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Based on record review, interview, and review of facility policy, it was determined the facility failed to ensure the designated member of the professional staff responsible for maintaining records maintained complete and accurate medical records for two (2) of three (3) sampled patients (Patient #1 and Patient #3). The facility failed to review paper medical record documents for completeness and accuracy before scanning the documents in the permanent medial record resulting in incomplete provisional reports of death being placed in Patient #1 and Patient #3's permanent medical record.

Findings:

Review of facility policy titled, "Paper Medical Records Documentation", dated 06/10/2019, revealed medical record information should be created and maintained in a manner that would ensure availability and integrity. Further review revealed general paper chart documentation guidelines stated no empty spaces should be left on paper documentation, blank lines should have a line crossed through them, and all entries were to be legible.

Review of Patient #1 medical record revealed the patient expired at the facility on 09/12/2021 at 9:37 PM in the emergency department. Further review revealed the facility scanned an incomplete provisional report of death into the medical record which was unsigned by the local registrar or deputy registrar and was unsigned by next of kin authorizing the facility to release Patient #1's body to the funeral home.

Review of Patient #3 medical record revealed the patient expired at the facility on 09/23/2021 at 2:37 AM in the emergency department. Further review revealed the facility scanned an incomplete provisional report of death into the medical record which was unsigned by a facility representative, and Patient #3 body was released to the coroner's office with no facility representative witness signature.

Interview with RN #1 on 11/03/2021 at 4:18 PM revealed she worked in the Emergency Department (ED) and had received no training on how to complete a provisional report of death. She stated the former Emergency Department (ED) Director was the local deputy registrar responsible for signing the provisional report of death for the facility, unless it was a coroner case, then he would sign in on the line of the certificate in place of the local deputy registrar.

Interview with RN #2 on 11/03/2021 at 4:35 PM revealed she worked in the ED and received no training on how to complete a provisional report of death, or on the facility policy and procedure for completing the form. She stated if there was a death in the department the provisional report of death was signed by the former ED Director, or by the coroner if it was a coroner case.

Interview with RN #3 on 11/05/2021 at 11:30 PM revealed he worked in the ED and he stated he also functioned as a night shift supervisor for the facility. He stated when there was a death in the department, the provisional report of death should be signed by the former ED Director and the coroner was called if the patient had not been seen by a physician in the past forty-eight (48) hours. RN #3 stated he had no specific training on completing a provisional report of a death on a patient.

Interview with RN #4 on 11/06/2021 at 11:10 PM revealed she was working in the ED when Patient #1 expired and completed the provisional report of death. She stated she recalled the form had not been signed by the former ED Director, but she thought the form had been signed by the next of kin. She further stated facility staff should sign as a witness on the form and she was unsure who was responsible to sign the form if the former ED Director signature was not on the form. The RN stated she had received no training on how to complete the provisional report of death form.

Interview with RN #5 on 11/09/2021 at 1:05 PM revealed she worked in the ED and had received no training on how to complete a provisional report of death form. She stated the provisional report of death had to be signed by the former ED Director, but she was not aware of any other issues with completing the forms.

Interview with Former ED Director on 11/08/2021 at 1:40 PM revealed staff had no recent training on completing provisional report of death forms and she provided the last related training in January 2021. She stated the facility had identified the provisional report of death forms were not completed properly, which prompted the training. The ED Director stated there was no documented record of the training because the it was only a verbal training with a laminated copy of a sample provisional report of death placed in the department for staff to refer to when completing the form. The ED Director stated the hospital did audits of patient death records, but the provisional report of death form was not on the review checklist for death record audits. However, she stated the provisional report of death form should have been on the audit checklist for review of patient records who had expired prior to scanning them into the permanent medical record.

Interview with Records Completion Credentialing Coordinator on 11/10/2021 at 12:55 PM revealed medical records reviewed all ED records and completed an ED analysis of each record. She further stated if a record was incomplete or documents were incomplete or inaccurate, they should be sent back to the department for correction and completion prior to being placed in the permanent medical record. Per the Records Completion Credentialing Coordinator, if provisional reports of death for Patient #1 and Patient #3 were incomplete, they should have been sent back to the department prior to being scanned into the permanent medical record and should have been caught by medical records staff during the ED scan analysis of paper documents.

