The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

JACKSON MEMORIAL HOSPITAL 1611 NW 12TH AVE MIAMI, FL 33136 Feb. 21, 2014
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the governing body failed to ensure that the medical staff is accountable to the governing body for the quality of care provided to the patients in 10 out 25 Sampled Patients (SP). (SP#1, SP#2, SP#8, SP#10, SP#11, SP#14, SP#15, SP#19, SP#20 and SP#24)

Findings include:

(1.) Clinical record review conducted from 02-19-14 to 02-21-14 of Sample Patient (SP) #1 revealed that the patient was admitted to the facility on on [DATE] with a chief complaint of nausea, vomiting, diarrhea and dehydration.
Review of the physician orders revealed that there were multiple orders written and signed by the House Physicians (MS (Medical Staff) #1 and MS#3) without proper authentication of the supervising Attending Physician (AP). The History and Physical (H & P) dated 04-18-12 done by MS#3 was not authenticated by the supervising AP. The progress note dated 04-19-12 and the discharge summary dated 05-15-12 done by MS#1 were not authenticated by the supervising Attending Physician.

Interview conducted on 02-20-14 at 1:20 p.m. with the Associate Director of Quality/ Compliance & Outcomes Management (MIT) confirmed above findings that the H&P, progress notes, discharge summary and physician orders of SP#1 were done by the HP without proper authentication of the AP.

Interview with Medical Staff (MS) #1 conducted on 2-19-14 at 3:25 p.m. revealed that he is a House Physician (HP) for transplant unit for 3 years. He stated that he received the education about the scope, privileges of HP practice in the facility. He stated that " he assists in clinical development of patient collection of data, physical examinations, collection of history and physical, transcribing orders of Attending Physician (AP), Resident, fell ows by telling him what to write and they sign the orders, assists clinical procedures or surgical procedures. That orders cannot be administered until signed by the medical staff. That everything he does is under the direct supervision of the AP or fell ow. Basically the AP/fell ow are present to sign. "

(MS) #1 further stated that " In 2012, the House Physician had different privileges under the system and able to write and sign and carried out orders but there's 6-8 hours need to be co-signed but not sure of the time frame for co-sign." MS#1 further stated "that in the personnel file, he got this privilege to write orders."

Review of the Job Description of MS#1 (signed on 5-17-11) conducted on 2-21-14 confirmed above findings that HP has the job specifics that include but not limited to: " Assess patient on admission for other medical reason either pre or post transplantation. Includes a physical examination, history and review of systems. Begins plan of care. "

Interview with the Associate Director of Quality/ Compliance & Outcomes Management (MIT) conducted on 2-21-14 at 11:05 a.m. confirmed above findings that HP can write orders. She stated that " plan of care includes writing orders which is now re-defined. "


