HospitalInspections.org

Cross refer to:

A0057
A0083

Based on a review of documentation, the governing body failed to appoint a chief executive officer who was responsible for managing the hospital.

Findings were:

A review of medical record deficiencies provided to the surveyors by staff #23 on 10-28-15, the following medical record deficiencies were noted:

· Staff #15 was responsible for 3 outstanding deficiencies (discharge summaries) for patients that had been discharged from the facility 42-51 days prior to 10-28-15.

· Staff #17 was responsible for 27 outstanding deficiencies (discharge summaries and progress notes) for patients that had been discharged from the facility 64-430 days prior to 10-28-15.

· Staff #18 was responsible for 16 outstanding deficiencies (discharge summaries, histories and physicals and progress notes) for patients that had been discharged from the facility 32-46 days prior to 10-28-15.

A review of QAPI meeting minutes showed no Health Information Management (to include medical record delinquencies) after the March 2015 meeting. In an interview with staff #23 on 10-28-15, staff #23 stated that he/she had been instructed by staff #25 and #26 to not submit medical record delinquency info to the QAPI nurse after the March 2015 meeting. Staff #23 stated that staff #25 and #26 said that a method of submitting the Health Information Management information to QAPI would be created (in order to combine the recently merged Health Information Management and Patient Financial Services departments). When asked if staff #23 had ever received any instructions on submitting the combined HIM/PFS to QAPI, staff #23 stated that he/she had not.

Facility policy titled "Quality Improvement Plan" states, in part:

"POLICY
2. All patient care services and other services affecting patient health and safety are evaluated."

· Review of the personnel record for the Director of Nursing (staff member # 2) revealed this employee does not currently have BCLS per their job description. In an interview on 10/27/15, staff member #2 verified they do not currently have Basic Cardiac Life Support (BCLS) certification. On 10/28/15 this employee provided documentation that they had been certified in BCLS the prior day on 10/27/15 after the surveyor noted this was required per their job description.

Facility based job description entitled, "Director of Nursing" stated in part,

"C. Licensure, Registry or Certification: Registered Nurse currently licensed by the State of Texas and BCLS required."

· Review of the personnel record for the Infection Control Nurse (staff member # 3) revealed this employee does not have a Bachelors of Science Nursing (BSN) required per the facility based job description. In an interview on 10/27/15, staff member # 1 confirmed this staff member does not have a Bachelors.

Facility based job description entitled, "Infection Prevention/Control (IPC) Program Nurse" stated in part,

"Minimum Qualification:...

Requires a current RN license with BSN required..."

Facility based job description entitled, "Licensed Vocational Nurse" stated in part,

"Licensure/Certifications:...

-BLS within 90 days of employment

-ACLS/PALS within one year of employment"

Facility based Emergency Department policy entitled, "Scope of Practice" stated in part,

"QUALIFICATIONS OF STAFF:...

· The Registered Nurse maintains a current state license as well as ACLS, PALS, TNCC and CPR certification.

· The Licensed Vocational Nurse maintains a current state license as well as CPR, ACLS, and PALS certification ..."

· Review of the personnel records for three Registered Nurse (RN) staff members # 8,9, and 10 revealed the following: 2 of the three (staff members # 8 and 10 ) did not have Pediatric Advanced Life Support (PALS) certification per facility based policy job description. 1 of the three (staff member #8) did not have Advanced Cardiac Life Support (ACLS) or Trauma Nurse Core Course (TNCC) certification per facility based policy job description.

· Review of the personnel records for three Licensed Vocational Nurses (LVN) staff members # 5, 6, and 7 revealed that 1 of the three (staff member #7) did not have documented Basic Life Support (BLS) certification from 8/2012 through 2/24/2014, per facility based job description.

· Review of the personnel records for three Licensed Vocational Nurses (LVN) staff members # 5, 6, and 7 revealed that one of the three (staff member #6 did not have Pediatric Advanced Life Support (PALS) certification per facility based policy and job description.

The above findings were confirmed on 10/28/15 in an interview with staff member # 22.

