HospitalInspections.org

Based on record review and interview, the governing body failed to implement a system to ensure all members of the medical staff and allied health professionals were credentialed and privileged according to the medical staff and governing body bylaws as evidenced by failure to to ensure all requirements for appointment to the medical staff and/or allied health professional had been collected and reviewed prior to recommendation by the medical staff and approval by the governing body for 6 of 6 physicians reviewed from a total of 8 credentialed physicians (S8, S10, S11, S14, S17, S18) and 2 of 2 nurse practitioners reviewed from a total of 4 nurse practitioners credentialed (S15, S16). Findings:

Medical Director S8
Review of Medical Director S8's credentialing file revealed his "Application for Appointment to the Medical Staff" was signed and dated by S8 on 10/15/10. Review of the "Medical Staff Committee of the Whole and Governing Board Approval Form" revealed it was signed by the Governing Board President on 03/05/11 with no documented evidence that S8's privileges and application were reviewed by and recommendation made by the Chairman of the Medical Staff or his designee. Further review of the entire credentialing file revealed no documented evidence that a new application had been completed by Medical Director S8 since 10/15/10, which was greater than 120 days (allowed for the application to be processed by the Medical Staff and Governing Board according to medical staff bylaws).

Review of the "Governing Board minutes" dated 05/06/11 revealed, in part, "...Medical Director S8 packet reviewed and confirmed his file is in good standing...".

Psychiatrist S10
Review of Psychiatrist S10's credentialing file revealed his "Application for Appointment to the Medical Staff" was signed and dated by S10 on 10/18/10. Review of S10's "Delineation of Privileges" revealed it was approved by the former Medical Director S19 on 01/27/11. Further review of the file revealed a "Request for Temporary Privileges" signed by Psychiatrist S10 with no documented evidence of the date S10 signed the request and signed by the Medical Director on 05/01/11. Further review revealed the "Medical Staff Committee of the Whole and Governing Board Approval Form" was signed on 04/28/11 by the Governing Board President, and Administrator S1 (a registered nurse and not a physician) signed in the blank labeled as "Chairman, MS-CoW (Medical Staff-Committee of the Whole).

Review of the "Governing Board minutes" dated 05/06/11 revealed, in part, "...Board agreed Psychiatrist S10 file complete and to move him from temporary status to full privileges...".

Physician S11
Review of Physician S11's credentialing file revealed he was appointed and granted privileges on 04/07/10. Further review revealed S11 requested privileges on 04/13/10, 6 days after his file had been reviewed and approved by the Medical Staff and Governing Board. Further review revealed the letter sent to S11 by the hospital notifying him of his appointment was dated 03/29/10, 9 days prior to his appointment.

Review of the "Governing Board minutes" dated 05/06/11 revealed, in part, "...Board reviewed and agreed following files were also in good standing - Physician S11...".

Physician S14
Review of Physician S14's credentialing file revealed he was appointed and granted privileges on 04/07/10. Further review revealed S14 requested privileges on 04/13/10, 6 days after his file had been reviewed and approved by the Medical Staff and Governing Board. Further review revealed the letter sent to S14 by the hospital notifying him of his appointment was dated 03/29/10, 9 days prior to his appointment.

Review of the "Governing Board minutes" dated 05/06/11 revealed, in part, "...Board reviewed and agreed following files were also in good standing - ...Physician S14...".

Nurse Practitioner (NP) S15
Review of NP S15's credentialing file revealed she was appointed and granted privileges on 04/15/10. Review of the "Delineation of Privileges" revealed S15 requested privileges on 01/27/11, more than 9 months after her appointment. Further review revealed the National Practitioner Data Bank was queried on 05/02/10, 17 days after her appointment, and her CDS (Controlled Dangerous substances) license had expired on 05/01/10.

Review of the "Governing Board minutes" dated 05/06/11 revealed, in part, "...Board reviewed and agreed following files were also in good standing - ...Nurse Practitioner S15...".

NP S16
Review of NP S16's credentialing file revealed she was appointed and granted privileges on 04/07/10. Review of the "Collaborative Practice Agreement" with Physician S14 revealed it was signed on 07/07/10, 3 months after S16's file had been reviewed and approved for appointment by the Governing Board.

Review of the "Governing Board minutes" dated 05/06/11 revealed, in part, "...Board reviewed and agreed following files were also in good standing - ...Nurse Practitioner S16...".

Pathologist S17
Review of Pathologist S17's credentialing file revealed his "Medical Staff Application" was completed on 05/20/11. Review of the "Request for Temporary Privileges" signed by Pathologist S17 on 05/20/11 revealed the medical director approved it on 05/19/11, the day prior to the request being submitted. Further review revealed the request had no documented evidence of approval by Administrator S1 as required by the medical staff bylaws. Further review revealed no documented evidence of privileges requested by S17 or approved by the Medical Staff and Governing Board.

Radiologist S18
Review of Radiologist S18's credentialing file revealed he was granted temporary privileges on 07/08/10. Further review revealed no documented evidence of a second or third request to extend the temporary privileges, not to exceed 90 days, as required by the medical staff bylaws after 30 days. An application for active membership was completed by Radiologist on 04/29/11, more than 8 months after he was granted temporary privileges for 30 days.

Review of the "Governing Board minutes" dated 05/06/11 revealed, in part, "...Radiologist S18 packet also reviewed by board and agreed that he is also now granted consulting privileges...".

In a face-to-face interview on 06/08/11 at 1:45pm with HR (human resources) Manager S4 and CFO (chief financial officer) S5 present, S4 indicated she had started her employment at Seaside Behavioral Center on 02/02/11 and would become the credentialing clerk as part of her job duties. S4 confirmed that she did not review any of the credentialing information presented for review to the Governing Board meeting of 05/06/11. During the same interview CFO S5 confirmed the above findings. S5 indicated the files reviewed by the Governing Board on 05/06/11 did not have new applications. He further indicated a new request for clinical privileges should be completed with each reapplication for appointment. S5 further indicated the hospital was aware of problems with the credentialing process and had recently contracted with a credentialing company to assist with fixing the problem.

Review of the "Medical Staff Bylaws" presented by Administrator S1 as their current bylaws revealed, in part, "...Article 5 Appointment and Reappointment ... no person shall exercise Clinical Privileges in the Hospital unless and until he or she applies for and receives appointment to the Medical Staff, or is granted clinical or temporary Privileges as set forth in these bylaws. ... 5.3 Duration of Appointment and Reappointment Appointments and reappointments to the Medical Staff shall be for a term of two (2) years... 5.4 Application for Initial Appointment and Reappointment ... Each application for initial appointment to the Medical Staff shall be in writing, submitted on the prescribed form with all provisions completed... and signed by the applicant. ... 5.4.3 Verification of Information The applicant shall deliver a completed application to the Chief Executive Officer. The application and all supporting materials then available shall be transmitted to the Medical Director. The Medical Director or his or her designee shall, within 60 days after receiving all completed information from the applicant, seek to collect or verify the references, licensure status, and other evidence submitted in support of the application. ... Any application or supporting information that remains incomplete more than sixty (60) days after the notice is sent to the applicant that the application or supporting information is incomplete shall be void and the applicant must complete a new application and submit the new application together with supporting information...5.4.4 "Committee of the Whole "(MS-COW) Action ...Within 60 days after receipt of the completed application and all supporting information, the "Committee of the Whole "(MS-COW) shall forward to the Chief Executive Officer for prompt transmittal to the Governing Board, a written report and recommendation as to Medical Staff appointment and, if appointment is recommended, as to membership category, Clinical Privileges to be granted, and any special conditions to be attached to the appointment. ... 5.4.6 Action on the Application The Governing Board shall consider the report and such other information available to it that may be relevant to the applicant's qualifications for Medical Staff membership and Clinical Privileges. Within sixty (60) days of receiving the application and recommendation of the "Committee of the Whole "(MS-COW) the Governing Board may accept, modify, or reject the recommendation... 5.5 Reappointments and Requests for Modifications of Staff Status or Privileges 5.5.1 Application A. Each Member shall submit to the Medical Director, not later than ninety (90) days prior to the expiration of the Member's appointment, the completed application form for reappointment to the Staff for the next two-year appointment period, and for renewal or modifications of Clinical Privileges. ... 5.5.3 Standards and procedure for Review When a Staff Member submits his or her first application for reappointment, and every two (2) years thereafter, or when the Member submits an application for modification of Staff status or Clinical Privileges, the Member shall be subject to a review generally following the procedures set forth in Sections 5.1 through 5.4.8. The Medical Director ... shall verify the information with respect to each application and reapplication with (a) the National Practitioner Data Bank ... (b) the ... State Medical Board and (c) other sources as may be required by state or federal law... Article 6 Clinical Privileges ... Each application for appointment and reappointment to the Medical Staff must contain a request for the specific Clinical Privileges desired by the applicant. ...6.3 Temporary Clinical Privileges ...Temporary Clinical Privileges are granted by the Chief Executive Officer upon recommendation of the Medical Director or designee... The Temporary Privileges may be granted for a period of time not to exceed 30 days. Temporary Privileges may be extended for two separate 30-day intervals upon approval of the Governing Board...".

