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Based on record review and interview, the facility failed to meet the Condition of Participation on Patient Rights as evidenced by the facility's failure to provide prompt resolution to documented grievances within a reasonable timeframe, include a designated legal representative to make informed decisions regarding patient care after appropriate legal documents were presented and the right to access requested parts of the clinical records within a reasonable timeframe. Refer to A-0119, A0131, and A-0148.

Based on record review and interview, the hospital ' s governing body failed to effectively addressed the patient ' s representative concerns in a timely manner for one (1) out of 30 sampled patients (SP)#1.
The findings include:
Clinical record review of Sample Patient (SP) #1 conducted on 11-30-10 revealed that she was admitted at the facility on 2-18-07 with a diagnosis of subarachnoid hemorrhage. Documentation showed a request for SP#1 ' s medical records by a legal firm on behalf of SP#1 ' s representative dated 6-15-10 addressed to the facility ' s Health Information Management Department including but not limited to: " Please provide copies of [SP#1 ' s name mentioned] CT x-ray scans, including copies on disc if available, at your earliest convenience. "
Documentation of the facility ' s reply to above mentioned request dated 7-19-10 included but not limited to: " Requests for medical records must include all the information below. One or more of the following core elements is missing from your request: Description of the information to be disclosed; and Name of person/company authorized to make use of disclosure. "
Documentation of the legal firm ' s reply regarding the third attempt to receive medical records dated 8-24-10 included but not limited to: " ...we received a letter on July 19, 2010, through Healthport, refusing to provide these medical records stating that the original request was missing " the following core elements " [as mentioned above].
Another documentation from the legal firm dated 10-5-10 regarding the fourth attempt to receive medical records of SP#1 included but not limited to: " Thank you for providing partial radiology records for [SP#1 ' s name mentioned] in response to our letters dated June 15,2010 and August 4, 2010. Once again, however, these records are incomplete. Please provide [SP#1 ' s legal representative ' s name mentioned] copies of all of [SP#1 ' s] radiological and imaging records, including CT, MRI and other radiological records on disc, in particular: All CT records of [SP#1 ' s] brain; and All brain flow studies. "
Documentation showed that all three requests dated 6-15-2010, 8-24-2010 and 10-5-2010 had copies addressed to the facility ' s President/Chief Executive Officer, the Chairperson of the Public Health Trust and SP#1 ' s legal representative.

Interview with SP#1 ' s legal representative conducted on 11-30-10 at 11am revealed that there were copies of the other medical records requested but is still waiting on the CT scan of the brain in disc or on films . She emphasized she wants the actual brain scan disc/films as earlier requested.

Interview with the Director of Medical Records conducted on 11-30-10 at 215pm revealed that the completed Authorization for Release of Confidential Medical Records form is forwarded to the Radiology department where the person requesting, picks up any disc and/or films. The director also stated that the Medical Records Department is not responsible for the release of the radiology discs and/or films.

Interview with the Corporate Director of Information Technology Division (CDIT) conducted on 11-30-10 at 345pm explained the process involved in transforming analog films into the digitized form. The Director stated that the Radiology Picture Archive Communication System (PACS) is involved in this process. He explained that prior to April 2008, CT scans were in films and stored by the facility's contractor (name mentioned). The Director (CDIT) also stated that a magnetic optical disc is not a medical record. The Director (CDIT) further stated that the film is the medical record. The Director (CDIT) explained that SP#1's films are not in the electronic PAC System but will be requested from the facility's contractor and promised the disc to be ready within 48 hours.
Interview with the Director of Radiology on 11/30/2010 at 4:00pm stated that the record log for the request and release of radiology disc and/or films would be found in the jacket of the film, and both are kept at an offsite location.

During the exit conference conducted on 11-30-10 at 520pm with the Administrative Officers present ,confirmed that the facility failed to provide SP#1's legal representative with the requested brain scan disc.

On 12/1/2010 a Copy of a the film of SP#1 CT scan of the brain was produced by the facility.

Based on record review and interview, the facility failed to promptly include the patient's legal representative selected by the patient, who was willing and able to make treatment decisions for the patient who had the right to make informed decisions as soon as proper documents were received in one (Sample Patient [SP]#1) of 30 sampled patients.