Based on a review of documentation, the governing body failed to be responsible for services furnished at the facility, regardless of whether or not they were furnished under contract.

Findings were:

During a review of credentialing files for 6 physicians (staff #15 through staff #20) that provided emergency room coverage for the facility through contract, 3 of the 6 physicians (staff #15, #17 and #18) failed to maintain current ACLS (advanced cardiac life support) certification, as required by their contract.

· Staff #15 - ACLS expired July 2015

· Staff #17 - ACLS expired September 2015

· Staff #18 - ACLS expired July 2015

A contract titled "SERVICE ORGANIZATION OF WEST TEXAS, EMERGENCY DEPARTMENT SERVICES AGREEMENT" stated, in part:

"ARTICLE IV
Physician's Obligations
4.5 Qualifications of Physician. Physician shall:
B. Become certified and maintain certification in, Advanced Cardiac Life Support (ACLS),... "

A hospital document provided to the surveyors on 10-28-15 and signed by staff #22 stated that:

· Staff #15 - (ACLS expired July 2015) Had worked 13 emergency room shifts between 8-1-15 and 10-28-15.

· Staff #17 - (ACLS expired September 2015) Had worked 4 emergency room shifts between 10-1-15 and 10-28-15.

· Staff #18 - (ACLS expired July 2051) Had worked 19 emergency room shifts between 8-1-15 and 10-28-15.

In an interview with staff #22 on 10-28-15, staff #22 verified that staff #15, #17 and #18 were all still currently providing emergency room coverage.

During a review of credentialing files for 6 physicians (staff #15 through staff #20) that provided emergency room coverage for the facility through contract, 2 of the 6 physicians (staff #16 and #17) failed to keep accurate and complete records for the Emergency Department, as required by their contract.

Documentation provided by the Health Information Management Department stated that:

· Staff #16 saw 3 emergency room patients between the dates of 5-31-14 and 7-30-14 whose charts still lacked an emergency physician's note.

· Staff #17 saw an emergency room patient on 8-25-15 whose chart still lacked an emergency physician's note.

The above findings were confirmed on 10/28/15 in an interview with staff member # 22.

Based on review of documentation and interview, the hospital failed to inform each patient whom to contact to file a grievance.

Findings were:

Review of the admission packet provided to patients included a section that covered patient rights. This did not include informing the patient and/or the patient's representative of the internal grievance process, including whom to contact to file a grievance (complaint). Nor did the facility notification of patient rights, provide the patient or the patient's representative a phone number and address for lodging a grievance with the State agency. The patient rights notification also did not inform the patient that he/she may lodge a grievance with the State agency (the State agency that has licensure survey responsibility for the hospital) directly, regardless of whether he/she has first used the hospital's grievance process.

In an interview on 10/28/15, staff member #22 confirmed that information addressing who file a grievance with was not included in the patient notification of rights provided by the facility.

Cross refer to:

A0273

Based on a review of documentation and interviews with staff, the facility failed to maintain a QAPI program that showed measurable improvement in indicators for which there is evidence that it will improve health outcomes; also failing to measure, analyze and track quality indicators and include data from all departments of the facility.

Findings were:

Documentation provided by the Health Information Management Department stated that:

· Staff #16 saw 3 emergency room patients between the dates of 5-31-14 and 7-30-14 whose charts still lacked an emergency physician's note.

· Staff #17 saw an emergency room patient on 8-25-15 whose chart still lacked an emergency physician's note.

· Staff #15 was responsible for 3 outstanding deficiencies (discharge summaries) for patients that had been discharged from the facility 42-51 days prior to 10-28-15.

· Staff #17 was responsible for 27 outstanding deficiencies (discharge summaries and progress notes) for patients that had been discharged from the facility 64-430 days prior to 10-28-15.

· Staff #18 was responsible for 16 outstanding deficiencies (discharge summaries, histories and physicals and progress notes) for patients that had been discharged from the facility 32-46 days prior to 10-28-15.

