HospitalInspections.org

Based on record review, policy review and interview, the hospital's Governing Body failed to ensure the enforcement of the Medical Staff Bylaws in regards to ensuring compliance with medical records services. This was evidenced by the licensed practitioners failure to comply with Medical staff Rules and Regulations of accurately dating, timing and authenticating clinical entries and by not completing their clinical record within 30 days of a patients discharge. Findings:

Record review of the Medical Staff Rules and Regulations approved by Governing Body on 2007 (pg 4 of 10) revealed (#7) "All clinical entries and summaries in the patient's medical record shall be accurately dated, timed and authenticated." #14 (pg 5 of 10) notes "A medical record will be considered delinquent if the medical record does not reflect the final diagnosis with completion of medical records within 30 days following discharge. The Hospital's Medical Records staff members will notify in writing on the 15th of the month of incomplete medical records pending delinquent status. " #15 (pg 5 of 10) notes "If the Medical Staff member becomes delinquent in his/her medical records, suspension of privilege will be suspended from the date of delinquency. The delinquent Medical Staff member and Medical Director will be notified in writing whenever privileges are suspended....The practitioner whose clinical responsibility are suspended will not be allowed to admit patients, perform consults, or other procedures or treat patients except those patients who were admitted to the hospital prior to the suspension."


Medical record review revealed system breakdowns in the hospital's enforcement of ensuring all entries entered into the patient's medical record were dated and/or timed and/or authenticated by the person responsible for providing the service furnished. These findings were noted in the medical records of 9 of 9 patients (Patient #1, Patient #2, Patient #7, Patient #11, Patient #12, Patient #R12, Patient #R13, Patient #R14, Patient #R16) whose medical records were reviewed for the dating/timing/authentication of medical records.

The hospital's Medical Director (S8) was interviewed on 4/11/12 at 9:30 a.m. When asked about the timing of entries in the medical record, Medical Director (S8) indicated that he does not time many entries in the medical record including progress notes. S8 reported that he does not want to time entries in the medical record due to concerns about Medicare Fraud. S8 reported that he sees a lot of patients in the hospital and does not want to time his entries.

A sample of 15 closed medical records of patients who have been discharged from the hospital for a period of greater than 60 days was reviewed. This review revealed that 10 of the 15 closed medical records were incomplete and delinquent as missing signatures were noted in the 10 medical records.

The previous administrator and current member of the governing body of the hospital (S11) was interviewed on 4/11/12 at 1:20 p.m. S11 verified that 10 of the 15 closed medical records were delinquent in that they were missing signatures of the licensed practitioner. S11 indicated that the hospital was unable to accurately track delinquent medical records as evidenced by being unable to determine the number of medical records that were not completed within 30 days of discharge. S11 reported that he did not know how many delinquent medical records were currently in the hospital. In addition, S11 verified that the physicians, including the Medical Director, were not timing entries into the medical record.

Based on record review and interview the hospital failed to ensure the Governing Body had in place a policy that assured a physician, on site or on call, would directly provide appraisals of emergencies or provide medical direction of on site staff during a medical emergency as evidenced by the emergency policy having no requirement that a physician provide medical direction (on site or on call) during a medical emergency. Findings:

Review of a hospital policy titled "Emergency Cart", policy number TX-SPEC.08, date adopted January 2007, no date of last revision, presented as current hospital emergency policy, revealed: "...Procedure: In the event of a medical emergency requiring cardiopulmonary resuscitation, the staff will call a Code Blue, 911, and begin CPR (cardiopulmonary resuscitation) on all patients unless the patient is identified as having a "Do Not Resuscitate" order executed through the Advance Directive. Available staff member brings the emergency cart to the location of the medical emergency. Staff continues CPR until Emergency Medical Personnel arrive to assume control of the emergency measures..."

In an interview on 04/09/12 at 1:15 p.m. with S2DON she confirmed that the emergency policy does not require staff to get medical direction from a physician during a medical emergency.

Based on interview and record review, the hospital's QAPI (Quality Assurance Performance Improvement) program failed to set priorities for its performance improvement activities that focus on high-risk and/or problem prone areas. This was evidenced by the hospital's failure to 1) identify and implement corrective measures relating to the dating and timing of entries entered into the patient's medical record; 2) identify and implement corrective measures relating to the hospital's inability to accurately track delinquent medical records as evidenced by being unable to determine the number of medical records that were not completed within 30 days of discharge; and 3) identify and implement corrective measures regarding delays and/or omissions relating to ordered laboratory test. Findings:


1. Failing to identify and implement corrective measures relating to the dating and timing of entries entered into the patient's medical record.

Medical record review revealed system breakdowns in the hospital's enforcement of ensuring all entries entered into the patient's medical record were dated and/or timed and/or authenticated by the person responsible for providing the service furnished. These findings were noted in the medical records of 9 of 9 patients (Patient #1, Patient #2, Patient #7, Patient #11, Patient #12, Patient #R12, Patient #R13, Patient #R14, Patient #R16) whose medical records were reviewed for the dating/timing/authentication of medical records.

The hospital's Medical Director (S8) was interviewed on 4/11/12 at 9:30 a.m. When asked about the timing of entries in the medical record, Medical Director (S8) indicated that he does not time many entries in the medical record including progress notes. S8 reported that he does not want to time entries in the medical record due to concerns about Medicare Fraud. S8 reported that he sees a lot of patients in the hospital and does not want to time his entries.

2. Failing to identify and implement corrective measures relating to the hospital's inability to accurately track delinquent medical records as evidenced by being unable to determine the number of medical records that were not completed within 30 days of discharge.

