HospitalInspections.org

37239

Based on review of Medical Staff Rules and Regulations, Medical Staff Bylaws, Governing Body Bylaws, hospital policies/procedures, medical records, documents, and staff interviews, it was determined that the hospital failed to comply with the provisions for the Governing Body requiring accountability for the Medical Staff and quality of patient care, as demonstrated by the failure to:

(A047) require that the medical staff visit emergency and direct admit/transfer patients every 12 - 24 hours, as required by the Medical Staff Rules and Regulations and Medical Staff Bylaws, for 11 of 12 patients (#'s 3, 4, 5, 7, 8, 9, 11, 12 and 14). The failure of medical staff in delaying patients' visits posed the high risk, to health and safety for patients, that potential problem/conditions are not identified and addressed in a timely manner.

(A049) require that the medical staff is accountable for completing documentation of patients' history and physical information, interval notes (progress notes), and discharge summaries; failure to limit the use of verbal orders; failure to require medical staff documented orders for patients in restraints; and failure to require the medical staff did not document "as needed" restraint orders. This failure poses the risk for quality medical care.

The cumulative effect of these systemic deficient practices resulted in the hospital's failure to meet the requirements for the Conditions of Participation for the Governing Body.

37239

Based on review of Medical Staff Rules and Regulations, hospital policies/procedures, medical records, documents, and staff interviews, it was determined that the hospital failed to comply with protecting and promoting each patients' rights, as evidenced by failure to:

(A117) inform patient's or patient's representative of patients rights in advance of providing care. This failure poses the risk that all patients/representatives are not ensured that they have the information necessary to exercise their rights.

(A165) require staff utilize the least restrictive intervention for 1 of 1 patient was effective to ensure the patient was safe prior to utilizing restraints (Patient #3). This failure poses high risk for patient injury when least restrictive interventions are not attempted.

(A169) require restraint orders were not written on an as needed basis for 1 of 1 patient. This failure poses a high risk to patients for unnecessary restraints and potential harm (Patient #3).

(A174) require that for 1 of 1 patient's in restraints staff discontinued the restraints at the earliest time possible (Patient #3). This failure poses a high health and safety risk for patients being restrained beyond the physician's order end times.

(A187) require staff documentation warranted the use of restraints for 1 of 1 patients. This failure poses the risk that patients are restrained without reason (Patient #3).

(A188) require medical staff documentation warranted the continued use of restraints. This failure poses the risk that patients are maintained in restraints without reason (Patient #3).

The cumulative effect of these systemic deficient practices resulted in the hospital's failure to meet the requirements for the Conditions of Participation for Patient Rights.

37239

Based on review of Governing Body Bylaws, Medical Staff Rules and Regulations, hospital policies/procedures, medical records, documents, and staff interviews, it was determined that the hospital failed to require the organized medical staff was responsible for the quality of patient care and operated in accordance with the bylaws, as demonstrated by the failure to:

(A356) require the medical staff limited the use of verbal/telephone (oral) orders for 13 of 13 medical records (Patient #'s 3 through 14, and #16). This deficient practice poses the risk of miscommunication of orders and resulting errors/patient harm.

(A358) require that the medical staff was accountable for completing the patients' medical history and physical within 24 hours after admission to the hospital for 8 of 8 medical records (Patient #'s 3, 4, 7, 8, 9, 11, 13 and 14). This failure poses the risk to health and safety for lack of continuity of care between physicians.

The cumulative effect of these systemic deficient practices resulted in the hospital's failure to meet the requirements for the Conditions of Participation for Medical Staff.

Based on review of Governing Body Bylaws, Medical Staff Rules and Regulations, hospital policies/procedures, medical records, documents, and staff interviews, it was determined that the hospital failed to require that staff providing medical record services were responsible to maintain complete medical records for each patient, as demonstrated by the failure to:

(A449) maintain medical records that justify a patients' admission and continued hospitalization through documented physician progress notes for 11 of 11 medical records (Patient #'s 3, 4, 5, 7, 8, 9, 10, 11, 12, 13 and 14). This failure poses a risk to patient health and safety in that the patients' assessments, response to interventions and progress are not documented to ensure continuity of care.

(A454) require that all verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner for 8 of 8 medical records reviewed for authentication (Patient #'s 3, 4, 7, 8, 9, 11, 14 and 16) and 7 of 7 physicians reviewed for compliance with medical records that were not authenticated within 48 hours (Physician #'s 3, 5, 13, 14, 15, 17 and 18). This failure poses a high risk for error when the medical record does not confirm the validity of physicians' orders.

(A458) maintain a medical record that contains a history and physical be in the medical record no more than 24 hours after admission for 8 of 8 patients (Patient #'s 3, 4, 7, 8, 9, 11, 13 and 14), and for 5 of 5 physicians reviewed for medical record documentation (Physician #'s 5, 8, 9, 10, and 17). This failure poses the risk that the medical record will not verify that patients received appropriate continuity of care.

(A464) require the medical records contained medical staff dictated/documented consultative evaluations, procedures/operations and findings at the time of service for 3 of 3 speciality physicians (Physician #'s 3, 15, and 18). This failure poses the health and safety risk to patients for lack of documentation for continuity of care.

(A468) require 11 of 11 discharged patients' medical records (Patient #'s 3, 4, 5, 7, 8, 9, 10, 11, 12,13, and 14) contained physicians dictated/recorded Discharge Summaries. This failure poses a risk to patient health and safety when the receiving facility and/or referral physician is/are not informed of the care provided and outcomes of the patient's hospitalization in order to ensure continuity of care.

The cumulative effect of these systemic deficient practices resulted in the hospital's failure to meet the requirements for the Conditions of Participation for the Medical Records Services.

