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1485 PARKWAY DRIVE

BLACKFOOT, ID 83221

FORM AND RETENTION OF RECORDS

Tag No.: A0438

Based on staff interview, review of medical records, policies and medical staff rules and regulations, it was determined the hospital failed to ensure that medical records were completed in a timely manner for 3 of 20 patients (#7, #15, and #19) whose surgical records were reviewed. This failure had the potential to interfere with subsequent medical treatment by preventing medical providers from obtaining timely information about procedures and courses of treatment. Findings include:

1. "Mountain View Hospital Medical Staff Rules and Regulations," section 5.5, dated 8/07/02, stated "Operative Reports shall be legibly written or dictated immediately following surgery..."

The Chief Compliance Officer was interviewed at 11:40 AM on 1/10/13. He stated the expectation was that surgeons would either dictate or hand write an operative report immediately following surgery.

The hospital did not complete operative reports promptly as follows:

a. Patient #15's medical record documented a 26 year old female who was admitted on 10/25/12 for breast augmentation surgery. She was discharged the same day. Her "OPERATIVE REPORT" stated it was dictated on 12/20/12, 55 days after the surgery was performed. Also, the operative report was not signed by the surgeon as of 1/10/13.

The Chief Compliance Officer reviewed the record at 11:40 AM on 1/10/13. He confirmed the "OPERATIVE REPORT" was not dictated until 12/20/12 and had not been signed. The Chief Compliance Officer confirmed that Patient #15's medical record did not contain a "Post-Operative Progress Note" written by the surgeon immediately following surgery.

Patient #15's medical record was not completed in a timely manner.



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b. Patient #7 was a 70 year old male admitted to the facility for right shoulder surgery on 4/04/12 and discharged 4/05/12. His medical record contained a document titled "OPERATIVE REPORT," which described the procedures performed, estimated blood loss and complications of the procedure. This document was dictated on 7/01/12, 87 days after Patient #7's surgery.

The Chief Compliance Officer reviewed Patient #7's record and was interviewed on 1/10/13 at 11:40 AM. He confirmed the "OPERATIVE REPORT" was not dictated until 7/01/12. The Chief Compliance Officer also confirmed the lack of a hand written "Post-Operative Progress Note" completed immediately after surgery.

Patient #7's record was not completed in a timely manner.

2. The facility policy "LEGAL MEDICAL RECORD STANDARDS," approved 8/20/09, stated "All inpatient Medical Records must be completed within 30 days from the date of discharge."



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The hospital did not complete discharge summaries promptly as follows:

a. Patient #19 was a 46 year old female admitted to the facility on 9/12/12 for a thyroidectomy. She was discharged on 9/14/12. Her medical record contained a "DISCHARGE SUMMARY," originally dictated 10/24/12, and revised on 11/05/12. The "DISCHARGE SUMMARY" was completed 40 days after Patient #19's discharge. The physician signed the discharge summary but did not indicate the date or time it was signed.

The Chief Compliance Officer was interviewed on 1/10/13 at 1:55 PM. He reviewed Patient #19's medical record and confirmed the "DISCHARGE SUMMARY" had been dictated more than 30 days after Patient #19's discharge from the facility. He acknowledged this was outside of the timeframe established by hospital policy.

Patient #19's medical record was not completed in a timely manner.

MEDICAL RECORD SERVICES

Tag No.: A0450

Based on interview, and review of policies and medical records it was determined the facility failed to ensure completion of all entries in the medical record for 15 of 20 patients (#1, #2, #3, #4, #5, #6, #7, #9, #11, #12, #14, #16, #18, #19, and #20) whose records were reviewed. Failure to ensure completion of all entries in the medical record resulted in lack of clarity of hospital events and incomplete medical records. Findings include:

The facility policy "LEGAL MEDICAL RECORD STANDARDS," approved 8/20/09 stated, "All Medical Records entries are to be dated, the time entered, and signed."

Medical record entries were incomplete as follows:

1. Patient #18 was a 58 year old male admitted on 9/12/12 for right knee surgery and 11/12/12 for left knee surgery.

a. The medical record for the admission on 9/12/12 contained the following incomplete documentation:

i. A document titled "OPERATIVE REPORT," dictated 9/27/12, was signed by the physician but was not dated or timed.

