HospitalInspections.org

Based on review of documents and interview with staff, the facility failed to ensure that all verbal orders were authenticated within 48 hours for 1 of 1 patient whose record was reviewed. Patient #1's medical record contained telephone orders issued by practitioners involved in the patient's care; however, they were not authenticated within 48 hours.

Findings were:

Review of the medical record of Patient #1 revealed multiple telephone orders that were not authenticated within 48 hours by the practitioner or another practitioner involved in the patient's care. Between the dates of 9/22/11 and 9/29/11, there were in excess of 50 telephone orders not authenticated within 48 hours. For example, on 9/22/11, a telephone order was received by a physician at 3:49 am. While the order was signed by the physician, it was not dated or timed; therefore, it could not be verified if the order was authenticated within 48 hours. On 9/23/2011, a physician issued a telephone order at 11:20 pm. It was electronically signed on 10/27/11 at 7:41 pm, over a month after it was issued.

The facility Medical Staff Rules and Regulations, last approved by the Governing Board in January 2012, contain a section entitled ORDERS SECTION. Rule #6 states "Telephone and Verbal orders are authenticated with the time frame specified by law and regulation. By CMS regulation, these orders must be signed within forty eight (48) hours."

These findings were acknowledged by the facility Chief Executive Officer in an in-person interview conducted the morning of 6/5/2012.

Based on review of documents and interview with staff, the facility failed to include a discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care for 1 of 1 patient whose record was reviewed. Patient #1 was transferred to another hospital on 9/30/2011, and there was no discharge summary included in the electronic medical record at the time of the survey, 6/4/2012.

Findings were:

The facility Medical Staff Rules and Regulations, last approved by the Governing Board in January 2012, state under the section entitled DISCHARGE SUMMARY, rule #34 , " A discharge summary shall be dictated on all medical records of patients hospitalized more than 48 hours. "

Review of the medical record for Patient #1 revealed that the patient was admitted to Forest Park Medical Center on 9/21/11 for elective revision of past weight-loss surgeries. Patient #1 was transferred for a higher level of care on 9/30/11; the patient was hospitalized for 9 days and there was no discharge summary included in the electronic medical record.

This finding was acknowledged by the facility Chief Executive Officer in an in-person interview conducted the morning of 6/5/2012.

Based on review of documents and interview with staff, the facility failed to ensure that operative reports were dictated as required in the hospital's Medical Staff Rules and Regulations for 1 of 1 patient whose record was reviewed. Patient #1 had two surgeries at the facility, and the full operative reports were not dictated until approximately a month following the surgeries.

Findings were:

The facility Medical Staff Rules and Regulations, last approved by the Governing Board in January 2012, under the section entitled SURGICAL CARE SECTION rule #4, state that "Operative reports must be dictated in the medical record immediately after the surgery and shall contain a description of the findings, the technical procedures used, any specimens removed, the postoperative diagnosis, and the name of the primary surgeon and assistant surgeons, and filed in the medical record as soon as possible after surgery."

Review of the medical record for Patient #1 revealed that the patient had surgery while inpatient at the facility. The operative report was not dated as to when the surgery occurred, but other progress notes in the record indicate the surgery was performed 9/27/11 by physician staff #3. While there was a handwritten operative note on the chart, the full operative report was dictated by staff #3 on 11/1/2011, 35 days after the surgery was performed.

Review of another operative report for Patient #1 revealed that the surgeon, staff #3, did not include the date of the surgery in the report; however, progress notes identify the date of surgery as 9/29/12. While there was a handwritten operative note on the chart, the full operative report was dictated by staff #3 on 11/1/2011, 33 days after the surgery was performed.

These findings were acknowledged by the facility Chief Executive Officer in an in-person interview conducted the morning of 6/5/2012.