HospitalInspections.org

Based on staff interviews and review of facility documents and computer database reports, the hospital failed to maintain a list of all contracted services, including the scope and nature of the services provided, as required.

The findings were:

1. On the first day of the survey (8/22/11), a request was made for a list of all contracted services, including the scope and nature of the services provided. On 8/23/11 at approximately 8:30 a.m., two lists were provided. One was a long list with the title "Contract Expiration Report" which contained a list of individual products or pieces of medical equipment or services that were under the control of the purchasing department. The list did not specify each service provided. For example, there were numerous entries in which the "Description" column and the "Vendor" column had the name/number of the vendor and no way to identify the service provided by the contracted vendor. There were many pieces of surgical and medical supplies that were identified individually on the list, all with the same vendor. The second list provided was a list titled "CURRENT PROVIDER SERVICES AGREEMENT/CONTRACTS, (the hospital name), AUGUST 22, 2011, PREPARED BY THE OFFICE OF GENERAL COUNSEL." The list was a 6-page list that contained other contracted services. Review of the list revealed that it did not appear to contain some key contracts that were not found on the other list, such as their contract for food and dietary services.

2. On 8/23/11 at approximately 2 p.m., the supervisor of contract administration for the office of general counsel was interviewed about the list and s/he provided a stack of 'screen shots" from their contract management database titled "(hospital) legal contract database." That stack of "screen shots" contained additional contracts that were not on the list prepared the previous afternoon by the office of general counsel. Some of the "screen shots" contained a description of the service provided, but others did not. In some "description" fields on the "screen shots" the description would contain information such as "Amendatory Agreement - amend the term," "Second Amendment to the Subscription Agreement," etc. with no description of the actual service provided. When "screen shots" that appeared on the previous general counsel list were compared, they contained services that were different than on the original list. Many professional contracts and services were contained on the second list, but did not appear on the first list. The contract for food services, personnel and dieticians was on the "screen shots" provided by the office of general counsel with the description "Amended (contractor name) contract to add 'AYR' or At Your Request room."

3. On 8/24/11 at approximately 8:30 a.m., the manager of purchasing was interviewed and s/he provided a second set of lists for the supplies, equipment and services provided by various vendors. Again the lists contained each item with the name of the vendor and the same kinds of descriptions found on the lists provided the previous day. The list contained the names of the vendors over and over again with each individual item they provided. As with the previous lists, the descriptions of services provided were not clearly described on the list.

4. On 8/24/11 the supervisor of contract administration for the office of general counsel provided a new list which was titled "Expenditure Report," which appeared to be a list of payments made to various vendors and for professionals services. The food and dietary contractor did appear on this multiple times, but the description field did not describe the service, except as "Amendment," "Amendment regarding Executive Chef," etc.. The list was a series of reports totaling 183 pages, with many contractors/vendors appearing multiple times on the list. The description fields did not constantly contain an understandable description of the services provided by the contractor/vendor.

Based on medical record review, facility policy and procedure, and staff interview the facility failed to ensure that nursing staff evaluation of care for each patient in one (#14) of 30 sample medical records. Specifically, the nurse failed to ensure that nursing notes reflected assessments, reassessments and intervention information necessary to monitor the patient's condition and provide appropriate care. This failure created a potential negative outcome.

A review of the medical record of sample patient #14 revealed:
On 8/21/11 Sample patient #14 was transported to facility by Emergency Medical Service after s/he "fell off his/her bed" at home. Initial complaints included: "blurry vision, bilateral arm pain, back pain, does not feel legs and can't move either leg". The patient had diagnoses including Diabetes, Asthma, Depression, Migraine, and Hypertension. The patient was admitted and a lumbar puncture (L.P.) was performed on 8/22/11 at 2:54 p.m.

A neurologist notation as consult, on 8/21/11 at 4:00 p.m., stated an adult patient "Fell off bed, dragged him/her self to front door to see if his/her neighbor was there. Then called neighbor, neighbor called ambulance". The patient was given 50% Dextrose on arrival to emergency room.

After the L.P. vital signs were documented in the electronic medical record (EMR) on 8/22/11. With the bed in a supine position at 4:05 p.m.: blood pressure 110/69, heart rate 84, respiration rate 18, oxygen saturation 97%, oxygen amount 2 Liters per minute.

On 8/22/11 8:07 p.m. and 8/23/11 8:59 p.m. Nursing assessments were documented in the EMR and did not include skin/wound assessment or interventions related to the patient's L.P.

