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Based on observation, staff interview, and policy and procedure review, the facility failed to ensure that outdated drugs are not available for patient use.


Findings Include:


On 10/19/15 at 11:05 a.m. observation of the medication refrigerator in the Emergency Department (ED) revealed five (5) opened, multi-dose, medication vials which were greater than 28 days past the date they were opened or past the "beyond-use-date" (BUD) printed on the medication label.The Director of Nursing was present during the observation and confirmed the findings.


Review of the facility's "Infection Control" policy (issued 9/3/15) revealed, "Infection Control - Multi-dose Vial Stability/Storage - Multi-dose medication vials with antimicrobial preservatives which have been opened or entered (e.g. needle punctured) the USP standard is that the BUD (Beyond-Use-Date) is 28 days unless otherwise specified by the manufacturer. ...".

Based on medical record review, document review, bylaws review, policy and procedure review, and staff interview, the facility:
1. failed to ensure 203 medical records were complete within 30 days following patient discharge,
2. failed to ensure the initial discharge planning was complete in nine (9) of 20 medical records,
3. failed to ensure physician verbal orders were co-signed within 24 hours in three (3) of 20 medical records, and
4. failed to ensure that records are legible, complete, accurately documented, and readily accessible for nine (9) out of 20 patients reviewed. Patients #11, #12, #13, #14, #15, #16, #18, #19, and #20.




Findings Include:


Record review revealed Patients #12, #13, #15, and #16 had verbal orders not signed by the physician.

During an interview on 10/20/15 at 10:05 a.m. the Medical Records Director stated, "Our doctors have 30 days to sign verbal orders."

Review of bylaws approved by medical staff on 10/15/15 revealed orders dictated over the telephone shall be signed by the person to whom dictated with the name of the physician per his or her own name. Within twenty-fours (24) hours, the attending physician shall sign such orders.



Review of the facility's Medical Records delinquent physician list revealed 203 incomplete medical records greater than 30 days following patient discharge. All 203 incomplete records involved one (1) physician and were from 2/2014 to present day and included discharge summaries not dictated, and History and Physicals and physician orders not dictated and/or signed.


During an interview on 10/20/15 at 10:15 a.m. the Medical Records Director confirmed the number of delinquent medical records (greater than 30 days after patient discharge) was 203. The delinquent records included both acute and swing bed medical records. The delinquent medical record count ranged from February 2014 to present and included orders, discharge summary, and history and physicals either not dictated and/or signed by the physician. She stated that 15 notification letters had been sent to the delinquent physician from 5/20/14 to 10/19/15.


Review of a copy of the 11 page October 19, 2015 physician notification letter sent to the delinquent physician by the facility revealed: "Dear (physician's name) This is a reminder the following Medical Records have been incomplete for 30 days or longer and require your immediate attention. To protect your medical staff privileges, these records must be completed as soon as possible. ...".


During an interview on 10/20/15 at 1:30 p.m. the Medical Records Consultant confirmed there were 203 delinquent medical records. She stated, "This has been reported to Administration and the physician involved. No action has been seen. No discussion in medical staff meeting minutes. No action by medical staff and no physician is off staff."



Review of the facility's "Health Information" policy (approved on 10/15/14 by the Medical Staff) revealed: "I. Purpose: Health Information shall maintain complete and accurate records of care ...III. General Policies and Procedures ...1. All significant clinical information pertaining to a patient shall be incorporated into the electronic medical record. The attending physician shall be responsible for preparation of a complete and legible record for each patient ...3 ...The electronic and paper medical records shall include: A ...medical history ...doctor's orders ...narrative discharge summary ...B. No Medical Record shall be considered as complete until all aspects of completion of a chart has been obtained ....7. History and physical examination shall in all cases be completed within 24 hours of admission of the patient ...8. All medical records must be complete within 30 days of discharge from the hospital ...including discharge summary ...".


Review of the facility's "By-Laws, Rules and Regulations " (reviewed and approved by the Medical Staff on 12/15/14) revealed: " ...Article XV ...Rules and Regulations ...14. The attending physician shall be held responsible for the preparation of a complete medical record ...No medical record shall be filed until it is complete ...24 ...At the time of discharge, the attending physician shall see that the record is complete ...".