Interview with the Medical Director on 11/09/2021 at 3:00 PM revealed the former ED Director had notified him the provisional reports of death were not properly completed but he could not recall when he was made aware of the issue. He further stated he was unaware of continued issues with completion of provisional reports of death, but staff should be made aware of what information was supposed to be documented and completed on the form.

Interview with Director of Quality and Compliance on 11/10/2021 at 1:30 PM revealed the facility monitored patient records to ensure they were checked for completeness and accuracy prior to being scanned into the permanent medical record. She further stated Patient #1 and Patient #3's incomplete provisional report of death form should have been caught by medical records staff, completed and corrected prior to being scanned into the permanent medical record. She stated she was not aware of any previous issues with provisional reports of death being incomplete, but staff should be trained on how to complete the form.

Interview with Former Chief Nursing Officer (CNO) on 11/08/2021 at 1:24 PM revealed she was unaware of specific issues with completion of provisional reports of death forms. She further stated the facility was in process of developing Quality Audits for death reviews, but no specific process was in place, yet.

Interview with Interim CNO on 11/10/2021 at 2:00 PM revealed she was unsure if staff had been trained on completion of provisional reports of death. She further stated medical records should have identified provisional reports of death were incomplete prior to scanning them into the permanent medical record. When asked, what was the potential outcome of incomplete or inaccurate records being placed in the permanent medical record, she responded it could potentially affect continuity of care in patients who were being transferred to other facilities or referred for other services.

Interview with the Administrator on 11/10/2021 at 2:00 PM revealed medical records staff was responsible for ensuring patient records were reviewed and completed prior to being scanned into the permanent medical record. She further stated incomplete or inaccurate records should be sent back to the department for completion or correction prior to being scanned into the permanent medical record, and staff should be trained on how to complete provisional reports of death. When asked, what was the potential outcome of incomplete or inaccurate records being placed in the permanent medical record, she responded complete and accurate records were important in maintaining continuity of care and treatment of all patients. She further stated inaccurate or incomplete records could potentially have a negative impact on further patient care.

Based on interview, record review and policy review, it was determined the facility failed to ensure patients and/or their legal representative had the right to be informed of and participate in the patient's treatment and were fully informed of the his/her total health status for one (1) of three (3) sampled patients (Patient #2). Staff interviews revealed staff reported abnormal laboratory findings for Patient #2 to Nurse Practitioner (NP) #1 on 10/13/2021. The NP ordered further diagnostic tests on 10/14/2021, to determine the cause of the abnormal findigs with no definite reason determined. On 10/15/2021, the NP ordered for Patient #1 to transferred to another facility (Facility #2) for further testing related to the abnormal laboratory findings; however, the facility failed to inform the patient or his/her responsible party of the laboratory findings and the reason for the transfer.

The findings include:

Review of the facility policy titled "Patient Rights and Organizational Ethics" last revised on 10/13/2019, revealed staff would preserve patients' rights to receive communication involving their cases in terms the patient could reasonably be expected to understand. According to the policy, if the patient was incapable of understanding a proposed treatment/procedure or was unable to communicate their wishes regarding care, the information would be made available to their legal representative.

Review of the medical record for Patient #2 revealed he/she was admitted to a swing bed at the facility on 10/06/2021 with diagnoses which included Dementia and a history of falls.

Review of Patient #2's record also indicated he/she had expired on 10/25/2021; therefore, was unable to be interviewed or observed during the investigation.

Review of the investigation conducted by the facility revealed at approximately 3:30 PM on 10/13/2021 staff sent a stool sample from Patient #2, to the laboratory. Medical Laboratory Technician (MLT) #1 informed Registered Nurse (RN) #8 (no time indicated) she observed one (1) spermatozoa (sperm) in the patients' stool under a microscope. The investigation review also indicated MLT #1 "called back later and said another lab tech said no sperm" was in Patient #2's stool when a second laboratory staff observed the sample under the microscope.

