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.

IBERIA GENERAL HOSPITAL AND MEDICAL CENTER 2315 E MAIN STREET NEW IBERIA, LA 70562 June 27, 2012
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
Based on record reviews, observations, and staff interviews, the hospital failed to meet the Condition of Participation (CoP) for Medical Records as evidenced by:

1) Failing to ensure physician's with delinquent medical records greater than thirty (30) days were automatically suspended and not allowed admitting clinical privileges as per the "Medical Staff Rules and Regulations" for the one-thousand, three-hundred, and eighty-nine (1389) delinquent medical records with two-thousand, five-hundred, and sixty (2560) entries with no dates, times and/or authentications recorded on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths) from 03/14/11 through 05/21/12 for 146 of the 202 medical staff as revealed by Medical Records computer generated report. There were 10 of 10 sampled medical staff, (S22MD, S23MD, S24MD, S25MD, S26MD, S27MD, S28MD, S29MD, S30MD, and S31MD) focused reviewed for delinquent medical records from 03/14/11 through 05/21/12. (See deficiency cited at A0432);

2) Failing to have a system in place to ensure all medical records were accurately written and promptly completed as evidenced by having one thousand three hundred and eighty-nine (1389) medical records delinquent greater than thrifty (30) days incomplete and inaccurate with no dates, times, and/or authentications recorded on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths) by the practitioners from 03/14/11 through 04/30/12, having eight hundred and nineteen (819) delinquent medical records greater than sixty (60) days incomplete and inaccurate with no dates, times and/or authentication recorded on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths) by the practitioners from 03/14/12 to 04/30/12, having four hundred and ninety-one (491) delinquent medical records greater than ninety (90) days incomplete and inaccurate with no dates, times, and/or authentication recorded on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths) by the practitioners, having three hundred and ninety-six (396) delinquent medical records greater than one hundred and twenty (120) days incomplete and inaccurate with no dates, times, and/or authentication recorded on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths) by the practitioners, and having two hundred and ninety-three (293) delinquent medical records in 2011 incomplete and inaccurate with no dates, times, and/or authentication recorded on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths) by the practitioners as per policy. (See deficiency cited at A0438); and

3) Failing to ensure all practitioner's entries in the patient's medical records were completed, dated, timed and/or authenticated by the person responsible for assessing the patient as per policies. This was evidenced during the review of the random ten (10) physician's delinquent records (S22MD, S23MD, S24MD, S25MD, S26MD, S27MD, S28MD, S29MD, S30MD, S31MD) from 03/14/11 through 04/30/12, who were reviewed for completion of dating, timing, and/or authentication recorded by the physicians, (S22MD through S31MD), on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths). There were one thousand three hundred and eighty-nine (1389) medical records delinquent greater than thirty (30) days with two thousand five hundred and sixty (2560) entries with no dates, times, and/or authentications recorded on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths) for 146 of the 202 medical staff from 03/14/11 through 04/30/12. There were eight hundred nineteen (819) medical records delinquent greater than sixty (60) days with one thousand five hundred and twenty-five (1525) entries with no dates, times, and/or authentications recorded on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths) for 127 of the 202 medical staff from 03/14/11 to 04/30/12 as revealed by Medical Records computer generated report. (See deficiency cited at A0450).
VIOLATION: ORGANIZATION AND STAFFING Tag No: A0432
Based on record reviews, observations, and staff interviews, the governing body failed to ensure physician's with delinquent medical records greater than thirty (30) days were automatically suspended and not allowed admitting clinical privileges as per the "Medical Staff Rules and Regulations" for the one-thousand, three-hundred, and eighty-nine (1389) delinquent medical records with two-thousand, five-hundred, and sixty (2560)entries with no dates, times and/or authentications recorded on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths) from 03/14/11 through 05/21/12 for 146 of the 202 medical staff as revealed by Medical Records computer generated report. There were 10 of 10 sampled medical staff, (S22MD, S23MD, S24MD, S25MD, S26MD, S27MD, S28MD, S29MD, S30MD, and S31MD) focused reviewed for delinquent medical records from 03/14/11 through 05/21/12. Findings:

On 06/27/12 from 11:00 a.m. through 2:15 p.m., observations of the medical records department were performed with S32Registered Health Information Management (RHIM). During this observation, a computer printout of the medical records delinquent greater than 30 days was printed. Review of the computer delinquent medical records printouts dated/timed 06/27/12 at 12:21 p.m. revealed there were 1389 medical records delinquent greater than 30 days with 2560 entries from 03/14/11 through 05/21/12 for 146 of the 202 medical staff as revealed by medical records computer generated report There were 10 of 10 sampled medical staff (S22, S23, S24, S25, S26, S27, S28, S29, S30, and S31) reviewed for delinquent medical records greater than 30 days. There were no "Delinquent Reports by Physicians" for the 1389 charts delinquent greater than 30 days for the 10 of 10 physicians (S22MD - S31MD) and/or for the 146 of the 202 medical staff listing the deficiencies submitted during the survey conducted from 06/18/12 through 06/27/12.

There was no documentation of the May of 2012, "Delinquent Medical Record Reports by Physicians" for the 146 of the 202 medical staff May provided during the survey from 06/18/12 to 06/27/12.

Review of the "Suspension Notice" letter faxed to the active medical staff for medical records delinquent greater than thirty (30) days read, "...in accordance with the Medical Staff Bylaws, Rules and Regulations, a physician's admitting and surgical privileges are to be suspended if he or she had failed to complete records within thirty days of them being made available to him or her. This is a suspension notice, indicating that you have incomplete records that have been made available to you for at least thirty days, as of the date of this letter. (Refer to the attached list of your incomplete records. Record's ages appear in the "Age" column on the Deficiency Report by Physician)...".

There was no documented evidence in the electronic delinquent record computer system of "Suspension Notices" faxed to the 146 of the 202 physicians for the 1389 medical records delinquent greater than 30 days with 2560 deficiencies from 03/14/11 to 05/21/12.

There were no "Suspension Notices" with "Deficiency Report by Physician" letters submitted for the 1389 medical records delinquent greater than 30 days with 2560 deficiencies from 03/14/11 to 05/21/12 for the 146 of the 202 physicians submitted during the survey conducted from 06/18/12 through 06/27/12.

In interviews on 06/26/12 at 9:15 a.m. and on 06/27/12 from 10:15 a.m. through 12:35 p.m., S32RHIM indicated all 1389 medical records in the medical records department are inaccurate, incomplete, and delinquent greater than 30 days with no dates, times and/or authentications recorded on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths) from 03/14/11 through 05/21/12 as per policy. S32RHIM further indicated she does not keep the "Deficiency Report by Physician" letters faxed to the physicians monthly. She stated the "Suspension Notices" with the attached "Deficiency Report by Physician" reports are put in the shred bin. S32RHIM provided the surveyor with twenty-seven (27) "Suspension Notices" for ten (10) physicians (S22MD-4 notices, S23MD-1 notice, S24MD-4 notices, S25MD-4 notices, S26MD-1 notice, S27MD-4 notices, S28MD-1 notice, S29MD-4 notices, S30MD-3 notices, and S31MD-1 notice) for 10 of 127 physicians with eight hundred and nineteen (819) delinquent medical records greater than sixty (60) days from 03/14/11 through 03/31/12 and for 10 of 491 physicians with four hundred and ninety-one (491) delinquent medical records greater than ninety (90) days from 03/14/11 to 04/30/12. S32RHIM indicated the hospital failed to follow the "Medical Staff Rules and Regulations" that states a medical record that has not been completed within 30 days after patient discharge it shall be considered delinquent and an automatic suspension shall be imposed on the thirtieth (30th) day following the date the record was made available to the appointee for completion for the 10 of 10 focused physicians out of the total of 146 of 202 physicians from 03/14/11 to 05/21/12.

During a telephone interview conducted on 06/27/12 at 1:45 p.m., S6Medical Director denied knowledge there were 1389 medical records delinquent greater than 30 days with incompleted, dated, timed and/or authenticated recorded on the entries from 03/14/11 through 04/30/12. S6Medical Director denied knowledge there were 819 charts delinquent greater than 60 days for 127 of 202 medical staff. S6Medical Director further denied knowledge there were 491 delinquent medical records greater than 90 days for 115 of 202 medical staff. S6Medical Director did not know the "Medical Staff Bylaws and Rules and Regulations" indicated an automatic suspension shall be imposed on the 30th day for delinquent records. The Medical Director, S6 indicated the physicians have ninety (90) days to complete a medical record. S6Medical Director denied knowledge that all medical records must be completed in 30 days from discharge of a patient as per the state requirement.

In an interview conducted on 06/27/12 at 1:55 p.m., S2Director of Nursing (DON) confirmed the "Medical Staff Bylaws", effective date of 11/17/11 and print date of 01/17/12 were the hospital's current bylaws. Further S2DON verified the hospital's "Medical Staff Rules and Regulations", effective date of 11/17/11, indicated an automatic suspension of physicians shall be imposed on the 30th day. The DON, S2 denied knowledge there were 1389 medical records delinquent greater than 30 days with incomplete and inaccurate records with no dates, times, and/or authentications recorded on the entries from 03/14/11 through 05/21/12. S2DON indicated the hospital is not following the bylaws and rules and regulations to automatically suspend the physician's clinical privileges for the 1389 delinquent medical records greater than 30 days as per protocol from 03/14/11 through 05/21/12.

During an interview conducted on 06/27/12 at 1:55 p.m., S1Administrator verified the "Medical Staff Bylaws" with an effective date of 11/17/11 and print date of 01/17/12 were the hospital's most current bylaws. S1Administrator denied knowledge the medical records department had a total of 1389 medical records delinquent greater than 30 days for 146 of 202 medical staff. The Administrator, S1 denied knowledge of an automatic suspension of the medical staff shall be imposed on the 30th day as per the "Medical Staff Bylaws and Rules and Regulations". S1Administrator indicated the hospital follows the bylaws and rules and regulations for delinquent medical records greater than 30 days by sending the physicians "Suspension Notices" as per protocol. The Administrator, S1 denied knowledge S32RHIM did not keep a copy of the "Suspension Notices" with the "Deficiency Report by Physician" attached to the letter and faxed to the physicians monthly as per protocol. S1Administrator did not know there were incomplete and inaccurate medical record entries from 03/14/11 through 04/30/12 for S22MD, S23MD, S24MD, S25MD, S26MD, S27MD, S28MD, S29MD, S30MD, S31MD) for the 819 delinquent medical records greater than 60 days. S1Administrator denied knowledge there were no automatic suspension of clinical privileges implemented for the 10 of 10 physician's (S22MD, S23MD, S24MD, S25MD, S26MD, S27MD, S28MD, S29MD, S30MD, S31MD) and/or for the other 136 of 202 medical staff with a total of 1389 delinquent medical records greater than 30 days as per the "Bylaws and Rules and Regulations. S1Administrator further denied knowledge there was no automatic suspension of admitting privileges implemented for the 9 of 10 physicians (S22, S23, S24, S25, S26, S27, S28, S29, S31) and/or for the one hundred and eighteen (118) of 202 medical staff with 819 delinquent medical records greater than 60 days imposed on the 30th day as per the Bylaws and Rules and Regulations.

In an interview held on 06/27/12 at 2:00 p.m., S21Medical Director of PI (performance improvement) verified the "Medical Staff Bylaws and Rules and Regulations", effective date of 11/17/11, Print date of 01/17/12 was the hospital's current "Medical Staff Bylaws and Rules and Regulations". The Medical Director of PI, S21 indicated there have not been any amendments to the "Bylaws" made since the 11/17/11. S21 further indicated an automatic suspension must be implemented for all medical records delinquent greater than 30 days as per the bylaws and rules and regulations. The Medical Director of PI, S21 denied knowledge the medical records department had a total of 1389 charts delinquent greater than 30 days with incomplete and inaccurate records with no dates, times and/or authentications recorded on the entries by the person responsible for providing the service from 03/14/11 through 04/30/12 as per protocol. S21Medical Director of PI did not know there were 819 delinquent medical records greater than 60 days.

The "Medical Staff Rules and Regulations", Effective date of 11/17/11, Printed date of 01/17/12, Article 2-Medical Records, Part A-General Information, Sec. (3)-Authentication, pages 5 - 7, and Article 16-Delinquency, read in part, "...A. A medical record that has not been completed within thirty (30) days after patient discharge shall be considered delinquent...C. An automatic suspension shall be imposed on the thirtieth (30th) day following the date the record was made available to the appointee for completion. Such suspension shall take the form of withdrawal of a physician's non-emergency admitting and surgical privileges, and shall be effective until the medical records are completed...E. Automatic suspension will not occur without written notification of delinquent medical record(s) as described above, unless the notification is undeliverable. Such suspension will not effect the appointee's ability to treat any inpatient or observation patient who is currently admitted to his care in the Hospital; however, such appointee may not electively admit patients, perform surgeries or other inpatient or outpatient procedures on patients who are admitted by other practitioners during the suspension, schedule future surgeries or outpatient procedures for him/herself to perform, or act as a consultant in other than emergency situations....G. Whenever an appointee has been on suspension for twelve (12) consecutive weeks, he/she will be required to attend the very next scheduled meeting of the Medical Executive Committee and explain his/her reason for continued delinquency. If the reason is not acceptable to the MEC, he/she will be given until the next meeting of the MEC to complete the delinquent records and be removed from suspension. If, by the time of the next meeting of the MEC the records are still not completed, his/her appointment to the Medical Staff and all clinical privileges shall be relinquished, resulting in automatic voluntary resignation from the MS, and expiration of all clinical privileges as required in these bylaws and applicable rules and regulations and without appeal. Reappointment will require a completely new application and shall carry with it an application fee...".

Review of the policy titled, "Appointment, Reappointment, and Clinical Privileges", Appointment Policy, Effective date of 11/17/11, Printed date of 01/17/12, with no revised/reviewed dates, Article 2-Actions Affecting Medical Staff Appointees, Part E-Other Actions, Sec. (1)-Failure to Complete Medical Records, page 27, the policy indicated the clinical privileges of any individual shall be voluntarily relinquished for failure to complete medical records in accordance with regulations governing them and after notification by the Department of Health Information Services of such delinquency.

Review of the "Medical Staff Bylaws", Effective date of 11/17/11, Printed date of 01/17/12, Article 2-Preamble, Sec. (2)-Process, pages 5 - 6, and Article 12-Appointment, Reappointment and Clinical Privileging, Indications and process for automatic suspension of MS membership & (and) clinical privileges, page 23, Part D-Indications and Process for Automatic Suspension of MS Membership and/or Clinical Privileges, Sec. (1) - Indications, and Sec. (2)- Process read in part, "...Article 2-Preamble section "37"...The purposes of the Medical Staff are:...Sec. (2)-Process...7, To establish, maintain, enforce and comply with the Bylaws, Rules and Regulations and Policy on Appointment, Reappointment and Clinical Privileges for the Medical Staff...Article 12-Appointment, Reappointment and Clinical Privileging, Part D-Indications and Process for Automatic Suspension of MS Membership and/or Clinical Privileges, Sec. (1)-Indications...a. Failure to complete medical records, the associated details of which are delineated in Article (2), Part E, Sec. (1) of the Appointment policy and Article 16 of the Rules and Regulations...Sec. (2)-Process...Whenever any of these indications occur, the individual's MS membership and/or clinical privileges will be voluntarily relinquished until the indication is resolved, the associated details of which are described in Article (2), Part E, Sections (1) - (5) of the Appointment Policy...".

The policy titled, "Documentation Rules For Medical Record Entries", with no policy number, Effective date of September of 2001 (09/01), Revised date of February of 2008 (02/2008), Reviewed date of 02/2012, revealed this policy applies to all physicians who are authorized to document in patient records. All entries shall be authenticated by the person making the entry. Authentication means establishment of authorship by written signature. Signatures shall include the first initial, last name, and title. All entries shall include date, and entries shall include time.

Review of the policy titled, "Outpatient Analysis", Policy Number XX-HI-0000, Last Revised date of June of 2012 (06/2012), with no created/effective dates, revealed it is the policy of the Health Information Services Department to ensure that outpatient records are analyzed for the accuracy, timeliness, authentication, and completion of documentation in accordance with Medical Staff Regulations and regulatory requirements.

The policy titled, "Policy/Procedure Name", Policy Number: XX-HI-000, Created date of 06/2008, Revised/Reviewed date of March of 2012 (3/12), revealed it is the policy of the Health Information Services Department to ensure that charts are completed in a timely manner.

