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Based upon review of records (policies/procedures, Medical Staff Bylaws/Rule, Health Information data reports) and interviews, the hospital failed to ensure compliance with the Condition of Participation for Governing Body as evidenced by:

1) The Governing Body failed to ensure the enforcement of the Medical Staff Bylaws/Rule by failing to ensure all members of the medical staff had privileges prior to providing services to hospitalized patients. (cross reference to findings cited at A0044)

2) The Governing Body failed to ensure the members of the Medical Staff were held accountable when their privileges were revoked for failure to adhere to the Medical Staff Bylaws/Rules and hospital policies/procedures relative to the completion of medical records. This was evidenced by 6 physicians (S11, S12, S22 ,S23, S24, and S25) who had their privileges revoked but were allowed to continue to admit patients, perform surgical and endoscopic procedures, and all other matters relative to patient care in the hospital. (cross reference to findings cited at A0049)

Based on review of policies/procedures, review of Medical Staff Bylaws/Rules, review of Health Information Management (HIM) data reports, and interviews, the hospital failed to ensure compliance with the Condition of Participation for Medical Staff as evidenced by:

Failing to ensure the medical staff was accountable to the governing body for the quality of medical care provided to patients. The hospital's Medical Director/Chief of Staff failed to ensure the enforcement of the medical staff bylaws relative to delinquent medical records. Six physicians (S11, S12, S22, S23, S24, and S25) whose privileges had been revoked were allowed to admit patients, perform surgery and/or other procedures related to hospitalized patients while their privileges were revoked. The six physicians had a combined total of 690 delinquent medical records. (cross reference to findings cited at A0347)

Based upon reviews of the Medical Staff Bylaws/Rules, hospital policies for Health Information Management (HIM), and interviews, the Governing Body failed to ensure all members of the medical staff had privileges approved prior to providing services to hospitalized patients. Findings:

Review of the Medical Staff Bylaws/Rules revealed physicians must have their requested privileges approved by the Governing Body and Medical Staff prior to the provision of services to hospitalized patients. Continued review of the Bylaws revealed physicians would have their privileges revoked if they failed to complete medical records in the required time frames.

Review of data reports relative to delinquent medical records provided by S5 RHIA/HIM Director (Registered Health Information Administrator), revealed 6 physicians (S11, S12, S22, S23, S24, S25) had a total of 690 incomplete medical records.

Review of letters addressed to each of the 6 physicians (S11, S12, S22, S23, S24, S25), dated 10/23/13 and 10/31/13, revealed "Please be advised that your privileges have been revoked until the listed charts have been complete."

The Governing Body allowed 6 physicians (S11, 12, 22, 23, 24, 25), one of who was the Medical Director/Chief of Staff (S12), whose privileges had been revoked, to continue to care for patients and perform surgery/endoscopic procedures on hospitalized patients. Their respective privileges had been revoked as a result of their incomplete medical records.

Based upon observation, reviews of records, Medical Staff Bylaws/Rules, Health Information Management (HIM) data reports, and interviews, the Governing Body failed to ensure the members of the Medical Staff were held accountable when their privileges were revoked for failure to adhere to the Medical Staff Bylaws/Rules and hospital policies regarding completion of medical records as evidenced by 6 physicians (S11, S12, S22, S23, S24, and S25) who had their privileges revoked but were allowed to continue to admit patients, perform surgical and endoscopic procedures, and all other matters relative to patient care in the hospital . Findings:

Review of the Medical Staff Bylaws/Rules revealed physicians would have their privileges revoked if they failed to complete medical records in the required time frames.

Review of data reports relative to delinquent medical records provided by S5 RHIA/HIM Director (Registered Health Information Administrator), revealed 6 physicians (S11, S12, S22, S23, S24, S25) had a total of 690 incomplete medical records.

Review of letters addressed to each of the 6 physicians (S11, S12, S22, S23, S24, S25), dated 10/23/13 and 10/31/13, revealed "Please be advised that your privileges have been revoked until the listed charts have been complete."

Review of letters informing physicians their privileges had been revoked revealed:

1) S11 Gen Surgeon was notified 10/23/13 he had incomplete records for no discharge summary for 4 patients (#s 8, 9, 10, 12) and 1 incomplete for no operative note for patient #11. Additionally, S11 Gen Surgeon was sent a letter on 10/31/13 for 300 incomplete records that included lack of signatures, report of operations, discharge notes, and orders.
An observation, 10/30/13 at 10:20 a.m., revealed S11 Gen Surgeon was performing surgeries on this date even though his privileges were revoked.

