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Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation for Patient's Rights as evidenced by failure to provide medications as ordered, failure to notify the physician of decreasing blood pressures, failure to document accurate assessments, and failure to provide continued assessments and interventions for 1 (#2) of 5 (#1, #2, #3, #4, #5) patients sampled that had been transferred to acute hospitals for a higher level of care (see findings tag A-0145).

Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation for Nursing as evidenced by:

1) failure of the nursing staff to notify the physician of a decline in patient status for 1 (#2) of 5 (#1, #2, #3, #4, #5) patients sampled for transfer to an acute hospital for a higher level of care (see findings at tag A-0395).

2) failure of the registered nurse to document an assessment and assume care of patients with declining health status that had been delegated to LPNs for 3 (#1, #2, #3) of 5 (#1, #2, #3, #4, #5) patients sampled (see findings at tag A-0395).

3) failure of the registered nurse to document interventions or a reassessment of a patient in respiratory distress for 2 hours and 18 minutes for 1 (#1) of 5 (#1, #2, #3, #4, #5) sampled patients (see findings at tag A-0395).

Based on record review and interview, the hospital's governing body failed to ensure that there were written policies in place for appraisal of persons experiencing a medical emergency that included initial treatment and referral, when appropriate, due to emergency services not being part of the services provided by the hospital.

Findings:

A request was made on 8/19/19 at 2:00 p.m. with S2DON and S1AsstAdm to provide a copy of the policy for patients experiencing a medical emergency, none was given.

In an interview on 8/20/19 at 10:15 a.m. with S2DON, he said, they did not have a policy for what the nurses should do during an emergency situation. He said, the expectation is to do CPR and call 911.

Based on record review and interview, the hospital failed to ensure services were provided that were free of neglect. This deficient practice is evidenced by failure to provide medications as ordered, failure to notify the physician of decreasing blood pressures, failure to document accurate assessments, and failure to provide continued assessments and interventions for 1 (#2) of 5 (#1, #2, #3, #4, #5) patients sampled that had been transferred to acute hospitals for a higher level of care.

Findings:

Review of the hospital's policy titled Patient Abuse and Neglect Policy revealed in part:

Neglect: Failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to: food, clothing, shelter, healthcare or supervision which is reasonable and necessary to obtain or maintain the vulnerable adults' physical or mental health or safety and is not the result of an accident or therapeutic conduct.

Review of Patient #2's medical record revealed, she was a 49 year old female admitted on 7/31/19 with the chief complaint of MRSA and Bacteremia. Other diagnosis included Chronic Obstructive Pulmonary Disease requiring home oxygen.

Review of Patient #2's medical record vital signs log revealed the following blood pressures documented:

8/3/19: 169/99, 150/97, 112/62

8/4/19: 133/80, 118/73

8/5/19: 134/81, 142/88, 146/83, 148/88

8/6/19: 132/65, 110/69, 103/60

8/7/19:
4:00 a.m. - 85/60
8:00 a.m. - 82/51
12:00 p.m.- 104/54
12:00 a.m. - 79/49

Further review revealed no physician notification documented of Patient #2's decreased blood pressures beginning on 4:00 a.m. on 8/7/19.

Review of Patient #2's medical record revealed a physician's admission order dated 7/31/19 at 2:30 p.m. for Duo Neb 2.5-.5 mg/3ml nebulizer (opens airways in lungs to make it easier to breathe for patients with COPD) every 6 hours while awake.

Review of Patient #2's MAR revealed printed instructions by the pharmacy to administer the Duo Neb every 6 hours while awake but an unknown staff member had written PRN (as needed) next to the instructions. Further review revealed, the medication was never documented as having been given from admission on 7/31/19 through transfer on 8/7/19. Review also revealed an order for Ventolin HFA 18gm- Inhale 2 puffs into the lungs every 4 hours as needed for wheezing or shortness of breath. Review revealed the Ventolin was never documented as having been given from Admission on 7/31/19 through transfer on 8/7/19.

Review of Patient #2's medical record revealed a nurse's note by S3RN dated 8/7/19, at 7:40 a.m., documenting Patient #2's lungs being "essentially clear" and "see flowsheet assessment."

