HospitalInspections.org

Based on observation and interview on 8/13/13, the facility failed to show documented evidence that the carts were checked twice a day according to facility policy.

Findings include:

Policy:
Review of facility policy dated 10/27/11 titled "Code Cart, Defibrillator, RSI Box And Clot Box Checks" revealed that code cart checks are completed twice daily in departments operating 24 hours per day.

During tour of the Medical-Surgical unit on 8/13/13, observation of the logs for the twice daily code cart checks for the Adult code cart and the Pediatric code cart revealed missing documentation for the twice daily code cart checks.

Review of the Adult code cart twice daily checks dating 5/1/13 through 8/12/13 revealed the following days without any code cart checks:



May 2013 8 days without any code cart checks
June 2013 3 days without any code cart checks
July 2013 8 days without any code cart checks
August 2013 1 day without any code cart checks

Further review of the Pediatric code cart twice daily checks dating 5/1/13 through 8/12/13 revealed the following days without any code cart checks:

May 2013 10 days without any code cart checks
June 2013 8 days without any code cart checks
July 2013 10 days without any code cart checks
August 2013 6 days without any code cart checks

During an interview with Staff E (Registered Nurse Clinical Manager) on 8/13/13, Staff E confirmed that there were days without any documented evidence of code cart checks.

Based on observation and interview the facility failed to maintain the security of the pharmacy to prevent access by unauthorized individuals to drugs and biological's.

Findings include:

During the tour of the hospital on 8/14/13 at 12:15 p.m. the pharmacy was inspected. The window which measured about 3' x 3' had a door bell to the right of the window. This bell was rung several times as surveyors waited, 4-5 minutes passed. At this time a bag of syringes were in arms reach, these were picked up by surveyor at which time Staff B (Director of pharmacy) entered the pharmacy by the back door. Prior to the pharmacist entering through the back door the department was empty. Staff B stated that the two other employees were at lunch and that he was called to the emergency department. Surveyor showed Staff B that anyone who wanted to could get into the pharmacy through the window opening. Staff B then opened the door allowing entrance to the pharmacy by the surveyor. Staff B then was asked if it would be OK to show how the pharmacy door that was adjacent to the open window could be opened through the window. Staff B said 'Yes", surveyor showed Staff B by going outside the window, reaching through the window, grabbing the door handle and opening the door thus showing Staff B that the pharmacy was not secure.

Interview on 8/14/13 at 12:15 pm with Staff B confirmed pharmacy was unattended and since the window was open, the pharmacy was not secure from unauthorized access.

Based on medication pass observation, interview and record review the facility failed to follow physician orders for medication administration for 1 in sample patient and 1 out of sample patient in a survey sample of 46 patients. (Patient identifiers are #40 & #47.)

Findings include:

Standard of Practice
The Potter-Perry, 2009, Review of "Fundamentals of Nursing," Patricia A. Potter and Anne Griffin Perry, Mosby, St. Louis, Missouri, 2009, 7th Edition, revealed the following, Chapter 23 Legal Implications in Nursing Practice, on page 336- Physicians' Orders states, "The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary..."


During medication pass review with Staff C (Registered Nurse) on 8/15/13 at approximately 10:30 a.m., Staff C was observed to administer sodium chloride 0.9% 10 ml IV push into the intravenous lock port of Patient #40.

Review of the medical record for physician orders revealed orders signed by the physician on 8/11/13 for sodium chloride 0.9% 5 ml IV push q 12 hours.

During an interview with Staff C on 8/15/13, Staff C confirmed that Staff C did not follow the physician order for the administration of medication to Patient #40 and that the physician's order was to administer 5 ml and not 10 ml of the sodium chloride 0.9% IV push.

During medication pass review with Staff D (Registered Nurse) on 8/15/13 at approximately 10:10 a.m., Staff D was observed to administer Levofloxacin 750 mg/150 ml IVPB (Intravenous Piggyback) to Patient #47 and set the pump delivery rate at 150 ml/hr (milliliters per hour).

During interview with Staff D on 8/15/13 after the medication was hung at the 150 ml/hr rate, the surveyor requested clarification of the administration rate as the surveyor had observed the physician order written in the COW (Computer on Wheels) and the label on the IVPB bag had a documented delivery rate of 100 ml/hour. Staff D confirmed the rate should be set at 100 ml/hr and was observed to return to the bedside of Patient #47 and reset the pump of the medication to a delivery rate of 100 ml/hr.

