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Based on interview, review of Medical Staff Rules and Regulations, review of Health Information Management (HIM) Policies and Procedures, and review of medical records, the hospital failed to ensure that the medical record service is administratively responsible for medical records.

Findings include:

1. The hospital failed to ensure that medical records are promptly completed and properly filed. Refer to A0438.

2. The hospital failed to ensure that all entries in medical records of inpatients are signed promptly. Refer to A0450.

3. The hospital failed to ensure that records of discharged patients are completed within 30 days of discharge, and prior to filing in permanent file. Refer to A0469.

Based on observation, interview, the Long Term Acute Care Hospital (LTACH) Plan for the Provision of Patient Care and policy review, the Governing Body failed to ensure that the medical staff is accountable for the quality of care provided to patients.

Findings include:

Refer to A-1160. The facility failed to ensure that respiratory care services are delivered in accordance with medical staff directives.

Based on observation, interview, the Long Term Acute Care Hospital Plan for the Provision of Patient Care and policy review, the facility failed to ensure that the patient has the right to receive care in a safe setting.

Findings include:
Refer to A-1160. The facility failed to ensure that respiratory care services are delivered in accordance with medical staff directives.

Based on restraint medical record review, interview and facility restraint policy review, the facility failed to ensure that each order for adult medical necessity restraint was renewed every twenty four (24) hours.

Findings include:

1. Three (3) of the three (3) in-house restraint medical records reviewed, revealed the telephone restraint orders had not been countersigned by the ordering physician within the required twenty four (24) hours. (Medical records # 1, 2 and 3.)

2. Interview with Health Information Staff confirmed the findings.

3. The LTACH failed to follow Clinical Services Policy and Procedure, Number: RO2-N, Restraints and Seclusion, Section 6, page 6: The original order may only be renewed (in accordance with age limits) for up to a total of twenty-four (24) hours, and thereafter, a physician or licensed independent practitioner (if allowed under State law) must see and assess the patient before issuing a new order.

Based on interview with staff, observation, review of HIM policies and procedures, review of Medical Staff Rules and Regulations, and review of medical records, the hospital failed to ensure that all medical records were promptly completed and properly filed.

Findings include:

1. Twelve discharged records were selected at random, from a list of discharges from January 31, 2011 - June 30, 2011, and reviewed .

2. It was observed that all but three (3) of the requested discharge medical records had been pulled from the permanent file. The only records with a deficiency slip were the three (3) records that came from the doctor's incomplete record area requesting reports to be dictated.

3. On seven (7) of twelve (12) discharged medical records reviewed, the history and physical exam had not been signed by the physician.

4. On six (6) of twelve (12) discharged medical records reviewed, consultative report(s) had not been signed by the consulting physician.

5. On eleven (11) of twelve (12) discharged medical records reviewed, all physician orders had not been signed by the physician responsible for the verbal or phone order. None of these orders had been tagged as unsigned.

6. On four (4) of nine (9) discharged medical records that had a discharge summary documented, the discharge summary had not been signed by the physician.

7. On interview with HIM staff on 08-03-11, at 11:30 a.m., it was confirmed that discharge records had not been checked for signatures prior to the medical records being filed as complete. When asked how long this practice had been going on, no one was certain. The Director of the Department had only been employed a month and the other employee only for a few months. Records that lacked dictation were noted as being deficient and placed in the doctor's incomplete file for the physician to dictate.

8. According to corporate HIM policy D03 - Delinquent Medical Record:
Counting and Reporting, a medical record is complete when the following physician documents are complete and authenticated: (a) history and physical; (b) consultation; (c) operative report; (d) discharge summary. It is mandatory to track all incomplete records at the time of discharge in the HMS system, by entering codes for either the dictation or for signatures on the dictated documents. According to this policy there is no mechanism to track records with unsigned physician orders as being incomplete since there are no codes listed for unsigned physician orders.

9. Since the records in permanent file are in straight numerical order, with the year denoted on the outside of the folder, the surveyor was unable to dtermine how far back incomplete medical records have been filed in the permanent file by randomly pulling medical records to check for signatures. It was determined that this has been going since approximately March, 2010.

10. The patient's medical record number is not recorded on all pages of the medical record Dictated reports, x-ray reports, and laboratory reports generated by the host facility have the medical record number the host facility has issued the patient, but the medical record number issued by the Long Term Acute Care Hospital (LTAC) is not on these type of documents in the patient's record.

Based on review of Medical Staff Rules and Regulations and review of medical records, the hospital failed to ensure that all entries are timed when entered into the medical record, that all dictation is signed, and that all verbal and/or telephone orders are signed by the physician within forty-eight (48) hours.

Findings include:

Twelve discharged records were selected at random from a list of discharges from January 31, 2011 - June 30, 2011, along with ten (10) inpatient medical records. A total of twenty-two (22) medical records were reviewed.

1. On eighteen (18) of twenty-two (22) medical records reviewed, all progress notes had not been timed when entered in the medical record.

2. On twenty-two (22) of twenty-two (22) medical records reviewed, all physician orders had not been timed when entered into the medical record. This included orders written by the physician and verbal orders taken by a nurse.

3. Verbal orders had not been signed by the physician responsible for the order within forty-eight (48) hours on nineteen (19) of twenty-two (22) medical records reviewed.

4. On nine (9) of ten (10) inpatient medical records reviewed, the history and physical exam had not been signed by the physician.

5. On five (5) of ten (10) inpatient medical records that had reports of consultations, the consults had not been signed by the consulting physician.

