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.

OPELOUSAS GENERAL HEALTH SYSTEM 539 EAST PRUDHOMME STREET OPELOUSAS, LA 70570 Feb. 11, 2015
VIOLATION: DISCHARGE PLANNING Tag No: A0799
Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation for Discharge Planning as evidenced by:


1) Failing to ensure patients with no primary care physician (PCP) were included in triggers for social services or case management in the nurses' admission assessment as evidenced by 1 (#2) of 5 (#1 - #5) patient records reviewed for discharge planning evaluations not having a discharge planning evaluation by social services or case management requested upon admission when the patient did not have a PCP from a total sample of 22 patients (#1 - 22) (see findings in tag A0800);


2) Failing to ensure:

a) Each patient identified during the nursing admission assessment as requiring a discharge planning evaluation had an evaluation conducted as evidenced by having a patient identified as having home health services prior to admission not having social services or case management triggered for a discharge planning evaluation for 1 (#1) of 5 (#1 - #5) patient records reviewed for discharge planning from a total sample of 22 patients;


b) A process had been developed to assure that all physicians were aware that they may request a discharge planning evaluation;


c) The discharge planning evaluation assessed that identified DME (durable medical equipment) that would be required at discharge was available and whether home or physical environmental modifications would be necessary prior to discharge for 2 (#1, #5) of 5 (#1 - #5) patient records reviewed for DME and/or home modification needs from a total sample of 22 patients; and


d) The discharge planning evaluation assessed whether the residential facility from which a patient was admitted from and would be returning to had the capability to provide the necessary post-hospital services for 1 (#5) of 1 patient admitted from a residential facility from a total of 5 (#1 - #5) patient records reviewed for discharge planning from a total sample of 22 patients (see findings in tag A0806).


3) Failing to ensure:


a) Each patient's discharge plan included a list of all medications the patient should be taking after discharge with clear indication of the changes from the patient's pre-admission medications and that patients were educated on the changes for 1 (#5) of 5 (#1 - #5) patient records reviewed for discharge planning from a total sample of 22 patients and


b) Necessary medical information was sent to the providers the patient was referred to prior to their first post-discharge appointment for 1 (#5) of 5 (#1 - #5) patient records reviewed for discharge planning from a total sample of 22 patients (see findings in tag A0820).


4) Failing to ensure there was documentation that a patient's discharge plan was reassessed when it was determined that a patient who required a wheelchair to ambulate due to impaired mobility at admission no longer needed the wheelchair and was able to ambulate by the time of discharge for 1 (#5) of 5 (#1 - #5) patient records reviewed for discharge planning from a total sample of 22 patients (see findings in tag A0821); and


5) Failing to ensure that the Inpatient Rehab Department's discharge planning process was assessed on an ongoing basis and integrated into the hospital's QAPI (Quality Assessment and Performance Improvement) program (see findings in tag A0843).
VIOLATION: CRITERIA FOR DISCHARGE EVALUATIONS Tag No: A0800
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure patients with no primary care physician (PCP) were included in triggers for social services or case management in the nurses' admission assessment as evidenced by 1 (#2) of 5 (#1 - #5) patient records reviewed for discharge planning evaluations not having a discharge planning evaluation by social services or case management requested upon admission when the patient did not have a PCP from a total sample of 22 patients (#1 - 22).


Findings:


Review of the Medical Staff By-laws and Rules and Regulations, presented by S1DON (Director of Nursing), revealed that discharge planning shall be an integral part of the hospitalization of each patient and shall begin as soon as possible after admission. Further review revealed that discharge planning shall include appropriate referral and transfer plans and methods to facilitate the provision of follow-up care.


Review of the hospital policy titled "Discharge Process", presented as a current policy by S5Director of Case Mgt. (Management), revealed that the nurse is responsible for initiation of the discharge planning process by assessing, identifying and referring any discharge planning needs and documentation in the medical record care plan any discharge planning activities.


Review of the "Case Manager Discharge Planning Form Initial Screening/Evaluation", presented by S5Director of Case Mgt. as the list of triggers that can be selected in the hospital's computer system during the nurses' admission assessment, revealed no documented evidence that social services or case management was listed in the "need for services screening."


Review of the hospital policy titled "Patient Assessment & (and) Reassessment", presented as a current policy by S5Director of Case Mgt., revealed that psychosocial data collection and screening begins at the time of admission by the clinical staff and if there is a need, the staff will request a further evaluation by social service personnel. Further review revealed that nurse or any clinical staff member can request a further evaluation based on triggers identified and developed by the Social Service Department. Review of the "Case Management/Discharge Planning Triggers" and the "Social Service/Discharge Planning Triggers" revealed no documented evidence that no identified PCP was listed as one of the triggers.


Review of Patient #2's medical record revealed she was a [AGE] year old female who was admitted on [DATE] with diagnoses of Sinus Tachycardia, COPD (Chronic Obstructive Pulmonary Disease), and Chest Pain. Review of her nursing admit assessment revealed she had no family physician. Further review revealed no documented evidence that a discharge planning evaluation was triggered for social services or case management during the nursing admission assessment.


