HospitalInspections.org

Based on staff interview and lack of facility evidence, the Critical Access Hospital (CAH) failed to ensure staff and patients were not exposed to unnecessary radiation hazards. The hospital reported 181 acute care patients for the most recent fiscal year. CAH is licensed for 20 beds with census upon entrance of 1 acute patient. Findings include:

A. On 4/03/12 at 3:00 PM, an interview conducted with the Radiology Supervisor revealed the department personnel failed to check the lead-lined protective aprons, gloves and shields for defects for over 2 years. Supervisor was not aware of any facility policy for routine checks to be completed.

B. In addition, the Supervisor pointed out 2 new aprons, recently acquired, that had never been checked for defects.

These items are worn by staff and patients during radiographic procedures to protect areas of the body from unnecessary radiation exposure. Facilities of this size routinely check their aprons, gloves and shields at least annually. Prevailing standards require that the structural integrity of new protective gear be checked prior to using them on patients and staff.

Based on medical record review, staff interview and review of facility policy , the Critical Access Hospital (CAH) failed to ensure 1 of 6 nursing care plans reviewed for inpatients (Patient 1) was kept current regarding the patient's condition. Findings include:

A. Record review on 4/5/12 at 10:00 AM revealed Patient 1 was admitted to the CAH on 3/30/12 with diagnoses of acute pancreatitis secondary to cholelithiasis, history of diverticulitis and history of hiatal hernia. Initial physician orders on 3/30/12 were NPO (nothing by mouth) and monitoring patient's intake and output. On 3/31/12 physician diet orders were increased from NPO to allowing patient to take "sips of water". Review of the care plan lacked dietary status or any update on what changes had been made in the patient's diet.

B. Review of the CAH care plan policy for acute care (policy is not dated) reads:
"GOAL: The nurse identifies expected outcomes individualized to the patient....

REVIEW: The nurse will review the care plans every 12 hours to keep the Plan of Care updated and individualized to the patient as possible."

C. Interview with Certified Dietary Mangager on 4/5/12 revealed uncertainty of who should be addressing care plans for patients with dietary needs but thought it should be the admitting nurse's responsibility. Review of the nurses notes dated 3/30/12 to 4/3/12 included mention of the physician's dietary order for "sips of water"; however, the dietary assessment on 4/2/12 included "encourage fluid intakes" which is conflicting information.

D. Interview with the Director of Nurses (DON) revealed the electronic medical record system the facility purchased has a "pre-set" care plan and the care plans read the same for all patients with the same problem. Care plans are used on the electronic system and not printed out for use by the nursing staff. When asked about Patient 1's care plan, DON stated the dietary issue could have been addressed in the care plan electronically.

Due to the failure of the Critical Access Hospital (CAH) to systematically organize medical records, (see C302 A) failure to ensure medical records were complete and accurately documented, (see C302 B) and failure to ensure medical records were completed and organized in a timely manner, (see C302 C, F, and E), the Condition of Participation: Clinical Records is not met.

Based on staff interviews, medical record reviews, review of policies and procedures and Critical Access Hospital (CAH) internal audit records, the CAH failed to ensure patient medical records were complete, accurately documented, readily accessible and/or systematically organized. The CAH is licensed for 20 beds and had 1 acute care patient upon entrance. Findings include:

A. On 4/3/12 at 1:00 PM during the initial hospital tour and interviews with the Director of Nursing (DON) and the Director of Health Information Management (HIM), observation of the Medical Records Department noted numerous stacks of medical records. The DON stated these records needed to be checked for completeness and coded for billing. When questioned about why the medical records had not been processed for billing the DON stated that CAH has some medical record responsibilities contracted out to 2 companies. One company does all the dictation and the other company does all the coding and billing. The Director of HIM was unsure of why things are like this. Neither the DON or Director of HIM could ensure the stacks of medical records were complete or accurate.

Interview with the Chief Financial Officer (CFO) on 4/5/12 at 1:30 PM revealed there were 110 medical records that were in the Medical Records Department waiting for billing and filing information. These medical records had been there since February and March 2012.

B. On 4/4/12 medical record reviews completed for 2 of 3 sampled surgical patients (Patients 5 and 7) revealed the medical records contained patient record information that had been filed in the wrong patient record. Examples include:

1. Patient 5 (inpatient closed surgical record) was admitted to the CAH on 2/22/12 for a total abdominal hysterectomy and bilateral scalpingo-oophorectomy. Located in the medical record for Patient 5 was an operative report for a different patient also requiring a total abdominal hysterectomy.
2. Patient 7 (outpatient closed surgical record) was admitted to the CAH on 03/13/12 for an outpatient surgical procedure to have a mass removed from the buttocks. Located within Patient 7's medical record was a medication administration sheet for a different patient that had required a colonoscopy or arthroscopy.