2) S24 Gen Surgeon was notified 10/31/13 for 188 incomplete charts. No indication as to what caused the charts to be incomplete.

3) S22 Gen Surgeon was notified 10/31/13 for 110 incomplete charts; no indication what the reason was for the incomplete charts.

4) S12 Gen Surgeon was notified 10/23/13 for 5 incomplete charts for lack of discharge summaries on patients #s 13-17. S12 Gen Surgeon was notified on 10/31/13 he had 48 incomplete charts; however no indication of the reason the charts were incomplete.

5) S23 OB/GYN physician was notified 10/31/13 he had 33 charts that were incomplete; no indication what the causes were that made the charts incomplete.

6) S25 Internal Medicine physician was allowed to admit, on 10/28/13, and provided care for Patient #3. S25 Internal Medicine physician's letter of privilege revocation was dated 10/23/13 for 1 incomplete chart for a discharge summary for a patient with a discharge date of 9/12/13.

The Governing Body allowed 6 physicians (S11, 12, 22, 23, 24, 25), one of whom was the Medical Director/Chief of Staff (S12) to continue to care for hospitalized patients and perform surgery/endoscopic procedures after their privileges had been revoked because of their incomplete medical records.

Based on review of the hospital's policy on grievance and staff interview the facility failed to ensure a reasonable timeframe was in place for reviewing, investigation, and resolving a grievance. Findings:

Review of the hospital's policy title Patient grievance process presented by S2 DON as being current revealed in parts; All efforts are made to effectively and expeditiously resolve the patient's grievance. All grievances..........must be investigated with efforts made toward resolution within 24 hours. The patient will be provided with written notice of : name of the CEO and /or designee. The steps taken to investigate and resolve the grievance; The final result of the grievance; The date of completion. The patient or his/her representative has the right to appeal a grievance determination; with determinations to be made within 30 days of appeal notification.

S2 DON presented an admission packet which she pointed out included the grievance process in which #3 read in part; The grievance form will be reviewed and addressed by the Administrator . Every effort will be made for review and response within 14 days, but no longer than 30 days.

In a face to face interview on 10/31/13 at 4:45 p.m. with S2 DON after the review of the policy confirmed the policy contained no timeframe for notification or resolution of grievance and should have.

In a face to face interview on 10/31/13 at 4:55 p.m. with S1 Administrator revealed the policy presented by S2 DON was the policy used by the hospital to interview, investigate, and resolve grievances. S1 Administrator confirmed after reviewing the policy confirmed there was no current documented stated time frame of notification of update or resolution of
grievance.

Based upon review of incident/accident reports, 1 of 7 medical records (#7), policies/procedures, and staff interviews, the hospital failed to follow state law LA. R.S. 40:2009.20 related to reporting to Health Standards Section an incident which occurred, on 09/13/2013 around 11-11:30PM, when 3 hospital staff members observed the sitter for Patient #7, "slapped" the patient on the head. Findings:

Review of incident/accident report revealed on 09/13/13, at 11:10PM, "the sitter for (name of patient #7) slapped her in the head two times consecutively around 11 to 11:30 p.m....Apparently, when turning on the in-room camera system to observe a sick pt in 103, the camera in 102 showed the sitter hitting the patient. The staff immediately checked on the patient, but did not confront the sitter at this time. Camera left on in room 102 to observe the patient with the sitter. DHH, Elderly Abuse Hotline, called and notified regarding the incident and informed of our plan of action and questioned if there was anything else to be completed...Daughter was notified of incident around 0420 a. m. Daughter arrived roughly around 0500 a. m. The police were called directly after the daughter to assist with escorting the sitter off the premises. Sitter was unaware previously that she was seen hitting the patient on the room camera. Sitter was awakened and asked to follow...outside the room....outside the room the police officer, (name S18 Police Officer), approached the sitter, informing her that she was going to be questioned and that she was not under arrest at this time, ...Incident discussed with daughter on arrival and information regarding the sitter service company taken at this time. (Names of S19 Case Manager and S20 Office Manager) of (name Company A) notified of investigation and accusation against (name S21 Sitter).

Continued review of the incident/accident report revealed "Bruising was noted to the patient's forehead this a.m. that was not there before the incident."