The "Governing Constitution and Body Bylaws", Reviewed/Revised date of May 27, 2010, Article II. Objectives and Article VII. Medical Staff, revealed it is the objective of the corporation to ensure compliance with all government, state, and hospital regulations, laws, and policies and procedures. The Medical Staff shall maintain Bylaws, Rules and Regulations and Policies relative to their duties and responsibilities and any amendments shall be submitted to the Board for approval. An amendment to the Bylaws, Rules and Regulations, or any Medical Staff Policy is required to comply with any federal, state, or local law or regulations or any standard or requirement of any hospital accrediting body, the Board. The Bylaws of the Medical Staff shall be consistent with and not conflict with these Bylaws.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on record reviews, observations, and staff interviews, the hospital failed to have a system in place to ensure all medical records were accurately written and promptly completed in accordance with Federal Regulations and policies as evidenced by having one thousand three hundred and eighty-nine (1389) medical records delinquent greater than thrifty (30) days incomplete and inaccurate with no dates, times, and/or authentications recorded on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths) by the practitioners from 03/14/11 through 04/30/12, having eight hundred and nineteen (819) delinquent medical records greater than sixty (60) days incomplete and inaccurate with no dates, times and/or authentication recorded on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths) by the practitioners from 03/14/12 to 04/30/12, having four hundred and ninety-one (491) delinquent medical records greater than ninety (90) days incomplete and inaccurate with no dates, times, and/or authentication recorded on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths) by the practitioners, having three hundred and ninety-six (396) delinquent medical records greater than one hundred and twenty (120) days incomplete and inaccurate with no dates, times, and/or authentication recorded on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths) by the practitioners, and having two hundred and ninety-three (293) delinquent medical records in 2011 incomplete and inaccurate with no dates, times, and/or authentication recorded on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths) by the practitioners as per policy. Findings:

On 06/25/12 from 9:15 a.m. through 3:15 p.m., on 06/26/12 from 9:15 a.m. through 10:00 a.m., and on 06/27/12 from 11:00 a.m. through 2:15 p.m., observations of the medical records department was performed with S32 Registered Health Information Management (RHIM). During this observation, a computer printout of the the medical records delinquent greater than 30 days, delinquent greater than 60 days, delinquent greater than 90 days, delinquent greater than 120 days, and delinquent in 2011. Review of the computer delinquent medical records printouts dated/timed 06/27/12 at 12:21 p.m. and 06/25/12 at 2:05 p.m. revealed there were 1389 medical records delinquent greater than 30 days incomplete and inaccurate with 2560 entries for 146 of the 202 medical staff with no dates, times and/or authentication recorded on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths) from 03/14/11 through 05/21/12. There were 819 medical records delinquent greater than 60 days incomplete and inaccurate with 1525 entries for the 127 of the 202 medical staff with no dates, times and/or authentications recorded on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths) from 03/14/11 to 04/30/12. There were 491 medical records delinquent greater than 90 days incomplete and inaccurate with 891 deficiencies with no dates, times and/or authentication recorded on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths) for the 115 of the 202 medical staff. There were 396 medical records delinquent greater than 120 days incomplete and inaccurate with 669 deficiencies with no dates, times and/or authentication recorded on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths) for the 100 of the 202 medical staff. There were 293 medical records delinquent in 2011 incomplete and inaccurate with 434 deficiencies with no dates, times, and/or authentication recorded on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths) for 85 of the 202 medical staff.

In interviews on 06/26/12 at 9:15 a.m. and on 06/27/12 from 10:15 a.m. through 12:35 p.m., S32RHIM indicated all 1389 medical records in the medical records department are inaccurate, incomplete and delinquent greater than 30 days with no dates, times and/or authentications recorded on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths) from 03/14/11 through 04/30/12 as per policy. S32RHIM further indicated there are 819 medical records delinquent greater than 60 days, 491 medical records delinquent greater than 90 days, 396 medical records delinquent greater than 120 days, and 293 medical records delinquent in 2011 in the medical record department that are inaccurate and incomplete with no dates, times and/or authentication recorded on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths) from 03/14/11 to 05/21/12 as per policy. S32RHIM denied knowledge there was a state law requiring all medical records are to be completed within 30 days following discharge of the patient. S32RHIM verified there was no medical record policy requiring all medical records to be completed within 30 days of discharge as per regulation. S32RHIM indicated the hospital failed to automatically suspend the physicians for medical records delinquent greater than 30 days for the 1389 delinquent medical records greater than 30 days as per the Rules and Regulations.

The policy titled, "Documentation Rules For Medical Record Entries", with no policy number, effective date of September of 2001 (09/01), last revised date of February of 2008 (02/2008), last reviewed date of February of 2012 (02/2012), revealed this policy applies to all physicians who are authorized to document in patient records. All entries shall be authenticated by the person making the entry. Authentication means establishment of authorship by written signature. Signatures shall include the first initial, last name, and title. All entries shall include date, and entries shall include time.

The policy titled, "Policy/Procedure Name", Policy Number: XX-HI-000, Created date of June of 2008 (06/2008), Revised/Reviewed date of February of 2012 (3/12), revealed it is the policy of the Health Information Services Department to ensure that charts are completed in a timely manner.

Review of the policy titled, "Outpatient Analysis", Policy Number XX-HI-0000, Last Revised date of June of 2012 (06/2012), with no created/effective dates, revealed it is the policy of the Health Information Services Department to ensure that outpatient records are analyzed for the accuracy, timeliness, authentication, and completion of documentation in accordance with Medical Staff Regulations and regulatory requirements.

The "Medical Staff Rules and Regulations", Effective date of 11/17/11, Printed date of 01/17/12, Article 2-Medical Records, Part A-General Information, Sec. (3)-Authentication, pages 5 - 7, and Article 16-Delinquency, read in part, "...A. A medical record that has not been completed within thirty (30) days after patient discharge shall be considered delinquent. B. Each appointee will be notified biweekly of the status of his/her incomplete records. Such notice shall include: number of incomplete records, number of delinquent records and deadline date for completion of records to avoid suspension. C. An automatic suspension shall be imposed on the thirtieth (30th) day following the date the record was made available to the appointee for completion. Such suspension shall take the form of withdrawal of a physician's non-emergency admitting and surgical privileges, and shall be effective until the medical records are completed...".

Review of the "Medical Staff Bylaws", Effective date of 11/17/11, Printed date of 01/17/12, Article 2-Preamble, Sec. (2)-Process, pages 5 - 6, and Article 12-Appointment, Reappointment and Clinical Privileging, Indications and process for automatic suspension of MS membership &clinical privileges, page 23, Part D-Indications and Process for Automatic Suspension of MS Membership and/or Clinical Privileges, Sec. (1) - Indications, and Sec. (2)- Process read in part, "...Article 2-Preamble section "37"...The purposes of the Medical Staff are:...Sec. (2)-Process...7 To establish, maintain, enforce and comply with the Bylaws, Rules and Regulations and Policy on Appointment, Reappointment and Clinical Privileges for the Medical Staff...Article 12-Appointment, Reappointment and Clinical Privileging, Part D-Indications and Process for Automatic Suspension of MS Membership and/or Clinical Privileges, Sec. (1)-Indications...a. Failure to complete medical records, the associated details of which are delineated in Article (2), Part E, Sec. (1) of the Appointment policy and Article 16 of the Rules and Regulations...Sec. (2)-Process...Whenever any of these indications occur, the individual's MS membership and/or clinical privileges will be voluntarily relinquished until the indication is resolved, the associated details of which are described in Article (2), Part E, Sections (1) - (5) of the Appointment Policy...".

Review of the policy titled, "Appointment, Reappointment, and Clinical Privileges", Appointment Policy, Effective date of 11/17/11, Printed date of 01/17/12, with no revised/reviewed dates, Article 2-Actions Affecting Medical Staff Appointees, Part E-Other Actions, Sec. (1)-Failure to Complete Medical Records, page 27, the policy indicated the clinical privileges of any individual shall be voluntarily relinquished for failure to complete medical records in accordance with regulations governing them and after notification by the Department of Health Information Services of such delinquency.

The "Governing Constitution and Body Bylaws", Reviewed/Revised date of May 27, 2010, Article II. Objectives and Article VII. Medical Staff, revealed it is the objective of the corporation to ensure compliance with all government, state, and hospital regulations, laws, and policies and procedures. The Medical Staff shall maintain Bylaws, Rules and Regulations and Policies relative to their duties and responsibilities and any amendments shall be submitted to the Board for approval. An amendment to the Bylaws, Rules and Regulations, or any Medical Staff Policy is required to comply with any federal, state, or local law or regulations or any standard or requirement of any hospital accrediting body, the Board. The Bylaws of the Medical Staff shall be consistent with and not conflict with these Bylaws.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on record reviews, observations, and staff interviews, the hospital failed to ensure all practitioner's entries in the patient's medical records were completed, dated, timed and/or authenticated by the person responsible for assessing the patient as per policies. This was evidenced during the review of the random ten (10) physician's delinquent records (S22MD, S23MD, S24MD, S25MD, S26MD, S27MD, S28MD, S29MD, S30MD, S31MD) from 03/14/11 through 04/30/12, who were reviewed for completion of dating, timing, and/or authentication recorded by the physicians, (S22MD through S31MD), on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths). There were one thousand three hundred and eighty-nine (1389) medical records delinquent greater than thirty (30) days with two thousand five hundred and sixty (2560) entries with no dates, times, and/or authentications recorded on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths) for 146 of the 202 medical staff from 03/14/11 through 04/30/12 as revealed by medical records computer generated report. There were eight hundred nineteen (819) medical records delinquent greater than sixty (60) days with one thousand five hundred and twenty-five (1525) entries with no dates, times, and/or authentications recorded on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths) for 127 of the 202 medical staff from 03/14/11 to 04/30/12. Findings:

On 06/25/12 from 9:15 a.m. through 3:15 p.m., on 06/26/12 from 9:15 a.m. through 10:00 a.m., and on 06/27/12 from 11:00 a.m. through 2:15 p.m., observations of the medical records department was performed with S32Registered Health Information Management (RHIM). During this observation, a computer printout of the the medical records delinquent greater than 30 days, greater than 60 days, and greater than ninety (90) days. Review of the computer delinquent medical records printouts dated/timed 06/27/12 at 12:21 p.m. and 06/25/12 at 2:05 p.m. revealed there were 1389 medical records delinquent greater than 30 days with 2560 deficiencies for 146 of the 202 medical staff from 03/14/11 through 05/21/12. There were 819 medical records delinquent greater than 60 days with 1525 deficiencies for 127 of the 202 medical staff from 03/14/11 to 05/21/12. There were four hundred and ninety-one (491) delinquent medical records greater than 90 days with eight hundred and nineteen (819) deficiencies for one hundred and fifteen (115) of the 202 medical staff from 03/14/11 to 03/31/12. There were no "Deficiency Report by Physician" specifically detailing the patient's name, medical record number, admitted , discharge date , age, deficiency, need, and/or chart location/days for the 146 of the 202 physicians with 1389 delinquent medical records greater than 30 days and/or for the 127 of the 202 physicians with 1525 delinquent medical records greater than 60 days.

There was a "Deficiency Report by Physician" attached to the "Suspension Notices" faxed to the physicians that included a lists of the patient's name, medical record numbers, admitted s, discharge date s, ages, deficiencies, needs, and/or chart's locations/days.

Review of the "Suspension Notice" letter faxed to the medical staff for medical records delinquent greater than thirty (30) days read in accordance with the Medical Staff Bylaws, Rules and Regulations, a physician's admitting and surgical privileges are to be suspended if he or she had failed to complete records within thirty days of them being made available to him or her. This is a suspension notice, indicating that you have incomplete records that have been made available to you for at least thirty days, as of the date of this letter. (Refer to the attached list of your incomplete records. Records ages appear in the "Age" column on the Deficiency Report by Physician.

There were twenty-seven (27) "Suspension Notices" provided on 06/27/112 at 11:40 a.m. for ten (10) medical staff physician's (S22MD-4 notices, S23MD-1 notice, S24MD-4 notices, S25MD-4 notices, S26MD-1 notice, S27MD-4 notices, S28MD-1 notice, S29MD-4 notices, S30MD-3 notices, and S31MD-1 notice) for delinquent medical records greater than 60 days and for delinquent medical records greater than 90 days. Review of the "Suspension Notices" is as follows:

S22MD:
There were a total of four (4) suspension notices dated 04/13/12, 04/26/12, 05/10/12, and 05/23/12 faxed to S22MD. The "Suspension Notice, Deficiency Report by Physician" letter dated 04/13/12 revealed S22MD had a total of 100 charts with 224 deficiencies with incomplete progress notes, orders, death summaries, history and physicals, consents, discharge notes,discharge orders, operative reports, queries, pronunciations, and/or time of death recorded by S22MD from 07/01/11 through 03/10/12.

Review of the "Suspension Notice, Deficiency Report by Physician" letter dated 04/26/12 revealed S22MD had 84 charts with 196 deficiencies with incomplete progress notes, orders, death summaries, history and physicals, consents, discharge notes, discharge orders, operative reports, queries, pronunciations, and/or time of deaths recorded from 08/04/12 to 03/27/12.

The "Suspension Notice, Deficiency Report by Physician" letter dated 05/10/12 revealed S22MD had 119 charts with 262 deficiencies that had incomplete progress notes, orders, death summaries, history and physicals, consents, discharge notes,discharge orders, operative reports, queries, pronunciations, and/or time of deaths recorded from 08/04/11 through 04/10/12.

Review of the "Suspension Notice, Deficiency Report by Physician" letter dated 05/23/12 revealed there were 121 charts with 265 deficiencies that included progress notes, orders, death summaries, history and physicals, consents, discharge notes,discharge orders, operative reports, queries, pronunciations, and/or time of deaths with no dating, timing, and/or authentication recorded by S22MD from 08/04/12 through 04/19/12.

S23MD:
There were a total of two (2) "Suspension Notices" dated 04/13/12 and 04/26/12 faxed/mailed to S23MD. Review of the "Suspension Notice, Deficiency Report by Physician" letter dated 04/13/12 and 04/26/12 revealed S23MD had 11 medical records with 11 deficiencies with no date, time, and/or authentication recorded on the death summaries, progress notes, orders, history and physical, discharge summary, and/or death summaries from 06/29/11 through 10/11/11.

S24MD:
There were four (4) "Suspension Notices" dated 04/13/12, 04/26/12, 05/10/12, and 05/23/12 faxed to S24MD. The "Suspension Notice, Deficiency Report by Physician" letters dated 04/13/12, 04/26/12, and 05/10/12 revealed there were 24 charts with 40 deficiencies with no dates, times, and/or authentications by S24MD on the progress notes, orders, consents, circumcision, and/or history and physical from 08/05/11 to 03/30/12.

Review of the "Suspension Notice, Deficiency Report by Physician" letter dated 05/23/12 revealed there were 25 charts with 41 deficiencies with no dates, times, and/or authentications recorded by S24MD from 08/05/11 through 04/11/12.

S25MD:
There were 4 "Suspension Notices" dated 04/13/12, 04/26/12, 05/10/12, and 05/23/12 faxed to S25MD. The "Suspension Notice, Deficiency Report by Physician" letter dated 04/13/12 revealed there were 44 charts with 71 deficiencies with no date, time, and/or authentication recorded by S25MD on the discharge summaries, orders, history and physicals, progress notes, consents, and discharge notes from 10/02/11 to 03/26/12.

Review of the "Suspension Notice, Deficiency Report by Physician" letter dated 04/26/12 revealed there were 50 patient medical records with 81 deficiencies with no recorded dates, times, and/or authentications by S25MD on the discharge summaries, orders, progress notes, history and physicals, consents, and discharge notes from 10/02/11 through 04/19/12.

The "Suspension Notice, Deficiency Report by Physician" letter dated 05/10/12 revealed there were 10 charts with 19 deficiencies with no dates, times, and/or authentications recorded by S25MD on the discharge summaries, history and physical, orders, progress notes from 12/19/11 to 03/20/12.

Review of the "Suspension Notice, Deficiency Report by Physician" letter dated 05/23/12 revealed there were 15 charts with 27 deficiencies with no recorded dates, times, and/or authentication by S25MD on the discharge summaries, orders, history and physicals, progress notes, and blood consent from 12/19/11 through 04/19/12.