S10 (Medical Records) was interviewed on 4/11/12 at 10:55 a.m. When asked for a list of delinquent medical records that were not complete within 30 days of a patient's discharge, S10 indicated there were no delinquent medical records in the hospital and no records that were not completed within 30 days of discharge.

A sample of 15 closed medical records of patients who have been discharged from the hospital for a period of greater than 60 days was reviewed. This review revealed that 10 of the 15 closed medical records were incomplete and delinquent as missing signatures were noted in the 10 medical records.

S10 (Medical Records) was interviewed on 4/11/12 at 11:00 a.m. S10 confirmed the missing signatures and reported she was unable to determine how many medical records were delinquent in the hospital.

Review of the Quality Assurance Performance Improvement data January, February, and March of 2012 revealed no documentation to indicate the hospital had identified and implemented corrective measures relating to the hospital's inability to accurately track delinquent medical records as evidenced by being unable to determine the number of medical records that were not completed within 30 days of discharge.

The Administrator (S1) and Director of Nursing (S2) were interviewed on 4/11/12 at 1:30 p.m. Both indicated that the hospital's Quality Assurance Performance Improvement program failed to identify and implement corrective measures relating to the hospital's inability to accurately track delinquent medical records as evidenced by being unable to determine the number of medical records that were not completed within 30 days of discharge.

3. Failing to identify and implement corrective measures regarding delays and/or omissions relating to ordered laboratory test.

Medical record review revealed laboratory test ordered for Patient #14 was not completed as ordered as there was no documentation in the medical record to indicate the ordered laboratory test was done for Patient #14. The Director of Nursing (S2) verified there was no documentation in the medical record to indicate the ordered laboratory test was done on Patient #14 as ordered.

Medical record review revealed delays were identified in obtaining laboratory tests that were ordered for Patient #2 and Patient #12. The delays in obtaining laboratory tests were verified during interviews with the Director of Nursing on 4/09/12 between 2:00 p.m. and 2:10 p.m. and on 4/10/12 between 11:00 a.m. and 11:05 a.m.

Review of the Quality Assurance Performance Improvement data January, February, and March of 2012 revealed no documentation to indicate the hospital had identified and implemented corrective measures relating to ensuring the documented collection of laboratory specimens was in compliance with acceptable time frames for the tests ordered including but not limited to fasting labs being drawn while the patient is in a fasting state.

The Administrator (S1) and Director of Nursing (S2) were interviewed on 4/11/12 at 1:30 p.m. Both indicated that the hospital's Quality Assurance Performance Improvement program failed to identify and implement corrective measures relating to ensuring the documented collection of laboratory specimens was in compliance with acceptable time frames for the tests ordered including but not limited to fasting labs being drawn while the patient is in a fasting state.

Based on observation, record review and interview the hospital failed to meet the Condition of Participation (CoP) of Nursing Services as evidenced by:

1. Failing to ensure patients with a moderate or high fall risk had in place the interventions required by hospital policy as evidenced by patient #10 being assessed as having a change in his fall risk score and sustaining a fall resulting in his right leg being "externally rotated" with no documentation of fall risk policy intervention implementation. (see findings at A0395)

2. Failing to ensure patients with a moderate or high fall risk had in place the interventions required by hospital policy as evidenced by failing to have interventions in place per the fall risk policy for 8 of 14 patients currently in the hospital on 04/10/12 at 9:10 a.m.(#2, #7, #18, #20, #R1, #R4, #R5, #R22). (see findings at A0395)

3. Failing to ensure patients with a moderate or high fall risk had in place the interventions required by hospital policy as evidenced by failing to implement interventions for patients with moderate fall risk scores per hospital policy on 04/11/12 at 10:43 a.m. by having 2 patients observed in their rooms alone (#7, #R1). (see findings at A0395)

4. Failing to ensure laboratory tests were completed as ordered and/or obtained in a timely manner after being ordered by the licensed practitioner for 3 of 10 patients (#14, #2, #12) sampled for the review of laboratory testing from a total sample of 42 patients. (see findings at A0395)

5. Failing to follow the licensed practitioner's orders of administering insulin based on the results of blood glucose monitoring (accuchecks) (#7) and failing to ensure the blood glucose levels were initiated by the nursing staff as ordered by the licensed practitioner (#1) for 2 of 20 patients out of a total of 42 patients. (see findings at A0395)

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Based on record review, observations and interview, the registered nurse failed to supervise and evaluate the care provided to patients by:

1. Failing to ensure patients with a moderate or high fall risk had in place the interventions required by hospital policy as evidenced by A) patient #10 being assessed as having a change in his fall risk score and sustaining a fall resulting in his right leg being "externally rotated" with no documentation of fall risk policy intervention implementation; B) failing to have interventions in place per the fall risk policy for 8 of 14 patients currently in the hospital on 04/10/12 at 9:10 a.m.(#2, #7, #18, #20, #R1, #R4, #R5, #R22); and C) failing to implement interventions for patients with moderate fall risk scores per hospital policy on 04/11/12 at 10:43 a.m. by having 2 patients observed in their rooms alone (#7, #R1). Findings:

A.
Review of the medical record for patient #10 revealed he was admitted on 02/10/2012. Review of the initial nursing assessment done on 02/10/2012 revealed patient #10 had a fall risk score of 3 (low) upon admission.

Review of the nursing assessment for 02/11/2012 revealed patient #10 now had a fall risk score of 10 due to medication changes (4 points added for the addition of Hypnotic, Neuroleptic, or Antianxiety medication and 2 points added for addition of Antidepressant) and unsteady gait (1 additional point). Review of the interventions documented on the Assessment/Re-Assessment form revealed there is no documentation that patient #10 was "not left unattended" per the hospital policy. Further review revealed no documented evidence of an Orange Arm Band being placed on patient #10 and no documented evidence of notification of the physician of patient #10's fall risk assessment changes.