(2.) Review of SP#2 medical records shows that the patient was admitted to the facility on [DATE] for abdominal pain. The patient was assigned an Attending Physician (AP). The patient ' s medical records shows that the History and Physical (H&P) on the 01/14/14 and the progress note on 01/15/14 completed by the same House Physician were both authenticated by the Attending Physician on 01/17/14. There were no other Attending Physician/Designee Notes from 01/14/14 thru 01/16/14. Progress note completed by a House Physician on 01/18/14 was authenticated by the AP on 01/20/14. There were no other Attending Physician/Designee Notes on 01/18/14.
Consultation Note dictated by a resident on 01/19/14 was authenticated by the Consulting Physician on 01/23/14. There were no other Attending Physician/Designee Notes on 01/19/14. Consultation on 01/24/14 documented by a resident was authenticated by the AP on 02/14/14. There were no other Attending Physician/Designee Notes on 01/24/14. Progress note completed by House Physicians on 01/29/14 and on 01/30/14 were both authenticated by the AP on 02/01/14. There were no other Attending Physician/Designee Notes on 01/29/14 and 01/30/14.
(3.) Review of SP#8 medical records shows that the patient was admitted to the facility on [DATE]. The patient ' s medical records show that Progress Notes completed by House Physicians, Residents and fell ows from 02/05/14 to 02/06/14 and from 02/09/14 to 02/12/14 were not authenticated and there is no documentation of Attending Physician/Designee activities in the patient ' s medical records on those dates. Consultation Note on 02/13/14 and Progress Note on 02/14/14 completed by a resident were both authenticated by the AP on 02/17/14. There were no other Attending Physician/Designee on 02/13/14 and 02/14/14.
(4.) Review of SP#10 medical records shows that the patient was admitted to the facility on [DATE]. Physician Progress Notes on 01/28/14 was not authenticated by the Attending and there were no other Attending Physician/Designee notes on 01/29/14.
(5.) Review of SP#11 medical records shows that the patient was admitted to the facility on [DATE]. Progress Notes written on 01/23/14 and 01/24/14 by a resident have not been authenticated and there were no other Attending Physician/Designee Notes on 01/23/14 and 0/24/14. Progress Notes on 02/06/14 written by a fell ow has not been authenticated. Progress Notes on 02/06/14 and 02/08/14, written by a resident, were both authenticated on 02/14/14. There were no other Attending Physician/Designee Notes from 02/06/14 thru 02/08/14.
(6.) Review of SP#14 medical records shows that the patient was admitted to the facility on [DATE]. Progress Notes written by residents on 02/10/14 thru 02/16/14 were not authenticated and there were no other Attending Physician/Designee notes from 02/10/14 thru 02/16/14.
(7.) Review of SP#15 medical records shows that the patient was admitted to the facility on [DATE]. Progress Note on 02/06/14 was authenticated on 02/14/14. Progress Notes on 02/08/14 and 02/09/14 was authenticated on 02/13/14. There were no other Attending Physician/Designee notes from 02/06/14 thru 02/09/14.
(8.) Review of SP#19 medical records shows that the patient was admitted to the facility on [DATE]. Progress notes by House Physicians and residents from 02/13/14 and 02/15/14 have not authenticated and there were no other Attending Physician/Designee notes for that date range.
(9.) Review of SP#20 medical records shows that the patient was admitted to the facility on [DATE]. Progress Notes on 02/15 /14 written by a House Physician have not been authenticated and there are no other Attending Physician/Designee notes for those days.
(10.) Review of SP#24 medical records shows that the patient was admitted to the facility on [DATE]. Progress note on 02/15/14 has not been authenticated and there were no other Attending Physician/Designee notes, as yet, on 02/19/14 or on 02/20/14.
Interview conducted on 02-20-14 at 10:00 a.m. with the Associate Director of Quality-Accreditation /Licensure confirmed above findings that SP#1, SP#2, SP#8, SP#10, SP#11, SP#14, SP#15, SP#19, SP#20 and SP#24 documentation of progress notes or History and Physical by the house staff (Residents/Interns and fell ows) were not appropriately authenticated by the supervising Attending Physician.

Review of the facility ' s medical staff rules and regulations [8.1. (d) Documentation] conducted on 02-20-14 shows that " resident/fell ow physicians are authorized to document appropriate patient care documentation and orders including provision of care commensurate with the physician ' s level of advancement and competence, under the general supervision of appropriate privileged medical teaching staff ... all entries in the medical record related to histories and physicals, operative reports, consultations, discharge summaries, and outpatient notes must be authenticated by the licensed independent practitioner directly supervising the resident. "

Review of the facility ' s medical staff rules and regulations [2.4 Progress Notes] conducted on 02-20-14 shows that " Progress Notes shall be written at least daily by the attending practitioner on critically ill patients, those where there is difficulty in diagnosis and management of the problem, and those with a significant deterioration in their clinical status. For those patients awaiting extended care facility placement, progress notes shall be as frequent as medically indicated. Progress notes shall be written at least daily by the attending practitioner or designee for all patients. The medical staff member must document his or her involvement with the patient in the medial record, reflecting his or her level of participation in the care of the patient and supervisions of learners also caring for the patient. The medical staff member may attest to progress notes written by learners, such as residents and fell ows, or designees, such as physician assistants and advance practice nurses. "
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review the facility failed to provide an ongoing Quality Assurance and Performance Improvement (QAPI) program include the program scope that measure, analyze, and track quality indicators, and use the data to monitor the effectiveness and safety of services and quality of care regarding the supervision of fell ows, Residents and House Physicians involved in the transplant service program in 5 sampled patients(SP) (#10, #11, #14, #15, and #19).

Findings include:
1. An interview with the Vice President (VP) of Quality and Patient Safety was conducted on 02/19/2014 at 5:30 p.m. The VP explained the Jackson Health System Medical Rules and regulations underwent a Comprehensive Amendment. The Amendment was presented at the Medical Executive Committee (MEC) on 06/12/2012 and the Board of Trustees (BOT) on 06/28/2012. The Amendment was passed and dated 07/19/2012 as the effective date.
During the interview with the VP the facility identified a concerns for supervision regarding the fell ows, Residents, and House Physicians in 2012.
The VP explained the facility was conducting a retroactive (4/2012) review of the house physician and /or ARP (Advanced Registered Nurse Practitioner) and the Attending Physician (AP) supervision or fell ow compliance. The compliance examination included medical record entries, progress note, and plans of care.
2. According to afternoon interviews conducted on 2/19/2014 at 1: 30 p.m. and 2/20/2014 at 3: 30 p.m. with the Associate Director of Quality Compliance and Outcomes and the Associate Director of Quality - Accreditation and Licensure, the QAPI interventions includes a Retro evaluation and baseline in 4/2012. The baseline was conducted in the last quarter of 2013.
The plan to evaluate and report of current compliance regarding supervision would be initiated for the first quarter of 2014 and be presented at the April 2014, QAPI, MEC and BOT meetings.