S26MD:
There was one (1) "Suspension Notice" dated 04/13/12 faxed to S26MD. Review of the "Suspension Notice, Deficiency Report by Physician" letter dated 04/13/12 revealed there were 15 charts with 22 deficiencies with no dates, times, and/or authentication recorded by S26MD on the history and physicals, orders, circumcision, progress notes, others, discharge summary from 06/02/11 to 04/08/12.

S27MD:
There were four (4) "Suspension Notices" dated 04/12/12, 04/26/12, 05/10/12, and 05/23/12 faxed to S27MD. The "Suspension Notice, Deficiency Report by Physician" letter dated 04/12/12 revealed there were 11 charts with 23 deficiencies that did not have dates, times, and/or authentication by S27MD recorded on the discharge notes, discharge summaries, orders, progress notes, and/or blood consents from 12/20/11 through 04/02/12.

Review of the "Suspension Notice, Deficiency Report by Physician" letter dated 04/26/12 revealed there were 14 charts with 31 deficiencies with no dates, times, and/or authentications recorded by S27MD on the discharge summaries, discharge notes, discharge order, blood consents, progress notes, and orders from 11/15/11 to 04/23/12.

The "Suspension Notice, Deficiency Report by Physician" letter dated 05/10/12 revealed there were 17 charts with 39 deficiencies with no dates, times, and/or authentications recorded by S27MD on the discharge notes, discharge orders, discharge summaries, orders, blood consents, and progress notes from 11/15/11 to 04/28/12.

Review of the"Suspension Notice, Deficiency Report by Physician" letter dated 05/23/12 revealed there were 14 charts with 31 deficiencies with no dates, times, and/or authentications recorded by S27MD on the discharge order, discharge notes, discharge summaries, orders, blood consents, and progress notes from 11/15/11 through 04/20/12.

S28MD:
There was one (1) "Suspension Notice" faxed to S28MD dated 05/10/12. Review of the "Suspension Notice, Deficiency Report by Physician" letter dated 05/10/12 revealed there was 67 charts with 112 deficiencies with no dates, times, and/or authentications recorded by S28MD on the orders, discharge summaries, discharge notes, death summary, operative reports, others, progress notes, informed consent, ASA class, and admit order from 06/14/11 to 04/04/12.

S29MD:
There were four (4) "Suspension Notices" faxed to S29MD on 04/13/12, 04/26/12, 05/10/12, and 05/23/12. The "Suspension Notice, Deficiency Report by Physician" letter dated 04/13/12 revealed there were 35 charts with 51 deficiencies with no dates, times, and/or authentications recorded by S29MD on the discharge notes, discharge summaries, history and physicals, orders, consult, consents, and death summary from 10/21/11 through 04/09/12.

Review of the "Suspension Notice, Deficiency Report by Physician" letter dated 04/26/12 revealed there were 38 charts with 58 deficiencies with no dates, times, and/or authentications recorded by S29MD on the discharge notes, discharge summaries, orders, history and physicals, death summaries, consult, orders, and consents from 09/10/11 to 04/20/12.

The "Suspension Notice, Deficiency Report by Physician" letter dated 05/10/12 revealed there were 36 charts with 53 deficiencies with no dates, times, and/or authentications recorded by S29MD on the discharge notes, discharge summaries, history and physicals, orders, consult, consents, and death summary from 09/10/11 through 04/09/12.

Review of the "Suspension Notice, Deficiency Report by Physician" letter dated 05/23/12 revealed there were 29 charts with 45 deficiencies with no dates, times, and/or authentications recorded by S29MD on the discharge notes, discharge summaries, history and physicals, death summaries, orders, and other from 09/10/11 to 04/23/12.

S30MD:
There were three (3) "Suspension Notices" faxed to S30MD on 04/13/12, 04/26/12, and 05/10/12. The "Suspension Notice, Deficiency Report by Physician" letters dated 04/13/12 and 04/26/12 revealed there were 13 charts with 17 deficiencies with no dates, times, and/or authentications recorded by S30MD on the orders, discharge summaries, discharge note, and progress notes from 06/29/11 through 02/29/12.

Review of the "Suspension Notice, Deficiency Report by Physician" letter dated 05/10/12 revealed there were 14 charts with 18 deficiencies with no dates, times, and/or authentications recorded by S30MD on the orders, discharge summaries, and progress notes from 06/29/11 to 04/30/12.

S31MD:
There was one (1) "Suspension Notice" faxed to S31MD on 05/10/12. Review of the "Suspension Notice, Deficiency Report by Physician" letter dated 05/10/12 revealed there was 69 charts with 122 deficiencies with no dates, times, and/or authentications recorded by S31MD on the discharge summaries, discharge notes, discharge order, operative reports, consult, history and physicals, others, consents, orders, consults, and anesthesia evaluation from 03/14/11 through 04/09/12.

Further review of the twenty-seven (27) "Suspension Notices" faxed to the 10 of 10 physicians, (S22MD - S31MD) for the delinquent medical records greater than 90 days and greater than 60 days revealed there were 8 physicians, (S22MD, S24MD, S25MD, S27MD, S28MD, S29MD, S30MD, and S31MD) of the 127 of 202 medical staff faxed "Suspension Notices" for delinquent medical records greater than 60 days from 03/14/11 to 04/30/12 and there were eight (8) physicians, (S22MD, S23MD, S24MD, S25MD, S26MD, S27MD, S29MD, and S30MD) of the 115 of 202 medical staff faxed "Suspension Notices" for deliquent medical records greater than 90 days from 03/14/11 to 03/31/12. These "Suspension Notices" were as follows:
Delinquent medical records greater than 90 days from 03/14/11 through 03/31/12 revealed S22MD had 2 notices dated 04/13/12 and 04/26/12, S23MD had 2 notices dated 04/13/12 and 04/27/12, S24MD had 2 notices dated 04/13/12 and 04/26/12, S25MD had 04/13/12 and 04/26/12, S26MD had 1 notice dated 04/13/12, S27MD had 2 notices dated 04/12/12 and 04/26/12, S29MD had 2 notices dated 04/13/12 and 04/23/12, S30MD had 2 notices dated 04/13/12 and 04/26/12; and
Deliquent medical records greater than 60 days from 03/14/11 to 04/30/12 revealed
S22MD had 2 notices dated 05/10/12 and 05/23/12, S24MD had 05/10/12 and 05/23/12, S25 had 2 notices dated 05/10/12 and 05/23/12, S27MD had 2 notices dated 05/10/12 and 05/23/12, S28MD had 1 notice dated 05/10/12, S29MD had 2 notices dated 05/10/12 and 05/23/12, S30MD had 1 notice dated 05/10/12, and S31MD had 1 notice dated 05/10/12.

The 10 of 10 physicians (S22MD - S31MD) had a total of sixty-eight (68) of 491 charts with ninety-three (93) of 891 deficiencies according to the "Deficiency Report by Physician" from 03/14/11 through 03/31/12. There were no "Suspension Notice" letters submitted for the other four hundred and twenty-three (423) of the 491 medical records delinquent greater than 90 days with ninety-three (93) deficiencies out of the 891 deficiencies for the 10 of 10 physicians out of the total 115 of 202 physicians from 03/14/11 to 05/21/12 submitted during the survey conducted from 06/18/12 to 06/27/12. Further the 10 of 10 physicians (S22MD -S31MD) had there a total of eighty-two (82) medical records delinquent with one hundred and twenty-one (121) of 1525 deficiencies from 03/14/11 through 04/30/12 for the 127 of 202 medical staff. There were no "Suspension Notices" submitted for the other seven hundred and thirty-seven (737) of the 819 delinquent medical records with of the other one thousand four hundred and four (1404) of the 1525 deficiencies for the 127 of 202 physicians from 03/14/11 to 04/30/12 presented to the surveyor during the survey from 06/18/12 through 06/27/12.

In interviews on 06/26/12 at 9:15 a.m. and on 06/27/12 from 10:15 a.m. through 12:35 p.m., S32RHIM indicated all 1389 medical records in the medical records department are inaccurate, incomplete and delinquent greater than 30 days with no dates, times and/or authentications recorded on the progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of death from 03/14/11 through 05/21/12 as per policy. S32RHIM further indicated there are 819 medical records delinquent greater than 60 days in the medical record department that are inaccurate, incomplete with no dates, times and/or authentications recorded on the progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths from 03/14/11 to 05/21/12 as per policy. S32RHIM confirmed there were 491 delinquent medical records with 891 incomplete and inaccurate entries (deficiencies) greater than 90 days for 115 of 202 medical staff as per policy. S32RHIM stated all "Suspension Notices" are faxed to the physician's office for all medical records delinquent greater than 30 days as per protocol. S32RHIM further stated these "Suspension Notices" are put in the shred bin and they are shredded by staff. S32RHIM indicated all "Suspension Notices" have an attached "Deficiency Report by Physician" that includes a list of the patient's names, date of admits, date of discharges, and deficiencies. S32RHIM the attached "Deficiency Report by Physician" is also put in the shred bin and shredded by staff. S32RHIM verified there were 28 "Suspension Notices" for 10 physicians (S22MD-4 notices, S23MD-1 notice, S24MD-4 notices, S25MD-4 notices, S26MD-1 notice, S27MD-4 notices, S28MD-1 notice, S29MD-4 notices, S30MD-3 notices, and S31MD-1 notice) submitted for delinquent medical records greater than 90 days from 03/14/11 through 03/31/12 and delinquent medical records greater than 60 days from 03/14/11 through 04/30/12. S32RHIM verified there were eight (8) physicians, (S22MD, S23MD, S24MD, S25MD, S26MD, S27MD, S29MD, and S30MD) of the 115 of 202 medical staff faxed "Suspension Notices" for deliquent medical records greater than 90 days from 03/14/11 to 03/31/12 and there were seven (7) physicians, (S22MD, S24MD, S25MD, S27MD, S28MD, S29MD, S30MD, and S31MD) of the 127 of 202 medical staff faxed "Suspension Notices" for delinquent medical records greater than 60 days from 03/14/11 to 04/30/12. S32RHIM denied knowledge there was a state law requiring all medical records are to be completed within 30 days following discharge of the patient. S32RHIM verified there was no medical record policy requiring all medical records are to be completed within 30 days of discharge. S32RHIM indicated the hospital failed to automatically suspend the physicians for medical records delinquent greater than 30 days as per policy and as per the Rules and Regulations. S32RHIM further indicated the medical record system is broken for all medical records to be completed within 30 days of discharge from the hospital.

During a telephone interview conducted on 06/27/12 at 1:45 p.m., S6Medical Director denied knowledge there were 1389 medical records delinquent greater than 30 days with incompleted, dated, timed and/or authenticated recorded on the entries from 03/14/11 through 04/30/12. S6Medical Director denied knowledge the "Medical Staff Bylaws and Rules and Regulations" indicated an automatic suspension shall be imposed on the 30 th day for delinquent records. The Medical Director, S6 indicated the physicians have ninety (90) days to complete a medical record. S6Medical Director denied knowledge all medical records must be complete and accurate in 30 days as per the minimal state requirement.

In an interview conducted on 06/27/12 at 1:55 p.m., S2Director of Nursing (DON) confirmed the "Medical Staff Bylaws", effective date of 11/17/11 and print date of 01/17/12 were the hospital's current bylaws. Further S2DON verified the hospital's "Medical Staff Rules and Regulations", effective date of 11/17/11, indicated an automatic suspension of physicians shall be imposed on the 30 th day. The DON, S2 denied knowledge there were 1389 medical records delinquent greater than 30 days with incomplete, inaccurate entries with no dates, times and/or authentications recorded on the entries from 03/14/11 through 04/30/12 and/or 819 medical records delinquent greater than 60 days with incomplete inaccurate, dating, timing and/or authentication recorded on entries from 03/14/11 to 04/30/12. S2DON indicated the hospital is not following the bylaws and rules and regulations to automatically suspend the physician's clinical privileges for the 1389 delinquent medical records greater than 30 days as per protocol.

During an interview conducted on 06/27/12 at 1:55 p.m., S1Administrator verified the "Medical Staff Bylaws" with an effective date of 11/17/11 and print date of 01/17/12 were the hospital's most current bylaws. S1Administrator denied knowledge the medical records department had a total of 1389 medical records delinquent greater than 30 days and 819 medical records delinquent greater than 60 days. The Administrator, S1 denied knowledge of an automatic suspension of the medical staff shall be imposed on the 30 th day following the date the record was made available to the appointee for completion as per the "Medical Staff Rules and Regulations". S1Administrator indicated the hospital follows the bylaws and rules and regulations for delinquent medical records greater than 30 days by sending the physicians "Suspension Notices" as per protocol. The Administrator, S1 denied knowledge S32RHIM did not keep a copy of the "Suspension Notices" faxed to the physicians monthly as per protocol. S1Administrator denied knowledge there were incomplete medical record entries from 03/14/11 through 04/30/12 with the physicians (S22, S23, S24, S25, S26, S27, S28, S29, S30, S31) with no suspension of clinical privileges for the medical records delinquent 30 days.

In an interview held on 06/27/12 at 2:00 p.m., S21Medical Director of PI (performance improvement) verified the "Medical Staff Bylaws and Rules and Regulations", Effective date of 11/17/11, Print date of 01/17/12 was the hospital's current. S21 indicated there have not been any amendments to the "Bylaws" since the 11/17/11. S21 further indicated an automatic suspension must be implemented for all medical records delinquent greater than 30 days as per the bylaws and rules and regulations. The Medical Director of PI, S21 denied knowledge the medical records department had a total of 1389 charts delinquent greater than 30 days with incomplete and inaccurate records with no dates, times and/or authentications recorded on the entries by the person responsible for providing the service from 03/14/11 through 04/30/12 as per protocol.

The policy titled, "Documentation Rules For Medical Record Entries", with no policy number, Effective date of 09/01, Revised date of 02/2008, Reviewed date of 02/2012, revealed this policy applies to all physicians who are authorized to document in patient records. All entries shall be authenticated by the person making the entry. Authentication means establishment of authorship by written signature. Signatures shall include the first initial, last name, and title. All entries shall include date, and entries shall include time.

Review of the "Medical Staff Bylaws", Effective date of 11/17/11, Printed date of 01/17/12, Article 2-Preamble, Sec. (2)-Process, pages 5 - 6, and Article 12-Appointment, Reappointment and Clinical Privileging, Indications and process for automatic suspension of MS membership &clinical privileges, page 23, Part D-Indications and Process for Automatic Suspension of MS Membership and/or Clinical Privileges, Sec. (1) - Indications, and Sec. (2)- Process read in part, "...Article 2-Preamble section "37"...The purposes of the Medical Staff are:...Sec. (2)-Process...7 To establish, maintain, enforce and comply with the Bylaws, Rules and Regulations and Policy on Appointment, Reappointment and Clinical Privileges for the Medical Staff...Article 12-Appointment, Reappointment and Clinical Privileging, Part D-Indications and Process for Automatic Suspension of MS Membership and/or Clinical Privileges, Sec. (1)-Indications...a. Failure to complete medical records, the associated details of which are delineated in Article (2), Part E, Sec. (1) of the Appointment policy and Article 16 of the Rules and Regulations...Sec. (2)-Process...Whenever any of these indications occur, the individual's MS membership and/or clinical privileges will be voluntarily relinquished until the indication is resolved, the associated details of which are described in Article (2), Part E, Sections (1) - (5) of the Appointment Policy...".

The "Medical Staff Rules and Regulations", Effective date of 11/17/11, Printed date of 01/17/12, Article 2-Medical Records, Part A-General Information, Sec. (3)-Authentication, pages 5 - 7, and Article 16-Delinquency, read in part, "...A. A medical record that has not been completed within thirty (30) days after patient discharge shall be considered delinquent. B. Each appointee will be notified biweekly of the status of his/her incomplete records. Such notice shall include: number of incomplete records, number of delinquent records and deadline date for completion of records to avoid suspension. C. An automatic suspension shall be imposed on the thirtieth (30 th) day following the date the record was made available to the appointee for completion. Such suspension shall take the form of withdrawal of a physician's non-emergency admitting and surgical privileges, and shall be effective until the medical records are completed...E. Automatic suspension will not occur without written notification of delinquent medical record(s) as described above, unless the notification is undeliverable. Such suspension will not effect the appointee's ability to treat any inpatient or observation patient who is currently admitted to his care in the Hospital; however, such appointee may not electively admit patients, perform surgeries or other inpatient or outpatient procedures on patients who are admitted by other practitioners during the suspension, schedule future surgeries or outpatient procedures for him/herself to perform, or act as a consultant in other than emergency situations....G. Whenever an appointee has been on suspension for twelve (12) consecutive weeks, he/she will be required to attend the very next scheduled meeting of the Medical Executive Committee and explain his/her reason for continued delinquency. If the reason is not acceptable to the MEC, he/she will be given until the next meeting of the MEC to complete the delinquent records and be removed from suspension. If, by the time of the next meeting of the MEC the records are still not completed, his/her appointment to the Medical Staff and all clinical privileges shall be relinquished, resulting in automatic voluntary resignation from the MS, and expiration of all clinical privileges as required in these bylaws and applicable rules and regulations and without appeal. Reappointment will require completely new application and shall carry with it an application fee...".

