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Based on interview and record review, the facility failed to follow its policies and procedures for completeness of medical record entries. Nine of 10 records reviewed for completeness of entries were found to contain incomplete physician orders, progress notes, and/or post-anesthesia evaluations (Patients #1-5, 7-10).

Failure to document complete record entries with authentication, date, and time places patients at risk for poor quality care by failing to establish baselines for future actions or assessments and failing to establish a timeline of events.


Findings include:

Staff #1 stated that hospital policy requires signing, dating, and timing of all record entries, including practitioner orders, progress notes, and post-anesthesia notes. S/he stated that the licensed nurse is required to note practitioner orders by signing, dating, and timing. The facility policy #835.019 " Medical Record Entries " reads in part:

· " All entries shall indicate date and time. "
· " All entries shall be authenticated by the practitioner ' s signature. "


PRACTITIONER ORDERS

Patient #3 was admitted to the hospital on 8/23/10. The surveyor reviewed the patient ' s medical record on 8/25/10. Eight practitioner orders written during those three days for medications and other treatments were found to be incomplete.

Four of the orders were labeled as admission orders. All of them lacked the time written by the physician. All of them lacked a signature, date, and time indicating that they had been noted and implemented by nursing staff. The four remaining incomplete orders lacked documented times, either by the physician or by the nurse noting the order.

Patient #2 was admitted on 8/18/10. The surveyor reviewed the patient ' s record on 8/24/10. Seven practitioner orders written during those seven days were noted to lack documentation of the time they were written. One of the orders had not been signed or dated by the physician. Two of the orders lacked the time noted by the nurse.

Similar instances of incomplete practitioner orders were found in reviewing the records for Patients #1, 4, 5, 7, 9, and 10. These findings were confirmed by Staff #1.


PROGRESS NOTES

On 8/24/10, the surveyor reviewed the medical record for Patient #2, admitted 8/18/10. Five progress notes failed to document the time of day the entry was made. One of these notes detailed a procedure to insert an intravenous catheter into a large vein for administration of fluids and medications. It included pre-, intra-, and post-procedural information. This note was not signed or dated by the physician.

On 8/25/10, the surveyor reviewed the record for Patient #3, admitted 8/23/10. During that three day period, the physician failed to document the time s/he wrote four progress notes.

These findings were confirmed by Staff #1.


POST-ANESTHESIA NOTES

Patient #1 was admitted to the hospital for knee surgery on 8/23/10. The surveyor reviewed the patient ' s medical record on 8/24/10. The post-anesthesia evaluation lacked a documented date and time for the entry.

On 8/25/10 the surveyor reviewed records for five other patients who had undergone surgery or other procedures under general anesthesia. There was no documentation of the time the post-anesthesia evaluation was performed for any of these patients (Patients #3, 7-10). These findings were confirmed by Staff #1.

Refer to tag A-1005 regarding deficiencies in documentation of patients ' post-anesthesia assessment data.

Based on interview and record review, the facility failed to comply with the requirement that radiology services only be provided on the order of practitioners authorized by the medical staff and governing body, and consistent with state law.

Failure to do so places patients at risk for unneeded or inappropriate radiology services, and shifts the responsibility for medical care planning from the licensed independent practitioner to nursing staff.

Findings include:

During survey of the Pain Clinic on 8/25/10 Staff #2 described clinic routines, services and processes. S/he stated that for many of the procedures performed in the clinic, radiology staff brought portable equipment to the procedure room and performed any required radiology services.

The surveyor reviewed two Pain Clinic patient records on 8/25/10 (Patients #4 and 5). In each record the surveyor found a physician order sheet on which orders had been written by Staff #2. The orders were not documented as verbal or telephone orders given by and read back to a licensed independent practitioner (LIP). The orders were not signed by a LIP.

The orders written by Staff #2 for these patients reflected the procedure the patient was to undergo, and ordered a C-arm (a radiology device). Staff #2 stated that s/he routinely wrote such orders in the patient ' s record, without consultation with or input from the LIP. S/he stated the purpose was to notify the Radiology department of the need for the equipment and the staff to perform radiology services. No protocol or other documentation was found in the patient records authorizing staff to write such orders.

Staff #1 and #2 confirmed that this nurse was not licensed in the State of Washington as a LIP. Review of the Medical Staff By-laws by Surveyor #18684 did not reveal provisions for writing of patient care and treatment orders by persons other than LIPs.



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Based on observation the facility failed to ensure that the requirements of the State food service regulations were being followed. More specifically, Washington State Retail Food Code Working Document, Chapter 246-215 WAC, a modification of the 2001 FDA Food Code hereafter referred to as the "Working Document".

Failure on the part of the facility to implement the requirements of the food service regulations puts patients, staff and visitors of the facility at risk of food borne illness.

References: Working Document" Chapter 3-304.15 Gloves Use Limitation, Chapter 3-305.14 Food Preparation; and Chapter 4-904.11 Kitchenware and Tableware

Findings include:

1. On 8/25/2010 the surveyor observed a food service employee in the process of preparing hamburger buns. The employee left the preparation station where the buns had been set out to retrieve cheese from the refrigerator. The employee was wearing gloves when putting out the buns but failed to change them after retrieving cheese from the refrigerator and before continuation of the bun preparation process.

