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Based on the number and nature of deficiencies, the facility failed to be in compliance with the Condition of Participation of Governing Body. Specifically, the governing body failed to ensure that the facility was in compliance with the other Condition of Medical Staff. In addition, the Governing Body failed to ensure that all medical practitioners, including allied health professional involved in the patients' care or preparing entries in the medical records were qualified, appointed, and adequately supervised. The Governing Body failed to ensure that the contracted medical staff/allied health professionals complied with all bylaws/rules and regulations and that all contracted care was provided in a safe and effective manner.

The facility failed to meet the following Standards under the Condition of Governing Body:

Tag A 0045 Medical Staff Appointments
The Governing Body failed to ensure that the designated dictationist preparing all patients' discharge summaries was qualified, credentialed and appointed as a member of the allied health professionals staff.

Tag A 0049 Medical Staff Accountability
The Governing Body failed to ensure that all standards of care outlined in the medical staff bylaws/rules and regulations were met. Specifically, the medical staff failed to ensure that medical staff requirements related to timely completion of a history and physical and completion of a discharge summary for each patient were enforced, as required.

Tag A 0084 Contracted Services
The Governing Body failed to ensure that all contracted services proved by a contracted group of physicians and allied health care providers and contracted laboratory services were provided in a safe and effective manner.

Based on staff/physician interviews, review of credential files, medical staff bylaws/rules and regulations and facility policies/procedures, the governing body of the facility failed to ensure that a designated dictationist that was completing all patient discharge summaries was qualified, credentialed and appointed to the allied health professional staff, as required. The failure created the potential for negative patient outcomes.

The findings were:

Reference Tag A0353 for findings related to the facility use of an unqualified and non-credentialed designated dictationist to review patient records and prepare discharge summaries for all patients at the facility.

Based on staff/physician interviews and review of medical records, policies/procedures, credential files, medical staff bylaws/rules and regulations and other facility documents, the governing body failed to hold the medical staff accountable for the quality of care provided to patients by a group of contracted physicians, nurse practitioners and other contracted providers employed by the contract physician group. The failure created the potential for negative patient outcomes.

The findings were:

Reference Tags A 0353 and A 0358 for findings related to the medical staff failure to ensure that all standards of care outlined in the medical staff bylaws/rules and regulations and the facility's "Provision of Care Plan" were met. Specifically, the medical staff failed to ensure that medical staff requirements related to provision of medical care, including timely completion of a history and physical and completion of a discharge summary for each patient were enforced, as required.

Based on review of medical records, medical staff bylaws/rules and regulations, policies/procedures, personnel/credential files and other facility documents, the governing body of the facility failed to ensure that the patient care services provided by contract were provided in a safe and effective manner. Specifically, the governing body failed to ensure that contracts for physician services, including allied health professionals were all credentialed, that allied health professionals were qualified and adequately supervised by the supervising medical staff providers. In addition, the governing body of the facility failed to ensure that contracted lab services provided test results, including "toxic" lab values in a timely to aid in medical decision-making. The failure created the potential for negative patient outcomes.

The findings were:

1. Contracted Psychiatric Care By A Psychiatric Nurse Practitioner and Contracted Medical Care Provided By A Medical Nurse Practitioner Without Consistent/Timely Oversight By Their Supervising Contracted Physicians:

Reference Tag A 0353 for findings related to the Governing Body's failure to ensure that the care provided by contracted nurse practitioners for psychiatric and medical care was supervised consistently and timely by the contracted supervising physicians.

2. Patient Discharge Summaries Completed By Contracted Medical Services Dictationist That Was Not Credentialed and Not Professionally Qualified:

Reference Tag A 0468 for findings related to the Governing Body's failure to ensure the patients' discharge summaries were completed by the physician or other qualified and credentialed allied health professional that had knowledge of, and participated in the care of the patient.


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3. Contract Laboratory Services:

The facility failed to monitor the effectiveness and safety of patient care after it had identified an issue with a contracted service that had the potential to jeopardize patient health in one (#21) of 21 sample patient records.