Review of the policy titled, "Outpatient Analysis", Policy Number XX-HI-0000, Last Revised date of 06/2012, with no created/effective dates, revealed it is the policy of the Health Information Services Department to ensure that outpatient records are analyzed for the accuracy, timeliness, authentication, and completion of documentation in accordance with Medical Staff Regulations and regulatory requirements.

The policy titled, "Policy/Procedure Name", Policy Number: XX-HI-000, Created date of 06/2008, Revised/Reviewed date of 3/12, revealed it is the policy of the Health Information Services Department to ensure that charts are completed in a timely manner.

Review of the policy titled, "Appointment, Reappointment, and Clinical Privileges", Appointment Policy, Effective date of 11/17/11, Printed date of 01/17/12, with no revised/reviewed dates, Article 2-Actions Affecting Medical Staff Appointees, Part E-Other Actions, Sec. (1)-Failure to Complete Medical Records, page 27, the policy indicated the clinical privileges of any individual shall be voluntarily relinquished for failure to complete medical records in accordance with regulations governing them and after notification by the Department of Health Information Services of such delinquency.

The "Governing Constitution and Body Bylaws", Reviewed/Revised date of May 27, 2010, Article II. Objectives and Article VII. Medical Staff, revealed it is the objective of the corporation to ensure compliance with all government, state, and hospital regulations, laws, and policies and procedures. The Medical Staff shall maintain Bylaws, Rules and Regulations and Policies relative to their duties and responsibilities and any amendments shall be submitted to the Board for approval. An amendment to the Bylaws, Rules and Regulations, or any Medical Staff Policy is required to comply with any federal, state, or local law or regulations or any standard or requirement of any hospital accrediting body, the Board. The Bylaws of the Medical Staff shall be consistent with and not conflict with these Bylaws.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observation, record review and interview the hospital failed to ensure the Nurse Call buttons on the hospital beds on the second floor and ICU (Intensive Care Unit) and the Bed Exit Alarms were transmitted to the nursing station as evidenced by the hospital failing to provide the necessary cable to interface the bed and the existing call systems in place. This resulted in the Nurse call buttons on the left and right handrails of every bed on the second floor and ICU to be non-functional and resulted in the Bed Exit Alarm to function only in the patients room instead of being transmitted to the Nursing Station. Findings:

In an interview on 06/27/12 at 9:30 am with S4RN, QA, and S2CNO both confirmed that the electronic plugs for the hospital beds to attach to the Gen 3 (call system on the 2nd floor/Med/Surg Unit) which would enable the nurse call buttons on the left and right side of the hospital beds to function and allow the bed exit alarm to be transmitted to the nursing station are not functional. S4RN, QA, and S2CNO both confirmed that the nurse call buttons on the hospital beds are non-functional. S4RN, QA, and S2CNO both confirmed there is no hospital policy in place to educate the patient/family regarding the non-functional buttons on the beds that are clearly labeled, "Nurse". Both stated that patients/family members are instructed to use the combination TV/Nurse button device which is attached to the wall by a cord to call for assistance.

In an interview on 06/27/12 at 10:10 am with S20Maintenance, S4RN, QA, and S2CNO present S20 was asked to determine the capability of the hospital beds and current Gen 3 call system on the 2nd floor and the Gen 5 call system in ICU as it relates to the nurse call buttons on the beds and the transmission of a bed exit alarm to the nursing station. On 06/27/12 at 10:50 am S20Maintenance, with S4RN, QA, and S3COO present, reported that he spoke with the manufacturer of the beds and was informed of the following: The Bed Exit Alarms could be tied into both the Gen 3 and Gen 5 call systems currently in place. This would allow a "High Priority" alarm to be transmitted to the nursing station when a patient with an activated Bed Exit Alarm left the hospital bed. S20Maintenance reported that a cable to connect the existing hospital beds to the existing call systems would make 100% of the beds capable of having the Nurse Call buttons on the beds and the Bed Exit Alarms transmitted to the Nursing Station. S20Maintenance confirmed that currently the 2 buttons marked "Nurse" on the beds are non-functional and the Bed Exit Alarms sound locally (in the room) only.
VIOLATION: MEDICAL STAFF - BYLAWS AND RULES Tag No: A0048
Based on record reviews, observations, and staff interviews, the governing body failed to ensure physicians delinquent medical records greater than thirty (30) days were automatically suspended and not allowed admitting clinical privileges as per the "Medical Staff Rules and Regulations" for the one thousand eighty-nine (1389) delinquent medical records with two thousand five hundred sixty (2560) deficiencies from 03/14/11 through 05/21/12 for 10 of 10 focused medical staff out of the total of 146 of the 202 medical staff, (S22, S23, S24, S25, S26, S27, S28, S29, S30, S31). Findings:

On 06/25/12 from 9:15 a.m. through 3:15 p.m., on 06/26/12 from 9:15 a.m. through 10:00 a.m., and on 06/27/12 from 11:00 a.m. through 2:15 p.m., observations of the medical records department was performed with S32Registered Health Information Management (RHIM). During this observation, a computer printout of the the medical records delinquent greater than thirty (30) days was printed. Review of the computer delinquent medical records printouts dated/timed 06/27/12 at 12:21 p.m. revealed there were 1389 medical records delinquent greater than 30 days with 2560 deficiencies from 03/14/11 through 05/21/12 for 10 of 10 focused medical staff out of a total of 146 of the 202 medical staff, (S22, S23, S24, S25, S26, S26, S28, S29, S30, S31).

There were no "Delinquent Report By Physician" for the 146 of 202 physicians with 1389 delinquent medical records from 03/14/11 through 05/21/12 presented during the survey from 06/18/12 to 06/27/12. Further there was no documentation of the monthly "Delinquent Medical Record Reports by Physicians" listing the patients, the date of discharges and/or deficiencies provided for the 146 of the 202 physicians for the 2560 deficiencies from 03/14/11 to 05/21/12 submitted during the survey conducted from 06/18/12 to 06/27/12.

There was no documented evidence in the electronic computer system of "Suspension Notices" faxed to the 10 of 10 physicians (S22MD - S31MD) and/or to the other 136 of the 202 physicians with 1389 medical records delinquent greater than 30 days from 03/14/11 to 05/21/12.

Review of the "Suspension Notice" letter faxed to the active medical staff for medical records delinquent greater than thirty (30) days read in accordance with the Medical Staff Bylaws, Rules and Regulations, a physician's admitting and surgical privileges are to be suspended if he or she had failed to complete records within thirty days of them being made available to him or her. This is a suspension notice, indicating that you have incomplete records that have been made available to you for at least thirty days, as of the date of this letter. (Refer to the attached list of your incomplete records. Records ages appear in the "Age" column on the Deficiency Report by Physician.

There were twenty-seven (27) "Suspension Notices" letter with "Deficiency Report by Physicians" provided on 06/27/112 at 11:40 a.m. for ten (10) medical staff physician's (S22MD-4 notices, S23MD-1 notice, S24MD-4 notices, S25MD-4 notices, S26MD-1 notice, S27MD-4 notices, S28MD-1 notice, S29MD-4 notices, S30MD-3 notices, and S31MD-1 notice) for the medical records delinquent greater than 60 days and delinquent greater than 90 days. These "Suspension Notices" letters were as follows:

S22MD:
There were a total of four (4) suspension notices dated 04/13/12, 04/26/12, 05/10/12, and 05/23/12 faxed to S22MD. The "Suspension Notice, Deficiency Report by Physician" letter dated 04/13/12 revealed S22MD had a total of 100 charts with 224 deficiencies with incomplete progress notes, orders, death summaries, history and physicals, consents, discharge notes,discharge orders, operative reports, queries, pronunciations, and/or time of death recorded by S22MD from 07/01/11 through 03/10/12.

Review of the "Suspension Notice, Deficiency Report by Physician" letter dated 04/26/12 revealed S22MD had 84 charts with 196 deficiencies with incomplete progress notes, orders, death summaries, history and physicals, consents, discharge notes, discharge orders, operative reports, queries, pronunciations, and/or time of deaths recorded from 08/04/12 to 03/27/12.

The "Suspension Notice, Deficiency Report by Physician" letter dated 05/10/12 revealed S22MD had 119 charts with 262 deficiencies that had incomplete progress notes, orders, death summaries, history and physicals, consents, discharge notes,discharge orders, operative reports, queries, pronunciations, and/or time of deaths recorded from 08/04/11 through 04/10/12.

Review of the "Suspension Notice, Deficiency Report by Physician" letter dated 05/23/12 revealed there were 121 charts with 265 deficiencies that included progress notes, orders, death summaries, history and physicals, consents, discharge notes,discharge orders, operative reports, queries, pronunciations, and/or time of deaths with no dating, timing, and/or authentication recorded by S22MD from 08/04/12 through 04/19/12.

S23MD:
There were a total of two (2) "Suspension Notices" dated 04/13/12 and 04/26/12 faxed/mailed to S23MD. Review of the "Suspension Notice, Deficiency Report by Physician" letter dated 04/13/12 and 04/26/12 revealed S23MD had 11 medical records with 11 deficiencies with no date, time, and/or authentication recorded on the death summaries, progress notes, orders, history and physical, discharge summary, and/or death summaries from 06/29/11 through 10/11/11.

S24MD:
There were four (4) "Suspension Notices" dated 04/13/12, 04/26/12, 05/10/12, and 05/23/12 faxed to S24MD. The "Suspension Notice, Deficiency Report by Physician" letters dated 04/13/12, 04/26/12, and 05/10/12 revealed there were 24 charts with 40 deficiencies with no dates, times, and/or authentication's by S24MD on the progress notes, orders, consents, circumcision, and/or history and physical from 08/05/11 to 03/30/12.

Review of the "Suspension Notice, Deficiency Report by Physician" letter dated 05/23/12 revealed there were 25 charts with 41 deficiencies with no dates, times, and/or authentication's recorded by S24MD from 08/05/11 through 04/11/12.

S25MD:
There were 4 "Suspension Notices" dated 04/13/12, 04/26/12, 05/10/12, and 05/23/12 faxed to S25MD. The "Suspension Notice, Deficiency Report by Physician" letter dated 04/13/12 revealed there were 44 charts with 71 deficiencies with no date, time, and/or authentication recorded by S25MD on the discharge summaries, orders, history and physicals, progress notes, consents, and discharge notes from 10/02/11 to 03/26/12.

Review of the "Suspension Notice, Deficiency Report by Physician" letter dated 04/26/12 revealed there were 50 patient medical records with 81 deficiencies with no recorded dates, times, and/or authentication's by S25MD on the discharge summaries, orders, progress notes, history and physicals, consents, and discharge notes from 10/02/11 through 04/19/12.

The "Suspension Notice, Deficiency Report by Physician" letter dated 05/10/12 revealed there were 10 charts with 19 deficiencies with no dates, times, and/or authentication's recorded by S25MD on the discharge summaries, history and physical, orders, progress notes from 12/19/11 to 03/20/12.

Review of the "Suspension Notice, Deficiency Report by Physician" letter dated 05/23/12 revealed there were 15 charts with 27 deficiencies with no recorded dates, times, and/or authentication by S25MD on the discharge summaries, orders, history and physicals, progress notes, and blood consent from 12/19/11 through 04/19/12.

S26MD:
There was one (1) "Suspension Notice" dated 04/13/12 faxed to S26MD. Review of the "Suspension Notice, Deficiency Report by Physician" letter dated 04/13/12 revealed there were 15 charts with 22 deficiencies with no dates, times, and/or authentication recorded by S26MD on the history and physicals, orders, circumcision, progress notes, others, discharge summary from 06/02/11 to 04/08/12.

S27MD:
There were four (4) "Suspension Notices" dated 04/12/12, 04/26/12, 05/10/12, and 05/23/12 faxed to S27MD. The "Suspension Notice, Deficiency Report by Physician" letter dated 04/12/12 revealed there were 11 charts with 23 deficiencies that did not have dates, times, and/or authentication by S27MD recorded on the discharge notes, discharge summaries, orders, progress notes, and/or blood consents from 12/20/11 through 04/02/12.

Review of the "Suspension Notice, Deficiency Report by Physician" letter dated 04/26/12 revealed there were 14 charts with 31 deficiencies with no dates, times, and/or authentication's recorded by S27MD on the discharge summaries, discharge notes, discharge order, blood consents, progress notes, and orders from 11/15/11 to 04/23/12.

The "Suspension Notice, Deficiency Report by Physician" letter dated 05/10/12 revealed there were 17 charts with 39 deficiencies with no dates, times, and/or authentication's recorded by S27MD on the discharge notes, discharge orders, discharge summaries, orders, blood consents, and progress notes from 11/15/11 to 04/28/12.

Review of the"Suspension Notice, Deficiency Report by Physician" letter dated 05/23/12 revealed there were 14 charts with 31 deficiencies with no dates, times, and/or authentication's recorded by S27MD on the discharge order, discharge notes, discharge summaries, orders, blood consents, and progress notes from 11/15/11 through 04/20/12.

S28MD:
There was one (1) "Suspension Notice" letter faxed to S28MD dated 05/10/12. Review of the "Suspension Notice, Deficiency Report by Physician" letter dated 05/10/12 revealed there was 67 charts with 112 deficiencies with no dates, times, and/or authentication's recorded by S28MD on the orders, discharge summaries, discharge notes, death summary, operative reports, others, progress notes, informed consent, ASA class, and admit order from 06/14/11 to 04/04/12.

S29MD:
There were four (4) "Suspension Notices" faxed to S29MD on 04/13/12, 04/26/12, 05/10/12, and 05/23/12. The "Suspension Notice, Deficiency Report by Physician" letter dated 04/13/12 revealed there were 35 charts with 51 deficiencies with no dates, times, and/or authentication's recorded by S29MD on the discharge notes, discharge summaries, history and physicals, orders, consult, consents, and death summary from 10/21/11 through 04/09/12.

Review of the "Suspension Notice, Deficiency Report by Physician" letter dated 04/26/12 revealed there were 38 charts with 58 deficiencies with no dates, times, and/or authentication's recorded by S29MD on the discharge notes, discharge summaries, orders, history and physicals, death summaries, consult, orders, and consents from 09/10/11 to 04/20/12.

The "Suspension Notice, Deficiency Report by Physician" letter dated 05/10/12 revealed there were 36 charts with 53 deficiencies with no dates, times, and/or authentication's recorded by S29MD on the discharge notes, discharge summaries, history and physicals, orders, consult, consents, and death summary from 09/10/11 through 04/09/12.

Review of the "Suspension Notice, Deficiency Report by Physician" letter dated 05/23/12 revealed there were 29 charts with 45 deficiencies with no dates, times, and/or authentication's recorded by S29MD on the discharge notes, discharge summaries, history and physicals, death summaries, orders, and other from 09/10/11 to 04/23/12.

S30MD:
There were three (3) "Suspension Notices" faxed to S30MD on 04/13/12, 04/26/12, and 05/10/12. The "Suspension Notice, Deficiency Report by Physician" letters dated 04/13/12 and 04/26/12 revealed there were 13 charts with 17 deficiencies with no dates, times, and/or authentication's recorded by S30MD on the orders, discharge summaries, discharge note, and progress notes from 06/29/11 through 02/29/12.

Review of the "Suspension Notice, Deficiency Report by Physician" letter dated 05/10/12 revealed there were 14 charts with 18 deficiencies with no dates, times, and/or authentication's recorded by S30MD on the orders, discharge summaries, and progress notes from 06/29/11 to 04/30/12.

S31MD:
There was one (1) "Suspension Notice" faxed to S31MD on 05/10/12. Review of the "Suspension Notice, Deficiency Report by Physician" letter dated 05/10/12 revealed there was 69 charts with 122 deficiencies with no dates, times, and/or authentication's recorded by S31MD on the discharge summaries, discharge notes, discharge order, operative reports, consult, history and physicals, others, consents, orders, consults, and anesthesia evaluation from 03/14/11 through 04/09/12.