The findings include:

Clinical record review of SP#1 conducted on 11-30-10 revealed that she was admitted to the facility on 2-18-07 at 1533 (333pm) with a diagnosis of subarachnoid hemorrhage. Documentation showed that the legal documents were signed and notarized such as the Health Care Directive, Durable Power of Attorney (DPOA), and Affidavit of Witnesses to the Durable Power of Attorney were faxed to the facility on 2-18-07 at 117pm Pacific Time (417pm Eastern Time) on sp#1 behalf. Review of the DPOA included but not limited to: " The undersigned, (SP#1 ' s name mentioned), as principal, hereby designates (SP#1 ' s legal representative named) to be the attorney-in-fact. The attorney-in-fact shall have the power to do all things with respect to ...as the principal could do if present and competent ...including the power to provide for the support, maintenance and health of the principal ...to provide informed consent for health care decisions on the principal ' s behalf. This power of attorney becomes effective upon the execution of this document and shall remain in effect, notwithstanding any uncertainty as to whether the principal is dead or alive. This power of attorney shall not be affected by the disability of the principal. "
Further review of SP#1 ' s clinical record showed the General Consent for Treatment form dated 2-19-07 at 146am and the Advance Directives Checklist dated 2-19-07 both were stamped with " Patient Unable to Sign " and both with signatures of two witnesses.
Nursing documentation at the Trauma Center dated 2-18-07 at 1720 (520pm) showed " Ventric placed by (two physicians named). No change in patient status. " There was no documented evidence of a consent signed for ventriculostomyby the legal representative of sp#1.

Interview with SP#1 ' s legal representative conducted on 11-30-10 at 11am revealed that she had legal documents faxed to the facility after being told that she cannot see SP#1 without the legal papers. She stated that legal documents were faxed to the facility at 1:17pm Pacific Time (4:17pm Eastern Time). She added that she was not allowed to fill out or sign admission forms. She further stated that she saw SP#1 at approximately 8:00pm during the last rites.

Interview with the facility Social Worker conducted on 11-30-10 at 2:20pm revealed that he met SP#1 ' s legal representative within 15 minutes of arrival, gathered SP#1 ' s medical information and psychosocial assessment and the information that SP#1 had Advanced Directives. He stated that he physically had SP#1 ' s Advanced Directives in his hands within 3 hours. He explained that it was a hectic day at the Trauma Center at the time with two deaths. He added that from his office to the Trauma Center, he saw SP#1 ' s legal representative at SP#1 ' s bedside and waved the legal documents showing that he got them, and SP#1 ' s legal representative responded with a thumbs up. He calculated this to happen approximately between 6:00pm to 630pm. He emphasized that he left past 8pm that night and did not have further contact with SP#1 nor SP#1 ' s legal representative.

Based on interview and record review the facility failed to provide sample patients(sp) #1 access to information contained the clinical records within a reasonable time frame.

Findings include:
1) Clinical record review of Sample Patient (SP)#1 conducted on 11-30-10 revealed that she was admitted at the facility on 2-18-07 with a diagnosis of subarachnoid hemorrhage. Documentation showed a request for SP#1 ' s medical records by a legal firm on behalf of SP#1 ' s representative dated 6-15-10 addressed to the facility ' s Health Information Management Department including but not limited to: " Please provide copies of [SP#1 ' s name mentioned] CT x-ray scans, including copies on disc if available, at your earliest convenience. "
Documentation of the facility ' s reply to above mentioned request dated 7-19-10 included but not limited to: " Requests for medical records must include all the information below. One or more of the following core elements is missing from your request: Description of the information to be disclosed; and Name of person/company authorized to make use of disclosure. "
Documentation of the legal firm ' s reply regarding the third attempt to receive medical records dated 8-24-10 included but not limited to: " ...we received a letter on July 19, 2010, through Healthport, refusing to provide these medical records stating that the original request was missing " the following core elements " [as mentioned above].
Another documentation from the legal firm dated 10-5-10 regarding the fourth attempt to receive medical records of SP#1 included but not limited to: " Thank you for providing partial radiology records for [SP#1 ' s name mentioned] in response to our letters dated June 15,2010 and August 4, 2010. Once again, however, these records are incomplete. Please provide [SP#1 ' s legal representative ' s name mentioned] copies of all of [SP#1 ' s] radiological and imaging records, including CT, MRI and other radiological records on disc, in particular: All CT records of [SP#1 ' s] brain; and All brain flow studies. "
Documentation showed that all three requests dated 6-15-2010, 8-24-2010 and 10-5-2010 had copies addressed to the facility ' s President/Chief Executive Officer, the Chairperson of the Public Health Trust and SP#1 ' s legal representative.

