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Based upon record review and staff interview it was determined that the facilty failed to provide care in a safe setting for 1 of 6 patients relative to patient identification and physicians orders for patient ID# 5.

On 6/15/2018 it was determined that the hospital failed to implement an effective plan of correction following a 3/29/2018 survey to ensure that patients were correctly identified and tests were ordered and performed on the correct patient. This includes an effective plan to address the "gap" identified by the hospital relative to having multiple patient records open simultaneously (following a test being ordered on the wrong patient). On 6/15/2018 it was determined that Immediate Jeopardy existed relative to placing orders on the wrong patient. The Immediate Jeopardy was removed on 6/15/2018 when the facility adjusted their electronic medical record to prevent users from having more than one patient record open at one time.

Findings are as follows:

Review of the hospital policy, Administration 102, titled "Patient Identification and Verification" states in part:

1. Purpose
"...The purpose of this policy is to ensure that all patients are properly identified and have their identity verified prior to any care, treatment or services being provided...."

II. Policy
"All patients must be properly identified prior to any care, treatment or services being provided .."

A self-report by the hospital revealed patient ID #5 "... had a CT (computed tomography) of brain and face ordered and performed intended for another patient.."

Record review revealed patient ID# 5 has a gastrostomey tube and was seen in the hospital emergency department on 6/9/2018 at 6:09 PM. The chief complaint was emesis (vomiting).

Further review of the patients medical record failed to reveal a photo of the patient; nor was there a picture of a laminate card indicating why a photo was not obtained.

A physician's order was placed on 6/10/2018 at 11:12 AM for a CT Brain Face without IV Contrast and an Opthalmology Consult. The CT Brain Face without IV contrast was performed on ID #5 on 6/10/2018 at 11:54 AM.

During an interview with the risk manager on 6/15/2018 at 4:00 PM, she stated that the CT of the brain and face as well as the Opthalmology Consult had been intended for another patient.

Interview with the Director of the Emergency Department on 6/15/2018 at 6:45 PM revealed that attending physician was rounding on her patient in the computer and went to close ID #5's record when an alert preseted on the screen. The physician responded to the alert thinking that she had closed ID #5's record, when it in fact had remained open.

Interview with the ordering physician on 6/18/2018 at 2:20 PM reported that she had more than one patient's electronic medical record open when she placed the orders. She had thought she had closed out of ID# 5's record when she ordered the CT scan, which was intended for another patient. She later realized the order was placed on the wrong patient. She was unable to provide evidence that she verified the patients identity prior to ordering the CT on ID #5.

In addition, during a subsequent interview on 6/19/2018 at 9:55 AM the risk manager confirmed that there was no picture of patient ID #5 nor was there a picture of a laminated card to indicate there was no photo available.

Refer to A 144.

Based upon record review and staff interview it was determined that the facilty failed to provide care in a safe setting for 2 of 6 patients relative to patient photo identification (ID# 5 and ID #1).

Findings are a follows:

Review of the hospital's Life Chart Photo Policy revised on 4/17/2018 revealed "it is the policy of Lifespan to take photo identification of patients to ensure proper identification for patient safety and the provision of quality/efficient medical services through proper identification."

Procedures "Photo identification will be made for all patients receiving clinical services." ...

"Adults 18 years or older will be required to have a photo identification picture taken every other year." ...

"If a patient refuses a photo, take a picture of the following" (a laminate card with) "Patient Refused Photo"

"If a patient is unavailable for a photo, take a picture of the following" (a laminate card with) "Unable to Obtain Photo."

1. Record review revealed patient ID# 5 was seen in the hospital emergency department on 6/9/2018 at 6:09 PM. Further review of the patients medical record failed to reveal a photo of the patient; nor was there a picture of a laminate card indicating why a photo was not obtained.

During an interview on 6/19/2018 at 9:55 AM the risk manager confirmed that there was no picture of patient ID #5 nor was there a picture of a laminated card to indicate there was no photo available. She noted that if a picture had been in place, when placing an order, the provider would have seen a prompt pop-up to confirm that the provider wanted to place orders for this patient.

Refer to A 0115

2. Review of patient ID # 1's record, who was seen in the emergency room on 6/15/2018, revealed patient ID #1 did not have a photo taken nor was there a picture of a laminated card to indicate that there was not a photo as is required under the hospitals Life Chart Photo Policy to ensure proper identification.

Interview with the risk manager on 6/19/2018 at 9:55 AM confirmed that patient ID #1 did not have a photo available on 6/15/2018 nor was there a picture of a laminate card to indicate that the photo was not available.