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Based on record review, policy review and interview, the hospital's Governing Body failed to ensure compliance of the Medical Staff By-Laws as evidenced by the licensed practitioner's failing to comply with Medical staff Rules and Regulations for completion of patient's medical records within 30 days following discharge.

Findings:

Review of the Medical Staff By-Laws, dated March 2022 revealed Medical Records 28. The attending physician shall be responsible for the preparation of a complete medical record for each of his patients, outpatients, or emergency patients. All medical records should be completed within thirty (30) days from the date of discharge. Those medical records not completed within thirty (30) days of discharge shall be considered delinquent. Notification of delinquent records will be sent to the physician and non-physician and non-completion within fifteen (15) days from the notification will necessitate notification of the Chief of Staff for intervention. The Chief of Staff actions shall be in accordance with the Article VII, Section 3A of the Medical Staff By-Laws.
Section 3A. Medical Records: "Medical records should be completed within 30 days from the date of the patient's discharge. Those medical records not completed within thirty (30) days of discharge shall be considered delinquent. A letter will be sent to the physicians by the Director of Medicals notifying him/her of the delinquency status of their medical records. If a member of the Medical Staff fails to complete their medical records within fifteen (15) days of receiving notice, the Chief of Staff will be notified and will send a second letter to the delinquent member. Medical records not completed after receipt of the letter from the Chief of Staff will be cause for the delinquency to be brought to the Medical Executive Committee for evaluation and action."

Interview on 02/15/23 at 12:50 p.m. with S9RHIA confirmed that the hospital did have delinquent records but she was not sure of how many and/or how far out of date they were.

Interview on 02/15/23 at 1:30 p.m. with S1CEO confirmed he was aware there was a problem with medical records not being completed within 30 days of discharge.

Based on record review and interview, the governing body failed to ensure the medical staff was accountable according to the Medical Staff By-Laws as evidenced by failing to complete medical records within 30 days following discharge.

Findings:

Review of the Medical Staff By-Laws, dated March 2022 revealed Medical Records 28. The attending physician shall be responsible for the preparation of a complete medical record for each of his patients, outpatients, or emergency patients. All medical records should be completed within thirty (30) days from the date of discharge. Those medical records not completed within thirty (30) days of discharge shall be considered delinquent. Notification of delinquent records will be sent to the physician and non-physician and non-completion within fifteen (15) days from the notification will necessitate notification of the Chief of Staff for intervention. The Chief of Staff actions shall be in accordance with the Article VII, Section 3A of the Medical Staff By-Laws.
Section 3A. Medical Records: "Medical records should be completed within 30 days from the date of the patient's discharge. Those medical records not completed within thirty (30) days of discharge shall be considered delinquent. A letter will be sent to the physicians by the Director of Medicals notifying him/her of the delinquency status of their medical records. If a member of the Medical Staff fails to complete their medical records within fifteen (15) days of receiving notice, the Chief of Staff will be notified and will send a second letter to the delinquent member. Medical records not completed after receipt of the letter from the Chief of Staff will be cause for the delinquency to be brought to the Medical Executive Committee for evaluation and action."

Interview on 02/15/23 at 1:30 p.m. with S1CEO confirmed he was aware there was a problem with medical records not being completed within 30 days of discharge. He further stated that there had been no letters sent to any physicians that he was aware of and no actions imposed on any physicians related to completion of medical records.

Based on observations, record reviews, and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by:

1.) having nurse call lights on the hand rails of patient beds that were non-functional for 14 of 19 beds located in the hospital. This failure had the potential to delay or prevent assistance from the nursing staff if the patient pressed the call light on the bed hand rail rather than the hand held call light; and

2.) failing to document 1:1 observation of a PEC patient in the emergency department for 1 (#25) of 1 (#25) patient records reviewed for observations from a total sample of 30.

Findings:

1.) Having nurse call lights on the hand rails of patient beds that were non-functional for 14 of 19 beds located in the hospital. This failure had the potential to delay or prevent assistance from the nursing staff if the patient pressed the call light on the bed hand rail rather than the hand held call light.