The Associate Director of Quality Compliance and Outcomes and the Associate Director of Quality - Accreditation and Licensure during the interview verified staff education including physicians and clinical staff regarding the Rules and Regulations of Medical Staff was actively conducted in 2013.
The Directors explained the baselines were scheduled to be presented to the QAPI and MEC meetings during the week of the survey.
The baselines results were shared on 2/19/2014. The thresholds were identified and the results ranges from 60% compliance with the number of charts where the documentation by the house physicians and/or ARNP(advanced registered nurse practitioner) were signed by the supervising physician within 24 hours of being written, to 0% (zero) compliance with the number of charts where the house physician /ARNP records the statement " progress note in consultation with attending or fell ow " in the progress notes. The Director commented this was to be expected as this retro-examination was prior to Quality Improvement education and prior to the Amendments to the Rules and Regulations of Medical Staff in 7/2012.

Review of the results for January 2014- ranges from 9/30 records reviewed, 30% compliance with the number of charts where the documentation by the house physicians is signed by the supervising physician within 24 hours of being written. 28/ 30 records reviewed , 93 % compliance with the number of charts where the house physician records the statement " progress note in consultation with attending or fell ow " in the progress notes. 4/9 records reviewed , 21% of charts where the supervising physician signed within the 24 hour authentication, and 19/19 records reviewed , 100% compliance for documentation in progress notes.


The Director commented this was to be expected as this retro-examination was prior to Quality Improvement education and prior to the Amendments to the Rules and Regulations of Medical Staff in 7/2012.

A review of the Comprehensive Amendment was conducted on 02/19/2014 the document included: " resident/fell ow physicians are authorized to document appropriate patient care documentation and orders including provision of care commensurate with the physician ' S level of advancement and competence, under the general supervision of appropriate privileged medical teaching staff ... all entries in the medical record related to histories and physicals, operative reports, consultations, discharge summaries, and outpatient notes must be authenticated by the licensed independent practitioner directly supervising the resident. "3. On 2/19/2014 at 10: 37 a.m. a visit to the SICU (Surgical Intensive Care Unit) floor was conducted. The tour included the SICU Nurse Unit Manager and the Director of Critical Care. After the tour of the patient care areas, the nurse manager was interviewed. The nurse manager explained the facility was a teaching hospital and the medical students included various training levels. The Nurse Manager explained the medical students included Post Graduate Year (PGY) 1-7. The Nurse Manager explained a PGY-1 would indicate the medical student was a First Year Post Graduate Medical Resident. A PGY 2 would indicate the Resident is in a Second Year of Post Graduate Medical Resident. This type of identifier for Resident Post Graduate study reflects the number of years of Post Graduate Residency.
The Nurse Manager explained a PGY-1 is also identified as an intern. An advanced PGY Resident is identified as a fell ow. A fell ow has almost completed the Residency for their area of study usually a PGY-5 or greater.
The nurse manager during the interview commented the care is directed by the Attending Physician (AP). fell ows, Resident Medical Physicians and Interns are on the unit and provide care to patients under the supervision of the Attending Physician.
During the interview the SICU manager commented AP ' s may be transplant physicians as well as other specialist types (Such as Cardiologist, Neurologist and Infectious Disease).The nurse manager explained the Attending Physician will conduct a daily rounding (examine and discuss patient medical status and plan of care) with the various Residents and fell ows. Once the rounds are completed the Residents and fell ows complete a plan of care for each patient and placed into the hospital electronic medical record (EMR).
The Nurse Manager verbalized the AP must " sign off " on the plan of care in the EMR and the AP documents in the EMR at minimum each day and the supervision parameters were shared with the in the SICU staff.

