HospitalInspections.org

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Based on record review and interview during the onsite Allegation Survey, the facility failed to ensure that the physician authenticated, dated and/or timed the Consents, Consultations, History & Physicals, Operative Reports and Physician Orders for fourteen (14) out of seventeen (17) medical records reviewed, as required by the facility's Bylaws (Patients #1,
#3, #13, #15, #16, #20, #23, #26, #27, #30, #31, #35, #36 and #45).

Findings:

Review of medical records revealed there were no physician signatures authenticating the dictated consult or Operative Report for Patient #3 on 03/15/11 and 03/23/11, Patient #23 on 03/31/11, Patient #26 on 04/02/11 and Patient #27 on 04/01/11.

Medical records with similar occurrences - Patients #16, #31 and #35.

Review of medical records revealed the Physicians' Orders were not signed by the physician for Patient #13 on 09/30/11, Patient #15 on 08/26/10 and Patient #36 on 03/29/11.

Review of medical records revealed the time and/or date was not documented on Physicians' Orders for Patient #1 on 03/28/11, 03/30/11, 03/31/11 and on 04/01/11 for four (4) separate orders.

Medical records with similar occurrences - Patients #3, #13, #15, #16, #20, #26, #30, #35 and #36.

Review of medical records for Patients #3, #25 and #30 revealed there was no documented evidence that the History & Physical (H & P) were authenticated by the physician.

Review of the current Medical Staff Bylaws under Section E Medical Records, documents that the practitioner of record is responsible for ensuring that "all clinical entries in the patients medical record shall be accurately dated, signed and should be timed."

Review of the policy entitled "Physician's Order Record/24 Hour Check" dated 03/01/2010, documented that the "Physician's name should be signed and the order will be dated and timed by the physician."

The findings were confirmed with the Director of Nursing of Intensive Care Services on 04/06/11 during the onsite visit.
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Based on record review and interview during the onsite Allegation Survey, the facility failed to ensure the Medical Staff secured autopsies in two (2) of seven (7) medical records reviewed as per Medical Staff Bylaws (Patients #15 and #16).

Findings:

Review of the medical records for Patients #15 and #16, revealed that the physician section of the "Expiration Progress Note" was blank and there was no documented evidence that the physician attempted to obtain an autopsy.

Review of the Medical Staff Bylaws: Rules and Regulation dated 2011, documented it shall be the duty of all Medical Staff members to attempt to obtain permission for an autopsy in all deaths except when the patient's religion or known wishes prohibits autopsy or it is legally prohibited.

This finding was confirmed with the Assistant Executive Director of Quality Management during the onsite visit.
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Based on record review and interview during the onsite Allegation Survey, the facility failed to ensure that the nurses in the Telemetry Unit consistently documented the interpretation of the cardiac rhythm and included the nurses' initial, date and time in five (5) out of five (5) records reviewed (Patients #24, #25, #26, #27 and #28).

Findings:

Review of the following medical records revealed that there is no documented evidence the nurses identified the cardiac rhythm, initialed, timed and/or dated the cardiac monitor strips for Patient #28 on 03/29/11 and 03/30/11 at 8:00PM, on 04/01/11 at 3:12PM, 6:54PM and 11:03PM, and on 04/02/11 at 8:15AM and 3:04PM, Patient #24 on 04/03/11 at 7:10PM, Patient #25 on 04/03/11 at 1:34AM, Patient #26 on 04/02/11 at 11:03PM and on 04/03/11 at 3:23PM and Patient #27 on 04/01/11 at 10:00PM, on 04/02/11 at 5:19AM and 11:03PM, on 04/03/11 at 7:01AM, 3:32PM and 11:09PM.

Review of the Policy entitled "AACN Procedure Manual for Critical Care: Nursing Procedures" in Section II - "Rhythm Strips" dated 12/10/10, documents that the nurse is to:

A. "Obtain and mount rhythm strips on all new admissions. Date and initial rhythm strips."

B. "Document rhythm strips at lease once a shift and when any change in patient's rhythm is detected."

Review of the job description of the "Monitor Tech/or Designee" documents that a cardiac monitor strip needs to be printed, reviewed, dated, timed, initialed by RN and affixed in the progress notes.

