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Based on record review and interview, the CAH failed to ensure medication variances and notification of the practitioner of medication variances was documented in the patient's record for 1 (#R3) of 2 (#R2, #R3) patient records reviewed for medication variances.

Findings:

Review of the hospital policy titled, "Medication Administration", policy number: OHS.NURS.034, revealed in part: 7. Medication occurrences must be immediately reported to the attending physician and nurse in charge. An occurrence report must be completed in the Occurrence Reporting System by the person discovering the occurrence as soon as possible.

Review of the CAH's medication variance report revealed Patient #R3 received a duplicated dose of Ambien, 5 mg (ordered PRN at hour of sleep) on 05/31/19 at 9:38 p.m. Further review revealed the patient had been administered the PRN sleep medication earlier in the shift by another nursing staff member who had failed to report the PRN sleep medication had already been administered.

Review of Patient #R3's EMR,assisted by S4IT, chart navigator, revealed there was no documentation of the medication variance in the patient's medical record and no documentation of practitioner notification of the variance in the EMR. On 06/04/19 at 4:18 p.m. S4IT verified Patient #R3's EMR lacked the above referenced documentation.

Based on record review, observation, and interview the CAH failed to ensure Emergency Department nursing services were provided to meet the needs of the patient. This deficient practice is evidenced by failing to ensure nursing staff continuously monitored telemetry patients and responded timely to alarms.

Findings:

Review of the medical record of Patient #7 revealed she was an 11 year old patient in the Emergency Department admitted on 06/03/19 with a diagnosis of vomiting. Further review revealed Patient #7 has a medical history of congenital muscular dystrophy.

On 06/03/19 at 10:30 a.m. the CAH's Emergency Department was observed with S2AVPN. The following event was noted during the observation:

10:30 a.m. the centrally located telemetry monitor in the nurses' station was alarming. Patient #7's heart rate was 163 bpm (163 bpm was above the monitor's high alarm parameter limit). Two staff ED Registered Nurses were noted to be in the nurses' station where the monitor was alarming and they failed to respond to the alarm.

Further observation revealed no staff member was present at the bedside of Patient #7, to examine the patient, when the high heartrate alarm was noted to be alarming.

Additional observation revealed no staff member was noted to be continuously observing the telemetry monitor and no staff member looked at the alarming telemetry monitor. S2AVPN, present during the observation, was asked who was caring for Patient #7. A staff Registered Nurse responded, "the patient has been vomiting and is dehydrated".

A staff Registered Nurse was observed approaching the bedside of Patient #7 and the alarm was silenced at 10:38 a.m. (8 minutes after the monitor was observed to be alarming over the high limit alarm parameters).

On 06/03/19 at 12:25 p.m. another observation was conducted of the ED and revealed Patient #7 was no longer in the ED. A Staff Registered Nurse reported Patient #7 was transferred to an outside hospital due to requiring a higher level of care.


In an interview on 06/03/19 at 10:40 a.m. with S2AVPN, she revealed no staff member was routinely assigned the task of continuously monitoring the ED's centrally located telemetry monitor in the nurses' station. S2AVPN confirmed that someone should have responded to the telemetry alarm and checked the patient.

In an interview on 06/04/19 at 1:10 p.m. with S2AVPN, she confirmed there was no ED policy regarding telemetry monitoring. S2AVPN reported ED staff had received training and had competency evaluations for telemetry monitoring completed during initial orientation and annually through a skills fair.

Based on record review, observation, and interview, the CAH failed to ensure the patient's medical records were protected from water damage and were completed within 30 days as evidenced by:
1. Failing to ensure the patients' medical records were stored in a manner where the medical records were protected from damage from water. This failed practice was evidenced by patient medical records being stored in the Medical Records Department on open shelving racks in rooms that had a sprinkler system; and
2. Failing to ensure the patients' medical records were promptly completed within 30 days after discharge as evidenced by 12 medical records delinquent greater than 200 days; 10 medical records delinquent greater than 120 days; 1 medical record delinquent greater than 60 days; and 8 medical records delinquent greater than 30 days.

Findings:

1. The CAH failed to ensure the medical records were protected from water damage.

Review of the medical record policy titled Protection and Recovery of Medical Records from Fire, Water or Vandalism presented as current policy revealed in part, Protection of Medical Records ...D. Records are protected from water damage by waterproof covering or storage in a sealed cabinet.

During an observation and interview of the medical records department on 06/03/19 at 12:45 p.m. with S17MRStaff in the presence of 2 surveyors and S2AVPN, S17MRStaff indicated the medical records are in a sprinkled room containing shelves of medical records which are not closed or covered. She indicated the area of uncovered medical records consisted of 134 sections approximately 6 feet long stored on open shelves were original medical records. She further indicated that if the sprinkler system was activated after hours, those sections of medical records would not be protected from water damage. S17MRStaff stated the vinyl covers rolled on top the open shelving units have never been used.