Review of the "Case Manager Discharge Planning Form", documented by S10Case Manager on 02/09/15 at 2:25 p.m., revealed that Patient #2 just moved from New Iberia to Sunset and did not have a PCP. Further review revealed Patient #2 was provided with the name, address, and phone number of a PCP.


In an interview on 02/10/15 at 12:55 p.m., S5Director of Case Mgt. indicated that triggers for social services and case management aren't done automatically through the hospital's computer system. She further indicated that it's a manual process done through the computer, meaning that when a nurse has identified a need for social services and/or case management, the nurse has to request the consult through the computer system. She further indicated that the case manager tries to see all patients, but hospital policy requires the triggered patients to have a discharge planning evaluation. S5Director of Case Mgt. confirmed that no PCP available was not a trigger in the computer system for social services or case management.


In an interview on 02/10/15 at 3:05 p.m., S10Case Manager indicated that she tries to speak with each new patient on her unit. She further indicated that she met with Patient #2 she discovered that Patient #2 did not have a PCP, since she had recently moved to the area. She further indicated that she (S10Case Manager) provided a list of physicians in the geographic area to Patient #2.


In an interview on 02/11/15 at 11:50 a.m. with S5Director of Case Mgt. and S4VP (Vice-President) of Clinical Operations present, both S5Director of Case Mgt. and S4VP of Clinical Operations confirmed that a patient without a PCP should trigger the need for a discharge planning evaluation.
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure:


1) Each patient identified during the nursing admission assessment as requiring a discharge planning evaluation had an evaluation conducted as evidenced by having a patient identified as having home health services prior to admission not having social services or case management triggered for a discharge planning evaluation for 1 (#1) of 5 (#1 - #5) patient records reviewed for discharge planning from a total sample of 22 patients;


2) A process had been developed to assure that all physicians were aware that they may request a discharge planning evaluation;


3) The discharge planning evaluation assessed that identified DME (durable medical equipment) that would be required at discharge was available and whether home or physical environmental modifications would be necessary prior to discharge for 2 (#1, #5) of 5 (#1 - #5) patient records reviewed for DME and/or home modification needs from a total sample of 22 patients; and


4) The discharge planning evaluation assessed whether the residential facility from which a patient was admitted from and would be returning to had the capability to provide the necessary post-hospital services for 1 (#5) of 1 patient admitted from a residential facility from a total of 5 (#1 - #5) patient records reviewed for discharge planning from a total sample of 22 patients.


Findings:


1) Each patient identified during the nursing admission assessment as requiring a discharge planning evaluation had an evaluation conducted:


Review of the Medical Staff By-laws and Rules and Regulations, presented by S1DON (Director of Nursing), revealed that discharge planning shall be an integral part of the hospitalization of each patient and shall begin as soon as possible after admission. Further review revealed that discharge planning shall include appropriate referral and transfer plans and methods to facilitate the provision of follow-up care.


Review of the hospital policy titled "Discharge Process", presented as a current policy by S5Director of Case Mgt. (Management), revealed that the nurse is responsible for initiation of the discharge planning process by assessing, identifying and referring any discharge planning needs and documentation in the medical record care plan any discharge planning activities.


Review of the "Case Manager Discharge Planning Form Initial Screening/Evaluation", presented by S5Director of Case Mgt. as the list of triggers that can be selected in the hospital's computer system during the nurses' admission assessment, revealed no documented evidence that social services or case management was listed in the "need for services screening."


Review of the hospital policy titled "Patient Assessment & (and) Reassessment", presented as a current policy by S5Director of Case Mgt., revealed that psychosocial data collection and screening begins at the time of admission by the clinical staff and if there is a need, the staff will request a further evaluation by social service personnel. Further review revealed that nurse or any clinical staff member can request a further evaluation based on triggers identified and developed by the Social Service Department. Review of the "Case Management/Discharge Planning Triggers" revealed a trigger included patients who were receiving home health services prior to admission.


Review of Patient #1's medical record revealed she was an [AGE] year old female admitted on [DATE] with diagnoses of Syncope and probable Bradyarrhythmia. Review of her nursing admission assessment revealed she was receiving home health services prior to admission. Further review of the assessment revealed no case management or social service triggers were identified.


In an interview on 02/10/15 at 12:45 p.m., S6RN (Registered Nurse) indicated that patients who had been receiving home health services prior to admission should trigger a discharge planning evaluation during the nurse's admit assessment.


In an interview on 02/10/15 at 12:55 p.m., S5Director of Case Mgt. indicated that triggers for social services and case management aren't done automatically through the hospital's computer system. She further indicated that it's a manual process done through the computer, meaning that when a nurse has identified a need for social services and/or case management, the nurse has to request the consult through the computer system. She further indicated that the case manager tries to see all patients, but hospital policy requires the triggered patients to have a discharge planning evaluation.


