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Based on record review and interview the Critical Access Hospital (CAH) failed to ensure clinical records were maintained in accordance with the hospital's Policies and Procedures as evidenced by Patient Medical Records containing a History and Physical ( H&P), performed within 30 days prior to the day of a patient's surgery/procedure, that did not have documentation of an updated H&P, that included a statement of the changes or absence of changes in a patient's condition ( since the time of the original H&P) and the time and date of the updated H&P for 4 (#17, #18, #19, #28) of 5 (#17, #18, #19, #27, #28) surgical/procedural records reviewed for an updated H&P, of a total of 34 sampled records.
Findings:


Review of hospital policy #8015, titled "History and Physical-Medical Staff" , provided by S9AdmAsst (Administrative Assistant), as current, revealed the following, in part:
"History and Physical:
A comprehensive medical history and physical examination shall be completed within 24 hours of admission to inpatient services, or prior to surgery or a procedure requiring anesthesia. A comprehensive H&P shall be completed prior to surgery and prior to procedures requiring anesthesia services, regardless of whether care is being provided on an inpatient or outpatient basis. H&P examinations may be completed ahead of time, though no more than 30 days prior to admission.... When an H&P is performed prior to admission, an updated H&P, including any changes in the patient's condition, must be completed and documented by a licensed practitioner..prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination are completed within 30 days before the admission or registration. If the licensed practitioner finds no change in the patient's condition since the H&P was completed, he/she shall indicate in the patient's medical record that the H&P was reviewed, the patient was examined, and that "no change" has occurred in the patient's condition since the H&P was completed. If the licensed practitioner finds changes in the patient's condition since the H&P was completed, he/she shall document the change(s) in the patient's medical record within 24 hours of admission or registration, but prior to surgery or a procedure requiring anesthesia services... H&P examinations by the appropriate practitioner privileged to perform H&Ps must be completed and recorded before any operative or invasive procedure is undertaken...

Review of Hospital Policy #8001, title Medical Record Content revealed the following, in part:
All entries in the medical record shall be dated, timed, and authenticated, in written or electronic form, by the person responsible for providing or revaluating the service provided. Additionally, the time and date of each entry (orders, reports, notes,etc.) must be accurately documented.
A comprehensive H&P examination shall be completed within 24 hours of admission.
When the medical history and physical examination are completed within 30 days of admission, the hospital must ensure that an updated medical record entry documenting an examination for any changes in the patient's condition is completed. This updated examination must be completed and documented in the the patient's medical record within 24 hours of admission, but prior to surgery or a procedure requiring anesthesia.

Review of Hospital Policy #8004, titled "Medical Record Guideline for Physicians" revealed the following, in part:
General Outlines: All entries must be timed, dated and authenticated.
History and Physical Examinations: A comprehensive H&P must be completed and recorded before any operative or invasive procedure is undertaken. When the H&P is completed within 30 days prior to admission, the hospital must ensure that an updated medical record entry documenting an examination for any changes in the patient's condition is completed. This updated examination must be completed and documented in the patient's medical record within 24 hours of admission but prior to surgery or a procedure requiring anesthesia.

Review of the Medical Staff Bylaws and Rules and Regulations revealed, in part under "B. Medical Records" the following:
1. The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient. Its contents shall be pertinent and current...2...If a complete history has been recorded and a physical examination performed within 30 days prior to admission, a durable, legible copy of this report may be used in the patient's hospital medical record,...The practitioner should document a review of this valid history and physical, patient re-examination, and note whether a change or no change in the patient's status has occurred

Patient #17
Review of the medical record for Patient #17 revealed he was admitted 7/13/15 for an outpatient colonoscopy with MAC (monitored anesthesia care). Further review revealed he had an H&P dated 6/26/15. A notation on the bottom of the H&P included the date, 7/13/15, and the signature of S6MD. No documentation was noted that the patient had been examined, the H&P reviewed, and whether there were any changes in Patient # 17's condition since the H&P on 6/26/15. Further review revealed no time was included in the notation to evidence a review was done prior to the patient's procedure.

Review of the medical record for Patient #18 revealed he was admitted 7/13/15 for an outpatient screening colonoscopy with MAC. Further review revealed no documentation that the patient had been examined, the H&P reviewed and whether there were any changes in Patient # 18's condition before the procedure, but since the H&P on 7/6/15. Further review revealed no time was included in the notation to evidence a review was done prior to the patient's procedure.


