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Based on record reviews and interviews, the hospital failed to ensure the requirements for the Condition of Participation for Governing Body were met as evidenced by the governing body failing to ensure:

1) patients are admitted to the hospital under the care of a doctor of medicine or osteopathy. This was identified for 3 (#6, #7, #8) of 4 (#6, #7, #8, #9) current inpatients out of a total sample of 9 (#1-#9) and 1 (#3) of 5 (#1-#5) closed sampled patients, (see findings in A-0064).

2) patients were under the care of a physician as evidenced by no documentation noted in the patient chart that a physician had seen, examined, and evaluated 1 (#3) of 5 (#1-#5) closed sampled patients, and 3 (#6, #7, #8) of 4 (#6, #7, #8, #9) current inpatients out of a total sample of 9 (#1-#9). (See findings in A-0066)

3) a process was in place that defined what tasks the nurse practitioner could perform while ensuring the patient was under the care and direction of the physician. This resulted in patients being admitted to the hospital under the services of a nurse practitioner (APRN) with no involvement from the physician for 4 (#4, #6, #7, #8 ) of 9 (#1-#9) sampled patients and 3 of 3 (#R1, #R2, #R3) random patients. (see findings in A-0064)

4) Nurse Practitioners practiced in accordance with the Medical Staff By-laws and Federal Rules and Regulations. This resulted in history & physical (H&P) examinations and medical consults being done by a nurse practitioner (S11APRN) for 5 of 9 (#3, #4, #6, #7 & #8) sampled patients. (see findings A-0046)

Based on review of Medical Staff By-laws, Rules & Regulations, review of credentialing files, and staff interview, the governing body failed to ensure nurse practitioners practiced in accordance with the Medical Staff By-laws and Federal Rules and Regulations. This resulted in history & physical (H&P) examinations and medical consults being done by a nurse practitioner (S11APRN) for 5 of 9 (#3, #4, #6, #7 & #8) sampled patients.
Findings:

Review of the hospital's Medical Staff By-laws, Rules & Regulations dated 03/16/11, and approved by S1ADM (Administrator) and S8MD (Medical Director) on 02/23/15 revealed in part the following:
Section 2-Delineation of Clinical Responsibilities: All patients of independent practitioners shall have a prompt history taken and comprehensive physical examination (H&P) performed by a physician who has such Responsibilities. A physician member of the Medical Staff shall be responsible for the care of any medical problems that may be present at the time of admission or that may arise during hospitalization and shall determine the risk and effect of any proposed procedure on the total health status of the patient.
Article V. Allied Health Professionals (AHPs) AHPS may be granted permission to participate in the provision of certain patient care services within the Hospital, but such permission shall not be construed to afford AHPs the rights of Medical Staff membership. Section 2. A. Nurse Practitioner (1) All nurse practitioners must have a binding contract agreement with a member of [hospital's] active medical staff. (2) Must have a supervising physician who is a member of [hospital's] active medical staff. Section 4 - Procedure for granting practice prerogatives; termination and corrective action: Applications for appointment, reappointment and Privileges for AHPs shall be submitted and processed in the same manner as provided in Article VI and VII for Medical Staff Membership and Clinical Responsibilities.
Article VI. Procedure for Appointment....When the recommendation of the Medical Executive Committee is favorable to the applicant, the Administrator/CEO (Chief Executive Officer) will forward it, together with all supporting documentation, to the Board for consideration at its next scheduled meeting....If the Board adopts the recommendation of the Medical Executive Committee, it shall become the final action of the Hospital.


Review of the clinical records for sampled Patients #3, #4, #6, #7, and #8 revealed the H&P and medical consults were done by S11APRN.

Review of the roster of current medical staff provided by S1ADM revealed the collaborating physician for S11APRN was S5Physician. The roster also revealed S14Physician was listed as consulting staff.

Review of the credentialing file for S11APRN revealed an application for appointment to Allied Health Professional Staff dated 02/12/14 and temporary privileges requested on 2/12/14 for Medical Examination and Treatment and Medical History & Physical Examination. The temporary privileges were signed by the Chief Executive Officer on 03/26/14 (temporary privileges not to exceed 120 days per By-laws). Review of the Allied Health Profession privileges dated 02/12/14 revealed S11APRN requested privileges for Medical History and Physical examination and General Medical Management. The privileges were approved by the MEC (Medical Executive Committee) on 07/30/14, but the signature line for the Governing Body approval was left blank. Review of the credentialing file revealed S14Physician had a collaborative agreement with S11APRN.

Review of the credentialing file for S14Physician revealed the physician's status approved by the Governing Body was "Consulting." The file revealed S14Physician had only consulting clinical privileges approved by the Governing Body on 06/26/14.

In an interview on 05/28/15 at 10:52 a.m., S6HIM Director (Health Information Management) stated approval of privileges went through the governing body but they did not sign the privileges request form. She confirmed that collaborating physician must be active medical staff member and confirmed S14Physician was a consulting medical staff member only.

In an interview on 05/28/15 at 3:00 p.m. S1ADM confirmed the governing body had not approved the privileges for S11APRN, and the Medical Staff By-laws indicated the H&P was to be done by a physician. He confirmed S14Physician was the collaborating physician but he only had consulting privileges and that was not in compliance with the by-laws. S1ADM confirmed S11APRN conducted the H&Ps and medical consults for the hospital.

Based on review of clinical records, review of Medical Staff By-laws, Rules & Regulations, review of hospital policy and procedures, and staff interview, the governing body failed to ensure:

1) patients are admitted to the hospital under the care of a doctor of medicine or osteopathy. This was identified for 3 (#6, #7, #8) of 4 (#6, #7, #8, #9) current inpatients out of a total sample of 9 (#1-#9) and 1 (#3) of 5 (#1-#5) closed sampled patients and,

2) a process was in place that defined what tasks the nurse practitioner could perform while ensuring the patient was under the care and direction of the physician. This resulted in patients being admitted to the hospital under the services of a nurse practitioner (APRN) with no involvement from the physician for 4 (#4, #6, #7, #8 ) of 9 (#1-#9) sampled patients and 3 of 3 (#R1, #R2, #R3) random patients.

Findings:

Review of the hospital's Medical Staff By-laws, Rules & Regulations dated 03/16/11, and approved by S1ADM (Administrator) and S8MD (Medical Director) on 02/23/15 revealed in part the following:
Definitions: 3. Allied Health Professional (AHP): individuals, other than those defined below under "Practitioner" and other than Hospital employees, who exercise independent judgment within the areas of his or her professional competence and the limits established by the Board, the Medical Staff, and Louisiana Practice Act, who provide direct patient care services in the hospital under a defined degree of supervision, and who must be granted Clinical Responsibilities through the procedures in these Bylaws to perform such services.
15. Medical Staff Member or Member: a Practitioner who has been granted and maintains Medical Staff membership and (except for honorary staff) Clinical Responsibilities in good standing pursuant to these Bylaws.
17. Practitioner: a Physician, Clinical Psychologist, or other individual eligible for medical staff membership, other than an employee of the Hospital, who has a current, unrestricted license issued by the State, and who is also permitted by the Hospital to provide patient care services without direction or supervision by another professional, in accordance with individually granted clinical responsibilities.
Article III. Membership on the Medical Staff of this System is a privilege that shall be granted only to professionally qualified and currently competent Practitioners (including those Practitioners under contract with the Hospital).
Article V. Allied Health Professionals (Health Professional Affiliates)
Allied Health Professionals (AHP) are health care providers other than Practitioners who hold a license, certificate, or such other legal credentials as are required by this State which authorizes the AHP to provide health care services. AHPs may be granted permission to participate in the provision of certain patient care services within the Hospital, but such permission shall not be construed to afford AHPs the rights of Medical Staff membership.
A. Nurse Practitioner: (2) Must have a supervising physician who is a member of [the hospital's] active medical staff.
Medical Staff Rules & Regulations
Admission and Discharge:
1. All attending Medical staff members with authority to admit patients will be governed by the official admitting policy of the hospital. 3. Patients may be admitted and discharged only on order of the attending medical staff member.

Review of the hospital policy titled, "Admissions" policy number CTS-001, revised date of 03/13 revealed in part the following: Only a qualified Practitioner may authorize admission to the inpatient, partial hospitalization, or intensive outpatient treatment programs.


1) the governing body failed to ensure patients are admitted to the hospital under the care of a doctor of medicine or osteopathy.

Patient #3
Review of the clinical record for Patient #3 revealed the patient was a 24 year old female admitted to the acute psychiatric unit on 04/20/15 with a diagnosis of Schizoaffective Disorder. The patient was discharged on 04/30/15.
Review of the physician's order revealed the admission orders revealed a pre-printed list of orders with check off boxes. Also pre-printed on the order form was, "Inpatient Admit to S5Psychiatrist." The pre-printed orders were checked and signed as verbal orders from S4APRN (Advanced Practice Registered Nurse) by S17RN on 04/20/15 at 7:10 p.m. S4APRN co-signed the verbal admission orders on 04/21/15 at 7:25 p.m.
Further review of the physician's orders for this hospital stay revealed all physician orders were written or were verbal orders by a nurse practitioner (APRN).
Review of the Physician/LIP progress notes revealed all of the progress notes were documented by S4APRN. There was no documented evidence in the progress notes of any communication or collaboration with the patient's admitting physician (S5Psychiatrist).
Review of the Psychiatric Evaluation dated 04/21/15 at 7:30 p.m. revealed the evaluation was documented by S4APRN.
Further review of the record revealed no documented evidence that S5Psychiatrist had seen, evaluated or examined Patient #3 during her hospital stay.

Further review of previous admissions for Patient #3 revealed the patient was hospitalized from 02/09/15 to 02/17/15 and the admitting physician was S5Psychiatrist. Review of the physician's orders, progress notes, and psychiatric evaluation for this hospital stay revealed all were written/signed by a nurse practitioner. There was no documented evidence in the progress notes of any communication or collaboration with the patient's admitting physician (S5Psychiatrist). Further review of the record revealed no documented evidence that S5Psychiatrist had seen, evaluated or examined Patient #3 during her hospital stay.