Based on record review and interview the hospital failed to ensure a physician was responsible for a patient's problem of an abnormal EKG (Electrocardiogram/test that records the heart's electrical activity) that was discovered during the patient's hospitalization by failing to follow through with the Primary Care Physician's progress note indicating the patient needed to be seen by a Medical Physician. Patient #18's abnormal EKG was never evaluated by a Medical Internist during his entire hospital stat from 4/19/2011 through 5/19/2011 (Abnormal EKG performed on 4/27/2011). This occurred for 1 of 2 patient's requiring evaluation of an abnormal EKG out of a total sample of 23. Patient #18. Findings:

Review of the hospital policy titled, "Consultations, #17, Effective Date 5/01/2011" presented by the hospital as their current policy revealed in part, "Consults Completed in the Psychiatric Service: Physician: Will order consultation on Physician's Order Sheet and prepare consultation request form indicating: Patient Information, Consultation being requested, Reason for Consultation, Significant related information including urgency of consult, Limitation and extent of the consultation, Sign,date and time the request, Sign, date and time acknowledgment of consultant's report, Act on consultation recommendations, including transfer and/or arranging continuing management. . . Attending Physician: Reviews and initials results. Notifies the patient of results and plans for follow-up care."

Review of Patient #18's Medical Record revealed the patient was admitted to the hospital on 4/19/2011 with diagnoses that included Dementia With Behavioral Disturbance. Further review revealed Admission Physician Orders dated 4/19/2011 at 1900 (7:00 p.m.) which included an order for "EKG". Review of Patient #18's EKG indicated the date performed was "4/27/2011 (8 days after the EKG had been ordered by the physician)" (at)" 6:34 a.m." with electronic interpretation of "sinus rhythm probable septal infarct . . . Abnormal EKG." Review of the entire medical record revealed no documented evidence to indicate justification of the delay in following physician's orders for an EKG on admission (4/19/2011). Review of Physician's Progress Note for Patient #18 dictated on 4/27/2011 (no documented time) by Physician, Psychiatrist S10 revealed in part, "He has an EKG, which was read as abnormal. It says sinus rhythm, probable septal infarct, minor mid and left precordial and high lateral repolarization disturbance, consider ischemia, small and negative T in aVL with flat or low negative T in V3, V4, V5, and V6, and that was done on 4/27/2011 at 6:34 in the morning. We will have Medicine follow on that EKG. . ." Review of Patient #18's entire medical record revealed no documented evidence that a Medical Consult had ever been ordered for Patient #18. Further review revealed no documented evidence that Patient #18 had ever been seen or evaluated by a Medical Physician after the Abnormal EKG had been performed on 4/27/2011 and Psychiatrist S10 had indicated in Progress notes that he would "have Medicine follow on that EKG".

This finding was confirmed by Administrator S1 in a face to face interview on 6/08/2011 at 9:30 a.m..

During a face to face interview on 6/09/2011 at 9:35 a.m., Medical Director S8 indicated abnormal EKGs should be reviewed by a Medical Internist.

Review of the Medical Staff Rules and Regulations submitted by Administrator S1 as the current rules and regulations for the medical staff revealed, in part, " ...10. Use of Physician Consultative Services 10.1 All attending physicians may request consultative services from other physicians at any time during a patient ' s hospital stay. ... 10.3 The consultative physician must have privileges at the hospital or the CEO (chief executive officer) and Medical Director may grant temporary privileges if necessary per temporary privileges policy. 10.6 The consultant shall make and sign (dated and timed) a report of his findings and recommendations which shall become a part of the medical record. ... 10.7 Physicians who have demonstrated competence and experience as determined by the credentialing process shall interpret EKGs (electrocardiograms). Completion of an approved residency in Cardiology or Internal Medicine shall constitute demonstrated competency and experience. Only physicians who have this delineated privilege shall interpret EKGs ... " .

Based on record review and interview the hospital failed to ensure their Quality Assessment Performance Improvement(QAPI) Plan was implemented to include measuring, analyzing, and tracking quality indicators and adverse patients events leading to corrective action as indicated and monitoring measurable data to ensure the corrective action was effective for 1 of 1 QAPI plan reviewed. Findings:

Review of the hospital's "Quality Assessment and Performance Improvement Program, 2011" presented by the hospital as their current plan revealed in part, "Program Components. Seaside Behavioral Center's QAPI Program has five major components: Leadership. . Defining, designing, and developing processes for quality/safety., Monitoring hospital processes through data collection, Performance action on identified needs, and Performance improvement evaluation. . .The components of this plan include: QAPI Activity Report which provides summary data about selected indicators . . . PDCA (Plan, Do, Check, Act): Plan the improvement. . . Do the improvement process. . . Check the result. . . Act to hold the gain and continue to improve the process. . . An indicator monitoring worksheet will be utilized to plan for monitoring, set the goal/benchmark for each indicator, and identify data collection methodology. Statistical tools and techniques will be used to analyze and display data. . ."

During a face to face interview on 6/09/2011 at 10:15 a.m., Administrator S1 indicated the hospital was in the early stages of developing an effective Quality Assurance Performance Improvement Program. S1 indicated the hospital had developed the plan and had identified Quality Indicators and Benchmarks; however, there had only been partial implementation of the program. S1 indicated she had no completed tracking and trending of Quality Indicators to present to the Survey Team. S1 indicated there had been some data collected however it had been limited.

Based on record review and interview, the hospital failed to ensure quality control practices were monitored for efficacy in order to identify and correct the problem prone practice where nursing staff were performing quality control checks on the hospital's capillary blood glucose machine without identifying the manufacturer's documented target parameters to ensure the machine was properly calibrated for 1 of 1 capillary blood glucose machine in use at the hospital. Findings:

Review of the hospital's "Glucometer Controls" log from the date of January 1, 2011 through June 7, 2011 revealed documentation identifying the "Date, Time", "High (Solution) Lot # (lot number)", "Low (Solution) Lot #", "High Result", and "Low Result". Review of the entire Glucometer Control Log revealed no documented evidence of the Lot Number for the Blood Glucose Test Strips, or the "Expected Results for use with MediSense or Optium Control Solutions (documented on the package insert for the Blood Glucose Test Strips)".

Observation/Review of the only open bottle of Blood Glucose Strips in the hospital revealed the Lot number was 47378.

Review of the package insert for Blood Glucose Test Strips Lot # 47378 revealed the following, "How do I check my system? Use a MediSense or Optium Control Solution to do a control solution test when you question your results and want to confirm that your monitor and test strips are working properly. . . Control results must be within the "Expected Results for Use with MediSense or Optium Control Solutions printed on these instructions for use. Check that the LOT number matches the test strip instructions for use and test strip foil packet. . . Lot 47378. Expected Results for Use with MediSense or Optium Control Solutions. Low: 31 - 61 mg/dL (milligrams per deciliter). . . High: 223 - 373 mg/dL."

Review of "Low Results" tested on the dates of January 1 through February 13 revealed all days tested had documented results ranging from 74 - 94 (current open bottle of test strips indicated expected range for "Low" to be 31 - 61). Review of the entire "Glucometer Controls" log revealed no documented evidence of the Lot number or Expected Parameters for any test performed.

During a face to face interview on 6/06/2011 at 1640 (4:40 p.m.), Administrator S1 indicated the hospital had no policy or procedure for Staff Performance of Quality Control Testing of the hospital's Capillary Glucose Machine. S1 further indicated that without documenting the test strip lot number and expected results, there would be no way to determine if the machine was working properly. S1 indicated many patients treated at the Geriatric Psychiatric Unit had Diabetes as a Secondary Diagnoses.

Review of Medical Records revealed the following sampled patients had a diagnoses of Diabetes: Patients #1, #3, #8, #10, #17, and #18.

Based on record review and interview the hospital failed to ensure the Medical Staff By-Laws were enforced as evidenced by failing to notify physicians of medical records approaching 30 days delinquent and failing to suspend admission privileges for physician's with delinquent medical records per the Medical Staff By-Laws. Findings:

In a telephone interview on 06/08/11 at 2:20 p.m. with S12, contracted RHIT (registered health information management technician), she stated that when a patient is discharged the medical record is scanned and electronically sent to her for coding and review. S12, contracted RHIT, further stated that she retains her deficiency report for the entire month and sends it to the hospital by the 10th of the following month. S12, contracted RHIT, confirmed that by holding her deficiency report until the 10th of the month following medical record review that some medical records are already 30 days delinquent when the report is submitted.

