HospitalInspections.org

Based on MR review, review of P&P, and 2 of 2 interviews with staff (A and B), in 5 of 7 MRs of Pts eligible for Medicare (Pt. #1, 2, 4, 5, and 11) out of a total of 30 MR, the facility failed to ensure all Pts eligible for Medicare are provided "An Important Message From Medicare" (IM) notice within 48 hours of admission and within 48 hours of discharge.

Findings include:

Facility policy titled An Important Message from Medicare dated 7/1/07, reviewed by surveyor 18816 on 11/17/11 in the PM, states under Policy "It is the responsibility of the Admissions personnel to present (IM) to each inpatient with Medicare coverage, including Medicare HMO's. This must be done within 48 hours of admission..This does not pertain to swingbed patients." Under Procedure it states "If the patient stay continues for another 48 hours of the original signing, another IM must be presented, signed, dated, and copied for the patient." It was confirmed in interview with DON A 11/17/11 at 11:30 AM the IM has not been given to Swing Bed Pts.

Per Pt #1's (admitted on 8/4/11) MR review by surveyor 18816 on 11/16/11 at 9:40 AM, there is no documentation Pt #1 was given the IM within 48 hours of admission nor within 48 hours of discharge. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Per Pt #2's (admitted on 9/3/11) MR review by surveyor 18816 on 11/16/11 at 10:15 AM, there is no documentation Pt #2 was given the IM within 48 hours of admission nor within 48 hours of discharge. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Per Pt #4's (admitted on 9/7/11) MR review by surveyor 18816 on 11/16/11 at 11:10 AM, there is no documentation Pt #4 was given the IM within 48 hours of admission nor within 48 hours of discharge. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Per Pt #5's (admitted on 8/30/11) MR review by surveyor 18816 on 11/16/11 at 11:25 AM, there is no documentation Pt #5 was given the IM within 48 hours of admission nor within 48 hours of discharge. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Per Pt #11's (admitted on 4/7/11) MR review by surveyor 18816 on 11/14/11 at 2:15 PM, there is no documentation Pt #11 was given the IM within 48 hours of admission nor within 48 hours of discharge. This is confirmed in interview with RN B on 11/16/11 at 3:45 PM.

Based on observations made during a tour of the facility on 11/14/11 and 11/16/11 while the surveyor was accompanied by hospital staff, the hospital failed to ensure the construction and maintenance of the hospital met the requirements of the '2000 Edition' of the Life Safety Code "Existing Health Care Occupancy" of the National Fire Protection Association (NFPA) for safety of patients, staff, and visitors. Refer to the deficiencies in the Life Safety Survey Report Forms for complete details.

Findings include:
It was observed and confirmed by Maintenance Staff T, that the facility was not in compliance with the following Life Safety Code violations. See C231 and Ktags for details:
K18-Positive latching to corridors
K29- Hazardous Separation
K34-Stairways and discharge
K52-Fire Alarm System
K67-HVAC system
K76- Medical Gas storage
K77- Medical Gas system
K130-Miscellaneous violations

The hospital failed to ensure that the floors, walls, and film processing/developer room in the radiology department are maintained to promote the safety and well-being of patients and staff. See Tag C222

The hospital failed to ensure all surgical patient are protected from the threat of fire. See Tag C231.

The cumulative effect of environment deficiencies result in the hospital's inability to ensure a safe environment for all patients, staff and visitors.

Based on 2 of 2 observations, P&P review, and 1 of 1 staff interview (H) by surveyor
#13469, the hospital failed to ensure that the floors, walls, and film processing/developer room in the radiology department are maintained to promote the safety and well-being of all patients and staff.

Findings by surveyor #13469:
P&P review on 11/16/11 in the afternoon revealed that the "Safety Management and Environment of Care" policy last review date 8/2011 directs the following: "2. Safety Committee Functions: a. To identify areas that are high potential for accidents. d. To maintain a preventative maintenance program for all departments of the hospital."

Per observation, while touring the radiology department with Radiology Manager (H) on 11/16/11 at 10:10 AM, the Dexa room where bone density and mammogram studies are conducted has a floor in disrepair. The floor is stained, has holes, chips, tears, and plugs from an old x-ray table. In addition, the walls are scuffed and in need of painting.

During this same tour, the processing/developer room concrete floor under the processing/developer tanks is deteriorating. The floor has buckled and is severely stained. The bricks around the perimeter of the floor under the tanks are also deteriorating. They are chipped and cracked. The wood platform that holds the 10 gallon tanks is also deteriorating and is leaning forward which could lead to the tanks falling off the wooden platform and spilling their contents on the floor and staff.

The above examples were confirmed by Radiology Manager (H) during the tour.

Based on observations made during a tour of the facility on 11/14/11 and 11/16/11 while the surveyor was accompanied by hospital staff, the hospital failed to ensure the construction and maintenance of the hospital met the requirements of the '2000 Edition' of the Life Safety Code "Existing Health Care Occupancy" of the National Fire Protection Association (NFPA) for safety of patients, staff, and visitors. Refer to the deficiencies in the Life Safety Survey Report Forms for complete details.

Findings per surveyor #14105 include:
It was observed and confirmed by Maintenance Staff T, that the facility was not in compliance with the following Life Safety Code violations. See Ktags for details:
K18-Positive latching to corridors
K29- Hazardous Separation
K34-Stairways and discharge
K52-Fire Alarm System
K67-HVAC system
K76- Medical Gas storage
K77- Medical Gas system
K130-Miscellaneous violations

Findings by Surveyor #13469:

Based on 6 of 6 surgical patient MR reviewed (Pt. #6, 7, 8, 9, 10, and 21) out of a total of 30 MR reviewed, P&P review, and 2 of 2 staff interviews (A and C) by surveyor #13469, the hospital failed to ensure that surgical patients are protected from fire.

The Association for Operating Room Nurses (AORN) Perioperative Standards and Recommendations, 2008 Edition indicate:
IX.d.1. Waterless, brushless, surgical-scrub solutions should be allowed to dry completely to decrease the potential to produce ignition by static electricity or sparks.
IX.d.3. Provide adequate time for the flammable surgical prep solution to dry completely and any fumes to dissipate before applying surgical drapes, using an active electrode or laser, or activating a fiber-optic light cable.
IX.d.5. Drapes should not be applied until prep solutions are dry, to prevent the accumulation of volatile fumes beneath them.

P&P review on 11/16/11 in the afternoon revealed that the "Safety Management/Environment of Care" policy last review date 8/2011 directs the following: "2. Safety Committee Functions: i. To maintain a life safety management program designed to protect patient, personnel, visitors and property from fire and the products of combustion's."

Per operating room P&P review, on 11/16/11 in the AM, the operating room policies do not include a policy to reduce the risks of fires due to the use of alcohol-based skin preparations in anesthetizing locations.

The hospital surgery P&P do not include the following guidelines:

A Using skin prep solutions that are 1) packaged to ensure controlled delivery to the patient in unit dose applicators, swabs or other similar applicators: and 2) provide clear and explicit manufacturer/supplier instructions and warnings. These instructions for use should be carefully followed.

B Ensuring that the alcohol-based skin prep solution does not soak into the patient's hair or linens. Sterile towels should be placed to absorb drips and runs during application and should then be removed from the anesthetizing location prior to draping the patient.

C Ensuring that the alcohol-based skin prep solution is completely dry prior to draping. This may take a few minutes or more, depending on the amount and location of the solution. The prepped area should be inspected to confirm it is dry prior to draping.

D Verifying that all of the above has occurred prior to initiating the surgical procedure. This can be done, for example, as part of the standardized pre-operative " time out " used to verify other essential information to minimize the risk of medical errors during the procedure.

In addition, the facility failed to document the implementation of these policies and procedures in the patient's MR.

Per interview, with OR Director (C) on 11/15/11 at 10:00 AM, the hospital operating room P&P do not address the use of alcohol-based skin preparations in anesthetizing locations. The surgery department does use the following alcohol based skin preps: Dura prep, Chlorhexidine, and Povidone-Iodine.

The following MR were reviewed between 11/14/11 at 2:20 PM and 11/17/11 at 1:45 PM: Pt. #6 who had surgery on 6/1/11, Pt. #7 who had surgery on 12/30/11, Pt. #8 who had surgery on 1/24/11, Pt. #9 who had surgery on 7/6/11, and Pt. #10 who had surgery on 8/3/11. Per MR review, intra-operative notes indicate that Chloreprep was used as a skin prep for Pt. #6, 7, 8, and 10, and Chloreprep and Providone Iodine was used as a skin prep for Pt. #9 The intra-operative notes do not identify if the staff ensured that these alcohol-based skin preps were dry prior to draping.

These examples were confirmed by DON (A) on 11/17/11 at 2:10 PM.

Example by surveyor 18816:
Per Pt #21's MR review by surveyor 18816 on 11/15/11 at 8:45 AM, the Perioperative documentation indicates a time out was conducted on 1/14/11 at 7:00 AM for a scheduled cesarean section. The Intraoperative documentation indicates Chloraprep, an alcohol based skin preparation, was used. There is no documentation the Chloraprep was dry prior to draping, allowing for potential fire hazard. This is confirmed in interview with DON A on 11/17/11 at 7:30 AM.

Based on observations, P&P review, 30 of 30 MR review, and staff interviews, the hospital is not organized in a manner to support it's policies and procedures and current standards of practice.

Findings include:
The GB (governing body) failed to assume responsibility for the hospital's total operation. See Tag C-241

The cumulative effect of these systemic problems resulted in the facility's inability to ensure safe and optimal patient care.

Based on observations, P&P review, staff interviews, and 30 of 30 MR review, the GB (governing body) failed to assume responsibility for the hospital's total operation. This affects all current and future patients and staff.

Findings include:

The GB failed to ensure the hospital environment and physical plant is safe. See Tag C220

The GB failed to ensure all hospital-wide services are compliant. See Tag C270

The GB failed to ensure there are accurate and concise medical records systems. See Tag C300

The GB failed to ensure that surgical patients are protected from fire. See Tag C-320

Based on 28 of 30 MR review, P&P review, observations and interviews with facility staff, the hospital failed to ensure that patient services are provided appropriately and in a safe manner. This affects all current and future patients.

Findings include:

1. The hospital failed to ensure there is a P&P committee that includes a community member to develop and review P&P's as necessary. See Tag C-272

2. The hospital failed to ensure that drugs and biological's are monitored and provided in a safe manner. See Tag C-276

3. The hospital failed to ensure that staff follow current infection control practices, that chemicals and disinfectants used in the facility are appropriate and used per manufacturers directions, and failed to have an on-going surveillance program to prevent sources of contamination and infections. See Tag C-278

4. The hospital failed to ensure that food is stored in a safe manner, surfaces are cleaned with an approved disinfectant, and tasks are performed in a sanitary manner. See Tag C-279

5. The hospital failed to ensure that laboratory staff are protected from exposure to hazardous chemicals. See Tag C-282

6. The hospital failed to ensure that MD orders are timed and dated when entered into the MR, that TO, VO, and SO MD authentication include a time and date to ensure accuracy of the orders within 24 hours, and that RN transcription of TO, VO and SO is complete. See Tag C-297

7. The hospital failed ensure that comprehensive nursing care plans are developed for each patient and are entered into the MR. See Tag C-298

The cumulative effect of these systemic problems resulted in the facilities inability to ensure safe and optimal patient care.

Based on 2 of 2 staff interviews (A and B) the facility failed to ensure there is a P&P committee that includes a community member to develop and review P&P's as necessary. This deficiency potentially affects all 6 inpatients at the facility during survey.

Findings include:
Per surveyor 18816 interview with DON A and ICO B on 11/16/11 at 2:00 PM, DON A and ICO B confirmed there is no committee that includes a community member to develop and review policies, rather the policies are reviewed and revised by the individual departments.

Based on observations, review of contracts, P&P review, and interviews with staff, the facility failed to ensure that drugs and biological's are provided in a safe manner. In 3 of 3 interviews (J, C, and U) the facility failed to ensure oversight of the pharmacy by the consulting pharmacist. In 2 of 2 tours, the facility failed to ensure outdated medications are not available to Pts. In 1 of 3 departments where controlled substances are stored and 1 of 1 interview (A), ED controlled substances are not monitored per P&P. In 1 of 1 observation and 3 of 3 interviews (C, D, B), multiple dose vials are accessed and stored in immediate patient treatment areas. These deficient practices potentially affected all 6 inpatients at the facility during survey.

Findings include:

Facility policy titled Outdated Drug Control revised 6/13/11, reviewed by surveyor 18816 on 11/17/11 in the PM, states under Procedures: 1. "The pharmacy personnel will constantly check all medication physically for dated items and remove all outdated packages from the shelves. 2. Full packages of outdated items will be isolated from dispensing stocks and returned to the source of supply..."

Per surveyor 18816 interview with P J on 11/15/11 at 11:00 AM, P J could not describe or explain the following: The process for reviewing narcotic counts; the process for reviewing the nurse log and medications removed from the medication room; if there were any herbal or homeopathic drugs used in the facility; the medication error process for reporting and investigation; if there were sample drugs in the facility; if there were any narcotics diverted adding he did not review the count sheets; how expired medications are disposed of; and if there were stop orders for medications.

P J stated in the interview he did not oversee Radiology, Emergency Room or Operation Room medications; RN's preparation of carcinogenic drugs; he does not review medication refrigerator temperatures; and gave conflicting statements regarding where medications were prepared by staff, under hood or not.

Per interview, with OR Director (C) on 11/15/11 at 10:00 AM by surveyor #13469, the contracted pharmacist has never come into the OR that she is aware of to ensure that drugs are stored, monitored and administered appropriately.

Per tour in the Medication room with P J on 11/15/11 at approximately 11:30 AM, P J and surveyor 18816 compared narcotic counts to the sign out log completed by RNs. The log showed 3 Fentanyl Patches removed on 10/20/11, the Controlled Substance-Proof-Of-Use Sheet showed 3 Fentanyl Patches removed at 10:00 AM on 10/20/11 and 1 Patch removed at 2:00 PM on 10/20/11. The actual count of the patches was 1 remaining, matching the proof of use sheet, but the log had no documentation of the 2:00 PM patch being signed out.

