HospitalInspections.org

Based on staff interview and medical record review, it was determined the hospital failed to ensure the medical records of 5 of 16 pregnant patients (#1, #3, #10, #23, and #27) whose records were reviewed, contained sufficient information to document patient care. This resulted in the hospital's inability to know what care was provided to patients and to support the need for the care provided. Findings include:

1. Patient #10's medical record documented a 29 year old female who presented to the emergency department on 4/14/10 at 1:34 PM. The face sheet stated her reason for the visit was "CONTRACTIONS, LEAKING FLUID." Records from her physician's office stated this was her third pregnancy and she had given birth 2 times. Minimal nursing notes were documented.

The first nursing note on the "LD-Flowsheet" was timed at 1:50 PM on 4/14/10. It listed a set of vital signs. The dilation, effacement, and station (indicators of labor) were documented at 2:06 PM and 3:07 PM. A nursing note explaining why the patient was being treated was not present in the medical record.

The Assistant Director for Health Information Management was interviewed on 4/23/10 at 12:50 PM. She stated the record was complete. She stated the L&D Unit used a different computerized record system from the rest of the hospital. She stated Health Information Management did not have access to those records; instead, a L&D nurse had to print the record and bring a hard copy to Health Information Management.

Staff F, the RN who cared for Patient #10, was interviewed on 4/26/10 at 9:10 AM. She reviewed the nursing notes. She then left and returned at 9:40 AM with a "LD-Flowsheet" that contained a nursing note dated 4/14/10 at 1:49 PM, that documented the reason for Patient #10's admission. She stated the computer printed what nurses tell it to print but, if they were not careful, the computer "will print odd things." The first medical record was not complete and the hospital did not know that it was not complete.

Patient #10's medical record documented a nursing note on 4/14/10 at 2:12 PM, which stated the physician was "notified of contractions and cervical status with plan to recheck cervix at 1500 (3:00 PM)." A physician telephone order, on 4/14/10 at 3:10 PM, stated "discharge if no cervical change." The final nursing note, on 4/14/10 at 3:09 PM, stated Patient #10 had been given discharge instructions and would return if there were any further problems. The condition of Patient #10's cervix was not documented. Also, the "Stored Fetal Strip" documented contractions indicating Patient #10 was in early labor. Nursing notes did not document this or why she was being discharged.

2. Patient #1's medical record documented a 19 year old female who presented to the emergency department on 4/02/10 at 7:52 PM. The face sheet of her medical record indicated she was approximately 29 weeks pregnant and stated her reason for admission was "DISCHARGE." The first nursing note on the "LD-Flowsheet" was dated 4/02/10 at 8:00 PM. It stated Patient #1 complained of pelvic cramping. The flowsheet stated Patient #1 did not have signs or symptoms of a urinary tract infection but stated a urine specimen was obtained. An order for a urine test was not documented. The note did not state why the urine specimen was obtained and results of the laboratory test were not included on the medical record. The nursing note on the flowsheet at 8:20 PM, stated "Dr. [name] in department. Report given on pt's c/o sharp pain to pelvic area, gestation, efm tracing. Orders received to discharge pt to home." The flowsheet stated Patient #1 was discharged 4/02/10 at 8:40 PM. An assessment of Patient #1's pain, e.g. number on a pain scale or whether it was related to contractions, was not documented. The record did not document if the pain had resolved or decreased prior to discharge. Even though the flowsheet stated the physician had given an order to discharge Patient #1, the order was not documented.

Staff A, the RN who cared for Patient #1 on 4/02/10, was interviewed on 4/26/10 at 1:05 PM. She reviewed the medical record and confirmed the missing documentation.

3. Patient #27's medical record documented a 19 year old female who presented to the emergency department on 3/31/10 at 5:19 PM. The face sheet stated the reason for the visit was "34 WEEKS PREGNANT BACK PAIN." The nursing note on the "LD-Flowsheet," dated 3/31/10 at 5:25 PM, stated "pt presents with right sided back pain, pt reports that she has been cleaning all day and cleaning carpets. pt reports that she feels fetal movement, [negative] for bleeding." At 5:28 PM, the nurse documented "clean cath dipped, negative findings, dr. [name] notified, pt to dc to home." The final nursing note on the flowsheet was dated 3/31/10 at 6:05 PM. It stated Patient #27 was not having contractions. A discharge note was not documented.

Patient #27's presenting complaint was back pain. The medical record did not include documentation of an assessment of her back pain. No medical history was documented. No documentation was present that Patient #27 stated she was having contractions or thought she was in labor. An order to discharge Patient #27 was not documented.

Staff D, the RN who treated Patient #27, was interviewed on 4/23/10 at 3:45 PM. She reviewed the record and confirmed the documentation was missing.

4. Patient #23's medical record documented a 24 year old female who presented to the emergency department on 3/13/10 at 10:53 PM. The face sheet stated the reason for the visit was "SEVERE ABDOMINAL PAIN AND [CRAMPING]." The nursing note on the "LD-Flowsheet," dated 3/13/10 at 11:00 PM, stated Patient #23 began having sharp cramping in her lower abdomen around 7:00 PM that night. An old medical record included with the patient chart documented she was pregnant and was due on 6/16/10. It also indicated she was diabetic. One set of vital signs (bp 105/64, p 103) was documented on 3/13/10 at 11:11 PM. A telephone order for laboratory tests and intravenous fluids was documented on 3/13/10 at 11:20 PM. Another telephone order to discharge Patient #23 when she was feeling better was documented on 3/14/10 at 12:33 AM. An assessment of Patient #23's pain was not documented. She was given a snack at 12:34 AM on 3/14/10. The nurse documented the patient was "feeling better" at 12:55 AM on 3/14/10. No specifics were documented. The final nursing note stated Patient #23 was discharged at 1:12 AM on 3/14/10. The note stated "Condition stable." A rationale for this determination was not documented.

Staff A, the RN who cared for Patient #23 on 3/13/10 and 3/14/10, was interviewed on 4/26/10 at 1:05 PM. She reviewed the medical record. She stated she did not clearly remember the encounter but she thought Patient #23's pain was not related to labor. She said she did not remember Patient #23's condition at discharge.

5. Patient #3's medical record documented a 28 year old female who presented to the emergency department on 4/04/10 at 7:01 PM. The face sheet stated the reason for the visit was "CONTRACTIONS DUE DATE 04-26-10." Nursing notes did not document Patient #3's behavior or demeanor. An old medical history by a physician assistant, dated 2/03/10, stated Patient #3 had a history of post partum depression. A telephone order for a urine toxicology screen was documented on 4/04/10 which stated Patient #3 could be discharged if the screen was negative. No reason for the test was documented. The results of the screen were negative. A discharge note was not present on the medical record. The last nursing note was at 9:00 PM on 4/04/10 and only documented Patient #3's vital signs.

Staff G, the RN who cared for Patient #3 on 4/04/10, was interviewed on 4/26/10 at 12:35 PM. She reviewed the medical record. She stated Patient #3 came to the unit covered in confetti. She said Patient #3 was "acting odd." She stated this was not documented.

The hospital's medical records for obstetrical patients were incomplete.