Observations:
Based on review of facility policy, medical record (MR) and interview with staff (EMP), it was determined the facility failed to follow its established policy for the documentation of complications by the physician performing services at the facility.
Findings include:
Review on May 6, 2024, of facility document "MEDICAL STAFF BYLAWS, POLICIES AND RULES AND REGULATIONS OF TOWER HEALTH [-] PHOENIXVILLE HOPSITAL MEDICAL STAFF BYLAWS" adopted July 11, 2023 revealed, "...4.A. CONTENT OF MEDICAL RECORD... All medical records for patients receiving an evaluation or treatment in the hospital or at an ambulatory care location will document the patient's care. This documentation will be the joint responsibility of the responsible practitioners and the Hospital ...(u) Complications, hospital acquired infections, and unfavorable reactions to medications and/or treatments ..."
Review on May 6, 2024, of wound flowsheet nurse comment section in MR9, revealed, Date of service 12/15/2023. Further review revealed "...[8:25 AM] sudden firm swelling noted under incision of posterior neck past margin[.] MD called to bedside for eval of potential hematoma ... [8:30 AM] removed dressing for incision and evacuation of post-op incisional hematoma by surgeon ...[8:35 AM] evacuated with suction by surgeon..." Further review of MR9 revealed no practitioner documentation of complications or unfavorable reactions regarding the hematoma being evacuated after the procedure.
Interview on May 6, 2024, at 1:20 PM with EMP1 confirmed the practitioner did not document complications or unfavorable reactions, which occurred immediately after the procedure before the patient was discharged. Further interview with EMP1 confrimed the practitioner's failure to document the complication or unfavorable reaction did not follow the facility's policy.
| | Plan of Correction - To be completed: 06/14/2024
The Administrator, Medical Director, President Chief Executive Officer, and the Chief Medical Officer collaborated to develop and approve the plan of correction for the lack of documentation of surgical complications in the medical record. The Chief Medical Officer contacted the responsible surgeon on May 17, 2024 to review the finding and was advised to adhere to the requirements of the Department of Health and the facility's Medical Staff Bylaws, Rules and Regulations and Policies. The ASC-Limerick Medical Director distributed a notice to all active surgeons of the facility on May 21, 2024, emphasizing the requirements to include documentation of complications, including surgical complications, in the medical record. The surgeons are required to read and acknowledge this memorandum and their responses will be tracked by the Administrator/designee until all are received. The Administrator or designee will conduct a record review of patients who had any complication during the surgical encounter. The responsible surgeon will be notified when there is incomplete documentation to provide opportunity for timely amendment to the record. The Administrator will report record review findings to the QAPI Committee. Additional individual corrective action, if necessary, will be undertaken in accordance with the facility's Medical Staff Bylaws and policies.
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