HospitalInspections.org

Based on observation, record review and interviews, the hospital failed to ensure obstetrical patients signed the Conditions of Treatment and/or Services form for every admission to the facility for 1of 3 obstetrical patient records reviewed out of a total sample of 32 medical records. (#23) Findings:

Review of the medical record for Patient #23 revealed the Conditions of Treatment and/or Services form was signed on 6/02/10 and it was witnessed by hospital personnel in the preadmission department. Further review of the medical record revealed 3 additional original Conditions of Treatment and/or Services forms that were signed by Patient #23 and also witnessed by hospital personnel in the preadmission department in the medical record but were not dated.

An interview was held with S2 (RN Clinical Manager) on 8/12/10 at 11:45 am. After review of the medical record for Patient #23 for the signed Conditions of Treatment and/or Services form on 6/02/10 and the 3 additional original Conditions of Treatment and/or Services forms that were signed by Patient #23 and also witnessed by hospital personnel but not dated, S2 indicated the preadmission department has patients presign but not date several copies of consents before admission in the event the obstetrical patient is admitted to the hospital more than once.

In interview with S5 (Patient Access Director) on 8/12/10 at 12:15 pm, S5 indicated obstetrical patients presign Conditions of Treatment and/or Services forms during the preadmission process and added these pre-signed and not dated forms are saved for six months. She added the presigned forms allows obstetrical patients to go directly up to labor and delivery instead of going to preadmit to sign and date paperwork.

Review of the the hospital policy titled OB Pre Admissions revealed no documentation that obstetrical patients were to pre-sign and not date Conditions of Treatment and/or Services forms upon each admission to the hospital.

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Based on observations, interviews and record reviews, the hospital failed to ensure a RN (registered nurse) supervised and evaluated the care provided to patients by 1) failing to ensure a post partum patient was assessed by a nurse at the beginning of a shift for 1 of 3 post partum records reviewed (#23); 2) failing to ensure the RN assessed the patient upon discharge from an outpatient procedure for 2 of 2 sampled outpatient records reviewed (#29, #30); 3) failing to ensure the RN interpreted telemetry strips as required by policy for 5 of 5 patients reviewed with telemetry orders from a total of 32 sampled patients (#12, #14, #15, #31, #32); 4) failing to ensure that laboratory tests were obtained as ordered by the licensed practitioner for 2 of 10 patients sampled for lab testing out of a total of 32 sampled patients (#6 & #19). Findings:


1) Post partum:
Review of the medical record for Patient #23 revealed her initial assessment following admission to the post partum unit was 8/10/10 at 10:10 pm. Further review of the medical record revealed no documentation of another assessment on Patient #23 until 8:30 pm on 8/11/10 which was 22 hours from the initial nursing assessment.

An interview was held with S4 LPN on 8/12/10 at 11:55 am. S4 indicated she was the nurse that had cared for Patient #23 on 8/11/10. She could offer no explanation why there was no documentation of a nursing assessment on Patient #23 at the beginning of her shift.

An interview was held with S3, Senior Director of Nursing on 8/12/10 at 1:25 pm. After review of the medical record for Patient #23, S3 indicated there was no documentation of a nursing assessment for the day shift on 8/11/10. S3 further indicated there had been a power surge on the morning of 8/11/10 but added the hospital had never lost documentation in the past. S3 reported all staff should check their documentation to ensure their charts are completed.

Review of the hospital policy and procedure titled Assessment and Re-Assessment revealed "...Patient assessments are completed and documented at the beginning of each 8 or 12 hour shift and when care is transferred to another level of care..."


2) Outpatient services:
Patient #29
Review of Patient #29's medical record revealed she had an outpatient procedure on 08/03/10 with the administration of Zofran, Decadron, Ranitidine, Benadryl, Taxol, and Carboplatin. Further review revealed no documented evidence of an assessment at the time of discharge to include the patient's condition upon discharge. Review of the "Outpatient Oncology Record", dated 08/03/10, revealed the "Discharge Instructions" section had the time of discharge, the RN initials, and the RN's signature documented. The section "Discharged in good condition. Ambulatory ( ) Wheelchair ( )" was left blank.

Patient #30
Review of Patient #30's "Physician's Orders" revealed an order on 05/24/10, with no documented evidence of the time the order was received, for recurring oncology outpatient for 90 days and dressing change and flush Hickman catheter per protocol. Review of the "Outpatient Oncology Record", dated 03/02/10, 07/20/10, 07/27/10, and 08/10/10, and the computer charting for Patient #30 revealed no documented evidence of an assessment of the patient's condition at the time of discharge.

