HospitalInspections.org

Based on review of the Health Information Management (HIM) department delinquent record reports, hospital policy and procedure, and Medical Executive meeting minutes the hospital failed to ensure medical records were complete and accurate within 30 days per State and Federal Regulations. This was evidenced by the hospital having a policy and procedure which allowed 52 days for medical record completion and 2) the incorrect documentation of patients' allergies on the medical records for 2 (#14, #16) of 30 (#1 - #30) sampled patients, and failing to complete a discharge summary within 30 days for 1 (#28) of 30 (#1 - #30) sampled patients. Findings:

Review of a hospital policy titled "Health Information Management", policy # 5-3.8.0, effective January 2008, no date of last revision, presented as current hospital policy, read in part: "Purpose: To define time frames for documentation completion of the medical record. Policy: The health record documentation shall be completed in an ongoing manner throughout the stay. When data entries are not completed by the time of discharge, the following time frames and definitions shall apply: *incomplete status: any record not complete within 30 days of discharge. *delinquent status: any record not complete beyond the initial 30 days. Procedure: Physician Health Record Completion Responsibilities. Document: History and Physical. Completion Time: 24 hours of admission...Document:Discharge Summary. Completion Time: 30 days after discharge...Policy and Procedure on Incomplete and Delinquent Charts...1. The Administrator or his designee shall notify each practitioner with a list of the practitioner's Incomplete and Delinquent Medical Records not less than weekly. 2. A special notice is given to a practitioner once an Incomplete medical record has been Incomplete for twenty-one (21) days...The notice will identify those medical records that will be considered Delinquent if they remain Incomplete on the thirtieth (30 th) day following discharge...4. Once a medical record remains incomplete for thirty (30) days, and it is determined to be Delinquent, the record will be designated as such on the weekly list provided to the practitioner. The practitioner shall also receive a FIRST NOTICE that he/she has a Delinquent medical record and will be given TWO (2) WEEKS to complete the medical record be placed on suspension at the Hospital. 5. If a record remains Delinquent upon the lapse of the first notice, the practitioner shall be given a SECOND NOTICE that he/she has a Delinquent medical record and will be given ONE week to complete the medical record or be placed on suspension at the Hospital. 6. If the Delinquent medical record is not completed upon the lapse of the SECOND NOTICE, the Health Information Staff will conduct a review of the medical record prior to suspension to affirm that the Delinquent medical record is indeed Incomplete. B. Suspension. 1. If the record is still Delinquent upon the lapse of the SECOND NOTICE, the Administrator shall suspend the practitioner's privileges..."

Review of the Medical Staff By Laws, Section 11.7, revealed: "...the attached Policy and Procedure on Incomplete and Delinquent charts shall govern timely completion of medical records. All medical records shall be completed within thirty (30) days of discharge. (Louisiana Minimum Standards for licensure - LAC (Louisiana Administrative Code 48:I, Chapter 93: 9387 K).)" Review of the Attachment revealed the same as hospital policy number 5-3.8.0 listed above.

Review of the Medical Executive Committee Meeting minutes from the 4th Quarter of 2012 reported at the January 23, 2013 meeting revealed: "Discussion: History and Physical Exams...Recommendations/Actions...Policy doesn't allow suspension until after 52 days and record is already delinquent by then...Discussion: Discharge Summaries dictated within 30 days of discharge...Recommendations/Actions...Policy doesn't allow suspension until after 52 days and record is already delinquent by then..."

Review of a document presented by S16HIM Director titled "St. Landry Extended Care Hospital Medical Records Chart Deficiency Listing by Physician" revealed the following by physician:

(S13MD) Total Physician Deficiencies - 1. Days (days since discharge) 66.
(S14MD) Total Physician Deficiencies - 4. (one over 30 days) Days 39.
(S15MD) Total Physician Deficiencies - 34 (18 over 30 days) Days 51, 51, 51, 47, 47, 47, 47, 45, 45, 45, 45, 44, 44, 44, 44, 44, 44, 44.

In an interview with S1Admin on 05/02/13 at 2:30 p.m. he stated that the current hospital policy allows 52 days for medical record completion prior to physician suspension. S1Admin stated the current policy cannot get the hospital in compliance with the Medical Staff By Laws or State and Federal Regulations.

In an interview on 05/03/13 at 10:05 a.m. with S16HIM Director he stated hospital policy 5-3.8.0 is "lenient" and should be in accordance with State and Federal regulations. S16HIM Director stated he is aware that the State and Federal regulations require medical record completion within 30 days of patient discharge.