Additional observations in the medication room included: One bottle of 100 proof alcohol, and one bottle of Brandy, neither had a "proof of use" sheet or means to ensure accountability and dispensing; the supply shelves had 2 vials Levothyroxine were expired 10/11; 3 vials of Ipecac expired 10/11; one vial carcinogenic medication Oxaliplatin expired 10/11 and 2 vials carcinogenic medication Gemcitabine expired 8/11.

Per surveyor review, on 11/17/11 in the PM, the facility contract with P J, dated 3/3/08, it states under #3 "Mr (J) will continue to ensure that the pharmacy is in compliance with all State, Federal, and Joint Commission (JCAHO) requirements."

Per surveyor 18816 interview, via phone call on 11/15/11 at 3:12 PM, with State of Wisconsin Pharmacist U, a contracted pharmacist is required to oversee all areas related to pharmacy including: Medication review, medication administration, all medications in all departments, and have knowledge of the processes in the facility related to medications.



13469

Findings per surveyor 313469:

P&P review on 11/17/11 in the AM revealed that the "Multi-dose vial usage/safe injection policy" last review date 7/12/11 directs the following: "Procedure: Safe Injection Practices: G. Dedicate multi-dose vials to a single patient whenever possible. If multi-dose vials well be used, the vial should be stored in centralized medication area and not enter the immediate patient room."

1. While touring the OR, with OR Manager (C) and CRNA (D) on 11/15/11 at 10:30 AM, CRNA (D) was noted to have two open multidose vials in his anesthesia cart (Neostigmine and Versed ). Per interview with CRNA (D) at the time of the observation, he prepares syringes from these multidose vials in the OR at the patient's bedside. Per (D), the multidose vials are then returned to the anesthesia cart to be used for future patients. Per (D), he was not aware that multidose vials should not be drawn-up and then kept in the immediate patient treatment area.

Per APIC (association for professionals in infection control and epidemiology) position paper 2010 "Safe Injection Practices" directs the following: "keep multi-dose vials away from the immediate patient environment" if the multiple dose vial is used for more than one patient.

Per CDC guidelines for safe injection practices: IV.H.7. Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer's recommendations; discard if sterility is compromised or questionable 453, 1003. Category IA

Per interview, with Infection Control Officer (B) on 11/15/11 at 9:00 AM, the facility follows CDC and APIC guidelines.

2. Per review of the controlled substance count sheets on 11/14/11 at 2:00 PM, the ED controlled substances are counted by only one RN instead of two, and are not counted at least daily.

The above example was confirmed in interview with DON (A) on 11/14/11 at 3:15 PM.

P&P review on 11/17/11 in the AM revealed that the "Narcotic Count" policy last review date 9/08 directs the following: Narcotic count must be completed at the beginning of each shift by a professional staff member from each shift."

Based on 13 of 13 observations, P&P review, and 14 of 14 staff interviews (C, D, B, O, V, A, F, G, H, M, R, Q, P, and K), the hospital failed to ensure that the OR is protected from unauthorized access, that all incidents related to infections and communicable diseases are monitored, that chemicals and disinfectants used in the facility are used per manufacturers directions and are authorized by the IC committee, that items exposed to body fluids and human waste are disposed of properly, that substerile and sterile areas of the OR are protected from dust, debris and cross-contamination, that patient supplies are kept clean, that linen is protected from dust, debris and cross-contamination, that staff follow universal precautions and isolation procedures, and that staff follow sterile dressing procedures per standards of practice and facility P&P.

This deficiency directly affects all six inpatients and one outpatient treated at the facility during survey, and directly affects 1 outpatient treated during the survey.

Findings by surveyor #13469:
P&P review on 11/16/11 in the afternoon revealed that the "Safety Management/Environment of Care" policy last review date 8/2011 directs the following: "1. To provide a safe environment for care of our patients in order to insure optimum healing conditions."

1. Per observation, while touring the OR with OR Director (C) and CRNA (D) on 11/15/11 at 10:30 AM, it was noted that the door leading directly into the substerile corridor of the OR suite does not alert all staff and visitors that only those with proper attire can proceed through the door. This OR entrance is located in an exit hallway and right next to the emergency department. This example was confirmed by (C) and (D) during the tour.

2. Per interview, with ICO (B) on 11/15/11 at 9:00 AM, it was revealed that (B) is keeping a log of nosocomial infections only. Per (B), the hospital is not keeping a log and monitoring all incidents related to infections and communicable diseases, including those identified through employee health services, contract staff, and volunteers.

3. Per interview, with ST (O) and ST/RN (V) on 11/16/11 at 2:30 PM, the brushes used to remove bioburden from surgical instruments are soaked in Quat disinfectant cleaner after use. After reviewing the MSDS sheet on the products use with (O) and (V) it was determined that this product is a Category 1 cleaner for surfaces only. There are precautions for exposure to skin, eyes, ingestion, and respiratory protection. This products use to clean brushes after cleaning surgical instruments is not appropriate. This was confirmed with (O) and (V) on 11/17/11 in the AM.

4. Per interview, with ST (O) and ST/RN (V) on 11/16/11 at 2:30 PM, the sponge to wipe down endoscopes immediately after use, the brushes that are run through the scopes, and the 20 cc syringes used to flush the scopes are discarded into regular open garbage cans. The sponges, brushes and syringes have been exposed to body fluids and human waste and therefore should be disposed of into closed, leakproof, and labeled or color-coded waste containers per OSHA guidelines for bloodborne pathogens 1910.1030(d)(4)(iii)(B)(1) and (1)(i), (1)(ii), and (1)(iii).

5. Per interview, with ST (O) and ST/RN (V) on 11/16/11 at 2:30 PM, the endoscopes used for esophagogastroduodenoscopys and colonoscopies are flushed and suctioned with a tubing run from the operating room suite, out the door, across the floor of the sub-sterile hallway and into the decontamination room. As this is happening, the OR is being cleaned and prepared for the next case. This procedure keeps the OR suite door open a crack allowing cross-contamination and is a hazard for tripping.

6. Per observation, while touring the OR with OR Director (C) on 11/15/11 at 11:30 AM, it was noted that the decontamination room (for used surgical instruments and endoscopes) does not have a door on it. This room leads directly into the sub-sterile hallway. As a result, the negative air pressure cannot be maintained when the OR suite door or exit hallway door is opened allowing for cross-contamination.

7. Per observation, while touring the OR with DON (A) and Surveyor #14105 on 11/16/11 at 9:15 AM, it was noted that clean patient supplies were kept in cupboards in the decontamination room. Per interview with DON (A) during the observation, clean supplies should not be kept in the decontamination room.

8. Per observation, while touring the OR with OR Director (C) on 11/15/11 at 11:30 AM, there were 4 E tanks of medical gas located in the decontamination room. Two oxygen, one nitrous oxide and one nitrogen tank. These tanks are taken directly into the sterile OR suite for use. The tanks are potentially contaminated and are taken from a dirty room to a sterile room.

9. Per observation, while touring the OR with OR Director (C) on 11/15/11 at 11:30 AM, housekeeping supplies are stored throughout the decontamination room on shelves, and the floor. There is potential for cross-contamination to the supplies used to clean the surgery department.

10. Per observation, while touring the clean linen storage room in the basement on 11/15/11 at 2:25 PM with Director of Housekeeping/Laundry (F), housekeeping chemicals, supplies and cleaning carts are also stored in the linen storage room. The linen carts are not covered and are therefore exposed to dust and debris with the housekeeping traffic and cleaning carts stored in the room.

During this observation, it was revealed that staff use a wedge to keep the door propped open a few inches as the door self-locks when closes. Keeping the door open allows dust and debris to enter the room and contaminate the clean linen that is not covered.

During this observation, it was noted that the shelves of cleaning supplies contained bottles of the following: 3M Creme cleaner which is used on sinks, Lysol disinfectant spray used to spray in the air when there is an odor and used on pillows, Shine up -Lemon Furniture polish which is used on stainless steel, comet cleaner with bleach used for bathrooms and Propower Stainless steel cleaner and polish. When Director (F) was asked if these products had been cleared for use in a hospital setting by the infection control committee she said "probably not".

Per interview with ICO (B) on 11/15/11 at 3:40 PM, (B) indicated that housekeeping supplies should not be kept in the same room with the linen and housekeeping staff were informed of this when the supplies were moved in there. In addition, per (B) she was aware of the products listed above and informed the housekeeping director that they have not been approved by the IC committee and should not be used until they have been reviewed for appropriateness in a hospital setting.

11. Per observation, while touring some housekeeping supplies in the basement on 11/15/11 at 2:25 PM with Director of Housekeeping/Laundry (F), it was noted that a large room containing food storage for the dietary department had been divided and a shelving unit separated the two which was open two feet to the ceiling. This housekeeping supply shelving unit is accessed from a hallway allowing dust and debris to enter the dietary food supply area.

12. Per interview, with Director of Housekeeping/Laundry (F) at 2:25 PM on 11/15/11, it was revealed that housekeeping staff are not doing quality control checks on the automated dispensing systems of the cleaning products used throughout the facility. As a result, the hospital cannot ensure that the products are dispensed according to manufacturers concentrations.

13. Per observation, while touring the therapy department with PT (G) on 11/16/11 at 11:00 AM, it was noted that the department contained one stuffed pheasant, one stuffed goose and two stuffed ducks that are not washable and allow for the collection of dust and debris.

14. Per observation, while touring the radiology department with RT Manager (H) on 11/16/11 at 10:10 AM, it was noted that oxygen tubing had been removed from its plastic container and connected to a wall oxygen supply meter. The end of the tubing was exposed and not protected from dust and debris entering the tubing end which could be blown into a patients lungs. Per interview with (H) during the tour, (H) said she did not know how long the tubing was hanging exposed to dust and debris.

During this same tour, the CAT (computerized axial tomography) room had a suction machine used for patients sitting on the floor allowing for cross-contamination. Per interview with (H), the machine should not be on the floor.


18816

Examples by surveyor 18816:

Facility policy titled Collection Instructions for Venous Blood Samples, review date 3/11/11, reviewed by surveyor 18816 on 11/17/11 at 3:00 PM, revealed there are no instructions where to set up supplies for a draw, and does not instruct to remove lab coat used in the hospital when returning to the lab.

Facility Personnel Requirements, n.d., reviewed by surveyor 18816 on 11/17/11 at 3:00 PM, states under B. Uniforms 3. "Disposable lab coats must be worn when testing or drawing patient samples."

Facility policy titled Prevention of Wound Infections dated 11/01/04, reviewed by surveyor 18816 on 11/17/11 at 3:00 PM, states under I.B. "Persons taking care of wounds can reduce risks by washing hands and using instruments to handle dressings. If touching the wound is necessary, wear sterile gloves...E. Standard precautions should be followed with all patients."

Facility Competency Statement 65-B.07a&b titled Performs Wound Care Sterile Dressing Change & Supplies, n.d., reviewed by surveyor 18816 on 11/17/11 at 3:00 PM, states under Policy: "Staff member will use sterile dressing technique for dressing changes unless indicated by physician." Under Steps it states 3. "Prepare a clean, dry work area at bedside. Use disinfectant solution to prepare work surface....7. Place linen saver or towel under the patient...10. Open sterile huck towel or other sterile barrier (glove cover) for the table...13. Clean wound with normal saline or prescribed cleanser..."

Facility Competency Statement 65-B.02b titled Maintain/Insert IV dated 11/2/07, reviewed by surveyor 18816 on 11/17/11 at 3:00 PM, states under #3. "Washes hands thoroughly....6. Puts on non-sterile gloves..."

Per surveyor 18816 interview with ICO B on 11/17/11 at approximately 3:15 PM, the competencies are in place of P&P for the facility.

The following was observed by surveyor 18816 on 11/16/11 and 11/17/11:

1. On 11/16/11 at 10:55 AM PHL M performed a blood draw on Pt #3. PHL M donned gloves gathered supplies from the lab tray, including tape, and coban (to secure the gauze rather than a Band-Aid) and placed them on Pt #3's bed. After completing the blood draw PHL M, with gloves still on, removed a pens from her pocket, documented on the lab tubes, picked up the unused supplies from the bed and placed them back in the lab tray for future use on another patient. PHL M then removed gloves and washed hands. PHL M returned to the lab, without the benefit of wearing gloves, removed the same pen from the pocket and documented on the order sheet, left the lab to copy the sheet in another room, returned and removed the blood tubes from the tray and placed in centrifuge and/or handed to other lab staff. PHL M did not remove the lab coat worn in Pt #3's room when she returned to the lab. Per interview with ICO B on 11/16/11 at 3:30 PM, the PHL should have removed her lab coat upon entering the lab.

2. On 11/17/11 at 10:00 AM, MD R was observed sitting on Pt #3's bed and performing an examination of lung and heart sounds. A sign on Pt #3's door indicates contact precautions (who was on precautions for Staphylococcus infection), and a cart with PPE (Personal Protective Equipment) for staff use is outside the door. MD R did not have on PPE or gloves. MD R did not wash his hands or clean the stethoscope with a disinfectant prior to leaving Pt #3's room. This was confirmed with RN P at 10:00 AM during the observation.

3. On 11/17/11 at 10:00 AM RN P and CRN Q completed what RN P called a sterile dressing change for Pt #3, who was on precautions for Staphylococcus infection. RN P gathered supplies, removed Pt #3's personal items from the bedside table and proceeded to set up for the dressing change.

RN P did not place a sterile drape prior to setting down supplies. RN P changed gloves without the benefit of washing her hands, did not wear a mask, did not place a drape, or protectant under the foot with the wound, and removed the old dressing, pulling the medicated gauze from the wound with her fingers.

RN P changed to sterile gloves, washing hands between. CRN Q, assisting RNP, donned sterile gloves and moved the garbage can using her left hand, and with the now contaminated gloves picked up and opened the cotton applicator for RNP to use to insert the medicated gauze into the wound. After RN P inserted the new medicated gauze in the wound, CRN Q, wearing the same contaminated glove, opened the 4x4 gauze dressing for RN P, and held it in place against the wound, with the contaminated hand, while RN P wrapped the wound in Kerlix gauze.

Once the procedure was done, RN P changed gloves without washing her hands and began removing supplies and replacing Pt #3's personal items back to the beside table. CRN Q removed gloves and began handling the trash bags for disposal without donning new gloves.