There were no "Suspension Notice" with "Deficiency Report by Physician" letters submitted for the one thousand one hundred and ninety-three (1389) medical records delinquent greater than 30 days with two thousand five hundred and sixty (2560) deficiencies from 03/14/11 to 05/21/12 for the 146 of the 202 physicians submitted during the survey conducted from 06/18/12 through 06/27/12.

There were no "Suspension Notice" letters provided for the 146 of 202 medical staff with 1389 delinquent medical records greater than 30 days provided during the survey from 06/18/12 to 06/27/12.

Review of the "Deficiency Report By Physician" for the 10 of 10 physicians (S22MD - S31MD) out of the 146 of 202 medical staff revealed the 10 physicians had a total of one hundred and ninety-six (196) charts out of the 1389 charts with three hundred and forty-four (344) out of the 2560 deficiencies. Further review revealed there was no detailed monthly "Delinquent Report by Physician" for May of 2012 including the lists of patients, date of discharges and deficiencies provided for the 146 of 202 medical staff and/or for the 10 of 10 physicians (S22MD - S31MD) with 1389 delinquent medical records greater than 30 days submitted during the survey from 06/18/12 through 06/27/12.

In interviews on 06/26/12 at 9:15 a.m. and on 06/27/12 from 10:15 a.m. through 12:35 p.m., S32RHIM indicated all 1389 medical records in the medical records department are inaccurate, incomplete and delinquent greater than 30 days with no dates, times and/or authentication's recorded on the entries (progress notes, physician orders, death summaries, history and physicals, blood and informed consents, discharge notes, discharge orders, discharge summaries, operative reports, queries, pronunciations, circumcision forms, others, and/or time of deaths) from 03/14/11 through 05/21/12 as per policy. S32RHIM further indicated she does not keep the "Deficiency Report by Physician" letters faxed to the physicians monthly. She stated the "Suspension Notices" with the attached "Deficiency Report by Physician" reports are put in the shred bin. S32RHIM provided the surveyor with twenty-eight (28) "Suspension Notices" for ten (10) physicians (S22MD-4 notices, S23MD-1 notice, S24MD-4 notices, S25MD-4 notices, S26MD-1 notice, S27MD-4 notices, S28MD-1 notice, S29MD-4 notices, S30MD-3 notices, and S31MD-1 notice). S32RHIM indicated the hospital failed to follow the "Medical Staff Rules and Regulations" for a medical record that has not been completed within 30 days after patient discharge shall be considered delinquent and an automatic suspension shall be imposed on the thirtieth (30th) day following the date the record was made available to the appointee for completion for the 10 of 10 focused physicians out of the total of 146 of 202 physicians from 03/14/11 to 05/21/12.

During a telephone interview conducted on 06/27/12 at 1:45 p.m., S6Medical Director denied knowledge there were 1389 medical records delinquent greater than 30 days with incomplete, dated, timed and/or authenticated recorded on the entries from 03/14/11 through 04/30/12. S6Medical Director denied knowledge the "Medical Staff Bylaws and Rules and Regulations" indicated an automatic suspension shall be imposed on the 30 th day for delinquent records. The Medical Director, S6 indicated the physicians have ninety (90) days to complete a medical record. S6Medical Director denied knowledge all medical records must be completed in 30 days from discharge of a patient as per the minimal state requirement.

In an interview conducted on 06/27/12 at 1:55 p.m., S2Director of Nursing (DON) confirmed the "Medical Staff Bylaws", effective date of 11/17/11 and print date of 01/17/12 were the hospital's current bylaws. Further S2DON verified the hospital's "Medical Staff Rules and Regulations", effective date of 11/17/11, indicated an automatic suspension of physicians shall be imposed on the 30 th day. The DON, S2 denied knowledge there were 1389 medical records delinquent greater than 30 days with incomplete and inaccurate records with no dates, times and/or authentication's recorded on the entries from 03/14/11 through 05/21/12. S2DON indicated the hospital is not following the bylaws and rules and regulations to automatically suspend the physician's clinical privileges for the 1389 delinquent medical records greater than 30 days as per protocol from 03/14/11 through 05/21/12.

During an interview conducted on 06/27/12 at 1:55 p.m., S1Administrator verified the "Medical Staff Bylaws" with an effective date of 11/17/11 and print date of 01/17/12 were the hospital's most current bylaws. S1Administrator denied knowledge the medical records department had a total of 1389 medical records delinquent greater than 30 days. The Administrator, S1 denied knowledge of an automatic suspension of the medical staff shall be imposed on the 30 th day as per the "Medical Staff Bylaws and Rules and Regulations". S1Administrator indicated the hospital follows the bylaws and rules and regulations for delinquent medical records greater than 30 days by sending the physicians "Suspension Notices" as per protocol. The Administrator, S1 denied knowledge S32RHIM did not keep a copy of the "Suspension Notices" with "Deficiency Report by Physician" attached to the letter and faxed to the physicians monthly as per protocol. S1Administrator denied knowledge there were incomplete medical record entries from 03/14/11 through 04/30/12 for S22MD, S23MD, S24MD, S25MD, S26MD, S27MD, S28MD, S29MD, S30MD, S31MD) and no automatic suspension of their clinical privileges was imposed for the medical records delinquent 30 days as per the Rules and Regulations.

In an interview held on 06/27/12 at 2:00 p.m., S21Medical Director of PI (performance improvement) verified the "Medical Staff Bylaws and Rules and Regulations", Effective date of 11/17/11, Print date of 01/17/12 was the hospital's current. S21 indicated there have not been any amendments to the "Bylaws" since the 11/17/11. S21 further indicated an automatic suspension must be implemented for all medical records delinquent greater than 30 days as per the bylaws and rules and regulations. The Medical Director of PI, S21 denied knowledge the medical records department had a total of 1389 charts delinquent greater than 30 days with incomplete and inaccurate records with no dates, times and/or authentication's recorded on the entries by the person responsible for providing the service from 03/14/11 through 04/30/12 as per protocol.

The "Medical Staff Rules and Regulations", Effective date of 11/17/11, Printed date of 01/17/12, Article 2-Medical Records, Part A-General Information, Sec. (3)-Authentication, pages 5 - 7, and Article 16-Delinquency, read in part, "...A. A medical record that has not been completed within thirty (30) days after patient discharge shall be considered delinquent...C. An automatic suspension shall be imposed on the thirtieth (30 th) day following the date the record was made available to the appointee for completion. Such suspension shall take the form of withdrawal of a physician's non-emergency admitting and surgical privileges, and shall be effective until the medical records are completed...E. Automatic suspension will not occur without written notification of delinquent medical record(s) as described above, unless the notification is undeliverable. Such suspension will not effect the appointee's ability to treat any inpatient or observation patient who is currently admitted to his care in the Hospital; however, such appointee may not electively admit patients, perform surgeries or other inpatient or outpatient procedures on patients who are admitted by other practitioners during the suspension, schedule future surgeries or outpatient procedures for him/herself to perform, or act as a consultant in other than emergency situations....G. Whenever an appointee has been on suspension for twelve (120 consecutive weeks, he/she will be required to attend the very next scheduled meeting of the Medical Executive Committee and explain his/her reason for continued delinquency. If the reason is not acceptable to the MEC, he/she will be given until the next meeting of the MEC to complete the delinquent records and be removed from suspension. If, by the time of the next meeting of the MEC the records are still not completed, his/her appointment to the Medical Staff and all clinical privileges shall be relinquished, resulting in automatic voluntary resignation from the MS, and expiration of all clinical privileges as required in these bylaws and applicable rules and regulations and without appeal. Reappointment will require completely new application and shall carry with it an application fee...".

Review of the policy titled, "Appointment, Reappointment, and Clinical Privileges", Appointment Policy, Effective date of 11/17/11, Printed date of 01/17/12, with no revised/reviewed dates, Article 2-Actions Affecting Medical Staff Appointees, Part E-Other Actions, Sec. (1)-Failure to Complete Medical Records, page 27, the policy indicated the clinical privileges of any individual shall be voluntarily relinquished for failure to complete medical records in accordance with regulations governing them and after notification by the Department of Health Information Services of such delinquency.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, record review, and interview the hospital failed to meet the Condition of Participation (CoP) of Patient Rights as evidenced by:

1) Failing to follow the hospital policy titled "Suicide Risk and Assessment and Prevention" for 1 ( #6) of 6 ER patients medical records reviewed. Patient # 6 was identified upon admission to the ER as high risk for suicide. The ER staff failed to implement the High Risk intervention of 1:1 supervision and removal of objects that may be used for self harm as required by hospital policy, resulting in Patient # 6 attempting suicide using a wrist restraint left in the patient's room. (see findings at A0144)

On 06/22/12 at 12:22 pm the hospital administrator S1 was notified of an Immediate Jeopardy. The Immediate Jeopardy situation is:

The hospital failed to ensure the Patient #6 had the right to care in a safe setting, and was free from neglect by the hospital failing to follow their policy titled Suicide Risk Assessment and Prevention. Patient #6 was triaged in the emergency room (ER) on 05/28/12 at 1850 (6:50 pm) with a Chief Complaint of stating he wanted to kill himself. Review of the initial Suicide Risk Assessment performed on 05/28/12 at 2055 (8:55 pm) by S8RN revealed the patient was "High Risk" according to hospital policy. The hospital failed to follow their policy requiring interventions which were not implemented, specifically 1:1 observation and removal of objects that may be used for self harm for 1 of 6 sampled patients (#6). The patient (#6) was restrained (one arm - left wrist) and physically held for lab to draw blood on 05/28/12 at 1937 (7:37 pm) without physician order. The Registered Nurse (S8RN) discarded the restraint in the patient's room (ER 5) waste bin. On 05/29/12 at 0700 (7:00 am) patient #6 verbalized a suicide plan to S9RN, whose Suicide Risk Assessment performed on 05/29/12 at 8:11 am also placed patient #6 in "High Risk." Hospital policy interventions were not implemented by S9RN and the physician (S6MD) was not notified. On 05/29/12 at 1140 (11:40 am) patient #6 was found by a housekeeper (S7) hanging from the restraint left in the room by S8RN. Patient #6 could not be seen by staff due to the curtain being partially drawn and there being no 1:1 monitoring per hospital policy.

The Immediate Jeopardy for Patient #6 began on 05/28/12 at 2055 (8:55 pm) when S8RN performed a Suicide Risk Assessment that, per hospital policy, required High Risk intervention 1:1 supervision, which were not implemented and ended upon his transfer on 05/29/12 at 4:50 pm.

The hospital saw 26 Psychiatric patients in the ER from 06/01/12. to 06/18/12. 26 of 26 patients were placed under a PEC (Physician's Emergency Certificate), 23 patients had documention by the ER MD as Suicidal and/or Danger to Self. 11 of the 26 patients were High Risk per the Suicide Risk Assessment, 5 of the 26 patients had no Suicide Risk Assessment performed. The hospital has no documented evidence of an investigation into the incident on 05/28/12 for Patient # 6. There continued to be no evidence of policy revision, staff education,training or staff increase to provide 1:1 supervision for high risk suicidal patients since the incident The Immediate Jeopardy continues for all Suicidal patients presenting to the ER.

On 06/26/12 at 3:05 pm the surveyor confirmed through observation, record review and interviews that the hospital did the following to remove the immediate jeopardy:

Immediate actions taken included: suicide proofing of room, re-education of staff present regarding suicide risk interventions, additional staff education was conducted by the ED Manager (S13RN) at shift change and via e-mai,. engaged in an agreement to secure officers for observation of PEC and high risk suicide patients, an initial crisis management team was appointed to evaluate and guide immediate implementation of patient safety measures, availability of needed resources, and required staff training and orientation (to include the need for an MD order for restraints), education packet was revised for future nurse training, the patients will be screened upon presentation to the emergency room (ER) and if found to be at risk the nursing supervisor will be immediately notified for any high risk suicide patient to provide staff for direct observation (as revised by policy 'Direct Observation of High Risk Suicidal Patient/PEC Patient').

While the immediate jeopardy was removed on 06/26/12 and the facility remains out of compliance at the conditon level due to the emergency room (ER) not providing Care in a Safe setting and not following their hospital policy and procedures to protect Physician's Emergency Certificate (PEC) high risk suicidal patients on 1:1 observation. Most staff not having been fully trained on new policies and changes to be made for the safety and security of patients.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on record review and interview the hospital failed to follow the hospitals grievance policy/procedure for 1 of 6 sampled patients (patient # 3) as evidenced by having no documented evidence of an investigation conducted or a written response given to the complainant, from a grievance received via telephone on 04/10/12 by S2CNO. Findings:

Review of a document typed and signed by S2CNO in response to a telephone call with the complainant on 4/10/12 at approximately 1400 (2:00 pm) revealed dissatisfaction about the care and services her mother (patient #3)received at the hospital. Further review revealed this document was not dated or timed. The complainant also requested that this conversation not be shared with her sister, (S40).

On 06/19/12 at 9:45 am a request was made to S2CNO for any documentation of an investigation and/or written response to the complainant about patient #3. S2CNO had no documentation of an investigation or written response to the grievances documented in the phone call with the family of patient #3 on 04/10/12 at 2:00 pm.

Review of a hospital policy titled "Complaint and Grievance Policy", effective June 2012, last reviewed 2/08, presented as current hospital policy, revealed in part: "I. to establish a process for timely referral, prompt review, investigation and resolution of patient complaints and grievances...III. Definition of terms...B. Grievance: is a written or verbal complaint by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to compliance with the CMS Conditions of Participation...C. Grievance Resolution Process. 1. Grievances may be received written, verbally, via electronic mail of facsimile, or by telephone...2. Upon receipt of a grievance, a patient advocate or member of senior management shall confer with the appropriate department leadership to review, investigate and resolve the issue with the patient and/or patient representative within seven days of receipt of the grievance...Abuse or neglect issues should be reviewed immediately...3...If the grievance will not be resolved within seven days, the complainant should be informed that the facility is working diligently to resolve the grievance and will follow up with a written response within 30 days...5. In resolution of the grievance, a written notice of the decision must be provided to the complainant that contains the name of a facility contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion of the investigation...7. At the discretion of the person conducting the investigation, other mechanisms may be utilized to resolve a grievance. For example, conducting a meeting with the complainant may be appropriate. However, in all cases a written notice of response with the aforementioned elements must be provided...
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


The patient has the right to receive care in a safe setting.

This STANDARD is not met as evidenced by:
Based on record review, observation and interviews the hospital failed to:

Follow the hospital policy titled "Suicide Risk and Assessment and Prevention" for 1(pt. #6) of 6 ER patients medical records reviewed. Pt. # 6 was identified upon admission to the ER as high risk for suicide. The ER staff failed to implement the High Risk intervention of 1:1 supervision and removal of objects that may be used for self harm as required by hospital policy, resulting in Pt. 6 attempting suicide using a wrist restraint left in the patient's room.

Findings
Review of the medical record for patient #6 revealed an admitted /time to the emergency room of 05/28/12 at 1849 (6:49p.m.). Patient #6 was triaged by S8RN at 1850 (6:50 pm) and the documentation by S8RN listed the "Chief Complaint" as "Pt. into ER after getting into argument with boyfriend and stating he would kill himself, denies suicidal ideations upon arrival." Further review of the Triage Form revealed S8RN documented patient #6 was "Nonurgent...Affect:Flat."

Review of nursing documentation dated/timed 05/28/12 at 2055 (8:55 p.m.) by S8RN revealed the following under "Physical Assessment" for patient #6: "Suicide Risk Assessment: In part...Things so bad lately; you'd rather die? Yes. Have you had thought of harming yourself? Yes. Have you ever attempted suicide? Yes. Ever treated for mood or mental disorder? Yes. Sex: Male. Age: 15-[AGE] years old. Depression: Yes. Prior History {previous suicide attempt}: Yes. Ethanol abuse {Drug, Alcohol, Substance}: No. Rational thinking loss: No. Support System loss: YES. Interpersonal crisis/conflict. Organized Plan: Denies plan, but has suicidal ideation. No significant other: BOYFRIEND. SAD PERSONS Total Score: Summation 6.000. Suicide Risk Leve {Score 5 or above}: High Risk Suicide Level (Score 5-10). Nursing Interventions/suicide precautions: High Risk Interventions (Score5-10). Suicide Hotline given to pt?: PEC (physician's emergency certificate).

