Volume 2024 | No. 2
SURVEYOR
CRITICAL ACCESS HOSPITAL
CHAPTER 07: MEDICAL RECORDS 07.01.00 Record protection Overview of the requirement:
Frequency of citation:
31%
Examples of surveyor findings:
n A patient whose documented preferred language is Spanish, was provided an informed consent for an EGD procedure in English. n Provider signatures were missing from anesthesia and surgical consent forms. n Train all relevant staff on the informed consent policy at regular intervals. n Review forms for their use of simple language understandable by the individual providing consent.
Medical records are maintained securely and only accessed by authorized persons. Compliance is assessed through observation and interview. Findings noted patient records that were not adequately protected from loss, destruction, and offered virtually unrestricted access.
Tips for complianc e:
Comment on deficiencies:
Educate all staff that informed consent is based on confirming comprehension. Develop a consistent, defined process to follow.
Frequency of citation:
38%
Examples of surveyor findings:
n The health information department keeps patient records on open shelves. Hospital staff other than department employees have badge access to the records. n A small storage room held 15 boxes of patient records. Environmental services personnel had access to the room after hours and were unobserved while in the room. n Medical records were stored in boxes in a shed in the parking lot. The cage for storage did not have walls to the ceiling and the access keys were kept by the maintenance personnel. Additional medical records awaiting scanning were stored in the mailroom. The door is locked with a keypad, but individuals from every department within the hospital have access to the mailroom. n Develop medical record policies that define the method of protecting open, closed, and archived medical records. n Patient records, including those awaiting scanning or long-term storage must be physically protected from destruction or damage. n Medical records including personally identifiable information (PHI) must be guarded from the risk of unauthorized access. Open filing systems should be limited to locked areas with restricted access.
CHAPTER 16: RESTRAINTS 16.00.07 Restraint or seclusion: Modification of the plan of care 16.00.08 Orders for restraint or seclusion
Overview of the requirement:
The use of restraint or seclusion requires an order from physician or other licensed independent practitioner privileged to order restraint or seclusion in the CAH. The order must be reflected as a modification to the patient’s plan of care. It must detail the rationale, intervention(s) selected, and the plan for monitoring and reassessments. Compliance is assessed through review of medical records. Surveyors noted variance between CAH policy and the use of restraints, including missing documentation indicating a modification in the plan of care.
Tips for complianc e:
Comment on deficiencies:
Frequency of citation:
16.00.07: 31%; 16.00.08: 38%
Examples of surveyor findings:
n The facility policy “Restraints,” states, “Restraints will be ordered by a physician who is a member of the medical staff and responsible for the care of the patient. The restraint order set will be used and includes a) The indication for restraint (violent or non-violent behavior). b) The type of restraint to be used (medication, side rails, soft restraints, etc.) c) The date and time restraint initiated. d) The date and time the order will expire. n In one of two non-violent restraint charts, the patient was placed in restraints on 4/6 but the physician made a late entry on 4/18. n Five records for non-violent restraints were reviewed. Three lacked documentation of which limbs were restrained. One documented of an order for mitten restraints. The facility policy The EMR includes an option for providers to order mitten restraints which is inconsistent with hospital policy that lists mittens as a restraint alternative, not an approved restraint. n A 12-year-old patient was placed in violent restraints and chemically restrained 30 minutes later. There was no order for the violent restraints or the chemical restraint in the medical record.
CHAPTER 08: SURGICAL SERVICES 08.00.06 Informed consent Overview of the requirement:
A patient must provide informed consent to proceed with a surgical service. The consent information is presented in a language and at a comprehension level that ensures that the patient understands what they are authorizing for their care. Compliance with this standard is assessed through medical record review. Most findings noted the use of medical terminology or other issues that would create a challenge in communicating the risks and benefits of the procedure.
Comment on deficiencies:
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