In an interview beginning at 2:30 PM on 1/14/13, the Chief Compliance Officer confirmed the time and date were missing from the report. He agreed this led to a lack of clarity as to when the report was authenticated.

ii. A document titled "PCA ORDERS" was signed by the physician and dated 9/12/12 but was not timed. This order specified the type, amount, and frequency of pain medication that Patient #18 could self-administer via a PCA pump.

iii. A document titled "Social Service Order/Referral Form" was signed by the physician's assistant on 9/14/12 but was not timed.

iv. A document titled "DISCHARGE ORDERS" was signed by the physician's assistant on 9/14/12 but not timed. The document contained orders for medication, durable medical equipment, weight bearing status and dressing changes.

v. A document titled "Admit Orders" was signed by the physician on 9/12/12 but was not timed. The orders contained medications to be administered, sequential compression devices for prophylaxis of deep vein thrombosis, an anesthesia pain consult and dressing reinforcement.

In an interview beginning at 1:45 PM on 1/10/13, the Chief Compliance Officer confirmed the times were missing from these orders. He agreed this led to a lack of clarity as to when the orders were written and signed by the physician or physician's assistant.
b. The medical record for the admission on 11/12/12 contained the following incomplete documentation:

i. A document titled "OPERATIVE REPORT," dictated 11/12/12, was not signed, dated, or timed by the physician as of 1/10/13.

In an interview beginning at 2:30 PM on 1/14/13, the Chief Compliance Officer confirmed that the physician's signature, date and time were missing from the report. He agreed Patient #18's record was not complete.

ii. A document titled "PCA ORDERS" was signed by the physician on 11/12/12 but was not timed. This order specified the type, amount, and frequency of pain medication Patient #18 could self-administer via a PCA pump.

iii. A document titled "Social Service Order/Referral Form" was signed by the physician's assistant on 11/14/12 but was not timed.

iv. A document titled "DISCHARGE ORDERS" was signed by the physician's assistant on 11/14/12 but was not timed. The document contained orders for medication, durable medical equipment, weight bearing status and dressing changes.

v. A document titled "Admit Orders" was signed by the physician on 11/12/12 but was not timed. The orders contained medications for administration, sequential compression devices for prophylaxis of deep vein thrombosis, an anesthesia pain consult and dressing reinforcement orders.

In an interview beginning at 1:45 PM on 1/10/13, the Chief Compliance Officer confirmed the times were missing from these orders. He agreed that this led to a lack of clarity as to when the orders were written and signed by the physician or physician's assistant.

Medical record entries for Patient #18 were not complete.

2. Patient #7 was a 70 year old male admitted on 4/04/12, 7/20/12, and 11/16/12 for right shoulder surgery.

a. The medical record contained the following incomplete documentation for the admission on 4/04/12:

i. A document titled "PHYSICIAN ORDERS" was signed by the physician on 4/04/12 but did not include a time. This document contained orders for activities, intravenous fluids, vital signs, medications and discharge instructions.

In an interview beginning at 1:45 PM on 1/10/13, the Chief Compliance Officer confirmed that the time was missing from the orders. He agreed that this led to a lack of clarity as to when the orders were written.

ii. A document titled "OPERATIVE REPORT," dictated 7/01/12, was signed by the physician but was not dated or timed.

In an interview beginning at 2:30 PM on 1/14/13, the Chief Compliance Officer confirmed the date and time were missing from the report. He agreed that this led to a lack of clarity as to when the report was authenticated.

b. Patient #7's medical record contained the following incomplete documentation for the admission on 7/20/12:

i. A document titled "PHYSICIAN ORDERS" was signed by the physician and dated 7/20/12 but did not include a time. This document contained orders for activities, intravenous fluids, vital signs, medications, an anesthesia pain consult and discharge instructions.

In an interview beginning at 1:45 PM on 1/10/13, the Chief Compliance Officer confirmed the time was missing from the orders. He agreed that this led to a lack of clarity as to when the orders were written.

ii. A document titled "OPERATIVE REPORT," dictated 8/14/12, was signed by the physician but was not dated or timed.