In an interview on 02/10/15 at 12:55 p.m., S7Case Manager indicated that social services was first triggered for a discharge planning evaluation when the physician ordered a social service consult for a nursing home evaluation. She confirmed that patients who had been receiving home health services prior to admission should trigger a discharge planning evaluation.


2) A process had been developed to assure that all physicians were aware that they may request a discharge planning evaluation:


In an interview on 02/10/15 at 10:25 a.m., S5Director of Case Mgt. indicated that new physicians have an orientation brochure but doesn't to what detail, if any, the request for a patient to receive a discharge planning evaluation is addressed. After reviewing the brochure, she confirmed that this information isn't addressed in the brochure.


In an interview on 02/10/15 at 2:00 p.m., S23Physician (Internal Medicine) indicated he was not aware of any special education that the medical staff received related to requesting a discharge planning evaluation when an evaluation was not triggered by the nurse or other clinical staff.


3) The discharge planning evaluation assessed that identified DME that would be required at discharge was available and whether home or physical environmental modifications would be necessary prior to discharge:


Review of the hospital policy titled "Discharge Process", presented as a current policy by S5Director of Case Mgt., revealed that the nurse is responsible for initiation of the discharge planning process by assessing, identifying and referring any discharge planning needs and documentation in the medical record care plan any discharge planning activities.


Review of the hospital policy for the Department of Behavioral Health titled "Discharge Planning", presented as a current policy by S3Nurse Mgr. (Manager) of Company A, revealed that the case manager will be the primary team member responsible for coordinating discharge planning. Further review revealed that the discharge planning will focus on helping patients finalize living arrangements and aftercare before discharge.


Patient #1


Review of Patient #1's medical record revealed she was an [AGE] year old female admitted on [DATE] with diagnoses of Syncope and probable Bradyarrhythmia. Review of her "Case Manager Discharge Planning Form documented on 02/09/15 at 9:53 a.m. by S7Case Manager revealed that she uses a walker for assistance and needs assistance with ambulation, preparing meals, and taking medications. There was no documented evidence of an assessment of whether identified DME required at discharge would be available and if any home or physical environmental modifications would be necessary.


Patient #5


Review of Patient #5's medical record revealed he was a [AGE] year old male admitted on [DATE] from the acute care hospital and was discharged on [DATE]. Further review revealed his admit diagnoses included Major Depressive Disorder, history of GERD (Gastroesophageal Reflux Disease), Hypertension, Seizure Disorder, and Urinary Frequency and Urgency.


Review of Patient #5's "Psychosocial Assessment" performed by S12LCSW (Licensed Clinical Social Worker) on 12/12/14 at 3:00 p.m. revealed that Patient #5 resided in a group home, had mobility impairment, and required a wheelchair to ambulate.


Review of Patient #5's "Social Service Progress Notes" revealed a note by S12LCSW on 12/17/15 at 3:00 p.m. that she spoke with the home manager of the residential group home where Patient #5 resided prior to his hospitalization . Further documentation revealed that Patient #5 was able to function independently and care for himself prior to hospitalization .


Review of Patient #5's medical record revealed no documented evidence an assessment of whether identified DME required at discharge would be available and if any home or physical environmental modifications would be necessary in order for Patient #5 to be able to return to the group home.


In a telephone interview on 02/06/15 at 12:15 p.m., S3Nurse Mgr. of Company A indicated that S12LCSW was the social worker who documented on Patient #5's medical record. She further indicated that S12LCSW isn't available to be interviewed, because she is currently on leave.


In an interview on 02/11/15 at 10:05 a.m., S3Nurse Mgr. of Company A indicated the case manager is the social worker. After reviewing the "Discharge Process" policy, she confirmed that the behavioral health policy for discharge planning didn't identify who the case manager was (social worker or discharge planner), and there was no responsibility designated for the discharge planner. She confirmed the medical record of Patient #5 did not include an assessment of whether the identified DME required by Patient #5 would be available after discharge and if his group home or physical environment would require any modifications to accommodate his wheelchair.


4) The discharge planning evaluation assessed whether the residential facility from which a patient was admitted from and would be returning to had the capability to provide the necessary post-hospital services:


Review of the hospital policy for the Department of Behavioral Health titled "Discharge Planning", presented as a current policy by S3Nurse Mgr. (Manager) of Company A, revealed that the case manager will be the primary team member responsible for coordinating discharge planning. Further review revealed that the discharge planning will focus on helping patients finalize living arrangements and aftercare before discharge.


Review of Patient #5's medical record revealed he was a [AGE] year old male admitted on [DATE] from the acute care hospital and was discharged on [DATE]. Further review revealed his admit diagnoses included Major Depressive Disorder, history of GERD, Hypertension, Seizure Disorder, and Urinary Frequency and Urgency.


Review of Patient #5's "Psychosocial Assessment" performed by S12LCSW on 12/12/14 at 3:00 p.m. revealed that Patient #5 resided in a group home, had mobility impairment, and required a wheelchair to ambulate.


