HospitalInspections.org

Based on a review of documentation and interviews with staff, the physician assistant, nurse practitioner or clinical nurse specialist failed to perform services in accordance with the facility's policies. Failure to do so can increase the risk of harm to patients.

Findings were:

Facility "Medical Staff Bylaws" and "Rules and Regulations" state, in part:
(Bylaws)
"ARTICLE III
MEDICAL STAFF MEMBERSHIP
...
3.1
c. By applying for and/or accepting appointment to the Medical Staff, or by applying for, accepting and/or exercising clinical privileges within the Hospital, each Applicant and each Member agrees to abide by the terms and provisions of these Bylaws, the Rules and Regulations of the Medical Staff, any departmental rules, policies and procedures and any other policies and procedures of the Hospital, all as adopted and amended and in effect from time to time.

7.5 Automatic Suspension
a. Medical Records. A temporary suspension in the form of withdrawal of a Practitioner's admitting privileges, effective until medical records are completed shall be imposed automatically after warning of delinquency for failure to complete medical records within fifteen (15) days of a patient's discharge.

11.3 Professional Activities Committee
c. (1) Medical Records
The Committee shall be responsible for assuring that all medical records meet the highest standards of patient care usefulnes and of historical validity. The Medical Staff representatives shall be specifically responsible for assuring that the medical records reflect realistic documentation of medical events. The Committee shall conduct a monthly review of currently maintained medical records to assure that they properly describe the condition and progress of the patient, the therapy provided, the results thereof, and the identification of responsibility for all actions taken, and that they are sufficiently complete at all times so as to meet the criterion of medical comprehension of the case in the event of transfer of physician responsibility for patient care. The Committee shall also conduct a review of records of discharged patients to determine the prompness, pertinence, adequace and completeness thereof.

(Rules and Regulations)
Pg 5
D. MEDICAL RECORDS
1. Required Content of a Medical Record
...
b. Conclusions of impressions drawn from the medical history and physical examination (appropriate to the age of the patient); including chief complaint or reasons for admission & present illness or diagnostic impression.
l. Discharge Summary, final progress note or transfer summary and Conclusions at Termination of Hospitalization (sic). Inclusive of final diagnosis and relevant diagnoses established during the course of care, discharge instructions to the patient and/or family.
Pg 8
Entries at Conclusion of Hospitalization
e. A discharge summary should be completed for all patients no later than 30 days following discharge.
Pg 9
10. Procedure for Delinquent Medical Records
Medical records of discharged patients are to be completed within 30 days following discharge..."

A review of the credentialing file for staff #11 revealed a letter, dated 4-7-15, which read "Dear [staff #11], Attached to this letter is a copy of Schleicher County Medical Center Bylaws, Rules and Regulations. As stated in the Bylaws you are to verify that you have received and read the information. We also need you to agree to abide by the Bylaws, Rules and Regulations by signing and returning this letter to me. Feel free to contact me if you have any questions. Sincerely, [staff #19]." The letter was signed and dated by staff #11 on 5-1-15.

A document provided by the Medical Records Department, signed by staff #19 titled "Delinquent Records as of August 12, 2015" revealed that staff #11 had cared for 12 Emergency Department patients with dates of service between 10-14-14 and 2-19-15, for whom all records were delinquent with regard to the review of systems and the physical exam. The same document revealed that staff #11 had cared for 2 inpatients (on 6-8-15 and 6-29-15) for whom both records were delinquent with regard to a discharge summary. When asked if staff #11 had had admitting privileges suspended within 2014 or 2015 due to delinquent records, staff #19 stated that staff #11 had not had admitting privileges suspended during 2014 or 2015.

A review of the credentialing file for staff #11 revealed documentation of Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS) effective 5-14-15. Staff #23 was asked to provide documentation of these certifications prior to 5-14-15 but was unable to do so.

A review of the credentialing file for staff #13 revealed documentation of ACLS from 3-29-13 to 3-29-15 but no documentation of recertification until 6-14-15 (resulting in an 11-week gap between expiration of ACLS and renewal of the same). Documentation of PALS certification became effective 3-23-15. Staff #23 was asked to provide documentation of PALS certification prior to 3-23-15 but was unable to do so.

Review of the facility on-call schedule from January 2014 through July 2015 revealed that both staff #11 and staff #13 provided Emergency Department coverage during each of the 19 months reviewed.

A review of Medical Staff Meeting Minutes for 2014 and 2015 revealed the following items addressed:

*6-16-14 - "[staff #1] mentioned that we need to get all of the providers recertified for ACLS, ATLS and PALS if their certifications have expired. She asked if [staff #19] could go through the provider's files and find out who all needs to be recertified."

*7-7-14 - "[staff #1] reported that all three providers (staff #11, #12, #13) need to take PALS...also [staff #11] needs ACLS..."

