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Based on record review and interview the hospital failed to conduct periodic appraisals of Allied Health Professionals (AHPs) for 4 (S19CST, S2RNFA, S22CRNA, S23CRNA) of 5 (S19CST, S20RNFA, S21APRN, S22CRNA, S23CRNA) AHPs reviewed for credentialing.
Findings:

Review of the Medical Staff Bylaws revealed the following, in part:
Article VI: Allied Health Professionals
Section 1: Qualification and Standards for Privileges: "In addition to such individuals who are employed by the Hospital, Allied Health Professionals who can document their experience, training, competence...may be granted privileges to function."
Section 2: Applications by Allied Health Professionals are processed as for members of the Medical Staff. Allied Health Professional Applicants shall be credentialed for privileges for a period of 2 years and may be credentialed biannually..."
Section 3: Clinical Privileges: " An Allied Health Professional practicing at the Hospital shall be entitled to exercise only those clinical privileges specifically granted to him/her by the Medical Executive Committee..."
Further review revealed additional records of AHPs would include, in part application for privileges.

In an interview 1/24/14 at 9:10 a.m. S5CC (Credentialing Coordinator) reported that she was responsible for physician credentialing files only. She further verified that she did not have any knowledge related to credentialing files or personnel files for anyone that worked at the hospital with the exception of physicians.


S19CST (Certified Surgical Technician): Review of a document titled, Allied Health Professional Guidelines, revealed, in part, "8. All initial appointments and reappointment shall be for a period of 24 months..." The document was signed by S19CST and dated 9/12/04. A document titled Allied Health Patient Care Privileges revealed a review and approval by the Medical Director dated 9/14/04, and a checked box by "Approved by Governing Body" with a date of 9/14/04. Further review of the file for S19CST revealed no request or approval of specific privileges to be performed by S19CST dated after 9/12/04. A document titled Allied Health Patient Care Privileges was signed by S19CST and dated 9/2/12, signed and dated as reviewed and approved by the Medical Director 9/3/12, but the box and date line of "Approved by Governing Body" were blank. No list of requested/ approved privileges was noted.

S20RNFA (Registered Nurse First Assistant): Review of the file of S2RNFA revealed in part, an application and Allied Health Professional Guidelines signed and dated 3/14/06. Further review revealed no request for or approval of specific privileges, and no evidence of review and/or approval by the Medical Staff or Governing Body at any time.

S22CRNA (Certified Registered Nurse Anesthetist): Review of the file of S22CRNA revealed, in part, an application for AHP appointment, AHP reappointment application, and a copy of the hospital's AHP guidelines, all signed by S22CRNA and dated 3/18/04. A document titled Allied Health Professional Delineation of Privileges, Certified Registered Nurse Anesthetist, included a description of a CRNA position, qualifications, and functions. Further review revealed no other application(s) for credentialing, or documentation of request for or approval/granting of privileges for the CRNA.

S23CRNA: Review of the file of S23CRNA revealed, in part, an application, a re-appointment application, and AHP Guidelines signed by S23CRNA and dated 1/5/06. Further review revealed no other applications, documentation of request(s) for reappointment/privileges, or approval by the Governing Body.

In an interview 1/24/14 at 1:30 p.m., S1ADM (Administrator) reported that S19 CST is a surgical technician that assists S24MD (Medical Doctor) when he performs surgery at the hospital. S1ADM further reported that S22CRNA was a contracted CRNA with S25Anesthesia, and S23CRNA was employed by the hospital. S1ADM reported that the hospital had not credentialed AHPs since their original credentialing, and was not currently credentialing or re-credentialing AHPs providing services in the hospital. S1ADM verified that there were no specific privileges requested or approved for any AHP.

Based on record review and interview the hospital failed to ensure Medical Staff By-Laws included a statement of privileges each category of practitioner may be granted as evidenced by no stated duties and privileges that may be granted to Allied Health Professionals.
Findings:

Review of the Medical Staff By-Laws revealed in addition to individuals employed by the hospital, Allied Health Professionals who could document their experience, training, competence, and adherence to professional standards could be granted privileges to function. Further review revealed, in part, the following:
Section 2. "Applications by Allied Health Professionals are processed as for members of the Medical Staff. Allied Health Professional applicants shall be credentialed for privileges for a period of two years and may be re-credentialed biannually...
Section 3. Clinical Privileges- An Allied Health Professional practicing at the Hospital shall be entitled to exercise only those clinical privileges specifically granted to him/her by the Medical Executive Committee..."

