The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ST VINCENT HOSPITAL 123 SUMMER STREET WORCESTER, MA 01608 Aug. 24, 2016
VIOLATION: CONTENT OF RECORD - CONSULTS Tag No: A0464
Based on records reviewed and interview the Hospital failed to ensure all consultative evaluation results were contained in medical records and promptly filed in medical records in order to be available to the physician or other care providers to use in making assessments of 1 (Patient #1) of 20 total sampled patients, condition and justify treatment.

Findings included:

Hospital policy titled Medical Record Requirements, dated 2015, indicated a complete and clinically pertinent medical record included radiology films, scans, and other forms of information.

The Surveyors interviewed the Senior Director of Quality & Patient Safety and Director of Risk Management, at 7:30 A.M. on 8/16/16. They said that the Hospital's internal investigation discovered that the content of Patient #1's medical record did not contain a Computerized Tomography (CT) scan report.

The Surveyor interviewed the Medical Records Associate Director at 9:30 A.M. on 8/23/16. The Medical Records Associate Director said that the Medical Records Department did not receive a CT scan report to enter into Patient #1's medical record. The Medical Records Associate Director said it was the physician's responsibility to provide the CT scan report to the Hospital for entry into Patient #1's medical record.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on records reviewed and interviews the Hospital failed to ensure Patient #1 received care in a safe setting. Patient #1 had surgery to remove his/her left kidney for a large mass (tumor), on 7/20/16. Surgeon #1 determined during the surgery that Patient #1's kidney did not have a tumor. Patient #1's admission and plan for surgery to remove the tumorous kidney was based on another patient's Computerized Tomography (CT) scan results, in error.

Findings included:

Physician Note, dated 7/12/16, indicated Patient #1 was referred to Surgeon #1 for hematuria (blood in the urine) and a kidney tumor. The Physician Note indicated Patient #1 had a CT scan as part of the hematuria evaluation that showed a 13 centimeter (large) left kidney tumor. The Physician Note indicated the kidney tumor was extremely large and the tumor extended to the kidney vein. The Physician Note indicated the plan of care included surgery to remove the kidney.

The Operative Report, dated 7/20/16, indicated Patient #1 had a preoperative diagnosis of a left kidney tumor and removal of the left kidney. The Operative Report indicated Surgeon #1 sent the kidney to the Pathology Department and during the surgery the Pathology Department notified Surgeon #1 that the kidney did not have a tumor. The Operative Report indicated Surgeon #1 inspected the removed kidney specimen and a postoperative diagnosis of no obvious kidney tumor. The Operative Report indicated that there were 2 patients of the same name who had a CT scan on the same day (6/8/16) and the birth dates were a few years apart.

The pathology report, dated 7/25/16, indicated Patient #1 did not have a kidney tumor.

The Hospital policy titled Medical Record Requirements, dated 2015, indicated a complete and clinically pertinent medical record included radiology films, scans, and other forms of information.

The Discharge Summary, dated 7/25/16, indicated Patient #1 had a Computerized Tomography (CT) scan performed at another hospital. Patient #1's medical record did not indicate it contained a CT scan report.

The Surveyors interviewed Surgeon #1 at 11:05 A.M. on 8/17/16. Surgeon #1 said Patient #1's plan of care included removal of the left kidney based on CT scan results performed at another hospital on [DATE]. Surgeon #1 said the CT scan showed a large kidney tumor. Surgeon #1 said there were 2 patients of the same name who had a CT scan on the same day and the birth dates were a few years apart.

The Surveyors interviewed the Chief Medical Officer (CMO) at 2:00 P.M. on 8/16/16. The CMO said that the error happened at the other hospital because there were 2 patients of the same name and the other hospital did not have a name alert in their computerized system. The CMO said surgeons' decide what imaging (CT scan) was needed to perform an operation. The CMO said he did not know the right information (reports) that should be included in the medical record.

Hospital policy titled Medical Record Requirements, dated 2015, indicated a complete and clinically pertinent medical record included radiology films, scans, and other forms of information.

The Surveyors interviewed the Senior Director of Quality & Patient Safety and Director of Risk Management at 7:30 A.M. on 8/16/16. They said that the Hospital's internal investigation discovered Patient #1's medical record did not contain a CT scan report.

The document titled Nurse Practitioner Job Description, dated 8/2014, indicated Nurse Practitioners were responsible for accurate and necessary medical history to assure accurate assessment of the patient condition and needs.