Sample patient #21's medical record was reviewed on 7/29/2010. The medical record revealed that the patient was an adult admitted on 2/7/2010 and discharged on 2/17/2010. On admission, it was documented on the "MEDICATION RECONCILIATION FORM" that the patient took Amitriptyline 350 mg by mouth every evening at home to treat depression. On 2/8, the previous dose of Amitriptyline was discontinued and the following was ordered by a psychiatrist: "Amitriptyline 300 mg PO QHS, Fasting Amitriptyline level 2/9/10 in AM..."

A lab requisition from the facility's contracted lab stated that an amitriptyline level was "collected" on the patient on 2/9/10 at 00:00 and "received" on 2/9/10 at 11:10. The lab requisition stated that it was "reported" on 2/12/10 at 23:09. The "COMBINED TOTAL" of the serum amitriptyline and nortriptyline levels was in the "Out of Range" section. In the "REFERENCE RANGE" it stated that the level was in the "TOXIC" category. There was no evidence as to when the facility was actually informed of this lab result. Handwritten documentation on this lab requisition stated "defer to Psych 2/13/10" with the initials of the facility's Medical Nurse Practitioner. Another handwritten undated note, initialed by one of the facility's psychiatrics, stated the following: "Not with evidence of toxicity, AMI changed from 350 q hs to 300 q hs. F/u as outpt with labs in 1-2 weeks or sooner if SE," indicating the physician did not see evidence the patient was toxic and the patient was to follow-up with lab draws in 1 - 2 weeks or sooner if side effects presented. This physician did not change the current dose of the patient's Amitriptyline until prior to the patient's discharge. The medical record did not contain evidence that the nursing staff notified a physician or practitioner of the toxic lab result or that someone from the contracted lab called the facility with the toxic lab result. It is unknown when a physician or practitioner was made aware of the lab result or when/if a nurse at the facility was informed.

On 2/16/2010, a practitioner ordered the patient to be discharged the following day. Additionally, fasting lithium and amitriptyline levels (both drug levels) were ordered to be checked the next morning, prior to discharge, and to be sent "STAT." Upon discharge, on 2/17, the patient was ordered the following among the PRESCRIPTIONS GIVEN AT DISCHARGE: "Amitriptyline 100 mg, Take 2 pills at bedtime," which indicated the dose was decreased to 200 mg. The next dose was ordered as the evening of 2/17. The following order was also written below the discharge medications: "Get Amitriptyline & Lithium levels done after this weekend (Ritalin & Lithium can both increase Amitriptyline levels) (2/22-2/24)." The patient was discharged with two outpatient appointments, one on the same day of discharge, and the patient's medication information was faxed to his/her primary care organization.

A lab requisition from the facility's contracted lab stated that another amitriptyline level was "collected" on the patient on 2/17/10 at 00:00 and "received" on 2/17/10 at 11:00. The lab requisition stated that it was "reported" on 2/26/10 at 23:42. The "COMBINED TOTAL" of the serum amitriptyline and nortriptyline levels was in the "Out of Range" section. In the "REFERENCE RANGE" it stated that the level was in the "TOXIC" category. This lab was higher than the lab result obtained earlier in the patient's admission and the date the lab was "reported" was 2/26/10, after the patient's discharge, despite the physician's order to "Send STAT." The medical record did not contain evidence that the nursing staff notified a physician or practitioner of the toxic lab result or that someone from the contracted lab called the facility with the toxic lab result. The facility did not have a process in place in regards to lab results after the discharge of a patient.

Nursing documentation revealed the patient had complaints in regards to medication side effects throughout his/her admission. On 2/12/10 a "Nursing Shift Progress Note" stated the following, in pertinent part: "(patient) thinks his medications are making (his/her) gait slower, etc. After dinner (s/he) took meds and (s/he) complained (s/he) is dizzy. (S/he) even refused (his/her) night smoke break because of it..." A Nursing Progress Note, dated 2/13/10 stated, in pertinent part: "...ate well but complained of being dizzy on his medication. (S/he) even journaled about it..." A Nursing Progress Note dated 2/14/10 stated, in pertinent part: "...reported feeling unsafe about discharge..." A Nursing Progress Note dated 2/16/10 stated, in pertinent part: "...was to discharge this shift but the decision was made to delay until tomorrow and have (him/her) go directly to one of (his/her) after-care appointments..." There was no evidence as to why the discharge was delayed to 2/17, as the last physician progress note is dated 2/15/10.