In a face-to-face interview on 08/12/10 at 11:15am, RN S15 confirmed there was no documented evidence on the paper record or in the computer charting of an assessment of Patient #29 and/or Patient #30 upon discharge from the Outpatient Unit. She further indicated the nurses do not take a patient's vital signs at discharge unless it's warranted, such as with the administration of blood.

In a face-to-face interview on 08/13/10 at 9:45am, Senior Director of Quality/Case Management indicated the hospital has no policy for the discharge of patients following an outpatient procedure.


3) Telemetry:
Patient #12
Review of Patient #12's medical record revealed an order on 08/09/10 at 8:15pm for "Telemetry". Further review revealed no documented evidence of a physician's order for the high and low settings and the symptoms and rhythm changes that would require the physician to be notified. Review of the telemetry strips documented in the chart revealed no documented evidence of the interpretation of the rhythm by a nurse or monitor technician.

Patient #31
Review of Patient #31's medical record revealed an order on 08/06/10 at 9:07am for "Telemetry". Further review revealed no documented evidence of a physician's order for the high and low settings and the symptoms and rhythm changes that would require the physician to be notified. Review of the telemetry strips documented in the chart revealed no documented evidence of the interpretation of the rhythm by a nurse or monitor technician.

Patient #32
Review of Patient #32's medical record revealed an order on 07/29/10 at 11:00am for "Telemetry". Further review revealed no documented evidence of a physician's order for the high and low settings and the symptoms and rhythm changes that would require the physician to be notified. Review of the telemetry strips documented in the chart revealed no documented evidence of the interpretation of the rhythm by a nurse or monitor technician.

In a face-to-face interview on 08/11/10 at 11:05am, RN S10 indicated the nurse usually used the EKG (electrocardiogram) strip on the chart when the nurse documented in the computer. She further indicated if the physician didn't order telemetry settings for high and low alarms, the telemetry unit would set the alarms.

In a face-to-face interview on 08/11/10 at 11:15am, Senior Director of Nursing S7 indicated the physician should order the parameters for the alarm settings for the patients with telemetry orders. In the same interview, Clinical Director of Med/Surg (medical/surgical) S10 confirmed there were no parameters ordered by the physician for Patients #12, #31, and #32.

In a face-to-face interview on 08/11/10 at 2:50pm, Senior Director of Nursing S7 confirmed the telemetry policy did not have parameters for high and low alarms. She also confirmed that the nurses were not printing telemetry strips and interpreting them, and the telemetry monitor technicians were not interpreting the strips and signing them when they placed the strips on the chart.

Review of the hospital policy titled "Telemetry Monitoring", last revised 01/04/10 and submitted by Senior Director of Nursing S7 as the hospital's current policy on telemetry monitoring, revealed, in part, "...Scope Adult patients requiring cardiac telemetry monitoring. ... Policy ...3. Verify physician's order to initiate and perform the following: ... c) charge nurse verifies that high/low alarm settings are activated d) obtain admit rhythm strip and secure to EKG and Hemodynamic Strip Sheet, document and place under the Telemetry tab in the hard chart e) interpret rhythm strip 4. Notify physician of symptomatic and/or clinically significant rhythm changes. ... 7. Monitor Tech (technician) obtains, interprets and post rhythm strips: a) on admit b) at the beginning of each shift c) every 4 hours d) PRN (as needed) changes in rhythm (the primary nurse is notified immediately) ... Procedure ... 3. On admit, the monitor tech and admitting nurse interpret the strip measuring the PR interval, QRS interval, ST segment, rate and rhythm (regular or irregular). That strip is posted by the nurse and monitor tech. 4. Every 4 hours the monitor tech runs a strip, interprets the rhythm and posts the strip on the EKG and Hemodynamic Strip Sheet. For any change in rhythm, the nurse is notified and two strips are posted on the EKG and Hemodynamic Strip Sheet. At the beginning of every shift, nurse must interpret and paste strip on a Hemodynamic strip sheet and placed under the Telemetry tab ...".

