HospitalInspections.org

Based on interviews, record reviews and observation the hospital failed to meet the Condition of Participation for nursing services as evidenced by:
1) Nurses administering Propofol without clarifying an incomplete physician's order and titrating the Propofol dosage without documenting a sedation scale for 2 (#3, #8) of 30 patients reviewed. (see findings in tag A0395)
2) Nurses administering Levophed without clarifying an incomplete physician's order for 3 (#3, #8, #22) of 30 patients reviewed. (see findings in tag A0395)
3) Failing to have documented nursing competencies specific to Propofol for 3 (S2DON, S5RN, S6RN) of 3 Nursing Personnel records reviewed for competencies. (see findings in tag A0395)
4) Failing to have policies or protocols for titration of Propofol or Levophed. (see findings in tag A0395)

Based on observation, interview and record review, 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 determine which physicians had medical records which were incomplete greater than 30 days after the patient was discharged. The hospital also failed to suspend physician privileges as per Hospital Policy and Medical Staff Rules and Regulations for 21 physicians with delinquent medical records greater than 60 days after discharge and 59 physicians with delinquent medical records greater than 90 days after discharge. (See findings in Tag A-0438)

2) Failing to ensure that patients' discharge medical records dating back to 2011 were stored in a manner to protect them from water damage in the event that the sprinkler system was activated as evidenced by hundreds of paper medical records being stored on open shelving in a sprinklered room. (See findings in Tag A-0438)

3) Failing to employ adequately trained personnel to ensure prompt completion of medical records as evidenced by 1 (S10MedicalRecords) of 1 full time employee in the Medical Records Department not having education, degree or certification in Medical Records Management. The hospital also failed to provide adequate direction of the department as evidenced by the consultant (S11DirMedRecords) listed by the hospital as the Director of Medical Records only making 2 site visits in 6 months and failing to recognize deficient practice in the Medical Records Department. This deficient practice resulted in the inability to accurately track delinquent medical records. (See findings in Tag A-0432)

Based on record reviews and interviews the hospital failed to ensure contracted dialysis services were provided in a safe and effective manner for 2 of 2 sampled hemodialysis patients (#1 and #6) reviewed in a total of 30 sampled patients.
Findings:

1. Patient #1:

Review of the medical record revealed the patient was a 79 year-old gentleman admitted to the hospital on 11/22/13. The patient had the diagnoses of renal failure, diabetes mellitus, dementia, and hypertension.

Review of the Physician Orders revealed an order dated 11/25/13 for hemodialysis Monday, Wednesday and Friday with a 3 K (potassium) bath.

Review of the Patient Treatment Record-Acute Treatment record dated 11/23/13 revealed the patient's post hemodialysis treatment weight and respirations were not recorded.

Review of the Patient Treatment Record-Acute Treatment record dated 11/25/13 revealed the patient's pre and post hemodialysis treatment weights and post temperature were not recorded.

Review of the Patient Treatment Record-Acute Treatment record dated 11/27/13 revealed the patient's pre and post hemodialysis treatment weights were not recorded.

Review of the Patient Treatment Record-Acute Treatment record dated 11/29/13 revealed the patient's pre and post hemodialysis treatment weights and post respirations were not recorded.

Review of the Patient Treatment Record-Acute Treatment record dated 12/02/13 revealed the patient's pre and post hemodialysis treatment weights and post respirations were not recorded. Further review revealed the patient received dialysis treatment with a 2 K bath. The physician order in the medical record was for a 3 K bath.

2. Patient #6:

Review of the medical record revealed the patient was a 54 year-old gentleman admitted to the hospital on 11/08/13. The patient had the diagnoses of end stage renal disease, chronic respiratory failure, and diabetes mellitus.

Review of the Physician Orders revealed an order dated 11/09/13 for hemodialysis Tuesday, Thursday, and Saturday with a 2 K bath.

Review of the Patient Treatment Record-Acute Treatment record dated 11/12/13 revealed the patient's pre and post hemodialysis treatment weights and post respirations were not recorded.

Review of the Patient Treatment Record-Acute Treatment record dated 11/16/13 revealed the patient's pre and post hemodialysis treatment weights, post treatment blood pressure, pulse and respirations were not recorded. Further review revealed the patient received dialysis treatment with a 3 K bath. The physician order in the medical record was for a 2 K bath.

Review of the Patient Treatment Record-Acute Treatment record dated 11/19/13 revealed the patient's post hemodialysis treatment weight and post respirations were not recorded.

Review of the Patient Treatment Record-Acute Treatment record dated 11/21/13 revealed the patient's pre and post hemodialysis treatment weights were not recorded.

Review of the Patient Treatment Record-Acute Treatment record dated 11/23/13 revealed the patient's pre and post hemodialysis treatment weights were not recorded.

Review of the Patient Treatment Record-Acute Treatment record dated 11/26/13 revealed the patient's post hemodialysis treatment weight and post respirations were not recorded.

Review of the Patient Treatment Record-Acute Treatment record dated 11/27/13 revealed the patient's pre and post hemodialysis treatment weights were not recorded.

In an interview on 12/02/13 at 12:47 p.m., S2DON indicated the hospital had a contract with a local dialysis company to provide dialysis services. S2DON indicated he would contact someone from the dialysis company to discuss the issues identified and for their policies and procedures related to the identified issues.

Review of the (name of local dialysis company) Patient Evaluation Pre Treatment in the company's Inpatient Services policies and procedures revealed, in part: Data Collection. Follow the steps below for obtaining pretreatment evaluation: Step 1. Obtain the patient's weight prior to treatment and document on the inpatient treatment record. Weight gains often represent patient's current volume status and aids in determining treatment fluid removal goals. 2. Obtain vital signs (blood pressure, pulse, respirations and temperature) and record results on the inpatient treatment record. Evaluation of vital signs is the first step in determining the stability of the patient.

