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Based on record review and interview the hospital's Medical Staff failed to enforce Medical Staff Bylaws by having 33 delinquent Medical Records (5 greater than 30 days, 5 greater than 60 days, and 23 greater than 90 days) with discharge dates ranging from 7/06/2010 through 2/25/2011. Findings:

Review of the hospital's Medical Staff Bylaws, presented by the hospital as current, revealed in part, "(page 29) Medical Records: Members of the Medical Staff are required to complete medical records within 30 days of a patient's discharge. A temporary suspension in the form of withdrawal of admitting and other related Privileges until medical records are completed shall be imposed by the Medical Director, or his or her designee, after notice of delinquency for failure to complete medical records within that period."

Review of the hospital policy titled, "Delinquent Medical Records. Original Date: 3-15-11" presented by the hospital as their current policy revealed in part, "All records are to be completed within 30 days after discharge. . . The staff will be notified, verbally, in morning FLASH (staff) meeting of audit deficiencies. The physicians will be notified, verbally, by medical Records as they make rounds in the hospital. After 14 days, a written notice will be sent to the physician and to the staff by the Medical Record Tech and Administration notifying them of any incomplete medical records and that all corrections must be made within 14 days. This written notification will describe disciplinary action if corrections are not made. At 30 days, the staff will no longer be scheduled for work until delinquencies are corrected and physicians will lose admitting privileges until deficiencies are corrected. A certified letter will be sent to the physician by the Administrator informing them of their suspension of privileges."

Review of a list of delinquent medical records, ranging from the discharge date of 7/06/2010 through the discharge date of 2/25/2011, provided by the Medical Records Department revealed Physician S3 had one delinquent medical record (greater than 30 days), Physician S4 had 2 delinquent medical records (1 greater than 30 days, 1 greater than 90 days), Physician S5 had 11 delinquent medical records (3 greater than 60 days, 8 greater then 90 days), Physician S6 had 9 delinquent medical records (2 greater than 30 days, 2 greater than 60 days, and 5 greater than 90 days), Physician S7 had 4 delinquent medical records (greater than 90 days), and Physician S8 had 6 delinquent medical records (1 greater than 30 days, and 5 greater than 90 days). Beacon Behavioral Hospital of New Orleans is a 24 bed hospital.

Medical Records Secretary S9 and Hospital Administrator S2 were interviewed face to face on 4/08/2011 at 9:20 a.m. S2 indicated the hospital had chosen not to suspend any physician for old delinquencies due to offering physicians an opportunity to get caught up with records who delinquency date existed prior to the hospital's Plan of Correction Date of 3/31/2011. S2 and S9 indicated at the time of the survey (4/07/2011 through 4/08/2011) there had been no "written notices" provided to physicians regarding 14 day delinquencies as indicated in the new policy titled, "Delinquent Medical Records". S2 and S9 indicated it was their plan to implement the policy after giving physicians an opportunity to correct delinquencies that existed prior to the adoption of the new policy/protocol. S2 indicated there had been no physician suspended from practice at the hospital.

Review of Medical Executive Committee Meeting Minutes dated 3/30/2011 revealed in part, "Surveyors wanted to see enforcement of the bylaws. Discussion of delinquent records. Resolution - physical placement of charts, process in the hospital for suspension privileges. Dictation discussed. . ."

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20638

Based on record review and interview the hospital failed to ensure a Registered Nurse supervise and evaluate the nursing care for each patient by failing to assess the cause of a gross documented weight loss for 1 of 1 patients reviewed with a substantial weight loss out of a total sample of 10 (Patient # 3). Findings:

Review of Patient #3's medical record revealed the patient was admitted to the hospital on 3/24/2011 with a documented weight of 158 pounds. Further review revealed Patient #3's documented weight on 4/01/2011 was 109 pounds (documented weight loss of 49 pounds in 8 days). Review of the entire medical record revealed no documented investigation/assessment of the documented 49 pound weight loss to include re-weighing the patient and/or investigation to see if there had been an error in one of the recorded weights.

The surveyor requested that Patient #3 be weighed on 4/08/2011 at 8:30 a.m. Patient #3's weight was 153 pounds- a weight loss of 5 pounds from the date of admission/15 days.