A review of QAPI meeting minutes showed no Health Information Management (to include medical record delinquencies) submitted or discussed after the March 2015 meeting. In an interview with staff #23 on 10-28-15, staff #23 stated that he/she had been instructed by staff #25 and #26 to not submit medical record delinquency info to the QAPI nurse after the March 2015 meeting, as a method of submitting the Health Information Management information to QAPI would be created (that would combine the recently merged Health Information Management and Patient Financial Services departments). When asked if staff #23 had ever received any instructions on submitting the combined HIM/PFS to QAPI, staff #23 stated that he/she had not.

Facility policy titled "Quality Improvement Plan" states, in part:

"POLICY
2. All patient care services and other services affecting patient health and safety are evaluated."

In an interview on 10/28/15, staff member #22 confirmed the above findings.

Cross refer to:

A0353

Based on a review of documentation and an interview with staff, the medical staff failed to enforce the bylaws to carry out its responsibilities.

Findings were:

A listing of current medical record deficiencies was provided to the surveyors by staff #23 on 10-28-15. The following medical record deficiencies were noted:

· Staff #15 was responsible for 3 outstanding deficiencies (discharge summaries) for patients that had been discharged from the facility 42-51 days prior to 10-28-15.

· Staff #17 was responsible for 27 outstanding deficiencies (discharge summaries and progress notes) for patients that had been discharged from the facility 64-430 days prior to 10-28-15.

· Staff #18 was responsible for 16 outstanding deficiencies (discharge summaries, histories and physicals and progress notes) for patients that had been discharged from the facility 32-46 days prior to 10-28-15.

"Hemphill County Hospital Medical Staff Bylaws" state, in part:

"ARTICLE II - MEMBERSHIP
2.5 BASIC RESPONSIBILITIES OF MEDICAL STAFF MEMBERSHIP
...
e. preparing and completing in timely fashion all medical records, including discharge summaries and history and physicals for the patient to whom the Member provides care in the Hospital...
ARTICLE IX - DISCIPLINARY PROCEDURES
9.1 AUTOMATIC SUSPENSION OR LIMITATION
...
c. MEDICAL RECORDS: All members of the Medical Staff are required to keep accurate and complete clinical records...In order to insure that incomplete charts are completed, the physicians with incomplete charts will be notified once weekly. Any physician who has outstanding incomplete charts shall not admit Patients (sic) to the Hospital until his or her records are current."

In an interview with staff #22 on 10-28-15, staff #22 confirmed that staff #15, #17 and #18 were all currently admitting patients to the facility and had not had privileges to do so suspended or curtailed in any way.

The above findings were confirmed on 10/28/15 in an interview with staff member # 22.

Cross refer to:

A0438
A0458

Based on a review of documentation and an interview with staff, the facility failed to maintain medical records that were accurately written and promptly completed.

Findings were:

Documentation provided by the Health Information Management Department stated that:

· Staff #16 saw 3 emergency room patients between the dates of 5-31-14 and 7-30-14 whose charts still lacked an emergency physician's note.

· Staff #17 saw an emergency room patient on 8-25-15 whose chart still lacked an emergency physician's note.

· Staff #15 was responsible for 3 outstanding deficiencies (discharge summaries) for patients that had been discharged from the facility 42-51 days prior to 10-28-15.

· Staff #17 was responsible for 27 outstanding deficiencies (discharge summaries and progress notes) for patients that had been discharged from the facility 64-430 days prior to 10-28-15.

· Staff #18 was responsible for 16 outstanding deficiencies (discharge summaries, histories and physicals and progress notes) for patients that had been discharged from the facility 32-46 days prior to 10-28-15.

"Hemphill County Hospital Medical Staff Bylaws" state, in part:

"ARTICLE II - MEMBERSHIP
2.5 BASIC RESPONSIBILITIES OF MEDICAL STAFF MEMBERSHIP
...
e. preparing and completing in timely fashion all medical records, including discharge summaries and history and physicals for the patient to whom the Member provides care in the Hospital..."

The above findings were confirmed on 10/28/15 in an interview with staff member # 22.

Based on a review of documentation and an interview with staff, all medical records did not show contain a history and physical conducted either no more than 30 days before or 24 hours after the patient's admission to the facility.

