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Based on record review, policy and procedure review and staff interview, the hospital failed to ensure their governing body effectively is legally responsible for the conduct of the hospital.


Findings include:



Cross Refer to A-0431 for the hospital's governing body's failure to ensure an accurately written, complete medical record is maintained for each patient; all entries/orders in the medical record contain a documented date, time and signature; consents are properly executed, and the medical record is promptly completed following patient discharge.

Based on record review, policy and procedure review and staff interview, the hospital failed to ensure an accurately written, complete medical record is maintained, all entries/orders in the medical record contain a documented date, time and signature, and consents are properly executed.


Findings include:


Cross Refer to A-0438 for the facility's failure to ensure the medical record is promptly completed following discharge.


Cross Refer to A-0450 for the facility's failure to ensure all entries in the medical record are accurately written, complete and contain a documented date, time and signature.


Cross Refer to A-0454 for the facility's failure to ensure all orders, including verbal orders, are dated, timed and authenticated by the ordering physician.


Cross Refer to A-0466 for the facility's failure to ensure a properly executed consent is documented.

Based on record review, document review, policy and procedure review and staff interview, the facility failed to ensure the medical record is promptly completed following discharge.


Findings include:


Cross Refer to A450 for the facility's failure to ensure the physician completed his/her portion of the medical record in a timely manner after discharge.


Review of the "Hospital Medical Record Statistics Form" revealed 46 physicians have delinquent incomplete medical records according to facility policy. The dates ranged from April 16, 2014 to current and include: physician orders, discharge summary, history and physicals, operative reports, and progress notes.


During an interview on 6/4/14 at 11:05 a.m. the Medical Records Director stated, "There are 105 delinquent medical records. Medical records are considered delinquent fourteen (14) days following patient discharge."


Review of facility's "Medical Record Guidelines For Staff" policy revealed: "...Procedure: ...Records shall be completed ...within 14 days following patient discharge ...".


Review of the facility's "Medical Staff Rules & Regulations" policy revealed: "..Article II Medical Records 2.1 Preparation/Completion of Medical Records: The Attending Physician shall be responsible for the preparation of a complete and legible Medical Record for each patient ...2.16 Delinquent Medical Records: Patient Medical Records are required to be completed within fourteen (14) days of discharge ...".

Based on medical record review, policy and procedure review and staff interview, the facility failed to ensure all entries were accurately written, complete and contain a documented date, time and signature for 13 of 39 patient's reviewed, Patient #13, #14, #16, #22, #24, #25, #27, #30, #32, #34, #35, #36 and #37.


Findings include:


Record review for Patient #22, #30, #32, #34, #35 and #37 revealed the "Consent to Operation, Anesthetics, and Other Medical Services", "Picc Line Insertion and Treatment Consent", "Condition of Admission", "Informed Consent for the Diagnostic and Treatment Program" and "Treatment Plan and Plan of Care Consent Form" contained no documented evidence of either the physician signature, date or time of physician signature, date the consent was obtained, and/or a patient or responsible person's signature.


Record review for Patient #22 and #32 revealed the "Anesthesia Record" contained no documented evidence of the total amount of medications administered during the procedure.


Record review for Patient #14, #16 and #32 revealed the "Pre and Post Anesthetic Evaluation" contained no documented evidence of the time the evaluation was completed.


Record review for Patient #27 revealed no documented evidence of the time the short stay history and physical (H&P) was completed.


Record review for Patient #13, #24, #25, #30, #35 and #36 revealed no documented evidence of either the date or time the physician orders and/or progress notes were written into the medical record; and/or that the verbal orders were authenticated by the ordering physician with 48 hours. This includes orders written by the physician, verbal and/or telephone orders taken by the nursing staff.


Record review for Patient #32 and #37 revealed no documented evidence the "Hospital Program Hemodialysis Form" contained the name of the registered nurse receiving report following the patient's treatment, and/or the physician's signature and/or the date and/or time.