This was confirmed with the Cardiac Intensive Care Nurse Manager on 4/7/11 during the onsite visit.
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Based on record review and interview during the onsite Allegation Survey, the facility failed to ensure that medication reconciliations were completed on admission for eleven (11) of forty-five (45) medical records reviewed, (Medical Records #1, #2, #4, #5, #6, #7, #8, #9, #13, #15 and #45), and the medication reconciliation was incomplete at discharge for six (6) of eight (8) closed medical records reviewed (Medical Records #5, #6, #7, #8, #9 and #10) as per hospital policy.


Findings:

Review of Medical Record #45 revealed no admission medication reconciliation.

Review of Medical Records #1, #2, #4, #5, #6, #7, #8, #9, #13 and #15, revealed incomplete admission medication reconciliations.

Review of Medical Records #5, #6, #7, #8, #9 and #10, revealed incomplete discharge medication reconciliations.

Review of the hospital policy titled, "Medication Reconciliation" dated 03/2008, stated: "To prevent medication errors, Medication Reconciliation must be done every time there is a transition of care, when new medications are ordered or existing medications are rewritten."

"The Admission Medication Reconciliation Form is used by the facility to document the patient's current medications. The form is a part of the admission history and must be completed by the nurse or prescriber for every patient."

"When the patient is discharged, the prescriber will complete the patient discharge instructions sheet as indicated. The Admissions/Discharge Medication History Form must be reconciled and given to all patients at discharge."

This finding was confirmed with the Assistant Director of Quality Management during the onsite visit.
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Based on record review and interview during the onsite survey, the facility failed to ensure the nursing staff administered medications prescribed by the physician.


Findings:


Review of Medical Record #45 revealed that the patient presented to the Emergency Room on 01/03/11 after sustaining a fall in her home. The patient's past medical history included craniotomy for brain tumor and recurrent seizures. The physician admitted the patient at 3:45PM with a diagnosis of subdural hematoma.

Review of the physician's order sheet dated 01/03/11 timed 4:30PM, revealed the physician prescribed Keppra 1000mg oral twice daily, Trilepetal 600mg oral twice daily and Decadron 2mg oral twice daily.

Review of the Medication Administration Record dated 01/03/11 revealed the boxes requiring the nurse's initials were blank. There was no documented evidence that the patient received the medications.

A neurology consultation obtained on 01/04/11 at 1014 documented: "This patient was admitted to the hospital after a fall. She was in the ED and although her admission orders included her seizure medications, the patient was in the ED for an extended length of time and did not receive medications. Last night she had an episode of slurred speech and left sided weakness."

These findings were confirmed with the Assistant Director of Quality Management during the onsite visit.
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1. Based on record review, observation, and staff interview during the onsite Allegation Survey, the facility failed to ensure that medications were administered within the required time frame and administered medications were documented on the Medication Administration Record (MAR) as per hospital policy for six (6) out of the fourteen (14) records reviewed (Patients #6, #14, #15, #17, #18 and #19).

Findings:

During observations on 04/05/11 at 2:43PM, a review of the MAR for Patient #19 documented Lasix 40mg oral (PO) twice a day (BID) was to be administered at 10:00AM and 6:00PM. However, the 04/05/11 10:00AM Lasix box was blank although the medication was due four and three-quarters (4 ?) hours prior. At 2:43PM an interview with Patient #19's nurse, Staff Member #4, revealed the medication was not administered, he needed to obtain the medication from the pharmacy.

During observations on 04/05/11 at 3:15PM, a review of the MAR for Patient #17 documented Vancomycin 250mg PO/NGT every six (6) hours at 6:00AM,12:00PM, 6:00PM and 12:00AM. However, the 04/04/11 12:00AM and 04/05/11 6:00AM boxes were blank. At 3:15PM an interview with Patient #17's nurse, Staff Member #2, revealed she did not know if the medications were administered.

