you received a verbal order, but rather automatically entered the time of the documentation of the verbal order. S4RN confirmed there was no ability to enter into the computer the indications for medications ordered, unless it was a PRN (as needed) order. PRN orders generated the requirement to enter an indication, diagnosis, or reason the medication was given.


Patient #4
Review of the medical record for Patient #4 revealed, in part, she was a 7 year old female that presented to the ED 4/6/15 at 7:23 p.m. via ambulance with a history of multiple seizures (a total of 6 that evening). The patient had a history of Cerebral Palsy, seizures, hydrocephalus, and spinal tuberculosis. The patient was assessed and an order written at 10:29 p.m. to transport her to a specialized children's hospital. The EMS (Emergency Medical System) team did not feel comfortable transporting the child to the accepting hospital (in another section of the state), secondary to her being on a transport ventilator. The receiving hospital was contacted and was to send a transport team. While awaiting the arrival of the transport team the child suffered a cardiac arrest at 6:19 a.m., was coded, and expired at 6:45 a.m. A printed copy of Patient #4's medical record, provided 3/3/15 as a complete medical record, did not include physician orders, monitoring pages, or an event record. The afore mentioned documents were provided 3/4/15 by S2Quality after review of the record revealed the physician orders, event record, and monitor results were not included in the medical record and were requested. Review of Nurse Documentation, Outcome: revealed, in part, the following:
4/7/14
12:32 a.m. Transferred by EMS (Emergency Medical Services) ground to (name of accepting hospital)
Discharge Assessment: Patient unresponsive, Oriented to none, Patient unable to independently bathe himself/herself, unable to independently dress himself/herself, unable to independently attend to toileting needs, unable to independently transfer in/out of bed and/or chair, unable to maintain full control of urinary and bowel functions, unable to independently feed himself/herself.
9:16 a.m. patient expired at April 07, 2014 at 6:46 a.m. ....

Review of Nursing Documentation, Assessment, revealed, in part, the following:
4/7/14
12:45 a.m. (Ambulance company) request transport team for transfer to (name of accepting hospital)
1:25 a.m. Transport team will be leaving (city of accepting hospital) in 5 minutes to pick up pt. (patient) via ground EMS....
5:17 a.m. Reassessment: Transport team from (accepting hospital) present in room for report. Care transferred at this time.
7:41 a.m. Mother chose (name of Funeral Home) - notified for release...

Review of Administered medications revealed, in part, at 8:08 a.m. Ativan 1 mg po (by mouth) by S4RN. A Note (#5 note under administered medications) read: Ativan 1 mg po ordered for (name of patient's mother), mother of deceased Patient #4. Administered to mother with Family at bedside. NADN (no acute distress noted).

In an interview 3/4/15 at 9:30 a.m., S4RN reviewed the chart of Patient #4 and reported that she started the day shift the morning that Patient #4 expired. She confirmed that she administered the Ativan to the patient's mother and charted it on Patient #4's chart. S4RN reported that she was in disagreement with the order, but the physician prevailed and she followed the order. S4RN verified her documentation, and that there was no assessment of the patient's mother, other than "no acute distress was noted " . S4RN confirmed there was no documentation of an assessment of allergies or reassessment of the mother's response to the administered mediation. S4RN reported that she was not sure what the hospital policy was for treatment of, or medication administration to, someone not registered as a patient and/or without a chart. The RN reported that she was not sure how the medication was charged, but verified that the mediation was listed as charge to Patient #4's account on the medical record reviewed. S4RN reported that she could not explain why documentation at 12:32 a.m. noted Patient #4 was discharged with an assessment under "Outcomes", but under "Assessments", at 12:45 a.m., the ambulance team requested a transport team and they were called.

In an interview 3/4/15 at 11:45 a.m. S2Quality briefly reviewed Patient #4's record. S2Quality verified that the documentation of Patient #4's transfer at 12:32 a.m. was not accurate and should not have been charted if the transfer did not happen. S2Quality reported that it was not the hospital's policy or usual procedure to administer medication to a person who was not a registered patient and document it on another patient's medical record, but she did not think the hospital had a specific policy regarding that. S2Quality agreed that the mother of Patient #4 should have had her own chart, assessments, and charges. No policy and procedure was provided related to documenting care provided to a person on another person's/patient's medical record.


In an interview 3/5/15 at 9:15 a.m. S11MedicalRecords reported she was an RHIA (Registered Health Information Administrator) and director of Medical Records. S11MedicalRecords reported that the hospital had a hybrid medical record, which meant it consisted of electronic medical records, paper records, electronic images, or any combination of these. S11MedicalRecords reported she thought, originally, the policy and training received from corporate was that physician orders were not a part of the complete medical record. S11MedicalRecords Records reported that when she reviewed the newest version of the Training Manual for "Printing Patient Documentation for Legal Medical Record" (Version 6/20.14), it did include the Physician Orders. S11MedicalRecords reported that different portions of the electronic medical records are generated from different systems, and are integrated into the medical record, and had to be printed from each source (for a complete paper copy).


During an observation 3/5/15 at 11:20 a.m. S10RN reported she was the Clinical Educator for the ED. An observation of the computer screens and demonstration of charting options in the MedHost system (electronic system used in the ED) was provided by S10RN. S10RN navigated through screens for entering different types of information such as nursing notes, physician's notes, assessments, and orders. On a screen for charting a patient response to a medication, S10RN demonstrated the drop down choices that are preset in the system. Besides the 26 preset (response to medication) choices, S10RN demonstrated a "note" icon that enabled free text to be entered. S10RN reported that there was almost always an option to free text from the "note" icon. S10RN demonstrated that a vital signs icon could be chosen, in addition, and vitals and/or a pain assessment could be entered as part of the response to medication administered. S10RN reported that most of the time, staff was used to using the dropdown box of preset choices, and it was much easier to choose that, rather than open the vital sign entry box to record an assessment of pain, nausea, temperature, or respiratory rate and status. S10RN demonstrated, on the computer screen, an icon of a clock that allowed the user to enter the time when an assessment or intervention was actually performed, and noted as a late entry. S10RN confirmed that charting on the MedHost system did allow staff (physicians, mid-level providers, and nurses) to enter accurate assessments, interventions, and responses to those interventions, as well as orders that would document a complete and accurate medical record. S10RN verified that staff did not always do this.