Review of personnel files for S19CST (Certified Surgical Technician), S20RNFA (Registered Nurse First Assistant), S21APRN (Advanced Practice Registered Nurse), S22CRNA (Certified Registered Nurse Anesthetist), and S23CRNA revealed no delineated privileges requested or granted for the practitioner.

In an interview 1/24/14 at 1:30 p.m. S1ADM (Administrator) verified that there were no duties or privileges stated in the Medical Staff By-Laws for each category of Allied Health Professional. S1ADM further verified, after review of the above noted AHP files, there were no documented privileges for any AHP providing services at the hospital.

Based on interview and record reviews the facility failed to ensure that the nursing staff developed a nursing care plan for each patient based on the patient's nursing assessment care needs and not solely those needs related to the admitting diagnosis or the operative procedure performed. This failed practice was evidenced by 3 out 3 (#1, #3, #4) current patients reviewed for care plans of a total sample of 30.
Findings:

A review of the Department of Nursing Policy, "Care Plan", as provided by S2DON as the most current, revealed that a nursing care plan was an individualized care plan developed for each patient based on the assessment made by the RN (Registered Nurse) and included a care plan for all patient's needs and/or problems identified from the nursing assessment.

A review of the form entitled Nursing Admission Assessment revealed a section for the admitting diagnosis of the patient and a section for any other health problems identified by the RN during the nursing assessment.

A review of the form entitled Nursing Care Flowsheet, revealed a section titled Daily Care Plan that identified the problems, the expected outcomes and goals met /not met for all the patient's care plan needs/problems identified on the Nursing Admission Assessment.

Patient #1
A review of the Nursing Admission Assessment by the RN for Patient #1, revealed the patient's admitting diagnosis was a history of breast cancer and Patient #1 was scheduled for a breast reconstruction surgery and was admitted to the facility after her surgery. A further review of the Nursing Admission Assessment revealed the patient had Diabetes, Anemia and Asthma. A review of the Nursing Care Flowsheets and the Care Plan revealed Patient #1 was care planned for Anxiety, alteration in urinary elimination, post operative bleeding and pain. There was no evidence of documentation of a care plan for Patient #1's Diabetes, Anemia or Asthma in the Nursing Care Flowsheets or in the Care Plan section.

Patient #3
A review of the Nursing Admission Assessment by the RN for Patient #3, revealed the patient's admitting diagnosis was a history of breast cancer and Patient #3 was scheduled for a breast reconstruction surgery. She was admitted to the facility after her surgery and was post-op day #3 on the day of review. A further review of the Nursing Admission Assessment revealed the patient had Hypothyroidism and was on anti-anxiety medication. A review of the Nursing Care Flowsheets and the Care Plan revealed Patient #3 was care planned for alteration in urinary elimination, post operative bleeding and pain. There was no evidence of documentation of a care plan for Patient #3's hypothyroidism or anti-anxiety medication use in the Nursing Care Flowsheets or in the Care Plan section.

Patient #4
A review of the Nursing Admission Assessment by the RN for Patient #4, revealed the patient's admitting diagnosis was Uterine Fibroids and Patient #4 was scheduled for a Myomectomy, was admitted to the facility after her surgery, and was post-op day #2 at the time of review. A further review of the Nursing Admission Assessment revealed the patient had Hypothyroidism and Anemia. A review of the Nursing Care Flowsheets and the Care Plan revealed Patient #4 was care planned for potential for infection and pain. There was no evidence of documentation of a care plan for Patient #4's Hypothyroidism or Anemia in the Nursing Care Flowsheets or in the Care Plan section.

In an interview on 01/24/14 at 1:10 p.m. with S12RN charge nurse, she was asked about the nursing assessments and the nursing care plans for each patient. S12RN indicated that nursing care plans are developed for each patient based on the nursing admission assessments. S12RN indicated that the nursing care plans for each patient can be found in the Daily Care Plan section of the Nursing Care Flowsheets. The nursing care plans for Patient #1, Patient #3 and Patient #4 were reviewed with S12RN. S12RN was asked about the care plans for these patient's other health problems that were identified by the nurses during the nursing admission assessments. S12RN indicated that the nursing care plans mostly addressed only the problems and needs associated with the patients admitting diagnosis or their surgical procedure. S12RN indicated they (the nurses) did not do care plans for the patient's other health problems.

Based on observation and interview the hospital failed to ensure 10 years (2004-2014) of patient medical records were properly stored by failing to maintain them in locations that were protected from fire and water damage.

