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Based on medical record review, interviews and document reviews the facility staff failed to enforce the medical staff bylaws and ensure a physician's order was obtained when patients were transferred and or discharged for 8 of 10 patients, Patient #1, 2, 3, 4, 5, 7, 9 and 10.

The findings include:


On 5/21/13 and 5/22/13 the medical records of Patients #1-10 were reviewed with the Clinical Document Specialist (CDS). The CDS also provided a copy of the Medical Staff Rules and Regulations with the last revision dated March 21, 2012. The Medical Staff Rules and Regulations state on page 11 Section B Medical Records Subsection 10 part b that "a medical record is complete when an order has been written by the attending practitioner or his designee discharging the patient." Page 18 of Medical Staff Rules and Regulations Section A states, "It is the duty of the Medical Staff to inform the patient or the appropriate family member of the patient's medical condition, including diagnosis/prognosis, and any risk or complications associated with medical or surgical procedures the patient will be undergoing."

Policy #7.14 which was last revised on 10/31/12 was also provided by the CDS. The policy states what will be copied and sent with the patient during various times. The section titled For Surgery has 7 items to be copied or completed and sent with the patient. Item #a is "Consultation sheet with reason for consult recorded" per the CDS and the Education Coordinator is not sent with the patient. In the section titled Emergency Transport to Acute Care (911) item b is a "Certificate for Transfer", which per the Education Coordinator is call a "Ticket to Ride" and is accessible through the documentation in the computer program is not completed or sent with the patient.

Patient #1 was sent for sent to another facility for testing on 3/8 and 13/13, the medical record did not contain a physicians order, nursing documentation or notification to the family of Patient #1's transfer to another facility for testing and did not contain nursing documentation related to Patient #1's condition upon return. The medical record did not contain a "Certificate to Transfer."

Patient #2 was transferred to another facility for testing on 3/7/13, the medical record did not contain a physicians order, nursing documentation or notification to the family of Patient #2's transfer to another facility for testing and did not contain nursing documentation related to Patient #2's condition upon return. Patient #2 was readmitted to the facility on 3/8/13. The medical record did not contain a "Certificate to Transfer."

Patient #3 was transferred to another facility on 3/24/13, the medical record did not contain a physicians order or nursing documentation of Patient #2's transfer to another facility. The medical record did not contain a "Certificate to Transfer."

Patient #4 was transferred to another facility on 4/18/13, the medical record did not contain a physicians order, nursing documentation or notification to the family of Patient #4's transfer to another facility and did not contain nursing documentation related to Patient #4's condition upon return. The medical record did not contain a "Certificate to Transfer."

Patient #5 was transferred to another facility on 4/19/13, the medical record did not contain a physicians order, nursing documentation or notification to the family of Patient #5's transfer to another facility and did not contain nursing documentation related to Patient #5's condition upon return. The medical record did not contain a "Certificate to Transfer."

Patient #7 was transferred to another facility on 5/17/13, the medical record did not contain a physicians order, nursing documentation or notification to the family of Patient #7's transfer to another facility and did not contain nursing documentation related to Patient #7's condition upon return. The medical record did not contain a "Certificate to Transfer."

Patient #9 was transferred to another facility on 5/15/13, the medical record did not contain a physicians order or nursing documentation of Patient #9's transfer to another facility. The medical record did not contain a "Certificate to Transfer."

Patient #10 was transferred to another facility on 5/17/13, the medical record did not contain a physicians order, nursing documentation or notification to the family of Patient #10's transfer to another facility. The medical record did not contain a "Certificate to Transfer."

Based on medical record review, interviews and document reviews the facility staff failed to ensure the documentation in the medical record was accurately written for four (4) of ten (10) patients (Patients #'s 1, 4, 7 and 9).

The findings include:

On 5/21/13 and 5/22/13 the medical records of Patients #1-10 were reviewed with the Clinical Document Specialist (CDS) and the Education Coordinator.

Patient #1's medical record indicated in the physician History and Physical 3/28/13 that Patient #1 had methicillin-resistant Staphylococcus aureus (MRSA) in the nares. Lab test results from swabs performed on Patient #1's nares on 3/16/13 and 3/29/13 indicated the results were negative for MRSA. Patient #1's physician stated, "I guess I was over zealous in my documentation. I must have been told that from some were or I would not have written it."

Patient #4's medical record indicated Patient #4 had received a blood transfusion on 4/3/13. The Blood Bank Transfusion Record indicated the blood was dispensed on 4/3/13 at 1209. The nursing documentation on 4/3/13 stated there was no time indicated and entered the time of 14:22 as the time the blood was released from the blood bank. The Education Coordinator stated, "The note and times are incorrect."

The section of the physician documentation in the Progress Note titled Review of Systems in Patient #7's medical record on 5/13/13 states, "Difficult to obtain. The patient has a trach" and on 5/15/13 states, "Difficult to obtain due to the patient having right vocal cord paralysis." The Education Coordinator and the CDS both were asked to review the medical record and indicate where Patient #7 had a trach or paralyzed vocal cords. Both stated, they could not find either the trach or the paralyzed vocal cords.

The section of the physician documentation in the Progress Note titled Laboratory and Diagnostic Data Available in Patient #9's medical record states either "no labs" or "none available" in the section for the dated of 5/13/13 through 5/17/13. The labs available in the record indicate the dates of 5/13/13 and 5/18/13. On 5/18/13 the Nurse Practitioner makes a note of the labs from 5/13 and 18/13.