Further review of the investigation revealed on 10/13/2021, RN #8 and laboratory staff (not named) reported to NP #1 laboratory staff had confirmed there was sperm in Patient #2's stool under a microscope. However, there was no evidence staff informed NP #1 of the conflicting reports of the two (2) laboratory staff of whether sperm was observed in the patients stool or not.

Review of Patient #2's record also revealed another stool sample was taken to the laboratory and observed under a microscope on 10/14/2021 and no sperm was identified. Continued review of the patient's record revealed no indication sperm was identified in Patient #2's stool as alleged.

Review of Patient #2's medical record revealed the patient was transferred to facility #2 on 10/15/2021 at approximately 9:00 PM for further evaluation and treatment regarding potential abnormal laboratory results.

Interview with Patient #2's family member on 11/03/2021 at 1:00 PM revealed he/she was the patient's legal representative. The family member also stated he/she was informed by phone from a staff member at Facility #2 on 10/16/2021 (the day after the patient was transferred) staff suspected sperm was detected in Patient #2's stool sample at the previous facility. The family member also stated he/she felt staff should have informed him/her of the suspected abnormal findings for Patient #2 when they were identified and also stated he/she should have been informed that the reason for the patients transfer was due to potential abnormal laboratory results.

Interview with NP #1 on 11/08/2021 at 4:15 PM revealed on 10/13/2021, RN #8 and laboratory staff (unable to recall who) reported to her one (1) sperm was observed in Patient #2's stool under a microscope; however, there was no laboratory report which confirmed the findings. NP #1 stated she conducted diagnostic tests in attempts to determine an underlying medical reason why sperm could be in his/her stool on 10/14/2021; however, the tests results indicated no definitive reason why this could occur. Therefore, NP #1 stated on 10/15/2021 she transferred Patient #2 to another facility so further testing could be conducted to determine a potential underlying medical reason why sperm could be detected in the patient's stool. However, the NP stated she never informed Patient #2 or his/her family member. NP #1 also stated Patient #2 and/or the patient's legal representative should have been informed of the potential abnormal findings on 10/13/2021 and should have been informed those findings were the reason for the patients transfer on 10/15/2021.

Interview with the Chief Executive Officer (CEO) on 11/10/2021 at 2:00 PM revealed patient's have the right to be fully informed of their health status and had the right to participate in their care/treatment provided at the facility. She also stated Patient #2 and/or his/her representative should have been informed of the potential abnormal laboratory findings on 10/13/2021 and those findings were the reason he/she was transferred to another facility for further testing on 10/15/2021.

Based on interview, record review, policy review, and review of the facility investigation, it was determined the facility failed to ensure an allegation of potential abuse was investigated and reported timely to the State Survey Agency (SSA) and Adult Protective Services (APS) for one (1) of three (3) sampled patients (Patient #2). On 10/15/2021, Nurse Practitioner #1 reported an allegation of potential abuse to the former Chief Nursing Officer (CNO) and requested an investigation into an incident regarding Patient #2. However, the CNO failed to report the allegation to APS until 10/18/2021 (three days later) and never reported the incident or the investigation findings within five (5) working days, to State Survey Agencies as required. In addition, when the SSA entered the facility on 11/03/2021 (19 days after the allegation occurred) the facility investigation was still ongoing.

The findings include:

Review of a facility policy titled "Abuse Policy," last revised on 10/02/2019, revealed if an employee had a reasonable cause to believe an adult had been a victim of abuse, the shift assistant nursing director as well as the department director would be notified immediately. According to the policy, the department director would report the allegation to the Department of Community Based Services (DCBS) centralized intake immediately. However, the policy failed to direct staff to report allegations of abuse to the State Survey Agency, or to ensure allegations were thoroughly investigated and/or to report investigation findings to the Survey Agency within five (5) working days as outlined in the regulatory guideline.

Review of the facility policy titled "Patient Rights and Organizational Ethics," last revised on 10/13/2019 revealed staff would preserve patients' rights and patients access would include reasonable expectations to receive care in a safe and secure environment, that was free from abuse.

Review of Patient #2's medical record revealed the facility admitted the patient on 10/06/2021 to a swing bed with diagnoses which included Dementia and a history of falls.

