HospitalInspections.org

Based on record review and interview, the Governing Body failed to enforce it's current bylaws, rules, and regulations for the Medical Staff for timely completion of consent for treatment, physician's discharge summary, physician's history and physical examination, in that,

A) 4 of 11 inpatient (Patient #1, #2, #6, and #10) medical records did not document patient or representative consent for treatment upon admission,

B) 1 of 5 discharged (Patient #16) patient medical record did not document a physician's discharge summary within 30 days of discharge,

C) 6 of 14 inpatient medical records (Patient #5, #6, #7, #8, #9, and #10) did not document a physician's history and physical examination within 24 hours of admission, and

D) 3 of 6 swing bed medical records (Patient #9, #11, and #15) did not document a physician's history and physician examination within 24 hours of admission change to swing bed status.

Findings included

A) Patient #1's, #2's, #6's, and #10's inpatient medical record did not document patient or representative consent for treatment upon admission.


B) Patient #16's patient medical record did not document a physician's discharge summary within 30 days of discharge.

C) Patient #5's, #6's, #7's, #8's, #9's, and #10's inpatient medical record did not document a physician's history and physical examination within 24 hours of admission.

D) Patient #9's, #11's, and #15's swing bed medical record did not document a physician's history and physician examination within 24 hours of admission change to swing bed status.


The facility's 2016 "Quality Assurance/Performance Improvement Committee" minutes revealed, "reporting of indicators...Medical records: current indicators and plan of correction discussed with no recommendations at this time..."

The facility's 2016 "Quality Assurance/Performance Improvement Indicator Monitoring" monthly forms revealed, "H&P's dictated within 24 hours of admission...Plan of correction...Continue to work with nursing staff to monitor that H&P's are completed at the time of admission and prior to all surgical cases. Continue to report to the medical staff as outlined in the r&r (rules and regulations)...Due date...Ongoing," and "H&P's dictated within 24 hours of admission...November 2016...76%...October 2016...73%...September 2016...71%...July 2016...77%...June 2016...77%...May 2016...80%...April 2016...80%...March 2016...74%...February 2016...78%...January 2016...70%..."

The facility's 2016 "Quality Assurance/Performance Improvement Indicator Monitoring" monthly forms revealed, "Discharge summaries dictated within 30 days of discharge... Plan of correction...Continued to send weekly notifications to the medical staff regarding incomplete and delinquent medical records as per the Medical Staff rules and regulations. Have contacted the administrator and COS assistance," and "Discharge summaries dictated within 30 days of discharge...October 2016...76%...September 2016...70%...July 2016...80%...June 2016...93%...April 2016...67%...March 2016...93%...February 2016...80%...January 2016...83%..." There was no data for November 2016.

During an interview on 1/25/17 ending at 4:30 PM, Personnel #2 was informed of the above findings. Personnel #2 reviewed each record and confirmed the findings. Personnel #2 was asked if the process had been followed for delinquent medical records and medical staff involved had been suspended in 2016. Personnel #2 stated, "No."

The facility's June 2013, last approved "Medical Staff Rules and Regulations" required, "A Physician member of the medical staff shall be responsible for the Medical Care and treatment of each patient in the hospital, for the prompt completeness and accuracy of the medical record...a discharge summary shall be dictated at the time of discharge...Evidence of informed consent...A completed mission history and physical shall be recorded or dictated within 24 hours following admission...a history and physical examination must be recorded on the chart or a note that the history and physical has been dictated and recorded on the progress notes before the stated time...Legibility is essential...A discharge summary shall be dictated at the time of discharge but no later than thirty (30) days following the discharge of the patient...A consent form, signed by the patient or on the patient's behalf by someone authorized to do so, shall be executed for every patient at the time of admission..."

The facility's June 2013, last approved "Medical Staff Bylaws" required, "Automatic Suspension...Medical Records...Temporary suspension in the form of withdrawal of a practitioner's admitting privileges, effective until medical records are completed, shall be imposed automatically seven days after warning of delinquency for failure to complete medical records within thirty (30) days of a patient's discharge. The medical record librarian shall notify the CEO of the practitioner's delinquency status...The practitioner will be permitted seven days after the warning in which to complete the delinquent records. If the delinquent records have not been completed within seven days, the delinquent practitioner's admitting privileges will be suspended by the CEO. Privileges will be reinstated upon completion of all delinquent medical records."

Based on record review and interview, the facility failed to ensure their hospital-wide QAPI (Quality Assurance/Performance Improvement) program the complexity of the hospital's organization and services, in that,

the 2016 QAPI program minutes did not reflect a quality review of:
complaints/grievances,
incidents,
Social Services/Discharge Planning,
Utilization Review/Length of Stay,
Outpatient Services,
the Environment of Care and Safety (physical environment),
Maintenance, or
Therapy services including OT/PT/ST (Occupational/Physical/Speech Therapy).


Findings included

The facility's 2016 QAPI minutes were reviewed. There was no indication of a quality review of complaints/grievances, incidents, Social Services/Discharge Planning, Utilization Review/Length of Stay, Outpatient Services, the Environment of Care and Safety (physical environment), Maintenance, or Therapy services including OT/PT/ST (Occupational/Physical/Speech Therapy).


During an interview on 1/25/17 ending at 4:30 PM, Personnel #2 was informed of the above findings. Personnel #2 reviewed the QAPI minutes and confirmed the findings.

