HospitalInspections.org

Based on medical record review and interview, the facility failed to ensure complete and accurate medical records for five (#'s 6, 11, 12, 18, 28) of thirty patients (#'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 ) reviewed.

The findings included:

Medical record review revealed Patient #6 presented to the Emergency Department (ED) on November 1, 2010, at 11:53 a.m., with complaints of squeezing chest pressure with exertion as well as at rest and pain described as 7 on a scale of 0 - 10 with 10 being worst pain ever. Review of the physician's note at 1:05 p.m. revealed diagnosis was Chest Pain - Possible Cardiac Etiology and "Case discussed with ... (named physician) who agrees the patient's condition merits admission to hospital." Continued review of the physician's notes revealed no documentation the diagnosis, laboratory results, diagnostic testing results, or need for admission were discussed with the patient.

Interview with the Risk Manager on January 7, 2011, at 1:40 p.m., in the Board Room, confirmed there was no documentation the patient was informed of the diagnosis, laboratory results, diagnostic testing results, or need for admission.

Medical record review revealed Patient #11 presented to the ED on October 15, 2010, at 1:09 p.m., with complaints of epigastric/lower sternal chest pain with radiation to both arms, sharp and intense. Review of the physician's assessment under Diagnostic Test Results revealed the value for glucose was 120 (normal 74 - 106) and marked as normal; value for BNP was 9 (normal 5-100) and marked as abnormal; value for CKMB was 1.50 (normal 0.00 - 8.00) and marked as abnormal; value for troponin was 0.05 (normal 0.00 - 0.05) and marked as abnormal.

Interview with the Risk Manager on January 7, 2001, at 1:40 p.m., in the Board Room, confirmed results which were abnormal were documented as normal, and those which were normal were documented as abnormal.

Medical record review revealed Patient #12 presented to the ED on October 14, 2010, at 6:56 p.m., with complaints of sharp, aching pain in left chest, radiating to left shoulder and left arm. Review of the physician's note at 7:14 p.m., revealed the patient was to be transferred to the hospital where ... had previous cardiac interventions. Review of the EMTALA/Transfer form revealed the sections on "Reason for Transfer" and "Risk and Benefit Analysis for Transfer" were not completed.

Interview with the Director of the ED on January 7, 2011, at 2:00 p.m., in the Board Room, confirmed the sections on "Reason for Transfer" and "Risk and Benefit Analysis for Transfer" were not completed.

Medical record review revealed Patient #18 presented to the ED on September 8, 2010, at 2:04 a.m., with complaints of pressure in middle of chest radiating to left arm, with nausea and shortness of breath. Review of the physician's note at 3:07 a.m., revealed the patient was diagnosed with Chest Pain - Possible Cardiac Etiology and admitted to the Telemetry Unit but there was no documentation the physician discussed the diagnosis, need for admission, results of diagnostic tests, and laboratory results with the patient.

Interview with the Risk Manager on January 7, 2011, at 1:40 p.m., in the Board Room, confirmed there was no documentation the physician informed the patient of the diagnosis, need for admission, laboratory, and diagnostic testing results.

Medical record review revealed Patient #28 presented to the ED on June 11, 2010, at 7:34 a.m., with complaints of substernal chest pain, sharp and constant. Review of the physician's notes at 8:24 a.m., revealed the patient was diagnosed with Acute Chest Pain and Acute Congestive Heart Failure and was admitted to the Telemetry Unit. Continued review of the physician's notes revealed no documentation the diagnosis, need for admission, laboratory, and diagnostic testing results were discussed with the patient.

Interview with the Risk Manager on January 7, 2011, at 1:40 p.m. in the Board Room, confirmed there was no documentation the physician informed the patient of the diagnosis, need for admission, results of laboratory and diagnostic testing.