HospitalInspections.org

Based on medical record review, document review and staff interview, it was determined that for 1 of 7 patients in the sample (Patient #1), the medical record contained inaccurate information. Findings include:

The hospital's educational training document entitled "Risk Management for Nurses" stated, "...Documentation...Characteristics...It's factual..."

Review of the emergency department (ED) job description for Clinical Nurse II stated, "...Performance Expectations...Adheres to Policies, Procedures, and standards of BMC including...Management of Information...Accurate documentation..."

A. Review of Patient #1's ED medical record revealed:

6/26/12
- 6:12 PM: Admission: Paramedic, Transport: Paramedic

6/27/12
- 12:26 AM: Nursing Procedure: Discharge Note - "Patient discharged to home, ambulating without assistance, driving self, unaccompanied..."

- 12:27 AM: Disposition - "Disposition Transport: Walk, Patient left the department..."

During an interview with ED Nurse Manager A on 8/7/12 at 12:30 PM, ED Nurse Manager A reported that Patient #1 had arrived by ambulance to the ED and that at the time of discharge, RN A had assisted Patient #1 in trying to secure a ride home. ED Nurse Manager A reported that during an audit of the medical record, it was determined that the information related to Patient #1 driving himself home at the time of discharge was inaccurate. ED Nurse Manager A reported that RN A had been "coached" on 7/2/12 and that education provided included the importance of ensuring that medical record documentation accurately reflected factual information.