Patient #14
The Medical Record for Patient #14 was reviewed. Patient #14 was admitted to the Intensive Care Unit/Critical Care Unit on 08/05/10. Review of the telemetry strips dated 08/08/10 12:53am, 7:17am, 7:02pm; 08/09/10 7:05am, 7:05pm; 08/10/10 7:03am, 7:08pm; and 08/11/10 9:36am revealed no documented evidence the strip was interpreted by the RN as evidenced by lack of documentation of the PR interval, QRS Interval and QT interval. This finding was confirmed by S19, Director of ICU on 08/11/10 at 10:45am. S19 indicated the CCU policy was to document on the telemetry strip the PR Interval, QRS Interval and QT interval and this was not done.

Patient #15
The Medical Record for Patient #15 was reviewed. Patient #15 was admitted on 08/08/10 to the Intensive Care Unit/Critical Care Unit. Review of the telemetry strips dated 08/08/10 10:38pm; 08/09/10 7:08am and 7:07pm; 08/10/10 7:11am and 7:44pm; and 08/11/10 (time illegible) revealed no documented evidence the strip was interpreted by the RN as evidenced by lack of documentation of the PR interval, QRS Interval and QT interval. This finding was confirmed by S19, Director of ICU on 08/11/10 at 10:45am.

Review of the hospital policy entitled "Cardiac Monitoring (Critical Care Units) with a review date of 03/03/10 revealed in part, "8. Obtain EKG strip and post on flow sheet. Document on strip PR interval, QRS interval and QT interval..


4) Laboratory Tests
Patient #6:
Review of Patient #6's medical record revealed orders dated 7/26/10 at 1:55 p.m. for "Vancomycin 1 gram IVPB q 12 h trough with 3rd dose" Review of the medical record revealed no evidence to indicate that the Vancomycin trough was obtained with the 3rd dose as ordered.

In an interview on 8/10/10 at 1:20 p.m., the Senior Director of Nursing (S3) confirmed that there was no indication that the Vancomycin trough was obtained as ordered.

Patient #19:
Review of Patient #19's "Physician's Orders" for 07/22/10 at 11:15pm revealed a verbal order for Gentamycin 120 mg (milligrams) IVPB (intravenous piggyback) now, then Gentamycin 100 mg every 8 hours IVPB. Further review revealed an order on 07/23/10 at 9:00am to obtain a Gentamycin peak and trough with the 3rd dose. Review of the lab results revealed a Gentamycin trough was reported on 07/23/10 at 4:22pm. Review of the complete medical revealed no documented evidence that a Gentamycin peak was performed as ordered.

In a face-to-face interview on 08/12/10 at 9:35am, Director of Oncology S11 indicated the order for the Gentamycin peak was entered in the system as a reminder for a future date when it was ordered on 07/22/10, but it was never entered in the computer to be done as ordered on 07/23/10. S11 confirmed there no documented evidence that a Gentamycin peak was drawn as ordered for Patient #19.

Based on record review and interviews, the hospital failed to ensure the patient's care plan was implemented as ordered by the physician by: 1) failing to administer sliding scale insulin as ordered for 1 of 32 sampled patients (#12); 2) failing to clarify telemetry orders to include parameters for high and low settings and receive orders for which symptoms and rhythms the physician was to be notified for 3 of 3 patients reviewed with telemetry from a total of 32 sampled patients (#12, #31, #32); 3) failing to obtain stat labs within 10 minutes as required by policy for 1 of 32 sampled patients (#19); 4) failing to obtain Gentamycin peak as ordered for 1 of 32 sampled patients (#19); 5) failing to develop a protocol for flushing a Hickman catheter for outpatients for 1 of 1 outpatient reviewed with a Hickman catheter from a total of 32 sampled patients (#30); and 6) failing to obtain orders for labs drawn for an outpatient for 1 of 2 outpatient records reviewed for labs from a total of 32 sampled patients (#30). Findings:

1) Sliding scale insulin:
Review of Patient #12's medical record revealed "Insulin Orders" on 08/09/10 at 10:15am for blood glucose monitoring before meals and at bedtime. Further review revealed an order for low-dose algorithm: pre-meal blood glucose of 150-199, give 1 unit Regular Insulin. Review of Patient #12's flowsheet revealed her blood glucose was 157 (high) at 9:22pm on 08/10/10. Review of the entire medical record revealed no documented evidence that insulin was administered as ordered.

In a face-to-face interview on 08/11/10 at 11:20am, Registered Nurse (RN) S10 confirmed insulin was not administered to Patient #12 after the nurse obtained the blood glucose reading of 157. She further confirmed there was no documented evidence in the hard chart or the computer charting of the reason the insulin was not administered. S10 confirmed there was no physician's order to hold the insulin order.

