HospitalInspections.org

Based on medical record review and interview, the hospital failed to ensure staff documented accurate information concerning patient's care and treatment in the medical record for 1 of 3 (Patient #1) sampled patients who presented to the hospital 's emergency department [ED] seeking care and treatment.

The findings included:

Review of the hospital's ED Provider Note dated 9/22/2023 at 8:49 PM, revealed Patient #1 presented to the Hospital #1 ED and reported a leg injury while being transferred from the bed to the chair with a chief complaint of right lower extremity bruising. The diagnostic results documented on the ED Provider Note were for Patient #2.

Review of the hospital's ED [Emergency Department] provider note dated 9/25/2023 at 8:08 PM, revealed, "...Pt [Patient #1] hurt right leg thursday during a transfer...Patient was here last Friday [9/22/2023] for an x-ray and transposition with copy and paste technology lead [sic] to a diagnosis of no fracture this patient was returned to the nursing home accordingly. It was noted the radiologic reading for this patient did reveal a nondisplaced fracture of the medial tibial plateau in the right fibular head. Patient was asked to return to the emergency department for splint replacement and appropriate referral to orthopedic surgeon..."

During an interview on 2/26/2024 at 11:05 AM, the ED Nursing Director stated, "Patient came here on 9/22/2023 saw [ED Physician #1]...copied [Patient #2]'s x-ray, diagnosed with a contusion and sent back..." The ED Nursing Director stated the (Named Nursing Home) Administrator called on 9/25/2023 and informed the ED Nursing Director that the wrong x-ray was included in the chart. The ED Nursing Director stated the Administrator was told they [nursing home] would have to bring Patient #1 back to the Emergency Department. The ED Nursing Director stated the ED Medical Director ordered an x-ray, placed a splint on Patient #1's right leg, and determined there was no need for admission or surgical intervention.

During an interview on 2/26/2024 at 2:46 PM, the Chief Quality Officer confirmed that to prevent the wrong x-ray diagnostic results from getting into the wrong chart, the hospital reiterated to the ED providers to copy and highlight and make sure the right patient x-ray was pasted into the right chart. The Chief Quality Officer stated the hospital emphasized to the ED providers to verify the name on the diagnostic results and what medical record it was being placed in.

During an interview on 2/26/2024 at 3:06 AM, the ED Medical Director explained that the incident involving the wrong x-ray being placed in Patient #1's chart involved the use of 2 computer systems. The ED Medical Director stated one of the computer systems was the hospital's primary system, and the second computer system was used by Radiology from Healthcare System #1. The ED Medical Director stated the ED providers should be more aware when and what they were copying and pasting from one computer system to the other.

During an interview on 2/26/2024 at 3:21 PM, the ED Nursing Director confirmed that she was made aware of the incident with Patient #1's medical record when "...the Nursing Home Administrator or Director called to let me know that there was wrong information in the wrong chart...I opened the chart and called x-ray and called her [Nursing Home Administrator] back and told her to bring her [Patient #1] back to re x-ray for fracture..." The ED Nursing Director stated Patient #1 had come to the ED on 9/22/2023, and ED Physician #1 inadvertently pasted the wrong x-ray results on Patient #1's medical record. The ED Nursing Director stated she treated it as an x-ray discrepancy (instance where a follow-up x-ray is required). The ED Nursing Director further stated that to prevent this type of occurrenc from happening in the future, that she, the Chief Quality Officer and the Chief Nursing Officer spoke with the ED Medical Director, and the ED Medical Director informed the ED providers that they were going to have to check the patients name to make sure it was on the right medical record.

During an interview on 2/27/2024 at 9:31 AM, ED Physician #1 confirmed that the hospital used 2 different computer systems, one system was used to pull up a patient x-ray, and then the provider copied and pasted the x-ray results into the medical record in the second computer system. ED Physician #1 confirmed he pasted the wrong x-ray results into Patient #1's medical record. ED Physician #1 confirmed the hospital's plan to prevent this from reoccurring was for the ED providers to be more attentive to checking the name on the x-ray results and the medical record.

During an interview on 2/28/2024 at 8:31 AM, the Chief Quality Officer confirmed that the facility failed to maintain an accurate medical record for Patient #1 on 9/22/2023.

During an interview on 2/28/2024 at 8:35 AM, when asked if the facility failed to maintain an accurate medical record for Patient #1 on 9/22/2023, the Chief Executive Officer (CEO) stated, "...[ED Physician #1] copied and pasted the wrong information...on 9/22[2023] the medical record was not accurate...the physician made an error." The CEO confirmed the medical record for Patient #1 was inaccurate on 9/22/2023.