Review of the flowsheet assessment revealed Patient #2 was documented as having O2 at 5L per Nasal cannula with clear breath sounds and normal, regular, unlabored symmetrical breathing with no abnormal breath sounds. Documentation by the same nurse at 6:30 p.m. revealed "assessment unchanged." There was no documentation of Patient #2 having respiratory difficulty or being in and out of consciousness.

Review of Patient #2's medical record revealed a nurse's note by S4LPN dated 8/7/19. The 7:10 p.m. flowsheet assessment listed Patient #2 as having O2 at 5L per Nasal cannula with clear breath sounds and normal, regular, unlabored symmetrical breathing with no abnormal breath sounds. Further review revealed a written nurse's note dated 7:10 p.m. (same time as the flowsheet assessment) indicating "Received report from nurse resuming care." Another documented note at 7:25 p.m. (10 minutes later) revealed "Rounded on patient. VS taking. Patient clammy skin. BP 79/45, O2 65-74, reported to charge nurse. Patient in respiratory distress." Further review revealed no documentation of a RN assessment, no documented attempt to provider ordered nebulizer or inhaler treatments, or any other interventions until Ambulance Company "A" arrived at 8:10 p.m.

Review of documentation by Ambulance Company "A" dated 8/7/19 beginning at 8:15 p.m. revealed, they had been dispatched to St Catherine's Memorial Hospital for an unknown aged female in respiratory distress.

Further documentation revealed: Upon Ambulance Company "A" arrival find 49 year old female lying semi fowlers in bed. Patient noted to be lethargic with labored respirations at 34 breaths a minute noted. Patient noted to have oxygen therapy via nasal cannula, further assessment reveals nasal cannula not attached to oxygen. Staff unavailable to give patient history. Patient noted to have bilateral rhonchi, SPO2%=74%. Staff unable to specifically state how long patient has been in distress, staff states "day shift reported she was in and out all day." Staff was unable to specifically state what the patient was "in and out of." Patient respirations assisted via BVM on oxygen at 15 LPM. Patient moved to ambulance via stretcher. Cardiac monitoring continued. Patient noted to become apneic and pulseless. Manual CPR started immediately. Airway suction attempted, unable to clear airway due to secretions.

Review of Patient #2's medical record from Hospital "A" revealed the following entry on 8/7/19 at 9:40 p.m.: 49 year old nursing home resident brought to the hospital for respiratory failure. Paramedics report they were called because patient had been "in and out of it all day" according to the nursing staff. On paramedics arrival to the scene patient was found altered with a Glasgow Coma Scale of approximately 3-4. She was noted to be tachypneic and tachycardic. Attempted intubation was made in the field and was unsuccessful. As a result LMA was placed. Paramedics reported the patient may have lost spontaneous circulation briefly. CPR was initiated in the field and she received 1 mg epinephrine. After approximately two minutes the patient had a return of spontaneous circulation. Past medical history is unavailable.

In an interview on 8/20/19, at 8:25 a.m., with S4LPN, she said Patient #2 was her patient on the night of 8/7/19 when she was transferred to a local hospital. S4LPN said, it was just her and the charge nurse S6RN working and she had arrived late at 7:15 p.m. S4LPN said, the nurse she would have been relieving had already given report to S6RN. S4LPN said, S6RN reported that Patient #2 had not been acting herself and they had moved her to a room closer to the nurse's station. S4LPN said, when she went in to Patient #2's room and tried to talk to Patient #2 she was not responding. S4LPN said, she got Patient #2's vital signs and they were low. She said, her O2 level was at 71%. S4LPN said, she told the charge nurse that Patient #2's O2 level had dropped to 65%. She said, Patient #2 had shallow breathing and her breath sounds were not clear. She said, the charge nurse contacted the doctor. She said, the oxygen was increased but she did not know to what level because she had not increased it. She said, that she and S6RN got Patient #2's chart together and then the paramedics came and took over. When asked by the surveyor, S4LPN agreed that Patient #2's condition could not have declined that much since 6:30 p.m. when the RN documented everything was clear with her lungs but she could not account for another person's documentation. S4LPN said, when she charted at 7:10 p.m. that Patient #2's breath sounds were clear must have been an accident.