2) Telemetry orders:
Patient #12
Review of Patient #12's medical record revealed an order on 08/09/10 at 8:15pm for "Telemetry". Further review revealed no documented evidence of a physician's order for the high and low settings and the symptoms and rhythm changes that would require the physician to be notified. Review of the telemetry strips documented in the chart revealed no documented evidence of the interpretation of the rhythm by a nurse or monitor technician.

Patient #31
Review of Patient #31's medical record revealed an order on 08/06/10 at 9:07am for "Telemetry". Further review revealed no documented evidence of a physician's order for the high and low settings and the symptoms and rhythm changes that would require the physician to be notified. Review of the telemetry strips documented in the chart revealed no documented evidence of the interpretation of the rhythm by a nurse or monitor technician.

Patient #32
Review of Patient #32's medical record revealed an order on 07/29/10 at 11:00am for "Telemetry". Further review revealed no documented evidence of a physician's order for the high and low settings and the symptoms and rhythm changes that would require the physician to be notified. Review of the telemetry strips documented in the chart revealed no documented evidence of the interpretation of the rhythm by a nurse or monitor technician.

In a face-to-face interview on 08/11/10 at 11:15am, Senior Director of Nursing S7 indicated the physician should order the parameters for the alarm settings for the patients with telemetry orders. In the same interview, Clinical Director of Med/Surg (medical/surgical) S10 confirmed there were no parameters ordered by the physician for Patients #12, #31, and #32.

In a face-to-face interview on 08/11/10 at 2:50pm, Senior Director of Nursing S7 confirmed the telemetry policy did not have parameters for high and low alarms.

Review of the hospital policy titled "Telemetry Monitoring", last revised 01/04/10 and submitted by Senior Director of Nursing S7 as the hospital's current policy on telemetry monitoring, revealed, in part, "...Scope Adult patients requiring cardiac telemetry monitoring. ... Policy ...3. Verify physician's order to initiate and perform the following: ... c) charge nurse verifies that high/low alarm settings are activated ...".

3) Stat labs drawn in 10 minutes:
Review of Patient #19's "Physician's Orders" revealed an order on 07/22/10 at 7:27am for CBC/CMP (complete blood count/complete metabolic profile) stat.

Review of the "PathNet Collections:Container Inquiry", presented by Senior Director of Nursing S7 as the print-out of when the lab received the specimens for Patient #19's CBC/CMP ordered on 07/22/10 at 7:27am, revealed they were received in the lab at 9:05am.

In a face-to-face interview on 08/12/10 at 9:40am, RN Charge nurse S13 indicated the stat lab for Patient #19 was entered into the computer at 7:28am on 07/22/10, but she was not able to provide documented evidence of this report. S13 could offer no explanation for the stat lab being ordered at 7:27am and delivered to the lab until 9:05am, when the hospital policy required stat labs to be performed within 10 minutes.

Review of the hospital policy titled "Stat Collection Policy", last revised 01/28/10 and submitted by Director of Oncology S11 as the current policy for stat labs, revealed, in part, "...All STAT requests are to be collected within 10 minutes of request. If phlebotomist assigned to area requesting STAT work is not available within 10 minutes (other stats, lunch breaks ...) any available phlebotomist must collect STAT. If no phlebotomists are available to collect STAT within 10 minutes, phlebotomy supervisor or lab manager must be notified ...".

4) Gentamycin peak:
Review of Patient #19's "Physician's Orders" for 07/22/10 at 11:15pm revealed a verbal order for Gentamycin 120 mg (milligrams) IVPB (intravenous piggyback) now, then Gentamycin 100 mg every 8 hours IVPB. Further review revealed an order on 07/23/10 at 9:00am to obtain a Gentamycin peak and trough with the 3rd dose.

Review of the lab results for Patient #19 revealed a Gentamycin trough was reported on 07/23/10 at 4:22pm. Review of the complete medical revealed no documented evidence that a Gentamycin peak was performed as ordered.

In a face-to-face interview on 08/12/10 at 9:35am, Director of Oncology S11 indicated the order for the Gentamycin peak was entered in the system as a reminder for a future date when it was ordered on 07/22/10, but it was never entered in the computer to be done as ordered on 07/23/10. S11 confirmed there no documented evidence that a Gentamycin peak was drawn as ordered for Patient #19.

