HospitalInspections.org

Based on record review and interviews the hospital failed to maintain accurate medical records in 1 of 14 sampled sleep study patients (Patient ID #1).

Findings include:

Record review revealed 1 (one) patient (ID#1) revealed that a default birth date of 1/12/1976 and sex of male was entered on patient (ID#1)'s final sleep report.

Interview on 10/24.2017 at 10:35 a.m. with staff, Regional Manager (ID #54) stated patient (ID #1) had a legitimate complaint. "The technician did not add a date of birth on the record and the computer defaults to the year of 1976 and gender male. The date of birth and gender were wrong".

Based on record review and interviews, the hospital failed to ensure the sleep laboratory followed inpatient services related to patient concerns and grievances in 1 (ID#1) of 14 sampled patients.

The findings:

Record review of notes dated 8/8/2017 written by staff (ID #54) stated she talked to patient (ID #1) regarding her sleep study, revealed she (ID#1) felt the report was not hers because the date and gender were wrong, and she wanted a refund.

On 10/24/2017 at 10:35 a.m. during an interview with staff, Regional Manager (ID #54) stated that she does not keep a log of complaints, because this was the first one she has had in four years. She also did not report it to the quality department, and stated the sleep laboratory had no policy for handling grievances in the department.

Record review revealed 1(one) patient (ID#1) revealed that a default birth date of 1/12/1976 and sex of male was entered on patient (ID#1)'s final sleep report.

Interview on 10/24/2017 at 10:35 a.m. with staff, Regional Manager (ID #54) stated patient (ID #1) had a legitimate complaint. The tech did not add a date of birth on the record and the computer defaults to the year of 1976 and gender male.