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Based on review of medical staff bylaws, policies/procedures, manuals, credential files, facility documents and staff interviews, the facility governing body and medical staff failed to ensure that the medical staff maintained up-to-date credential file documentation for 8 (sample credential files #2, #3, #4, #5, #6, #7, #8, #9) of 9 credential files reviewed. The governing body failed to ensure that the medical staff complied with the credentialing requirements contained in the medical staff bylaws and other documents.

The findings were:

1. Review of the medical staff regulation document "Credentials Manual Performance, Improvement Plan, Fair Hearing Plan," on 1/4/11 revealed the following, in pertinent parts:
"...Article 2
QUALIFICATIONS, CONDITIONS AND RESPONSIBILITIES
2.A. QUALIFICATIONS
2.A.1 Threshold Eligibility Criteria:

To be eligible to apply for initial appointment or reappointment to the Medical Staff, physicians, dentists, oral surgeons, podiatrists, and psychologists must:
(a) have a current, unrestricted license, certification, or registration to practice in Colorado.
(b) where applicable to their practice, have a current, unrestricted DEA registration; ...
(d) have current, valid professional liability insurance coverage in a form and in amounts satisfactory to the Hospital;...
(p) maintain board certification and, to the extent required by the applicable specialty/subspecialty board, satisfy recertification requirements. Recertification shall be assessed at reappointment...

6.C. AUTOMATIC RELINQUISHMENT
...6.C.2. Action by Government Agency or Insurer and Failure to Satisfy Threshold Eligibility Criteria:
(a) Any action taken by any licensing board, professional liability insurance company, court or government agency regarding any of the matters set forth below, or failure to satisfy any of the threshold eligibility criteria set forth in this Policy, must be promptly reported by the Medical Staff member to the CEO and the President of the Medical Staff.
(c) Any individual's appointment and clinical privileges shall be automatically relinquished or restricted as indicated if any of the following occur:
(1) Licensure: Revocation, expiration, suspension, or the placement of restrictions on any individual's license, certification, registration, or other legal credential authorizing practice in the State of Colorado. If restrictions are placed on any legal credentials, the clinical privileges affected by such limitations or restriction are automatically suspended;
(2) Controlled Substance Authorization: Revocation, expiration, suspension, or the placement of restrictions on an individual's DEA controlled substance authorization will result in a suspension of a practitioner's right to prescribe medications covered by the DEA certificate;
(3) Insurance Coverage: Termination or lapse of an individual's professional liability insurance coverage, or other action causing the coverage to fall below the minimum required by the Community Board or cease to be in effect, in whole or in part....
(d) An individual's appointment and clinical privileges shall also be automatically relinquished, without entitlement to the procedural rights outlined in this Manual, if the individual fails to satisfy any of the other threshold eligibility criteria set forth in this Manual.
(e) Automatic relinquishment shall take effect immediately upon notice to the Hospital and continue until the matter is resolved, if applicable.
(f) Failure to resolve the underlying matter leading to an individual's clinical privileges being automatically relinquished in accordance with paragraphs (b)(1), (b)(2) or (b) (3) above, within 90 days of the date of relinquishment, shall result in automatic resignation from the Medical Staff."

NOTE: In the previous paragraph labelled (f), it refers to (b) (1-3), but in the document, there is no (b). It is mislabeled as (c) (1-3) in describing the requirements for licensure, DEA, and liability insurance.

Review of the Medical Staff Organizational Policy "Allied Health Professional Credentialing," on 1/5/11 revealed the following, in pertinent parts:
"PURPOSE: To provide a mechanism for the granting of permission to provide services for individuals not eligible for medical staff membership.
COMPLIANCE RESPONSIBILITY: Medical Staff Services Department
...General: Describes process for Allied Health Practitioners (AHPs) must be qualified by academic and clinical or other training to practice in a clinical or supportive role in providing services. These practitioners may provide services only as permitted by this institution and in keeping with all applicable rules, policies, and procedures of the Medical Staff and (facility).
Practitioners: Currently the following types of allied health practitioners may be granted permission to provide services. This category includes, but is not limited to, the following:
Licensed Supervised AHPs are those AHPs who use some independent judgement but still require supervision as determined by licensure and/or the hospital. The licensed supervised AHP's scope of practice is defined by an inventory of services. Examples include certified registered nurse anesthetists, nurse practitioners, clinical nurse specialists, nurse midwives, social workers, physician assistants, and clinical research nurses. Licensed supervised AHPs must have a sponsor who is a member of the active medical staff...
Qualifications: To be permitted to provide services, an applicant
must:
A. Be a graduate of a recognized and accredited school or have completed a requisite course of study and/or training in his or her discipline.
B. Be legally qualified to practice in the given discipline in the State of Colorado;
C. Meet the specific qualifications and requirements established by (facility) and (facility) Medical Staff;
D. Meet malpractice insurance conditions as established by the Community Board; and
E. Agree to abide by the rules, procedures of (facility)...
Licensure, Certification, Liability Insurance: Proof of current certification and liability insurance will be required to be submitted upon expiration on an ongoing basis. If the AHP is not CPR/BLS/ACLS certified at the time of appointment or reappointment, a 90-day grace period may be granted in which to submit current certification. Should the AHP fail to submit proof of certification within the 90-day timeframe, the AHP's right to provide services in the hospital will be terminated...."

Review on 1/5/11 of the facility's corporate hospital system occupational health policy "TB Quantiferon Gold," revealed the following, in pertinent parts:
"I. SCOPE
All (corporate hospital system) facilities using Tuberculosis Quantiferon Gold Blood Testing.
II. PURPOSE
To prevent the transmission of tuberculosis among patient, healthcare workers, physicians, and volunteers in our facilities.
III. POLICY
All associates, non-associates, physician and volunteers who work in a patient care facility of (corporate hospital system) shall be responsible for adhering to the tuberculosis guidelines set up by the Occupational Health Department...."

Review on 1/5/11 of the 11/16/10 meeting minutes for the infection control committee for the facility revealed the following, in pertinent parts:
"...TB Gold Test
- TB gold test - currently the physicians go to the outpatient lab when they are due for a TB test.
- (Infectious Disease Consultant Physician) - with low risk facilities - screening is only done for new hires, and then an annual symptom survey. (Another facility in the corporate system) medical staff was not comfortable with not having the annual testing - they requested the annual TB skin test.
- (Medical director/president of the medical staff) said that we may need a policy on what our process will be with the TB gold test and annual symptom survey. Adding that if a person feels symptoms or are exposed they must be tested again...."

An interview conducted on 1/4/11 at approximately 4:00 p.m., with the infection control nurse and the manager of medical staff services revealed the following information: They stated that all physicians and allied health professionals were expected to have annual TB testing. They further stated that additional screenings and use of the "gold test" assay test were being reviewed and incorporated into the requirements for staff and medical staff at the facility. They stated the review process was not completed. They provided copies of the above cited 11/16/10 infection control meeting minutes and the corporate system "TB gold test" policy, as supporting information being considered in the policy review.