5) Hickman catheter:
Review of Patient #30's medical record revealed an order on 05/24/10, with no documented evidence of the time the order was received, for the patient to be recurring outpatient for 90 days and to change the dressing and flush the Hickman catheter per protocol.

Review of the hard copy chart and the computer medical record revealed the Hickman catheter was flushed 1 time a week.

In a face-to-face interview on 08/12/10 at 11:25am, RN S15 indicated she flushed Hickman catheters per hospital protocol. When informed that the policy presented by Senior Director Nursing 7 for "Central Line Flushing Protocol Changes" stated that Hickman catheters should be flushed 2 times a week, S15 indicated the outpatient unit did not use the inpatient protocol. She further indicated she didn't know if the outpatient unit had a protocol for flushing Hickman catheters, but the physician wanted it flushed 1 time a week. S15 confirmed there was no documented evidence of an order on Patient #30's medical record denoting this order for flushing 1 time a week.

Review of the "Central Line Flushing Protocol Changes", presented by Senior Director Nursing 7 when asked for the policy for flushing Hickman catheters, revealed, in part, "...Hickman catheter ... 5 ml (milliliters) heparin 10u/ml (units per milliliter) 2x/week & prn (2 times a week and as needed) ...".

6) Orders obtained for labs drawn in outpatient setting:
Review of Patient #30's medical record revealed a CBC (complete blood count), CMP (complete metabolic profile), Ferritin Serum, and eGFR (estimated glomerular filtration rate) were drawn on 08/03/10. Review of the entire outpatient record revealed no documented evidence of an order for these lab tests to be drawn.

In a face-to-face interview on 08/12/10 at 11:25am, RN S15 confirmed there was no physician order in the medical record for the labs that were drawn on 08/03/10.

In a face-to-face interview on 08/12/10 at 11:45am, Director of Oncology S11 confirmed there was no evidence of a verbal order received for Patient #30's labs when she checked the verbal order file.

Based on record reviews and interviews, the hospital failed to ensure that orders from the licensed practitioner were carried out regarding the administration of medications; failed to ensure medications were administered within the 1 hour time frame; and failed to ensure that the ordering practitioner was notified of medication errors at the time of occurrence. This was noted for 3 of 15 patients (#5, #15 and #20) whose medical record was reviewed for medication administration out of a total sample of 32 patients. Findings:

Patient #5: Medical record review revealed that the patient was admitted to the hospital on 8/04/10. Review of the record revealed orders dated 8/04/10 (order not timed) for "Sanctra one tab po q hs" and a clarification order dated 8/4/10 (order not timed) for "Sanctura 1 tab po q hs home meds". Review of the medication administration record revealed that the Sanctura was not administered to the patient on 8/04/10 or 8/05/10 as ordered. Further review of the orders revealed an order dated 8/06/10 to discontinue the Sanctura and start Detrol. There was no documentation in the record to indicate that the ordering practitioner was notified of the omitted doses of Sanctura and no documentation to indicate that a medication variance report had been completed relating to the two medication errors. In an interview on 8/10/10 at 11:00 a.m., the Senior Director of Nursing (S3) confirmed that there was no documentation in the record to indicate that the Sanctura was administered as ordered and no documentation to indicate that the physician was notified of the medication omissions.

Patient #20: Medical record review revealed that the patient was admitted to the hospital on 8/02/10. The patient's diagnosis included Septic Shock. Review of the record revealed an order, dated 8/03/10 at 6:00 p.m., for 500mg of Meropenem to be administered intravenously every 24 hours with instructions to "start now". Review of the medication administration record revealed that the first dose of Meropenem was not administered until 9:23 p.m. which was 3 hours and 23 minutes after being ordered to "start now". There was no documentation in the record to indicate that the ordering practitioner was notified of the delay in the administration of this IV medication and no documentation to indicate that a medication variance report had been completed relating to this medication error. In an interview on 8/13/10 at 10:00 a.m., the Senior Director of Nursing (S7) confirmed that the documentation in the record indicated that the Meropenem was administered 3 hours and 23 minutes after being ordered to "start now" and that there was no documentation to indicate that the physician was notified of the delay in the administration of the Meropenem.

