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Based on a review of facility documents and interviews with staff (EMP), it was determined that Conemaugh Miners Medical Center failed to follow their adopted Medical Staff Rules and Regulations for the enforcement of delinquent medical records.

Findings:

A review of Conemaugh Miners Medical Center, Medical Staff By-Laws "... 7.4-4 Medical Records. Practitioners are required to complete medical records within a reasonable time, which may be prescribed by the medical staff rules and regulations. A limited suspension in the form of withdrawal of admitting and other related privileges until medical records are complete shall be imposed by the MEC after notice of delinquency for failure to complete medical records within the required period ... ." Revised March 2011.

A review of Conemaugh Miners Medical Center, Medical Staff Rules and Regulations ... Article IX, Section 10: Medical Record Review: "... (a) Failure to complete medical records within thirty (30) days of discharge will result in the summary suspension of privileges. (b) Protocol is as follows: The Medical Record Department will generate an incomplete suspension report biweekly to each physician who has incomplete and/or delinquent records. All physicians with delinquent charts greater than 30 days will be notified via certified letter that they have seven (7) days after receipt of the letter to complete their records. All physicians with records not completed within the time frame will report to the Medical Staff President and the CEO and/or their designee for disciplinary action. These physicians will be immediately notified that their privileges have been summarily suspended for 30 days or until competition of the delinquent records. If the records are not completed within 30 days, the suspension will continue. All suspensions of greater than thirty (30) days are reportable to the National Practitioner Data Bank ... ."

1. A review of Conemaugh Valley Deficiency Chart, Total by Physician, printed on August 4, 2015, revealed a total of 78 delinquent records (> 30 days) and 36 records delinquent greater than 120 days.

2. An interview was conducted with EMP3, on August 12, 2015 at approximately 1:30 PM. "The staff at Miners does not have the capability to run the biweekly report. Yes, there are 78 delinquent medical records, we are not following the Medical Staff Rules and Regulations. During the transition, this process dropped off. This has not been in place since January. We have never sent a certified letter to the physicians."

Based on a review of facility policy, medical records (MR), and staff interview (EMP), it was determined that Conemaugh Miners Medical Center failed to follow their adopted Nursing policy regarding the documentation of post-mortem care for four of seven medical records reviewed.

Findings include:

A review of Conemaugh Miners Medical Center, Dying Patient Care policy, reviewed January 22, 2014, revealed, "Purpose: ... Upon the death of a patient, the appropriate notification and recording of pertinent facts will appear in the Medical Record. ... Charting: Record in Nurses Notes on Remarks column ... Make a note of Funeral Home that the body released to. ... ."

1. A review of seven medical records (MR) dated March 5, 2015, through April 24, 2015, revealed that four records failed to have nursing documentation that the patient's body was removed by the funeral home or the coroner. (MR4, MR5, MR9, MR27)

2. An interview was conducted with EMP1 on August 12, 2015, at approximately 10:00 AM. "We do not have a good process for documenting the removal of a body. The Nursing staff is to be documenting in the chart. We do keep a Receipt Book that is to be signed when the body is removed, but that is not being used consistently, and we have no policy in place."

Based on a review of facility documents, medical records (MR), and interviews with staff it was determined that Conemaugh Miners Medical Center failed to adopt policies consistent with State Law, and failed to ensure that documentation of Informed Consent was given to patients prior to receiving blood transfusions for two of two medical records (MR1 and MR2).

Findings include:

A review of Conemaugh Miners Medical Center, Blood Administration policy, approved January 2015, revealed, "Blood Administration Procedure: Check physician order. ... Check to see that the Blood Consent Form is completed. ... If the Blood Consent Form was not completed prior to ordering the blood/blood product, obtain the consent now. If the emergency is such that the physician orders the blood/blood product to be given without a consent, note this on the order sheet and proceed with administration. ... ."

A review of Request For Blood Transfusion and Release form, revised December 2008, revealed, "... I, [blank], hereby request and consent to and authorize the transfusion of blood or blood compenents to me during my hospitalization at Miners Medical Center, Hastings, Pennsylvania, whenever deemed necessary or desirable by me attending physician, Dr. [blank] or by the Anesthesiologist or by any designee of my attending physician.
Previous to making such request and in giving such consent, I acknowledge that I have been informed and fully understand the transfusion or administration of blood components to me may result in viral hepatitis or other serious untoward reactions, which may not become evident for several months. ... I further acknowledge that I have read the above or had the same read to me and I understand and consent to the same in all respects.
[blank] Patient or Person Authorized to Consent [blank] Date [blank] Time
[blank] Witness "

1. A review of MR1 and MR2 revealed the absence of a physician's signature on the Informed Consent for blood transfusion.

2. An interview was conducted with EMP1 on August 13, 2015, at approximately 10:00 AM. "We have not directed the physicians to sign the blood consent. The nurses go by the physician order."

Based on a review of facility documents, medical records (MR), and staff interview (EMP), it was determined that Conemaugh Miners Medical Center failed to implement their adopted Anesthesia policies regarding Informed Consent for two of two medical records reviewed (MR12, MR13), and failed to follow their adopted policy to ensure a clean environment shall be maintained within the Surgical Suite.


