HospitalInspections.org

Based on document review and interview, in one (1) of one (1) medical record reviewed, the facility did not implement its policy to ensure a patient prompt access to her complete medical record (Patient # 1).

Findings Include:

Review of the hospital's Policy and Procedure titled "Patient Access to Protected Health Information," revised 02/24/17 revealed that the facility must respond to request for medical records within ten (10) working days.


Review of the facility's "Request for Access" forms identified a request for medical record was received from Patient #1 on 04/21/17 and the facility documented a response on 05/18/17.

On 05/30/17 the facility received another request from Patient #1, indicating she had not received a complete medical record and stated she was missing some portion of the medical record, notably, the ambulance report, the ER report, and pages 1-7.
There was no documented response by the facility.

On 07/05/17 the patient's request indicated she came to the facility and was requesting all documentation that was not yet provided to her.

These findings were confirmed with Staff A, Senior Associate Executive Director and Staff B, Associate Director of Quality Management during the exit conference on 07/13/17 at 4:30 PM.

Based on document review and interview, in one (1) of 10 personnel files reviewed, it was determined the facility failed to follow its policy for training and certification of Emergency Department staff nurse.

Findings include:

Review of the personnel files revealed that Staff F, ER nurse, does not have current ACLS and PALS certifications,
which is a requirement for the Emergency Department (ED) staff nurse, as per facility's ED Staff Nurse Job Description.

This finding was confirmed with Staff B, Associate Director of Quality Management and Staff K , Personnel Labor Relations Associate, on 7/13/17 at approximately 4:30 PM.

Based on medical record review, document review and interview, in one (1) of 10 medical records reviewed, nursing staff did not implement physician orders for daily vital signs assessment (Patient # 1).

Findings include:

Review of medical record for Patient #1 identified that the patient was admitted to the psychiatric unit on 12/14/16 at 2:42 PM.
On 12/23/16 at 4:05 PM, physician ordered daily vital signs.

Review of Vital Signs Trend Report showed that there were no daily vital signs documented in the medical record for four (4) consecutive days, 12/24 to 12/27/16.

Review of the hospital's Policy and Procedure titled "Measurement of Vital Signs," revised 11/2016 revealed that vital signs must be taken daily while a patient is on the psychiatry unit.

During interview conducted on 07/12/17 at 1:40 PM, Staff J, Registered Nurse and Staff Z , Nurse Manager, confirmed that vital signs should be taken daily on the inpatient psychiatry unit, in accordance with the facility's policy.