The facility's policy, titled "CRITICAL RESULTS ("PANIC VALUES")" was reviewed and stated the following, in pertinent part:
"...2. DEFINITION: Critical test results (lab/radiology) are any values/interpretations where delay in reporting may result in serious adverse outcomes for the patient...
3. PROCEDURE:...
b. If there is a critical test result and or critical values the contracting Lab or Radiology will notify the charge nurse...
d. The charge nurse will notify the patient's attending physician or on call physician.
e. The charge nurse will document the Critical Lab Value or Radiology interpretation in the patient medical record on the "Physician Orders in the Rational" section, the results, date and time they received notification of the critical interpretation and date and time the physician was notified..."

Review of facility internal documents on 7/28/2010 revealed the patient expired after discharge. The facility identified that critical labs after discharge were not communicated to appropriate physicians and that there was no protocol in place to do so. The facility identified that the patient had expired prior to the lab being processed. The facility planned to revise the critical lab policy so that values would be reported to the physician after discharge. The facility also planned to audit the reporting of critical labs.

The facility did not have a revised policy in place which detailed instructions of reporting critical labs after discharge. After the survey, a draft policy was provided. Within the facility's internal documents, it did not identify the need to audit the compliance of their contracted lab for notification of critical and/or toxic results to facility staff per their policy. It also did not identify that a stat lab was not done within a stat timeframe. Additionally, the facility had not evaluated the timeliness of results from the contracted lab. In summary, the patient had a previous toxic amitriptyline lab value, continued to express physical complaints, and results from ordered lab testing done prior to the patient's discharge were not expedited and followed up on by a qualified practitioner. A policy change and evaluation of contract laboratory services were not promptly initiated related to this event. The Governing Body failed to ensure that contracted laboratory services were monitored and evaluated effectively for quality of care and safety of services...This failure created the potential for that type of event to occur with other patients.

Based on the number and nature of deficiencies, the facility failed to be in compliance with the Condition of Participation of Medical Staff. Specifically, the Medical Staff

The facility failed to meet the following Standards under the Condition of Medical Staff:

Tag A 0353 Medical Staff Bylaws
The Medical Staff failed to enforce bylaws to carry out its responsibilities. Specifically, the Medical Staff failed to ensure Medical Staff requirements related to timely completion of a history and physical and completion of a discharge summary for each patient were enforced.

Tag A 0358 Medical Staff Responsibilities
The Medical Staff failed to ensure history and physicals were completed by a physician, or an allied health provider under the direct/timely supervision of a physician, as required.

Based on staff/physician interviews and review of medical records, medical staff bylaws and rules/regulations and credential files, the medical staff failed to enforce bylaws to carry out its responsibilities. Specifically, the medical staff failed to ensure that medical staff requirements related to timely completion of a history and physical and completion of a discharge summary for each patient were enforced. The failure created the potential for negative patient outcome.

The findings were:

1. Timely Completion of History & Physical Examination:

Review of the "Medical Staff Rules and Regulations" on 7/27/10, revealed the following, in pertinent parts:
"...II. Admissions
...G. An initial medical history and physical examination shall be done on each patient within (24) twenty-four hours..."

On 7/28/10, review of the 21 sample medical records revealed the following findings: The history and physical were not completed within (24) twenty-four hours after admission for sample patients #18 and #21.

Review of sample record #18 revealed the patient was admitted on 5/15/10 and the history and physical was completed on 5/19/10, the day the patient was discharged.

Review of sample record #21 revealed no evidence of any history and physical (H & P) being completed. The "Discharge Summary", which was completed by a designated non-provider dictationist, contained no evidence that a physical exam was ever completed. The dictationist stated under the "Physical Exam": "The patient was assessed by the nurse on 02/07/10 at 1515 (3:15 p.m.). Blood pressure was 147/92 with a pulse of 116. S/he was 180 pounds and 6 feet 1 inch tall. Current ongoing medical problems including having suicidal thoughts. S/he denied any known allergies to medication. His/her last hospitalization was at (the facility) in 11/2009 for depression with suicidal ideation. S/he also has had multiple stays at (the facility) and also at (another facility). S/he reported a history of alcohol use for 20 years, last using 25 years ago. S/he reported history of back injury and cervical disc repair."

