HospitalInspections.org

Based on record review and interview the hospital failed to document the advanced directives status at the time of admission for 2 (#3 and #14) of 28 patients sampled.

Findings:

1. During record review for Patient #3 it was noted that the patient was admitted on 2/16/13 and discharged on 2/26/13. Review of the biopsychosocial assessment page 8 the advanced directives section was left blank.

2. During record review for Patient #14 it was noted that the patient was admitted on 1/10/13 and discharged on 1/13/13. Review of the biopsychosocial assessment page 8 the advanced directives section was left blank.

Interview with the DON and the nursing supervisor on 2/27/13 at 2 PM stated that the advanced directives are documented on the biopsychosocial assessment page 8. They both stated that the advanced directives were not documented for patients #3 and #15.

Review of the hospital policy and procedures revealed that there are no policies concerning advanced directives documentation.

Based on record review and interview the hospital failed to ensure that policies and procedures were followed for patients placed in seclusion specific to patient specific length of time for the seclusion and signed telephone/verbal orders for 7 (#3, #8, #10, #13, #14, #15 and #27) of 27 patients sampled.

Findings:

During record review for Patient #3, it was revealed that on 2/17/13 at 10 AM she was placed in seclusion. Review of the order revealed that it is a verbal order. The order did not indicate the length of time of the seclusion in the space designated on the pre-printed order form.

During record review for Patient #8, it was revealed that on 1/16/13 at 10:15 AM he was placed in seclusion. Review of the order revealed that it was a verbal order. The order did not indicate the length of time of the seclusion in the space designated on the pre-printed order form. The physician documented that he signed the order on 1/17/13 at 9:20 AM.

During record review for Patient #10, it was revealed that on 2/4/13 at 2:20 AM she was placed in seclusion. Review of the order revealed that it was a telephone order. The order did not indicate the length of time of the seclusion in the space designated on the pre-printed order form. The order was not signed by the physician.

During record review for Patient #13, it was revealed that on 2/6/13 at 3:25 PM he was placed in seclusion. Review of the order revealed that it was a telephone order. The order did not indicate the length of time of the seclusion in the space designated on the pre-printed order form. The space was left blank to specific the length of time.

During record review for Patient #14, it was revealed that on 1/10/13 at 9:45 PM he was placed in seclusion. Review of the order revealed that it was a telephone order. The order did not indicate the length of time of the seclusion in the space designated on the pre-printed order form.

During record review for Patient #15, it was revealed that on 6/3/12 at 1:30 PM she was placed in seclusion. Review of the order revealed that it was a telephone order. The order did not indicate the length of time of the seclusion in the space designated on the pre-printed order form. On 6/4/12 at 8:55 AM, the patient was again placed in seclusion. Review of the order revealed that the physician did not specify a length of time for the seclusion.

During record review for Patient #27, it was revealed that on 9/15/12 at 10:30 PM she was placed in seclusion. Review of the order revealed that it was a telephone order. The order did not indicate the length of time of the seclusion in the space designated on the pre-printed order form. On 9/22/12 at 10:15 PM, she was placed in seclusion. Review of the order revealed that it was a telephone order. The order did not indicate the length of time of the seclusion in the space designated on the pre-printed order form. There was no physician's signature for the telephone order. Patient #27 also had telephone orders for seclusion dated 9/14/12, 9/15/12, and 9/16/12 which were all signed on 9/19/12.

Interview with the nurse supervisor on 2/27/13 at 2:30 PM confirmed that Patients #8 , #10 and #27's orders were not signed. She stated that the seclusion orders contain the criteria by age of the limit for seclusion. She stated that the space to designate the length of time was left blank for Patients # 3, #8, #10, #13, #14, #15 and #27.


Review of the hospital's policy titled Special Treatment Procedure Adult effective September 2011 and approved by the QA in April, 2012 page #5 Emergency Initiation revealed that an initial face to face visit will be conducted by the prescriber within one hour of seclusion initiation.

Review of the Medical Bylaws 2012/2013 approved on 6/25/12 revealed on page 19 F "All entries in the record must be dated, signed and credentialed by the responsible clinician."

Review of the hospital's Policy #400 titled Medication Orders effective 2011 and approved by QA in April, 2012 revealed that B2 Telephone or verbal orders are signed by the prescriber or authorized prescriber within 24 hours and are a part of the clinical record. There were no other policies concerning the timeliness of authenticated orders.