Further review of previous admissions for Patient #3 revealed the patient was hospitalized from 03/17/15 to 04/08/15 and the admitting physician was S5Psychiatrist. Review of the physician's orders, progress notes, and psychiatric evaluation for this hospital stay revealed all were written/signed by a nurse practitioner. There was no documented evidence in the progress notes of any communication or collaboration with the patient's admitting physician (S5Psychiatrist). Further review of the record revealed no documented evidence that S5Psychiatrist had seen, evaluated or examined Patient #3 during her hospital stay.

In an interview on 05/28/15 at 8:10 a.m. with S5Psychiatrist confirmed that only the nurse practitioner saw Patient #3. S5Psychiatrist stated she had very little oversight at this hospital. She stated S4APRN primarily does this hospital. She stated at any point in time if a nurse practitioner had a question, she was available. S5Psychiatrist confirmed she did not consult with S4APRN on Patient #3. She stated she was not involved in her treatment team. S5Psychiatrist stated, "We had been seeing Patient #3 since 2013 in the office." When asked if she had evaluated Patient #3 in the clinic or during any previous admissions, she stated she had never evaluated her, even in the clinic.

In an interview on 05/28/15 at 8:34 a.m. with S4APRN, she confirmed she was familiar with Patient #3 and the patient had been seen in her practice since 2013. She stated her practice consisted of S5Psychiatrist and 3 nurse practitioners. She stated she did consult with S5Psychiatrist. After reviewing the clinical records for all 3 admissions for Patient #3, she confirmed there was no documentation of any collaboration with S5Psychiatrist on any of the records. S4APRN confirmed the patient was not seen or evaluated by a physician, only by a nurse practitioner. She stated if the patient was an uncomplicated patient she could evaluate, treat, and discharge the patient without any consultation with S5Psychiatrist. She stated patients are admitted under S5Psychiatrist's services, but she treats them. She confirmed it would if be safe to say a patient's entire stay may not involve the physician.

In an interview on 05/28/15 at 3:00 p.m., S18RN confirmed she worked the day shift on the adult acute unit and stated the nurse practitioners usually made rounds, wrote orders and saw S5Psychiatrist's patients. She stated she had only seen S5Psychiatrist at this hospital once in the 2 years she had been employed at the hospital.

Patient #6
Review of the clinical record for Patient #6 revealed the patient was a 52 year old female admitted on 05/18/15 with a diagnosis of Schizoaffective Disorder, and she was a current inpatient on the acute adult unit. Review of the demographic form (face sheet) of the clinical record revealed the Admitting and Attending Physician was identified as S7APRN. Review of the pre-printed admission orders revealed the following was pre-printed on the top of the orders: "Inpatient Admit to S8MD (Medical Director), S7APRN, DNP (Doctor Nurse Practitioner)." The orders revealed the following signatures: "T.O.R.B.V. (Telephone order read back verification) Dr. S7APRN/S21LPN 05/18/15 at 3:53 p.m.." The order revealed S7APRN signed the orders on 05/19/15 at 9:15 a.m.
Further review of the physician's orders for this hospital stay revealed all physician orders were written or were verbal orders by a nurse practitioner (APRN).
Review of the Physician/LIP progress notes revealed all of the progress notes were documented by S7APRN. There was no documented evidence in the progress notes of any communication or collaboration with the patient's admitting physician (S8MD). Review of the progress note documented by S7APRN on 05/26/15 at 9:25 a.m., revealed S9Psychiatrist documented the following: "*Pt. seen today. Agree with Tx. plan. 05/26/15 2:22 p.m.
Review of the Psychiatric Evaluation dated 05/19/15 at 9:30 a.m. revealed the evaluation was documented by S7APRN. The evaluation revealed S9Psychiatrist signed beside the signature of S7APRN and dated/timed her signature as 05/19/15 at 12:35 p.m.
Further review of the record revealed no documented evidence that a physician/psychiatrist had seen, evaluated or examined Patient #6 during her hospital stay.

In a telephone interview on 05/28/15 at 5:30 p.m., S9Psychiatrist was asked what her documentation, "Pt. seen today" indicated on the progress notes. S9Psychiatrist stated, "I just laid eyes on the patient, I did not assess her." She stated she reviewed the nurse practitioner notes and the treatment plan. S9Psychiatrist stated she was only involved in treatment teams on the adolescent unit and stated S8MD and S7APRN do the treatment teams on the adult units. She stated the hospital started a new policy 2 weeks ago and according to the new policy she was required to review and sign the psychiatric evaluation (done by the nurse practitioner) and the treatment plan. She stated she also has to "lay eyes" on the patient one time a week. S9Psychiatrist stated the hospital did not indicate how that was to be documented, so she has been documenting it on the bottom of the nurse practitioner progress notes. S9Psychiatrist stated an evaluation of the patient was not conducted when she documented "Pt. seen today."

Patient #7
Review of the clinical record for Patient #7 revealed the patient was a 37 year old male admitted on 05/25/15 with a diagnosis of Chronic Paranoid Schizophrenia, and he was a current inpatient on the acute adult unit. Review of the demographic form of the clinical record revealed the Admitting and Attending Physician was identified as S7APRN. Review of the pre-printed admission orders revealed the following was pre-printed on the top of the orders: "Inpatient Admit to S8MD (Medical Director), S7APRN, DNP (Doctor Nurse Practitioner)." The orders revealed the following signatures: "T.O.R.B.V. (Telephone order read back verification) Dr. S7APRN/S23RN 05/25/15 at 3:53 p.m.." The order revealed S7APRN signed the orders on 05/26/15 at 12:57 a.m.
Further review of the physician's orders for this hospital stay revealed all physician orders were written or were verbal orders by a nurse practitioner (APRN).
Review of the Physician/LIP progress notes revealed all of the progress notes were documented by S7APRN. There was no documented evidence in the progress notes of any communication or collaboration with the patient's admitting physician (S8MD).
Review of the Psychiatric Evaluation dated 05/26/15 at 9:10 a.m. revealed the evaluation was documented by S7APRN. The evaluation revealed S9Psychiatrist signed beside the signature of S7APRN and dated/timed her signature as 05/26/15 at 2:00 p.m.
Further review of the record revealed no documented evidence that a physician/psychiatrist had seen, evaluated or examined Patient #7 during his hospital stay.

Patient #8
Review of the clinical record for Patient #8 revealed the patient was a 33 year old male admitted on 05/22/15 with a diagnosis of Schizoaffective Disorder, and he was a current inpatient on the acute adult unit. Review of the demographic form of the clinical record revealed the Admitting and Attending Physician was identified as S7APRN. Review of the pre-printed admission orders revealed the following was pre-printed on the top of the orders: "Inpatient Admit to S8MD (Medical Director), S7APRN, DNP (Doctor Nurse Practitioner)." The orders revealed the following signatures: "T.O.R.B.V. (Telephone order read back verification) Dr. S7APRN/S23RN 05/22/15 at 8:50 p.m.." The order revealed S7APRN signed the orders on 05/23/15 at 12:35 p.m.
Further review of the physician's orders for this hospital stay revealed all physician orders were written or were verbal orders by a nurse practitioner (APRN).
Review of the Physician/LIP progress notes revealed all of the progress notes were documented by S7APRN. There was no documented evidence in the progress notes of any communication or collaboration with the patient's admitting physician (S8MD).
Review of the Psychiatric Evaluation dated 05/26/15 at 10:10 a.m. revealed the evaluation was documented by S7APRN. The evaluation revealed on 5/26/15 at 2:02 p.m. S9Psychiatrist documented beneath the signature of S7APRN "Pt (patient) seen today. Agree with treatment plan."
Further review of the record revealed no documented evidence that a physician/psychiatrist had seen, evaluated or examined Patient #8 during his hospital stay.

In a telephone interview on 05/28/15 at 5:30 p.m., S9Psychiatrist stated she reviewed the nurse practitioner notes and the treatment plan. She stated the hospital started a new policy 2 weeks ago and according to the new policy she was required to review and sign the psychiatric evaluation (done by the nurse practitioner) and the treatment plan. She stated she also has to "lay eyes" on the patient one time a week. S9Psychiatrist stated the hospital did not indicate how that was to be documented, so she has been documenting it on the bottom of the nurse practitioner progress notes. S9Psychiatrist confirmed she had not evaluated Patient #7 or #8.

2) the governing body failed to ensure a process was in place that defined what tasks the nurse practitioner could perform while ensuring the patient was under the care and direction of the physician.

Review of the current census on 5/28/15 revealed S7APRN was listed as the attending physician for 20 of the 22 patients on the East unit. S8MD was listed as the attending physician on the other 2 patients.

Review of the medical record face sheet (patient information) for Patient #4 revealed the Attending physician was listed as S7APRN.

Review of the medical records for Patient's #R1, #R2, #R3 and #6, #7, #8 revealed S7APRN was listed as the admitting physician and the attending physician. Further review revealed S7APRN had written all of the progress notes and performed the psychiatric evaluations for the patients. She had signed the discharge summaries for Patient #R3 and Patient #4 and had a space with her name under it waiting to be signed for Patient #R1 and Patient #R2. Review of the admission orders revealed the top of the document had Inpatient Admit to: S8MD, S7APRN. S7APRN was written in a larger font and in a bolder print than S8MD.

In an interview on 05/28/15 at 8:34 a.m., S4APRN stated she did admit patients to another nurse practitioner when she was on call. She stated they do assign patients to S7APRN ' s services and stated S7APRN was a LIP (Licensed Independent Practitioner). S4APRN stated S7APRN had collaborative practice agreement with S8MD but stated she does not admit to S8MD, she admitted patients to S7APRN's services.

In an interview on 5/28/15 at 10:00 a.m. with S8MD, she verified she was the medical director of the hospital. She stated, "Dr. S7APRN admits her own patients. She is one of the equal staff members." S8MD said S7APRN was an independent practitioner and a doctor, so patients could be admitted to S7APRN and managed by her. S8MD said she was not managing the patients admitted to S7APRN because they were her (S7APRN) patients. S8MD also verified S7APRN had a doctorate in nursing and was not a medical doctor.

In an interview on 5/28/15 at 10:45 a.m. with S22HIM Manager, she said S7APRN had patients admitted to her because she was a doctor. When S22HIM Manager was told S7APRN was an advanced practice registered nurse, she said she thought S7APRN was a psychiatrist.

In an interview on 5/28/15 at 12:15 p.m. with S1ADM, he said S7APRN was having patients admitted to her directly.