Findings:
On 1/24/14 at 10:09 a.m. in an interview with S4HIM, she reported the hospital retained 10 years of medical records. She explained the records were all stored onsite at the hospital. S4HIM also said the hospital did not utilize the services of an outside medical record storage company. S4HIM was then asked if the hospital's medical record storage areas were sprinklered to protect the records from fire or covered in any way to protect them from water damage. S4HIM said the records were not covered to protect them from water damage and she wasn't sure if the medical record storage areas were sprinklered.

On 1/24/14 at 3:00 p.m. in an interview with S1ADM (Administrator), she confirmed the medical record storage areas in the hospital lobby/entrance (indoor storage area) and the metal shed (outside Storage #1) were not sprinklered. S1ADM also confirmed the cinderblock warehouse storage area (outside Storage #2) and the cinderblock storage room (outside Storage #3) were sprinklered. She said none of the storage areas had any type of protection from water damage.

On 1/ 24 /14 at 10:30 a.m., a tour was conducted of the hospital's medical record storage areas. Observations of the hospital's method of record storage were made at this time. S4HIM conducted the tour. S4HIM explained the medical records were stored as follows:

Indoor storage area:
Hospital's lobby/entrance:
Medical Records: Years: 2011-2014
Medical records stored on open shelves; Not sprinklered; No covers to protect from water damage.

Outside storage areas:
Storage #1:
Medical Records: Years: 2005-2006
Metal Shed, located outdoors, in the Doctor's parking garage, not attached to the hospital; Door padlocked, doorframe not sealed- light could be seen around the doorframe; Records stored in cardboard boxes; Not sprinklered; Not covered to protect from water damage.

Storage #2:
Medical Records: Years: 2007, 2008, 2009, 2010
Cinderblock Warehouse; Door: Key code entry; Records stored in cardboard boxes on open shelves; Sprinklered; Not covered to protect from water damage. Records stored in the warehouse with other supplies for the hospital.

Storage #3:
Medical Records: Year: 2004
Cinderblock Storage room; Door: Key code entry; Records stored in cardboard boxes on open shelves; Radiology films stored in manila folders on open shelves; Sprinklered; not covered to protect from water damage. Records stored in a storage room with Housekeeping linen carts, dust mops, brooms.

Based on interview and record review the hospital failed to ensure patient medical records were promptly completed by failing to have an effective process in place for identification, tracking and correction of delinquent patient medical records as evidenced by incomplete patient records from 10/2013, 11/2013 and 12/2013 for 4 of 4 (#11,#13,#R1,#R2) records reviewed for completeness of a total sample of 33.

Findings:

Review of the Medical Records Policy and Procedure, revised/reviewed 1/2013, revealed in part:
Documentation:
A medical record shall be maintained on each individual patient at the hospital whether as an inpatient or an outpatient. The recording person must date and authenticate all entries into the medical record to assure accuracy and completeness. The medical records shall be reviewed on an ongoing basis to assess the completeness and timeliness of documentation that impacts patient care.

Delinquent Records:
Medical records are to be completed within 14 days following discharge. After 14 days, physicians with incomplete records will be notified that they have 7 days to complete the record before the Medical Director is notified of the deficiency. At the end of the 7 day period, if records are not completed, the Medical Director may suspend Medical Staff privileges beginning on a specific date.

Deficiency Tracking Procedure:
On the 1st and the 15th of each month (or the next business day thereafter), compile a list of any charts over 14 days old, listing the patient name and the specific deficiency by the physician.

Review of the hospital's Medical Records Chart Audit Checklist form revealed charts were audited for signature, dating, and timing of entries/orders.

Review of sampled patient records from 10/2013, 11/2013, and 12/2013 revealed the following incomplete entries:

Patient #11
Review of Patient #11's medical record revealed an admission date of 12/9/13. Further review of Patient #11's hospital record revealed the following:
Hospital Short Stay Record history and physical, dated 11/20/13 at 7:00 a.m., signed by S14MD, with a fax transmission date and time of 11/21/13 at 3:54 p.m. ( surgery was performed 12/9/13).
Dictated Discharge Summary with Date of Admission: 12/9/13; Date of Discharge: 12/12/13, dictated by S14MD which was not authenticated, dated or timed.

Patient #13
Review of Patient #13's medical record revealed an admission date of 10/15/13.
Further review of Patient #13's hospital record revealed the following:
Dictated Discharge Summary with Date of Admission: 10/15/13; Date of Discharge: 10/19/13, dictated by S15MD, authenticated, dated, but not timed.

