HospitalInspections.org

The Hospital reported a census of two patients.
Based on record review, policy review, and staff interview the Hospital failed to assure 10 of 10 patient discharge summaries completed by the allied health providers included the date, time and their signature (pt #'s 2, 3, 4, 5, 10, 13, 15, 16, 17 and 19).

Findings include:

- Document review on 8/22/12 at 4:00pm of the hospital's policy titled "Rules and Regulations of the Medical Staff" directed " all clinical entries, including progress notes, in the patient ' s medical record shall be accurately dated, timed and authenticated. "

- Patient #2 ' s medical record revealed an admission date of 1/5/12 to the hospital with a diagnosis of left total knee replacement. The medical record revealed a discharge summary on 1/17/12 which lacked proper authentication including signature, date, and time of the physician assistant who completed the summary.

- Patient #3 ' s medical record revealed an admission date of 2/1/12 to the hospital with a diagnosis of right total knee replacement. The medical record revealed a discharge summary on 2/11/12 which lacked proper authentication including signature, date, and time of the physician assistant who completed the summary.

- Patient #4 ' s medical record revealed an admission date of 3/26/12 to the hospital with a diagnosis of left total knee replacement. The medical record revealed a discharge summary on 4/2/12 which lacked proper authentication including signature, date, and time of the physician assistant who completed the summary.

Administrative Staff A interviewed on 8/21/12 at 4:30pm acknowledged the discharge summaries lacked the signature, date, and time of the physician assistant who dictated the summary.

Staff F interviewed on 8/21/12 at 4:30pm acknowledged the discharge summaries lacked the signature, date, and time of the physician assistant who dictated the summary.

The Hospital's failure to assure allied health staff properly authenticated their discharge summaries including date, time and signature also affected patient #'s 5, 10, 13, 15, 16, 17 and 19.




The Hospital reported a census of two patients. Based on record review, policy review, and staff interview the Hospital failed to ensure the pathologist who completed the pathology report, for 11 of 11 sampled medical records, documented the time of authentication of this report. (#'s 2, 4, 6, 9, 12, 14, 15, 16, 19, 20, and 21).

Findings include:

- Document review on 8/22/12 at 4:00pm of the hospital's policy titled "Rules and Regulations of the Medical Staff" directed " all clinical entries, including progress notes, in the patient ' s medical record shall be accurately dated, timed and authenticated. "

- Patient #2 ' s medical record revealed an admission date of 1/5/12 to the hospital with a diagnosis of left total knee replacement. The medical record revealed a pathology report dated 1/9/12 which lacked the time of the provider ' s authentication.

- Patient #4 ' s medical record revealed an admission date of 3/26/12 to the hospital with a diagnosis of left total knee replacement. The medical record revealed a pathology report dated 3/29/12 which lacked the time of the provider ' s authentication.

- Patient #14 ' s medical record revealed an admission date of 3/7/12 for a surgical procedure documented as colonoscopy with biopsy.
The medical record revealed a pathology report dated 3/9/12 which lacked the time of the provider ' s authentication.

Administrative Staff A interviewed on 8/21/12 at 4:30pm acknowledged the pathology reports lacked the time of the report.

Staff F interviewed on 8/21/12 at 4:30pm acknowledged the pathology reports lacked the time of the report.

The Hospital's failure to assure all entries in the medical record are timed also affected patient #'s 6, 9, 12, 15, 16, 19, 20, and 21.