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Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.24, MEDICAL RECORD SERVICES, was out of compliance.

A 0432 - The organization of the medical record service must be appropriate to the scope and complexity of the services performed. The hospital must employ adequate personnel to ensure prompt completion, filing, and retrieval of records. The hospital failed to comply with Federal and State regulations through the co-mingling of medical records services with the separately certified skilled nursing facility (SNF). This failure allowed unauthorized personnel from a separately certified facility access to medical records and Protected Health Information (PHI).

Based on interviews and document review, nursing staff provided dialysis care without specific physician orders in 2 out of 3 medical records for patients receiving dialysis services (Patients #2 and #9). Additionally, in 1 out 10 medical records, nursing failed to notify the physician of a change in condition when the patient developed a wound (Patient #1).

This failure created an unsafe patient care environment in which the patients' interventions and treatments were not properly monitored by a supervising physician.

FINDINGS

POLICY

According to the policy, Renal Dialysis Performed on a Nursing Unit, Physician Responsibility includes order dialysis with specifics. The Hemodialysis Provider Responsibility includes perform dialysis as ordered and maintain written records of the procedure and the patient's response to treatment. Places copy in the patient medical record.

1. The facility failed to ensure the nursing staff provided care according to physician orders.

a) Review of the medical record for Patient #2 revealed s/he was admitted to the facility for services along with Hemodialysis (HD) treatments. According to the Pre-Admission Assessment form, dated 12/06/16, Patient #2 routinely received dialysis treatments on Monday, Wednesday, and Friday (MWF).

Review of Hemodialysis Orders showed Patient #2's first treatment was scheduled on Wednesday, 12/07/16. The physician orders did not specify the dialysis treatment schedule for the patient while s/he was hospitalized; however, a Physician Progress Note written by the Nephrologist, dated Monday 12/12/16, documented the patient was to have dialysis on this date. HD treatment sheets within the medical record corresponded with the MWF schedule for treatments.

Review of Patient Care Notes, dated 12/12/16 at 7:31 a.m., revealed the RN documented Patient #2 was"due for dialysis today." However, there was no documentation to show the patient received his/her scheduled dialysis.

A Physician Progress note, dated 12/13/16, documented Patient #2 received dialysis on 12/13/16, a Tuesday, for 45 minutes. However, there was no HD treatment sheet to show the dialysis treatment had occurred. Additionally, there was no documentation or order to show the reason Patient #2's treatment was not completed on Monday 12/12/16 and was changed from Monday to Tuesday.

An interview was conducted with the contracted HD nurse, Registered Nurse #4 (RN), on 03/01/17 at 10:16 a.m. RN #4 stated there should be a treatment sheet filled out for Patient #2 even if the HD treatment was only 45 minutes long. S/he reported all orders were documented on the Hemodialysis order sheet (HD sheet). S/he reported if the patient was unable to receive their dialysis treatment per the preplanned schedule a nephrologist would be notified and any new orders would be recorded on the HD sheet.

b) A review of the medical record for Patient #9 revealed s/he was admitted to the facility for wound care and end-stage renal disease requiring HD on 10/24/16. The patient had dialysis on Monday, 10/24/16 the day of his/her admission. According to the History and Physical, dated 10/24/16, the physician documented the patient was on dialysis with the current schedule of MWF. There were no HD treatment sheets to show dialysis treatments had been completed for Wednesday 10/26/16 and Friday 10/28/16. The documentation showed dialysis had been suspended from 10/31/16 to 11/12/16.

Review of Progress Notes, dated 11/13/16 showed dialysis was to resume on Monday 11/13/16 with a MWF schedule. However, there were no HD treatment sheets for dialysis treatments from Monday 11/13/16 until Monday 12/12/16, approximately one month of missing documentation . As example,

According to Patient Care Notes, on 11/14/16 at 12:22 p.m., the patient's Pseudoephedrine was held until the dialysis treatment was complete. There was no hemodialysis treatment sheet in the medical record which documented the treatment and the patients response to the treatment.

On 12/02/16 at 7:00 a.m., the RN documented the dialysis nurse was preparing for hemodialysis treatment. There was no written record of the treatment and the patients response to treatment in the medical record.

In the month of January 2017, there were 3 occasions Patient #9 received dialysis on non-scheduled days and no documentation or orders were present to show why the schedule was altered.

c) On 03/02/17 at 11:46 a.m., an interview was conducted with RN #10, who stated if the nephrologist had not specified the specific days for dialysis s/he depended on the direction of the HD nurse for the patient's schedule. If the patient was not provided dialysis treatments on their scheduled day the HD nurse should have informed the primary nurse and documented the order from the nephrologist.