Based on review of the Governing Body Bylaws, Medical Staff Rules and Regulations, medical records, and staff interviews, it was determined that the governing authority failed to require that the medical staff visit patients as required by the Medical Staff Rules and Regulations, for 11 of 12 patients (#'s 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, and 14). This deficient practice posed the high risk of health and safety to patients that problem conditions are not identified and addressed in a timely manner when the medical staff delay patient visits, as demonstrated by the failure of the medical staff to:

1. visit emergency patient admits within 12 hours of admission to the general care area;

2. visit direct patient admits or transfers from other facilities within 24 hours; and

3. visit patients admitted to Medical/Surgical, Telemetry and Intensive Care Units (ICU) at least every 24 hours.

Findings include:

The Governing Body Bylaws, last revised 4/27/2016, requires: "...Governing Body Responsibility...the Governing Body shall conduct a review and evaluation of activities on a continuing basis to assess, preserve, and improve the overall quality and efficiency of patient care in the Hospital...provide...support and facilitate...the ongoing operation...of quality of patient care...."

The Medical Staff Rules and Regulations, last revised 9/24/2014, requires: "...Section 1, Admission of Patients, 1.4...attending...must see patient with in time frames provided...1.4.1. Emergency Admits...directly from the emergency department into the general care or observation area: within 12 hours...1.4.2. Direct Admits: admission or transfer from another facility: within 24 hours...1.5. Visitation Requirements... attending... must see the patient within the time frames provided or shorter...1.5.1. Med/Surg, Telemetry, Intensive Care Unit: each patient will be evaluated by a physician at least every 24 hours...."

1. There was no evidence to verify that the physicians visited ED patients within 12 hours of admission to the inpatient unit:

Patient #4: admitted 6/06/2016, rhabdomyolysis
Patient #7: admitted 6/06/2016, limb cellulitis
Patient #9: admitted 6/07/2016, cholelithiasis
Patient #10: admitted 6/07/2016, diabetes, alcohol intoxication
Patient #11: admitted 6/07/2016, hip fracture
Patient #12: admitted 6/06/2016, chest pain
Patient #14: admitted 5/27/2016, pancreatitis, alcohol intoxicated

2. There was no evidence to verify that the physicians visited patients (admitted and transferred from other facilities) within 24 hours of admission to the inpatient unit:

Patient #3: admitted 5/27/2016, seizures, alcohol intoxication
Patient #5: admitted 6/08/2016, hip fracture
Patient #8: admitted 5/31/2016, pancreatitis, alcohol induced
Patient #13: admitted 6/06/2016, congestive heart failure

3. There was no evidence to verify that the physician visited patients in the inpatient unit every 24 hours:

Patient #3: admitted 5/27/2016, as stated
Patient #4: admitted 6/06/2016, as stated
Patient #5: admitted 6/08/2016, as stated
Patient #7: admitted 6/06/2016, as stated
Patient #8: admitted 5/31/2016, as stated
Patient #9: admitted 6/07/2016, as stated
Patient #10: admitted 6/07/2016, as stated
Patient #11: admitted 6/07/2016, as stated
Patient #12: admitted 6/06/2016, as stated
Patient #13: admitted 6/06/2016, as stated
Patient #14: admitted 5/27/2016. as stated

Based on review of the Governing Body Bylaws, Medical Staff Rules and Regulations, Bylaws of the Medical Staff, policy and procedure, medical records, and staff interviews, it was determined that the governing authority failed to require medical staff accountability. These deficient practices pose a risk to patient health and safety when patients' assessments, response to treatment, discharge goals are not documented to ensure continuity of care, patient rights are violated when there is no documentation of physician orders for restraints, and visitation every 24 hours for 1 of 1 patient in restraints, as demonstrated by the medical staff's failure for:

1. documenting patients' history and physical information (8 of 11 medical records), interval notes/progress notes (11 of 11 medical records), and discharge summaries (11 of 11 medical records) within the 12 - 24 hour timeframes required by Medical Staff Rules and Regulations,

2. excessive use of verbal orders in 13 of 13 medical records, with 1,230 of 1,488 total physician orders (82.7%) being verbal,

3. one of 1 patients restrained without orders (Patient #3),

4. one of 1 patients restrained on a "as needed" order (Patient #3),

5. visitation every 24 hours for 1 of 1 patient in restraints (Patient #3).

Findings include:

1. Medical Staff Rules and Regulations, last revised 9/24/2014, requires: "...7.2 History and Physical Examination...shall be dictated/documented by the attending physician...and filed into the patient's medical record within 24 hours of patient's admission for the following...inpatients...7.7 Progress Notes...recorded at the time of observation...to permit continuity of care and transferability...must be recorded daily...7.1.14 Discharge summary...must recapitulate...the reason for admission, pertinent physical findings...laboratory test...operative/special procedures and the findings...treatment...condition on discharge and prognosis, plan for future management and follow-up care, instructions to the patient...7.8.1 Discharge Summary...must be recorded for all patients by the attending physician...."

Hospital policy titled Dictation and Transcription, reference #HIMS_220 (last revised 03/2016) requires: "...History and Physical dictation is to be completed by the attending physician within 24 hours of admission...Discharge Summaries...dictated by the attending physician at the time of discharge...."

The medical staff failed to document/dictate the following:

Patients' history and physical information within 24 hours of admission for 8 of 11 medical records (Patients #3, 4, 7, 8, 9, 11, 13, and 14);

Progress notes (interval notes) daily for 11 of 11 medical records (Patients #3, 4, 5, 7, 8, 9, 10, 11, 12, 13, and 14)

Discharge Summaries for 11 of 11 medical records (Patient #'s 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, and 14).

Director of Health Information Management Services (HIMS) #6 confirmed during interview 6/13/2016 at 1500 that physicians did not dictate/record in the medical records as described for patients #3, #4, #5, #7 through #14.

2. The Medical Staff Rules and Regulations requires: "...6.3.3. Verbal/telephone orders should be used only to meet the care needs of a patient and should be limited to those situations in which it is impossible or impractical...to write the order...."

The hospital policy titled Verbal and Telephone Orders - General, 2403 PolicyStat ID #2528261 (last revised 6/16) requires, "...Verbal/telephone orders are utilized infrequently...should only be used...limited to those situation in which it is impossible or impractical for the prescribing practitioner to write the order...it is the policy...not to allow...for the purposes of medical staff practitioners' convenience...."