In an interview on 5/28/15 at 12:30 p.m. with S7APRN, she said she had a doctorate in nursing. She said she had a collaborative agreement with S8MD and patients were not admitted to her because at the top of the admission orders it had written to admit to S8MD, S7APRN. She said someone had talked to someone working for the state and they said as long as the physician was listed as "admit to" on the admission orders they were covered. She said she could not remember who was talked to at the state but they possibly worked in the psychiatric division. When told S8MD said patients were admitted directly to her, S7APRN said she does not know why S8MD said that.


30364

Based on record review and interview, the governing body failed to ensure patients were under the care of a physician as evidenced by no documentation noted in the patient chart that a physician had seen, examined, and evaluated 1 (#3) of 5 (#1-#5) closed sampled patients, and 3 (#6, #7, #8) of 4 (#6, #7, #8, #9) current inpatients out of a total sample of 9 (#1-#9).
Findings:

Patient #3
Review of the clinical record for Patient #3 revealed the patient was a 24 year old female admitted to the acute psychiatric unit on 04/20/15 with a diagnosis of Schizoaffective Disorder. The patient was discharged on 04/30/15.
Review of the physician's order revealed the admission orders revealed a pre-printed list of orders with check off boxes. Also pre-printed on the order form was, "Inpatient Admit to S5Psychiatrist." The pre-printed orders were checked and signed as verbal orders from S4APRN (Advanced Practice Registered Nurse) by S17RN on 04/20/15 at 7:10 p.m. S4APRN co-signed the verbal admission orders on 04/21/15 at 7:25 p.m.
Further review of the physician's orders for this hospital stay revealed all physician orders were written or were verbal orders by a nurse practitioner (APRN).
Review of the Physician/LIP progress notes revealed all of the progress notes were documented by S4APRN. There was no documented evidence in the progress notes of any communication or collaboration with the patient's admitting physician (S5Psychiatrist).
Review of the Psychiatric Evaluation dated 04/21/15 at 7:30 p.m. revealed the evaluation was documented by S4APRN.
Further review of the record revealed no documented evidence that S5Psychiatrist had seen, evaluated or examined Patient #3 during her hospital stay.

Further review of previous admissions for Patient #3 revealed the patient was hospitalized from 02/09/15 to 02/17/15 and the admitting physician was S5Psychiatrist. Review of the physician's orders, progress notes, and psychiatric evaluation for this hospital stay revealed all were written/signed by a nurse practitioner. There was no documented evidence in the progress notes of any communication or collaboration with the patient's admitting physician (S5Psychiatrist). Further review of the record revealed no documented evidence that S5Psychiatrist had seen, evaluated or examined Patient #3 during her hospital stay.

Further review of previous admissions for Patient #3 revealed the patient was hospitalized from 03/17/15 to 04/08/15 and the admitting physician was S5Psychiatrist. Review of the physician's orders, progress notes, and psychiatric evaluation for this hospital stay revealed all were written/signed by a nurse practitioner. There was no documented evidence in the progress notes of any communication or collaboration with the patient's admitting physician (S5Psychiatrist). Further review of the record revealed no documented evidence that S5Psychiatrist had seen, evaluated or examined Patient #3 during her hospital stay.

In an interview on 05/28/15 at 8:10 a.m. with S5Psychiatrist confirmed that only the nurse practitioner saw Patient #3. S5Psychiatrist stated she had very little oversight at this hospital. She stated S4APRN primarily does this hospital. She stated at any point in time if a nurse practitioner had a question, she was available. S5Psychiatrist confirmed she did not consult with S4APRN on Patient #3. She stated she was not involved in her treatment team. S5Psychiatrist stated, "We had been seeing Patient #3 since 2013 in the office." When asked if she had evaluated Patient #3 in the clinic or during any previous admissions, she stated she had never evaluated her, even in the clinic.

In an interview on 05/28/15 at 8:34 a.m. with S4APRN, she confirmed she was familiar with Patient #3 and the patient had been seen in her practice since 2013. She stated her practice consisted of S5Psychiatrist and 3 nurse practitioners. She stated she did consult with S5Psychiatrist. After reviewing the clinical records for all 3 admissions for Patient #3, she confirmed there was no documentation of any collaboration with S5Psychiatrist on any of the records. S4APRN confirmed the patient was not seen or evaluated by a physician, only by a nurse practitioner. She stated if the patient was an uncomplicated patient she could evaluate, treat, and discharge the patient without any consultation with S5Psychiatrist. She stated patients are admitted under S5Psychiatrist's services, but she treats them. She confirmed it would if be safe to say a patient's entire stay may not involve the physician.

In an interview on 05/28/15 at 3:00 p.m., S18RN confirmed she worked the day shift on the adult acute unit and stated the nurse practitioners usually made rounds, wrote orders and saw S5Psychiatrist's patients. She stated she had only seen S5Psychiatrist at this hopsital once in the 2 years she had been employed at the hospital.

Patient #6
Review of the clinical record for Patient #6 revealed the patient was a 52 year old female admitted on 05/18/15 with a diagnosis of Schizoaffective Disorder, and she was a current inpatient on the acute adult unit. Review of the demographic form (face sheet) of the clinical record revealed the Admitting and Attending Physician was identified as S7APRN. Review of the pre-printed admission orders revealed the following was pre-printed on the top of the orders: "Inpatient Admit to S8MD (Medical Director), S7APRN, DNP (Doctor Nurse Practitioner)." The orders revealed the following signatures: "T.O.R.B.V. (Telephone order read back verification) Dr. S7APRN/S21LPN 05/18/15 at 3:53 p.m.." The order revealed S7APRN signed the orders on 05/19/15 at 9:15 a.m.
Further review of the physician's orders for this hospital stay revealed all physician orders were written or were verbal orders by a nurse practitioner (APRN).
Review of the Physician/LIP progress notes revealed all of the progress notes were documented by S7APRN. There was no documented evidence in the progress notes of any communication or collaboration with the patient's admitting physician (S8MD). Review of the progress note documented by S7APRN on 05/26/15 at 9:25 a.m., revealed S9Psychiatrist documented the following: "*Pt. seen today. Agree with Tx. plan. 05/26/15 2:22 p.m.
Review of the Psychiatric Evaluation dated 05/19/15 at 9:30 a.m. revealed the evaluation was documented by S7APRN. The evaluation revealed S9Psychiatrist signed beside the signature of S7APRN and dated/timed her signature as 05/19/15 at 12:35 p.m.

Further review of the record revealed no documented evidence that a physician/psychiatrist had seen, evaluated or examined Patient #6 during her hospital stay.

Patient #7
Review of the clinical record for Patient #7 revealed the patient was a 37 year old male admitted on 05/25/15 with a diagnosis of Chronic Paranoid Schizophrenia, and he was a current inpatient on the acute adult unit. Review of the demographic form of the clinical record revealed the Admitting and Attending Physician was identified as S7APRN. Review of the pre-printed admission orders revealed the following was pre-printed on the top of the orders: "Inpatient Admit to S8MD (Medical Director), S7APRN, DNP (Doctor Nurse Practitioner)." The orders revealed the following signatures: "T.O.R.B.V. (Telephone order read back verification) Dr. S7APRN/S23RN 05/25/15 at 3:53 p.m.." The order revealed S7APRN signed the orders on 05/26/15 at 12:57 a.m.
Further review of the physician's orders for this hospital stay revealed all physician orders were written or were verbal orders by a nurse practitioner (APRN).
Review of the Physician/LIP progress notes revealed all of the progress notes were documented by S7APRN. There was no documented evidence in the progress notes of any communication or collaboration with the patient's admitting physician (S8MD).
Review of the Psychiatric Evaluation dated 05/26/15 at 9:10 a.m. revealed the evaluation was documented by S7APRN. The evaluation revealed S9Psychiatrist signed beside the signature of S7APRN and dated/timed her signature as 05/26/15 at 2:00 p.m.

Further review of the record revealed no documented evidence that a physician/psychiatrist had seen, evaluated or examined Patient #7 during his hospital stay.

Patient #8
Review of the clinical record for Patient #8 revealed the patient was a 33 year old male admitted on 05/22/15 with a diagnosis of Schizoaffective Disorder, and he was a current inpatient on the acute adult unit. Review of the demographic form of the clinical record revealed the Admitting and Attending Physician was identified as S7APRN. Review of the pre-printed admission orders revealed the following was pre-printed on the top of the orders: "Inpatient Admit to S8MD (Medical Director), S7APRN, DNP (Doctor Nurse Practitioner)." The orders revealed the following signatures: "T.O.R.B.V. (Telephone order read back verification) Dr. S7APRN/S23RN 05/22/15 at 8:50 p.m.." The order revealed S7APRN signed the orders on 05/23/15 at 12:35 p.m.
Further review of the physician's orders for this hospital stay revealed all physician orders were written or were verbal orders by a nurse practitioner (APRN).
Review of the Physician/LIP progress notes revealed all of the progress notes were documented by S7APRN. There was no documented evidence in the progress notes of any communication or collaboration with the patient's admitting physician (S8MD).
Review of the Psychiatric Evaluation dated 05/26/15 at 10:10 a.m. revealed the evaluation was documented by S7APRN. The evaluation revealed on 5/26/15 at 2:02 p.m. S9Psychiatrist documented beneath the signature of S7APRN " Pt (patient) seen today. Agree with treatment plan. "

Further review of the record revealed no documented evidence that a physician/psychiatrist had seen, evaluated or examined Patient #8 during his hospital stay.

In a telephone interview on 05/28/15 at 5:30 p.m., S9Psychiatrist was asked what her documentation, "Pt. seen today" indicated on the progress notes. S9Psychiatrist stated, "I just laid eyes on the patient, I did not assess her." She stated she reviewed the nurse practitioner notes and the treatment plan. S9Psychiatrist stated she was only involved in treatment teams on the adolescent unit and stated S8MD and S7APRN do the treatment teams on the adult units. She stated the hospital started a new policy 2 weeks ago and according to the new policy she was required to review and sign the psychiatric evaluation (done by the nurse practitioner) and the treatment plan. She stated she also has to "lay eyes" on the patient one time a week. S9Psychiatrist stated the hospital did not indicate how that was to be documented, so she has been documenting it on the bottom of the nurse practitioner progress notes. S9Psychiatrist stated an evaluation of the patient was not conducted when she documented "Pt. seen today."