Review of Patient #5's "Social Service Progress Notes" revealed a note by S12LCSW on 12/17/15 at 3:00 p.m. that she spoke with the home manager of the residential group home where Patient #5 resided prior to his hospitalization . Further documentation revealed that Patient #5 was able to function independently and care for himself prior to hospitalization . There was no documented evidence that the manager of the group home had been informed of the current condition of Patient #5 and whether the group home would be able to provide the necessary services upon discharge.


In a telephone interview on 02/06/15 at 12:15 p.m., S3Nurse Mgr. of Company A indicated that S12LCSW was the social worker who documented on Patient #5's medical record. She further indicated that S12LCSW isn't available to be interviewed, because she is currently on leave.


In an interview on 02/11/15 at 10:05 a.m., S3Nurse Mgr. of Company A confirmed the medical record of Patient #5 did not include documentation that the group home manager had been informed of Patient #5's current medical condition to determine whether the group home would be able to provide the services required by Patient #5 upon discharge.
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure:


1) Each patient's discharge plan included a list of all medications the patient should be taking after discharge with clear indication of the changes from the patient's pre-admission medications and that patients were educated on the changes for 1 (#5) of 5 (#1 - #5) patient records reviewed for discharge planning from a total sample of 22 patients and


2) Necessary medical information was sent to the providers the patient was referred to prior to their first post-discharge appointment for 1 (#5) of 5 (#1 - #5) patient records reviewed for discharge planning from a total sample of 22 patients.


Findings:


Review of the hospital policy for the Department of Behavioral Health titled "Discharge Planning", presented as a current policy by S3Nurse Mgr. (Manager) of Company A, revealed that the case manager will be the primary team member responsible for coordinating discharge planning. Further review revealed that the discharge planning will focus on helping patients finalize living arrangements and aftercare before discharge.


1) Each patient's discharge plan included a list of all medications the patient should be taking after discharge with clear indication of the changes from the patient's pre-admission medications and that patients were educated on the changes:


Review of Patient #5's medical record revealed he was a [AGE] year old male admitted on [DATE] from the acute care hospital and was discharged on [DATE]. Further review revealed his admit diagnoses included Major Depressive Disorder, history of GERD (Gastroesophageal Reflux Disease), Hypertension, Seizure Disorder, and Urinary Frequency and Urgency.


Review of Patient #5's list of current medications at the time of admit revealed he was taking 2 tablets of Depakote 500 mg (milligrams) by mouth at bedtime and Seroquel 200 mg by mouth at 8:00 a.m. and 2:00 p.m. Review of his list of medications at discharge revealed no documented evidence that he was prescribed to continue Depakote and Seroquel. Further review revealed no documented evidence that it was clearly indicated that there had been a change in the medications Patient #5 had been taking prior to admission and the medications prescribed at discharge. There was no documented evidence that Patient #5 was educated on the change in his medication regime.


In an interview on 02/11/15 at 10:45 a.m., S3Nurse Mgr. (Manager) with Company A confirmed there was no documentation in Patient #5's medical record that he had been educated on the changes in his medications from prior to admission and those prescribed at the time of his discharge.


2) Necessary medical information was sent to the providers the patient was referred to prior to their first post-discharge appointment:


Review of Patient #5's medical record revealed he was a [AGE] year old male admitted on [DATE] from the acute care hospital and was discharged on [DATE]. Further review revealed his admit diagnoses included Major Depressive Disorder, history of GERD, Hypertension, Seizure Disorder, and Urinary Frequency and Urgency.


Review of Patient #5's "Social Service Progress Notes" revealed an entry on 12/22/14 at 8:34 a.m. by S12LCSW (Licensed Clinical Social Worker) of a late entry for 12/19/14 indicating that Patient #5 had been discharged on [DATE] at 7:00 p.m. and had a follow-up appointment at Company C on 12/22/14 at 9:00 a.m. and that discharge paperwork was sent to "next level of care provider." There was no documented evidence of which next level of care provider was sent discharge paperwork and what specific paperwork was sent.


Review of the "Outpatient Services Consent To Release Information" signed by Patient #5 on 01/20/15, presented by S2Director of HIM (Health Information Management), revealed the diagnosis, medical history and physical, lab and x-ray reports, records of prescribed medications, discharge summary, and emergency room records were requested to be released to Company C. Review of the "Audit Trail by MRN (medical record number) Report", presented by S2Director of HIM when evidence of information that was requested and released to medical providers of patients, revealed that Patient #5's discharge summary, history and physical, emergency care record, lab reports, and x-ray reports were released to Company C on 01/21/15, 30 days after the date of Patient #5's first follow-up appointment at Company C. Further review revealed that physician progress notes, the history and physical, psychiatric evaluation, and lab reports were released to Hospital A on 01/08/15.


Review of Patient #5's discharge summary, dictated and transcribed on 01/15/15 and released to Company C on 01/21/15, revealed "Medications At Discharge: See discharge orders. This patient is discharged on 1 antipsychotic." There was no documented evidence of the antipsychotic that was prescribed, and there was no documented evidence that the physician's discharge orders that contained the list of medications prescribed at discharge were released to Company C or Hospital A.