Review of a sample of 9 Medical Staff and Allied Health Professional Staff credential files on 1/4/11 revealed the following findings:

1. Review of sample credential file #2 revealed that the physician's malpractice insurance policy documentation was for an insurance period that expired 4/1/10. The facility was later able to obtain documentation of a newer policy that expires on 4/1/11. In addition, the physician's required annual TB test had been done on 7/22/09 and was due for a new test 7/22/10.

2. Review of sample credential file #3 revealed that the physician's malpractice insurance policy documentation was for an insurance period that expired 1/1/11. The facility was later able to obtain documentation of a newer policy due to expire on 1/1/12.

3. Review of sample credential file #4 revealed that the physician's malpractice insurance policy documentation was for an insurance period that expired 11/1/10. The facility later provided a letter from the insurance company, dated 10/26/10, that stated that they intended to renew the policy on 11/1/10, but there was no evidence that the new renewal policy had actually been issued. The letter of intent to renew also contained no information about the dollar amount of coverage. It also did not contain the name of the physician, only the name of the physician's practice group. On the last day of the survey, the facility provided a new letter from the insurance company verifying that the policy had been renewed on 11/1/10 and was due to expire on 11/1/12. That documentation contained the name of the physician and dollar amount of coverage.
In addition, the physician's required annual TB test had been done on 7/29/09 and was due for a new test 7/29/10. The facility later provided documentation of a TB gold assay test conducted on 8/6/10. Finally, the credential file did not contain evidence of current board certification, as required. Prior to the end of the survey, the facility was able to provide documentation of current board certification due to expire 12/31/13.

4. Review of sample credential file #5 revealed that the physician's malpractice insurance policies, from two separate companies both expired on 1/1/11. The facility was later able to obtain documentation of a newer policy due to expire on 1/1/12. In addition, the credential filed documentation indicated that the physician's board certification had expired 7/1/10. Prior to the end of the survey, the facility was able to provide additional documentation that the physician's board certification had been renewed, with an expiration date of 7/1/11.

5. Review of sample credential file #6 revealed that the physician's malpractice insurance policy documentation was for an insurance period that expired 8/21/10. The facility was later able to obtain documentation of a newer policy due to expire on 8/21/11.

6. Review of sample credential file #7 revealed that the certified registered nurse anesthetist (CRNA) had an expired ACLS (Advanced Cardiovascular Life Support). The ACLS, along with the pre-requisite BLS (Basic Life Support) certification, expired on 5/31/10. The ACLS certification was required as a part of the medical staff's CRNA privileges requirements. In addition, the medical staff's CRNA privileges required that the CRNA have a current re-certification with the AANA (American Association of Nurse Anesthetists). The file indicated that the AANA certification had expired in 7/10. Finally, the file contained evidence that the CRNA's required annual TB test had been done on 5/9/09 and was due for a new test 5/9/10. Prior to the end of the survey, the facility was able to provide evidence that BLS and ACLS certification was current with expiration date of 6/25/12 (BLS) and 5/12 (ACLS). The facility provided evidence of AANA re-certification with and expiration date of 8/31/11. The facility provided evidence that a new TB test had been completed on 4/5/10, with an expiration date of 4/5/11.

7. Review of sample credential file #8 revealed that the certified family nurse practitioner (C-FNP) had an expired BLS (Basic Life Support) certification. The BLS (Basic Life Support) certification, which expired in 10/10, was required as a part of the medical staff's C-FNP privileges requirements. In addition, the C-FNP's malpractice insurance policy documentation was for an insurance period that expired 7/1/10. Prior to the end of the survey, the facility was able to provide evidence of BLS re-certification with an expiration date of 10/12 and evidence of a renewed malpractice insurance policy with an expiration date of 7/1/11.

8. Review of sample credential file #9 revealed that the certified physician assistant (C-PA) had an expired professional license. The license expired 1/1/10. Prior to the end of the survey, the facility was able to provide documentation that the professional license had been renewed with an expiration date of 1/31/12. In addition, the C-PA's malpractice insurance expired 11/1/10. The C-PA's malpractice insurance policy documentation was for an insurance period that expired 11/1/10. The facility later provided a letter from the insurance company, dated 10/26/10, that stated that they intended to renew the policy on 11/1/10, but there was no evidence that the new renewal policy had actually been issued. The letter of intent to renew also contained no information about the dollar amount of coverage. It also did not contain the name of the C-PA, only the name of the physician's practice group. On the last day of the survey, the facility provided a new letter from the insurance company verifying that the policy had been renewed on 11/1/10 and was due to expire on 11/1/11. That documentation contained the name of the C-PA and dollar amount of coverage.
In addition, the medical staff's C-PA privileges required that the C-PA have a current re-certification with the NCCPA (National Commission on Certification of Physician Assistants).
The file indicated that the NCCPA certification had expired in 12/09. Prior to the end of the survey, the facility provided evidence that of an NCCPA re-certification with an expiration date of 12/31/11. Finally, the file contained a required form stating that the C-PA conducted "point of care" testing. The form required the signature of the C-PA's supervising physician, but the form had not been signed at the time of the most recent re-appointment in 1/10, despite the fact that the C-PA's privileges stated, "Physician Assistant with Prescriptive Authority; Point of Care Testing." By the end of the survey, the point of care testing form had still not been signed by the supervising physician, as required.

In summary the facility governing body and medical staff failed to ensure that the credential files for 8 (sample credential files #2, #3, #4, #5, #6, #7, #8, #9) of 9 providers contained current documentation of the threshold membership and other requirements contained in the medical staff bylaws and policies/procedures. The facility failed to ensure that a system was in place to update credential files as licenses, certifications, insurance policies and TB testing as they expired between re-appointment cycles. The facility relied on an outside credentialing data base to update information, but did not utilize the data base contents to maintain complete and up-to-date credential files to comply with medical staff requirements.

Based on staff interviews and review of facility policies and procedures, the facility failed to ensure that the standardized policy/procedure manuals developed by the contract vendor for housekeeping services for the facility was reviewed to ensure that the services were provided in a safe and effective manner. The facility failed to institute a mechanism to routinely review the manuals for content/quality to ensure that the procedures utilized were in compliance with the facilities policies and procedures related to infection control, patient privacy and all other relevant facility policies/procedures. The failure created the potential for negative patient outcomes:

The findings were:

1. On 1/5/11, the housekeeping procedure/training manuals provided by the contract vendor were reviewed and revealed the following findings:
Review of the manuals revealed no evidence that they had been reviewed for content or quality to ensure that they were complete and accurately reflected the standards for quality and included all relevant facility policies/procedures. None of the policies/procedures indicated any alteration or customization to meet the needs and quality standards of the facility. There was no indication that the manuals had been reviewed by infection control, quality assurance or any specific service or area to insure that the contracted housekeeping services were integrated into the mission, goals and standards of the facility. Neither the facility, nor any facility policy or procedure, were mentioned or identified in the manuals to indicate an attempt to customize the manuals to meet the needs of the facility.

