HospitalInspections.org

Based on interview and record review, the facility failed to ensure that the medical record services department "Health Information Management (HIM)" held administrative responsibility to maintain complete, accurate and accessible inpatient medical records for 4 discharged patients (#'s 1, 2, 22 and 23) out of 44 medical records reviewed resulting in the potential for less than optimal outcomes for patient #'s 1, 2, 22 and 23.
Findings include: See specific tags:


See specific tags:
A-0438
The facility failed to maintain complete, accurate and accessible inpatient medical records for 4 discharged patients (#'s 1, 2, 22 and 23) out of a total of 44 records reviewed resulting in the potential for less than optimal outcomes for patient #'s 1, 2, 22 and 23).

Based on interview and record review, the facility failed to maintain complete, accurate and accessible inpatient medical records for 4 discharged patients (#'s 1, 2, 22 and 23) out of a total of 44 records reviewed resulting in the potential for less than optimal outcomes for patients (#'s 1, 2, 22 and 23).

A review of the medical record for patient #1 was conducted on 12/8/2020 at 1330 and the following was revealed:

Patient #1 presented to the Emergency Department (ED) on 10/6/2020 1450 via ambulance. The triage note dated 10/6/2020 at 1547 documented a chief complaint of Altered Mental Status. Further review revealed a "CODE Stroke" (term used medical emergency alert) was called on 10/6/2020 at 1755 while the patient was off the unit for a CT (Cat Scan) imaging. Further record review revealed there was no documentation for the time patient #1 was in the resuscitation room of the ED on 10/6/2020.

The ED triage nurse (staff Q) was interviewed via phone on 12/9/2020 at (1500). She stated the ED uses a team nursing approach and she did the paper portion of the triage. Staff Q said she recalled patient (#1) was rushed back from CT (Cat Scan) to the resuscitation bay on 10/6/2020. The patient returned with the SWAT nurse (staff O) and she believed ED staff nurse (R) but was not positive who the ED nurse was. She explained the patient (#1) was coded and resuscitated. When asked about the Code Stroke she stated it generally begins in the resuscitation room with IV access and then the patient goes to CT with the ED nurse and or SWAT nurse. One of the nurses stays with the patient in CT and returns with them to ED. The nurse that accompanies the patient gives report to the CT technician. She could not recall the patient prior to her return to the ED. She stated she did not go to CT with the patient and was unsure who did. When queried she stated all paperwork for patients in the resuscitation bay is on paper.

A phone interview was conducted with Medical Doctor (staff U) on 12/9/2020 at approximately 0915. Staff U was patient #1's attending physician in the ED on 10/6/2020.
He stated he recalled patient #1. He stated the patient was brought to the ED by EMS (emergency medical services) for altered mental status and had a skin issue. He explained the patient (#1's) son provided patient's history. Staff U said he recalled a "code stroke" was called, and the patient went to CT. He stated he saw the patient before and after CT. When queried regarding allergies, he stated it would be the normal routine to ask about medications, allergies, and medical history. He did not recall if the patient had an allergy to iodine. He stated if a patient had an allergy it would be his routine to premedicate the patient with Benadryl and Solumedrol prior to the CT scan. He stated a Code Stroke is an emergency and it is a collaborative team who reviews the patient's history. He stated if the benefits outweigh the risks and a delay would be detrimental to the patient a CT may be done without premedication. It may have been necessary to go to CT emergent without premedication for this patient, but he could not recall. When queried regarding missing ED paper chart documentation for patient #1, he stated he was not previously aware of missing documents from the record. Staff U stated the patient was in a resuscitation bay and paper documentation is used. Order sheets, testing, labs, therapeutics would all be documented on paper. Any exams would be documented on the tri flow pamphlet. Without the record he stated he can't review the circumstances of the code stroke for this patient. Staff U stated he was not aware of any investigation related to this patient.

On 12/9/2020 at 1130 a review of Incident/Accident/Adverse events reports logs were reviewed with the facility Director of Compliance and the Compliance RN (staff A and B) who both stated that the ED portion of patient #1's record was missing. An event report was entered by medical records when it was discovered in November 2020.

Review of the facility event log documented an event reported on 11/13/2020 for patient #1 that identified a concern with 'Medical Documentation & Patient Record" and nature of event as 'Medical Record Issue" in the MICU (Medical Intensive Care Unit).

The event log identified three additional patients with 'Medical Record Issues' on 11/13/2020 two in the MICU and one from another unit. (Patient #2, 22 and #23). On 12/9/2020 at 1140 when queried about corrective actions to prevent or decrease the risk of reoccurence of "missing patient records" Staff A and B stated at that time, "we are still looking, nothing has changed."

An interview was conducted with ED Nursing Director (staff J), the ED Manager (staff K) and the ED Operations Supervisor (staff M) on 12/10/2020 at approximately 1400.
At that time when queried about the ED missing paper chart portion for patient #1, staff K and staff J both responded they were not aware that the receiving unit did not receive the paper ED documentation for patient #1. Staff J said, they would have received a call requesting the documentation. Staff J said to her knowledge that never happened.

On 12/11/2020 at 1410, an interview and review of inpatient and outpatient medical records logs were reviewed with Health Information Manager (HIM) Staff JJ. Staff explained the medical records for all patients were "Hybrid" (electronic and paper) records. Staff JJ said her department was missing the paper documentation for patient #'s 1, 2, 22 and #23.

Patient #1 was admitted to the facility on 10/6/2020 and was discharged (transferred) on 10/7/2020.
Patient #2 was admitted to the facility on 10/18/2020 and discharged on 10/24/2020.
Patient #22 was admitted to the facility on 10/4/2020 and was discharged on 10/7/2020.
Patient #23 was admitted to the facility on 10/5/2020 and was discharged on 10/7/2020.

At that time, Staff JJ said she was aware that the charts had not been collected by her staff. She explained the processes for chart collection. Staff JJ said she submitted electronic incident reports for the missing charts. Staff JJ said, however to date the charts had not been found. When asked to explain if any staff education or retrieval of closed charts had been implemented Staff JJ said not to her knowledge.

On 12/11/2020 at 1530 Staff K provided a blank copies of the documents that would have been in the missing paperwork. At that time Staff K said, this includes Resuscitation/Trauma Record, which included arrival time date, allergies, medications, past medical history, chief complaint, staff team members, physical exam, procedures, vital signs, neuro assessment, IV's, prescribed medications, progress notes, and physician record. Code sheets would also have been in the paper record per staff K.