HospitalInspections.org

Based on review of facility documentation and medical records (MR) and staff interviews(EMP), it was determined that the facility failed to ensure that all entries in the medical record were complete, legible, authenticated, dated and timed for 19 of 35 medical records (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR9, MR18, MR20, MR21, MR22, MR28, MR29, MR30, MR32, MR33, MR34, and MR35).

Findings include:

Review of The Ellwood City Hospital HIPAA Policy & Procedure "Workstation Use And Security/Electronic Signature," origin date January 2005 revealed, "7. ... A. Log on using your individual username and password; ... 8. ... any documentation produced by the information system identifying a specific user shall serve as the electronic signature for that user.

Review of Ellwood City Hospital Medical Record Department "The Patient Medical Record" revealed, "Responsibility for Documentation Any health care physician, practitioner, professional, or paraprofessional involved in the treatment of a patient shall have the responsibility for documenting and authenticating care rendered. ..."

Review of the "Nursing Documentation" policy reviewed August 23, 2011, revealed, "Documentation ... II. ... A. All entries include month, day, year, and time."

On April 16, 2015, at approximately 10:20 AM review of the "Ellwood City Hospital Medical Staff Rules & Regulations" revised May 2014 revealed, "Department of Medicine ... II. MEDICAL RECORD 1. The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient. ... 7. All clinical entries in the patient's medical record shall be accurately dated, and authenticated."

1. On April 15, 2015, at approximately 10:15 AM review of MR1 revealed a consultation report dictated on March 27, 2015, and electronically authenticated by the physician on April 2, 2015. In the medications section of the report there were blank spaces to indicate missing information.

Continued review of MR1 revealed illegible entries on the physician progress notes sheet dated 4/1 and 3/2.

Review of this record also revealed physician orders and progress notes which were dated 4/1, 4/2, 4/3, 4/4, 4/5 and 4/6. There was no time on any of the above entries to identify when they were placed into the medical record.

During an interview on April 16, 2015, at approximately 10:30 AM EMP10 confirmed that there should not be blank spaces in the consultation report if it was reviewed and signed by the physician. EMP10 also was unable to read the progress notes identified above and confirmed there were no times on the above entries.

2. On April 15, 2015, at approximately 1:30 PM review of MR2 revealed the patient had an outpatient procedure at the facility on April 2, 2015. The History & Physical (H&P), the pre-operative orders and the anesthesia consent were all dated April 2, 2015. However, there was no time on any of the above entries to identify when they were placed into the medical record.

On April 16, 2015, at approximately 10:30 AM EMP10 confirmed there were no times on any of the above entries.

3. On April 16, 2015, at approximately 8:15 AM review of MR3 revealed the patient had an outpatient procedure at the facility on April 13, 2015. The anesthesia consent was dated April 13 but there was no time to indicate when this entry into the medical record was made.

On April 16, 2015, at approximately 10:30 AM EMP10 confirmed there was no time on the anesthesia consent for MR3.

4. On April 16, 2015, at approximately 9:00 AM review of MR4 revealed the patient had an outpatient procedure at the facility on April 13, 2015. The H&P and anesthesia consent were both dated April 13. However, there was no time on either of the above entries to identify when they were placed into the medical record.

Review of MR4 also revealed a diagnostic report which was electronically authenticated on April 14, 2015. Further review of the document revealed a physician group, not an individual physician as the author of the authentication.

During an interview on April 16, 2015, at approximately 10:30 AM EMP10 confirmed there were no times on the above entries and there was no way to identify which physician authenticated this diagnostic report.

5. On April 16, 2015, at approximately 9:15 AM review of MR5 revealed an untimed "Paramedical Progress Note" indicating a physician ordered exam was completed on April 9.

Continued review of MR5 revealed physician orders and progress notes dated 4/10, 4/12, 4/13 and 4/14. There was also an anesthesia consent dated 4/14. There was no time on any of the above documents to indicate when these entries were placed into the medical record.

On April 16, 2015, at approximately 10:30 AM EMP10 confirmed the above identified documents were not timed.