2)
Patient #14
Patient #14 was a 66-year-old male admitted to the hospital on 04/22/13 with the diagnoses of pneumonia, COPD (chronic obstructive pulmonary disease), hypertension, diabetes mellitus, urinary tract infection, and allergies to the medications doxycycline and penicillin.
Review of Patient #14's medical record revealed the above-mentioned allergies were documented on the History and Physical by the physician, the Rx (prescription) Link for Windows, Patient Profile Report, The Admit/Resumption of Care Orders; and the Medication Administration Record (MAR).
Review of the Nursing Admission History and Assessment form revealed documentation of an allergy to Penicillin. The allergy alert sticker on the front cover of the medical record documented the allergies as "NKDA" (no known drug allergies). Further review revealed that the sections labeled "Drug Allergies" at the top of the physician order sheets were left blank.
In a face-to-face interview on 04/30/13 at 4:25 p.m., S2RN (Registered Nurse) confirmed that Patient #14 was allergic to penicillin and doxycycline, and there was inaccurately written documentation of Patient #14's medication allergies on the medical record.
Patient #16
Patient #16 was a 74-year-old female admitted to the hospital on 04-12-13 with the diagnoses of pneumonia, respiratory acidosis, encephalopathy, confusion, and allergies to the medications ACE inhibitors and ARB (Angiotensin Receptor Antagonist).
Review of Patient #16's medical record revealed the above-mentioned allergies documented on the History and Physical by the physician, the Pharmacy Communication Notice, and the Admit/Resumption of Care Orders.
Further review of the medical record revealed documentation of allergies as "NKDA" on the Medication Administration Record dated 04/29/13, and the Rx Link for Windows Patient Profile Report dated 04/12/13. The Nursing Admission History and Assessment section entitled "Allergies" under the "Allergic to Medication:" section had "No" documented indicating Patient #16 was not allergic to any medications.
In a face-to-face interview on 04/30/13 at 2:15 p.m., S3RN confirmed that Patient #16 was allergic to ACE inhibitors and ARB, and there was inaccurately written documentation of Patient #16's medication allergies on the medical record.
3)

Patient # 28
Review of the medical record for patient # 28 revealed she had been admitted to the hospital on 8/24/12, with admitting diagnoses of Obstructive chronic bronchitis, urinary tract infection, pneumonia, pulmonary collapse, she was discharged on 9/19/12 to SNF (skilled nursing facility).
Review of the discharge summary revealed that it was authenticated by S6MD with dictated/type date of 10/30/12.
Interview on 5/2/13 at 11:26 a.m. with S5HIM Asst. confirmed that the Discharge Summary was dictated on 10/30/12 and placed on medical records on 10/31/12 (42 days after the patient was discharged).





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31206

Based on record review and interview the hospital failed to ensure medical record entries were dated, timed, and/or authenticated within 10 days per hospital policy as evidenced by verbal orders not being authenticated/dated/timed for 11 (#1, #8, #9, #14, #16, #17, #18, #19, #24, #25, #26) of 11 focused medical record reviews in a total patient sample of 30 (#1 - #30). Findings:

Review of a hospital policy titled "Health Information Management", policy # 5-2.3.0, effective January 2008, last revised 04/11, presented as current hospital policy, revealed: "Purpose: To define a process for documenting and authenticating care provided. Policy: The health care provider who treats a patient shall have the responsibility for documenting and authenticating the care provided. Such documentation shall be legible, dated, timed, and in accordance with...specifically mandated regulatory...standards...medical record content policy of this health care institution...D. Timed, Dated, and Authenticated Signatures. All orders, including verbal orders, must be timed, dated, and authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient and is authorized to write orders...All verbal orders will be authenticated within 10 days..."

Review of a hospital policy titled "Health Information Management", policy # 5-3.8.0, effective January 2008, no date of last revision, presented as current hospital policy, read in part: "Purpose: To define time frames for documentation completion of the medical record. Policy: The health record documentation shall be completed in an ongoing manner throughout the stay. When data entries are not completed by the time of discharge, the following time frames and definitions shall apply: *incomplete status: any record not complete within 30 days of discharge. *delinquent status: any record not complete beyond the initial 30 days. Procedure: Physician Health Record Completion Responsibilities. Document: History and Physical. Completion Time: 24 hours of admission...Document:Discharge Summary. Completion Time: 30 days after discharge...Policy and Procedure on Incomplete and Delinquent Charts...1. The Administrator or his designee shall notify each practitioner with a list of the practitioner's Incomplete and Delinquent Medical Records not less than weekly. 2. A special notice is given to a practitioner once an Incomplete medical record has been Incomplete for twenty-one (21) days...The notice will identify those medical records that will be considered Delinquent if they remain Incomplete on the thirtieth (30th) day following discharge...4. Once a medical record remains incomplete for thirty (30) days, and it is determined to be Delinquent, the record will be designated as such on the weekly list provided to the practitioner. The practitioner shall also receive a FIRST NOTICE that he/she has a Delinquent medical record and will be given TWO (2) WEEKS to complete the medical record be placed on suspension at the Hospital. 5. If a record remains Delinquent upon the lapse of the first notice, the practitioner shall be given a SECOND NOTICE that he/she has a Delinquent medical record and will be given ONE week to complete the medical record or be placed on suspension at the Hospital. 6. If the Delinquent medical record is not completed upon the lapse of the SECOND NOTICE, the Health Information Staff will conduct a review of the medical record prior to suspension to affirm that the Delinquent medical record is indeed Incomplete. B. Suspension. 1. If the record is still Delinquent upon the lapse of the SECOND NOTICE, the Administrator shall suspend the practitioner's privileges..."