RN P was not observed to clean the wound in any manner prior to inserting new medicated gauze per policy.

4. On 11/17/11 at 10:40 AM RN K was observed completing an IV (Intravenous) start for outpatient Pt #31. After adding Venofer (iron supplement) to the IV bag, RN K gathered supplies and entered the room with Pt #31. RN K proceeded to start the IV without the benefit of washing hands or donning gloves. After initiating the IV treatment, RN K , without donning gloves gathered all the supplies including the contaminated needle for disposal and left the room without washing her hands.

Based on observation, review of P&P and 2 of 2 interviews with staff (N, F), in 2 of 2 observations (N) the facility failed to ensure food is stored in a safe manner, surfaces are cleaned with an approved disinfectant, and tasks are performed in a sanitary manner. This deficiency potentially affects all 6 inpatients at the facility during survey.

Findings include:

Facility policy titled Health and Grooming of Personnel, revised 9/30/08, reviewed by surveyor 18816 on 1/16/11 in the PM, states under 2. "All clean clothes, lab coats , or aprons are to be changed into at work and must be cleaned daily or more often as necessary."

Facility policy titled Daily Cleaning Procedures, revised 9/30/08, reviewed by surveyor 18816 on 11/16/11 in the PM, states under 4) Work Counters A. "Must be washed frequently throughout shift, with Microquat, (using 1/3 oz. Microquat per 1/2 gallon water). B. Counters must be sanitized at the end of each shift using 1/3 oz. Microquat per 1/2 gallon water."

Per surveyor 18816 observation on 11/15/11 at 7:3 0 AM, the refrigerators and freezers contained the following unlabeled food stuffs: Shrimp, chicken, ham, bacon, turkey, squash, and brown sugar mixture. The following items in the refrigerator did not have open dates identified to track for disposal: Cottage cheese, sour cream, Ranch dressing. The refrigerator also contained a large uncovered can of grease next to ready to eat food.

During this same observation, at approximately 7:45 AM C N dished up poached eggs, hard boiled eggs and hot cereal into bowls and placed them on a serving counter accessible to the corridor for employees. The items remained on the counter for 1/2 hour with no means to maintain heat, then the poached eggs were disposed of at 8:00 AM, the remaining food was placed on a tray and in a refrigerator by DM F.

Survey 18816 observation of C N preparing a casserole on 11/15/11, at 8:00 AM, C N mixed rice and meat wearing gloved hands, removed the gloves, washed, after drying, placed the paper towels on a cart, donned clean gloves and picked up the used paper towels for disposal thus contaminating the clean gloves.

At 9:30 AM, C N was observed cleaning a counter where bread dough was just kneaded, using a mixture of Mikro-Quat. Per the Mikro-Quat label it states "Light-Duty Cleaning and Sanitizing-Non-Food contact Surfaces...Use 1/3 oz. Mikro-Quat per gal. (235 ppm) of warm or hot water..." When asked concentration of Mikro-Quat at 9:30 AM, C N said one squirt to into a sherbet bucket (1 gal.) DM F measured "one squirt" to be 1/2 oz, and confirmed the bucket was approximately 1 gallon.

Per interview with DM F during the observation, the Mikro-Quat was approved by the IC committee. Follow up with DM F on 11/16/11 at 10:45 AM, the appropriate cleanser should be Oasis 146, Multi-Quat Sanitizer, not Mikro-Quat. Per interview with ICO B on 11/15/11 at 9:50 AM, the Mikro-Quat was not approved by the IC committee for use in the kitchen.

Per surveyor 18816 observation on 11/15/11 at 9:30 AM, C N performed dishwashing tasks. C N did not wear an apron to protect her clothing, had the water pressure high, causing spray and food debris to cover the front of her scrub. When the trays of dishes finished in the dishwashing cycle, C N wearing dishwashing gloves used for pre-scrub, would pull the clean dishes from the washer, touching and contaminating the clean dish in the corner of the tray. This was repeated for 4 trays. C N when finished with the pre-scrub, still wearing the dishwashing gloves, picked up the metal Pt identifier and condiment holders, that had been within 3 feet of the spray, and carried them to the kitchen tray line area. C N returned to the dishwashing area, removed the gloves and began spraying down the cart to transport food. Within 2 feet of the food cart cleaning area, there is a 2 tiered cart with clean rags for cleaning, allowing for potential contamination from the spray during cleaning the food cart. These practices allow for potential cross contamination.

During the entire observation from 7:30 AM to 8:30 AM and at 9:30 AM the shutter was open at the serving window that opens directly to a public hallway allowing for potential contamination in air flow to enter the kitchen area during preparation and tray line.

Based on observation, P&P review, and 1 of 1 staff interview (E) by surveyor #13469, the hospital failed to ensure that all laboratory staff are protected from exposure to hazardous chemicals.

Findings include:
Per observation, while touring the laboratory with Lab Manager (E) at 1:30 PM on 11/15/11, it was noted that the laboratory has a refrigerator that contained food for staff. In addition, the following personal items of staff were found in the laboratory: a coat and a backpack laying on the floor.

Per review of laboratory P&P on 11/15/11 in the afternoon, the "Department Plan and Standards" policy last review date 5/11/11, directs the following: "III. Personnel Requirements: F. No food, drink, smoking or applying makeup is allowed in the lab. See Chemical Hygiene Plan."

Review of the OSHA exposure to hazardous chemicals in laboratories chemical hygiene plan on 11/16/11 directs the following: "3. Standard Operating Procedures. B. 5. Do not store, handle or consume food or beverages in storage areas, refrigerators, glassware or utensils that are also used for laboratory operation."

Per interview, with Lab Manager (E) on 11/16/11 in the AM, staff food and personal items should not be kept in the laboratory.

Based on 28 of 30 MR reviewed (#6, 7, 8, 9, 10, 17, 18, 19, 20, 1, 2, 3, 4, 5, 11, 12, 15, 16, 21, 2 2, 23, 24, 25, 26, 27, 2 8, 29, 30), P&P review, review, and 4 of 4 staff interviews (A, B, C, P), the hospital failed to ensure that MD orders are timed and dated when entered into the MR, that TO, VO, and SO MD authentication include a time and date to ensure accuracy of the orders within 24 hours per medical staff rules and regulations, and that RN transcription of TO, VO and SO is complete.

Findings include:
Examples by surveyor #13469:
P&P review on 11/16/11 in the AM revealed that the medical records policy effective date 3/31/93 directs the following: "14. All physician orders should include a date, time and signature."

Per review of medical staff rules and regulations on 11/15/11 in the PM page 42 directs the following: "24. An order shall be considered to be in writing if dictated to a RN and signed by the attending physician or dentist within twenty-four (24) hours."

The following MR were reviewed between 11/14/11 at 2:20 PM and 11/17/11 at 1:45 PM: Pt. #6 who had surgery on 6/1/11, Pt. #7 who had surgery on 12/30/11, Pt. #8 who had surgery on 1/24/11, Pt. #9 who had surgery on 7/6/11, Pt. #10 who had surgery on 8/3/11, Pt. #13 who was seen in the ED on 5/20/11 and then transferred, Pt. #14 who was seen in the ED on 4/21/11 and then discharged, Pt #17 who was seen in the ED on 8/16/11 and then transferred, Pt. #18 who was seen in the ED on 4/12/11, admitted and then transferred, Pt. #19 who was seen in the ED on 4/17/11 and then discharged, Pt. #20 who was seen in the ED on 5/1/11 and then discharged.

1. TO, VO, and SO are countersigned by the MD. The countersignature does not include the time and date when the MD validated the orders. As a result, it is unclear if the orders were countersigned within 24 hours per medical staff rules and regulations. Examples include:

Pt. #6 TO, VO, and SO orders dated 6/1/11, TO dated 6/2/11, and VO dated 6/3/11,
Pt. #7 VO's dated 12/30/11, Pt. #8 VO dated 1/24/11 and 1/25/11, Pt. #10 VO dated 8/3/11, Pt. #18 TO dated 4/12/11 and VO dated 4/13/11. These examples were confirmed by DON (A) on 11/17/11 at 2:10 PM.

2. VO's dated 8/3/11 at 5:00 PM found in the MR of patient #10 were not countersigned and validated by the MD at the time of the record review on 11/17/11 at 10:00 AM. These examples were confirmed by DON (A) on 11/17/11 at 2:10 PM.

3. Nursing staff accepting VO, TO and SO documentation is incomplete. Examples include:

Pt. #6 VO dated 6/1/11 does not include the time the VO was received from the MD by the RN.

Pt. #7 VO dated 12/30/11 does not include the time the VO was received from the MD by the RN.

Pt. #8 VO dated 1/24/11 completed by the RN reads as follows: "VO P. CRNA/ and then the RN name." The nurse does not identify the name of the CRNA or time the VO.

Pt. #9 VO dated 7/6/11 does not include the time the VO was received from the MD. VO dated 1/24/11 and 1/25/11 obtained from the MD by the RN does not identify the time the orders were received.

The above examples were confirmed by DON (A) on 11/17/11 at 2:10 PM.

4. ED MD orders authenticated by the MD do not include a date and a time for Pt. #6, 17, 18, 19, and 20. These examples were confirmed by DON (A) on 11/17/11 at 2:10 PM.


18816

Examples by surveyor 18816:
1. Orders not authenticated with a signature, date and/or time:
Per Pt #1's MR reviewed by surveyor 18816 on 11/16/11 at 9:40 AM, there are VO, TO and/or SOs, written between 8/4/11 and 8/9/11, that are not authenticated by the MD with a signature, date and/or time within 24 hours of the written order, per staff rules and regulations. This is confirmed in interview with DON A, on 11/17/11 at 11:30 AM.
Per Pt #2's MR reviewed by surveyor 18816 on 11/16/11 at 10:15 AM, there are VO, TO and/or SOs, written between 9/3/11 and 9/10/11, that are not authenticated by the MD with a signature, date and/or time within 24 hours of the written order, per staff rules and regulations. This is confirmed in interview with DON A, on 11/17/11 at 11:30 AM.
Per Pt #4's MR reviewed by surveyor 18816 on 11/16/11 at 11:10 AM, there are VO, TO and/or SOs, written between 9/7/11 and 9/23/11, that are not authenticated by the MD with a signature, date and/or time within 24 hours of the written order, per staff rules and regulations. This is confirmed in interview with DON A, on 11/17/11 at 11:30 AM.
Per Pt #5's MR reviewed by surveyor 18816 on 11/16/11 at 11:20 AM, there are VO, TO and/or SOs, written between 8/30/11 and 9/2/11, that are not authenticated by the MD with a signature, date and/or time within 24 hours of the written order, per staff rules and regulations. This is confirmed in interview with DON A, on 11/17/11 at 11:30 AM.
Per Pt #11's MR reviewed by surveyor 18816 on 11/14/11 at 2:15 PM, there are VO, TO and/or SOs, written between 4/7/11 and 4/10/11, that are not authenticated by the MD with a signature, date and/or time within 24 hours of the written order, per staff rules and regulations. This is confirmed in interview with RN B, on 11/16/11 at 3:45 PM.
Per Pt #16's MR reviewed by surveyor 18816 on 11/14/11 at 3:35 PM, there are VO, TO and/or SOs, written between 6/3/11 and 6/4/11, that are not authenticated by the MD with a signature, date and/or time within 24 hours of the written order, per staff rules and regulations. This is confirmed in interview with DON A, on 11/17/11 at 6:15 AM.
Per Pt #21's MR reviewed by surveyor 18816 on 11/15/11 at 8:45 PM, there are VO, TO and/or SOs, written between 1/14/11 and 1/17/11, that are not authenticated by the MD with a signature, date and/or time within 24 hours of the written order, per staff rules and regulations. This is confirmed in interview with DON A, on 11/17/11 at 7:30 AM.
Per Pt #22's MR reviewed by surveyor 18816 on 11/15/11 at 10:50 AM, there are VO, TO and/or SOs, written between 1/14/11 and 1/17/11, that are not authenticated by the MD with a signature, date and/or time within 24 hours of the written order, per staff rules and regulations. This is confirmed in interview with RN C, on 11/17/11 at 9:45 AM.
Per Pt #25's MR reviewed by surveyor 18816 on 11/16/11 at 6:55 AM, there are VO, TO and/or SOs, written between 2/28/11 and 3/3/11, that are not authenticated by the MD with a signature, date and/or time within 24 hours of the written order, per staff rules and regulations. This is confirmed in interview with RN C, on 11/17/11 at 9:15 AM.
Per Pt #26's MR reviewed by surveyor 18816 on 11/16/11 at 7:20 AM, there are VO, TO and/or SOs, written between 2/28/11 and 3/3/11, that are not authenticated by the MD with a signature, date and/or time within 24 hours of the written order, per staff rules and regulations. This is confirmed in interview with RN C, on 11/17/11 at 9:45 AM.
Per Pt #28's MR reviewed by surveyor 18816 on 11/16/11 at 9:10 AM, there are VO, TO and/or SOs, written between 10/15/11 and 10/17/11, that are not authenticated by the MD with a signature, date and/or time within 24 hours of the written order, per staff rules and regulations. This is confirmed in interview with RN C, on 11/17/11 at 9:45 AM.
Per Pt #29's MR reviewed by surveyor 18816 on 11/16/11 at 9:15 AM, there are VO, TO and/or SOs, written between 10/24/11 and 10/25/11, that are not authenticated by the MD with a signature, date and/or time within 24 hours of the written order, per staff rules and regulations. This is confirmed in interview with RN C, on 11/17/11 at 9:15 AM.
Per Pt #30's MR reviewed by surveyor 18816 on 11/16/11 at 9:25 AM, there are VO, TO and/or SOs, written between 10/24/11 and 10/25/11, that are not authenticated by the MD with a signature, date and/or time within 24 hours of the written order, per staff rules and regulations. This is confirmed in interview with RN C, on 11/17/11 at 9:45 AM.