The Surveyor interviewed Nurse Practitioners #1 & #2 at 12:20 P.M. on 8/23/16. The Nurse Practitioners said the Pre-Admission Testing Unit did not always receive reports and physician notes prior to their assessment of the patient prior to surgery. The Nurse Practitioners said that they use CT scan reports to confirm the diagnoses.

Refer to the Conditions of Participation:
1.) 42 CFR 482.21 Quality Assessment & Performance Improvement and
2.) 42 CFR 482.24 Medical Record Services.
VIOLATION: QAPI Tag No: A0263
Based on records reviewed and interviews the Hospital failed to ensure:

1.) Immediate, robust and thorough Quality Assessment and Performance Improvement (QAPI) preventative actions in 1 (Patient #1) of 20 total sampled patients that reduced medical errors after a Hospital credentialed and privileged surgeon removed Patient #1's kidney in error, and,

2.) Failed to ensure thorough documentation and corrective action plans for 3 (Patients #3, #4 and #5) of 5 sampled reports that the Hospital identified as a Patient Identification event.

Findings included:

1.) The Hospital failed to ensure QAPI activities analyzed processes of care, Hospital services and operations thoroughly in 1 (Patient #1) of 20 total sampled patients after a Hospital credentialed and privileged surgeon removed Patient #1's kidney in error.

2.) The Hospital failed to ensure QAPI activities analyzed processes of care, Hospital services and operations thoroughly in 3 (Patients #3, #4 and #5) of 5 sampled reports identified as a patient identification event.

Refer to TAG: A-0273.

The Hospital failed to ensure QAPI activities identified robust opportunities for improvement, timely implementation of identified opportunities for improvement and track performance to ensure that improvements were sustained in 1 (Patient #1) of 20 total sampled patients after a Hospital credentialed and privileged surgeon removed Patient #1's kidney in error.

Refer to TAG: A-0283

The Hospital failed to ensure QAPI activities implemented preventive actions and mechanisms that include feedback and learning throughout the Hospital of compliance to the Hospital's Patient Identification Policy, for both Hospital staff and all members of the Medical Staff, for 1 (Patient #1) of 20 total sampled patients, that reduced medical errors after a Hospital credentialed and privileged surgeon removed Patient #1's kidney in error.

Refer to TAG: A-0286
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on records reviewed and interviews the Hospital failed to ensure that Quality Assessment and Performance Improvement (QAPI) activities analyzed processes of care, Hospital services and operations, thoroughly, in 4 (Patient #1, #3, #4 and #5) of 20 total sampled patients, after a Hospital credentialed and privileged surgeon removed Patient #1's kidney in error.

Findings included:

1.) Refers to Patient #1:

Physician Note, dated 7/12/16, indicated Patient #1 was referred to Surgeon #1 for hematuria (blood in the urine); a Computerized Tomography (CT) scan showed a 13 centimeter (large) left kidney tumor and the plan of care included surgery to remove the kidney.

The Operative Report, dated 7/20/16, indicated Patient #1 had surgery for removal of the left kidney. The Operative Report, indicated Surgeon #1 sent Patient #1's kidney to the Pathology Department and, during the surgery, the Pathology Department did not see a kidney tumor. The Operative Report indicated Surgeon #1 confirmed that he also did not see a kidney tumor. The Operative Report indicated Surgeon #1 evaluated Patient #1's CT scan and confirmed a kidney tumor. The Operative Report indicated that on further inspection, Surgeon #1 discovered 2 patients with the same name that had a CT scan on the same day.

The Pathology Report, dated 7/25/16, indicated Patient #1 did not have a kidney tumor.

Patient #1's medical record, at the Hospital, did not indicate it contained a CT scan report.

Hospital policy titled Medical Record Requirements, dated 2015, indicated a complete and clinically pertinent medical record included radiology films, scans, and other forms of information.

Hospital policy titled Universal Protocol Preventing Wrong Site, Wrong Side, Wrong Procedure, Wrong Patient Surgical and Invasive Procedures, dated 4/17/14, indicated that standards of practice included diagnostic and radiologic images were properly labeled and displayed.