Patient #R1
Review of Patient #R1's medical record revealed an admission date of 12/05/13.
Further review of Patient #R1's hospital record revealed the following:
Physician Orders:
11/26/13 4:00 p.m.- Admit to S26MD on 12/3/13; T&CM (type and crossmatch) & transfuse 2 units PRBC (packed red blood cells); Pre-medicate with: Tylenol 1 gm (gram) po (by mouth); Benadryl 25mg po; Recheck H/H ( hemoglobin/hematocrit) on 12/4 in a.m. report results to S26MD.
Order authenticated by S26MD, but not dated and timed.

12/2/13 4:45 p.m.- Pt. (patient) may have H/H drawn 3 hours post transfusion; redraw type and screen.
T.O.R.B. (telephone order read back) S26MD/S3RN.
Order authenticated by S26MD, but not dated and timed.

12/4/13 4:30 p.m.- Repeat H&H in a.m., Report to S26MD.
Order authenticated by S26MD, but not dated and timed.

12/4/13 9:00 a.m.- Type and match for 2 units of PRBC and transfuse both; Pre-medicate with: Tylenol 1 gm po; Benadryl 25mg po before blood; may be discharged after blood given.
Order authenticated by S26MD, but not dated and timed.

Patient #R2
Review of Patient #R2's medical record revealed an admission date of 10/14/13 and a discharge date of 10/16/13. Further review of Patient #R2's hospital record revealed the following:
Physician Orders:
10/15/13 8:30 a.m. Regular diet; order authenticated and dated by S26MD but not timed.
10/15/13 8:30 a.m. hold Ducolax supp. (suppository); order authenticated by S26MD but not timed or dated.

In an interview on 1/27/14 at 10:09 a.m., with S4HIM, she was asked how delinquent records were tracked. S4HIM said she reviews charts on the 1st and the 15th of the month and calls the doctor's office to notify him/her of his/her delinquent charts. She said she calls again in a couple of days if the chart has not been completed after the first notification call. S4HIM said she does not keep a written log of notification calls or follow-up calls for delinquent charts. She said she stacks the charts that need to be signed and asks surgery staff to assist her in getting the delinquent records signed the next time the doctor is in the hospital. S4HIM said she notifies S1ADM to get her involved in the process of bringing the delinquent charts up to date. She explained all communication with S1ADM is verbal and no written record of the process/progress of following up on delinquent records is kept. She said S1ADM calls the doctors and asks them to come in and complete their charts. S4HIM said they have never sent out a letter for delinquent charts. She also said to her knowledge none of the doctors have been suspended for not signing delinquent charts. S4HIM was asked if she could produce a list of records noting the number of days delinquent and she replied she did not keep a list of delinquent records. She was asked if any of records were 30, 60 or 90 days delinquent and she replied, " I doubt any of the records are 60 to 90 days out because I try not to let them get that far out ".

On 1/27/14 at 3:00 p.m., in an interview with S1ADM, she said the charts are reviewed on the 1st and the 15th of each month for delinquencies. She explained she has involved the nurses in the hospital to assist S4HIM in the process of getting the delinquent records completed. She said she was " like the Principal " and the nurses would tell the doctors they were going to send them to her if they didn't complete their records. She said she also has the nurses perform chart audits to check patient records for completeness. S1ADM said she has not sent out letters for delinquent records and no one has had their privileges suspended for delinquent records. S1ADM reviewed the records that had been randomly pulled from 10/2013, 11/2013, and 12/2013, noted the incomplete entries, and confirmed the charts were not complete. S1ADM acknowledged their system for identification and tracking of delinquent records had not worked because they had missed some of the incomplete entries.

Based on interviews and records reviews, the facility failed to have policies and procedures written, implemented and enforced for a Time Out protocol in the surgical services department to ensure patient safe surgical care and practices. This failed practice was evidenced by no Time Out policy documented in their surgical services manual and no documented adherence to Time Out protocols. This failed practice affects all patients undergoing surgery or other invasive procedures at the facility.