The Director of HIMS provided the All Orders Report - Summary dated 6/09/16 and confirmed during an interview conducted 6/09/16, that the Summary verified physicians' verbal orders in the medical records (#3 through #14, and #16). The Summary revealed that 1,230 of 1,488 (82.7%) orders were verbal/phone.

3. Hospital policy titled Restraints, 1228, PolicyStat ID #2237271 (last revised 4/2008) requires: "...Restraint orders will be re-written at a maximum of every 24 hours...should a verbal order be obtained this order must be countersigned...within a 24 hour timeframe...."

The Director of HIMS (#6) confirmed during an interview conducted 6/09/2016 that Patient #3 was in restraints with no physician orders, as follows:

5/28/2016 @ 0100 through 5/28/2016 @ 0500,
5/30/2016 @ 0005 through 5/30/2016 @ 0755,
5/31/2016 @ 0755 through 5/31/2016 @ 1926,
6/03/2016 @ 0134 through 6/03/2016 @ 2000.

The physician ordered the restraints be discontinued on 6/03/2016 @ 0526; however, the patient remained in restraints for an additional 12.5 hours with no order.

4. Hospital policy titled Restraints, 1228, PolicyStat ID: #2237271 (last revised 4/2008) requires: "...any order for restraint will not be written on a PRN (as needed)...basis...." was followed by medical staff.

Patient #3's medical record confirmed the following physician orders:

05/28/2016 at 1500: "...Medical Restraint...frequency...AS NEEDED...."
5/28/2016 at 2253: "...Medical Restraint...Start time: 5/29/2016...0005...frequency...AS NEEDED...."

The Director of HIMS #6, the Director of Quality and Performance Improvement RN #5, Inpatient Charge RN #33, and Inpatient/ICU RN #34, all confirmed during interviews conducted on 6/09/2016, that the physician's restraint orders were documented "AS NEEDED".

5. The Medical Staff Rules and Regulations, last revised 9/24/2014, requires: "...Visitation Requirements...attending...must see the patient within the time frames provided or shorter...1.5.1. Med/Surg, Telemetry, Intensive Care Unit: each patient will be evaluated by a physician at least every 24 hours...."

Patient #3 was received in transfer and admitted directly to the Intensive Care Unit (ICU) on 5/27/16 at 0025 in delirium tremor seizures secondary to alcohol intoxication, according to physician's History and Physical dated 6/02/2016.

There was no evidence to verify that the physician visited Patient #3 every 24 hours to evaluate the need for restraints, as required.

Director of HIMS #6 confirmed during medical record review with the surveyors conducted on 6/13/2016, that the physician failed to dictate/document every 24 hour visits.

37239

Based on observation on tour, review of hospital postings, and staff interviews, the hospital failed to conspicuously post patient rights and patients were not informed of their rights during admission. This deficient practice poses a risk that patients would not be aware of their rights to appropriate care, treatment, and services.

Findings include:

Patient Rights were not posted/observed in any areas of the hospital during multiple tours conducted 6/7/2016 through 6/17/2016.

Director of Quality and Performance Improvement RN #5 and Registration Representative #17 both indicated during interviews on 6/07/2016, and Registration Representative #38 indicated during an interview on 6/08/2016, that the hospital lobby postings titled "It's the Law" and "Notice of Privacy Practices", reflected the patient rights.

The surveyors confirmed that the lobby postings titled "It's the Law" and "Notice of Privacy Practices" do not identify patient rights, as required and described in the hospital's policy titled Patient Rights and Responsibilities, 1011 PolicyStat IC: 1683891, last approved 7/2015, as follows (in part): "...Patient's right to:...become informed for his or her rights...exercise these rights...considerate and respectful care...remain free from seclusion or restraints...receive information from his/her physician about his/her illness...participate in the development and implementation his or her plan of care...."

The hospital policy titled Patient Registration, Reg-100, PolicyStat ID: 1604019, last revised 4/2015, requires: "...Registrar will...make the patient's (admission) packet by attaching...Conditions of Admission form, Advanced Directive form (for non-minor patients only), the Patient Rights and the Notice of Privacy Practices pamphlets...."

The hospital admission form, filed in the patients' records, titled Conditions of Admission and Authorization for Medical Treatment (undated) requires: "...I (patient) have been provided with a copy of the...Patient Rights and Responsibilities...." The form includes a "box" that requires the patient to initial confirming that the patient received these rights.

Director of HIMS #6 provided a copy of the Your Rights as a Hospital Patient, 2 page tri-fold document, during an interview conducted on 6/09/2016. Page 2 of the tri-fold revealed a page that was difficult to read, print in small font with no spacing between words. The Director of HIMS #6 indicated "I didn't know they (registration personnel) didn't have them (tri-folds) and no longer gave them out (to patients)".

Registration Representative #17 indicated: "...The Notice of Privacy Practices form (filed in the patients' records)...is the patient rights...we don't give them a pamphlet or booklet...never have since I've been here...." The surveyors observed that the forms included in the admission packet, provided by Registration Representative #17 on 06/8/2016, containing the Conditions of Admission and Authorization for Medical Treatment, Advance Directives Screening Form, Notice of Privacy Practices, and Emergency Room Registration Form, do not include patient rights.

Seventeen of 17 patient records #2 through #13, #16, #37, #39, #48, and #49 revealed that the patients marked the "box" to indicate they received a copy of their patient rights, however, the hospital cannot provide evidence to confirm that the rights the patients received met the requirements as defined.

Patient #3 confirmed during interview on 6/08/2016, that the hospital did not provide a written copy of patient rights.

Patient #37 confirmed during interview on 6/08/2016, that the hospital did not provide a written copy of patient rights.

Patient #39 and family at bedside confirmed during interviews on 6/09/2016, that the hospital did not provide a written copy of patient rights.

The hospital failed to provide Patient Rights to patients.