Review of LA. R.S. 40:2009.20 revealed: "B. (1) Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services, or any registered nurse, licensed practical nurse, nurse's aide, home and community based service provider employee or worker, personal care attendant, respite worker, physician's assistant, physical therapist, or any other direct care giver having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect..."

Interview with S2 Director of Nursing (DON), on 10/31/13 at 7:00PM, revealed when asked if patient abuse was reported to DHH-Health Standards Section within 24 hours, she replied she called Department of Health and Hospitals (DHH) and reported the occurrence to the DHH, Elderly Abuse Hotline, within 5 hours of the incident.

Interview with S1 Administrator, on 10/31/13 at 7:00PM, revealed when called by S2 DON, during the early morning hours of 09/13/13, he instructed her to contact DHH and report the abuse by Patient #7's sitter.

Both S1 Administrator and S2 DON stated they thought DHH was the organization they were to contact, they confirmed they did not know Health Standards Section (the regulatory agency of DHH), was the section of DHH to be contacted.

Based upon reviews of the Medical Staff Bylaws/Rules, duties of the Medical Staff Director/Chief of Staff, Health Information Management (HIM) data reports and policy on medical record completion, and interviews, the Medical Director/Chief of Staff failed to ensure physicians (S11, S12, S22, S23, S24, S25) were held accountable for compliance with Medical Staff Bylaws relative to the completion of medical records as evidenced by 690 incomplete medical records of the above 6 physicians. The delinquent records were due to lack of signatures on informed consent forms (S12), discharge summaries not completed (S11, S12, S22, S23, S24, S25), physician orders, no documented operative note and report of operations (S11), and a lack of documented history and physicals (S12) prior to endoscopic procedures. Findings:

Review of the Medical Staff Bylaws/Rules revealed the Governing Body had approved the Med (Medical) Staff bylaws. Continued review of the Med Staff bylaws revealed the Med Staff were expected to complete and perform examinations as required in the bylaws and if there were delinquent medical records (incomplete for lack of signatures, lack of discharge summaries greater than 30 days after patient discharge, lack of documented history and physicals) the physician would lose privileges to admit patients, perform surgery/procedures,and consult on patients until such time they completed all delinquent medical records.

Review of a document titled "Medical Director Agreement" revealed: "...effective as of the 1st day of July 2003...Representation and Warranties of Director Director represents and warrants the following: ...(f) ...Director's Facility medical staff membership or clinical privileges have never been suspended, curtailed or revoked by the medical staff or governing body...(g) Director is and shall remain a member in good standing of the active Medical Staff of Facility with clinical privileges sufficient to permit Director to perform all services required of Director under this Agreement..."

Review of an HIM policy titled "4014-Delinquent Medical Records" revealed: "POLICY: It is the policy of the Health Information Management Department to have all charts complete within 30 days of the patient's discharge. Records older than 30 days will be considered delinquent and it is the responsibility of the Health Information Management staff to notify a practitioner of suspension when he/she has delinquent medical records. PROCEDURE: Physicians will be notified on the fifteenth (15th) of every month...through a letter. Physicians will be revoked of all privileges on the thirtieth (30th) of every month if deficient charts are not completed...Should the Health Information Management Department not receive a physician response...within 15 days of the first notice, the physician will be notified by a second letter that his/her privileges have been revoked until all charts are complete...also submits his/her name to Administration and departments...the physician will be notified by letter that their privileges are revoked, in accordance with the hospital bylaws, until all... unsigned documents over 30 days old are electronically signed...hospital departments are notified...when the suspension of privileges has been lifted..."

Continued review of HIM policies revealed: "...45. Medical Record Delinquency - Completion of all medical records is expected within (30) days of patient discharge...the Medical Director may suspend Staff Privileges beginning on a specified date...Practitioner May Not: a. admit patients; b. treat patients in hospital setting...;c. schedule elective procedures/surgeries...; d. perform surgery..."

Interview with S5 Registered Health Information Administrator (RHIA), on 10/30/13 at 1:30 p.m., revealed letters had been sent to the physicians who had delinquent medical records. When asked if or what type of sanctions were applied to the physicians, S5 RHIA replied letters were sent to the physicians informing them that their privileges were revoked until the listed charts were completed.

Review of copies of letters, dated 10/23/13 and 10/31/13, revealed there were two (2) signature lines, one for S1 Administrator and one for S5 RHIA/HIM Director.

