QA Investigation Results

Pennsylvania Department of Health
MILTON S HERSHEY MEDICAL CENTER
Health Inspection Results
MILTON S HERSHEY MEDICAL CENTER
Health Inspection Results For:


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Initial Comments:

This report is the result of an unannounced onsite complaint investigation (HBG14C022H) completed on November 6, 2014, at Milton S Hershey Medical Center. It was determined the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 PA Code, Part IV, Subparts A and B, November 1987, as amended June 1998.





Plan of Correction:




115.32 (a) LICENSURE
CONTENTS

Name - Component - 00
115.32 Contents

(a) The medical record shall contain sufficient information to identify the patient clearly, to justify the diagnosis and treatment, and to document the results accurately.

Observations:


Based on review of medical records (MR) and interview with staff (EMP), it was determined that the facility failed to ensure that all entries in the medical record were accurately documented for one of one medical records reviewed (MR1).

Findings include:

1) A review on November 6, of MR1 revealed an outpatient note dated September 23, 2014, that contained an incorrect middle initial of the patient.

An interview conducted on November 6, 2014, with EMP1, at 9:30 AM confirmed the middle initial was incorrect.

2) Further review of MR1 revealed a home medication was listed incorrectly. It was listed as Percocet but should have been listed as Vicodin.

An interview conducted on November 6, 2014, with EMP4, at 9:40 AM confirmed the home medication was listed incorrectly.

3) The medical record indicated the patient was a "No show" for an appointment on October 6, 2014. The patient did arrive for the October 6, 2014 appointment.

An interview conducted on November 6, 2014, with EMP4, at 9:45 AM confirmed the electronic record indicated the patient was a "No show" even though the patient arrived for the October 6, 2014, appointment.

4) The electronic medical record listed various diseases and procedures that the patient did not have. Those diseases/procedures were then noted as "in error" but still automatically populated other forms, such as the "ED Summary" and were displayed as "Cancelled."

An interview conducted on November 6, 2014, with EMP4, at 9:50 AM confirmed the various diseases/procedures were listed under the "Problem list" as "Cancelled" even though the patient does not have those diseases/procedures.
















Plan of Correction:

Finding 1: A patient medical record review on November 6, 2014 revealed an outpatient note dated September 23, 2014 which documented an incorrect middle initial of the patient.

Plan of Correction:

1. On November 12, 2014, the Penn State Hershey (PSHMC) Neurology Outpatient Practice Site Manager reviewed the process of collecting and accurately documenting patient information with the Affinity Scheduler who incorrectly documented the patient’s middle initial.

2. On November 12, 2014, the PSHMC Neurology Outpatient Practice Site Manager spoke to all Affinity Schedulers and reviewed the process for collecting and documenting patient information. In addition, this information will be discussed at a staff meeting on November 21, 2014. All Affinity Scheduling staff is required to attend the meeting.

3. On November 19, 2014, a PSHMC Physician’s Assistant corrected the patient’s middle initial on the September 23, 2014 office visit document with an addendum.

4. The PSHMC Neurology Outpatient Practice Site Manager will address all reported instances of incorrect documentation of patient names to ensure compliance is maintained.


Finding 2: Also, a patient medical record review on November 6, 2014 revealed a home medication was listed incorrectly. It was listed as Percocet but should have been listed as Vicodin.

Plan of Correction:

1. On October 17 -18, 2014, the PSHMC Physician Assistant and Neurology Practice Medical Director amended the patient’s September 23, 2014 Neurology clinic note to reflect the accurate pain medication.

2. On November 12, 2014, the Penn State Hershey Medical Center (PSHMC) Neurology Outpatient Practice Site Attending Nurse reviewed the correct process of collecting and documenting patient medication information with the Medical Assistant who documented the medication in the medical record.

3. On November 19, 2014, The PSHMC Neurology Vice Chairman for Clinical Affairs sent an email communication to all providers reviewing medication reconciliation requirements.

4. On November 21, 2014, the PSHMC Neurology Outpatient Practice Site Manager will review the correct process for collecting and documenting patient medication with all Clinical Staff in a staff meeting. All Clinical Staff is required to attend the meeting.

5. The PSHMC Neurology Outpatient Practice Site Manager will address all reported instances of incorrect patient medication documentation to ensure compliance is maintained.


Finding 3: The medical record indicated the patient was a “No Show” for an appointment on October 6, 2014. The patient did arrive for the October 6, 2014 appointment.
Plan of Correction:

1. On October 8, 2014, the Penn State Hershey Medical Center (PSHMC) Ophthalmology Outpatient Practice Site Manager reviewed correct scheduling process with the patient scheduling staff member who made the scheduling error.

2. On November 12, 2014, the PSHMC Ophthalmology Outpatient Medical Office Associate II sent an email communication to all Ophthalmology patient scheduling staff regarding the correct scheduling process.

3. A November 18, 2014 review of the patient’s electronic medical record does not indicate that the patient was a “No Show” on October 6, 2014.

4. The PSHMC Ophthalmology Outpatient Practice Site Manager will address all reported instances of incorrectly documented “No Show” appointments to ensure compliance is maintained.


Finding 4: The electronic medical record listed various diseases and procedures that the patient did not have. Those diseases/procedures were then noted as “in error” but still automatically populated other forms, such as the “ED Summary” and were displayed as “Cancelled”.

Plan of Correction:


1. On October 8, 2014, the Penn State Hershey Medical Center (PSHMC) Ophthalmology physician followed the PSHMC process to correct the inaccurate diseases and procedures listed in the patient’s electronic medical record (EMR). The EMR then indicated that these items were “cancelled”.
Note: PSHMC uses the Cerner system to create the electronic patient medical record. In the Cerner system, when the term “Cancelled” is noted next to items on a patient’s disease list or procedure list, it indicates that the entry of the item was made in error and the patient never had the problem and/or never had the procedure performed.

2. On October 8, 2014, the PSHMC Ophthalmology Outpatient Practice Site Manager reviewed the process for patient identification (name and date of birth) and accurate documentation of patient information with the Ophthalmology Assistant who entered the information into the incorrect patient medical record. In addition, the PSHMC Ophthalmology Outpatient Practice Site Manager reviewed PSHMC’s Patient Identification policy with the Ophthalmology Assistant.

3. On November 11, 2014, the PSHMC Ophthalmology Outpatient Practice Site Manager sent an email communication to all Ophthalmology clinical staff instructing them to verify the patient name and birthdate in the electronic medical record (EMR) prior to documenting any patient information in the EMR. In addition, the PSHMC Ophthalmology Outpatient Practice Site Manager attached PSHMC’s Patient Identification policy to the email for clinical staff review.

4. The PSHMC Ophthalmology Outpatient Practice Site Manager will address all reported instances of incorrectly documented diseases and procedures to ensure compliance is maintained.