In an observation on 02/13/2023 at 10:30 a.m. - 11:30 a.m. of room (f) revealed a patient bed with the nurse call light on the hand rails that was non-functional.

In an interview on 02/13/2023 at 11:45 a.m. S3M/SDirector verified there were 14 of 19 Hill-Rom patient beds in the hospital with the nurse call light on the hand rails that were non-functional.

2.) Failing to document 1:1 observation of a PEC patient in the emergency department for 1 (#25) of 1 (#25) patient records reviewed for observations from a total sample of 30.

Review of the hospital's policy titled "Emergency Department: Suicide Precautions in the Emergency Department/Psych Holds" revealed in part, if patient is deemed to be suicidal, homicidal or gravely disabled, care will be provided and house supervisor notified of need of 1:1 observation.

Review of Patient #25's medical record revealed an arrival date of 02/10/2023 at 10:35 a.m. with a chief complaint of psych problem. Further review revealed a PEC (Physician's Emergency Certificate) was completed on 02/10/2023 by S13MD. Review of the PEC revealed Patient #25 was suicidal, dangerous to self, and unwilling. Further review of Patient #25's medical record revealed no documentation that Patient #25 was placed on a 1:1 observation during her stay in the emergency department.

In an interview on 02/15/2023 on 12:12 p.m. S2CNO verified Patient #25 should have been on 1:1 observation while in the emergency department. S2CNO verified there was no documentation in Patient #25's medical record of being on 1:1 observation while in the emergency department.

Based on record review and interview, the hospital failed to ensure the Emergency Department (ED) direct care staff received the education, training and demonstrated knowledge in the use of non-physical intervention skills for 2 (S10RN, S11RN) of 3 (S9RN, S10RN, S11RN) Emergency Department employee personnel files reviewed for documentation of training.

Findings:

Review of S10RN's personnel file revealed no documentation of training for non-physical intervention skills.

Review of S11RN's personnel file revealed no documentation of training for non-physical intervention skills.

In an interview on 02/15/2023 at 11:50 a.m. S2CNO verified S10RN and S11RN had no documentation of training for non-physical intervention skills in their personnel files.

Based upon record review and interviews, the hospital failed to ensure accurate data was collected and reported through the Quality Assurance/Performance Improvement (QA/PI) Program, as evidenced by the failure to identify and report accurate information for the delinquency of medical records to implement corrective actions, track performance, and to ensure improvements were sustained.

Findings:

Review of the document titled "Monthly Compliance Report", given to surveyor by S7Quality revealed Overall Delinquency Rate for the 4th quarter at 19% (YTD-15%), H&P compliance (YTD- 97%), OP report (YTD- 99%), Discharge (YTD- 95%).

Review of the document given to surveyor by medical records dated 02/15/23 titled Deficient Chart Aging Report revealed total deficient charts for (31-100) #38, (101-200) #33, (Over 200) #75 for a total of 146 delinquent records.

Interview on 02/15/23 at 12:50 p.m. with S9RHIA confirmed that the hospital did have delinquent records but she was not sure of how many and/or how far out of date they were. She further stated that she is contracted with the hospital and comes on-site monthly. Surveyor asked if the information was reported to QA and she stated "yes", but the information was not an accurate representation of how many due to the system the hospital used for medical records did not accurately compile the data.

Interview on 02/15/23 at 2:00 p.m. with S7Quality stated that she was new and was unable to provide requested documents for breakdown of delinquent medical records. The only documented information reported was compliance rate for H&P rate of 99%, OR report 99%, Discharge rate 95%. She further confirmed the information was inaccurate.

Based on record review, interview, and policy review, the hospital failed to ensure the nursing staff developed and kept a current individualized and comprehensive nursing care plans. This deficient practice was evidenced by failure of the nursing staff to include all identified medical diagnoses and failure to include nursing interventions for 3 (#2, #5, #9) of 9 (#1-#9) current sampled patients from a total sample of 30.

Findings:

Review of the hospital policy titled Plan of Care, revised dated 12/11 revealed in part: The Registered Nurse will initiate plan of care based on assessment and evaluation of patient needs and this is consistent with therapies of other disciplines. The Plan of Care must be initiated within 12 hours of admission by the RN on the Medsurg Unit and within 4 hours of admission in the Intensive Care Unit.

