HospitalInspections.org

Based on a review of the Medical Staff By Laws, Rules and Regulations, staff interviews and a review of the most recent annual program evaluation, the Critical Access Hospital(CAH) Medical Staff failed to complete patients' medical records in a timely manner, or maintain compliance with the By Laws regarding medical record completion.

This failed practice had the potential to affect all patients receiving services at the CAH.

On the first suevey day, the hospital reported a total of 61 delinquent medical records.

According the most recent annual program evaluation the CAH had admitted at total of 92 acute patients.
The medical staff consisted of 2 family practitioners and one nurse practitioner
Findings include:

1. The Medical Staff By Laws, Rules and Regulations page 8 (4) m, Completion of Records stated,
"The discharge summary, stating the practitioners final diagnosis, shall be dictated within seven(7) days of discharge...within fourteen (14) days of discharge...the record shall be complete."

2. The 2015 annual program evaluation identified medical record completion by the 2 physicians as failing to meet the minimum threshold of 30 days, in 3 of the 4 quarters.

3. On 12-7-2016 at 11:30 AM. the Health Information Director confirmed that a total of 61 medical records were delinquent as of 11-29-16. Further review of these records revealed some dated back as far as April of 2016.

4. Interview with the administrator and physicians B and C on 12-1-16 at 12:30 PM confirmed a long history of a pattern of practice of failure to maintain compliance with medical record completion.

Based on a review of surgical privileges, as compared with the surgical log, and staff interview, the Critical Access Hospital(CAH) failed to grant privileges that matched actual practice in accordance with safe patient practices.

This failed practice had the potential to affect all patients recieving surgical services at the hospital.

The (CAH) reported 92 acute patients admitted during the last fiscal year.

Findings include:

1. A review of the privileges granted for Surgeon A revealed privileges were for Thyroidectomy (removal of the thyroid gland located in the front of the neck which governs hormone and metabolic funcions) Splenectomy (removal of the Spleen, an organ that filters impurities from the blood)), Bowel Resection (removel of part or all of the bowel) . All of the afore mentioned procedures carry considerable risk for the patient, both during and immediately after surgery.

2. A review of the surgery log from 2009 until the present confirmed none of the above mentioned procedures had been preformed, indicating the staff would not be familiar with post-operative patient care and would put the patient at considerable risk during the recover period.

3. An interview with the Quality Assurance Coordinator on 12-1-16 at 10:30 AM confirmed the facility staff lacked experience in the above mentioned procedures, since they had not been performed in this facility in at least 7 years.