Based on review of policy and procedure, patient medical records, and staff interviews, it was determined that the hospital failed to require that 1 of 1 patient was not restrained when no imminent harm to self or others was evident (Patient #3). This deficient practice violated the patient's rights.

Findings include:

Hospital policies/procedures require the following:

Patient Rights and Responsibilities, 1011, PolicyStat ID: 1683891 last revised 1/2006, requires: "...patient's right to...remain free from...restraints of any form that are not medically necessary or are used as a means of...convenience...."

Restraints, 1228, PolicyStat ID: 2237271, last revised 4/2008 (staff verified policy currently active), requires: "...Patients have the right to be free from restraints that are not medically necessary or are used for other than patient benefit and safety...."

Patient #3 was received in transfer and admitted directly to the Intensive Care Unit (ICU) on 5/27/16 at 0025 in delirium tremor seizures secondary to alcohol intoxication, according to physician's History and Physical dated 6/02/2016.

The Patient Assessment Report XRestraint Assessment in Patient #3's medical record, confirmed the clinical staff's documentation of the patient's behavior while in restraints, as "asleep", "calm", or "awake" as follows:

5/27/2016 @0230 through 5/27/2016 @1815,
5/29/2016 @0001 through 5/29/2016 @0800,
5/29/2016 @2000 through 5/30/2016 @0001,
5/30/2016 @0200 through 5/30/2016 @0600,
5/30/2016 @2000 through 5/31/2016 @0600,
6/02/2016 @0200 through 6/02/2016 @0400,
6/03/2016 @1000 through 6/03/2016 @1200,
6/03/2016 @1400 through 6/03/2016 @2000.

Director of HIMS #6 confirmed in interview on 6/13/2016 that Patient #3 was in restraints continuously with no documentation to verify that the patient was in eminent harm to self or others, during the dates and times identified above.

37239

Based on hospital policy and procedure, medical records, and staff interviews, it was determined that the hospital failed to require one of 1 patient was not restrained according to the physician's "as needed" orders (Patient #3). This deficient practice violated the patient's rights to be free of restraints unless deemed by the physician as appropriate.

Findings include:

The hospital policy titled Restraints, 1228, PolicyStat ID: #2237271 (last revised 4/2008) requires: "...any order for restraint will not be written on a PRN (as needed)...basis...."

Patient #3's medical record confirmed the following physician orders:

05/28/2016 at 1500: "...Medical Restraint...frequency...AS NEEDED...."
5/28/2016 at 2253: "...Medical Restraint...Start time: 5/29/2016...0005...frequency...AS NEEDED...."

The Director of HIMS #6, the Director of Quality and Performance Improvement RN #5, Inpatient Charge RN #33, and Inpatient/ICU RN #34, all confirmed during interviews conducted on 6/09/2016, that the physician documented restraints "AS NEEDED". The Director of HIMS #6 further confirmed that the nursing staff placed Patient #3 in continuous restraints from 5/28/2016 at 1500 to 5/30/2016 at 0755, according to the physician's order for "as needed" restraints, in violation of hospital policy.

37239

Based on review of hospital polices/procedures, medical records, and staff interviews, it was determined the hospital failed to require the patient received care based on current physician orders for one of 1 patients in restraints (Patient #3). This deficient practice poses a risk of injury or harm, when a patient's restraints are continued past the physician's order to discontinue the restraints.

Findings include:

The hospital policy titled Restraints, 1228, PolicyStat ID #2237271 (last revised 4/2008) requires: "...be ended at the earliest possible time...."

The Director of HIMS (#6) confirmed during an interview conducted 6/09/2016 that Patient #3 remained in restraints past the physician's order to discontinue written on 6/03/2016 @ 0526. Patient was in restraints 6/03/2016 till 1200, and 6/03/2016 @ 1400 to 2000.

Based on policy and procedure, medical records, and staff interviews, it was determined that the hospital failed to require one of 1 patient in restraints (Patient #3) was not restrained when no condition or symptom warranted the use of restraints. This deficient practice violated the patient's rights to not be be unreasonably restrained.

Findings include:

Hospital policies/procedures require the following:

Patient Rights and Responsibilities, 1011, PolicyStat ID: 1683891 last revised 1/2006, requires: "...patient's right to...remain free from...restraints of any form that are not medically necessary or are used as a means of...convenience...."

Restraints, 1228, PolicyStat ID: 2237271, last revised 4/2008 (staff verified policy currently active), requires: "...Patients have the right to be free from restraints that are not medically necessary or are used for other than patient benefit and safety...."

Patient #3 was received in transfer and admitted directly to the Intensive Care Unit (ICU) on 5/27/16 at 0025 in delirium tremor seizures secondary to alcohol intoxication, according to physician's History and Physical dated 6/02/2016.

The Patient Assessment Report XRestraint Assessment in Patient #3's medical record, confirmed the nursing staff's documentation of the patient's behavior while in restraints, as "asleep", "calm", or "awake" as follows:

5/27/2016 @0230 through 5/27/2016 @1815,
5/29/2016 @0001 through 5/29/2016 @0800,
5/29/2016 @2000 through 5/30/2016 @0001,
5/30/2016 @0200 through 5/30/2016 @0600,
5/30/2016 @2000 through 5/31/2016 @0600,
6/02/2016 @0200 through 6/02/2016 @0400,
6/03/2016 @1000 through 6/03/2016 @1200,
6/03/2016 @1400 through 6/03/2016 @2000.

Director of HIMS #6 confirmed in interview on 6/13/2016 that Patient #3 was in restraints continuously with no documentation to verify, from physicians or nursing personnel, that the patient was in eminent harm to self or others, during the dates and times identified above, thus violating the patient's rights to be free from restraints when not medically necessary and warranted.

Based on review of Medical Staff Rules and Regulations, policy and procedure, medical records, and staff interviews, it was determined that the hospital failed to require that the physicians visited the patient and documented the continual need for restraints for one of 1 patient in restraints (Patients #3) to include what interventions were used and failed. This deficient practice violated the patient's rights to be free of restraints when not indicated.