Patient #2

Review of the medical record for patient #2 revealed an admit date of 02/09/23 with a diagnosis of COPD, CHF, HTN, DM, A-Fib, and obesity. Further review of the Physicians orders dated 02/10/23 revealed orders for accuchecks AC&HS, and insulin per S/S.

Review of the Care Plan for patient #2 revealed no care plan for diabetic goals and/or interventions.

Interview on 02/14/23 at 9:15 a.m. with S6IC confirmed there was no care plan addressing diabetic goals or interventions.

Patient #5
Review of the medical record for patient #5 revealed an admit date of 02/11/23 with diagnosis of CHF, A-Fib, Cellulitis, Anemia, DM, and GERD.

Review of the Care Plan for patient #5 revealed no care plan for goals and interventions for the patient's cardiac diagnosis.

Interview on 02/14/23 at 9:45 a.m. with S6IC confirmed there was no care plan addressing cardiac goals or interventions.

Patient #9

Review of the medical record for patient #9 revealed an admit date of 02/11/23 with a diagnosis of DM, GERD, CVA, and HTN. Further review of the Physicians orders dated 02/13/23 revealed orders for accuchecks AC&HS, and insulin per S/S.

Review of the Care Plan for patient #9 revealed no care plan for diabetic goals and/or interventions.

Interview on 02/14/23 at 10:00 a.m. with S6IC confirmed there was no care plan addressing diabetic goals or interventions.

Based on record review and interview, the nursing staff failed to administer PRN medications in accordance with accepted standards of practice. This deficiency is evidenced by failure of the nursing staff to monitor the therapeutic effect of PRN medications in 3 (Pt. #12, Pt. #13, Pt. #14) of 4 (Pt. #11, Pt. #12, Pt. #13, Pt. #14) patients reviewed for therapeutic assessment after medication administration.
Findings:

Patient #12
Review of the electronic medical record for Patient #12, navigated by S6IC, revealed an order placed 11/15/22 at 2:58 p.m. for hydromorphone hcl 2mg/mL IV push every 4 hours as needed for pain 6-10. Review of the electronic medication administration record revealed on 11/21/2022 at 2:09 a.m. hydromorphone hcl 2mg was administered via IV push for a pain level of 7. Further review revealed no documentation of the therapeutic effectiveness of the medication.

In an interview on 02/14/2023 at 11:48 a.m., S6IC indicated there was no therapeutic effectiveness documented.


Patient #13
Review of the electronic medical record for Patient #13, navigated by S6IC, revealed an order placed 12/07/2022 for acetaminophen 325mg. 2 tablets every 6 hours as needed for mild pain of 1-3.. Review of the electronic medication administration record revealed on 12/13/2022 at 2:29 a.m. acetaminophen 325mg 2 tablets was administered for a pain level of 10. Further review revealed no documentation of the therapeutic effectiveness of the medication. Review of the electronic medication administration record revealed on 12/13/2022 at 3:14 p.m., acetaminophen 325mg 2 tablets was administered for a pain level of 7. Further review revealed no documentation of the therapeutic effectiveness of the medication.

In an interview on 02/14/2023 at 11:57 a.m. S6IC indicated there was no therapeutic effectiveness documented.


Patient #14
Review of the electronic medical record for Patient #14, navigated by S6IC, revealed an order placed 12/20/2022 at 7:18 p.m. for hydromorphone hcl 2mg/mL IV push every 3 hours as needed for pain. Review of the electronic medication administration record revealed on 12/21/2022 at 2:17 p.m. hydromorphone hcl 2mg was administered via IV push for a pain level of 8. Further review revealed no documentation of the therapeutic effectiveness of the medication.

In an interview on 02/14/2023 at 12:05 p.m. S6IC indicated there was no therapeutic effectiveness documented.

Based on record review and interview, the hospital failed to have a system in place to ensure medical records were completed within 30 days of discharge.

