HospitalInspections.org

Based on document review and staff interview it was determined the facility failed to demonstrate measurable improvements for the indicator of patient falls and hand hygiene during approximately 15 months of collecting and analyzing data.

Findings include:

The Performance Improvement Indicators for 2014 included Goal 7: Reduce the risk of healthcare associated infections, hand hygiene and Goal 15: The organization identifies safety risks inherent in its patient population as Performance Standards. The Goal for each Performance Standard was indicated to be 100%. The Dimension of Performance for each Performance Standard was documented as Efficacy, Safety, and Effectiveness.

The review of Risk Management and Performance Improvement reports failed to reveal evidence of tracking or trending of compliance with hand hygiene requirements. The review of Quality Committee meeting minutes failed to reveal the inclusion of any reporting related to hand hygiene performance improvement activities. The facility was unable to comply with a request to produce documentation of the Performance Improvement activities related to hand hygiene.

The Risk Management 4th Quarter Data-2014, 1st Quarter Data 2015, and the Performance Improvement Reports for 2014 and 2015 all included data indicating the facility was tracking patient falls. The data reflected a generally upward trend between January 2014 and March 2015. The rate per 1000 patient days was 3.62 in January 2014 and 5.26 in March 2015. There were significant variances from month to month ranging from a low of 2.73 to a high of 6 per 1000 patient days. The review of the Quality Committee meeting minutes, Risk Management Recommendations/Actions and Governing Body meeting minutes for 2014 related to reporting on Patient Falls revealed the data was reported without any recommendations for action or follow-up other than to continue to collect and analyze data.

An interview was conducted with the Director of Clinical Services and the Infection Control/Staff Educator on 4/7/15 at approximately 11:30 a.m. The Director of Clinical Services indicated the most recent observations showed staff compliance with hand hygiene was at 80%. He confirmed the finding there was no evidence of collection or analysis of the data related to compliance with hand hygiene requirements.

An interview was conducted with the Director of Quality Management on 4/8/15 at approximately 3:30 p.m. She confirmed the finding the facility had not developed or implemented a plan of improvement that resulted in an improvement in patient safety related to a reduction in the frequency of patient falls between January 2014 and the present.

Based on document review, policy review, and staff interview it was determined the facility failed to enforce the medical staff bylaws regarding medical staff responsibilities for the timely completion of medical records.

Findings include:

The Medical Record Timeliness and Delinquency Data Trending report was reviewed on 4/8/15. The report indicated there were 110 or 37% of all discharged patients, delinquent records in January 2015,and 125 or 42% of all discharged patients delinquent records in February 2015.

Page 5 of the Medical Staff Bylaws, Article 3 Medical Staff Membership, 3.1.1. indicated a requirement of membership on the medical staff required compliance with the provisions of the Bylaws, Rules and regulations, and the Facility's policies and procedures.

Page 8 of the Medical Staff Bylaws, 3.3.10 General Responsibilities of Staff Membership indicated members of the medical staff were required to prepare and complete medical records in a timely manner for all patients under the physician's care.

Page 54 of the Medical Staff Bylaws, 8.2 Corrective Action, 8.4.4 Medical Records indicated a Member who has failed to complete medical records within 7 days after receiving warning shall be suspended from admitting patients.

The facility policy "Incomplete Record Notification", Policy Number HIM-40-302, approved 10/2014, indicated the policy applied to any physician with incomplete or delinquent medical records. The Procedure included information that a Reminder Letter would be sent to notify the physician he/she had incomplete medical records. A Warning Letter would be sent via mail, email or text, 10 working days from the date of the Reminder Letter advising action which will be taken in five days from the warning letter. A Suspension Letter is sent if there is no response to the Warning Letter. The physician is given 5 days from the date of the Suspension Letter to complete charts, or his admitting privileges will be temporarily suspended.

