HospitalInspections.org

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Based on interview and record review, the hospital failed to ensure that all medical record entries had the time of the entry documented when three of the three sampled psychiatric records (three of the total seven sampled records) did not have the time of entry documented on the Conditions of Admission, the Notice of Certification, the Behavioral Health Interdisciplinary Plan of Care, the Restraint Reduction Data, and the Weekly Treatment Plan Meeting, and one of one sampled psychiatric record did not have the time of entry documented on the Denial of Rights form.

Findings:

On 12/14/11 at 10:15 AM, record review of Patient 3's medical record indicated that the forms Condition of Admission, Notice of Certification, Behavioral Health Interdisciplinary Plan of Care, Weekly Treatment Plan meeting, and Restraint Reduction Data did not have the time of entry documented on them.

The Compliance Liaison and Director of Cardiopulmonary and Neurology Diagnostics (CL) reviewed Patient 3's medical record and confirmed that the times of entry were not documented.

On 12/14/11 at 11:45 AM, the Director of Behavioral Health (DBH) reviewed the medical records of Patients 6 and 7 and this DBH stated that the forms Condition of Admission, Notice of Certification, Behavioral Health Interdisciplinary Plan of Care, Weekly Treatment Plan meeting, and Restraint Reduction Data had not been timed when they were entered into Patient 6's and Patient 7's medical records. The DBH also stated that Patient 6's Denial of Rights form did not had the time documented when the form was completed.

The CL confirmed that these forms did not have the time of entry documented for Patients 6 and 7.

The DBH and the CL acknowledged that all medical record entries are required by law to have a date, time, and signature.

The hospital was asked to provide a copy of its policy regarding the requirement that all medical record entries have a date, time, and signature. On 12/14/11 at 2:35 PM, the Director of Quality and Performance Improvement provided the Behavioral Health Services "Denial of Rights" policy and procedure which stated "The documentation must include date, time and signature of the professional person authorizing the denial of the right(s)." The Behavioral Health Unit did not follow this policy for Patient 6.




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Based on observation, interview, and record review, the hospital failed to ensure that staff followed the infection control guidelines regarding hand washing (hand hygiene) when three dietary aides exited isolation rooms and continued to perform their duties without first sanitizing their hands.

Findings:

On 12/14/11 at 12:20 PM, Dietary Staff # 1 was observed pushing aside the privacy curtain at the entrance and delivering a lunch tray in Room 608; he did not wear any personal protective equipment (gloves, gowns, or masks). Room 608 had a sign at the entrance which said "STOP, 'Contact Precautions,' Wear Gloves, Gowns required for direct contact with patient or environment, Mask for Coughing Patient or Cough Inducing Procedures, Visitors must speak with nurse before entering room." Dietary Staff #1 exited the room and pushed the dietary cart down the hall before he utilized sanitizing gel on his hands from the dispenser in the hallway.

On 12/14/11 at 12:30 PM, Dietary Staff # 2 was observed delivering lunch trays in the opposite hallway of 6th floor. This Dietary Staff was not wearing any personal protective equipment as he went quickly from room to room delivering trays. Dietary Staff # 2 also removed a tray from Room 622 and placed it in the dietary cart. Dietary Staff # 2 did not sanitize his hands between patient rooms which included Rooms 620 and 622, both of which had signs for "Contact Precautions."

On 12/14/11 at 12:35 PM, Dietary Staff # 3 was observed delivering lunch trays on the 8th Floor. Dietary Staff # 3 was not wearing any personal protective equipment as he went quickly from room to room delivering trays. Dietary Staff # 3 did not sanitize his hands between patient rooms even though Room 820 had a sign for "Contact Precautions."

The Compliance Liaison and Director of Cardiopulmonary and Neurologic Diagnostics (CL) observed the three Dietary Staff delivering lunch trays. When asked, the CL confirmed the three Dietary Staff had not sanitized their hands after leaving the four rooms with "Contact Precautions" and before proceeding with their duties, including entering the rooms of patients who were not in isolation.

The hospital's posted signs for "Contact Precautions" instructed staff entering the patient room to wear gloves.

The hospital's policy and procedure "Hand Hygiene Policy" dated 2011, stated hands should be sanitized (antimicrobial gel or soap and water washing) "after contact with inanimate objects in the immediate vicinity of the patient." Inanimate objects would include the overbed table and any personal supplies patients keep on this table for ease of use. Dietary staff need to move these personal objects and reposition overbed tables in order to deliver trays.

The hospital's "Infection Precautions for Hospitalized Patients" dated 7/29/10, page 13, stated that with Contact Precautions "Visitors should be advised to use waterless alcohol hand gel/foam or wash their hands before leaving the room."

The hospital did not ensure that all staff followed the minimum infection control guidelines to prevent the spread of infection to other patients.