Findings include:

Medical Staff Rules and Regulations, last revised 9/24/2014, requires: "... shall be dictated/documented by the attending physician...7.7 Progress Notes...recorded at the time of observation...to permit continuity of care...must be recorded daily...."

Patient Rights and Responsibilities, 1011, PolicyStat ID: 1683891 last revised 1/2006, requires: "...patient's right to...remain free from...restraints of any form that are not medically necessary or are used as a means of...convenience...."

Restraints, 1228, PolicyStat ID: 2237271, last revised 4/2008 (staff verified policy currently active), requires: "...Patients have the right to be free from restraints that are not medically necessary or are used for other than patient benefit and safety...Selected only when other less restrictive measures have been found to be ineffective to protect the patient or others from harm...and documentation that other, less restrictive measures have been found to be ineffective...."

Director of HIMS #6 confirmed in interview on 6/13/2016 that the Patient Assessment Report XRestraint Assessment (from nursing personnel) for Patient #3 confirmed that the patient was in restraints continuously with no documentation from the physician, to verify that the patient was in eminent harm to self or others and/or what interventions had been tried and failed during the dates and times the patient was restrained.

Nursing documentation of the patient's behavior while in restraints was "asleep", "calm", or "awake" as follows:

5/27/2016 @0230 through 5/27/2016 @1815,
5/29/2016 @0001 through 5/29/2016 @0800,
5/29/2016 @2000 through 5/30/2016 @0001,
5/30/2016 @0200 through 5/30/2016 @0600,
5/30/2016 @2000 through 5/31/2016 @0600,
6/02/2016 @0200 through 6/02/2016 @0400,
6/03/2016 @1000 through 6/03/2016 @1200,
6/03/2016 @1400 through 6/03/2016 @2000.

Physicians failed to document daily responses to interventions attempted that warranted the continual use of restraints for Patient #3 from 5/27/2016 through 6/03/2016.

Based on review of the hospital's Medical Staff Rules and Regulations, policies, documents, medical records, and staff interviews, it was determined that the hospital failed to require the medical staff limited the use of verbal/telephone (oral) orders, for thirteen of 13 medical records (Patient #'s 3 through 14, and #16). This deficient practice poses the risk of miscommunication of orders and resulting errors/patient harm.

Findings include:

The Medical Staff Rules and Regulations requires: "...6.3.3. Verbal/telephone orders should be used only to meet the care needs of a patient and should be limited to those situations in which it is impossible or impractical...to write the order...."

The hospital policy titled Verbal and Telephone Orders - General, 2403 PolicyStat ID #2528261 (last revised 6/16) requires: "...Verbal/telephone orders are utilized infrequently...should only be used...limited to those situation in which it is impossible or impractical for the prescribing practitioner to write the order...it is the policy...not to allow...for the purposes of medical staff practitioners' convenience...."

The Director of HIMS provided the All Orders Report - Summary and confirmed during an interview conducted 6/09/2016, physicians' verbal orders as follows:

Patient #3: 302 of 315 (302/315) orders were verbal (95.8%): 5/27/2016 through 6/8/2016,

Patient #4: 64/83 (77.1%): 6/05/2016 through 6/09/2016,

Patient #5: 28/31 (90.3%): 6/07/2016 through 6/09/2016,

Patient #6: 48/60 (80%): 6/08/2016 through 6/09/2016,

Patient #7: 24/31 (77.4%): 6/08/2016 through 6/09/2016,

Patient #8: 145/214 (67.7%): 5/30/2016 through 6/09/2016,

Patient #9: 73/94 (77.7%): 6/06/2016 through 6/09/2016,

Patient #10: 37/37 (100%): 6/07/2016 through 6/09/2016,

Patient #11: 75/96 (78.1%): 6/06/2016 through 6/09/2016,

Patient #12: 19/24 (79.2%): 6/07/2016 through 6/09/2016,

Patient #13: 97/126 (77%): 6/06/2016 thought 6/09/2016,

Patient #14: 228/287 (79.4%): 5/27/2016 through 6/09/2016,

Patient #16: 138/150 (92%): 6/07/2016 through 6/09/2016.

The above 12 medical records confirmed that a total of 1230 of 1488 physican orders were verbal for an average of 82.7%.

Based on review of Medical Staff Rules and Regulations, policy and procedure, medical records, and staff interviews, it was determined that the Medical Staff failed to follow Rules and Regulations for required time frames for documenting patients' history and physical information. This deficient practice poses a risk to patient health and safety in that the patients' assessments are not documented to ensure continuity of care, as demonstrated by the failure of the medical staff to dictate/document patients' history and physical information within 24 hours of admission for 8 of 11 medical records (Patients #3, 4, 7, 8, 9, 11, 13, and 14).

Findings include:

Medical Staff Rules and Regulations, last revised 9/24/2014, requires: "...7.2 History and Physical Examination...shall be dictated/documented by the attending physician...and filed into the patient's medical record within 24 hours of patient's admission for the..."

Hospital policy titled Dictation and Transcription, reference #HIMS_220, (last revised 03/2016) requires: "...History and Physical dictation is to be completed by the attending physician within 24 hours of admission...."

Director of HIMS #6 confirmed during medical record reviews with the surveyors conducted on 6/13/2016, that the physicians failed to dictate/document patients' History and Physical within 24 hours of admission, as follows:

Patient #3 - admission 5/27/2016,
Patient #4 - admission 6/06/2016,
Patient #7 - admission 6/06/2016,
Patient #8 - admission 5/31/2016,
Patient #9 - admission 6/07/2016,
Patient #11 - admission 6/07/2016,
Patient #13 - admission 6/06/2016,
Patient #14 - admission 5/27/2016.

Physicians did not complete medical record dictation/documentation within 24 hours of patients' admissions, as the Medical Staff Rules and Regulations require.