6. On April 16, 2015, at approximately 9:45 AM review of MR6 revealed the "Venous Thromboembolism and Pulmonary Embolism Prophylaxis - Nursing Risk Assessment" form completed with RN signature, however there was no space for a date or time of the RN signature.

Continued review of this record revealed physician progress notes and orders dated 4/12 and 4/13 and an anesthesia consent which was dated 4/10. There was no corresponding time to any of the above entries to identify when they were placed into the medical record.

During an interview on April 16, 2015, at approximately 10:30 AM EMP10 confirmed there was no way to identify when the nursing assessment form was completed without a date and time. EMP10 also confirmed the progress notes and consent also were not timed.

7. On April 16, 2015, at approximately 10:00 AM review of MR7 revealed the patient had an outpatient procedure at the facility on April 1, 2015. The anesthesia consent was dated 4/1 but there was no corresponding time to identify when it was placed into the medical record.

On April 16, 2015, at approximately 10:30 AM EMP10 confirmed the above consent form did not contain a time.

8. On April 16, 2015, at approximately 10:15 AM review of MR9 revealed a diagnostic report electronically authenticated on April 14, 2015. Further review of the document revealed a physician group, not an individual physician as the author of the authentication.

Continued review of MR9 revealed a "History & Physical" dictated April 13, 2015, and electronically authenticated on April 14, 2015. The medications section contained a blank space indicating missing information.

On April 16, 2015, at approximately 10:30 AM EMP10 confirmed the above identified documentation issues.

9. Review of MR18 revealed a diagnostic report electronically authenticated on April 13, 2015. Further review of the document revealed a physician group, not an individual physician as the author of the authentication.

10. Review of MR20 revealed a diagnostic report electronically authenticated on April 9, 2015. Further review of the document revealed a physician group, not an individual physician as the author of the authentication.

11. Review of MR21 revealed a History and Physical and a diagnostic report, both electronically authenticated on April 8, 2015. Further review of the documentation revealed a physician group, not individual physicians as the author of the authentication.

12. Review of MR22 revealed a History and Physical and a diagnostic report, electronically authenticated on April 14 and 13, 2015 (respectively). Further review of the documentation revealed a physician group, not individual physicians as authoring the authentication's.

On April 16, 2015, at 12:41 PM, EMP27 was not able to identify the individual author of the aforementioned authentication's documented on MR18, MR20, MR21 and MR22. EMP27 further confirmed that the authentication's could be any one of "17 or 18 physicians in that group."

13. Review of MR28 revealed a a chest X-ray and a CT-Guided biopsy, right lung lesion electronically authenticated on May 29, 2014, as well as a chest X-ray electronically authenticated on May 30, 2014 by a physician group, not an individual physician.

14. Review of MR29 revealed a chest x-ray was marked as electronically authenticated by a physician group, not an individual physician.

Interview on April 14, 2015 with EMP1 at approximately 2:55 PM confirmed the incomplete documentation in MR28 and MR29.

15 Review of MR30 revealed a transcribed Consultation Note that included, "Partial bilateral cerumen impaction: ___ [blank] remove at chairside ..." The consultation was signed by the physician without clarification of what was missing from the dictated consult.

16. Review of MR32 revealed a transcribed H&P with a list of current medications including "Capoten 12.5 mg ___ [blank] p.o. b.i.d..." The transcription was signed by the physician without clarification of what was missing from the dictated H&P.

17. Review of MR33 revealed the patient was admitted to "swing-bed" on March 31, 2015. A consultation was written on March 31, 2015, for a physician that had seen the patient in the acute hospital to see the patient in the "swing-bed." A copy of the acute hospital consult, dictated March 29, 2015, prior to admission to the "swing-bed admission, was in the record with no update stating that the patient's condition had not changed since the dictated consultation.

Interview on April 16, 2015, at approximately 10:40 AM with EMP10 confirmed the above findings for MR28, MR29, MR30, MR32, and MR33.