An interview was conducted with the Director of Quality Management on 4/8/15 at approximately 3:30 p.m. She confirmed the definition of "delinquent records" as reported on the Trending Report was records that had not been completed by the physician more than 30 days following the patient's discharge. She confirmed all physicians were sent warning notices by mail, email or text advising them of their delinquent records requiring completion. She confirmed an unknown number of records remained incomplete beyond the time frames of the Warning Letter. She indicated no physicians were currently suspended and none had been suspended in the previous year. Following a review of the Medical Staff Bylaws, she confirmed the finding the facility policy was not consistent with the Bylaws. She confirmed the finding the Bylaws were not enforced with regard to incomplete medical records.

Based on record review and interview it was determined the facility failed to ensure complete and accurate records on four (#4, #7, #8, #20) of twenty records reviewed.

Findings include:

1. Patient #4 was admitted 02/26/2015 for psychiatric care. The informed consent of electroconvulsive therapy (ECT) was dated and signed on 03/03/2015 at 8:00 a.m. The number of times per week was left blank and the number of weeks the treatment was to occur was blank. The not to exceed number of treatments and the number of not to exceed days from the first treatment were left blank.

An interview was conducted with the ECT Supervisor, the Assistant Director of Nursing (ADON) and the Director of HIM/Medical Records, and Director of Quality Management on 4/8/15 at approximately 11:30 a.m. They confirmed the above findings and stated the form was not completed or accurate.

2. Patient #7 had received 17 ECT (Electroconvulsive Therapy) treatments on an outpatient basis in January and February 2015. The ECT Recovery Room Protocol dated 2/20/15 and signed by the LPN (Licensed Practical Nurse) included documentation the patient's IV (intravenous) catheter was discontinued with the tip intact at 7:55 a.m. A detailed review of the record failed to reveal a physician's order to start or discontinue an IV.

Patient #7's ECT Anesthesia Monitoring Record dated 2/26/15 and signed by the anesthesiologist included a section where the anesthesia drugs and dosages could be written. Under the column labeled Dosage, the numbers 20, 150, 50, and 30 were written in boxes. The column labeled Drugs had boxes corresponding to the the Dosages, where the names of the medications could be written. The boxes under Drugs were all blank. The lower left corner of the form had a patient identification label placed over the anesthesiologist's signature, obscuring it.

A thermal paper strip dated 2/26/15 at 6:17 a.m. and labeled EEG Strip was observed to be folded in thirds and taped to the physician report of ECT treatment. The strip appeared to contain documentation of the strength and duration of the electrical charge delivered. There was no EEG wave form recorded on the strip.

Patient #7's ECT Recovery Room Protocol forms dated 2/19/15 and 2/20/15 were observed to have several vital sign monitoring thermal paper print-outs taped to the forms in such a way that the vital sign documentation was not visible and the taped forms covered over written documentation.

An interview was conducted with the ECT Supervisor and the Assistant Director of Nursing (ADON) on 4/8/15 at approximately 11:15 a.m. They confirmed the finding the record did not contain physicians orders related to the care of Patient #7 for her outpatient ECT therapy on 2/19/15. They confirmed the finding the anesthesiologist had failed to document the names of the anesthetic medications he administered, rendering the record incomplete and inaccurate. They confirmed the finding the purpose of the EEG strip was to document the brain wave activity and time of the electric shock delivered to the patient. They confirmed the finding the manner in which forms were taped on top of other documentation rendered the documentation incomplete and inaccurate.

3. Patient #8 was admitted on 2/13/15 at 9:47 p.m. The complete Evaluation/Inpatient Psychiatrist was dated 2/14/15. The time the examination was performed was not documented.

An interview was conducted with the Director of Quality Management on 4/8/15 at approximately 3:30 p.m. She confirmed the finding the lack of time documentation made it impossible to determine if the examination was performed within 24 hours of the patient's admission as required.

4. Patient #20 was admitted on 12/29/2014. The Pre-anesthesia assessment listing potential anesthesia problems was left blank. The ECT Anesthesia monitoring Record listed medication: Labetalol 10 milligrams intravenous was given post ECT however no time was listed.