2. The CAH failed to ensure the patients' medical records were promptly completed within 30 days after discharge.

Review of the Rules and Regulations revealed in part ....V. Completion of Medical Records / Delinquency:
1. 30 Day Limit; Medical Staff members shall complete each medical record within a time period not exceeding 30 days following the discharge of the patient ....When a medical record remains incomplete for a time period exceeding 30 days following discharge, that medical record shall be defined as delinquent.
2. Punitive Measures; ...When an individual Medical Staff member is responsible for or causes one medical record to be delinquent on any day that a chart count is performed ....the following will occur: A. Scheduling of surgeries/procedures will not be allowed. B. Only emergency surgical procedures will be allowed until the medical records are completed. (NOTE: Admitting privileges may be administratively suspended until medical records are completed.)

Review of the policy titled Chart Content, Timeliness, and Delinquency Reporting presented as current policy revealed in part the Health Information Management Director/Supervisor or designee reviews records for completion of history and physicals, operative reports, discharge summaries, and verbal orders ....HIM notifies the physician of their deficiencies ....If the documentation remains incomplete, HIM reports the information to the hospital Administration.

Review of the physicians' medical record deficiency report presented on 06/05/19 at 8:25 a.m. by S5AVPF revealed the following:

S6MD: 3 records > 30 days delinquent
S7MD: 1 record > 30 days delinquent
S8MD: 1 record > 30 days delinquent
S9MD: 1 record > 30 days delinquent
S10MD: 1 record > 30 days delinquent; 1 record > 120 days delinquent
S11MD: 1 record > 30 days delinquent
S12MD: 1 record > 60 days delinquent; 11 records > 120 days delinquent
S13MD: 2 records > 120 days delinquent
S14MD: 1 record > 120 days delinquent
S15MD: 2 records > 120 days delinquent
S16MD: 4 records > 120 days delinquent
S18MD: 1 record > 120 days delinquent

In an interview on 06/05/19 at 11:00 a.m., S5AVPF revealed she had been employed in the role as S5AVPF for 9 months and the process for physician delinquent medical records was that she informs S23VPMA and he sends a letter to the physicians. She stated she is unaware of any punitive measures taken regarding deficient medical records.

In an interview on 06/05/19 at 1:20 p.m. with S22CorpDirHIM revealed the department notifies the physicians weekly of any open chart records. They send a notification letter to S23VPMA to notify him of the deficient records. We keep notifying the physicians and making them aware. We do not have a medical record closure process and we do not suspend physicians.

Based on record review and interview, the CAH failed to ensure an effective system was in place to assure patient medical records were protected from unauthorized access and use. This deficient practice was evidenced by the ability of staff of separately licensed and certified hospitals, being able to access patient records from Ochsner St. Anne General Hospital, whether the staff were involved in the care of the patient or not.
Findings:

Review of hospital policy and procedure # OHS.IS.008 titled, "Data Access Control", issued October 2009 and last revised November 2016, provided by S5AVPF as current, revealed, in part, the following:
"IV. Policy Statements, A. Data access controls shall be implemented to protect ePHI and/or other Confidential data from unauthorized view and/or modification. B. Authorization to data and applications shall be made on a need to know basis to perform a specified job related task, function, or role....V. Procedures/Standards and Roles & Responsibilities...B. Management Responsibilities: 1. User access must be restricted to the Information assess required to meet an approved business need or perform prescribed job responsibilities (limited need to know basis)...System Administrator Responsibilities:...17. System Administrators must perform at least annual reviews of access profiles to ensure only authorized users are allowed access to ePHI and/or other confidential data and that access is granted on a need to know basis.

Patient #5
Patient #5 was a 70 year old male who presented to Ochsner St Anne's ED on 06/03/19 at approximately 6:00 a.m. with a chief complaint of shortness of breath and vomiting. Patient #5's health rapidly declined and required transfer to Hospital "b" at 10:05 a.m. via flight transportation.

On 06/05/19 at 3:35 p.m. review of medical record of Patient #5 with S2AVPN, who demonstrated how Hospital "b's" medical records for Patient #5 could be accessed and verified the same was true of Hospital "b" staff's ability to access Ochsner St Anne Medical Center patient's medical records.

In an interview 6/04/19 at 3:25 p.m. S2AVPN reported there were no safeguards in place in the EMR system used by Ochsner St Anne Medical Center to prevent employees of other hospitals, under the same health care system, from accessing Ochsner St Anne Medical Center patients' medical records. S2AVPN confirmed the processes in place involved retroactive reviews of who accessed the medical records after the fact, but did not prevent unauthorized access. She indicated access (whether authorized or unauthorized) to Ochsner St Anne Medical Center patient records included staff at multiple hospitals, each with different provider numbers.


39791

Based on record review and interview, the CAH failed to ensure the quality and appropriateness of all patient care services affecting patient health and safety, and other services, including services provided via contract, were evaluated through the CAH's QAPI Program. This deficient practice was evidenced by failure of the CAH to include
Company "A" (neurologic diagnostic services), Company "B" (hospice provider), and Company "C" (hospital service provider), in the hospital wide QAPI plan.

Findings:

Review of the CAH's QAPI documentation and contracted services list revealed no documented evidence that contracted services provided by Company "A" (neurologic diagnostic services), Company "B" (hospice provider), and Company "C" (hospital service provider), were included in the QAPI plan.

In an interview on 06/05/19 at 1:40 p.m., with S3QA, she confirmed evaluation of the contracted services provided by Company "A', Company "B", and Company "C" were not included in the CAH's QAPI plan.