Review of the (name of local dialysis company) Evaluating the Patient Post Treatment in (name of the local dialysis company) Inpatient Services policies and procedures revealed, in part: Procedure: Follow the steps below to evaluate the patient post dialysis treatment: Step 3. Obtain and document the patient's respirations, noting rate and quality. Compare to the pre-dialysis rate. 4. Obtain and document the patient's temperature. 9. Weigh the patient and compare to pretreatment weight. Document results on the treatment record. The purpose is to evaluate if the patient obtained the calculated volume removal goal.

In an interview on 12/03/13 at 9:53 a.m., S4RNDialysis indicated patients' weights and vital signs should be recorded pre and post dialysis. S4RNDialysis indicated if a patient was to be dialyzed on a different potassium bath than ordered by the physician, the physician should be notified and a new order should be written.

In an interview on 12/4/13 at 1:00 p.m. with S1CEO, he stated he was responsible for contracted services. He stated he was not aware there was a problem with dialysis services.

Based on record review and interview the hospital failed to ensure the Quality Assurance Performance Improvement (QAPI) program measured , analyzed, and tracked quality indicators and other aspects of performance that assessed processes of care, hospital service and operations by failing to include Medical Records (since 7/2013), Housekeeping, Lab, and Dialysis in their QAPI program.

Findings:

Review of the QAPI program binder revealed Medical Records (since 7/2013), Housekeeping, Lab, and Dialysis had not been included in the hospital's QAPI program.

In an interview on 12/4/13 at 1:20 p.m. with S3DirQuality, he said he was Director of QAPI. He confirmed Medical Records, Housekeeping, Lab, and Dialysis was not included in the QAPI program,but they should have been.

30364


Based on interview, record review, and observation the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as evidenced by:
1) administering Propofol without clarifying an incomplete physician's order and titrating the Propofol dosage without documenting a sedation scale for 2 (#3, #8) of 30 patients reviewed.
2) administering Levophed without clarifying an incomplete physician's order for 3 (#3, #8, #22) of 30 patients reviewed.
3) failing to have documented nursing competencies specific to Propofol for 3 (S2DON, S5RN, S6RN) of 3 Nursing Personnel records reviewed for competencies.
4) failing to have policies or protocols for titration of Propofol or Levophed.
5) failing to ensure insulin was administered per the sliding scale as ordered by the physician for 1 (#2) of 5 (#1, #2, #6, #8, #10) records reviewed for insulin administration.
Findings:
Review of the Vasoactive Infusion Policy stated in part:
Maintain: to continue an infusion at a fixed, physician determined rate. The rate may be changed by new physician orders, but is not up to the discretion of the nurse.

1) Administering Propofol without clarifying an incomplete physician's order and titrating the Propofol dosage without documenting a sedation scale.
Patient #3 (current patient)
Review of the Physician Order Sheet for Patient #3 revealed the following orders:
12/1/13 5:23 p.m. Propofol drip for light sedation.
Further review of the medical record revealed no rate, no clarification of the order, no sedation scale to be used and no titrating parameters.
Review of the nurse's notes for Patient #3 dated 12/1/13 revealed Diprovan (Propofol) documented as having been started at 5:00 p.m. at a rate of 5 and increased to a rate of 10 at 5:30 p.m. No sedation scale was documented.
In an interview on 12/2/13 at 2:50 p.m. with S5RN, she said she was taking care of Patient #3. S5RN said the physician's order for the drip was incomplete and the nurses use the Richmond Agitation Sedation Scale (RASS) to begin the drip and wean the drip. S5RN said the hospital did not have a copy of the RAS scale on the unit or in the patient's chart. S5RN also said she had not been documenting the RAS scale but she was sure she would be after the survey.
In an interview on 12/2/13 at 3:10 p.m. with S2DON, he stated Patient #3's orders for Propofol did not have a dose or rate, but should have. S2DON said the hospital used the RAS score to titrate drips for patients on sedation, but now went to Ramsay scale. S2DON said Patient #3 did not have a specific scale ordered by the physician.S2DON also verified the nurses did not document a sedation scale in their notes for Patient #3.
Patient #8
Review of the Physician's Order for Patient #8 dated 11/14/13 revealed the following order at 1620: Diprovan Drip Titrate Ramsay 2-3.
Further review revealed no orders for a beginning dose and no clarification of the order by the nursing staff.
Review of the nurse's notes for Patient #8 from 11/14/13 through 11/19/13 revealed no documentation of the Ramsay scale.
In an interview on 12/2/13 at 3:14 p.m. with S2DON, he stated Patient #8's orders for Propofol did not have a dose or rate, but should have.

2) Administering Levophed without clarifying an incomplete physician's order.
Patient #3 (current patient)
Review of the Physician Order Sheet for Patient #3 revealed the following orders:
12/1/13 at 6:30 p.m. O.K. to start Levophed. Titrate to keep SBP>80.
Further review revealed no order for the beginning dosage, no titration parameters, no clarification of the order.
Review of the Nurse's Notes dated 12/1/13 for Patient #3 revealed Levophed was started at 9.4 at 7:00 p.m., decreased to 4.7 at 12:00 midnight, and discontinued at 2:00 a.m.
In an interview on 12/2/13 at 3:10 p.m. with S2DON, he stated Patient #3's order for Levophed did not have an initial dose or rate, but should have. S2DON said the hospital had a preprinted order sheet for Levophed, but it was not filled out for Patient #3.
Patient #8
Review of the Physician's Order for Patient #8 dated 11/15/13 revealed the following order at 0015: Levophed to maintain SBP >85
Further review revealed no orders for a beginning dose or clarification of the incomplete order.
In an interview on 12/2/13 at 3:16 p.m. with S2DON, he stated Patient #8's order for Levophed did not have an initial dose or rate, but should have.
Patient #22

Review of a Physician Order for Patient #22 dated 11/29/13 at 00:05 revealed an order to start Levophed to keep systolic blood pressure greater than 90.
Further review revealed no order for an initial dose or rate.

Review of the Daily Nursing Record dated 11/28/13 - 11/29/13 revealed at 00:15 the patient was started on a Levophed drip at 3mcg/min.

