HospitalInspections.org

Based on document review, medical record review and staff interview, the hospital failed to ensure the medical staff followed its own Bylaws, Rules and Regulations when completing patient medical records in six (6) of ten (10) medical records (Patient #1, 2, 3, 4, 5 and 6) reviewed. This has the potential to negatively impact all patient care by not promoting continuity of care. Findings include:

1. Weirton Medical Center Medical/Dental Staff Rules and Regulations, last updated 11/08, state in part "...III. MEDICAL RECORDS...1...A complete history and physical (H&P) examination shall be on the patient's chart within twenty-four (24) hours after admission...If the H&P is done by a non-independent practitioner such as a Physician's Assistant (PA) or Nurse Practitioner (NP), the attending physician will retain accountability for the patient's medical history and physical examination...2. Histories, physical examinations and summaries shall be read, approved and countersigned by the attending physician...6. All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided...9. The patient's medical record shall be completed within thirty (30) days of discharge..."

2. Review of the medical record for Patient #1 revealed the H&P was dictated 1/25/10 and the Discharge (D/C) Summary was dictated 1/27/10 with no documented evidence of authentication of either by the physician.

3. Review of the medical record for Patient #2 revealed the D/C Summary was dictated 1/29/10 but not authenticated until 3/9/10.

3. Review of the medical record for Patient #3 revealed the H&P was dictated 1/27/10 with no documented evidence of authentication. The patient was discharged 1/29/10 but the D/C Summary was not dictated until 4/7/10. There is also no documented evidence of authentication of the D/C Summary.

4. Review of the medical record for Patient #4 revealed the H&P was dictated 1/26/10 with no documented evidence of authentication. There were a total of five (5) dictated Progress Notes ranging from 1/27/10 through 1/31/10 with no documented evidence of physician authentication. A Consult Report was dictated 1/29/10 with no documented evidence of authentication. The patient was discharged 1/31/10 with the D/C Summary being dictated 2/24/10 and no documented evidence of authentication.

5. Review of the medical record for Patient #5 revealed two (2) H&Ps dictated. The patient was admitted 1/15/10. The first H&P was dictated 1/16/10 and authenticated 1/18/10. The second H&P was dictated by a different physician on 1/21/10 with no documented evidence of authentication. An Operative Report was dictated on 1/22/10 with no documented evidence of authentication. There were a total of twelve (12) dictated Progress Notes ranging from 1/14/10 through 1/25/10 with no documented evidence of physician authentication. The D/C Summary was dictated 1/25/10 with no documented evidence of authentication.

6. Review of the medical record for Patient #6 revealed the patient was admitted on 11/14/10 at 2300. At the time of the medical record review (11/17/10 at 1100), there was no H&P on the record. The medical records department was contacted and there was no H&P dictated by the physician.

7. During an interview with the Chief Nursing Officer (CNO) in the afternoon of 11/17/10 the medical records were reviewed and the CNO agreed with the above findings.

Based on document review, medical record review and staff interview, the hospital failed to ensure the medical staff follows its own Bylaws, Rules and Regulations by authenticating telephone and/or verbal orders within forty-eight (48) hours in six (6) of ten (10) medical records (Patients #1, 3, 5, 6, 7 and 10) reviewed. This has the potential to negatively impact all patient care by the physician(s) not being able to identify transcription errors and potential patient safety risks in a timely manner. Findings include:

1. Weirton Medical Center Medical/Dental Staff Rules and Regulations, last updated 11/08, states in part "...6...Verbal orders shall be signed, dated and timed within 48 hours. Physicians covering for each other may sign each others verbal orders. Signing physician then becomes responsible for the order..."

2. Review of the medical record for Patient #1 revealed a total of ten (10) verbal and/or telephone orders ranging from 1/25/10 through 1/28/10 with no documented evidence of physician authentication.

3. Review of the medical record for Patient #3 revealed a total of five (5) verbal and/or telephone orders ranging from 1/27/10 through 1/29/10 with no documented evidence of physician authentication.

4. Review of the medical record for Patient #5 revealed a total of seven (7) verbal and/or telephone orders ranging from 1/17/10 through 1/25/10 with no documented evidence of physician authentication.

5. Review of the medical record for Patient #6 revealed a total of eight (8) verbal and/or telephone orders dated 11/15/10 with no documented evidence of physician authentication as of late afternoon 11/17/10.

6. Review of the medical record for Patient #7 revealed a total of six (6) verbal and/or telephone orders dated 11/15/10 with no documented evidence of physician authentication as of late afternoon 11/17/10.

7. Review of the medical record for Patient #10 revealed a total of four (4) verbal and/or telephone orders ranging from 11/12/10 through 11/15/10 with no documented evidence of authentication as of late afternoon 11/17/10.

8. During an interview in the late afternoon of 11/17/10 with the Chief Nursing Officer (CNO) the medical records were reviewed and the CNO agreed with the above findings.