2. On 1/5/11 at approximately 3:30 p.m., the contract housekeeping manager was interviewed about the manuals and was unable to provide any evidence that the manuals had been reviewed by the facility. This was also confirmed within a few minutes after the interview with the site manager for the contract vendor. The lack of facility review of the housekeeping manuals was also confirmed by the quality and infection control managers, as well as the CEO (chief executive officer) during the exit conference on 1/6/11 at approximately 1:30 p.m.

Based on a review of staff documents and staff interviews, the governing body failed to ensure that the hospital maintained a complete list of all contracted services, as required.

The findings were:

A list of all contracted services was requested both verbally and on the initial list of documents requested at the entrance conference on 1/3/11 at approximately 1:30 p.m. Review of the list and during multiple subsequent contacts/interviews with staff, as other conditions of participation/standards were surveyed, revealed that the list of contracted services was incomplete. The following services or providers under contract were not found on the provided contract list:
- contracted laundry services
- contracted housekeeping services
- contracted radiology technicians
- contracted long-term storage and destruction of medical records
- contracted disposal of biomedical waste
- contracted inspection, routine maintenance and repair of biomedical equipment
- contracted director of the surgical services department.

Based on medical record review and staff interview it was determined the facility failed to document in two of thirty-two open and closed medical records that the patients had been provided information regarding Advanced Directives. The findings were:

On 1/5/11 the medical record of sample #15 was reviewed. The patient was a female in her fifties admitted on 7/27/10 and discharged on 8/3/10. There was documentation in the record that the patient did not have a Living Will and the patient requested to be given information regarding Advanced Directives, "but not today", 7/28/10. There was no additional documentation provided in the medical record that this occurred.

Interview with the Quality R.N. (Registered Nurse) on 1/5/11 revealed the clergy person on duty was notified and did speak with the patient, however, there was no documented evidence in the medical record that this occurred.

On 1/5/11 the medical record of sample #20 was reviewed. The patient was a female in her thirties, admitted on 9/10/10 and discharged on 9/16/10. There was documentation in the record that the patient did not have a Living Will. No other documentation regarding Advanced Directives had been documented.

Based on staff interview, medical record review, and review of facility documents the facility failed to document the analysis of causes of adverse patient events and medical errors when they were reported to the facility's Quality and Patient Safety Department.

The findings were:

The facility's Quality and Patient Safety Department received a report on 10/20/2010 at approximately 10:20 AM that stated, that in the case of Sample patient #31, "[Operating Physician] used the harmonic scalpel during the procedure when drapes removed a dime size first degree burn noticed on left lateral thigh."

A review of sample patient #31's medical record revealed a nursing note that stated, "when getting patient ready to transfer to bed at end of procedure noted to have small blistered pink area approx[imate] size of a dime at left lateral hip/thigh area. Site observed by [physician] with written orders noted."

An interview with the Director of Quality and Patient Safety on 1/5/2011 at approximately 10:45 AM revealed that it was determined in the review of Sample patient #31's incident that the physician did not follow the standard of practice of handing the harmonic scalpel to the surgical technician between uses.

A request was made to review any documentation of the analysis and investigation of the incident on 1/5/2011 at approximately 11:30 AM.

An interview with the Chief Nursing Officer/Vice President of Patient Services on 1/6/2011 at approximately 9:00 AM revealed that the facility had developed a plan to prevent future patient burns from a similar incident. S/he stated that the plan was developed on 1/5/2011 and when asked if there was documentation of review prior to 1/5/2011 s/he stated, "I'll check but I'm not convinced there is much out there."

The Chief Nursing Officer/Vice President of Patient Services stated on 1/6/2011 at approximately 11:00 AM that no documentation was available that reflected the analysis of causes of the adverse patient event for sample patient #31.

Based on staff interview, medical record review, and review of facility documents the facility failed to have documentation that showed that preventative actions and mechanisms were implemented when medical errors and adverse patient events occurred.

The findings were:

Cross Reference to A 287 - QAPI Improvement Activities: for findings related to the facility's failure to document the analysis of causes of adverse patient events and medical errors when they were reported to the facility's Quality and Patient Safety Department.

Based on review of medical records and medical staff bylaws, policies/procedures, manuals, credential files, facility documents and staff interviews, the facility governing body and medical staff failed to ensure that the medical staff enforced their bylaws regarding maintained up-to-date credential file documentation and ensuring that physician orders were reviewed/authenticated to ensure accuracy and prevent errors.

The findings were:

1. Credential Files:

The facility governing body and medical staff failed to ensure that the medical staff maintained up-to-date credential file documentation for 8 (sample credential files #2, #3, #4, #5, #6, #7, #8, #9) of 9 credential files reviewed.

The facility governing body and medical staff failed to ensure that the cited credential files contained current documentation of the threshold membership and other requirements contained in the medical staff bylaws, policies/procedures and manuals. The facility failed to ensure that a system was in place to update credential files as licenses, certifications, insurance policies and TB testing as they expired between re-appointment cycles. The facility relied on an outside credentialing data base to update information, but did not utilize the data base contents to maintain complete and up-to-date credential files, to comply with medical staff requirements.

Reference Tag A 0047 Governing Body - Medical Staff - Bylaws for specific findings.

2. Physician Orders:

A review of medical records and the Medical Staff Operations and Functions Manual, it was determined the Medical Staff failed to enforce their bylaws. This failure created the potential for negative patient outcome due to a lack of an effective system to determine an error in the physician's order and to correct the order timely. This failure reflects on physician accountability. The findings were:

Cross Reference to A 406, A 450, A 454 and A 468

On 1/4/11 through 1/6/11 a sample of thirty-two open and closed medical records were reviewed. It was identified that nine (sample #s 7, 13, 18, 20, 23, 25, 26, 27 and 30) of thirty-two medical records had no authentication by physicians of their orders. It was evidenced there was a lack of an effective auditing system to ensure that all orders were signed and medical records were completed.

Based on medical record review, staff interview and review of the Medical Staff Operations and Functions Manual, it was determined the facility failed to assure that all orders in closed medical records were authenticated by the physician, and to enforce the Medical Staff Functions. Two (sample #20 and #23) of thirty-two open and closed medical records revealed drug protocols that were not signed by the physician. This failure created the potential for medication errors and negative patient outcome. The findings were:

On 1/15/11 the following closed medical records were reviewed and revealed drug protocols not signed by the physician. Specifically, sample #20, a female in her thirties admitted on 9/10/10 for abdominal pain and discharged on 9/16/10. The medical record contained three potassium replacement protocols, one phosphorous replacement protocol, and two magnesium replacement protocols that were not signed by the physician. There was no documented order, signed by a physician for these protocols.
Sample #23 was a male in his fifties admitted on 9/18/10 for a bowel resection and discharged on 9/25/10. The record contained a telephone order for a "Mid Level pain protocol without a bowel protocol". That order was not signed by the physician.