3) Failing to have documented nursing competencies specific to Propofol.
Review or the medical record for Patient #3 revealed S5RN administered Propofol on 12/2/13.
Review of the Personnel file for S5RN revealed no documented competencies for Propofol.
Review of the Medical Record for Patient #3 revealed S6RN documented the telephone order for Propofol on 12/1/13.
Review of the Personnel file for S6RN revealed no documented competencies for Propofol.
Review of the Personnel file for S2DON revealed no competencies for Propofol.
In an interview on 12/4/13 at 2:00 p.m. with S2DON he verified Propofol was not specifically included in staff training on moderate sedation.

4) Failing to have policies or protocols for titration of Propofol or Levophed.
Review of the Hospital Polices revealed no Policies or Protocols for Propofol or Levophed administration.
In an interview on 12/2/13 at 3:10 p.m. with S2DON, he stated neither Propofol nor Levophed had a protocol, only the general policy for sedation which did not have titration parameters or a beginning dose for Propofol. He said the hospital used the RAS score to titrate drips for patients on sedation, but now went to RAMSAY scale because it was the one Hospital "B" used. S2DON verified neither Patient #3 or #8 had sedation scales documented in the medical records.

5) failing to ensure insulin was administered per the sliding scale as ordered by the physician for 1 (#2) of 5 (#1, #2, #6, #8, #10) records reviewed for insulin administration.
Patient #2
Patient #2 was a 75-year-old female admitted to the hospital on 11/26/13 with the diagnoses of Stage 4 Sacral Decubitus Ulcer, Diabetes Mellitus (Type II), Malnutrition, Renal Failure, Dementia, Urinary Tract Infection, and a history of a Cerebral Vascular Accident.
Review of Patient #2's medical record revealed insulin sliding scale physician orders for Patient #2 dated 11/26/13 at 3:10 p.m. as follows:
Accuchecks are to be performed every 6 hours; rapid acting insulin is to be administered according to the sliding scale: For glucose levels of: 150-199 give 1 unit of insulin, 200-249, give 2 units of insulin; 250-299, give 3 units of insulin; 300-349 give 4 units of insulin; 350-400 give 5 units of insulin, and over 401 give 6 units of insulin.
Review of the medical record for Patient #2 revealed the nurse's notes dated 11/27/13 at 6:00 a.m. indicated a blood glucose reading of 178 by S20RN (identified by S20DON). Further review of the medical record revealed no evidence of the ordered amount of insulin (1 unit) being administered to Patient #2.
In an interview on 12/02/13 at 4:00 p.m., S2DON indicated he reviewed Patient #2's medical record and verified there was no documentation in Patient #2's medical record to indicate the insulin for the 11/27/13 6:00 a.m. glucose value of 178 had been administered to Patient #2.
In a telephone interview on 12/04/13 at 10:20 a.m., S20RN indicated that he could not recall the particular incident in question as stated above. S20RN further indicated he could not remember if he had administered the insulin to Patient #2.
Further review of the medical record for Patient #2 revealed the nurse's notes dated 11/29/13 at 4:00 p.m. indicated a blood glucose reading of 162 by S21LPN (identified by S20DON). Further review of the medical record revealed no evidence of the ordered amount of insulin (1 unit) had been administered to Patient #2.
In an interview on 12/02/13 at 4:00 p.m., S2DON indicated he reviewed Patient #2's medical record and verified there was no documentation in Patient #2's medical record to indicate the insulin for the 11/29/13 4:00 p.m. glucose value of 162 had been administered to Patient #2.


31048

Based on interview and record review the hospital failed to ensure the nursing staff developed a comprehensive nursing care plan for each patient by failing to address all identified problems for 4 (#2, #3, #7, #10) of 10 (#1- #10) patients reviewed for care planning. Findings:

Review of the Hospital Policy titled Plan of Care-Nursing, Policy #: CSM 140, stated in part:
An individualized nursing plan of care will be initiated by an RN on admission for every inpatient and will be developed into a multidisciplinary plan of care within 7 days of admission.
2. The RN will initiate an individualized plan of care, taking into consideration the patient's physical, psychosocial, and mental needs.
4. The nursing plan of care will be reviewed by nursing every shift, the plan of care will be updated as the patient's meds indicate and at discharge.
The plan of care will be documented in the medical record.

Patient #2
Patient #2 was a 75-year-old female admitted to the hospital on 11/26/13 with the diagnoses of Stage 4 Sacral Decubitus Ulcer, Diabetes Mellitus (Type II), Malnutrition, Renal Failure, Dementia, Urinary Tract Infection, and a Cerebral Vascular Accident.
Review of Patient #2's medical record revealed a physician's order dated 11/26/13 at 4:35 p.m. for respiratory therapy services to monitor Patient #2's oxygen saturation level twice per day; to provide 3 liters of oxygen via nasal cannula and to titrate oxygen to keep oxygen saturation levels greater than 90 percent. Further review revealed Patient #2 had a Stage 4 (deep bed sore that exposes bone) decubitus ulcer (bed sore) to her sacral (buttock area).
Review of Patient #2's "Interdisciplinary Plan of Care" revealed the following problems were not identified and addressed for Patient #2: (a) alteration in respiratory function; (b) alteration in comfort related to pain.
In an interview on 12/02/13 at 3:45 p.m., S2DON indicated he reviewed Patient #2's medical record and verified that the above referenced problems were not identified and addressed on Patient #2's Interdisciplinary Plan of Care.
Patient #3
Review of Patient #3's medical record revealed an admission date of 10/31/13 with diagnoses that included the following: Respiratory Distress, Impaired Cardiovascular Function (Inadequate Tissue Perfusion).

Review of Patient #3's medical record revealed the following MD (Medical Doctor)orders:
Restraint Orders dated 11/8/13-12/1/13.
12/1/13 18:30 O.K. (okay) to start Levophed. Titrate to keep Systolic Blood Pressure > (greater than) 80.
12/1/13 17:23 Propofol drip for light sedation
12/1/13 16:50 Please intubate patient and place on AC 12/500/+5/100% Intubation order: Obtain ABG's (Arterial Blood Gases) after 1 hour; Q a.m. ABG's. Q 2 hour 2.5 Albuterol.