Telephone interview with S12 Gen (General) Surgeon/Medical Staff Director/Chief of Staff, on 10/31/13 at 9:00 a.m., revealed when asked why he had not enforced the Med Staff bylaws and upheld the revocation of S11, S22, S23, S24, S25 as well as his own, S12 Gen Surgeon replied he was not aware of the situation. S12 Gen Surgeon/Med Staff Director/Chief of Staff stated he had not been informed by S1 Administrator or S5 RHIA of the severity of the delinquent medical records.

Continued telephone interview, with S12 Gen Surgeon/Medical Staff Director/Chief of Staff, revealed if a physicians privileges were revoked they were not allowed to work until the delinquent records were completed. The surveyors informed S12 Gen Surgeon/Medical Staff Director/Chief of Staff that S25 Internal Medicine physician had a letter, dated 10/23/13, informing him that his privileges were revoked; however, on 10/28/13 he had admitted a patient and continued to care for this patient (identified as patient #3). It was also noted that all 6 physicians (S11, 12, 22, 23, 24, 25) were allowed to continue their hospital practice even though their privileges were revoked. S12 Gen Surgeon/Med Staff Director/Chief of Staff stated he would be returning to the hospital on 11/01/13 at which time he would investigate the situation.

The Governing Body and S12 Gen Surgeon/Medical Director failed to enforce the Medical Staff Bylaws and follow the policies of the hospital relative to delinquent medical records. Physicians whose privileges had been revoked were allowed to admit patients, perform surgery/procedures, and other issues related to patient care while their privileges were revoked.

Based on review of the Medical Staff Bylaws/Rules, interview with S5 RHIM (Register Health Information Management, review 23 of 23 closed medical records reviewed for patients (#18, #19, #20, #21, #22, #23,#24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39 & #40), review of the Informed Consent policy, and interviews, the hospital failed to ensure, properly executed informed consent was completed in the patient medical record prior to surgery/endoscopy as evidence by 4 physicians ( S11, S12, S22, S24) not signing the consent form prior to performing an endoscopic procedure. Findings:

Review of the Medical Staff Bylaws/Rules and the Hospital Policy revealed an informed consent must be signed by the patient and or by the patient's legal proxy on the patient's behalf, the performing physician, and a witness.

Review of 23 closed medical records for patients #18, #19, #20, #21, #22, #23,#24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39 & #40 revealed endoscopic procedures were performed by 4 physicians ( S11,S12,,S22 S24) who failed to signed the informed consent. The inform consent contained patient signature, and witnessed by a staff nurse with no documented physician's signature.

In a face to face interview on 10/30/13 at 2:30 p.m. with S5 RHIM revealed informed consents should be obtained by the physician prior to performing a surgical procedure/endoscopic, and 4 physicians ( S11, S12, S22,S24) failed to signed informed consents prior to endoscopic procedure.

In a face to face interview on 10/30/13 at 3:15 p.m. with S2 DON revealed informed consent are obtained by the surgeon prior to performing a surgical procedure/endoscopic, after review of the 23 consents confirmed 4 physicians (S11, S12, S22,S24) failed to signed the informed consent as per the Hospital Policy and Medical Staff Bylaws.

Based upon reviews of records, hospital Health Information Management (HIM) policies, and interviews, the hospital failed to ensure the healthcare provider documented a discharge summary as evidenced by 667 medical records lacking discharge summaries that required completion by 6 physicians (#s S11, 12, 22, 23, 24, and 25). Findings:

Review of data reports relative to delinquent medical records provided by S5 RHIA/HIM Director (Registered Health Information Administrator), revealed 6 physicians (S11, S12, S22, S23, S24, S25) had a total of 690 incomplete medical records. 667 of the total 690 were lacking documented discharge summaries.

Review of an HIM policy titled "4014-Delinquent Medical Records" revealed: "POLICY: It is the policy of the Health Information Management Department to have all charts complete within 30 days of the patient's discharge. Records older than 30 days will be considered delinquent and it is the responsibility of the Health Information Management staff to notify a practitioner of suspension when he/she has delinquent medical records. PROCEDURE: Physicians will be notified on the fifteenth (15th) of every month...through a letter. Physicians will be revoked of all privileges on the thirtieth (30th) of every month if deficient charts are not completed...Should the Health Information Management Department not receive a physician response...within 15 days of the first notice, the physician will be notified by a second letter that his/her privileges have been revoked until all charts are complete...also submits his/her name to Administration and departments...the physician will be notified by letter that their privileges are revoked, in accordance with the hospital bylaws, until any unsigned documents over 30 days old are electronically signed...hospital departments are notified...when the suspension of privileges has been lifted..."

