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.

ROBERT WOOD JOHNSON UNIVERSITY HOSPITAL SOMERSET 110 REHILL AVE SOMERVILLE, NJ 08876 Oct. 22, 2012
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and review of facility policy, "End of Life Care and Organ-Tissue Donation," it was determined that the facility failed to ensure that the policy and procedure for end of life care was implemented.

Findings include:

Reference: Facility policy titled, "End of Life Care and Organ-Tissue Donation" states under Procedures: "IV. PLACEMENT IN A NONRESUSCITATIVE CATEGORY- C. Documentation Placement in a non-resuscitative category requires that the attending physician write a care category note in the progress note in the medical record. The note should include: 1) the patient's diagnosis and prognosis; 2) the reason why CPR is inappropriate; and 3) a statement that outlines discussions held with the patient or surrogate if appropriate. This may also be noted on the DNR Order or Withholding/Withdrawing Consent Form itself ..."

1. Review of Medical Record #9 revealed the following:

a. The patient, a [AGE] year old female was brought to the ED on 5/26/12 following two episodes of vomiting brown liquid. She was seen in the ED two days prior for coffee ground emesis, and was discharged at that time. According to the History and Physical, the patient has aphasia and dementia. A DNR order was written by the physician on 5/27/12.

i. There was no evidence in the medical record of a care category note that included the patient's diagnosis and prognosis, the reason why CPR is inappropriate, and a statement that outlines discussions held with the patient or surrogate, as required by the above referenced policy.

2. Review of Medical Record #17 revealed the following:

a. The patient, an [AGE] year old female, was admitted to the facility on [DATE] with mental status changes and rapid atrial fibrillation. A DNR order was written by the physician on 5/6/12.

i. There was no evidence in the medical record of a care category note that included the patient's diagnosis and prognosis, the reason why CPR is inappropriate, and a statement that outlines discussions held with the patient or surrogate, as required by the above referenced policy.

3. Review of Medical Record #18 revealed the following:

a. The patient, a [AGE] year old female, was brought to the Emergency Department (ED) on 5/4/12 with shortness of breath, fever, constipation and respiratory distress. A DNR order was written by the physician on 5/4/12.

i. There was no evidence in the medical record of a care category note that included the patient's diagnosis and prognosis, the reason why CPR is inappropriate, and a statement that outlines discussions held with the patient or surrogate, as required by the above referenced policy.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
Based on document review, observation and staff interview, it was determined that the facility failed to maintain a medical record.

Findings include:

1. The facility failed to ensure that unauthorized individuals cannot gain access to or alter medical records. (Cross refer A442).

2. The facility failed to ensure that a post recovery assessment note by the anesthesiologist was made in the medical record, after release from the recovery room. (Cross refer A449).
VIOLATION: CONFIDENTIALITY OF MEDICAL RECORDS Tag No: A0441
Based on staff interview and document review, it was determined that the facility failed to ensure that unauthorized individuals cannot gain access to or alter Medical Record #1.

Findings include:

Reference #1: Facility policy, Legal Medical Record-(Designated Record Set, Retention and Destruction, Accuracy and Completion)" that stipulates, "... ...C. Medical records shall be maintained in a safe and secure area. Safeguards to prevent loss, destruction and tampering will be maintained as appropriate. Records will be released from Health Information Management Services only in accordance with the provisions of this policy and other" facility "Privacy Policies and Procedures."

1. The paper portion of Medical Record #1 was not secured in the facility in accordance with facility policy, "Legal Medical Record-(Designated Record Set, Retention and Destruction, Accuracy and Completion)."

a. On 8/1/12 at 11:00 AM, Staff #2 stated that the paper portion of Medical Record #1 went missing between 12/20/11 and 12/23/11. Staff #2 stated that during this timeframe, the exact location of the paper portion of Medical Record #1 was not known. Staff #2 stated that on 3/15/12, more than two months later, he/she received a call from Staff #11's office stating that the paper portion of Medical Record #1 was found in an interoffice envelope in Staff #11's office.

b. On 8/1/12, Staff #2 provided a document dated 3/19/12 that stated on 12/23/11, Patient #1's legally authorized representative came in to ask for a copy of Patient #1's medical record and that HIM (Health Information Management) staff began looking for this chart to possibly find the name of the patient's Power of Attorney in the chart. Patient #1's legally authorized representative said he/she would get the paperwork and return instead of waiting. At that time, the chart could not be found by staff.

c. On 8/1/12 at 2:00 PM, Staff #5 confirmed the above findings.
VIOLATION: CONTENT OF RECORD Tag No: A0449
Based on staff interview and medical record review, it was determined that the facility failed to ensure that a post recovery assessment note by the anesthesiologist was made in the medical record, after release from the recovery room.

Findings include:

1. In Medical Record #1, the "Anesthesia Record" dated 12/5/11 did not contain a completed "Anesthesia Post Recovery Assessment."

2. In Medical Record #2, the "Anesthesia Record" dated 11/9/12 did not contain an entry under the "Anesthesia Post Recovery Assessment."

3. In Medical Record #8, the "Anesthesia Record" dated 6/30/11 did not contain an entry under the "Anesthesia Post Recovery Assessment." In addition, the "Anesthesia Initial Post-Op Assessment" contained a signature and date but no assessment or time.

4. In Medical Record #10, the "Anesthesia Record" dated 3/28/11 did not contain the time of the "Anesthesia Pre-Op Assessment, Anesthesia Initial Post-Op Assessment" and the "Anesthesia Post Recovery Assessment" were completed.

5. In Medical Record #12, the "Anesthesia Record" dated 9/26/11 did not contain a completed "Anesthesia Post Recovery Assessment."

6. In Medical Record #13, the "Anesthesia Record" dated 2/2/11 did not contain a completed "Anesthesia Post Recovery Assessment."

7. During an interview on 10/22/12, Staff #1 and Staff #2 confirmed the above findings.
VIOLATION: CONTENT OF RECORD - DISCHARGE DIAGNOSIS Tag No: A0469
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of 7 of 16 Medical Records (#1, #5, #6, #11, #13, #15, #16) on 10/22/12, it was determined that the facility failed to ensure the discharge summary was completed within the required 30-days.

Findings include:

1. Review of Medical Record #1 evidenced that Patient #1 expired at the facility on 12/18/11. The discharge summary was completed on 3/6/12. This was more than 1 month past the required 30-day completion date.

2. Review of Medical Record #5 revealed that the patient was discharged from the facility on 10/12/10. The discharge summary was completed on 11/17/10. This was 5 days past the required 30-day completion date.

3. Review of Medical Record #6 revealed that the patient was discharged from the facility on 12/21/11. The discharge summary was completed on 2/17/12. This was 27 days past the required 30-day completion date.

4. Review of Medical Record #11 revealed that the patient was discharged on [DATE]. The discharge summary was completed on 11/7/11. This was more than 6 months past the required 30-day completion date.

5. Review of Medical Record #13 revealed that the patient was discharged from the facility on 2/7/11. The discharge summary was completed on 5/2/11. This was 56 days past the required 30-day completion date.

6. Review of Medical Record #15 revealed that the patient was discharged on [DATE]. The discharge summary was completed on 2/6/12. This was 22 days past the required 30-day completion date.

7. Review of Medical Record #16, revealed that the patient was discharged on [DATE]. There was no discharge summary in the record. This was more than 15 months past the required 30-day completion date.

8. During an interview on 10/22/12, Staff #1 and Staff #2 confirmed the above findings.