Review of a document submitted by S12, contracted RHIT, to S1Administrator revealed: "April 2011, I reviewed the charts for April 2011 for Completeness, Correct Chart Order, Complete Documentation and Signatures in all areas of the chart. The following charts were reviewed:". Review of the document revealed 30 medical records were reviewed. A sample of 5 (patients #19, #20, #21, #22, and #23) of the medical records were reviewed and revealed discrepancies noted by S12, contracted RHIT.

Review of the medical records for patients #19, #20, #21, #22, and patient #23 revealed none of the listed discrepancies were corrected as of the date of review on 06/08/11 at 10:45 a.m.

In an interview/record review on 06/08/11 at 10:45 a.m. with S1Administrator she reviewed the medical records of patients #19, #20, #21, #22, and patient #23 and confirmed that none of the medical record discrepancies identified by S12, contracted RHIT, were corrected. S1Administrator further confirmed that all 30 of the records would be greater than 30 days delinquent.

In an interview on 06/08/11 at 8:45 a.m. with S1Administrator she stated that the hospital could not provide a current list of medical records that were delinquent because there was no system in place for tracking delinquent medical records. S1Administrator confirmed that there was no enforcement of the Medical Staff By-Laws regarding suspension of admission privileges due the inability of the hospital to accurately track delinquent medical records. S1Administrator confirmed that no suspension letters, due to delinquent Medical Records, had been sent to any physician since she became Administrator in 01/11.

Review of the Medical Staff By-Laws, last approved 03/31/11 by the Governing Body, under section 7. Inpatient Medical Records read in part: "7.16. The patient's medical record shall be complete at the time of discharge, including progress notes, final diagnosis and discharge summary. When this is not possible because final laboratory or other essential reports have not been received at time of discharge, the patient's chart will be available in a stated place in the Medical Records Department. 7.17. If the record remains incomplete thirty (30) days after discharge, the CEO or designee shall notify the responsible staff member that his/her name will be placed on the "No Admit" list fifteen (15) days from the date of notice. 7.18. If the record still remains incomplete fifteen (15) days after the physician is placed on the "No Admit" list, suspension of Medical Staff privileges may occur. If the physician is responsible for the care of patients in the Hospital at the time of suspension, the physician shall continue to be responsible for the patient until discharge; however, no new patients may be admitted."





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Based on record review and interview the hospital failed to ensure:
1) nursing staff implemented physicians' plan of care/orders for medications, wound care, labs, and/or EKGs (electrocardiograms) in a timely manner for 7 of 23 sampled patients (#2, #4, #8, #10, #12,#14, #18) and
2) a nursing care plan was developed, updated, and/or kept current for 5 of 23 sampled patients (Patient #3, #4, #7, #12, #14). Findings:

1) Plan of care/orders:
Patient #2
Review of Patient #2's medical record revealed she was admitted on 05/31/11 with diagnoses of dementia with behavioral disturbances, CVA (cerebrovascular accident), depression, pancreatitis, UTI (urinary tract infection), HTN (hypertension, psychosis, hypothyroidism, hyperlipidemia, and constipation. Further review revealed physician's orders for TSH (thyroid stimulating hormone), B12, and Folate. Review of Patient #8's medical record on 06/06/11, 6 days after admission and the order for the blood work, revealed no documented evidence that the blood work was drawn or the results had been added to the record. A second review of the medical record on 06/08/11 revealed results for the TSH, B12, and Folate, drawn on 06/01/11 had been faxed to the hospital on 06/07/11 at 8:38am.

In a face-to-face interview on 06/08/11 at 3:00pm, Charge Nurse S3 indicated it should not take 6 days to obtain lab results. She further indicated lab results were usually received within 24 to 48 hours after being drawn. S3 further indicated if the nurse had not received the lab results within 1 to 2 days, the nurse should check the lab requisition book to be sure the lab was drawn and then call to check with the lab. S3 further indicated the nurses don't document the phone call placed to the lab to check on lab results.

Patient #4
Review of Patient #4's medical record revealed she was admitted on 05/12/11 with diagnoses of schizophrenia, UTI, HTN, OCD (obsessive compulsive disorder), bipolar, seizure disorder, ADHD (attention deficit hyperactivity disorder), Tourette's Syndrome, and delusional disorder. Review of the "Physician Orders" revealed the following orders:
05/12/11 at 0100 (1:00am) - Bactrim DS 1 by mouth twice a day for 7 days;
05/12/11 at 1310 (1:10pm) - D/C (discontinue) admit orders for medications; Continue Bactrim DS 1 by mouth twice a day for 7 days;
05/17/11 at 7:30pm - Repeat UA with CS (urinalysis with culture and sensitivity) when finished Bactrim; and
05/27/11 at 0720 (7:20am) - Bactrim DS 1 twice a day for 7 days.
Review of Patient #4's MAR (medication administration record) for 05/18/11 at 7:00am through 05/19/11 at 6:59am revealed the Bactrim DS was completed on 05/18/11 at 2100 (9:00pm).
Review of Patient #4's lab results revealed urine was collected for UA with C&S on 05/23/11, 5 days after the Bactrim was last given. Further review revealed a UA with C&S was collected on 05/26/11 with no documented evidence of an order for this testing.
Review of Patient #4's MARs revealed the second round of Bactrim was initiated on 05/27/11 at 9:00pm. Further review revealed Bactrim was administered on the following days and times:
05/28/11 at 9:00am and 9:00pm; the Bactrim section of the MAR was labeled "day #1";
05/29/11 at 9:00am and 9:00pm; the Bactrim section of the MAR was labeled "day 2";
05/30/11 at 9:00am and 9:00pm; the Bactrim section of the MAR was labeled "day 4";
05/31/11 at 9:00am and 9:00pm; the Bactrim section of the MAR was labeled "day 5";
06/01/11 at 9:00am and 9:00pm; there was no documented evidence of the number of day for administration;
06/02/11 at 9:00am and 9:00pm; there was no documented evidence of the number of day for administration;
06/03/11 at 9:00am and 9:00pm; there was no documented evidence of the number of day for administration;
06/04/11 at 9:00am; the Bactrim section of the MAR was labeled "completed 06/04/11 0900 (9:00am)".
Further review revealed Bactrim was administered over 9 days, rather than 7 days as ordered, and for a total of 16 doses rather than 14 doses as ordered.

In a face-to-face interview on 06/08/11 at 3:00pm, Charge Nurse S3 confirmed the above findings and indicated the Bactrim should have been numbered for each dose given.

Patient #8
Review of Patient #8's Medical Record revealed the patient was admitted to the hospital on 5/26/2011. Further review revealed physician's orders dated 5/26/2011 at 11:00 a.m. for B12, Folate (labs). Review of Patient #8's medical record revealed the order dated 5/26/2011 was not carried out until 5/31/2011 (5 days after the physician ordered the test). Review of the entire medical record revealed no documented justification for the delay in obtaining the test.

During a face to face interview on 6/08/2011 at 1410 (2:10 p.m.), Administrator S1 indicated Patient #8's B12 and Folate should have been drawn on 5/27/2011.

Patient #10
Review of Patient #10's Medical Record revealed the patient was admitted to the hospital on 05/13/11. Further review revealed physician's orders dated 05/13/11 for RPR (rapid plasma reagin), TSH (thyroid stimulating hormone), B12, and Urinalysis. Review of Patient #10's medical record revealed the order dated 05/13/11 was not carried out until 05/16/11 (3 days after the physician ordered the test). Review of the entire medical record revealed no documented justification for the delay in obtaining the test.

In an interview with S1Administrator on 06/07/11 at 12:30 p.m. she confirmed the test were not done for three days after being ordered by the physician, S8MD. S1Administrator could offer no explanation for the delay in ordering the laboratory tests.

Patient #12
Review of Patient #12's Medical Record revealed the patient was admitted to the hospital on 5/22/2011. Further review revealed physician's orders dated 5/22/2011 at 1625 (4:25 p.m.) for EKG. Review of Patient #12's medical record revealed the order dated 5/22/2011 was not carried out until 5/25/2011 at 6:00 a.m. (3 days after the physician ordered the test). Review of the entire medical record revealed no documented justification for the delay in obtaining the test.

During a face to face interview on 6/08/2011 at 1420 (2:20 p.m.), Administrator S1 indicated Patient #12 was calm and cooperative upon admission. S1 indicated Patient #12 should have had her EKG done on the night of her admission(5/22/2011).

Patient #14
Review of Patient #14's medical record revealed she was admitted on 02/15/11 with diagnoses of major depression and anxiety disorder.
Review of the "Physician Orders" revealed an order on 02/17/11 at 1445 (2:45pm) for "daily wound care, clean with wound cleaner, pat dry cover with Mepilex".
Review of Patient #14's MARs, "Daily Nursing Assessment, and "Daily Treatment Plan Update and Team Progress Note" revealed no documented evidence that wound care was performed on 02/19/11, 02/20/11, 02/21/11, 02/24/11, and 02/25/11.