18. Review of MR34 revealed blank boxes in the "Medical Decision Making", "Treatment/Management/Course" and condition "unchanged," improved," and "stable" on the Emergency Department-Physician Record.

19 Review of MR35 revealed the Emergency Department-Physician Record did not include a disposition of the patient or condition at the time of transfer. The medical record also included a Physician Certification for Transfer that contained blanks to be completed for the physician that was certifying the need for the Transfer, a blank for the patient's name, and a blank for the name of the hospital the patient was being transferred to. Interview on April 16, 2015, with EMP10 at approximately 10:30 AM confirmed the missing documentation in MR30, MR32, MR33, MR34 and MR35.

Based on review of facility documentation and staff interviews (EMP), it was determined the facility failed to ensure all medical records were completed within 30 days following discharge.

Findings include:

Review of "Change in Policy & Procedure: Chart Completion," no date provided, revealed, "Definition: Delinquent Chart: Any chart requiring completion (i.e. signature, dictation, etc.) that is > 30 days following discharge. Policy: A. In accordance with the Rules and Regulations of the Medical Staff, medical records of discharged patients are to be completed within 30 days unless there are extenuating circumstances. B. Any member of the active Medical Staff having any outstanding delinquent record(s) is suspended. A physician suspended for delinquent records will be permitted to care for patients presently in-house but will not be permitted to admit or perform elective surgery on any patient. C. Any member of the affiliate, courtesy, or consulting staff are required to complete delinquent medical records before or at the time of exercising any further privileges at the hospital ... Should any chart(s) become > 30 days delinquent, Suspension will result ..."

Review of the Medical Staff Rules & Regulations revised May of 2014, revealed, "II. Medical Record 1. The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient ... 4. Pertinent progress notes shall be recorded at the time of observation, sufficient to permit continuity of care and transferability... 16. The patient's medical record shall be complete at time of discharge, including progress notes, final diagnosis and/or (dictated) clinical resume'..."

1. Review of a list of delinquent medical records provided by the facility on April 14, 2015, at approximately 1:20 PM revealed there were twelve physician names on a list of incomplete medical records. The total number of delinquent medical records were listed as 53. Further review of the list revealed 19 medical records on the list (the list only showed a total of 18 records) from one physician that were from February 18, 2013, to October 20, 2014. When asked, EMP29 replied, "[EMP38] has been suspended since March of 2013." When asked to clarify how many physicians were suspended, EMP29 said, "Just [EMP38]." No explanation was provided as to why there were: 1.) Consults performed by EMP38 after the suspension for December 26, 2013, May 21, 2014, July 15, 2014, August 30, 2014, September 4, 2014; 2.) Physician orders by EMP38 from April 23, 2013, September 29, 2013, October 2, 2013, October 29, 2013, December 26, 2013, March 31, 2014, April 8, 2014, May 31, 2014, August 30, 2014, October 20, 2014, November 8, 2014; 3.) History and physical from October 29, 2013; discharge summary from October 29, 2013; and an Operative report from December 29, 2013.

Further review of the information provided revealed two medical records were for delinquencies from October 2014, for EMP36 who is now deceased. One record from October 27, 2014, was for an Emergency Room sheet for EMP35. Two records were for a consult and a summary from December 15, 2014, and January 26, 2015, respectively for EMP44. One record was an attestation, a discharge summary and a history and physical from January 16, 2015, for EMP43. There were additional listings of consults on March 3, 2015, and March 14, 2015, for EMP43. One ER sheet was not completed for EMP40 from January 3, 2015.

2. Interview on April 14, 2015, at approximately 1:20 PM with EMP29 revealed there was one physician that was currently suspended, EMP38. EMP29 was unable to explain why other physicians were not suspended, or why hospital processes were not followed to remove delinquent records for the deceased physician and why another physician was not able to sign off for a terminated physician.

3. Interview on April 14, 2015, at approximately 2:55 PM with EMP1 revealed EMP1 was unable to say why physicians were not suspended for all records beyond 30 days or why the physician was able to continue providing patient care after he/she was suspended..