HospitalInspections.org

Based on record review and interview, the hospital failed to follow its policy and procedure to ensure that medical records were completed within 30 days of discharge.

Findings:

Review of the facility policy titled Delinquent Medical Records revealed, in part:
Procedure:
4. If the staff member has any incomplete medical records that have aged at least 21 days post discharge, a letter will be sent to include a warning that the record(s) will be delinquent at thirty (30) days post discharge and the staff member's privileges will be suspended in accordance with hospital by-laws/rules and regulations if any records become delinquent.
5. A chart which is not completed within (30) days of discharge will be deemed delinquent and could trigger the following steps:
a. A written notice will be signed by the CEO of Chief of Staff notifying the physician of the suspension of his/her privileges.
b. The notice will be delivered to the physician unless the physician is out of town, then it will be delivered to his/her office manager.
c. Once the suspension notice has been issued, the Admitting Office, Nursing Supervisor(s), Administration and the Medical Office Staff (MSO) will be notified of the suspension.
d. The suspension will be lifted when ALL delinquent records (30 days past discharge) are complete....

Review of the Patient Deficiency Summary report dated 07/18/23 revealed 167 patient records were delinquent for a period ranging between 31 to 999 days. On 07/18/23 at 1:50 p.m., an interview with S10HIM revealed there was a glitch in the system that prevented some corrected deficiencies from being cleared out of the system. She confirmed that although some had been completed, there were still some delinquencies that dated back to 2022.

On 07/19/23 at 11:00 a.m., S10HIM presented an updated Patient Deficiency Report that revealed 123 deficiencies remained. S10HIM confirmed at this time that this was an accurate number of delinquencies, and that some dated as far back as 2022. Further interview with S10HIM at this time confirmed that letters were sent to physicians at least weekly to request completion of delinquent records, but interview with S2CNO at this time confirmed that there had been no suspensions of privileges or any other further disciplinary actions taken to ensure compliance.

Based on policy review, observation and interview, the hospital failed to develop and implement an effective system in controlling infections and communicable diseases of patients as evidenced by failing to maintain a sanitary environment.
Findings:

Review of the hospital's housekeeping policy titled, "Ancillary Areas revealed in part:
Purpose-To outline procedures designed to clean and disinfect all ancillary area departments. Dust technical equipment such as x-ray machines, CT scan control, and computer room, if applicable. Clean examination rooms and tables.

Review of the hospital's "Environmental Tours Checklist" revealed in part: Safety Function-Element of Performance #11 - Furnishings are clean and in good condition, free of rips, tears or other physical damage? (e.g. mattresses, chairs, couches, tables, lamps, etc.)

Observations on 07/17/2023 at 12:00 of patient rooms designated as clean and ready for patient admissions, revealed room a with an infusions pump which was not covered or labeled as clean.

In an interview at this time, S2CNO acknowledged the dirty infusion pump located in room a.

Observations of the lab areas on 07/17/2023 at 1:50 p.m. revealed the phlebotomy patient's chair with rips/tears to the vinyl covering of the hinged arm rest.

In an interview at this time, S8LM acknowledged the finding and confirmed the arm rest could not be properly sanitized due to the rips/tears of the vinyl covering.

Observations of the radiology areas on 07/07/2023 at 2:25 p.m. revealed: grime and debris on the Shimatzu portable x-ray machine; room #1 with rips/tears to the vinyl coverings on the patient's pillow and exam table pad and grime and debris on the wall vacuum meter; and, room #2 with rips/tears to the vinyl coverings on the patient's pillow.

In an interview at this time, S9RM acknowledged the finding and confirmed the pillows and table pad could not be properly sanitized due to the rips/tears of the vinyl coverings.