Based on observation and interview, the hospital failed to ensure patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for patients admitted for acute inpatient psychiatric services by failing to ensure the patients' environment was free of ligature risks and safety hazards. Findings:

In an observation on 05/26/15 at 2:50 p.m. of the adult acute unit (East) with S2DON (Director of Nursing), the doors to the patients' rooms and the bathroom doors were observed to have door hinges set apart widely enough to allow for potential ligature. S2DON confirmed patients are allowed to close the door to their rooms and confirmed the bathroom doors posed a ligature risk. S2DON stated there were 22 beds (11) rooms on this unit and confirmed the door hinges were the same in all the patient rooms.

The hinges of the doors to the patient rooms and bathrooms were observed to be secured to the door and the frame with non-tamper resistant screws. The sinks in the patient rooms were observed to have flanged handles that could be used as ligature points. S2DON confirmed the observations.

Toilet holders in the patient bathrooms were observed to have non-tamper screws. S2DON stated the toilet paper holders had been recently replaced with a type of holder that did not have a removable rod. S2DON confirmed the screws that secured the holder to the wall were not tamper resistant.

An observation in the patient room between Room a and Room b (no number on room) revealed the electrical outlet between the patient beds was not a GFCI (Ground-Fault Circuit Interrupter). S2DON contacted S24Env. of Care Director who arrived during the observation of the room and confirmed the electrical outlet between the patient beds was not a GFCI type of outlet. S24Env. of Care Director stated the electrical outlets were changes to GFCI years ago. He stated this patient room was used as a nurse's station in the past and the outlet was not changed after the room was changed to a patient room.

Based on review of Medical Staff By-laws, review of credentialing files, review of the policies and procedures, review of clinical records, and staff interview, the Medical Staff failed to be accountable to the Governing Body for the quality of medical care provided as evidenced by failing to ensure Allied Health Professionals (AHPs) were credentialed and practiced in accordance with Medical Staff By-laws, Rules & Regulations
Findings:

Review of the hospital's Medical Staff By-laws, Rules & Regulations dated 03/16/11, and approved by S1ADM (Administrator) and S8MD (Medical Director) on 02/23/15 revealed AHPs may be granted permission to participate in the provision of certain patient care services, but were not afforded the rights of Medical Staff membership. Nurse practitioners were listed under Allied Health Professionals and the by-laws required an binding agreement with an active medical staff member and a supervising physician who was an active member of the medical staff. Further review of the Medical Staff Rules & Regulations revealed patients may be admitted an discharged only on order of the attending medical staff member, the attending medical staff member had the responsibility for the development and implementation of the patient's treatment plan, and the attending medical staff member or designee shall completed the discharge summary. The Rules & Regulations also revealed a board certified or qualified psychiatrist of the medical staff would be a member of the treatment team when psychotropic medications were used, and the attending medical staff member must approve all treatment plans.

Review of the credentialing file for S4APRN revealed a request for clinical privileges for Allied Health Professional that included Admission to Adult Psychiatry, Admission to Adolescent Psychiatry, and Psycho-pharmacotherapy. The request was signed by the MEC (Medical Executive Committee) on 11/30/13 and by the Governing Body on 11/15/13. Review of the credentialing file revealed the collaborating physician was S5Psychiatrist. A letter from the CEO (Chief Executive Officer) dated 11/15/13 indicating requested privileges were granted for a period from 11/15/13 to 11/15/15. The letter revealed the status of S4APRN was Allied Health Professional.

Review of the credentialing file for S10APRN revealed a request for clinical privileges for Allied Health Professional that included Admission to Adult Psychiatry, Admission to Adolescent Psychiatry, and Psycho-pharmacotherapy. The request was signed by the MEC (Medical Executive Committee) on 11/30/13 and by the Governing Body on 11/15/13. Review of the credentialing file revealed the collaborating physician was S5Psychiatrist. A letter from the CEO (Chief Executive Officer) dated 11/15/13 indicating requested privileges were granted for a period from 11/15/13 to 11/15/15. The letter revealed the status of S10APRN was Allied Health Professional.

Review of the clinical record for Patient #3 revealed the patient was a 24 year old female admitted to the services of S5Psychiatrist on the acute psychiatric unit on 04/20/15 with a diagnosis of Schizoaffective Disorder. The patient was discharged on 04/30/15.
Review of the record revealed no documented evidence that S5Psychiatrist had seen, evaluated or examined Patient #3 during her hospital stay, or was a member of the treatment team. Review of the record revealed all orders, progress notes, and the psychiatric evaluation were documented by S4APRN.

In an interview on 05/28/15 at 8:10 a.m. with S5Psychiatrist confirmed that only the nurse practitioner saw Patient #3. S5Psychiatrist stated she had very little oversight at this hospital. S5Psychiatrist confirmed she did not consult with S4APRN on Patient #3. She stated she was not involved in her treatment team. S5Psychiatrist confirmed she had never evaluated Patient #3, even in the clinic.

In an interview on 05/28/15 at 8:34 a.m. with S4APRN, there was no documentation of any collaboration with S5Psychiatrist. S4APRN confirmed the patient was not seen or evaluated by a physician, only by a nurse practitioner. She stated if the patient was an uncomplicated patient she could evaluate, treat, and discharge the patient without any consultation with S5Psychiatrist. She stated patients are admitted under S5Psychiatrist's services, but she treats them.

Review of the credentialing file for S7APRN revealed a request for clinical privileges for Allied Health Professional that included Admission to Adult Psychiatry, Admission to Adolescent Psychiatry, and Psycho-pharmacotherapy. The request was signed by the MEC and by the Governing Body. Review of the credentialing file revealed the collaborating physician was S8MD (Medical Director). A letter from the CEO revealed the status of S10APRN was Allied Health Professional.

Review of the current census on 5/28/15 revealed S7APRN was listed as the attending physician for 20 of the 22 patients on the East unit. S8MD was listed as the attending physician on the other 2 patients.

Review of the clinical records for Patient #6, #7, and #8 revealed the patients were current inpatients on the Adult Acute Unit (East). Review of the demographic form (face sheet) of the clinical records revealed the Admitting and Attending Physician was identified as S7APRN for all 3 patients. Review of the pre-printed admission orders revealed the following was pre-printed on the top of the orders: "Inpatient Admit to S8MD (Medical Director), S7APRN, DNP (Doctor Nurse Practitioner)."
Further review of the physician's orders for this hospital stay revealed all physician orders were written or were verbal orders by a nurse practitioner (APRN) for all 3 patients. The psychiatric evaluation was documented by S7APRN, and S7APRN signed the treatment plan under "Physician approval of treatment plan."
Further review of the records revealed no documented evidence that a physician/psychiatrist had seen, evaluated or examined Patient #6, #7, #8 during their hospital stay.

In an interview on 5/28/15 at 10:00 a.m. with S8MD, she verified she was the medical director of the hospital. She stated, "Dr. S7APRN admits her own patients. She is one of the equal staff members." S8MD said S7APRN was an independent practitioner and a doctor, so patients could be admitted to S7APRN and managed by her. S8MD said she was not managing the patients admitted to S7APRN because they were her (S7APRN) patients. S8MD confirmed that she only attended treatment teams when it was her patient. She stated patients that are followed by nurse practitioners do not have psychiatrist on treatment team. After reviewing the Medical Staff By-laws, Rules & Regulations, she confirmed Article V, AHP section indicated AHPs are not members of the medical staff. She also confirmed the Rules & Regulations indicated the psychiatrist was to be a member of the treatment team. She confirmed being a member of the treatment team meant being present for the treatment team meetings. She stated the hospital ' s current practice related to Nurse Practitioners was not in compliance with the bylaws and the hospital needed to look at that. She stated the Nurse Practitioners function as independent practitioners. S8MD confirmed provisions throughout the bylaws for members of medical staff to admit and discharge were not adhered to by the current practices.

In an interview on 5/28/15 at 10:45 a.m. with S22HIM Manager, she said S7APRN had patients admitted to her because she was a doctor. When S22HIM Manager was told S7APRN was an advanced practice registered nurse, she said she thought S7APRN was a psychiatrist.

In an interview on 5/28/15 at 12:15 p.m. with S1ADM, he said S7APRN was having patients admitted to her directly.

In an interview on 5/28/15 at 12:30 p.m. with S7APRN, she said she had a doctorate in nursing. She said she had a collaborative agreement with S8MD and patients were not admitted to her because at the top of the admission orders it had written to admit to S8MD, S7APRN. She said someone had talked to someone working for the state and they said as long as the physician was listed as "admit to" on the admission orders they were covered. She said she could not remember who was talked to at the state but they possibly worked in the psychiatric division. S7APRN stated the collaborative agreement only indicates collaboration when she needs it and does not require supervision by the collaborating physician.

Review of the clinical records for sampled Patients #3, #4, #6, #7, and #8 revealed the H&P and medical consults were done by S11APRN.

Review of the credentialing file for S11APRN revealed an application for appointment to Allied Health Professional Staff dated 02/12/14 and temporary privileges requested on 2/12/14 for Medical Examination and Treatment and Medical History & Physical Examination. The temporary privileges were signed by the Chief Executive Officer on 03/26/14 (temporary privileges not to exceed 120 days per By-laws). Review of the Allied Health Profession privileges dated 02/12/14 revealed S11APRN requested privileges for Medical History and Physical examination and General Medical Management. The privileges were approved by the MEC (Medical Executive Committee) on 07/30/14, but the signature line for the Governing Body approval was left blank.

In an interview on 05/28/15 at 3:00 p.m. S1ADM confirmed the governing body had not approved the privileges for S11APRN, and the Medical Staff By-laws indicated the H&P was to be done by a physician. S1ADM confirmed S11APRN conducted the H&Ps and medical consults for the hospital.

Based on review of Medical Staff By-laws, Rules & Regulation, review of credentialing files, review of clinical records, and staff interview, the medical staff failed to enforce its By-laws as evidenced by:

1) nurse practitioners conducting history and physical (H&P) assessments and medical consults when medical staff bylaws required H&P assessments and medical consults to be done by physicians for 5 of 5 (#3, #4, #6, #7, #8) sampled patients reviewed for H&Ps and medical consults;

2) psychiatrists failing to participate in the patient's treatment team as stipulated in the by-laws for 4 of 4 (#3, #6, #7, #8) sampled patients reviewed for treatment planning.

