HospitalInspections.org

Based on staff interview, medical staff bylaw review, minutes review, credentialing files review, documentation review, and policy and procedure review the facility's Governing Body:
1) failed to ensure the facility's medical records were completed no later than 30 days following patient discharge; and
2) failed to ensure the facility correctly carried out its responsibilities for reappointing the privileges for Physician #4, #6 and #7, three (3) of eight (8) physicians reviewed.

Findings Include:


1. Cross Refer to A046 for the facility's failure to to carry out its responsibilities for reappointing the priviliges of Physician #4, #6 and #7.

2. Cross Refer to A431 for the facility's failure to ensure medical records were completed no later than 30 days following discharge.


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Based on staff interview, medical staff bylaw review, minutes review, credentialing files review, documentation review, and policy and procedure review, the facility failed to ensure their responsibilities were carried out for reappointing the privileges for Physician #4, #6 and #7, three (3) of eight (8) physicians reviewed.

Findings Include:

Review of the facility's Medical Staff bylaws, Rules and Regulation, adopted March 2014, revealed, "The Administrator shall, every two years provide each Staff member with a "Reappointment" application. Each staff member who desires reappointment shall at least 90 days prior to such expiratory date, Send his/her "Reappointment" application to the administrator."

Review of physician's credentialing files revealed that three (3) physician's were practicing without re-appointment.
a) Physician #4 was last reappointed on 11-28-12. His privileges expired on 11-28-14. His application for re-appointment was blank. He is noted as reappointed in credentialing minutes for September 12, 2012. There was no documented evidence to support the process was followed.
b) Physician #6 was last reappointed on 12-21-11. His privileges expired on 12-21-13. His application for re-appointment was blank. (There was no documented evidence in the file for reappointment for 2013-2015)
c) Physician #7 was last reappointed on 12-21-11. His privileges expired on 12-21-13. His application for re-appointment was blank.

Review of the medical staff minutes for the past 12 months revealed no documented evidence of any credentialing reported. Review of the Board of Trustee Minutes for the past 12 months revealed no documented evidence of any credentialing being presented.

On 04/22/15 at 1:30 p.m. the Administrative Assistant stated that she does the credentialing for all physicians. She also stated, "I am sorry. We are trying to get caught up. I have put the applications on the charts and have sent the physicians copies." When asked why these were not re-appointed in 2014 as they ran out of their 2 year contracts she stated, "We have had a lot of changes in the past four months and this got behind." She provided a note saying three (3) physicians would be brought up at medical staff on May, 2015.

In the exit conference on 04/23/15 at 11:40 a.m. the Administrator was presented with these findings. No further documentation was presented.

Based on documentation review and staff interview, the facility failed to ensure adverse patient events are tracked as part of the Performance Improvement (PI) activities.


Findings Include:


Review of the facility's "Performance Improvement (data by department) for October 2014 to September 2015" revealed no documented evidence of adverse patient events reported by Risk Management.


During an interview on 4/23/15 at 9:00 a.m. the PI Manager was asksed if Risk Management reported adverse patient events to her for tracking. She stated, "No."


During an interview on 04/23/15 at 9:40 a.m. the Risk Manager was asked how adverse patient events were tracked by their facility. She stated, "We document and review our adverse events/incidents, but do not have any tracking or reporting to PI at this time."

Based on documentation review, policy and procedure review and staff interview, the facility failed to ensure medical records are completed no later than 30 days following discharge.

Findings Include:

Cross Refer to A438 for the facility's failure to ensure 224 delinquent records were completed within 30 days after discharge.

Based on documentation review, policy and procedure review and staff interview, the facility failed to ensure medical records were completed no later than 30 days following discharge.


Findings Include:


Review of the facility's April 21, 2015 "30 Day Deficiency Report" revealed the facility had 205 medical records not completed within 30 days following discharge. The delinquent dates ranged from June 2014 to present and involved 12 physicians.


During an interview on 04/22/15 at 9:40 a.m. the Medical Records Director stated that the facility had 224 delinquent medical records. She stated, "133 of the records belong to one (1) physician. We have notified physicians of the need to complete the medical records." When asked if she documented the notification process, she stated, "Yes." No documented evidence was presented for review.


During an interview on 04/23/15 at 10:30 a.m. Medical Records Clerk #1 confirmed the delinquent medical records ranged from June 2014 to present and included: history and physicals, discharge summaries, progress notes, operative notes, cardiology dictation and orders. When asked to see the documentation for off-staff physicians, she stated, "(Physician #1) is off-staff." She confirmed he was suspended around April 6,2015 and stated, "I don't have access to the documentation." She confirmed the Medical Record Department had the information and was out of the building for a meeting today. No further documentation was presented for review.


Review of the facility's "Delinquency and Suspension of Physicians/Practitioners" policy revealed: "Purpose: To define the timeliness of chart documentation, delinquency of documentation, and the suspension process upheld at the hospital ...Procedure: 1. Promptness of record completion/chart documentation: ...c. Records of discharged patients shall be completed by a physician within ...thirty (30) days for full completion, per Medical Staff Rules and Regulations and State requirements. i. Suspension and/or termination of staff membership and/or clinical privileges of practitioners who are persistently delinquent in completing records. Persistently delinquent would constitute more than one month ...".


Review of the facility's "Medical Staff Bylaws, Rules and Regulations" revealed: "...Article XIV ...Medical Staff Rules and Regulations ...Medical Record: ...(16) Records of discharged patients shall be completed within (30) days following discharge. Suspension or termination of staff membership and/or clinical privileges of practitioners who are persistently delinquent in will be processed accordingly ...".