Interview with the Quality RN on 1/5/11 revealed that it had been accepted practice that protocols could be initiated, but there should be an order in the patient's record for these protocols and signed by the physician ordering them.

Review of the Medical Staff Operations and Functions Manual in pertinent part: ARTICLE XI, Health Record Guidelines, Section 4, "All clinical entries in the health record must be accurately dated, timed and authenticated." ARTICLE XVI, Health Record Order Guidelines, Section 3. "When telephone or oral orders are issued, they must be authenticated by the responsible or designated practitioner within 48 hours after the order is given. Authentication includes signatures, identifiable initials, or computer entry."

Based on the number and nature of deficiencies cited, the facility failed to be in compliance with the Condition of Participation of Medical Record Services. The facility failed to ensure that medical records were protected from unauthorized use.

The facility failed to meet the following standards under the condition of Medical Records.

Tag A 442 Security of Medical Records: The facility failed to ensure that patient records were protected from unauthorized access.

Tag A 450 Medical Record Services: The facility failed to assure all medical record entries were authenticated by the physician in five (samples # 7, 13, 25, 26 and 30) of thirty closed medical records reviewed. Specifically, these orders were documented on a one of two page written and preprinted order set, of which only the second page was signed, dated and timed by the physician.

Tag A 454 Orders Dated and Signed: The facility failed to assure that all orders, including verbal orders were signed by the ordering physician. Three (samples # 18, 20 and 23) of thirty closed medical records contained physician orders not authenticated by the physician.

Based on facility tour, staff interview, and review of facility documents the facility failed to ensure that patient records were protected from unauthorized access.

The findings were:

A tour of the Medical Record department conducted on 1/6/2011 at approximately 10:45 AM revealed that the most recent medical records were stored in two on-site locations. The first floor Medical Record department contained the most current medical records of patients treated at the hospital and had three entry doors. Two of the doors required a key to open the door. The third door had a punch code door lock that required a combination to open.

An interview with the Director of Patient Access during the tour of the first floor medical record department revealed that medical records for years after 2007 were kept in the first floor medical record department and that medical records from 2007 were kept on the third floor in a storage area as the facility was awaiting the records to be transported by a contracted service for off-site storage where records preceding 2007 were currently stored. When asked how records in the first floor department were kept secure, s/he stated that there was limited access to the department, which included the medical record department staff and "house managers for after hours access."

A review of a facility document, that listed personnel with "Grand Master Keys" that opened all the doors in the facility including the medical records office, revealed that 17 staff members were given such a key. The list included staff members from Shipping/Receiving, contracted housekeeping, biomedical technology, human resources, and information technology.

A tour of the third floor storage area was conducted on 1/6/2011 at approximately 11:00 AM with a staff member of the Medical Records department as well as the corporate Director of Regulatory Readiness. The tour revealed that access to the third floor was limited by a badge reader in the elevator as well as a badge reader for the door to the storage area. Within the storage area various items were stored which included extra hospital beds, security training supplies, electronics, and shelves with boxes that contained medical records as well as medical records placed on shelves that were not in boxes. No extra security measures were in place that prevented access to the medical records.

A review of a facility document, that listed personnel with card access to the third floor storage which contained medical records awaiting transport to off-site storage, revealed that "73 Cardholders have access to SASMC 1-3 3rd Floor Storage". The list included seven entries that stated "Fire Dept" which indicated cards given to the local fire department and an entry that stated "Temp #11".

An interview with the facility's Mechanic and Plant Operations personnel member on 1/6/11 at approximately 12:15 PM revealed that the list of personnel that had card access to the third floor storage indicated the person listed had access to the third floor elevator and the storage room. When asked who would have the ability to change the combination code on the lock to the first floor medical record department, s/he stated that s/he was the only one in the facility that could do so. When asked when the last time the code was changed, s/he stated that the code had not been changed.

In summary, the facility failed to ensure that access to on-site record storage areas was restricted to essential personnel and that appropriate security measures were in place to prevent unauthorized access or use.

Based on medical record review, staff interview and review of the Medical Staff Operations and Functions Manual it was determined the facility failed to assure all medical record entries were authenticated by the physician as required by the Medical Staff, in five (samples # 7, 13, 25, 26 and 30) of thirty-two open and closed medical records reviewed. Specifically, these orders were documented on a one of two page written and preprinted order set, of which only the second page was signed, dated and timed by the physician. The findings were:

On 1/6/11 the following closed medical records were reviewed and revealed a two page written and preprinted order set of which only the second page was signed, dated and timed by the ordering physician.

Sample #7 was a male in his twenties admitted for left tonsillar swelling on 7/1/10 and discharged on 7/2/10. A two page order set, titled "Medicine Admission Orders" was noted by the nurse on 7/1/10. Only the second page had a physician's signature. The first page of the order set did contain orders for narcotics and antibiotics.

Sample #13 was a male in his seventies admitted for bilateral pulmonary emboli's on 7/16/10 and discharged on 7/18/10. A two page order set, titled "Medicine Admission Orders" was noted by the nurse on 7/16/10. The first page contained physician orders, however, only the second page had a physician signature.

Sample #25 was a female in her forties admitted for shortness of breath on 9/22/10 and discharged on 9/23/10. A two page order set, titled "Medicine Admission Orders" was noted by the nurse on 9/22/10. The first page contained physician orders, however, only the second page had a physician signature.

Sample #26 was a male in his fifties admitted for a fever on 9/28/10 and discharged on 10/1/10. A two page order set, titled "Medicine Admission Orders", was noted by the nurse on 9/28/10. The first page contained physician orders, however, only the second page had a physician signature.

Sample #30 was a male in his fifties admitted for alcohol withdrawal on 12/11/10 and discharged on 12/13/10. A two page order set, titled "Medicine Admission Orders" was noted by the nurse on 12/11/10. The first page contained orders, however, only the second page had a physician signature.

Interview with the Quality RN on 1/5/11 revealed that signing only the second page of the pre-printed orders was accepted by the medical staff as appropriate practice.

Review of the Medical Staff Operations and Functions Manual in pertinent part: ARTICLE XI, Health Record Guidelines, Section 4, "All clinical entries in the health record must be accurately dated, timed and authenticated." ARTICLE XVI, Health Record Order Guidelines, Section 3. "When telephone or oral orders are issued, they must be authenticated by the responsible or designated practitioner within 48 hours after the order is given. Authentication includes signatures, identifiable initials, or computer entry."

Based on medical record review, staff interview and review of the Medical Staff Operations and Functions Manual, it was determined that the facility failed to assure that all orders, including verbal orders were signed by the ordering physician and to enforce the Medical Functions. Three, (samples # 18, 20 and 23) of thirty-two open and closed medical records contained physician orders not authenticated by the physician. The findings were:

On 1/15/11 the following closed medical records were reviewed and contained unsigned orders.

