HospitalInspections.org

Based on record review and staff interview, the facility failed to ensure notification of provider and arrival onsite within 30 minutes being documented in 4 of 5 (Patients 22, 23, 24 &25) emergency room (ER) patient's electronic medical records. This failed practice had the potential to affect all ER patients. The facility had 1436 emergency room visits for fiscal year 2022.

Findings include:

A. Review of Patient 22's medical record (9/6/23 at 10:00 AM) revealed an ER visit on 5/30/23 for hypertensive urgency (very high blood pressure). Review of the entire medical record revealed a lack of evidence of documentation of provider notification and provider arrival onsite with 30 minutes.

-Review of Patient 23's medical record (9/6/23 at 10:20 AM) revealed an ER visit on 6/8/23 for unstable angina (chest pain). Review of the entire medical record revealed a lack of evidence of documentation of provider notification and provider arrival onsite with 30 minutes.

-Review of Patient 24's medical record (9/6/23 at 10:33 AM) revealed an ER visit on 7/18/23 for COPD exacerbation (Chronic Obstructive Pulmonary Disease)(disease that causes airflow blockage and breathing problems). Review of the entire medical record revealed a lack of evidence of documentation of provider notification and provider arrival onsite with 30 minutes.

-Review of Patient 25's medical record (9/6/23 at 10:45 AM) revealed an ER visit on 7/26/23 for chest pain and shortness of breath. Review of the entire medical record revealed a lack of evidence of documentation of provider notification and provider arrival onsite with 30 minutes.

B. Interview with Interim ADON (9/6/23 at 11:00 AM) confirmed the above ER medical records lacked provider notification and arrival to the ER within 30 minutes of notification.

Based on record review and staff interview, the facility failed to provide re-appointment credentialing verification for 2 of six 6 Medical Staff (Physician's B & D) reviewed. The facility Medical Staff Roster included a credentialed medical staff of 88 individual members with Active, Courtesy or Consulting privileges and 55 individual members with Telemedicine privileges.


Findings include:

A. Review of Patient 30 medical record on 9/6/23 revealed on 7/5/2023, Medical Staff Physician D performed a TKA for sampled patient 30.

-Review of the credential file for Staff Physician D (courtesy-orthopaedic surgeon) revealed re-credentialing privileges requested and approved by Medical Staff and Governing Body in August 2022 (for a two year time period) which did not include the procedure Total Knee Arthroplasty- TKA/ (knee joint re-placement).

-Interview with Medical Records Manager (9/6/2023 at 3:50 PM) revealed that surgery staff have online access to approved credential files with the new electronic format used and a copy of privileges is not provided to surgery department at the time of appointments/re-appointments for their verification of procedures approved by Governing Body.

B. Review of the credential file for Staff Physician B (active) revealed an initial appointment in September 2021 and reappointment in June 2023 with surgical privileges for Gastrointestinal Conditions (stomach/intestinal) and gynecological (female reproductive) surgeries without any verification of training/experience/clinical competence in these surgical fields.

-Medical Records Manager responsible for completing credential files confirmed that the training/competence verification was not contained in the credential file information at the time of appointment/re-appointment.

-Interview with Medical Records Manager (9/6/23 at 3:50 PM) revealed a new computerized credentialing request list had been implemented in the past year and the process for reviewing the complete list of privileges for each type of practitioner had not been verified for the services approved to be provided at the hospital.

Based on medical record review and staff interview the facility failed to ensure that 1 of 5 swing bed residents (Patient 34) reviewed had a completed nutritional assessment. This failed practice has the potential to affect all swing bed residents of the CAH. The number of swing bed admissions at the facility for Fiscal Year Ending 2022 was 32.

Findings are:

A. Review of Patient 34's medical record (9/7/23 at 10:30 AM) revealed a swing bed admission of 8/18/23-8/29/23 for Diverticulitis (inflammation or infection in one or more small pouches in the digestive tract) and Hypokalemia (low blood potassium levels). Review of the entire medical record revealed a lack of evidence of a nutritional assessment.

B. Interview with the Chief Information Officer (CIO) (9/11/23 at 12:19 PM) confirmed the above medical record lacked evidence of a completed nutritional assessment.

