HospitalInspections.org

Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to ensure the Registered Nurse was available and providing cardiac monitoring on the medical/surgical unit.

Findings include:

Review on August 13, 2014, of the facility document, "Job Description Job Title: Registered Nurse Department: Med/Surg [medical/surgical] Unit," dated revised March 1, 2014, revealed "Summary Utilizing the Nursing Process, the Registered Nurse is accountable for delivery of total patient care of assigned patients during his/her shift. The Registered Nurse is responsible for meeting the established Standards of Care, managing assigned personnel, and promoting collaboration among the health care providers. Minimum Qualifications ... Successful completion of Coronary Care Course. CPR [Cardiopulmonary Resuscitation] or ACLS [Advance Cardiovascular Life Support] certified. ..."

Review on August 13, 2014, of the facility policy "Nursing Department Policy and Procedure Subject - Cardiac Monitoring," dated approved September 12, 2013, revealed "Policy - The purpose of telemetry monitoring is to provide 24 hour cardiac monitoring for the evaluation of conditions that interfere with normal heart function, including, but not limited to the following: Disturbance of rate and/or rhythm Disorders of conduction Enlargement of heart chambers Presence of MI [Myocardial Infarction- heart attack] Electrolyte imbalance Administration of certain IV [Intravenous] medications. ... It is the responsibility of the primary or charge nurse to report any significant events regarding telemetry to the physician. ..."

An observation tour of the Medical/Surgical Department conducted on August 13, 2014, at approximately 10:00 AM revealed a cardiac monitor unit at the nursing station recording the heart rhythm of one patient. The nursing station was staffed by the ward clerk at the time of the observation. Nurses were observed in an empty patient room receiving CPR education and a group of nurses were in a meeting located in the conference room behind the nursing station. There was no nurse with a Coronary Care Course education present at the nursing station to monitor the patient's cardiac rhythm.

Interview with EMP5 on August 13, 2014, at approximately 10:05 AM confirmed no nurse was present at the nursing station to observe the cardiac monitor. EMP5 confirmed the ward clerk had not taken the Coronary Care Course and was not ACLS certified.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure a physical examination was present in the medical record for eight of 16 Emergency Room records reviewed (MR1, MR2, MR3, MR4, MR5, MR6, MR7, and MR8).

Findings include:

Review on August 12, 2014, of the facility "Rules and Regulations of the Medical Staff," dated approved 2009 and reviewed January 2014, revealed "... E. Emergency Services ... If an individual comes to the emergency department and a request is made on the individuals behalf for examination and treatment for a medical condition, the individual will be provided an appropriate medical screening examination within the the capability of the emergency department, including routinely available ancillary testing to determine whether or not an emergency condition exists. ..."

Review on August 13, 2014, of the facility "EMTALA Guidelines for Emergency Department Services," last reviewed January 2014, revealed "Policy - All patients presenting to Endless Mountains Health System's Emergency Department seeking care or presenting elsewhere on the hospital's main campus and requesting emergency care, must be accepted and evaluated regardless of the patient's ability to pay. ... I. Medical screening exams (MSEs) should include at a minimum the following: 1. Emergency Department Log Entry, including disposition of the patient 2. Patient's triage record 3. Vital signs 4. History 5. Physical exam of affected systems 6. Exam of known chronic conditions 7. Necessary testing to rule out emergency medical conditions 8. Notification and use of on-call staff to complete previously mentioned guidelines 9. Notification and use of on-call physicians to diagnose and/or stabilize the patient as necessary 10. Vital signs upon discharge or transfer 11. Complete documentation of the medical screening exam. ..."

The following medical records were reviewed on August 12 and 13, 2014:

Review of MR1 revealed the patient presented to the Emergency Room (ER) on August 11, 2014, with dizziness and neck pain. There was no documentation in MR1 of a physican examination.

Review of MR2 revealed the patient presented to the ER on August 11, 2014, with the complaint of flank pain. There was no documentation in MR2 of a physican examination.

Review of MR3 revealed the patient presented the ER on February 17, 2014, with the complaints of bruising and pain in the right eye after a fall. There was no documentation in MR3 of a physican examination.

Review of MR4 revealed the patient presented to the ER on August 25, 2013, with the complaint of lower extremity pain after twisting the ankle. There was no documentation in MR4 of a physican examination.