Review of the medical record for Patient #19 revealed he was admitted 7/13/15 for an outpatient colonoscopy with MAC. Further review revealed no documentation that the patient had been examined, the H&P reviewed and whether there were any changes in Patient # 19's condition before the procedure, but since the H&P on 7/2/15. Further review revealed no time was included in the notation to evidence a review was done prior to the patient's procedure.



Review of the medical record for Patient #28 revealed she was admitted 6/22/15 for and Esophagogastroduodenoscopy (EGD) and MAC. Further review revealed no documentation that the patient had been examined, the H&P reviewed and whether there were any changes in Patient # 28's condition before the procedure, but since the H&P on 5/21/15. Further review revealed no time was included in the notation to evidence a review was done prior to the patient's procedure.


In an interview 7/14/15 @ 3:25 p.m. S4RN (Registered Nurse), with S2CNO (Chief Nursing Officer) present, verified the prior H&Ps for Patients #17, #18, #19, #28 had a signature of S6MD only, with no documentation as to whether or not the patient's condition had changed, and if so, in what way. S4RN verified there was no documented time on an entry or signature to confirm the patients had been examined for changes prior to their procedure. S4RN confirmed the medical records did not have documentation of an updated H&P as per hospital Policy and Procedures and per Medical Staff Bylaws.

Based on interview and record review, the CAH failed to ensure patient records contained a summary of each episode/encounter as evidenced by failure to ensure a discharge summary was executed on patients as they are discharged and admitted from service to service for 2 (#14,#16) of 2 (#14,#16) hospice patient records reviewed and 2 (#11,#16) of 2 (#11,#16) swing bed patient records reviewed.

Findings:

Review of the Health Information Management Policy, titled, medical Record Content, Reference #8001, revealed the following, in part:
Discharge Summary:
Should be dictated within 24 hours following patient's discharge except in unusual situations where pathology or autopsy findings are awaited.
Must recapitulate the reason for the hospitalization.
The discharge summary or final summary shall include:
Admitting diagnosis/reason for admission; final diagnosis and any associated diagnosis; consultants; history; pertinent physical findings; pertinent clinical laboratory findings; all procedures performed; hospital course; discharge medications; the condition of the patient on discharge; discharge instructions, which include activity, diet, medications and follow-up appointments;
A copy of discharge instructions given to the patient is filed in the medical record;
The medical record must be completed within 30 days post patient discharge from the hospital.

Hospice Patients:

Patient #14

Review of Patient #14's medical record revealed she was admitted to acute inpatient status on 3/25/15. Further review revealed she was admitted to Hospice Services on 3/30/15 with admission diagnoses including the following: palliative care and Chronic Renal Failure. Additional review revealed no documented evidence of a discharge summary when the patient was discharged from acute inpatient status on 3/30/15 and admitted for contracted inpatient Hospice Services.

Patient #16

Review of Patient #16's medical record revealed he was admitted to acute inpatient status on 3/12/15 with an admission diagnosis of Aspiration Pneumonia. Further review revealed he was discharged from acute inpatient status and admitted to Swing Bed status on 3/18/15. Additional review revealed he was admitted to Hospice Services on 3/28/15. Additional review revealed no documented evidence of a discharge summary when the patient was discharged from Swing Bed status on 3/28/15 and admitted for contracted inpatient Hospice Services.

Swing Bed Patients:

Patient #11

Review of Patient #11's medical record revealed she was admitted to acute inpatient status on 5/13/15 with an admission diagnosis of abdominal pain with ileus. Further review revealed she was discharged from acute inpatient status and admitted to Swing Bed status on 5/18/15. Additional review revealed no documented evidence of a discharge summary when the patient was discharged from acute inpatient status on 5/18/15 and admitted to Swing Bed status.

Patient #16

Review of Patient #16's medical record revealed he was admitted to acute inpatient status on 3/12/15 with an admission diagnosis of Aspiration Pneumonia. Further review revealed he was discharged from acute inpatient status and admitted to Swing Bed status on 3/18/15. Additional review revealed no documented evidence of a discharge summary when the patient was discharged from acute inpatient status on 3/18/15 and admitted to Swing Bed status.

In an interview on 7/15/15 at 11:56 a.m. with S3HIM (Health Information Management) she verified patients who were placed on Swing Bed status from Acute Inpatient status were discharged when they changed services. She also verified patients who were admitted for contracted inpatient Hospice services from acute inpatient services had also been discharged when they had changed services. She agreed all patients should have a discharge summary when they are discharged from each service.