Based on medical record review and staff interview, the facility failed to ensure the Important Message from Medicare was received and signed before discharge for 2 of 22 patients (Patients 15 and 34) reviewed and failed to ensure the Medicare Outpatient Observation Notice was received and signed before discharge for 1 of 3 observation patients (Patient 7). This failed practice had the potential to affect all patients at facility. The number of acute inpatient admissions for Fiscal Year (FY) 2022 was161. The number of observation admissions for FY 2022 was 95. The number of swing bed admissions was 32.

Findings include:

A. Review of Patient 7's medical record (9/7/23 at 9:29 AM) revealed an observation admission of 3/15/23-3/20/23 for Chronic Obstructive Pulmonary Disease (COPD) exacerbation (disease that causes airflow blockage and breathing problems). Review of the entire medical record revealed a lack of evidence of the Medicare Outpatient Observation Notice delivered and signed before discharge.

-Review of Patient 15's medical record (9/7/23 at 1:21 PM) revealed an inpatient admission of 7/5/23-7/10/23 for urinary tract infection. Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare delivered and signed before discharge.

-Review of Patient 34's medical record (9/7/23 at 10:30 AM) revealed a swing bed admission of 8/18/23-8/29/23 for Diverticulitis (inflammation or infection in one or more small pouches in the digestive tract) and Hypokalemia (low blood potassium levels). Review of the entire medical record revealed a lack of evidence of the Important Message from Medicare delivered and signed before discharge.

B. Interview with the Chief Information Officer (CIO) (9/11/23 at 12:19 PM) confirmed the above medical records lacked evidence of an Important Message from Medicare notice or a Medicare Outpatient Observation Notice.

Based on record review and staff interview, the facility failed to complete comprehensive assessments for 1 of 4 swing bed residents (Patient 33) and lacked comprehensive care plans on 3 of 4 swing bed residents (Patients 32, 34 & 35). This failed practice had the potential to affect all swing bed residents. The facility had 32 swing bed admissions for fiscal year 2022.

Findings include:

A. Review of Resident 32's medical record (9/6/23 at 3:30 PM) revealed a swing bed admission of 3/25/23-4/14/23 for fracture of right hip requiring operative repair, status post total hip replacement and cellulitis (bacterial skin infection). Review of the entire medical record revealed a lack of evidence of a comprehensive care plan being completed.

- Review of Resident 33's medical record (9/7/23 at 9:45 AM) revealed a swing bed admission of 5/1/23-5/18/23 for post covid syndrome, post covid chronic joint pain, urinary tract symptoms and weakness. Review of the entire medical record revealed a lack of evidence of a comprehensive assessment being completed.

- Review of Resident 34's medical record (9/7/23 at 10:30 AM) revealed a swing bed admission of 8/18/23-8/29/23 for diverticulitis (inflammation or infection in one or more small pouches in the digestive tract) and hypokalemia (low blood potassium levels). Review of the entire medical record revealed a lack of evidence that the comprehensive care plan being completed.

- Review of Resident 35's medical record (9/7/23 at 1:15 PM) revealed a swing bed admission of 6/27/23-7/13/23 for hypercalcemia (too much calcium in blood), weakness, renal cell carcinoma (cancer of kidneys) and large B-cell carcinoma (cancer that starts in white blood cells). Review of the entire medical record revealed a lack of evidence that the comprehensive care plan being completed.

B. Interview with the Swing Bed Coordinator (9/7/2023 at 11:15 AM) confirmed that 3 of 4 swing bed medical records lacked documentation of comprehensive care plans and 1 of 4 lacked documentation of comprehensive assessment.

Based on record review and staff interview, the facility failed to provide any documentation or evidence of testing, training or planning exercises for the facility staff as required for Emergency Preparedness since 11/4/22. This failed practice had the potential to affect all patients and staff of the facility. The facility listed 103 employees and provided care in the previous year ending June 2022 for 161 inpatients, 95 observation patients, 32 swing bed patients and 1436 emergency room patients.

Findings include:

A. Record review of the Emergency Preparedness (EP) binders provided by facility during survey, revealed the most recent drill was completed on 11/4/2022 to address Emergency Response for accidental chemical exposure of multiple victims by the previous Director of Nursing (DON). The EP binder lacked evidence of any additional training plan, live event documentation, or other "After Action" reports for the facility EP program to document ongoing training and EP planning as required.

B. Interview with CEO (Chief Executive Officer) (9/6/23 at 3:10 PM) confirmed that the last EP exercise/drill was completed on 11/4/22 and stated the facility is in the process to hire a new EP Coordinator.