Interview with SP#1 ' s legal representative conducted on 11-30-10 at 11am revealed that there were copies of the other medical records requested but is still waiting on the CT scan of the brain in disc or on films . She emphasized she wants the actual brain scan disc/films as earlier requested.

Interview with the Director of Medical Records conducted on 11-30-10 at 215pm revealed that the completed Authorization for Release of Confidential Medical Records form is forwarded to the Radiology department where the person requesting, picks up any disc and/or films. The director also stated that the Medical Records Department is not responsible for the release of the radiology discs and/or films.

Interview with the Corporate Director of Information Technology Division (CDIT)conducted on 11-30-10 at 345pm explained the process involved in transforming analog films into the digitized form. The Director stated that the Radiology Picture Archive Communication System (PACS) is involved in this process. He explained that prior to April 2008, CT scans were in films and stored by the facility's contractor (name mentioned). The Director(CDIT) also stated that a magnetic optical disc is not a medical record. The Director(CDIT) further stated that the film is the medical record. The Director(CDIT) explained that SP#1's films are not in the electronic PAC System but will be requested from the facility's contractor and promised the disc to be ready within 48 hours. The Director did not give a clear statement about the record log for requests and releases of radiology discs.
Interview with the Director of Radiology on 11/30/2010 at 1600 stated that the record log for the request and release of radiology disc and/or films would be found in the jacket of the film, and both are kept at an offsite location.

Based on observation of the medical records department, interview of medical records director and radiology staff; and a sample of 30 patients medical record reviews; the hospital does not assure that the medical record of 12 of 30 sampled patients was completed, appropriately stored, or is retrievable upon request.








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Based on record review, interview and observation, the facility failed to meet the Condition of Participation on Medical Records as evidenced by the facility's failure to provide complete and accurate information entered into the medical records, system-wide prompt retrieval of medical records requested within a reasonable timeframe, and appropriate storage of medical records to protect and maintain its integrity. Refer to A-0438, A-0439, and A-0449.

Based on record review, observation, and interview, the hospital failed to maintain a system for an accurate, prompt completion, easy retrieval, and readily accessible medical records for 10 of 30 sampled patients(SP). (SP#1, SP#9, SP#10, SP#11, SP#12, SP#14, SP#20, SP#22, SP#23, SP#24) and proper storage and protection from water damage of medical records for several random inpatients and outpatients.
The findings include:
1) Clinical record review of Sample Patient (SP)#1 conducted on 11-30-10 revealed that the patient was admitted on 2-18-07 with a diagnosis of subarachnoid hemorrhage and discharged on 2-21-07 with a final diagnosis of death secondary to subarachnoid hemorrhage with herniation. Trauma Center Nursing documentation showed she underwent ventriculostomy on 2-18-10 at 1720. There was no documented evidence of a consent signed for the mentioned procedure.
Further review of SP#1 ' s record showed four pages of Respiratory Therapy notes with no date and time; one page of Ventilator Flowsheet with no date and time; and five pages of Critical Care Flowsheets with no dates.
Physician documentation showed conflicting information in SP#1 ' s Discharge Summary dated 2-19-07 included in one paragraph written as follows: " At 11 in the morning, the patient was declared dead, prior to that by physical examination by 2 days. Organ team notified. The patient was declared to be expired on 1045am this morning secondary to subarachnoid hemorrhage with herniation. "
Documentation showed SP#1 ' s name with an " s " on most pages and without " s " on some pages.
Documentation showed SP#1 ' s age as 39 years old on most documents, 50 years old on the Anesthesiology Airway Management Progress Record, and 43 years old in the imaging results from the Cerner System.
Documentation showed SP#1 ' s admission date as 1-1-80 and a discharge date of 5-30-07 in the imaging results retrieved from the Cerner System.