Medical Staff Rules & Regulations, dated 6/2016, indicated that the attending practitioner was responsible for the preparation of a complete medical record. The Medical Staff Rules & Regulations indicated that a complete medical record included diagnostic and therapeutic procedures and test results. Examinations or procedures, radiologic, performed outside the Hospital may be submitted to the appropriate Hospital Department for review at the discretion of the operating surgeon.

The Hospital Performance Improvement Committee Meeting Minutes, draft, dated 8/5/16, indicated a surgical event where Patient #1's kidney was removed based on the wrong CT scan. The Hospital Performance Improvement Committee Meeting Minutes indicated a Corrective Action Plan (CAP) included: (1) reinforce the need for 2 patient identifiers, name and birth date with all staff, (2) Review Information Technology issues in the Operating Room and (3) revise the Universal Protocol to include language "correct" imaging studies are present if needed for the surgery. The Hospital Performance Improvement Committee Meeting Minutes did not indicate a tracking process to assure compliance with the identified CAP. The Hospital Performance Improvement Committee Meeting Minutes did not indicate that Patient #1's medical record did not contain the CT scan report.

The Surveyors interviewed the Senior Director of Quality & Patient Safety and Director of Risk Management, at 7:30 A.M. on 8/16/16. They said that the Hospital's internal investigation discovered that the content of Patient #1's medical record did not contain a CT scan report.

The Surveyor interviewed the Medical Records Associate Director at 9:30 A.M. on 8/23/16. The Medical Records Associate Director said the Hospital policy on the medical record content was according to the Hospital Medical Staff bylaws. The Medical Records Associate Director said that the Medical Records Department did not receive a CT scan report to enter into Patient #1's medical record. The Medical Records Associate Director said it was the physician's responsibility to provide the CT scan report to the Hospital for entry into Patient #1's medical record.

The Surveyors interviewed the Chief Medical Officer (CMO) at 2:00 P.M. on 8/16/16. The CMO said surgeons' decide what imaging (CT scan) was needed to perform an operation. The CMO said he did not know the right information (reports) to include in the medical record.

The Surveyor interviewed Nurse Practitioners #1 & #2 at 12:20 P.M. on 8/23/16. The Nurse Practitioners said the Pre-Admission Testing Unit did not always receive reports and physician notes prior to their assessment of the patient prior to surgery. The Nurse Practitioners said that they use CT scan reports to confirm the diagnoses. Nurse Practitioners #1 & #2 said they addressed their concerns with their Nurse Manager.

The Surveyor interviewed the Pre-Admission Testing Unit Nurse Manager, at 1:45 P.M. on 8/23/16. The Pre-Admission Testing Unit Nurse Manager said Nurse Practitioners #1 & #2 addressed their concerns with her and she met with and addressed the concerns with the Senior Director of Perioperative Services and two physicians, twice. The Pre-Admission Testing Unit Nurse Manager said she did not remember the dates of the meetings and meeting minutes were not recorded. The Pre-Admission Testing Unit Nurse Manager said concerns remained, staff has difficulty getting the reports and documents from the doctors' offices, and the issues had been ongoing for a while, years.

The Surveyor interviewed the Senior Director of Perioperative Services, at 9:10 A.M. on 8/24/16. The Senior Director of Perioperative Services said that reports and documents do not come to the Pre-Admission Testing Unit as timely as the staff would like and all the reports and documents were in the patient's medical record prior to surgery. The Senior Director of Perioperative Services said it was the responsibility of the Pre-Admission Testing Unit staff to gather the reports and documents.


Refer to TAG A-0431 Condition of Participation: Medical Record Services.

2.) Refers to Patients #3, #4 & #5:

Hospital policy titled Patient Identification, dated 7/22/15, indicated that patient identifiers were the patients first and last name, the patient's birth date and the patient's medical record number was used only when the patient's date of birth was unavailable.

A Hospital report, dated 6/27/16, indicated the Hospital banded Patient #3's son with the patient identification bracelet and not Patient #3. The Hospital report indicated that Patient #3 did not speak English. The Hospital report did not indicate the Hospital conducted an investigation of how the patient identification error happened and if Hospital staff utilized an interpreter. The Hospital report indicated the action and disposition section of the form was blank.

A Hospital report, dated 7/11/16, indicated a Radiology Technician discovered Patient #4 without a patient identification bracelet and called the patient care unit to bring the band down. The Hospital report did not indicate follow-up.