2. On 8/25/2010 the surveyor observed a food service employee in the process of preparing gelatin (jello). During the preparation process a pitcher being used for mixing was placed into a sink that had not been cleaned or sanitized as indicated by food debris in the sink. The pitcher was then refilled at another sink without benefit of being cleaned and sanitized and the preparation process was repeated.

3. On 8/25/2010 the surveyor observed a food service employee transporting a stack of bowls from the kitchen area to the service area. While transporting the bowls the employee stabilized the stack by placing his/her chin into the top bowl.

Based on observation, interview, and record review, the facility failed to develop and implement a policy and procedure for management of Malignant Hyperthermia (MH) in accordance with acceptable standards of care.

Failure to do so places patients at risk of inadequate care in the event of a MH crisis, potentially resulting in permanent disability or death.

MH is a rare but life-threatening emergency reaction to general anesthesia. According to the Malignant Hyperthermia Association of the United States (MHAUS) the syndrome must be identified and treated early in its course in order for there to be a successful outcome.

During tour of the peri-operative area on 8/24/10, the surveyor observed that MH triggering agents were present in the operating rooms (ORs). Review of medical records for surgical patients (#8-10) and interview with Staff #3 confirmed that these agents were routinely used to anesthetize patients.

MHAUS specifies that 36 vials of the medication used to treat a MH crisis (dantrolene) be immediately available to areas where triggering agents are used. The surveyor examined the contents of the MH cart. Fourteen vials of the drug were found. The inventory list indicated that 14 was the quantity intended to be supplied. Staff #1 stated that the remaining supply in-house would be available in the obstetrics OR, located separately from the main ORs, and also in the Pharmacy.

Staff #1 consulted with obstetrics unit staff and reported that 14 vials were supposed to be supplied to that area, according to the checklist. However s/he stated that staff in that area had opened the cart and found 13 vials. Staff #1 also consulted the Pharmacy staff, and stated s/he was informed that there were no further supplies of the drug located there. Therefore the total known to be in-house at that time was 27 vials, rather than the 36 specified by MHAUS. Later that afternoon Staff #1 reported that Pharmacy staff had found three vials, bringing the total in-house up to 30.

The surveyor reviewed the policy " Malignant Hyperthermia, Staff Response " , revision date 10/08. Page 3, " DRUGS " reads in part: " 14-Dantrolene vials 20mg (14 to be obtained from OB and remaining from area pharmacy ' s [sic].) " The policy did not define " remaining " and thus did not indicate the total number which should be available. Nor was it clear in the policy whether the remaining vials were to be obtained from the in-house pharmacy or from an unspecified outside source.

The MH cart checklists for both the main ORs and the OB area indicated that seven containers of chilled irrigation solution should be maintained in the refrigerator on the carts. The size of the containers was not specified. The surveyor observed six 1-liter containers in the main operating room MH cart on 8/24/10. The MH policy specified that eight chilled containers, 1-liter capacity, should be on the carts.

Further review of the MH policy showed that it specified the patient should be monitored in critical care for a minimum of 24 hours in the post-acute phase. MHAUS specifies that a patient who has undergone a MH crisis should be monitored in a critical care unit for 36 hours following the event, since the symptoms may recur during that time frame.

The above findings were confirmed by Staff #1. Staff #1 stated on 8/26/10 that the required supply of dantrolene had been obtained and all involved staff fully informed prior to initiating any further surgical procedures using MH triggering agents.

Based on interview and record review, the facility failed to develop and follow policies and procedures for post-anesthesia evaluation that meet the regulation and reflect professional standards of anesthesia care.

Failure to do so places patients at risk of unrecognized complications of anesthesia care and potential delays in any necessary treatment.

Findings include:

On 8/24-25/10 the surveyor reviewed medical records for six patients who had undergone surgery or other procedures using general anesthesia (Patients #1, 3, 7-10). Incomplete documentation of the post-anesthesia evaluation by an individual qualified to administer anesthesia was found for all six patients.

Patient #1 ' s post-anesthesia evaluation did not reflect the date or time it had been performed; therefore it was not possible to determine whether it had occurred within the 48 hour time frame required by regulation.

" Practice Guidelines for Post-anesthetic Care " , in the journal Anesthesiology, Volume 96, #3, March, 2002, provides guidelines from the American Society of Anesthesiologists for routine post-anesthesia assessment. These include:

· Respiratory function, including respiratory rate, airway patency, and oxygen saturation
· Cardiovascular function, including pulse rate and blood pressure
· Mental status
· Temperature
· Pain
· Nausea and vomiting
· Postoperative hydration

Per Staff #1, the facility policy is to document the post-anesthesia evaluation on the form titled " Anesthetic Record - PART I " , but that a separate progress note could also be used to document the evaluation. No " PART II " or further extension of the form was found to exist. In reviewing the six patients ' records, the Anesthetic Record form was used to document the evaluation, and no separate progress notes were found.

The Anesthetic Record form contains a box approximately 1 " X 3 " at the bottom of the page, labeled " Post-Op Visit " . This box contains prompts to fill in or check off certain types of information regarding the patient ' s status. The form does not provide prompts or open space to document the following:

· Airway patency
· Oxygen saturation
· Temperature
· Pain
· Nausea and vomiting
· Hydration status

Due to the lack of spaces for documenting these issues, the evaluations for all six patients failed to address them.

Patient #7 ' s evaluation lacked documentation of respiratory rate, blood pressure, pulse, and level of consciousness. Failures to document these assessments were also found for Patients #8-10.

The above findings were confirmed by Staff #1.