Review of the Medical Staff By Laws, Section 11.7, revealed: "...the attached Policy and Procedure on Incomplete and Delinquent charts shall govern timely completion of medical records. All medical records shall be completed within thirty (30) days of discharge. (Louisiana Minimum Standards for licensure - LAC (Louisiana Administrative Code 48:I, Chapter 93: 9387 K).)" Review of the Attachment revealed the same as hospital policy number 5-3.8.0 listed above.

Review of the Medical Executive Committee Meeting minutes from the 4th Quarter of 2012 reported at the January 23, 2013 meeting revealed: "Discussion: History and Physical Exams...Recommendations/Actions...Policy doesn't allow suspension until after 52 days and record is already delinquent by then...Discussion: Discharge Summaries dictated within 30 days of discharge...Recommendations/Actions...Policy doesn't allow suspension until after 52 days and record is already delinquent by then..."

Patient #1
Record review of patient #1 medical record revealed that he is an 83 year old male admitted to the hospital on 3/26/13 with the diagnoses of LLL Pneumonia (Left lower lobe), ASHF (Acute Systolic Heart Failure), MRSA (methicillin-resistant Staphylococcus aureus) bacteremia, stage III chronic kidney disease, thrombocytopenia, chronic obstructive pulmonary disease, and anemia.

Review of admit orders revealed verbal orders given by S15MD on 3/26/13 were not authenticated, dated, or timed. Verbal order written on 3/29/13 at 3:00 p.m., 3/31/13 at 1:03 p.m., 4/1/13 no time, and 4/2/13 at 3:17 p.m. were not authenticated, dated or timed by the physician.

Patient #8

Review of the medical record for patient #8 on 04/30/13 at 11:00 a.m. revealed she was admitted on 4/9/13 for Unstageable ulcer to R (right) foot, Stage II (pressure ulcer) to L (left) distal foot, lateral L foot blister, sepsis, pneumonia, severe PCM (protein calorie malnutrition) and PAD (peripheral artery disease). Review of the admission orders revealed they were taken as a verbal order on 04/09/13.

In an interview on 04/30/13 at 2:20 p.m. with S2RN, she confirmed the admission orders did not contain the date/time the verbal orders were authenticated by the physician who gave the verbal order within 10 days per hospital policy.

Patient #9

Review of the medical record for patient #9 on 04/30/13 at 11:00 a.m. revealed she was admitted on 4/9/13 for CHF (congestive heart failure) and COPD (chronic obstructive pulmonary disease). Review of the admission orders revealed they were taken as a verbal order on 04/09/13.

In an interview on 04/30/13 at 11:00 a.m. with S2RN, she confirmed the admission orders were not authenticated by the physician who gave the verbal order within 10 days per hospital policy.

Patient #14
Patient #14 was a 66-year-old male admitted to the hospital on 04/22/13 with the diagnoses of pneumonia, COPD (chronic obstructive pulmonary disease), hypertension, diabetes mellitus, and urinary tract infection.
Review of Patient #14's medical record revealed the verbal admission orders dated 04/19/13 were not authenticated, dated, and timed by S9MD.
Further review of Patient #14's medical record revealed a verbal order for admit medications dated 04/22/13 at 10:57 p.m. by S15MD was not authenticated, dated and timed.
In a face-to-face interview on 04/30/13 at 4:30 p.m., S2RN confirmed the above referenced orders for Patient #14 were not authenticated, dated, and timed.

Patient #16
Patient #16 was a 74-year-old female admitted to the hospital on 04/12/13 with the diagnoses of pneumonia, heart failure, encephalopathy, and dysphagia.
Review of Patient #16's medical record revealed the following orders by S18MD were not authenticated, dated or timed: 1) verbal order for admission medications dated 04/12/13 at 11:45 p.m.; 2) verbal order dated 04/12/13 at 11:50 p.m. for "potassium chloride 40 mEq (milliequivalents) by mouth times one dose (liquid)," 3) verbal order dated 04/15/13 at 5:00 p.m. to "discontinue above order; Dulcolax suppository per rectum every other day as needed for constipation." 4) verbal order dated 04/17/13 at 1:00 p.m. to "change 1.25 milligrams Xopenex nebulizer treatments to three times per day and every two hours as needed for shortness of breath and wheezing."
In a face-to-face interview on 04/30/13 at 2:15 p.m., S3RN confirmed that the above referenced verbal orders for Patient #16 were not authenticated, dated, and timed.