Medical records with similar occurrences - Patients #6 and #15.

During observations on 04/05/11 at 3:00PM, a review of the MAR for Patient #14 documented Asprin 81mg PO daily to be administered at 10:00AM. However, the 04/05/11 10:00AM box was blank. At 3:00PM an interview with Patient #14's nurse, Staff Member #2, revealed the medication was administered but she forgot to sign the MAR.

During observations on 04/05/11 at 3:20PM, a review of the MAR for Patient #18 documented Solumedrol 80mg PO every eight (8) hours at 6:00AM, 2:00PM and 10:00PM. However, the 04/05/11 6:00AM box was blank. At 3:20PM an interview with Patient #18's nurse, Staff Member #3 revealed when she called the night nurse at home, the night nurse told her she gave the medication but forgot to sign the MAR.

Review of the hospital policy entitled "Medication Administration Record: 24 Hour Medication Check" dated 2011, documented "the Medication Administration Record is utilized to assure that all medications administered by the nurse are documented. The nurse who administers the medication places his/her initial in the box corresponding to the date and time the medication was administered. Medications must be administered within the proper time frame which is one (1) hour before to one (1) hour after the time the medication is scheduled (ordered) to be given."


2. Based on record review and staff interview during the Allegation Survey the hospital failed ensure that the nursing staff implemented the facility's policy which requires the nurse who "picks up the order" indicate the actions taken then sign, time and date the order in four (4) out of forty-six (46) medical records reviewed (Patients #1, #15, #20 and #45).

Findings:

Review of physician's orders for Patient #15 dated 01/04/11 at 3:50AM, documented an order for a STAT CAT scan of the head. The physician's order form then documented on 01/04/11 at 4:20AM "transfer to ICU, MRI in the AM, neuro-checks every hour and neurology consult called by Dr. Shah."

Review of the progress notes dated 01/04/11 at 4:00AM, reveled that the physician assistant accompanied the patient to radiology for the STAT CAT scan of the head and when transferred to the ICU, the but there is no documentation by the nurse that the order was "picked up" as required by the hospital's policy.

Medical records with similar occurrences - Patients #1, #20 and # 45.

Review of the hospital policy entitled "Physician's Order Record" dated 03/01/2010 documented the nurse will pick up the physician's orders, sign his/her full name, title, date and time in the space provided and indicate the action taken next to each order.

These findings were confirmed with the Associate Executive Director of Patient Care Services during the onsite visit.
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Based on record review and staff interview during the onsite Allegation Survey, the facility failed to ensure that the telephone orders documented the recipient's name for two (2) out of eighteen (18) records reviewed (Patients #1 and #15) and that the telephone orders were authenticated by the prescribing physician within forty-eight (48) hours as per hospital policy for six (6) out of eighteen (18) records reviewed (Patients #1, #3, #12, #13, #15 and #16).

Findings:

Review of physician's orders for Patient #1 dated 03/03/11 documented a telephone order to "discontinue Morphine, give Vicodin 1 tablet every 6 hours as needed for pain and Xanax 0.25mg by mouth twice a day as needed for anxiety." There was no documented evidence of the recipient's name.

Medical record with similar occurrence - Patient #15.

Review of the physician's orders for Patient #3 dated 03/24/11 at 5:30PM documented a telephone order to "renew Vancomycin 25mg oral every 8 hours" which was not authenticated by the prescribing physician.

Medical records with similar occurrences - Patients #1, #12, #13, #15 and #16.

Review of the hospital policy entitled "Medication and/or Treatment Orders: Protocol For Verbal and Telephone Orders" dated 2010, documented when documenting a telephone order the recipient's name will follow the prescriber's name and "the prescriber must sign the order within as soon as possible, but no later than 48 hours after the order was issued."

These findings were confirmed with the Associate Executive Director of Patient Care Services during the onsite visit.