In a face-to-face interview on 06/08/11 at 3:00pm, Charge Nurse S3 confirmed there was no documented evidence that Patient #14's wound care was performed on the above-listed dates.

Patient #18
Review of Patient #18's Medical Record revealed the patient was admitted to the hospital on 4/19/2011. Further review revealed physician's orders dated 4/19/2011 at 1900 (7:00 p.m.) for EKG. Review of Patient #18's medical record revealed the order dated 4/19/2011 was not carried out until 4/27/2011 at 6:34 a.m. (8 days after the physician ordered the test). Review of the entire medical record revealed no documented justification for the delay in obtaining the test. Review of documentation dated 4/27/2011 at 6:00 a.m. revealed in part, "Requested pt (patient) to allow EKG and he agreed." Review of Patient #18's entire medical record revealed no documented evidence of any attempt to obtain an EKG prior to the date of 4/27/2011.

This finding was confirmed by Administrator S1 in a face to face interview on 6/08/2011 at 9:30 a.m. who further indicated the hospital had no policy regarding EKGs.

Review of the hospital policy titled, "Clinical Laboratory Tests, Effective Date 5/01/2011" presented by the hospital as their current policy revealed in part, "Program Nursing Staff: Notes and signs the lab order. Prepares the lab requisition form. . . Notified lab of services needed. . . charts type of lab test completed on the patient chart or reason why test was not completed. . . Lab service is on the unit every day Monday - (through) Friday for routine labs."

Review of the hospital policy titled "Wound Care Sterile, No-Touch and Clean Techniques, Policy No. (number): NS-0202 developed 05/01/11 and submitted by Administrator S1 as one of their current wound care policies, revealed, in part, :...13. Document findings, procedure, and patient response in medical record...".

2) Nursing care plan:
Patient #3
Review of Patient #3's Medical Record revealed the patient was admitted to the hospital on 5/17/2011 with diagnoses that included Dementia With Behavior Disturbance. Review of Patient #3's Psychiatric Evaluation dated 5/18/2011 (no documented date) revealed in part, "The patient was born and raised in Vietnam. She does not speak much English. She is able to utter some words. . . She was reportedly aggressive, agitated, and bit off the finger of a (Nursing Home) staff member". Review of Patient #3's Medical History dated 5/18/2011 at 1900 (7:00 p.m.) revealed in part, "Speaks only Vietnamese". Review of Patient #3's Physician Progress notes dated 5/19/2011 (no documented time) revealed in part, "She reportedly bit another resident at (Nursing Home) and when I attempted to talk with her, she reached out, grabbed my hand, and tried to put it in her mouth several times. . ." Review of Patient #3's Progress notes dated 5/24/2011 (no documented time) revealed in part, "She has tried to scratch other patients. . ." Review of Patient #3's "Daily Treatment Plan update and team progress note" revealed in part, "Pt (patient) does not understand or can speak English. The pt. had a bowel movement and smeared feces all over her gerichair and had to be removed from group to care for her needs. . . continues to spit. unable to assess pt due to language barrier. . . patient is taking feces out of diaper and smearing it on tray. . ." Review of Patient #3's Physician Progress notes dated 5/26/2011 (no documented time) revealed in part, "She is throwing . . . feces all around her. She gets aggressive. She has tried to bite the staff too. . ." Review of Patient #3's Physician Progress notes dated 5/27/2011 (no documented time) revealed in part, "She continues to want to grab people's hand and bite them and continues to spit and hit staff though this has become less during her stay here." Review of Patient #3's Physician Progress notes dated 5/28/2011 at 2:00 p.m., revealed in part, "throwing feces. . spitting intermittently. ." Review of Patient #3's Physician Progress Notes dated 5/29/2011 (no documented time) revealed in part, "She is slightly calmer and easier to redirect, but is still putting her hand in her diaper, taking her feces out, spreading it on the table, and putting her fingers in her mouth. . ." Review of Patient #3's Physician Progress Notes dated 5/30/2011 (no documented time) revealed in part, "The patient was found on the floor this a.m. and had smeared feces all over and continues to take feces and smear them on her head and face. . ."

During a face to face interview on 6/06/2011 at 1605 (4:05 p.m.), Patient #3's son (visiting his mother at the hospital) indicated Patient #3 only understood English. Patient #3's son indicated that although his mother (#3) did not have any recall as to who he (son) was, she (#3) would still converse with him (son) in Vietnamese. Patient #3's son asked Patient #3 in Vietnamese to stick out her tongue for the surveyor to evaluate the patient's hydration status. Patient #3 followed her son's Vietnamese spoken instruction and protruded her tongue.

Review of Patient #3's Master Treatment Plan and Treatment Plan Reviews dated 5/17/2011 (Master Treatment Plan), 5/24/2011, 5/31/2011, and 6/07/2011 revealed no documented evidence of identifying the patient's (#3) language barrier as a problem or planning interventions to address the patient's language barrier. Further review revealed no documented evidence of identifying Patient #3's inappropriate behavior; of playing with and throwing feces, as a problem nor identifying interventions as to how staff were to address the behavior and protect other patients from harmful effects of the behavior.

Patient #4
Review of Patient #4's medical record revealed she was admitted on 05/12/11 with diagnoses of schizophrenia, UTI, HTN, OCD), bipolar, seizure disorder, ADHD), Tourette's Syndrome, and delusional disorder.
Review of Patient #4's "Master Treatment Plan" initiated 05/12/11 revealed some of the problems identified were high blood pressure and UTI.
Review of Patient #4's "Daily Treatment Plan Update and Team Progress Note" for 05/20/11 revealed Patient #4 had a blood pressure of 177/122 which required notification of the physician.
Review of the "Treatment Plan Review" of 05/24/11 revealed Problem #3 was HTN, and the progress was "B/P (blood pressure) ranges 134/82 - 159/87". Further review revealed no documented evidence of the significant increase in blood pressure to 177/122 on 05/20/11. Further review revealed the problem of UTI was resolved when the Bactrim regime was completed on 05/18/11. There was no documented evidence that the UA with C&S had been collected on 05/23/11 and awaiting the results before considering the UTI resolved.

In a face-to-face interview on 06/08/11 at 3:00pm, Charge Nurse S3 confirmed the treatment plan updates were not accurate.

Patient #7
Review of Patient #7's medical record revealed she was admitted on 02/17/11 at 0320 (3:20am) with diagnoses of Bipolar with Homicidal Ideations. Review of the physician "Progress Note" for 02/21/11 revealed Psychiatrist S10 documented "she is up walking throughout the unit, talking to other patients, touching other patients inappropriately...". Review of Medical Director S8's "Progress Note" of 03/01/11 revealed "at times, she is sexually inappropriate too".
Review of Patient #7's "Daily Treatment Plan Update and Team Progress Note" revealed the following documentation on the respective dates:
02/21/11 - "pt. (patient) was told to stop touching on a male pt and reminded about inappropriate touching"; and
No documented evidence of the date - pt instructed about touching the male pts".
Review of the "Master Treatment Plan" initiated on 02/21/11 and the "Treatment Plan Review" of 03/02/11 revealed no documented evidence Patient #7 was care planned for inappropriate sexual behavior.

In a face-to-face interview on 06/08/11 at 3:00pm, Charge Nurse S3 indicated Patient #7's sexual inappropriateness should have been included in her master treatment plan.

Patient #12
Review of Patient #12's Medical Record revealed the patient was admitted to the hospital on 5/22/2011 with diagnoses that included Dementia with Behavioral Disturbance.

During observations of the Hospital's Multidisciplinary Treatment Team Meeting dated 6/07/2011 at 10:15 a.m., the team discussed Patient #12. This discussion revealed that Patient #12 had been found kissing another patient, disrobing and walking down the hall, and being found naked in another patient's room.

Review of Patient #12's entire Medical Record revealed no documented evidence of any incidents involving Patient #12 kissing another patient, disrobing and walking down the hall, and being found naked in another patient's room.

During a face to face interview on 6/07/2011 at 1:00 p.m., Medical Director S8 confirmed that Patient #12 was the patient that had been found disrobing and walking down the hallway as well as being found in another patient's bathroom naked.

During a face to face interview on 6/07/2011 at 1315 (1:15 p.m.), Registered Nurse S9 indicated she had received information in report at the change of shift that Patient #12 had been found in another patient's bathroom naked and also had been found disrobing and walking down the hall. S9 indicated she could not recall who had provided her with the information in report and was not sure which incidents had occurred the night before versus other days during the patient's hospital stay. S9 confirmed there was no documented evidence in the Medical Record for Patient #12 regarding these incidents.

Review of Patient #12's medical record on 6/08/2011 (1 day after the Multidisciplinary Treatment Team Meeting held on 6/07/2011) at 1530 (3:30 p.m.) revealed no documented evidence that the problem of disrobing and entering other patient's rooms naked had been identified on the Master Treatment Plan or Treatment Plan Reviews as a problem (Master Treatment Plan 5/24/2011, Reviews 5/31/2011 and 6/07/2011). Further there was no documented evidence of planned interventions for addressing Patient #12's behavior of disrobing and entering other patient's rooms.