4. Medical Record Review: " EMR " for the transplant patients currently in the SICU were reviewed. During the record review the Nurse Manager explained the AP ' s are to document in the medical record each day. The AP is to insure the supervision of the fell ows, Residents and Interns by reviewing EMR entries and " signing off " on those entries. (a.) Review of SP#10 medical records shows that the patient was admitted to the facility on [DATE]. Physician Progress Notes on 01/29/14 was not authenticated by the Attending and there were no other Physician notes on 01/29/14.
(b.) Review of SP#11 medical records shows that the patient was admitted to the facility on [DATE]. Progress Notes written on 01/23/14 and 01/24/14 by a resident have not been authenticated and there were no other Physician Notes on 01/23/14 and 0/24/14. Progress Notes on 02/06/14 written by a fell ow has not been authenticated. Progress Notes on 02/06/14 and 02/08/14, written by a resident, were both authenticated on 02/14/14. There were no other Physician Notes from 02/06/14 thru 02/08/14.
(c.) Review of SP#14 medical records shows that the patient was admitted to the facility on [DATE]. Progress Notes written by residents on 02/10/14 thru 02/16/14 were not authenticated and there were no other physician notes from 02/10/14 thru 02/16/14.(d.) Review of SP#15 medical records shows that the patient was admitted to the facility on [DATE]. Progress Note on 02/06/14 was authenticated on 02/14/14. Progress Notes on 02/08/14 and 02/09/14 was authenticated on 02/13/14. There were no other physician notes from 02/06/14 thru 02/09/14.(e.) Review of SP#19 medical records shows that the patient was admitted to the facility on [DATE]. Progress notes by House Physicians and residents from 02/13/14 thru 02/15/14 have not authenticated and there were no other physician notes for that date range.
During the interview and review of the medical records on 02/19/2014 at 10:37 a.m. the Nurse Manager identified there were medical records that were not " signed off " by the Attending Physician or Designee. The nurse manager continued to verify this by commenting the medical record should contain an Attending Physician, Designee, or Physician Specialist should have "signed off" on the EMR entries. At that time the Nurse Manager commented the Attending Physician daily entry in the EMR constitutes supervision. The Nurse Manager included it was her understanding a fell ow could "sign off or authenticate" a Resident entry. The Director of Critical Care commented she would check on the official meanings of authentication, and which practitioners required supervision and what that "supervision would entail". The Nurse Manager explained the EMR is the Attending Physician is authenticating and in agreement with the documentation regarding the care of the patient as written by the Resident as a part of the supervision and the Attending Physician is ultimately responsible for the patient care. The authentication is evident on the EMR with an electronic signature, date and time of authentication as verbalized by the Nurse Manager. .
An Interview conducted on 02-20-14 10:00 a.m. with the Associate Director of Quality-Accreditation /Licensure confirmed the medical record findings that SP#10, SP# 11, SP# 14, SP#15, and SP# 19 documentation of progress notes or the History and Physical by the house staff (Residents/Interns and fell ows) were not appropriately authenticated by the supervising Attending Physician.

5. Additional interviews were conducted with the SICU staff on the evening of 2/20/2013:At 5:21 p.m.- The Assistant Director of the SICU was interviewed. The Assistant Director explained the AP must authenticate and sign off for the Intern, Resident and fell ow.At 5:23 p.m.. - A random nurse was interviewed in the SICU. The Nurse reported the AP is expected to sign the notes entered by the fell ow, Resident and Intern.
At 5:35 p.m. - A nurse in the SICU-A was interviewed. The nurse reported the fell ow is permitted to sign off on the EMR. The AP is expected to enter a note each day and sign off on the resident and intern notes.
6. A meeting with Associate Director Quality of the Miami Transplant Institute, Vice President of Quality and Patient Safety, and Associate Director of Quality Accreditation and Licensure was conducted on 2/20/2014 at 6:00 p.m. The results of the interviews and medical record entry authentication of the fell ows, Residents, Interns and House Physicians were discussed with Administrative staff members. The Vice President verbalized a " disconnect " with staff members regarding the rules and regulations. He continued by commenting the Rules and Regulations require additional evaluation. The Vice President and the Associate Director Quality of the Miami Transplant Institute commented education initiated. The effectiveness of the current QAPI interventions require additional evaluation. During the meeting the hospital administration identified Education regarding Attending Physician supervision and authentication. Associate Director of Quality Accreditation and Licensure explained the supervision is complicated due the complexity of the Resident and fell owship Programs. The Associate Director commented additional education and evaluation of the training is needed.
The Vice President commented the education interventions would include: Physicians, fell ows, Residents, House Physicians, and Clinical Staff. The facility did employ Quality Improvement measures regarding the fell ow, Resident and House Physician supervision by the Attending Physician introducing the Amended Rules and Regulations of Medical Staff in 2012 and the facility retro-threshold study in November 2013.
The facility failed to provide ongoing evaluation of an identified 2012 and 2013 quality indicator. The facility failed to provide ongoing analysis of the intervention measures to produce improved outcomes.
The QAPI program did not identify the staff "disconnect" as described by the VP regarding the supervision concern. This is evident in the findings of lack of supervision of the fell ows, Residents and House Physicians as identified in the EMR and the interviews with multiple staff.
The staff interview discrepancies as identified during the survey process regarding the facility Rules and Regulations, included the clinical nursing staff. The clinical nursing staff and their immediate directors are on the front line to improve the compliance with the appropriate supervision.
The VP commented the staff including physicians requires additional training to insure the rules and regulations for the medical staff are identified enforced and appropriately practiced to insure patient and health outcomes.
The facility failed to provide a continued tracking mechanism to insure the educational measures and facility administrative interventions (Rules and Regulations) produced a uniformed and accurate understanding of the Rules and Regulations of the Medical Staff with in the transplant program.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interviews, facility record review and medical record review reveal the facility governing body failed to provide an ongoing Quality Assurance and Performance Improvement (QAPI) program including : (1) That the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated. (2) present a QAPI program that include the program scope and data regarding the supervision of fell ows, Residents and House Physicians involved in the transplant service program , and in 5 sampled patients(SP) #10, #11, #14, #15, and #19.