During an interview on 11-30-10 at 4:45 pm with the Quality Monitoring Coordinator and during the exit conference at 17:11pm confirmed that the there was many discrepancies noted within the documentation in the medical records of sampled patient #1 as well as with many of sample patients medical records.
2) Review of records of SP#9 conducted on 11-30-10 showed that there were no documented evidence of the required signatures for patient education and discharge planning.
Review of the hospital policy and procedure Code: MR-RI-1; Section: Health Information Management Release of Information; Subject: Authorization for Release of Confidential Medical Records Form conducted on 11-30-10 confirmed above finding. Review of procedure #9 showed: " The medical record must be completed prior to release of information whether the record is to be copied or examined. However, it is referred that the patient ' s records be released within 10 days of a written request regardless of completion. Therefore, the record should be completed as quickly as possible in order to release it within the 30 day time period.
Review of SP#10 conducted on 11-30-10 revealed that the patient had a procedure done on the right foot. There was no documented evidence of any signed informed consent obtained from the patient prior to the procedure. There was also no documented evidence of any discharge instructions signed by the patient.
During record review conducted on 11-30-10 of SP#11 medical records revealed that SP#11 was discharged from the facility on 03-14-2010. Further review of records of SP#11 showed absence of a discharge summary.
Review of SP#12 conducted on 11-29-10 revealed that the patient was admitted on 02-16-10 to 02-1710. Further review of records revealed that there was no documented evidence of any discharge instructions signed by the patient.
Review of records of SP#14 conducted on 11-30-10 showed that there were no required signatures for patient education and discharge planning
Interview on 11-30-10 at 4:45 pm with the Quality Monitoring Coordinator confirmed that the the above documentation was absence from the medical records of SP #9, SP#10, SP#11, SP#12, and SP#14.
3) Based on observation conducted on 11-29-10 thru 11-30-10 showed that there was a slow process of retrieving all the medical records of 30 sample patients (SP). The surveyor gave the list of sample patients on 11-29-10 at 11:00 am but there were 5 sample medical records that were not provided during the 2-day survey (SP#20, SP#22, SP#23, and SP#24).
Interview with the Quality Monitoring Coordinator conducted on 11-30-10 at 4:45 pm confirmed above finding that the medical records requested by the surveyors on 11-29-10 at 11:00 am of SP#20, SP#22, SP#23, and SP#24 were not available for review. He/she further added that the personnel at the Medical Records were gone for the day.
Interview with the Director of Medical Records conducted on 11-30-10 at 10:35 am confirmed above finding that those records were completed beyond 30 day time period. He/she further added that the delay was due to waiting for the doctor to complete the document. There was also an occasion when there was a Medicaid audit and they had to do a lot of records.
4) Observation during the tour of the Medical Records Department was conducted on 11-30-10 at 12:40 pm with the hospital Quality Monitoring Coordinator and the Medical Records Director. In room L-107, known as a Research Room, it was observed that there were approximately 300 patient records on open wire racks on the left side of the room. The patient records were observed to be wet, curled up at the edges, and smeared ink on pages. The Medical Records Director stated that on 11/21/10, the water sprinkler went off and drenched the patient records. Two fans were noted on the table in the room. The surveyor asked if the records have duplicates or how they would be salvaged. The director stated that a national company specializing in drying records would be utilized. The surveyor asked for evidence of plan, none was available.
5) Interview with the Director of Medical Records conducted on 11-30-10 at 1045am revealed that the Admit Date of 1-1-1980 is a " Do Not Use Account " brought over from the CARE System to the CERNER System. She had no further explanation as to why the " Do Not Use Account " has been used.

6) Based on review of the Medical Records Request Log (SMART log) conducted on 11-29-10 showed that there were medical records requested and completed or sent to requesters after 30 day time period.
Interview of the Medical Records Director, was conducted on 11/29/10 and 11/3010, regarding the system to retrieve patient records upon request. The requestor must complete a Request for Records form, show proper authorization for records, and drivers license or identification. Patients request for all of their records, however, only portions of the patient medical record was released. The director stated that the requests are dated on the log as received and completed when sent to the requestor. The log did not reflect the specific hospitalization being requested. When asked for the log of requests for patient #1, none were available. The Medical Record Director stated that most of the Request of Retrieval for records is outsourced to Healthport Technologies, LLC. When the surveyor asked what quality assurance measures were being monitored for this contractor, none were available.
Interview of the Medical Records Director on 11/30/10, revealed that request for radiology films or scans were referred to the Radiology Department, due to the technology utilized to duplicate studies. When the surveyor asked for any referrals for the Radiologic medical records, none were available. Interview of the Radiology Director and staff on 11/30/10, was conducted. A request was made of the tracking of requests for radiologic tests and completion of the request. No quality tracking was available according to the staff. The staff explained that Iron Mountain is the contractor which stores these films, images, and studies. When asked regarding the quality assurance monitoring of the contractor for compliance with records requests, none was available.