Patient #15: The medical record for Patient #15 was reviewed. The patient was admitted on 08/08/10 at 10:31pm with diagnoses of S/P CVA, left sided hemiplegia. Review of the Physician Orders date 08/08/10 at 11:43pm revealed orders for Tegretol (Carbamazepine) 200mg per NG (Nasal Gastric tube) ever 12 hours and Clonidine 0.1 mg NG every 12 hours. Review of the Medication Administration Record dated 08/09/10 revealed Carbamazepine and Clonidine were administered on 08/09/10 at 11:10am 2 hours and 10 minutes after the scheduled time of administration. This finding was confirmed by S20 ICU/CCU Charge Nurse. S20 indicated the medications were scheduled to
begin at 9am. Further she indicated the policy is a 1 hour time frame before and after the scheduled time and there was no documented evidence the patient was off the unit for any reason or was NPO for diagnostic studies.

S17, Senior Director of Performance Improvement, in a face to face interview on 08/12/10 at 1pm indicated there were no medication variances for the late administration of the medications.

The hospital's policy/procedure titled Medication Administration (presented as a current policy/procedure) was reviewed. The policy/procedure documents that medications are to be administered utilizing the eight (8) rights of Medication Administration which are documented as the right patient, the right medication, the right dose, the right time, the right route, the right technique, the right schedule, and the verification of allergies. The policy/procedure documents that stat administrations should be administered as soon as possible, within one hour of receiving physicians order. There was no documentation in the policy to address now orders. Medication Administration Time Frames revealed routine scheduled medications : administer within one hour before or one hour after scheduled time.

In an interview on 8/13/10 at 10:15 a.m., the Director of Quality (S17) indicated that the now order should have been carried out within one hour of being ordered.

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Based on record review and interview, the hospital failed to ensure all clinical entries were accurate, timed, dated, and authenticated appropriately for 6 of 12 patients reviewed for timing and dating of entries from a total of 32 sampled medical records (#5, #8, #12, #13
#18, #19). Findings:

Patient #5
Review of Patient #5's medical record revealed physician orders dated 8/04/10 that were not timed and progress notes dated 8/04/10, 8/05/10, 8/06/10, 8/08/10, 8/09/10 and 8/10/10 that were not timed. In an interview on 8/10/10 at 11:05 a.m., S3 confirmed that the entries were not timed.

Patient #12
Review of Patient #12's "Physician's Orders" revealed an order on 08/10 at 2210 (10:10pm). Further review revealed no documented evidence of the year, whether the order was a verbal or telephone order, and the nurse documented with her last name only (did not have first initial and professional titled). In a face-to-face interview on 08/11/10 at 10:50am, Clinical Director of Med/Surg (medical/surgical) S9 indicated a nurse should sign documents in the medical record using at least her first initial and last name and include her professional title.

Patient #18
Review of Patient #18's medical record revealed a physician's order on 08/11/10 with no documented evidence of the time the order was written.
In a face-to-face interview on 08/11/10 at 2:10pm, Director of Oncology S11 confirmed the physician's order was not timed.

Patient #19
Review of Patient #19's "Physician's Orders" revealed an admit order with no documented evidence of the date and time the order was written. Further review revealed an order timed at 1820 (6:20pm) with no documented evidence of the date the order was written (it was signed off by the nurse on 08/03/10. Further review revealed an order to consult radiology for drainage of an abscess with no documented evidence of the date and time the order was written. Review of Patient #19's "Physician's Orders" revealed 4 verbal orders dated 07/21/10 and received by Registered Nurse (RN) S14 between orders dated 08/03/10.
In a face-to-face interview on 08/12/10 at 10:05am, RN S14 indicated he was a RN in the Special Procedures unit. S14 confirmed, after reviewing Patient #19's medical record, that the physician's verbal orders received and written should have been dated 08/03/10 and not 07/21/10, He could offer no explanation for the error in documentation.

Patient #8: Review of the Physician Orders for Patient #8 dated 07/26/10, 07/31/10 and 08/01/10 revealed no time the order was written. This was verified by S17 Senior Director of Performance Improvement.

Patient #13: Review of the Physician Orders for Patient #13 dated 07/30/10 and 08/06/10 revealed no time the order was written. This was verified by S17 Senior Director of Performance Improvement.

In a face-to-face interview on 08/13/10 at 9:45am, Senior Director of Quality/Case Management S17 indicated the medical staff rules and regulations do not address the timing of medical record entries. She presented an action plan that was instituted in 2009 that addressed this issue.