Patient #17
Patient #17 was a 59-year-old male admitted to the hospital on 04/10/13 with the diagnoses of infected decubitus ulcer of the right hip, diabetes mellitus, and paraplegia.
Review of Patient #17's medical record revealed the following orders were not authenticated, dated, and timed by S18MD: 1) verbal admission orders (including medication orders) dated 04/10/13 at 4:00 p.m.; 2) a verbal order on 04/10/13 at 3:30 p.m. for a "Fentanyl patch 100 mcg (micrograms)/per hour transdermal film extended release, one patch topical every 72 hours. Due 04/12/13 at 1400"; 3) a verbal order on 04/10/13 at 4:15 p.m. for "wound care for right hip wound-cleanse with normal saline, pack with Mesalt, apply MB (Mepilex Border) every day and as needed, until S18MD evaluated on tomorrow. Right lateral shin-cleanse with normal saline, apply Medihoney and cover with MB every day"; 4) a verbal order written on 04/11/12 at 8:45 a.m. for "one packet Arginaid by mouth twice a day, 30 milliliters Proteinex by mouth twice a day."
Further review of Patient #17's medical record revealed a verbal order dated 04/16/13 at 9:50 p.m. by S19MD. for a "stat EKG (electrocardiogram), O2 (oxygen) at 2 liters per minute per nasal cannula; cardiac enzymes and nitroglycerine 0.4 mg (milligrams), one tablet sublingual up to 3 doses every 5 minutes as per chest pain protocol" was not authenticated, dated, or timed.
In a face-to-face interview on 05/02/13 at 3:08 p.m., S3RN (Registered Nurse) confirmed the above referenced verbal orders for Patient #17 were not authenticated, dated, and timed.
Patient #18

Review of the medical record for patient #18 on 04/30/13 at 1:30 p.m. revealed she was admitted on 4/8/13 for Severe Inflammatory Response Syndrome, sepsis, COPD (chronic obstructive Pulmonary Disease, L-Spine (lumbar spine) MRSA (methicillin resistant staphylococcus aureus)/osteomyelitis, anemia, and pneumonia. Review of the admission orders revealed they were taken as a verbal order on 04/18/13.

In an interview on 04/30/13 at 2:20 p.m. with S2RN she confirmed the admission orders did not contain the date/time the verbal orders were authenticated by the physician who gave the verbal order within 10 days per hospital policy.

Patient #19

Review of the medical record for patient #19 on 05/01/13 at 10:00 a.m. revealed he was admitted on 4/9/13 for LLL (left lower lobe) pneumonia, C-Diff (clostridium difficile), gross hematuria, and Stage III Coccyx pressure ulcer. Review of the admission orders revealed they were taken as a verbal order on 04/09/13.

In an interview on 05/01/13 at 2:20 p.m. with S2RN she confirmed the admission orders did not contain the date/time the verbal orders were authenticated by the physician who gave the verbal order within 10 days per hospital policy.

Patient # 24
Review of the medical record for patient # 24 revealed he had been admitted to the hospital on 4/12/13 admitting diagnoses Osteomyelitis, Infected sacral decubitus ulcer with sepsis requiring IV antibiotics, Colostomy diversion, protein calorie malnutrition, and anemia.

Review of the physician orders revealed verbal orders written on the dates of 4/12-4/17/13 were not authenticated, timed or dated by S7 MD.

In an interview conducted on 05/01/13 at 12:34 p.m., S10LPN confirmed that verbal orders dated 04/12/13, 04/13/13, 04/14/13, 04/16/13, and 04/17/13 were authenticated by S7MD but were not dated or timed when authenticated. S10LPN confirmed the verbal orders dated/timed 04/15/13 at 4:15 p.m. were not authenticated by S7MD within 10 days, as hospital policy requires.

Patient # 25
Review of the medical record for patient # 25 revealed she had been admitted to the hospital on 4/12/13 with diagnoses of UTI (Urinary Tract Infection) with Klebsiella, Acidosis, and Dehydration.
Review of admission orders dated 04/12/13 revealed the orders were received as verbal orders and were not authenticated/dated/timed by S8MD. Further review of the physician's orders revealed verbal orders written on 04/13/13, 04/14/13, and 04/17/13 were not authenticated, dated, or timed by the physician.
In an interview conducted on 05/01/13 at 12:36 p.m. with S10LPN confirmed that the orders were not authenticated, dated or timed by S8MD within 10 days per hospital policy.

