HospitalInspections.org

Based on medical record review, document review, and staff interview it was determined that the facility's electronic medical record system failed to protect the security of entries, with potential impact to all patients who have received care at the facility since implementation of the EMR. Findings include:

Medical record review for Patient #1 with Employee #10 on 8/15/2023 revealed:

Documentation that Employee #3 turned or repositioned the patient on the following dates and times:
7/6/23 at 4:10, 12:00, 14:00, 16:00, 17:00, 18:00, 20:00, 22:00, 23:49
7/7/23 at 2:47, 3:52, 8:00, 12:00, 14:00, 16:00, 18:00, 22:00
7/8/23 at 00:00, 2:00, 2:37, 4:00, 6:00, 8:00, 12:00, 14:00, 18:00, 23:50
7/9/23 at 2:00, 6:00, 10:00, 11:00, 12:00, 15:00, 18:00, 20:00

During an interview with Employee #3 the above findings were discussed.

While reviewing the chart together, Employee #3 clicked into the field for turning on 7/6/23 at 11:00. This field was reviewed earlier with Employee #10 and showed the turn was done by Employee #11.

After Employee #3 clicked in the field, it showed that Employee #3 was the one who completed the turn.

Employee #3 indicated uncertainty at the cause of the overwrite but stated it was likely that this chart had been audited by him previously.

The medical record failed to protect the security of entries by over writing the author of the original entry during auditing review.