Review of MR5 revealed the patient presented to the ER on May 24, 2013, with the complaint of right-sided abdominal pain. There was no documentation in MR5 of a physican examination.

Review of MR6 revealed the patient presented to the ER on August 3, 2014, with the complaints of abdominal pain and weight loss. There was no documentation in MR6 of a physican examination.

Review of MR7 revealed the patient presented to the ER on July 31, 2014, after falling from the back of a truck. There was no documentation in MR7 of a physican examination.

Review of MR8 revealed the patient presented to the ER on August 6, 2014, with suicidal ideation. There was no documentation in MR8 of a physican examination.

Interview on August 11, 2014, with EMP3 confirmed there was no documentation of the physician's examination of the patients for MR1 thru MR8. EMP3 stated the physicians dictate the physician examination, and the facility no longer maintained a paper copy of the physician examination in the medical record. These examinations are to be scanned into the electronic medical record.

Interview on August 13, 2014, with EMP4 confirmed the physicians' notes, which include the history and physical, are dictated and then scanned into the medical record. EMP4 confirmed they could not provide the physician examinations, and did not see them anywhere in the electronic medical record. EMP4 confirmed there was no documentation of physician physical examinations in MR1, MR2, MR3, MR4, MR5, MR6, MR7, and MR8.

Interview with OTH1 on August 11, 2014, during the emergency room tour confirmed there was no documentation of a physician examination in MR2. OTH1 stated the note would be dictated. MR2 was discharged from the ER at 10:42 AM. The tour was conducted at 2:00 PM.

Cross reference:
485.638(a)(1) Records Systems

Based on review of facility documents, medical records ((MR), and staff interview (EMP), it was determined the facility failed to ensure the emergency room history and physical examinations were included in the medical record.

Findings include:

Review of the facility medical records policy "Transcription of Health Information," last reviewed January 2014, revealed "Policy - EMHS [Endless Mountain Health System] has adopted this Policy to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the requirement of the proposed HIPAA security regulations to protect the security of electronic health information, as well as to meet our duty to protect the confidentiality and integrity of confidential health information, as required by law, professional ethics, and accreditation requirements. ... Medical Dictation/Transcription System Purpose The medical record department shall provide and coordinate a centralized dictation transcription system to support the documentation process associated with quality patient care. This service shall be provided in order to achieve the following: ... Promote timely and accurate entrees into the medical record ... Processing Time and Priority Designation As far as possible all material entered into the dictation system shall be transcribed and delivered to appropriate place by medical record personnel with the time frames noted here. These processing times are established in recognition of the time-sensitive value of medical records entries. Routine dictation shall be processed within these time frames: History and Physical 24 hours Discharge summaries 30 days Operative reports 24 hours when possible Emergency Department Notes 24 hours Radiology reports 24 hours when possible. ..."

Review of the facility delinquency reports from June 13, 2013, to August 2014 revealed a total of 98 Emergency Department Notes were delinquent.

Interview on August 13, 2014, with EMP4 confirmed the delinquent Emergency Department Notes were the history and physical examinations completed by the physician in the Emergency Room as the medical screening examination.

Cross Reference:
485.635(b)(1) Patient Services

Based on review of facility documents, meeting minutes, and staff interview (EMP), it was determined the facility failed to ensure the Quality Improvement Committee met monthly and failed to ensure Pharmacy, Admissions, Telemetry, Surgical Services, Safety and Security, Central Processing, Imaging, Case Management, Utilization Review, Medical Records, Nutrition, Rehabilitation, Engineering and Maintenance presented quality indicators to the Quality Improvement Committee for evaluation.

Findings include:

Review on August 12, 2014, of the "Endless Mountains Health Systems Quality Improvement Plan," dated reviewed December 2013, revealed "Purpose: The purpose of the Quality Improvement Plan for EMHS [Endless Mountain Health Systems] is to establish, implement, monitor, and document evidence of an ongoing QI (Quality Improvement) process. This process should include effective mechanisms for reviewing and evaluating the care of the clients entrusted to its care. This plan is designed to integrate and coordinate all activities pertaining to quality review. It provides for a comprehensive, objective assessment of patient care, focused on the resolution of known or suspected problems that may have a direct or indirect impact on patient care. Objectives: To ensure the delivery of patient care at the maximal achievable level of quality in a safe and cost effective manner. To enhance personnel performance. To reduce and or eliminate unnecessary risks and hazards identified in the hospital. To implement identifying, assessing, improving, and evaluating professional practice. To ensure routine and reliable evaluation of patient practices and professional competency. To develop and implement effective mechanisms for the collection documenting and disseminating Quality Improvement findings to the appropriate committees. To enhance coordination and communication among all hospital services through a cross functioning QI process for the improvement or patient care and professional practice. ... Authority and Accountability: ... The Quality Improvement Committee This committee is a multidisciplinary, which will meet monthly, and more frequently as circumstances dictate. The QI Committee will be responsible for the directing, monitoring and reviewing of all QI activities at Endless Mountains Health Systems. The committee will report directly to the CEO who will present the QI activities to the governing body. The members of the QIC are comprised of representatives of the administration, medical staff, nursing department, QI Department and ancillary services. The QI Committee will review the care provided by the medical staff, nursing and all ancillary services to include all health care practitioners employed or contracted by EMHS. ..."

1) Review on August 12, 2014, of Quality Improvement Committee meeting minutes for 2013 revealed the Committee did not meet in November and December of 2013.

Interview with EMP2 on August 12, 2014, at approximately 10:30 AM confirmed the Quality Improvement Committee did not meet in November and December of 2013.

2) Review on August 12, 2014, of the Quality Improvement meeting minutes for 2013 revealed the following indicators for Quality Improvement review: Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), and the Operating Room Sterile Processing.

Review of the Quality Improvement meeting minutes for 2014 revealed the following indicators for Quality Improvement review: COPD, Total Hip Replacement, and Total Knee Replacement.

Continued review of the Quality Improvement meeting minutes revealed no documentation of discussion or presentation of indicators for review for the following Departments of the hospital: Pharmacy, Admissions, Telemetry, Surgical Services, Safety and Security, Central Processing, Imaging, Case Management, Utilization Review, Medical Records, Nutrition, Rehabilitation, Engineering and Maintenance.

Interview with EMP2 at approximately 11:00 AM confirmed there was no documentation in the Quality Meeting Minutes of discussion, presentation or quality indicators for the departments of the hospital noted above.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure there was an effective system for monitoring and evaluating the quality of patient care and services provided under contract.

Findings include:

Review on August 12, 2014, of the "Endless Mountains Health Systems Quality Improvement Plan," dated reviewed December 2013, revealed "Purpose: The purpose of the Quality Improvement Plan for EMHS [Endless Mountain Health Systems] is to establish, implement, monitor, and document evidence of an ongoing QI [Quality Improvement] process. This process should include effective mechanisms for reviewing and evaluating the care of the clients entrusted to its care. This plan is designed to integrate and coordinate all activities pertaining to quality review. It provides for a comprehensive, objective assessment of patient care, focused on the resolution of known or suspected problems that may have a direct or indirect impact on patient care. ... Authority and Accountability: ... The Quality Improvement Committee This committee is a multidisciplinary, which will meet monthly, and more frequently as circumstances dictate. The QI Committee will be responsible for the directing, monitoring and reviewing of all QI activities at Endless Mountains Health Systems. The committee will report directly to the CEO who will present the QI activities to the governing body. The members of the QIC are comprised of representatives of the administration, medical staff, nursing department, QI Department and ancillary services. The QI Committee will review the care provided by the medical staff, nursing and all ancillary services to include all health care practitioners employed or contracted by EMHS. ..."

Review on August 12, 2014, of the list of contracted services, provided by the facility, revealed the following services were provided through contract: Laundry, Trash Disposal, Elevators, Omnicell (a medication dispensing system), Teleradiology, Communications Systems, including nurse call bell, Pest Control, Transcription and Medical Record Storage Services, Laboratory and X-Ray equipment, Biomed, Fire Safety services, and Food services.

Review on August 12, 2014 of Quality Improvement Committee meeting minutes for 2012, 2013, and up to August 2014 revealed no documentation the contracted services provided to the hospital were included in the hospital's Quality Improvement Committee review.

Interview with EMP2 on August 12, 2014, at approximately 10:30 AM confirmed there was no documentation the contracted services provided to the hospital were included into the Quality Improvement Committee and brought forward to the Governing Body.