Findings:
The National Patient Safety Statistical Report in the National Patient Safety Goals has identified wrong patient, wrong site, wrong procedure sentinel events as the second most frequently reported sentinel event in relation to safe practices in the operating room and thereby established their Time Out protocols. Time Out protocols have been consistently supported by The Joint Commission, the World Health Organization, the Council on Surgical and Perioperative Safety (CSPS) and the AORN (Association of peri-Operative Registered Nurses) for its ability to increase awareness of safe practices that lead to optimal outcomes for patients undergoing surgery and other invasive procedures and the perioperative nurse's ability to speak up for safe practices in the operating room. The AORN Perioperative Standards and Recommended Practices (2013 edition) under Patient Care, Recommendation IV.a.5. states that perioperative nursing should follow accreditation agencies, having deemed status with CMS, requirements by complying with their elements of performance to include in part: evidence of compliance with the National Patient Safety Goal's Time Out protocols. Time Out protocols include in part: a documented confirmation of the correct site and procedure with the patient (when possible) to include date, time and staff involved; documented verification by staff of surgical site marking with physician and patient to include initials; documented verification of surgical site on X-rays by staff when applicable; documented Time Out when patients enter the surgical suite and a documented Time Out prior to incision to include in part: documented verification of correct patient, site and procedure; informed consent present, correct patient position, any X-rays verified and marked, antibiotics verified, blood available if applicable, implants available if applicable, and drying of skin prep. Documentation should also include the times the 2 Time Outs were done and the documented names of all the required staff in the room.

A review of the surgical forms entitled Perioperative Record and the form entitled Moderate Sedation Flow Sheet, as identified by S3RN Director of Surgical Services, was the 2 forms used by the operating room nurses during surgical and other invasive procedures revealed no identified area on the forms for the documentation of a Time Out protocol that identified the Time Out documentation criteria (as noted above), the times the Time Out was preformed or the staff involved in the Time Out. A review of the form entitled Anesthesia Record, as identified by S10CRNA, was the form used by the anesthesia department during surgical and other invasive procedures revealed an area to document only the time when the surgical site was identified with no area identified to document the staff who were involved in the surgical site identification. The form entitled Surgical Safety Checklist, as identified by S7RN operating room nurse, was the surgical checklist form and had only "yes" boxes or "N/A" boxes and did not identify the Time Out documentation criteria (as noted above), the times the Time Out was preformed or the staff involved in the Time Out.

In an interview on 01/24/14 at 10:00 a.m. with S7RN, operating room nurse, he was asked about the facility's Time Out policy. He indicated that he was not aware of any Time Out policy and that the Surgical Safety Checklist form was only a check off sheet for "yes" or "N/A" answers and he was not aware that the Time Out protocol was a 2 part procedure with specific documentation criteria. S7RN further indicated that there was no area on either of the surgical forms entitled Perioperative Record and the form entitled Moderate Sedation Flow Sheet for any Time Out documentation.

In an interview on 01/24/14 at 11:20 a.m. with S9CRNA, she was asked about the facility's Time Out policy. She indicated that the facility's Time Out protocol was a function of the circulating nurse and she was not aware of a Time Out policy for anesthesia. S9CRNA further indicated that she only marked on her Anesthesia Record when the surgical site was identified with no other documentation of the staff who were involved in the surgical site identification or documentation of any other Time Out criteria. S9CRNA further indicated the operating room nurse would tell her what time to put down on her record.

In an interview on 01/23/14 at 3:00 p.m. with S3RN Director of Surgical Services, she indicated the surgical services department followed the AORN Perioperative Standards and Recommended Practices. S3RN was asked about the facility's Time Out policy. S3RN indicated the facility did not have a Time Out policy and further indicated that the surgical services department did not adhere to the Time Out protocols as indicated by AORN.

Based on record review and interview the hospital failed to ensure that a medical history and physical (H&P) was completed and documented no more than 30 days before admission and, if a history and physical was completed during 30 days prior to admission, an updated assessment was performed and documented prior to the surgical procedure for 6 of 6 (#3, #4, #5, # 6, #11, #14) surgical patients reviewed for a History and Physical prior to surgery out of a total sample of 30.

Review of the Medical Staff By-Laws revealed, in part, the following: Section 7. Medical Records, (d.) "A preoperative history and physical examination must be performed and recorded or dictated by an Anesthesiologist or Surgeon on all patients receiving treatment in the operating rooms immediately before surgery and made part of the medical record." (i) " All medical records shall contain [a] history and physical examination (HP) for each patient performed no more than 30 days before or twenty four (24) hours after an admission or registration, but always prior to surgery or other procedure requiring anesthesia services and placed in the patient's medical record within twenty four (24) hours after admission. This requirement applies to both inpatient and outpatients. The HP must be in the medical record prior to any high-risk procedure. In the event that the HP is completed thirty (30) days prior to admission the HP shall be updates [updated] to document any changes in the patient's condition. If there are no changes to the HP as written, the physician can simply document an update note stating that the HP has been reviewed, that the patient has been examined and that the physician concurs with the findings of the HP completed on the specific date or that "no change" has occurred in the patient ' s condition since the HP was [performed]."


