HospitalInspections.org

Based on policy review, ED Log Review and staff and physician interviews, hospital staff failed to complete a full medical record for walk-ins that presented to the Hospital Admission Office for evaluation or care for 7 of 11 walk-in patient documents reviewed (Patients #7, #8, #9, #11, #13, #1, #3)

The findings include:

Review of a hospital policy titled, "Medical Records" effective 05/21/2021 revealed, "...POLICY: Each patient who is evaluated...has a record written in sufficient detail and organized to identify the patient, support the diagnosis...Significant clinical information pertaining to the patient is incorporated in the medical record...I. Record Content...records include at least the following: A. Identification data, including patient's name, address, date of birth, next of kin, name of any legally authorized representative, and hospital number; (if not obtainable, the reason is entered in the record)...III. Patient records are kept confidential, secure...authenticated, legible and complete... ."

1. Review on 05/10/2022 of a Handwritten Arrival Log of patients presenting to the hospital in 2022 revealed Patient #7 was a 49-year-old who arrived at the hospital on 02/03/2022 at 1115. The Log failed to reveal Patient #7's chief complaint and had no medical record number assigned. Review of an email written by MD (Medical Doctor) #1 and sent to the ACMO (Assistant Chief Medical Officer) on 02/03/2022 at 1227 revealed, "I saw (Patient #7) today at 1130 outside of Admissions. ..." Review revealed the physician went and saw the patient, spoke with a therapist and guardian and determined Patient #7 did not meet admission criteria. Review of the hospital's medical records failed to reveal a medical record was created for Patient #7 and MD #1's email failed to reveal the time Patient #7, her therapist and guardian departed the hospital campus.

2. Review on 05/12/2022 of a Handwritten Arrival Log of patients presenting to the hospital in 2022 revealed Patient #8 was a 17-year-old who arrived at the hospital on 02/07/2022 at 1627. The Log failed to reveal Patient #8's chief complaint or an assigned medical record number. Review of an unsigned and undated typed note revealed, "(Patient #8...This evening (2/7/22), I was called by the admissions office to see patient, who was accompanied by her mother. ..." Document review revealed the MD saw the patient and also spoke with the relative. Document review failed to reveal a medical record number for Patient #8 or her departure time from the hospital campus. Review failed to reveal a full medical record was created for Patient #8.

3. Review on 05/12/2022 of a Handwritten Arrival Log of patients presenting to the hospital in 2022 revealed Patient #9, an 82-year-old who arrived at the hospital on 03/29/2022 at 1410. The Handwritten Arrival Log revealed Patient #9 had a history of Dementia and Bipolar disorder but failed to reveal an assigned medical record number. Review revealed the physician saw the Patient #9 and a relative of the patient in the admission office. Document review revealed the physician evaluated the patient and advised the family member that Patient #9 did not meet criteria for admission. Review failed to reveal a full medical record was created for Patient #9.

4. Review on 05/12/2022 of the hospital's Electronic Arrival Log revealed Patient #11 arrived at the hospital on 09/21/2021 at 1527 as a "Volunteer walk-in from (Nearby County)...outpatient appt process started, taken to shelter by (named hospital's police department). The Electronic Admissions Log failed to reveal Patient #11's date of birth, age or an assigned medical record number. Review revealed an undated handwritten note that was signed by MD (Medical Doctor) #1 but failed to reveal a medical record number or a complete medical record was created for Patient #11.

5. Review on 05/12/2022 of a Handwritten Arrival Log of patients presenting to the hospital in 2022 revealed Patient #13, a male of unknown age arrived at the hospital on 03/15/2022 at 0415. The Handwritten Arrival Log failed to reveal Patient #13's last name, date of birth, chief complaint or an assigned medical record number. Review of an undated typed note signed by a physician indicated the patient was evaluated outside of the admissions office. Document review revealed the patient did not meet criteria for state admission and did not give his last name. Review of the document failed to reveal a medical record number for Patient #13 or departure time from the hospital campus.

6. Review on 05/12/2022 of a handwritten Arrival Log of patients presenting to the hospital in 2021 revealed Patient #1 presented to the Admission Unit with a guardian on 05/17/2021. Review of a typed note revealed a name and approximate time seen and the last name of a physician was handwritten at the top. Review revealed the physician was called to the admission office to see a patient who presented with family/ guardian. Review revealed the physician observed the patient and spoke with the guardian. Review revealed the guardian was informed the patient did not meet criteria for admission. Review of the documents did not reveal a medical record number or a complete medical record for Patient #1.

7. Review of 05/12/2022 of handwritten and typed documents revealed Patient #3 arrived to the Admission Unit on 08/18/2021 at 1900. Document review revealed the physician was called to the admission unit and spoke with/evaluated the patient. Review revealed the physician informed the patient she did not meet criteria for admission. Review did not reveal a medical record number or a complete medical record was available for Patient #3.

Interview on 05/10/2022 at 1221 with the ACMO revealed that the psychiatry providers dictated an evaluation note for every patient who presented to the admission/intake area. Follow-up interview on 05/11/2022 at 0958 revealed that some walk-in patients did not have a medical record created due to system errors, but when that occurred the provider typed a note and sent a copy to the ACMO through the hospital's secured messenger system.

Interview on 05/10/2022 at 1234 with RN #3 revealed the patients who met criteria for admission had a medical record created for the psychiatrist to document their evaluation in. Interview revealed that patients who did not meet criteria for admission were given back their belongings, changed back into their clothes and provided with resources and instructions for follow-up care. Interview revealed a medical record number was not created for every patient who presented to the admissions/intake unit.

Interview on 05/11/2022 at 0956 with MD #1 revealed a MRN (medical record number) was not always created for walk-in patients because there was not always enough information provided to do so.

Interview on 05/11/2022 at 1105 with the HIM (Health Information Management) Director revealed that patients who came in for an evaluation, but were not admitted were not always given a MRN. Interview revealed the hospital's current system required a patient's full name, date of birth, preliminary diagnosis, county of residence, MCO name and number and several other pieces of data that walk-in patients were often unable to provide at the time of presentation. Interview revealed the hospital's current system was not user friendly and required a lot of information in order to create a MRN.

Interview on 05/12/2022 at 1157 with the CEO and CMO revealed that with COVID, "they were seeing some patients outside. The CMO stated, "They did all the essentials, but sometimes they weren't able to get all of their information. The CEO stated, "We are working on a better process." Interview revealed the hospital's process for creating MRN's on walk-in patients needed to be improved.

NC00185983, NC00185799, NC00187866, NC00188628