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Based on interview and record review, the hospital failed to ensure reappointment for NPs 1 and 2 was based upon provider qualifications when review of performance evaluation documentation showed the performance evaluations were incomplete and inaccurate and were based on flawed methods for creating performance evaluation summaries. This failure created the risk of substandard healthcare by medical staff members.

Findings:

The hospital's policy titled Ongoing Professional Practice Evaluation (OPPE) effective 5/7/14, read in part, "The information resulting from the OPPE shall be used in conjunction with other peer review evaluative methods to determine whether to continue, limit or revoke an existing privilege(s)."

The hospital's policy titled Credentialing Process effective 4/8/14, read in part, "Upon receipt of the application, the (hospital) will conform to the Credentials Verifications Methods and Requirements as delineated in attachments A and B, which includes: ...Obtain Quality Assessment Clinical Performance Profile recommendation of the department chair in a timely manner to permit adequate review and evaluation."

A list of allied health providers approved after 5/18/14, was requested and provided. From that list, NPs 1 and 2 were selected for review. Documentation showed both NPs were approved by the Governing Body on 5/30/14.

During a review of the credential and performance evaluation data for NPs 1 and 2, the files showed both providers were reappointed on 5/30/14. Both provider files contained performance review summary sheets for the year 2013, with a column containing a list of evaluation criteria and a column for the scores associated with the criteria. The criteria included such items as the number of patient encounters, the number of cases reviewed for the provider, the number of cases in which provider performance was found deficient and the number of errors made in prescribing. However, the scoring columns showed one NP had five patient encounters while the other NP had "0." All of the other criteria scores were "0" for both of the NPs. The bottom of each sheet was signed by the department chairperson on 5/14/14.

The NPs' patient rosters since 5/18/14, were requested for review. NP 1 saw 17 patients and NP 2 saw 30 patients between 5/18 and 6/14/14. The number of patients seen in 2013, by both NPs was requested. The 2013 data for NP 1 was provided from the electronic health record system and showed six patient encounters in 2013, while the data for NP 2 showed 666 patient encounters.

During an interview with Medical Staff Leader 1 on 6/17/14 at 1130 hours, he reviewed the provider performance evaluation summary sheets signed 5/14/14, for NP 1 and NP 2. The Medical Staff Leader concurred the documentation appeared incorrect. The Medical Staff Leader stated the data did not reflect the number of patients seen and there was no peer review data.

The Medical Staff Leader stated he believed peer review and performance quality assessment was done by the departments with which the NPs were associated and the reviews were in the department's files. The departmental files for NPs 1 and 2 were requested for review.

During a follow-up interview with Medical Staff Leader 1 on 6/17/14 at 1430 hours, he stated NP 1 provided services in the pediatric clinic, and records were kept on paper in that clinic. The Medical Staff Leader stated the OPPE data was abstracted via a computer program. The Medical Staff Leader stated he believed the visits were documented on paper by NP 1 were not included in the data abstracted.

The Medical Staff Leader stated it could be that the computer system was also not picking up data on services provided by NP 2 at the offsite inpatient psychiatry building.

During an interview with the Director of Accreditation on 6/17/14 at 1445 hours, she stated that NP 1 provided services at the hospital but was actually employed by another entity, and there was no departmental personnel file for NP 1 at the hospital. The Director stated she was unable to state how many allied health staff at the hospital were employees of another entity and did not have departmental personnel files at the hospital.

During a second interview with the Director of Accreditation on 6/17/14 at 1510 hours, she stated any file for NP 2 would be housed at the inpatient psychiatry unit which was at a separate geographic location from the main campus. NP 2's file, or a summary of its contents, was requested, but was not provided at the time of the survey exit on 6/17/14 at 1600 hours.

Based on interview and record review, the hospital failed to ensure the medical records were complete and accurate for three of 23 sampled patients (Patients 86, 88 and 90). This could lead to lack of knowledge in providing care to these patients.

Findings:

1. Review of the hospital's P&P titled Legal Health/Medical Record dated 11/12/13, showed all entries should be made as soon as possible after the care is provided, or an event or observation is made. Pre-dating or backdating an entry is not permitted. When an error is made in a medical record entry, the original entry must not be obliterated, and the inaccurate information shall remain accessible.

When a pertinent entry was missed or not written in a timely manner, the author must meet the following requirements:

* Identify the new entry as a "late entry."

* Enter the current date and time- do not attempt to give the appearance that the entry was made on a previous date or an earlier time.

* Identify or refer to the date and circumstance for which the late entry or addendum is written.

* Document the current date and time.

* Write "addendum" and state the reason for the addendum referring back to the original entry.

1. Review of Patient 86's medical record was initiated on 6/16/14, and showed the patient was admitted to the hospital on 6/3/14.

The Authorization for and Informed Consent for Surgery or Special Diagnostic or Therapeutic Procedures form showed Patient 86 signed and consented for bone marrow biopsy and aspiration. The form was signed by MD AF on 6/4/14 at 0907 hours. However, there was no date and time to show when the patient signed the form. Further review showed the section of witness was left blank.

During an interview and concurrent medical record review was conducted with RN AD and RN AE on 6/16/14 at 1450 hours, both staff confirmed the Informed Consent for Surgery or Special Diagnostic or Therapeutic Procedure form was not completed as shown above.

A follow-up review of Patient 86's medical record was conducted on the next day, 6/17/14. The same above form showed Patient 86 signed and consented for the procedure on 6/4/14 at 0907 hours. The section for a witness signature was completed by MD AG and signed on 6/4/14 at 0907 hours.