Continued review of HIM policies revealed: "45. Medical Record Delinquency - Completion of all medical records is expected within (30) days of patient discharge...the Medical Director may suspend Staff Privileges beginning on a specified date...Practitioner May Not: a. admit patients; b. treat patients in hospital setting...;c. schedule elective procedures/surgeries...; d. perform surgery..."

Review of letters addressed to each of the 6 physicians (S11, S12, S22, S23, S24, S25), dated 10/23/13 and 10/31/13, revealed "Please be advised that your privileges have been revoked until the listed charts have been complete."

Review of letters informing physicians their privileges had been revoked revealed:

1) S11 Gen Surgeon was notified 10/23/13 he had incomplete records for no discharge summary for 4 patients (#s 8, 9, 10, 12). Additionally, S11 Gen Surgeon was sent a letter on 10/31/13 for 300 incomplete records that included lack of signatures, report of operations, discharge notes, and orders.

2) S24 Gen Surgeon was notified 10/31/13 for 188 incomplete charts. No indication as to what caused the charts to be incomplete.

3) S22 Gen Surgeon was notified 10/31/13 for 110 incomplete charts; no indication what the reason was for the incomplete charts.

4) S12 Gen Surgeon was notified 10/23/13 for 5 incomplete charts for lack of discharge summaries on patients #s 13-17. S12 Gen Surgeon was notified on 10/31/13 he had 48 incomplete charts; however no indication of the reason the charts were incomplete.

5) S23 OB/GYN physician was notified 10/31/13 he had 33 charts that were incomplete; no indication what the causes were that made the charts incomplete.

6) S25 Internal Medicine physician's letter of privilege revocation was dated 10/23/13 for 1 incomplete chart for a discharge summary for a patient with a discharge date of 9/12/13.

Interview, 10/31/13 at 10:40 a.m., with S5 RHIA/HIM Director confirmed there was a total of 690 delinquent medical records that had various reasons for the delinquency; however, S5 RHIA/HIM Director agreed there were medical records that dated back to July 2013 and 1 record that dated back to 2006 which required discharge summaries.

Based upon observations, reviews of policies/procedures, and interviews, the Infection Control Officer failed to ensure all hospital staff members, including housekeeping and maintenance employees, were in compliance with all infection control program requirements as evidenced by 2 members of housekeeping (S3 Housekeeper, S4 Supervisor Housekeeping), who were not aware of the contact times (according to manufacturers directions for use), required to ensure disinfection of environmental surfaces. Findings:

Observations, on 10/29/13 at 11:15 a.m., revealed S3 Housekeeper was in Room 105 cleaning/disinfecting it following a patient's discharge. The surveyor noticed the solution bottle that S3 Housekeeper was holding; she was asked if that was the approved disinfectant for use. S3 Housekeeper stated it "was". Further questioning revealed S3 Housekeeper was using "Neutron" to clean/disinfect all environmental surfaces, including the medical equipment (IV pump which was in Room 105), and the bathroom. The surveyor asked S3 Housekeeper how long the surfaces needed to remain visibly wet in order for disinfection to be completed; S3 Housekeeper replied, "I'm not sure". The surveyor asked to see the manufacturers' directions for use (DFU); S3 Housekeeper stated she would get her supervisor to bring the DFU to the surveyor.

S4 Supervisor Housekeeping presented the DFU to the surveyor, the Neutron solution was approved for use on floors. S4 Supervisor Housekeeping did not know the time frame as required by the solution (Neutron) DFU.

There failed to be documented evidence that monitoring and evaluation for requiring disinfectants, antiseptics, and germicides to be used in accordance with the manufacturers' guidelines/DFU was implemented.

There failed to be documented evidence that provisions to monitor compliance with all policies, procedures, protocols and other infection control program requirements relative to housekeeping was conducted.

Interviews, 10/31/13 at 6:30 p.m., with S1 Administrator and S2 Director of Nursing confirmed the Neutron solution was for use on floors and Cavicide was the agent to be utilized on other environmental surfaces.

S6 Registered Nurse, Infection Control Officer was informed of the lack of knowledge of the housekeeping staff relative to the DFU for the hospital's disinfectants, antiseptics, and germicides.