HospitalInspections.org

Based on a review of facility documents and medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure that patients were informed of their discharge appeal rights for three of four medical records reviewed (MR28, MR29, and MR30).

Findings include:

Review of the facility's "Notification of Hospital Discharge Appeal Rights (CMS-4105-F)" revised September 2013 revealed, "Medicare beneficiaries who are hospital inpatients have a statutory right to appeal to a QIO (Currently Quality Insights) for an expedited review when a hospital, with physician concurrence, determines that inpatient care is no longer necessary. This policy is in place to ensure that St. Clair Hospital complies with all aspects of this law. ...The follow up delivery of the IMM ("An Important Message from Medicare") should be given to the patient as early as possible so that the patient has adequate time to consider and act on the information. But the follow up IMM should not be delivered more than two calendar days before discharge. "

A review of MR28 revealed that a Medicare beneficiary patient was discharged on September 17, 2013. Further review of MR28 revealed no documented evidence that a follow up delivery of the IM was presented to the patient or the patient's representative.

A review of MR29 revealed that a Medicare beneficiary patient was discharged on September 17, 2013. Further review of MR29 revealed no documented evidence that a follow up delivery of the IM was presented to the patient or the patient's representative.

A review of MR30 revealed that a Medicare beneficiary patient was discharged on September 18, 2013. Further review of MR30 revealed no documented evidence that a follow up delivery of the IM was presented to the patient or the patient's representative.

An interview with EMP1 on November 7, 2013 at 9:30 AM confirmed the above findings. EMP1 also indicated, "Three out of four didn't have the second signature."

Based on a review of facility documents and medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure the patient had a right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives for four of four medical records reviewed (MR33, MR34, MR35, and MR36).

Findings include:

A review of the facility policy "Patient Rights and Responsibilities" dated February 26, 2013 revealed, "You have the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives."

A review of facility policy "Medical Advance Directive, Physician Orders for Life Sustaining Treatment (POLST), Mental Health Declaration, and Mental Health Power of Attorney Policy" revealed, "If a Medical Advance Directive exists but the patient does not present a copy at the time of registration, the registrar will: 1) Incorporate that information into the Hospital's computer system. 2) Notify the nursing unit via the front sheet. 3) Ask the patient to have the Medical Advance Directive brought to the nursing unit. ... 2. Nursing Unit Medical Advance Directives During the nursing unit admission process or when necessary nursing can verify the presence of an Advanced Directive and communicate with the Physician for appropriate implementation."

A review of MR33's Admission Assessment dated October 22, 2013 revealed, "Adult Patient Profile ... Unit arrival time 10-22-2013 ... Advance Care Planning: Has a Medical Advance Directive instructed to bring a copy to the hospital." Further review revealed no documentation that an attempt was made to have a copy placed on the patient's medical record.

A review of MR34's Admission Assessment dated October 31, 2013 revealed, "Adult Patient Profile ... Unit arrival time 10-31-2013 ... Advance Care Planning: Has a Medical Advance Directive instructed to bring a copy to the hospital." Further review revealed no documentation that an attempt was made to have a copy placed on the patient's medical record.

A review of MR35's Admission Assessment dated November 05, 2013 revealed, "Adult Patient Profile ... Unit arrival time 11-05-2013 ... Advance Care Planning: Has a Medical Advance Directive instructed to bring a copy to the hospital." Further review revealed no documentation that an attempt was made to have a copy placed on the patient's medical record.

A review of MR36's Admission Assessment dated November 03, 2013 revealed, "Adult Patient Profile ... Unit arrival time 11-03-2013 ... Advance Care Planning: Has a Medical Advance Directive instructed to bring a copy to the hospital." Further review revealed no documentation that an attempt was made to have a copy placed on the patient's medical record.

An interview with EMP11 on November 7, 2013 at approximately 10:50AM confirmed the above findings and revealed, "There is no follow up."

Based on a review of facility documents and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to maintain a complete and accurate medical record for six of seven medical records reviewed (MR52, MR53, MR54, MR56, MR57, MR58).

Findings include:

A review of facilty policy "Patient Safety and Occurrence Reporting" dated May 30, 2013 revealed "...if a medical record exists, document a factual synopsis of the occurrence...Appendix A Examples of Occurrences...Any medication occurrence (e,g,. wrong patient, wrong medication, wrong time, wrong route, wrong dose.... ."

A review of facility documentaion revealed that a medication occurrence that involved
MR52 occurred on September 10, 2013. A subsequent review of MR52 revealed no factual synopsis of the medication occurrence documented in the medical record.

