HospitalInspections.org

Based on review of medical records, credential files, Medical Staff Bylaws and Medical and
Professional Staff Rules and Regulations and staff interview, the Critical Access Hospital (CAH) failed to ensure that 1 of 2 physician assistants (PA - M) assisting in surgery received approval by the Governing Body for this privilege. Review of the last Annual Evaluation dated 12/13/11 revealed a total of 488 surgeries were performed in fiscal year 2011. Interview with the Surgery Supervisor on 5/17/12 at 1:30 PM revealed that only 2 physician assistants have assisted with surgery at the CAH. Findings are.

A. Review of the Operative Report for Patient 17 dated 5/14/12 listed PA - M as the "Assistant.". Review of the Operative Report for Patient 43 dated 4/2/12 listed PA - M as the Assistant. Further review of this Operative Report for Patient 43 revealed "The assistant surgeon did the graft preparation."

B. Review of the Medical Staff Roster with a date of 5-2012 revealed PA - M was not listed on this roster. Interview with the HIM (Health Information Management) Director on 5/15/12 at 10:30 AM revealed there was no credential file for PA - M.

C. Review of the Medical and Professional Staff Rules and Regulations with a Board approval date of 4/25/12 revealed the following under Assistants at Surgery: "The surgeon shall utilize such assistants at surgery as he or she deems appropriate, and such assistants may include any practitioner, AHP [Allied Health Professional], nurse, aide, or technician who is properly trained, qualified, and credential consistent with the Medical Staff Bylaws".

The Medical Staff Bylaws with an approved dated of 4/25/12 revealed the following definition for AHP:
"...an individual who is permitted by law and by the Hospital to render certain health care services in the Hospital, but who is not eligible for independent clinical privileges. Allied Health Professionals must be either employees of the Hospital under written contract to the Hospital for their services, or approved by the Board with the advice of the Medical Staff. Allied Health Professions include, but are not limited to Mid-Level Practitioners (MLP)." Under the definitions section the Bylaws list MLPs as "Certified Registered Nurse Practitioners (CRNPs), Certified Registered Nurse Anesthetists (CRNAs), Certified Nurse Midwives (CNWs), and Physician's Assistants (PAs)".

Further review of the Medical Staff Bylaws, under the section titled Appointment of Allied Health Professionals and Mid-Level Practitioners was documented "Allied Health Professionals (including Mid-Level Practitioners) who are not employees of the Hospital and who do not provide services under a written contract with the Hospital, must be approved by the Board with the advice of the Active Staff".

D. Interview with the CEO (Chief Executive Officer) on 5/17/12 from 9:50 AM - 10:00 AM revealed the following:
- PA - M had previously been approved by the Board in 2007;
- They had received information that PA - M was leaving the area;
- PA - M was removed from the list of Board Approved AHP in 2008.

Based on medical record review, review of Medical Staff Bylaws and staff interview, the facility failed to ensure medical records were completed within 30 days as required by the Medical and Professional Staff Rules and Regulations for 5 of 14 sampled acute medical inpatients (Patients 1, 2, 6, 7 and 9). This Critical Access Hospital (CAH) had a census of 2 acute care inpatients, 5 swing bed patients, and 3 oupatient surgery patients on the day of entrance. Findings are:

A. Review of the Demographic Sheet for Patient 1 documented the patient was admitted on 3/4/12 and was discharged on 3/6/12. Review of the medical record revealed the discharge summary was dictated on 4/13/12, or 38 days after discharge. This was confirmed by the facility's RN Clinical Analyst (RNCA) during the record review on 5/15/12.

B. Review of the Demographic Sheet for Patient 2 documented the patient was admitted on 2/16/12 and discharged on 2/20/12. Review of the medical records found the discharge summary was dictated on 5/2/12, or 72 days after discharge. The information was confirmed by RNCA during the record review on 5/15/2012.

C. Review of the Demographic Sheet for Patient 6 revealed the patient was admitted on 4/5/12 and discharged on 4/11/12. Review of the medical record on the afternoon of 5/16/12 failed to find a discharge summary, and when the RNCA asked the Health Information Management (HIM) staff if there was a report waiting to be transcribed she learned that none had been dictated as of that date, or 36 days post discharge.

D. Review of the Demographic Sheet for Patient 7 revealed the patient had been admitted on 2/16/12 and had been discharged on 2/20/12. Further review of the medical record found the discharge summary had been dictated on 5/1/12, or 71 days after discharge. Confirmed by RNCA during the record review on 5/15/12.

E. Review of the Demographic Sheet for Patient 9 revealed the patient had been admitted on 12/16/11 and was transferred to another higher level hospital for ventilation services not provided at this hospital later on 12/16/11. Review of the full medical record found the discharge summary was dictated on 4/24/12, or 130 days after discharge. Confirmed by RNCA while reviewing the record on 5/16/12.

F. An interview with the Director of HIM was completed on 5/15/12 beginning at 2:45 PM. In the interview she related that they did have a discharge analysis process they complete on all discharged patients. The record is placed in a mailbox for that physician/provider to complete the record. They also have a tracking system for each record until completed, and at 23 days after discharge, if the record has not been completed, the provider is informed of the need to finish the record. She did confirm that despite their system for tracking and contacting the providers they would still have some records that were not finished within the 30 day timeframe.