HospitalInspections.org

Based of review of facility documents and staff interviews (EMP), it was determined that the facility failed to ensure that all entries in the medical record were authenticated and dated by the person making the entry for three of 20 medical records. (MR6, MR13, and MR20)

Review of the facility policy on September 29, 2016, at approximately 11:00 AM, which was updated by the facility on May 2016, revealed "Millcreek Community Hospital...Entries in the Medical Records...1. Entries are only made by people authorized to document in the medical record...All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible. (CoP Section 482.24) (Pa Code 115.33)...6..."

1. Review of MR6 on September 29, 2016, at approximately 2:00 PM revealed a form "Behavioral Health Receipt of Patient Rights and Services" which was signed by the witness and the patient. Both entries were dated and timed September 15, 2016, at 1330, however there was a sticker on the form that indicated, "Patient's condition prevents the admitting office from getting this form signed on admission. Please ask patient to sign as soon as possible."

Another entry on this form indicated, "Pt declined 9/28/16"

It could not be determined when the patient actually signed the form, and it could not be determined who documented the entry on September 28, 2016.

2. Review of MR13 on September 29, 2016, at approximately 2:30 PM revealed a form "Behavioral Health Receipt of Patient Rights and Services" which was signed by the witness and the patient. Both signature lines were dated and timed September 27, 2016, at 1530, however there was a sticker on the form that indicated, "Patient's condition prevents the admitting office from getting this form signed on admission. Please ask patient to sign as soon as possible."

It could not be determined who requested the patient to sign the form or when the form was signed by the patient.

3. Review of MR20 on September 29, 2016, at approximately 2:40 PM revealed a form "Behavioral Health Receipt of Patient Rights and Services" which was signed by the witness but not the patient. Both signature lines were dated and timed September 8, 2016, at 1140. There was a sticker on the form that indicated, "Patient's condition prevents the admitting office from getting this form signed on admission. Please ask patient to sign as soon as possible."

Another entry on this form indicated, "Pt declined 9/12/16"

It could not be determined who completed the entry on September 12, 2016.

4. During an interview on September 29, 2016, at approximately 8:50 AM, EMP4 confirmed that the entries for MR6, MR13, and MR20 should have been signed, timed and dated. EMP4 also confirmed that the stickers are placed on the forms by the Emergency Department staff, and the Behavioral Health Staff are responsible to reapproach the patient to sign the patient right's form after admission to the unit.

5. During an interview on September 29, 2016, at approximately 10:00 AM, EMP15 confirmed that the he/she documented the dates and times for the patients' signatures for MR6, MR13, and MR20, even though the patients did not sign on the day of admission. EMP15 confirmed that the stickers are placed on the medical records when the patients cannot or refuse to sign the admission forms.