On 8/24/11 at 9:05 a.m. the nursing care plan documentation in EMR stated "Content Taught-Skin" "dressing application" and under the "Pt. specific: Comfort" "r/t (related to) generalized pain in back from lumbar puncture."

The Nursing Manager stated on 8/24/11 at approximately 2:00 p.m. "I would have expected that the lumbar puncture site was checked post procedure ... Nurses are very good."

A review of the facilities polices/procedures conducted 8/24/11 revealed the following, in PERTINENT parts:

A. No: P-2.009 Patient Assessment and Interdisciplinary
Collaboration
"Primary health care team members are responsible for":
1. "Notifying other team members as appropriate of changes in patient's condition".
2. "Ongoing assessment and reassessment are completed by team members pertinent to their specialized area of focus on a regular and consistent basis".
3. "Further assessment and reassessment are determined by the patient's needs and diagnosis, when indicated by physician order, practice guidelines and policies related to the patient's needs (i.e., restraints), and in response to changes in condition or critical events".
4. "Care and treatment needs of the patient will be provided based on the plan of care and ongoing evaluation (reassessment) of the patient's response to care".

B. Guideline for Acute Care Nursing
1. "Factors determining reassessment criteria and frequency may include treatments/procedures".
2. "The plan of care includes outcome-oriented goals related to the current health care episode and specific interventions targeted toward achievement of goals".
3. "All interventions are individualized to the patient's specific situation and address their physical, psychosocial, and other problems related to the current health care episode".
4. "Documentation must include: assessment findings; interventions and effectiveness of intervention(s); plan of care and goal achievement; patient and family teaching".

In summary, the patient had a L.P. performed on 8/22/11 and the site was not documented on until 8/24/11, approximately two days after the L.P. procedure. There was no documentation readily available to staff about the patients condition related to the L.P. site.

Additionally, no consent or procedure note was present in the medical record upon review 8/24/11 at approximately 11:00 am. The consent and procedure note were later provided by the CMO after being found in another patient's medical record.

Based on tours/observations, staff interviews and review of facility policies/procedures, the hospital failed to ensure that patient medical record information was retained for 10 years, as required by state licensure regulations. Specifically, the facility failed to ensure that radiology films were retained as a part of the medical record, as required, for 10 years.

The findings were:

1. Review on 7/28/11 of the State Health Facilities licensure regulations titled "6 CCR 1011-1 - CHAPTER II General Licensure Standards," revealed the following, in pertinent parts:
"Part 5. ACCESS TO PATIENT MEDICAL RECORDS
5.1 DEFINITIONS
5.1.2 PATIENT RECORD - A patient record is a documentation of services pertaining to medical and health care that are performed at the direction of a physician or other licensed health care provider on behalf of the patient by physicians/dentist, nurses, technicians and other health care personnel. Patient records include such diagnostic documentation as X-rays and EKG's. Patient records do not include doctors' office notes, which are the notes by a physician of observations about the patient made while the patient is in a non-hospital setting and maintained in the physician's office."

Review on 7/28/11 of the State Health Facilities licensure regulations titled "6 CCR 1011-1 - CHAPTER IV General Hospitals," revealed the following, in pertinent parts:
"Part 8. MEDICAL RECORDS DEPARTMENT
8.102 PROGRAMMATIC FUNCTIONS
(2) Medical records shall be preserved as original records, on microfilm or electronically:
(a) for minors, for the period of minority plus 10 years (i.e., until the patient is age 28) or 10 years after the most recent patient usage, whichever is later.
(b) for adults, for 10 years after the most recent patient care usage of the medical record."

2. On 8/22/11 the facility policy/procedure titled "Legal Health Records" was reviewed and revealed the following, in pertinent parts:
"I. PURPOSE:
To define the legal health record, including it's required content, retention, and destruction...
III. RESPONSIBILITY;
a. It is the responsibility of the Director of Health Information Management (HIM), working in conjunction with Information Services Department (IS) and the Legal Department to:
...3. Develop and administer a health records retention schedule that complies with applicable regulatory and business requirements...
IV. METHODOLOGY:
...R. Legal Heath Record retention and destruction:
1. patient health information may be destroyed according to the retention schedule after the applicable retention period is reached (see Attachment A)...
ATTACHMENT A
MANDATORY RETENTION PERIOD FOR HEALTH INFORMATION
Department: Dental
Record Type: Dental Records: effective 1/99
Media: Paper
Retention: Adults: 7 years, Minors; age of majority (18) + 7 years...
Department: Radiology
Record Type: Exams: Computed tomography (CT), Radiology exams Including PACS imaging information, Echocardiograms, Interventional Special Procedures, Magnetic Resonance Imaging (MRI), nuclear Medicine, Ultrasound, Mammography
Media: X-Rays
Retention: Adults: 5 years + current year, Minors: age of majority (18) + 7 years, Mammograms: Lifetime..."