Review of physician orders for Patent #47 on 8/15/13 revealed an order signed by the physician on 8/14/13 for the following:

Levofloxacin I.V. 750 mg/150 ml D5W 100 ml/hr IVPB q 12 hours, infuse over 90 minutes.

The facility failed to follow written and signed physician orders for medication administration for Patient #40 and #47 as listed above.

Based on interview and record review the facility failed to ensure physician compliance with facility established policy and procedure for completion of chart documentation on discharged records.

Findings include:

Review of the MEDICAL STAFF RULES & REGULATIONS
"1. Admission...
2. Medical Records
The provider is responsible for the preparation of a complete medical record on his/her patient. All medical record entries are signed an dated be the provider...
A. Requirements
1.) A brief note is written and placed in the progress note on admission if the H&P is not available. The H & P must be performed no more 7 days before or written 24 hours of admission.
2.) Patients having surgery must have an H & P and/or an H & P addendum to a previously written H& P completed within 7 days prior to surgery and on the chart prior to the procedure. If the H & P is not available, then the hand written pre-operative note must be on the chart before the patient is admitted to surgery. Except in emergent circumstances, this note includes:...
Surgical cases, must have a brief post-operative note written immediately after surgery with post op diagnosis. A dictated operative note must be completed within 24 hours and signed within 72 hours of the operative procedure...
6.) A discharge summary is completed on all inpatients within 14 days of the patient's discharge. A brief discharge note is completed on all observation care patients within 14 days of the service, which includes: a) medical necessity for observation care, and b) a summary of the patient's course during their observation care...
C. Medical Record Completion
All records should be completed within 2 weeks of discharge, must be completed within 30 days. Notices will be sent to the member of the Medical Staff twice a week. On or about day 21 post discharge, the Director of Health Information service, or designee, will notify the Medical Staff President, or designee, of any records that remain deficient for an individual provider. The President of the Medical Staff, or designee, will contact the provider regarding the medical record deficiencies and expectation for completion within the next 7 days/within the 30 day time limit.

Providers with records incomplete more than 30 days after discharge are placed on Non-Admit status until the records are completed. While under Non-Admit status, a provider may not admit patients to the Hospital or perform schedule elective procedures, but must continue to provide care for those patients directly under his/her care prior to Non-Admit status and must continue to cover emergency call, including admitting patients while in that function..."

Review of the facility generated "Medical Record Deficiencies" report that was generated by Staff F, (Lead Coder) on 8/15/13 reveals the total number of violations for dictations and signatures deficiencies. The report revealed 11 physicians for a total number of 30 violations. The list also includes physicians that are travelers and no longer at the facility.

Patient #27
During review of Patient #27's medical record on 8/15/13 it was found that Staff H (ARNP, Referring Physician had written a discharge summary dated 7/13/13 which was the date of service. This same discharge summary report had not been signed as of 8/15/13.


Patient #28
During review of Patient #28's medical record on 8/15/13 revealed that Staff I (Medical Doctor) had written two Progress Notes dated 5/26/13 and 5/28/13 which were the date of services. These same Progress Notes have not been signed as of 8/15/13. An Operative Report dated 5/26/13 written by Staff I had not been signed by 8/15/13. A History and Physical written on 5/26/13 by Staff I had not been signed by 8/15/13.

Patient #29
Review of Patient #29's medical record on 8/15/13 revealed that Staff J (CRNA) had written a Consultation note dated 5/6/13 which was the date of service. This same Consultation note has not been signed as of 8/15/13. A History and Physical written on 8/5/13 by Staff K, (Medical Doctor) has not been signed by 8/15/13.


Interview with Staff F on 8/15/13, revealed that Staff F generates a reports that goes to Staff G (Medical Staff Coordinator) who then sends an email to the President of Medical Staff with the names of the physicians that have incomplete records.

Interview with Staff G, revealed that no physician has been placed on Non-Admit status. Review of several physician's files reveals no letters were sent to the physicians that were over the 30 days.


13504

Review of the facility's medical records revealed that Staff A (Surgeon) had written an operative report dated 4/10/13 which was the date of service. This same operative report was not signed until 6/12/13, almost two months after the transcribed report date.

Review of the surgical schedule for the month of May revealed that Staff A performed two surgical cases both dated 5/22/13. Both these surgical cases were beyond designated 30 day record completion period. According to Medical Staff Rules and Regulations incomplete records, results in suspension of admission privileges and elective surgery privileges, neither of which occurred.