Review of Patient #3's current care plan revealed no entries identifying restraint use, Intubation, and continuous infusion drips (Levophed and Propofol) as identified problems.

In an interview on 12/2/13 at 4:25 p.m. with S2DON, he confirmed Patient #3's care plan was incomplete. He verified the care plan had not addressed continuous infusion drips (Propofol and Levophed), restraint use, or Intubation.
Patient #7
Patient #7 was a 43-year-old male admitted to the hospital on 11/22/13 at 7:43 p.m. with the diagnoses of Psoas Muscle Abscess (Paraspinal), Empyema without Fistula, Obesity, Anemia, Hypertension, Constipation, and Left Lung Chest Tube.
Review of the Nursing Admission Assessment completed on 11/22/13 revealed Patient #7 had two areas on his body with skin tears; a chest tube inserted into his lung; and two drains inserted into his left flank (back) area.
Review of Patient #7's "Interdisciplinary Plan of Care" revealed the following problem was not identified and addressed for Patient #7: alteration in skin integrity.
In an interview on 12/03/13 at 2:50 p.m., S2DON indicated he reviewed Patient #7's medical record and verified that the above referenced problem was not identified and
addressed on Patient #7's Interdisciplinary Plan of Care.
Patient #10
Patient #10 was an 87-year-old female admitted to the hospital on 11/30/13 at 6:55 p.m. with the diagnoses of Infected Decubitus, Anemia, Dementia, Psychosis, Hypertension, Diabetes, Depression, High Cholesterol, Reflux Esophagitis, Recurrent Urinary Tract Infection, and Congestive Heart Failure.
Review of the admit physician's order dated 12/01/13 for Patient #10 revealed admitting diagnoses as anemia and multiple Decubitus; and a medical history of congestive heart failure, hypertension, end-stage renal disease, diabetes mellitus, high cholesterol, reflux, anemia, dementia, depression, and psychosis. Further review of the physician's orders revealed an order for respiratory care services.
Review of Patient #10's Nursing Admission Assessment completed on 11/30/13 revealed Patient #10 was assessed as having a "Chief Complaint/History of Present Illness" as anemia, and multiple decubitus, and a past medical history of heart disease, hypertension, kidney/bladder issues, anemia, diabetes, reflux, dementia, depression, psychosis, and recurrent urinary tract infections. Further review revealed Patient #10 was assessed as unable to communicate, hard of hearing, had a feeding tube, and an indwelling urinary drainage catheter.
Review of Patient #10's "Interdisciplinary Plan of Care" revealed the only problem identified and addressed for Patient #10 was "Alteration in Cardiovascular: D. Hypertension."
In an interview on 12/03/13 at 2:40 p.m., S2DON indicated he reviewed the medical record for Patient #10 and verified the only problem identified and addressed for Patient #10 on the Interdisciplinary Plan of Care was that for hypertension.


31048

Based on interviews and record review, the hospital failed to employ adequately trained personnel to ensure prompt completion of medical records as evidenced by 1 (S10MedicalRecords) of 1 full time employee in the Medical Records Department not having education, degree or certification in Medical Records Management. The hospital also failed to provide adequate direction of the department as evidenced by the consultant (S11DirMedRecords) listed by the hospital as the Director of Medical Records only making 2 site visits in 6 months and failing to recognize deficient practice in the Medical Records Department. This deficient practice resulted in the inability to accurately track delinquent medical records.
Findings:

Review on 12/2/13 of the contract titled Medical Records Support Agreement between the Hospital and S11DirMedRecords revealed it had been signed on 12/2/13.
Review of email communication provided by the hospital between S10MedicalRecords and S11DirMedRecords revealed the following in part:
10/11/13 from S10MedicalRecords to S11DirMedRecords: Hey S11DirMedRecords, I'm completely confused as to what I need to complete. I have no clue on what form or system or method that (the previous employee) used. This will be my 1st chart audit ...I really need help! Do you audit every chart?
Reply: I audit 10 charts from every month. I forgot to send a completed audit form yesterday so I attached one today.

In an interview on 12/2/13 at 12:40 with S10MedicalRecords, she said the Physician delinquency list had not been updated since the last week in July 2013. S10MedicalRecords said she had no record of how many discharged patients' records were delinquent. She said neither she nor the hospital had sent delinquency letters or suspension of privileges notices to physicians. She said she could not verify the oldest delinquent record. She also said delinquencies were not tracked for Quality Assurance (QA) purposes. S10MedicalRecords said she had no degree or certification in Medical Record Management and she was the only employee in the office with no supervisors or directors.

In an interview on 12/2/13 at 4:00 p.m. with S3DirQuality, he stated the contract with S11DirMedRecords as the HIM (Health Information Manager) was signed today. He also verified delinquent records had not been discussed in the MEC meetings since July 2013 and the CEO, Medical Director and CCO had not been made aware of the number of delinquent records per physician as per the policy for delinquent medical records. S3DirQuality said the medical records department was short staffed. S3DirQuality also verified all of the discharge medical records should be audited monthly, not only 10 as stated in the email from S11DirMedRecords.

In an interview on 12/3/13 at 10:15 a.m. with S11DirMedicalRecords, she stated she was contracted as the director of the medical records department and was ultimately responsible for the department. S11DirMedicalRecords said she had been to the medical records department twice since 7/13/13. S11DirMedicalRecords said she thought S10MedicalRecords was keeping track of delinquencies. S11DirMedicalRecords said she was not aware the delinquencies had to be reported to the CEO, CCO, and Medical Director. S11DirMedicalRecords said the hospital had to play catch up because the previous owners left it in such a mess. S11DirMedicalRecords verified she had been assisting with medical records, but had only signed a contract on 12/2/13 after the survey was initiated..S11DirMedicalRecords also said she was unaware S10MedicalRecords did not know she was her director.

In an interview on 12/4/13 at 1:00 p.m. with S1CEO, he stated he had recognized a problem with the Medical Record Department when the hospital took over control of the former hospital in July 2013. S1CEO stated the medical records department needed at least one other person to get caught up with delinquent charts and credentialing because they were short staffed. When asked what he has done to rectify the situation, he said he had run an ad this week for another staff member.