Patient # 26
Review of the medical record for patient # 26 revealed she had been admitted to the hospital on 4/20/13 with the diagnoses of Diabetes insipidus, hyperosmolality, and bacteremia.
Review of admission orders revealed verbal orders dated 4/20/13 were not authenticated, dated, or signed by S8MD.
An interview on 5/1/13 at 12:36 p.m. with S10LPN confirmed that the orders were not authenticated, dated or timed by S8MD within 10 days per hospital policy.





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31206

Based on record review and interview the hospital failed to ensure the patients medical contained a History and Physical (H&P) within 24 hours of admission per hospital policy for 9 (#7,#9, #10, #11, #14, #24, #25, #27, #28) of 9 focused record reviews for H&P within 24 hours in a total sample of 30 (#1 - #30). Findings:

Review of a hospital policy titled "Health Information Management", policy number 5-3.8.0, effective January 2008, no date of last revision, presented as current hospital policy, read in part: "Purpose: To define time frames for documentation completion of the medical record...Procedure: Physician Health Record Completion Responsibilities...Document: History and Physical. Completion Time: 24 hours of admission..."

Patient #7 was an 89-year-old male admitted to the hospital on 04/17/13 at 8:00 p.m. with the diagnoses of pneumonia, leukocytosis anemia, Alzheimer's disease, aphasia, hypertension, COPD (chronic obstructive pulmonary disease) and a history of seizures.
Review of Patient #7's medical record revealed the H&P (History and Physical) was dictated by S20MD on 04/24/13 at 7:18 a.m., and was transcribed on 04/24/13 at 7:53 a.m. Further review revealed the H&P was authenticated, timed, and dated on 05/11/13 at 8:05 a.m.
In a face-to-face interview on 05/01/13 at 3:15 p.m., S2RN (Registered Nurse) confirmed Patient #7's H&P was dictated, transcribed, authenticated, dated, and timed as stated above.

Patient #9
Review of the medical record for patient #9 revealed she was admitted on 04/09/13. Review of the H&P revealed it had a DD (date dictated) of 04/26/13 and a DT (date typed) of 04/27/13.

In an interview on 04/30/13 at 11:00 a.m. with S2RN she confirmed the H&P was not the medical record within 24 hours of admission.

Patient #10
Patient #10 was an 87-year-old female admitted to the hospital on 04/09/13 at 3:30 p.m. with the diagnoses of respiratory failure, COPD, hypertension, and CAD (coronary artery disease).
Review of Patient #10's medical record revealed the H&P was dictated by S21MD on 04/11/2013 and transcribed on 04/12/13 at 5:06 a.m. Further review revealed the H&P was not authenticated, dated, or timed.
In a face-to-face interview on 05/02/13 at 1:10 p.m., S2RN confirmed Patient #10's H&P was dictated and transcribed as stated above, and the H&P had not been authenticated, dated and timed by S21MD

Patient #11
Patient #11 was a 61-year-old male admitted to the hospital on 04/27/13 at 5:45 p.m. with the diagnoses of a crush injury to the left foot, hypertension and A-fib (atrial fibrillation).
Review of Patient #11's medical record revealed the H&P was dictated by S15MD on 04/29/13 and transcribed on 04/29/13 at 7:25 a.m. Further review revealed the H&P was not authenticated, dated, and timed.
In a face-to-face interview on 05/02/13 at 1:10 p.m., S2RN confirmed that Patient #11's H&P was not authenticated, dated, and timed.

Patient #14
Patient #14 was a 66-year-old male admitted to the hospital on 04/22/13 with the diagnoses of pneumonia, COPD, hypertension, diabetes mellitus, and a urinary tract infection.
Review of Patient #14's medical record revealed the H&P was dictated by S15MD on 04/23/13 and transcribed on 04/23/13 at 7:45 a.m. Further review revealed the H&P was not authenticated, dated, and timed.
In a face-to-face interview on 04/30/13 at 4:30 p.m., S2RN confirmed that Patient #14's H&P was not authenticated, dated, and timed.


Patient # 24

Review of the medical record for patient # 24 revealed he had been admitted to the hospital on 4/12/13 admitting diagnoses Osteomyelitis, Infected sacral decubitus ulcer with sepsis requiring IV antibiotics, Colostomy diversion, protein calorie malnutrition, and anemia.

Review of the History & Physical for patient #24 a DD(date dictated) of 4/18/ 13 and a DT (date typed) of 4/18/13.
Interview on 5/1/13 at 2:00 pm with S4RN, ADON, she confirmed that the H&P was not on the medical records within 24 hours of admission.
Interview on 5/1/13 at 2:20 p.m. with S5 HIM Assistant verified the History & Physical for patient #24 was not completed and place in the medical records within 24 hours of patient admission. She stated it was completed on 4//18/13 and placed on the medical record on 4/19/13.

