HospitalInspections.org

Based on records review and interviews, the hospital failed to meet the requirements for the Condition of Participation for Governing Body as evidenced by:


1) failing to ensure that patients were admitted to the hospital on the recommendation of a licensed practitioner. This is evidenced by 130 hospice patients (1/01/14 through 1/06/15) being cared for by hospital staff and utilizing hospital resources in a licensed/certified hospital bed without being admitted to the hospital (see findings tag A-0065).


2) failing to ensure that contracted services were furnished to permit the hospital to comply with all applicable conditions of participation and standards for contracted services. This is evidenced by failing to admit 130 patients (1/01/14 through 1/06/15) receiving hospice care to the hospital. (see findings tag A-0083).


3) failing to ensure that contracted services were performed in a safe and effective manner as evidenced by failing to ensure hospice services were included in the quality assurance and performance improvement program (see findings A-0084).

Based on records review and interviews, the hospital failed to meet the requirements for the Condition of Participation for Quality Assurance Performance Improvement (QAPI) as evidenced by:


1) failing to collect data and identify opportunities for improvement in a high-volume area. This is evidenced by failing to recognize problem areas, implement improvement strategies and measure the success for patients receiving hospice services in the hospital for 130 of 142 patients cared for in the past year at the main campus (see findings tag A-0283).


2) the governing body failed to ensure the hospital's QAPI (Quality Assurance Performance Improvement) program reflected the complexity of the services offered in the hospital as evidenced by failing to include hospice services which were furnished under contract (see findings tag A-0308).

Based on records review and interviews, the hospital failed to meet the requirements for the Condition of Participation for Medical Records as evidenced by:


1) failing to ensure a system was in place to ensure completion of medical records within 30 days of discharge. The hospital also failed to monitor hospice patients' medical records and include them in the delinquency rates (see findings tag A-0438).


2) failing to ensure the effective implementation of a system relative to the completion of History & Physical examinations within 24 hours of admission. This was evidenced by the hospital's inability to provide documented evidence of a medical history and physical examination within 24 hours of admission for 9 of 9 (#1, #2, #3, #5, #6, #7, #8, #9, and #10) sampled patients who were admitted to a hospital bed for hospice services (see findings tag A-0458).


3) failing to ensure the effective implementation of a system relative to the completion of Discharge Summaries within 30 days of discharge. This was evidenced by the hospital's inability to provide documented evidence of a discharge summary for 6 of 6 (#2, #3, #7, #8, #9, and #10) sampled patients who were admitted to a hospital bed for hospice services (see findings tag A-0468).

Based on interview and records review, the hospital failed to meet the requirements for the Condition of Participation for Infection Control as evidenced by failing to ensure the implementation of a system for identifying, reporting, investigating, and controlling infections and communicable diseases of all patients being cared for in the hospital. This is evidenced by not collecting and including infection control data for 130 hospice patients out of a total of 142 patients at the main campus since 1/01/14 (see findings tag A-0749).

Based on records review and interviews, the hospital failed to ensure that patients were admitted to the hospital on the recommendation of a licensed practitioner. This is evidenced by 130 hospice patients (1/01/14 through 1/06/15) being cared for by hospital staff and utilizing hospital resources in a licensed/certified hospital bed without being admitted to the hospital.


Findings:


Review of a list of patients/individuals provided by the hospital that had been cared for at the main campus of the hospital from 1/01/14 to 1/06/15 revealed a total of 130 patients admitted for Hospice Services and 12 patients admitted for LTAC (Long Term Acute Care) Services.


In an interview on 1/05/15, at 9:30 a.m., S1CEO indicated that the hospital did not admit the hospice patients to the hospital. S1CEO reported that the hospice patients were directly admitted to hospice services and were never admitted as hospital inpatients. S1CEO indicated the hospice patients were being cared for in the hospital beds. S1CEO indicated that the Hospice facilities "Lease" space and services from the hospital.