"Review of the assessment documentation by S5MD, dated and timed 05/28 at 1915 (7:15 pm),
revealed the following: in part "HPI (history of present illness) Chief Complaint: suicidal thoughts...context: broke up with boyfriend. Associated Complaints: refuse to elaborate. Suicide Risk Assessment: male, prior attempt X 2 (twice) OD (overdose)...self injury: intent: no answer...Past Hx (history): prior suicide attempt. Psychiatric problems: depression...Psyc (psychiatric): mental status: poor eye contact, depressed, refuse to talk.".

Review of a document titled "Physician Emergency Certificate (PEC)" revealed S5MD examined patient #6 on 05/28/12 at 1915 (7:15) and placed him under (PEC) Pysician Emergency Certificate on 05/28/12 at 1055 (10:55 pm). Review of the "Findings of Examination" documented by S5MD revealed the following: "History of Present Illness: 22 y/o (year old) with suicidal ideation secondary to broke up with boyfriend today. + (positive) previous suicide attempts X 2 in the past. Physical Findings: PMHX (patient medical history): depression. Mental Condition: Flat affect, poor eye contact, refusing to answer questions..." S5MD documented that patient #6 was "Currently Suicidal, Dangerous to Self, and Unwilling to seek voluntary admission.

In an interview on 06/21/12 at 11:15 am withS8RN he stated he was the nurse who triaged patient #6 on 05/28/12 at 1850 (6:50 pm). S8RN stated that patient #6 told him during triage that he (#6) "did not mean it" when asked about stating he wanted to kill himself. S8RN further stated that "if he (#6) said it he probably meant it." S8RN confirmed the Suicide Risk
Assessment he performed on patient #6 placed #6 in the "High Risk" category. S8RN confirmed the PEC filled out by S5MD, ER, indicated patient #6 had Suicidal Ideations, a history of two Suicide attempts, was a Danger to Self, and was Unwilling to seek voluntary admission. S8RN stated he was responsible for the care of patient #6 on the night shift of 05/28/12 - 05/29/12. S8RN stated that the room (ER 5) was not cleared of items patient #6 could potentially use for self harm including the otoscope (cord), ophthalmoscope (cord), power cord for otoscope/ophthalmoscope, and 2 - 2' X 3' signs hanging on the walls. S8RN stated he could not recall if a cardiac monitor was in the room. S8RN stated there was no 1:1 observation per policy for patient #6 as "I had several other patients." S8RN further stated patient #6 should have been placed on 1:1 observation. S8RN confirmed the 1:1 observation level required by hospital policy was never documented or carried out. S8RN further reported that as recently as June 19th, 2012 (one day after the survey started and two days prior to this interview) that when he came on duty at 10:00 pm he was given on patient under PEC and "almost
immediately" was assigned another. S8RN stated there are patients under PEC "almost every shift here."

In an interview on 06/22/12 at 9:00 am with S11Lab Asst. she stated she drew patient #6's blood on 05/28/12 at 1937 (7:37 pm) (11 minutes after the order was put into the computer). S11 stated "the patient was not cooperating, was holding his arms on his chest." S11 stated she identified herself and told patient #6 she needed to draw blood for tests ordered by the physician. S11 stated the patient did not respond. S11 stated she asked for the patients (#6) arm and the patient "resisted" extension of the arm and she called for nursing assistance.

In an interview on 06/22/12 at 9:25 am with S12RN, ER, he stated he and one other RN entered ER 5 to assist S11 in regards to the blood work ordered on patient #6.S12RN stated he was not sure who brought the restraints into ER 5. S12RN stated that patient #6 was restrained on both of his upper extremities. S12RN confirmed there was no physician order to restrain patient #6 for a blood draw. S12RN stated "you never know what he is going to do" so both arms were restrained. S12RN stated he left the room and informed S8RN that "his patient (#6) was restrained." S12RN stated he does not know when the restraints were removed.

"Review of a document titled "Emergency Department Nursing Notes and Interventions" revealed the following documentation by S9RN for the day shift (7 am - 7 pm) on 05/29/12: "0700 (7:00 am): Pt. resting quietly, NAD noted, admits to suicidal ideations D/T (due to) argument w (with) BF (boyfriend), states he thought of "connecting the dots" which pt. interpreted as cutting throat from one ear to the other, calm, cooperative, denies agitation at this time, pt reports being depressed and off meds (medications) for approx 1 week, hx inpt (inpatient) stays in past, TV (television) placed in pt room. 0730 (7:30 am): Meal tray ordered, linens changed. 0830 (8:30 am): AAOX3. NAD noted. Monitoring pt. 0930 (9:30 am): assessment unchanged. 1030(10:30 am) Assessment unchanged. 1100 (11:00 am): Attempting to find placement. Contacting multiple facilities. Monitoring pt. 1140 (11:40 am): As (S7Housekeeper), walks past room, pt has restraint around neck hanging from bed.blue/purple in color w legs kicking. Placed in bed, + pulses, restraint removed from neck. placed on monitor. BP 132/75 HR 116 O2 sat 97% RA. eyes closed not responding to verbal stimulus. ammonia tablet to nose. bruising/red to neck. 1140 (11:40 a.m.) Pt shaking head, staring eyes open. Dr. (S6MD) at bedside to examine pt. bil (bilateral) wrist restraints applied. room safeguarded per ______ protocol. curtain open. TV removed from room. IV started per aseptic technique. flushes easily. taped & secure. SL (saline lock). Pt tol (tolerate) well. O2 2L (liters per minute) placed. monitoring pt. 1205 (12:05 pm): At bedside speaking w pt regarding events. pt states "I'm mad. I wish y'all would have just let me die." continued therapeutic communication to allow pt to open up. will continue to monitor. 1230 (12:30 pm): meds given per order. see MAR(medication administration record). 1240 (12:40 pm) (S10RN) at side. pt speaking more freely with nurse. no changes noted from previous story assessment this am. will continue to monitor pt...1335 (1:35 pm): pt loosening restraints. bil restraints reinforced. will continue to monitor. 1345 (1:45 pm): pt requesting to urinate. pt refusing catheter. condom cath applied. pt tol well. (S9RN) and (name) inserted cath. 1445 (2:45 pm) pt resting quietly. restraints remain reinforced. NAD noted. monitoring pt. 1536 (3:36pm): spoke w (name), administrator at (hosp "a"). states (physician name) accepts pt. 1550 (3:50pm): report given to (name), RN. 1601 (4:01 pm): IPSO (local sheriff's office) contacted regarding transportation. states will send trooper asap. 1640(4:40 pm): IPSO here for transport. pt out of ER.

In an interview on 06/21/12 at 1:45 pm with S9RN she confirmed the documentation that patient #6 voiced suicidal ideations with a plan to her at 7:00 am on 05/29/12. S9RN further confirmed this was not reported to S6MD, ER. S9RN stated that a group of high school students began a tour of the ER around 11:30 am on 05/29/12. Patient #6 reported to S9RN that this was making him nervous and requested the curtain be drawn. S9RN stated she told the patient "no". S9RN reported that patient #6 made the same request to S10RN. S10RN reportedly pulled the curtain from Right to Left to approximately half-way across the bed. S9RN stated that she could see patient #6 from the nursing station "but he must have gotten out of bed at some point then he was found hanging by (S7). S9RN stated she had 4 other patients and was leaving the desk to care for her other patients. S9RN confirmed her Suicide Risk Assessment performed on 05/29/12 at 8:11 am did place patient #6 in the High Risk category. S9RN further stated patient #6 was not placed on 1:1 observation and the room was not cleared of potentially dangerous items per hospital policy. S9RN further stated "it is common to have High Risk patients and other patients assigned to her during a shift. S9RN stated that
she did not notify anyone on 05/29/12 that staffing was inadequate to do the 1:1 policy required
observation of patient #6. S9RN stated that S7 called out for help from ER 5.S9RN stated she saw S7 on the right side of the bed pulling patient #6 up. S9RN stated the restraint was still taut. S9RN stated "I do not think so" when asked if patient #6's buttock were touching the ground. S9RN stated the legs of patient #6 were "twitching, not really kicking." S9RN stated patient #6 was breathing when the restraint was removed and the his face was bluish/purple. S9RN stated patient #6 was placed on the bed, was still unresponsive and was placed on a cardiac monitor. S9RN stated NH 3 was placed under the nose of patient #6, which woke patient up. S9RN stated patient #6 had bruising and redness to his neck.

In a telephone interview on 06/21/12 at 3:23 pm with S10RN she stated she had partially closed the curtain in the front of ER 5 because the students in the ER were causing the patient anxiety. S10RN further stated that there "was a large TV at the left side of the bed that was almost 5 feet tall and it was wider that the gap between the wall and the left side of the bed so it was out by the foot of the bed." S10RN stated the curtain was drawn from right to left "to the middle of the bed. S10RN stated she was aware patient #6 was suicidal. S10RN stated she did not ask the nurse responsible for the patient, S9RN, if patient #6 was High Risk.

Further review of the PEC revealed S6MD documented the following dated 05/28/12 at 1 pm (1:00 pm). (the date is incorrect as the incident she documented did not occur until 05/29/12): Addendum: Pt tried to strangle himself with restraints lab had used to draw blood in am earlier shift. He smiled inappropriately after restraint removed/awake AO (alert, oriented) X3.

Review of a handwritten statement signed by S7Housekeeper dated/timed 5/29/12 at 1130 (11:30 a.m.) revealed the following: "Was passing ER 5. Noticed something on floor from food tray and when I entered room, found pt dangling from left of side bed with wrist restraint around neck then to the right side of the bed. Noted he was kicking. I screamed for help as I was picking him up. Then nursing came and Dr. (S6MD) and we picked him up and put him on the bed and removed restraint from neck."

In an interview on 06/21/12 at 10:15 am S7 stated he noticed something on the floor and entered ER 5 to pick it up. S7 stated "looking into the room it looked like no one was there." S7 stated at that time he noticed "half of the patient's head above the mattress and noticed the restraint across the bed to the Left upper hand rail." S7 stated he went around to the Right side of the bed. S7 stated he noticed patient #6 was not moving and his eyes were closed. S7 stated he grabbed patient #6 under his armpits and attempted to get #6's upper body on the bed. S7 stated he called out for help and S9RN, quickly followed by other staff. S7 stated that he did not clearly remember if S9RN or S6MD removed the restraint from the neck of patient #6. S7 stated that he backed out of the room as medical personnel arrived. S7 documented on a diagram of the room that (as facing room from hall) the curtain was drawn from Right to Left to approximately to the the right edge of the centered bed, covering about 3 feet of the opening. S7 further stated that there was a large TV on the Left side of the bed.

In an interview on 06/21/12 with S13RN, ER Director, he again stated there was no documented investigation of the 05/29/12 incident in ER 5 by patient #6, no documented evidence of any training/in-services held as a result of the incident or investigation, and no documented policy or procedure changes as a result of the incident/investigation. S13RN confirmed patient #6 had an initial Suicide Risk Assessment that placed him at High Risk. S13RN stated patient #6 was not placed on 1:1 and the environment was not made safe per hospital policy. S13RN was asked if he was aware that staff states they are unable to cover 1:1 due to staffing issues. S13RN replied that the 1:1 observation on patient #6 was not done. S13RN then stated 80% of 1:1 High Risk Interventions are not covered per hospital policy.

In an interview on 06/21/12 at 9:35 am with S2CNO the RN Assignment sheets for 05/28/12
and 05/29/12 were requested. S2CNO stated she "does not recall if the hospital had a policy on RN Charge Nurse Assignments based on staffing or acuity." S2CNO further stated that an investigation was done in regards to the incident on 05/29/12 involving patient #6 but "there was no documentation of the investigation, nor policy or procedure changes no additional ER staff, and no staff education and/or training" after the incident. S2CNO further stated there is no video equipment located inside of the emergency room .

In an interview on 06/21/12 at 12:15 pm with S6MD she stated she was the ER Physician on duty on 05/29/12 and is also the Medical Director of the ER. S6MD stated that patient #6 was a High Risk patient. S6MD stated that there was no documented evidence of an investigation into the incident on 05/29/12 in ER 5 involving patient #6 and there should have been. S6MD further stated the Suicide Precautions and Interventions required by hospital policy were not implemented. S6MD stated she was aware the restraint used by patient #6 to attempt suicide was discarded in the trash inside of the patients room the night before. S6MD stated that the ERMD does not order the observation status on patients. S6MD stated patient #6 should have been placed on 1:1 observation on 05/29/12 at 0700 (7:00 am) when he voiced suicidal ideations and a plan to S9RN. S6MD stated the she, the ERMD, was not informed of this statement. S6MD stated that at around 11:40 am when she entered ER 5 she went to the left side of the bed. (as facing from hall). S6MD stated she put her fingers under the restraint around the neck of patient #6. S6MD stated the restraint was removed, she could not recall by whom, and there was "redness" to the neck of patient #6. S6MD stated she palpated a carotid pulse at this time. S6MD stated an NH 3 (ammonia) capsule was placed under the nose of patient #6. S6MD stated patient #6 was AAOX3 immediately. S6MD stated that noCPR (cardiopulmonary resuscitation), and no Ambu-bag were used to resuscitate patient #6. S6MD stated she ordered bilateral arm restraints to be placed on patient #6 at 11:40 am on 05/29/12. S6MD stated the ER "does not have enough staff to do 1:1." S6MD further stated that the lack of adequate staffing was the reason for restraint use and the application of a urine catheter for patient #6. S6MD stated she has brought the issue of Psychiatric patients and staffing to the CNO, past and present, and there has been no change. S6MD stated the hospital CFO (Chief Financial Officer) canceled the ER Security 3 years ago. S6MD stated the issue of ER Security has been brought up by her at several ER meetings in the last 6 months and that there has been no action taken in response for 2-3 years. S6MD stated she was not aware of any documentation of investigation into the incident involving patient #6, and she was not aware if any education/training was done as a result of the incident. S6MD stated the second restraint order given by her (05/29/12 at 1340 (1:40 pm)) for the use of Nonviolent restraint use on patient #6 was due to inadequate staffing. S6MD reviewed the 1 hour face to face evaluation of patient #6 performed at 12:40 pm as a result of the first application of restraints and stated there was no documentation to indicate the need for continued restraint of patient #6. S6MD again stated the patient restraint was a result of "staffing issues." S6MD further stated that the administration of Ativan 1 mg IVP at 12:30 pm as ordered by herself was in fact used as a chemical restraint and was used due to low staffing in the ER. there should have been an investigation that was documented in regards to the incident in ER 5 on 05/29/12 at approximately 11:30 am.
VIOLATION: PATIENT RIGHTS: ACCESS TO MEDICAL RECORD Tag No: A0148
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record reviews, observations, and staff interviews, the hospital failed to ensure the patient's right to access information contained in his or her clinical was obtained within a reasonable time frame as evidenced by a copy of the medical record for Patient #3 (now deceased ) being requested from next of kin (daughter) on 03/29/12 per La RS:1299.96 (2)(b)(i) in part ..".in the case of a deceased patient, the executor of his will, the adminitrator of his estte, the surving spouse or the children of the deceased patient." No copy of the medical record was provided to the family member for ninety-one (91) days due (as of the date of the survey). Findings:

Review of the "Pending Report By Charge, All Pending Requests", Run Date of 06/25/12, Received Date Range of 03/01/12 to 06/25/12 at 3:10 p.m. revealed a request for a copy of the medical record for Patient #3 was requested by a family member on 03/29/12. Further review of the Pending Requests Report revealed the "Status Reason" was "Chart Incomplete" and it was "89" days old since the request. This report was reviewed by the surveyor and S32Registered Health Information Management (RHIM) on 06/27/12 at 10:30 p.m. (two days later which made the date of request ninety-one (91) days old).

