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Based on review of facility documents, credential files, and staff interviews (EMP), it was determined that the facility failed to ensure that all physicians were currently credentialed for one of 26 credential files reviewed (CF4).

Findings include:

Review of Medical Staff Bylaws, Policies and Rules and Regulations of Aria Health Credentials Policy, approved December 21, 2009, revealed "3.B.3 Duration of Provisional Period: 9a) The duration of the provisional period for initial appointment and privileges will be from 12 to 24 months, as recommended by the Credentials Committee." "Procedure For Reappointment All terms, conditions, requirements, and procedures relating to initial appointment will apply to continued appointment and clinical privileges and to reappointment...5.A.3. Reappointment Application: (a) An application for reappointment will be furnished to members at least six months prior to the expiration of their current appointment term. A completed reappointment application must be returned to the Medical Staff Office within 30 days ... "

Review of Medical Staff Bylaws, Policies and Rules and Regulations of Aria Health Part IV Committee Manual approved December 21, 2009, revealed "3.E.2. Duties: ...(c) review periodically information available regarding the competence of staff members ( including ongoing and focused professional practice evaluation data) and, as a result of such reviews, make recommendations for the granting of clinical privileges, reappointment, and the assignment to the appropriate division/departments:.."

1. Review of the Credentials Committee meeting minutes dated April 14, 2008, revealed that CF4 was approved for Full appointment (for an additional year), expiring May 1, 2009.

Review of CF4 on March 4, 2010, revealed initial appointment for one year on May 1, 2007. There was no documented evidence of a reappointment application for the year 2009.

Review of physician schedules revealed this physician worked 295.25 hours from May 2009 until March 4, 2010, without being credentialed.

2. Interview with EMP11 on March 4, 2010, at approximately 3:00 PM confirmed, "I thought that CF4 was appropriately credentialed".

3. Interview with EMP12 on March 4, 2010, at approximately 2:30 PM confirmed that CF4 was not currently credentialed. Interview with EMP12 also confirmed that if hospital staff checked the computer program that provides the current credentialing status of physicians, the program shows that the physician is currently credentialed. EMP12 further confirmed that the credentialing program status was incorrect.

Based on review of facility documents and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to inform patients of their rights, in advance of furnishing or discontinuing patient care whenever possible for nine of ten medical records reviewed (MR45, MR47, MR48, MR49, MR50, MR51,MR52, MR53 and MR54).

Findings include:

Review of facility policy "Important Message from Medicare", effective July 7, 2007, revealed "CMS requires hospitals to deliver a notice to patients within 24 hours of admission. The hospital is required to obtain and document the patient's receipt of the initial notice (signature of the patient is sufficient). The patient's signature implies understanding of the form. In the event the patient is confused, unresponsive and no available family this should be noted on the form signed and dated by the person attempting to deliver the notice. In addition, CMS requires that any patient with a LOS greater than 3 days, receive a second notice upon identification of pending discharge. CMS has advised that the 2nd notification process cannot be part of the process for date of discharge, but has advised that hospitals focus on day before discharge."

1) Review of MR45 revealed that the patient was admitted on February 26, 2010, and was discharged on March 3, 2010. Further review of MR3 revealed no documented evidence that the patient was given or notified of the "An Important Message From Medicare About Your Rights" form prior to or after discharge from the facility.

2) Review of MR47 revealed that the patient was admitted on February 27, 2010, and was discharged on March 3, 2010. Further review of MR47 revealed no documented evidence that the patient was given or notified of the "An Important Message From Medicare About Your Rights" form prior to or after discharge from the facility.

3) Review of MR48 revealed that the patient was admitted on February 27, 2010, and was discharged on March 3, 2010. Further review of MR48 revealed no documented evidence that the patient was given or notified of the "An Important Message From Medicare About Your Rights" form prior to or after discharge from the facility.

4) Review of MR49 revealed that the patient was admitted on February 18, 2010, and was discharged on February 21, 2010. Further review of MR49 revealed no documented evidence that the patient was given or notified of the "An Important Message From Medicare About Your Rights" form prior to or after discharge from the facility.

5) Review of MR50 revealed that the patient was admitted on February 20, 2010, and was discharged on February 23, 2010. Further review of MR50 revealed no documented evidence that the patient was given or notified of the "An Important Message From Medicare About Your Rights" form on admission to the facility.

6) Review of MR51 revealed that the patient was admitted on February 16, 2010, and was discharged on February 22, 2010. Further review of MR51 revealed no documented evidence that the patient was given or notified of the "An Important Message From Medicare About Your Rights" form prior to or after discharge from the facility.

7) Review of MR52 revealed that the patient was admitted on February 19, 2010, and was discharged on March 3, 2010. Further review of MR52 revealed no documented evidence that the patient was given or notified of the "An Important Message From Medicare About Your Rights" form on admission to the facility, and prior to or after discharge from the facility.