Several unsuccessful attempts were made by the hospital to contact the other nurses that had worked on 8/7/19 (S3RN, S6RN and S7LPN) for an interview regarding the care of Patient #2.

In an interview on 8/20/19, at 9:45 a.m., with S5NP, she said that she took call for the hospital. S5NP said, she remembered getting a call at shift change on 8/7/19 about Patient #2 being in distress, but she had not been notified before that time about the patient's blood pressure being low, being lethargic or having any respiratory distress.

In an interview on 8/21/19, at 8:40 a.m., with S2DON, he said that the Duo Neb for Patient #2 was ordered every 6 hours while awake and someone wrote PRN on the MAR so the medication was not given as ordered. S2DON said, S3RN's documentation was not accurate because Patient #2's respiratory status and level of consciousness was documented as being normal at 6:30 p.m. and that would not be possible. He verified S4LPN's documentation of Patient #2's respiratory status did not match on 8/7/19 between 7:10 p.m. and 7:25 p.m. and was inaccurate. He verified there was no documented RN assessment after Patient #2 had a change in condition but there should have been. S2DON also verified the physician should have been notified on the morning 8/7/19 when Patient #2's blood pressure started decreasing. S2DON also verified the nurses should have documented interventions if any were done.

A review was made of the personnel files of the 4 nurses that had worked on 8/7/19. Review of S4LPN's personnel file revealed no documented competencies. Review of S6RN's personnel file revealed no current CPR card, no documented training, and no competencies. Review of S3RN's personnel file revealed no documented orientation to the hospital. Review of S7LPN's personnel file revealed no orientation to the hospital. Further review revealed none of the four nurse's had current performance evaluations. S2DON and S1AsstAdm were asked to review the personnel files for the above mentioned missing documentation but none was provided.

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by:

1) failure of the nursing staff to notify the physician of a decline in patient status for 1 (#2) of 5 (#1, #2, #3, #4, #5) patients sampled for transfer to an acute hospital for a higher level of care; and

2) failure of the registered nurse to document an assessment and assume care of patients with declining health status that had been delegated to LPNs for 3 (#1, #2, #3) of 5 (#1, #2, #3, #4, #5) patients sampled; and

3) failure of the registered nurse to document interventions or a reassessment of a patient in respiratory distress for 2 hours and 18 minutes for 1 (#1) of 5 (#1, #2, #3, #4, #5) sampled patients; and

4) failure of the registered nurse to ensure documentation by a LPN was accurate for 1 (#2) of 5 (#1, #2, #3, #4, #5) sampled patients; and

5) failure of the registered nurse to ensure vital signs were obtained as ordered for 1 (#2) of 5 (#1,#2,#3,#4,#5) sampled patients.


Findings:

1) Failure of the nursing staff to notify the physician of a decline in patient status.

Review of the Hospital Policy titled Documentation revealed in part:

13. All changes in patient status are to be reported to the MD/NP ASAP; the name and title of the practitioner are to be documented.


Review of Patient #2's medical record revealed, she was a 49 year old female admitted on 7/31/19 with the chief complaint of MRSA and Bacteremia. Other diagnosis included Chronic Obstructive Pulmonary Disease requiring home oxygen.

Review of Patient #2's medical record vital signs log revealed the following blood pressures documented:

8/3/19: 169/99, 150/97, 112/62

8/4/19: 133/80, 118/73

8/5/19: 134/81, 142/88, 146/83, 148/88

8/6/19: 132/65, 110/69, 103/60

8/7/19:
4:00 a.m. - 85/60
8:00 a.m. - 82/51
12:00 p.m.- 104/54
12:00 a.m. - 79/49

Further review revealed no physician notification documented of Patient #2's decreased blood pressures beginning on 4:00 a.m. on 8/7/19.