Review of the nursing assessment for 02/14/2012 revealed patient #10 was found on the floor of his room at 4:50 a.m. on 02/15/2012 with his "R (right) leg/foot externally rotated." Patient #10 was transferred to the emergency room of an acute care hospital. Further review of the nursing documentation for the night shift of 02/14/2012 revealed no documentation that patient #10 had an Orange Arm Band or was not left unattended per hospital policy.

In an interview on 04/09/12 at 3:00 p.m. with S2DON she confirmed there was no care plan in the medical record for patient #10 related to Fall Risk. S2DON confirmed the interventions documented in the check boxes on the Assessment/Re-Assessment Form do not include the policy required intervention that "patient is not left unattended."

In an interview on 04/10/2012 at 8:20 a.m. with S2DON she confirmed the changes on 02/11/2012 of patient #10's fall risk score from 3 (low risk) to 10 (moderate risk). S2DON further confirmed there was no documentation of notification of the physician of assessment changes on 02/11/2012, no documentation of an Orange Arm Band being placed on patient #10, and no documentation that patient #10 was "not left unattended" per hospital policy.

B.
In an observation on 04/10/12 at 9:10 a.m. with S4RN Charge Nurse, all patient's were checked for compliance with the hospital policy related to fall risk and interventions. The following was noted:

Patient #R1 had a fall risk score of 11 (moderate risk). Patient #R1 had no Orange Arm Band per hospital policy.

Patient #R4 had a fall risk score of 9 (low risk). Patient #R4 had no arm band per hospital policy.

Patient #R22 had a fall risk score of 12 (moderate risk). Patient #R22 was alone in her room unattended and had no Orange Arm Band per hospital policy.

Patient #2 had a fall risk score of 8 (low risk). Patient #2 had no arm band per hospital policy.

Patient #R5 had a fall risk score of 15 (moderate). Patient #R5 had no Orange Arm Band per hospital policy and was ambulating in the hall unattended.

Patient #7 had a fall risk score of 20 (high risk). Patient #7 was alone in his room unattended and had no Red Arm Band per hospital policy.

Patient #18 had a fall risk score of 17 (moderate). Patient #18 had no Orange Arm Band per hospital policy.

Patient #20 had a fall risk score of 18 (moderate). Patient #20 had no Orange Arm Band per hospital policy.

Patient #R2 had a fall risk score of 6 (low). Patient #R2 had no arm band per hospital policy.

In an interview on 04/10/12 at 9:25 a.m. with S2DON she stated she "does not have the staff to follow the policy." S2DON stated that the MHT's (mental health technicians) are not aware of the hospital policy that requires patients with moderate and high fall risk to have interventions which include "Patient is not left unattended."

On 04/10/12 at 11:05 a.m. S2DON provided a list of all active patients and the fall risk score documented by the RN Charge Nurse for the current shift. Review of the current patient census revealed there were 14 patients. Of the 14 patients present 3 had a low fall risk score; 10 had a moderate risk score; and 1 had a high risk score. Review of the Charge RN assignment sheet revealed there were 4 MHT's on duty. 2 of the MHT's were assigned 4 patients and 2 of the MHT's were assigned 3 patients.

C.
In an observation made on 04/11/12 at 10:43 a.m. with S3RN, Charge Nurse, she confirmed that Patient #7 (fall risk score of 18 (moderate) per her assessment on 04/11/12) was in his room unattended and Patient #R1 (fall risk score of 11 (moderate) per her assessment on 04/11/12) was in her room unattended.

Review of a hospital policy titled "Fall Assessment/Re-Assessment and Precautions", date adopted March 2008, date revised January 2010, presented as current hospital policy, revealed: "Policy: All patients will be assessed and identified for the potential of being at risk for falls upon admission; patient is re-assessed at the beginning of each shift thereafter. Purpose: To assess the patient's potential for falling and decrease the risk. Procedure: The Admitting RN (registered nurse): Assessment: At the time of patient's admission, evaluates the patient's ambulatory status and completes Fall Risk criteria. If a score of 6 or greater is obtained, initiates fall precaution. Patients will be scored as follows: 0-9 low risk; 10-19 moderate risk; 20-30 high risk. Low Risk: Yellow arm band, q (every) 15 (minute) Checks, Bathroom light on, Clear Pathways, Arm Bands, Stickers, Call bell at Bed side. Moderate Risk: Orange Arm Band, Low risk Interventions, Patient is not left unattended, Patient reminded to call for assistance, Optional Bed Alarm. High Risk: Red Arm Band, Low and Moderate risk Interventions, Optional (1:1) one to one, Bed Alarm Mandatory..."


2. Failing to ensure laboratory tests were completed as ordered and/or obtained in a timely manner after being ordered by the licensed practitioner for 3 of 10 patients (#14, #2, #12) sampled for the review of laboratory testing from a total sample of 42 patients. Findings:

Patient #14: Review of the Admit Orders/Initial Plan of Care dated 3/19/12 at 2130 (9:30 p.m.) for Patient #14 revealed orders for labs which included a U/A (urinalysis) and a Hemocysteine level. Further review of the medical record revealed no laboratory results for the two tests or any documentation as to why the labs had not been collected.
In an interview on 4/10/12 at 12:30 p.m. with the Director of Nursing S2, she verified the U/A and Hemocysteine levels had been ordered on 3/19/12. She also said she could not find evidence in the medical record that either lab test had been completed. She said the labs should have been done or documented as to why they had not been done. S2 said the labs not being drawn was an error.