Findings:


1) Nurse practitioners conducting history and physical (H&P) assessments and medical consults when medical staff bylaws required H&P assessments and medical consults be done by physicians:

Review of the hospital's Medical Staff By-laws, Rules & Regulations dated 03/16/11, and approved by S1ADM (Administrator) and S8MD (Medical Director) on 02/23/15 revealed in part the following:
Section 2-Delineation of Clinical Responsibilities: All patients of independent practitioners shall have a prompt history taken and comprehensive physical examination performed by a physician who has such Responsibilities. A physician member of the Medical Staff shall be responsible for the care of any medical problems that may be present at the time of admission or that may arise during hospitalization and shall determine the risk and effect of any proposed procedure on the total health status of the patient.
Article V. A. Nurse Practitioner (1) All nurse practitioners must have a binding contract agreement with a member of [hospital's] active medical staff.


Patient #3
Review of the clinical record for Patient #3 revealed the patient was a 24 year old female admitted to the acute psychiatric unit on 04/20/15 with a diagnosis of Schizoaffective Disorder. The patient was discharged on 04/30/15.
Review of the Medical Admission Health History and Physical dated 04/21/15 at 2:20 p.m. revealed the H&P was done by S11APRN (Advanced Practice Registered Nurse). Further review of the record revealed a medical consult was done by S11APRN on 04/23/15.

Further review of previous admissions for Patient #3 revealed the patient was hospitalized from 02/09/15 to 02/17/15 and the H&P was done by S11APRN. Further review of the record revealed a medical consult was done by S11APRN on 02/12/15.

Further review of previous admissions for Patient #3 revealed the patient was hospitalized from 03/17/15 to 04/08/15 and the H&P was done by S11APRN. Further review of the record revealed medical consults were done by S11APRN on 03/19/15, and 03/26/15.


Patient #4
Review of the medical record for Patient #4 revealed he was admitted to the hospital on 4/14/15 with diagnosis which included Schizoaffective Disorder. Further review revealed the History and Physical had been completed on 4/15/15 by S11APRN.


Patient #6
Review of the medical record for Patient #6 revealed the patient was a 52 year old female admitted to the hospital on 5/18/15 with diagnosis of Schizophrenia and she was a current inpatient. Further review of the record revealed the History and Physical had been completed on 5/19/15 by S11APRN.


Patient #7
Review of the medical record for Patient #7 revealed he was admitted to the hospital on 5/25/15 with diagnosis which included Chronic Paranoid Schizophrenia and he was a current inpatient. Further review of the record revealed the History and Physical had been completed on 5/26/15 by S11APRN.


Patient #8
Review of the medical record for Patient #8 revealed he was admitted to the hospital on 5/22/15 with diagnosis which included Schizoaffective Disorder and he was a current inpatient. Further review of the record revealed the History and Physical had been completed on 5/23/15 by S11APRN.


Review of the credentialing file for S11APRN revealed Allied Health Professional privileges for medical history & physical examination and general medical management were requested by S11APRN on 02/12/14, but the request was not approved by the Governing Body. Further review of the credentialing file revealed S11APRN did not have a collaborative practice agreement with any physician currently on the medical staff with active privileges (as required in the medical staff by-laws).

In an interview on 05/28/15 at 9:50 a.m., S8MD (Medical Director) confirmed S11APRN does the H&P and medical consults.

In an interview on 05/28/15 at 3:00 p.m. S1ADM confirmed the governing body had not approved the privileges for S11APRN and the Medical Staff By-laws indicated the H&P was to be done by a physician. He confirmed the collaborating physician for S11APRN only had consulting privileges and that was not in compliance with the Medical Staff By-laws that required the collaborating physician to have active privileges.



2) Psychiatrists failing to participate in the patient's treatment team as stipulated in the by-laws:

Review of the hospital's Medical Staff By-laws, Rules & Regulations dated 03/16/11, and approved by S1ADM and S8MD on 02/23/15 revealed in part the following:
Medical Records and Orders:
5. When there is the use of psychotropic medications, a board certified or qualified psychiatrist of the medical staff will be a member of the treatment team.


Patient #3
Review of the clinical record for Patient #3 revealed the patient was a 24 year old female admitted to the acute psychiatric unit on 04/20/15 with a diagnosis of Schizoaffective Disorder. The patient was discharged on 04/30/15.
Review of the Multidisciplinary Treatment Plan dated 04/21/15 revealed the Physician Approval of Treatment Plan was signed only by S4APRN.

Further review of previous admissions for Patient #3 revealed the patient was hospitalized from 02/09/15 to 02/17/15 and the Multidisciplinary Treatment Plan dated 04/21/15 revealed the Physician Approval of Treatment Plan was signed only by S4APRN.

Further review of previous admissions for Patient #3 revealed the patient was hospitalized from 03/17/15 to 04/08/15 and the Multidisciplinary Treatment Plan dated 02/12/15 revealed the Physician Approval of Treatment Plan was signed only by S4APRN.

Review of all 3 admissions revealed the patient had received psychotropic medications.

In an interview on 05/28/15 at 8:10 a.m. with S5Psychiatrist confirmed that only the nurse practitioner saw Patient #3. S5Psychiatrist confirmed she did not consult with S4APRN on Patient #3. She stated she was not involved in her treatment team.

In an interview on 05/28/15 at 8:34 a.m. with S4APRN, she confirmed she was familiar with Patient #3 and the patient had been seen in her practice since 2013. After reviewing the clinical records for all 3 admissions for Patient #3, she confirmed there was no documentation of any collaboration with S5Psychiatrist on any of the records. S4APRN confirmed she signed the treatment plans and S5Psychiatrist was not involved in the treatment team.

Patient #6
Review of the medical record for Patient #6 revealed the patient was a 52 year old female admitted to the hospital on 5/18/15 with diagnosis of Schizophrenia and she was a current inpatient on the adult acute unit. Further review of the record revealed the Multidisciplinary Treatment Plan dated 05/26/15 revealed the Physician Approval of Treatment Plan was signed by S7APRN at 9:25 a.m. The treatment plan was co-signed by S9Psychiatrist on 05/26/15 at 2:22 p.m. Review of the record revealed the patient was receiving psychotropic medications.

Patient #7
Review of the medical record for Patient #7 revealed he was admitted to the hospital on 5/25/15 with diagnosis which included Chronic Paranoid Schizophrenia and he was a current inpatient on the adult acute unit. Further review of the record revealed the Multidisciplinary Treatment Plan dated 05/26/15 revealed the Physician Approval of Treatment Plan was signed by S7APRN at 9:05 a.m. The treatment plan was co-signed by S9Psychiatrist on 05/26/15 at 9:05 a.m. Review of the record revealed the patient was receiving psychotropic medications.

Patient #8
Review of the medical record for Patient #8 revealed he was admitted to the hospital on 5/22/15 with diagnosis which included Schizoaffective Disorder and he was a current inpatient on the adult acute unit. Further review of the record revealed the Multidisciplinary Treatment Plan dated 05/26/15 revealed the Physician Approval of Treatment Plan was signed by S7APRN and co-signed by S9Psychiatrist on 05/26/15.
Review of the record revealed the patient was receiving psychotropic medications.

In a telephone interview on 05/28/15 at 5:30 p.m., S9Psychiatrist stated she reviewed the nurse practitioner notes and the treatment plan. S9Psychiatrist stated she was only involved in treatment teams on the adolescent unit and stated S8MD and S7APRN do the treatment teams on the adult units. She stated the hospital started a new policy 2 weeks ago and according to the new policy she was required to review and sign the treatment plan.

Based on record review and interview, the hospital:
1) failed to ensure discharge summaries were written by qualified health care personnel for 8 of 8 (#1, #2, #3, #4, #5, #R1, #R2, #R3) discharged patients' records reviewed;

2) failed to ensure patients' discharge summaries authenticated by a nurse practitioner were co-authenticated by a physician responsible for the patient during the hospital stay for 2 (#4, #R3) of 8 (#1, #2, #3, #4, #5, #R1, #R2, #R3) discharged patient records reviewed;

Findings:

1) Failing to ensure discharge summaries were written by qualified health care personnel.

Review of the medical records for Patients #1, #2, #3, #4, #5, #R1, #R2 and #R3 revealed the discharge summaries had been dictated by S20RHIA (Registered Health Information Administrator).

In an interview on 05/27/15 at 1:15 p.m. S6HIM Director (Health Information Manager) S20RHIA was contracted to dictate discharge summaries. She stated S20RHIA reviewed the patient's record and summarized the record and dictated the discharge summary. She stated they do require that S20RHIA sign that she dictated the summary, and the physician signs the discharge summary. After reviewing the discharge summary for Patient #3 dated 04/20/15 she confirmed the discharge summary was dictated by S20RHIA.

In an interview on 05/28/15 at 8:10 a.m. S5Psychiatrist stated the hospital had someone on staff who does the discharge summaries and she signed them. She stated she usually just reviews the discharge summary done by the contracted staff and signed it.

In an interview on 5/28/15 at 3:30 p.m., S1ADM verified the discharge summaries mentioned above were dictated by S20RHIA and she did not have a medical background or involvement in the discharged patients' care. S1ADM said she gathered the information from the charts and compiled the summary for the physician to review.


2) Failing to ensure patients' discharge summaries authenticated by a nurse practitioner were co-authenticated by a physician responsible for the patient during the hospital stay.

Patient #4
Review of the medical record for Patient #4 revealed he was admitted to the hospital on 4/14/15 with diagnosis including Mood Disorder and was discharged on 4/21/15. Further review revealed his discharge summary had been written by S7APRN (advanced practice registered nurse) and had not been co-signed by a physician.

Patient #R3
Review of the medical record for Patient #R3 revealed he was admitted to the hospital on 4/16/15 with diagnosis including Bipolar Disorder and was discharged on 4/24/15. Further review revealed his discharge summary had been written by S7APRN and had not been co-signed by a physician.

In an interview on 5/28/15 at 10:00 a.m. with S8MD, she said she was the Medical Director of the hospital. She said S7APRN did her own discharge summaries and did not have them co-signed by a physician. S8MD verified S7APRN was not a medical doctor.