Based on observation and interview on 8/13/13, the facility failed to show documented evidence that the carts were checked twice a day according to facility policy.

Findings include:

Policy:
Review of facility policy dated 10/27/11 titled "Code Cart, Defibrillator, RSI Box And Clot Box Checks" revealed that code cart checks are completed twice daily in departments operating 24 hours per day.

During tour of the Medical-Surgical unit on 8/13/13, observation of the logs for the twice daily code cart checks for the Adult code cart and the Pediatric code cart revealed missing documentation for the twice daily code cart checks.

Review of the Adult code cart twice daily checks dating 5/1/13 through 8/12/13 revealed the following days without any code cart checks:



May 2013 8 days without any code cart checks
June 2013 3 days without any code cart checks
July 2013 8 days without any code cart checks
August 2013 1 day without any code cart checks

Further review of the Pediatric code cart twice daily checks dating 5/1/13 through 8/12/13 revealed the following days without any code cart checks:

May 2013 10 days without any code cart checks
June 2013 8 days without any code cart checks
July 2013 10 days without any code cart checks
August 2013 6 days without any code cart checks

During an interview with Staff E (Registered Nurse Clinical Manager) on 8/13/13, Staff E confirmed that there were days without any documented evidence of code cart checks.

Based on observation and interview the facility failed to maintain the security of the pharmacy to prevent access by unauthorized individuals to drugs and biological's.

Findings include:

During the tour of the hospital on 8/14/13 at 12:15 p.m. the pharmacy was inspected. The window which measured about 3' x 3' had a door bell to the right of the window. This bell was rung several times as surveyors waited, 4-5 minutes passed. At this time a bag of syringes were in arms reach, these were picked up by surveyor at which time Staff B (Director of pharmacy) entered the pharmacy by the back door. Prior to the pharmacist entering through the back door the department was empty. Staff B stated that the two other employees were at lunch and that he was called to the emergency department. Surveyor showed Staff B that anyone who wanted to could get into the pharmacy through the window opening. Staff B then opened the door allowing entrance to the pharmacy by the surveyor. Staff B then was asked if it would be OK to show how the pharmacy door that was adjacent to the open window could be opened through the window. Staff B said 'Yes", surveyor showed Staff B by going outside the window, reaching through the window, grabbing the door handle and opening the door thus showing Staff B that the pharmacy was not secure.

Interview on 8/14/13 at 12:15 pm with Staff B confirmed pharmacy was unattended and since the window was open, the pharmacy was not secure from unauthorized access.

Based on medication pass observation, interview and record review the facility failed to follow physician orders for medication administration for 1 in sample patient and 1 out of sample patient in a survey sample of 46 patients. (Patient identifiers are #40 & #47.)

Findings include:

Standard of Practice
The Potter-Perry, 2009, Review of "Fundamentals of Nursing," Patricia A. Potter and Anne Griffin Perry, Mosby, St. Louis, Missouri, 2009, 7th Edition, revealed the following, Chapter 23 Legal Implications in Nursing Practice, on page 336- Physicians' Orders states, "The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary..."


During medication pass review with Staff C (Registered Nurse) on 8/15/13 at approximately 10:30 a.m., Staff C was observed to administer sodium chloride 0.9% 10 ml IV push into the intravenous lock port of Patient #40.

Review of the medical record for physician orders revealed orders signed by the physician on 8/11/13 for sodium chloride 0.9% 5 ml IV push q 12 hours.

During an interview with Staff C on 8/15/13, Staff C confirmed that Staff C did not follow the physician order for the administration of medication to Patient #40 and that the physician's order was to administer 5 ml and not 10 ml of the sodium chloride 0.9% IV push.

During medication pass review with Staff D (Registered Nurse) on 8/15/13 at approximately 10:10 a.m., Staff D was observed to administer Levofloxacin 750 mg/150 ml IVPB (Intravenous Piggyback) to Patient #47 and set the pump delivery rate at 150 ml/hr (milliliters per hour).

During interview with Staff D on 8/15/13 after the medication was hung at the 150 ml/hr rate, the surveyor requested clarification of the administration rate as the surveyor had observed the physician order written in the COW (Computer on Wheels) and the label on the IVPB bag had a documented delivery rate of 100 ml/hour. Staff D confirmed the rate should be set at 100 ml/hr and was observed to return to the bedside of Patient #47 and reset the pump of the medication to a delivery rate of 100 ml/hr.