Patient #2: Medical record review revealed Patient #2 was admitted to the hospital on 3/21/12. Review of the Psychiatric Evaluation (dated 3/22/12) revealed Patient #2's Axis I diagnosis included Bipolar Disorder. Review of the History & Physical (dated 3/21/12) revealed Patient #2's medical diagnoses included Hyponatremia. Review of the medical record revealed orders (dated 3/22/12-not timed) for "AM labs: BMP, UA, Urine Sodium, Urine Osmolarity, Serum Osmolarity, Fasting lipid panel, Serum uric acid". Review of the laboratory results revealed a "Draw Date" of 3/23/12 at 10:33 a.m. for the fasting lipid panel. Review of the nursing documentation revealed Patient #2 ate 100% of his breakfast prior to 7:30 a.m. on 3/23/12. There was no documentation in the medical record to indicate the fasting lipid panel was drawn prior to Patient #2 eating breakfast on 3/23/12. Further review of the medical record revealed orders (dated 3/23/12 at 3:00 p.m.) for "BMP, Urine Sodium, Serum Osmolarity, Urine Osmolarity on Sat 3/24 and MUST BE FASTING" . Review of the laboratory results revealed the "Draw Date" of the Urine Sodium and Urine Osmolarity was 3/23/12 at 10:33 a.m. Review of the laboratory results revealed the "Draw Date" of the BMP and Serum Osmolarity was 3/23/12 at 10:09 a.m. Review of the nursing documentation revealed Patient #2 ate 100% of breakfast prior to 8:00 a.m. on 3/24/12. There was no documentation in the medical record to indicate the laboratory tests were obtained while Patient #2 was in a fasting state. Further review of the medical record revealed orders (dated 3/25/12 at 9:00 a.m.) for "Redraw Serum Osmolarity & Urine Osmolarity in AM (Mon 3/26) BOTH specimens MUST be drawn close together in time. MUST BE FASTING!". Review of the laboratory results revealed a "Draw Date" of 3/26/12 at 10:09 a.m. for the Serum Osmolarity and the Urine Osmolarity. Review of the nursing documentation revealed Patient #2 ate 100% of breakfast prior to 8:00 a.m. on 3/26/12. There was no documentation in the medical record to indicate the laboratory tests were obtained while Patient #2 was in a fasting state as ordered.

The Director of Nursing (S2) was interviewed on 4/09/12 between 2:00 p.m. and 2:10 p.m. S2 reviewed the medical record and verified there was no documentation in the medical record to indicate the labs were drawn while Patient #2 was in a fasting state. S2 reported that labs are routinely drawn between 6:00 a.m. and 8:00 a.m. and stated that the "Draw Date" as documented on the laboratory reports is incorrect. When asked if there was any documentation in the medical record to indicate a time the lab specimens were drawn other than the "Draw Date" time listed on the laboratory reports, S2 replied no.

Patient #12: Medical record review revealed Patient #12 was admitted to the hospital on 3/05/12. Review of the Psychiatric Evaluation (dated 3/06/12-no time documented) revealed Patient #12's Axis I diagnosis was Major Depression with Psychotic Features. Review of the admission orders (dated 3/05/12 at 6:30 p.m.) revealed orders for a urinalysis. Review of the laboratory results revealed the "Draw Date" for the urinalysis was 3/07/12 at 9:50 a.m. (greater than 39 hours after being ordered). Review of the results of the urinalysis revealed the presence of white blood cells and bacteria. Review of the medical record revealed a culture was obtained on the urinalysis with results returned on 3/09/12. Review of the medical record revealed Patient #12 was started on Bactrim DS (antibiotic) on 3/09/12. Review of the medical record revealed no documentation to indicate a reason for the delay in obtaining the urinalysis on Patient #12.

The Director of Nursing (S2) was interviewed on 4/10/12 between 11:00 a.m. and 11:05 a.m. S2 reviewed the medical record and verified there was no documentation in the medical record to indicate the reason for the delay in obtaining the urinalysis on Patient #12. When asked if the delay in obtaining the urinalysis on Patient #12 resulted in a delay in Bactrim DS treatment for Patient #12, S2 indicated that the delay in obtaining the urinalysis could have resulted in a delay in treatment.


3. Failing to follow the licensed practitioner's orders of administering insulin based on the results of blood glucose monitoring (accuchecks) (#7) and failing to ensure the blood glucose levels were initiated by the nursing staff as ordered by the licensed practitioner (#1) for 2 of 20 patients out of a total of 42 patients. Findings:

Patient #7: On 4/9/12 at 10:55 a.m. an observation of patient #7 revealed several areas on both arms with large areas of ecchymosis. On his left elbow, a transparent dressing was visible. Patient #7 stood up and began walking with a forward gait with the assistance from a mental health technician.

Record review of patient #7's clinical record revealed patient #7 had a history of diabetes. Record review of the Admission Medication Reconciliation Form dated 3/27/12 timed at 19:15 (7:15 p.m.) revealed patient #7 was receiving Glimepride (an oral anti-diabetic medication) 2 mg orally T.I.D. (three times a day).

Record review of Physician's orders dated 3/28/12 revealed an order for Accuchecks to be done every 12 hours with S/S (sliding scale). The "S/S" was underlined three times by the physician.

Record review of Admission Medication Reconciliation Form dated 3/27/12 and timed at 1915 (7:15 p.m.) revealed Accuchecks were to be done before meals (ac) and hour of sleep (hs) with a sliding scale. On 3/28/12, new orders were written by the licensed practitioner to change the Accucheck schedule from ac and hs to "Accuchecks every 12 hours with SS" *(the SS was underlined in bold).