2. Orders written without a date, time and/or signature:
Per Pt #1's MR reviewed by surveyor 18816 on 11/16/11 at 9:40 AM, there are orders that are written between 8/4/11 and 8/9/11 without a date, time and/or signature . This is confirmed in interview with DON A, on 11/17/11 at 11:30 AM.
Pt #3's MR reviewed by surveyor 18816 on 11/17/11 at 8:45 AM revealed there are orders that are written on 11./16/11 without a date, time and/or signature. This is confirmed in interview with RN P, on 11/17/11 at 9:00 AM.
Per Pt #4's MR reviewed by surveyor 18816 on 11/16/11 at 9:40 AM, there are orders that are written between 9/7/11 and 9/23/11 without a date, time and/or signature . This is confirmed in interview with DON A, on 11/17/11 at 11:30 AM.
Per Pt #11's MR reviewed by surveyor 18816 on 11/14/11 at 2:15 PM, there are orders that are written between 4/7/11 and 4/10/11 without a date, time and/or signature. This is confirmed in interview with RN B, on 11/16/11 at 3:45 PM.
Per Pt #12's MR reviewed by surveyor 18816 on 11/14/11 at 2:45 PM, there are orders that are written on 11/20/11 without a date, time and/or signature. This is confirmed in interview with DON A, on 11/17/11 at 6:15 AM.
Per Pt #15's MR reviewed by surveyor 18816 on 11/14/11 at 3:00 PM, there are orders that are written on between 12/5/11 and 12/9/11 without a date, time and/or signature. This is confirmed in interview with DON A, on 11/17/11 at 6:15 AM.
Per Pt #16's MR reviewed by surveyor 18816 on 11/14/11 at 3:35 PM, there are orders that are written on on 6/3/11 without a date, time and/or signature. This is confirmed in interview with DON A, on 11/17/11 at 6:15 AM.
Per Pt #21's MR reviewed by surveyor 18816 on 11/15/11 at 6:55 AM, there are orders that are written on between 1/14/11 and 1/17/11 without a date, time and/or signature. This is confirmed in interview with DON A, on 11/17/11 at 7:30 AM.
Per Pt #22's MR reviewed by surveyor 18816 on 11/15/11 at 10:15 AM, there are orders that are written on between 1/14/11 and 1/17/11 without a date, time and/or signature. This is confirmed in interview with RN C, on 11/17/11 at 9:45 AM.
Per Pt #23's MR reviewed by surveyor 18816 on 11/15/11 at 10:55 AM, there are orders that are written on between 2/1/11 and 2/2/11 without a date, time and/or signature. This is confirmed in interview with DON A, on 11/17/11 at 7:15 AM.
Per Pt #24's MR reviewed by surveyor 18816 on 11/15/11 at 11:45 AM, there are orders that are written on between 2/1/11 and 2/2/11 without a date, time and/or signature. This is confirmed in interview with RN C, on 11/17/11 at 9:45 AM.
Per Pt #25's MR reviewed by surveyor 18816 on 11/16/11 at 6:55 AM, there are orders that are written on between 2/28/11 and 3/3/11 without a date, time and/or signature. This is confirmed in interview with RN C, on 11/17/11 at 9:15 AM.
Per Pt #27's MR reviewed by surveyor 18816 on 11/16/11 at 7:50 AM, there are orders that are written on between 10/15/11 and 10/17/11 without a date, time and/or signature. This is confirmed in interview with RN C, on 11/17/11 at 9:15 AM.
Per Pt #28's MR reviewed by surveyor 18816 on 11/16/11 at 9:10 AM, there are orders that are written on between 10/15/11 and 10/17/11 without a date, time and/or signature. This is confirmed in interview with RN C, on 11/17/11 at 9:45 AM.
Per Pt #29's MR reviewed by surveyor 18816 on 11/16/11 at 9:15 AM, there are orders that are written on between 10/24/11 and 10/25/11 without a date, time and/or signature. This is confirmed in interview with RN C, on 11/17/11 at 9:15 AM.

3. VO, TO and SOs not written correctly:
Per Pt #1's MR reviewed by surveyor 18816 on 11/16/11 at 9:40 AM, there are VO, TO and/or SOs, written between 8/4/11 and 8/9/11, that are not written as VO, TO and SOs including dates, times and/or signatures of authors. This is confirmed in interview with DON A, on 11/17/11 at 11:30 AM.
Per Pt #2's MR reviewed by surveyor 18816 on 11/16/11 at 10:15 AM, there are VO, TO and/or SOs, written between 9/3/11 and 9/10/11, that are not written as VO, TO and SOs including dates, times and/or signatures of authors. This is confirmed in interview with DON A, on 11/17/11 at 11:30 AM.
Per Pt#3's MR reviewed by surveyor 18816 on 11/16/11 at 8:45 AM, there are VO, TO and/or SOs,written on 11/17/11, that are not written as VO, TO and SOs including dates, times and/or signatures of authors. This is confirmed in interview with RN P, on 11/17/11 at 9:00 AM.
Per Pt #4's MR reviewed by surveyor 18816 on 11/16/11 at 11:10 AM, there are VO, TO and/or SOs, written between 9/7/11 and 9/23/11, that are not written as VO, TO and SOs including dates, times and/or signatures of authors. This is confirmed in interview with DON A, on 11/17/11 at 11:30 AM.
Per Pt #5's MR reviewed by surveyor 18816 on 11/16/11 at 11:20 AM, there are VO, TO and/or SOs, written between 8/30/11 and 9/2/11, that are not written as VO, TO and SOs including dates, times and/or signatures of authors. This is confirmed in interview with DON A, on 11/17/11 at 11:30 AM.
Per Pt #12's MR reviewed by surveyor 18816 on 11/14/11 at 2:45 PM, there are VO, TO and/or SOs, written on 11/20/10, that are not written as VO, TO and SOs including dates, times and/or signatures of authors. This is confirmed in interview with DON A, on 11/17/11 at 6:15 AM.
Per Pt #16's MR reviewed by surveyor 18816 on 11/14/11 at 3:35 PM, there are VO, TO and/or SOs, written between 6/3/11 and 6/4/1, that are not written as VO, TO and SOs including dates, times and/or signatures of authors. This is confirmed in interviews with DON A, on 11/17/11 at 6:15 AM.
Per Pt #25's MR reviewed by surveyor 18816 on 11/16/11 at 6:55 AM, there are VO, TO and/or SOs, written between 2/28/11 and 3/3/11, that are not written as VO, TO and SOs including dates, times and/or signatures of authors. This is confirmed in interview with RN C, on 11/17/11 at 9:15 AM.
Per Pt #27's MR reviewed by surveyor 18816 on 11/16/11 at 7:50 AM, there are VO, TO and/or SOs, written between 10/15/11 and 10/17/11, that are not written as VO, TO and SOs including dates, times and/or signatures of authors. This is confirmed in interview with RN C, on 11/17/11 at 9:15 AM.

Based on 22 of 24 MR reviewed requiring a nursing care plan (6, 8, 10, 18, 1, 2, 3, 4, 5, 11, 15, 16, and 21 through 30) out of a total of 30 MR reviewed, and 3 of 3 staff interviews (A, B, C) , the hospital does not ensure that nursing care plans developed for each patient are complete to provide a structured framework for all disciplines involved in patient care to organize, interpret and communicate data pertinent to the care of each patient, and to include those nursing care plans into the medical record. This affected all 6 patients in the facility at the time of the survey.

Findings by surveyor #13469:

The following MR were reviewed between 11/14/11 at 2:20 PM and 11/17/11 at 1:45 PM: Pt. #6 who had surgery on 6/1/11, Pt. #8 who had surgery on 1/24/11, Pt. #10 who had surgery on 8/3/11, and Pt. #18 who was seen in the ED on 4/12/11, admitted and then transferred.

There was no evidence found during MR review for Pt. #6, 8, 10, and 18 that nursing staff developed a nursing care plan based on assessment of patient needs, developing nursing interventions with evidence of patient response to the interventions, and updating or revising the nursing care plan as needed to meet each patients needs. These examples were confirmed by DON (A) on 11/17/11 at 2:10 PM.

Per interview with DON (A) on 11/16/11 in the morning, the nursing Cardex contains part of the nursing care plan, but this Cardex is thrown away at the end of the patient's hospital stay and therefore does not become a part of the permanent MR. In addition, not all required elements of the care plan are found on the Cardex.



18816

Examples by surveyor 18816:

Pt #1's MR reviewed by surveyor 18816 on 11/16/11 at 9:40 AM revealed there is no careplan in the MR. This is confirmed in interview with DON A on 11/17/11 a 11:30 AM.

Pt #2's MR reviewed by surveyor 18816 on 11/16/11 at 10:15 AM revealed there is no careplan in the MR. This is confirmed in interview with DON A on 11/17/11 a 11:30 AM.

Pt #3's MR reviewed by surveyor 1886 on 11/17/11 at 8:45 AM revealed the careplan for Pt #3 admitted on
11/16/11, does not contain goals. This is confirmed in interview with RN P on 11/17/11 at 9:00 AM.

Pt #4's MR reviewed by surveyor 18816 on 11/16/11 at 11:10 AM revealed there is no careplan in the MR. This is confirmed in interview with DON A on 11/17/11 a 11:30 AM.

Pt #5's MR reviewed by surveyor 18816 on 11/16/11 at 11:20 AM revealed there is no careplan in the MR. This is confirmed in interview with DON A on 11/17/11 a 11:30 AM.

Pt #11's MR reviewed by surveyor 18816 on 11/14/11 at 2:15 PM revealed there is no careplan in the MR. This is confirmed in interview with RN B on 11/16/11 at 3:45 PM.

Pt #15's MR reviewed by surveyor 18816 on 11/14/11 at 3:00 PM revealed there is no careplan in the MR. This is confirmed in interview with DON A on 11/17/11 at 6:15 AM.

Pt #16's MR reviewed by surveyor 18816 on 11/14/11 at 3:35 PM revealed there is no careplan in the MR. This is confirmed in interview with DON A on 11/17/11 at 6:15 AM.

Pt #21's MR reviewed by surveyor 18816 on 11/15/11 at 8:45 AM revealed there is no careplan in the MR. This is confirmed in interview with DON A on 11/17/11 at 7:30 AM.

Pt #22's MR reviewed by surveyor 18816 on 11/15/11 at 10:15 AM revealed there is no careplan in the MR. This is confirmed in interview with RN C on 11/17/11 at 9:45 AM.

Pt #23's MR reviewed by surveyor 18816 on 11/15/11 at 10:50 AM revealed there is no careplan in the MR. This is confirmed in interview with DON A on 11/17/11 at 7:15 AM.

Pt #24's MR reviewed by surveyor 18816 on 11/15/11 at 11:45 AM revealed there is no careplan in the MR. This is confirmed in interview with RN C on 11/17/11 at 9:45 AM.

Pt #25's MR reviewed by surveyor 18816 on 11/16/11 at 6:55 AM revealed there is no careplan in the MR. This is confirmed in interview with RN C on 11/17/11 at 9:15 AM.

Pt #26's MR reviewed by surveyor 18816 on 11/16/11 at 7:20 AM revealed there is no careplan in the MR. This is confirmed in interview with RN C on 11/17/11 at 9:45 AM.

Pt #27's MR reviewed by surveyor 18816 on 11/16/11 at 7:50 AM revealed there is no careplan in the MR. This is confirmed in interview with RN C on 11/17/11 at 9:15 AM.

Pt #28's MR reviewed by surveyor 18816 on 11/16/11 at 9:10 AM revealed there is no careplan in the MR. This is confirmed in interview with RN C on 11/17/11 at 9:45 AM.

Pt #29's MR reviewed by surveyor 18816 on 11/16/11 at 9:15 AM revealed there is no careplan in the MR. This is confirmed in interview with RN C on 11/17/11 at 9:15 AM.

Pt #30's MR reviewed by surveyor 18816 on 11/16/11 at 9:25 AM revealed there is no careplan in the MR. This is confirmed in interview with RN C on 11/17/11 at 9:45 AM.

Based on interviews with facility staff, 30 of 30 MR reviewed, and P&P review, the hospital failed to ensue that it have a complete, comprehensive and accurate MR for each patient.

Findings include:

1. The hospital failed to ensure that each MR is complete and that entries into the MR are accurate. See Tag C-302

2. The hospital failed to ensure that consents are properly executed, that patient health status is assessed, that discharge summaries are completed per hospital medical staff rules and regulations, that discharge instructions provide each patient/representative relevant information concerning continuing health care needs at the time of discharge and become a permanent part of the MR, that a preliminary diagnosis is documented on the ED notes by the MD, and that disposition information is complete. See Tag C-304

3. The hospital failed to ensure that there is evidence of consultative findings in the MR.
See Tag C-305

4. The hospital failed to ensure that operative reports are dictated timely, that times of treatment are documented, that nursing staff document patient/representative teaching, that nursing assessments and response to treatment are complete, and that communication notes with the OPO are complete. See Tag C-306

5. The hospital failed to ensure that every entry into the MR is timed, dated and authenticated.
See Tag C-307


The cumulative effect of these systemic medical records problems resulted in the hospitals inability to ensure that all MR are complete and accurately reflect treatment rendered at the facility.

Based on 5 of 30 MR reviewed (6, 7, 18, 29, 30), medical staff rules and regulations review, and 2 of 2 staff interviews (A, C), the hospital failed to ensure that each MR is complete and that entries into the MR are accurate.

Findings by surveyor #13469:
Medical staff rules and regulations reviewed on 11/15/11 in the AM directs the following: page 40. "7. The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient. Its contents shall be pertinent and current."

The following MR were reviewed between 11/14/11 at 2:20 PM and 11/17/11 at 1:45 PM: Pt. #6 who had surgery on 6/1/11, Pt. #7 who had surgery on 12/30/11, Pt. #18 who was seen in the ED on 4/12/11, admitted and then transferred, Pt. #19 who was seen in the ED on 4/17/11 and then discharged.

1. Per MR review, Pt. #6 had an IV (intravenous) line started as evidenced by IV antibiotics and IV pain medications administered the day of surgery on 6/1/11. A note written at 9:30 AM (with no date or identification of the writer) indicates that the CRNA started the IV. There was no evidence found in the MR the time the IV was started, the location of the IV site, the identity of the CRNA, what IV solution was hung and how fast it was infusing at the time of the IV start. The ED notes do not identify the means of transportation and who accompanied the patient from the ED to the inpatient nursing unit. An "assessment and checklist" form was found in the MR of patient #6. The form does not identify what this checklist is for. The form does not include the hospital's name. The form indicates the patient "arrived at 9:00 AM per wheelchair." The information does not identify where this patient came from. The pediatric nursing history assessment dated 6/1/11 indicates the patient "arrived at 9:10 AM per wheelchair." The information does not identify where this patient came from and with whom.

