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Based on observation, interview, chart review, policy and document review, the contracted dialysis nurse failed to comply with the written contract provisions and the hospital privileges granted her concerning verbal orders and transcription of same. For one patient, this nurse calculated the dosage for the acid bath components and dialyzed the patient for one and one half hours without a current written doctor's order. The same nurse failed to document water testing between patients and used the same sink for clean and dirty procedures.

The findings include:
1. The contract between the hospital and dialysis provider, "Acute Dialysis Service Agreement," reads, "1.04 PROVIDER and HOSPITAL shall jointly and mutually develop a written protocol governing specific responsibilities and procedures to be used by Provider Staff in rendering Services to Patients, and PROVIDER shall provide policies, procedures, and techniques pertaining to the methods by which the Services are rendered at HOSPITAL pursuant to this Agreement.........Provider Staff shall not be responsible for providing any medical and/or nursing treatment .............in any way undertake the practice of medicine or the practice of nursing, render medical opinions or in any way interact with Patients, except to provide the Services pursuant to this Agreement."
2. The surveyor reviewed the "Delineation of Privileges (DOP) of Dialysis Nurses," as present in the credential file of the above mentioned dialysis nurse. Writing orders, either verbal or telephone, and transcribing them is not a part of this DOP.
3. During tour of the Medical Surgical unit at 2:45 PM on May 7, 2012, accompanied by the Chief Nursing Officer, the surveyor observed a patient being dialyzed in room 376. The contracted dialysis nurse had started the patient's dialysis at 1:26 PM. Review of the patient's chart revealed there was no written order for dialysis for May 7, 2012. Upon questioning, the dialysis nurse replied that she had calculated the acid bath according the the patient's lab work, then mixed it. She reported that she had talked to the nephrologist and that he would be coming in to write the dialysis orders later.
4. In a 3:00 PM interview with the nephrologist, he confirmed he had talked to the dialysis nurse earlier about this patient, as he had been in the hospital earlier to see and write orders for another dialysis patient. Review of the medical record revealed he wrote orders for this patient's dialysis at 3:05 PM. The dialysis nurse signed that she had noted the orders.
5. Review of the water log at 2:45 PM on May 7, 2012, revealed that the dialysis nurse had not documented the water checks between patients. She reported she had checked them but had just not documented them yet. The water system used is a portable reverse osmosis unit and two carbon tanks. The surveyor requested the dialysis nurse demonstrate the total chlorine water check. During this procedure the dialysis nurse used the water port after the second carbon tank rather than the port after the primary carbon tank. She said she uses the primary carbon tank port only in the first test of the morning. She reported no reason why she changed ports.
6. At 2:35 PM, the dialysis nurse was observed disposing of a liquid from a bicarbonate or an acid jug into the clean sink without any protective gown or eye, nose and mouth protection. The sink counter was cluttered with personal items.

Based on a complaint investigation, record review and interview, the agency's quality committee failed to ensure data collected related to medical records was used to identify opportunities for improvement and changes that lead to improvement in the delinquency of medical records completion.

Findings:

A complaint investigation was completed by two Medical Facilities Inspectors from the Virginia Department of Health-Office of Licensure and Certification on May 7, 2012 through May 9, 2012. Twenty-eight clinical records were reviewed during the investigation, including emergency department patients. Four of 16 emergency department records were not completed in a timely manner by the attending clinician, according to the hospitals own policy:

Patient # 10 presented to the emergency department on 11/27/2011. The clinical record was not completed by the attending ED physician (Employee # 11) until 3/19/2012, as evidenced by the electronic signature in the areas of past surgical history and history of present illness.
Patient # 16 presented to the ED on 1/17/2012. The clinical record was not complete until 4/28/2012 as evidenced by the attending clinician's (Employee # 11) electronic signature on that date.
Patient # 18 presented to the ED on 1/17/2012 and the clinical record was not complete until 4/28/2012 as evidenced by the clinician's electronic signature on that date.
Patient # 19 presented to the ED on 12/03/2012 and the medical record was not completed until 4/24/2012 as evidenced by the physician's (Employee # 11) signature on that date.

Employee # 6 was interviewed on 5/7/2012 at 3:30 p.m. and the manner in which incomplete clinical records was tracked was requested. A list of delinquent records- labeled "Physician's Suspension List" from November 2011 through May 2012, was presented. Multiple physicians were repeatedly listed as having multiple delinquent records, including Employee # 11. This list also included physician's assistants (PA's) who had delinquent documentation. Examples of clinician's with repeated delinquent documentation:
Employee # 11: November 2011-42 incomplete records; December-6; January-17; February-65; March-26. The Medical Records Director confirmed these records were continued month to month and also included new delinquent records. Employee # 27: November-31; December-32; January-32; February-32; March-22; April-8; May-8. The Medical Records Director confirmed this physician is a locum tenen (temporary) physician and was not always present, and that the delinquent records were the same ones delinquent month to month. Employee # 28 (a PA) : November-33; December-52; January-58; February-63.