Findings:

Review of the hospital's policy titled "Health Information Management: Delinquent and Incomplete Records" revealed in part, medical records should be completed within 30 days from the date of the patient's discharge. Those medical records not completed with thirty (30) days of discharge shall be considered delinquent. A letter will be sent to physicians by the Director of Medical Records notifying him/her of the delinquency status of their medical records. If a member of the Medical Staff fails to complete their medical records within fifteen (15) days of receiving this notice, the Chief of Staff will be notified and will send a second letter to the delinquent member. Medical records not completed after receipt of letter from the Chief of Staff will be cause for the delinquency to be brought to the Medical Executive Committee for evaluation and action.

In an interview on 02/15/2023 at 1:26 p.m. S12HIM verified the hospital had delinquent medical records greater than 30 days. S12HIM provided the survey with a list of delinquent medical records greater than 30 days. There were 38 delinquent medical records greater than 30 days. There were 33 delinquent medical records greater than 100 days. There were 75 delinquent medical records greater than 200 days.

Interview on 02/15/23 at 1:30 p.m. with S1CEO confirmed he was aware there was a problem with medical records not being completed within 30 days of discharge. He further stated that there had been no letters sent to any physicians that he was aware of and no actions imposed on any physicians related to completion of medical records.

Based on observation and interview, the hospital failed to ensure that outdated, mislabeled or otherwise unusable drugs and biologicals were not available for patient use as evidenced by having expired medications.

Findings:

Review of the hospital's policy titled "Pharmacy: Medication Storage" revealed in part:
5. Outdated and unusable drugs are safely sequestered from patients and not stored in drug preparation areas.
a. The pharmacy will ensure that outdated and unusable drugs are not available for dispensing or administration.
b. Pharmacy will ensure that any outdates or unusable medications will be returned to pharmacy and segregated until removed from the hospital.

In an observation on 02/13/2023 at 10:30 a.m. - 11:30 a.m. of the ICU unit revealed the following expired IV fluids:
5 of 6: 0.45% Sodium Chloride Injection USP 1000mL, 3 with an expiration date of July 2022 and 2 with an expiration date of December 2022
2 of 4: 5% Dextrose Injection USP 1000mL with an expiration date of March 2022

In an interview during the observation, S1CEO verified the above stated medications were expired.

Based on record review, observations, and interviews the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by failing to ensure expired supplies were not available for patient use.

Findings:

Review of the hospital's policy titled "Stock Rotation expired items" revealed in part, all stock items will be stored using the rotation system and the oldest products will be issued first. This prevents stock deterioration and/or expiration of sterile products. The Materials Management Director or designee will inspect the Storeroom on a monthly basis to ensure that stock is being rotated according to schedule. Each department is responsible for the same rotation of items, and insuring there are no expired supplies in their own department.

In an observation on 02/13/2023 at 10:30 a.m. - 11:30 a.m. of the medical surgical unit revealed 1 of 10 packs of sterile gloves with an expiration date of 10/2021.

In an interview on 02/13/2023 at 10:40 a.m. S3M/SDirector verified the sterile gloves were expired.

In an observation on 02/13/2023 at 10:30 a.m. - 11:30 a.m. of the ICU unit revealed 1 of 3 chest drain packages with an expiration date of 01/09/2023.

In an interview on 02/13/2023 at 11:10 a.m. S1CEO verified the chest drain package was expired.

In an observation on 02/13/2023 at 2:08 p.m. - 2:55 p.m. of the emergency department revealed 46 BD Lever Lock Cannulas were expired. 2 with the expiration date of 03/31/2022, 42 with the expiration date of 09/30/2022, and 2 with the expiration date of 12/31/2021.

In an interview during the observation, S1CEO verified the above stated supplies were expired.

In an observation on 02/14/2023 at 8:55 a.m. - 10:40 a.m. of the surgery department revealed the following expired supplies:
2 Lo-Pro Oral/Nasal Tracheal Tube Cuffed 5.5mm with expiration dates of 06/28/2021 and 06/05/2022;
1 Lo-Pro Oral/Nasal Tracheal Tube Cuffed 6.0mm with the expiration date of 01/29/2023;
1 Lo-Pro Oral/Nasal Tracheal Tube Cuffed 7.0mm with the expiration date of 11/29/2021;
1 LMA 5 with the expiration date of 02/28/2021;
1 LMA 4 with the expiration date of 05/28/2021; and
1 LMA 3 with the expiration date of 04/28/2021.