2. Operating Room Progress Notes for Pt. #7 dated 12/30/11 procedure start time has a write-over in the time. It is unclear if the start time is 0907 or 0807. The procedure finish time is scratched out and unreadable. A new time was written next to it. Per interview with DON (A) at 9:30 AM on 11/17/11 staff are to draw a line through a mistake and initial with a time and date vs. scratching out the incorrect information. The medication allergy reconciliation notes contain a write-over in the date. It is unclear if the date is 11/30/10 or 12/20/10.

3. Pt. #18 ED nursing notes dated 4/12/11 indicate the patient was admitted to room 210-2. The notes do not indicate how the patient was transported to the nursing unit from the ED and who accompanied the patient.


18816

Example from surveyor 18816:

Pt #29's MR review by surveyor 18816 on 11/16/11 at 9:15 PM revealed Pt 29 was admitted in labor on 10/7/11. The MR indicates Pt #29 delivered at 10:10 AM on 10/7/11.
Pt #30's MR reviewed by surveyor 18816 on 11/16/11 at 9:25 AM revealed it is the infant of Pt #29. The birth documentation in Pt #30's MR is dated 10/24/11 at 10:10 AM. These records were confirmed with RN C on 11/17/11 at 9:15 AM and 9:45 AM respectively.

Based on 29 of 30 MR reviewed (Pt. #1 through 11 and 13 through 30), review of medical staff rules and regulations, P&P review, and 4 of 4 interviews with facility staff (A, B, C, P), the hospital failed to ensure that consents are properly executed, that patient health status is assessed, that discharge summaries are completed per hospital medical staff rules and regulations, that discharge instructions provide each patient/representative relevant information concerning continuing health care needs at the time of discharge and become a permanent part of the MR, that a preliminary diagnosis is documented on the ED notes by the MD, and that disposition information is complete.

Findings by surveyor #13469:
Medical staff rules and regulations reviewed on 11/15/11 in the AM directs the following: page 40 "7. This record (medical record) shall be complete including authenticating signatures within 30 days of the patient's discharge." "discharge instructions including medications, physical activity, diet and follow up care.

The following MR were reviewed between 11/14/11 at 2:20 PM and 11/17/11 at 1:45 PM: Pt. #6 who had surgery on 6/1/11, Pt. #7 who had surgery on 12/30/11, Pt. #8 who had surgery on 1/24/11, Pt. #9 who had surgery on 7/6/11, Pt. #10 who had surgery on 8/3/11, Pt. #13 who was seen in the ED on 5/20/11 and then transferred, Pt. #14 who was seen in the ED on 4/21/11 and then discharged, Pt #17 who was seen in the ED on 8/16/11 and then transferred, Pt. #18 who was seen in the ED on 4/12/11, admitted and then transferred, Pt. #19 who was seen in the ED on 4/17/11 and then discharged, Pt. #20 who was seen in the ED on 5/1/11 and then discharged.

General consents for treatment for Pt. #6, 7, 8, 9, 10, 13, 14, 18, 19 and 20 do not include the time the consents were obtained, or include information as to why they were not obtained.

General consents for treatment for Pt. #17 and 18 do not include the date or time and the name of the witness who indicated that the patients were unable to sign the consent.

Consents for anesthesia services do not include the time the patient signed the consent nor the full name and title of the anesthesia staff who witnessed the consent for patient #6.

Consents for anesthesia services do not include the time and date the patient signed the consent nor the full name and title of the anesthesia staff who witnessed the consent for patients #7. #9, and #10.

Consents for anesthesia services do not include the the full name and title of the anesthesia staff who witnessed the consent for patient #8.

The above examples were confirmed in interview by DON (A) on 11/17/11 at 2:10 PM.

Pt. #6 was seen in the ED with abdominal pain and vomiting on 6/1/11. Admission vitals were taken at 7:25 AM. The patient was admitted to hospital at 8:50 AM. There were no additional vital signs taken between 7:25 AM and discharge to the floor at 8:50 AM to ensure that this patient was stable for transfer to the nursing unit. Per interview, with DON (A) on 11/17/11 at 9:30 AM, it would be expected that more than one set of vital signs be taken while in the ED. This example was confirmed in interview by DON (A) on 11/17/11 at 2:10 PM.

Patient #6 was discharged from the hospital on 6/3/11. The discharge summary was not dictated by the MD until 7/25/11. This discharge summary exceeded the 30 day completion date per medical staff rules and regulations reviewed on 11/14/11. Per medical staff rules and regulations Article X #7. MR "shall be complete including authentications signatures within 30 days of the patient's discharge." This example was confirmed in interview by DON (A) on 11/17/11 at 2:10 PM.

DI (discharge instructions) are incomplete and directions are not clear. Examples include:
Pt. #6 had an appendectomy on 6/1/11. The DI do not include care of the dressing/wound, signs and symptoms of infection to watch for (uncontrolled pain, drainage, redness, swelling, fever), any other complications associated with this surgery to be aware of, and who to call.

Pt. #7 had a laparoscopic cholecystectomy and incisional liver biopsy on 12/30/10. The DI do not include signs and symptoms of infection to watch for (uncontrolled pain, drainage, redness, swelling, fever), any other complications associated with this surgery to be aware of, and who to call.

Pt. #8 had a laparoscopic ventral incisional hernia repair with mesh on 1/24/11. The DI dated 1/26/11 do not include signs and symptoms of infection to watch for (uncontrolled pain, drainage, redness, swelling,), any other complications associated with this surgery to be aware of, and who to call.

Pt. #10 had distal amputation ischemic left great toe on 8/3/11. The DI give the patient wound care instructions that are conflicting in nature. #3 Directs the patient to "Keep your bandages clean and dry. Do not remove the bandages." The do not is underlined. At the end of bullet point #4 the EI direct the patient to do a "dressing change daily on right foot, 2-3 days for left foot. It is unclear what dressing change procedure is to be used for the right and left foot. The patient is instructed to change his dressing and to not remove the dressing. These instructions are unclear and confusing. In addition, the DI do not include signs and symptoms of infection to watch for (drainage, redness, swelling,), any other complications associated with this surgery to be aware of, and who to call.

Pt. #14 was seen in the ED for chest pain and then discharged. Pt. #14 DI dated 4/21/11 do not instruct the patient what signs and symptoms of chest pain/cardiac problems to watch for and when to return to the ED or seek emergency medical services.

Pt. #19 was seen in the ED for abdominal pain. This patient was 5 months pregnant. The DI do not direct the patient what to do if she continues to have abdominal cramps, develops a fever related to the bacterial vaginosis, or has any new symptoms potentially related to the pregnancy that would direct her to seek emergency medical treatment.

The above examples were confirmed in interview by DON (A) on 11/17/11 at 2:10 PM.

Pt. #6 ED notes dated 6/1/11 do not include a preliminary diagnosis by the MD to justify admission to the hospital. The MD notes direct the reader to a dictated note. The ED note must identify the preliminary diagnosis until the dictated note is processed and entered into the MR. This example was confirmed in interview by DON (A) on 11/17/11 at 2:10 PM.

Pt. #13 ED notes dated 6/1/11 do not include a preliminary diagnosis by the MD to justify transfer to an acute care hospital. The MD notes direct the reader to a dictated note. The ED note must identify the preliminary diagnosis until the dictated note is processed and entered into the MR. This example was confirmed in interview by DON (A) on 11/17/11 at 2:10 PM.

Pt. #14 ED notes dated 4/21/11 do not include a preliminary diagnosis by the MD The MD notes are blank. Pt. #14 was discharged from the ED. The ED note must identify the preliminary diagnosis until the dictated note is processed and entered into the MR in the event this patient returns to the ED with subsequent practitioners. This example was confirmed in interview by DON (A) on 11/17/11 at 2:10 PM.

Pt. #17 ED notes dated 8/16/11 do not include a preliminary diagnosis by the MD to justify transfer to an acute care hospital. The MD ED notes describe a possible stroke but do not identify a preliminary diagnosis. The ED note must identify the preliminary diagnosis until the dictated note is processed and entered into the MR. This example was confirmed in interview by DON (A) on 11/17/11 at 2:10 PM.

Pt. #18 ED notes dated 4/12/11 do not include a preliminary diagnosis by the MD to justify admission to the hospital. The MD notes are left blank. The ED note must identify the preliminary diagnosis until the dictated note is processed and entered into the MR. This example was confirmed in interview by DON (A) on 11/17/11 at 2:10 PM.

Pt. #19 ED notes dated 4/17/11 do not include a preliminary diagnosis by the MD The MD notes are blank. Pt. #14 was discharged from the ED. The ED note must identify the preliminary diagnosis until the dictated note is processed and entered into the MR in the event this patient returns to the ED with subsequent practitioners. This example was confirmed in interview by DON (A) on 11/17/11 at 2:10 PM.

Pt. #19 ED nursing notes dated 4/17/11 do not include a temperature. This patient had bacterial vaginosis. Pt. #19 presented with abdominal cramping and is 5 months pregnant. There was no evidence that a non-stress test for the baby was done. Per interview with DON (A) on 11/17/11 at 2:10 PM, a non-stress test for the baby should have been done.

The above examples were confirmed in interview by DON (A) on 11/17/11 at 2:10 PM.



18816

Examples by surveyor 18816:
Discharge instructions are incomplete or are not found in the MR.
Pt #1's MRs reviewed by surveyor 18816 on 11/16/11 at 9:40 AM revealed there are no copies of discharge instructions to confirm information given to the Pt. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Pt #2's MRs reviewed by surveyor 18816 on 11/16/11 at 10:15 AM revealed there are no copies of discharge instructions to confirm information given to the Pt. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Pt #4's MRs reviewed by surveyor 18816 on 11/16/11 at 11:10 AM revealed there are no copies of discharge instructions to confirm information given to the Pt. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Pt #5's MRs reviewed by surveyor 18816 on 11/16/11 at 11:20 AM revealed there are no copies of discharge instructions to confirm information given to the Pt. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Pt #21's MRs reviewed by surveyor 18816 on 11/15/11 at 8:45 AM revealed there are no copies of discharge instructions to confirm information given to the Pt. This is confirmed in interview with DON A on 11/17/11 at 7:30 AM.

Pt #22's MRs reviewed by surveyor 18816 on 11/15/11 at 10:15 AM revealed there are no copies of discharge instructions to confirm information given to the Pt. This is confirmed in interview with RN C on 11/17/11 at 9:45 AM.

Pt #23's MRs reviewed by surveyor 18816 on 11/16/11 at 9:40 AM revealed there are no copies of discharge instructions to confirm information given to the Pt. This is confirmed in interview with DON A on 11/17/11 at 7:15 AM.

Pt #24's MRs reviewed by surveyor 18816 on 11/15/11 at 11:45 AM revealed there are no copies of discharge instructions to confirm information given to the Pt. This is confirmed in interview with RN C on 11/17/11 at 9:45 AM.

Pt #25's MRs reviewed by surveyor 18816 on 11/16/11 at 6:55 AM revealed there are no copies of discharge instructions to confirm information given to the Pt. This is confirmed in interview with RN C on 11/17/11 at 9:15 AM.

Pt #26's MRs reviewed by surveyor 18816 on 11/16/11 at 7:20 AM revealed there are no copies of discharge instructions to confirm information given to the Pt. This is confirmed in interview with RN C on 11/17/11 at 9:45 AM.

Pt #27's MRs reviewed by surveyor 18816 on 11/16/11 at 7:50 AM revealed there are no copies of discharge instructions to confirm information given to the Pt. This is confirmed in interview with RN C on 11/17/11 at 9:15 AM.

Pt #28's MRs reviewed by surveyor 18816 on 11/16/11 at 9:10 AM revealed there are no copies of discharge instructions to confirm information given to the Pt. This is confirmed in interview with RN C on 11/17/11 at 9:45 AM.

Pt #29's MRs reviewed by surveyor 18816 on 11/16/11 at 9:15 AM revealed there are no copies of discharge instructions to confirm information given to the Pt. This is confirmed in interview with RN C on 11/17/11 at 9:15 AM

Pt #30's MRs reviewed by surveyor 18816 on 11/16/11 at 9:25 AM revealed there are no copies of discharge instructions to confirm information given to the Pt. This is confirmed in interview with RN C on 11/17/11 at 9:45 AM.

Examples of consents not in file, completed prior to admission, not dated and/or timed:
Pt #1's MR review by surveyor 18816 on 11/16/11 at 9:40 AM revealed the consent to treatment is not on file for the admission to Swing Bed on 8/4/11. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Pt #2's MR review by surveyor 18816 on 11/16/11 at 10:15 AM revealed the consent to treatment is not on file for the admission to Swing Bed on 9/3/11. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Pt #3's MR review by surveyor 18816 on 11/17/11 at 8:45 AM revealed the consent to treatment is not timed when signed on 11/16/11, and the consent for anesthesia is not dated and timed for surgery performed on 11/16/11. This is confirmed in interview with RN P on 11/17/11 at 9:00 AM.

Pt #4's MR reviewed by surveyor 18816 on 11/16/11 at 11:10 AM revealed the consent to treatment is not timed when signed on 9/7/11. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Pt #5's MR reviewed by surveyor 18816 on 11/16/11 at 11:20 AM revealed Pt #5 the consent to treatment is not timed when signed on 9/1/11. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Pt #11's MR reviewed by surveyor 18816 on 11/14/11 at 2:15 PM revealed the consent to treatment is not timed when signed on 4/8/11. This is confirmed in interview with RN B on 11/16/11 at 3:45 PM.

Pt #15's MR reviewed by surveyor 18816 on 11/14/11 at 3:00 PM revealed the consent to treatment is not signed by the Pt or witness and is not timed when dated 12/6/11. This is confirmed in interview with DON A on 11/17/11 at 6:15 AM.

Pt #16's MR reviewed by surveyor 18816 on 11/14/11 at 3:35 PM revealed the consent to treatment is not timed when signed on 6/3/11. This is confirmed in interview with DON A on 11/17/11 at 6:15 AM.