Sample #18 was a female in her fifties admitted for a fractured pelvis on 9/5/10 and discharged on 9/9/10. Specifically, there was a telephone order for "discharge and for Lovenox 40 mg Sub Q X 1 now", dated 9/9/10, by the nurse receiving the order. There was no physician authentication of that order.

Sample #20 was a female in her thirties admitted for abdominal pain on 9/10/10 and discharged on 9/16/10. There was a "Post PICC Insertion" order set that was not authenticated by the physician. Additionally, there was a telephone order, dated 9/10/10, written by the nurse receiving the order for "JPs (Jackson Pratts) to bulb suction, wound vac to -125 mmHG, continual suction, pain per anesthesia, not authenticated by the physician. There also were two verbal orders, on 9/10/10, one for "Diflucan 250 mg IV now" and another "Change Diflucan to 200 mg IV now and Levaquin 500 mg IV now in OR".

Sample #23 was a male in his fifties admitted for a bowel resection on 9/18/10 and discharged on 9/25/10. There was a telephone order, dated 9/24/10, for Bolus 1 Liter of LR, then run D5NS with 20 MEQ KCL at 125 cc, not signed by the physician. A telephone order, dated 9/23/10, Advance to Regular bland diet, and Percocet 1-2 PO Q 4 H PRN pain, not signed by the physician, and on 9/23/10 a telephone order for "AM KUB x-ray", also not signed by the physician. Additionally, on 9/18/10, a telephone order for Tylenol 500 mg 1 to 2 tabs PO Q4H for temp over 101.0, pain. On 9/18/10 a telephone order to "Give 1 mg Dilaudid IV loading dose X 1 now; 15 mg Toradol IV X 1 now. Also, a "Patient Controlled Analgesia" order form, which was a telephone order received by the nurse, on 9/18/10, also not signed by the physician.

Interview with the Quality RN on 1/6/11 revealed that the medical records department reviews for completeness of the chart, however, apparently does not audit for physician signatures. The Quality RN confirmed that the orders were not signed.

Review of the Medical Staff Operations and Functions Manual in pertinent part: ARTICLE XI, Health Record Guidelines, Section 4, "All clinical entries in the health record must be accurately dated, timed and authenticated." ARTICLE XVI, Health Record Order Guidelines, Section 3. "When telephone or oral orders are issued, they must be authenticated by the responsible or designated practitioner within 48 hours after the order is given. Authentication includes signatures, identifiable initials, or computer entry."

Based on review of medical records, review of the "Medical Staff Operations and Functions Manual," and staff interview, it was determined that one of thirty-two medical records did not contain a discharge summary with outcome of hospitalization, disposition of care and provision for follow-up care.

On 1/6/2011, medical record sample #11 was reviewed and did not contain a discharge summary or a final progress note. The patient's stay was over 48 hrs. Admission date for labor and delivery was documented as 07/08/10 at 15:13 and discharge date and time was documented as 07/10/10 at 15:30. An interview with the department director of obstetrics confirmed the absence of any progress note or discharge summary during review of the medical record.

On 1/6/11, review of a facility policy titled "Medical Staff Operations and Functions Manual," in pertinent part: Article XVII states under "Discharge Health Record Guidelines" and Section 2 that "A clinical discharge summary must be dictated on all health records of patients hospitalized over 48 hours..." and Section 3 states "A final health progress note may be substituted for the clinical discharge summary in cases of patients with problems that require hospitalization for less than 48 hours..." and Section 5 states "A health record is considered complete when:..."Discharge summaries have been dictated within 30 days of discharge."

Based on medical record review and staff interview it was determined the facility failed to document in the patient's medical record that a "Choice List" was presented to the patient prior to discharge in one, (sample #18), of thirty-two open and closed medical records. The findings were:

Sample #18 was a female in her fifties admitted to the facility for a fractured pelvis on 9/5/10 and discharged on 9/9/10. The patient was discharged with Home Health for Physical Therapy and Occupational Therapy. There was no documented evidence in the medical record that the list of Home Health providers was presented to the patient.

Interview with the Case Manager, on 1/5/11 at 3:30 p.m., revealed that there is only one Home Health provider in the local area where the patient lived, which was local. H/she stated that because there was only one provider h/she did not think it was necessary to do this.

Based on review of medical staff bylaws, policies/procedures, manuals, credential files, facility documents and staff interviews, the facility governing body and medical staff failed to ensure that the medical staff maintained up-to-date credential file documentation for 8 (sample credential files #2, #3, #4, #5, #6, #7, #8, #9) of 9 credential files reviewed. The governing body failed to ensure that the medical staff complied with the credentialing requirements contained in the medical staff bylaws and other documents.

The findings were:

1. Review of the medical staff regulation document "Credentials Manual Performance, Improvement Plan, Fair Hearing Plan," on 1/4/11 revealed the following, in pertinent parts:
"...Article 2
QUALIFICATIONS, CONDITIONS AND RESPONSIBILITIES
2.A. QUALIFICATIONS
2.A.1 Threshold Eligibility Criteria:

To be eligible to apply for initial appointment or reappointment to the Medical Staff, physicians, dentists, oral surgeons, podiatrists, and psychologists must:
(a) have a current, unrestricted license, certification, or registration to practice in Colorado.
(b) where applicable to their practice, have a current, unrestricted DEA registration; ...
(d) have current, valid professional liability insurance coverage in a form and in amounts satisfactory to the Hospital;...
(p) maintain board certification and, to the extent required by the applicable specialty/subspecialty board, satisfy recertification requirements. Recertification shall be assessed at reappointment...

6.C. AUTOMATIC RELINQUISHMENT
...6.C.2. Action by Government Agency or Insurer and Failure to Satisfy Threshold Eligibility Criteria:
(a) Any action taken by any licensing board, professional liability insurance company, court or government agency regarding any of the matters set forth below, or failure to satisfy any of the threshold eligibility criteria set forth in this Policy, must be promptly reported by the Medical Staff member to the CEO and the President of the Medical Staff.
(c) Any individual's appointment and clinical privileges shall be automatically relinquished or restricted as indicated if any of the following occur:
(1) Licensure: Revocation, expiration, suspension, or the placement of restrictions on any individual's license, certification, registration, or other legal credential authorizing practice in the State of Colorado. If restrictions are placed on any legal credentials, the clinical privileges affected by such limitations or restriction are automatically suspended;
(2) Controlled Substance Authorization: Revocation, expiration, suspension, or the placement of restrictions on an individual's DEA controlled substance authorization will result in a suspension of a practitioner's right to prescribe medications covered by the DEA certificate;
(3) Insurance Coverage: Termination or lapse of an individual's professional liability insurance coverage, or other action causing the coverage to fall below the minimum required by the Community Board or cease to be in effect, in whole or in part....
(d) An individual's appointment and clinical privileges shall also be automatically relinquished, without entitlement to the procedural rights outlined in this Manual, if the individual fails to satisfy any of the other threshold eligibility criteria set forth in this Manual.
(e) Automatic relinquishment shall take effect immediately upon notice to the Hospital and continue until the matter is resolved, if applicable.
(f) Failure to resolve the underlying matter leading to an individual's clinical privileges being automatically relinquished in accordance with paragraphs (b)(1), (b)(2) or (b) (3) above, within 90 days of the date of relinquishment, shall result in automatic resignation from the Medical Staff."