During a face to face interview on 4/08/2011 at 8:20 a.m., Director of Nursing S1 indicated the gross difference in weight for Patient #3 from his admission on 3/24/2011 when the patient weighed 158 pounds to the date of 4/01/2011 when the patient's recorded weight was 109 pounds was most likely an error; however, the nurse providing care to the patient should have noticed the gross difference in numbers and should have assessed the findings to include re-weighing the patient.

20638

Based on record review and interview the hospital failed to ensure an updated current nursing plan of care was in place for 1 of 1 patients reviewed for modifying the nursing care plan post seclusion placement out of a total sample of 10. (Patient #2). Findings:

Review of Patient #2's Medical Record revealed the patient was admitted to the hospital on 3/31/2011. Further review revealed Patient #2 was placed in Seclusion on 4/01/2011 at 12:45 p.m. and released at 1440 (2:40 p.m.). Further review revealed Patient #2 was again placed in Seclusion on 4/02/2011 at 12:50 p.m. and released on 4/02/2011 at 3:30 p.m.

Review of Patient #2's entire Medical Record revealed no documented evidence that the Patient's Treatment Plan/Nursing Plan of Care was modified to reflect the use of Seclusion as an intervention for disruptive behavior (need for seclusion, provision of safety, physical needs assessment/provisions, etc.).

During a face to face interview on 4/08/2011 at 8:30 a.m., Director of Nursing S1 confirmed there had been no modification of Patient #2's Plan of Care regarding the use of Seclusion on 4/01/2011 or 4/02/2011. S1 indicated staff should have updated the plan of care.

Based on record review and interview the hospital failed to ensure Medical Records were completed within 30 days of discharge as per hospital policy for 33 of 33 delinquent medical records reviewed (5 greater than 30 days, 5 greater than 60 days, and 23 greater than 90 days) with discharge dates ranging from 7/06/2010 through 2/25/2011. Findings:

Review of the hospital's Medical Staff Bylaws, presented by the hospital as current, revealed in part, "(page 29) Medical Records: Members of the Medical Staff are required to complete medical records within 30 days of a patient's discharge. A temporary suspension in the form of withdrawal of admitting and other related Privileges until medical records are completed shall be imposed by the Medical Director, or his or her designee, after notice of delinquency for failure to complete medical records within that period."

Review of the hospital policy titled, "Delinquent Medical Records. Original Date: 3-15-11" presented by the hospital as their current policy revealed in part, "All records are to be completed within 30 days after discharge. . . The staff will be notified, verbally, in morning FLASH (staff) meeting of audit deficiencies. The physicians will be notified, verbally, by medical Records as they make rounds in the hospital. After 14 days, a written notice will be sent to the physician and to the staff by the Medical Record Tech and Administration notifying them of any incomplete medical records and that all corrections must be made within 14 days. This written notification will describe disciplinary action if corrections are not made. At 30 days, the staff will no longer be scheduled for work until delinquencies are corrected and physicians will lose admitting privileges until deficiencies are corrected. A certified letter will be sent to the physician by the Administrator informing them of their suspension of privileges."

Review of a list of delinquent medical records, ranging from the discharge date of 7/06/2010 through the discharge date of 2/25/2011, provided by the Medical Records Department revealed Physician S3 had one delinquent medical record (greater than 30 days), Physician S4 had 2 delinquent medical records (1 greater than 30 days, 1 greater than 90 days), Physician S5 had 11 delinquent medical records (3 greater than 60 days, 8 greater then 90 days), Physician S6 had 9 delinquent medical records (2 greater than 30 days, 2 greater than 60 days, and 5 greater than 90 days), Physician S7 had 4 delinquent medical records (greater than 90 days), and Physician S8 had 6 delinquent medical records (1 greater than 30 days, and 5 greater than 90 days). Beacon Behavioral Hospital of New Orleans is a 24 bed hospital.

