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Based on observation, staff interview, and policy review, the facility failed to ensure staff follows approved medical staff policy and procedures for the insertion of intravenous (IV) access.


Findings Include:


On 01/23/17 at 2:00 p.m. observation was made of an Emergency Department (ED) Registered Nurse (RN) inserting an IV for an ED patient. During the procedure the RN removed the tip of the glove off of his index finger before insertion of the IV. After the procedure the RN stated, "I know I took the tip of my glove off. I cannot feel patient's veins with my finger with the glove on."


Review of the facility's "Guidelines for Infection Control in Intravenous Therapy" (dated 12/17/14) revealed: "...B. Peripheral Cannula Insertion... Gloves must be worn when inserting a peripheral IV as per OSHA requirements. Palpation of the insertion site may not be performed after the application of a skin antiseptic, unless aseptic technique is used. Aseptic technique must be maintained for the insertion and care of intravascular catheters..."


During an Exit Conference on 01/25/17 at 1:30 p.m. these findings were discussed. No further documentation was provided by the facility.

Based on record review, medical staff bylaws review and staff interview, the facility failed to promptly authenticate, date and time physician's orders on four (4) of six (6) closed patient records reviewed, Patient #12, #13, #14 and #15.


Findings Include:


Review of six (6) closed patient medical records revealed that four (4) contained Physician's Orders which had not been signed, dated and/or timed by the Physician and/or Nurse Practitioner:
Record #12 had no time for an order dated 08/16/16 and no date or time for a second order dated 08/16/16.
Record #13 had no date and time for orders dated 08/11/16, 8/12/16 and 8/18/16.
Record #14 had no date and time for orders dated 7/7/16 and 7/9/16.
Record #15 had no date and time for orders dated 7/7/16 and 7/9/16.

During an interview 01/24/17 at 10:53 a.m. the Director of Quality confirmed medical records for Patient #12, #13, #14, and #15 failed to have orders signed, dated and/or timed by the physicians and/or nurse practitioner giving the order. The Director of Quality revealed this is an ongoing problem with the doctors to date and sign orders.

Review of the facility's medical staff bylaws "Rule and Regulations 2.14 Orders 2.14(a) Written/Verbal/Telephone Treatment Orders" revealed: "Orders for treatment shall be in writing, dated, timed and authenticated."

During an Exit Conference on 01/25/17 at 1:30 p.m. these findings were discussed. No further documentation was provided by the facility.

Based on document review, policy review, and staff interview, the facility failed to ensure 382 medical records were complete within 30 days following patient discharge.


Findings Include:


Review of the facility's Medical Records Delinquent Physician List revealed 382 incomplete medical records greater than 30 days following patient discharge. All 382 incomplete records were greater than 120 days delinquent and included discharge summaries not dictated, physician orders, psychiatric evaluation reports, and progress reports.


During an interview on 01/23/17 at 2:07 p.m. the Medical Records Director confirmed the number of delinquent medical records was 382, included both the Acute and Chemical Dependency Unit, and all 382 were greater than 120 days delinquent. She stated she just started employment with this facility in September 2016 and was trying to get the delinquent charts up to date. In addition, she stated she sends the delinquent medical record report to administration on the 7th day of every month.



During an interview on 01/23/17 at 3:10 p.m. the Director of Quality and the Chief Executive Officer (CEO) both confirmed the facility's delinquent list of 382 medical records. The Director of Quality stated, "The facility's policy states that 60 days is considered delinquent. We were without a Medical Records Director for several months...we have a goal of less than 20 percent of delinquent medical records." The CEO stated, "The physicians whom have delinquent records have received a Focused Professional Practice Evaluation and the Evaluation will be reviewed in 30 days and if not improved will go before the Medical Evaluation Board for recommendations."


Review of a copy of the Focused Professional Practice Evaluation revealed: "Dear (physician's name), During the FPPE period the following issues were identified: certification forms review were not signed by physician and Documentation: per guidelines is not being completed the required 3 times a week. This ongoing evaluation allows us to improve any identified practice trends that impact quality of care and safety. The performance analysis data will be present to the applicable Medical Staff Committee(s) with a copy maintained in your quality file."


Review of the facility's "Rules and Regulations" (dated December,2014) revealed: "2.16 Delinquent Medical Records... Patient medical records are required to be completed within thirty (30) days of notification by the Health Information Management Department (HIM). The HIM Department will provide each physician with a list of his/her incomplete medical records every seven (7) days. At the twenty-first (21st) day for any incomplete medical records, the letter will include a warning that the record(s) will be delinquent at thirty (30) days and the physician's privileges will be suspended if any records become delinquent."


During an Exit Conference on 01/25/17 at 1:30 p.m. these findings were discussed. No further documentation was provided by the facility for review.

Based on observation, staff interview, and policy/procedure review, the facility failed to ensure proper storage of hazardous waste.

Findings Include:


On 01/24/17 at 9:55 a.m. an Operating Room (OR) observation revealed two (2) red cans for hazardous waste in the OR. One container was small and contained a label on the side that was hard to visualize. The other one was larger, round and had no liner or sign. Both were underneath a box of gloves and a hand sanitizer that hung on the wall above. The gloves and the hand sanitizer could not be reached without brushing against the hazardous waste containers.


Review of the facility's "Hazardous Materials and Waste Management Plan" policy (Revision Date 1/9/2015) revealed:
"... II. Scope ... designed to assure compliance with applicable codes and regulations.
III. Fundamentals: ... F. Segregation of hazardous waste at the point of generation is an effective means of controlling the potential for exposure or spills during collection, transport, storage and disposal.
VI. Process for Managing the Risks ... Inventory of Hazardous Materials and Waste... The manager of each department has an inventory of hazardous or regulated waste and is responsible for managing their safe storage and handling... Licensed contractors transport chemical, chemotherapeutic and medical waste... Management of Hazardous Materials and Waste... Infectious and regulated medical waste... Labeled and specialized containers are used to collect and transport these waste... Management of Hazardous Materials and Waste Storage Space - The Safety Officer or designee assesses the appropriateness of space for handling and storgage of hazardous materials and waste... Waste Labeling - All hazardous wastes are labeled from generation to removal. Some waste, such as bio hazardous wastes are labeled by placement in a red bag; other waste are labeled with specific signs or with text labels. Bio hazardous Waste: These are placed in red bags, then placed in cardboard boxes, or plastic bins with external labeling as bio hazardous waste, or in a labeled roll-away container provided by the vendor... Separation of Waste Handling Areas - (Facility) maintains appropriate handling and storage areas for hazardous waste that are separated and maintained to minimize the possibility of contamination of food, clean and sterile goods, or contact with staff..."

Review of the facility's "Exposure Control Plan 2016" revealed: ... Regulated Waste - Regulated waste will be handled to minimize contact with bloodborne pathogens... Containers will be labeled with the international biological hazard symble and the wording 'Biohazard or Biomedical Waste'... Medical Infectious Waste:... Labels - ...Biomedical Waste... Placed in red bag or red container marker with biomedical waste label..."