A review of facility documentaion revealed that a medication occurrence that involved MR53 occurred on September 18, 2013. A subsequent review of MR53 revealed no factual synopsis of the medication occurrence documented in the medical record.

A review of facility documentaion revealed that a medication occurrence that involved MR54 occurred on September 14, 2013. A subsequent review of MR54 revealed no factual synopsis of the medication occurrence documented in the medical record.

A review of facility documentaion revealed that a medication occurrence that involved MR56 occurred on September 16, 2013. A subsequent review of MR56 revealed no factual synopsis of the medication occurrence documented in the medical record.

A review of facility documentaion revealed that a medication occurrence that involved MR57 occurred on September 18, 2013. A subsequent review of MR57 revealed no factual synopsis of the medication occurrence documented in the medical record.

A review of facility documentaion revealed that a medication occurrence that involved MR58 occurred on September 22, 2013. A subsequent review of MR58 revealed no factual synopsis of the medication occurrence documented in the medical record.

During interview on November 7, 2013 at approximately 11:00 AM when asked if medication occurrences are documented in the patient's medical record EMP13 revealed, "...No, they are documented on the occurrence report... ."

Based on a review of facility documents and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure the patient medical record entries were legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures for four of eight medical records reviewed (MR8, MR9, MR10, and MR34).

Findings include:

A review of facility policy "Medical Staff Bylaws Section E - Rules & Regulations" dated September 27, 2012 revealed, "IV. Conduct of Care ... 1. The practitioner's orders must be written clearly, legibly and completely."

A review of facility policy "Medication Ordering" dated December 12, 2012 revealed, "B. Medication orders are written clearly and transcribed accurately. 1. The requirements of a medication order include a. Drug name (generic or brand name). ... 2. Practitioner's orders must be written clearly, legibly and completely. Doses affected by illegible or improperly written orders will not be dispensed or administered until rewritten or clarified."

A review of the facility policy "General Nursing Standards Manual" dated May 2013 revealed, "Manual Documentation ... 8. Errors in documentation will be identified as follows: a. Date, initial and mark a single line through the entry and enter "Mistaken Entry" above it."

A review of MR8 on November 6, 2013 revealed the following physician orders:
"10/31/13 1053 AM increase IVF(intravenous fluid) rate to 125 ml/HR(hour)"
"11/1/13 ... Resume other pre-op orders/meds(medication)"
"11/5/13 2 P decrease IVF to 50cc/hour"
"11/5/13 1425 decrease IVF to 50cc/hr may D/C(discontinue) with po(by mouth) well"
The above orders failed to include the name of the intravenous fluid, as per policy.

Interview with EMP14 on November 6, 2013, at approximately 11:10 AM confirmed the above findings and revealed, "I would say no those are not complete orders."

Further review of MR8 revealed a physician order dated October 31, 2013 that had a word scribbled out. The error did not have a date, initial, single line through the entry, or marked "Mistaken Entry" above it, as per policy.

Further interview with EMP14 on November 6, 2013 at approximately 11:10 AM confirmed the above findings and revealed, "Oh my, that is not a line."

A review of MR9 on November 6, 2013 revealed the following physician order:
"11/5/13 1300 Continue current IV fluids at 80cc/hr till taking po, then D/C Resume pre op diet." The orders failed to include the name of the intravenous fluid and name of diet, as per policy.

An interview with EMP14 on November 6, 2013 at approximately 11:45 AM confirmed the above findings.

Further review of MR9 revealed the "Authorization for Surgery or Special Procedures" form had five words scribbled out. The error did not have a date, initial, single line through the entry, or marked "Mistaken Entry" above it, as per policy.

Interview with EMP14 on November 6, 2013 at approximately 11:45 AM confirmed the above findings and revealed, "That's scribble."

A review of MR10 on November 6, 2013 revealed the following physician order: "11/6/13 1108 A decrease IVF to 80 cc/hr. " The order failed to include the name of the intravenous fluid, as per policy.

A review of MR34 on November 6, 2013 revealed the following physician order: "11/4/13 decrease IV rate 70 cc/hr." The order failed to include the name of the intravenous fluid, as per policy.

Further review of MR34 revealed a physician order dated November 3, 2013 with the dosage scribbled out. The error did not have a date, initial, single line through the entry, or marked "Mistaken Entry" above it, as per policy.

Interview with EMP13 on November 7, 2013 at approximately 10:15 AM confirmed the above findings and revealed, "It [order] doesn't include the name of the fluids."

The Physical Environment Condition was found to be out of compliance during a Life Safety Survey completed on November 14, 2013. Further details are outlined in that Division of Life Safety Survey Report.