Review of the hospital's agreement with the hospice providers revealed that the "Hospital will provide inpatient acute care services that are palliative in nature to control pain and manage symptoms of terminal illness, including, but not limited to, room and board, treatments, medications on the approved formulary, nursing services on a 24-hour per day, dietary, housekeeping, recreational and religious activities, ancillary and oxygen services, standard medical equipment, and disposable medical supplies." Further, it required that "All Hospice inpatient admissions to Hospital shall be authorized by the Hospice Medical Director and Hospice Designee, and admitted by an attending physician that is a member of the hospital's medical staff."

Based on records review and interviews, the governing body failed to ensure that contracted services were furnished to permit the hospital to comply with all applicable conditions of participation and standards for contracted services. This is evidenced by failing to admit 130 patients (1/01/14 through 1/05/15) receiving hospice care to the hospital.


Findings:


Review of a list of patients/individuals (provided by the hospital) that had been cared for at the main campus of the hospital from 1/01/14 to 1/06/15 revealed a total of 130 patients admitted for Hospice Services and 12 patients admitted for LTAC (Long Term Acute Care) Services.


Review of 14 contracts between hospice companies and the hospital revealed in part:
Part II: Services to Be Provided By Hospital


A. Hospital will make inpatient beds available to Hospice patients referred by hospice.


C. At the request of Hospice, Hospital will provide inpatient acute care services that are palliative in nature to control pain and manage symptoms of terminal illness, including, but not limited to, room and board, treatments, medications on the approved formulary, nursing services on a 24-hour per day, dietary, housekeeping, recreational and religious activities, ancillary and oxygen services, standard medical equipment, and disposable medical supplies.


D. All inpatient services provided by Hospital will be furnished in a safe and effective manner by personnel, and must be provided as directed in the Hospice patient's plan of care and under the direction of the patient's attending physician.


Part III. Services To Be Provided By Hospice


B. All Hospice inpatient admissions to Hospital shall be authorized by the Hospice Medical Director and Hospice Designee, and admitted by an attending physician that is a member of the hospital's medical staff.


Review of the quality assurance program with S2Quality revealed hospice services were not included in the hospital's QAPI (Quality Assurance Performance Improvement) program.


In an interview on 1/5/15 at 9:30 a.m. with S1CEO, he said the hospital did not admit the hospice patients they were caring for to the hospital, the hospice's just "leased" space and services from them. He said the hospice patients were directly admitted to hospice services and were never admitted as inpatients. S1CEO said the patients were admitted directly to hospice by the hospice physician.

In an interview conducted on 1/5/15 at 1:35 p.m. with S5DON, she said the hospice companies rented the hospital beds from the hospital. S5DON said the hospice patients were not inpatients at the hospital although they were placed in the licensed long term acute care beds. She said the hospital billed the hospice companies a flat rate daily to lease the beds and for the hospital staff to provide care. S5DON said when a patient is admitted under hospice, the hospice was responsible for the patient.

In an interview on 1/6/15 at 9:52 a.m. with S2Quality, she verified she did not include the hospice services in the QAPI program. S2Quality said the hospice services were contracted and they were reviewed for quality by the individual hospice agencies. S2Quality said the hospice patients were not admitted to the hospital.

Based on record review and interview, the governing body failed to ensure contracted services were performed in a safe and effective manner as evidenced by failing to ensure hospice services were included in the quality assurance and performance improvement program.


Findings:


Review of a list of patients/individuals (provided by the hospital) that had been cared for at the main campus of the hospital from 1/01/14 to 1/06/15 revealed a total of 130 patients admitted for Hospice Services and 12 patients admitted for LTAC (Long Term Acute Care) Services. The hospital provided 14 contracts with hospice companies to provide hospice services at the hospital.


Review of the quality assurance program with S2Quality revealed hospice services were not included in the hospital's QAPI (Quality Assurance Performance Improvement) program.


In an interview on 1/06/15, at 9:52 a.m., with S2Quality, she verified she did not include the hospice services in the hospital's QAPI program.

Based on records review and interviews, the hospital failed to ensure grievances involving hospice patients at the hospital were investigated and resolved by the grievance committee.