Based on record review and interview the hospital failed to ensure that physician's orders for medications were authenticated per hospital policy for 1 (#10) of 27 patients sampled.

Findings:

During record review for Patient #10, it was revealed that on 2/4/13 at 2:20 AM a telephone order for Ativan 1 mg IM (intramuscularly) for one dose was documented on the Emergency Treatment Order form. The order contains no physician's signature.

The nurse supervisor, during interview on 2/27/13 at 2:30 PM, stated that Patient, #10's emergency treatment order was not signed.

Review of the hospital's Policy #400 titled Medication Orders effective 2011 and approved by QA in April, 2012 revealed that B2 Telephone or verbal orders are signed by the prescriber or authorized prescriber within 24 hours and are a part of the clinical record.

29257


Based on interviews and chart review, the facility failed to ensure the prompt retrieval of medical records for 1 (patient # 20) of 27 patients, and to ensure that medical records were maintained in an orderly manner.

Findings:

Twenty-seven (27) records (both current and discharged) were chosen for review for this survey.

During interview with the medical records manager on 2/26/13 at 10 AM, she stated that Patient #20's medical record was at an out of town/out of county outpatient location. She stated that she could request that the medical record be returned to the hospital and it would be available to the survey team the next day. She stated that once a patient is discharged from the hospital the medical record is sent to the outpatient clinic in their area to ensure that the patient receives the physician's ordered care and services. She stated that a copy of the record is not maintained at the hospital site. She stated that if the patient returns to the hospital as an in-patient, the courier will return the medical record. She stated that the hospital maintains a chart order form for both current and discharged medical records. She stated that the medical records are not kept in the specified order as the high turn over of the patient population makes it impossible for her to organize the medical records.

A list of the medical record (chart) order was obtained. Review of the hospital's policy and procedure manual revealed that there were no specific policies concerning the order that the medical record is to be maintained.

32416


Based on record review and interview, the hospital failed to ensure that the patients' medical records were complete and authenticated per hospital policies and procedures 7 (#3, #8, #10, #13, #14, #15 and #27) of 27 patients sampled.

Findings:

During record review for Patient #3, it was revealed that on 2/17/13 at 10 AM she was placed in seclusion. Review of the order revealed that it is a verbal order. The order did not indicate the length of time of the seclusion in the space designated on the pre-printed order form.

During record review for Patient #8, it was revealed that on 1/16/13 at 10:15 AM he was placed in seclusion. Review of the order revealed that it was a verbal order. The order did not indicate the length of time of the seclusion in the space designated on the pre-printed order form. The physician documented that he signed the order on 1/17/13 at 9:20 AM.

During record review for Patient #10, it was revealed that on 2/4/13 at 2:20 AM she was placed in seclusion. Review of the order revealed that it was a telephone order. The order did not indicate the length of time of the seclusion in the space designated on the pre-printed order form. The order was not signed by the physician.

During record review for Patient #13, it was revealed that on 2/6/13 at 3:25 PM he was placed in seclusion. Review of the order revealed that it was a telephone order. The order did not indicate the length of time of the seclusion in the space designated on the pre-printed order form. The space was left blank to specific the length of time.

During record review for Patient #14, it was revealed that on 1/10/13 at 9:45 PM he was placed in seclusion. Review of the order revealed that it was a telephone order. The order did not indicate the length of time of the seclusion in the space designated on the pre-printed order form.

During record review for Patient #15, it was revealed that on 6/3/12 at 1:30 PM she was placed in seclusion. Review of the order revealed that it was a telephone order. The order did not indicate the length of time of the seclusion in the space designated on the pre-printed order form. On 6/4/12 at 8:55 AM, the patient was placed in seclusion. Review of the order revealed that the physician did not specify a length of time for the seclusion.

During record review for Patient #27, it was revealed that on 9/15/12 at 10:30 PM she was placed in seclusion. Review of the order revealed that it was a telephone order. The order did not indicate the length of time of the seclusion in the space designated on the pre-printed order form. On 9/22/12 at 10:15 PM, she was placed in seclusion. Review of the order revealed that it was a telephone order. The order did not indicate the length of time of the seclusion in the space designated on the pre-printed order form. There was no physician's signature for the telephone order. Patient #27 also had telephone orders for seclusion dated 9/14/12, 9/15/12, and 9/16/12 which were all signed on 9/19/12.