Review of physician orders for Patent #47 on 8/15/13 revealed an order signed by the physician on 8/14/13 for the following:

Levofloxacin I.V. 750 mg/150 ml D5W 100 ml/hr IVPB q 12 hours, infuse over 90 minutes.

The facility failed to follow written and signed physician orders for medication administration for Patient #40 and #47 as listed above.

Based on interview and record review the facility failed to ensure physician compliance with facility established policy and procedure for completion of chart documentation on discharged records.

Findings include:

Review of the MEDICAL STAFF RULES & REGULATIONS
"1. Admission...
2. Medical Records
The provider is responsible for the preparation of a complete medical record on his/her patient. All medical record entries are signed an dated be the provider...
A. Requirements
1.) A brief note is written and placed in the progress note on admission if the H&P is not available. The H & P must be performed no more 7 days before or written 24 hours of admission.
2.) Patients having surgery must have an H & P and/or an H & P addendum to a previously written H& P completed within 7 days prior to surgery and on the chart prior to the procedure. If the H & P is not available, then the hand written pre-operative note must be on the chart before the patient is admitted to surgery. Except in emergent circumstances, this note includes:...
Surgical cases, must have a brief post-operative note written immediately after surgery with post op diagnosis. A dictated operative note must be completed within 24 hours and signed within 72 hours of the operative procedure...
6.) A discharge summary is completed on all inpatients within 14 days of the patient's discharge. A brief discharge note is completed on all observation care patients within 14 days of the service, which includes: a) medical necessity for observation care, and b) a summary of the patient's course during their observation care...
C. Medical Record Completion
All records should be completed within 2 weeks of discharge, must be completed within 30 days. Notices will be sent to the member of the Medical Staff twice a week. On or about day 21 post discharge, the Director of Health Information service, or designee, will notify the Medical Staff President, or designee, of any records that remain deficient for an individual provider. The President of the Medical Staff, or designee, will contact the provider regarding the medical record deficiencies and expectation for completion within the next 7 days/within the 30 day time limit.

Providers with records incomplete more than 30 days after discharge are placed on Non-Admit status until the records are completed. While under Non-Admit status, a provider may not admit patients to the Hospital or perform schedule elective procedures, but must continue to provide care for those patients directly under his/her care prior to Non-Admit status and must continue to cover emergency call, including admitting patients while in that function..."

Review of the facility generated "Medical Record Deficiencies" report that was generated by Staff F, (Lead Coder) on 8/15/13 reveals the total number of violations for dictations and signatures deficiencies. The report revealed 11 physicians for a total number of 30 violations. The list also includes physicians that are travelers and no longer at the facility.

Patient #27
During review of Patient #27's medical record on 8/15/13 it was found that Staff H (ARNP, Referring Physician had written a discharge summary dated 7/13/13 which was the date of service. This same discharge summary report had not been signed as of 8/15/13.


Patient #28
During review of Patient #28's medical record on 8/15/13 revealed that Staff I (Medical Doctor) had written two Progress Notes dated 5/26/13 and 5/28/13 which were the date of services. These same Progress Notes have not been signed as of 8/15/13. An Operative Report dated 5/26/13 written by Staff I had not been signed by 8/15/13. A History and Physical written on 5/26/13 by Staff I had not been signed by 8/15/13.

Patient #29
Review of Patient #29's medical record on 8/15/13 revealed that Staff J (CRNA) had written a Consultation note dated 5/6/13 which was the date of service. This same Consultation note has not been signed as of 8/15/13. A History and Physical written on 8/5/13 by Staff K, (Medical Doctor) has not been signed by 8/15/13.


Interview with Staff F on 8/15/13, revealed that Staff F generates a reports that goes to Staff G (Medical Staff Coordinator) who then sends an email to the President of Medical Staff with the names of the physicians that have incomplete records.

Interview with Staff G, revealed that no physician has been placed on Non-Admit status. Review of several physician's files reveals no letters were sent to the physicians that were over the 30 days.


13504

Review of the facility's medical records revealed that Staff A (Surgeon) had written an operative report dated 4/10/13 which was the date of service. This same operative report was not signed until 6/12/13, almost two months after the transcribed report date.

Review of the surgical schedule for the month of May revealed that Staff A performed two surgical cases both dated 5/22/13. Both these surgical cases were beyond designated 30 day record completion period. According to Medical Staff Rules and Regulations incomplete records, results in suspension of admission privileges and elective surgery privileges, neither of which occurred.