A Hospital report, dated 8/6/16, indicated Patient #5 registered with another patient name. The Hospital report indicated that the Hospital corrected Patient #5's registration and the report indicated the event was resolved. The Hospital report indicated Patient #5 had two (2) medical record numbers on the report. The Hospital report did not indicate if the other patient existed in the Hospital electronic medical record (EMR) system, the report did not indicate if the Hospital treated Patient #5 as the other patient and the report did not indicate if the Hospital corrected the other patient's EMR.

The Surveyor interviewed the Associate Director for Medical Records at on 8/24/16. The Associate Director for Medical records said the Patient #5's medical record was corrected from the incorrect medical record number) to the correct medical record number.

Patient #5's medical record indicated (and the Surveyor observed on 8/24/16), that Patient #5's medical record indicated an incorrect medical record number, on sixteen (16) forms and electronic medical records. The forms and electronic medical records included 1.) Consent for Transfer Form, dated 8/8/16; 2.) Acknowledgement of Receipt of Notice of Privacy Practices, dated 8/6/16; 3.) Condition of Treatment Agreement Form, dated 8/6/16, with Un-Sampled Patient #1's name; 4.) Condition of Treatment Agreement Form, dated 8/6/16; 5.) Application for and Authorization of Temporary Involuntary hospitalization Form, dated 8/6/16; 6.) Section 12 Checklist, dated 8/6/16; 7.) Emergency Department (ED) Provider Chart Summary, dated 8/6/16; 8.) ED Nursing Chart Summary, dated 8/6/16, with Un-Sampled Patient #1's name; 9.) ED Orders Summary, dated 8/6/16;
10.) ED Disposition Summary, dated 8/6/16; 11.) Consultation Sheet, dated 7/7/16; 12.) Medication Discharge Summary, dated 8/10/16;
13.) Discharge Report, dated 8/10/16; 14.) Laboratory Results, dated 8/6/16; 15.) Constant Observation Flow Sheets, dated 8/6/16 through 8/7/16 and 16.) Emergency Services Program (ESP) Comprehensive Assessment, dated 8/6/16.

These forms and electronic medical records did not indicate Patient #5's corrected medical record number. These forms and electronic medical records did not indicate that the Hospital merged or corrected Patient #5's and the other patient's medical records.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
The Hospital failed to ensure that Quality Assessment and Performance Improvement (QAPI) activities timely implemented identified opportunities for improvement and tracked performance to ensure that improvements were sustained, in 1 (Patient #1) of 20 total sampled patients, after a Hospital credentialed and privileged surgeon removed Patient #1's kidney in error.

Findings included:

The Operative Report indicated Surgeon #1 conducted Patient #1's surgery on 7/20/16.

The Hospital Performance Improvement Committee Meeting Minutes, draft, dated 8/5/16, indicated a surgical event where Patient #1's kidney was removed based on the wrong Computerized Tomography (CT) scan. The Hospital Performance Improvement Committee Meeting Minutes indicated a Corrective Action Plan (CAP) included: (1.) reinforce the need for 2 patient identifiers, name and birth date with all staff, (2.) Review Information Technology issues in the Operating Room and (3.) revise the Universal Protocol to include language that "correct" imaging studies are present if needed for the surgery.

The Hospital Performance Improvement Committee Meeting Minutes did not indicate a tracking process to assure compliance with the identified CAP. The Hospital Performance Improvement Committee Meeting Minutes did not indicate that Patient #1's medical record did not contain the CT scan report and the Hospital Performance Improvement Committee Meeting Minutes did not indicate further investigation that Patient #1's medical record did not contain a CT scan report.

Hospital policy titled Patient Identification, dated 7/22/15, indicated that patient identifiers were the patient's first and last name, the patient's birth date and the patient's medical record number was used only when the patient's birth date was unavailable.

Education records titled Staff In-service and Multidisciplinary Meeting, dated 7/20/16 and 8/17/16 respectively, indicated approximately 29 (approximately 32%) of approximately 90 of the Surgical Services staff did not attend the education offering on patient identification.

The Surveyors interviewed the Chief Medical Officer (CMO) at 2:00 P.M. on 8/16/16. The CMO said that he discussed at the Chiefs Meeting and the Medical Executive Meeting the expectation to use 2 patient identifiers per Hospital policy. The CMO said that he did not know if all physicians received the information and would send out an email (electronic mail) today (8/16/16).