In an interview on 12/4/13 at 1:30 p.m. with S7MedicalDirector, she said the Medical Record Department had problems with such a large turnover in ownership of the hospital. S7MedicalDirector said the department maybe has not had the emphasis as it should have. S7MedicalDirector said she believed the Medical Record Department was short staffed.

Based on record reviews, and interviews, the hospital failed to:
1) ensure a system was in place to determine which physicians had medical records which were incomplete greater than 30 days after the patient was discharged. The hospital also failed to suspend physician privileges as per Hospital Policy and Medical Staff Rules and Regulations for 21 physicians with delinquent medical records greater than 60 days after discharge and 59 physicians with delinquent medical records greater than 90 days after discharge
2) ensure that patients' discharge medical records dating back to 2011 were stored in a manner to protect them from water damage in the event that the sprinkler system was activated as evidenced by hundreds of paper medical records being stored on open shelving in a sprinklered room.

Findings:

1) ensure a system was in place to determine which physicians had medical records which were incomplete greater than 30 days after the patient was discharged.

Review of the Hospital Policy titled Delinquent Medical Records, Policy HIM07, Origin Date 12/2012 revealed in part:
Policy: Patient medical records will be considered complete when required documentation is complete and authenticated as required.
Procedure:
1. All physicians are responsible for completing their medical records within 30 days of a patient's discharge. Medical records are considered delinquent when not completed within this timeframe.
2. The CEO, CCO, and Medical Director will be given a list of delinquent physicians and records at least monthly.
3. The following should be reported at each MEC meeting:
a. Number of delinquent records by physician;
b. Total # of delinquent records;
c. Total number of discharges per month;
d. % of b and c that were delinquent.
If the record is still incomplete 30 days after discharge action will be taken as outlined in the Hospital Medical Staff Rules and Regulations.

Review of the Hospital Medical Staff Rules and Regulations dated March 14, 2013 stated in part:
9. Medical records that are incomplete thirty (30) days after patient discharge are considered delinquent. When a physician has a medical record thirty (30) days or greater from the date of discharge, the physician will be notified of delinquent medical records. The physician will be sent a letter requiring completion of the delinquent charts before sixty (60) days delinquent. If the physician has any medical records in a delinquent status at sixty (60) days post discharge then the physician's privileges will be automatically suspended. When delinquent medical records reach 90 days incomplete, then the physician's privileges will be considered voluntarily relinquished. Notice of this action will be submitted to the National Practitioner's Data Bank and the Board of Medical Examiners for the state in which Hospital is located.

In an interview on 12/2/13 at 12:40 with S10MedicalRecords, she said the Physician delinquency list had not been updated since the last week in July 2013. S10MedicalRecords said she had no record of how many discharged patients' records were delinquent. She said neither she nor the hospital had sent delinquency letters or suspension of privileges notices to physicians. She said she could not verify the oldest delinquent record. She also said delinquencies were not tracked for Quality Assurance (QA) purposes. S10MedicalRecords said she had no degree or certification in Medical Record Management and she was the only employee in the office with no supervisors or directors.

In an interview on 12/2/13 at 4:00 p.m. with S3DirQuality, he stated the contract with S11DirMedRecords as the HIM (Health Information Manager) was signed today. He also verified delinquent records had not been discussed in the MEC meetings since July 2013 and the CEO, Medical Director and CCO had not been made aware of the number of delinquent records per physician as per the policy for delinquent medical records.

In an interview on 12/3/13 at 9:15 a.m. with S3DirQuality, he said the Medical Staff Rules and Regulations stated a physician shall be suspended if they have records greater than 60 days delinquent. S3DirQuality also said no physicians have been suspended although there were medical records delinquent greater than 60 days.

In an interview on 12/3/13 at 10:15 a.m. with S11DirMedicalRecords, she stated she was contracted as the director of the medical records department and was ultimately responsible for the department. S11DirMedicalRecords said she had been to the medical records department twice since 7/13/13. S11DirMedicalRecords said she thought S10MedicalRecords was keeping track of delinquencies. S11DirMedicalRecords said she was not aware the delinquencies had to be reported to the CEO, CCO, and Medical Director. S11DirMedicalRecords said the hospital had to play catch up because the previous owners left it in such a mess.

In an interview on 12/4/13 at 10:00 a.m. with S2DON, he provided a list of delinquent medical records compiled by S10MedicalRecords on 12/3/13 as per request of the survey team. The list revealed the following:
64 Physicians with Delinquent Medical Records
21 Physicians with delinquent medical records greater than 60 days
45 Medical Records delinquent greater than 60 days
59 Physicians with delinquent medical records greater than 90 days
68 Medical records delinquent greater than 90 days
Further review revealed the following:
S14Physician had 5 delinquent medical records greater than 60 days and 17 greater than 90 days.
S15Physician had 5 delinquent medical records greater than 60 days and 13 greater than 90 days.
S7MedicalDirector had 3 delinquent medical records greater than 60 days and 9 greater than 90 days.
S16Physician had 4 delinquent medical records greater than 60 days and 4 greater than 90 days with the oldest dated 12/29/12.
S17Physician had 3 delinquent medical records greater than 60 days and 6 greater than 90 days with the oldest dated 3/23/13.

In an interview on 12/4/13 at 1:00 p.m. with S1CEO, he stated he had recognized a problem with the Medical Record Department when the hospital took over control of the former hospital in July 2013. S1CEO stated the medical records department needed at least one other person to get caught up with delinquent charts and credentialing because they were short staffed. When asked what he has done to rectify the situation, he said he had run an ad this week for another staff member. S1CEO also verified the contract with S11DirMedicalRecords was signed on 12/3/13. S1CEO also verified no suspension of privileges had been enforced on physicians although the Medical Staff Rules and Regulations required removal of privileges for delinquent medical records.