Patient #2 had expired on 10/25/2021; therefore, was unable to be observed and/or interviewed.

Review of the facility investigation revealed on 10/13/2021 at approximately 3:30 PM staff sent a stool sample from Patient #2, to the laboratory. Medical Laboratory Technician (MLT) #1 informed Registered Nurse (RN) #8 (no time indicated) she observed one (1) spermatozoa (sperm) in the patients stool under a microscope. Further review of the investigation revealed MLT #1 "called back later and said another lab tech said no sperm" was in the patients stool when the second laboratory staff observed the sample under the microscope.

Interview with MLT #1 on 11/04/2021 at 1:00 PM revealed she informed RN #8 that she observed what she thought was one (1) sperm in Patient #2's stool on 10/13/2021. However, she stated she had not looked at sperm under a microscope in over twenty (20) years and without a laboratory confirmation, which the facility was not capable of, she should not have "assumed" that was what she saw and also stated looking back "I know" it wasn't sperm. She also stated she had a second MLT look at the same sample on 10/13/2021, and she did not have any indication sperm was in Patient #2's stool sample.

Further review of the investigation revealed on 10/13/2021, RN #8 and laboratory staff (not named) reported to NP #1 laboratory staff had confirmed there was sperm in Patient #2's stool under a microscope. However, there was no evidence staff informed the NP of the conflicting reports of the two (2) laboratory staff of whether sperm was observed in the patients stool or not.

Further review of Patient #2's record revealed no laboratory tests which confirmed sperm was identified in Patient #2's stool as alleged.

Continued review of the facility investigation revealed on 10/14/2021 another stool sample for Patient #2 was sent to the laboratory and observed under a microscope and no sperm was identified.

Interview with NP #1 on 11/08/2021 at 4:15 PM confirmed RN #8 and laboratory staff (unable to recall who) informed her on 10/13/2021 that one (1) sperm was observed in the patients stool under a microscope; however there was no laboratory report to confirm the findings. The NP stated she conducted diagnostic tests in attempts to determine an underlying medical reason why sperm could be in Patient #2's stool on 10/14/2021; however, the results of the tests provided no definitive reason why this could occur. Therefore, the NP stated on 10/15/2021 she informed the former CNO of the reported sperm observed in Patient #2's stool, and she was unable to confirm a medical reason as to why this could occur for the patient. NP #1 stated she requested the CNO investigate care/treatment of Patient #2, regarding the abnormal findings, to ensure the patient had not been abused in the facility.

Continued review of the facility investigation confirmed on 10/15/2021, NP #1 reported the abnormal findings in Patient #2's stool, with no known medical reason to explain the findings, to the previous CNO; however, the investigation indicated the CNO did not report the allegation of abuse to APS until 10/18/2021 (3 days later) and failed to report the allegation of abuse to State Survey Agencies regarding Patient #2.

Interview with the former CNO on 11/05/2021 at 1:30 PM revealed she had been the facility CNO for less than three (3) months when the allegation of potential abuse was reported to her by NP #1 regarding Patient #2 on 10/15/2021. She stated she had not been trained to report allegations of abuse to APS and to State Survey Agencies immediately but not later than two (2) hours as outlined in the regulatory guidelines. However, she stated as a nurse, she was aware abuse allegations should be reported timely and stated she should not have waited three (3) days to inform APS of the allegation regarding Patient #2. The CNO also stated she was not aware the State Survey Agencies should receive reports of the facility's investigation findings within five (5) working days. She stated the investigation to ensure Patient #2 had not been abused at the facility was ongoing when her employment at the facility ended approximately fourteen (14) days after the allegation was voiced.

Interview with the Chief Executive Officer (CEO) on 11/10/2021 at 2:00 PM revealed the previous CNO informed her on 10/15/2021 (unsure of exact time) NP #1 voiced an investigation needed to occur, to ensure Patient #2 had not been abused at the facility regarding potential abnormal laboratory results. However, the CEO stated she was not aware allegations of potential abuse should have been reported immediately, or no later than two (2) hours to the State Survey Agency and APS. The CEO also stated the facility should have operated within the regulatory requirements when the allegation was identified on 10/15/2021.