This finding was confirmed in a face to face interview by Administrator S1 on 6/08/2011 at 1530 (3:30 p.m.). S1 indicated the Medical Record should contain all inappropriate behaviors exhibited by patients along with a detailed description of the behavior and interventions utilized by staff to address the inappropriate behavior. S1 further indicated patients' Treatment Plans should be updated to address inappropriate behaviors with planning for staff interventions as needed.

Patient #14
Review of Patient #14's medical record revealed she was admitted on 02/15/11 with diagnoses of major depression and anxiety disorder.
Review of the "Physician Orders" revealed an order on 02/17/11 at 1445 (2:45pm) for "daily wound care, clean with wound cleaner, pat dry cover with Mepilex".
Review of Patient #14's "Admit Nursing Assessment Form" completed by RN (registered nurse) S9 on 02/15/11 at 1630 (4:30pm) revealed S9 assessed a Stage II pressure ulcer to the right lower extremity.
Review of Patient #14's "Master Treatment Plan" initiated on 02/18/11 and the "Treatment Plan Review" conducted on 02/22/11 and 03/02/11 revealed no documented evidence that Patient #14's wound assessments and wound care was incorporated in her treatment plan.

In a face-to-face interview on 06/08/11 at 3:00pm, Charge Nurse S3 confirmed Patient #14's wound was not included in her treatment. S3 indicated the wound assessments and care should have been a part of her treatment plan.

Review of the hospital policy titled, "Treatment Planning, #19, Effective Date 5/01/2011" presented by the hospital as their current policy revealed in part, "Treatment Team meetings are held at least weekly in order to monitor patient's progress, summarize, and revise the plan as needed. However, the treatment plan may be altered at any time a patient's status indicates. . . Each time a problem or deficit is identified during the course of the assessment/evaluation process (or throughout the treatment process) it should have an indication of resolution. . . It should be determined whether or not each problem can and should be addressed at this level of care. . . For each problem identified, it should be determined if the problem will be addressed or deferred. . . The problem definition is a description of the problem being addressed that conveys to the reader the observable behaviors the patient demonstrates. . . The intervention strategies are the actions and approaches to be taken by the staff in assisting the patient in resolving the identified problem and reaching the discharge goal. The frequency of the intervention is the number of times per day, per week, etc., that the interventions will occur. Intervention strategies must be very specific. . ."

Review of the hospital policy titled "Wound Assessment and Documentation", policy no. NS-026 developed 05/01/11 and submitted by Administrator S1 as their current policy for wound assessment, revealed, in part, "...18. Update Master Treatment Plan to reflect change...".


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Based on record review and interview the hospital failed to ensure there was an adequate medical record system in place to ensure prompt completion of medical records as evidenced by the failure to have a hospital employee with adequate education, skills, qualifications and experience to ensure timely completion of medical records. Findings:

In an interview on 06/08/11 at 9:00 a.m. with S13, Director of Medical Records, he stated his primary role in medical records is to scan the records into the computer so the record can be sent electronically to S12, contracted RHIT (registered health information management technician), for coding. S13 confirmed his personnel file contained a Job Description for Director of Medical Records dated March 2011. S13 further confirmed that he did not have the 6 months of experience in medical records as required by the Job Description. S13 stated he had been present on one occasion when S12, contracted RHIT, was in the hospital and that no training took place.

In a telephone interview on 06/08/11 at 2:20 p.m. with S12, contracted RHIT, she stated that when a patient is discharged the medical record is scanned and electronically sent to her for coding and review. S12, contracted RHIT, further stated that she retains her deficiency report for the entire month and sends it to the hospital by the 10th of the following month. S12, contracted RHIT, confirmed that by holding her deficiency report until the 10th of the month following medical record review that some medical records are already 30 days delinquent when the report is submitted. S12, contracted RHIT, stated she visits the hospital every 3 months.

Review of a document submitted by S12, contracted RHIT, to S1Administrator revealed: "April 2011, I reviewed the charts for April 2011 for Completeness, Correct Chart Order, Complete Documentation and Signatures in all areas of the chart. The following charts were reviewed:". Review of the document revealed 30 medical records were reviewed. A sample of 5 of the medical records were reviewed and the discrepancies noted by S12, contracted RHIT, were as follows:

"(patient # 19) Dr. (S8MD) need to sign physician admit orders and preliminary treatment plan, Dr. (S11MD) needs to sign H&P (History and Physical), Dr. (S10MD) needs to sign Psyc Eval."

(patient # 20) Dr. (S8MD) needs to sign telephone order for 02/27, (S15APRN) and Dr. (S11MD) needs to sign verbal order for 02/23, (S15APRN) and Dr. (S11MD) needs to sign order for 02/16, Dr. (S8MD) need to sign sliding scale order, Dr. (S10MD) needs to sign PN (progress note) for 02/28, 02/23, 02/21, and discharge summary, Dr. (S11MD) needs to sign H&P.

(patient # 21) Discharge order needs to be signed, Dr.(S11MD) needs to sign (S15APRN)'s order for 04/03, 04/06, and 04/07, Dr. (S14MD) needs to sign (S16APRN)'s order for 04/07, Dr. (S8MD) needs to sign telephone admit orders and preliminary treatment plan, Dr. (S11MD) needs to sign H&P, Dr. (S10MD) needs to sign PN for 03/31, 04/06, and 04/04.

(patient # 22) Dr. (S10MD) needs to sign psyc eval.

(patient # 23) Dr.(S11MD) needs to sign H&P, Dr. (S10MD) needs to sign PN for 04/04."

Review of the medical records for patients #19, #20, #21, #22, and patient #23 revealed none of the above listed discrepancies were corrected as of the date of review on 06/08/11 at 10:45 a.m.

In an interview/record review on 06/08/11 at 10:45 a.m. with S1Administrator she reviewed the medical records of patients #19, #20, #21, #22, and patient #23 and confirmed that none of the medical record discrepancies identified by S12, contracted RHIT, were corrected.

In an interview on 06/08/11 at 8:45 a.m. with S1Administrator she stated that the hospital could not provide a current list of medical records that were delinquent because there was no system in place for tracking delinquent medical records. S1Administrator confirmed that there was no enforcement of the Medical Staff By-Laws regarding suspension of admission privileges due the inability of the hospital to accurately track delinquent medical records. S1Administrator stated that this also prevents the Medical Records department from reporting to QAPI regarding delinquent Medical Records. S1Administrator confirmed that no suspension letters due to delinquent Medical Records had been sent to any physician since she became Administrator in 01/11.

Review of the Job Description for the contracted RHIT revealed: "Job Description. Job Title: Health Information Management Consultant. Reports to: Hospital Administrator. Requirements: Consultant must be an accredited Health information Practitioner with a valid RHIT, a Registered Health Information Management Technician (RHIT) credentialed with the American Health Information Management Association (AHIMA). Responsibilities: 1. Visits the Hospital Health Information Management Department for a minimum of 8 hours per month. 2. Advises in the development of appropriate sections of the Health Information Management Policy and Procedure Manual and other department manuals in order to realize the needs of the Facility. 3. Advise in the development of Hospital records which meet the needs of the Facility. 4. Assist in the clarification and description of functions in the Health Information Management Department...6. Assist in the development of managerial and supervisory skill of the Health Information Management Department Staff...9. Assist in the developing and conducting In-service Training Programs for personnel in the Health Information Management Department. 10. Assist and advise Administrative and Medical Staff, including Nursing Staff, in maintaining Medical Records' systems which comply with Licensing and Accreditation Standards of Patient Care...14. Check, on a periodic basis, an inactive Medical Records which need o.k. for filing. 15. Consultation with Director of Health Information Management Director (or appropriate personnel) on the status of Medical Records and obtain a detailed report of specific records requiring attention. 16. Submit a monthly, written report to Administration on the status of the Health Information Management Department - to include time in, time out and total hours in the facility. The Job Description/Job Responsibilities was signed by S12, RHIT on March 1, 2011.

Review of a contract with S12, RHIT, revealed in part: "AGREEMENT. CONSULTANT FOR HOSPITAL HEALTH INFORMATION SYSTEM AND QUALITY IMPROVEMENT. In order to comply with Federal, State and Local requirements and to maintain accurate and adequate medical records, this facility, SEASIDE BEHAVIORAL CENTER hereafter called Hospital, does hereby enter into an agreement with (S12, RHIT), CCS (certified coding specialist), an [sic] Registered Health Information Technician licensed by the American Health Information Association (AHIMA), hereafter called Consultant. A. RELATIONSHIP. Hospital and consultant agree that their relationships that of independent contractors and not of employer and employee or principal and agent. B. SCOPE OF WORK. Consultant agrees to provide in accordance with attached job description the following services to the Hospital: 1. Assistance to Hospital in developing and maintaining good medical record management. 2. Advice in development and conduction of In-Service Training Programs for record keeping personnel. 3. Advice in development of medical records policies and procedures manual. 4. Assistance and advice in maintaining a medical record system which will comply with licensing and accreditation standards and requirements...C. PERIOD OF AGREEMENT AND TERMINATION. Performance of services agreed upon will commence on March 1,2010..."