NOTE: In the previous paragraph labelled (f), it refers to (b) (1-3), but in the document, there is no (b). It is mislabeled as (c) (1-3) in describing the requirements for licensure, DEA, and liability insurance.

Review of the Medical Staff Organizational Policy "Allied Health Professional Credentialing," on 1/5/11 revealed the following, in pertinent parts:
"PURPOSE: To provide a mechanism for the granting of permission to provide services for individuals not eligible for medical staff membership.
COMPLIANCE RESPONSIBILITY: Medical Staff Services Department
...General: Describes process for Allied Health Practitioners (AHPs) must be qualified by academic and clinical or other training to practice in a clinical or supportive role in providing services. These practitioners may provide services only as permitted by this institution and in keeping with all applicable rules, policies, and procedures of the Medical Staff and (facility).
Practitioners: Currently the following types of allied health practitioners may be granted permission to provide services. This category includes, but is not limited to, the following:
Licensed Supervised AHPs are those AHPs who use some independent judgement but still require supervision as determined by licensure and/or the hospital. The licensed supervised AHP's scope of practice is defined by an inventory of services. Examples include certified registered nurse anesthetists, nurse practitioners, clinical nurse specialists, nurse midwives, social workers, physician assistants, and clinical research nurses. Licensed supervised AHPs must have a sponsor who is a member of the active medical staff...
Qualifications: To be permitted to provide services, an applicant
must:
A. Be a graduate of a recognized and accredited school or have completed a requisite course of study and/or training in his or her discipline.
B. Be legally qualified to practice in the given discipline in the State of Colorado;
C. Meet the specific qualifications and requirements established by (facility) and (facility) Medical Staff;
D. Meet malpractice insurance conditions as established by the Community Board; and
E. Agree to abide by the rules, procedures of (facility)...
Licensure, Certification, Liability Insurance: Proof of current certification and liability insurance will be required to be submitted upon expiration on an ongoing basis. If the AHP is not CPR/BLS/ACLS certified at the time of appointment or reappointment, a 90-day grace period may be granted in which to submit current certification. Should the AHP fail to submit proof of certification within the 90-day timeframe, the AHP's right to provide services in the hospital will be terminated...."

Review on 1/5/11 of the facility's corporate hospital system occupational health policy "TB Quantiferon Gold," revealed the following, in pertinent parts:
"I. SCOPE
All (corporate hospital system) facilities using Tuberculosis Quantiferon Gold Blood Testing.
II. PURPOSE
To prevent the transmission of tuberculosis among patient, healthcare workers, physicians, and volunteers in our facilities.
III. POLICY
All associates, non-associates, physician and volunteers who work in a patient care facility of (corporate hospital system) shall be responsible for adhering to the tuberculosis guidelines set up by the Occupational Health Department...."

Review on 1/5/11 of the 11/16/10 meeting minutes for the infection control committee for the facility revealed the following, in pertinent parts:
"...TB Gold Test
- TB gold test - currently the physicians go to the outpatient lab when they are due for a TB test.
- (Infectious Disease Consultant Physician) - with low risk facilities - screening is only done for new hires, and then an annual symptom survey. (Another facility in the corporate system) medical staff was not comfortable with not having the annual testing - they requested the annual TB skin test.
- (Medical director/president of the medical staff) said that we may need a policy on what our process will be with the TB gold test and annual symptom survey. Adding that if a person feels symptoms or are exposed they must be tested again...."

An interview conducted on 1/4/11 at approximately 4:00 p.m., with the infection control nurse and the manager of medical staff services revealed the following information: They stated that all p

Based on staff interviews and review of facility policies and procedures, the facility failed to ensure that the standardized policy/procedure manuals developed by the contract vendor for housekeeping services for the facility was reviewed to ensure that the services were provided in a safe and effective manner. The facility failed to institute a mechanism to routinely review the manuals for content/quality to ensure that the procedures utilized were in compliance with the facilities policies and procedures related to infection control, patient privacy and all other relevant facility policies/procedures. The failure created the potential for negative patient outcomes:

The findings were:

1. On 1/5/11, the housekeeping procedure/training manuals provided by the contract vendor were reviewed and revealed the following findings:
Review of the manuals revealed no evidence that they had been reviewed for content or quality to ensure that they were complete and accurately reflected the standards for quality and included all relevant facility policies/procedures. None of the policies/procedures indicated any alteration or customization to meet the needs and quality standards of the facility. There was no indication that the manuals had been reviewed by infection control, quality assurance or any specific service or area to insure that the contracted housekeeping services were integrated into the mission, goals and standards of the facility. Neither the facility, nor any facility policy or procedure, were mentioned or identified in the manuals to indicate an attempt to customize the manuals to meet the needs of the facility.

2. On 1/5/11 at approximately 3:30 p.m., the contract housekeeping manager was interviewed about the manuals and was unable to provide any evidence that the manuals had been reviewed by the facility. This was also confirmed within a few minutes after the interview with the site manager for the contract vendor. The lack of facility review of the housekeeping manuals was also confirmed by the quality and infection control managers, as well as the CEO (chief executive officer) during the exit conference on 1/6/11 at approximately 1:30 p.m.

Based on a review of staff documents and staff interviews, the governing body failed to ensure that the hospital maintained a complete list of all contracted services, as required.

The findings were:

A list of all contracted services was requested both verbally and on the initial list of documents requested at the entrance conference on 1/3/11 at approximately 1:30 p.m. Review of the list and during multiple subsequent contacts/interviews with staff, as other conditions of participation/standards were surveyed, revealed that the list of contracted services was incomplete. The following services or providers under contract were not found on the provided contract list:
- contracted laundry services
- contracted housekeeping services
- contracted radiology technicians
- contracted long-term storage and destruction of medical records
- contracted disposal of biomedical waste
- contracted inspection, routine maintenance and repair of biomedical equipment
- contracted director of the surgical services department.

Based on medical record review and staff interview it was determined the facility failed to document in two of thirty-two open and closed medical records that the patients had been provided information regarding Advanced Directives. The findings were:

On 1/5/11 the medical record of sample #15 was reviewed. The patient was a female in her fifties admitted on 7/27/10 and discharged on 8/3/10. There was documentation in the record that the patient did not have a Living Will and the patient requested to be given information regarding Advanced Directives, "but not today", 7/28/10. There was no additional documentation provided in the medical record that this occurred.