Based on review of hospital polices/procedures, medical records, and staff interviews, it was determined that the hospital failed to require the nursing staff planned patient care according to physician orders for 1 of 1 patients in restraints (Patient #3). This deficient practice poses a risk of injury and/or harm to patients in restraints without physician direction (orders).

Findings include:

The hospital policy titled Restraints, 1228, PolicyStat ID #2237271 (last revised 4/2008) requires: "...Restraint orders will be re-written at a maximum of every 24 hours...."

Patient #3 was received in transfer and admitted directly to the Intensive Care Unit (ICU) on 5/27/16 at 0025 in delirium tremor seizures secondary to alcohol intoxication, according to physician's History and Physical dated 6/02/2016.

The Director of HIMS (#6) confirmed during an interview conducted 6/09/2016 that the patient was in restraints with no physician orders, as follows:

5/28/2016 @ 0100 through 5/28/2016 @ 0500,
5/30/2016 @ 0005 through 5/30/2016 @ 0755,
5/31/2016 @ 0755 through 5/31/2016 @ 1926,
6/03/2016 @ 0134 through 6/03/2016 @ 2000.

The physician ordered the restraints be discontinued on 6/03/2016 @ 0526; however, the nursing staff maintained the patient in restraints for an additional 12.5 hours with no physician order.

Based on review of Medical Staff Rules and Regulations, policy and procedure, medical records, and staff interviews, it was determined that the staff providing Medical Record Services failed to require that medical records contained medical staff documentation of patients' progress and response to medications and services for 11 of 11 medical records (Patient #'s 3, 4, 5, 7, 8, 9, 10, 11, 12, 13 and 14). This deficient practice poses a risk to patient health and safety if the medical records do not confirm patients' progress/response to interventions to ensure continuity of care.

Findings include:

Medical Staff Rules and Regulations, last revised 9/24/2014, requires: "...7.7 Progress Notes...recorded at the time of observation...to permit continuity of care and transferability...must be recorded daily...."

Director of HIMS #6 confirmed no physicians' progress notes were recorded daily, during medical record reviews conducted with the surveyors on 6/13/2016 as follows:

Patient #3: admitted 5/27/2016. No notes 5/27/2016 to 6/03/2016,

Patient #4: admitted 6/06/2016. Transferred to a higher level of care 6/10/2016. No notes 6/06/2016 to 6/10/2016,

Patient #5: admitted 6/08/2016. Discharged 6/11/2016. One progress note dictated on 6/13/2016.

Patient #7: admitted 6/06/2016. Discharged to a skilled nursing facility on 6/15/2016. No notes 6/06/2016 to 6/08/2016, and 6/10/2016 to 6/13/2016,

Patient #8: admitted 5/31/2016. No notes 5/31/2016 to 6/03/2016,

Patient #9: admitted 6/07/2016. No notes 6/07/2016 to 6/08/2016,

Patient #10: admitted 6/08/2016. No notes 6/09/2016 to 6/11/2016,

Patient #11: admitted 6/07/2016. No notes 6/07/2016 to 6/09/2016. Progress notes dated 6/10/2016 and 6/11/2016 were dictated on 6/12/2016,

Patient #12: admitted 6/06/2016. No notes 6/06/2016 to 6/08/2016, and 6/10/2016,

Patient #13: admitted 6/06/2016. No notes 6/06/2016 to 6/08/2016, and 6/10/2016 to 6/11/2016,

Patient #14: admitted 5/27/2016. No notes 5/27/2016 to 6/4/2016, 6/8/2016, and 6/10/2016 to 6/12/2016.

Medical records failed to include physicians' dictated/documented daily progress notes for 11 of 11 medical records (Patients #3, 4, 5, 7, 8, 9, 10, 11, 12, 13, and 14).

Based on review of Medical Staff Rules and Regulations, policies, medical records, hospital documents and staff interviews, it was determined that the staff providing Medical Records Service failed to require medical records contained physician order authentication for eight of 8 records reviewed for authentication (Patient #'s 3, 4, 7, 8, 9, 11, 14 and 16) and seven of 7 physicians reviewed for compliance with medical records that were not authenticated within 48 hours (Physician #'s 3, 5, 13, 14, 15, 17 and 18). This deficient practice poses the risk for error when the medical record does not confirm the validity of physicians' orders.

Findings include:

The Medical Staff Rules and Regulations requires: "...6.3.3...verbal/telephone orders shall be authenticated by the ordering practitioner...no longer than 48 hours after the order was communicated...."

The hospital policy titled Verbal and Telephone Orders - General, 2401 PolicyStat #2528261 (last revised 6/2016) requires: "...Prescribing practitioner...must authenticate the written record of the verbal/telephone order as soon as...possible...no later than 48 hours after the order was communicated...."

The hospital's All Orders Report Summary confirmed unauthenticated physician orders and/or physician orders authenticated greater than 48 hours after the order was communicated, as follows:

Patient #3: 168 unauthenticated orders, 38 orders signed greater than 48 hours, 5/27/2016 to 6/09/16,

Patient #4: 7 unauthenticated orders, 6/05/2016 to 6/09/16,

Patient #7: 6 unauthenticated orders, 6/08/2016 to 6/09/2016,

Patient #8: 97 unauthenticated orders, 7 orders signed greater than 48 hours, 5/30/2016 to 6/09/2016,

Patient #9: 10 unauthenticated orders, 6/06/2016 to 6/09/2016,

Patient #11: 9 unauthenticated orders, 6/06/2016 to 6/06/2016,

Patient #14: 131 unauthenticated orders, 4 orders signed greater than 48 hours, 5/27/2016
to 6/09/2016,

Patient #16: 16 unauthenticated orders, 6/07/2016 to 6/09/2016.