Pt #21's MR reviewed by surveyor 18816 on 11/15/11 at 8:45 AM revealed the consent to treatment is not timed when signed, the consent for surgery signed by the Pt on 1/14/11, is not signed by the MD on 1/26/11, and the consent for anesthesia is not dated and timed. This is confirmed in interview with DON A on 11/17/11 at 7:30 AM.

Pt #22's MR reviewed by surveyor 18816 on 11/15/11 at 10:15 AM revealed the consent to treatment is not timed when signed on 1/7/11, the consent for circumcision is not signed by the MD, the consent for Hepatitis vaccine is not timed when signed on 1/15/11. This is confirmed in interview with RN C on 11/17/11 at 9:45 AM.

Pt #23's MR reviewed by surveyor 18816 on 11/15/11 at 10:50 AM revealed the consent to treatment is not timed when signed on 2/1/11. This is confirmed in interview with DON A on 11/17/11 at 7:15 AM.

Pt #24's MR reviewed by surveyor 18816 on 11/15/11 at 11:45 AM revealed the consent to treatment is not timed when signed on 2/2/11, the consent for Hepatitis vaccine is not timed when signed on 2/2/11. This is confirmed in interview with RN C on 11/17/11 at 9:45 AM.

Pt #25's MR reviewed by surveyor 18816 on 11/15/11 at 10:50 AM revealed Pt #23 was admitted on 2/28/11, the consent to treatment on file is dated 12/27/11 and is not timed. This is confirmed in interview with RN C on 11/17/11 at 9:15 AM.

Pt #26's MR reviewed by surveyor 18816 on 11/15/11 at 7:20 AM revealed Pt #26 was born on 3/1/11,the consent to treatment is signed on 12/27/11 and not timed, the consent for circumcision is not signed by the MD, the consent for Hepatitis vaccine is not timed when signed on 3/1/11. This is confirmed in interview with RN C on 11/17/11 at 9:45 AM.

Pt #27's MR reviewed by surveyor 18816 on 11/16/11 at 6:55 AM revealed Pt #25 was admitted on 10/15/11, the consent to treatment is signed on 10/11/11 and is not timed, the consent to anesthesia for pain relief is not dated and timed. This is confirmed in interview with RN C on 11/17/11 at 9:15 AM.

Pt #28's MR reviewed by surveyor 18816 on 11/16/11 at 9:10 AM revealed the consent to treatment is not timed when signed on 10/16/11. This is confirmed in interview with RN C on 11/17/11 at 9:15 AM.

Pt #29's MR reviewed by surveyor 18816 on 11/15/11 at 10:50 AM revealed Pt #29 was admitted on 10/7/11, the consent to treatment on file is dated 9/01/11 and is not timed. This is confirmed in interview with RN C on 11/17/11 at 9:15 AM.

Pt #30's MR reviewed by surveyor 18816 on 11/16/11 at 9:25 AM revealed Pt #26 was born on 10/24/11,the consent to treatment is signed on 4/26/11 and not timed, the consent for Hepatitis vaccine is not timed when signed on 10/24/11. This is confirmed in interview with RN C on 11/17/11 at 9:45 AM.

Based on 2 of 3 MR requiring a consult note out (Pt. #6, 21) out of 30 MR reviewed, review of medical staff rules and regulations, and 1 of 1 staff interview (A), the hospital failed to ensure that there is evidence of consultative findings in the MR.

Findings by surveyor #13469:
Medical staff rules and regulations reviewed on 11/15/11 in the AM directs the following: page 40 "11. Consultations shall show evidence of a review of the patient's record by a consultant, pertinent findings on examination of the patient, the consultant's opinion and recommendation."

Per review, of Pt. #6 MR on 11/14/11 at 2:20 PM, the MR did not contain a consult note. Pt. #6 MD H&P dated 6/1/11 indicates that a referral was made to a surgeon for a consult to determine if Pt. #6 needed an appendectomy. The MR did not contain evidence that the surgeon examined the patient or discussed the risks and benefits of an appendectomy with the parents of this 10 year old. This patient did have an appendectomy as evidenced by an operative report dated 6/1/11.


18816

Example by surveyor 18816:

Pt #21's MR reviewed by surveyor 18816 on 11/15/11 at 8:15 AM revealed there is no consultant note by the surgeon for the cesarean section. This is confirmed in interview with DON A on 11/17/11 at 7:30 AM.

Based on 17 of 30 MR reviewed, P&P review, and 2 of 2 staff interview (A, C), the hospital failed to ensure that 1 of 7 operative reports are dictated timely (Pt. #7), that nursing staff document patient/representative teaching (Pt.#6, #7 and #9), that nursing documentation include evidence of comprehensive pain assessments and response to pain treatment for 9 of 9 patients with pain (#6, 8, 10, 2, 4, 11, 15, 21, 25), and that nursing communication notes with the OPO are complete in 4 of 4 death records reviewed (#11, 12, 15,and 16). That FHT are monitored per hospital P&P in 4 of 4 patients in labor (#23, 25, 27, 29). that nursing staff include evidence of evaluation of infant circumcision wound for Pt. #22.

Findings include:
P&P review on 11/17/11 in the AM revealed that the nursing "Pain Management" last review date 7/26/11 directs the following that the nurse is to assess and reassess pain reports by the patient, use the 0 - 10 pain rating scale, assess the duration, location, character, causative/relieving factors, effect on mood and activities of daily living and intensity of pain with each assessment. In addition the degree of pain relief and presence of side effects is assessed at an interval appropriate to the intervention and/or 1 hour, whichever is least.

Medical staff rules and regulations reviewed on 11/15/11 in the AM directs the following: page 40 "10. Operative reports shall be written or dictated immediately following surgery, but no longer than 24 hours following surgery."

Facility policy titled Labor review date 1/99, reviewed by surveyor 18816 on 11/17/11 in the PM, states under #5. "Place external FHT (fetal hearttone) monitor on patient for baseline reading - 1 hour upon admission then intermittent minimum [sic] 1/2 hour out of 3. a. FHT every 1 hour in first stage of labor; every 1/2 hour in second stage of labor and oftener as indicated."

Examples by surveyor #13469:
The following MR were reviewed between 11/14/11 at 2:20 PM and 11/17/11 at 1:45 PM: Pt. #6 who had surgery on 6/1/11, Pt. #7 who had surgery on 12/30/11, Pt. #8 who had surgery on 1/24/11, Pt. #9 who had surgery on 7/6/11, and Pt. #10 who had surgery on 8/3/11.

The following MR do not include comprehensive pain assessments to include type of pain, the specific location of pain, the intensity, what makes it worse, what makes it better, interventions used and the patients response to interventions.

Per nursing documentation dated 6/1/11 at 2:00 PM, patient #6 complains of "pain at incision." At 3:00 PM on 6/1/11 the nurse indicates Pt. #6 has "pain increase with ambulation." At 4:00 PM the nurse indicates that Pt. #6 is having "pain right lower quadrant." At 8:00 PM, 9:30 PM, and 11:40 PM on 6/1/11 the patient #6 "complains of pain and was medicated". On 6/2/11 at 7:00 AM Pt. #6 was given Morphine for pain for a level of 8 out of 10 on a pain scale. This documentation does not identify the type of pain, the location of the pain, what makes it worse, what makes it better, any other interventions attempted before pain medication was used, and the patients response to the pain medication.

A pain management flow sheet was also found in Pt. #6 MR. There are three medication interventions listed at 7:00 AM, 8:00 AM and 11:00 AM. There are no dates on the page. The documentation does not include the type of pain, what makes it worse, what makes it better, or if any other interventions were used to lessen the pain prior to using pain medication. Nursing staff failed to reassess the patients response to pain medication after the 11:AM dose.

Per nursing documentation dated 1/24/11 at 3:00 PM, patient #8 complains of "much pain with movement and Morphine was given." The nursing assessment does not identify the type of pain, the intensity on a scale of 1 - 10, what makes it worse, what makes it better, any other interventions attempted before pain medication was used.

At 4:00 PM Pt. #8 "states pain is bad and Toradol was given." The nursing assessment does not identify the type of pain, the intensity on a scale of 1 - 10, what makes it worse, what makes it better, any other interventions attempted before pain medication was used.

At 7:00 PM, 9:00 PM, and 11:00 PM the nurse documents that the patient #8 "complains of pain, PRN (as needed) given." The pain assessments do not include type of pain, the specific location of pain, the intensity, what makes it worse, what makes it better, interventions used and the patients response to medication interventions.

Per nursing documentation dated 8/3/11 at 3:00 PM, patient #10 complains of "pain 8/10 and Percocet given." The pain assessments does not include type of pain, the specific location of pain, what makes it worse, what makes it better, any other interventions attempted before pain medication was used. At 11:30 AM the nurse documents that the patient only "got some relief from the Percocet. This reassessment does not identify the intensity of the pain to reveal how much relief from the Percocet the patient got.

At 1:45 PM the nursing documentation indicates that "Demerol/Visteril was given to Pt. #10 for 8/10 pain. The pain assessment does not include type of pain, the specific location of pain, what makes it worse, what makes it better, any other interventions attempted before pain medication was used. There was no evidence of a reassessment of Pt. #10 pain within 1 hour following the pain medication.

Per interview, with DON (A) on 11/17/11 at 2:10 PM the above examples were confirmed. Per (A), some nursing staff use the flow sheet to document pain assessments and interventions and some use progress notes. Per (A), it is not being done consistently among the nursing staff. In addition, (A) confirmed that the assessments and reassements of pain are incomplete.

The nursing "assessment and checklist" form, in the pre-op teaching section, is blank for Pt.
#6 and #7. It is unclear if the patients/representative received pre-operative teaching. For Pt. #9, the pre-operative teaching note indicate it was "done - no questions". It is not clear what pre-operative teaching was done.

Pt. #7 had a laporoscopic cholecystectomy and incisional liver biopsy on 12/30/10. The operative report was not dictated by the surgeon until 3/10/11.


18816


Examples by surveyor 18816:
The following are examples of incomplete documentation/assessments:

Pt#2's MR reviewed by surveyor 18816 on 11/16/11 at 10:15 AM revealed the Initial Pain Assessment form is incomplete. Pt #2 was given pain medications on 9/4 /11 at 6:50 PM, on 9/5/11 at 7:15 AM, and on 9/5/11 at 10:10 PM. There is no documentation of pain assessment and if any relief, on 9/6/11 at 4:30 AM and 11:15 PM. There is no documentation of level of pain and if medication provided relief. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Pt #4's MR reviewed by surveyor 18816 on 11/16/11 at 10:10 AM revealed Pt #4 was given pain medications on 9/12/11 at 3:00 AM and at 8:00 AM, on 9/13/11 at 4:15 AM, 11:50 AM and 8:30 PM. There is no follow up documentation on pain relief. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Pt #11's MR reviewed by surveyor 18816 on 11/14/11 at 2:15 PM revealed the Initial Pain Assessment form is incomplete. There is no documentation of the decision by the Organ Procurement Organization on donation status. This is confirmed in interview with RN B on 11/16/11 at 3:45 PM.

Pt #12's MR reviewed by surveyor 18816 on 11/14/11 at 2:45 PM revealed there is no documentation of the decision by the Organ Procurement Organization on donation status. This is confirmed in interview with DON A on 11/17/11 at 6:15 AM.

Pt #15's MR reviewed by surveyor 18816 on 11/14/11 at 3:00 PM revealed pain medication was given on 12/7/10 12:45 AM and at 11:30 AM, there is no follow up documentation on pain relief. There is no documentation of the decision by the Organ Procurement Organization on donation status. This is confirmed in interview with DON A on 11/17/11 at 6:15 AM.

Pt #16's MR reviewed by surveyor 18816 on 11/14/11 at 3:35 PM revealed there is no documentation of the decision by the Organ Procurement Organization on donation status. This is confirmed in interview with DON A on 11/17/11 at 6:15 AM.

Pt #21's MR reviewed by surveyor 18816 on 11/15/11 at 8:15 AM revealed pain medication was given on 1/15/11 at 11:30 AM with no follow up on pain relief. There are two documents of Postpartum nursing progress notes that do not have dates, these have times medications were given as 3:30 AM, 5:00 PM, and 8:45 PM; there is no follow up documentation on relief of pain. Pt #21 was admitted in labor on 1/14/11 at 12:30 AM, there are FHTs documented at 1:00 AM and 3:30 AM, there is no other documentation of fetal status or Pt contractions prior to cesarean delivery at approximately 7:00 AM. This is confirmed in interview with DON A on 11/17/11 at 7:30 AM.

Pt #22's MR reviewed by surveyor 18816 on 11/15/11 at 10:15 AM revealed there is no evaluation of the infants circumcision wound. This is confirmed in interview with RN C on 11/17/11 at 9:45 AM.

Pt #23's MR reviewed by surveyor 18816 on 11/15/11 at 10:50 AM revealed Pt #23 was admitted in labor on 2/1/11 at 3:10 PM. There is one documented FHTs at 3:00 PM prior to delivery at 5:42 PM. This is confirmed in interview with DON A on 11/17/11 at 7:15 PM.

Pt #25's MR reviewed by surveyor 18816 on 11/16/11 at 6:55 AM revealed pain medication was given on 3/2/11 at 11:00 AM and at 7:00 PM, there is no follow up documentation on relief of pain. This is confirmed in interview with RN C on 11/17/11 at 9:15 AM.

Pt #27's MR reviewed by surveyor 18816 on 11/16/11 at 7:50 AM revealed Pt #27 was admitted in labor on 10/15/11 at 6:08 PM, up to 10:50 PM there are FHTs documented twice at 6:10 PM and 8:30 PM. This is confirmed in interview with RN C on 11/17/11 at 9:15 AM.

Pt #29's MR reviewed by surveyor 18816 on 11/16/11 at 9:15 AM revealed Pt #29 was admitted in labor on 10/7/11 at 8:15 AM. FHTs documented twice at 8:15 AM and 8:30 AM prior to delivery at 10:10 AM. This is confirmed in interview with RN C on 11/17/11 at 9:15 AM.

Based on 29 of 30 MR reviewed (#1 through 11 and 12 through 30), review of medical staff rules and regulations, and 4 of 4 staff interviews (A, B, C, P), the hospital failed to ensure that every entry into the MR is timed, dated and authenticated.