Findings:

Review of the hospital policy and procedure titled Complaint and Grievance by Patient, Number: C01-RR, revealed in part:


St. Theresa Specialty Hospital has established a mechanism for receiving, acting upon, and responding to patients, families, and visitors expressing concern for patient treatment "and all areas of quality care" (the Grievance Process). It is the policy of the Hospital to respond to such complaints promptly. It is also the policy of the Hospital to establish a process to respond to concerns and complaints and to assure patients, families, the patient's representative, and visitors are aware of this process and their rights to access it.


Review of a list of patients provided by the hospital that had been cared for at the main campus of the hospital from 1/01/14 to 1/06/15 revealed there had been 130 hospice patients and 12 long term acute patients.


Review of the grievance log for the hospital revealed no grievances related to the patients admitted for hospice services.


In an interview on 1/06/15, at 9:28 a.m., S2Quality said the hospital did not investigate grievances or complaints about patients admitted for hospice services in the hospital even if they were complaints against the care provided by the hospital staff. S2Quality indicated all of the complaints regarding hospice patients were sent directly to the hospice companies.

Based on records review and interviews, the hospital failed to collect data and identify opportunities for improvement in a high-volume area. This is evidenced by failing to recognize problem areas, implement improvement strategies and measure the success for patients receiving hospice services in the hospital for 130 of 142 patients cared for in the past year at the main campus.


Findings:


Review of the quality assessment performance improvement data collected by S2Quality revealed no data relative to patients receiving hospice services in the hospital.


In an interview on 1/07/15, at 4:42 p.m., S2Quality verified information relative to patient safety, medical errors and adverse events for patients admitted for hospice services was not included in the hospitals Quality Assurance Performance Improvement program. S2Quality indicated that this data was not being monitored by the hospital. S2Quality indicated that the hospital did not collect any data for the hospice patients receiving care at the hospital because they were patients of the hospice and not the hospital. S2Quality indicated that it was the responsibility of the hospices taking care of the patients to perform quality assurance performance improvement activities on patients admitted for hospice services.

Based on records review and interviews, the hospital failed to ensure patient safety, medical errors and adverse events were accurately measured, analyzed and tracked for all patients being cared for in the hospital. This is evidenced by failing to include quality assurance performance improvement data for 130 hospice patients out of a total of 142 patients admitted for services at the hospital's main campus since 1/01/14.


Findings:


Review of the quality assessment performance improvement data collected by S2Quality revealed no data relative to patients receiving hospice services in the hospital. Review of data relative to patient safety, medical errors and adverse events revealed no evidence to indicate the hospital was including patients receiving hospice services in the hospital.


In an interview on 1/07/15, at 4:42 p.m., S2Quality verified information relative to patient safety, medical errors and adverse events for patients admitted for hospice services was not included in the hospitals Quality Assurance Performance Improvement program. S2Quality indicated that this data was not being monitored by the hospital.

Based on record review and interview, the governing body failed to ensure the hospital's QAPI (Quality Assurance Performance Improvement) program reflected the complexity of the services offered in the hospital as evidenced by failing to include hospice services which were furnished under contract. Findings:

Review of a list of patients, provided by the hospital, that had been cared for at the main campus of the hospital from 1/01/14 to 1/06/15 revealed that there had been 130 hospice patients and 12 long term acute care patients. The hospital had contracts with multiple hospice companies to provide hospice services at the hospital.


Review of the quality assurance performance improvement data with S2Quality revealed hospice services were not included in the hospital's QAPI program.


In an interview on 1/07/15, at 4:42 p.m., S2Quality verified information relative to patients admitted for hospice services was not included in the hospitals Quality Assurance Performance Improvement program. S2Quality indicated that this data was not being monitored by the hospital. S2Quality indicated that the hospital did not collect any data for the hospice patients receiving care at the hospital because they were patients of the hospice and not the hospital. S2Quality indicated that it was the responsibility of the hospices taking care of the patients to perform quality assurance performance improvement activities on patients admitted for hospice services.

Based on records review and interviews, the hospital failed to ensure that nursing care plans were developed for 9 of 9 (#1, #2, #3, #5, #6, 7, #8, #9, and #10) sampled patients admitted for hospice services.