Review of documentation by Ambulance Company "A" dated 8/7/19 beginning at 8:15 p.m. revealed, they had been dispatched to St Catherine's Memorial Hospital for an unknown aged female in respiratory distress. Further documentation revealed: Upon Ambulance Company "A" arrival find 49 year old female lying semi fowlers in bed. Patient noted to be lethargic with labored respirations at 34 breaths a minute noted. Patient noted to have oxygen therapy via nasal cannula, further assessment reveals nasal cannula not attached to oxygen. Staff unavailable to give patient history. Patient noted to have bilateral rhonchi, SPO2%=74%. Staff unable to specifically state how long patient has been in distress, staff states "day shift reported she was in and out all day." Staff was unable to specifically state what the patient was "in and out of."

In an interview on 8/20/19 at 8:25 a.m. with S4LPN, she said, Patient #2 was her patient on the night of 8/7/19 when was transferred to a local hospital. S4LPN said, it was just her and the charge nurse S6RN working and she had arrived late at 7:15 p.m. S4LPN said, the nurse she would have been relieving had already given report to S6RN. S4LPN said, S6RN reported that Patient #2 had not been acting herself and they had moved her to a room closer to the nurse's station.

In an interview on 8/20/19 at 9:45 a.m. with S5NP, she said she took call for the hospital. S5NP said, she remembered getting a call at shift change on 8/7/19 about Patient #2 being in distress but she had not been notified before that time about the patient's blood pressure being low, being lethargic or having any respiratory distress.

Review of Patient #2's medical record revealed no documentation on the day shift of 8/7/19 of the physician or nurse practitioner of Patient #2 being moved closer to the nurse's station because her condition had changed, her declining blood pressures, or Patient #2 being "in and out" during the day.

In an interview on 8/7/19 at 8:40 a.m. with S2DON, after reviewing Patient #2's hospital record, he verified the physician should have been notified on 8/7/19 when Patient #2's blood pressure decreased. S2DON said Patient #2 started deteriorating the morning of 8/7/19.


2) Failure of the registered nurse to document an assessment and assume care of patients with declining health status delegated to LPNs .

Review of the LSBN's "Administrative Rules Defining RN Practice LAC46: XLVII §3703. Definition of Terms Applying to Nursing Practice" revealed that the RN retains the accountability for the total nursing care of the individual and is responsible for and accountable to each consumer of nursing care for the quality of nursing care he or she receives, regardless of whether the care is provided solely by the RN or by the RN in conjunction with other licensed or unlicensed assistive personnel. The RN shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. This assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required. Any situation where tasks are delegated should meet the following criteria:

a) the person has been adequately trained for the task;

b) the person has demonstrated that the task has been learned;

c) the person can perform the task safely in the given nursing situation;

d) the patient's status is safe for the person to carry out the task;

e) appropriate supervision is available during the task implementation;

f) the task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all.

Further review revealed the RN may delegate to LPNs the major part of the nursing care needed by individuals in stable nursing situations, i.e., when the following three conditions prevail at the same time in a given situation:

a) nursing care ordered and directed by the RN or physician requires abilities based on a relatively fixed and limited body of scientific fact and can be performed by following a defined nursing procedure with minimal alteration, and responses of the individual to the nursing care are predictable; and

b) change in the patient's clinical conditions is predictable; and

c) medical and nursing orders are not subject to continuous change or complex modification.


Patient #1

Review of Patient #1's medical record revealed, she had been admitted on 5/23/19 at 7:30 p.m. with osteomyelitis.

Review of documentation by S8LPN dated 6/5/19 at 8:10 p.m. revealed, Patient #1 was complaining of not feeling well. Review revealed, Patient #1 also complained of stomach pain and shortness of breath. Documentation revealed the current SPO2 was 65%-75% and the charge nurse notified. Further review revealed 4 L of O2 was administered per nasal cannula and the SPO2 peaked at 75%. At 8:20 p.m., S5NP was documented as having been notified.

Review of the final entry at 10:28 p.m. revealed Patient #1 was transferred to Hospital "B" via Ambulance Company "B".

Further review of Patient #1's medical record revealed no assessment documented on 6/5/19 by a RN after the above mentioned decline was discovered at 8:10 p.m.