In a telephone interview on 02/06/15 at 12:15 p.m., S3Nurse Mgr. of Company A indicated that S12LCSW was the social worker who documented on Patient #5's medical record. She further indicated that S12LCSW isn't available to be interviewed, because she is currently on leave.


In an interview on 02/06/15 at 10:00 a.m., S2Director of HIM indicated the the department didn't keep track of what information was sent to providers for care. She further indicated if the hospital was sent an authorization to release medical records, it would be in the individual's patient record.


In an interview on 02/06/15 at 10:20 a.m. after reviewing Patient #5's medical record, S2Director of HIM indicated it looked like Patient #5's behavioral health admission record was sent to Hospital A and not any of his hospital admission records (Patient #5 had been admitted to the Behavioral Health Unit after an acute care stay).


In an interview on 02/11/15 at 10:45 a.m., S3Nurse Mgr. with Company C indicated that requested records are sent by fax, and she doesn't keep the fax transmittals. She further indicated that she can't say what medical information was actually sent to Company C by S12LCSW on 12/22/14 at 8:34 a.m.
VIOLATION: REASSESSMENT OF A DISCHARGE PLAN Tag No: A0821
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the hospital failed to ensure there was documentation that a patient's discharge plan was reassessed when it was determined that a patient who required a wheelchair to ambulate due to impaired mobility at admission no longer needed the wheelchair and was able to ambulate by the time of discharge for 1 (#5) of 5 (#1 - #5) patient records reviewed for discharge planning from a total sample of 22 patients.


Findings:


Review of the hospital policy for the Department of Behavioral Health titled "Discharge Planning", presented as a current policy by S3Nurse Mgr. (Manager) of Company A, revealed that the case manager will be the primary team member responsible for coordinating discharge planning. Further review revealed that the discharge planning will focus on helping patients finalize living arrangements and aftercare before discharge. Further review revealed that discharge planning will be ongoing throughout the patient's stay with any changes in discharge plans being documented in the medical records.


Review of Patient #5's medical record revealed he was a [AGE] year old male admitted on [DATE] from the acute care hospital and was discharged on [DATE]. Further review revealed his admit diagnoses included Major depressive Disorder, history of GERD (Gastroesophageal Reflux Disease), Hypertension, Seizure Disorder, and Urinary Frequency and Urgency.


Review of Patient #5's "Psychosocial Assessment" performed by S12LCSW (Licensed Clinical Social Worker) on 12/12/14 at 3:00 p.m. revealed that Patient #5 resided in a group home, had mobility impairment, and required a wheelchair to ambulate. Further review revealed he was discharged on [DATE] at 7:00 p.m. ambulatory. There was no documented evidence in Patient #5's medical record of an assessment of the change in his condition to determine whether he no longer required a wheelchair to ambulate.


In a telephone interview on 02/06/15 at 12:15 p.m., S3Nurse Mgr. of Company A indicated that S12LCSW was the social worker who documented on Patient #5's medical record. She further indicated that S12LCSW isn't available to be interviewed, because she is currently on leave.


In an interview on 02/11/15 at 10:05 a.m., S3Nurse Mgr. of Company A confirmed the medical record of Patient #5 did not include an assessment of the change in his condition and whether he no longer required a wheelchair to ambulate.
VIOLATION: REASSESSMENT OF DISCHARGE PLANNING PROCESS Tag No: A0843
Based on record reviews and interview, the hospital failed to ensure that the Inpatient Rehab Department's discharge planning process was assessed on an ongoing basis and integrated into the hospital's QAPI (Quality Assessment and Performance Improvement) program.

Findings:


Review of the hospital's Inpatient Rehab Department's policy titled "Utilization Review/Resource Management Plan Inpatient Rehab", presented by S5Director of Case Mgt. (Management), revealed that responsibilities of the Rehab Healthcare Staff included establishing a baseline measure to set goals for improvements that included reviewing, monitoring, and trending total monthly admissions, discharges, and average monthly length of stay. Further review revealed that results of the reviews, trending, and monitoring would be reported to the Clinical Director of the Rehab Unit. The Director of Case Management would bring reported information to the PI (Performance Improvement) Council and medical Staff Executive Committee at least quarterly.


In an interview on 02/11/15 at 1:20 p.m., S24Director of Quality indicated that the Inpatient Rehab Department's discharge planning data was not reported to and integrated in the hospital's QAPI program.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation for Medical record Services as evidenced by:


1. Failing to have a functioning medical record system that incorporated all data in real time for staff viewing during the provision of patient care. This is evidenced by the hospital's electronic medical record system failing to capture the medical screening examination (MSE) for viewing at the time of completion for 17 (#6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22) medical records reviewed for medical screening examinations (MSE) from a total sample of 22 patients (#1-#22). (see findings in tag A0438).