d) On 03/02/17 at 11:55 a.m., an interview was conducted with Licensed Practical Nurse #11 (LPN) who stated s/he reviewed physician's dialysis orders to know what the patient schedule was for dialysis treatment. If the orders were not clear, s/he would ask the HD nurse for clarification. S/he stated patients were scheduled for a certain pattern to keep the patient's electrolytes balanced (such as every Mon., Wed., and Fri., or Tues., Thurs., and Sat.). LPN #11 stated s/he would not look for an order if the dialysis schedule was changed, and questioned if s/he was suppose to.

e) On 03/02/17 at 9:19 a.m., an interview was conducted with Director Of Nursing #8 (DON) who confirmed the HD nurse would not be allowed to change the patient schedule for dialysis treatment and there should be a treatment sheet for every treatment that had been provided even if the treatment did not run the whole time. S/he stated the contracted dialysis company would call the facility the night before scheduled treatments and provide the names of patients scheduled for dialysis the next day. If a dialysis patient was not on the schedule for that particular day all staff nurses knew they were to speak up if their patient was not on the schedule for the correct day. S/he stated if dialysis treatments were ended early, the HD nurse was expected to report to the staff nurse, who would in turn notify the hospitalist and document in the nursing progress notes about the notification.

f) On 03/02/17 at 8:45 a.m., an interview was conducted with Director of Quality/Risk Management #2 (Director) who stated the dialysis nurse would have to follow the previously physician's ordered schedule the patient was on when admitted. S/he confirmed the HD nurse could not change the day of dialysis treatments without a direct order from the nephrologist. Director #2 stated it was the responsibility of the staff nurse to know the dialysis schedule of their assigned patients and to speak up when the schedule was not followed.

g) On 03/02/17 at 9:53 a.m., an interview was conducted with Physician #9 who stated a dialysis nurse would not be allowed to change the dialysis schedule of a patient. S/he further stated, if the patient could not dialyze, the HD nurse would be required to contact the nephrologist. Physician #9 stated s/he expected the HD nurse to ask the hospitalist or staff nurse to add new orders for changes to the dialysis treatment schedule.

2. The nursing staff failed to notify the physician of a change in condition and performed treatments without a physician order.

a) Review of the medical record of Patient #1 revealed the patient was admitted to the facility for recovery from a complicated abdominal surgery requiring strengthening and rehabilitation. The patient sustained a wound on his/her left hand after arriving at the facility. The nursing staff documented the presence of the wound for five consecutive days, 12/17/16 to 12/21/16, and implemented non-pharmaceutical treatments consisting of ice application and elevation.

However, there was no documentation the physician was notified of the wound and that s/he provided orders for treatment

b) On 03/02/17 at 9:31 a.m., an interview was conducted with DON # 8 who stated nursing staff should report any new wounds to the physician. The nursing staff should also obtain orders for non-pharmaceutical treatments.

Based on observation and interviews, the hospital failed to comply with Federal and State regulations through the co-mingling of medical records services with the separately certified skilled nursing facility (SNF).

This failure allowed unauthorized personnel from a separately certified facility access to medical records and Protected Health Information (PHI).

FINDINGS

POLICY

According to the policy Health Information Management, the hospital will provide Health Information Management (HIM) services to meet the information management needs of the hospital and medical staff, in caring for patients. The Director of HIM is responsible for carrying out the general policies and of the hospital, and in the conduct of the HIM department.

1. The hospital commingled the medical records department and services with a separately certified SNF.

a) On 03/01/17 at 11:34 a.m. a tour of the medical records department was conducted with the Director of HIM (Director #3). Observations were made of front row shelves which housed blue folders. Director #3 stated the blue folders were the records for the outpatient pain clinic which was part of the hospital. On the subsequent rows of shelving were housed manilla folders which Director #3 identified as the hospital inpatient medical records and the SNF medical records. Director #3 stated the SNF medical records were identified by the red letters "SNF" stamped on the front of the medical record. S/he further explained when a patient was discharged from the hospital and admitted to the SNF, the same medical record number was maintained but an encounter number was applied to the record. Both records from the separately certified facilities were then stored on the same shelf by patient name.

b) A second interview was conducted with Director #3 on 03/01/17 at 3:13 p.m. Director #3 stated the HIM department performed coding of diagnoses for the SNF and the services were performed by hospital HIM staff during the same hours as services were provided for the hospital. Director #3 confirmed there was no schedule separation for services performed for each facility. S/he also confirmed one list containing admissions and discharges from both facilities was printed to identify records which required HIM work. Director #3 stated there was one medical record specialist who managed the discharge records for the two separate facilities.

c) During an interview with the Director of Quality/Risk Management (Director #2), on 03/01/17 at 11:20 a.m., s/he confirmed the SNF was a separately certified facility. S/he further confirmed the medical records from the hospital and the separately certified SNF were stored together and managed by the hospital's HIM director.

d) On 03/01/12 at 3:42 p.m., an interview was conducted with Chief Executive Officer #1 (CEO). CEO #1 stated the SNF was a separately certified facility. S/he further confirmed the medical records for the SNF and the hospital were stored in the same location and managed by the same hospital staff during the same hours of operation.