HospitalInspections.org

Based on document review, staff interviews, review of the professional staff rules and regulations and medical staff by-laws, the facility failed to ensure that the medical staff was accountable to the governing body for the quality of care provided to all patients. This was demonstrated by 74 physicians who had failed to complete medical records within 30 days after discharge during the period between 5/21/12 and 7/31/12. Findings include:

During an interview on 8/1/12 at 10:00 a.m., staff member K, the Medical Staff Services Supervisor, stated that providers with incomplete medical records more than 30 days after discharge were sent a letter signed by the Chief of Staff. The provider was put on an on-hold list, and the provider was flagged in the facility computerized documentation and ordering system so that the registration desk would know that the provider could not admit patients. Staff member L, during this interview, stated that the physician hold list was updated and kept current on the hospital intranet.

During review of the facility document, "Medical Staff By-laws" (with an approval date of 3/17/11), on 7/31/12 at approximately 2:30 p.m., item number 6.9.4 "Failure to Complete Medical Records" read as follows: "For failure to complete medical records in a timely fashion, a practitioner shall be placed on the 'admission hold list' and his clinical privileges and his right to admit patients shall be automatically suspended as described in the Rules and Regulations."

Review of the facility document labeled "Current Document On Hold Report" on 8/1/12 at approximately 8:30 a.m., read as follows: "Privileges of the Physician below have been suspended. Privilege Hold or Suspension means: 1. No new admissions. and 2. No hands-on procedures except the patients already hospitalized and under the physician's care prior to suspension." Review of the document revealed that during the period between 5/21/12 and 7/31/12, the number of physicians on the list was 74.

During review of the facility document "Professional Staff Rules and Regulations" on 8/1/12 at 3:50 p.m., item number 7 read as follows: "All patient charts must be completed within seven (7) days following the date the chart is available for completion."

Based on document review, staff interviews, review of the professional staff rules and regulations and medical staff by-laws, the facility failed to ensure that the medical staff enforced the bylaws to carry out its responsibilities of suspending a practitioner's privileges and their right to admit patients if medical records were not completed by medical staff in a timely manner. Findings include:

During an interview on 8/1/12 at 10:00 a.m., staff member K, Medical Staff Services Supervisor, stated that providers with incomplete records, more than 30 days after discharge, were sent a letter signed by the Chief of Staff. The provider was put on an on-hold list, and the provider was flagged in the facility computerized documentation and ordering system so that the registration desk would know that the provider could not admit patients. Staff member L stated that the physician hold list was updated and kept current on the hospital intranet.

During review of the facility document "Medical Staff By-laws", (with an approval date of 3/17/11), on 7/31/12 at approximately 2:30 p.m., item number 6.9.4 "Failure to Complete Medical Records" read as follows: "For failure to complete medical records in a timely fashion, a practitioner shall be placed on the 'admission hold list' and his clinical privileges and his right to admit patients shall be automatically suspended as described in the Rules and Regulations."

Review of the facility document labeled "Current Document On Hold Report" on 8/1/12 at approximately 8:30 a.m., read as follows: "Privileges of the Physician below have been suspended. Privilege Hold or Suspension means: 1. No new admissions. and 2. No hands-on procedures except the patients already hospitalized and under the physician's care prior to suspension." Review of the document revealed that in the period between 5/21/12 and 7/31/12, the number of physicians on the list was 74.

During review of the facility document "Professional Staff Rules and Regulations" on 8/1/12 at 3:50 p.m., item number 7 read as follows: "All patient charts must be completed within seven (7) days following the date the chart is available for completion."

During an interview on 8/1/12 at approximately 4:00 p.m., staff member L, a patient registration employee, stated that they do not have access to flagged information, and that Patient Flow had that information. Staff member M, a Patient Flow staff member, stated that the flagged information comes from Patient Registration. Staff member N, a patient registration staff member, stated that even though a physician is flagged as suspended, she is still able to enter the doctor's name to admit the patient. Staff member O, the Patient Registration Manager, stated that if a physician is flagged as suspended or on privilege hold status, registration staff call medical records and if appropriate, medical records staff remove the flag. She stated that this is not really a problem, because the facility Hospitalist providers do most of the admitting.

During an interview on 8/1/12 at approximately 4:15 p.m., staff member P, the Emergency Department Director, stated that 99% of the admissions were done by facility employee Hospitalists and Intensivists and they were not on the list. The survey staff asked for a current list of Hospitalists and Intensivists on the 'On-hold' list. At approximately 4:20 p.m. on 8/1/12, staff member P brought a list that contained the names of 5 Intensivists and 11 Hospitalists. On this list, one Intensivist and 4 Hospitalists were on the suspended on-hold list.

Based on document review, staff interview, review of professional staff rules and regulations and medical staff by-laws, the facility failed to ensure that medical records were promptly completed no later than 30 days after discharge. Findings include:

On 7/31/12 at 1:50 p.m., during an interview with staff member J, the Medical Record Supervisor, stated that she tracked the number of medical records that were incomplete or not signed by the physician within 30 days of discharge.
According to the facility document labeled "Hospital Medical Record Statistics Form" completed on 6/30/12, for the quarter that ended on 6/1/12, there were 297 records that were incomplete or not signed by the physician. Review of the document indicated that the number of incomplete records varied from 305 records in quarter 3 to 482 in quarter 1. According to staff member J, those quarterly numbers comprised 17.5% to 28.4% of discharged patient records.

During review of the facility document "Medical Staff By-laws" (with an approval date of 3/17/11) on 7/31/12 at approximately 2:30 p.m., item number 6.9.4 "Failure to Complete Medical Records" read as follows: "For failure to complete medical records in a timely fashion, a practitioner shall be placed on the 'admission hold list' and his clinical privileges and his right to admit patients shall be automatically suspended as described in the Rules and Regulations."

During review of the facility document "Professional Staff Rules and Regulations" on 8/1/12 at 3:50 p.m., item number 7 read as follows: "All patient charts must be completed within seven (7) days following the date the chart is available for completion."

In a second interview with staff member J on 8/1/12 at 9:00 a.m., the staff member verified the information given on 7/31/12, and repeated the same numbers of incomplete records.