During interviews on 06/26/12 at 9:15 a.m. and on 06/27/12 from 10:15 a.m. through 12:35 p.m., S32RHIM verified a complete copy of the medical record was requested by a family member on 03/29/12 as indicated on the "Pending Requests Report". S32RHIM indicated Patient #3's chart is incomplete and no chart may be given to a patient and/or family member. S32RHIM confirmed Patient #3 was discharged from the hospital on [DATE]. S32RHIM indicated the medical record department offers the patient and/or family member a copy of an incomplete record upon their request. S32RHIM denied knowledge if the family member of Patient #3 requested a complete copy of the record and/or denied an incomplete copy of the record. S32RHIM did not know there was a state law requiring all medical records to be completed within 30 days following discharge of the patient. S32RHIM verified it is not hospital policy to provide a patient and/or legal representative a copy of an incomplete medical record. S32RHIM verified there was no medical record policy requiring all medical records to be completed within 30 days of discharge. S32RHIM indicated there is no policy requiring a complete copy of the medical record to be provided to a patient and/or family member in a specified timeframe. S32RHIM indicated 91 days is not a timely manner and acceptable time frame for a patient and/or representative to receive a complete copy of a medical record. S32RHIM further indicated a timely manner would be 30 days from the date the patient was discharged from the hospital. S32RHIM further indicated the medical record department failed to ensure the patient's right to access his or her medical record was followed in a timely manner as per the regulation.

The policy titled, "Requests for Copies of Medical Records, Number: XXX-HI-000, Created date of 03/04/2009, with no reviewed and/or revised dates, revealed it is policy for the Health Information Services Department to provide patients with copies of Medical Records upon request. Release of information to the patient and/or legal representative is done in accordance with the facility's Confidentiality of and Release of Patient Information. Detailed procedures for release of information can be referred to in the Release of Information (ROI) manual. A requests for a complete copy of a chart by a patient and/or legal representative are not made until the record is complete. The deficiency system should be checked to ensure the completion of the chart(s). When a requestor desires a copy of the incomplete record, an Incomplete Record stamp should be affixed to the facesheet and the authorization form. The customer service representative is to provide the Charting Coordinator with a list of charts pending completion for ROI processing. When there are delays, the HIM Manager or supervisor should be notified to assist the Charting Supervisor with expediting the completion of the record. The requestor should be provided with periodic updates to the status of the pending requests. Further review of the "Requests for Copies of Medical Records" policy revealed there was no documentation of a specified timeframe in which a complete and/or incomplete copy of a patient's medical record should be provided to a patient and/or legal representative.

Review of the policy titled, "Confidentiality of and Release of Patient Information", Developed date of 08/02/99, Effective date of 08/02/99, Revised date of 02/2008, and Reviewed date of 03/2012, revealed this policy applies to every person working in the facility, including, but not limited to, employees, physicians, volunteers, students, contract laborers, and vendors. The purpose of this policy is to define when the release of health information is permitted by and when consent for release of information is required, and who may have access to patient's records. All requests for health records or health information shall be directed to the Health Information Services (HIS). Release of information from the health records shall be carried out in accordance with all applicable legal, accrediting, and regulatory agency requirements, and in accordance with written institutional policy. All information contained in the health record is confidential and the release of information will be closely monitored. A properly completed and signed HIPPA-complaint authorization (attached) is required for release of all health information.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on record reviews and staff interviews, the hospital failed to measure and analyze the quality indicators reported by the medical records department for the delinquent medical records as evidenced by failing to identify, track, trend, implement corrective actions and monitor the compliance for the one thousand three hundred and eighty-nine (1389) delinquent medical records greater than thirty (30) days, the eight hundred and nineteen (819) delinquent medical records greater than sixty (60) days, the four hundred and ninety-one (491) delinquent medical records greater than ninety (90) days, the three hundred and ninety-six (396) delinquent medical records greater than one hundred and twenty (120) days and/or the two hundred and ninety-three (293) delinquent medical records in 2011 that are incomplete and inaccurate with no dates, times, and/or authentication recorded on the entries by the practitioners. Findings:

On 06/25/12 from 9:15 a.m. through 3:15 p.m., on 06/26/12 from 9:15 a.m. through 10:00 a.m., and on 06/27/12 from 11:00 a.m. through 2:15 p.m., observations of the medical records department was performed with S32Registered Health Information Management (RHIM). During this observation, a computer printout of the the medical records delinquent greater than 30 days, greater than 60 days, greater than ninety (90) days, greater than 120 days, and delinquency in 2011. Review of the computer delinquent medical records printouts dated/timed 06/27/12 at 12:21 p.m. and 06/25/12 at 2:05 p.m. revealed there were 1389 delinquent medical records greater than 30 days with two thousand five hundred and sixty (2560) deficiencies for 146 of 202 medical staff from 03/14/11 to 05/21/12. There were 819 medical records delinquent greater than 60 days with one thousand five hundred and twenty-five (1525) deficiencies for 127 of the 202 medical staff from 03/14/11 to 05/21/12. There were 491 delinquent medical records greater than 90 days with eight hundred and ninety-one (891) deficiencies for 115 of the 202 medical staff from 03/14/11 to 03/31/12. There were 396 delinquent medical records greater than 120 days with six hundred and sixty-nine (669) deficiencies for 100 of 202 medical staff from 03/14/11 to 02/28/12. There were 293 delinquent medical records for 2011 with four hundred and thirty-four (434) deficiencies for 85 of 202 medical staff from 03/14/11 to 01/31/12.

There were no "Deficiency Report by Physician" specifically detailing the patient's name, medical record number, admitted , discharge date , age, deficiency, need, and/or chart location/days for the 127 of the 202 physicians with 1525 delinquent medical records greater than 60 days, for the 115 of 202 medical staff for the 491 records with 891 deficiencies greater than 90 days, for the 100 of 202 medical staff for the 550 records with 669 deficiencies greater than 120 days, and/or for the 85 of 202 medical staff for the 293 charts with 434 deficiencies in 2011 presented during the survey from 06/18/12 through 06/27/12.

The "Medical Executive Committee" Meeting was held Tuesday, May 15, 2012. Further review of the meeting minutes revealed section, V. New Business was a) Delinquency Statistics. The March 2012 medical record delinquency reports were presented. The delinquency rate for the year was thirty-six (36) percent. The year to date rate is thirty-seven (37) percent. Suspensions by section for March were reported as well as the average delinquent charts by section as seen in the tables below. S23MD and S22MD (both named) have been sent a letter since they have been on twelve (12) weeks consecutive suspension. Further review of the report revealed the delinquency by physician section (credentialing) was reported for a total of one, hundred and thirty-two (132) physicians for the month of March. There were a total of forty (40) physician's listed on the suspension by section. The recommendation was to continue to track and trend.

Review of the "Quality Measures Relevant To Management of Information" report for the Year 2012 revealed January had a total of one, thousand twenty-one (1021) delinquent charts, February had a total of one, thousand and forty-eight (1048) delinquent charts, March had a total of one, thousand and fifty-three (1053) delinquent charts, April had a total of one, thousand, one hundred and eighty-nine (1189) delinquent charts and May had a total of one, thousand, one hundred, and seventeen (1117) delinquent charts. Further review of this report was Compared to the previous Year of 2011. Review of the Comparative Year of 2011 revealed January had a total of eight hundred and forty-seven (847) delinquent charts, February had a total of eight hundred and eighty-seven (887) delinquent charts, March had a total of eight hundred and one (801) delinquent charts, April had a total of nine hundred and ninety (990) delinquent charts, and May had a total of eight hundred and thirty-two (832) delinquent charts.

In an interview on 06/27/12 at 12:35 p.m., S32Registered Health Information Management (RHIM) verified there were 1389 medical records delinquent greater than 30 days with 2560 deficiences for 146 of 202 medical staff, 819 medical records delinquent greater than 60 days with one thousand five hundred and twenty-five (1525) deficiencies for 127 of the 202 medical staff from 03/14/11 to 05/21/12, 491 delinquent medical records greater than 90 days with eight hundred and ninety-one (891) deficiencies for 115 of the 202 medical staff from 03/14/11 to 03/31/12, 396 delinquent medical records greater than 120 days with six hundred and sixty-nine (669) deficiencies for 100 of 202 medical staff from 03/14/11 to 02/28/12, and 293 delinquent medical records for 2011 with four hundred and thirty-four (434) deficiencies for 85 of 202 medical staff from 03/14/11 to 01/31/12. S32RHIM indicated the delinquent medical records have been steadily increasing since last year, 2011. S32RHIM reported presenting the 819 (April of 2012) delinquent medical records greater than 60 days with 1525 deficiencies with incomplete and inaccurate entries for 127 of 202 medical staff from 03/14/11 through 04/30/12 at the May 15, 2012 Medical Executvie Committee Meeting on the "Quality Measures Relevant to Management of Information" report. S32RHIM stated there has been no changes implemented regarding the identification of problems with the medical staff failing to complete a medical record in a timely manner of 30 days after discharge as per the "Bylaws and Rules and Regulations". S32RHIM further stated there has been no trending to identify the time frames required for the medical staff to complete a medical record, and/or no monitoring to ensure the medical staff following the "Bylaws and Rules and Regulations" that a medical record must be completed within 30 days after discharge.

In an interview held on 06/27/12 at 2:00 p.m., S21Medical Director of PI (performance improvement) verified the "Medical Staff Bylaws and Rules and Regulations", Effective date of 11/17/11, Print date of 01/17/12 was the hospital's current. S21 indicated there have not been any amendments to the "Bylaws" since the 11/17/11. S21 further indicated an automatic suspension must be implemented for all medical records delinquent greater than 30 days as per the bylaws and rules and regulations. The Medical Director of PI, S21 denied knowledge the medical records department had a total of 1389 charts delinquent greater than 30 days with incomplete and inaccurate records with no dates, times and/or authentication recorded on the entries by the person responsible for providing the service from 03/14/11 through 04/30/12 as per protocol. S1Medical Director of PI further denied knowledge there were 819 delinquent medical records greater than 60 days with incomplete and inaccurate records with no dates, times, and/or authentication recorded on the entries by the person responsible for providing service to the patients from 03/14/11 through 04/30/12.

Review of the "Medical Staff Bylaws", Effective date of 11/17/11, Printed date of 01/17/12, Article 2-Preamble, Sec. (2)-Process, pages 5 - 6, and Article 12-Appointment, Reappointment and Clinical Privileging, Indications and process for automatic suspension of MS membership &clinical privileges, page 23, Part D-Indications and Process for Automatic Suspension of MS Membership and/or Clinical Privileges, Sec. (1) - Indications, and Sec. (2)- Process read in part, "...Article 2-Preamble section "37"...The purposes of the Medical Staff are:...Sec. (2)-Process...7 To establish, maintain, enforce and comply with the Bylaws, Rules and Regulations and Policy on Appointment, Reappointment and Clinical Privileges for the Medical Staff...Article 12-Appointment, Reappointment and Clinical Privileging, Part D-Indications and Process for Automatic Suspension of MS Membership and/or Clinical Privileges, Sec. (1)-Indications...a. Failure to complete medical records, the associated details of which are delineated in Article 16 of the Rules and Regulations...Sec. (2)-Process...Whenever any of these indications occur, the individual's MS membership and/or clinical privileges will be voluntarily relinquished until the indication is resolved, the associated details of which are described in Article (2), Part E, Sections (1) - (5) of the Appointment Policy...".

The "Medical Staff Rules and Regulations", Effective date of 11/17/11, Printed date of 01/17/12, Article 2-Medical Records, Part A-General Information, Sec. (3)-Authentication, pages 5 - 7, and Article 16-Delinquency, read in part, "...A. A medical record that has not been completed within thirty (30) days after patient discharge shall be considered delinquent....".
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on record reviews and staff interviews, the hospital failed to measure and analyze the quality indicators reported by the medical records department for the delinquent medical records as evidenced by failing to identify, track, trend, implement corrective actions and monitor the compliance for the one thousand three hundred and eighty-nine (1389) delinquent medical records greater than thirty (30) days, the eight hundred and nineteen (819) delinquent medical records greater than sixty (60) days, the four hundred and ninety-one (491) delinquent medical records greater than ninety (90) days, the three hundred and ninety-six (396) delinquent medical records greater than one hundred and twenty (120) days and/or the two hundred and ninety-three (293) delinquent medical records in 2011 that are incomplete and inaccurate with no dates, times, and/or authentication recorded on the entries by the practitioners. Findings:

On 06/25/12 from 9:15 a.m. through 3:15 p.m., on 06/26/12 from 9:15 a.m. through 10:00 a.m., and on 06/27/12 from 11:00 a.m. through 2:15 p.m., observations of the medical records department was performed with S32Registered Health Information Management (RHIM). During this observation, a computer printout of the the medical records delinquent greater than 30 days, greater than 60 days, greater than ninety (90) days, greater than 120 days, and delinquency in 2011. Review of the computer delinquent medical records printouts dated/timed 06/27/12 at 12:21 p.m. and 06/25/12 at 2:05 p.m. revealed there were 1389 delinquent medical records greater than 30 days with two thousand five hundred and sixty (2560) deficiencies for 146 of 202 medical staff from 03/14/11 to 05/21/12. There were 819 medical records delinquent greater than 60 days with one thousand five hundred and twenty-five (1525) deficiencies for 127 of the 202 medical staff from 03/14/11 to 05/21/12. There were 491 delinquent medical records greater than 90 days with eight hundred and ninety-one (891) deficiencies for 115 of the 202 medical staff from 03/14/11 to 03/31/12. There were 396 delinquent medical records greater than 120 days with six hundred and sixty-nine (669) deficiencies for 100 of 202 medical staff from 03/14/11 to 02/28/12. There were 293 delinquent medical records for 2011 with four hundred and thirty-four (434) deficiencies for 85 of 202 medical staff from 03/14/11 to 01/31/12.

There were no "Deficiency Report by Physician" specifically detailing the patient's name, medical record number, admitted , discharge date , age, deficiency, need, and/or chart location/days for the 127 of the 202 physicians with 1525 delinquent medical records greater than 60 days, for the 115 of 202 medical staff for the 491 records with 891 deficiencies greater than 90 days, for the 100 of 202 medical staff for the 550 records with 669 deficiencies greater than 120 days, and/or for the 85 of 202 medical staff for the 293 charts with 434 deficiencies in 2011 presented during the survey from 06/18/12 through 06/27/12.

The "Medical Executive Committee" Meeting was held Tuesday, May 15, 2012. Further review of the meeting minutes revealed section, V. New Business was a) Delinquency Statistics. The March 2012 medical record delinquency reports were presented. The delinquency rate for the year was thirty-six (36) percent. The year to date rate is thirty-seven (37) percent. Suspensions by section for March were reported as well as the average delinquent charts by section as seen in the tables below. S23MD and S22MD (both named) have been sent a letter since they have been on twelve (12) weeks consecutive suspension. Further review of the report revealed the delinquency by physician section (credentialing) was reported for a total of one, hundred and thirty-two (132) physicians for the month of March. There were a total of forty (40) physician's listed on the suspension by section. The recommendation was to continue to track and trend.

Review of the "Quality Measures Relevant To Management of Information" report for the Year 2012 revealed January had a total of one, thousand twenty-one (1021) delinquent charts, February had a total of one, thousand and forty-eight (1048) delinquent charts, March had a total of one, thousand and fifty-three (1053) delinquent charts, April had a total of one, thousand, one hundred and eighty-nine (1189) delinquent charts and May had a total of one, thousand, one hundred, and seventeen (1117) delinquent charts. Further review of this report was Compared to the previous Year of 2011. Review of the Comparative Year of 2011 revealed January had a total of eight hundred and forty-seven (847) delinquent charts, February had a total of eight hundred and eighty-seven (887) delinquent charts, March had a total of eight hundred and one (801) delinquent charts, April had a total of nine hundred and ninety (990) delinquent charts, and May had a total of eight hundred and thirty-two (832) delinquent charts.

In an interview on 06/27/12 at 12:35 p.m., S32Registered Health Information Management (RHIM) verified there were 1389 medical records delinquent greater than 30 days with 2560 deficiences for 146 of 202 medical staff, 819 medical records delinquent greater than 60 days with one thousand five hundred and twenty-five (1525) deficiencies for 127 of the 202 medical staff from 03/14/11 to 05/21/12, 491 delinquent medical records greater than 90 days with eight hundred and ninety-one (891) deficiencies for 115 of the 202 medical staff from 03/14/11 to 03/31/12, 396 delinquent medical records greater than 120 days with six hundred and sixty-nine (669) deficiencies for 100 of 202 medical staff from 03/14/11 to 02/28/12, and 293 delinquent medical records for 2011 with four hundred and thirty-four (434) deficiencies for 85 of 202 medical staff from 03/14/11 to 01/31/12. S32RHIM indicated the delinquent medical records have been steadily increasing since last year, 2011. S32RHIM reported presenting the 819 (April of 2012) delinquent medical records greater than 60 days with 1525 deficiencies with incomplete and inaccurate entries for 127 of 202 medical staff from 03/14/11 through 04/30/12 at the May 15, 2012 Medical Executvie Committee Meeting on the "Quality Measures Relevant to Management of Information" report. S32RHIM stated there has been no changes implemented regarding the identification of problems with the medical staff failing to complete a medical record in a timely manner of 30 days after discharge as per the "Bylaws and Rules and Regulations". S32RHIM further stated there has been no trending to identify the time frames required for the medical staff to complete a medical record, and/or no monitoring to ensure the medical staff following the "Bylaws and Rules and Regulations" that a medical record must be completed within 30 days after discharge.