Findings include:
1. An interview with the Vice President (VP) of Quality and Patient Safety was conducted on 02/19/2014 at 5:30 p.m. The VP explained the Jackson Health System Medical Rules and regulations underwent a Comprehensive Amendment. The Amendment was presented at the Medical Executive Committee (MEC) on 06/12/2012 and the Board of Trustees (BOT) on 06/28/2012. The Amendment was passed and dated 07/19/2012 as the effective date.
During the interview with the VP the facility identified a concerns for supervision regarding the fell ows, Residents, and House Physicians in 2012.
The VP explained the facility was conducting a retroactive (4/2012) review of the house physician and /or ARP (Advanced Registered Nurse Practitioner) and the Attending Physician (AP) supervision or fell ow compliance. The compliance examination included medical record entries, progress note, and plans of care.
2. According to afternoon interviews conducted on 2/19/2014 at 1:30 p.m. and 2/20/2014 at 3:30 p.m. with the Associate Director of Quality Compliance and Outcomes and the Associate Director of Quality - Accreditation and Licensure, the QAPI interventions includes a Retro evaluation and baseline in 4/2012. The baseline was conducted in the last quarter of 2013.
The plan to evaluate and report of current compliance regarding supervision would be initiated for the first quarter of 2014 and be presented at the April 2014, QAPI, MEC and BOT meetings.

The Associate Director of Quality Compliance and Outcomes and the Associate Director of Quality - Accreditation and Licensure during the interview verified staff education including physicians and clinical staff regarding the Rules and Regulations of Medical Staff was actively conducted in 2013.

A review of the Comprehensive Amendment was conducted on 02/19/2014 the document included: " resident/fell ow physicians are authorized to document appropriate patient care documentation and orders including provision of care commensurate with the physician ' S level of advancement and competence, under the general supervision of appropriate privileged medical teaching staff ... all entries in the medical record related to histories and physicals, operative reports, consultations, discharge summaries, and outpatient notes must be authenticated by the licensed independent practitioner directly supervising the resident. "
On 2/19/2014 at 10: 37 a.m. a visit to the SICU (Surgical Intensive Care Unit) floor was conducted. The tour included the SICU Nurse Unit Manager and the Director of Critical Care. After the tour of the patient care areas, the nurse manager was interviewed. The nurse manager explained the facility was a teaching hospital and the medical students included various training levels.
The nurse manager during the interview commented the care is directed by the Attending Physician (AP). fell ows, Resident Medical Physicians and Interns are on the unit and provide care to patients under the supervision of the AP. During the interview the SICU manager commented the AP may be transplant physicians as well as other specialist types (Such as Cardiologist, Neurologist and Infectious Disease).The nurse manager explained the AP will conduct a daily rounding (examine and discuss patient medical status and plan of care) with the various Residents and fell ows. Once the rounds are completed the Residents and fell ows complete a plan of care for each patient and placed into the hospital electronic medical record (EMR).
The Nurse Manager verbalized the AP must " sign off " on the plan of care in the EMR and the AP documents in the EMR at minimum each day and the supervision parameters were shared with the in the SICU staff.