17091

Based on review of clinical records, review of Medical Staff By-laws, Rules & Regulations, review of hospital policy and procedures, and staff interview, the governing body failed to ensure:

1) patients are admitted to the hospital under the care of a doctor of medicine or osteopathy. This was identified for 3 (#6, #7, #8) of 4 (#6, #7, #8, #9) current inpatients out of a total sample of 9 (#1-#9) and 1 (#3) of 5 (#1-#5) closed sampled patients and,

2) a process was in place that defined what tasks the nurse practitioner could perform while ensuring the patient was under the care and direction of the physician. This resulted in patients being admitted to the hospital under the services of a nurse practitioner (APRN) with no involvement from the physician for 4 (#4, #6, #7, #8 ) of 9 (#1-#9) sampled patients and 3 of 3 (#R1, #R2, #R3) random patients.

Findings:

Review of the hospital's Medical Staff By-laws, Rules & Regulations dated 03/16/11, and approved by S1ADM (Administrator) and S8MD (Medical Director) on 02/23/15 revealed in part the following:
Definitions: 3. Allied Health Professional (AHP): individuals, other than those defined below under "Practitioner" and other than Hospital employees, who exercise independent judgment within the areas of his or her professional competence and the limits established by the Board, the Medical Staff, and Louisiana Practice Act, who provide direct patient care services in the hospital under a defined degree of supervision, and who must be granted Clinical Responsibilities through the procedures in these Bylaws to perform such services.
15. Medical Staff Member or Member: a Practitioner who has been granted and maintains Medical Staff membership and (except for honorary staff) Clinical Responsibilities in good standing pursuant to these Bylaws.
17. Practitioner: a Physician, Clinical Psychologist, or other individual eligible for medical staff membership, other than an employee of the Hospital, who has a current, unrestricted license issued by the State, and who is also permitted by the Hospital to provide patient care services without direction or supervision by another professional, in accordance with individually granted clinical responsibilities.
Article III. Membership on the Medical Staff of this System is a privilege that shall be granted only to professionally qualified and currently competent Practitioners (including those Practitioners under contract with the Hospital).
Article V. Allied Health Professionals (Health Professional Affiliates)
Allied Health Professionals (AHP) are health care providers other than Practitioners who hold a license, certificate, or such other legal credentials as are required by this State which authorizes the AHP to provide health care services. AHPs may be granted permission to participate in the provision of certain patient care services within the Hospital, but such permission shall not be construed to afford AHPs the rights of Medical Staff membership.
A. Nurse Practitioner: (2) Must have a supervising physician who is a member of [the hospital's] active medical staff.
Medical Staff Rules & Regulations
Admission and Discharge:
1. All attending Medical staff members with authority to admit patients will be governed by the official admitting policy of the hospital. 3. Patients may be admitted and discharged only on order of the attending medical staff member.

Review of the hospital policy titled, "Admissions" policy number CTS-001, revised date of 03/13 revealed in part the following: Only a qualified Practitioner may authorize admission to the inpatient, partial hospitalization, or intensive outpatient treatment programs.


1) the governing body failed to ensure patients are admitted to the hospital under the care of a doctor of medicine or osteopathy.

Patient #3
Review of the clinical record for Patient #3 revealed the patient was a 24 year old female admitted to the acute psychiatric unit on 04/20/15 with a diagnosis of Schizoaffective Disorder. The patient was discharged on 04/30/15.
Review of the physician's order revealed the admission orders revealed a pre-printed list of orders with check off boxes. Also pre-printed on the order form was, "Inpatient Admit to S5Psychiatrist." The pre-printed orders were checked and signed as verbal orders from S4APRN (Advanced Practice Registered Nurse) by S17RN on 04/20/15 at 7:10 p.m. S4APRN co-signed the verbal admission orders on 04/21/15 at 7:25 p.m.
Further review of the physician's orders for this hospital stay revealed all physician orders were written or were verbal orders by a nurse practitioner (APRN).
Review of the Physician/LIP progress notes revealed all of the progress notes were documented by S4APRN. There was no documented evidence in the progress notes of any communication or collaboration with the patient's admitting physician (S5Psychiatrist).
Review of the Psychiatric Evaluation dated 04/21/15 at 7:30 p.m. revealed the evaluation was documented by S4APRN.
Further review of the record revealed no documented evidence that S5Psychiatrist had seen, evaluated or examined Patient #3 during her hospital stay.

Further review of previous admissions for Patient #3 revealed the patient was hospitalized from 02/09/15 to 02/17/15 and the admitting physician was S5Psychiatrist. Review of the physician's orders, progress notes, and psychiatric evaluation for this hospital stay revealed all were written/signed by a nurse practitioner. There was no documented evidence in the progress notes of any communication or collaboration with the patient's admitting physician (S5Psychiatrist). Further review of the record revealed no documented evidence that S5Psychiatrist had seen, evaluated or examined Patient #3 during her hospital stay.

Further review of previous admissions for Patient #3 revealed the patient was hospitalized from 03/17/15 to 04/08/15 and the admitting physician was S5Psychiatrist. Review of the physician's orders, progress notes, and psychiatric evaluation for this hospital stay revealed all were written/signed by a nurse practitioner. There was no documented evidence in the progress notes of any communication or collaboration with the patient's admitting physician (S5Psychiatrist). Further review of the record revealed no documented evidence that S5Psychiatrist had seen, evaluated or examined Patient #3 during her hospital stay.

In an interview on 05/28/15 at 8:10 a.m. with S5Psychiatrist confirmed that only the nurse practitioner saw Patient #3. S5Psychiatrist stated she had very little oversight at this hospital. She stated S4APRN primarily does this hospital. She stated at any point in time if a nurse practitioner had a question, she was available. S5Psychiatrist confirmed she did not consult with S4APRN on Patient #3. She stated she was not involved in her treatment team. S5Psychiatrist stated, "We had been seeing Patient #3 since 2013 in the office." When asked if she had evaluated Patient #3 in the clinic or during any previous admissions, she stated she had never evaluated her, even in the clinic.

In an interview on 05/28/15 at 8:34 a.m. with S4APRN, she confirmed she was familiar with Patient #3 and the patient had been seen in her practice since 2013. She stated her practice consisted of S5Psychiatrist and 3 nurse practitioners. She stated she did consult with S5Psychiatrist. After reviewing the clinical records for all 3 admissions for Patient #3, she confirmed there was no documentation of any collaboration with S5Psychiatrist on any of the records. S4APRN confirmed the patient was not seen or evaluated by a physician, only by a nurse practitioner. She stated if the patient was an uncomplicated patient she could evaluate, treat, and discharge the patient without any consultation with S5Psychiatrist. She stated patients are admitted under S5Psychiatrist's services, but she treats them. She confirmed it would if be safe to say a patient's entire stay may not involve the physician.

In an interview on 05/28/15 at 3:00 p.m., S18RN confirmed she worked the day shift on the adult acute unit and stated the nurse practitioners usually made rounds

Based on record review and interview, the governing body failed to ensure patients were under the care of a physician as evidenced by no documentation noted in the patient chart that a physician had seen, examined, and evaluated 1 (#3) of 5 (#1-#5) closed sampled patients, and 3 (#6, #7, #8) of 4 (#6, #7, #8, #9) current inpatients out of a total sample of 9 (#1-#9).
Findings:

Patient #3
Review of the clinical record for Patient #3 revealed the patient was a 24 year old female admitted to the acute psychiatric unit on 04/20/15 with a diagnosis of Schizoaffective Disorder. The patient was discharged on 04/30/15.
Review of the physician's order revealed the admission orders revealed a pre-printed list of orders with check off boxes. Also pre-printed on the order form was, "Inpatient Admit to S5Psychiatrist." The pre-printed orders were checked and signed as verbal orders from S4APRN (Advanced Practice Registered Nurse) by S17RN on 04/20/15 at 7:10 p.m. S4APRN co-signed the verbal admission orders on 04/21/15 at 7:25 p.m.
Further review of the physician's orders for this hospital stay revealed all physician orders were written or were verbal orders by a nurse practitioner (APRN).
Review of the Physician/LIP progress notes revealed all of the progress notes were documented by S4APRN. There was no documented evidence in the progress notes of any communication or collaboration with the patient's admitting physician (S5Psychiatrist).
Review of the Psychiatric Evaluation dated 04/21/15 at 7:30 p.m. revealed the evaluation was documented by S4APRN.
Further review of the record revealed no documented evidence that S5Psychiatrist had seen, evaluated or examined Patient #3 during her hospital stay.

Further review of previous admissions for Patient #3 revealed the patient was hospitalized from 02/09/15 to 02/17/15 and the admitting physician was S5Psychiatrist. Review of the physician's orders, progress notes, and psychiatric evaluation for this hospital stay revealed all were written/signed by a nurse practitioner. There was no documented evidence in the progress notes of any communication or collaboration with the patient's admitting physician (S5Psychiatrist). Further review of the record revealed no documented evidence that S5Psychiatrist had seen, evaluated or examined Patient #3 during her hospital stay.

Further review of previous admissions for Patient #3 revealed the patient was hospitalized from 03/17/15 to 04/08/15 and the admitting physician was S5Psychiatrist. Review of the physician's orders, progress notes, and psychiatric evaluation for this hospital stay revealed all were written/signed by a nurse practitioner. There was no documented evidence in the progress notes of any communication or collaboration with the patient's admitting physician (S5Psychiatrist). Further review of the record revealed no documented evidence that S5Psychiatrist had seen, evaluated or examined Patient #3 during her hospital stay.

In an interview on 05/28/15 at 8:10 a.m. with S5Psychiatrist confirmed that only the nurse practitioner saw Patient #3. S5Psychiatrist stated she had very little oversight at this hospital. She stated S4APRN primarily does this hospital. She stated at any point in time if a nurse practitioner had a question, she was available. S5Psychiatrist confirmed she did not consult with S4APRN on Patient #3. She stated she was not involved in her treatment team. S5Psychiatrist stated, "We had been seeing Patient #3 since 2013 in the office." When asked if she had evaluated Patient #3 in the clinic or during any previous admissions, she stated she had never evaluated her, even in the clinic.