Findings:


Review of the hospital's Clinical Services policies and procedures revealed, in part:


Subject: Nursing Care Plan. Purpose: To provide a mechanism for initiating and updating the Nursing Care Plan.


Procedure: 1. A personalized Nursing Care plan is initiated within twenty-four hours of admission for each patient.


1. Patient #1: Review of the medical record revealed Patient #1 was a hospice patient with the diagnosis of Lung Cancer. Patient #1 was discharged from the hospital on 12/16/14. Further review of the medical record revealed no documented evidence a nursing care plan was developed.


2. Patient #2: Review of the medical record revealed Patient #2 was a hospice patient with the diagnosis of cerebral vascular accident. Patient #2 was discharged from the hospital on 8/4/14. Further review of the medical record revealed no documented evidence a nursing care plan was developed.


3. Patient #3: Review of the medical record revealed Patient #3 was a hospice patient with the diagnosis of Breast Cancer. Patient #3 was discharged from the hospital on 12/04/14. Further review of the medical record revealed no documented evidence a nursing care plan was developed.


4. Patient #5: Review of the medical record revealed Patient #5 was a hospice patient with the diagnosis of Chronic Obstructive Pulmonary Disease. Patient #5 was discharged from the hospital on 12/12/14. Further review of the medical record revealed no documented evidence a nursing care plan was developed.


5. Patient #6: Review of the medical record revealed Patient #6 was a hospice patient with the diagnosis of Cerebrovascular Accident. Patient #6 was discharged from the hospital on 12/27/14. Further review of the medical record revealed no documented evidence a nursing care plan was developed.


6. Patient #7: Review of the medical record revealed Patient #7 was a hospice patient admitted to treat unresolved pain. Patient #7 was discharged from the hospital on 11/21/14. Further review of the medical record revealed no documented evidence a nursing care plan was developed.


7. Patient #8: Review of the medical record revealed Patient #8 was a hospice patient with the diagnosis of Respiratory Failure. Patient #8 was discharged from the hospital on 10/08/14. Further review of the medical record revealed no documented evidence a nursing care plan was developed.


8. Patient #9: Review of the medical record revealed Patient #9 was a hospice patient with the diagnosis of Colon Cancer. Patient #9 was discharged from the hospital on 12/01/14. Further review of the medical record revealed no documented evidence a nursing care plan was developed.


9. Patient #10: Review of the medical record revealed Patient #10 was a hospice patient with the diagnosis of Rectal Cancer. Patient #10 was discharged from the hospital on 04/10/14. Further review of the medical record revealed no documented evidence a nursing care plan was developed.


In an interview on 01/05/15, at 1:28 p.m., S5DON indicated hospice patients were not admitted to the hospital. S5DON indicated it was the patients' hospice agency that was responsible for developing a nursing care plan for their patients.

Based on personnel records reviews and staff interviews, the hospital failed to ensure that nursing personnel received education and training for providing care to the individual needs of patients admitted for hospice services.


Findings:


Review of a list of patients that had been cared for at the main campus of the hospital from 01/01/14 to 01/06/15 revealed that there had been 130 hospice patients and 12 long term acute care patients.


Review of the hospital's personnel files for S7RN, S8RN, S9RN, and S10RN revealed no documented evidence they received education and training for the care of hospice patients in the year 2014.


In an interview on 01/07/15, at 11:11 a.m., S5DON indicated the hospital had no documented evidence that nursing personnel received education and training for the care of hospice patients in the year 2014. S5DON indicated any hospice related training for the hospital's nursing staff would be kept at the hospice agency that provided the training.

Based on observations and interviews, the hospital:


1) failed to ensure that a system was in place to ensure completion of medical records within 30 days of discharge. The hospital also failed to monitor hospice patients' medical records and include them in the delinquency rates.


2) failed to ensure that paper medical records were protected from water damage in the event the sprinkler system was activated.


Findings:


1) Failed to ensure that a system was in place to ensure completion of medical records within 30 days of discharge. The hospital also failed to monitor hospice patients' medical records and include them in the delinquency rates.