6. On three (3) of five (5) inpatient medical records reviewed that had operative procedures performed, the dictated operative notes had not been signed by the physician.

Based on review of Medical Staff Rules and Regulations and review of medical records, the hospital failed to ensure that all medical records are completed within thirty (30) days of discharge.

Findings include:

1. On 08-03-11, a count of incomplete medical records in the physicians' incomplete medical record files revealed twelve (12) medical records delinquent over thrity (30) days. However, this count did not reflect the number of incomplete medical records in permanent files. According to the information provided the surveyor by HIM staff, the facility has had three hundred and one (301) discharges since October 1, 2010, or an average of thirty-one (31) discharges per month. HIM was unable to run computer reports after that date due to the change of ownership that occurred in September, 2010. Refer to A0438.

2. There are incomplete medical records lacking physician's signatures dating back to April, 2010, filed in permanent file.

Based on observation, interview, the Long Term Acute Care Hospital Plan for the Provision of Patient Care and policy review, the Infection Control Officer failed to develop and implement policies governing control of infections and communicable diseases for the Respiratory Therapy Department concerning the assisting with Bronchoscopes.

Findings include:
Refer to A-1160. The facility failed to ensure that the respiratory care services are delivered in accordance with medical staff directives.

Based on observation, interview, the Long Term Acute Care Hospital Plan for the Provision of Patient Care and policy review, the facility failed to ensure that the respiratory care services are delivered in accordance with medical staff directives.

Findings include:

On 08/03/2011, at 3:35 p.m., the Respiratory Room (department) was toured. The Respiratory Therapy Manager was present. The small department was noted to house an Arterial Blood Gas (ABG) machine with supplies, respiratory supplies, oxygen cylinders in a rack, a table space for charting, a Bronchosopy Cart and a blue basin with a lid. The surveyor asked the Respiratory Therapy Manager to explain what was in the blue basin and he/she reported that it was filled with Cidex OPA (ortho-Phthalaldehyde) and used to soak the bronchoscopes. The Respiratory Therapy Manager opened the blue basin to reveal the Cidex OPA and test strips with a Cidex OPA Solution Log book.

The surveyor asked the Respiratory Therapy Manager to provide the bronchoscopy policies and procedures. Upon review of the policies and procedures, it was determined that:

The Long Term Acute Care Hospital Company Respiratory Care Manual policy and procedure, Number RC 705, Assisting With Bronchoscopy section Post Procedure, page 9, refers to a scope washer which is an automatic endoscope reprocessor. The Respiratory Therapy Manager reported that the facility uses manual processing and does not possess an automatic endoscope reprocessor.

On 08/04/2011, at 9:37 a.m., the Surveyor asked the Respiratory Therapy Manager to explain where the bronchoscopes were performed and where and how was the cleaning of the scopes performed.

The Respiratory Therapy Manager reported that respiratory therapy staff assist the physician with performing the bronchoscopy procedure in the patient's room and when the procedure is completed, the scope is flushed and the outside of the scope is wiped with PDI (Professional Disposables International) Sani-cloth germicidal disposable wipe. The Respiratory Therapy Manager reported that the dirty bronchoscope is then placed in a red bio-hazard bag and taken to the Rehabilitation Room (department) to be cleaned.

The Rehabilitation Room (department) which provides physical therapy, occupational therapy and speech/language pathology for the Long Term Acute Care Hospital patients was entered and a patient was receiving therapy in front of the two compartment sink. The room was small and full of equipment with the therapists conducting various job duties.

The surveyor asked the Respiratory Therapy Manager (RT) what occurs if therapy is being provided. The Manager stated that the bronchoscopy cart and scope are placed outside the Respiratory Room's door in the hallway.

The Respiratory Therapy Manager reported that if there is no patient receiving therapy, the bronchoscopy cart and Cidex OPA blue basin are brought into the Rehabilitation Room and the two compartment sink is used to complete the process of cleaning, flushing, disinfecting. The scope is placed into the Cidex OPA basin. Once the scope has soaked for twenty (20) minutes, the final rinse is completed and it is dried and placed in the second drawer of the scope cart for the next use. The Respiratory Therapy Manager reported that the two compartment sink is cleaned with PDI (Professional Disposables International) Sani-cloth germicidal disposable wipes. The Cidex bath and scope cart are then taken back to the Respiratory Department until the next scope procedure.

On 08/04/2011, at 11:00 a.m., the Infection Control Officer was asked by surveyor what monitoring was being done for Respiratory Therapy regarding the Bronchoscopes. He/she reported that there were none.

At 12:15 p.m., the Respiratory Therapy Manager reported that he/she is not reporting to Infection Control.

The surveyor interviewed the Infection Control Officer and Chief Nursing Officer concerning the patient population which is known to be immuno compromised, using the Rehabilitation Room for reprocessing of soiled scopes, and the inconsistencies of policies and procedures. Both responded that there was not enough space to accomplish the reprocessing in another location.

Based on the afore findings the LTACH failed to achieve the Hospital Plan for the Provision of Patient Care. Refer to:

Section 2. Patient Care Goals: that states A. To continue the healing process of the catastrophically ill patient in a safe environment where a comprehensive clinical team approach will provide care geared to maximize recovery.

Section 3. Scope and Methodology of Services notes that the hospital offers many programs including but not limited to:
Pulmonary-ventilator weaning
Medically complex-including multi-system and/or organ dysfunction, infectious disease
Wound management
Neuro/trauma including coma recovery.