Patient # 25

Review of the medical record for patient # 25 revealed she had been admitted to the hospital on 4/12/13 with diagnoses of UTI (Urinary Tract Infection) with Klebsiella, Acidosis, and Dehydration.
Interview on 5/1/13 at 2:00 p.m. with S5HIM Assistant confirmed that patient #25's H&P was not completed and placed in medical records within 24 hours of admission. According to S5HIM Asst., S6MD dictated the H&P on 4/18/13.

Patient # 27

Review of the medical record for patient # 27 revealed he had been admitted to the hospital on 1/3/13, admitting diagnosis Septicemia nos, urinary tract infection, E-coil infection, Pseudomonas infection nos, MRSA nos; he was discharged home on 1/16/13 with home health.
Review H&P for patient #27 revealed it was authenticated by S6MD, dictation dated 2/11/13 & dictation type dated 2/11/13.
Interview on 5/2/13 at 11:26 a.m. with S5 HIM Asst. confirmed that the H& P was dictated on 2/11/13 and placed in the medical records on the same day. She confirmed that the H&P was not in the medical records within 24 hours of admission.

Patient # 28

Review of the medical record for patient # 28 revealed she had been admitted to the hospital on 8/24/12, admitting diagnosis Obstructive chronic bronchitis, urinary tract infection, pneumonia, pulmonary collapse, she was discharged on 9/19/12 to SNF.

Review of the history & physical revealed it was authenticated by S6MD, dictation date 8/28/12 dictation typed date 8/29/12.
Interview on 5/2/13 at 11:26 a.m. with S5 HIM Asst. verified that the H& P was dictated on 8/28/12 and placed in the medical records on 8/29/12. She further confirmed that the H&P was not in the medial records within 24 hours of admission.


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31206

Based on observation and interview the hospital failed to ensure outdated, mislabeled drugs or biologicals were not available for patient use as evidenced by 1) expired medications being available for use in the patient medication refrigerator and 2) having a partial vial of a single dose medication vial on a medication cart available for patient use. Findings:

Review of a hospital policy titled "Pharmacy", policy number 10-14.17.0., effective January 2004, no date of last revision or review, presented as current hospital policy, read in part: "Purpose: To define guidelines for the clear and accurate labeling of drugs. Procedure: All drugs stocked in the pharmacy, supplied to floor stock, or dispensed to patients shall be clearly and accurately labeled. Procedure:...Label Contents. All labels shall include at least:...expiration date, where applicable..."

1) In an observation of the medication room on 04/30/13 at 11:00 a.m. the following medications were available for patient use: One vial of Tuberculin Purified Protein Derivative 5TU/0.1 ml (milliliter) (1 ml total) date opened 3/11/13; 3 IVPB's (intravenous piggybacks) containing 50 mg (milligrams) Diflucan/50 cc (cubic centimeters) Normal Saline with use by dates of preparation and labeled "use by 7 days" of 04/18/13, 04/19/13, and 04/20/13; and one Intralipid 20% 250 ml with a use by date of 04/27/13.

In an interview with S3RN at the time of observation she confirmed the above listed medications were expired and should not be available for patient use.

2) Observation of a medication cart on 5/1/13 at 11:20 a.m. revealed a patient drawer had an open vial of Pitressin (vasopressin) 1 ml (milliliter) not dated. S11RN verified that the vial was opened and not dated and should have been dated. According to S11RN the vial was a single dose vial and it should have been discarded and not placed back in the bin for re-use.


31206

Based on observation and interview the hospital failed to ensure equipment was maintained to an acceptable level of safety and quality as evidenced by having Glucometer Control solutions with no date opened. This failure renders the control solutions expiration date unknown, thereby affecting quality control on the Glucometer's used to check patients blood sugar. Findings:

In an observation made on 04/30/13 at 10:51 a.m. with S3RN the Glucometer Control solutions used to check the Glucometer for accuracy were noted to have no date as to when the bottle was opened. Review of the manufacturer's instructions revealed: "bottle is good for three months after opening or until the expiration date printed on the label."

In an interview with S3RN at the time of the observation she stated there is no way to tell if and when the control solution would expire as the date opened was not on the bottle. S3RN stated the control solutions must be considered expired.

Based on record review, staff interview, and review of Louisiana Physical Therapy Practice Act and Louisiana State Board Medical Examiners, the hospital failed to ensure that physical therapy (PT) and occupational therapy (OT) services were provided only under the orders of a licensed practitioner by failing to obtain physician's orders for therapy services provided after the initial evaluation by the therapist for 8 ( #1,#18, #19, #20, #22, #24, #25,#26) of 8 focused record reviews for PT orders in a total sample of 30 (#1 - #30) patients. Findings:

Review of a hospital policy titled "Therapy", policy number 12-3.1.0, effective May 2003, last revised 04/08, presented as current hospital policy revealed in part: "Purpose: To outline a process for the initiation of physical therapy, occupational therapy, and/or speech pathology services. Policy: All patients who are to receive therapy services will receive an evaluation performed by a qualified therapist, prior to initiation of treatment, after a physician's order is obtained..."