In an interview during the observation, S1CEO verified the above stated supplies were expired.

Based on record review, observations and interviews, the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented. This deficient practice was evidenced by the hospital failing to maintain a sanitary environment.

Findings:

Review of the hospital's policy titled "Environmental Services: Infection Control" revealed in part, it is the policy of the Environmental Services Department to follow all standards of Infection Control and to present, as much as possible, an aesthetic, clean, and contamination-free environment in the hospital.

In an observation on 02/13/2023 at 10:30 a.m. - 11:30 a.m. of the ICU unit revealed a chair with a tear in the cover that could not be disinfected.

In an interview during the observation, S1CEO verified the chair was torn.

In an observation of 02/13/2023 at 2:08 p.m. - 2:55 p.m. of the emergency department revealed the following:
In room 'a' the frame of the stretcher bed, the frame of the bedside table, and the base of the IV pole had numerous areas of rust that was unable to be disinfected.
In room 'b' the frame of the stretcher bed and the frame of the bedside table had numerous areas of rust that was unable to be disinfected.

In an interview during the observation, S1CEO verified the above stated findings.

In an observation on 02/14/2023 at 8:55 a.m. - 10:40 a.m. of the surgery department revealed the following:
In room 'c' the frame of the stretcher bed and the base of the IV pole had numerous areas of rust that was unable to be disinfected.
In room 'd' the frame of the stretcher bed and the base of the IV pole had numerous areas of rust that was unable to be disinfected.
In room 'e' there was a chair with a tear in the seat cover that could not be disinfected.

In an interview during the observation, S1CEO verified there were multiple rust spots on the base of the IV poles and on the frames of the stretcher beds.

In an interview during the observation, S8DOS verified the tear in the seat cover on the chair in the OR room.

Based on record reviews and interview, the hospital failed to ensure a properly executed informed consent for a surgical procedure that must be in the patient's medical record before surgery, except in emergencies, as evidenced by failing to ensure the informed consent for anesthesia included documentation of the specified type of anesthesia to be administered during surgery for 2 (#29 and #30) of 2 (#29 and #30) patient records reviewed for informed consent from a total sample of 30.

Findings:

Review of the hospital's policy titled "Organizational: Informed Consent" revealed in part, there will be appropriate informed consent for all appropriate procedures and treatments. Information on the consent will include:
1) Identity of the patient
2) The date
3) The procedure or treatment to be rendered
4) The name(s) of the individual(s) who will perform the procedure or treatment
5) Indication that alternate means of therapy and the possibility of risks or complications have been explained to the patient
6) Authorization for disposition of any tissue or body parts as indicated
7) Signature of the patient or other individual empowered to give consent
8) Said signature witnessed
9) Practitioner who obtains consent
10) No abbreviations will be used
11) All blanks will be filled with required information

Informed consents are required for all surgical procedures and invasive procedures (e.g arterial catheterization, pulmonary artery catheterization, central venous catheterization, endoscopies), anesthesia, and blood administration.

Patient #29
Review of Patient #29's medical record revealed an admission date of 02/08/2023 with a pre-operative diagnosis of chronic cholecystitis. Review of the consent for anesthesia services revealed there was no documentation of the specific type of anesthesia to be administered during the surgical procedure.

In an interview on 02/14/2023 at 3:49 p.m. S8DOS verified the type of anesthesia should be documented on the anesthesia consent. S8DOS verified type of anesthesia was not identified on the anesthesia consent.

Patient #30
Review of Patient #30's medical record revealed an admission date of 02/14/2023 with a pre-operative diagnosis of abdominal pain and gastritis. Review of the consent for anesthesia services revealed there was no documentation of the specific type of anesthesia to be administered during the surgical procedure.

In an interview on 02/15/2023 at 10:13 a.m. S8DOS verified the type of anesthesia should be documented on the anesthesia consent. S8DOS verified type of anesthesia was not identified on the anesthesia consent.