The facility's "Quality Assurance/Performance Improvement Plan 2016" required, "All patient care services and other services affecting patient health and safety are evaluated...analysis of data is completed in order to identify and resolve any breakdowns that may result in sub-optimal patient care and safety...scope of the program is comprehensive, including all departments, services, disciplines and practitioners...selecting indicators for monitoring...monitoring indicators...revising indicators based on compliance with expectations and needs/problems identified through day to day business activities..."

Based on observation, record review and interview, the facility failed to ensure the right of the patient, within the limits of law, to personal privacy and confidentiality of information, in that,

the facility routinely placed an inpatient list with first, last name, and room number in public view.

Findings included

During the morning of 1/23/17, two surveyors saw a patient list in the main entrance hallway on a table in public view. The list stated, "Public Condition Sheet...1/23/17..." The list contained the first and last names of 8 patients (Patient #1, #6, #7, #8, #9, #10, #11, and #15) and their respective room number.

The facility's "Condition of Admissions" consent included "Disclosure to the media/clergy...Because disclosure to the media does not constitute treatment, payment, or Health Care operations activity, (Name listed) hospital may not disclose patient health information to the media without prior authorization. The hospital may verbally informed the patient and disclosure to the local newspaper and members of the local clergy as permitted with respect from the patient. In emergency situations, when the patient is unable to communicate or is incapacitated and therefore not able to agree, prohibit, or restrict the disclosures outlined above, the hospital will not disclose any information to the media which would be in the best interest of the patient. Do you want information shared it with a local media.. Do you want your name shared with the local clergy..."

The patient's records were reviewed. Both patient #7 and #8 said "No"to the public disclosure. Their names were disclosed.

Patient #1, #2, #6, and #10 were not afforded the opportunity to decline or accept a public disclosure. Their names were disclosed.


During an interview on 1/23/17 at 11:24 AM, Personnel #2 was shown and informed the list was found as described above. Personnel #2 was asked if this was common practice. Personnel #2 stated, "Yes." Personnel #2 was informed this did not protect the patient's right to privacy. Personnel #2 stated, "We have them sign if it is okay to share their (the patient) information."

Personnel #2 later stated that the list was for "Clergy." Personnel #2 was informed that the patient's had not given consent for the disclosure. Personnel #2 stated, "I understand your concern."

The undated, "Patient Rights" policy reflected, "consider it, respectful care...Respect for personal dignity...Make decisions involving his or her Health Care...Personal privacy and confidentiality of information..."

Based on record review and interview, the facility failed to ensure medically-related social services were provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being to all patients, in that,

2 of 6 patient (Patient #9 and #15) records did not reflect a social worker assessment and follow-up.

Findings included

Patient #9's and #15's records did not reflect a social worker assessment and follow-up.

During an interview on 1/25/17 ending at 4:30 PM, Personnel #2 was informed of the above findings. Personnel #2 reviewed the records and confirmed the findings.

The facility's 11/01/12 "Social Services" policy required, "complete a Social History & Assessment within five business days of admission..."

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed within 7 days after the completion of the comprehensive assessment by an interdisciplinary team, that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs, and, to the extent practicable, the participation of the resident, the resident's family or the resident's legal representative; and periodically reviewed and revised by a team of qualified persons after each assessment, in that,

A) 2 of 6 swing bed patients (Patient #9 and #15) medical records did not document a comprehensive care plan and timely review by the interdisciplinary team including the patient, the attending physician, respiratory and speech therapy, as appropriate, and

B) 6 of 6 swing bed patient (Patient #6, #7, #8, #9, #11, and #15) medical records did not document the physician's certification on admission to indicate that a skilled level of care services were required to be given on an in-patient basis because of skilled nursing or rehabilitative services and did not document a timely physician's re-certification of the reason for continued need for extended care and the expected time period of need.

Findings included

A) Patient #9's and #15's swing bed patient medical record did not document a comprehensive care plan and timely review by the interdisciplinary team including the patient, the attending physician, respiratory and speech therapy, as appropriate.

B) Patient #6's, #7's, #8's, #9's, #11's, and #15's swing bed patient medical record did not document the physician's certification on admission to indicate that a skilled level of care services were required to be given on an in-patient basis because of skilled nursing or rehabilitative services and did not document a timely physician's re-certification of the reason for continued need for extended care and the expected time period of need.

During an interview on 1/25/17 ending at 4:30 PM, Personnel #2 was informed of the above findings. Personnel #2 confirmed the findings.

The facility's 11/01/12 "Swing Bed Admission Care Plan" policy required, "initiated on every patient admitted to the Swing-Bed program...Within 12 hours of admission...Reviewed at least once per week with revisions to the care plan being documented and communicated to the appropriate care givers...The care plan review includes, as appropriate to the patient needs, input from, but not limited to...Nursing...Dietary...Physical therapy...Occupational therapy...Social services...Activity director...others as needed..."

The facility's 11/01/12 "Swing-Bed Certification/Re-Certification" policy required, "all patients admitted...Swing-Bed program will have a certification and re-certification statement completed and signed by the attending Physician...Certification as to be obtained at admission...Indicate that a skilled level of care services are required to be given on an inpatient basis because of the individual's need, on a daily basis for skilled nursing services or skilled rehabilitation services...Re-certification must be made no later than 14 days after initial certification...Must contain an adequate written record of the reasons for continued need for extended Care Services, the estimated period of time the patient will need to remain in the hospital, and any plans, where appropriate, for Home Care..."