HospitalInspections.org

Based upon review of 1 (patient #18) of 31 Emergency Department (ED) medical records, policies/procedures, and interviews the hospital failed to ensure medical records contained accurate documentation as evidenced by S7 ED physician documentation a normal Complete Blood Count (CBC) on patient #18 when the CBC was not done. Findings:

Review of patient #18's ED medical record revealed physicians orders, dated 12/26/11 at 1:40am for laboratory studies that included: CBC with differential, Troponin Level (checks for cardiac muscle damage), Chemistry, Dilantin drug level (seizure medication patient #18 had been taking), and PT/PTT (checks for bleeding times), and documented by S7 ED physician.

Continued review revealed all laboratory results were located in the ED medical record with the exception of the results of the CBC with differential.

Review of hospital laboratory policy #3.04 revealed: "Subject: Results Reporting...II. Procedure...9. Test results (exception: Test Not Performed Report, see Section F.1)...F. A laboratory report must be issued for all laboratory requests received in the laboratory except for...1. Special situations such as patient death prior to completion of results, cancellation of test, etc. must be noted in the final report. 2. LIS Procedure A TEST NOT PERFORMED (TNP) procedure must be ordered for any test canceled and the reason for cancellation must be documented in the final report..."

Interview on 02/15/12, at 9:15am, with S12 Medical Record/Health Information Management (HIM) revealed when questioned as to where the results for the CBC with differential could be located if it was not in the medical record, S12 stated the results should have been in the medical record if the test had been done. S12 stated she would research the issue and notify the surveyors. S12 returned, 02/15/12, at 9:30am, with a "Lab Specimen Internal Inquiry form", dated 12/26/11 at 1:49am, which stated "cancelled" reason: "unable to collect".

On, 02/17/12, at 10:15am an interview was conducted with S13 Director Laboratory Services/QA. Upon questioning S13 in regard to the missing CBC results she revealed a copy of computer documentation that the CBC with Differential was cancelled by the laboratory technician because the specimen was not adequate for the test. Surveyors requested the name of the laboratory technician who conducted the testing. S16 Lab Tech was identified as the technician working on 12/26/11 when the laboratory studies were ordered.

Telephone interview, 02/17/12 at 1:10pm, with S16 Lab Tech revealed he was working on the night shift, on 12/26/11, when laboratory tests were ordered for patient #18. S16 stated if there lacked a sufficient sample to run the test he would telephone the ED nurse or floor nurse and report the ordered test was not done because of lack of sample. When questioned who was responsible for notifying the physician when the CBC was not done on patient #18, S16 replied it was the ED nurses responsibility. Review of the ED medical record (patient #18) revealed there lacked documentation that ED personnel documented the telephone call from the laboratory; nor was there documentation by the ED personnel that S7 ED physician was notified the CBC was not done.

Telephone interview, 02/15/12, 10:30am, with S7 ED physician revealed he had ordered a CBC along with other laboratory tests on 12/26/11 for patient #18. S7 was questioned as to why he had circled "normal" for the results on the CBC when it had not been done; he stated, "If I documented normal it was obviously a mistake on my part".

Telephone interview, 02/17/12, 1:00pm, with S9 RN ED revealed when questioned if she remembered not getting CBC results or a call from the lab that the CBC could not be done; she replied, "no". S9 stated that in a situation where the ED staff could not obtain a blood specimen for testing they would notify the laboratory and request that they come an attempt to obtain the specimen.

ED personnel, the ED physician, and Medical Records Personnel all failed to note the CBC results had not been obtained; however, S7 ED physician had documented results as normal.

Based upon review of Emergency Department Quality Assurance (QA) data, Quality Assurance meeting minutes, and staff interviews, the hospital failed to ensure the QA program evaluated the appropriateness of diagnosis and treatment furnished in the emergency department as evidence by failing to conduct reviews of all patients who returned to the emergency department within a 24 hour period and review all patient transfers for appropriateness. Findings:

Interview with ED Director RN S3 on 02/15/12 at 1:50 PM revealed when questioned what QA data was collected for the Emergency Department, RN S3 replied for patient transfers, the only information collected was if the patient stayed in the ED prior to transfer for four hours or greater. When asked if there was any on-going monitor related to patients who returned to the ED within a 24 hour period, RN S3 replied "yes".

Review of the QA data related to patients who returned to the ED within a 24 hour period revealed the ED record was to be reviewed for 1) Was 1st diagnosis appropriate? 2)Were lab/x-ray/other treatments appropriate on 1st visit? 3) Were subsequent visits related to the first? 4) If visits were related was the possibility of return documented? 5) Were subsequent visits due to non-compliance to d/c instructions? Review of the QA data for the month of December 2011 revealed patient #18, who had two ED visits within a 4 1/2 hour period, was omitted from the data collection.

Review of 5 of 8 (#8, #14, #22, #25, #27) ED records for patients who were transferred out of a sample size of 31 ED patient records reviewed revealed there failed to be evidence the appropriateness of the transfer was evaluated.

Based upon review of the hospital's Quality Assurance Performance Improvement (QAPI) Plan/meeting minutes, and interviews the hospital failed to ensure all patient care services were evaluated for the effectiveness of the care provided as evidenced by a failure of the contracted Emergency Department physician services (Contract Service A) to have a documented evaluation. Findings:

Review of the Performance Improvement Committee meeting minutes, dated October 2011, revealed the hospital failed to meet patient satisfaction goals in the areas of inpatient, pain management and Emergency Department; and the majority of patient complaints "were attributed to care in the Emergency Department..."

Interview, on 02/17/2012, 12:50pm, with S20 Administrative Assistant revealed Contract Service A was utilized to provide physicians for the Emergency Department (ED) and the contract agreement had been in effect since 2009. When asked for the evaluation of Contract Service A and the name of the individual who would have done the evaluation for the services provided by the contracted physicians; she replied they have not had an evaluation this year. The surveyor then asked for the last evaluation on record for Contract Service A; at this time S20 stated they have never had an evaluation.

Subsequent interviews, 02/17/2012, 1:00pm, with S20, S4 RN Corporate Compliance, and S2 Director of Nursing (DON) revealed S2 DON stated she would be the one to complete the evaluation on the contracted services for the ED. S20 stated it was her oversight and she should have given S2 DON the form for the evaluation.

S4 RN Corporate Compliance and S2 DON agreed Contract Service A should have received an annual evaluation for the services they provided to patients who were seen and treated in the ED. S2, S4, and S20 agreed the services should have been evaluated and had not been evaluated since the contract was established in 2009.