During an interview on 6/4/14 at 3:45 p.m. the Medical Records Director and the Assistant Quality Improvement (QI) Coordinator were asked if all entries written into the medical record should be dated, time and signed. Both stated, "Yes". When asked if verbal orders should be co-signed by the ordering physician, both stated "Yes". They were both asked if admission, treatment and surgical consents should be completed including signatures, dates and timed. They both stated, "Yes". The Assistant QI Coordinator stated, "Consents should be completely filled out." The Assistant QI Coordinator was asked what the facility policy stated to do if a patient was unable to sign a consent. She stated, "We get the responsible person to sign and if no one is available, we try to contact a family member for telephone consent."


Review of the facility's "Medical Record Guidelines For Staff" revealed: "...Procedure: ...All entries must be timed, dated and authenticated ...".



Review of facility policy "Verbal And Written Orders-General" revealed: "...Verbal/Telephone Orders: ...The order will be entered into the electronic health record and signed by the ordering physician electronically within 48 hours ...".


Review of facility policy "Policy On Consent To Treatment And Informed Consent" revealed: "..I. Policy: Each patient's medical rcord must contain evidence of the patient's or his legal representative's voluntary and informed consent for procedures and treatment ...IV. Types Of Consents: A ...For those patients who cannot ...write, the patient may indicate consent by "marking" the Consent for Treatment form ...C. Telephone Consent:..In such situations, hospital personnel and/or physician shall obtain a witness to listen to the consent ...".


Review of facility's "Pre And Post Anesthesia Evaluation Policy" revealed: "...Procedure: ...Pre Anesthesia Evaluation and Note: The pre anesthesia evaluation must be completed ...Post Anesthesia Evaluation ...All patients receiving general, regional, or monitored anesthesia shall have a post anesthesia evaluation ...".


Review of facility policy "Intraoperative Anesthesia Care" revealed: "...Policy: The attending Anesthesiologist/Anesthetist will perform and document all appropriate intra-operative care ... The intra-operative anesthesia record shall, at a minimum, include: ...dosage ...of drugs and anesthesia agents ...".


Review of the facility's "Medical Staff Rules & Regulations" revealed: "...2.8 Clinical Entries/Authentication: All clinical entries in the patient's medical record shall be accurately dated, timed in a 24-hour format, and authenticated. Authentication shall be defined as the establishment of authorship by written signature, identifiable initials or computer key ...3.1 General Consent Form: A general consent form, signed by or on behalf of every patient admitted to the hospital, must be obtained at the time of admission. The patient business admissions office should notify the Attending Physician whenever such consent has not been obtained. When so notified it shall, except in emergency situations, be the practitioner's obligation to obtain proper consent before the patient is treated in the hospital. 3.2 Written/Verbal/Telephone Treatment Orders: ...A verbal order or telephone order shall be considered to be in writing if dictated to a nurse and signed by the nurse and countersigned by the physician giving the order ...4.4 Surgical Consent: A written, informed and signed surgical consent shall be obtained and placed on the patient's chart prior to all operative procedures ...The consent form shall be signed by the patient ...4.7 Anesthesia: ...The anesthetist or anesthesiologist shall maintain a complete sedations or anesthesia record to include evidence of pre-sedation or pre-anesthesia evaluation ...Also included in the record shall be a pre-sedation and pre-induction evaluation and a post-sedation or post-anesthesia follow-up of the patient's condition by the anesthetist prior to transport to the OR holding areas ...The Anesthesia Provider will be responsible to obtain and document informed consent for anesthesia in the medical record ...".

Based on medical record review, policy and procedure review and staff interview, the facility failed to ensure all orders, including verbal orders, are dated, timed and authenticated by the ordering physician for five (5) of 39 patients reviewed, Patient #13, #24, #25 #30 and #36.


Findings include:


Cross Refer to A-0450 for the facility's failure to ensure all physician orders are dated, timed and authenticated by the ordering physician according to facility policy.

Based on medical record review, policy and procedure review and staff interview, the facility failed to ensure a properly executed consent was documented for Patient #22, #30, #32, #34, #35 and #37, six (6) of 39 patients reviewed.