Interview with the nurse supervisor on 2/27/13 at 2:30 PM confirmed that Patients #8 , #10 and #27's orders were not signed. She stated that the seclusion orders contain the criteria by age of the limit for seclusion. She stated that the space to designate the length of time was left blank for Patients # 3, #8, #10, #13, #14, #15 and #27.

Review of the hospital's policy titled Special Treatment Procedure Adult effective September 2011 and approved by the QA in April, 2012 page #5 Emergency Initiation revealed that an initial face to face visit will be conducted by the prescriber within one hour of seclusion initiation.

Review of the Medical Bylaws 2012/2013 approved on 6/25/12 revealed on page 19 F "All entries in the record must be dated, signed and credentialed by the responsible clinician."

Review of the hospital's Policy #400 titled Medication Orders effective 2011 and approved by QA in April, 2012 revealed that B2 Telephone or verbal orders are signed by the prescriber or authorized prescriber within 24 hours and are a part of the clinical record. There were no other policies concerning the timeliness of authenticated orders.

32416



Based on record review and interview the hospital failed to ensure that telephone/verbal orders were complete and authenticated within 48 hours and/or per hospital policies and procedures for 7 (#3, #8, #10, #13, #14, #15 and #27) of 27 patients sampled.

Findings:

During record review for Patient #3 it was revealed that on 2/17/13 at 10 AM she was placed in seclusion. Review of the order revealed that it is a verbal order. The order did not indicate the length of time of the seclusion in the space designated on the pre-printed order form.

During record review for Patient #8 it was revealed that on 1/16/13 at 10:15 AM he was placed in seclusion. Review of the order revealed that it was a verbal order. The order did not indicate the length of time of the seclusion in the space designated on the pre-printed order form. The physician documented that he signed the order on 1/17/13 at 9:20 AM.

During record review for Patient #10 it was revealed that on 2/4/13 at 2:20 AM she was placed in seclusion. Review of the order revealed that it was a telephone order. The order did not indicate the length of time of the seclusion in the space designated on the pre-printed order form. The order was not signed by the physician.

During record review for Patient #13 it was revealed that on 2/6/13 at 3:25 PM he was placed in seclusion. Review of the order revealed that it was a telephone order. The order did not indicate the length of time of the seclusion in the space designated on the pre-printed order form. The space was left blank to specific the length of time.

During record review for Patient #14 it was revealed that on 1/10/13 at 9:45 PM he was placed in seclusion. Review of the order revealed that it was a telephone order stating "Seclusion/holding order expires in blank hours." The space was left blank to specific the length of time.

During record review for Patient #15 it was revealed that on 6/3/12 at 1:30 PM she was placed in seclusion. Review of the order revealed that it was a telephone order. The order did not indicate the length of time of the seclusion in the space designated on the pre-printed order form. On 6/4/12 at 8:55 AM the patient was placed in seclusion. Review of the order revealed that the physician did not specify a length of time for the seclusion.

During record review for Patient #27 it was revealed that on 9/15/12 at 10:30 PM she was placed in seclusion. Review of the order revealed that it was a telephone order. The order did not indicate the length of time of the seclusion in the space designated on the pre-printed order form. On 9/22/12 at 10:15 PM she was placed in seclusion. Review of the order revealed that it was a telephone order. The order did not indicate the length of time of the seclusion in the space designated on the pre-printed order form. There was no physician's signature for the telephone order. Patient #27 also had telephone orders for seclusion dated 9/14/12, 9/15/12, and 9/16/12 which were all signed on 9/19/12.

Interview with the nurse supervisor on 2/27/13 at 2:30 PM stated that Patients #8 , #10 and #27's orders were not signed. She stated that the seclusion orders contain the criteria by age of the limit for seclusion. She stated that the space to designate the length of time was left blank for Patients # 3, #8, #10, #13, #14, #15 and #27.

It is noted that Patient #8 and #14 were discharged from the hospital in January, 2013. Patient #15 was discharged from the hospital in June, 2012. Patient #27 was discharged from the hospital in September, 2012.

Review of the hospital's policy titled Special Treatment Procedure Adult effective September 2011 and approved by the QA in April, 2012 page #5 Emergency Initiation revealed that then initial face to face visit will be conducted by the prescriber within one hour of seclusion initiation.

Review of the Medical Bylaws 2012/2013 approved on 6/25/12 revealed on page 19 F "All entries in the record must be dated, signed and credentialed by the responsible clinician.