The "Discharge Summary" contained no finding from an H & P completed by a physician or medical nurse practitioner during the hospitalization.

2. Discharge Summaries Completed By Attending Psychiatrist Or Other Qualified Health Care Personnel:

Review on 7/27/10 of the facility policy and procedure "Discharge Summary Documentation and Dictation," revealed the following, in pertinent parts:
"...POLICY:
The goal of the Discharge Summary is to summarize the therapeutic and other significant events that occurred during an inpatient admission. The Discharge Summary provides. concise details for reasons leading to admission, diagnosis, investigations, and as a record of response to a variety of therapeutic interventions. A comprehensive Discharge Summary should ensure effective continuity of care in the community after discharge.

A Discharge Summary is required documentation for all patients in accordance with (the facility) Medical Staff Rules and Regulations. Dictation of the Discharge Summary and its authentication is the responsibility of the attending physician. At (the facility), the attending physician has the option to designate a qualified individual to dictate the Discharge Summary. When the attending physician exercises this option, they remain responsible for the accuracy of content and quality of the Discharge Summary as well as the authentication of the Discharge Summary. A qualified designee in the State of Colorado would include a Licensed Clinical Social Worker, a licensed Physician's Assistant, a licensed Nurse Practitioner, as well as a Licensed Professional Counselor. The Administrative Assistant will maintain a credential file for the designee which will be reviewed and updated and reviewed in accordance with (the facility) Medical Staff Bylaws. Additionally, the designee must be approved by the Medical Executive Committee..."

Review on 7/27/10 of the "credential file" of the designated dictationist for the "Discharge Summary," revealed the following findings: The designated dictationist file contained a one-page professional resume and a second page from a "degree verification service." The professional resume had only one employment experience that was at all related to the his/her designated responsibilities. The experience was the most recent experience (8/2008 to 2/2010) working as a group living counselor at a youth treatment center. The resume identified that the s/he had a bachelor of arts degree in psychology and a minor in business administration. The second page in the file validated the degrees had been granted, including the name and location of the school and the date ( 2007) the degree was conferred. In addition, the professional resume identified a position from 10/07 to 5/08 working as an "internal wholesaler" for a national life insurance company. The resume contained no evidence of inpatient acute care psychiatric hospital experience or any medical field experience.

The file contained no evidence of appointment to the allied professional staff or having been through a credentialing process.

On 7/27/10 at approximately 9:30 a.m., the director of medical records was interviewed and revealed that the designated dictationist was an employee of the physicians' contract group, not an employee of the facility.

On 7/27/10 at approximately 10:30 a.m., the chief clinical officer was interviewed and revealed that the designated dictationist did all dictations of Discharge Summaries for all medical staff at the facility. When asked about the qualifications for the position, s/he stated the dictationist had no healthcare background but was working as social worker at the youth facility mentioned in the resume. The file was reviewed by the surveyor with the chief clinical officer and it was determined that the dictationist had no social work background and no healthcare background to prepare for the current position.

On 7/27/10 at approximately 11 a.m., the administrative assistant who was responsible for all credential files was interviewed and revealed the two-page file reviewed was a file for the contracted physician group and the facility had no personnel or credential file for the dictationist. S/he confirmed the dictationist had never been reviewed, credentialed or granted allied health privileges by the governing body.

Based on review of medical records and medical staff bylaws and rules and regulations and staff/physician interviews and policies/procedures, the facility's medical staff failed to ensure history and physicals were completed by a physician, or an allied health provider under the direct/timely supervision of a physician as required. The failure created the potential for a negative outcome for patients.