Interview with the Quality R.N. (Registered Nurse) on 1/5/11 revealed the clergy person on duty was notified and did speak with the patient, however, there was no documented evidence in the medical record that this occurred.

On 1/5/11 the medical record of sample #20 was reviewed. The patient was a female in her thirties, admitted on 9/10/10 and discharged on 9/16/10. There was documentation in the record that the patient did not have a Living Will. No other documentation regarding Advanced Directives had been documented.

Based on staff interview, medical record review, and review of facility documents the facility failed to document the analysis of causes of adverse patient events and medical errors when they were reported to the facility's Quality and Patient Safety Department.

The findings were:

The facility's Quality and Patient Safety Department received a report on 10/20/2010 at approximately 10:20 AM that stated, that in the case of Sample patient #31, "[Operating Physician] used the harmonic scalpel during the procedure when drapes removed a dime size first degree burn noticed on left lateral thigh."

A review of sample patient #31's medical record revealed a nursing note that stated, "when getting patient ready to transfer to bed at end of procedure noted to have small blistered pink area approx[imate] size of a dime at left lateral hip/thigh area. Site observed by [physician] with written orders noted."

An interview with the Director of Quality and Patient Safety on 1/5/2011 at approximately 10:45 AM revealed that it was determined in the review of Sample patient #31's incident that the physician did not follow the standard of practice of handing the harmonic scalpel to the surgical technician between uses.

A request was made to review any documentation of the analysis and investigation of the incident on 1/5/2011 at approximately 11:30 AM.

An interview with the Chief Nursing Officer/Vice President of Patient Services on 1/6/2011 at approximately 9:00 AM revealed that the facility had developed a plan to prevent future patient burns from a similar incident. S/he stated that the plan was developed on 1/5/2011 and when asked if there was documentation of review prior to 1/5/2011 s/he stated, "I'll check but I'm not convinced there is much out there."

The Chief Nursing Officer/Vice President of Patient Services stated on 1/6/2011 at approximately 11:00 AM that no documentation was available that reflected the analysis of causes of the adverse patient event for sample patient #31.

Based on staff interview, medical record review, and review of facility documents the facility failed to have documentation that showed that preventative actions and mechanisms were implemented when medical errors and adverse patient events occurred.

The findings were:

Cross Reference to A 287 - QAPI Improvement Activities: for findings related to the facility's failure to document the analysis of causes of adverse patient events and medical errors when they were reported to the facility's Quality and Patient Safety Department.

Based on review of medical records and medical staff bylaws, policies/procedures, manuals, credential files, facility documents and staff interviews, the facility governing body and medical staff failed to ensure that the medical staff enforced their bylaws regarding maintained up-to-date credential file documentation and ensuring that physician orders were reviewed/authenticated to ensure accuracy and prevent errors.

The findings were:

1. Credential Files:

The facility governing body and medical staff failed to ensure that the medical staff maintained up-to-date credential file documentation for 8 (sample credential files #2, #3, #4, #5, #6, #7, #8, #9) of 9 credential files reviewed.

The facility governing body and medical staff failed to ensure that the cited credential files contained current documentation of the threshold membership and other requirements contained in the medical staff bylaws, policies/procedures and manuals. The facility failed to ensure that a system was in place to update credential files as licenses, certifications, insurance policies and TB testing as they expired between re-appointment cycles. The facility relied on an outside credentialing data base to update information, but did not utilize the data base contents to maintain complete and up-to-date credential files, to comply with medical staff requirements.

Reference Tag A 0047 Governing Body - Medical Staff - Bylaws for specific findings.

2. Physician Orders:

A review of medical records and the Medical Staff Operations and Functions Manual, it was determined the Medical Staff failed to enforce their bylaws. This failure created the potential for negative patient outcome due to a lack of an effective system to determine an error in the physician's order and to correct the order timely. This failure reflects on physician accountability. The findings were:

Cross Reference to A 406, A 450, A 454 and A 468

On 1/4/11 through 1/6/11 a sample of thirty-two open and closed medical records were reviewed. It was identified that nine (sample #s 7, 13, 18, 20, 23, 25, 26, 27 and 30) of thirty-two medical records had no authentication by physicians of their orders. It was evidenced there was a lack of an effective auditing system to ensure that all orders were signed and medical records were completed.

Based on medical record review, staff interview and review of the Medical Staff Operations and Functions Manual, it was determined the facility failed to assure that all orders in closed medical records were authenticated by the physician, and to enforce the Medical Staff Functions. Two (sample #20 and #23) of thirty-two open and closed medical records revealed drug protocols that were not signed by the physician. This failure created the potential for medication errors and negative patient outcome. The findings were:

On 1/15/11 the following closed medical records were reviewed and revealed drug protocols not signed by the physician. Specifically, sample #20, a female in her thirties admitted on 9/10/10 for abdominal pain and discharged on 9/16/10. The medical record contained three potassium replacement protocols, one phosphorous replacement protocol, and two magnesium replacement protocols that were not signed by the physician. There was no documented order, signed by a physician for these protocols.
Sample #23 was a male in his fifties admitted on 9/18/10 for a bowel resection and discharged on 9/25/10. The record contained a telephone order for a "Mid Level pain protocol without a bowel protocol". That order was not signed by the physician.

Interview with the Quality RN on 1/5/11 revealed that it had been accepted practice that protocols could be initiated, but there should be an order in the patient's record for these protocols and signed by the physician ordering them.

Review of the Medical Staff Operations and Functions Manual in pertinent part: ARTICLE XI, Health Record Guidelines, Section 4, "All clinical entries in the health record must be accurately dated, timed and authenticated." ARTICLE XVI, Health Record Order Guidelines, Section 3. "When telephone or oral orders are issued, they must be authenticated by the responsible or designated practitioner within 48 hours after the order is given. Authentication includes signatures, identifiable initials, or computer entry."

Based on the number and nature of deficiencies cited, the facility failed to be in compliance with the Condition of Participation of Medical Record Services. The facility failed to ensure that medical records were protected from unauthorized use.

The facility failed to meet the following standards under the condition of Medical Records.

Tag A 442 Security of Medical Records: The facility failed to ensure that patient records were protected from unauthorized access.

Tag A 450 Medical Record Services: The facility failed to assure all medical record entries were authenticated by the physician in five (samples # 7, 13, 25, 26 and 30) of thirty closed medical records reviewed. Specifically, these orders were documented on a one of two page written and preprinted order set, of which only the second page was signed, dated and timed by the physician.

Tag A 454 Orders Dated and Signed: The facility failed to assure that all orders, including verbal orders were signed by the ordering physician. Three (samples # 18, 20 and 23) of thirty closed medical records contained physician orders not authenticated by the physician.