C. On 4/4/12 medical record reviews completed for 1 of 3 sampled surgical patients (Patient 5) revealed the medical record was not completed within 30 days of discharge as required by CAH policy. Examples include:

1. Patient 5's medical record was delinquent past the 30 days as patient was discharged on 2/24/12, which is 39 days following discharge and the date of this review. There was no operative report for Patient 5 in the medical record.

2. Review of CAH policy dated October 2011 and titled "Medical Records Completion" states: Medical Records staff will monitor and require medical records to be completed within 30 days of discharge of the patient. The doctor will be notified by letter of charts past 15, 20 days of discharge of the patient.."

3. Interview with the DON on 4/11/12 at 9:30 AM revealed the medical records department failed to notify physicians when medical record delinquencies occurred.

D. Record review on 4/4/12 for closed swingbed Patient 9 revealed inaccurate and incomplete record information as evidenced by:

1. Patient was admitted to the CAH on 3/30/12 for rehabilitation with physical therapy and occupational therapy after a left hip replacement performed at another hospital. History and physical in the medical record was completed at the local health clinic and dated 3/20/12.

2. Review of the CAH policy titled Medical Records Content reads: "The history and physical examination is recorded in the medical record at the time of the patient admission. If a complete physical examination has been performed within 30 days prior to admission, such as in the office of a physician staff member a durable legible copy may be used in the patient medical records provided there have been no changes prior to the original exam, or changes have been documented at the time of admission, an amendment is needed with updates and signatures."

3. The physician admission progress notes failed to reflect whether the patient's history and physical were still current and failed to indicate if the patient had experienced any changes in condition as directed by CAH policy.

4. Review of the admission physician orders dated 3/30/12 indicated a regular diet, following physician order the medical record reads: " May have regular diet for holiday meals" and is marked "no", making the medical record inconsistent with the admission orders.

5. Interview with the Nurse Coordinator on 4/4/12 revealed she was unsure why the diet orders did not match, why the initial admission progress notes were not written, or why the history and physical was not identified or documented as current for Patient 9.

E. On 4/5/12 at 1:00 PM through 2:30 PM interviews were conducted with the Administrator, DON, CFO to discuss the problems identified with the Medical Records Department. Interviews revealed:

1. There have been 5 additional admissions clerks hired and trained within the past 6 months. Part of their responsibilities are to provide 24 hour assistance with medical records, including initially assembling and reviewing all medical records to ensure the records are complete with all required information.

2. Administrator stated he was aware of problems in the medical records department; however, there were too many other things that needed to be taken care of first.

3. There were 110 medical records in boxes or stacked in piles in the Medical Records Department that still required staff reviews and coding for billing. Administrator, DON and CFO could not ensure what condition the medical records or Medical Records Department was in and did not know the exact number of medical records that were incomplete or inaccurate.

4. Under the direction of the DON, 100% of the 110 unfiled medical records were reviewed in the Medical Records Department for completeness and accuracy from 4/5/12 to 4/11/12.

F. On 4/11/12 interviews, observation and review of facility audit information revealed the CAH had identified the following pertaining to the Medical Records Department:

1. An interim health information manager was appointed and will remain in that position until a permanent medical records manager is hired and trained.

2. 110 medical records were internally reviewed/audited with the following results identified:
- 3 additional medical records had incorrect information filed that was for a different patient, and
- 28 medical records that were previously thought to be complete actually lacked information and required either dictation from the practitioner involved, reports of laboratory results or sleep studies, documentation of medications/injections, or co-signatures of midlevel practitioner orders.

Based on staff interview and a lack of evidence, the Critical Access Hospital (CAH) failed to evaluate radiological impressions determined by the Active Medical Staff, as compared with Radiologist interpretations. The hospital reported an annual acute care census of 181 patients for the most recent fiscal year. CAH has 20 licensed beds and census upon entrance was one acute care patient. Findings include:

A. On 4/3/2012 at 3:00 PM during the evaluation of the Radiology Department, an interview with the Radiology Supervisor revealed that Family Practice Physicians routinely evaluate the x-ray images of patients who present in the Emergency Department after 7:00 PM. These practitioners provide an initial impression of the radiographic images and initiate treatment based on these initial impressions.

The following day, the images are interpreted by a Radiologist, who provides the final diagnosis. The Quality Assurance program failed to compare and evaluate these 2 reports for accuracy and appropriateness of the diagnoses and treatment.