HospitalInspections.org

Based on interview and record review, the facility failed to ensure that medical record entries were complete and accurate. The facility failed to ensure that medical records for Patient ID #s 10-34, who sought care through the Emergency Department between January 17, 2024 through February 17, 2025, had the correct Emergency Department attending physician, who provided care, listed as the Emergency Department physician of record (Patient ID #s 10-34).

Findings included:

Record review of Physician Staff ID # 76 credentialing file with Director of Medical Staff ID # 63 on 2/25/25 at 10:45 am revealed physician staff ID #76 was credentialed through the facility's regional credentialing office and granted privileges on 1/14/24.

Record review of ED Provider schedule from 1/1/24 to 2/25/2025 with Director of Medical Staff ID #63 on 2/25/25 at 10:50 am revealed Physician Staff ID #76 had not been scheduled for any shifts at the facility ever.

Record review of Medical Record Provider report for Physician Staff ID #76 titled "Physician Statistics" for dates 1/1/24 through 2/25/25 provided by Director of HIM Staff ID # 53 revealed that 35 patient records had been assigned to Physician Staff ID # 76 for signature at different points after the patients arrived to seek care in the facility's main ED. Director of Clinical Informatics Staff ID #58 confirmed that the attending MD could be assigned through registration process by business office representatives, by the nurse who started encounter, by the physician when they were "signing up for the patient" or forwarded by an advanced practice provider for attending physician co-signature after they saw a patient in the ED. She confirmed there was no audit process in place by the medical records department to ensure that records had been sent to the correct provider for signature.

Record review of facility policy titled "General Record Information", effective 11/2023, stated "Procedure 1. Purposes of the medical record: a. To document the hospitalization and care rendered. B. To serve as a means of communication between the physician and other healthcare professionals caring for the patient ....d. to ensure the delivery of quality patient care." It further stated "16. Legibility: All entries in the medical record must be legible and complete, and must be authenticated by the person making the entry in the medical record."

Interview with Director of Clinical Informatics HIM Staff ID #58 on 2/25/25 at 11:50 am, she confirmed that the Meditech medical record system does not allow physicians to refuse signatures on ED notes which are routed to the wrong provider. She stated it requires the forwarding provider to retract and resend the medical record to the correct provider. She confirmed that the Meditech electronic medical record system reflected that physician staff ID #76 was the attending ED provider for patient ID #s 10-34. She confirmed that all charts had notes which were ultimately routed to other providers for final signatures. She confirmed that the medical record should have the treating ED physician listed as the ED attending physician in the medical record.

Interview with Director of HIM Staff ID #53 on 2/25/25 at 10:45 am. She confirmed that the facility does not have a process for identifying discrepancies between physician of record and the responsible physician who signed the medical record. She confirmed the processes currently in place were to ensure compliance with the chart closure timeline within 30 days. She described this as meaning that all pending or open orders and notes had to be completed. She confirmed there was no process for ensuring that providers who had same last names were be routed the correct charts.