An interview was conducted with the ECT Supervisor, the Assistant Director of Nursing (ADON) and the Director of HIM/Medical Records, and Director of Quality Management on 4/8/15 at approximately 11:30 a.m. They confirmed the above findings and stated the form was not completed or accurate.

Based on document review and staff interview it was determined the facility failed to ensure a successful plan of correction was implemented for the improvement of compliance with hand hygiene requirements.

Findings include:

The Performance Improvement Indicators for 2014 included Goal 7: Reduce the risk of healthcare associated infections, hand hygiene.

The review of Quality Committee meeting minutes for 2014 and 2015 failed to reveal the inclusion of any reporting related to hand hygiene performance improvement activities. The facility was unable to comply with a request to produce documentation of the Performance Improvement activities related to hand hygiene.

An interview was conducted with the Director of Clinical Services and the Infection Control/Staff Educator on 4/7/15 at approximately 11:30 a.m. The Director of Clinical Services indicated hand hygiene compliance was determined through monthly observations of clinical staff. He indicated the most recent observations showed staff compliance with hand hygiene was at 80%. He confirmed the finding the facility had not developed or implemented a plan to improve the compliance rate for hand hygiene.

Based on interview and review of facility policies it was determined the facility failed to have and implement a policy and procedure regarding organ procurement responsibilities.

Findings include:

An interview was conducted with the Assistant Director of Nursing (ADON) and the Director of HIM/Medical Records, Director of Quality Management on 4/8/15 at approximately 11:30 a.m. confirmed there was no policy or procedure.

Based on record review, policy review and interview it was determined the facility failed to to have outpatient orders for continued electroconvulsive therapy (ECT) for four (#4, #7, #15, #19) of twenty records reviewed.

Findings include:

1. Patient #4 was admitted 02/26/2015 and discharged on 03/31/2015. The patient was receiving ECT as inpatient and continued as outpatient without new orders.

Per facility policy titled "ECT- Outpatient", #ECT-155, Issued 08/2013 Reviewed 02/2015 and "Protocol for Electroconvulsive Therapy (ECT)", #NA, Revised 08/2014 revealed an order for or to continue ECT as an outpatient required a physician order.

An interview was conducted with the ECT Supervisor and the Assistant Director of Nursing (ADON) on 4/8/15 at approximately 11:30 a.m. confirming the above findings.

2. Patient #7's record revealed there were no orders for outpatient Electroconvulsive Therapy (ECT).

Per facility policy titled "ECT- Outpatient", #ECT-155, Issued 08/2013 Reviewed 02/2015 and "Protocol for Electroconvulsive Therapy (ECT)", #NA, Revised 08/2014 revealed an order for or to continue ECT as an outpatient required a physician order.

An interview was conducted with the ECT Supervisor and the Assistant Director of Nursing (ADON) on 4/8/15 at approximately 11:30 a.m. confirming the above findings.

3. Patient #15's record revealed there were no orders for outpatient Electroconvulsive Therapy (ECT).

Per facility policy titled "ECT- Outpatient", #ECT-155, Issued 08/2013 Reviewed 02/2015 and "Protocol for Electroconvulsive Therapy (ECT)", #NA, Revised 08/2014 revealed an order for or to continue ECT as an outpatient required a physician order.

An interview was conducted with the ECT Supervisor and the Assistant Director of Nursing (ADON) on 4/8/15 at approximately 11:30 a.m. confirming the above findings.

4. Patient #19's record revealed there were no orders for outpatient Electroconvulsive Therapy (ECT).

Per facility policy titled "ECT- Outpatient", #ECT-155, Issued 08/2013 Reviewed 02/2015 and "Protocol for Electroconvulsive Therapy (ECT)", #NA, Revised 08/2014 revealed an order for or to continue ECT as an outpatient required a physician order.

An interview was conducted with the ECT Supervisor and the Assistant Director of Nursing (ADON) on 4/8/15 at approximately 11:30 a.m. confirming the above findings.