8) Review of MR53 revealed that the patient was admitted on February 19, 2010, and was discharged on March 2, 2010. Further review of MR53 revealed no documented evidence that the patient was given or notified of the "An Important Message From Medicare About Your Rights" form on admission to the facility.

9) Review of MR54 revealed that the patient was admitted on February 24, 2010, and was discharged on March 3, 2010. Further review of MR54 revealed no documented evidence that the patient was given or notified of the "An Important Message From Medicare About Your Rights" form prior to or after discharge from the facility

10) Interview with EMP10 on March 4, 2010, at approximately 9:30 AM confirmed the above findings and revealed "No, there is no signature or note that the [Important Message form] was given, I have absolutely recognized the issue."

Based on review of facility documents and medical records (MR), and interviews with staff (EMP), it was determined the facility failed to ensure that less restrictive interventions/alternatives were attempted prior to the use of restraints for three of four restraint medical records reviewed (MR58, MR60, and MR61).

Findings include:

Review of policy "Restraints (Physical) for Behavior Management and Acute Medical Surgical Care", dated December 1, 2009, revealed "Documentation As soon as possible after implementation of the restraint the RN will document: ... Each episode of use is recorded to include: ... Alternatives or less restrictive interventions attempted."

1. Review of MR58 revealed this patient was restrained on February 23, 2010, at 5 AM, and February 28, 2010 at 6 PM. There was no documented evidence that any alternative interventions were attempted or determined to be ineffective for both of these restraint episodes.

2. Review of MR60 revealed this patient was restrained on March 2, 2010, at 8 AM. There was no documented evidence that any alternative interventions were attempted or determined to be ineffective.

3. Review of MR61 revealed this patient was restrained on February 19, 2010, at 9:30 AM and 7:30 PM, February 20, 2010, at 1:30 AM, 2:30 PM, and 11:50 PM, and February 27, 2010, at 1:30 PM . There was no documented evidence that any alternative interventions were attempted or determined to be ineffective for these restraint episodes.

4. Interview with EMP1 on March 3, 2010, at approximately 2 PM confirmed the above findings.

Based on review of facility documents and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure medications were administered in accordance with the orders of the practitioner responsible for the patient's care as specified under 482.12(c), and accepted standards of practice for three of three medical records reviewed (MR 55, MR56, and MR57).

Findings include:

Review of facility policy "Medications, Administration Of ", effective July 1, 2009, revealed "Policy: Medications are administered using the following guidelines ... Documentation of Medication Administration: ... Document patient response to medication as appropriate."

1. Review of MR55 revealed physician orders, dated March 2, March 3, and March 4, 2010, as follows: (Versed) ... Titration: To Ramsey Scale of 4 to 5." Further review of MR55 revealed there was no documented evidence that the Ramsey Scale was completed 59 of 72 times.

2. Review of MR 56 revealed a physician's order, dated February 5, 2010, " ... Diprivan ... Titration: To Ramsey Scale of 4 to 5." Further review of MR56 revealed no documented evidence of a Ramsey score.

3. Review of MR57 revealed a physician's order, dated February 11, 2010, " ... Diprivan ... Titration to Ramsey Scale of 4 to 5." Further review of MR57 revealed no documented evidence of a Ramsey score.

4. Interview of EMP12 on March 4, 2010, at approximately 2:15 PM confirmed the above findings and revealed, "The Ramsey score is to be documented every hour; we have no policy on specific Ramsey score documentation."

Based on review of Medical Staff Rules And Regulations, facility documents, and staff interview (EMP), it was determined the facility failed to complete medical records within 30 days following discharge for 1,754 medical records.

Review of "Medical Staff Bylaws, Policies, And Rules And Regulations" dated December 21, 2009, revealed "2.8. Delinquent Medical Records: (a) It is the responsibility of the physician to prepare and complete medical records in a timely fashion in accordance with the specific provisions of these Rules and Regulations and other relevant policies initiatives of the Hospital. A medical record will not be permanently filed until it is completed by the responsible physician, or it is ordered filed by the Executive Committee. (b) Each medical record, including short stay medical records, will be completed within 30 days following discharge. Upon initial notification to the Health Information Management (HIM) of non-compliant behavior, the physician will be afforded an opportunity to immediately correct any deficiencies or errors (c) A second notice of non-compliant behavior will be issued by HIM for any failure to timely correct the deficiencies identified in the first notice. Although there will also be another opportunity to correct any errors and deficiencies, the second notice will formally notify the physician that continuing non-compliance will result in an automatic relinquishment and/or resignation of appointment from the Medical Staff and of all clinical privileges. (d) Upon issuance of a third notice of non-compliance by HIM, the elective and admitting clinical privileges of any individual shall be deemed to be automatically relinquished. Such relinquishment shall continue until all the records of the individuals's patients are fully compliant. Failure to complete the medical records that caused relinquishment of such privileges shall constitute automatic resignation of all clinical privileges and resignation from the Medical Staff."