Record review of a template of Physician's Orders for Medication, Diet, and Treatments, the following was written: "Insulin Sliding Scale". Regular Humalog Insulin. Further down the page reads. 61-150 units = 0 units; 151-299 units = 2 units; 201 - 250 units = 4 units; 201-250 = 6 units; 251-300 = 6 units; 301-359 =8 units; and 351-499 = 10 units. "

Record review of Medication Administration Record (MAR) revealed Accuchecks were being done at 0700 and 1600. On 3/28/12 at 0700, glucose reading was 129; at 1600, there was no documentation the accucheck was performed and no glucose reading was noted. On 3/29/12, at 0700, the glucose reading was 169; at 1600, the glucose reading was 207. No documentation of insulin being given on this day. On 3/20/12 at 0700, glucose reading was 162; at 1600, glucose reading was 209. Four (4) units of Regular insulin was administered at 1600. On 3/31/12 at 0700, the glucose reading was 155; the 1600 glucose reading was 196. No documentation of insulin being given on this day. On 4/1/12, at 0700, the glucose reading was 187; at 1600, the glucose reading was 200. No documentation of insulin being given on this day. On 4/2/12, to 0700, the glucose reading was 163; at 1600, the glucose reading was 164. No documentation of insulin being given on this day. On 4/3/12, no documentation the accucheck was performed at 0700. At 1600, the blood glucose level was 197. Two (2) units of Regular insulin was administered at 1600.

On 4/10/12 at 1:10 p.m. in an interview S2 DON, she confirmed patient #7 was a diabetic and needed to be on a sliding scale. She stated all diabetics are placed on a Sliding Scale when admitted to the hospital. If the physician ordered Accuchecks, the nurses are to place the Standing Physician's Orders for Medication, Diet, and Treatments on the chart for the physician's signature and then to follow the Insulin Sliding Scale. During this interview, S2 DON confirmed the chart did not contain the Standing Physician's Orders for Medication, Diet, and Treatments from the licensed practitioner regarding the amount of insulin to be given based on the results of the blood glucose monitoring (Accuchecks) on patient #7's chart. S2 DON confirmed that patient #7 should have received 2 units of Regular insulin on 3/29/12 based on the accucheck reading of 169 at 0700 (7:00 a.m.) and 4 units of Regular insulin based on the accucheck reading of 207 at 1600 (4:00 p.m.). S2 DON confirmed patient #7 should have received 2 units of Regular insulin on 3/30/12 based on the accucheck reading of 162 at 0700. S2 confirmed patient #7 should have received 2 units of Regular insulin on 3/31/12 based on the accucheck reading of 155 at 0700 and 2 units of Regular insulin based on accucheck reading of 196 at 1600. S2 confirmed patient #7 should have received 2 units of Regular insulin on 4/1/12 based on the accucheck reading of 187 at 0700 and 2 units of Regular insulin based on accucheck reading of 200 at 1600. S2 confirmed patient #7 should have received 2 units of Regular insulin on 4/2/12 based on the accucheck reading of 163 at 0700 and 2 units of Regular insulin based on accucheck reading of 164 at 1600. S2 confirmed no accucheck was documented at 0700 on 4/3/12. S2 stated she did not know if patient #7 received an accucheck at 0700 on 4/3/12.

Also during this interview, S2 stated the hospital had no policy regarding the use of accuchecks and administration of insulin.

Patient #1: Review of the Admission Medication Reconciliation Form for Patient #1 dated 3/29/12 at 17:30 (5:30 p.m.) revealed an order for blood glucose levels to be checked BID (twice per day).
Review of the Medication Administration Record for Patient #1 revealed blood glucoses were scheduled to have been checked at 0700 (7:00 a.m.) and 2100 (9:00 p.m.) daily. No entries were recorded for 3/29/12 or 3/30/12.
Review of the Insulin Flow Sheet for Patient #1 revealed blood glucose levels were not recorded as having been checked until 3/31/12 at 0700.
Review of the medical record for Patient #1 revealed no documentation in the Nurse ' s Notes or the Physician ' s Orders to hold the blood glucose checks or as to why the levels had not been started until 3/31/12.
In an interview on 4/9/12 at 2:55 p.m. with Director of Nurses S2, she verified the blood glucose levels for Patient #1 had not been documented as having been checked on 3/29/12 or 3/30/12. She said she did not know why the levels had not been started until 3/31/12 and it was an error by the nursing staff. She said the blood glucose levels for Patient #1 should have been started on 3/29/12 at 2100.




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30364

Based on observation, record review and interview the hospital failed to meet the Condition of Participation (CoP) of Medical Records as evidenced by:

1. failing to have a system in place to ensure qualified staff (1) compile data for quality assurance activities, and (2) verify the contents of the medical records are completed within 30 days in accordance with State laws as evidenced by staff assigned to the medical records department have other job duties besides medical records, which reduces their time to compile data for quality assurance activities and verify the charts are completed within 30 days after a patient's discharge. (see findings at A0432)

2. failing to have a system in place to accurately track delinquent medical records as evidenced by being unable to determine the number of medical records that were not completed within 30 days of discharge. A total of Fifteen (15) randomly selected closed medical records were reviewed for completion within thirty (30) days of discharge. Ten (10) of the fifteen (15) closed medical records reviewed were found to be incomplete and delinquent for a period of greater than thirty (30) days following discharge after it was reported that the hospital had a zero (0) medical record delinquency rate. (see findings at A0438)