The findings were:

1. Review on 7/28/10 of the policy/procedure "Provision of Care Plan," revealed the following, in pertinent parts:
"...3.0 Organization
...(the facility) utilizes the 'medical model' for patient treatment...
5.3 Assessment and Evaluation Procedures
Assessment of all patients begins on admission and is integral to the treatment process. Treatment planning is individualized according to individual needs identified through assessments. Primary assessments include the following:
5.3.1 Inpatient Treatment
...Medical History and Physical: Performed by the physician within 24 hours of admission. Includes review of symptoms, history of previous medical problems, present illness, family medical history and review of systems...
5.5.10 Medical Services - Medical services may be provided by a qualified physician under the direction of the admitting psychiatrist. The consulting physician is responsible for a complete medical history and general physical examination, and neurological assessment. A laboratory work-up including a drug screen, blood chemistry, and tuberculin skin test may be ordered. A chest x-ray, HCG, HIV, pregnancy test, will be provided as indicated from the medical history and clinical evaluation. The physician is also responsible for the diagnostic work-up and test evaluation of any detected or suspected medical disorders, as well as their clinical management..."

2. Reference Tag A 0353 Medical Staff Bylaws for medical records findings related to failure of the supervising medical physician to provide timely oversight and review of the clinical work and decision-making of the medical nurse practitioner, who provided approximately 70% of the medical coverage for patients for history and physicals and management of medical conditions for the patients at the facility. Review of the records revealed that most of the supervision and oversight occurred weeks to months after the care had been provided.

Based on staff interviews and review of medical records, it was determined that the facility's nurses failed to evaluate and document the nursing care for each patient. In 2 of 21 sample medical records, patients did not have a documented bowel movement throughout their entire admission. This failure created the potential for a negative patient outcome.

The findings were:

A review of 21 medical records on 7/27/2010 and 7/28/2010 revealed that 20 patients (sample #s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 18, 19, 20, & 21) did not have documented bowel movements, specifically on the "Nursing Shift Progress Notes," where a section is designated to document if the patient had a bowel movement during that shift.

An interview with the Director of Nursing was conducted on 7/28/2010 at approximately 11:20 a.m. S/he stated BMs (bowel movements) are documented only in the nurse progress notes.

An interview with the facility's Clinical Director was conducted on 7/28/2010 at approximately 2:00 p.m. The Clinical Director stated that the Director of Nursing delegates Nurse Managers to do a certain number of chart audits every month.

Twenty-one sample medical records were reviewed on 7/28/2010. Sample record #1 contained ten Nurse Progress Notes (NPNs), 2 which "No" BM checked that shift, 8 which were without documentation.
Record #2 contained 10 NPNs, two which checked "No" BM, eight which were without documentation.
Record #3 contained 17 NPNs, all which were without documentation in regards to BMs.
Record #4 contained 13 NPNs and all were without BM documentation.
Record #5 contained 34 NPNs and all were without BM documentation.
Record #6 contained 12 NPNs, one which checked "No" BM and 11 without any indication.
Record #7 contained 16 NPNs, one which was designated as "No" BM that shift and 15 which did not have designation.
Record # 8 contained 28 NPNs, one was marked as "No" BM and 27 were without any documentation of BMs.
Record #9 contained 14 NPNs, two charted as "No" BM and 12 without any indication.
Record #10 contained 16 NPNs and all were without charting in regards to BMs.
Record #11 contained 94 NPNs, nine documented as "No" BMs and 85 without any BM documentation.
Record #12 contained 27 NPNs, all of which were without BM charting.
Record #13 contained 13 NPNs, one contained documentation of "No" BM and 12 did not designate Yes/ No.
Record #14 contained 20 NPNs, two of which contained charting of "No" BM and 18 did not contain charting.
Record #15 contained 12 NPNs, one of which was documented as "No" BM and 11 contained no documentation.
Record #16 contained 17 NPNs, all without BM documentation.
Record #18 contained 15 NPNs, two of which were designated with a "No" in regards to BMs and 12 were without documentation. Record #19 contained 14 NPNs and all were without BM documentation.
Record #20 contained 28 NPNs, two of which were checked as "No" BM and 26 which did not have an indication.
Lastly, sample record #21 contained 29 NPNs, one that was documented as "No" BM and 28 that did not contain documentation.