Review of the hospital policy titled "Receiving Verbal and Telephone Orders", revised 12/18/09 and submitted by Clinical Director of Med/Surg S9 as the current policy for receiving and documenting verbal orders, revealed, in part, "...7. Verbal or telephone orders are recorded on the yellow verbal order sticker and affixed to the Physician's Order Sheet and include the following information: ... d) The order received: ... iii) document order as such: "read back" phone/verbal order (RB po/vo or ORB po/vo) then physician's name and your professional signature...".

Review of the Medical Staff Bylaws, presented by Senior Director of Quality/Case Management S17 as the hospital's current bylaws, revealed, in part, " ...Patient Care ...5. All orders for treatment or diagnostic procedures shall be in writing on the Patient's chart. A verbal order shall be considered to be in writing if dictated to a registered nurse or a licensed practical nurse and subsequently signed by the Practitioner. Orders dictated over the telephone shall be signed by the nurse to whom dictated, with the name of the dictating Practitioner, per his or her name. ...Medical Records ... Contents The attending and consulting Medical Staff members with the assistance of appropriate Hospital employees and departments shall be responsible for the preparation of a legible, pertinent, current, and complete medical record for each Patient. ... Orders All clinical entries shall be accurately dated. ... Telephone or verbal orders shall be authenticated ... Authentication must be timed and dated, and may be by written signature or initials ... Operative And Procedural Reports ... Clinical Entries All entries in the Patient's medical record shall be accurately dated and authenticated ...".

Based on record reviews and interviews, the hospital's pharmacy services failed to ensure that accurate drug administration times were recorded in the computerized medication delivery database to ensure that medications ordered "stat" and "now" would be administered within one hour of being ordered as indicated in the hospital's policy/procedure. This was noted for 1 of 3 patients (#20) whose medical record was reviewed for the administration of medicaitons ordered "now" out of a total sample of 32 patients. Findings:

Patient #20: Medical record review revealed that the patient was admitted to the hospital on 8/02/10. The patient's diagnosis included Septic Shock. Review of the record revealed an order, dated 8/03/10 at 6:00 p.m. for 500mg of Meropenem to be administered intravenously every 24 hours with instructions to "start now". Review of the medication administration record revealed that the first dose of Meropenem was not administered until 9:23 p.m. which was 3 hours and 23 minutes after being ordered to "start now". Further review of the medication administration record revealed that pharmacy services scheduled the medication to be administered at 8:00 p.m. which was 2 hours after being ordered to "start now".

The hospital's policy/procedure titled Medication Administration (presented as a current policy/procedure) was reviewed. The policy/procedure documents that medications are to be administered utilizing the eight (8) rights of Medication Administration which are documented as the right patient, the right medication, the right dose, the right time, the right route, the right technique, the right schedule, and the verification of allergies. The policy/procedure documents that stat administrations should be administered as soon as possible, within one hour of receiving physicians order. There was no documentation in the policy to address now orders. In an interview on 8/13/10 at 10:15 a.m., the Director of Quality (S17) indicated that the now order should have been carried out within one hour of being ordered.

The Director of Pharmacy was interviewed on 8/13/10 at 10:50 a.m. The Director of Pharmacy reviewed the medical record of Patient #20 and confirmed that the administration time for the Meropenem should have been within one hour of being ordered at 6:00 p.m.

Based on observation, record review, and interview, the hospital failed to ensure hospital policy was followed for the code cart system by having a code cart located on the Med/Surg (medical/surgical) unit without the code cart lock. Findings:

Observation on 08/11/10 at 9:40am revealed the crash cart located in the public hallway of the Med/Surg Unit without the code cart lock. The drawers were able to be opened by the surveyor who observed the presence of medications in the drawers.

In a face-to-face interview on 08/11/10 9:42am, Registered Nurse (RN) Charge Nurse S6 indicated that pharmacy was replacing the flushes earlier. She further indicated the cart should be locked with the code cart lock.

Review of the hospital policy titled "Code Cart Exchange System", last revised 12/18/09 and presented by Senior Director Of Quality/Case Management S17 as the hospital's current policy for the crash cart, revealed, in part, " ...After inventory verification is completed, lock cart with Pharmacy issued code cart lock ... ".