In an interview on 12/4/13 at 1:30 p.m. with S7MedicalDirector, she said the medical record delinquencies maybe has not had the emphasis it should have. S7MedicalDirector said she knew there were a large number of medical record delinquencies, but she had no one on the staff have their privileges suspended or revoked as per the Medical Staff Rules and Regulations.

2) ensure that patients' discharge medical records dating back to 2011 were stored in a manner to protect them from water damage in the event that the sprinkler system was activated.

An observation was made of the medical record room on 12/2/13 at 12:40 p.m. with S10MedicalRecords. Two rolling carts contained in the center of the room contained 38 medical records. Half of the 14 open shelving units containing paper records were approximately 4 feet wide and 7 shelves high. The other 7 shelves were approximately 6 feet wide and 7 shelves high.

In an interview on 12/2/13 at 1:00 p.m. with S10MedicalRecords, she verified the paper medical records were on open shelving and not protected from water damage if the sprinkler system was activated. S10MedicalRecords stated she could not determine how many records were stored in the room, but she approximated several hundred. S10MedicalRecords said the records were discharge records dating back to 2011 and there were no electronic copies of the records.

Based on interview and record review, the hospital failed to have a system in place which allowed for timely retrieval of patient medical records by diagnosis and procedure in order to support medical are evaluation studies.

Findings:

Review of the hospital policy titled Health Information Management, Policy #: HIM-403, revealed the following, in part:
Policy: The facility's ability to retrieve pertinent information shall be assured by the use of an acceptable coding system for disease and operation classifications, and by the use of an indexing system to facilitate the acquisition of medical statistical information.
Procedure: This information is available for performance improvement activities, marketing and planning for the hospital and for physician reference.

In an interview on 12/2/13 at 12:40 p.m. with S10MedicalRecords, she stated she was unable to access and print a list of patients by diagnosis and/or procedure. S10MedicalRecords said she would have to pull individual paper records and look for diagnosis because she had no computer program to look up records by diagnosis. S10MedicalRecords said she had no supervisor and that she was the only staff member employed in the Medical Record Department. S10MedicalRecords also said she had no degree or certification related to medical record management.

In an interview on 12/3/13 at 10:15 a.m. with S11DirMedRecords, she stated she was contracted as the Director of the Medical Record Department. She also said she was ultimately responsible for the Medical Record Department. When told S10MedicalRecords stated she was unable to retrieve medical records based on diagnosis or procedure, S11DirMedicalRecords said she was not aware of that.

Based on record review and interview the hospital failed to ensure that medical record entries were not authenticated, dated and timed, in written or electronic form, by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures as evidenced by:
1) Failing to ensure that medical record entries were authenticated for 1 (#7) of 20 (#1-#20) records reviewed for authentication out of 30 records reviewed.
2) Failing to ensure that orders were dated and timed for 3 (#3, #8, #10) of 20 (#1-#20) records reviewed for date and time.

Findings:
1) Failing to ensure that medical record entries were authenticated

Patient #7
Patient #7 is a 43-year-old male admitted to the hospital on 11/22/13 with the diagnoses of Psoas Muscle Abscess (Paraspinal), Empyema without Fistula, Obesity, Anemia, Hypertension, Constipation, Left Lung Chest Tube, and Gastrointestinal Disorders.
Review of the medical record revealed the History and Physical (H&P) for Patient #7 was not authenticated, dated, or timed.
In an interview on 12/03/13 at 2:50 p.m., S2DON verified and confirmed the H&P was not authenticated, dated, or timed.
2) Failing to ensure that orders were dated and/or timed.

Patient #3

Review of Patient #3's medical record revealed the following orders not dated and timed by the physician (dated by nursing staff):
Orders signed, but not dated and timed:
Restraint Orders: 11/12/13, 11/14/13, 11/17/13, 11/18/13, 11/19/13, 11/21/13, 11/22/13, 11/23/13, and 11/25/13.
Physician ' s telephone orders: 11/20/13, 1600: Change Levaquin to 250 milligrams (mg) Intravenous (IV) every (q) day per renal function
11/27/13, no time: Discontinue (D/C) NPH Insulin in a.m.; Novalin 70/30 20 units subcutaneous (sub q) q a.m.; Free T4, Free T3 next Monday.
12/01/13, 1723: Propofol drip for light sedation.

Restraint Orders signed and dated, but not timed: 11/8/13, 11/10/13, 11/11/13, 11/13/13, 11/15/13, and 11/19/13.

Patient #8

Review of Patient #8's medical record revealed the following orders not dated and timed by the physician (dated by nursing staff):
Orders signed, but not dated and timed:
Restraint Orders: 11/13/13, 11/14/13, 11/16/13, 11/18/13
Physician's telephone orders: 11/15/13 0015: Titrate Levophed to maintain systolic blood pressure greater than 85.
11/16/13, 9:15 p.m., Match and Cross match 2 units of blood; Transfuse 2 units of blood; CBC, Basic Metabolic Profile (BMP) in a.m.
11/17/13 10:50 a.m.: CMP in a.m.
11/18/13 15:30 p.m.: Change Lantus to 15 units sub q every (q) a.m. and 15units q p.m.
11/19/13 9:50 a.m.: CBC, CMP in a.m.
11/20/13 9:30 p.m.: Discontinue Amlodipine; Change Lasix to 80 mg IV push (IVP) q 12 hours; CBC, CMP in a.m.

In an interview on 12/3/13 at 1:35 p.m. with S2DON, he verified that the above mentioned physician's orders for Patient #3 and Patient #8 were not dated and timed.

Patient #10
Patient #10 is an 87-year-old female admitted to the hospital on 11/30/2013 with the diagnoses of Infected Decubitus, Anemia, Dementia, Psychosis, Hypertension, Diabetes, Depression, High Cholesterol, Reflux Esophagitis, Recurrent Urinary Tract Infection, and Congestive Heart Failure.
Review of the medical record revealed a physician's order dated 12/03/13 for: blood cultures times two sites; urine analysis with culture and sensitivity; start Zosyn 3.375 grams intravenous piggyback every 8 hours; consult with infectious disease physician; discontinue Rocephin; complete blood count, comprehensive metabolic panel, partial albumin in am; bilateral sequential compression device for lower extremities for deep vein thrombosis prophylaxis. Further review revealed the order was not timed.
Review of the medical record revealed a physician's order dated 12/02/13 for: free T3 thyroid; preoxidized antibiotic draw tomorrow; stat Synthroid 0.05 mg via feeding tube every day. Further review revealed the order was not timed.
In a face-to-face interview on 12/03/13 at 2:40 p.m., S2DON verified and confirmed the above referenced physician's order was not timed.