Review of the hospital Rules and Regulations of the Medical Staff revealed in part:


12. The attending physician shall complete the medical record at the time of the patient's discharge, to include progress notes, final diagnosis and discharge summary.


13. If the medical record is incomplete thirty (30) days after discharge, a written notice shall be sent to the physician by the CEO notifying him that he has seven (7) days to complete the medical records or his admitting privileges will be suspended. The clinical privileges of any individual shall be deemed to be automatically relinquished for failure to complete medical records in accordance with applicable regulations governing the same, after notification by the Hospital of such delinquency and failure to complete the medical records within the seven days period. This relinquishment shall continue until all the records of the individual patients are no longer delinquent. Failure to complete the medical records that caused relinquishment of the clinical privileges within 30 days from the relinquishment of such privileges shall constitute a voluntary resignation from the Medical Staff.


Review of a list of delinquent medical records revealed the following physician delinquencies:


S11MD- 1 medical record 91-120 days delinquent
S12MD- 1 medical record 121-150 days delinquent
S13MD- 2 medical records 61-90 days delinquent
S14MD- 1 medical record 31-60 days delinquent
S15MD- 1 medical record 61-90 days delinquent
S16MD- 2 medical records 31-60 days delinquent, 1 medical record 61-90 days delinquent, and 1 medical record 91-120 days delinquent
S17MD- 1 medical record 31-60 days delinquent


In an interview on 1/07/15, at 3:45 p.m., with S3HIM, he said the medical staff bylaws required suspension of physicians with delinquencies greater than 30 days, but as of this time nobody had been suspended. S3HIM also verified the hospice patients' medical records from the main campus (130 hospice patients out of 142 total patients at the main campus since 1/1/14) were not monitored and included in the hospital's delinquency rate.


2) Failed to ensure that paper medical records were protected from water damage in the event the sprinkler system was activated.


Observation on 1/05/15, at 11:00 a.m., revealed paper medical records were retained on open shelving units in the medical records manager's office. Further observation revealed that the office had a sprinkler system in the ceiling.


In an interview on 1/7/15, at 1:15 p.m., with S3HIM, he verified the hospital's medical records were not protected against water damage in the event the sprinkler system was activated. S3HIM said the hospital had a water proof covering for the records but it had not been being used. S3HIM said there was a year's worth of records on the shelves which was approximately 140 medical records.


In an interview on 1/7/14, at 3:30 p.m., with S1CEO, he verified there was not a copy of the paper medical records stored at the hospital and they had not been scanned into a computer system.

Based on records review and staff interviews, the hospital failed to ensure a discharge summary was authenticated by the physician for 1 of 10 sampled patients (#4).


Findings:


Review of the hospital Health Information Management policies and procedures revealed in part:


Subject: Discharge Record Analysis.


Procedure: A. The discharge summary shall be completed and signed within 30 days of discharge.


Patient #4: Review of the medical record revealed Patient #4 was a long term care patient with the diagnoses of Acute Pancreatitis.


Review of the medical record revealed Patient #4 was discharged from the hospital on 11/06/14. Review of the Discharge Summary dated 11/06/14, revealed it was not authenticated by the physician.


In an interview on 01/07/15, at 2:29 p.m., S3HIM confirmed the patient's discharge summary was not authenticated timely by the physician.

Based on records review and staff interviews, the hospital failed to ensure all physician orders were dated, timed, and authenticated for 8 of 10 sampled patients (#1, #3, #4, #6, #7, #8, #9, and #10).


Findings:


Review of the hospital Health Information Management policies and procedures revealed, in part:


Subject: Concurrent Analysis of Medical Records.


Policy: It shall be the policy of the hospital to perform concurrent analysis on in-house medical records to ensure completeness and accuracy of documentation prior to discharge.


Procedure: D. The clinical team should also use colored stickers to flag unsigned verbal orders to meet regulatory requirements. E. All attempts should be made to secure completion and authentication of these items prior to patient discharge.