In an interview beginning at 2:30 PM on 1/14/13, the Chief Compliance Officer confirmed the date and time were missing from the report. He agreed that this led to a lack of clarity as to when the report was authenticated.

c. Patient #7's medical record contained the following incomplete documentation for the admission on 11/16/12:

i. A document titled "PeriOp Form/Physician's Orders" was dated 11/16/12 but was not signed by a physician or timed as of 1/10/13. This document contained orders for Patient #7 to continue his home medication after discharge.

In an interview beginning at 1:45 PM on 1/10/13, the Chief Compliance Officer confirmed that the signature and time were missing, which caused this order to be incomplete and lack authentication and clarity as to when the orders were written.

ii. A document titled "PCA ORDERS" was signed by the physician on 11/16/12 but was not timed. This order specified the type, amount, and frequency of pain medication that Patient #7 could self-administer via a PCA pump.

In an interview beginning at 1:45 PM on 1/10/13, the Chief Compliance Officer confirmed the time was missing from the order. He agreed that this led to a lack of clarity as to when the order was written and signed by the physician.

iii. A document titled "OPERATIVE REPORT," dictated 12/18/12, was signed by the physician but was not dated or timed.

In an interview beginning at 2:30 PM on 1/14/13, the Chief Compliance Officer confirmed the time and date were missing from the report. He agreed that this led to a lack of clarity as to when the report was authenticated.

Medical record entries for Patient #7 were incomplete.

3. Patient #2 was a 26 year old male admitted on 7/12/12 for left shoulder surgery. The medical record contained the following incomplete documentation:

a. A document titled "OPERATIVE REPORT," dictated on 7/12/12, was signed by the physician but was not dated or timed.

In an interview beginning at 2:30 PM on 1/14/13, the Chief Compliance Officer confirmed the time and date were missing from the report. He agreed that this led to a lack of clarity as to when the report was authenticated.

b. A document titled "PCA ORDERS" was signed by the physician but was not dated or timed. This order specified the type, amount, and frequency of pain medication Patient #2 could self-administer via a PCA pump.

c. A document titled "Day Surgery Orders & Instructions" was signed by the physician but was not dated or timed. This document contained orders for medication, incision care, activity and physical therapy treatments for Patient #2 after discharge.

d. A document titled "Admission Orders" was signed by the physician but was not dated or timed. This document included orders for medication, activity, wound care and discharge procedures.

In an interview beginning at 1:45 PM on 1/10/13, the Chief Compliance Officer confirmed the dates and times were missing from these orders. He agreed that this led to a lack of clarity as to when the orders were written and signed by the physician.

Medical record entries for Patient #2 were incomplete.

4. Patient #1 was an 80 year old female admitted 7/12/12 as an outpatient for sinus surgery. The medical record contained the following incomplete documentation:

a. A document titled "OPERATIVE REPORT," dictated 7/19/12, was signed by the physician but was not dated or timed.

In an interview beginning at 2:30 PM on 1/14/13, the Chief Compliance Officer confirmed the time and date were missing from the report. He agreed that this led to a lack of clarity as to when the report was authenticated.

b. A document titled "PHYSICIAN ORDERS" contained a list of orders for activities, intravenous fluids, vital signs, medications and discharge instructions. Orders were selected from this list but the document was not signed, dated or timed.

In an interview beginning at 1:45 PM on 1/10/13, the Chief Compliance Officer confirmed the signature, date and time were missing. He stated this order was incomplete and lacked authentication and clarity as to when the order was written.

Medical record entries for Patient #1 were incomplete.

5. Patient #16 was a 56 year old male admitted on 10/25/12 as an outpatient for sinus surgery. His medical record contained a document titled "PHYSICIAN ORDERS" that was signed by the physician but was not dated or timed. This document contained orders for activities, intravenous fluids, vital signs, medications and discharge instructions.

In an interview beginning at 1:45 PM on 1/10/13, the Chief Compliance Officer confirmed the date and time were missing from the order. He agreed that this led to a lack of clarity as to when the order was written and signed by the physician.

Medical record entries for Patient #16 were incomplete.