The physicians' and physician assistants' Credentialing files were reviewed with Employee # 15. The files of physicians who were re-credentialed, did not evidence a review or consideration of the physician's repeated delinquent documentation, when re-appointed.

On 5/8/2012 at 9:00 a.m. the facility's Health Informations Manager (Employee # 10) was interviewed. Employee # 10 stated that physicians were expected to complete medical record documentation within twenty-eight to thirty days, but the Medical Staff by-law goals were shorter. Employee # 10 stated that physician's were aware of the delinquent documentation, as each time a physician logged onto a computer system, they were alerted to delinquencies. Employee # 10 was unaware of different policies governing emergency room physicians and stated that the Health Information Manager (Employee # 25) in (Name of City) was responsible for notification to physician's of delinquent medical records completion. Employee # 10 stated she did not notify the physician's of delinquent charting and was not aware of action taken related to delinquent documentation. The Chief Nurse Executive identified the Medical Records Director in (Name of City) responsible for ensuring complete and accurate medical records, as Employee # 26.

Employee # 26, the Medical Records Director was not primarily assigned to this hospital. Employee # 26 was interviewed by telephone conference on 5/08/2012 at 11:18 a.m. The Chief Nurse Executive was present during this interview. The Medical Records Director stated that physicians' were "generally notified" of delinquencies in completion of medical records by fax (facsimile), e-mail or telephone. The Medical Records Director stated that the delinquency report was created and sent to this hospital and that the Chief Nurse Executive (CNE) would receive a message. The Director stated that the delinquent records were tracked by the age of the delinquent record, and were of the deficient record reporting list sent to the CNE. The Medical Records Director stated that the Emergency Department record documentation expectations were the same as the policies for in-patient records and physicians with admitting privileges. The Medical Records Director stated the delinquency information at the facility she was primarily assigned to in (Name of City) (this hospital's sister facility with the same governing body), were sent to the credentialing committee, but that was not done at this hospital. The Chief Nurse Executive stated the information is "captured" in the facility's Quality Program and the physicians are notified of the delinquent documentation, but were not being suspended if not completed within the specified time frame, according to the Medical Staff policies. The Medical Records Director stated only elective surgeries were suspended if the scheduled physician was delinquent, no other suspensions were occurring. Evidence that physicians with delinquent charting received verbal warnings, written notification, certified letters or suspension, according to facility policy was requested of the Chief Nurse Executive. The CNE stated this information was not available as this policy was not implemented.

On 5/09/2012 at 3:20 p.m. the Chief Nurse Executive and Employee # 23 (Outcomes Specialist) were interviewed regarding the Quality Committees review of delinquent clinical records. The quality team did review the collected data related to the delinquent documentation, but did not ensure the stated action to be taken was enforced. The quality team did not provide evidence that the collected data was acted upon or action was taken to improve the identified area of deficient practice.

Based on a complaint investigation, record review and interview, the facility staff failed to ensure all patient medical records were completed consistent with hospital policies.

Findings:

A complaint investigation was completed by two Medical Facilities Inspectors from the Virginia Department of Health-Office of Licensure and Certification on May 7, 2012 through May 9, 2012. Twenty-eight clinical records were reviewed during the investigation, including emergency department patients. Four of 16 emergency department records were not completed in a timely manner by the attending clinician, according to the hospitals own policy:

Patient # 10 presented to the emergency department on 11/27/2011. The clinical record was not completed by the attending ED physician (Employee # 11) until 3/19/2012, as evidenced by the electronic signature in the areas of past surgical history and history of present illness.
Patient # 16 presented to the ED on 1/17/2012. The clinical record was not complete until 4/28/2012 as evidenced by the attending clinician's (Employee # 11) electronic signature on that date.
Patient # 18 presented to the ED on 1/17/2012 and the clinical record was not complete until 4/28/2012 as evidenced by the clinician's electronic signature on that date.
Patient # 19 presented to the ED on 12/03/2012 and the medical record was not completed until 4/24/2012 as evidenced by the physician's (Employee # 11) signature on that date.