Review of the Louisiana Revised Statutes, 37:2401-37:2424 Chapter 29. Louisiana Physical Therapy Practice Act revealed in part the following:
§2418. Authority to practice as a physical therapist or physical therapist assistant
A. A physical therapist or physical therapist assistant licensed in Louisiana is authorized to practice physical therapy as defined in this Chapter. A physical therapist is responsible for managing all aspects of the physical therapy care of each patient. B. Without prescription or referral, a physical therapist may perform an initial evaluation or consultation of a screening nature to determine the need for physical therapy and may perform physical therapy or other services provided in Subsection C of this Section. However, implementation of physical therapy treatment shall otherwise be based on the prescription or referral of a person licensed to practice medicine, surgery, dentistry, podiatry, or chiropractic. C. Except as to an initial evaluation or consultation, as provided in Subsection B of this Section, physical therapy services may be performed without a prescription or by referral only under the following circumstances: (1) To a child with a diagnosed developmental disability pursuant to the child's plan of care. (2) To a patient of a home health care agency pursuant to the patient's plan of care. (3) To a patient in a nursing home pursuant to the patient's plan of care. (4) Related to conditioning or to providing education or activities in a wellness setting for the purpose of injury prevention, reduction of stress, or promotion of fitness.(5) To an individual for a previously diagnosed condition or conditions for which physical therapy services are appropriate after informing the health care provider rendering the diagnosis. The diagnosis shall have been made within the previous ninety days. The physical therapist shall provide the health care provider who rendered such diagnosis with a plan of care for physical therapy services within the first fifteen days of physical therapy intervention..."

Review of the Louisiana State Board of Medical Examiners Subchapter B. Standards of Practice revealed in part the following:
A. This Subchapter provides the minimum standards for occupational therapy practice applicable to all persons licensed to practice occupational therapy in the state of Louisiana.
4915. Individual Program Implementation
A. Implementation of direct occupational therapy to individuals for their specific medical condition or conditions shall be based on a referral or order from a physician licensed to practice in the state of Louisiana.

Patient #1

Record review of patient #1 medical record revealed that he is an 83 year old male admitted to the hospital on 3/26/13 with the diagnosis of LLL Pneumonia (Left lower lobe), ASHF (Acute Systolic Heart Failure), MRSA (methicillin-resistant Staphylococcus aureus) bacteremia, stage III chronic kidney disease, thrombocytopenia, chronic obstructive pulmonary disease, and anemia.
Review of admission orders revealed an order written for PT/OT evaluate and treat per therapist evaluation.
Staff interview on 4/30/13 at 3:00 p.m. with S17PT confirmed that orders were not written by the physician responsible for the care of the patient indicating he agrees with the therapeutic regimen recommended by the therapist after the evaluation and before the initiation of therapy.

Patient #18

Review of the medical record for patient #18 revealed she was admitted on 4/8/13 for Severe Inflammatory Response Syndrome, sepsis, COPD (chronic obstructive Pulmonary Disease, L-Spine (lumbar spine) MRSA (methicillin resistant staphylococcus aureus)/osteomyelitis, anemia, and pneumonia. Review of the admission orders revealed an order for "PT (physical therapy) Eval (evaluate) and Treat per Therapist Evaluation."

Patient #19

Review of the medical record for patient #19 on 05/01/13 at 10:00 a.m. revealed he was admitted on 4/9/13 for LLL (left lower lobe) pneumonia, C-Diff (clostridium difficile), gross hematuria, and Stage III Coccyx pressure ulcer. "PT Eval and Treat per Therapist Evaluation."


Patient #20

Review of the medical record for patient #20 revealed he was admitted on 04/12/13 with a diagnosis of ARF (acute renal failure) with ESRD (end stage renal disease), anemia, DMII (diabetes mellitus Type 2), and HTN (hypertension). Review of the admission orders revealed an order for "PT Eval and Treat per Therapist Evaluation."

Patient #22

Review of the medical record for patient #22 revealed she was admitted on 4/29/13 with a diagnosis of Bilateral heel ulcers, left buttock and sacral pressure ulcers. Review of the admission orders revealed an order for "PT Eval and Treat per Therapist Evaluation."

In an interview on 05/01/13 at 11:10 a.m. with S17PT she stated a PT cannot write orders for therapy. S17PT confirmed there is no order from the physician responsible for the care of the patient indicating he agrees with the therapeutic regimen recommended by the therapist after the evaluation and before the initiation of therapy.