1. Patient #10: Review of the medical record revealed Patient #10 was a hospice patient with the diagnosis of Rectal Cancer.

Review of the hospital Physician s Orders revealed the following:
04/08/14: Verbal Order to place a Foley catheter not authenticated by the physician.


2. Patient #8: Review of the medical record revealed Patient #8 was a hospice patient with the diagnosis of Respiratory Failure.

Review of the hospital Physician's Orders revealed the following:

09/11/14: Verbal Orders for medications not timed and dated when authenticated by the physician.

09/17/14: Verbal Orders for medications not timed and dated when authenticated by the physician.

09/17/14: Verbal Orders for medications not authenticated by the physician.

09/19/14: Verbal Orders for medications not authenticated by the physician.


3. Patient #4: Review of the medical record revealed Patient #4 was a long term care patient with the diagnoses of Acute Pancreatitis.

Review of the hospital Physician's Orders revealed the following:

10/26/14: Verbal Orders for medications not authenticated by the physician.

11/05/14: Verbal Order to discontinue daily weights not authenticated by the physician.


4. Patient #7: Review of the medical record revealed Patient #7 was a hospice patient admitted to treat unresolved pain.

Review of the hospital Physician's Orders revealed the following:

11/04/14: Verbal Orders for medications not authenticated by the physician.

11/05/14: Verbal Orders for medications not authenticated by the physician.

11/07/14: Verbal Orders for medications not authenticated by the physician.

11/10/14: Verbal Orders for medications not authenticated by the physician.


5. Patient #9: Review of the medical record revealed Patient #9 was a hospice patient with the diagnosis of Colon Cancer.

Review of the hospital Physician's Orders revealed the following:

11/11/14: Verbal Orders for medications not authenticated by the physician.

11/12/14: Verbal Orders for medications not authenticated by the physician.

11/13/14: Verbal Orders for medications not authenticated by the physician.


6. Patient #3: Review of the medical record revealed Patient #3 was a hospice patient with the diagnosis of Breast Cancer.

Review of the hospital Physician's Orders revealed the following:

11/30/14: Verbal Orders for medications not authenticated by the physician.

12/01/14: Verbal Orders for medications not authenticated by the physician.


7. Patient #1: Review of the medical record revealed Patient #1 was a hospice patient with the diagnosis of Lung Cancer.

Review of the hospital Physician's Orders revealed the following:

12/12/14: Order for Coumadin 1 mg not timed when written by the physician.


8. Patient #6: Review of the medical record revealed Patient #6 was a hospice patient with the diagnosis of Cerebrovascular Accident.

Review of the hospital Physician's Orders revealed the following:

12/26/14: Verbal Orders for oxygen not authenticated by the physician.


In an interview on 01/07/15 at 2:28 p.m., S3HIM confirmed the physicians' orders were not dated, timed, and authenticated timely.

Based on records review and staff interviews, the hospital failed to ensure completion of History & Physical examination were dompleted within 24 hours of admission. This was evidenced by the hospital's failure to provide documented evidence of a medical history and physical examination completed within 24 hours of admission for 9 of 9 (#1, #2, #3, #5, #6, #7, #8, #9, and #10) sampled patients who were admitted to a hospital bed for hospice services.


Findings:


Review of the hospital Health Information Management policies and procedures revealed, in part:

Subject: Concurrent Analysis of Medical Records.

Policy: It shall be the policy of the hospital to perform concurrent analysis on in-house medical records to ensure completeness and accuracy of documentation prior to discharge.

Procedure: A. New admissions will be checked daily to verify a History & Physical is on the chart within 24 hours of admission.


1. Patient #1: Review of the medical record revealed that Patient #1 was a hospice patient with the diagnosis of Lung Cancer. Patient #1 was admitted to a hospital bed for hospice services on 12/09/14. Further review of the medical record revealed no documented evidence of a medical history and physical examination.


2. Patient #2: Review of the medical record revealed that Patient #2 was a hospice patient with the diagnosis of Cerebral Vascular Accident. Patient #2 was admitted to a hospital bed for hospice services on 07/29/14. Further review of the medical record revealed no documented evidence of a medical history and physical examination.