The hospital's document "Unresolved Deficiencies by Responsibility Discharge Date 30 - 120 Days Deficient" as of 6/15/16 confirmed:

Physician #3 - Cardiologist: 2 orders signed greater than 48 hours, 2 unauthenticated orders 6/06/2016 to 6/09/2016,

Physician #5 - Physician Emergency Medicine: 230 orders signed greater than 48 hours 2/16/2016 to 5/16/2016,

Physician #13 - Doctor of Osteopathy: 1 consent signed greater than 48 hours, 5/07/2016,

Physician #14 - Physician Internal Medicine: 12 unauthenticated orders, 27 orders authenticated greater than 48 hours, 5/29/2016 to 6/08/2016,

Physician #15 - Physician Orthopedic Medicine: 4 unauthenticated orders, 1 order signed greater than 48 hours, 6/08/2016,

Physician #17 - Physician Emergency Medicine: 6 unauthenticated orders 5/04/2016 to 5/13/2016,

Physician #18 - Physician Internal Medicine: 2 unauthenticated consents, 46 orders signed greater than 48 hours 2/20/2016 to 6/15/2016, 406 orders unauthenticated 5/27/2016 to 6/15/2016.

The Director of HIMS #6 confirmed during an interview conducted on 6/15/2016 that the medical records did not contain physician's authentication as required by policy and rules and regulations.

Based on review of Medical Staff Rules and Regulations, policies, medical records, hospital documents and staff interviews, it was determined that the staff providing Medical Records Service failed to require that the medical staff completed a history and physical for 8 of 8 patients no greater than 24 hours after the patient was registered or admitted (Patient #'s 3, 4, 7, 8, 9, 11, 13 and 14), and for 5 of 5 physicians reviewed for medical record documentation no greater than 24 hours (Physician #'s 5, 8, 9, 10, and 17). This deficient practice poses the risk that the medical record will not verify that patients received appropriate continuity of care.

Findings include:

Medical Staff Rules and Regulations, last revised 9/24/2014, requires: "...7.2 History and Physical Examination...shall be dictated/documented by the attending physician...and filed into the patient's medical record within 24 hours of patient's admission for the following...inpatients...."

Hospital policy titled Dictation and Transcription, reference #HIMS_220 (last revised 03/2016) requires: "...History and Physical dictation is to be completed by the attending physician within 24 hours of admission...."

Hospital documents titled Unresolved Deficiencies by Responsibility Discharge Date 0-30 Days and Unresolved Deficiencies by Responsibility Discharge Date 30 - 120 Days Deficient - as of 6/15/16 confirmed the medical records were incomplete as follows:

Physician #5 - Physician Emergency Medicine: 2 incomplete initial history examination (hpi/exam) within 24 hours,

Physician #8 - Physician Emergency Medicine: 47 incomplete hpi/exam 3/09/2016 to 4/03/2016,

Physician #9 - Physician Emergency Medicine: 12 incomplete hpi/exam 2/18/2016 to 6/15/2016,

Physician #10 - Physician Emergency Medicine: 2 incomplete hpi/exam 2/18/2016 to 6/15/2016,

Physician #17 - Physician Emergency Medicine: 1 incomplete hpi/exam 5/14/2016

Medical records did not include physicians dictated/documented patients' History and Physical within 24 hours of admission for patient records that the surveyors reviewed 6/07/2016 through 6/17/2016 as follows:

Patient #3 - admission 5/27/2016,
Patient #4 - admission 6/06/2016,
Patient #7 - admission 6/06/2016,
Patient #8 - admission 5/31/2016,
Patient #9 - admission 6/07/2016,
Patient #11 - admission 6/07/2016,
Patient #13 - admission 6/06/2016,
Patient #14 - admission 5/27/2016.

The Director of HIMS #6 confirmed during an interview conducted on 6/15/2016, that the medical records did not medical records confirm that the medical staff completed a history and physical no greater than 24 hours after the patient was registered or admitted.

Based on review of Medical Staff Rules and Regulations, policies, medical records, hospital documents and staff interviews, it was determined that the staff providing Medical Records Service failed to require that medical records contained medical staff dictated/documented consultative evaluations, procedures/operations and findings at the time of service for 3 of 3 speciality physicians (Physician #'s 3, 15, and 18). This deficient practice poses the health and safety risk to patients for lack of documentation for continuity of care.

Findings include:

The Medical Staff Rules and Regulations last revised 9/24/2014 requires: "...7.5 Operative and Special Procedure Reports...shall be dictated immediately following the procedure...."

Hospital policy titled Dictation and Transcription, reference #HIMS_220, (last revised 03/2016) requires: "...Reports of Consultation and/or Operative reports are dictated at the time of the consultation and/or surgery/procedure...."

Hospital documents titled Unresolved Deficiencies by Responsibility Discharge Date 0-30 Days and Unresolved Deficiencies by Responsibility Discharge Date 30 - 120 Days Deficient - as of 6/15/16 confirmed:

Physician #3 Cardiologist: 9 consultative, 2 stress tests, and 37 echo procedures 2/12/2016 to 5/09/2016, were not dictated/documented at the time of service.

Physician #15 Orthopedic Medicine: 9 Operating Room reports and 6 consultations 2/19/2016 to 5/04/2016, were not dictated/documented at the time of service.

Physician #18 Internal Medicine: 5 consultations 6/08/2016 to 6/12/2016 were not dictated/documented at the time of service.

The Director of HIMS #6 confirmed during an interview conducted on 6/15/2016, that the medical records did not contain physician's dictation/documentation for consultations, procedures, and operations at the time of service.

Based on review of the Medical Staff Rules and Regulations, policy and procedure, medical records, and staff interviews, it was determined that the staff providing Medical Record Services failed to require 11 of 11 discharged patients' medical records (Patient #'s 3, 4, 5, 7, 8, 9, 10, 11, 12,13, and 14) contained physicians dictated/recorded Discharge Summaries. This deficient practice poses a risk to patient health and safety when the receiving facility and/or referral physician is/are not informed of the care provided and outcomes of the patient's hospitalization in order to ensure continuity of care.

Findings include:

The hospital's Medical Staff Rules and Regulations, last revised 9/24/2014 and currently valid require: "...Section 7 Medical Records...7.1.14 Discharge summary...must recapitulate...the reason for admission, pertinent physical findings...laboratory test...operative/special procedures and the findings...treatment...condition on discharge and prognosis, plan for future management and follow-up care, instructions to the patient...7.8.1 Discharge Summary...must be recorded for all patients by the attending physician...."