In an interview held on 06/27/12 at 2:00 p.m., S21Medical Director of PI (performance improvement) verified the "Medical Staff Bylaws and Rules and Regulations", Effective date of 11/17/11, Print date of 01/17/12 was the hospital's current. S21 indicated there have not been any amendments to the "Bylaws" since the 11/17/11. S21 further indicated an automatic suspension must be implemented for all medical records delinquent greater than 30 days as per the bylaws and rules and regulations. The Medical Director of PI, S21 denied knowledge the medical records department had a total of 1389 charts delinquent greater than 30 days with incomplete and inaccurate records with no dates, times and/or authentication recorded on the entries by the person responsible for providing the service from 03/14/11 through 04/30/12 as per protocol. S1Medical Director of PI further denied knowledge there were 819 delinquent medical records greater than 60 days with incomplete and inaccurate records with no dates, times, and/or authentication recorded on the entries by the person responsible for providing service to the patients from 03/14/11 through 04/30/12.

Review of the "Medical Staff Bylaws", Effective date of 11/17/11, Printed date of 01/17/12, Article 2-Preamble, Sec. (2)-Process, pages 5 - 6, and Article 12-Appointment, Reappointment and Clinical Privileging, Indications and process for automatic suspension of MS membership &clinical privileges, page 23, Part D-Indications and Process for Automatic Suspension of MS Membership and/or Clinical Privileges, Sec. (1) - Indications, and Sec. (2)- Process read in part, "...Article 2-Preamble section "37"...The purposes of the Medical Staff are:...Sec. (2)-Process...7 To establish, maintain, enforce and comply with the Bylaws, Rules and Regulations and Policy on Appointment, Reappointment and Clinical Privileges for the Medical Staff...Article 12-Appointment, Reappointment and Clinical Privileging, Part D-Indications and Process for Automatic Suspension of MS Membership and/or Clinical Privileges, Sec. (1)-Indications...a. Failure to complete medical records, the associated details of which are delineated in Article 16 of the Rules and Regulations...Sec. (2)-Process...Whenever any of these indications occur, the individual's MS membership and/or clinical privileges will be voluntarily relinquished until the indication is resolved, the associated details of which are described in Article (2), Part E, Sections (1) - (5) of the Appointment Policy...".

The "Medical Staff Rules and Regulations", Effective date of 11/17/11, Printed date of 01/17/12, Article 2-Medical Records, Part A-General Information, Sec. (3)-Authentication, pages 5 - 7, and Article 16-Delinquency, read in part, "...A. A medical record that has not been completed within thirty (30) days after patient discharge shall be considered delinquent....".
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the hospital failed to ensure the Chief Nursing Officer staffed the Emergency Department with adequate types and numbers of nursing personnel and staff necessary to provide the goods and services needed by the patients as evidenced by not having adequate staffing present on 05/29/12 to meet the hospital policy required 1:1 observation of 1 of 6 sampled patients (#6). Findings:

Review of the medical record for patient #6 revealed an admitted /time to the emergency room of 05/28/12 at 1849 (6:49 p.m.). Patient #6 was triaged by S8RN at 1850 (6:50 pm) and the documentation by S8RN listed the "Chief Complaint" as "Pt. into ER after getting into argument with boyfriend and stating he would kill himself, denies suicidal ideations upon arrival." Further review of the Triage Form revealed S8RN documented patient #6 was "Nonurgent...Affect: Flat."

Review of nursing documentation dated/timed 05/28/12 at 2055 (8:55 p.m.) by S8RN revealed the following under "Physical Assessment" for patient #6: in part..."Suicide Risk Assessment: Things so bad lately; you'd rather die? Yes. Have you had thought of harming yourself? Yes. Have you ever attempted suicide? Yes. Ever treated for mood or mental disorder? Yes. Sex: Male. Age: 15-[AGE] years old. Depression: Yes. Prior History {previous suicide attempt}: Yes. Ethanol abuse {Drug, Alcohol, Substance}: No. Rational thinking loss: No. Support System loss: YES. Interpersonal crisis/conflict. Organized Plan: Denies plan, but has suicidal ideation. No significant other: BOYFRIEND. . SAD PERSONS Total Score: Summation 6.000. Suicide Risk Level {Score 5 or above}: High Risk Suicide Level (Score 5-10). Nursing Interventions/suicide precautions: High Risk Interventions (Score 5-10). Suicide Hotline given to pt?: PEC (physician's emergency certificate)."

In an interview on 06/21/12 at 11:15 am with S8RN he stated he was the nurse who triaged patient #6 on 05/28/12 at 1850 (6:50 pm). S8RN stated that patient #6 told him during triage that he (#6) "did not mean it" when asked about stating he wanted to kill himself. S8RN further stated that "if he (#6) said it he probably meant it." S8RN confirmed the Suicide Risk Assessment he performed on patient #6 placed #6 in the "High Risk" category. S8RN confirmed the PEC filled out by S5MD, ER, indicated patient #6 had Suicidal Ideations, a history of two Suicide attempts, was a Danger to Self, and was Unwilling to seek voluntary admission. S8RN stated he was responsible for the care of patient #6 on the night shift of 05/28/12 - 05/29/12. S8RN stated that the room (ER 5) was not cleared of items patient #6 could potentially use for self harm including the otoscope (cord), ophthalmoscope (cord), power cord for otoscope/ophthalmoscope, and 2 - 2' X 3' signs hanging on the walls. S8RN stated he could not recall if a cardiac monitor was in the room. S8RN stated there was no 1:1 observation per policy for patient #6 as "I had several other patients." S8RN stated that he "passed by" the room of patient #6 and noticed the patient was restrained on one arm, he could not recall which arm. S8RN stated another nurse, S12RN, told him the patient (#6) was restrained "because he would not comply with the lab draw." S8RN stated he went into patient #6's room, removed the restraint, and discarded it in the waste basket inside of ER 5. S8RN stated patient #6 did inform him of the previous suicide attempts in triage. S8RN further stated patient #6 should have been placed on 1:1 observation. S8RN confirmed the 1:1 observation level required by hospital policy was never documented or carried out. S8RN further reported that as recently as June 19th, 2012 (one day after the survey started and two days prior to this interview) that when he came on duty at 10:00 pm he was given on patient under PEC and "almost immediately" was assigned another. S8RN stated there are patients under PEC "almost every shift here."

Review of the assessment documentation by S5MD, dated and timed 05/28 at 1915 (7:15 pm), revealed the following: "HPI (history of present illness) Chief Complaint: suicidal thoughts...context: broke up with boyfriend. Associated Complaints: refuse to elaborate. Suicide Risk Assessment: male, prior attempt X 2 (twice) OD (overdose)...self injury: intent: no answer...Past Hx (history): prior suicide attempt. Psychiatric problems: depression...Psyc (psychiatric): mental status: poor eye contact, depressed, refuse to talk." Review of the "Medical Clearance for Psychiatric Referral" revealed S5MD did not document that patient # 6 had been medically cleared for referral/transfer. Review of the "Clinical Impression" section revealed that S5MD did not document a differential/provisional diagnosis for patient #6.

Review of a document titled "Physician Emergency Certificate (PEC)" revealed S5MD examined patient #6 on 05/28/12 at 1915 (7:15) and placed him under PEC on 05/28/12 at 1055 (10:55 pm). Review of the "Findings of Examination" documented by S5MD revealed the following: "History of Present Illness: 22 y/o (year old) with suicidal ideation secondary to broke up with boyfriend today. + (positive) previous suicide attempts X 2 in the past. Physical Findings: PMHX (patient medical history): depression. Mental Condition: Flat affect, poor eye contact, refusing to answer questions..." S5MD documented that patient #6 was "Currently Suicidal, Dangerous to Self, and Unwilling to seek voluntary admission."

Review of a document titled "Emergency Department Nursing Notes and Interventions" revealed the following documentation by S9RN for the day shift (7 am - 7 pm) on 05/29/12: "0700 (7:00 am): Pt. resting quietly, NAD noted, admits to suicidal ideations D/T (due to) argument w (with) BF (boyfriend), states he thought of "connecting the dots" which pt. interpreted as cutting throat from one ear to the other, calm, cooperative, denies agitation at this time, pt reports being depressed and off meds (medications) for approx 1 week, hx inpt (inpatient) stays in past, skin warm and dry, RR (respiratory rate) clear unlabored, VSS (vital signs stable), BP 138/79, HR 88, RR 17, O2 (oxygen) sat (saturation) 100% RA (room air), afebrile, gowned, TV (television) placed in pt room. 0730 (7:30 am): Meal tray ordered, linens changed. 0830 (8:30 am): AAOX3. NAD noted. Monitoring pt. 0930 (9:30 am): assessment unchanged. 1030 (10:30 am) Assessment unchanged. 1100 (11:00 am): Attempting to find placement. Contacting multiple facilities. Monitoring pt. 1140 (11:40 am): As (S7Housekeeper), walks past room, pt has restraint around neck hanging from bed. blue/purple in color w legs kicking. Placed in bed. + pulses. restraint removed from neck. placed on monitor. BP 132/75 HR 116 O2 sat 97% RA. eyes closed not responding to verbal stimulus. ammonia tablet to nose. bruising/red to neck. 1140 (11:40 a.m.) Pt shaking head, staring eyes open. Dr. (S6MD) at bedside to examine pt. bil (bilateral) wrist restraints applied. room safeguarded per IMC protocol. curtain open. IV started per aseptic technique. flushes easily. taped & secure. SL (saline lock). Pt tol (tolerate) well. O2 2L (liters per minute) placed. monitoring pt. 1205 (12:05 pm): At bedside speaking w pt regarding events. pt states "I'm mad. I wish y'all would have just let me die." continued therapeutic communication to allow pt to open up. will continue to monitor. 1230 (12:30 pm): meds given per order. see MAR (medication administration record). 1240 (12:40 pm) (S10RN) at side. pt speaking more freely w nurse. no changes noted from previous story assessment this am. will continue to monitor pt...1335 (1:35 pm): pt loosening restraints. bil restraints reinforced. will continue to monitor. 1345 (1:45 pm): pt requesting to urinate. pt refusing catheter. condom cath applied. pt tol well. (S9RN) and (name) inserted cath. 1445 (2:45 pm) pt resting quietly. restraints remain reinforced. NAD noted. monitoring pt. 1536 (3:36 pm): spoke w (name), administrator at (hosp "a"). states (physician name) accepts pt. 1550 (3:50 pm): report given to (name), RN. 1601 (4:01 pm): IPSO (local sheriff's office) contacted regarding transportation. states will send trooper asap. 1640 (4:40 pm): IPSO here for transport. pt out of ER."

Review of nursing documentation dated/timed 05/29/12 at 8:13 a.m. by S9RN revealed the following under "Mental Status Assessment" for patient #6: "Orientation: Person, Place, Time, Situation. Level of Awareness: Alert. Affect: Appropriate. Posture: Relaxed. Speech: Appropriate. Mood: Calm. Perception: Reality Oriented. Motor Activity: Normal. Thought Process: Appropriate. Thought Content: Appropriate. Memory: Short Term. Judgement: Poor. Appearance: Gowned.

In an interview on 06/21/12 at 9:35 am with S2CNO the RN Assignment sheets for 05/28/12 and 05/29/12 were requested. S2CNO stated she "does not recall if the hospital had a policy on RN Charge Nurse Assignments based on staffing or acuity." Room.

In an interview on 06/21/12 at 1:45 pm with S9RN she confirmed the documentation that patient #6 voiced suicidal ideations with a plan to her at 7:00 am on 05/29/12. S9RN further confirmed this was not reported to S6MD, ER. S9RN stated she had 4 other patients and was leaving the desk to care for her other patients. S9RN confirmed her Suicide Risk Assessment performed on 05/29/12 at 8:11 am did place patient #6 in the High Risk category. S9RN further stated patient #6 was not placed on 1:1 observation and the room was not cleared of potentially dangerous items per hospital policy. S9RN further stated "it is common to have High Risk patients and other patients assigned to her during a shift." S9RN stated that she did not notify anyone on 05/29/12 that staffing was inadequate to do the 1:1 policy required observation of patient #6. S9RN stated patient #6 had bruising and redness to his neck. S9RN was asked if restraints were the least restrictive method to ensure the safety of patient #6 to which she replied: "1:1 would have been least restrictive if there was adequate staffing." S9RN stated that ER 5 was safeguarded per hospital policy after the incident. S9RN stated that patient #6 was about 5'6" and approximately 140 pounds. S9RN stated that "if there were adequate staffing" she would have escorted patient #6 to the restroom versus using a condom catheter. S9RN reviewed the 1 hour face to face assessment performed by herself at 12:40 pm (1 hour after the 11:40 am restraint application) and stated that "if 1:1 observation were in place he (patient #6) would not be restrained nor would he have a condom catheter." S9RN reviewed the 1340 (1:40 pm) Nonviolent Restraint order and stated "Patient (#6) would not be restrained if there were adequate staffing." S9RN stated that Nursing must implement interventions listed in hospital policy. S9RN stated patient #6 should have been on High Risk interventions per hospital policy from the start of her shift. S9RN stated she does tell S13RN, ER Dir., of the staffing issues in the ER. S9RN stated that S13RN responds that he is aware it is a problem and is limited on what he can do. S9RN stated this has been a problem for the two years she has been working in the ER. S9RN stated she was aware patient #6 was High Risk on admission assessment but "1:1 does not happen routinely because there is not enough staff."

In an interview on 06/21/12 with S13RN, ER Dir., he confirmed patient #6 had an initial Suicide Risk Assessment that placed him at High Risk. S13RN stated patient #6 was not placed on 1:1 and the environment was not made safe per hospital policy. S13RN stated he "was not sure where" the restraint #6 used to attempt suicide came from. S13RN confirmed the 05/29/12 at 8:11 am Risk Assessment required High Risk Interventions that were not implemented. S13RN stated he was "unaware" if the 05/29/12 7:00 statement by patient #6, documented by S9RN, was reported to the physician (S6MD) responsible for the care of patient #6. S13RN was asked if he was aware that staff states they are unable to cover 1:1 due to staffing issues. S13RN replied that the 1:1 observation on patient #6 was not done. S13RN then stated 80% of 1:1 High Risk Interventions are not covered per hospital policy.

In an interview on 06/21/12 at 12:15 pm with S6MD she stated she was the ER Physician on duty on 05/29/12 and is also the Medical Director of the ER. S6MD stated that patient #6 was a High Risk patient. S6MD stated the Suicide Precautions and Interventions required by hospital policy were not implemented. S6MD stated she was aware the restraint used by patient #6 to attempt suicide was discarded in the trash inside of the patients room the night before. S6MD stated patient #6 should have been placed on 1:1 observation on 05/29/12 at 0700 (7:00 am) when he voiced suicidal ideations and a plan to S9RN. S6MD stated she ordered bilateral arm restraints to be placed on patient #6 at 11:40 am on 05/29/12. S6MD stated the ER "does not have enough staff to do 1:1." S6MD further stated that the lack of adequate staffing was the reason for restraint use and the application of a urine catheter for patient #6. S6MD stated she has brought the issue of Psychiatric patients and staffing to the CNO, past and present, and there has been no change. S6MD stated the hospital CFO (Chief Financial Officer) canceled the ER Security 3 years ago. S6MD stated the issue of ER Security has been brought up by her at several ER meetings in the last 6 months and that there has been no action taken in response for 2-3 years. S6MD stated the second restraint order given by her (05/29/12 at 1340 (1:40 pm)) for the use of Nonviolent restraint use on patient #6 was due to inadequate staffing. S6MD reviewed the 1 hour face to face evaluation of patient #6 performed at 12:40 pm as a result of the first application of restraints and stated there was no documentation to indicate the need for continued restraint of patient #6. S6MD again stated the patient restraint was a result of "staffing issues." S6MD further stated that the administration of Ativan 1 mg IVP at 12:30 pm as ordered by herself was in fact used as a chemical restraint and was used due to low staffing in the ER.