HospitalInspections.org

Based on review of facility documents and interview with facility staff (EMP), it was determined that the facility failed to follow adopted policies for completing medical records within 30 days following discharge.

Findings Include:

Review of "Chart Count-Incomplete/Delinquent Charts" policy and procedure dated May 2013, revealed, " ... Policy: To complete all medical records within 30 days of discharge as established by Pennsylvania laws and the Pennsylvania Department of Health. ... ."

Review of "Punxsutawney Area Hospital Medical Staff Rules and Regulations" dated June 2013, revealed, " ... Article X-Medical Records ... Section 10. Medical Record Review (a) ... Each month, the President of the Medical Staff will notify each physician, in writing, when he/she has failed to complete medical records within thirty (30) days of the patient's discharge. ... ."

1) Review of "Delinquent Physician Report" facility documentation revealed that 19 medical records were delinquent for the month ending January 30, 2013, 37 medical records were delinquent for the month ending February 30, 2013, 36 medical records were delinquent for the month ending March 30, 2013, 36 medical records were delinquent for the month ending April 30, 2013, 52 medical records were delinquent for the month ending May 30, 2013, and 46 medical records were delinquent for the month ending June 30, 2013.

2) Interview with EMP1, conducted on July 16, 2013, at 11:30 AM confirmed the findings, and also confirmed that the delinquent medical records were not completed within the 30 days.

Based on review of facility documents, and staff interview (EMP), it was determined the facility failed to follow adopted policies by ensuring the recording of food temperatures.

Findings include:

Review of the facility's policy entitled "Food Temperature", dated July 2013, revealed "... Policy: It is the policy of the Punxsutawney Area Hospital Dietary Department that all food served be kept at proper serving temperatures. A. Procedure: A. Hot Solid Foods. 1. All hot foods are served at temperatures between 140-180 [degrees] Fahrenheit ... B. 1. All cold foods are served between 35 [degrees] - 45 [degrees] Fahrenheit ... C. Hot Liquid Foods. 1. All hot liquid foods are served at temperatures between 150 [degrees] - 160 [degrees] Fahrenheit ... D. Checking Food Temperatures. 1. Temperatures of all hot food items are checked using a temperature probe. 2. These temperatures are taken prior to each meal and are recorded on the proper form."

1) Surveyor requested documentation that the facility had recorded food temperatures per adopted policy. No applicable documentation was provided.

2) Interview with EMP2 on July 17, 2013, confirmed that the temperatures have not been documented.

Based on review of facility documents, and staff interview (EMP), it was determined that the facility failed to follow adopted policies by ensuring the documentation of daily temperature and humidity for the four operating rooms within the surgical suite, failed to follow adopted policies by maintaining temperature and humidity requirements for the surgical suite operating rooms, and failed to follow adopted policies related to the recording of reason for temperature deviations.

Findings include:

Review of the facility's policy entitled "Temperature and Humidity Control", revised April 29, 2013, revealed "... Procedure: 1. Operational ranges. Operating Room Suites. All surgical rooms will operate with temperatures between 68 and 75 degrees and humidity will be maintained between 20 and 60 percent ... Staff occupying the rooms are to ensure that the thermostat is set at a temperature within the ranges stated in section #1 of this policy. If a temperature is needed outside of this range because of clinical needs, staff may change the thermostat and record the reason for the deviation from policy in the log book within each department. Humidity and Temperatures are recorded once a day by the energy management system. Those logs are maintained by the VP of Support Services ... ."

1) The temperature and humidity logs for the surgical suites for April 2, 2013 to July 16, 2013, were reviewed. The logs indicated the facility has four operating rooms within the surgical suite.

2) During review of the temperature and humidity log for the surgical suite, it was noted that there were no temperature and humidity daily recordings for the period of May 1, 2013 to May 13, 2013.

Interview with EMP3, on July 17, 2013, at approximately 10:30 AM, revealed that there is no report available for this time frame, and that the data is lost, as the report had not been printed.

3) Continued review of the logs revealed that there were approximately 40 instances where the humidity was out of range for at least one of the operating rooms, and that there were approximately 107 instances where the temperature was out of range for at least one of the operating rooms.

Interview with EMP5, on July 18, 2013, at approximately 1:20 PM, confirmed that there have been instances in which the humidity and temperature in the operating rooms are out of range.

4) Surveyor requested the log book for the Surgical Services Suite. Review of documentation provided to surveyor, entitled "OR Temperature Deviation Log", revealed notations dated April 17, 2013 to July 1, 2013, of only nine instances in which the temperature deviation was documented.