3. failing to ensure all entries entered into the patient's medical record were dated and/or timed and/or authenticated by the person responsible for providing or evaluating the services provided. This was evidenced during the review of 9 of 9 patients (Patient #1, Patient #2, Patient #7, Patient #11, Patient #12, Patient #R12, Patient #R13, Patient #R14, Patient #R16) whose medical records were reviewed for the dating/timing/authentication of medical records from a total sample of 42 patients. (see findings at A0450)

Based on observation, policy review, record review, and interview, the hospital failed to have a system in place to ensure qualified staff (1) compile data for quality assurance activities, and (2) verify the contents of the medical records are completed within 30 days in accordance with State laws as evidenced by staff assigned to the medical records department have other job duties besides medical records, which reduces their time to compile data for quality assurance activities and verify the charts are completed within 30 days after a patient's discharge. Findings:


On 4/10/12 at 9:00 a.m. in a face-to-face interview with S1 Administrator confirmed there were no medical records summaries in the Contract Services book since June 28, 2011. She stated the hospital had hired a new Medical Record Consultant, whose contract began November 1, 2011. S1 stated the DON (S2) performed monthly medical record reviews.

On 4/10/12 at 9:50 a.m. in a face-to-face interview with S2 DON, she stated she performs chart audits. When asked to see her audit information, S2 DON stated she does not keep the chart audit information. She stated she places a black dot on the back of the clinical record to indicate she has checked the chart.

On 4/10/12 at 10:00 a.m. in a face-to-face interview with S12 Ward Clerk/Medical Records, she stated she "breaks down" the clinical records when a patient is discharged. She places different colored tabs so the physicians know which records they have to sign in order to complete the record. She does this on both current and closed records. She added she keeps a list of which charts the physicians or nursing staff need to sign. S12 stated S10 Assistant Administrator completes the chart review and files the completed record. S12 added the clinical records are kept in the Medical Records room for 6 months and then are transferred to an off-campus storage location. The files are not destroyed; just stored in case the record needs to be retrieved.

On 4/10/12 at 11:00 a.m. in a face-to-face interview with S11 Administrator/Owner, he stated the Medical Record Consultant did not have any time sheets for the times she has reviewed charts; only invoice statements.

On 4/11/12 at 7:50 a.m. in a face-to-face interview with S10 Assistant Administrator, she stated her job duties include Utilization Review, Medical Credentialing, Billing (Front-end), and Medical Records. She stated she codes the bills and another staff member communicates with CMS and Insurance Companies. S10 stated the process of Medical Records includes S12 Ward Clerk tags the clinical record and makes sure the physicians have signed all of the records. Then she (S10) boxes the charts in cardboard boxes. She keeps 6 months of medical records in these boxes; she has some records in the large 3 drawer fire box. S10 explained she was waiting for one of the physician's discharge summaries before she files the record in the cardboard boxes. She stated she keeps some of the History & Physicals, and Discharge summaries are scanned and placed on an external hard drive. She also keeps the Face Sheets in a binder next to her desk.

S10 stated S2 DON is responsible for ensuring the charts are checked and physicians' signatures are all present in the clinical record before the chart gets sent to her (S10). S10 stated the physicians do not like to time their entries in the clinical records and this has been identified by the Medical Record Consultant (S13). S10 stated there was no full-time or part-time person responsible for Medical Records...each person (S2 DON, S12 Ward Clerk/Medical Records, and S10 Assistant Administrator) is responsible for their portion of the management of medical records.

Record review of policy titled "Health Information Management: HIM-09 Authentication Process of Medical Records" (pg 1 of 3) under Policy reads "It is the responsibility of the Coordinator of the Health Information Management Department to assure authenticity and integrity of the medical record of discharged patients within 30 days post-discharge." Under Purpose, "To assure that medical records are completed within 30 days post-discharge and that medical records are accurate for clients assessed, cared for, treated or served."

26313

Based on observation, interview, and medical record review, the hospital failed to have a system in place to accurately track delinquent medical records as evidenced by being unable to determine the number of medical records that were not completed within 30 days of discharge. A total of Fifteen (15) randomly selected closed medical records were reviewed for completion within thirty (30) days of discharge. Ten (10) of the fifteen (15) closed medical records reviewed were found to be incomplete and delinquent for a period of greater than thirty (30) days following discharge after it was reported that the hospital had a zero (0) medical record delinquency rate. Findings:

On 4/11/12 at 10:15 a.m. in an interview with S1 Administrator, when asked how many medical records currently stored in the medical records room were more than 60 days delinquent. S1 stated there were no delinquent medical records longer than 60 days and there were no delinquent medical records longer than 30 days.
S10 (Medical Records) was interviewed on 4/11/12 at 10:55 a.m. When asked for a list of delinquent medical records that were not complete within 30 days of a patient's discharge, S10 indicated there were no delinquent medical records in the hospital and no records that were not completed within 30 days of discharge.

A sample of 15 closed medical records of patients who have been discharged from the hospital for a period of greater than 60 days was reviewed. This review revealed that 10 of the 15 closed medical records were incomplete and delinquent as missing signatures were noted in the 10 medical records. The following deficiencies were identified:

Patient R7: Review of a telephone order for Patient R7 dated 8/30/11 at 1700 (5:00 p.m.) to discontinue accuchecks with S.S. (sliding scale insulin) had never been signed by the physician.
Patient R8: Review of a telephone order for Patient R8 dated 9/28/11 at 0740 (7:40 a.m.) to discharge the patient to a local hospital had never been signed by the physician. Further review revealed the Physician ' s Discharge Orders for R8 dated 9/28/11 had never been signed by the physician.
Patient R9: Review of the Multidisciplinary Treatment Plan Review and Update form for Patient R9 dated 8/30/11 had never been signed by the physician.
Patient R10: Review of a physician ' s order for Patient R10 dated 10/7/11 at 9:25 a.m. for a local home health company to resume services had never been signed by the physician.