The Medical Executive Committee General Session Meeting Minutes, dated 8/11/16, indicated that the CMO informed members present to remind staff to check the name and birth date when accessing any imaging studies, electronic medical records and laboratory results. The Medical Executive Committee General Session Meeting Minutes did not indicate actions and did not indicate follow-up.

An email from the CMO dated 8/16/16, indicated the critical importance of always identifying patients with the two identifiers of name and birth date and, in addition, when accessing a patient's imaging studies, laboratory results and electronic medical records you must also make sure to use two identifiers.

The Surveyors interviewed the Senior Director of Quality & Patient Safety and Director of Risk Management, at 7:30 A.M. on 8/16/16. They said that the Hospital's internal investigation conducted on 7/26/16 discovered that the Hospital (1) had computer connection to the Internet concerns in the operating room; (2) computers used for viewing imaging tests (for example a Computerized Tomography (CT) scan, in the operating room, would stop working after a period of time (a computer time out delay) and the surgeons needed a longer time out delay set on the computers; and (3) some images did not display the patient's birth date.

The Surveyor interviewed Registered Nurse (RN) #1 at 1:10 P.M. on 8/16/16. RN #1 said, yesterday, a patient's imaging tests in the operating room did not display the patient's birth date.

The Surveyors interviewed the Information Technology Specialist for Imaging Services at 1:00 P.M. on 8/17/16. The Information Technology Specialist for Imaging Services said the concern of a patient's imaging tests not displaying the patient's birth date in the operating room was corrected one (1) hour ago, (during the Survey).

The email dated 8/18/16 at 12:14 P.M., indicated 20 computers in the 18 operating rooms were evaluated and corrected for the internet connection concerns, (during the Survey).

The email dated 8/18/16 at 11:16 A.M. indicated that the computer time out delay concern was corrected, (during the Survey).

The Senior Director of Quality & Patient Safety and Director of Risk Management said the revision of the Universal Protocol to include language "correct" imaging studies were present, if needed for the surgery was scheduled for committee approval, (not implemented).
VIOLATION: OPERATING ROOM POLICIES Tag No: A0951
Based on records reviewed and interviews the Hospital failed to ensure that the Surgical Services were designed to implement and enforce Hospital policies to achieve and maintain high standards of medical practice and patient care in 1 (Patient #1) of 20 total sampled patients after a Hospital credentialed and privileged surgeon removed Patient #1's kidney in error.

Findings included:

Hospital policy titled Patient Identification, dated 7/22/15, indicated that patient identifiers were the patients first and last name, the patient's birth date and the patient's medical record number was used only when the patient's date of birth was unavailable.

The Chiefs Meeting Minutes, dated 7/21/16, indicated the Chief Medical Officer directed meeting members to make sure your staff were checking "name" and "birth date" whenever accessing imaging studies, electronic medical records and laboratory results. The Chiefs Meeting Minutes did not indicate a tracking process to ensure compliance with this performance improvement action to reduce medical errors.

The email dated 8/16/16 and sent from the Chief Medical Officer, indicated a safety reminder to use 2 patient identifiers, patient name and patient birth date, for accessing patient data, imaging studies, laboratory results and electronic medical records. (The email was sent during the Survey.)

Education Records titled Operating Room Staff In-Service, Patient Identification, OR Roster, dated 8/17/16 and Operating Room Multidisciplinary Meeting, OR Roster, dated 7/27/16, indicated that approximately 32% of the staff attended the re-learning regarding patient identification.

Hospital policy titled Medical Record Requirements, dated 2015, indicated a complete and clinically pertinent medical record included radiology films, scans, and other forms of information.

The Surveyors interviewed the Senior Director of Quality & Patient Safety and Director of Risk Management, at 7:30 A.M. on 8/16/16. They said that the Hospital's internal investigation discovered that the content of Patient #1's medical record did not contain a Computerized Tomography (CT) scan report.

The Surveyor interviewed Nurse Practitioners #1 & #2 at 12:20 P.M. on 8/23/16. The Nurse Practitioners said that the Pre-Admission Testing Unit does not always receive reports and physician notes prior to their assessment of the patient prior to surgery. The Nurse Practitioners said that they use CT scan reports when performing a patient's pre-admission testing assessment to confirm diagnoses.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on records reviewed and interview: 1.) The Governing Body failed to assure Quality Assessment & Performance Improvement activities were thoroughly defined and implemented for 1 (Patient #1) of 20 total sampled patients after a Hospital credentialed and privliged surgeon removed Patient #1's kidney in error and 2.) The Governing Body failed to assure all improvement actions were evaluated.