Patient #2

Review of Patient #2's medical record revealed, she was a 49 year old female admitted on 7/31/19 with the chief complaint of MRSA and Bacteremia. Other diagnosis included Chronic Obstructive Pulmonary Disease requiring home oxygen.

In an interview on 8/20/19 at 8:25 a.m. with S4LPN, she said, Patient #2 was her patient on the night of 8/7/19 when was transferred to a local hospital. S4LPN said that in report on 8/7/19 at 7:10 p.m., S6RN said, Patient #2 had not been acting herself and they had moved her to a room closer to the nurse's station. S4LPN said, when she went in to Patient #2's room at 7:25 p.m. and tried to talk to Patient #2 she was not responding. S4LPN said, she got Patient #2's vital signs and they were low. She said, her O2 level was at 71%. S4LPN said, she told the charge nurse that Patient #2's O2 level had dropped to 65%. She said, Patient #2 had shallow breathing and her breath sounds were not clear. She said, the charge nurse contacted the doctor. She said, the oxygen was increased but she did not know to what level because she had not increased it. She said that she and S6RN got Patient #2's chart together and then the paramedics came and took over.

Review of Patient #2's medical record revealed no documentation from a registered nurse of an assessment of the patient or interventions provided by the registered nurse with her decline in condition.


Patient #3

Review of Patient #3's medical record was admitted on 6/6/19 with the chief complaint of sepsis and osteomyelitis

Review of Patient #3's medical record revealed the following entry dated 7/3/19 at 12:25 p.m. by S9LPN: Patient was in hallway in wheelchair incoherent, took patient to the room, VS were taken , called MD. Was given orders to transport to ER at 12:30 p.m. Called Ambulance Company "B" to transfer patient. Patient had O2 sats in 80's, O2NC given to patient on 10, O2 came up to 97%. Documentation at 1:00 p.m. revealed Patient #3 was transferred to Hospital "A".

Review of Patient #3's medical record revealed no assessment by a registered nurse on 7/3/19.

In an interview on 8/21/19 at 8:40 a.m. with S2DON, he verified that there was no RN assessment after the above mentioned patients had a change in condition but there should have been.


3) Failure of the registered nurse to document interventions or a reassessment of a patient in respiratory distress for 2 hours and 18 minutes.

Review of Patient #1's nurse's notes documentation by S8LPN dated 6/5/19 revealed the following entries:

8:10 p.m. - Patient is complaining of not feeling well. Patient also complain of stomach pain and shortness of breath. Currently SPO2 is 65%-75%. Charge nurse notified. 4L of O2 administered via nasal cannula. SPO2 peaks at 75%.

8:20 p.m. - S5NP notified. Patient will be transferred to Hospital "B" for evaluation.

10:28 p.m. - Patient transferred to Hospital "B" via Ambulance Company "B".

Review of Patient #1's medical record revealed no assessments or interventions documented by the registered nurse or LPN after the discovery of Patient #1's oxygen saturations not increasing over 75% at 8:10 p.m. until the time of transfer at 10:28 p.m. (2 hours and 18 minutes).

In an interview on 8/21/19 at 8:40 a.m. with S2DON, He verified on Patient #1's medical record there should have been a reassessment and interventions after the oxygen saturations were discovered to be 65-75%.


4) Failure of the registered nurse to ensure documentation by a LPN was accurate.

Review of the Hospital Policy titled Documentation revealed in part:

1. Rounds are to be made every 2 hours accompanied by appropriate documentation.

2. Documentation must be factual, legible, complete and compliant with standards of practice.

3. Documentation is only to take place after assessment or care is given.


Review of Patient #2's Transfer Notification Form revealed, she had been admitted on 7/31/19 and had been transferred on 8/7/19 at 8:25 p.m.

Review of Patient #2's nursing notes dated 8/7/19 revealed a pre-printed sections with boxes divided hourly to be "checked" to demonstrate when nursing rounds had been completed for turning the patient every 2 hours, checking the patient's IV site, patient had their ID bracelet present, the patient's call bell was in reach, and the patient's bed locked and in low position. Further review revealed, the boxes had been checked as having being done every 2 hours from 8:00 p.m. on 8/7/19 through 6:00 a.m. on 8/8/19 although Patient #2 had been transferred on 8/7/19 at 8:25 p.m.