Review of the facility's "Amendment to Medical Staff By-Laws, Rules and Regulations" (dated 05/23/07) revealed: "12. A complete history and physical examination shall, in all cases, be written (dictated) and validated with signature and time by the attending physician, within 24 hours after admission of the patient ...".


Record review revealed Patients #11, #12, #13, #14, #15, #16, #18, #19, and #20 had no documented evidence of discharge planning during their hospital stay.


During an interview on 10/19/15 at 2:45 p.m. Registered Nurse (RN) #4 confirmed discharge planning was incomplete.


During interview on 10/20/15 at 10:30 a.m. RN #3 stated, "We do discharge planning on admission with the initial assessment and it is updated throughout the patient stay and again at discharge. I do not know why the patients discharge plan was not done."



Review of the facility's "Discharge Planning Program" revealed each department has the responsibility for the providing of discharge planning services. Nursing: assessment/initiation, referrals/consultations, teaching and preparation, evaluation of knowledge and skills related to discharge planning, documentation and written patient instructions and high risk screening.

Based on medical record review, document review, bylaws review, staff interview, and policy and procedure review, the facility failed to ensure medical records are promptly completed in accordance with State law and CAH policy.


Findings include:

Cross Refer to C300 for the facility's failure to ensure medical records are complete within 30 days following patient discharge, the initial discharge planning is completed in medical records, physician verbal orders are co-signed within 24 hours in medical records, and medical records are legible, complete, accurately documented, and readily accessible.

Based on medical record review, document review, bylaws review, policy and procedure review, and staff interview, the facility:
1. failed to ensure 203 medical records were complete within 30 days following patient discharge,
2. failed to ensure the initial discharge planning was complete in nine (9) of 20 medical records,
3. failed to ensure physician verbal orders were co-signed within 24 hours in four (4) of 20 medical records,
4. failed to ensure that records are legible, complete, accurately documented, and readily accessible for nine (9) of 20 patients reviewed. Patients #11, #12, #13, #14, #15, #16, #18, #19, and #20.


Findings Include:


Cross Refer to C300 for the facility's failure to ensure medical records were complete within 30 days following patient discharge, initial discharge planning is complete, physician verbal orders are co-signed within 24 hours, and records are legible, complete, accurately documented, and readily accessible.












33607

Based on record review, document review, bylaws review, staff interview, and policy and procedure review, the facility failed to ensure the medical record contains all practitioner's orders properly signed/authenticated for four (4) of 20 patients reviewed. Patients #12, #13, #15, and #16.


Findings Include:


Cross Refer to C300 for the facility's failure to ensure Patients #12, #13, #15, and #16's medical records were complete and properly signed/authenticated by the physician.

Based on record review, policy review, and staff interview, the facility failed to carry out physician's orders and failed to update Nursing Care Plans for two (2) of three (3) inpatient patient's reviewed, Patient #7 and Patient #8.


Findings Include:


Record review for Patient #7 revealed a diagnosis of Congestive Heart Failure (CHF) and a physician's order for daily weights. Review of documented weights for Patient #7 revealed no weight was recorded on October 18, 2015. Patient #7 weighed 159 pounds (lbs) on 10/17/15 and 165.2 lbs on 10/19/15, a weight gain of 6.2 lbs. There was no documented evidence noting the physician was notified or that the patient's Care Plan was updated.


Record review for Patient #8 revealed a diagnosis of CHF and a 10/4/2015 physician's order for daily weights. Review of documented weights for Patient #8 revealed no documented evidence that a weight was recorded for 10/10/15. There was no documented evidence the physician was notified or that the care plan was updated daily.


During an interview on 10/19/15 at 2:45 p.m. Nurse #1 stated that she was not aware of any written protocol or policy to notify the physician of the weight gain. "I just know as a nurse when to notify the physician."



Interview with the Director of Nursing (DON) on 10/19/15 at 3:20 p.m. revealed, "Care Plans are computer generated and have been a problem. The physician visited and assessed (Patient #7) the next day."


Review of the facility's "Care Plan Policy and Procedure" (last approved on October 9, 2014) revealed, "It is the policy to provide an individualized, interdisciplinary Plan of Care for all patients and the Plan of care shall be updated daily ...".