According to Lippincott, Fundamentals of Nursing, Third Edition, page 1268, in pertinent part: "The normal frequency of bowel movements cannot be stated arbitrarily. Although many adults pass one stool each day, healthy people have been observed to have more frequent or less frequent bowel movements. Some people have a bowel movement two or three times a week; others, as often as two three times a day." Lippincott, page 1270, also states, in pertinent part: "Other types of medications may affect bowel elimination and stool characteristics. Narcotic analgesics (opioids), antacids containing aluminum, and anticholinergic medications all have the potential to cause constipation by decreasing gastrointestinal motility." It is clear that patients may go several days without having a bowel movement, but often medications that psychiatric patients are prescribed have potential to put them at a higher risk of constipation and attention must be paid to each patient's bowel routine in order to prevent constipation and further complications.

In summary, despite routine chart audits, the facility failed to recognize that nurses did not routinely monitor and document patients' bowel movements. Although patients may have bowel movements infrequently or irregularly, proper documentation of such is a necessity. This failure did not ensure adequate medical care was provided within an acute care hospital and did not evidence that the hospital's nursing care was overseen appropriately.

Based on staff interviews, review of personnel files and staffing schedules, the facility failed to ensure the nursing department maintained personnel files, including facility specific job descriptions, comprehensive orientations, periodic evaluations, and thorough background reviews prior to working at the facility, for all contracted agency nursing staff. This failure created the potential for a negative patient outcome.

The findings were:

Review of thirteen personnel files was completed on 7/27/10 and 7/28/10, including review of three agency nurse files. The three agency Registered Nurse (RN) files, #5, #6, and #13, all worked for the same agency company. None of the three personnel files contained a job description. None of the files contained a resume or application which detailed the nurses' previous work experience. Personnel file #6 contained a self-evaluation completed prior to the nurse's presence at the facility which stated that the nurse had one or greater years experience in all the areas of psychiatric care. Personnel file #13 did not contain any self-evaluation or other type of evaluation. Personnel file #5 contained a summarized version of the self-evaluation, which stated that the nurse had "theory, no practical" experience in "Psych." Each agency nurse personnel file reviewed contained an evaluation done by a staff nurse after the agency nurse's first shift worked at the facility. However, no other evaluations, from the facility or the agency company, were evidenced in the files. The "EVALUATION OF SHIFT" done on sample personnel #5 stated, in pertinent part: "Nurse is an OBGYN nurse and no psych background. Nurse was adequate but needed a lot of guidance." Additionally, this nurse's file contained areas that should have been further questioned by the facility or staffing coordinator. Review of agency staffing usage for 2010 revealed that sample personnel #5 did not work a second shift at the facility. However, sample personnel #6 had worked seven total shifts and sample #13 had worked five total shifts at the facility this year without further evaluations.

An interview with the Director of Nursing (DON) was conducted on 7/27/2010 at approximately 2:30 p.m. In regards to review of agency nurses' backgrounds and previous work experience, s/he stated that it is part of the facility's contract with the agency company. "They know what we are looking for and meet our need." The DON also stated that periodic evaluations may be completed, but often the nurses take them back with them to the agency. Further interview with the DON was conducted on 7/27/10 at approximately 3:45 p.m. In regards to agency nurse orientation, s/he stated, "They come in the night they work early and do the orientation. It is not set-up now that they come in early, so we are looking at doing a ten hour shift and then two hours before doing orientation." It was revealed by the DON that the staffing coordinator is a LPN (Licensed Professional Nurse) and the task of staffing is delegated to him/her but overseen by the DON.

An additional interview with the DON was conducted on 7/28/2010 at approximately 11:20 a.m. After consulting with the nurse agency company the facility uses and consulting with the staffing coordinator, it was determined that no periodic evaluations on agency nurses were in existence. The DON also stated, "We don't have a specific job description for agency nurses." The DON verified that agency nurses usually work on night shift and that staffing on night shift is "thinner," as the patients are sleeping and group therapy is not occurring.

In summary, it was evidenced by staff interview and personnel file review that the facility did not do background or experience reviews prior to nurses working at the hospital. The facility failed to ensure all agency nurses had psychiatric experience, which is necessary when caring for psychiatric patients. The facility also failed to maintain job descriptions for each agency nurse, which would detail the expectations the facility would have of those nurses. The facility did not provide a thorough orientation for agency nurses prior to them working their first shifts and did not periodically evaluate the work of each agency nurse. These failures put all patients at risk and may create additional responsibility for staff nurses, specifically on the night shift when less nurses are staffed and agency nurses frequently work.