Medical Record Review: EMR " for the transplant patients currently in the SICU were reviewed. During the record review the Nurse Manager explained the AP ' s are to document in the medical record each day. The AP is to insure the supervision of the fell ows, Residents and Interns by reviewing EMR entries and " signing off " on those entries. (a.) Review of SP#10 medical records shows that the patient was admitted to the facility on [DATE]. Physician Progress Notes on 01/29/14 was not authenticated by the Attending and there were no other Physician notes on 01/29/14.
(b.) Review of SP#11 medical records shows that the patient was admitted to the facility on [DATE]. Progress Notes written on 01/23/14 and 01/24/14 by a resident have not been authenticated and there were no other Physician Notes on 01/23/14 and 0/24/14. Progress Notes on 02/06/14 written by a fell ow has not been authenticated. Progress Notes on 02/06/14 and 02/08/14, written by a resident, were both authenticated on 02/14/14. There were no other Physician Notes from 02/06/14 thru 02/08/14.
(c.) Review of SP#14 medical records shows that the patient was admitted to the facility on [DATE]. Progress Notes written by residents on 02/10/14 thru 02/16/14 were not authenticated and there were no other physician notes from 02/10/14 thru 02/16/14.(d.) Review of SP#15 medical records shows that the patient was admitted to the facility on [DATE]. Progress Note on 02/06/14 was authenticated on 02/14/14. Progress Notes on 02/08/14 and 02/09/14 was authenticated on 02/13/14. There were no other physician notes from 02/06/14 thru 02/09/14.(e.) Review of SP#19 medical records shows that the patient was admitted to the facility on [DATE]. Progress notes by House Physicians and residents from 02/13/14 thru 02/15/14 have not authenticated and there were no other physician notes for that date range.
During the interview and review of the medical records on 02/19/2014 at 10:37 a.m. the Nurse Manager identified there were medical records that were not " signed off " by the Attending Physician or Designee. The nurse manager continued to verify this by commenting the medical record should contain an Attending Physician, Designee, or Physician Specialist should have "signed off" on the EMR entries.
The Nurse Manager commented the Attending Physician daily entry in the EMR constitutes supervision. The Nurse Manager included it was her understanding a fell ow could "sign off or authenticate" a Resident entry. The Director of Critical Care commented she would check on the official meanings of authentication, and which practitioners required supervision and what that "supervision would entail". The Nurse Manager explained the EMR is authenticated by the AP. The authentication is the AP is authenticating and in agreement with the documentation regarding the care of the patient as written by the Resident as a part of the supervision and the Attending Physician ultimate responsibility of the patient care. The authentication is evident on the EMR with a electronic signature date and time of authentication as verbalized by the Nurse Manager. .
Interview conducted on 02-20-14 at 10:00 a.m. with the Associate Director of Quality-Accreditation /Licensure confirmed the medical record findings that SP#2, SP#8, SP#10, SP#19, SP#20 and SP#24 documentation of progress notes or History and Physical by the house staff (Residents/Interns and fell ows) were not appropriately authenticated by the supervising Attending Physician.

Additional interviews were conducted with the SICU staff on the evening of 2/20/2013:At 5:21 p.m.- The Assistant Director of the SICU was interviewed. The Assistant Director explained the AP must authenticate and sign off for the Intern, Resident and fell ow.At 5:23 p.m.. - A random nurse was interviewed in the SICU. The Nurse reported the AP is expected to sign the notes entered by the fell ow, Resident and Intern.
At 5:35 p.m. - A nurse in the SICU-A was interviewed. The nurse reported the fell ow is permitted to sign off on the EMR. The AP is expected to enter a note each day and sign off on the resident and intern notes.

A meeting with Associate Director Quality of the Miami Transplant Institute, Vice President of Quality and Patient Safety, and Associate Director of Quality Accreditation and Licensure was conducted on 2/20/2014 at 6:00 p.m. The results of the interviews and medical record entry authentication of the fell ows, Residents, Interns and House Physicians was discussed with Administrative staff members. The Vice President verbalized a " disconnect " with staff members regarding the rules and regulations. He continued by commenting the Rules and Regulations require additional evaluation. The Vice President and the Associate Director Quality of the Miami Transplant Institute commented education initiated. The effectiveness of the current QAPI interventions require additional evaluation. During the meeting the hospital administration identified Education regarding AP supervision and authentication. Associate Director of Quality Accreditation and Licensure explained the supervision is complicated due the complexity of the Resident and fell owship Programs. The Associate Director commented additional education and evaluation of the training is needed.
The Vice President commented the education interventions would include: Physicians, fell ows, Residents, House Physicians, and Clinical Staff.
The facility did employ Quality Improvement measures regarding the fell ow, Resident and House Physician supervision by the Attending Physician introducing the Amended Rules and Regulations of Medical Staff in 2012 and the facility retro-threshold study in November 2013. The facility failed to provide ongoing evaluation of an identified 2012 and 2013 quality indicator. The facility failed to provide ongoing analysis of the intervention measures to produce improved outcomes.
Though the facility provided educational and Rules and Regulation for Medical Staff, the facility QAPI program did not identify the staff "disconnect" regarding the supervision concern. This is evident in the findings of lack of supervision of the fell ows, Residents and House Physicians as identified in the EMR. The staff discrepancies as identified during the survey process regarding the facility Rules and Regulations, included the clinical nursing staff. The clinical nursing staff and their immediate directors are on the front line to improve the compliance with the appropriate supervision. The staff requires additional training to insure the rules and regulations for the medical staff are identified enforced and appropriately practiced to insure patient and health outcomes.
The facility Governing Body failed to provide a continued and ongoing tracking mechanism to insure the educational measures and facility administrative interventions (Rules and Regulations) produced a uniformed and accurate understanding of the Rules and Regulations of the Medical Staff with in the transplant program.
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review the facility failed to ensure that The medical staff are organized under written bylaws and are responsible to the governing body in authenticating the progress notes, history and physicals, discharge summary, and physician orders at least daily by the attending practitioner in accordance with the facility's rules and regulations in 10 out of 25 sampled patients (SP), SP#1, SP#2, SP#8, SP#10, SP#11, SP#14, SP #15, SP#19, SP#20, and SP#24.