During an interview and concurrent medical record review with the Assistant Nursing Director on 6/17/14 at 0835 hours, the Assistant Nursing Director was made aware the above Authorization for and Informed Consent for Surgery or Special Diagnostic or Therapeutic Procedures form for Patient 86 was altered.


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2. On 6/17/14, Patient 88's medical record review was conducted and showed the patient was a pediatric patient admitted to the hospital on 6/16/14, for a surgical procedure.

The Pediatric Admission form showed the patient's height was 5 feet 6 inches and the weight was 183 kg (equal to 402.6 pounds).

The Orthopaedic's Admission/Transfer Orders dated 6/16/14 at 0750 hours, showed the orders included the pain medications (morphine and Norco) and IV antibiotics. The sections on the order sheet for the physician to document the height and weight of the patient were left blank.

The Physician's Orders dated 5/6/14 at 0935 hours, showed the orders included IV fluid of 110 ml/hr and antibiotics. The sections on the order sheet for the physician to document the height and weight of the patient were left blank.

The Physician's Orders dated 6/16/14 at 1529 hours, showed the patient's weight was recorded, but the height was missing.

The findings were concurred with RN AN on 6/17/14 at 1000 hours. RN AN stated all the forms should be filled out. They should not be left blank.


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3. The medical record for Patient 90 was reviewed on 6/16/14, and showed the patient presented to the Emergency Department on 5/29/14, and was seen by members of the surgical team.

A note dated 5/29/14 at 0449 hours, by an attending physician read, "Surgery History & Physical Attending: I agree with above assessment. We have to consider the possibility of a tumor at the ampulla." However, there was no history and physical assessment above the physician's note. The History and Physical was written by the resident physician on 5/29/14 at 0945, five hours later.

During an interview with the Interim HIM Director on 6/16/14 at 1555 hours, she concurred the note of agreement by the attending physician was written prior to the history and physical examination note with which it stated agreement.

Based on interview and record review, the hospital failed to ensure the medical records were complete and accurate for three of 23 sampled patients (Patients 86, 88 and 90). This could lead to lack of knowledge in providing care to these patients.

Findings:

1. Review of the hospital's P&P titled Legal Health/Medical Record dated 11/12/13, showed all entries should be made as soon as possible after the care is provided, or an event or observation is made. Pre-dating or backdating an entry is not permitted. When an error is made in a medical record entry, the original entry must not be obliterated, and the inaccurate information shall remain accessible.

When a pertinent entry was missed or not written in a timely manner, the author must meet the following requirements:

* Identify the new entry as a "late entry."

* Enter the current date and time- do not attempt to give the appearance that the entry was made on a previous date or an earlier time.

* Identify or refer to the date and circumstance for which the late entry or addendum is written.

* Document the current date and time.

* Write "addendum" and state the reason for the addendum referring back to the original entry.

1. Review of Patient 86's medical record was initiated on 6/16/14, and showed the patient was admitted to the hospital on 6/3/14.

The Authorization for and Informed Consent for Surgery or Special Diagnostic or Therapeutic Procedures form showed Patient 86 signed and consented for bone marrow biopsy and aspiration. The form was signed by MD AF on 6/4/14 at 0907 hours. However, there was no date and time to show when the patient signed the form. Further review showed the section of witness was left blank.

During an interview and concurrent medical record review was conducted with RN AD and RN AE on 6/16/14 at 1450 hours, both staff confirmed the Informed Consent for Surgery or Special Diagnostic or Therapeutic Procedure form was not completed as shown above.

A follow-up review of Patient 86's medical record was conducted on the next day, 6/17/14. The same above form showed Patient 86 signed and consented for the procedure on 6/4/14 at 0907 hours. The section for a witness signature was completed by MD AG and signed on 6/4/14 at 0907 hours.

During an interview and concurrent medical record review with the Assistant Nursing Director on 6/17/14 at 0835 hours, the Assistant Nursing Director was made aware the above Authorization for and Informed Consent for Surgery or Special Diagnostic or Therapeutic Procedures form for Patient 86 was altered.


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2. On 6/17/14, Patient 88's medical record review was conducted and showed the patient was a pediatric patient admitted to the hospital on 6/16/14, for a surgical procedure.

The Pediatric Admission form showed the patient's height was 5 feet 6 inches and the weight was 183 kg (equal to 402.6 pounds).

The Orthopaedic's Admission/Transfer Orders dated 6/16/14 at 0750 hours, showed the orders included the pain medications (morphine and Norco) and IV antibiotics. The sections on the order sheet for the physician to document the height and weight of the patient were left blank.

The Physician's Orders dated 5/6/14 at 0935 hours, showed the orders included IV fluid of 110 ml/hr and antibiotics. The sections on the order sheet for the physician to document the height and weight of the patient were left blank.

The Physician's Orders dated 6/16/14 at 1529 hours, showed the patient's weight was recorded, but the height was missing.

The findings were concurred with RN AN on 6/17/14 at 1000 hours. RN AN stated all the forms should be filled out. They should not be left blank.


26881


3. The medical record for Patient 90 was reviewed on 6/16/14, and showed the patient presented to the Emergency Department on 5/29/14, and was seen by members of the surgical team.

A note dated 5/29/14 at 0449 hours, by an attending physician read, "Surgery History & Physical Attending: I agree with above assessment. We have to consider the possibility of a tumor at the ampulla." However, there was no history and physical assessment above the physician's note. The History and Physical was written by the resident physician on 5/29/14 at 0945, five hours later.

During an interview with the Interim HIM Director on 6/16/14 at 1555 hours, she concurred the note of agreement by the attending physician was written prior to the history and physical examination note with which it stated agreement.