Patient #3
Review of the medical record for Patient #3 revealed she was admitted to the hospital and had a surgical removal of bilateral breast implants with a Bilateral DIEP Flap reconstruction (breast reconstruction using the patient's own tissue from the lower abdomen) 1/21/14. Further review revealed a History and Physical with a faxed date of 1/8/14. No signature of a practitioner or date the History and Physical was documented was noted to verify the H&P was performed within 30 days of Patient #3's admission and surgery.

Patient #4
Review of the medical record for Patient #4 revealed she was admitted to the hospital 1/22/14 and had a Myomectomy performed that day. Further reviewed revealed an H&P with a dictation and transcription date of 1/21/14. The transcribed H&P was signed by S22MD, dated 1/22/14 and timed 8:25 a.m. Further review of the medical record revealed no documentation of an update to the H&P prior to the surgical procedure on 1/22/14.

Patient #5
Review of the medical record for Patient #5 revealed she was admitted to the hospital 1/21/14 for Total Abdominal Hysterectomy on the same day. Further review revealed an H&P dictated and transcribed 1/20/14 with the transcribed copy signed and dated 1/22/14 at 6:40 a.m. by S26MD. Further review of the record revealed no documentation of an update to the H&P prior to the surgical procedure on 1/21/14.

In an interview, 1/27/14 at 3:00 p.m. S1ADM, reviewed medical records for Patients #3, 4, and 5. She verified that the H&P for Patient #3 had no date to verify the date it was performed. S1ADM verified there was no update to the H&P documented on the day of the surgery on the medical records of Patients 4 and 5. S1ADM confirmed that an update to the H&P for Patients 4 and 5 should have been documented on the medical record prior to surgery.


30172

A review of the computer generated forms, entitled Physician's Short Stay Record, used by S16MD and S17MedDir revealed a form that included 2 sections. The top section on the form was a brief history and physical record and the bottom section of the form was the surgical operative report.

A review of S16MD's Physician's Short Stay Record- History and Physical section on the computer generated form for Patient #6 revealed that the completed form with Patient #6's History and Physical was faxed to the facility on 01/23/14 and pre-signed and pre-dated by the physician for 01/24/14. A review of Patient #6 medical record revealed no evidence of an updated history and physical on the day of surgery (01/24/14).

A review of S17MedDir Physician's Short Stay Record- History and Physical section on the computer generated form for Patient #14 revealed that the completed form with Patient #14's History and Physical was faxed to the facility on 10/25/13 and pre-signed and pre-dated by the physician for 01/24/14. A review of Patient #14's medical record revealed no evidence of an updated history and physical on the day of surgery (01/24/14).

In an interview on 01/24/14 at 12:35 p.m. with S12RN charge nurse, she indicated that this form (Physician's Short Stay Record) was the only form used by S16MD and S17MedDir for their patient's initial history and physical and the update.

In an interview on 01/24/14 at 3:30 p.m. with S16MD, he was asked about the computer generated Physician's Short Stay Record- History and Physical form that were completed and signed by S16MD and faxed to the facility prior to the surgical procedure. S16MD indicated he completed the patient's history and physical at the office visit and computer generated his signature with the surgery date and then faxes it over to the facility.

In an interview on 01/27/14 at 11:45 a.m. with S1ADM, she was asked about the computer generated forms that were completed, signed and dated by S16MD and S17MedDir and faxed to the facility prior to the surgical procedures. S1ADM indicated that this was the protocol for S16MD's and S17MedDir's surgical procedures at the facility. S1ADM indicated that the physicians did the patient's history and physical in their office and pre-dated the forms with the date of the surgery. S1ADM indicated the forms were being used incorrectly and the date on the form could not be used for both the initial history and physical date and the updated history and physical date.


30984

Patient #11
Review of Patient #11's medical record revealed an Admission date of 12/9/13 and diagnoses that included the following: history of right breast cancer, right mastectomy and staged reconstruction. Further review of Patient #11's medical record revealed the following:
Hospital Short Stay Record History and Physical, dated 11/20/13 at 7:00 a.m., signed by S14MD, with a fax transmission date and time of 11/21/13 at 3:54 p.m. (surgery was performed 12/9/13).