2. Failing to ensure the effective implementation of a system relative to the completion of medical records for patients admitted in the ED. 169 ED patient records were identified to be delinquent dating back to April of 2014 with 17 (#6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22) being incomplete due to no documented medical screening examination (MSE) from a total sample of 22 patients (#1-#22) reviewed who were admitted to the ED. (see findings in tag A0438).


3. Failing to ensure Medical Staff By-laws, Rules and Regulations, and hospital policies and procedures related to physicians with delinquent medical records were implemented as evidenced by not implementing hospital policies and procedures for 5 (S13, S14, S15, S16, S17) of 6 (S13, S14, S15, S16, S17, S18) physicians with delinquent medical records. (see findings in tag A0438).
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure:

1) a functioning medical record system that incorporated all data in real time for staff viewing during the provision of patient care. This is evidenced by the hospital's electronic medical record system failing to capture the medical screening examination (MSE) for viewing at the time of completion for 17 (#6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22) medical records reviewed for medical screening examinations (MSE) from a total sample of 22 patients (#1-#22).


2) the effective implementation of a system relative to the completion of medical records for patients admitted in the ED. 169 ED patient records were identified to be delinquent dating back to April of 2014 with 17 (#6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22) being incomplete due to no documented medical screening examination (MSE) from a total sample of 22 patients (#1-#22) reviewed who were admitted to the ED.


3) Medical Staff By-laws, Rules and Regulations, and hospital policies and procedures related to physicians with delinquent medical records were implemented as evidenced by not implementing hospital policies and procedures for 5 (S13, S14, S15, S16, S17) of 6 (S13, S14, S15, S16, S17, S18) physicians with delinquent medical records.


Findings:


1. Failed to have a functioning medical record system that incorporated all data in real time for staff viewing during the provision of patient care. This is evidenced by the hospital's electronic medical record system failing to capture the medical screening examination (MSE) for viewing at the time of completion for 17 (#6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22) medical records reviewed for medical screening examinations (MSE) from a total sample of 22 patients (#1-#22).


Review of Patient #19's ED record revealed she (MDS) dated [DATE]. Further review revealed no documented evidence that a MSE was performed by S21ED Physician.


Review of the ED records for Patients #7, #14, #15, #16, and #21 revealed they (MDS) dated [DATE]. Further review revealed there was no documented evidence that a MSE was performed by S20ED Physician.


Review of the ED records for Patients #17, #18, and #20 revealed they (MDS) dated [DATE]. Further review revealed there was no documented evidence that a MSE was performed by S20ED Physician.


Review of the ED records for Patients #8, #13, and #22 revealed they (MDS) dated [DATE]. Further review revealed there was no documented evidence that a MSE was performed by S20ED Physician.


Review of the ED records for Patients #6, #9, #10, #11, and #12 revealed they (MDS) dated [DATE]. Further review revealed no documented evidence that a MSE was performed by S20ED Physician.


In an interview on 02/05/15 at 11:15 a.m., S1DON indicated that the ED record is not able to be seen until it had been signed electronically by the ED physician. She further indicated that the ED record doesn't enter the HPF (Horizon Patient Folder) system until the ED physician completes the ED record.


In an interview on 02/05/15 at 11:20 a.m., S17Project Manager IT (Information Technology) confirmed that the patient's ED record isn't able to be printed until the physician has completed the record. She further indicated that this process was to assure that the chart is complete before it "makes it to a permanent record." She indicated that S1DON, the ED Director, or any staff member in the ED or Medical Records could access the record from HEC (Horizon Emergency Care), but they would only see what's been documented up to the time they're viewing it on the computer screen and would not be able to print the record in the event the record was requested by a physician or another facility.


2. Failed to ensure the effective implementation of a system relative to the completion of medical records for patients admitted in the ED. 169 ED patient records were identified to be delinquent dating back to April of 2014 with 17 (#6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22) being incomplete due to no documented medical screening examination (MSE).


Review of the hospital policy titled "Delinquent Chart Procedure", revised December 2014 and presented as the current policy by S2Director of HIM (Health Information Management), revealed that a delinquent medical record was defined as a medical record that remains incomplete 30 days after discharge.


Review of the Medical Staff Rules and Regulations, reviewed and approved by the Board on 05/21/14 and presented as the current Medical Staff Rules and Regulations by S1DON (Director of Nursing), revealed that the attending staff member shall be authenticated by countersigning the history or physical examination recorded by any individual who is not a member of the Medical Staff. Further review revealed that a complete medical record shall include a report of a physical examination and emergency care provided to the patient prior to arrival (for admission).


Review of the list of incomplete ED records from the Main Campus, presented by S1DON, revealed 169 ED patient records that were delinquent, with the longest date being 04/29/14. Further review revealed 167 of the 169 ED records were services provided by S19Physician between 04/29/14 through 11/22/14.


Review of the list of incomplete ED records from the off-site campus, presented by S1DON, revealed one ED record that was delinquent with a date of service of 12/13/14.


In an interview on 02/05/15 at 2:20 p.m., S1DON indicated that she was not aware there were incomplete ED patient records until it was identified by the surveyor.


