HospitalInspections.org

Based on review of credential files, review of the Bylaws of the Medical Staff and staff interview; the Critical Access Hospital (CAH) failed to follow the Medical Staff Bylaws in the reappointment of 7 of 9 physicians reviewed (Physicians I, K, L, M, N, P and Q). The Medical Staff roster listed 96 physicians. This failed practice has the potential to affect all patients receiving services at the hospital.

Findings are:

A. Review of the Bylaws of the Medical Staff (approved by the Board of Directors 6/21/16 and revised in August 2012) revealed the following under Article VI Procedure for Appointment and Re-Appointment, Section 3 Reappointment Process:
" Each recommendation concerning the reappointment of a Medical Staff member and the clinical privileges to be granted upon reappointment shall be based upon such member's...professional judgment...ability to take history and physical exam, record keeping...patient management, physician-patient relationship, participation in Medical Staff affairs, compliance with hospital and Medical Staff Bylaws and Rules and Regulations, use of hospital facilities for his patients...attendance at Medical Staff meetings...his general attitude toward patients, hospital and the public, professional competence, clinical judgment in the treatment of patients.... "

B. Review of the credential files for Physicians I, K, L, M, N, P and Q revealed information on current license, current Drug Enforcement Administration (DEA) license, query of the National Practitioner Data Bank (provides information on malpractice payments and certain adverse actions related to the physician being queried), malpractice insurance, list of privileges, the reappointment application, peer references and hospital references. However, these files lacked information related to the physician's practice at Sidney Regional Medical Center i.e. number of patients admitted, number of procedures performed, medical record completion, whether there were any complaints against the physician, any quality issues identified.

C. Interview with the Chief Executive Officer (CEO) via telephone on 1/28/16 from 8:55 AM to 9:00 AM confirmed when the physician's credential files were presented to the Medical Staff and the Board of Director there was no other information available other than what was in the credential files.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to have complete, accurate and readily accessible medical records for 4 of 42 sampled records. Of the 4 records: 2 outpatient records (Patients 41 and 42) lacked a nursing assessment; 1 inpatient record (Patient 11) lacked a swallow evaluation by Speech Therapy (An evaluation of the strength, movement, and coordination of muscles of the mouth and throat used in chewing and swallowing); and 1 inpatient record (Patient 7) lacked a diagnosis for a foley catheter (A tube in the bladder to drain the urine). This failed practice of incomplete medical records has the potential to affect all patients that were provided services at the CAH.

Findings are:

A. A review of Patient 11's medical record revealed a Physician order on 12/23/15 for Speech Therapy -Swallow Evaluation- Diagnosis: Dysphagia (difficulty swallowing), Aspiration (introduction of food or fluid into the windpipe or lungs), and MS (Multiple Sclerosis-disease of the central nervous system) when Patient 11 was admitted to acute level of care. Review of the medical record lacked any documentation that Speech Therapy provided the Swallow Evaluation during Patient 11's hospital stay.

- An interview with the HIM (Health Information Management) Director on 1/27/16 at 9:10 AM verified that Patient 11's medical record lacked a Swallow Evaluation during the hospital stay from 12/23/15-12/26/15.

-An interview with the Director of Nurses (DON) on 1/26/16 at 3:30 PM revealed, that the Speech Therapist was on vacation that week and the back up Speech Therapist didn't get called.