Findings were:

During a review of medical record deficiencies provided to the surveyors by staff #23 on 10-28-15, the following medical record deficiencies were noted:

· Staff #18 was responsible for 2 incomplete medical records that were incomplete due to a lack of a history and physical. One patient had discharged from the facility on 9-26-15 and the other on 10-1-15.

"Hemphill County Hospital Medical Staff Bylaws" state, in part:

"ARTICLE II - MEMBERSHIP
2.5 BASIC RESPONSIBILITIES OF MEDICAL STAFF MEMBERSHIP
...
e. preparing and completing in timely fashion all medical records, including discharge summaries and history and physicals for the patient to whom the Member provides care in the Hospital...
ARTICLE IX - DISCIPLINARY PROCEDURES
9.1 AUTOMATIC SUSPENSION OR LIMITATION
...
c. MEDICAL RECORDS: All members of the Medical Staff are required to keep accurate and complete clinical records...In order to insure that incomplete charts are completed, the physicians with incomplete charts will be notified once weekly. Any physician who has outstanding incomplete charts shall not admit Patients (sic) to the Hospital until his or her records are current."

In an interview with staff #22 on 10-28-15, staff #22 confirmed that staff #18 was currently admitting patients to the facility and had not had privileges to do so suspended or curtailed in any way.

The above findings were confirmed on 10/28/15 in an interview with staff member # 22.

Cross refer to:

A1112

Based on a review of documentation and interviews with staff, the facility failed to provide adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility.

Findings were:

During a review of credentialing files for 6 physicians (staff #15 through staff #20) that provided emergency room coverage for the facility through contract, 3 of the 6 physicians (staff #15, #17 and #18) failed to maintain current ACLS (advanced cardiac life support) certification, as required by their contract.

· Staff #15 - ACLS expired July 2015

· Staff #17 - ACLS expired September 2015

· Staff #18 - ACLS expired July 2015

A contract titled "SERVICE ORGANIZATION OF WEST TEXAS, EMERGENCY DEPARTMENT SERVICES AGREEMENT" stated, in part:

"ARTICLE IV
Physician's Obligations
4.5 Qualifications of Physician. Physician shall:
B. Become certified and maintain certification in, Advanced Cardiac Life Support (ACLS),... "

A hospital document provided to the surveyors on 10-28-15 and signed by staff #22 stated that:

· Staff #15 - (ACLS expired July 2015) Had worked 13 emergency room shifts between 8-1-15 and 10-28-15.

· Staff #17 - (ACLS expired September 2015) Had worked 4 emergency room shifts between 10-1-15 and 10-28-15.

· Staff #18 - (ACLS expired July 2051) Had worked 19 emergency room shifts between 8-1-15 and 10-28-15.

Facility based Emergency Department policy entitled, "Scope of Practice" stated in part,

"QUALIFICATIONS OF STAFF:...

· The Registered Nurse maintains a current state license as well as ACLS, PALS, TNCC and CPR certification.

· The Licensed Vocational Nurse maintains a current state license as well as CPR, ACLS, and PALS certification ..."

· Review of the personnel records for three Registered Nurse (RN) staff members # 8,9, and 10 revealed the following: 2 of the three (staff members # 8 and 10 ) did not have Pediatric Advanced Life Support (PALS) certification per facility based policy job description. 1 of the three (staff member #8) did not have Advanced Cardiac Life Support (ACLS) or Trauma Nurse Core Course (TNCC) certification per facility based policy job description.

· Review of the personnel records for three Licensed Vocational Nurses (LVN) staff members # 5, 6, and 7 revealed that 1 of the three (staff member #7) did not have documented Basic Life Support (BLS) certification from 8/2012 through 2/24/2014, per facility based job description.

· Review of the personnel records for three Licensed Vocational Nurses (LVN) staff members # 5, 6, and 7 revealed that one of the three (staff member #6 did not have Pediatric Advanced Life Support (PALS) certification per facility based policy and job description.

The above findings were confirmed on 10/28/15 in an interview with staff member # 22.