Based on record reviews and interviews the hospital failed to ensure physicians dated and timed all entries in the medical record as per hospital Policies and Procedures. This deficient practice was evidenced by physician orders that were not dated and/or timed for 11 of 11
(#1, #2, #10, #15, #17, #18, #19, #24, #27, #28, #29) records reviewed for timed, dated, and authenticated physician orders from a total sample of 34.
Findings:

Review of a hospital policy from Health Information Management (HIM) titled "Electronic Signature", effective 7/1/15, approved by the Medical Staff, and provided by S2CNO (Chief Nursing Officer) as current, revealed the following:
To ensure timely authentication of telephone and verbal orders by physicians to include the signature, date and time completed according to the By Laws and regulatory standards.
Policy:
Physicians must date, time and sign all entries, in the medical records, either manually or electronically. All verbal orders and telephone orders must be dated, timed and signed within 10 days...

Review of Hospital Policy #8001, provided by S9AdmAsst (Administrative Assistant) as current, revealed, in part, that , "All entries in the medical record shall be dated, timed, and authenticated in written or electronic form, by the person responsible for providing or evaluating the service provided. Additionally, the time and date of each entry (orders, reports, notes, etc.) must be accurately documented.

Review of Hospital Policy #8004, titled, "Medical Record Guideline for Physicians", provided by S3HIM as current, revealed the following, in part:
General Outlines: * All entries must be timed, dated, and authenticated...
Progress Notes:... Must be timed and dated...
Verbal Orders: The prescribing practitioner must date, time, and authenticate the verbal/telephone order within 48 hours of giving the order (or in a timeframe that complies with state regulation)...

Review of notes from a Medical Staff Committee Meeting 1/13/15, provided by S3HIM (Health Information Management), revealed a note under the agenda that read," Incomplete orders -must be clarified, missing route, missing time/date, abbreviations." In an interview 7/16/15 at 11:30 a.m. S3HIM confirmed that the subject of incomplete orders, including missing time and date was discussed with the medical staff.


Patient #1
Review of Patient #1's medical record revealed he was admitted on 07/11/15 with the admitting diagnoses of UTI (Urinary Tract Infection), Sepsis with hypotensive episode and unresponsiveness. Further review of Patient #1's medical record revealed the following read back verbal order had been authenticated by S10MD(Medical Doctor) but had not been dated/timed: -7/11/15 at 2:15 p.m. Clean wound to sacrum & posterior thigh with Seaclens; apply Normlgel and Alldress daily & prn (as needed).

Patient # 2
Review of Patient #2's medical record revealed he was admitted to the hospital on 07/10/15 with the admitting diagnoses of Hypotension, Hypothermia, Dehydration, and CHF (Congestive Heart Failure). Further review of Patient #2's medial record revealed the following read back verbal orders had been authenticated by S10MD but had not been dated/timed: -07/10/15 at 11:24 p.m. 1) Leave bear hugger on low setting. 2) Give Duoneb (duonebulitizer) now. 3) Bipap(Bilevel positive airway pressure) per Respiratory 4) Give Lasix 20 mg (milligrams)( IVP( Intravenous push) x 1 if systolic above 110.

Patient #10
Review of Patient #10's medical record revealed he was admitted to the hospital on 07/12/15 with admitting diagnoses of Multifocal Bronchopneumonia and Hyponatremia. Further review of Patient #10's medical record revealed the following read back verbal orders had been authenticated by S10MD but had not been dated/timed: -07/12/15 at 3:56 p.m. Medication Reconciliation Form ( list of all patient's home medications) -07/14/15 at 8:15 a.m. 1) Change H2O (water) flush to NS (normal saline) 2) am (a.m.) CBC(complete blood count), bmp (basic metabolic panel), Magnesium 3) Have his mother call me 4) Do f/u (follow/up) A/B (antigen/B) antibody today - 07/14/15 at 10:15 p.m. Resume tube feeding as follows: 1) Gluceria 1.5 - 2 cans every 8 hours for a total of 6 cans daily. 2) H2O flush- 240 ml (milliliters) every 6 hours.