B. A review of Patient 7's, medical record from 1/14/16- 1/18/16 revealed the following:
-A 1/14/16 14:15 (2:15 PM) Emergency Room note from the Physician Assistant revealed: Patient 7 arrived per the community ambulance with a chief complaint of fever and an episode of "passing out" at the nursing home this morning... Denies any headache, chest pain, shortness of breath, or cough. No abdominal pain, nausea or vomiting. No problem with urination... Impression: Fever, UTI (urinary tract infection), Suspected lung infection. Disposition: Admit to the hospital.
-Admission orders from the Physician Assistant at 1/14/15 16:34 (4:34 PM) "Foley Cath (catheter) with routine cares".
-A review of the random Nurses Notes for Patient 7 revealed:
-1/14/16 13:44 (1:44 PM) "Assisted pt (patient) to bedside commode, Pt tolerated. Pt has small loose stool and urine noted.";
-1/14/16 1400 (2:00 PM) "Assisted pt to BSC (bedside commode) 2 person assist. Urine specimen obtained. Pt tolerated.";
-1/14/16 18:31 (6:31 PM) "Foley catheter inserted using # 16 french (size of catheter)"; "gait unsteady, moderate assist (needs moderate assistance with walking)";
-1/15/16 9:00 AM "Gait steady, Transfers with x1 minimal assist and gait belt (needs minimal assistance with walking).";"Foley catheter in place, draining.";
-1/16/16 7:15 AM "Urine appearance dark yellow, Foley catheter in place, draining.";
-1/16/16 11:45 AM "Patient ambulates with one assist 300 feet, tolerates well, gait steady, returns to room and up in bedside chair for lunch.";
-1/17/16 13:35 (1:35 PM) "Foley cath D/C (discontinued)"; 19:10 (7:01 PM) "Denies urinary symptoms, Voiding without difficulty"

-Review of Patient 7's Discharge Summary dated 1/18/16 revealed final diagnoses of:
1) Acute pyelonephritis with sepsis (kidney infection with a the presence of a systemic illness)
2) Acute Bronchitis (inflammation of the breathing tubes within the lungs)
3) Fever due to the above.

-An interview with the Director of Nurses (DON) on 1/26/16 at 3:30 PM verified Patient 7's medical record lacked a diagnosis for the foley catheter.





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C. Review of Patient 41's outpatient record, revealed the patient was seen by an Orthopedic Physician on 12/18/15 and received an injection of Depo Medrol (an anti-inflammatory medication) and lidocaine (medication used to numb tissue) for pain in both shoulders. Review of the entire electronic outpatient record with the Director of Physicians Clinics revealed no nursing assessment with vital signs.

D. Review of Patient 42's outpatient record, revealed the patient was seen by a Podiatrist for a torn ligament in the right ankle/foot area. Review of the entire electronic outpatient record with the Director of Physicians Clinic revealed no nursing assessment with vital signs.

Interview with the Director of Physicians Clinics on 1/27/16 at 11:22 AM revealed the nurses take vital signs and document the information on the bottom of the face sheet which is then given to the physician. When the physician is finished with the face sheet it is shredded.

Based on record review, staff interview and review of Medical Staff Rules and Regulations, the Critical Access Hospital (CAH) failed to ensure that 5 of 5 (Patients 32, 33, 34, 35 and 36) patients medical records included an updated History and Physical (H&P) at the time of the Patients Swing bed admission. This failed practice has the potential to affect all patients that were admitted to Swing bed at the CAH.

Findings are:

A. A review of Patient 32's medical record revealed that the patient was admitted to Swing bed status on 1/23/16. The History and Physical for Patient 32 which was located on the Swing bed record was dated 1/18/16.

B. A review of Patient 33's medical record revealed that the patient was admitted to Swing bed status on 1/22/16. The History and Physical for Patient 33 which was located on the Swing bed record was dated 1/13/16.

C. A review of Patient 34's medical record revealed that the patient was admitted to Swing bed status on 12/16/15. The History and Physical for Patient 34 which was located on the Swing bed record was dated 12/4/15.

D. A review of Patient 35's medical record revealed that the patient was admitted to Swing bed status on 12/22/15. The History and Physical for Patient 35 which was located on the Swing bed record was dated 12/13/15.

E. A review of patient 36's medical record revealed the the patient was admitted to Swing bed status on 1/1/16. The History and Physical for Patient 36 which was located on the Swing bed record was dated 12/28/15.

F. Review of the Medical Staff Rules and Regulations (dated July 2012) revealed under the Medical Records section:
- " ...A complete admission history and physical examination shall be recorded by the admitting Medical Staff member no more than thirty days prior and within twenty-four hours after admission and prior to any surgical procedure. This report should include all pertinent findings resulting from an assessment of all the systems of the body. When the H&P is conducted within 30 days before admission or registration, an update must be completed and documented by a licensed practitioner who is credentialed and privileged by the medical Staff to perform an H&P ... "
- " ...When a patient is re-admitted within 30 days for the same or related problem, an interval history and physical examination note reflecting any subsequent changes may be used in addition to the original information to the record. To be acceptable, outside records shall be in form approved by the Health Center and shall be compatible with its current medical records system ... "

G. An interview with the HIM (Health Information Management) Director on 1/26/16 at 10:10 AM verified that Patient 32, 33, 34, 35 and 36 ' s medical records lacked a current H&P at the time of admission to Swing bed status.