3. On 8/23/11 at approximately 10:30 a.m., a health information manager was interviewed during a tour of the department. The interview revealed that the facility does not retain radiology films that are not digitalized for the 10 years required. S/he stated that the long term storage of non-digitalized radiology films only retained films for seven years.

4. On 8/23/11 at approximately 1:00 p.m., the manager of quality and compliance provided the surveyor with a copy of an e-mail s/he had received from the health information manager who had participated in the tour of the department. The e-mail contained the following, in pertinent parts:
"The surveyor that came to HIM with (quality improvement physician) asked how long we retain our x-ray films. We retain them for 7 years, adult and (18) + 7 years, mammograms life time. I told the surveyor that I would check our warehouse location and make sure that we just had the 7 years. This is correct. S/he stated that we are required to keep them for 10 years same as the paper medical records. Would you be able to relay this information to the surveyor? Thank You."

An unannounced onsite recertification survey was conducted (see event ID #IZR121) August 30 through September 9, 2011 by two (2) Life Safety Code Inspectors and included an inspection for compliance with the fire safety requirements of NFPA (National Fire Protection Association) 101, Life Safety Code, (2000 edition) and NFPA 99 Health Care Facilities (1999 Edition). The facility failed to comply with the regulations set forth. Deficiencies were cited under Life Safety Code tags K0017, K0018, K0025, K0027, K0029, K0038, K0040, K0046, K0050, K0051, K0052, K0056, K0062, K0072, K0074, K0076, K0077, K0130, K0147 and K0211.
See survey event ID #IZR121 for full details of the cited deficiencies.

Based on staff interviews and review of medical records and facility policies/procedures, the hospital failed to ensure that all patients were evaluated at an early stage of hospitalization, to determine if they are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning. The failure created the potential for negative patient outcomes in three of thirty sample medical records.

The findings were:

1. Review of the policy/procedure titled "Discharge Planning" on 8/23/11 revealed the following, in pertinent parts:
"I. PURPOSE
To outline the process utilized to ensure every patient receives adequate planning to meet his/her continued health care needs post-discharge from (the facility).
II. POLICY
A. All hospitalized patients will be screened for continuing care needs and will have a discharge plan developed and implemented...
III. DEFINITIONS
Discharge Planning is a process that involves assessing patient needs for continuing care and implementing a plan that matches these needs with available and appropriate resources through a multidisciplinary approach....
V. METHODOLOGY
A. Throughout hospitalization, the patient will be assessed for discharge needs. Additional information available about the patient's needs will be utilized in the assessment process...The appropriate consults and referrals necessary to meet the patients needs will be made as soon as possible after admission...
C. Multidisciplinary planning conferences are held as needed to plan for the discharge in a timely manner.
D. The patient/family/significant other will be involved in preparing for discharge by participating in the plan and will be made knowledgeable about their role in providing care post-discharge. When possible the discharge will be outlined prior to admission...
G. All aspects of the discharge planning process will be documented in the medical record by all responsible care providers..."

2. On 8/23/11 at approximately 10 a.m., an interview was conducted with the head of the discharge planning team. S/he stated that morning multidisciplinary rounds are conducted on all units and the social workers attend and hear about all new patients and participate in assessing their discharge needs.

3. On 8/24/11 at approximately 2 p.m., a social worker was interviewed about discharge planning and the multidisciplinary rounds. S/he stated that the social worker does not document in the patient's chart unless a referral is received. S/he stated that documentation of any discharge needs that are addressed in the multidisciplinary morning rounds are the responsibility of the physician.

4. An interview with a Charge Nurse of the 2B unit was conducted on 8/23/11 at approximately 12:30 p.m. S/he stated that "social rounds are done with medical rounds... If there are social issues, the physician lets the Social Worker know... Nursing initiates discharge planning. The Social Worker only sees certain patients..."