Findings by surveyor #13469:
Medical staff rules and regulations reviewed on 11/15/11 in the AM directs the following: page 41 "13. All clinical entries in the patient's medical record shall be accurately dated and authenticated."

The following MR were reviewed between 11/14/11 at 2:20 PM and 11/17/11 at 1:45 PM: Pt. #6 who had surgery on 6/1/11, Pt. #7 who had surgery on 12/30/11, Pt. #8 who had surgery on 1/24/11, Pt. #9 who had surgery on 7/6/11, Pt. #10 who had surgery on 8/3/11, Pt. #13 who was seen in the ED on 5/20/11 and then transferred, Pt. #14 who was seen in the ED on 4/21/11 and then discharged, Pt #17 who was seen in the ED on 8/16/11 and then transferred, Pt. #18 who was seen in the ED on 4/12/11, admitted and then transferred, Pt. #19 who was seen in the ED on 4/17/11 and then discharged, Pt. #20 who was seen in the ED on 5/1/11 and then discharged.

Dictated notes found in the MR of Pt. #6, 7, 8, 9, 10, 13, 14, 17, 18, 19, and 20 do not include the times the notes were dictated and transcribed. Examples include: discharge summaries, H&P, consult notes, operative notes, radiology reports, and ED notes.

The following examples were identified in Pt. #6 MR: Notice of Privacy and AD forms signed by the patient and witness do not include the times they were signed for Pt. #6.
Page 2 of 2 ED nursing and MD notes found in Pt. #6 MR was separated from page #1. Page #2 does not identify what the form is, does not include the patients name, or the date and time the MD signed the form. Respiratory therapy record documentation dated 6/1/11 does not identify who completed the notes. Initials are found without the name and title of the person who wrote their initials. Dietary progress notes dated 6/1, 6/2, 6/2, 6/3 do not include the year. The nursing intra-operative notes do not identify the name of the person who administered the antibiotic nor the time the antibiotic was started per IV. The medication profile, graphic sheet dated 6/1 does not include the year. A form dated 6/1/11 assessing systems such as skin, respiratory, circulatory etc. does not include the identity of the form or of the person who completed the form. A Pediatric Observation Record form with an entry at 9:30 does not identify the date or the name of the person who completed the form. A Pediatric observation record form dated 6-11 had the day of the month whole punched out. The Post anesthesia note for Pt. #6 does not identify the time or date the evaluation was completed by the CRNA to ensure that proper anesthesia recovery was accomplished for this patient who received general anesthesia. The pre-anesthesia note and intra-operative notes dated 6/1 do not include the year.

Dictated notes found in the MR of Pt. #6, 7, 8, 9, 10, 13, 14, 17, 18, 19, and 20 do not include the date and time the notes were countersigned and validated by the MD. Examples include: discharge summaries, H&P, consultation notes, radiology reports, operative notes, and ED notes.

MD orders do not identify the time the orders were entered into the MR by the physician. Examples include: Pt. #6 orders dated 6/1/11, and 6/2/11, Pt. #7 orders dated 12/30/11, Pt. #8 MD orders dated 1/24/11, and Pt. #10 orders dated 8/31/11.

MD progress notes found in the MR are not dated/timed. Examples include: Pt. #6, Pt.
#7, Pt. #8, and #10.

The following examples were identified in Pt. #7 MR: The nursing "assessment and checklist" dated 12/30 does not include the year. Pre-operative, intra-operative and post-operative notes by anesthesia dated 12/30 do not include the year. The PACU nursing notes dated 12/30 do not include the year. The medication allergy reconciliation notes completed by the RN do not include the time the notes were entered into the MR. The "Physician Order/Medication Reconciliation" orders post-operatively do not identify the time the orders were entered into the MR. Nursing notes with times between 11:25 AM and 7:00 PM do not include a date when they were entered into the MR by the RN.

The operating room surgical safety checklist does not include a date or a time when it was entered into the MR for patients #6, 7, 8, and 9.

The operating room surgical safety checklist does not include a time when it was entered into the MR for patient #10.

The operating room count sheet does not include a date or a time when it was entered into the MR for Pt. #6, 7, and 8.

The following examples were identified in Pt. #8 MR: The H&P update signed by the MD does not include the time or date the MD countersigned and validated the information on the form completed by the RN. It is unclear if the H&P update was reviewed by the MD prior the patient #8 surgery on 1/24/11. The pre-admission checklist for surgical's form dated 1/12/11 does not include the time the RN entered the information into the MR. RT notes dated 1/24/11 and 1/25 do not identify the identity of the person who completed the entries of treatments on page one. The back of the form include progress notes written by the RT do not include the time the notes were entered into the MR. Pre-operative, intra-operative and post-operative notes by anesthesia dated 1/24 do not include the year. The medication profile dated 1/24 through 1/26 does not include a year with the dates. The graphic sheet dated 1/24 through 1/27 does not include the year. The nursing admission assessment form is 5 pages long. The pages are separated and do not include the number for each page (page 2 of 5 etc.), the name of the patient on each separated page and the hospital name on each page that is separated. The skin integrity risk assessment form does not include a date, time or name and title of the person who completed the form. The post operative record flow sheet does not identify the date of the entries. Nursing progress notes timed between 3:00 PM and 5:45 AM on 1/24 do not include a year.

The following examples were identified in Pt. #9 MR: Pre-operative, intra-operative and post-operative notes by anesthesia dated 7/6 do not include the year. The operating room progress notes indicate the patient had surgery on 7/7/11 which is inaccurate. This patient had a knee arthroscopy on 7/6/11 not 7/7/11.

The following examples were identified in Pt. #10 MR: Pre-operative, intra-operative and post-operative notes by anesthesia dated 8/3 do not include the year. Nursing notes from 7:00 PM through midnight do not include a day and year when completed by the RN. The post operative DI found in Pt. #10 MR do not include a date or time the patient signed the form.

The ED nursing notes dated 5/20/11 for Pt. #13 do not identify the time the vital signs were taken.

The following examples were identified in Pt. #17 MR: The NIH stroke scale form and acute stroke assessment form dated 8/16/11 does not identify the name and title of the person who completed the forms. The guidelines for use of t-PA patients with ischemic stroke form found in Pt. #17 MR does not identify the date and time the documentation was entered into the MR, and name with the title of the person who completed the form. In addition, the form does not include the name of the hospital. The transport form does not identify the date and time the documentation was entered into the MR, and name with the title of the person who completed the form. The transfer form completed by the MD and RN does not include an RN signature after the statement "I have reviewed the information above and certify it is correct"

The following examples were identified in Pt. #18 MR: The guidelines for use of t-PA patients with ischemic stroke form found in Pt. #18 MR does not identify the date and time the documentation was entered into the MR, and name with the title of the person who completed the form. In addition, the form does not include the name of the hospital. The NIH stroke scale form and acute stroke assessment form dated 4/12/11 does not identify the name and title of the person who completed the forms. The nursing admission assessment form is 5 pages long. The pages are separated and do not include the number for each page (page 2 of 5 etc.), the name of the patient on each separated page and the hospital name on each page that is separated. The skin integrity risk assessment form does not include a date, time or name and title of the person who completed the form. In addition, the form is incomplete. the scores are not determined. The neurologic observation record does not include the name of the hospital, nor the names and titles of the staff who completed the flow sheets.

All of the above examples were confirmed in interview with DON (A) on 11/17/11 at 2:10 PM.


18816

Examples by surveyor 18816 of dictations and progress notes not timed by MDs:

Pt #28's MR reviewed by surveyor 18816 on 11/16/11 at 9:10 AM revealed the Nurses Initial Profile is not signed, dated or timed by who completed the form. This is confirmed in interview with RN C on 11/17/11 at 9:15 AM.

Pt #1's MR review by surveyor 18816 on 11/16/11 at 9:40 AM revealed there are dictated H&P, dictated Discharge Summary and/or progress notes written between 8/4/11 and 8/9/11 that are not dated and/or timed when authenticated and/or written. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Pt #2's MR review by surveyor 18816 on 11/16/11 at 10:15 AM revealed there are dictated H&P, dictated Discharge Summary and/or progress notes written between 9/3/11 and 9/10/11 that are not dated and/or timed when authenticated and/or written. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Pt #3's MR review by surveyor 18816 on 11/17/11 at 8:45 AM revealed there are dictated H&P, dictated Discharge Summary and/or progress notes written on 11/16/11 that are not dated and/or timed when authenticated and/or written. This is confirmed in interview with RN P on 11/17/11 at 9:00 AM.

Pt #4's MR review by surveyor 18816 on 11/16/11 at 11:10 AM revealed there are dictated H&P, dictated Discharge Summary and/or progress notes written between 9/7/11 and 9/23/11 that are not dated and/or timed when authenticated and/or written. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Pt #5's MR review by surveyor 18816 on 11/16/11 at 11:20 AM revealed there are dictated H&P, dictated Discharge Summary and/or progress notes written between 8/30/11 and 9/2/11 that are not dated and/or timed when authenticated and/or written. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Pt #11's MR review by surveyor 18816 on 11/14/11 at 2:15 PM revealed there are dictated H&P, dictated Discharge Summary and/or progress notes written between 4/7/11 and 4/10/11 that are not dated and/or timed when authenticated and/or written. This is confirmed in interview with RN B on 11/16/11 at 3:45 PM.

Pt #15's MR review by surveyor 18816 on 11/14/11 at 2:45 PM revealed there are dictated H&P, dictated Discharge Summary and/or progress notes written between 12/5/11 and 12/93/11 that are not dated and/or timed when authenticated and/or written. This is confirmed in interview with DON A on 11/17/11 at 6:15 AM.

Pt #16's MR review by surveyor 18816 on 11/14/11 at 3:35 PM revealed there are dictated H&P, dictated Discharge Summary and/or progress notes written on 6/3/11 that are not dated and/or timed when authenticated and/or written. This is confirmed in interview with DON A on 11/17/11 at 6:15 AM.

Pt #21's MR review by surveyor 18816 on 11/15/11 at 8:45 AM revealed there are dictated H&P, dictated Discharge Summary and/or progress notes written between 1/14/11 and 1/17/11 that are not dated and/or timed when authenticated and/or written. This is confirmed in interview with DON A on 11/17/11 at 7:30 AM.

Pt #22's MR review by surveyor 18816 on 11/15/11 at 10:15 AM revealed the initial physical is not signed, the discharge physical is not timed and there is no procedure note regarding the circumcision. This is confirmed in interview with RN C on 11/17/11 at 9:45 AM.

Pt #23's MR review by surveyor 18816 on 11/15/11 at 10:50 AM revealed there are dictated H&P, dictated Discharge Summary and/or progress notes written between 2/1/11 and 2/2/11 that are not dated and/or timed when authenticated and/or written. This is confirmed in interview with DON A on 11/17/11 at 7:15 AM.

Pt #24's MR review by surveyor 18816 on 11/15/11 at 11:45 AM revealed the initial physical is not signed and the discharge physical is not timed. This is confirmed in interview with RN C on 11/17/11 at 9:45 AM.

Pt #25's MR review by surveyor 18816 on 11/16/11 at 6:55 AM revealed there are dictated H&P, dictated Discharge Summary and/or progress notes written between 2/28/11 and 3/3/11 that are not dated and/or timed when authenticated and/or written. This is confirmed in interview with RN C on 11/17/11 at 9:15 AM.

Pt #26's MR review by surveyor 18816 on 11/16/11 at 7:20 AM revealed the initial physical is not signed, the discharge physical is not timed and there is no procedure note regarding the circumcision. This is confirmed in interview with RN C on 11/17/11 at 9:45 AM.

Pt #27's MR review by surveyor 18816 on 11/16/11 at 7:50 AM revealed there are dictated H&P, dictated Discharge Summary and/or progress notes written between 10/15/11 and 10/17/11 that are not dated and/or timed when authenticated and/or written. This is confirmed in interview with RN C on 11/17/11 at 9:15 AM.

Pt #28's MR review by surveyor 18816 on 11/16/11 at 10:15 AM revealed the initial physical is not signed and the discharge physical is not timed. This is confirmed in interview with RN C on 11/17/11 at 9:45 AM.

Pt #29's MR review by surveyor 18816 on 11/16/11 at 9:15 AM revealed there are dictated H&P, dictated Discharge Summary and/or progress notes written between 10/24/11 and 10/25/11 that are not dated and/or timed when authenticated and/or written. This is confirmed in interview with RN C on 11/17/11 at 9:15 AM.

Pt #30's MR review by surveyor 18816 on 11/16/11 at 9:25 AM revealed the initial physical is not signed and the discharge physical is not timed. This is confirmed in interview with RN C on 11/17/11 at 9:45 AM.

Pt #1's MR reviewed by surveyor 18816 on 11/16/11 at 9:40 AM, revealed there are progress notes written by staff between 8/4/11 and 8/9/11 that do not have times. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Pt #2's MR reviewed by surveyor 18816 on 11/16/11 at 10:15 AM, revealed there are progress notes written by staff between 9/3/11 and 9/10/11 that are not timed. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Pt #4's MR reviewed by surveyor 18816 on 11/16/11 at 11:10 AM, revealed there are progress notes written by staff between 9/7/11 and 9/23/11 that are not timed. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Pt #5's MR reviewed by surveyor 18816 on 11/16/11 at 11:20 AM, revealed there are progress notes written by staff between 8/30/11 and 9/2/11 that are not timed. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Pt #11's MR reviewed by surveyor 18816 on 11/14/11 at 2:15 PAM, revealed there are progress notes written by staff between 4/7/11 and 4/10/11 that are not timed. This is confirmed in interview with RN B on 11/16/11 at 3:34 PM.

Pt #15's MR reviewed by surveyor 18816 on 11/14/11 at 3:00 PM, revealed there are progress notes written by staff between 12/5/11 and 12/9/11 that are not timed. This is confirmed in interview with DON A on 11/17/11 at 6:15 AM.

Pt #16's MR reviewed by surveyor 18816 on 11/14/11 at 3:35 PM, revealed there are progress notes written by staff on 6/3/11 that are not timed. This is confirmed in interview with DON A on 11/17/11 at 6:15 AM.

Pt #21's MR reviewed by surveyor 18816 on 11/15/11 at 8:45 AM, revealed there are progress notes written by staff between 1/14/11 and 1/17/11 that are not timed. This is confirmed in interview with DON A on 11/17/11 at 7:30 AM.