Patient #15
Review of Patient #15's medical record revealed he was admitted on 2/10/15 with an admission diagnosis of Cardiopulmonary Arrest. Further review of Patient #15's medical record revealed the following orders had been authenticated and timed by the ordering/prescribing physician, but had not been dated:
-2/10/15 9:11 p.m.: D/C (discontinue) Lovenox prophylaxis; CBC (complete blood count), BMP (basic metabolic profile) in a.m. The order was taken verbally as a RBTO (read back telephone order) by the nurse. -2/10/15 9:15 p.m.: O2 (oxygen) at 2 Liters NC (nasal cannula) humidified. The order was taken verbally as a RBPO by the nurse. -11/15 8:50 a.m.: 1. Change IVF (intravenous fluids) to D5 (5% dextrose) 1/2 NS (normal saline) @ (at) 80cc (cubic centimeters) /hr. (hour) add 20 Meq (millequivalents) KCL (potassium chloride)/liter 2. Check blood cultures x (times) 2, check urine culture if not done.

Patient # 24
Review of Patient #24's medical record revealed she was admitted on 3/26/15 with an admission diagnosis of Acute or Chronic Renal Failure. Further review of Patient #24's medical record revealed the following orders had been authenticated by the ordering/prescribing physician, but had not been dated or timed: -4/1/15 4:35 p.m.: D/C Diprovan and Lasix; Increase Spironolactone to 25 mg twice a day; Start Bumex 2 mg IVP twice a day. The order was taken verbally as a RBPO by the nurse.
In an interview on 7/15/15 at 11:56 a.m. with S3HIM (Health Information Management) she agreed all entries in the patient record should have been authenticated, dated and timed. She also verified that not all of the entries in the medical records referenced above were authenticated, dated and/or timed.
Patient #17

Review of the medical record for Patient #17 revealed he was admitted 7/13/15 for an outpatient procedure in the surgical department. Further review revealed Endoscopy Physician Standing Orders (pre-operative, intra-operative, and post-operative) that were initiated and signed off by nurses in each area. S6MD signed his name at the bottom of the order page, but no date or time of the authentication signature was documented.

Patient #18

Review of the medical record for Patient #18 revealed he was admitted 7/13/15 for an outpatient procedure in the surgical department. Further review revealed Endoscopy Physician Standing Orders (pre-operative, intra-operative, and post-operative) that were initiated and signed off by nurses in each area. S6MD signed his name at the bottom of the order page, but no date or time of the authentication signature was documented.

Patient #19

Review of the medical record for Patient #19 revealed he was admitted 7/13/15 for an outpatient procedure in the surgical department. Further review revealed Endoscopy Physician Standing Orders (pre-operative, intra-operative, and post-operative) that were initiated and signed off by nurses in each area. S6MD signed his name at the bottom of the page, but no date or time of the authentication signature was documented.

Patient #27

Review of the medical record for Patient #27 revealed he was admitted 6/22/15 for an outpatient Percutaneous Gastronomy Tube insertion in the surgical department. Further review revealed Endoscopy Physician Standing Orders (pre-operative, intra-operative, and post-operative) that were initiated and signed off by nurses in each area. S6MD signed his name at the bottom of the page, but no date or time of the authentication signature was documented.

Patient #28

Review of the medical record for Patient #28 revealed she was admitted 6/22/15 for an outpatient procedure in the surgical department. Further review revealed Endoscopy Physician Standing Orders (pre-operative, intra-operative, and post-operative) that were initiated and signed off by nurses in each area. S6MD signed his name at the bottom of the page, but no date or time of the authentication signature was documented.

Patient #29

Review of the medical record for Patient #29 revealed she was admitted 6/30/15 for an outpatient procedure in the surgical department. Further review revealed Endoscopy Physician Standing Orders (pre-operative, intra-operative, and post-operative) that were initiated and signed off by nurses in each area. S6MD signed his name at the bottom of the page, but no date or time of the authentication signature was documented.


In an interview 7/14/15 at 3:25 p.m. S4RN, with S2CNO present, verified S6MD's signature was not dated and timed on the Endoscopy standing orders for Patients #17, #18, #19, #27, #28, and #29.



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31206

Based on record review and interview the CAH (Critical Access Hospital) failed to ensure all services (including contracted services) were included in the CAH's quality assurance program. Findings:

Review of the Quality Assurance Program revealed that contracted services were not included in the CAH's Quality Assurance Program.

An interview was conducted with S8QA (Quality Assurance/Performance Improvement) Officer on 7/15/15 at 11:00 a.m. She revealed contracted services were not included in the Quality Assurance Program of the CAH.