HospitalInspections.org

Based on documentation in 10 of 10 medical records reviewed (Patient #s 1 through 10) it was determined that the hospital failed to ensure that all entries in the medical records were legible, complete, dated, timed, and/or authenticated. Findings include, but are not limited to:

1. The record of Patient #1 who was admitted on 04/13/2011 was reviewed.
The Perfusion Record form completed for a surgical procedure conducted on 04/14/2011 contained nine entries that had been altered by writeovers or obliterated by scribbling over/scratching out. Those entries included time and other perfusion related values. The form was not authenticated by the author of the entries.
The Perfusion Open Heart Checklist was not dated.
Entries on the Plan of Care form dated 04/13/2011 and 04/14/2011 lacked the time of the entries.
An entry on a CVOR Surgery Report Sheet was scratched out and the form was not dated, timed or authenticated.
The two page Conditions of Admission form which reflected a form revision dated of "8/28/07" contained spaces for the patient's signature and date and initials to acknowledge receipt of other information. Those spaces were all blank.

2. The record of Patient #2 who was admitted on 07/22/2011 was reviewed.
A Discharge Summary, which included a physical exam, and which was dictated and transcribed on 07/30/2011, lacked the date of service and discharge date.
The Perfusion Record form included spaces for "Blood Type" and "Total Time" which were blank.
The Perfusion Open Heart Checklist contained 41 items. Item #'s 24, and 36 through 41 were not checked to reflect completion as all other items were. Additionally the form was not dated or timed.
A Universal Protocol Checklist for a coronary artery bypass graft surgery was dated "7/24". The date was incomplete and inaccurate as that procedure was performed on 07/25/2011. Additionally, two entries on the form lacked the time of the entry.
The time the patient signed an Informed Consent form for a coronary angiogram on 07/22/2011 had been altered by a writeover.
The Adult Nursing Assessment form dated 07/22/2011 contained a space for documentation as to whether the patient was given advance directive information. That space was blank and did not reflect whether or not the information was provided.
The Inpatient/Outpatient Conditions of Admission and Consent for Medical Treatment form which reflected a form revision dated of "2/08" contained six spaces for the patient to indicate advance directive choices and to acknowledge receipt of information. Those spaces were blank on the form signed by the patient on 07/22/2011.

3. The record of Patient #4 who was admitted on 05/09/2011 was reviewed.
The date a History and Physical Exam Update Interval Note form had been completed and dated had been written over.
The Perfusion Record form reflected that the surgery date was "4-10-11", an entry under "Allergies and History" was written over, and the "Total Time" was blank.
Entries on a Universal Protocol Checklist dated 05/10/2011 were not authenticated and timed. The time recorded for one entry had been scribbled over/scratched out.
Entries on pages 3, 4, and 5 of the Critical Care Ongoing Monitoring Tool for "5/10 - 5/11/2011" had been written over, as well as on page 5 for "5/14/11 - 5/15/11", and page 5 for "5/16 - 5/17/2011".
A Post Angiogram [Vital Signs/Site] Check Flow Sheet contained an incomplete date, only the month and day or the month and year as "5/11", and two times which had been written over or scratched out.
The date on an untitled form for "IABP" (Intra Aortic Balloon Pump) monitoring had been written over.
Pulse findings on a second untitled form for "IABP" monitoring dated "5/11 - 5/12/11" had been written over.
Physician Progress Notes dated 05/16/2011 were not timed.
The Adult Nursing Assessment form dated 05/09/2011 contained a space for documentation as to whether the patient was given advance directive information. That space was blank and did not reflect whether or not the information was provided.

4. The record of Patient #5 who was admitted on 06/19/2009 was reviewed.
A History and Physical Exam Update Interval Note form was dated 06/18/2009, the day prior to admission, and did not reflect the time the note had been written.
A second History and Physical Exam Update Interval Note form had been completed and was dated 06/05/2009 and was not timed.
An Operative Report which was dictated on 06/19/2009 and transcribed on 06/20/2009 contained "_____" in two locations in the text which indicated that the dictated verbiage was omitted during transcription rendering the report incomplete. One sentence read as: "The left ventricular outflow tract easily admitted a 23 [millimeter] Edwards sizer, _____ 25 was clearly too large for [him/her]."
Page 1 of the Cardiopulmonary Bypass Record form reflected that the date of surgery was "6-19-09". It contained an entry under "Blood Flow" which had been written over.
Page 2 of the Cardiopulmonary Bypass Record form reflected that, contradictory to page 1, the date of surgery was "6/18/09".
Page 3 of the Cardiopulmonary Bypass Record form reflected that the original "Lot #" for the anticoagulant used during the procedure had been scribbled over/scratched out.
The Perfusion Checklist contained a series of boxes next to checklist steps/tasks which were completed with a checkmark. The last step/task was "All equipment clean & decontaminated post procedure". That box was blank.
Four entries on page 1 of an Invasive Procedure, Time-Out, and Site Marking Verification Checklist had been altered, and the time of the entries in the "Pre-Procedure Site Marking" section had not been recorded. Additionally, all signatures and titles of persons documenting on the form using their initials had not been recorded as required on page 2 of the form.
The Adult Nursing Assessment form dated "6/15/09", four days prior to the admission date, contained an entry under "Reason for Admission" that had been scratched out.

5. The record of Patient #6 who was admitted on 07/20/2009 was reviewed.
The Cardiopulmonary Bypass Record form reflected that the date of surgery was 07/23/2009. On page 1 of the form the entries for "UF Device:", "Product #" and "Lot/Serial #" had been crossed out without an explanation.
The Perfusion Checklist contained a series of boxes next to checklist steps/tasks which were completed with a checkmark. The last step/task was "All equipment clean & decontaminated post procedure". That box was blank.
The patient's signature on the Patient Informed Consent form for a "Central Venous Access" procedure was not dated and timed.
Physician Progress Notes dated 07/21/2009, 07/23/2009, 07/24/2009 were not timed.
An untitled form for documentation of a blood transfusion had a date of 07/23/2009 and contained five entries that had been altered or written over, including the date, times, and staff names. Additionally, vital signs were blank for five of the eight time interval spaces on the form.
A Respiratory Care Continuous Ventilation form dated 07/24/2009 contained two entries that had been altered.
Pages 1, 2, and 3 of a Critical Care Ongoing Monitoring Tool dated "7/23/09 - 7/24/09" contained entries that had been altered by writeovers or scribbling over.
An Ongoing Monitoring Tool Interdisciplinary Care Notes dated 07/25/2009 contained two entries that had been scribbled over/scratched out.

6. Similar findings were also identified in the records of Patient #s 3, 7, 8, 9, and 10.