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6. Patient #19 was a 46 year old female admitted to the facility on 9/12/12 for a thyroidectomy. She was discharged on 9/14/12. Her record lacked dated and timed medical record entries as follows:

a. Patient #19's medical record contained a "PHYSICIAN ORDERS" form. The physician selected orders from a pre-printed list for Patient #19's admission, monitoring during the peri-operative phase, medications to be administered as needed, and discharge orders. The physician signed the orders but did not date or time the orders.

In an interview beginning at 1:55 PM on 1/10/13, the Chief Compliance Officer confirmed the date and time were missing from the physician orders. He agreed this led to a lack of clarity as to when the order was written and signed by the physician.

b. Patient #19's medical record contained a detailed "OPERATIVE REPORT" dictated on 10/09/12. The physician signed the report but the physician's signature was not dated or timed. It was not possible to know when the dictation was authenticated.

c. Patient #19's medical record contained a "DISCHARGE SUMMARY" originally dictated 10/24/12, and revised on 11/05/12. The physician signed the document but the physician's signature was not dated or timed. It was not possible to know when the dictation was authenticated.

During an interview on 1/14/13 at 2:30 PM, the Chief Compliance Officer confirmed the physician failed to date and time the dictated reports.

Medical record entries were not dated and timed for Patient #19.

7. Patient #9 was a 13 year old female admitted to the facility on 10/17/12 for outpatient sinus surgery. Her record lacked dated and timed medical record entries as follows:

a. Patient #9's medical record contained a "PHYSICIAN ORDERS" form. The physician selected orders from a pre-printed list for Patient #9's admission, monitoring during the peri-operative phase, medications to be administered as needed, and discharge orders. The physician signed the orders but did not date or time the orders.

In an interview beginning at 1:55 PM on 1/10/13, the Chief Compliance Officer confirmed the date and time were missing from the physician orders. He agreed this led to a lack of clarity as to when the order was written and signed by the physician.

b. Patient #9's medical record contained a detailed "OPERATIVE REPORT" dictated by the physician on 10/17/12. The physician signed the report but the physician's signature was not dated or timed. It was not possible to know when the dictation was authenticated.

During an interview on 1/14/13 at 2:30 PM, the Chief Compliance Officer confirmed the physician failed to date and time the dictated report.

Medical record entries were not dated and timed for Patient #9.

8. Patient #12 was a 57 year old female admitted to the facility on 9/20/12 for outpatient sinus surgery. Her record lacked dated and timed medical record entries as follows:

a. Patient #12's medical record contained a "PHYSICIAN ORDERS" form. The physician selected orders from a pre-printed list for Patient #12's admission status, monitoring during the peri-operative phase, medications to be administered as needed, and discharge orders. The physician signed the orders but did not date or time the orders.

In an interview beginning at 1:55 PM on 1/10/13, the Chief Compliance Officer confirmed the date and time were missing from the physician orders. He agreed this led to a lack of clarity as to when the order was written and signed by the physician.

b. Patient #12's medical record contained a detailed "OPERATIVE REPORT" dictated by the physician on 9/20/12. The physician signed the report but the physician's signature was not dated or timed. It was not possible to know when the dictation was authenticated.

During an interview on 1/14/13 at 2:30 PM, the Chief Compliance Officer confirmed the physician failed to date and time the dictated report.

Medical record entries were not dated and timed for Patient #12.

9. Patient #3 was a 61 year old male admitted to the facility on 10/10/12 for outpatient sinus surgery. His record lacked dated and timed medical record entries as follows:

a. Patient #3's medical record contained a "PHYSICIAN ORDERS" form. The physician selected orders from a pre-printed list for Patient #3's admission status, monitoring during the peri-operative phase, medications to be administered as needed, and discharge orders. The physician signed the orders but did not date or time the orders.

In an interview beginning at 1:55 PM on 1/10/13, the Chief Compliance Officer confirmed the date and time were missing from the physician orders. He agreed this led to a lack of clarity as to when the order was written and signed by the physician.

b. His medical record contained a detailed "OPERATIVE REPORT" dictated by the physician on 10/10/12. The physician signed the report but the physician's signature was not dated or timed. It was not possible to know when the dictation was authenticated.

During an interview on 1/14/13 at 2:30 PM, the Chief Compliance Officer confirmed the physician failed to date and time the dictated report.