5. a. Review of sample medical record #7 was conducted on 8/23/11. The patient was admitted for a stroke on 8/6/11. Nursing did not begin documenting on discharge planning within their care plans, or elsewhere, until 8/8/11, and such documentation was not specific to post-discharge needs. For example, it stated, "Plan for home care needs: mobility," "Goal: Patient/ significant other will be prepared for discharge." The patient was referred on 8/22/11 to the social worker, who documented one note and stated, "Progress towards placement," and in turn consulted the contracted company who completes Medicaid applications. The notes and planning for this patient were not clearly evidenced.

b. Review of sample medical record #13 was conducted on 8/23/11. The patient was admitted to the medical floor on 8/21/11, as evidenced by the Resident's History and Physical done 8/22/11 at 12:15 a.m. The patient was admitted for sepsis. As of 8/23/11 at 3:00 p.m., no discharge planning documentation existed in the chart, by nursing, social worker, or any other discipline. Such observation was confirmed by the Chief Quality Officer.

c. Review of sample record #29 revealed that the patient was an adult patient admitted with abdominal pain with history of alcoholism and end stage liver disease. The patient was admitted through the emergency department on 8/19/11 and the record review was completed on the last day of the survey, 8/24/11. The patient was stated to be "homeless," when reviewed by the utilization review staff on the day after admission. The history and physical stated that the patient "sometimes live with friend (name)." The patient required oxygen and used a walker. There were no notes from social workers, who are the designated discharge planners in the facility, per the nurse assisting with the chart review. At the time of the review, the patient's physician was present in the area and stated that the patient was not actually homeless. S/he stated the patient did not have a home, but was going to go home, probably that day, to live with father. The record contained no notes that confirmed that the patient had a father in the area. Despite the fact that the patient was probably going home that day on oxygen, there were no notes about contact with a father or friend to confirm that the patient actually had a place to live. The nurse reviewing the record on the computer with the surveyor stated that if a homeless patient required oxygen at discharge, they would need a social work consult to arrange for "respite," which was a homeless shelter that had a nurse and where patients could stay during the day with a designated bed and where oxygen could be used and delivered to the patient. The record contained no documentation of discharge planning needs from the multidisciplinary rounds and the care plans stated that the "patient/family/significant others needed to be prepared for discharge," but there was no evidence that it was provided.

Based on staff interview and review of facility policies/procedures, the facility failed to ensure the organization of each service offered was appropriate to its scope. Specifically, the facility provided both inpatient and outpatient audiology services and did not maintain formalized and approved policies/procedures for those services. This failure created the potential for a negative outcome.

The findings were:

An interview was conducted on 8/23/11 at approximately 8:00 a.m., with the Director of all inpatient and outpatient rehabilitation services. S/he stated that audiology was not a service under her/him and instead under the "ENT (Ear Nose and Throat) Clinic." Such was confirmed at approximately 8:50 a.m. with the Director of QAPI/ Patient Safety/Risk. S/he stated that inpatient audiology services offered could be "newborn hearing screenings, occasionally a bedside audiogram, and if the patient is stable they may go to the ENT Clinic."

An interview was conducted with the Director of Audiology on 8/23/11 at approximately 9:10 a.m. S/he stated that medical direction came from the lead attending Physician in the ENT Clinic and that the Director of Audiology's direct manager was the Nurse Practitioner manager for Outpatient Surgical Services, the Eye Clinic, and the ENT Clinic. The Director's policies pertaining to audiology were requested. At 11:00 a.m., s/he stated, "These are our protocols," and provided several typed protocols for specific procedures/tests. The only formalized policy with a Denver Health letterhead, Director's signature, and dates of approval was one for outpatient services in regards to allowing audiologists to see former patients prior to obtaining a physician's order. When the Director was asked what "policies," though not formalized, would pertain to inpatient procedures, s/he stated initial audiogram and newborn infant hearing screening. S/he stated that all the other procedures would be for outpatients, however, it was noted that inpatients, if stable, could go to the outpatient clinic to obtain treatment.

The Director of QAPI/ Patient Safety/Risk was asked about the lack of formalized policies pertaining to audiology services and s/he stated, "We haven't had department specific policies and procedures/ a scope of services for each department in the past. We now have a new policy and procedure person/role." S/he stated that now each department would have work done on their specific policies/procedures. Each other service, Physical, Occupational, and Speech Therapies, under the Condition of Rehab maintained formalized policies.