Review of Patient #2's nurse's notes dated 8/7/19 and documented by S4LPN revealed a pre-printed section for pulmonary with choices to be "checked" indicating the patient's assessment. Review of the documentation of Patient #2's assessment at 7:10 p.m. revealed her pulmonary status was selected to be normal, no edema, unlabored, symmetrical, no abnormal breath sounds with breathing patterns within normal limits and breath sounds clear. Review of the narrative nurse's notes revealed at 7:10 p.m. S4LPN was getting report and Patient #2's assessment was not done until 7:25 p.m. where the assessment was documented as: Patient clammy skin, BP 79/45, O2 65%-74%. Patient in respiratory distress.

In an interview on 8/20/19 at 8:25 p.m. with S4LPN, she said, documenting that Patient #2's breath sounds were clear on 8/7/19 must have been an accident. S4LPN also said, charting every 2 hours rounding during the entire night was also a mistake.

In an interview on 8/21/19 at 8:40 a.m. with S2DON, he verified S4LPN's documentation of Patient #2's respiratory status did not match on 8/7/19 between 7:10 p.m. and 7:25 p.m. and was inaccurate. He also verified S4LPN had filled out the 2 hour rounding for the whole night and Patient #2 was transferred out at 8:25 p.m.


5) Failure of the registered nurse to ensure vital signs were obtained as ordered.

Review of Patient #2's admission orders dated 7/31/19 at 2:30 p.m. revealed, vital signs were to be obtained as per hospital protocol.

Review of a vital sign Flowsheet presented by S2DON revealed vital signs were to be taken on patients at 4:00 a.m., 8:00 a.m., 12:00 p.m.. and 8:00 p.m. He said, the hospital did not have a policy or protocol but it was to be done per the flowsheet 4 times a day.

Review of Patient #2's vital sign sheet revealed, she was missing the 4:00 a.m. set of vital signs on 8/1/19, 8/3/19, and 8/5/19 the 8:00 p.m. set of vital signs on 8/4/19.

Based on record review and interview, the hospital failed to ensure the nursing staff developed and kept current, individualized, and comprehensive nursing care plans. This deficient practice was evidenced by failure of the nursing staff to identify interventions and expected outcomes for identified problems for 1 (#2) of 5 (#1, #2, #3, #4, #5) sample patients .

Findings:

Review of a hospital policy titled Care Plans and Updates revealed in part:

2. All care plans in the care plan section of the chart are prioratized, dated, appropriate interventions and expected outcomes checked off and initialed by the nurse caring for the patient.


Review of Patient #2's medical record revealed the plan of care had problems identified as activities of daily living function altered, elimination altered, potential for infection, potential for injury/fall, alteration in exchange and discharge planning. None of the identified problems had interventions or expected outcomes listed.

In an interview on 8/21/19, at 8:40 a.m., with S2DON, he verified Patient #2's care plans were incomplete.

Based on record review and interview, the hospital failed to ensure non-employee licensed nurses working in the hospital were oriented and evaluated for competency for 2 (S11RN, S12RN) of 2 (S11RN, S12RN) contracted staff.

Findings:

Review of documentation provided by S2DON revealed 2 agency nurses had worked as charge nurses in the hospital in August 2019. Review revealed S11RN had worked 8/2/19, 8/3/19, 8/18/19, and 8/19/19. Review revealed S11RN had worked 8/4/19, 8/5/19, 8/9/19, 8/10/19, 8/16/19, and 8/17/19.

In an interview on 8/21/19 at 8:45 a.m. with S2DON, he said S11RN and S12RN had not had any orientation or competency evaluations.

Based on observation, record review, and interview, the hospital failed to ensure drugs and biologicals were administered in accordance with orders of the practitioners responsible for the patient's care. This deficient practice is evidenced by failure of the nursing staff to administer a respiratory medicine to a patient as ordered for 1 (#2) of 1 (#2) patients sampled with Chronic Obstructive Pulmonary Disease.

Findings:

Review of Patient #2's medical record revealed, she was a 49 year old admitted on 7/31/19 at with diagnosis including COPD.