31048

Based on interview and record review the hospital failed to ensure patient medical records had an updated History and Physical within 24 hours after admission for 6 (#2, #7, #10, #13, #14, #16) of 30 patients reviewed.
Findings:
Review of the hospital Medical Staff Rules and Regulations, MEC (Medical Executive Committee) approved: March 14, 2013; Board approved: March 14, 2013 revealed the following, in part:
Medical Records and Orders: 2. a. A physician shall be responsible for a complete Admission History and Physical examination, which shall be recorded within 24 hours after admission. If a complete history has been recorded and a physical examination performed within 30 days prior to the patient's admission to the hospital, a reasonable, durable, legible copy of such reports may be used in the patient's Hospital medical record in lieu of the Admission History and Physical, provided the reports were recorded by the attending or admitting physician. In such instances, an interval Admission note that includes all additions to the history and any subsequent changes in the physical findings must also be recorded.
Patient #2
Patient #2 was a 75-year-old female admitted to the hospital on 11/26/13 with the diagnoses of Stage 4 Sacral Decubitus Ulcer, Diabetes Mellitus (Type II), Malnutrition, Renal Failure, Dementia, Urinary Tract Infection, and a Cerebral Vascular Accident.
Review of Patient #2's medical record revealed no indication that a History and Physical (H&P) was completed at Louisiana Continuing Care Hospital. Documentation in the medical record revealed a H&P was completed on 11/26/13 at 1:30 p.m. which was prior to Patient #2's admission to Louisiana Continuing Care Hospital. Review of the "Physician's Orders for Admission for Transfer" revealed orders to admit Patient #2 to Louisiana Continuing Care Hospital on 11/26/13 at 4:25 p.m.
In an interview on 12/02/13 at 3:30 p.m., S2DON indicated Louisiana Continuing Care Hospital accepts H&Ps from Hospital "B" if the H&P is completed within 30 days of the patient's admission to Louisiana Continuing Care Hospital. S2DON indicated that for patients whose H&P is completed within 30 days prior to admission, an update to the H&P is to be performed and documented within 24 hours after admission to Louisiana Continuing Care Hospital. S2DON reviewed the medical record of Patient #2 and verified there was no update to the H&P within 24 hours after Patient #2's admission to Louisiana Continuing Care Hospital.
Patient #7
Patient #7 was a 43-year-old male admitted to the hospital on 11/22/13 at 7:43 p.m. with the diagnoses of Psoas Muscle Abscess (Paraspinal), Empyema without Fistula, Obesity, Anemia, Hypertension, Constipation, Left Lung Chest Tube, and gastrointestinal disorders.
Review of the medical record revealed a H&P dictated on 11/23/13 at 8:39 p.m. and transcribed on 11/24/13.
In an interview on 12/03/13 at 2:50 p.m., S2DON indicated he reviewed the medical record of Patient #7 and verified that the H&P had been placed on the medical record greater than 24 hours after Patient #7 was admitted to the Louisiana Continuing Care Hospital.
Patient #10
Patient #10 was an 87-year-old female admitted to the hospital on 11/30/13 at 6:55 p.m. with the diagnoses of Infected Decubitus, Anemia, Dementia, Psychosis, Hypertension, Diabetes, Depression, High Cholesterol, Reflux Esophagitis, Recurrent Urinary Tract Infection, and Congestive Heart Failure.
Review of Patient #10's medical record revealed no indication that a History and Physical (H&P) was completed at Louisiana Continuing Care Hospital. Documentation in the medical record revealed a H&P was completed on 11/30/13 at 12:53 p.m. which was prior to Patient #10's admission to Louisiana Continuing Care Hospital.
In an interview on 12/02/13 at 3:30 p.m., S2DON indicated Louisiana Continuing Care Hospital accepts History and Physicals (H&Ps) from Hospital "B" if the H&P is completed within 30 days of the patient's admission to Louisiana Continuing Care Hospital. S2DON indicated that for patients whose H&P is completed within 30 days prior to admission, an update to the H&P is to be performed and documented within 24 hours after admission to Louisiana Continuing Care Hospital. S2DON reviewed the medical record of Patient #10 and verified there was no update to the H&P within 24 hours after Patient #10's admission to Louisiana Continuing Care Hospital.
Patient#13

Review of Patient #13's medical record revealed an Admission date of: 11/8/13 at 18:40 and diagnoses that included the following: Pneumonitis, Acute Kidney Failure, Hypotension, Congestive Heart Failure.

Further review of Patient #13's medical record revealed a Discharge History and Physical from Hospital "B" dated 11/7/13, electronically signed on 11/8/13 at 4:22 p.m.

Review of Patient #13's medical record revealed an Addendum to History and Physical, dated: 11/11/13 and timed:10:00 a.m. The only documentation noted on the addendum was "dictated."

Patient #14

Review of the medical record revealed the patient was an 82 year-old female admitted to the hospital on 11/19/13. The patient had the diagnoses of sepsis, hypertension, and chronic kidney disease.

Review of the medical record revealed an Addendum to History & Physical that was dated 11/21/13 and not timed. The only documentation noted on the addendum was
"dictated."

In an interview with S7MD on 12/4/13 at 1:30 p.m., she confirmed updated patient History and Physical assessments should have been completed within 24 hours after admission.

Patient #16

Review of the medical record revealed the patient was a 39 year-old female admitted to the hospital on 11/15/13. The patient had the diagnoses of acute pancreatitis, acute respiratory failure, sepsis, depressive disorder, anxiety, and tracheostomy.

Review of the medical record revealed an incomplete Addendum to History & Physical that was dated 11/19 and not timed. The only documentation noted on the addendum was "dictated."