Review of the hospital's Policy #400 titled Medication Orders effective 2011 and approved by QA in April, 2012 revealed that B2 Telephone or verbal orders are signed by the prescriber or authorized prescriber within 24 hours and are a part of the clinical record. There were no other policies concerning the timeliness of authenticated orders.

Based on review of the record review and interviews, the hospital failed to ensure verification that medication orders are reviewed by a pharmacist prior to dispensing specific to 7 (#8, #10,#13, #14, #17, #19 and #27) of 27 patients sampled.

Findings :

1. Interview with the pharmacist on 02/27/2013 at 9:15 AM revealed that he is at the facility at least once a week, as needed, and can be reached by phone 24/7. He stated that he does review patients' charts, but if a patient leaves within that week that it is primarily the physician's responsibility to check allergies and medications before given.

2. Review of Contract for professionals FY 2012-2013 on page 1. Number 8, indicates: To participate in the centers medical staff committee and continuous quality improvement activities as needed. b. Monitor adverse drug reactions; c. Monitor charts for proper ordering and dosing of medications; e. Develop staff training programs; f. Monitor food and drug interactions.

3. Interview with Registered Nurse ( RN ) on 02/27/2013 at 8:30 AM revealed that they log in medications on a separate piece of paper. They use stock medications for all medications given out. They do not send, scan, or fax any medication sheet to the pharmacist. They use the medication record to add or subtract medications given to the patient.

4. Interview with psychiatrist on 02/27/2013 at 10:55 AM revealed that the physician does review the medications with the patient. On new admissions, he will go over the patient's home medications and then order medications as needed.

5. During closed record review for Patient #8, who was admitted on 1/13/13 and discharged on 1/21/13, revealed that his medication profile, physician's orders and MAR (Medication Administration Record) was not signed by the pharmacist.

7. During closed record review for Patient #10, who was admitted on 12/14/12 and discharged on 12/17/12, revealed that his medication profile, physician's orders and MAR (Medication Administration Record) was not signed by the pharmacist.

8. During closed record review for Patient #13, who was admitted on 2/5/13 and discharged on 2/20/13, revealed that his medication profile, physician's orders and MAR (Medication Administration Record) was not signed by the pharmacist.

9. During closed record review for Patient #14, who was admitted on 1/10/13 and discharged on 1/11/13, revealed that his medication profile, physician's orders and MAR (Medication Administration Record) was not signed by the pharmacist.

10. During closed record review for Patient #17, who was admitted on 12/12/12 and discharged on 12/17/12, revealed that his medication profile, physician's orders and MAR (Medication Administration Record) was not signed by the pharmacist.

11. During closed record review for Patient #19, who was admitted on 12/14/12 and discharged on 12/17/12, revealed that his medication profile, physician's orders and MAR (Medication Administration Record) was not signed by the pharmacist.

12. During closed record review for Patient #27, who was admitted on 9/21/12 and discharged on 9/26/12, revealed that his medication profile, physician's orders and MAR (Medication Administration Record) was not signed by the pharmacist.

13. Interview with the Director of Nursing (DON) on 2/27/13 at 2 PM revealed that the pharmacist signs the MAR to indicate that he reviewed the medication.

14. Review of the hospital's policies and procedures revealed that there was no specified system in which the pharmacist is to verify he reviewed the ordered medications for interactions with other prescribed medications or food.




29257

Based on observation and interview, the hospital failed to properly maintain the hospital in proper working order to assure patient safety specific to loose handrails.
Findings:
1.) Observations during tour conducted on 2/25/13 at 10 AM of the APU (Adult Patient Unit) revealed that three hand rails were loose. The handrail near the day room, across from the treatment room is loose and can be jiggled when tugged. Also, the handrails on either side of the medication room door are loose. The handrail to the left of the door is very loose.
2.) On 02/27/13 at 1 PM, an interview and tour was conducted with the Maintenance Director. It was brought to his attention that the handrails were loose. He stated that his assistant performs daily rounds and that he performs monthly inspections. He stated that if there is a problem with maintenance, the nurses fill out a work order and the problem is taken care of immediately unless they need a part. He stated that he would have his assistant work on the handrails as soon as possible. He was unable to provide a maintenance schedule or daily round audits of the hand rail checks. There were no policies or procedures concerning the maintenance of the handrails.