HospitalInspections.org

Based on document review and staff interview, the Governing Body failed to ensure that the Critical Access Hospital organizational structure requirements were met for 25 of 25 beds. The Governing Body (GB) failed to ensure medical staff operated under current signed bylaws. The GB failed to ensure an annual review was completed.(see Tag C-241).

Based on document review and staff interview, the Governing Board failed to oversee the total operation of the hospital for 25 of 25 beds. The Governing Board failed to enforce established Medical Staff Bylaws, Rules and Regulations addressing the requirements for completion of medical charts. The Governing Board failed to ensure that the requirements for completion of an annual program review were met for the period from 2011 through 2014. Findings include:

1. Incomplete Medical Charts:
On 5/20/14 at 11:45 a.m., staff member C, a medical records worker, stated there was not a process to get the providers to finish their charts. A spread sheet was e-mailed weekly to staff member A, the CEO, detailing the number of incomplete records and the responsible provider. An e-mail to the CEO dated 5/6/14 documented that 21 charts were incomplete. The spreadsheet e-mailed to the CEO on 5/20/14 indicated that there were 31 incomplete medical charts as of that date. The facility records policy indicated that the CEO was expected to contact the providers and follow the medical staff rules and regulations regarding incomplete charts. Staff member C stated the medical charts were to be completed no later than 15 days after the discharge of a patient.

On 5/20/14 at 1:00 p.m., facility staff provided a copy of the current Medical Staff Bylaws, Rules and Regulations. The Bylaws were dated 8/2002 and were not signed. A signed copy of the bylaws had not be provided by the end of the survey. Section D of the bylaws included language indicating that "all charts must be completed within fifteen (15) days of discharge." Section C of the bylaws included the item Grounds for Automatic Termination of Staff Membership and Privileges. "Failure to complete medical charts in a timely and lawful manner, within fifteen (15) days after receiving written notice of the deficiency from the CEO. 2. ...The CEO shall promptly notify the practitioner of the automatic termination and the reason therefore. Within ten (10) days of such notice, the practitioner may submit written documentation to the CEO that negates the reason for such automatic termination. The Board of Directors shall determine whether the documentation provided negates the termination..."

On 5/20/14 at 3:30 p.m., Staff member A stated he had received the e-mails on incomplete charts, but had not followed up with the Governing Board.


2. Annual Review
On 5/20/14 at 3:30 p.m., staff member A was asked to provide the most recently completed annual review. The CEO stated he was not aware of an annual review.

On 5/21/14 at 10:00 a.m., staff member B, the QA manager, stated an annual evaluation had not been completed since 2008. "I know we were cited for this on the last survey in 2011. Nothing has been done."

Review of the bylaws of the Governing Board showed that board members were expected to provide overall management of the hospital. This included enforcement of the Medical Staff Bylaws and ensuring that the annual review was completed.

Based on record review and staff interview, the hospital lacked a signed consent form for 1 (#1) of 4 closed medical charts. Findings include:

Patient #1 was admitted to the hospital on 8/22/13 with diagnoses including urinary tract infection and hypopotassemia. The medical chart did not contain a informed consent form.

On 5/20/14 at 11:45 a.m., staff member C stated all medical charts required a consent form.

Based on record review and staff interview, facility staff failed to ensure that entries in 2 (#s 1 and 3) of 4 charts were properly authenticated by the providers. Findings include:

1. Patient #1 was admitted to the hospital on 8/22/13 with diagnoses which included urinary tract infection and hypopotassemia. The medical chart lacked a provider's signature on the 8/22/13 physician's order for acute care. Three separate lab results on 8/23/13 lacked a signature and the date and time of signature.

2. Patient #3 was admitted to the hospital on 7/21/13 with diagnoses including fever and abnormality of gait. The medical chart included the providers signature but did not include the time of the provider signed his/her signature on the emergency department orders.

On 5/20/14 at 11:45 a.m., medical record staff member C stated all entries should be "signed, timed, and dated."

Based on document review and staff interviews, the facility failed to conduct or arrange for the completion of the required annual program evaluation for 3 of 3 years between 2011 and 2013. Findings include:

The facility failed to complete or arrange for the required annual program evaluation to be completed for the years 2011, 2012, and 2013. Refer to C-0331.

Based on staff interviews, the facility failed to carry out, or arrange for, an annual evaluation of the total CAH program for 3 of 3 years. Findings include:

On 5/20/14 at 3:30 p.m., during an interview with staff member A, the CEO, he stated that he was not aware of an annual evaluation having been completed.

On 5/21/14 at 10:00 a.m., staff member B, the QA manager, stated the annual evaluation had not been completed since 2008. "I know the hospital was cited for this on the last survey in 2011. Nothing has been done to correct the problem."

Facility staff were unable to provide evidence of a program evaluation for the years 2011, 2012, and 2013.

Based on staff interview the hospital failed to review annually the health care policies including the medical record policies since 2010. Findings include:

On 5/20/14 at 2:00 p.m. staff member D the HIM director, stated policies of the hospital had not been reviewed annually. A new computer program was purchased and she was working on the policies.

On 5/21/14 at 10:00 a.m., staff member B stated the hospital policies have not been reviewed in a long time.