S10 (Medical Records) and the previous administrator and current member of the governing body of the hospital (S11) were interviewed on 4/11/12 at 11:00 a.m. S10 and S11 confirmed the missing signatures and reported they were unable to determine how many medical records were delinquent in the hospital.

The previous administrator and current member of the governing body of the hospital (S11) was interviewed on 4/11/12 at 1:20 p.m. S11 indicated that the hospital was unable to accurately track delinquent medical records as evidenced by being unable to determine the number of medical records that were not completed within 30 days of discharge. S11 reported that he did not know how many delinquent medical records were currently in the hospital.

Record review of policy titled " Health Information Management: HIM -09 Authentication Process of Medical Records " (pg 2 of 3) reveals " A chart is considered complete when the discharge summary is completed and signed, psychiatric evaluation is completed and signed by the attending physician and the physician signs all physician orders, and progress notes. "

Based on record review and interview, the hospital failed to ensure all entries entered into the patient's medical record were dated and/or timed and/or authenticated by the person responsible for providing or evaluating the services provided. This was evidenced during the review of 9 of 9 patients (Patient #1, Patient #2, Patient #7, Patient #11, Patient #12, Patient #R12, Patient #R13, Patient #R14, Patient #R16) whose medical records were reviewed for the dating/timing/authentication of medical records from a total sample of 42 patients. Findings:

Patient #1: Review of the medical record for Patient #1 revealed the Informed Consent for Psychotropic Medications form and the Admit Orders/Initial Plan of Care sheet had not been dated or timed by the physician.
Review of the medical record for Patient #1 revealed the physician had not timed the Admission Medication Reconciliation Form or the Admission History and Physical. Further review revealed the physician had also not timed the Progress Notes dated 3/30/12, 3/31/12, 4/2/12, 4/3/12, 4/4/12, 4/6/12, or 4/9/12. The Progress Note dated 3/30/12 had not been signed or dated by the physician.
In an interview on 4/9/12 at 2:45 p.m. with Director of Nursing (S2), S2 verified the documents listed above for Patient #1 had not been dated and/or timed by the physician. S2 said all documents signed by the physician should have been dated and timed.


Patient #2: Medical record review revealed physician orders dated 3/21/12 and 3/22/12 that were not timed and physician progress notes dated 3/23/12, 3/24/12, 3/26/12, 3/27/12, 3/28/12, 3/29/12, 3/30/12, 3/31/12, 4/02/12, 4/03/12, 4/04/12, 4/06/12 and 4/09/12 that were not timed. In an interview on 4/09/12 at 2:00 p.m., the Director of Nursing (S2) verified the orders and progress notes were not timed by the physician.

Patient #7: Medical record review revealed Patient #7 was admitted from a nursing home on 3/27/12 at 1900 (7:00 p.m.) with an admitting diagnosis of Alzheimer's. Record review of the Admit Orders/Initial Plan of Care was dated and signed by the admitting psychiatrist on 3/27/12. There was no documentation of the time this entry was made by the psychiatrist. Record review of the Telephone Order Read Back (TORB) Admission Medication Reconciliation Form dated 3/27/12 was signed by the psychiatrist. There was no documentation of the time this entry was made by the psychiatrist. Record review of the TORB dated 3/28/12 and timed 1530 (3:30 p.m.) by the nurse revealed missing documentation the medical doctor had authenticated this order. Record review of the TORB dated 3/29/12 and timed 1640 (4:40 p.m.) by the nurse revealed the psychiatrist's signature authenticating the order, but no time on the entry. Record review of the TORB dated 3/31/12 at 2115 (9:15 p.m.) and 2120 (9:25 p.m.)by the nurse revealed the psychiatrist's signature authenticating the orders, but no time on the two entries. Record review of the TORB dated 4/7/12 at 1655 (2:55 p.m.) revealed the psychiatrist's signature authenticating the orders, but no time on the entry. Record review of the Verbal Order dated 4/9/12 at 6:15 p.m., revealed no signature or time of the entry by the psychiatrist. Record review of Physician Progress Notes dated 3/30/12, 4/2/12, 4/3/12, 4/4/12, 4/6/12, and 4/9/12 revealed the physician's signature, but no time the entry was made. Record review of the Physician Progress Note dated 3/31/12 by Geriatric Nurse Practitioner revealed no time for the entry.

Patient #11: Review of the medical record for patient #11 revealed 15 of 15 progress notes had no time documented by the physician.
Patient #12: Medical record review revealed the psychiatric evaluation dated 3/06/12 that was not timed, physician orders dated 3/06/12 that were not timed and physician progress notes dated 3/09/12, 3/10/12, 3/12/12, 3/13/12, 3/14/12, 3/16/12 and 3/17/12 that were not timed. In an interview on 4/10/12 at 10:35 a.m., the Director of Nursing (S2) verified the psychiatric evaluation, the orders and progress notes were not timed by the physician.


Patient #R12: Medical record review revealed Patient #R12 was admitted on 1/4/12 at 1340 (1:40 p.m.) for a Depressive Disorder and discharged 1/26/12. Record review of Admit Orders/Initial Plan of Care reveals the psychiatrist's signature for this Telephone Order Read Back (TORB) authenticating the entry, but no time as to when this entry was made. Record review of the TORB Admission Medication Reconciliation Form dated 1/4/12 and timed at 1340 (1:30 p.m.) was signed authenticating the entry, but no time as to when this entry was made. Record review of the page 2 of the Physician's Discharge Orders (no date or time) revealed missing documentation of the physician's signature, date, and time of the entry.