3. Patient #3: Review of the medical record revealed that Patient #3 was a hospice patient with the diagnosis of Breast Cancer. Patient #3 was admitted to a hospital bed for hospice services on 11/30/14. Further review of the medical record revealed no documented evidence of a medical history and physical examination.


4. Patient #5: Review of the medical record revealed that Patient #5 was a hospice patient with the diagnosis of Chronic Obstructive Pulmonary Disease. Patient #5 was admitted to a hospital bed for hospice services on 12/10/14. Further review of the medical record revealed no documented evidence of a medical history and physical examination.


5. Patient #6: Review of the medical record revealed that Patient #6 was a hospice patient with the diagnosis of Cerebrovascular Accident. Patient #6 was admitted to a hospital bed for hospice services on 12/26/14. Further review of the medical record revealed no documented evidence of a medical history and physical examination.


6. Patient #7: Review of the medical record revealed that Patient #7 was a hospice patient admitted to treat unresolved pain. Patient #7 was admitted to a hospital bed for hospice services on 10/31/14. Further review of the medical record revealed no documented evidence of a medical history and physical examination.


7. Patient #8: Review of the medical record revealed that Patient #8 was a hospice patient with the diagnosis of Respiratory Failure. Patient #8 was admitted to a hospital bed for hospice services on 09/15/14. Further review of the medical record revealed no documented evidence of a medical history and physical examination.


8. Patient #9: Review of the medical record revealed that Patient #9 was a hospice patient with the diagnosis of Colon Cancer. Patient #9 was admitted to a hospital bed for hospice services on 11/11/14. Further review of the medical record revealed no documented evidence of a medical history and physical examination.


9. Patient #10: Review of the medical record revealed that Patient #10 was a hospice patient with the diagnosis of Rectal Cancer. Patient #10 was admitted to a hospital bed for hospice services on 02/21/14. Further review of the medical record revealed no documented evidence of a medical history and physical examination.


In an interview on 01/07/15, at 2:31 p.m., S3HIM confirmed the hospice patients medical records did not contain evidence of medical history and physical examinations.

Based on records review and interviews, the hospital failed to ensure that medical records contained hospice agency information necessary to monitor the patient's condition for 9 of 9 (#1, #2, #3, #5, #6, 7, #8, #9, and #10) sampled patients admitted to a hospital bed for hospice services.


Findings:


Review of the hospital medical records for patients #1, #2, #3, #5, #6, 7, #8, #9, and #10 revealed that they were sent to the hospital for inpatient hospice care. Review of the medical records revealed there was minimal documentation from the patients' hospice agencies. There were no hospice nurses notes and no hospice plans of care in the medical records.


In an interview on 01/05/15, at 1:28 p.m., S5DON indicated hospice patients were not admitted to the hospital. S5DON indicated the patients' hospice agency kept a medical record for their patients and the hospital kept a medical record. S5DON indicated the hospice agency should leave a copy of the hospice plan of care at the hospital, but this was not done consistently.



Review of the hospital's agreement with the hospice providers revealed that the "Hospital will provide inpatient acute care services that are palliative in nature to control pain and manage symptoms of terminal illness, including, but not limited to, room and board, treatments, medications on the approved formulary, nursing services on a 24-hour per day, dietary, housekeeping, recreational and religious activities, ancillary and oxygen services, standard medical equipment, and disposable medical supplies." Further, it required that "All Hospice inpatient admissions to Hospital shall be authorized by the Hospice Medical Director and Hospice Designee, and admitted by an attending physician that is a member of the hospital's medical staff."

Based on records review and staff interviews, the hospital to ensure the completion of Discharge Summaries within 30 days of discharge. This was evidenced by the hospital's failure to provide documented evidence of a discharge summary for 6 of 6 (#2, #3, #7, #8, #9, and #10) sampled patients who were admitted to a hospital bed for hospice services.


Findings:


Review of the hospital Health Information Management policies and procedures revealed, in part: Subject: Discharge Record Analysis. Procedure: The Health Information Management Department must check for the following information when performing the analysis process for each record: A. The discharge summary shall be completed and signed within 30 days of discharge.