In an interview on 02/05/15 at 4:15 p.m., S1DON indicated the Medical Staff Rules and Regulations required the physician to authenticate the ED records completed by nurse practitioners. She further indicated that the list of incomplete ED records from the Main Campus had a large list of patients due to the physician not having authenticated the nurse practitioners' ED records.


In an interview on 02/06/15 at 9:15 a.m., S2Director of HIM confirmed the delinquent ED patient records were not included in the list of delinquent medical records. She indicated that there was no process or system in place to determine if an ED patient record was delinquent or incomplete. She confirmed that the 169 ED patient records were actually delinquent medical records.


Review of Patient #19's ED record revealed she (MDS) dated [DATE]. Further review revealed no documented evidence that a MSE was performed by S21ED Physician.


Review of the ED records for Patients #7, #14, #15, #16, and #21 revealed they (MDS) dated [DATE]. Further review revealed there was no documented evidence that a MSE was performed by S20ED Physician.


Review of the ED records for Patients #17, #18, and #20 revealed they (MDS) dated [DATE]. Further review revealed there was no documented evidence that a MSE was performed by S20ED Physician.


Review of the ED records for Patients #8, #13, and #22 revealed they (MDS) dated [DATE]. Further review revealed there was no documented evidence that a MSE was performed by S20ED Physician.


Review of the ED records for Patients #6, #9, #10, #11, and #12 revealed they (MDS) dated [DATE]. Further review revealed no documented evidence that a MSE was performed by S20ED Physician.


In a telephone interview on 02/05/15 at 1:30 p.m., S20ED Physician indicated that all of her ED records were completed until her recent "4 day run" when they were very busy in the ED. She further indicated that there was only one physician with two nurses in the ED at the off-site campus. S20ED Physician indicated that she does a complete exam, but when she's busy, such as having 12 patients with her being the only physician, she keeps hand-written notes during her patient visits. She further indicated that when she lets the patient leave, she has the diagnosis and the prescriptions given to the patient documented in the ED record, and then she goes back later and documents the complete note. S20ED Physician confirmed that she did not complete the above-listed ED patient records.


In an interview on 02/06/15 at 10:15 a.m., S2DON confirmed that no one at the hospital was aware there was a problem with incomplete ED patient records (no documented MSEs) until it was identified by the surveyor.



3. Failed to ensure Medical Staff By-laws, Rules and Regulations, and hospital policies and procedures related to physicians with delinquent medical records were implemented as evidenced by not following the procedures developed related to physicians with delinquent medical records:


Review of the Medical Staff Rules and Regulations, reviewed and approved by the Board on 05/21/14 and presented as the current Medical Staff Rules and Regulations by S1DON, revealed the following information related to delinquent medical records:

"(a) The Administrator of such delinquency shall voluntarily relinquish the elective admitting privileges of an individual for failure to complete medical records in accordance with applicable regulations governing it, after notification.

(b) Failure of a staff member to complete the medical records that caused voluntary relinquishment of clinical privileges for a period of more than thirty (30) days from the relinquishment of such privileges shall constitute voluntary relinquishment of all clinical privileges and resignation from the Medical Staff.

(c) No Medical Staff member or other individual shall be permitted to complete a medical record on an unfamiliar patient in order to retire that record."


Review of the hospital policy titled "Delinquent Chart Procedure", revised December 2014 and presented as the current policy by S2Director of HIM, revealed the the scope included all medical records of Inpatient, Same day Surgery, Procedure, Observation, and Emergency department. Further review revealed the HIM staff were responsible for determining the number of delinquent records and reporting delinquencies to the Chief of Staff, the Chief Executive Officer (CEO), and the appropriate Medical Staff committee at least quarterly. A delinquent medical record was defined as a medical record that remains incomplete 30 days after discharge.

Review of the procedure for handling delinquent medical records included the following:

1) On a weekly basis the Physician Relations Clerk will determine the number of delinquent records for each physician.

2) Each week a list of physicians with delinquent records will be compiled along with the appropriate notices.

3) First Notice: Physicians who have any records that have reached "warning" status (15 days post discharge) will receive a written notice informing them of the need to complete their records.

4) Second Notice: Physicians who were on First Notice the previous week and have still not completed their records will receive a second written notice. This notice will inform them that they have one week to complete their records before they voluntarily relinquish their admitting privileges.

5) No Admit List: One week following the Second Notice any physician who has delinquent records will voluntarily relinquish his/her admitting privileges. Physicians who are placed on the No Admit List will be notified verbally and in writing.

6) Resignation From Medical Staff: When a physician remains on the No Admit List for more than 30 days, this shall constitute voluntary relinquishment of all clinical privileges and resignation from the Medical Staff. On the fourth week in which a physician is being placed on the No Admit List, he will be notified that he has one additional week before voluntary resignation from the Medical Staff. Both the CEO and the Chief of Staff will sign this notice which will be sent via certified mail. The physician will be given one more week after the above notice. If his delinquent records remain incomplete at this point, he will be notified that this constitutes voluntary resignation from the Medical Staff, and he will be removed from active status three days following this notice.