Patient #R13: Medical record review revealed Patient #R13 was admitted to the hospital on 1/4/12 for Bipolar disorder and depression and was discharged home to the family on 1/12/12. Record review of Physician's Orders (pg 1 and 2) revealed a Telephone Order Read Back dated 1/12/12 and timed at 11:00 a.m. by the nurse, was missing the physician's signature to authenticate the TORB order and time of the entry. Record review of Physician's Discharge Orders (pg 2 of 3 and 3 of 3) dated 1/12/12 and timed at 11:50 a.m. revealed missing documentation of the physician's signatures and time of entry. On page 1 of the Physician's Discharge Orders, the physician signed, but did not date or time the entry.

Patient #R14: Medical record review revealed Patient #R14 was admitted on 1/5/12 and discharged on 1/20/12. Patient #R14 had a history of diabetes and was placed on an Insulin Sliding Scale on 1/6/12 at 1345 (1:45 p.m.). Record review of the Physician's Orders for Medication, Diet, and Treatments revealed a verbal order read back order by the medical physician. There was missing documentation the medical physician had authenticated this verbal order with a signature, dating, and time of entry.

Patient #R16: Medical record review revealed Patient #R16 was admitted on 1/9/12 with diagnoses of Major depression with psychosis, rule out (R/O) vascular dementia and was discharged 1/25/12. Record review of the Physician's Discharge Orders (2 pages) revealed no physician signature, date, or time to authenticate these discharge orders on either page.

Record review of policy titled " Health Information Management: HIM -09 Authentication Process of Medical Records " (pg 2 of 3) reveals " A chart is considered complete when the discharge summary is completed and signed, psychiatric evaluation is completed and signed by the attending physician and the physician signs all physician orders, and progress notes. "

The hospital's Medical Director (S8) was interviewed on 4/11/12 at 9:30 a.m. When asked about the timing of entries in the medical record, Medical Director (S8) indicated that he does not time many entries in the medical record including progress notes. S8 reported that he does not want to time entries in the medical record due to concerns about Medicare Fraud. S8 reported that he sees a lot of patients in the hospital and does not want to time the entries.


26313






30364

26458


Based on observation and interview, the hospital failed to ensure equipment/supplies were maintained at an acceptable level of quality as evidenced by 1) failing to ensure Glucometer control solutions and test strips manufacturer's recommendations were followed; 2) failing to ensure the floors and doors in patient care areas were in good repair; 3) failing to ensure the electrical receptacles in patient rooms were equipped with GFI (ground fault interrupter) circuits; and 4) failing to ensure all screw heads on the patient care unit were tamper proof. Findings:

1. Glucometer control solutions and test strips.
In an observation made with S9LPN on 04/09/12 at 12:45 p.m. it was noted that the Glucometer control solutions (used for accuracy checks of the Glucometer) and Test strips (used for patient blood glucose checks) had no documented evidence of the date they were opened. Review of the manufacturer's instructions on the label for both the control solutions and test strips revealed "expires 3 months after opening."

In an interview on 04/09/12 at 1:10 p.m. with S2DON she confirmed the manufacturer's instruction require both the control solutions and test strips to be discarded 3 months after opening and the only way to ensure compliance is by documenting the opening date on the containers.

2. Floors and doors on the patient care unit.
Observations on 4/09/12 between 10:30 a.m. and 11:00 a.m. in the presence of S2 (Director of Nursing) revealed the following:
-Sections of broken and/or missing and/or cracked floor tile were noted throughout the hospital including but not limited to the hallway, the patient dining area, and Patient Room #106 near the window in this room. S2 verified there were sections of flooring that were cracked and/or missing in the areas identified during this observation.

Observations on 4/11/12 at 10:30 a.m. revealed the outside of the door to Patient Room #103 was splintered at the bottom.

3. Electrical receptacles.
Observations on 4/09/12 between 10:30 a.m. and 11:00 a.m. in the presence of S2 (Director of Nursing) revealed the following:
-The electrical receptacles in Patient Room #101, Patient Room #102, and Patient Room #103 were not equipped with GFI (ground fault interrupter) circuits. S2 could provide no evidence to indicate the electrical receptacles were equipped with GFI circuits.

4. Tamper proof screw heads.
Observations on 4/09/12 between 10:30 a.m. and 11:00 a.m. in the presence of S2 (Director of Nursing) revealed the following:
-Non tamper proof screw heads were noted on the windows throughout the hospital and on the electrical receptacles in Patient Room #101, Patient #102, and Patient Room #103. The electrical receptacle cover was noted to be loose in Patient Room #101 and was easily removed by turning the non-tamper proof screw counterclockwise resulting in an exposed electrical receptacle in this room with no protective covering. S2 verified the screw heads were not tamper proof and verified the electrical receptacle covering was easily removed by hand resulting in an exposed receptacle in this patient room.

Based on observation, record review and interview, the hospital failed to meet the Condition of Participation of Special Provisions Applying to Psychiatric Hospitals by failing to be in compliance with one of the Conditions of Participation (CoP of Nursing Services at ?482.23) specified in ?482.1 through ?482.23 and ?482.25 through ?482.57.
(See findings at A0385, and A0395).

Based on observation, record review and interview, the Psychiatric hospital failed to meet the Conditions of Participation specified in ?482.1 through ?482.23 and ?482.25 through ?482.57 by failing to be in compliance with the Hospital's Condition of Participation requirements for Nursing Services at ?482.23. (See findings at A0385, A0395).