Findings include :

(1.) Clinical record review conducted from 02-19-14 to 02-21-14 of Sample Patient (SP) #1 revealed that the patient was admitted to the facility on on [DATE] with a chief complaint of nausea, vomiting, diarrhea and dehydration.
Review of the physician orders revealed that there were multiple orders written and signed by the House Physicians (Medical Staff) (MS #1 and MS#3) without proper authentication of the supervising Attending Physician (AP). The History and Physical (H & P) dated 04-18-12 done by MS#3 was not authenticated by the supervising AP. The progress note dated 04-19-12 and the discharge summary dated 05-15-12 done by MS#1 were not authenticated by the supervising Attending Physician.

Interview conducted on 02-20-14 at 1:20 p.m. with the Associate Director of Quality/ Compliance & Outcomes Management (MIT) confirmed above findings that the H&P, progress notes, discharge summary and physician orders of SP#1 were done by the HP without proper authentication of the AP.

Interview with MS #1 conducted on 2-19-14 at 3:25 p.m. revealed that he is a House Physician (HP) for transplant unit for 3 years. He stated that he received the education about the scope, privileges of HP practice in the facility. He stated that " he assists in clinical development of patient collection of data, physical examinations, collection of history and physical, transcribing orders of Attending Physician (AP), Resident, fell ows by telling him what to write and they sign the orders, assists clinical procedures or surgical procedures. That orders cannot be administered until signed by the medical staff. That everything he does is under the direct supervision of the AP or fell ow. Basically the AP/fell ow are present to sign. "

Medical Staff (MS) #1 further stated that " In 2012, the House Physician had different privileges under the system and able to write and sign and carried out orders but there's 6-8 hours need to be co-signed but not sure of the time frame for co-sign." MS#1 further stated "that in the personnel file, he got this privilege to write orders."

Review of the Job Description of MS#1 (signed on 5-17-11) conducted on 2-21-14 confirmed above findings that HP has the job specifics that include but not limited to: " Assess patient on admission for other medical reason either pre or post transplantation. Includes a physical examination, history and review of systems. Begins plan of care. "

Interview with the Associate Director of Quality/ Compliance & Outcomes Management (MIT) conducted on 2-21-14 at 11:05 am confirmed above findings that HP can write orders. She stated that " plan of care includes writing orders which is now re-defined. "


(2.) Review of SP#2 medical records shows that the patient was admitted to the facility on [DATE] for abdominal pain. The patient was assigned an Attending Physician (AP). The patient ' s medical records shows that the History and Physical (H&P) on the 01/14/14 and the progress note on 01/15/14 completed by the same House Physician were both authenticated by the Attending Physician on 01/17/14. There were no other Attending Physician/Designee Notes from 01/14/14 thru 01/16/14. Progress note completed by a House Physician on 01/18/14 was authenticated by the AP on 01/20/14. There were no other Attending Physician/Designee Notes on 01/18/14.
Consultation Note dictated by a resident on 01/19/14 was authenticated by the Consulting Physician on 01/23/14. There were no other Attending Physician/Designee Notes on 01/19/14. Consultation on 01/24/14 documented by a resident was authenticated by the AP on 02/14/14. There were no other Attending Physician/Designee Notes on 01/24/14. Progress note completed by House Physicians on 01/29/14 and on 01/30/14 were both authenticated by the AP on 02/01/14. There were no other Attending Physician/Designee Notes on 01/29/14 and 01/30/14.
(3.) Review of SP#8 medical records shows that the patient was admitted to the facility on [DATE]. The patient ' s medical records show that Progress Notes completed by House Physicians, Residents and fell ows from 02/05/14 to 02/06/14 and from 02/09/14 to 02/12/14 were not authenticated and there is no documentation of Attending Physician/Designee activities in the patient ' s medical records on those dates. Consultation Note on 02/13/14 and Progress Note on 02/14/14 completed by a resident were both authenticated by the AP on 02/17/14. There were no other Attending Physician/Designee on 02/13/14 and 02/14/14.
(4.) Review of SP#10 medical records shows that the patient was admitted to the facility on [DATE]. Physician Progress Notes on 01/28/14 was not authenticated by the Attending and there were no other Attending Physician/Designee notes on 01/29/14.
(5.) Review of SP#11 medical records shows that the patient was admitted to the facility on [DATE]. Progress Notes written on 01/23/14 and 01/24/14 by a resident have not been authenticated and there were no other Attending Physician/Designee Notes on 01/23/14 and 0/24/14. Progress Notes on 02/06/14 written by a fell ow has not been authenticated. Progress Notes on 02/06/14 and 02/08/14, written by a resident, were both authenticated on 02/14/14. There were no other Attending Physician/Designee Notes from 02/06/14 thru 02/08/14.
(6.) Review of SP#14 medical records shows that the patient was admitted to the facility on [DATE]. Progress Notes written by residents on 02/10/14 thru 02/16/14 were not authenticated and there were no other Attending Physician/Designee notes from 02/10/14 thru 02/16/14.
(7.) Review of SP#15 medical records shows that the patient was admitted to the facility on [DATE]. Progress Note on 02/06/14 was authenticated on 02/14/14. Progress Notes on 02/08/14 and 02/09/14 was authenticated on 02/13/14. There were no other Attending Physician/Designee notes from 02/06/14 thru 02/09/14.
(8.) Review of SP#19 medical records shows that the patient was admitted to the facility on [DATE]. Progress notes by House Physicians and residents from 02/13/14 and 02/15/14 have not authenticated and there were no other Attending Physician/Designee notes for that date range.
(9.) Review of SP#20 medical records shows that the patient was admitted to the facility on [DATE]. Progress Notes on 02/15 /14 written by a House Physician have not been authenticated and there are no other Attending Physician/Designee notes for those days.
(10.) Review of SP#24 medical records shows that the patient was admitted to the facility on [DATE]. Progress note on 02/15/14 has not been authenticated and there were no other Attending Physician/Designee notes, as yet, on 02/19/14 or on 02/20/14.
Interview conducted on 02-20-14 at 10:00 a.m. with the Associate Director of Quality-Accreditation /Licensure confirmed above findings that SP#1, SP#2, SP#8, SP#10, SP#11, SP#14, SP#15, SP#19, SP#20 and SP#24 documentation of progress notes or History and Physical by the house staff (Residents/Interns and fell ows) were not appropriately authenticated by the supervising Attending Physician.