Patient #24

Review of the medical record for patient # 24 revealed he had been admitted to the hospital on 4/12/13 admitting diagnosis Osteomyelitis, Infected sacral decubitus ulcer with sepsis requiring IV antibiotics, Colostomy diversion, protein calorie malnutrition, and anemia. Admission orders included full code, IV antibiotics of Gentamycin.
Review of the admission orders revealed orders for PT evaluate and treat per therapist evaluation
Staff interview on 4/30/13 at 3:00 p.m. with S17PT PT confirmed that orders were not written by the physician responsible for the care of the patient indicating he agrees with the therapeutic regimen recommended by the therapist after the evaluation and before the initiation of therapy.

Patient #25

Review of the medical record for patient # 25 revealed she had been admitted to the hospital on 4/12/13 with diagnosis of UTI (Urinary Tract Infection) with Klebsiella, Acidosis, and Dehydration.
Review of the admission orders revealed orders for PT evaluate and treat per therapist evaluation.
Staff interview on 4/30/13 at 3:00 p.m. with S17PT PT confirmed that orders were not written by the physician responsible for the care of the patient indicating he agrees with the therapeutic regimen recommended by the therapist after the evaluation and before the initiation of therapy.

Patient #26

Review of the medical record for patient # 26 revealed she had been admitted to the hospital on 4/20/13 with the diagnosis of Diabetes insipidus, hyperosmolality, and bacteremia.
Review of the admission orders revealed orders for PT evaluate and treat per therapist evaluation.
Staff interview on 4/30/13 at 3:00 p.m. with S17PT PT confirmed that orders were not written by the physician responsible for the care of the patient indicating he agrees with the therapeutic regimen recommended by the therapist after the evaluation and before the initiation of therapy.












31206

Based on record reviews and interviews, the hospital failed to provide services prescribed by the licensed practitioner responsible for the patient's care by failing to administer respiratory treatments as ordered by the physician for 3 (#10, #14, and #16) of 30 patients' (#1-#30) medical records reviewed for respiratory orders.
Findings:
Policy Number: 4-5.1.0, Administration of Inhaled Medications, revealed in part, "A physician must prescribe all medications administered via the inhalation route. The order specifies: type of medication, dosage, delivery and frequency."
"The actual administration of the inhaled medication may not exceed 60 minutes before or after the scheduled medication delivery due time for medications prescribed at an interval greater than or equal to four hours. In the absence of a specific physician's orders standard administration times of inhaled medications are as follows: every day: 0800; bid (twice per day) or every shift: 0800, 2000; every 4 hours: 0700,1100, 1500,1900, 2300, 0300; every 6 hours: 0700, 1300, 1900, 0100; every 8 hours: 0700, 1500, 2300; tid (three times per day): 0700, 1300, 1900; qid (four times per day): 0700, 1100, 1500, 1900."

Patient #10
Patient #10 was an 87-year-old female admitted to the hospital on 04/09/13 with the diagnoses of respiratory failure, COPD (chronic obstructive pulmonary disease), hypertension, and coronary artery disease.
Review of Patient #10's medical record revealed respiratory treatments with the medication, albuterol, were ordered to be given three times per day by the physician on 04/18/13. Further review revealed that the albuterol medication treatments were administered on 04/21/13 at 9:05 a.m. and at 2300 (11:00 p.m.)
In a face-to-face interview on 05/02/13 at 10:15 a.m., S12RRT (Registered Respiratory Therapist) confirmed that a respiratory treatment was not given on 04/21/13 as ordered by the physician.

Patient #14
Patient #14 was a 66-year-old male admitted to the hospital on 04/22/13 with the diagnoses of pneumonia, COPD, hypertension, diabetes mellitus, and urinary tract infection.
Review of Patient #14's medical record revealed respiratory treatments with the medication, albuterol, were ordered on 04/26/13 at 9:30 a.m. to be given every four hours. Further review revealed that the albuterol respiratory treatments were administered on 04/26/13 at 7:50 a.m., 1:30 p.m., 7:35 p.m., and 11:40 p.m.
In a face-to-face interview on 04/30/13 at 4:10 p.m., S12RRT confirmed that the respiratory treatments with the medication, albuterol, were not administered every four hours on 04/26/13 as ordered by the physician.

Patient #16
Patient #16 was a 74-year-old female admitted to the hospital on 04/12/13 with the diagnoses of pneumonia, systolic heart failure, encephalopathy, and dysphagia.
Review of Patient #16's medical record revealed an order on 04/19/13 at 4:25 p.m. for respiratory treatments with the medication Brovana, 15 micrograms, per nebulizer twice a day. Further review of the medical record revealed that Brovana nebulizer treatments were not administered to the patient since 04/19/13.
In a face-to-face interview on 04/30/13 at 2:15 p.m., S12RRT confirmed that the respiratory treatments with the medication, Brovana, were not administered to the patient as ordered by the physician.
In a face-to-face interview on 04/30/13 at 2:15 p.m., S3RN confirmed that the respiratory treatments with the medication, Brovana, were not administered to the patient as ordered by the physician.