HospitalInspections.org

Based on record review and interview the hospital failed to ensure 1) the physician providing care to a patient failed to identify herself by name when providing care to patients in the Emergency Room for 1 of 9 sampled patients. (Patient #5) and 2) all outpatients or their representative of their patient rights as hospital patients. Findings:

1) Review of the complaint letter from the spouse of Patient #5 revealed the complainant kept referring to someone entering the room as "the blonde lady." Investigation of the complaint revealed the "blonde lady" was the ER Physician, S4MD.

In an interview that was held with S4MD, ER, on 3/3/2011 at 11:15 a.m., she indicated that she did not recall introducing herself to Patient #5 when she cared for him on 12/26/2010. S4MD, ER, reported that her name is monogrammed on the scrubs she wears to work in the Emergency Room and her name is on the blackboard in the patient's room, so the patients can see her name.

In an interview on 3/3/201 at 10:55 a.m. with S1RN, Director QA/Safety, she stated that it is the expectation of the hospital that all physicians introduce themselves to the patients that are under their care.

Review of the hospital policy and procedure titled "Patient Rights and Responsibilities " revealed "The patient has the right to know the name, function, and qualifications of each physician and healthcare worker who is providing care to the patient in a timely manner (upon admission or prior to the procedure). A patient may request such information form the physician of healthcare facility..."

2) Review of the Treatment Authorization, Financial Assignment and Acknowledgements form that is to be signed by the patient or their representative in the Emergency Department revealed under the section titled Patient Right and Responsibilities, " ...I/we, understand that as an outpatient, a copy of the Patient Rights and Responsibilities is available upon request..."

An interview was held with S3, ER Admission Supervisor on 3/2/2011 at 11:15 am. She confirmed that a copy of the Patient Rights and Responsibilities is available only upon request to outpatients at the hospital.

Based on record review and interview the hospital failed to ensure the documentation in the medical records from the Emergency Department under the Consultation Section were accurate for 3 of 9 charts reviewed. (#1, #5, #9) Findings:

Review of the medical record for Patient #1 revealed he was admitted to the Emergency Department on 12/1/2010 with a diagnosis of Allergic Reaction. Further review of the Emergency Department chart under the section titled Consultations revealed, " Have reviewed the available ER record, I, S4MD have reviewed the non physician/resident practitioners documentation, personally taken the patient's history, performed an exam and agree with physical finds, diagnosis and management plan, and surgical procedures were done with my personal participation. Other assessments: acne scars, no swell, no rash seen, 12/1/2010 16:21." This documentation was electronically signed by S4MD at 1621 (4:21 p.m.).

Review of the medical record for Patient #5 revealed he was admitted to the Emergency Department on 12/26/2010 with a chief complaint of foot pain. Further review of the Emergency Department chart under the section titled Consultations revealed, " Have reviewed the available ER record, I, S4MD, have reviewed the non physician/resident practitioners documentation, personally taken the patient's history, performed an exam and agree with physical finds, diagnosis and management plan, and surgical procedures were done with my personal participation..." This documentation was electronically signed by S4 MD ER at 1305 (1:05 p.m.).

Review of the medical record for Patient #9 revealed he was admitted to the Emergency Department on 12/7/2010 with diagnoses of Urinary Tract Infection and Possible Syncope. Further review of the Emergency Department chart under the section titled Consultations revealed, " I, S7MD, ER, have reviewed the the non physician/resident practitioners documentation, personally taken the patient's history, performed an exam and agree with physical finds, diagnosis and management plan, and surgical procedures were done with my personal participation 12/8/2010 11:36." This documentation was electronically signed by S17 MD ER at 11:36 a.m.

An interview was held with S4 MD ER, on 3/3/2011 at 11:15 am. After review of the medical records for Patient's #1 and #5, she confirmed the documentation under the Consultation section in the Emergency Room record pretaining to surgical procedures performed on Patient's #1 and #5 was inaccurate since there were no surgical procedure performed on the patients while in the Emergency Room.

In an interview held with S2RN, ER Director, on 3/3/2011 at 12:00 pm, she confirmed the eletronic medical record section under Consultations used in the Emergency Department had been identifed as a problem with the defalut section that included surgical procedures when a surgical procedure had not been performed. S2RN, ER, Director, added this documentation error is in the process of being corrected.

Based on record review and interview the hospital failed to ensure that all practitioners had annual Tuberculosis Screening for 1 of 4 practitioners files reviewed. Findings:

Review of the credentialing and health screening file for S4MD, ER, revealed no documentation of a current Tuberculosis Screening. This finding was confirmed by S1Director QA/Safety on 3/3/2011 at 1:45 pm. She further indicated that all practitioners are expected to have annual Tuberculosis Screening.