Findings included:

1.) The Hospital policy titled Patient Identification, dated 7/22/15, indicated that patient identifiers were the patients first and last name, the patient's birth date and the patient's medical record number was used only when the patient's date of birth was unavailable.

The Hospital Performance Improvement Committee Meeting Minutes, draft, dated 8/5/16, indicated a surgical event where Patient #1's kidney was removed based on the wrong Computerized Tomography (CT) scan. The Hospital Performance Improvement Committee Meeting Minutes indicated a Corrective Action Plan (CAP) included: (1) reinforce the need for 2 patient identifiers, name and birth date with all staff, (2) Review Information Technology issues in the Operating Room and (3) revise the Universal Protocol to include language "correct" imaging studies are present, if needed for the surgery. The Hospital Performance Improvement Committee Meeting Minutes did not indicate a tracking process to assure compliance with the identified CAP. The Hospital Performance Improvement Committee Meeting Minutes did not indicate it contained that Patient #1's medical record did not contain the CAT scan report.

The Hospital internal investigation did not indicate an immediate corrective action of notification to all members of the Medical Staff regarding the Hospital's policy on Patient Identification.

Hospital policy titled Medical Record Requirements, dated 2015, indicated a complete and clinically pertinent medical record included radiology films, scans, and other forms of information.

The Surveyors interviewed the Senior Director of Quality & Patient Safety and Director of Risk Management, at 7:30 A.M. on 8/16/16. They said that the Hospital's internal investigation discovered Patient #1's medical record did not contain a CT scan report.

The Hospital internal investigation did not indicate a plan to thoroughly investigate why Patient #1's CT scan report was not included in Patient #1's medical record. The Hospital internal investigation did not indicate a plan to thoroughly investigate if other clinically pertinent medical record forms of information were included in the medical record in compliance with the Medical Record Services Condition of Participation.

Refer to TAG: A-0431, Condition of Participation, Medical Record Services.

Hospital policy titled Universal Protocol Preventing Wrong Site, Wrong Side, Wrong Procedure, Wrong Patient Surgical and Invasive Procedures, dated 4/17/14, indicated that standards of practice included diagnostic and radiologic images were properly labeled and displayed.

Medical Staff Rules & Regulations, dated 6/2016, indicated that the attending practitioner was responsible for the preparation of a complete medical record. The Medical Staff Rules & Regulations indicated that a complete medical record included diagnostic and therapeutic procedures and test results. Examinations or procedures, radiologic, performed outside the Hospital may be submitted to the appropriate Hospital Department for review at the discretion of the operating surgeon.

Refer to TAG A-0431 Condition of Participation: Medical Record Services.

The Hospital Performance Improvement Committee Meeting Minutes, draft, dated 8/5/16, indicated a surgical event where Patient #1's kidney was removed based on the wrong CAT scan. The Hospital Performance Improvement Committee Meeting Minutes indicated a Corrective Action Plan (CAP) included: (1.) reinforce the need for 2 patient identifiers, name and birth date with all staff, (2.) Review Information Technology issues in the Operating Room and (3.) revise the Universal Protocol to include language that "correct" imaging studies are present if needed for the surgery.

The Hospital Performance Improvement Committee Meeting Minutes did not indicate a tracking process to assure compliance with the identified CAP. The Hospital Performance Improvement Committee Meeting Minutes did not indicate it contained, that Patient #1's medical record did not contain the CAT scan report and the Hospital Performance Improvement Committee Meeting Minutes did not indicate further investigation that Patient #1's medical record did not contain a CAT scan report.

(2.) The Surveyors interviewed the Senior Director of Quality & Patient Safety and Director of Risk Management, at 7:30 A.M. on 8/16/16. They said that the Hospital's internal investigation conducted on 7/26/16, discovered that the Hospital (1) had computer connection to the internet concerns in the operating room; (2) computers used for viewing imaging tests (for example a Computerized Axial Tomography (CAT) scan, in the operating room, would stop working after a period of time (a computer time out delay) and the surgeons needed a longer time out delay set on the computers; and (3) some images did not display the patients birth date.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on records reviewed and interviews the Hospital failed to ensure the protection of Patient #1's right to care in a safe setting. Patient #1 had surgery to remove his/her left kidney, on 7/20/16. During the surgery Surgeon #1 determined that Patient #1's kidney did not have a tumor. It was later determined that Patient #1's admission and plan for surgery to remove the tumorous kidney was based on another patient's Computerized Tomography (CT) scan results, in error.