Medical Records Secretary S9 and Hospital Administrator S2 were interviewed face to face on 4/08/2011 at 9:20 a.m. S2 indicated the hospital had chosen not to suspend any physician for old delinquencies due to offering physicians an opportunity to get caught up with records who delinquency date existed prior to the hospital's Plan of Correction Date of 3/31/2011. S2 and S9 indicated at the time of the survey (4/07/2011 through 4/08/2011) there had been no "written notices" provided to physicians regarding 14 day delinquencies as indicated in the new policy titled, "Delinquent Medical Records". S2 and S9 indicated it was their plan to implement the policy after giving physicians an opportunity to correct delinquencies that existed prior to the adoption of the new policy/protocol. S2 indicated there had been no physician suspended from practice at the hospital.

Review of Medical Executive Committee Meeting Minutes dated 3/30/2011 revealed in part, "Surveyors wanted to see enforcement of the bylaws. Discussion of delinquent records. Resolution - physical placement of charts, process in the hospital for suspension privileges. Dictation discussed. . ."

20638

Based on record review and interview the hospital failed to ensure all entries in medical records were timed for 3 of 10 medical records reviewed (Patient's # 4, #6, #10). Findings:

Review of Patient #4's medical record revealed "Physician's Progress Notes" dated 3/30/2011, 4/02/2011, and 4/03/2011 with no documented time as to when the entries were made.

Review of Patient #6's medical record revealed "Physician's Progress Notes" dated 4/06/2011 with no documented time as to when the entry had been made.

Review of Patient #10's medical record revealed "Physician's Progress Notes" dated 4/02/2011 with no documented time as to when the entry had been made.

During a face to face interview on 4/08/2011 at 11:00 a.m., Director of Nursing S1 confirmed there had been no timing of entries on the above listed "Physician's Progress Notes" for Patients #4, #6, #10. S1 indicated the hospital had placed Instructional Sheets as Reminders in all medical records since the last survey (confirmed with record review) reminding physicians and staff of the need to time all entries. S1 indicated the hospital may need to revise the "Physician's Progress Notes" form to assist Physicians in remembering to document the time of entries.

20638

Based on record review and interview the hospital failed to ensure documented medical history and physical examinations were in patient records within 24 hours of admission for 3 of 10 sampled patients (#1, #5, #8). Findings:

Review of Patient #1's medical record revealed the patient was admitted to the hospital on 4/04/2011. Further review revealed the patient's dictated History and Physical Examination was transcribed on 4/06/2011 (2 days after admission to the hospital).

Review of Patient #5's medical record revealed the patient was admitted to the hospital on 3/25/2011. Further review revealed the patient's hand written History and Physical Examination was documented on 3/27/2011 (2 days after admission to the hospital).

Review of Patient #8's medical record revealed the patient was admitted to the hospital on 3/31/2011. Further review revealed the patient's dictated History and Physical Examination was transcribed on 4/02/2011 (2 days after admission to the hospital).

During a face to face interview on 4/08/2011 at 11:00 a.m., Director of Nursing S1 confirmed documented History and Physical Examinations for Patient #1, #5, and #8 were not on the medical record within 24 hours of admission as they should have been.

20638

Based on record review and interview the hospital failed to ensure an updated current nursing plan of care was in place for 1 of 1 patients reviewed for specific treatment modalities utilized when a patient had been placed in seclusion for management of disruptive behavior out of a total sample of 10 (Patient #2). Findings:

Review of Patient #2's Medical Record revealed the patient was admitted to the hospital on 3/31/2011. Further review revealed Patient #2 was placed in Seclusion on 4/01/2011 at 12:45 p.m. and released at 1440 (2:40 p.m.). Further review revealed Patient #2 was again placed in Seclusion on 4/02/2011 at 12:50 p.m. and released on 4/02/2011 at 3:30 p.m.

Review of Patient #2's entire Medical Record revealed no documented evidence that the Patient's Treatment Plan/Nursing Plan of Care was modified to reflect specific treatment modalities utilized when the patient was placed in seclusion for management of disruptive behavior.

During a face to face interview on 4/08/2011 at 8:30 a.m., Director of Nursing S1 confirmed there had been no modification of Patient #2's Plan of Care regarding the use of Seclusion on 4/01/2011 or 4/02/2011. S1 indicated staff should have updated the plan of care to include the specific treatment modalities utilized when the patient was placed in seclusion.