The Medical Staff By-laws were presented by the Chief Nurse Executive (Employee # 1) on 5/7/2012. In reference to the physicians' failure to complete medical records: "...6.4.7 Medical Records: After a written warning of failure to complete medical records in a timely fashion as required in the rules and regulation, or pursuant to any hospital staff policy or procedure and, after a reasonable opportunity to complete the same, a practitioner's clinical privileges (except with respect to his/her patients already in the hospital), his/her rights to admit patients and to consult with respect to patients, and his/her voting and office-holding prerogatives are automatically suspended effective on the date specified in the written warning and continuing until the delinquent medical records are completed. The procedures for enforcing his provision shall be set forth in the medical staff policies and procedures." The "Medical Staff Rules and Regulations" were also presented by Employee # 1 on 5/08/2012. These regulations stated, regarding delinquent medical records: "...B. Medical Records...9. The patient's medical record shall be complete at the time of discharge, if practicable, but no later than twenty-one (21) days following discharge. A warning letter would be sent and a phone call made by Medical Records to a physician seven (7) days before a chart is delinquent. A record of all calls from Medical Records to physicians will be kept....Any physician who has not dictated a discharge note or signed a chart within 21 days after discharge or within five (5) days after notification by Medical Records that late reports have returned will be notified by the President of (Name of Hospital) (registered mail) that a suspension of his admitting privileges is impending..." The Medical Staff Rules and Regulations did not include how a physician without admitting privileges, such as the ED physicians', would be held accountable for their failure to complete medical records according to the by-laws and hospital's regulations.

A list of the facility's delinquent records tracking document was requested. Employee # 6 presented documents labeled "Physician's Suspension List" from November 2011 through May 2012. Multiple physicians were repeatedly listed as having multiple delinquent records, including Employee # 11. This list also revealed physician's assistants were included and had multiple delinquent documentation.

The physicians' and physician assistants' Credentialing files were reviewed with Employee # 15. The files of physicians who were re-credentialed, did not evidence a review or consideration of the physician's repeated delinquent documentation when re-appointed.

On 5/8/2012 at 9:00 a.m. the facility's Health Informations Manager (Employee # 10) was interviewed. Employee # 10 stated that physicians were expected to complete medical record documentation within twenty-eight to thirty days, but the Medical Staff by-law goals were shorter. Employee # 10 stated that physician's were aware of the delinquent documentation, as each time a physician logged onto a computer system, they were alerted to delinquencies. Employee # 10 was unaware of different policies governing emergency room physicians and stated that the Health Information Manager (Employee # 25) in (Name of City) was responsible for notification to physician's of delinquent medical records completion. Employee # 10 stated she did not notify the physician's of delinquent charting and was not aware of action taken related to delinquent documentation. The Chief Nurse Executive identified the Medical Records Director in (Name of City) responsible for ensuring complete and accurate medical records, as Employee # 26.

Employee # 26, the Medical Records Director was not primarily assigned to this hospital. Employee # 26 was interviewed by telephone conference on 5/08/2012 at 11:18 a.m. The Chief Nurse Executive was present during this interview. The Medical Records Director stated that physicians' were "generally notified" of delinquencies in completion of medical records by fax (facsimile), e-mail or telephone. The Medical Records Director stated that the a delinquency report was created and sent to this hospital and that the Chief Nurse Executive (CNE) would receive a message. The Director stated that the delinquent records were tracked by the age of the delinquent record, and were of the deficient record reporting list sent to the CNE. The Medical Records Director stated that the Emergency Department record documentation expectations were the same as the policies for in-patient records and physicians with admitting privileges. The Medical Records Director stated the delinquency information at the facility she was primarily assigned to in (Name of City) (this hospital's sister facility with the same governing body), were sent to the credentialing committee, but that was not done at this hospital. The Chief Nurse Executive stated the information is "captured" in the facility's Quality Program and the physicians are notified of the delinquent documentation, but were not being suspended if not completed within the specified time frame, according to the Medical Staff policies. The Medical Records Director stated only elective surgeries were suspended if the scheduled physician was delinquent, no other suspensions were occurring. Evidence that physicians with delinquent charting received verbal warnings, written notification, certified letters or suspension, according to facility policy was requested of the Chief Nurse Executive. The CNE stated this information was not available as this policy was not implemented.

Employee # 11 was interviewed on 5/08/2012 at 12:02 a.m. regarding delinquent medical records entries. Employee # 11 stated she did receive a list of delinquent charting each week, including the patients' names and missing elements.

On 5/09/2012 at 3:20 p.m. the Chief Nurse Executive and Employee # 23 (Outcomes Specialist) were interviewed regarding the Quality Committees review of delinquent clinical records. The quality team did review data related to the delinquent documentation, but did not ensure the stated action to be taken was enforced.

No further information to evidence the facility implemented its own policy regarding the timely completion of medical records was presented during this inspection.