*8-18-14 - "Our three providers (staff #11, #12, #13) need PALS certificates...Also [staff #11] needs ACLS..."

*10-20-14 - "[staff #11] needs ACLS and PALS."

*11-10-14 - "[staff #11] still needs ACLS and PALS."

*12-15-14 - "[staff #11] still needs ACLS and PALS."

*1-12-15 - "[staff #23] reported that [staff #13] has started working on hers and [staff #11] has not started yet."

*2-16-15 - "[staff #11] needs PALS and ACLS."

*3-23-15 - "[staff #11] still needs ACLS and PALS."

*4-13-15 - "[staff #11] still needs ACLS and PALS."

*5-18-15 - "[staff #19] reported that [staff #11] completed her PALS and ACLS."

During a telephone interview with staff #12 on the evening of 8-12-15, staff #12 was informed that staff #11 had provided physician or mid-level coverage in the emergency department for a minimum of 16 months without documentation of current ACLS certification or PALS certification. Staff #12 was asked to clarify which certifications/trainings the facility required to perform physician or mid-level coverage in the emergency department, and to clarify the requirements specified in the Medical Staff Bylaws, Rules & Regulations.. Staff #12 stated "I just can't imagine anyone providing care without having ACLS." When told that the need for staff #11 to obtain current ACLS as well as PALS certification had been discussed in Medical Staff meetings held on dates ranging from 7-7-14 through 4-13-15, staff #12 stated "It's my position that it's best practice" and stated that the facility had a "parent/leasing" company. Staff #12 stated that the parent/leasing company had said (regarding ACLS and PALS certification "These people need to have it." When asked why staff #11 had never been removed from the emergency department schedule, staff #12 stated "I don't have an absolute, good answer for that." When asked why it took so long for staff #11 to obtain the necessary certifications, staff #12 stated that, each month, the Medical Staff Members would assume that staff #11 was working on it. Staff #12 stated "I guess it did go too far."

The above was confirmed in an exit conference with the Chief Nursing Officer, Chief Executive Officer, Medical Records Director and Human Resources Manager on the evening of 8-12-15 in the facility conference room.

Based on a review of documentation and interviews with staff, the facility failed to maintain clinical records that were complete and accurately documented. Failure to provide accurate documentation or to complete the record can disrupt continuity of care and result in an increased possibility of patient harm.

Findings were:

Facility "Medical Staff Bylaws" and "Rules and Regulations" state, in part:
(Bylaws)
"ARTICLE III
MEDICAL STAFF MEMBERSHIP
...
3.1
c. By applying for and/or accepting appointment to the Medical Staff, or by applying for, accepting and/or exercising clinical privileges within the Hospital, each Applicant and each Member agrees to abide by the terms and provisions of these Bylaws, the Rules and Regulations of the Medical Staff, any departmental rules, policies and procedures and any other policies and procedures of the Hospital, all as adopted and amended and in effect from time to time.

7.5 Automatic Suspension
a. Medical Records. A temporary suspension in the form of withdrawal of a Practitioner's admitting privileges, effective until medical records are completed shall be imposed automatically after warning of delinquency for failure to complete medical records within fifteen (15) days of a patient's discharge.

11.3 Professional Activities Committee
c. (1) Medical Records
The Committee shall be responsible for assuring that all medical records meet the highest standards of patient care usefulnes and of historical validity. The Medical Staff representatives shall be specifically responsible for assuring that the medical records reflect realistic documentation of medical events. The Committee shall conduct a monthly review of currently maintained medical records to assure that they properly describe the condition and progress of the patient, the therapy provided, the results thereof, and the identification of responsibility for all actions taken, and that they are sufficiently complete at all times so as to meet the criterion of medical comprehension of the case in the event of transfer of physician responsibility for patient care. The Committee shall also conduct a review of records of discharged patients to determine the prompness, pertinence, adequace and completeness thereof.

(Rules and Regulations)
Pg 5
D. MEDICAL RECORDS
1. Required Content of a Medical Record
...
b. Conclusions of impressions drawn from the medical history and physical examination (appropriate to the age of the patient); including chief complaint or reasons for admission & present illness or diagnostic impression.
l. Discharge Summary, final progress note or transfer summary and Conclusions at Termination of Hospitalization (sic). Inclusive of final diagnosis and relevant diagnoses established during the course of care, discharge instructions to the patient and/or family.
Pg 8
Entries at Conclusion of Hospitalization
e. A discharge summary should be completed for all patients no later than 30 days following discharge.
Pg 9
10. Procedure for Delinquent Medical Records
Medical records of discharged patients are to be completed within 30 days following discharge..."