1. Patient #10: Review of the medical record revealed that Patient #10 was a hospice patient with the diagnosis of Rectal Cancer. Patient #10 was discharged from the hospital on 04/10/14. Further review of the medical record revealed no documented evidence of a discharge summary.


2. Patient #2: Review of the medical record revealed that Patient #2 was a hospice patient with the diagnosis of Cerebral Vascular Accident. Patient #2 was discharged from the hospital on 08/04/14. Further review of the medical record revealed no documented evidence of a discharge summary.


3. Patient #8: Review of the medical record revealed that Patient #8 was a hospice patient with the diagnosis of Respiratory Failure. Patient #8 was discharged from the hospital on 10/08/14. Further review of the medical record revealed no documented evidence of a discharge summary.


4. Patient #7: Review of the medical record revealed that Patient #7 was a hospice patient admitted to treat unresolved pain. Patient #7 was discharged from the hospital on 11/21/14. Further review of the medical record revealed no documented evidence of a discharge summary.


5. Patient #9: Review of the medical record revealed that Patient #9 was a hospice patient with the diagnosis of Colon Cancer. Patient #9 was discharged from the hospital on 12/01/14. Further review of the medical record revealed no documented evidence of a discharge summary.


6. Patient #3: Review of the medical record revealed that Patient #3 was a hospice patient with the diagnosis of Breast Cancer. Patient #3 was discharged from the hospital on 12/04/14. Further review of the medical record revealed no documented evidence of a discharge summary.


In an interview on 01/07/15, at 2:31 p.m., S3HIM confirmed the hospice patients medical records did not contain evidence of a discharge summary. S3HIM indicated the hospice patients' medical records from the main campus, (130 hospice patients out of 142 total patients at the main campus since 01/01/14), were not monitored because hospice patients were not admitted to the hospital.



Review of the hospital's agreement with the hospice providers revealed that the "Hospital will provide inpatient acute care services that are palliative in nature to control pain and manage symptoms of terminal illness, including, but not limited to, room and board, treatments, medications on the approved formulary, nursing services on a 24-hour per day, dietary, housekeeping, recreational and religious activities, ancillary and oxygen services, standard medical equipment, and disposable medical supplies." Further, it required that "All Hospice inpatient admissions to Hospital shall be authorized by the Hospice Medical Director and Hospice Designee, and admitted by an attending physician that is a member of the hospital's medical staff."

Based on records review and interviews, the hospital's infection control officer failed to ensure the implementation of a system for identifying, reporting, investigating, and controlling infections and communicable diseases of all patients being cared for in the hospital. This is evidenced by not collecting and including infection control data for 130 hospice patients out of a total of 142 patients at the main campus since 1/01/14.


Findings:


Review of the document titled Hospital Infection Control Manual, Number: 1.1, revealed in part:

I. Policy: The administration and staff of this facility recognize their responsibility to maintain an effective hospital-wide Infection Control program. The purpose of this program is to provide an environment safe from infection for patient, staff and visitors.


Review of a list of patients that had been cared for at the main campus of the hospital from 1/1/14 to 1/6/15 revealed there had been 12 long term acute patients and 130 hospice patients.


Review of the Quality Improvement data for the Hospital with S2Quality on 1/6/14, at 9:52 a.m., revealed no infection control data being collected for the hospice patients being cared for in the hospital.


In an interview on 1/7/15, at 4:50 p.m., with S2Quality, she said she collected data for infection control for quality assurance. S2Quality verified the majority of patients at the hospital main campus were hospice patients being cared for by the hospital staff. S2Quality said the hospice patients had not actually been admitted to the hospital, so no data was being collected, analyzed or trended for the hospice patients. S2Quality also verified the hospital did not look at hospital acquired infections, catheter infections or proper use of personal protective equipment for the hospice patients. S2Quality said hospice was contracted so the individual hospice companies should be looking at infection control practices not the hospital. S2Quality said the hospice patients were not patients of the hospital.