Review of a document titled "DIRECTOR OF RESIDENT HEALTH INFORMATION/RECORD SYSTEM & COORDINATOR FOR QRM (QUALITY AND RISK MANAGEMENT) ACTIVITY OF THE HEALTH AND INFORMATION DEPARTMENT" revealed in part: "ROLE: To provide guidance and coordination for establishment of and maintenance of a system which identifies Quality and or Risk Management within the scope of the Health Information and Record System. SCOPE OF RESPONSIBILITIES: (1) On-site record review and analysis of the facility's Health Information (Medical Record) System. (2) Informing Administrator and Director of Nursing Services of an identified existing and/or potential problem area in: Medical Record Documentation...(3) Suggest and assist with any remedial action (s) to be implemented.(4) Evaluate results of suggested/implemented action which promotes compliance with the facilities record documentation policies and all Medicare/Medicaid regulatory requires [sic] for Medical Records. (5) Assist with in-service training and development of staff members assigned primary responsibility for: Medical Records..."

Review of the Medical Staff By-Laws, last approved 03/31/11 by the Governing Body, under section 7. Inpatient Medical Records read in part: "7.16. The patient's medical record shall be complete at the time of discharge, including progress notes, final diagnosis and discharge summary. When this is not possible because final laboratory or other essential reports have not been received at time of discharge, the patient's chart will be available in a stated place in the Medical Records Department. 7.17. If the record remains incomplete thirty (30) days after discharge, the CEO or designee shall notify the responsible staff member that his/her name will be placed on the "No Admit" list fifteen (15) days from the date of notice. 7.18. If the record still remains incomplete fifteen (15) days after the physician is placed on the "No Admit" list, suspension of Medical Staff privileges may occur. If the physician is responsible for the care of patients in the Hospital at the time of suspension, the physician shall continue to be responsible for the patient until discharge; however, no new patients may be admitted."

Based on record review and interview the hospital failed to ensure medical records were completed within 30 days of discharge. This was evidenced by 5 of 5 records sampled from 30 medical records reviewed in April 2011 by the contracted RHIT (registered health information management technician) having no corrective action taken on the discrepancies noted by the contracted RHIT (#19, #20, #21, #22, #23). Findings:

In a telephone interview on 06/08/11 at 2:20 p.m. with S12, contracted RHIT, she stated that when a patient is discharged the medical record is scanned and electronically sent to her for coding and review. S12, contracted RHIT, further stated that she retains her deficiency report for the entire month and sends it to the hospital by the 10th of the following month. S12, contracted RHIT, confirmed that by holding her deficiency report until the 10th of the month following medical record review that some medical records are already 30 days delinquent.

Review of a document submitted by S12, contracted RHIT, to S1Administrator revealed: "April 2011, I reviewed the charts for April 2011 for Completeness, Correct Chart Order, Complete Documentation and Signatures in all areas of the chart. The following charts were reviewed: ". Review of the document revealed 30 medical records were reviewed. A sample of 5 of the medical records were reviewed and the discrepancies noted by S12, contracted RHIT, were as follows:

"(patient # 19) Dr. (S8MD) need to sign physician admit orders and preliminary treatment plan, Dr. (S11MD) needs to sign H&P (History and Physical), Dr. (S10MD) needs to sign Psyc Eval."

(patient # 20) Dr. (S8MD) needs to sign telephone order for 02/27, (S15APRN) and Dr. (S11MD) needs to sign verbal order for 02/23, (S15APRN) and Dr. (S11MD) needs to sign order for 02/16, Dr. (S8MD) need to sign sliding scale order, Dr. (S10MD) needs to sign PN (progress note) for 02/28, 02/23, 02/21, and discharge summary, Dr. (S11MD) needs to sign H&P.

(patient # 21) Discharge order needs to be signed, Dr.(S11MD) needs to sign (S15APRN)'s order for 04/03, 04/06, and 04/07, Dr. (S14) needs to sign (S16APRN)'s order for 04/07, Dr. (S8MD) needs to sign telephone admit orders and preliminary treatment plan, Dr. (S11MD) needs to sign H&P, Dr. (S10MD) needs to sign PN for 03/31, 04/06, and 04/04.

(patient # 22) Dr. (S10MD) needs to sign psyc eval.

(patient # 23) Dr.(S11MD) needs to sign H&P, Dr. (S10MD) needs to sign PN for 04/04."

Review of the medical records for patients #19, #20, #21, #22, and patient #23 revealed none of the above listed discrepancies were corrected as of the date of review on 06/08/11 at 10:45 a.m.

In an interview/record review on 06/08/11 at 10:45 a.m. with S1Administrator she reviewed the medical records of patients #19, #20, #21, #22, and patient #23 and confirmed that none of the medical record discrepancies identified by S12, contracted RHIT, were corrected.

In an interview interview on 06/08/11 at 8:45 a.m. with S1Administrator she stated that the contracted RHIT (S12) had last been to the hospital in April 2010. S1Administrator confirmed this was not in compliance with the Job Description of the contracted Health Information Management Consultant Responsibilities, specifically item #1 which requires the contracted RHIT to spend a minimum of 8 hours per month at the hospital.

In an interview on 06/08/11 at 8:45 a.m. with S1Administrator she stated that the hospital could not provide a current list of medical records that were delinquent because there was no system in place for tracking delinquent medical records. S1Administrator confirmed that there was no enforcement of the Medical Staff By-Laws regarding suspension of admission privileges due the inability of the hospital to accurately track delinquent medical records. S1Administrator stated that this also prevents the Medical Records department from reporting to QAPI regarding delinquent Medical Records. S1Administrator confirmed that no suspension letters due to delinquent Medical Records had been sent to any physician since she became Administrator in 01/11.

Review of the Job Description for the contracted RHIT revealed: "Job Description. Job Title: Health Information Management Consultant. Reports to: Hospital Administrator. Requirements: Consultant must be an accredited Health information Practitioner with a valid RHIT, a Registered Health Information Management Technician (RHIT) credentialed with the American Health Information Management Association (AHIMA). Responsibilities: 1. Visits the Hospital Health Information Management Department for a minimum of 8 hours per month. 2. Advises in the development of appropriate sections of the Health Information Management Policy and Procedure Manual and other department manuals in order to realize the needs of the Facility. 3. Advise in the development of Hospital records which meet the needs of the Facility. 4. Assist in the clarification and description of functions in the Health Information Management Department...6. Assist in the development of managerial and supervisory skill of the Health Information Management Department Staff...9. Assist in the developing and conducting In-service Training Programs for personnel in the Health Information Management Department. 10. Assist and advise Administrative and Medical Staff, including Nursing Staff, in maintaining Medical Records' systems which comply with Licensing and Accreditation Standards of Patient Care...14. Check, on a periodic basis, an inactive Medical Records which need o.k. for filing. 15. Consultation with Director of Health Information Management Director (or appropriate personnel) on the status of Medical Records and obtain a detailed report of specific records requiring attention. 16. Submit a monthly, written report to Administration on the status of the Health Information Management Department - to include time in, time out and total hours in the facility." The Job Description/Job Responsibilities was signed by S12, contracted RHIT, on March 1, 2011.

Review of a contract with S12, contracted RHIT, revealed in part: "AGREEMENT. CONSULTANT FOR HOSPITAL HEALTH INFORMATION SYSTEM AND QUALITY IMPROVEMENT. In order to comply with Federal, State and Local requirements and to maintain accurate and adequate medical records, this facility, SEASIDE BEHAVIORAL CENTER hereafter called Hospital, does hereby enter into an agreement with (S12, RHIT, CCS, an [sic] Registered Health Information Technician licensed by the American Health Information Association (AHIMA), hereafter called Consultant. A. RELATIONSHIP. Hospital and consultant agree that their relationships that of independent contractors and not of employer and employee or principal and agent. B. SCOPE OF WORK. Consultant agrees to provide in accordance with attached job description the following services to the Hospital: 1. Assistance to Hospital in developing and maintaining good medical record management. 2. Advice in development and conduction of In-Service Training Programs for record keeping personnel. 3. Advice in development of medical records policies and procedures manual. 4. Assistance and advice in maintaining a medical record system which will comply with licensing and accreditation standards and requirements...C. PERIOD OF AGREEMENT AND TERMINATION. Performance of services agreed upon will commence on March 1,2010..."