Findings include:


Cross Refer to A-0450 for the facility's failure to ensure surgical and anesthesia consents were properly executed for Patient #22, #30, #32, #34, #35 and #37.

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Based on documentation review, policy and procedure review and staff interview, the facility failed to notify the organ recover agency of a patient death in a timely manner.


Findings include:


Review of the facility report "2014 Donation Referral Compliance & Conversion Rates" revealed documented evidence the facility failed to meet the one hour compliance referral time when calling in a patient death. In February 2014 two (2) patient deaths were not called in within one (1) hour. In March 2014 one (1) patient death was not called in within one (1) hour.


On 6/4/2014 the Chief Nursing Officer was asked if she was aware of any problems delaying calling in of patient deaths as specified in the hospital's facility policy. She stated, "No."


Review of facility policy "Organ/Tissue Donation/Donation after Cardiopulmonary Death" (revised 02/27/2014) revealed: "III. Donor Referral Procedure A. Upon determination of cardiac death or the potential for organ donation, the charge nurse will be responsible for notifying MORA (the organ recovery agency) by calling the Donor Referral Line... MORA should be notified ideally within one hour of patient meeting clinical triggers for organ donation referrals."



Review of the facility's "Medical Staff Rules and Regulations" revealed: "...4.8 Organ & Tissue Donations: The hospital shall refer all inpatient deaths, emergency room deaths and dead arrival cases to the designated organ procurement agency ...".

Based on observation, document review and staff interview, the facility failed to provide safety measures that demonstrate immediate availability and accuracy of their equipment services with their crash carts. The facility failed to fire defibrillators daily on three (3) of three (3) carts observed and failed to have suction tubing readily available on two (2) of the three (3) crash carts observed.

Findings include:

1. Review of the facility's Daily Emergency Cart/Defibrillator/AED Check List revealed a list of eight (8) things to do to under the heading "Process For Daily Emergency Cart/Defibrillator Check"

On 6/03/14 at 11:00 a.m. observation of the defibrillators on two (2) carts revealed a printed out tape with handwritten dates below the tapes. The tapes from both machines showed a firing of the machine followed by the dates: 05/28, 05/30 and 06/01. There was no documented evidence the facility was checking the machine's firing process daily.

In an interview on 6/03/14 at 2:30 p.m., the Director of the Emergency Room (ER) stated that the staff shouldn't have written dates on the tapes. When asked how the facility keeps up with the firing of the defibrillators, he stated, "We don't fire them every day. They shouldn't have kept those tapes." The Director submitted no further documented evidence that the machines were being fired daily.

On 6/3/2014 at 3:30 p.m. observation of the 4th floor crash cart revealed documented evidence on the defibrillator tape that it was fired on 05/28 and 06/02/14. During the observation the Director of Obstetrics stated they do not keep the defibrillator tapes to show they are firing it daily. There was no evidence submitted to show that they were firing daily.

2. Review of the facility's Crash Cart Supply List revealed that it stated there would be suction with tubing on the crash carts. During the observations of the three (3) crash carts there was no tubing seen on the carts. Observation in the ER on 6/3/2014 revealed there was suction on each wall, but no tubing. The tubing was kept behind a locked door in one of the trauma rooms.

During an interview on 6/03/14 at 11:00 a.m. an ER Registered Nurse (RN) stated the hospital is a Level III Trauma Center and they have all of the tubing in the trauma room.

While discussing the availability of tubing on 6/03/14 at 11:23 a.m., a staff Licensed Practical Nurse (LPN) stated that they get suction tubing out of the large trauma room. The LPN demonstrated the procedure of leaving the cart in Suite 14, running to the large trauma room, using the key pad to open the cabinet, retreiving the tubing and running back to the suite. This took the LPN two (2) minutes and four (4) seconds.

These findings were discussed during the 6/3/2014 afternoon meeting with hospital staff at 5:00 p.m. and discussed again in exit conference on 6/04/14 at 4:45 p.m. No further documentation was provided.