Medical record entries were not dated and timed for Patient #3.

10. Patient #14 was a 65 year old male admitted to the facility on 9/26/12 for outpatient hernia surgery. His record lacked authentication, dates, and times as follows:

a. Patient #14's medical record contained a form titled, "Post-Operative Progress Note." There was documentation of the pre-operative and post-operative diagnoses, the procedure performed, and details of the surgical procedure. The form was not signed, dated or timed as of 1/10/13.

In an interview beginning at 1:55 PM on 1/10/13, the Chief Compliance Officer confirmed the physician failed to sign, date, and time the progress note. He agreed this led to a lack of clarity as to when the note was written and signed by the physician.

b. Patient #14's medical record contained an "OPERATIVE REPORT" dictated by the physician on 9/26/12. The physician signed the report but the physician's signature was not dated or timed. It was not possible to know when the dictation was authenticated.

During an interview on 1/14/13 at 2:30 PM, the Chief Compliance Officer confirmed the physician failed to date and time the dictated report.

Medical record entries were not dated and timed for Patient #14.

11. Patient #11 was a 73 year old female admitted to the facility on 9/18/12 for left knee surgery. She was discharged on 9/20/12. Her record lacked dated and timed medical record entries as follows:

a. Patient #11's medical record contained an "OPERATIVE REPORT" dictated by the physician on 9/18/12. The physician signed the report but the physician's signature was not dated or timed. It was not possible to know when the dictation was authenticated.

b. Patient#11's medical record contained a "DISCHARGE SUMMARY" dictated by the physician on 9/29/12. The physician signed the document but the physician's signature was not dated or timed. It was not possible to know when the dictation was authenticated.

During an interview on 1/14/13 at 2:30 PM, the Chief Compliance Officer confirmed the physician failed to date and time the dictated reports.

Medical record entries were not dated and timed for Patient #11.

12. Patient #6 was a 35 year old female admitted to the facility on 10/09/12 for a hysterectomy. She was discharged from the facility on 10/10/12. Her medical record contained an "OPERATIVE REPORT" dictated by the physician on 10/09/12. The physician signed the report but the physician's signature was not dated or timed. It was not possible to know when the dictation was authenticated.

During an interview on 1/14/13 at 2:30 PM, the Chief Compliance Officer confirmed the physician failed to date and time the dictated report.

Medical record entries were not dated and timed for Patient #6.



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13. Patient #20's medical record documented a 40 year old female who had outpatient septoplasty (nose surgery) performed on 9/14/12. Her medical record contained the following incomplete documentation:

a. Her medical record contained "PHYSICIAN PREPRINTED ORDERS" which included admission orders, treatment orders, diet orders, intravenous fluid orders, medication orders for post- anesthesia care as well as following discharge, and discharge orders. The orders were signed by the physician but they were not dated or timed.

The Chief Compliance Officer was interviewed beginning at 1:45 PM on 1/10/13. He confirmed Patient #20's orders were not dated or timed.

b. In addition, Patient #20's "OPERATIVE REPORT," dictated 9/14/12, was signed by the physician but the physician's signature was not dated so it was not possible to know when the dictation was authenticated.

The Chief Compliance Officer was interviewed at 2:30 PM on 1/14/13. He confirmed Patient #20's "OPERATIVE REPORT" was not dated to indicate when it was signed.

14. Patient #4's medical record documented a 14 year old female who had an outpatient tonsillectomy and adenoidectomy performed on 11/16/12. Her medical record contained "DISCHARGE ORDERS" to discharge her and for five different medications. The orders were signed by the physician but they were not dated or timed.

The Chief Compliance Officer was interviewed beginning at 1:45 PM on 1/10/13. He confirmed Patient #4's orders were not dated or timed.

15. Patient #5's medical record documented a 31 year old female who had outpatient sinus surgery and nasal surgery performed on 11/15/12. Her medical record contained "PHYSICIAN ORDERS" for discharge and two different medications. The orders were signed by the physician but they were not dated or timed.

The Chief Compliance Officer was interviewed beginning at 1:45 PM on 1/10/13. He confirmed Patient #5's orders were not dated or timed.

Medical record entries were incomplete.