Review of Patient #2's medical record revealed a physician's admission order dated 7/31/19 at 2:30 p.m. for Duo Neb 2.5 - .5 mg/3ml nebulizer (opens airways in lungs to make it easier to breathe for patients with COPD) every 6 hours while awake.

Review of Patient #2's MAR revealed printed instructions by the pharmacy to administer the Duo Neb every 6 hours while awake but an unknown staff member had written PRN (as needed) next to the instructions. Further review revealed, the medication was never documented as having been given from admission on 7/31/19 through transfer on 8/7/19 (8 days).

Review of Patient #2's Transfer Notification Form revealed, she was transferred on 8/7/19 at 8:25 p.m. The reason for transfer was listed as labored breathing, change in mental status and decreased oxygen saturations.

In an interview on 8/21/19, at 8:40 a.m., with S2DON, he said, the Duo Neb was ordered every 6 hours and someone wrote PRN on the medication administration record so the medication was not given as ordered.

Based on record review and interview, the hospital failed to ensure all medical records were completed within 30 days of discharge or outpatient care as evidenced by 4 of 5 sampled patient records. The hospital also failed to have a system in place to accurately track the number of deficient medical records in the hospital.

Findings:

Review of the hospital bylaws revealed a section titled Notification of Physician Delinquent Medical Records and Suspension. Review revealed in part the following:

Physician's will be notified regarding the status of their charts. They will be notified by letter, certified letter, phone calls, and/or fax transmissions when appropriate. A medical record will be considered delinquent if not completed within 30 days after discharge.

1. The physician will receive a reminder of his/her incomplete records 15 days after the discharge of the patient.

2. The physician will be notified, by letter, of his/her incomplete records 21 days after discharge.

3. If the records remain incomplete, a letter from the CEO will be mailed, certified, return receipt requested, 28 days after discharge, giving the physician seven days to complete his/her charts. According to the given deadline in the letter, the physician will have their admitting privilege suspended until all records are completed.


Patient #1

Review of Patient #1's medical record revealed, she was admitted on 5/23/19 and had been discharged on 6/5/19. Review of Patient #1's admission orders dated 5/23/19, at 7:10 p.m., revealed, not signed by the physician. Further review revealed, verbal orders on 5/24/19 at 9:30 p.m., 5/27/19 at 2:14 p.m., and 5/29/19 at 3:45 p.m. were not authenticated by the physician.


Patient #3

Review of Patient #3's medical record revealed, she was admitted on 6/6/19 and had been discharged on 7/3/19. Review of Patient #3's admission orders dated 6/6/19 at 4:00 p.m. was not signed by the physician. Further review revealed, verbal orders on 7/2/19 at 3:00 p.m. and 7/3/19 at 12:30 p.m. were not authenticated by the physician.


Patient# 4

Review of Patient #4's medical record revealed, he was admitted on 7/3/19 and had been discharged on 7/23/19. Review of Patient #4's admission orders dated 7/3/19 at 2:35 p.m. was not signed by the physician. Further review revealed, a verbal order on 7/5/19 at 2:00 p.m. was not authenticated by the physician.


Patient #5

Review of Patient #5's medical record revealed he was admitted on 5/30/19 and had been discharged on 7/25/19. Review of Patient #5's admission orders dated 5/30/19 at 10:45 a.m. was not signed by the physician. Further review revealed, a verbal order on 5/30/19 at 10:45 a.m. was not authenticated by the physician.


In an interview on 8/20/19 at 1:20 p.m. with S1AsstAdm, she said, she was not sure who the RHIA was. When told 4 of 4 medical records reviewed had delinquencies and asked how many delinquent records the hospital had, she verified she did not have a system in place to track medical record delinquencies. S1AsstAdm said the RHIA had quit a month or so ago and they had not replaced her. She said the administrator had been doing the job, but she was not a RHIA. S1AsstAdm said they had not followed the bylaws for sending a letter to physicians or suspending them for delinquent records.

In an interview on 8/21/19 at 8:40 a.m. with S2DON, he verified physician's should authenticate verbal orders within 10 days.