In an interview on 05/28/15 at 8:34 a.m. with S4APRN, she confirmed she was familiar with Patient #3 and the patient had been seen in her practice since 2013. She stated her practice consisted of S5Psychiatrist and 3 nurse practitioners. She stated she did consult with S5Psychiatrist. After reviewing the clinical records for all 3 admissions for Patient #3, she confirmed there was no documentation of any collaboration with S5Psychiatrist on any of the records. S4APRN confirmed the patient was not seen or evaluated by a physician, only by a nurse practitioner. She stated if the patient was an uncomplicated patient she could evaluate, treat, and discharge the patient without any consultation with S5Psychiatrist. She stated patients are admitted under S5Psychiatrist's services, but she treats them. She confirmed it would if be safe to say a patient's entire stay may not involve the physician.

In an interview on 05/28/15 at 3:00 p.m., S18RN confirmed she worked the day shift on the adult acute unit and stated the nurse practitioners usually made rounds, wrote orders and saw S5Psychiatrist's patients. She stated she had only seen S5Psychiatrist at this hopsital once in the 2 years she had been employed at the hospital.

Patient #6
Review of the clinical record for Patient #6 revealed the patient was a 52 year old female admitted on 05/18/15 with a diagnosis of Schizoaffective Disorder, and she was a current inpatient on the acute adult unit. Review of the demographic form (face sheet) of the clinical record revealed the Admitting and Attending Physician was identified as S7APRN. Review of the pre-printed admission orders revealed the following was pre-printed on the top of the orders: "Inpatient Admit to S8MD (Medical Director), S7APRN, DNP (Doctor Nurse Practitioner)." The orders revealed the following signatures: "T.O.R.B.V. (Telephone order read back verification) Dr. S7APRN/S21LPN 05/18/15 at 3:53 p.m.." The order revealed S7APRN signed the orders on 05/19/15 at 9:15 a.m.
Further review of the physician's orders for this hospital stay revealed all physician orders were written or were verbal orders by a nurse practitioner (APRN).
Review of the Physician/LIP progress notes revealed all of the progress notes were documented by S7APRN. There was no documented evidence in the progress notes of any communication or collaboration with the patient's admitting physician (S8MD). Review of the progress note documented by S7APRN on 05/26/15 at 9:25 a.m., revealed S9Psychiatrist documented the following: "*Pt. seen today. Agree with Tx. plan. 05/26/15 2:22 p.m.
Review of the Psychiatric Evaluation dated 05/19/15 at 9:30 a.m. revealed the evaluation was documented by S7APRN. The evaluation revealed S9Psychiatrist signed beside the signature of S7APRN and dated/timed her signature as 05/19/15 at 12:35 p.m.

Further review of the record revealed no documented evidence that a physician/psychiatrist had seen, evaluated or examined Patient #6 during her hospital stay.

Patient #7
Review of the clinical record for Patient #7 revealed the patient was a 37 year old male admitted on 05/25/15 with a diagnosis of Chronic Paranoid Schizophrenia, and he was a current inpatient on the acute adult unit. Review of the demographic form of the clinical record revealed the Admitting and Attending Physician was identified as S7APRN. Review of the pre-printed admission orders revealed the following was pre-printed on the top of the orders: "Inpatient Admit to S8MD (Medical Director), S7APRN, DNP (Doctor Nurse Practitioner)." The orders revealed the following signatures: "T.O.R.B.V. (Telephone order read back verification) Dr. S7APRN/S23RN 05/25/15 at 3:53 p.m.." The order revealed S7APRN signed the orders on 05/26/15 at 12:57 a.m.
Further review of the physician's orders for this hospital stay revealed all physician orders were written or were verbal orders by a nurse practitioner (APRN).
Review of the Physician/LIP progress notes revealed all of the progress notes were documented by S7APRN. There was no documented evidence in the progress notes of any communication or collaboration with the patient's admitting physician (S8MD).
Review of the Psychiatric Evaluation dated 05/26/15 at 9:10 a.m. revealed the evaluation was documented by S7APRN. The evaluation revealed S9Psychiatrist signed beside the signature of S7APRN and dated/timed her signature as 05/26/15 at 2:00 p.m.

Further review of the record revealed no documented evidence tha

Based on review of Medical Staff By-laws, review of credentialing files, review of the policies and procedures, review of clinical records, and staff interview, the Medical Staff failed to be accountable to the Governing Body for the quality of medical care provided as evidenced by failing to ensure Allied Health Professionals (AHPs) were credentialed and practiced in accordance with Medical Staff By-laws, Rules & Regulations
Findings:

Review of the hospital's Medical Staff By-laws, Rules & Regulations dated 03/16/11, and approved by S1ADM (Administrator) and S8MD (Medical Director) on 02/23/15 revealed AHPs may be granted permission to participate in the provision of certain patient care services, but were not afforded the rights of Medical Staff membership. Nurse practitioners were listed under Allied Health Professionals and the by-laws required an binding agreement with an active medical staff member and a supervising physician who was an active member of the medical staff. Further review of the Medical Staff Rules & Regulations revealed patients may be admitted an discharged only on order of the attending medical staff member, the attending medical staff member had the responsibility for the development and implementation of the patient's treatment plan, and the attending medical staff member or designee shall completed the discharge summary. The Rules & Regulations also revealed a board certified or qualified psychiatrist of the medical staff would be a member of the treatment team when psychotropic medications were used, and the attending medical staff member must approve all treatment plans.

Review of the credentialing file for S4APRN revealed a request for clinical privileges for Allied Health Professional that included Admission to Adult Psychiatry, Admission to Adolescent Psychiatry, and Psycho-pharmacotherapy. The request was signed by the MEC (Medical Executive Committee) on 11/30/13 and by the Governing Body on 11/15/13. Review of the credentialing file revealed the collaborating physician was S5Psychiatrist. A letter from the CEO (Chief Executive Officer) dated 11/15/13 indicating requested privileges were granted for a period from 11/15/13 to 11/15/15. The letter revealed the status of S4APRN was Allied Health Professional.

Review of the credentialing file for S10APRN revealed a request for clinical privileges for Allied Health Professional that included Admission to Adult Psychiatry, Admission to Adolescent Psychiatry, and Psycho-pharmacotherapy. The request was signed by the MEC (Medical Executive Committee) on 11/30/13 and by the Governing Body on 11/15/13. Review of the credentialing file revealed the collaborating physician was S5Psychiatrist. A letter from the CEO (Chief Executive Officer) dated 11/15/13 indicating requested privileges were granted for a period from 11/15/13 to 11/15/15. The letter revealed the status of S10APRN was Allied Health Professional.

Review of the clinical record for Patient #3 revealed the patient was a 24 year old female admitted to the services of S5Psychiatrist on the acute psychiatric unit on 04/20/15 with a diagnosis of Schizoaffective Disorder. The patient was discharged on 04/30/15.
Review of the record revealed no documented evidence that S5Psychiatrist had seen, evaluated or examined Patient #3 during her hospital stay, or was a member of the treatment team. Review of the record revealed all orders, progress notes, and the psychiatric evaluation were documented by S4APRN.

In an interview on 05/28/15 at 8:10 a.m. with S5Psychiatrist confirmed that only the nurse practitioner saw Patient #3. S5Psychiatrist stated she had very little oversight at this hospital. S5Psychiatrist confirmed she did not consult with S4APRN on Patient #3. She stated she was not involved in her treatment team. S5Psychiatrist confirmed she had never evaluated Patient #3, even in the clinic.

In an interview on 05/28/15 at 8:34 a.m. with S4APRN, there was no documentation of any collaboration with S5Psychiatrist. S4APRN confirmed the patient was not seen or evaluated by a physician, only by a nurse practitioner. She stated if the patient was an uncomplicated patient she could evaluate, treat, and discharge the patient without any consultation with S5Psychiatrist. She stated patients are admitted under S5Psychiatrist's services, but she treats them.

Review of the credentialing file for S7APRN revealed a request for clinical privileges for Allied Health Professional that included Admission to Adult Psychiatry, Admission to Adolescent Psychiatry, and Psycho-pharmacotherapy. The request was signed by the MEC and by the Governing Body. Review of the credentialing file revealed the collaborating physician was S8MD (Medical Director). A letter from the CEO revealed the status of S10APRN was Allied Health Professional.

Review of the current census on 5/28/15 revealed S7APRN was listed as the attending physician for 20 of the 22 patients on the East unit. S8MD was listed as the attending physician on the other 2 patients.

Review of the clinical records for Patient #6, #7, and #8 revealed the patients were current inpatients on the Adult Acute Unit (East). Review of the demographic form (face sheet) of the clinical records revealed the Admitting and Attending Physician was identified as S7APRN for all 3 patients. Review of the pre-printed admission orders revealed the following was pre-printed on the top of the orders: "Inpatient Admit to S8MD (Medical Director), S7APRN, DNP (Doctor Nurse Practitioner)."
Further review of the physician's orders for this hospital stay revealed all physician orders were written or were verbal orders by a nurse practitioner (APRN) for all 3 patients. The psychiatric evaluation was documented by S7APRN, and S7APRN signed the treatment plan under "Physician approval of treatment plan."
Further review of the records revealed no documented evidence that a physician/psychiatrist had seen, evaluated or examined Patient #6, #7, #8 during their hospital stay.

In an interview on 5/28/15 at 10:00 a.m. with S8MD, she verified she was the medical director of the hospital. She stated, "Dr. S7APRN admits her own patients. She is one of the equal staff members." S8MD said S7APRN was an independent practitioner and a doctor, so patients could be admitted to S7APRN and managed by her. S8MD said she was not managing the patients admitted to S7APRN because they were her (S7APRN) patients. S8MD confirmed that she only attended treatment teams when it was her patient. She stated patients that are followed by nurse practitioners do not have psychiatrist on treatment team. After reviewing the Medical Staff By-laws, Rules & Regulations, she confirmed Article V, AHP section indicated AHPs are not members of the medical staff. She also confirmed the Rules & Regulations indicated the psychiatrist was to be a member of the treatment team. She confirmed being a member of the treatment team meant being present for the treatment team meetings. She stated the hospital ' s current practice related to Nurse Practitioners was not in compliance with the bylaws and the hospital needed to look at that. She stated the Nurse Practitioners function as independent practitioners. S8MD confirmed provisions throughout the bylaws for members of medical staff to admit and discharge were not adhered to by the current practices.

In an interview on 5/28/15 at 10:45 a.m. with S22HIM Manager, she said S7APRN had patients admitted to her because she was a doctor. When S22HIM Manager was told S7APRN was an advanced practice registered nurse, she said she thought S7APRN was a psychiatrist.