Review of a document titled "DIRECTOR OF RESIDENT HEALTH INFORMATION/RECORD SYSTEM & COORDINATOR FOR QRM (QUALITY AND RISK MANAGEMENT) ACTIVITY OF THE HEALTH AND INFORMATION DEPARTMENT" revealed in part: "ROLE: To provide guidance and coordination for establishment of and maintenance of a system which identifies Quality and or Risk Management within the scope of the Health Information and Record System. SCOPE OF RESPONSIBILITIES: (1) On-site record review and analysis of the facility's Health Information (Medical Record) System. (2) Informing Administrator and Director of Nursing Services of an identified existing and/or potential problem area in: Medical Record Documentation...(3) Suggest and assist with any remedial action (s) to be implemented.(4) Evaluate results of suggested/implemented action which promotes compliance with the facilities record documentation policies and all Medicare/Medicaid regulatory requires [sic] for Medical Records. (5) Assist with in-service training and development of staff members assigned primary responsibility for: Medical Records..."

Review of the Medical Staff By-Laws, last approved 03/31/11 by the Governing Body, under section 7. Inpatient Medical Records read in part: "7.16. The patient's medical record shall be complete at the time of discharge, including progress notes, final diagnosis and discharge summary. When this is not possible because final laboratory or other essential reports have not been received at time of discharge, the patient's chart will be available in a stated place in the Medical Records Department. 7.17. If the record remains incomplete thirty (30) days after discharge, the CEO or designee shall notify the responsible staff member that his/her name will be placed on the "No Admit" list fifteen (15) days from the date of notice. 7.18. If the record still remains incomplete fifteen (15) days after the physician is placed on the "No Admit" list, suspension of Medical Staff privileges may occur. If the physician is responsible for the care of patients in the Hospital at the time of suspension, the physician shall continue to be responsible for the patient until discharge; however, no new patients may be admitted."

Based on record review and interview, the hospital failed to ensure the UR (utilization review) committee performed a review of an inpatient who received hospital services that exceeded 30 days as required by hospital policy for 1 of 1 inpatient reviewed for utilization of services (#R4). Findings:

Review of the hospital's "Utilization Review Tool" revealed Random Patient R4 was admitted on 03/02/11 with a diagnosis of Major depression. Further review revealed R4 was discharged on 05/10/11. Further review revealed the UR review was conducted on 05/20/11 by the former RN (registered nurse) responsible for UR (no longer employed at the hospital), 47 days after the original 30 days from admission. Review of the findings documented revealed, in part, "Increased LOS (length of stay) due to patient and family requiring interpreter as their primary language is Spanish, difficulty reaching family members to arrange for discharge placement and patient's family resides in Guatemala unable to obtain VISA to assist with discharge placement...". There was no documented evidence that a physician not directly involved in the care of Random Patient R4 had reviewed the medical record to determine the medical necessity for continued stay.

In a face-to-face interview on 06/09/11 at 8:00am, Administrator S1 indicated the medical record of Random Patient R4 had not been reviewed by the contracted psychiatrist who reviewed services provided by Medical Director S8 and Psychiatrist S10. S1 confirmed R4's medical record was not reviewed for medical necessity for continued stay as required by the hospital policy. S1 indicated she could not provide documentation of the 10 charts reviewed monthly as required by their policy.

Review of the hospital policy titled "Utilization Review Plan", Policy No. (number) PP-78 developed 12/09/05 and submitted by Administrator S1 as their current UR Plan, revealed, in part, "...E. The facility will also review any stay that exceeds 30 days, has generated abnormally high costs, requires excessive services beyond the norm, or is attended by a physician whose patterns of care are found to be questionable. ... 4. Admissions, services, or stays that are determined to be unnecessary will be referred to entire UR Committee. ...Consequently all patients are reviewed not less than weekly for the appropriateness of their stay and care. ... Any outliers or extended stays will be referred for automatic UR Committee review...". Further review of the plan revealed no documented evidence that the hospital had identified what would be considered an outlier or the criteria for such.

Review of the hospital policy titled "Utilization Review", Policy No. UR-02-001 and submitted as one of the UR policies, revealed, in part, "...The case manager (s) will monitor at least 20% (per cent) of the admissions monthly against the criteria. A utilization review tool will be use to document the record review findings. ... Criteria ...4. Documentation of medical necessity for continued stay. 5. Length of day increased due to delay in discharge planning...".

Based on record review and interview the hospital failed to ensure a Comprehensive Treatment plan was developed, updated, and/or kept current for 5 of 23 sampled patients (Patient #3, #4, #7, #12, #14). Findings:

Patient #3
Review of Patient #3's Medical Record revealed the patient was admitted to the hospital on 5/17/2011 with diagnoses that included Dementia With Behavior Disturbance. Review of Patient #3's Psychiatric Evaluation dated 5/18/2011 (no documented date) revealed in part, "The patient was born and raised in Vietnam. She does not speak much English. She is able to utter some words. . . She was reportedly aggressive, agitated, and bit off the finger of a (Nursing Home) staff member". Review of Patient #3's Medical History dated 5/18/2011 at 1900 (7:00 p.m.) revealed in part, "Speaks only Vietnamese". Review of Patient #3's Physician Progress notes dated 5/19/2011 (no documented time) revealed in part, "She reportedly bit another resident at (Nursing Home) and when I attempted to talk with her, she reached out, grabbed my hand, and tried to put it in her mouth several times. . ." Review of Patient #3's Progress notes dated 5/24/2011 (no documented time) revealed in part, "She has tried to scratch other patients. . ." Review of Patient #3's "Daily Treatment Plan update and team progress note" revealed in part, "Pt (patient) does not understand or can speak English. The pt. had a bowel movement and smeared feces all over her gerichair and had to be removed from group to care for her needs. . . continues to spit. unable to assess pt due to language barrier. . . patient is taking feces out of diaper and smearing it on tray. . ." Review of Patient #3's Physician Progress notes dated 5/26/2011 (no documented time) revealed in part, "She is throwing . . . feces all around her. She gets aggressive. She has tried to bite the staff too. . ." Review of Patient #3's Physician Progress notes dated 5/27/2011 (no documented time) revealed in part, "She continues to want to grab people's hand and bite them and continues to spit and hit staff though this has become less during her stay here." Review of Patient #3's Physician Progress notes dated 5/28/2011 at 2:00 p.m., revealed in part, "throwing feces. . spitting intermittently. ." Review of Patient #3's Physician Progress Notes dated 5/29/2011 (no documented time) revealed in part, "She is slightly calmer and easier to redirect, but is still putting her hand in her diaper, taking her feces out, spreading it on the table, and putting her fingers in her mouth. . ." Review of Patient #3's Physician Progress Notes dated 5/30/2011 (no documented time) revealed in part, "The patient was found on the floor this a.m. and had smeared feces all over and continues to take feces and smear them on her head and face. . ."

During a face to face interview on 6/06/2011 at 1605 (4:05 p.m.), Patient #3's son (visiting his mother at the hospital) indicated Patient #3 only understood English. Patient #3's son indicated that although his mother (#3) did not have any recall as to who he (son) was, she (#3) would still converse with him (son) in Vietnamese. Patient #3's son asked Patient #3 in Vietnamese to stick out her tongue for the surveyor to evaluate the patient's hydration status. Patient #3 followed her son's Vietnamese spoken instruction and protruded her tongue.

Review of Patient #3's Master Treatment Plan and Treatment Plan Reviews dated 5/17/2011 (Master Treatment Plan), 5/24/2011, 5/31/2011, and 6/07/2011 revealed no documented evidence of identifying the patient's (#3) language barrier as a problem or planning interventions to address the patient's language barrier. Further review revealed no documented evidence of identifying Patient #3's inappropriate behavior; of playing with and throwing feces, as a problem nor identifying interventions as to how staff were to address the behavior and protect other patients from harmful effects of the behavior.

Patient #4
Review of Patient #4's medical record revealed she was admitted on 05/12/11 with diagnoses of schizophrenia, UTI, HTN, OCD), bipolar, seizure disorder, ADHD), Tourette's Syndrome, and delusional disorder.
Review of Patient #4's "Master Treatment Plan" initiated 05/12/11 revealed some of the problems identified were high blood pressure and UTI.
Review of Patient #4's "Daily Treatment Plan Update and Team Progress Note" for 05/20/11 revealed Patient #4 had a blood pressure of 177/122 which required notification of the physician.
Review of the "Treatment Plan Review" of 05/24/11 revealed Problem #3 was HTN, and the progress was "B/P (blood pressure) ranges 134/82 - 159/87". Further review revealed no documented evidence of the significant increase in blood pressure to 177/122 on 05/20/11. Further review revealed the problem of UTI was resolved when the Bactrim regime was completed on 05/18/11. There was no documented evidence that the UA with C&S had been collected on 05/23/11 and awaiting the results before considering the UTI resolved.

