HospitalInspections.org

Based on record review and interview, this facility failed to ensure that 1. Updates to the history and physical were completed prior to surgery on 2 out of 9 surgical patient medical record reviews (Patient #5 and 6), and 2. The update to the history and physical completed by a physician assistant was co-signed in a timely manner by the physician in 1 out of 9 surgical patient medical record reviews (Patient #8).

Findings include:

The facility's policy titled, "Medical Records/Patient's Health Information," #1534_15010_182, dated 5/14/2013 was reviewed on 12/29/2014 at 12:50 p.m. The policy states in part on page 3, "The interval-updated note must be recorded within twenty-four (24) hours of admission and must be attached to the history and physical in the patient's hospital medical record within twenty-four (24) hours after admission. The interval-updated note must be signed, dated and timed by the physician."

In an interview with Interim Chief Nursing Officer (I-CNO) A on 12/29/2014 at 3:50 p.m. regarding this policy statement, I-CNO A stated that A interprets this statement to mean that the medical doctor (MD) should do the update to the history and physical (H&P). I-CNO A stated that this policy statement does not indicate a physician assistant (PA) may do the update.

On 12/29/2014 at 4:10 p.m. an interview with the Supervisor of Health Information (S-HI) I was conducted. S-HI I stated that the expected time-frame for MD co-signatures at this facility is 24 hours.

A medical record review (MR) was conducted on Patient (Pt.) #5's closed surgical MR on 12/29/2014 at 12:50 p.m. accompanied by Registered Nurse (RN) E. Pt. #5's surgery was 8/26/2014, the H&P was completed 8/21/2014. The interval note completed for the update to the H&P which was completed by MD Q prior to surgery states, "I have attempted to contact this patient by phone to return their call or discuss lab results, but there is no response. Will try again later." There is no other note identifying if there have been any changes in Pt. #5 since the H&P was completed, therefore no update to the H&P was done prior to surgery.

RN E confirmed this finding at the time of the MR review and stated, "[The MD] must have clicked on the wrong smart phrase." (A smart phrase is a series of phrases pre-prepared in the computer for the provider to enable them to choose which phrase fits their need for select situations.)

A MR review was conducted on Pt. #6's closed surgical MR on 12/29/2014 at 1:15 p.m. accompanied by RN E. Pt. #6's surgery was 8/27/2014, the H&P was completed 8/22/2014. The interval note completed for the update to the H&P which was completed by MD Q prior to surgery states, "I have attempted to contact this patient by phone to return their call or discuss lab results, but there is no response. Will try again later."
There is no other note identifying if there have been any changes in Pt. #6 since the H&P was completed, therefore no update to the H&P was done prior to surgery.

RN E confirmed these findings at the time of the MR review.

A MR was conducted on Pt. #8's closed surgical MR on 12/29/2014 at 2:25 p.m. accompanied by RN E. Pt. #8's surgery was 9/3/2014, the H&P was completed 8/22/2014. The interval note completed for the update to the H&P was completed by PA O prior to surgery. This note was co-signed by MD P on 9/15/2014, a time frame exceeding the hospital expectation of 24 hours.

These findings were discussed with, and confirmed by S-HI I on 12/29/2014 at 4:10 p.m.

Based on record review and interview, this facility failed to ensure that properly executed surgical consents were in the patient's medical record prior to surgery in 3 out of 9 medical records reviewed (Patient #5, 6, and 8).

Findings include:

The facility policy titled, "Informed Consent/Informed Refusal Adults and Minors," #189, dated 6/13 was reviewed on 12/29/2014 at 4:00 p.m. In exhibit A of the policy, "Consent form requirements," the policy states in part, "A Consent Form must include at least the following information: 3. Date and time the Consent Form was signed." The policy also indicates that the form must be signed by the practitioner who discloses the relevant treatment information to the patient and the exhibit includes an example of the practitioner disclosure with a signature line and areas for signature date and time.

The facility policy titled, "Medical Records/Patient's Health Information," #1534_15010_182, dated 5/14/2013 was reviewed on 12/29/2014 at 12:50 p.m. The policy states in part on page 7, "VIII. Authentication of Clinical Entries All clinical entries in the patient's record must be legible, accurately dated, timed (military time) and individually authenticated. Authentication means to establish authorship by written signature, identifiable initials, electronic signature, or computer key."

The facility policy titled, "Medical Record Documentation," #162, dated 11/12, was reviewed on 12/29/2014 at 4:05 p.m. The policy states in part on page 2, "5. Date, Time, Authentication: All Medical Record entries must be dated and authenticated...by the individual who made the entry."

A (MR) review was conducted on Patient (Pt.) #5's closed surgical MR on 12/29/2014 at 12:50 p.m. accompanied by Registered Nurse (RN) E. Pt. #5's surgery was 8/26/2014. The surgical consent, signed by the medical doctor (MD), is timed and dated by an unidentified person and not the MD. Accurate time and date of the signature cannot be determined if the MD fails to complete this at the time of the signature.

These findings were discussed with and confirmed by RN E at the time of the MR review.

A MR review was conducted on Pt. #6's closed surgical MR on 12/29/2014 at 1:15 p.m. accompanied by RN E. Pt. #6's surgery was 8/27/2014. The surgical consent, signed by the MD is dated by an unidentified person and not the MD, and does not include a time it was signed.

These findings were discussed with and confirmed by RN E at the time of the MR review.

A MR review was conducted on Pt. #8's closed surgical MR on 12/29/2014 at 2:25 p.m. accompanied by RN E. Pt. #8's surgery was 9/3/2014. Pt. #8 had two separate surgical procedures, each requiring a surgical consent form. The consent form for the catheter insertions into the tubes of the kidneys (Ureters) does not include a time the MD signed and and dated the form.

These findings were discussed with and confirmed by RN E at the time of the MR review.

In an interview with the Supervisor of Health Information (S-HI) I on 12/29/2014 at 4:10 p.m. the above examples were discussed. S-HI I stated S-HI I was not sure this was a health information department issue but agreed that the MD should be signing and dating their own signatures to maintain the integrity of the record.