Findings include:

A review of Conemaugh Miners Medical Center, General Medical Staff Rules Regarding Surgical Care policy, revised 2014, revealed, "Policy Implementation Statements (Medical Staff Rules and Regulations): No patient will be released from a Nursing Station for transfer to the Surgical Suite for surgery and anesthesia unless the chart contains a signed Surgical/Anesthesia Consent Form, a History and Physical, and a completed Surgical Checklist. ... ."

A review of facility policy, Division of Anesthesia: Pre-Anesthesia Preparation, revised December 2014, revealed, "Pre-operative Evaluation: All patients to receive scheduled anesthesia are evaluated by an Anesthesiologist/CRNA prior to receiving sedation or mind-altering medication. If the patient has received any sedation or mind-altering medications, the patient's representative or guardian will complete the form. Documentation shall include the following: consent form ... The anesthesiologist/CRNA discusses the anesthetic procedure, incurred risks and probable outcomes and post procedure care with the patient and/or legal guardian and families. ... ."

1. A review of medical record MR12 and MR13 revealed no documented evidence of the Surgical/Anesthesia Consent Form, and of the Anesthesiologist/CRNA discussing the anesthetic procedure, incurred risks and probable outcomes and post procedure care with the patient and/or legal guardian and families.

2. An interview was conducted with EMP1 on August 13, 2015 at 11:45 AM. EMP1 confirmed the above findings and revealed, "I did not know we had a separate Anesthesia Consent that we are not using."


A review of Pre-Anesthesia Preparation, policy and procedure dated December 2014, revealed, "... Anesthesia machines, Carts and Related Equipment ... The Anesthesiologist or CRNA cleans and re-supplies anesthesia machine and cart in advance of time scheduled for their use. Daily cleaning of machines and carts consists of removing soiled supplies and thoroughly wiping the exteriors with a germicidal agent.

A review of Cleaning, Housekeeping Department, Subject: Operating Room policy and procedure, dated 2014, revealed, "... OR staff is responsible for cleaning technical equipment, Recovery Room beds, table tops, shelves and stands containing OR supplies. ... ."
1. A tour of the Surgical Suite was conducted with EMP5 on August 13, 2015, at approximately 10:30 AM. During the tour, the top of the anesthesia machine was noted to have a moderate amount of dust return upon a finger sweep.
2. EMP5 revealed that the Anesthesia staff does not clean the anesthesia machine.
3. A telephone interview was conducted with EMP6 on August 17, 2015, at 1:15 PM. EMP6 stated that the Housekeeping staff is not responsible for cleaning of the equipment in the Operating Room, Anesthesia staff is supposed to do that.

Based on a review of facility documents and staff interview (EMP) it was determined that Conemaugh Miners Medical Center failed to document prior arrangements for transfer to another health care facility for two of four medical records reviewed.

Findings:

A review of Conemaugh Miners Medical Center, Medical Staff Rules and Regulations ... Article XII: Discharge: ... Section 3: Transfer of Patients. A patient shall not be transferred to another medical care facility unless prior arrangements for admission to that facility have been made. Clinical records of sufficient content to insure continuity of care shall accompany the patient. Method of transfer will be made according to policy ... ." revised November 2008.

A review of Conemaugh Miners Medical Center, Policy Code 678-449. Provision of Patient Care Services. Subject: Transfer of Patients from Emergency Department to another Facility: ... Purpose: To provide for the systematic transfer of patients from the Emergency Department to other clinical facilities ... Procedure: Transfer To Another Hospital. Consult private attending physician. Document on the Emergency Department chart notification of family physician, the name of the accepting physician and the time of acceptance ... Notify receiving facility, and document acceptance of patient. Report given to receiving Unit or facility. Patient and/or family are informed by MD of need for transfer and risks and benefits are explained. Send a copy of the chart ... Consent to transfer is signed. ... ."

1. A review of MR15 revealed that the patient presented to Conemaugh Miners Medical Center, Emergency Department on June 30, 2015. An involuntary Commitment (302) was initiated and the patient Disposition is documented as Transferred. MR15 revealed no documented evidence of a Transfer Form being completed, which would include: a reason for transfer, risks of the transfer, the receiving facility, the accepting physician, the mode of transportation, the consent to transfer and the physician's certification.

2. A review of MR14 revealed that the patient presented to Conemaugh Miners Medical Center, Emergency Department on May 19, 2015. A Voluntary Commitment (201) was initiated and the record indicates that the patient was transferred to an outside hospital for psychiatric treatment. The patient Disposition is documented as Discharged. MR14 revealed no documented evidence of a Transfer Form being completed, which would include: a reason for transfer, risks of the transfer, the receiving facility, the accepting physician, the mode of transportation, the consent to transfer and the physicians certification.

3. An interview was conducted with EMP1 on August 12, 2015, at approximately 1:00 PM. EMP1 confirmed the findings.