Findings included:

The Hospital failed to ensure Patient #1 received care in a safe setting.

Refer to TAG: A-0144.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on records reviewed and interview the Hospital failed to ensure that Quality Assessment and Performance Improvement (QAPI) activities implemented preventative actions that included feedback and learning throughout the Hospital of compliance to the Patient Identification Policy for both Hospital and Medical Staffs for 1 (Patient #1) of 20 total sampled patients after a Hospital credentialed and privileged surgeon removed Patient #1's kidney in error.

Findings included:

The Operative Report indicated Surgeon #1 conducted Patient #1's surgery on 7/20/16.

The Hospital internal investigation and corrective actions, dated 7/26/16, did not indicate that Quality Assessment and Performance Improvement (QAPI) preventative feedback and learning action was implemented throughout the Hospital of compliance to the Patient Identification Policy for both Hospital staff and members of the Medical Staff.

The Chiefs Meeting Minutes, dated 7/21/16, indicated the Chief Medical Officer directed meeting members to make sure your staff were checking "name" and "birth date" whenever accessing imaging studies, electronic medical records and laboratory results. The Chiefs Meeting Minutes did not indicate a tracking process to ensure compliance with this performance improvement action to reduce medical errors.

The email dated 8/16/16 and sent from the Chief Medical Officer, indicated a safety reminder to use two patient identifiers, patient name and patient birth date, for accessing patient data, imaging studies, laboratory results and electronic medical records. (The email was sent during the Survey.)

Education Records titled Operating Room Staff In-Service, Patient Identification, Operating Room Roster, dated 8/17/16 and Operating Room Multidisciplinary Meeting, Operating Room Roster, dated 7/27/16, indicated that approximately 32% of the staff attended the re-education regarding patient identification.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
Based on records reviewed and interviews the Hospital failed to ensure in 1 (Patient #1) of 20 total sampled patients that a complete medical record, including diagnostics and radiology reports were integrated into Patient #1's medical record.

Findings included:

The Hospital failed to ensure the medical record of 1 (Patient #1) of 20 sampled patients contained complete information regarding evaluations, including radiology reports, to aide physicians and other care providers in making assessments of the patient's condition to justify continued hospitalization and support the diagnosis.

Refer to TAG A-0449

The Hospital failed to ensure all consultative evaluation results were contained in medical records and promptly filed in medical records in order to be available to the physician or other care providers to use in making assessments of 1 (Patients 1) of 20 total sampled patients, condition and support the diagnosis.

Refer to TAG A-0464
VIOLATION: CONTENT OF RECORD Tag No: A0449
Based on records reviewed and interview the Hospital failed to ensure the medical record for 1 (Patient #1) of 20 total sampled patients, contained complete information regarding evaluations, including radiology reports were available to the physician and other care providers to use in making assessments of the patient's condition, to justify continued hospitalization and support the diagnosis.

Findings included:

Physician Note, dated 7/12/16, indicated Patient #1 had a diagnosis, of a kidney mass (tumor) and that a Computerized Tomography (CT) scan showed a large kidney tumor.

History and Physical, dated 7/20/16, indicated Patient #1 was admitted to the Hospital with a diagnosis of a kidney tumor and surgery to remove the kidney.

Hospital policy titled Medical Record Requirements, dated 2015, indicated a complete and clinically pertinent medical record included radiology films, scans, and other forms of information.

The Surveyors interviewed the Senior Director of Quality & Patient Safety and Director of Risk Management, at 7:30 A.M. on 8/16/16. They said that the Hospital's internal investigation discovered that the content of Patient #1's medical record did not contain a Computerized Tomography (CT) scan report.

The Surveyor interviewed the Medical Records Associate Director at 9:30 A.M. on 8/23/16. The Medical Records Associate Director said that the Medical Records Department did not receive a CT scan report to enter into Patient #1's medical record. The Medical Records Associate Director said it was the physician's responsibility to provide the CT scan report to the Hospital for entry into Patient #1's medical record.