Hospital policy titled Dictation and Transcription, reference #HIMS_220 (last revised 03/2016) requires: "...Discharge Summaries...dictated by the attending physician at the time of discharge...."

Hospital documents titled Unresolved Deficiencies by Responsibility 0 to 30 and Unresolved Deficiencies by Responsibility 30 to 120 Days Deficient as of 6/15/16 confirmed physicians did not document discharge summaries at the time of discharge, as follows:

Physician #14: 21 patients discharged 5/20/2016 to 6/12/2016, and 1 patient discharge summary dictated 6/13/2016 for an admission in 3/2016,

Physician #18: 21 patients discharged 5/07/2016 to 6/12/2016.

Director of Health Information Management Services (HIMS) #6 confirmed during interview 6/15/2016 at 1500, that medical records did not contain physicians' Discharge Summaries documented at time of discharge for patients, as follows:

Patient #3: date of service (DOS) 5/27/2016 to 6/08/2016. No discharge summary as of 6/13/2016.

Patient #4: transferred to higher level of care 6/09/2016, discharge summary dictated 6/14/2016,

Patient #5: discharged 6/11/2016, discharge summary dictated 6/13/2016,

Patient #9: discharged 6/10/2016, discharge summary dictated 6/13/2016,

Patient #10: discharged 6/11/2016, discharge summary dictated 6/13/2016,

Patient #12: discharged 6/10/2016, discharge summary dictated 6/13/2016,

Patient #13: discharged 6/11/2016, discharge summary dictated 6/14/2016.

Medical records are not maintained to provide continuity of care post discharge.

Based on observation during tour, review of hospital policies/procedures, documents and staff interviews, it was determined the hospital failed to require that in the case of an emergency (code blue) that the procedure/equipment used is maintained in working order. This deficient practice poses a high risk for injury or death in case of emergency if staff is unsure of the procedure, which system to use, and that the system is functional.

Findings include:

Observation on tour 6/08/2016 through 6/17/2016 revealed that units of the hospital use different methods of calling "codes". Radiology / Computerized Tomography (CT) / Magnetic Resonance Imaging (MRI) use the "red phone"on wall, "code button" blue button on wall, leave the patient to "yell out door", and/or call the emergency room from the office area of the department. Intensive Care Unit uses code "button" on the wall in the patient's room, if no response call overhead. The Inpatient unit uses overhead paging system.

Hospital policies require the following:

Code Blue Procedure, 1014, PolicyStat ID: 1683869, (last revised 01/06) requires: " ...code should be called according to the hospital's pre-established code procedure...."

Cardiopulmonary Resuscitation Emergency Treatment, 1016, PolicyStat ID: 1683867, (last revised 1/06) requires: "...Stay with the patient! 'Code Blue' will be called over the intercom by the Unit Secretary for the Emergency Department (ED), after s/he has been notified by department personnel...."

Cardiac Arrest - Code Blue, 1249, PolicyStat ID: 1628807 (last revised 1/08) revealed: "...All cardiac arrests within the Intensive Care Unit...the staff will overhead page 'Code Blue' and indicate room number...."

Cardiac Arrest - Code Blue, 2200, PolicyStat ID: 1602067, last revised 1/2015 revealed: "...All cardiac arrests with the Emergency Department...will...overhead page 'Code Blue'...."

Participation in Emergency Department's Code Blue, 5004, PolicyStat ID: 2019031, last revised 3/2016 revealed: "...respiratory care practitioners will take following steps in calling a CODE BLUE...by using the 'CODE/fire' button on the hospital telephone and announcing code blue...."

The (Department) Guidelines for Design and Construction of Hospital and Health Care Facilities 2001 requires: "...A staff emergency assistance system for staff to summon additional assistance...shall annunciate visually and audibly...at the nursing station of the nursing unit with backup to another staffed area from which assistance can be summoned...."

The ED is built in a square configuration with 18 patient bays encircling the nurses' station. The nurses' station contains multiple computers, monitors, and desk phones. In addition to the desk phones, the desk phone nearest the telemetry monitors on the counter is designated to receive emergency calls from the red phones. Also there is a gray metal panel with a simple phone receiver resting on top of the panel (located nearest the CT room) that was equipped with multiple visual indicators (buttons) that lit up when a code arrest was called from the blue code arrest button on the wall in CT (no button identified for ICU).

CT/MRI/X-Ray Technician #10 confirmed during interview 6/8/2016 at 1030, that the red phone in the CT room is used with the code button on the wall, and "yelling out door". Tech #10 demonstrated the code call process on 6/8/2016 at 1040, for the purpose of confirming the process for the surveyors, as follows:

In the event of a code arrest in CT, the staff will pick up the red phone on the wall and push the blue code button. The surveyor observed that the phone handset was taped to the cradle on the receiver. The staff indicated that when the receiver is lifted, this "triggers" a blinking light and a ring on the designated phone in ED.

The surveyor observed that the designated phone in the ED blinks but does not ring and the ED staff were not aware and did not respond. In addition the designated phone in ED is not manned. The surveyor confirmed that the Code Blue button quietly sounded (beeped) in the ED at the gray metal panel. The surveyor observed that multiple ED staff members to be "wondering" what the beeping indicated and attemping to turn off the sound. The gray metal panel is not manned.

The Plant Operations Manager #48 confirmed that the designated phone did not ring, only flashed, and that the ED staff did not respond to the phone.

CT/MRI/X-Ray Technician #10 confirmed that if a patient is in the MRI room the staff leaves the patient - unattended - to go to the MRI control room to use the phone to call the ED for assistance and then return to patient.

The hospital does not maintain a working emergency assistance call system, as described in the Guidelines for Design and Construction of Hospital and Health Care facilities 2001 (architectural requirements) effective at the time of initial licensure and remains the current Department requirements for this hospital.