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.
|UNIV. OF VERMONT - FLETCHER ALLEN HEALTH CARE||111 COLCHESTER AVE BURLINGTON, VT 05401||June 4, 2013|
|VIOLATION: FORM AND RETENTION OF RECORDS||Tag No: A0438|
|Based on staff interviews and record review the facility failed to assure a complete and accurate medical record was maintained for 1 of 10 applicable records reviewed. (Patient #1). Findings include:
1. Per review of the medical record Patient #1 had a lab requisition, dated 4/16/12, that identified an area of the male genitalia as the source of a culture specimen obtained that day. However, the requisition further identified the Associated Diagnosis as "Wound infection following cesarean section, postpartum".
The director of the medical lab confirmed the documentation error during interview on the afternoon of 5/30/13. The inaccuracy of the medical record was also confirmed by the nurse who had been responsible for completing the lab requisition. The nurse stated, during interview at 12:30 PM on the afternoon of 5/1/13, that the requisition had been completed electronically and the diagnosis was chosen from a drop down box. S/he confirmed it appeared the wrong diagnosis had inadvertently been checked off.
2. Per review of the record Patient #1 was admitted to the facility at 6:29 PM on the evening of 4/16/13 for treatment of a wound infection. Although a nurse's note, dated 4/16/13, stated the patient's "IV (intravenous) was D/C'd (discontinued) and patient left AMA (against medical advice)" at 8:45 PM, there was no evidence that an AMA form had been signed by the patient nor any indication that the patient had refused to sign the form. The facility's policy for Patients off the Unit (Includes AMA, Out on Pass, Elopement) , with a publish date of 10/12/2012 and identified by staff as the currently established policy, stated under Patients Who Wish to Leave the Unit without Permission: 2. "If a competent patient with decision-making capacity wishes to be discharged from the hospital against medical advice (AMA).......The patient may leave after signing AMA form.....If the patient refuses to sign the form, the patient's refusal to sign the form shall be documented in the record."
During interview, at 1:30 PM on 5/1/13, the Nurse Director of the Medical Surgical Units, confirmed that there should be evidence that the patient signed the AMA form or documentation of the refusal to sign.