A review of the credentialing file for staff #11 revealed a letter, dated 4-7-15, which read "Dear [staff #11], Attached to this letter is a copy of Schleicher County Medical Center Bylaws, Rules and Regulations. As stated in the Bylaws you are to verify that you have received and read the information. We also need you to agree to abide by the Bylaws, Rules and Regulations by signing and returning this letter to me. Feel free to contact me if you have any questions. Sincerely, [staff #19]." The letter was signed and dated by staff #11 on 5-1-15.

A document provided by the Medical Records Department, signed by staff #19 titled "Delinquent Records as of August 12, 2015" revealed that staff #11 had cared for 12 Emergency Department patients with dates of service between 10-14-14 and 2-19-15, for whom all records were delinquent with regard to the review of systems and the physical exam. The same document revealed that staff #11 had cared for 2 inpatients (on 6-8-15 and 6-29-15) for whom both records were delinquent with regard to a discharge summary. When asked if staff #11 had had admitting privileges suspended within 2014 or 2015 due to delinquent records, staff #19 stated that staff #11 had not had admitting privileges suspended during 2014 or 2015.

The above was confirmed in an exit conference with the Chief Nursing Officer, Chief Executive Officer, Medical Records Director and Human Resources Manager on the evening of 8-12-15 in the facility conference room.

Based on a review of documentation and interviews with staff, the facility failed to maintain clinical records that contained a brief summary of the episode, disposition and instructions to the patient. Failure to complete this summary can interfere with continuity of care and increase the risk of harm for returning patients.

Facility "Medical Staff Bylaws" and "Rules and Regulations" state, in part:
(Bylaws)
"ARTICLE III
MEDICAL STAFF MEMBERSHIP
...
3.1
c. By applying for and/or accepting appoitment to the Medical Staff, or by applying for, accepting and/or exercising clinical privileges within the Hospital, each Applicant and each Member agrees to abide by the terms and provisions of these Bylaws, the Rules and Regulations of the Medical Staff, any departmental rules, policies and procedures and any other policies and procedures of the Hospital, all as adopted and amended and in effect from time to time.

7.5 Automatic Suspension
a. Medical Records. A temporary suspension in the form of withdrawal of a Practitioner's admitting privileges, effective until medical records are completed shall be imposed automatically after warning of delinquency for failure to complete medical records within fifteen (15) days of a patient's discharge.

11.3 Professional Activities Committee
c. (1) Medical Records
The Committee shall be responsible for assuring that all medical records meet the highest standards of patient care usefulnes and of historical validity. The Medical Staff representatives shall be specifically responsible for assuring that the medical records reflect realistic documentation of medical events. The Committee shall conduct a monthly review of currently maintained medical records to assure that they properly describe the condition and progress of the patient, the therapy provided, the results thereof, and the identification of responsibility for all actions taken, and that they are sufficiently complete at all times so as to meet the criterion of medical comprehension of the case in the event of transfer of physician responsibility for patient care. The Committee shall also conduct a review of records of discharged patients to determine the prompness, pertinence, adequace and completeness thereof.

(Rules and Regulations)
Pg 5
D. MEDICAL RECORDS
1. Required Content of a Medical Record
...
b. Conclusions of impressions drawn from the medical history and physical examination (appropriate to the age of the patient); including chief complaint or reasons for admission & present illness or diagnostic impression.
l. Discharge Summary, final progress note or transfer summary and Conclusions at Termination of Hospitalization (sic). Inclusive of final diagnosis and relevant diagnoses established during the course of care, discharge instructions to the patient and/or family.
Pg 8
Entries at Conclusion of Hospitalization
e. A discharge summary should be completed for all patients no later than 30 days following discharge.
Pg 9
10. Procedure for Delinquent Medical Records
Medical records of discharged patients are to be completed within 30 days following discharge..."

A review of the credentialing file for staff #11 revealed a letter, dated 4-7-15, which read "Dear [staff #11], Attached to this letter is a copy of Schleicher County Medical Center Bylaws, Rules and Regulations. As stated in the Bylaws you are to verify that you have received and read the information. We also need you to agree to abide by the Bylaws, Rules and Regulations by signing and returning this letter to me. Feel free to contact me if you have any questions. Sincerely, [staff #19]." The letter was signed and dated by staff #11 on 5-1-15.

A document provided by the Medical Records Department, signed by staff #19 titled "Delinquent Records as of August 12, 2015" revealed that staff #11 had cared for 2 inpatients (on 6-8-15 and 6-29-15) for whom both records were delinquent with regard to a discharge summary. When asked if staff #11 had had admitting privileges suspended within 2014 or 2015 due to delinquent records, staff #19 stated that staff #11 had not had admitting privileges suspended during 2014 or 2015.

The above was confirmed in an exit conference with the Chief Nursing Officer, Chief Executive Officer, Medical Records Director and Human Resources Manager on the evening of 8-12-15 in the facility conference room.