In an interview on 5/28/15 at 12:15 p.m. with S1ADM, he said S7APRN was having patients admitted to her directly.

In an interview on 5/28/15 at 12:30 p.m. with S7APRN, she said she had a doctorate in nursing. She said she had a collaborative agreement with S8MD and patients were not admitted to her because at the top of the admission orders it had written to admit to S8MD, S7APRN. She said someone had talked to someone working for the state and they said as long as the physician was listed as "adm

Based on review of Medical Staff By-laws, Rules & Regulation, review of credentialing files, review of clinical records, and staff interview, the medical staff failed to enforce its By-laws as evidenced by:

1) nurse practitioners conducting history and physical (H&P) assessments and medical consults when medical staff bylaws required H&P assessments and medical consults to be done by physicians for 5 of 5 (#3, #4, #6, #7, #8) sampled patients reviewed for H&Ps and medical consults;

2) psychiatrists failing to participate in the patient's treatment team as stipulated in the by-laws for 4 of 4 (#3, #6, #7, #8) sampled patients reviewed for treatment planning.

Findings:


1) Nurse practitioners conducting history and physical (H&P) assessments and medical consults when medical staff bylaws required H&P assessments and medical consults be done by physicians:

Review of the hospital's Medical Staff By-laws, Rules & Regulations dated 03/16/11, and approved by S1ADM (Administrator) and S8MD (Medical Director) on 02/23/15 revealed in part the following:
Section 2-Delineation of Clinical Responsibilities: All patients of independent practitioners shall have a prompt history taken and comprehensive physical examination performed by a physician who has such Responsibilities. A physician member of the Medical Staff shall be responsible for the care of any medical problems that may be present at the time of admission or that may arise during hospitalization and shall determine the risk and effect of any proposed procedure on the total health status of the patient.
Article V. A. Nurse Practitioner (1) All nurse practitioners must have a binding contract agreement with a member of [hospital's] active medical staff.


Patient #3
Review of the clinical record for Patient #3 revealed the patient was a 24 year old female admitted to the acute psychiatric unit on 04/20/15 with a diagnosis of Schizoaffective Disorder. The patient was discharged on 04/30/15.
Review of the Medical Admission Health History and Physical dated 04/21/15 at 2:20 p.m. revealed the H&P was done by S11APRN (Advanced Practice Registered Nurse). Further review of the record revealed a medical consult was done by S11APRN on 04/23/15.

Further review of previous admissions for Patient #3 revealed the patient was hospitalized from 02/09/15 to 02/17/15 and the H&P was done by S11APRN. Further review of the record revealed a medical consult was done by S11APRN on 02/12/15.

Further review of previous admissions for Patient #3 revealed the patient was hospitalized from 03/17/15 to 04/08/15 and the H&P was done by S11APRN. Further review of the record revealed medical consults were done by S11APRN on 03/19/15, and 03/26/15.


Patient #4
Review of the medical record for Patient #4 revealed he was admitted to the hospital on 4/14/15 with diagnosis which included Schizoaffective Disorder. Further review revealed the History and Physical had been completed on 4/15/15 by S11APRN.


Patient #6
Review of the medical record for Patient #6 revealed the patient was a 52 year old female admitted to the hospital on 5/18/15 with diagnosis of Schizophrenia and she was a current inpatient. Further review of the record revealed the History and Physical had been completed on 5/19/15 by S11APRN.


Patient #7
Review of the medical record for Patient #7 revealed he was admitted to the hospital on 5/25/15 with diagnosis which included Chronic Paranoid Schizophrenia and he was a current inpatient. Further review of the record revealed the History and Physical had been completed on 5/26/15 by S11APRN.


Patient #8
Review of the medical record for Patient #8 revealed he was admitted to the hospital on 5/22/15 with diagnosis which included Schizoaffective Disorder and he was a current inpatient. Further review of the record revealed the History and Physical had been completed on 5/23/15 by S11APRN.


Review of the credentialing file for S11APRN revealed Allied Health Professional privileges for medical history & physical examination and general medical management were requested by S11APRN on 02/12/14, but the request was not approved by the Governing Body. Further review of the credentialing file revealed S11APRN did not have a collaborative practice agreement with any physician currently on the medical staff with active privileges (as required in the medical staff by-laws).

In an interview on 05/28/15 at 9:50 a.m., S8MD (Medical Director) confirmed S11APRN does the H&P and medical consults.

In an interview on 05/28/15 at 3:00 p.m. S1ADM confirmed the governing body had not approved the privileges for S11APRN and the Medical Staff By-laws indicated the H&P was to be done by a physician. He confirmed the collaborating physician for S11APRN only had consulting privileges and that was not in compliance with the Medical Staff By-laws that required the collaborating physician to have active privileges.



2) Psychiatrists failing to participate in the patient's treatment team as stipulated in the by-laws:

Review of the hospital's Medical Staff By-laws, Rules & Regulations dated 03/16/11, and approved by S1ADM and S8MD on 02/23/15 revealed in part the following:
Medical Records and Orders:
5. When there is the use of psychotropic medications, a board certified or qualified psychiatrist of the medical staff will be a member of the treatment team.


Patient #3
Review of the clinical record for Patient #3 revealed the patient was a 24 year old female admitted to the acute psychiatric unit on 04/20/15 with a diagnosis of Schizoaffective Disorder. The patient was discharged on 04/30/15.
Review of the Multidisciplinary Treatment Plan dated 04/21/15 revealed the Physician Approval of Treatment Plan was signed only by S4APRN.

Further review of previous admissions for Patient #3 revealed the patient was hospitalized from 02/09/15 to 02/17/15 and the Multidisciplinary Treatment Plan dated 04/21/15 revealed the Physician Approval of Treatment Plan was signed only by S4APRN.

Further review of previous admissions for Patient #3 revealed the patient was hospitalized from 03/17/15 to 04/08/15 and the Multidisciplinary Treatment Plan dated 02/12/15 revealed the Physician Approval of Treatment Plan was signed only by S4APRN.

Review of all 3 admissions revealed the patient had received psychotropic medications.

In an interview on 05/28/15 at 8:10 a.m. with S5Psychiatrist confirmed that only the nurse practitioner saw Patient #3. S5Psychiatrist confirmed she did not consult with S4APRN on Patient #3. She stated she was not involved in her treatment team.

In an interview on 05/28/15 at 8:34 a.m. with S4APRN, she confirmed she was familiar with Patient #3 and the patient had been seen in her practice since 2013. After reviewing the clinical records for all 3 admissions for Patient #3, she confirmed there was no documentation of any collaboration with S5Psychiatrist on any of the records. S4APRN confirmed she signed the treatment plans and S5Psychiatrist was not involved in the treatment team.

Patient #6
Review of the medical record for Patient #6 revealed the patient was a 52 year old female admitted to the hospital on 5/18/15 with diagnosis of Schizophrenia and she was a current inpatient on the adult acute unit. Further review of the record revealed the Multidisciplinary Treatment Plan dated 05/26/15 revealed the Physician Approval of Treatment Plan was signed by S7APRN at 9:25 a.m. The treatment plan was co-signed by S9Psychiatrist on 05/26/15 at 2:22 p.m. Review of the record revealed the patient was receiving psychotropic medications.

Patient #7
Review of the medical record for Patient #7 revealed he was admitted to the hospital on 5/25/15 with diagnosis which included Chronic Paranoid Schizophrenia and he was a current inpatient on the adult acute unit. Further review of the record revealed the Multidisciplinary Treatment Plan dated 05/26/15 revealed the Physician Approval of Treatment Plan was signed by S7APRN at 9:05 a.m. The treatment plan was co-signed by S9Psychiatrist on 05/26/15 at 9:05 a.m. Review of the record revealed the patient was receiving psychotropic medications.

Patient #8
Review of th

Based on record review and interview, the hospital:
1) failed to ensure discharge summaries were written by qualified health care personnel for 8 of 8 (#1, #2, #3, #4, #5, #R1, #R2, #R3) discharged patients' records reviewed;

2) failed to ensure patients' discharge summaries authenticated by a nurse practitioner were co-authenticated by a physician responsible for the patient during the hospital stay for 2 (#4, #R3) of 8 (#1, #2, #3, #4, #5, #R1, #R2, #R3) discharged patient records reviewed;

Findings:

1) Failing to ensure discharge summaries were written by qualified health care personnel.

Review of the medical records for Patients #1, #2, #3, #4, #5, #R1, #R2 and #R3 revealed the discharge summaries had been dictated by S20RHIA (Registered Health Information Administrator).

In an interview on 05/27/15 at 1:15 p.m. S6HIM Director (Health Information Manager) S20RHIA was contracted to dictate discharge summaries. She stated S20RHIA reviewed the patient's record and summarized the record and dictated the discharge summary. She stated they do require that S20RHIA sign that she dictated the summary, and the physician signs the discharge summary. After reviewing the discharge summary for Patient #3 dated 04/20/15 she confirmed the discharge summary was dictated by S20RHIA.

In an interview on 05/28/15 at 8:10 a.m. S5Psychiatrist stated the hospital had someone on staff who does the discharge summaries and she signed them. She stated she usually just reviews the discharge summary done by the contracted staff and signed it.

In an interview on 5/28/15 at 3:30 p.m., S1ADM verified the discharge summaries mentioned above were dictated by S20RHIA and she did not have a medical background or involvement in the discharged patients' care. S1ADM said she gathered the information from the charts and compiled the summary for the physician to review.


2) Failing to ensure patients' discharge summaries authenticated by a nurse practitioner were co-authenticated by a physician responsible for the patient during the hospital stay.

Patient #4
Review of the medical record for Patient #4 revealed he was admitted to the hospital on 4/14/15 with diagnosis including Mood Disorder and was discharged on 4/21/15. Further review revealed his discharge summary had been written by S7APRN (advanced practice registered nurse) and had not been co-signed by a physician.

Patient #R3
Review of the medical record for Patient #R3 revealed he was admitted to the hospital on 4/16/15 with diagnosis including Bipolar Disorder and was discharged on 4/24/15. Further review revealed his discharge summary had been written by S7APRN and had not been co-signed by a physician.

In an interview on 5/28/15 at 10:00 a.m. with S8MD, she said she was the Medical Director of the hospital. She said S7APRN did her own discharge summaries and did not have them co-signed by a physician. S8MD verified S7APRN was not a medical doctor.


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