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Based on interview and record review, the facility failed to accurately maintain one patient's (Pt A's) medical record when another patient's vital signs (blood pressure, pulse, oxygen saturation) and heart monitor strips were identified as Pt A's. In addition, Pt A's physician made a late entry into the medical record and did not identify it as a late entry. These failures have the potential to give an inaccurate picture of any patient's health status and response during the time of treatment.


On 3/13/12, the facility reported to the Department of an incident that Pt A was seen and treated in the Emergency Department (ED). Within 5 minutes of discharge, Pt A coded and died.

During a review of Pt A's medical record on 4/12/12 at 9:30 AM, it was noted that Pt A was admitted to the ED on 3/11/12, 3/12/12 and 3/13/12. The 3/13/12 re-admission was at 1:55 AM, 5 minutes after discharge from the 3/12/12 visit. The family member present at that time did not want any resuscitative measures utilized for Pt A and she died. On 3/11/12 at 2:25 AM, Pt A was admitted to the ED. Pt A was 83 years old, 4 days from her 84 th birthday. Her chief complaint was shortness of breath and wheezing on arrival. Pt A was noted by the nurse to be anxious. At 3:30 AM it was noted by the nurse that she was less anxious. Pt A received a breathing treatment, an IV antibiotic and cortisone during the time she was in the ED. She was discharged at 6:15 AM with a diagnosis of chronic bronchitis and emphysema. The noted "Condition" at discharge on the nurses notes was "improved." On 3/12/12, Pt A was again brought to the ED at 10:21 PM with the complaint of "shortness of breath, progressively worse" at triage (initial notes of the nurse admitting the patient to the ED). It was noted by the nurse that Pt A was anxious with moderate (respiratory) distress. Initially, the nurse was unable to count Pt A's breathing rate because she was yelling. The nurse charted that Pt A refused a breathing treatment and was yelling "get me out of here." From 11 PM to 1:25 AM, Pt A had a total of 4 mg of Ativan (anti-anxiety medication). There was a vital sign sheet printed from the patient monitoring system with Pt A's name on it. The sheet's starting time was 9:34 PM. There was heart tracings that had Pt A's name on it and timed at 9:35 PM. The Quality-Risk Nurse (QRN) stated, "I think the ED staff didn't clear the machines of those vital signs and heart tracings from the previous patient. However, the vital signs and heart tracings recorded during the time of her ED stay ((10:21 PM-1:50 AM) are hers."

During an interview on 4/12/12 at 10:40 AM with the ED nurse supervisor (NS), she was asked about the time discrepancy of Pt A's printed vital sign sheet and heart monitor tracings on the 3/12/12 chart. NS stated, "Whoever discharged the previous patient did not clear that patient's vital signs. Same thing with the monitor strips. We don't have a policy and procedure about this, but clearing the data scopes is taught in orientation----that each patient's data is cleared upon discharge. I did speak to the nurse who didn't clear the information the next day." During this interview, NS was asked if she could read the physician's Progress Notes (they were practically illegible). She stated the physician made a late entry on the 3/12/12 chart's progress notes, after the patient died. She stated, "It should have been identified as a late entry and timed."

The facility policy and procedure titled "Amendments, Corrections and Deletions to the Electronic Medical Records", provided by NS, was reviewed on 4/12/12 at 11:10 AM. The Policy read: "....All attempts to correctly identify patients and their medical conditions should be make prior to documenting within the record....Terms Amendment: a clarification made to the health information after the original documentation has been final (and) signed by the provider....Late Entry within the Health Record: A late entry is a pertinent entry that was missed or not written in a timely manner. Provider: 1. Identify the new entry as 'late entry' 2. Enter the current date and time--do not attempt to give the appearance that the entry was made on a previous date or an earlier time. The entry must be signed. 3. Identify or refer to the date and circumstance for which the late entry is written."