In a face-to-face interview on 06/08/11 at 3:00pm, Charge Nurse S3 confirmed the treatment plan updates were not accurate.

Patient #7
Review of Patient #7's medical record revealed she was admitted on 02/17/11 at 0320 (3:20am) with diagnoses of Bipolar with Homicidal Ideations. Review of the physician "Progress Note" for 02/21/11 revealed Psychiatrist S10 documented "she is up walking throughout the unit, talking to other patients, touching other patients inappropriately...". Review of Medical Director S8's "Progress Note" of 03/01/11 revealed "at times, she is sexually inappropriate too".
Review of Patient #7's "Daily Treatment Plan Update and Team Progress Note" revealed the following documentation on the respective dates:
02/21/11 - "pt. (patient) was told to stop touching on a male pt and reminded about inappropriate touching"; and
No documented evidence of the date - pt instructed about touching the male pts".
Review of the "Master Treatment Plan" initiated on 02/21/11 and the "Treatment Plan Review" of 03/02/11 revealed no documented evidence Patient #7 was care planned for inappropriate sexual behavior.

In a face-to-face interview on 06/08/11 at 3:00pm, Charge Nurse S3 indicated Patient #7's sexual inappropriateness should have been included in her master treatment plan.

Patient #12
Review of Patient #12's Medical Record revealed the patient was admitted to the hospital on 5/22/2011 with diagnoses that included Dementia with Behavioral Disturbance.

During observations of the Hospital's Multidisciplinary Treatment Team Meeting dated 6/07/2011 at 10:15 a.m., the team discussed Patient #12. This discussion revealed that Patient #12 had been found kissing another patient, disrobing and walking down the hall, and being found naked in another patient's room.

Review of Patient #12's entire Medical Record revealed no documented evidence of any incidents involving Patient #12 kissing another patient, disrobing and walking down the hall, and being found naked in another patient's room.

During a face to face interview on 6/07/2011 at 1:00 p.m., Medical Director S8 confirmed that Patient #12 was the patient that had been found disrobing and walking down the hallway as well as being found in another patient's bathroom naked.

During a face to face interview on 6/07/2011 at 1315 (1:15 p.m.), Registered Nurse S9 indicated she had received information in report at the change of shift that Patient #12 had been found in another patient's bathroom naked and also had been found disrobing and walking down the hall. S9 indicated she could not recall who had provided her with the information in report and was not sure which incidents had occurred the night before versus other days during the patient's hospital stay. S9 confirmed there was no documented evidence in the Medical Record for Patient #12 regarding these incidents.

Review of Patient #12's medical record on 6/08/2011 (1 day after the Multidisciplinary Treatment Team Meeting held on 6/07/2011) at 1530 (3:30 p.m.) revealed no documented evidence that the problem of disrobing and entering other patient's rooms naked had been identified on the Master Treatment Plan or Treatment Plan Reviews as a problem (Master Treatment Plan 5/24/2011, Reviews 5/31/2011 and 6/07/2011). Further there was no documented evidence of planned interventions for addressing Patient #12's behavior of disrobing and entering other patient's rooms.

This finding was confirmed in a face to face interview by Administrator S1 on 6/08/2011 at 1530 (3:30 p.m.). S1 indicated the Medical Record should contain all inappropriate behaviors exhibited by patients along with a detailed description of the behavior and interventions utilized by staff to address the inappropriate behavior. S1 further indicated patients' Treatment Plans should be updated to address inappropriate behaviors with planning for staff interventions as needed.

Patient #14
Review of Patient #14's medical record revealed she was admitted on 02/15/11 with diagnoses of major depression and anxiety disorder.
Review of the "Physician Orders" revealed an order on 02/17/11 at 1445 (2:45pm) for "daily wound care, clean with wound cleaner, pat dry cover with Mepilex".
Review of Patient #14's "Admit Nursing Assessment Form" completed by RN (registered nurse) S9 on 02/15/11 at 1630 (4:30pm) revealed S9 assessed a Stage II pressure ulcer to the right lower extremity.
Review of Patient #14's "Master Treatment Plan" initiated on 02/18/11 and the "Treatment Plan Review" conducted on 02/22/11 and 03/02/11 revealed no documented evidence that Patient #14's wound assessments and wound care was incorporated in her treatment plan.

In a face-to-face interview on 06/08/11 at 3:00pm, Charge Nurse S3 confirmed Patient #14's wound was not included in her treatment. S3 indicated the wound assessments and care should have been a part of her treatment plan.

Review of the hospital policy titled, "Treatment Planning, #19, Effective Date 5/01/2011" presented by the hospital as their current policy revealed in part, "Treatment Team meetings are held at least weekly in order to monitor patient's progress, summarize, and revise the plan as needed. However, the treatment plan may be altered at any time a patient's status indicates. . . Each time a problem or deficit is identified during the course of the assessment/evaluation process (or throughout the treatment process) it should have an indication of resolution. . . It should be determined whether or not each problem can and should be addressed at this level of care. . . For each problem identified, it should be determined if the problem will be addressed or deferred. . . The problem definition is a description of the problem being addressed that conveys to the reader the observable behaviors the patient demonstrates. . . The intervention strategies are the actions and approaches to be taken by the staff in assisting the patient in resolving the identified problem and reaching the discharge goal. The frequency of the intervention is the number of times per day, per week, etc., that the interventions will occur. Intervention strategies must be very specific. . ."







25065

Based on record review and interview the hospital failed to ensure progress notes reflected inappropriate behaviors exhibited by a patient to include failure to recommend revisions for the patient's treatment plan for 1 of 23 sampled patients (#12). Findings:

Patient #12: Review of Patient #12's Medical Record revealed the patient was admitted to the hospital on 5/22/2011 with diagnoses that included Dementia with Behavioral Disturbance.

During observations of the Hospital's Multidisciplinary Treatment Team Meeting dated 6/07/2011 at 10:15 a.m., the team discussed Patient #12. This discussion revealed that Patient #12 had been found kissing another patient, disrobing and walking down the hall, and being found naked in another patient's room.

Review of Patient #12's entire Medical Record revealed no documented evidence of any incidents involving Patient #12 kissing another patient, disrobing and walking down the hall, or being found naked in another patient's room. Further review revealed no documented evidence of notes recommending a need to revise Patient #12's Treatment Plan based on inappropriate behaviors of kissing another patient, disrobing and walking down the hall, or being found naked in another patient's room.

During a face to face interview on 6/07/2011 at 1:00 p.m., Medical Director S8 confirmed that Patient #12 was the patient that had been found disrobing and walking down the hallway as well as being found in another patient's bathroom naked.

During a face to face interview on 6/07/2011 at 1315 (1:15 p.m.), Registered Nurse S9 indicated she (S9) had received information in report at the change of shift that Patient #12 had been found in another patient's bathroom naked and also had been found disrobing and walking down the hall. S9 indicated she (S9) could not recall who had provided her with the information in report and was not sure which incidents had occurred the night before versus other days during the patient's hospital stay. S9 confirmed there was no documented evidence in the Medical Record for Patient #12 regarding these incidents.

Review of Patient #12's medical record on 6/08/2011 (1 day after the Multidisciplinary Treatment Team Meeting held on 6/07/2011) at 1530 (3:30 p.m.) revealed no documented evidence that the problem of disrobing and entering other patient's rooms naked had been identified on the Master Treatment Plan or Treatment Plan Reviews as a problem (Master Treatment Plan 5/24/2011, Reviews 5/31/2011 and 6/07/2011). Further there was no documented evidence of planned interventions for addressing Patient #12's behavior of disrobing and entering other patient's rooms.

This finding was confirmed in a face to face interview by Administrator S1 on 6/08/2011 at 1530 (3:30 p.m.). S1 indicated the Medical Record should contain all inappropriate behaviors exhibited by patients along with a detailed description of the behavior and interventions utilized by staff to address the inappropriate behavior. S1 further indicated patients' Treatment Plans should be updated to address inappropriate behaviors with planning for staff interventions as needed.

Review of the hospital policy titled, "Treatment Planning, #19, Effective Date 5/01/2011" presented by the hospital as their current policy revealed in part, "Treatment Team meetings are held at least weekly in order to monitor patient's progress, summarize, and revise the plan as needed. However, the treatment plan may be altered at any time a patient's status indicates. . . Each time a problem or deficit is identified during the course of the assessment/evaluation process (or throughout the treatment process) it should have an indication of resolution. . . It should be determined whether or not each problem can and should be addressed at this level of care. . . For each problem identified, it should be determined if the problem will be addressed or deferred. . . The problem definition is a description of the problem being addressed that conveys to the reader the observable behaviors the patient demonstrates. . . The intervention strategies are the actions and approaches to be taken by the staff in assisting the patient in resolving the identified problem and reaching the discharge goal. The frequency of the intervention is the number of times per day, per week, etc., that the interventions will occur. Intervention strategies must be very specific. . ."