7) A physician who is out of town, on vacation, or ill will not be placed on the No Admit List if the HIM Department is notified of his/her absence.

8) Any physician with an operative report not done on the day of the procedure will not be allowed to schedule surgery cases nor perform surgery, except for patients who have already been admitted .


Review of the No Admit list, presented by S2Director of HIM as the current list of physicians who were not able to admit patients due to delinquent medical records, revealed S14Physician was on the list for the first week, S15Physician was on the list for the second week, S16Physician was on the list for the third week, and S13Physician was on the list for the fourth week.


Review of the list of delinquent medical records, presented as the current list by S2Director of HIM, revealed S14Physician's delinquent medical record was from 12/29/14. Further review revealed S15Physician's longest delinquent medical record was from 12/24/15. S16Physician's longest delinquent medical record was dated 12/10/14, and S13Physician's longest delinquent medical record was dated 11/24/14.


Review of the letters sent to physicians by S2Director of HIM revealed the following:

1) S14Physician's letter dated 02/03/15 (65 days after the patient was discharged ) informing him that he had voluntarily relinquished his elective admitting privileges effective the date of the letter, and that his name will remain on the "No Admit List" until all delinquent records are completed. There was no documented evidence that S14Physician received a "First Notice" letter 15 days after the patient was discharged , a "Second Notice" letter the following week informing him that he has one week to complete his delinquent records before voluntarily relinquishing his admitting privileges, and a certified letter signed by the CEO and the Chief of Staff the fourth week of being on the "No Admit List" informing him that he has one additional week before voluntary resignation from the Medical Staff as required by hospital policy.

2) S15Physician's first letter dated 01/27/15 (34 days after the patient was discharged ) informed him that he was voluntarily relinquishing his elective admitting privileges effective the date of the letter, and his name will remain on the "No Admit List" until all delinquent records were completed. His second letter dated 02/03/15 informed him he was entering his second week of voluntary relinquishment of elective admitting privileges. There was no documented evidence that S15Physician received his first notice on 01/08/15, his second notice on 01/15/15, and written notice on 01/15/15 that he was voluntarily relinquishing his admitting privileges as required by hospital policy.

3) S16Physician's first letter dated 01/20/15 (41 days after the patient was discharged ) informed him that he had voluntarily relinquished his elective admitting privileges effective the date of the letter and his name will remain on the "No Admit List" until all delinquent records were completed. His second letter dated 01/27/15 informed him he was entering his second week of voluntary relinquishment of elective admitting privileges. His third letter dated 02/03/15 informed him that he was entering his third week of voluntary relinquishment of elective admitting privileges. There was no documented evidence that S16Physician received his first notice on 12/25/15 (15 days after discharge), his second notice on 01/01/15 (one week after the first notice), and written notice the week later on 01/08/15 notifying him that he would voluntarily relinquish his admitting privileges and be placed on the "No Admit List" as required by hospital policy.

4) S13Physician's first letter dated 01/13/15 (50 days after the patient was discharged ) informed him that he had voluntarily relinquished his elective admitting privileges effective the date of the letter and his name will remain on the "No Admit List" until all delinquent records were completed. His second letter dated 01/20/15 informed him he was entering his second week of voluntary relinquishment of elective admitting privileges. His third letter dated 01/27/15 informed him that he was entering his third week of voluntary relinquishment of elective admitting privileges. A certified letter signed by the CEO and the Chief of Staff dated 02/03/15 informed S13Physician that failure to complete his delinquent records would result in relinquishment of all clinical privileges, thus constituting a resignation from the Medical Staff effective 02/13/15. There was no documented that a first notice had been sent 15 days after the longest patient's discharge (11/24/15) on 12/09/14, a second notice had been sent one week later on 12/16/15, written notice one week later on 12/23/15 of voluntary relinquishment of admitting privileges and placement of his name on the "No Admit List", a certified letter on 01/15/15 (fourth week of being on the "No Admit List") notifying him of one additional week before his voluntary resignation from the Medical Staff, notification on 01/22/15 of his voluntary resignation from the medical Staff, and removal of S13Physician from active status on 01/25/15 according to the hospital's policies and Medical Staff Rules and Regulations.


Review of the list of delinquent medical records revealed S22Physician had a delinquent medical record from 01/01/15 with no documented evidence that he had received a first notice, second notice, and had been placed on the No Admit List.


In an interview on 02/06/15 at 9:15 a.m., S2Director of HIM indicated that the process for handling delinquent medical records required the physician to placed on a "No Admit List" when his/her patient's medical record remained incomplete 31 days after discharge. She further indicated when a physician remained on the "No Admit List" for 30 days, the physician voluntarily resigned his privileges. She indicated that the hospital had physicians on the "No Admit List", but no physicians have had voluntary resignation. After review of the above information regarding the physician letters, S2Director of HIM confirmed that the hospital's policies and procedures were not correctly implemented related to physicians with delinquent medical records.