Pt #23's MR reviewed by surveyor 18816 on 11/15/11 at 10:50 AM, revealed there are progress notes written by staff between 2/1/11 and 2/2/11 that are not timed. This is confirmed in interview with DON A on 11/17/11 at 7:15 AM.

Pt #25's MR reviewed by surveyor 18816 on 11/16/11 at 6:55 AM, revealed there are progress notes written by staff between 2/28/11 and 3/3/11 that are not timed. This is confirmed in interview with RN C on 11/17/11 at 9:15 AM.

Based on 6 of 6 surgical patient MR reviewed (Pt. #6, 7, 8, 9, 10, and 21) out of a total of 30 MR reviewed, P&P review, and 2 of 2 staff interviews (A and C) by surveyor #13469, the hospital failed to ensure that surgical patients are protected from fire.

Findings include:
Examples by surveyor #13469:

The Association for Operating Room Nurses (AORN) Perioperative Standards and Recommendations, 2008 Edition indicate:
IX.d.1. Waterless, brushless, surgical-scrub solutions should be allowed to dry completely to decrease the potential to produce ignition by static electricity or sparks.
IX.d.3. Provide adequate time for the flammable surgical prep solution to dry completely and any fumes to dissipate before applying surgical drapes, using an active electrode or laser, or activating a fiber-optic light cable.
IX.d.5. Drapes should not be applied until prep solutions are dry, to prevent the accumulation of volatile fumes beneath them.

P&P review on 11/16/11 in the afternoon revealed that the "Safety Management/Environment of Care" policy last review date 8/2011 directs the following: "2. Safety Committee Functions: i. To maintain a life safety management program designed to protect patient, personnel, visitors and property from fire and the products of combustion's."

Per operating room P&P review, on 11/16/11 in the AM, the operating room policies do not include a policy to reduce the risks of fires due to the use of alcohol-based skin preparations in anesthetizing locations.

The hospital surgery P&P do not include the following guidelines:

A Using skin prep solutions that are 1) packaged to ensure controlled delivery to the patient in unit dose applicators, swabs or other similar applicators: and 2) provide clear and explicit manufacturer/supplier instructions and warnings. These instructions for use should be carefully followed.

B Ensuring that the alcohol-based skin prep solution does not soak into the patient's hair or linens. Sterile towels should be placed to absorb drips and runs during application and should then be removed from the anesthetizing location prior to draping the patient.

C Ensuring that the alcohol-based skin prep solution is completely dry prior to draping. This may take a few minutes or more, depending on the amount and location of the solution. The prepped area should be inspected to confirm it is dry prior to draping.

D Verifying that all of the above has occurred prior to initiating the surgical procedure. This can be done, for example, as part of the standardized pre-operative " time out " used to verify other essential information to minimize the risk of medical errors during the procedure.

In addition, the facility failed to document the implementation of these policies and procedures in the patient's MR.

Per interview, with OR Director (C) on 11/15/11 at 10:00 AM, the hospital operating room P&P do not address the use of alcohol-based skin preparations in anesthetizing locations. The surgery department does use the following alcohol based skin preps: Dura prep, Chlorhexidine, and Povidone-Iodine.

The following MR were reviewed between 11/14/11 at 2:20 PM and 11/17/11 at 1:45 PM: Pt. #6 who had surgery on 6/1/11, Pt. #7 who had surgery on 12/30/11, Pt. #8 who had surgery on 1/24/11, Pt. #9 who had surgery on 7/6/11, and Pt. #10 who had surgery on 8/3/11. Per MR review, intra-operative notes indicate that Chloreprep was used as a skin prep for Pt. #6, 7, 8, and 10, and Chloreprep and Providone Iodine was used as a skin prep for Pt. #9 The intra-operative notes do not identify if the staff ensured that these alcohol-based skin preps were dry prior to draping.

These examples were confirmed by DON (A) on 11/17/11 at 2:10 PM.

Example by surveyor 18816:
Per Pt #21's MR review by surveyor 18816 on 11/15/11 at 8:45 AM, the Perioperative documentation indicates a time out was conducted on 1/14/11 at 7:00 AM for a scheduled cesarean section. The Intraoperative documentation indicates Chloraprep, an alcohol based skin preparation, was used. There is no documentation the Chloraprep was dry prior to draping, allowing for potential fire hazard. This is confirmed in interview with DON A on 11/17/11 at 7:30 AM.

The cumulative effect of the above examples resulted in the facility's inability to ensure that patient safety and well-being is ensured.

Based on 7 of 7 surgery MR reviewed out of a total of 30 MR reviewed, review of medical staff rules and regulations, and 1 of 1 staff interview (A), the hospital failed to ensure that the post-anesthesia evaluations are complete for Pt. #6, 7, 8, 9, 10, 21 and 27.

Findings include:
Examples by surveyor #13469:
Per review of medical staff rules and regulations dated 2/24/11 direct the following: page 45 #36. "the anesthetist shall maintain an anesthetic record which should include at least evidence of pre-anesthetic evaluation and post-anesthetic follow-up of the patient's condition, including level of consciousness, vital signs, status of intravenous lines, dressings, tubes, etc."

The following MR were reviewed between 11/14/11 at 2:20 PM and 11/17/11 at 1:45 PM: Pt. #6 who had surgery on 6/1/11, Pt. #7 who had surgery on 12/30/11, Pt. #8 who had surgery on 1/24/11, Pt. #9 who had surgery on 7/6/11, Pt. #10 who had surgery on 8/3/11.

Pt. #6, 7, 8,and 10 were given general anesthesia, and Pt. #10 received monitored anesthesia care with sedation. The post anesthesia notes indicate that the patients had no complications and tolerated the anesthesia. These examinations do not include the following information to be considered complete: cardiopulmonary status (to include a blood pressure, pulse, and respirations), level of consciousness, any follow-up care and/or observations.

Pt. #9 was given a spinal block with sedation. The post anesthesia note indicates that the patient had no complications and tolerated the anesthesia. The examination does not include the following information to be considered complete: Cardiopulmonary status (to include a blood pressure, pulse, and respirations), level of consciousness, return of feeling and/or movement to the lower part of the body, any follow-up care and/or observations.


18816

Example by surveyor 18816:

Pt #21's MR reviewed by surveyor 18816 on 11/13/11 at 8:45 AM revealed Pt #21 had a cesarean section on 1/14/11. The post anesthesia note states "No apparnt[sic] anes (anesthesia) comp (complications) 1/17/11 Tol (tolerated) procedure (illegible) c/o (complaint) slight (illegible) 9:00 AM piritis [sic] resolved VSS (vital signs stable) Going home today." There is a signature and "date 11/14 time 830". This does not constitute a complete post anesthesia note that includes cardiopulmonary status, level of consciousness, follow care, observations and complications,with a signature, date and time for each entry. This is confirmed in interview with DON A on 11/17/11 at 7:30 AM.

Pt #27's MR reviewed by surveyor 1886 on 11/16/11 at 7:50 AM revealed she had an epidural to alleviate labor pain on 10/15/11. The post anesthesia note states "No apparnt [sic] anes complications VSS. Pt tol well offers no complaints." This does not constitute a complete post anesthesia note that includes cardiopulmonary status, level of consciousness, follow care, observations and complications. This is confirmed in interview with DON A on 11/17/11 at 7:30 AM.

Based on interview and review of QAPI information with staff in 1 of 1 interview (A and B) the facility failed to ensure the QAPI committee duties included review of contracted services. This deficiency potentially affects all 6 inpatients at the facility during the survey.

Findings include:
Per surveyor 18816 interview with DON A and IC B on 11/16/11 at 2:00 PM, and review of QAPI information during the same interview, there is no annual review of contracted services (pharmacy) including assessing the quality of services to ensure they meet the requirements of the appropriate COP. See tag C276.

Based on MR review, review of P&P and interview with staff, in 4 of 4 Swing Bed MRs (1, 2, 4 and 5), out of a total 30 MRs reviewed, the facility failed to ensure there is an advanced directive (AD) on file if one exists, and/or offered information and assistance to complete an AD if there is none.

Findings include:

Facility policy titled Advanced Directive (n.d.) reviewed by surveyor 18816 on 11/17/11 in the PM, states under Procedures (3)...During the admission process, or as soon as reasonably possible, admitting personnel will ask the patient whether he/she has completed an advance directive. If an advance directive has been completed, the person who documents the patient's admission will ask for a copy of the advance directive so that it may be placed in the patient's record. If a copy of the patient's advance directive is not immediately available, the patient will be requested to provide the name and telephone number of their Health Care agents. If an advance directive has not been completed, or if the patient is unfamiliar with advance directives, the admitting nurse will ask the patient whether they would like to receive further information on advance directives...If so, the patient should be directed to the Patient Discharge Planner and /or Patient Advocate."

Pt #1's MR review, by surveyor 1886 on 11/16/11 at 9:40 AM, revealed the Nursing Admission Assessment (NAA) indicated Pt #1 has a living will (also known as AD). There is no documentation in the MR the AD was requested, and no copy in the MR. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Pt #2's MR review, by surveyor 1886 on 11/16/11 at 10:15 AM, revealed the NAA indicated Pt #2 does not have an AD. There is no documentation Pt #2 was provided information on AD or offered assistance to complete an AD. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Pt #4's MR review, by surveyor 1886 on 11/16/11 at 11:10 AM, revealed the NAA indicated Pt #4 does not have an AD. There is no documentation Pt #4 was provided information on AD or offered assistance to complete an AD. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Pt #5's MR review, by surveyor 1886 on 11/16/11 at 11:40 AM, revealed the NAA indicated Pt #5 has an AD. There is no documentation in the MR the AD was requested, and no copy in the MR. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Based on review of patient admission packets and 1 of 1 staff interview (A) by surveyor
#13469, the hospital does not ensure that patients/representatives are given a copy of all patient rights at the time of admission.

Findings include:
Per review of the admission packet on 11/22/11 11:00 AM, the right for married couples to share a room is not specifically stated in the patient rights brochure given to swing bed patients/representatives at the time of admission. This was confirmed by DON (A) on 11/30/11 at 8:58 AM per email.

Based on review P&P, review of MRs and interview with staff, in 4 of 4 Swing Bed MRs (1, 2, 4, and 5), out of a total 30 MRs reviewed, the facility failed to ensure they provide activities appropriate to the individual Swing Bed Pt.

Findings include:
Facility policy titled Swing Bed Program, Rehabilitation Therapy reviewed 5/05, reviewed by surveyor 18816 on 11/17/11 in the PM, states under Policy: B. "Activities Therapy will see all Swing Bed patients for an initial evaluation. A written eval will be included in the medical record along with recommendations and treatment plans. The activities evaluation will be reviewed and approved by the attending physician (by signature) during the initial care conference. Any changes or updates will be reported at future care conferences by the activity therapist and again co-signed by the attending physician."

Per surveyor 18816 review of Swing Bed MRs for Pts 1, 2, 4 and 5, on 11/16/11 between 9:40 AM and 11:30 AM, the MRs have no documentation of activities evaluation, approved by the MD, or offered to Pts 1, 2, 4, and 5, during their stay as Swing Bed Pts.

Per surveyor 18816 interview on 11/15/11 at 2:20 PM regarding the facility Swing Bed program, RN L confirmed there is no activity program that includes group activities or unique activities preferred by the Pts. RN L stated there is a cart with books and games, but confirmed there is no activities calendar for Pts to chose activities.

Based on review of P&P, review of MRs and interview with staff, in 4 of 4 Swing Bed records (1, 2, 4 and 5), out of a total 30 MRs reviewed, the facility failed to ensure there is a direct or contracted Social Worker to provide social services to Swing Bed Pts.

Findings include:

Facility policy titled Swing Bed Program, Rehabilitation Therapy reviewed 5/05, reviewed by surveyor 18816 on 11/17/11 in the PM, states under Policy: E. "Social Services will see all hospital patients who meet the Social Service or Discharge Planning Screening criteria and all Swing Bed patients to guide and counsel the patient concerning discharge planning, extended care placement, medicare coverage, etc. Social Services will also see a patient upon referral from the physician, family, hospital staff or other interested parties."

Per surveyor 18816 review of Swing Bed MRs for Pts 1, 2, 4 and 5, on 11/16/11 between 9:40 AM and 11:30 AM, the MRs have no documentation of social services assessing and/or providing services to the Swing Bed Pts.

Per surveyor 18816 interview with RN L on 11/15/11 at 2:20 PM, there is no social worker on staff as either a direct or contracted employee to provide social services to the Swing Bed Pts..

Based on MR review, review of P&P and interview with staff, in 4 of 4 Swing Bed MRs (1, 2, 4 and 5), out of a total of 30 MRs reviewed, the facility failed to ensure there is a comprehensive care plan completed for each swing bed patient.

Findings include:

Pt #s 1, 2, 4 and 5 MR's reviewed on 11/16/11 between 9:40 AM dn 11:40 AM by surveyor 18816 revealed there are no care plans in the MRs, including diagnosis, interventions, goals and evaluations. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM, adding the care plans are on the Cardex and not saved in the MR.

Based on review of MR, review of P&P and interview with staff, in 3 of 4 Swing Bed MRs requiring nutrition assessments (1, 2, and 5), out of a total 30 MRs reviewed, the facility failed to ensure the nutrition assessments are completed per P&P.

Findings include:

Facility policy titled Nutrition Assessment, Nutrition Screening reviewed 10/10, reviewed by surveyor 18816 on 11/17/11 in the PM, states under Policy "Hospitalized patients with increased nutritional risk will be identified so they may receive diet intervention/nutrition support/diet modification to improve nutrient intake."

Pt #1's MR review, by surveyor 18816 on 11/16/11 at 9:40 AM, revealed there is no nutrition assessment completed after admission to the Swing Bed program on 8/4/11. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Pt #2's MR review, by surveyor 18816 on 11/16/11 at 11:10 AM, revealed there is no nutrition assessment completed after admission to the Swing Bed program on 9/3/11. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.

Pt 5's MR review, by surveyor 18816 on 11/16/11 at 10:15 AM, revealed there is no nutrition assessment completed after admission to the Swing Bed program on 8/30/11. This is confirmed in interview with DON A on 11/17/11 at 11:30 AM.