HospitalInspections.org

The Critical Access Hospital (CAH) revealed a census of 9 patients. Based on document review, medical record review and staff interview the CAH failed to completely and accurately document Emergency Department records for 3 of 10 Emergency Records reviewed.(#2, #3, #10)

Findings include:

- The Medical Staff Bylaws, last revised 4/09 and reviewed on 8/3/11, documented "ARTICLE X: MEDICAL RECORD COMPLETION...i.The attending physician will be responsible for the preparation of a complete and legible medical record for each patient...vii.Patient Discharge:...5. In all instances, the content of the medical record shall be sufficient to justify the diagnosis and warrant the treatment and end result..."

- The medical record of patient #10 reviewed on 8/2/11 revealed the patient presented to the Emergency Department (ED) on 7/17/11 at 3:00 am. with complaint of domestic abuse and head injury. Registered Nurse( RN) B performed a triage assessment, documented no signs of trauma, no current vomiting, alert and in no acute distress. RN B contacted Advanced Registered Nurse Practitioner (ARNP) A at 3:20am. ARNP A did not come in to see this patient, but later in the day, ARNP A documented the following (...Dx (diagnosis) Domestic Abuse. Not seen by me. No evidence of injury. Pt. (patient) very intoxicated...), without observation and examination of the patient.

ARNP A, on 8/3/11 at 10:20am, stated the patient left before being seen and stated they had to put a diagnosis on the chart or "...coding would be all over me..." ARNP A verified this information obtained from RN B and stated their documentation lacked this clarification.

- The medical record of patient #3 reviewed on 8/2/11 revealed the patient presented to the ED on 2/13/11 with complaint of abdominal pain. RN C performed a triage assessment of the patient. The medical record documented a Kidney, Ureter, Bladder (KUB) test was performed and medication given to the patient. RN C failed to document notification of the ARNP on call and when this patient went to Radiology and returned. ARNP D failed to document examination of the patient and written order for medications.

RN C on 8/2/11 at 2:30pm verified they failed to document ARNP notification and when the patient went for their Radiology test. Medical Record Administration E on 8/3/11 at 8:45am verified ARNP D failed to document an assessment and orders for tests and medications.

- The medical record of patient #2 reviewed on 8/2/11 revealed the patient presented to the ED on 2/12/11 with complaint of blood in their catheter post surgery to repair stricture 1 month previous. The nurses notes documented that Physician Assistant (PA) F came to the ED to see the patient and ordered treatment, which was done. The medical record on 8/2/11, 5 months after treatment, failed to have any documentation by the PA.

Health Information Management staff member E, on 8/3/11 at 1:30pm verified this medical record lacked any documentation by the PA.