Based on review of policies/procedures, medical staff rules and regulations, other facility documents and staff interviews, the facility failed to ensure that each patient's medical record contained a discharge summary by the MD/DO or other qualified practitioner with admitting privileges. The facility allowed the attending psychiatrist to utilize a designated non-provider dictationist to review the medical record and dictate a discharge summary for the psychiatrist. The designated non-provider dictationist was not a part of the treatment team and had no prior knowledge of the patient and no direct contact with the patient as a part of the chart review/dictation process. After the dictated discharge summary was transcribed, it was to be reviewed for accuracy by the psychiatrist and then signed by the psychiatrist. The facility failed to ensure that discharge summaries were completed by the attending psychiatrist or other qualified health care personnel with knowledge of the patient and who met the minimum qualification outlined in hospital policies/procedures and was appointed/credential by the governing body, as required. The failure created the potential for incomplete and inaccurate representation of the course of medical and psychiatric treatment of the patient because the discharge summary was prepared by a designated non-provider dictationist with no medical knowledge base and a very limited psychiatric knowledge base.

The findings were:

Review on 7/27/10 of the facility policy and procedure "Discharge Summary Documentation and Dictation," revealed the following, in pertinent parts:
"...POLICY:
The goal of the Discharge Summary is to summarize the therapeutic and other significant events that occurred during an inpatient admission. The Discharge Summary provides, concise details for reasons leading to admission, diagnosis, investigations, and as a record of response to a variety of therapeutic interventions. A comprehensive Discharge Summary should ensure effective continuity of care in the community after discharge.

A Discharge Summary is required documentation for all patients in accordance with (the facility) Medical Staff Rules and Regulations. Dictation of the Discharge Summary and its authentication is the responsibility of the attending physician. At (the facility), the attending physician has the option to designate a qualified individual to dictate the Discharge Summary. When the attending physician exercises this option, they remain responsible for the accuracy of content and quality of the Discharge Summary as well as the authentication of the Discharge Summary. A qualified designee in the State of Colorado would include a Licensed Clinical Social Worker, a licensed Physician's Assistant, a licensed Nurse Practitioner, as well as a Licensed Professional Counselor, The Administrative Assistant will maintain a credential file for the designee which will be reviewed and updated and reviewed in accordance with (the facility) Medical Staff Bylaws. Additionally, the designee must be approved by the Medical Executive Committee..."

Review on 7/27/10 of the "credential file" of the designated dictationist for the "Discharge Summary," revealed the following findings: The designated dictationist file contained a one-page professional resume and a second page from a "degree verification service." The professional resume had only one employment experience that was at all related to the his/her designated responsibilities. The experience was the most recent experience (8/2008 to 2/2010) working as a group living counselor at a youth treatment center. The resume identified s/he had a bachelor of arts degree in psychology and a minor in business administration. The second page in the file validated the degrees had been granted, including the name and location of the school and the date ( 2007) the degree was conferred. In addition, the professional resume identified a position from 10/07 to 5/08 working as an "internal wholesaler" for a national life insurance company. The resume contained no evidence of inpatient acute care psychiatric hospital experience or any medical field experience.

The file contained no evidence of appointment to the allied professional staff or having been through a credentialing process.

On 7/27/10 at approximately 9:30 a.m., the director of medical records was interviewed and revealed that the designated dictationist was an employee of the physicians' contract group, not an employee of the facility.

On 7/27/10 at approximately 10:30 a.m., the chief clinical officer was interviewed and revealed the designated dictationist did all dictations of Discharge Summaries for all medical staff at the facility. When asked about the qualifications for the position, s/he stated the dictationist had no healthcare background but was working as social worker at the youth facility mentioned in the resume. The file was reviewed by the surveyor with the chief clinical officer and it was determined the dictationist had no social work background and no healthcare background to prepare for the current position.

On 7/27/10 at approximately 11 a.m., the administrative assistant who was responsible for all credential files was interviewed and revealed that the two-page file reviewed was a file for the contracted physician group and that the facility had no personnel or credential file for the dictationist. S/he confirmed the dictationist had never been reviewed, credentialed or granted allied health privileges by the governing body.