Review of the facility ' s medical staff rules and regulations [8.1. (d) Documentation] conducted on 02-20-14 shows that " resident/fell ow physicians are authorized to document appropriate patient care documentation and orders including provision of care commensurate with the physician ' s level of advancement and competence, under the general supervision of appropriate privileged medical teaching staff ... all entries in the medical record related to histories and physicals, operative reports, consultations, discharge summaries, and outpatient notes must be authenticated by the licensed independent practitioner directly supervising the resident. "

Review of the facility ' s medical staff rules and regulations [2.4 Progress Notes] conducted on 02-20-14 shows that " Progress Notes shall be written at least daily by the attending practitioner on critically ill patients, those where there is difficulty in diagnosis and management of the problem, and those with a significant deterioration in their clinical status. For those patients awaiting extended care facility placement, progress notes shall be as frequent as medically indicated. Progress notes shall be written at least daily by the attending practitioner or designee for all patients. The medical staff member must document his or her involvement with the patient in the medial record, reflecting his or her level of participation in the care of the patient and supervisions of learners also caring for the patient. The medical staff member may attest to progress notes written by learners, such as residents and fell ows, or designees, such as physician assistants and advance practice nurses. "
VIOLATION: MEDICAL STAFF RESPONSIBILITIES Tag No: A0358
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based upon interview and record review the facility failed to ensure that the History and Physical was authenticated by the Attending Physician within 24 hours of completion by the House Physician and in accordance with the hospital's rules and regulations in 1 out of 25 Sampled Patients ( SP) #2.


The findings include:

Review of SP#2 medical record shows that the patient was admitted to the facility on [DATE] for abdominal pain. The patient was assigned an Attending Physician. The patient ' s medical records shows that the History and Physical (H&P) on the 01/14/14 was completed by a House Physician, and was authenticated by the Attending Physician on 01/17/14( 3 day later). There were no other Attending Physician/Designee Notes from 01/14/14 thru 01/16/14.

Review of the facility's Job specifics for Transplant International Medical Graduate shows that the House Physician can assist the surgeon technically during invasive procedures, and during daily rounds. Duties include, performing a history and physical exam (H&P), completing a review of systems (ROS), participating in pre and post-operative care, completing medication reconciliation, and executing orders and plan of care as directed by the supervising fell ow or attending."

Review of the facility ' s medical staff rules and regulations [2.4 Progress Notes] conducted on 02-20-14 shows that Progress notes shall be written at least daily by the attending practitioner or designee for all patients. The medical staff member must document his or her involvement with the patient in the medial record, reflecting his or her level of participation in the care of the patient and supervisions of learners also caring for the patient. The medical staff member may attest to progress notes written by learners, such as residents and fell ows, or designees, such as physician assistants and advance practice nurses.

Interview conducted on 02-20-14 1:20 p.m. with the Associate Director of Quality-Accreditation /Licensure confirmed above findings that SP#2 History and Physical by the House Physician was not appropriately authenticated by the supervising Attending Physician.