30364




31048

Based on interview and record review, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice as evidenced by the pharmacist failing to review all non-emergent medication orders before the first dose was dispensed for 1(#3) of 1(#3) patients reviewed for medication orders written after pharmacy working hours.
Findings:

Review of the Physician Order Sheet for Patient #3 revealed the following orders:
12/1/13 5:20 p.m. Solumedrol 40mg (milligrams) IV (intravenous) TID (three times a day).
12/1/13 5:23 p.m. Propofol drip for light sedation.

Review of the Pyxis (Medication Dispensing Machine) overrides by the nursing staff from 12/1/13 revealed Patient #3 had the following medications removed after pharmacy working hours:
5:28 p.m. - Propofol Injectable 10mg/ml (milliliters) 50ml emulsion
7:50 p.m. - Solu-Medrol 40mg Vial 40mg/ml

Review of the MAR (Medication Administration Record) for Patient #3 revealed the following:
Solumedrol 40mg IV TID was documented as having been given at 12/1/13 at 10:00 p.m.
Propofol drip for light sedation documented on 12/1/13 (no time entered)

Review of the nurse's notes dated 12/1/13 for Patient #3 revealed Diprovan (Propofol) was documented at 5:30 p.m. as infusing at 23 mcg/kg/min (micrograms/kilograms/minute).

In an interview on 11/2/13 at 12:15 p.m. with S9DirPharmacy, he said the pharmacy hours were 8:00 a.m. - 4:30 p.m. Monday through Friday and 8:00 a.m. - 12:00 p.m. on weekends and holidays. S9DirPharmacy said a pharmacist did not review first doses of medications before the first dose was administered after pharmacy working hours unless called by the staff with a question. S9DirPharmacy said if a medicine order was a first dose and written after pharmacy hours, a retrospective review was done when the pharmacy staff arrived the next morning. S9DirPharmacy said the charge nurse and a high acuity nurse could override the Pyxis and remove medications that had not been reviewed by the pharmacist. S9DirPharmacy verified the Solumedrol and Propofol ordered for Patient #3 on 12/1/13 were written after he had left for the day and he did not review the medications before the first doses were administered. S9DirPharmacy also verified the Propofol order was incomplete and should have been clarified because it did not contain a dosage.

Based on record review and interview the hospital failed to ensure the person designated as Infection Control Officer had acquired and documented specialized training in infection control practices. Findings:
Review of the Infection Control Program Manual revealed no documentation of specialized training in infection control practices for the designated Infection Control Officer.
In an interview on 12/04/13 at 3:05 p.m., S12LPN (Licensed Practical Nurse) indicated she was the designated Infection Control Officer for Louisiana Continuing Care Hospital. She further indicated that she is not APIC (Association for Professionals in Infection Control and Epidemiology) or SHEA (Society for Healthcare Epidemiology of America) certified. S12LPN indicated that her training for infection control involved webinar courses, teaching from S3DirQuality, the previous infection control officer at Louisiana Continuing Care Hospital, the local public health department, and various other sources over time. S12LPN indicated she was not able to provide any documentation of her credentials and/or educational programs or experience regarding infection control practices other than an electronic digital certificate from the National Health Safety Network which allowed her access into the National Health Safety Network website.
In an interview on 12/04/13 at 3:30 p.m., S3DirQuality indicated S12 LPN was appointed as the Infection Control Officer by S1CEO. He also indicated he was not able to provide any documentation of specialized training for infection control practices for S12LPN.

Based on record review and interview, the hospital failed to ensure that a medical director of respiratory care services was appointed to supervise respiratory care services. Findings:
Review of the "Minutes of Governing Board Meeting" dated 06/30/13 revealed S7Medical Director was approved as Medical Director and Chief of Staff. Further review of the minutes revealed no appointment of a director of respiratory care services.
In an interview on 12/2/13 at 12:55 p.m., S2DON indicated the director of respiratory care services was S7Medical Director.
In an interview on 12/4/13 at 2:50 p.m., S7Medical Director indicated she had not been appointed as director of respiratory care services, and no other physician had been appointed as director of respiratory care services at Louisiana Continuing Care Hospital.

Based on record review and interview the hospital failed to ensure respiratory therapy services were provided under the orders of a physician as evidenced by S13Respiratory Therapist discontinuing respiratory therapy services without a physician's order to discontinue respiratory therapy services for 1 (#2) of 20 (#1-#20) records reviewed for respiratory therapy services in a total sample of 30 records reviewed. Findings:
Review of Patient #2's medical record revealed a physician's order dated 11/26/13 at 4:35 p.m. for respiratory therapy services to monitor Patient #2's oxygen saturation level twice per day; to provide 3 liters of oxygen via nasal cannula and to titrate oxygen to keep oxygen saturation levels greater than 90 percent. Further review of the medical record revealed no physician's order to discontinue respiratory therapy services for Patient #2.
Review of the "Respiratory Therapy Note" entry by S13Respiratory Therapist, dated 11/30/13 at 8:11 a.m., revealed the following text documented: "Patient monitored for 4 days and no oxygen needed. Will remove patient from respiratory services." No further respiratory care services were documented as being provided on Patient #2's medical record after the 11/30/13 entries.
In an interview on 12/02/13 at 3:30 p.m., S2DON indicated that a physician's order is needed to initiate, change, and discontinue respiratory care services to patients. S2DON reviewed Patient #2's medical record and verified a physician's order was not written in Patient #2's medical record to discontinue respiratory care services on 11/30/13, and S13Respiratory Therapist should have gotten a physician's order to discontinue respiratory care services on Patient #2.
In an interview on 12/04/13 at 9:30 a.m., S13Respiratory Therapist indicated that a physician's order is required to initiate, change, or discontinue respiratory care services for patients. S13Respiratory Therapist reviewed the medical record for Patient #2 and verified that no physician's order was obtained to discontinue respiratory care services for Patient #2 on 11/30/13. S13Respiratory Therapist further indicated that a physician's order should have been obtained to discontinue respiratory care services for Patient #2.