Based on record review, interview and policy review the facility failed to be able to promptly retrieve the complete medical record of 6 of 30 sampled patient(SP)#1, SP # 10 , SP#20, SP#22, SP#23, and SP#24 who was evaluated and/or treated in any part or location of the hospital within the last 5 years


Findings include:
1) Clinical record review of Sample Patient (SP) #1 conducted on 11-30-10 revealed that a request for SP#1 ' s medical records by a legal firm on behalf of SP#1 ' s representative dated 6-15-10 was addressed to the facility ' s Health Information Management Department including but not limited to " Please provide copies of [SP#1 ' s name mentioned] CT x-ray scans, including copies on disc if available, at your earliest convenience. "
Documentation of the facility ' s reply to above mentioned request for SP #1 medical record was dated 7-19-10 stated: Requests for medical records must include all the information below. One or more of the following core elements is missing from your request:
Description of the information to be disclosed; and the Name of person/company authorized to make use of disclosure.
Documentation of the legal firm ' s reply regarding the third attempt to receive medical records dated 8-24-10 included : ...we received a letter on July 19, 2010, through Healthport, refusing to provide these medical records stating that the original request was missing " the following core elements " [as mentioned above]. In subsequent telephone call with Healthport, we were informed that [facility ' s name mentioned] was refusing to turn over the records, but that the request would be investigated. Please provide us with these CT scans at your earliest convenience. "
Another documentation from the legal firm dated 10-5-10 regarding the fourth attempt to receive medical records of SP#1 included but not limited to: " Thank you for providing partial radiology records for [SP#1 ' s name mentioned] in response to our letters dated June 15,2010 and August 4, 2010. Once again, however, these records are incomplete. Please provide [SP#1 ' s legal representative ' s name mentioned] copies of all of [SP#1 ' s] radiological and imaging records, including CT, MRI and other radiological records on disc, in particular: All CT records of [SP#1 ' s] brain; and All brain flow studies. "
Documentation showed that all three requests dated 6-15-2010, 8-24-2010 and 10-5-2010 had copies addressed to the facility ' s President/Chief Executive Officer, the Chairperson of the Public Health Trust and SP#1 ' s legal representative.

Interview with SP#1 ' s legal representative conducted on 11-30-10 at 11am revealed that she has copies of the other medical records requested but is still waiting on the CT scan of the brain disc. She emphasized she wants the actual brain scan disc as previously requested.



2) On 11/29/2010 during a review of sample patient # 10 complet medical records retrieved from the medical records department revealed that sample patient # 10 had a procedure done on the right foot. There was no documention in the medical record of any signed informed consents . There is also no documented evidence in the medical record of SP's # 10 discharge instructions .
On 11/30/2010 at during an interview the Quality manager verified that the there was no evidence in the medical records of a signed informed consent prior to the procedure and there is also no documented evidence in the medical record that SP # 10 of any discharge instructions

On 11/29/2010 during a record review of sample patient (SP) # 12 medical records revealed that this sampled patient was admitted on 2/16/2010 to 02/17/2010. Review of sample patient #12 medical records retrieved from the medical records department revealed that sample patient # 12 has no documented evidence of any discharge instructions .

On 11/30/2010 at 16:00 during an interview the Quality manager verified that the there was no evidence in the medical records that an informed consent was obtained from the patient prior to the procedureand there is also no documented evidence in the medical record that SP # 12 signed any discharge instructions

3) On 11/29/2010 at 12noon, 3pm, and at 4:30pm and 11/30/2010 at 10:00am, 1200, 1400, 1500, and at the exit conference- several requests were made by the surveyor team to obtain complete medical records for all of 30 sampled patients and as 11/30/2010, there were 4 of the 30 sample patient (SP)# 20, SP#22, SP#23, and SP#24 of whom there weren't any records received by the time of exit.