On 1/27/14 at 3:00 p.m., in an interview with S1ADM, she reviewed Patient #11's medical record and confirmed an updated History and Physical should have been completed . She verified the date on the History and Physical was 11/20/13 and the surgery had been performed on 12/9/13.

Based on interviews and record reviews the facility failed to ensure that informed consents were properly executed by the physicians responsible for the surgical procedures in a manner consistent with the facility's Medical Staff Policies and Procedures. This failed practice was evidenced by 3 out of 30 medical records reviewed for informed consents as being obtained by the nursing staff.

Findings:
A review of the Medical Staff Policies and Procedures, as provided by S1ADM as the most current, revealed that the physician performing the procedure was responsible for obtaining the full informed consent from the patient regarding the surgical procedure.

A review of the Department of Nursing Policy, "Consents", as provided by S1ADM as the most current, revealed that the nurse's responsibility was to witness the consent form after they established that the patient understood the nature and the purpose of the surgical procedure. The Department of Nursing Policy, "Consents", further revealed that it was the responsibility of the patient's physician performing the surgical procedure to explain the procedure to the patient and obtain the patient's consent and the nurse present will witness the patient's surgical consent by signing as a witness on the surgical consent form .

A review of the medical record of Patient #9 revealed a computer generated surgical consent form that was faxed to the facility on 01/22/14 and was pre-signed, pre-dated and pre-timed by S16MD for 01/24/14 at 9:00 a.m. The surgical consent form further revealed that the nurse,as a witness, and the patient signed the surgical consent on 01/24/14 at 10:05 a.m. and that S16MD hand dated and timed the consent again at 01/24/14 at 11:40 a.m. Patient #9's surgical procedure was on 01/24/14.

A review of the medical record of Patient #12 revealed a computer generated surgical consent form that was faxed to the facility on 01/21/14 and was pre-signed, pre-dated and pre-timed by S16MD for 01/24/14 at 9:00 a.m. The surgical consent form further revealed the nurse,as a witness, and the patient signed the surgical consent on 01/24/14 at 10:50 a.m. No other date or time by the physician was evidenced on the surgical consent form. Patient #12's surgical procedure was on 01/24/14.

A review of the medical record of Patient #31 revealed a computer generated surgical consent form that was faxed to the facility on 01/16/14 and was pre-signed, pre-dated and pre-timed by S16MD for 01/24/14 at 9:00 a.m. The surgical consent further revealed that the nurse,as a witness, and the patient signed the surgical consent on 01/24/14 at 8:40 a.m. and that S16MD hand dated and timed the consent again at 01/24/14 at 10:00 a.m. Patient #31's surgical procedure was on 01/24/14.

In an interview on 01/24/14 at 12:35 p.m. with S13RN, she was asked about the computer generated surgical consent forms for patients. S13RN indicated that the surgical consents are faxed by the physician's office prior to the patient's surgery date, pre-signed, pre-dated and pre-timed by the physician. S13RN indicated that the nurses would obtain the patient's signature on the surgical consent prior to the patient's surgical procedure. S13RN was asked if the physician who was to perform the procedure was present when the patient signed the surgical consent. S13RN indicated , "no". S13RN was asked if the patient verbalized understanding of the surgical procedure and the surgical consent. S13RN indicated that she did not usually ask the patients if they understood the surgical consent or the procedure or if the physician explained the surgical procedure to the patient nor did she document this information in her nurse's notes. S13RN indicated that if the patient had questions she would notify the physician.

In an interview on 01/24/14 at 1:50 p.m. with S12RN charge nurse, she was asked about the computer generated surgical consents for patients and the process (as noted above in interview with S13) her nurses used for obtaining the signature of the patients on the surgical consent forms. S12RN indicated that this was the process used by her nurses for all surgical patients, even those surgical consents that were not computer generated, who presented to the facility without a signed surgical consent.

In an interview on 01/24/14 at 4:00 p.m. with S1ADM, she was informed of the information obtained in the interviews above. S1ADM indicated that it was the performing physician's responsibility in this facility to obtain the patient's signature on the surgical consent form and not the nursing staff and that the nurses were only a witness to the patient's signature.

Based on interviews and record reviews the facility failed to ensure that the physician's surgical operative report was not signed, dated and timed prior to the surgical procedure. This failed practice was evidenced by 2 of 2 physician's surgical operative reports out of a sample of 30 medical records reviewed for surgical operative reports as being signed, dated and timed prior to the surgical procedure.