Based on review of the Quality Assurance Process Improvement committee meeting minutes, review of the Performance Improvement Plan and staff interview; the Critical Access Hospital (CAH) failed to include 2 of 10 services (nutritional services and environmental services) provided by the CAH and 3 of 4 services (vascular ultrasound, nuclear medicine and lithotripsy) provided through contract in the Quality Assurance Process Improvement program. This failed practice has the potential to affect all patients of the CAH.

Findings are:

A. Review of the Performance Improvement Plan with a last revised date of 11/17/15 revealed the following under "PROCEDURE":
-"3.11 The Performance Improvement Program evaluates all patient care services provided by contract staff and SRMC [Sidney Regional Medical Center] personnel...."; and,
-"3.14 Every Department within SRMC is responsible for implementing performance improvement activities and must be conducted as a part of the hospital wide Performance Improvement Committee Activities".

B. Interview with the Director of Nutrition Services, Manager of Nutrition Services and Vice-President of Extended Care Services on 1/26/16 from 9:30 AM to 11:00 AM revealed the department keeps statistical data, tracks temperatures and complaints but did not report this information to the Quality Assurance Process Improvement committee.

C. Interview with the Director of Quality and Education on 1/27/16 from 1:00 PM to 2:30 PM revealed the following:
-Nutrition Services and Environmental services were not included in the reporting to the Quality Assurance Process Improvement Committee; and,
-The contracted services of Lithotripsy, Nuclear Medicine and Vascular Ultrasound were not included in the Quality Assurance program at the CAH.

D. Review of the Quality Assurance Process Improvement committee meeting minutes for 1/13/15, 4/13/15, 7/15/15, 10/12/15 and 1/12/16 (Quality Assurance Process Improvement committee meets quarterly) revealed that no quality information had been reported for the services of nutrition, environmental, nuclear medicine, vascular ultrasound and lithotripsy.

Based on staff interview, Swing bed packet information and review of 5 of 5 Swing bed patient records (Patients 32, 33, 34, 35 and 36); the CAH (Critical Access Hospital) failed to ensure that a qualified professional directed the patient activities program for the Swing bed patients and complete the Swing bed Activity Assessment.
This had the potential to effect all patients admitted to swing beds.

Findings are:

A. An interview with the Social Worker on 1/27/16 at 4:15 PM, verified:
-That the social services staff does the Activity documentation for the Swing bed patients.
-That there is not a qualified activity professional completing the Activity Assessments currently at the hospital for the Swing bed patients.
-That before the new hospital was built that the old hospital was connected to the extended care facility. There was a qualified activity person at the extended care facility that could do the assessments. The Swing bed patients could also join in on the extended care facility activities if they desired.

C. The record review for Swing bed Patients 32, 33, 34, 35 and 36 revealed that the records lacked an Activity Assessment completed by a qualified professional.

D. A review of the "WELCOME To The Swing Bed Program" Patient Orientation Packet that is provided to each Swing bed patient on admission stated, "Activities- The social worker will evaluate your leisure needs, abilities and interests..."

Based on record review and staff interview, the facility failed to ensure that swing bed patient records included a recapitulation (a concise summary) of the swing bed stay for 2 of 5 (Patients 34, and 35) discharged swing bed records reviewed. This had the potential to affect all discharged swing bed patients.

Findings are:

A. A review of Patient 34's medical record lacked a recapitulation of the patient's swing bed stay from 12/16/15-1/1/16.

B. A review of Patient 35's medical record lacked a recapitulation of the patient's swing bed stay from 12/22/15-12/29/15.

C. An interview with the Social Worker on 1/18/16 at 9:30 AM revealed, that the Social Worker had been to a Swing bed seminar in November but due to the move in December into the new hospital wasn't able to implement everything yet.