Based on medical record review, staff interview and review of the Medical Staff Operations and Functions Manual it was determined the facility failed to assure all medical record entries were authenticated by the physician as required by the Medical Staff, in five (samples # 7, 13, 25, 26 and 30) of thirty-two open and closed medical records reviewed. Specifically, these orders were documented on a one of two page written and preprinted order set, of which only the second page was signed, dated and timed by the physician. The findings were:

On 1/6/11 the following closed medical records were reviewed and revealed a two page written and preprinted order set of which only the second page was signed, dated and timed by the ordering physician.

Sample #7 was a male in his twenties admitted for left tonsillar swelling on 7/1/10 and discharged on 7/2/10. A two page order set, titled "Medicine Admission Orders" was noted by the nurse on 7/1/10. Only the second page had a physician's signature. The first page of the order set did contain orders for narcotics and antibiotics.

Sample #13 was a male in his seventies admitted for bilateral pulmonary emboli's on 7/16/10 and discharged on 7/18/10. A two page order set, titled "Medicine Admission Orders" was noted by the nurse on 7/16/10. The first page contained physician orders, however, only the second page had a physician signature.

Sample #25 was a female in her forties admitted for shortness of breath on 9/22/10 and discharged on 9/23/10. A two page order set, titled "Medicine Admission Orders" was noted by the nurse on 9/22/10. The first page contained physician orders, however, only the second page had a physician signature.

Sample #26 was a male in his fifties admitted for a fever on 9/28/10 and discharged on 10/1/10. A two page order set, titled "Medicine Admission Orders", was noted by the nurse on 9/28/10. The first page contained physician orders, however, only the second page had a physician signature.

Sample #30 was a male in his fifties admitted for alcohol withdrawal on 12/11/10 and discharged on 12/13/10. A two page order set, titled "Medicine Admission Orders" was noted by the nurse on 12/11/10. The first page contained orders, however, only the second page had a physician signature.

Interview with the Quality RN on 1/5/11 revealed that signing only the second page of the pre-printed orders was accepted by the medical staff as appropriate practice.

Review of the Medical Staff Operations and Functions Manual in pertinent part: ARTICLE XI, Health Record Guidelines, Section 4, "All clinical entries in the health record must be accurately dated, timed and authenticated." ARTICLE XVI, Health Record Order Guidelines, Section 3. "When telephone or oral orders are issued, they must be authenticated by the responsible or designated practitioner within 48 hours after the order is given. Authentication includes signatures, identifiable initials, or computer entry."

Based on medical record review, staff interview and review of the Medical Staff Operations and Functions Manual, it was determined that the facility failed to assure that all orders, including verbal orders were signed by the ordering physician and to enforce the Medical Functions. Three, (samples # 18, 20 and 23) of thirty-two open and closed medical records contained physician orders not authenticated by the physician. The findings were:

On 1/15/11 the following closed medical records were reviewed and contained unsigned orders.

Sample #18 was a female in her fifties admitted for a fractured pelvis on 9/5/10 and discharged on 9/9/10. Specifically, there was a telephone order for "discharge and for Lovenox 40 mg Sub Q X 1 now", dated 9/9/10, by the nurse receiving the order. There was no physician authentication of that order.

Sample #20 was a female in her thirties admitted for abdominal pain on 9/10/10 and discharged on 9/16/10. There was a "Post PICC Insertion" order set that was not authenticated by the physician. Additionally, there was a telephone order, dated 9/10/10, written by the nurse receiving the order for "JPs (Jackson Pratts) to bulb suction, wound vac to -125 mmHG, continual suction, pain per anesthesia, not authenticated by the physician. There also were two verbal orders, on 9/10/10, one for "Diflucan 250 mg IV now" and another "Change Diflucan to 200 mg IV now and Levaquin 500 mg IV now in OR".

Sample #23 was a male in his fifties admitted for a bowel resection on 9/18/10 and discharged on 9/25/10. There was a telephone order, dated 9/24/10, for Bolus 1 Liter of LR, then run D5NS with 20 MEQ KCL at 125 cc, not signed by the physician. A telephone order, dated 9/23/10, Advance to Regular bland diet, and Percocet 1-2 PO Q 4 H PRN pain, not signed by the physician, and on 9/23/10 a telephone order for "AM KUB x-ray", also not signed by the physician. Additionally, on 9/18/10, a telephone order for Tylenol 500 mg 1 to 2 tabs PO Q4H for temp over 101.0, pain. On 9/18/10 a telephone order to "Give 1 mg Dilaudid IV loading dose X 1 now; 15 mg Toradol IV X 1 now. Also, a "Patient Controlled Analgesia" order form, which was a telephone order received by the nurse, on 9/18/10, also not signed by the physician.

Interview with the Quality RN on 1/6/11 revealed that the medical records department reviews for completeness of the chart, however, apparently does not audit for physician signatures. The Quality RN confirmed that the orders were not signed.

Review of the Medical Staff Operations and Functions Manual in pertinent part: ARTICLE XI, Health Record Guidelines, Section 4, "All clinical entries in the health record must be accurately dated, timed and authenticated." ARTICLE XVI, Health Record Order Guidelines, Section 3. "When telephone or oral orders are issued, they must be authenticated by the responsible or designated practitioner within 48 hours after the order is given. Authentication includes signatures, identifiable initials, or computer entry."

Based on review of medical records, review of the "Medical Staff Operations and Functions Manual," and staff interview, it was determined that one of thirty-two medical records did not contain a discharge summary with outcome of hospitalization, disposition of care and provision for follow-up care.

On 1/6/2011, medical record sample #11 was reviewed and did not contain a discharge summary or a final progress note. The patient's stay was over 48 hrs. Admission date for labor and delivery was documented as 07/08/10 at 15:13 and discharge date and time was documented as 07/10/10 at 15:30. An interview with the department director of obstetrics confirmed the absence of any progress note or discharge summary during review of the medical record.

On 1/6/11, review of a facility policy titled "Medical Staff Operations and Functions Manual," in pertinent part: Article XVII states under "Discharge Health Record Guidelines" and Section 2 that "A clinical discharge summary must be dictated on all health records of patients hospitalized over 48 hours..." and Section 3 states "A final health progress note may be substituted for the clinical discharge summary in cases of patients with problems that require hospitalization for less than 48 hours..." and Section 5 states "A health record is considered complete when:..."Discharge summaries have been dictated within 30 days of discharge."

Based on medical record review and staff interview it was determined the facility failed to document in the patient's medical record that a "Choice List" was presented to the patient prior to discharge in one, (sample #18), of thirty-two open and closed medical records. The findings were:

Sample #18 was a female in her fifties admitted to the facility for a fractured pelvis on 9/5/10 and discharged on 9/9/10. The patient was discharged with Home Health for Physical Therapy and Occupational Therapy. There was no documented evidence in the medical record that the list of Home Health providers was presented to the patient.

Interview with the Case Manager, on 1/5/11 at 3:30 p.m., revealed that there is only one Home Health provider in the local area where the patient lived, which was local. H/she stated that because there was only one provider h/she did not think it was necessary to do this.