Findings:
A review of the Medical Staff Policies and Procedures, as provided by S1ADM as the most current, revealed that the operating physician was to fill out or dictate the surgical operative report immediately following the surgical procedure. The Medical Staff Policies and Procedures further revealed that the operating physician after completing the surgical operative report was to sign, date and time on the designated line at the time the surgical operative report was completed.

A review of the computer generated forms used by S16MD and S17MedDir revealed a form that included 2 sections. The top section on the form was a brief history and physical record and the bottom section of the form was the surgical operative report which included in part: information on the operation, the pre-operative medicines, the operative findings, the discharge progress notes and the final diagnosis.

A review of S16MD's operative report on the computer generated form on 1/24/14 at 1:30 p.m. for Patient #6 revealed that the completed surgical operative report was faxed to the facility on 01/23/14 and was computer generated signed and dated by the physician for 01/24/14. The operative report on the computer generated form further revealed that the surgical operative report was already completed by the physician and indicated he had already dictated the operation, the pre-operative medicines, the operative findings, the discharge progress notes and the final diagnosis.

In an interview on 01/24/14 at 1:50 p.m with S13RN in the out patient department, she indicated that Patient #6 had not had his surgical procedure performed yet and was still in the out patient area.

A review of the medical record of Patient #14 revealed that S17MedDir used the same computer generated form as S16MD for his brief history and physical record and his surgical operative report. A further review of Patient #14's medical record revealed that the form was completed and was faxed to the facility on 10/26/13 and was computer generated signed and dated by the physician for 01/21/14. The form revealed the operating physician had also initialed the form on 01/21/14 at 7:00 a.m. verifying the completed information on the form. A review of Patient #14's Perioperative Record revealed that the surgical procedure was performed on 01/21/14 at 10:17 a.m.

In an interview on 01/24/14 at 3:30 p.m. with S16MD, he was asked about the computer generated forms that were completed, signed and dated by S16MD and faxed by his office to the facility prior to the surgical procedure. S16MD indicated that was his protocol for all of his surgical procedures at the facility.

In an interview on 01/27/14 at 11:45 a.m. with S1ADM, she was asked about the computer generated forms that were completed, signed and dated by S16MD and S17MedDir and faxed by their offices to the facility prior to the surgical procedures. S1ADM indicated that this was the protocol for S16MD and S17MedDir surgical procedures at the facility.

Based on interview and record review the hospital failed to have sufficient personnel available to respond to the respiratory care needs of the patient population being served by failing to ensure back up respiratory staff was available in the event the only respiratory therapist, contracted with the hospital, was unavailable.
Findings:
Review of the hospital's contract, executed 6/12/2009, with an area Respiratory Consulting Company, owned by S18RT, revealed the following, in part:
Recitals:
Whereas, Company is a Louisiana Limited Liability Company;
Whereas, the Company desires to retain the consultant to supervise the respiratory therapy for Company and Consultant desires to be engaged by Company to provide respiratory therapy services for Company, upon the terms and conditions hereinafter set forth.
Now, Therefore, for and in consideration of the premises and agreements contained herein and other good and valuable consideration, the receipt and adequacy of which are hereby forever acknowledged and confessed, the parties agree as follows:
Article 1:
Obligations of Consultant:
1. Availability of professional Services: Consultant shall provide direction for Company's respiratory therapy services as outlined in " Licensing and Certification Regulations for Hospitals " , February 7, 1995.
2. Supervision of Certain personnel. Consultant shall assist in the supervision of all assistants, respiratory therapy personnel, and other health care personnel providing services on behalf of Company.
Further review of the hospital's contract with an area Respiratory Consulting Company revealed no specifics detailing services to be provided, names of respiratory staff and/or backup staff to be provided, or hours of availability.

In an interview on 1/24/14 at 9:25 a.m. S1ADM (Administrator), confirmed the hospital had only one respiratory therapist on staff (S18RT- a contracted employee). She confirmed the hospital had no back-up respiratory therapist and no policies regarding back-up respiratory staff in the event S18RT was not available.

In an interview on 1/27/14 at 1:45 p.m., with S18RT, he said he had been employed with the hospital since 2007 or 2008 as a contracted employee, through his own Respiratory Consulting Company. He also said he had an additional job as the Director of Respiratory Services at another area hospital (located in a city 27 miles from the survey hospital).

In an interview on 1/27/14 at 2:10 p.m., with S12RN, she said S18RT was consulted per Medical Doctor (MD) order if a patient required respiratory services such as chest physiotherapy (CPT) or pulmonary toileting.