On 11/29/2010 at 10:45 am during an interview with the Director of Medical Records revealed that some of the medical records are computerized and the rest are scanned before sending it to an offsite location.

11/30/2010 at 10:45am during an interview with the Director of Medical Records revealed that the records were kept offsite and were in the process of being brought from that location.

On 11/30/2010 at 17:11 during an interview with the Quality Monitor Coordinator also revealed that there weren't any medical records retrieved and/or provided for 4 of the 30 sample patients (SP)#20, SP# 22, SP# 23, and SP#24 during the survey nor at the time of the exit conference .

4) Observation during the tour of the Medical Records Department was conducted on 11-30-10 at 12:40 pm with the hospital Quality Monitoring Coordinator and the Medical Records Director. In room L-107, known as a Research Room, it was observed that there were approximately 300 patient records on open wire racks on the left side of the room. The patient records were observed to be wet, curled up at the edges, and smeared ink on pages. The Medical Records Director stated that on 11/21/10, the water sprinkler went off and drenched the patient records. Two fans were noted on the table in the room. The surveyor asked if the records have duplicates or how they would be salvaged. The director stated that a national company specializing in drying records would be utilized. The surveyor asked for evidence of plan, none was available.

Based on record review and interview, the facility failed to ensure that the patient ' s legal documents are promptly filed in the patient ' s medical records in one (Sample Patient [SP]#1) of 30 sampled patients, available for the healthcare team to plan for the patient ' s care and make decisions on the provision of care to the patient.

The findings include:

Clinical record review of SP#1 conducted on 11-30-10 revealed that she was admitted to the facility on 2-18-07 at 1533 (333pm) with a diagnosis of subarachnoid hemorrhage. Documentation showed that legal documents signed and notarized such as the Health Care Directive, Durable Power of Attorney (DPOA), and Affidavit of Witnesses to the Durable Power of Attorney, were faxed to the facility on 2-18-07 at 117pm Pacific Time (417pm Eastern Time). Review of the DPOA included but not limited to: " The undersigned, (SP#1 ' s name mentioned), as principal, hereby designates (SP#1 ' s legal representative named) to be the attorney-in-fact. The attorney-in-fact shall have the power to do all things with respect to ...as the principal could do if present and competent ...including the power to provide for the support, maintenance and health of the principal ...to provide informed consent for health care decisions on the principal ' s behalf. This power of attorney becomes effective upon the execution of this document and shall remain in effect, notwithstanding any uncertainty as to whether the principal is dead or alive. This power of attorney shall not be affected by the disability of the principal. "
Further review of SP#1 ' s clinical record showed the General Consent for Treatment form dated 2-19-07 at 146am and the Advance Directives Checklist dated 2-19-07 both stamped with " Patient Unable to Sign " and both with signatures of two witnesses.
Nursing documentation at the Trauma Center dated 2-18-07 at 1720 (520pm) showed " Ventric placed by (two physicians named). No change in patient status. " There was no documented evidence of a consent signed for ventriculostomy.

Interview with SP#1 ' s legal representative conducted on 11-30-10 at 11am revealed that she had legal documents faxed to the facility after being told that she cannot see SP#1 without the legal papers. She stated that legal documents were faxed to the facility at 117pm Pacific Time (417pm Eastern Time). She added that she was not allowed to fill out or sign admission forms. She further stated that she saw SP#1 at approximately 8pm during the last rites.

Interview with the facility Social Worker conducted on 11-30-10 at 220pm revealed that he met SP#1 ' s legal representative within 15 minutes of arrival, gathered SP#1 ' s medical information and psychosocial assessment and the information that SP#1 had Advanced Directives. He stated that he physically had SP#1 ' s Advanced Directives in his hands within 3 hours. He explained that it was a hectic day at the Trauma Center at the time with two deaths. He added that from his office to the Trauma Center, he saw SP#1 ' s legal representative at SP#1 ' s bedside and waved the legal documents showing that he got them, and SP#1 ' s legal representative responded with a thumbs up. He calculated this to happen approximately between 6 to 630pm.