Review of policy "Chart Analysis" dated April 15, 2008, revealed "The Health Information Management Department (HIM) shall conduct a quantitative analysis of the medical records. Forms that are missing or incomplete will be flagged for completion by the physician/health care provider within the time limits set forth by the Rules and Regulations of the Bylaws of the Medical Staff."

Review of policy "Physician Incomplete Record Warning and Suspension" dated September 1, 2006, revealed "Delinquent Record - A record that is still incomplete 30 days or more post discharge. ... 3. Weekly reminder e-mail letters are sent to any physician with one or more incomplete records as recorded in the Physician Deficiency database. The number and type of deficiency will be noted. 4. On the 15th of each month, a Physician Deficiency report will be run to identify all Physicians with one or more delinquent records A 1st Warning Letter will be issued via e-mail and fax. 5. The HIM Staff will contact the physician via telephone, beeper, fax or direct contact to remind them to complete records. 6. On the 1st day of the next month, the Physician Deficiency Report will be run to identify any physicians who remain on the list with one or more delinquent records. For those who already received a 1st Warning Letter, a 2nd Warning Letter will be issued via e-mail and fax. 7. Administration will be notified of all physicians on the 2nd Warning Letter list. 8. On the 15th of the same month the Physician Deficiency report will be run to identify any physicians who remain on the list with one or more delinquent records. For those who already received a 1st and 2nd Warning Letter and have not responded to attempts to get records completed or who do not have an active Action Plan approved, a 3rd and Final Suspension Letter will be issued from the President of the Medical Staff, the Chief Medical Officer, and the Chief Compliance Officer. 9. The Suspension List will be generated and distributed to Administration, President of the Medical Staff, Chief Medical Officer, the Department and Division head of the Section, Chief Nursing Officer, Directors of Nursing, Director of Patient Access, Compliance Committee members and the Performance Improvement Department. 10. The Surgical Scheduler and Patient Access staff will not schedule any elective surgical or medical admissions for any physician on the list. ... 12. Physicians will remain on suspension until all records are completed. ... 14. Any physician remaining on suspension longer than 30 days is referred to the Chief Medical Officer."

1. Interview with EMP3 on March 3, 2010, at 3:00 PM revealed, "There are 1,754 delinquent medical records as of today. That is about 15.3 percent. I'm not sure what the latest one is. I think it may be greater than a year. Upon discharge the medical record has to be completed within 30 days. The process is, they (physicians) are notified several times. If they refuse to come into compliance, we recommend suspension." When asked if any physicians have been suspended, EMP3 responded, "No, there have not been any suspensions since I have been here for the last three years. The last time suspension was recommended was in the fall. No, no one was suspended. There is a weekly report sent to the COO(chief operating officer) and the CMO(chief medical officer)."

2. A request was made to review the oldest 50 delinquent charts. Review of facility documentation revealed the most delinquent medical records were from April 17, 2008, thru July 11, 2008.

3. Interview with EMP3 on March 3, 2010, at approximately 4:00 PM confirmed the above findings and revealed "Yes they are from 2008, no, no one has been suspended. We have not pursued suspension this round."

Further interview with EMP3 revealed "Credentialing for all three campuses and policies for all three campuses are the same. The leadership is also the same. The Medical Staff informs HIM (Health Information Management) when a physician is not longer credentialed, sometimes it takes them awhile. Every Monday the system generates the auto E-mail for delinquent medical records and I get a return receipt via E-mail. The second warning letter E-mail is forwarded to Administration. The third letter was not sent because Action Plans were done. The action plan is, I speak to them (physicians) and they tell me what they are going to do to complete them." When asked if there was any documentation of this "action plan process", EMP3 responded, "No I don't have any documentation."

3) Interview with EMP4 on March 3, 2010, at approximately 4:30 PM confirmed the above findings and revealed, "No I have been in this position for about a year and no one has been suspended."

4) Review of "HIM (Health Information Management) Meeting Minutes from March 2009 thru February 2010 revealed, "HIM Department Meeting Minutes ... March 2009 ... Incomplete Records HIM will be initiating suspension for any medical staff non compliance with completion policy. Med Rec Techs (Medical Record Technicians) will distribute presuspension [sic] letters to any non-compliant medical staff."

Review of "HIM (Health Information Management) Meeting Minutes "HIM Department Meeting Minutes ... May 2009 ... Incomplete Records HIM will be initiating suspension for any medical staff non compliance with completion policy. Med Rec Techs (Medical Record Technicians) will distribute presuspension[sic] letters to any non-compliant medical staff."

Review of "HIM (Health Information Management) Meeting Minutes "HIM Department Meeting Minutes dated October 2009, and February 2010 revealed no documented evidence of incomplete medical records.