HospitalInspections.org

30196


A. Based on document review, observational tour, and interview it was determined for 1 of 3 (Pts #3) medical records reviewed, the Hospital failed to ensure the observation precautions were followed per policy and physician order.

Findings include:

1. Hospital policy entitled, "Observation Levels," (revised 11/19/12) required, "Policy...A. Three levels of staff monitoring are provided: 1. Standard Observation (assess and document at 15 minute intervals)... F. In addition to recording the whereabouts of patients at ordered intervals, the purpose of observations is to provide a system of progressive intensity of patient observation, precaution and oversight based on patient acuity and type of symptoms, and overall needs..."

2. On 11/16/15 at approximately 9:30 AM an observational tour was conducted on the Geriatric Psychiatric Unit. The findings were as follows:

3. Pt #3 was a 56 year old male admitted on 11/6/15 with orders for precautions including: suicide, fall, assault and "HP".

4. The precaution documentation record for Pt #3 dated 11/13/15 and 11/15/16 listed the precaution types as documented in the physician order, however a registered nurse (RN) (E #4) and another RN (E #5) could not clarify the HP precaution order, to determine the level of precaution needed.

5. On 11/16/15 at approximately 10:00 AM during the record review process the Program Director (E #1) verified these findings, but also could not clarify the HP precaution order. During an interview with E #1 at on 11/16/15 at approximately 10:30 AM, E#1 stated HP was meant to designate Homicide Precautions.

B. Based on document review and interview it was determined for 2 of 3 (Pts #1, #3) observational precaution records, the Hospital failed to ensure documentation on the observation flow sheet was completed per protocol.

Findings include:

1. On 11/16/15 the Hospital's revised precaution documentation record was reviewed. The record included a required registered nurse (RN) signature during each hour of observation. The precaution documentation records for Pts #1, #3 included the following:

- Pt #1's precaution documentation record dated 11/15/16 lacked hourly RN documentation for 1:00 AM, 2:00 AM, and 3:00 AM.

- Pt #1's precaution documentation record dated 11/16/15 lacked hourly RN documentation for 3:00 AM, 4:00 AM, and 5:00 AM.

- Pt. #3's precaution documentation record dated 11/13/15 lacked hourly RN documentation for 2:00 AM and 3:00 AM.

- Pt #3's precaution documentation record dated 11/15/15 lacked hourly RN documentation for 1:00 AM, 2:00 AM, and 3:00 AM.

2. On 11/15/16 at approximately 10:50 AM an interview was conducted with the Program Director (E #1). E # 1 stated the RN should document on an hourly basis on the precaution documentation record.

Based on document review and interview it was determined the Hospital failed to ensure medical records were completed within 30 days after the patient's discharge. This potentially affected all patients associated with the 517 delinquent records.

Findings include:

1. The policy entitled "SSH Medical Record Delinquency" (approved 9/1/15) was reviewed on 11/16/15 at 1:20 PM, and included, "Policy: A. The term 'deficient' or 'deficiency' or 'deficient medical record' refers to a medical record in which one or more components of the medical record have not been completed at the time of the patient's discharge. Medical records in this deficient status are referred to as deficiencies through the first 30 days after the patient discharge..."

2. On 11/16/15 at 1:15 PM, the Hospital presented an attestation letter dated 11/16/15, documenting the Hospital has a total of 517 delinquent records.

3. On 11/16/15 at 1:20 PM, an interview was conducted with the Health Information Manager (E #2). E #2 stated the delinquent number had been reduced to approximately 300 in October. The number has risen related to medical record upgrades.


30461

19840




19843


Based on document review, observation, and interview, it was determined for 1 of 7 (MD #1) staff in the semi-restricted gastrointestinal (GI) procedure room, the Hospital failed to ensure staff adhered to the surgical dress code policy.

Findings include:

1. Hospital policy titled, "Wearing Apparel in the Operating Room" [OR], (revised 10/14), was reviewed on 11/16/15 at 2:10 PM. The policy required, 1. All persons entering the operating room must be properly dressed 3. ...change into scrub attire, shoes, and hair covers...."

2. Hospital policy titled, "Traffic Patterns in Preoperative Practice Setting", (revised 10/14), was reviewed on 11/16/15 at 2:20 PM. The policy required, Policy: B. Semi-restricted area - This area is limited to authorized personnel and patients. Personnel are required to wear surgical attire and cover all head and facial hair..."

3. On 11/16/15 at 1:40 PM, an observational tour was conducted in the periopertive area. At 1:55 PM, a GI physician (MD #1) was performing a GI procedure without wearing a hair cover.

4. The OR Acting Charge Nurse (E #3) was interviewed on 11/16/15 at 2:00 PM. E #3 stated the GI procedure room was semi-restricted and did not know why MD #1 was not wearing a hair cover, which is required in the semi-restricted areas.