HospitalInspections.org

This is a RECITE

Based on review of the facility's plan of correction, staff interview and information in regard to the current delinquent records number, the facility failed to ensure that medical records were completed within 30 days following the discharge of a patient. The facility census was 184 patients.

Findings include:

The facility developed a plan of correction for this citation that stated there would be weekly discussions with the Chief Medical Officer and the Health Information Management (HIM) Director to review physicians currently on the pending suspension list; physicians are to be placed on suspension when records are incomplete 30 days post discharge; reminder phone calls were to be made to all physicians who have been on the impending suspension list for a week; a "streaming" note was to be placed on the physicians dashboards on 03/09/11 reminding them to complete their medical records; the Medical Executive Committee discussed the importance of compliance and agreed to support and ensure enforcement of suspension as delineated in the Credentialing Manual.
Review of the current delinquent records list revealed that there were 56 physicians with a total of 724 delinquent records as of 03/22/11. A copy of the "reworded" suspension letter was also reviewed. The letter to be sent to the physicians stated " The Medical Staff Bylaws require that all medical records be complete within (30) days of a patient's discharge. Any records listed below with a day count of 23 or greater must be completed within the next 7 days or you will be placed on the suspension list. While on the suspension list you will not be permitted to admit patients, consult on patients, schedule or perform surgery. Should you have patients in-house when you go on the suspension list you will be permitted to continue their episode of care to discharge."
This letter, per Staff L's interview on the morning of 03/24/11, was scheduled to be sent to all 56 physicians today. Staff L stated that they had just gotten the "go ahead and send them" sign. Staff L further stated that phone calls to all 56 physicians were also being made.
During review of the information presented during the survey, it was noted that on 03/10/11 six (6) physicians were called to discuss their delinquent records and 2 were to meet with Staff P to discuss their delinquent records. On 03/17/11, eight (8) physicians were called, told that the next call would come from the hospital Administration if delinquent medical records were not completed. Five physicians were to meet with Staff P to discuss their delinquent records and 1 physician was to meet with Staff O.

During the survey the nursing units were visited and medical records were reviewed. While on one of the nursing units a physician was noted to be attending "team" meeting, writing orders and seeing patients. This physician was noted to have 75 delinquent medical records. When asked why the physician was "working", Staff L stated that they did not know and that Staff L had been suspended a while ago but that with the new letters and notification perhaps they were waiting to enforce the suspension.

Review of the delinquent record list of physicians revealed that one physician had 128 delinquent records, another 82, and a third 63. Review of the daily census sheet revealed that these and several other of these physicians were still admitting patients as of 03/23/11.

The number of delinquent records at the time of the original survey was 457 and at the resurvey the number was 724. This information was shared with staff L and Staff M.


21893

This is a re-cite

The Condition of Physical Environment is NOT MET.

Based on the observations made during the post survey re-visit by Life Safety Code, staff interviews and review of documentation presented by the facility, the facility failed to ensure that all of the areas of the hospital and the off-site locations were constructed and maintained to ensure the safety of the patients. The hospital had a census of 184 patients.

Findings include:

Please see the Life Safety Code Survey for a full explanation of the findings under the following K-tags:

The following deficiencies were found not corrected and were re-cited during the Life Safety Code survey:
K12 - addressed the facility failure to ensure the building construction type and height met an approved construction type for the height, composition and use of the building.

K38- addressed the facility failure to ensure that exit access was arranged so that exits were readily accessible at all times with regards to snow, ice and access to the public way.

K103 - addressed the facility failure to ensure interior walls and partitions in buildings were noncombustible or limited-combustible materials.


The following K130 information was relevant to the ambulatory surgery center (ASC) only:

Failure to ensure the exit access was arranged so that exits are readily accessible at all times in accordance with section 7.1. for 2 public way exits.

Hazardous areas were re-cited due to the amount of combustibles stored in the basement which did not meet proper construction for a hazardous area.

This is a recite

Based on the results of the re-survey from Life Safety Code which included observations, interviews and review of documentation presented by the facility, the facility failed to meet the provisions of Life Safety Code of the National Fire Protections Association. The facility had a current census of 184 patients.

Findings include:

The following areas were found not corrected and were re-cited during the Life Safety Code survey:
The following K130 information was relevant to the ambulatory surgery center (ASC) only:

Failure to ensure the exit access was arranged so that exits are readily accessible at all times in accordance with section 7.1. for 2 public way exits.

Hazardous areas were re-cited due to the amount of combustibles stored in the basement which did not meet proper construction for a hazardous area.