Based on observation, record review, and interview, the hospital failed to ensure the pharmacist developed a system to assure that patient medications labeled with a time for administration were not available for use past that time. Findings:

Observation of the medication room on the Oncology floor on 08/11/10 at 12:50pm revealed the following:
1000 ml (milliliter) bag of Potassium Chloride 20 meq (milliequivalents) with the label for Patient R1 - to be administered 08/10/10 at 1149 (11:49am);
Vancomycin 1000 mg (milligrams) in D5W (dextrose in water) 250 ml for Patient R1 - to be administered 08/10/10 at 2100 (9:00pm);
1000 ml Potassium Chloride 30 meq with the label for Patient R2 in the refrigerator - to be administered 08/10/10 at 0348 (3:48am); and
1000 ml Potassium Chloride 30 meq with the label for Patient R2 in the refrigerator - to be administered 08/10/10 at 2002 (8:02pm).

In a face-to-face interview on 08/11/10, Registered Pharmacist (RPh) S12 indicated the pharmacy technician delivers medications 2 times a day to units, so any medications that had not been administered should be returned to the pharmacy. S12 confirmed that the bags of fluids were good until the expiration date on the bag, since there were no additives in the labeled bags of fluids. S12 further indicated the IV (intravenous) medications labeled to be administered the previous day should not have been present in the medication room without a new label applied.

In a face-to-face interview on 08/12/10 at 12:50pm, Senior Director of Nursing S7 indicated there was no policy that addressed picking up medications not administered from the unit medication rooms.

Based on record review and interview, the hospital failed to ensure the Utilization Review (UR) Plan included that notification of adverse decisions would be given within 2 days to the hospital, patient, and the practitioners responsible for their care. Findings:

Review of the hospital's Utilization Review Plan, last revised 06/08/10 and submitted by Senior Director of Quality/Case Management S17 as the hospital's current UR Plan, revealed that the policy did not designate that notification of an adverse decision would be given within 2 days to the hospital, the patient, and the practitioner(s) responsible for the care of the patient.

In a face-to-face interview on 08/13/10 at 9:00am, Senior Director of Quality/Case Management S17 indicated the hospital's policy did not state that all parties would be notified within 2 days of an adverse notification. She further indicated the policy did not state that the hospital and practitioner(s) would be notified; it only stated that the patient would be notified.

25452

Based on observations, record review, and interviews, the hospital failed to ensure the supplies were maintained to ensure safety of the patients and public by: 1) having 2 housekeeping closets on the Med/Surg (medical/surgical) floor unlocked with disinfectant cleansers, acid bathroom cleaner, glass cleaner, and gum and label remover stored on the shelves; 2) having needles stored in an unlocked latex free cart located in a public hallway on the Oncology floor; 3) having expired IV (intravenous) start kits on the crash cart in Radiology; 4) having mold/mildew in the showers of 3 patient rooms and sections of loose and/or missing baseboard in patient rooms on the adult psychiatric unit; and 5) having the hospital kitchen with broken, cracked and/or missing ceramic tiles, baseboard and corner molding and stainless steel separating and/or missing from the walls, sections of the drop ceiling frame with rust and/or mildew, and sections of dirt/grime buildup on the walls and vents. Findings:
1) Housekeeping closets:
Observation on 08/11/10 at 9:45am revealed 2 housekeeping closets on the Med/Surg floor unlocked with cleaning products stored on the shelves. One closet had Lemon-Eze Creme Cleansers, glass cleaner, and disinfectant cleansers present. The other housekeeping closet had acid bathroom cleaner and gum and label remover stored on the shelf.

In a face-to-face interview on 08/11/10 at 9:55am, Housekeeping Supervisor S8 indicated the hospital policy stated that housekeeping chemicals should be kept secure. S8 confirmed that the chemicals should not be in the housekeeping closet.

Review of the hospital policy titled "Adequate and Appropriate Space and Equipment Is Provided for the Safe Handling and Storage of Hazardous Materials and Waste", presented by Senior Director of Nursing (Sr. DON) S7 as the current policy for housekeeping storage of chemicals, revealed, in part, "...All hazardous materials are received into the department by appropriate personnel and stored in a supply closet for chemicals only. ... Storage areas are kept under lock and key ...".

2) Latex free cart:
Observation on 08/11/10 at 12:50pm revealed an unlocked cart labeled "latex free cart" in the public hallway outside patient rooms on the Oncology Unit. Further observation revealed the second drawer of the cart contained 14 21 gauge 1 ? inch safety glide needles.

In a face-to-face interview on 08/11/10 at 1:20pm, Registered Nurse (RN) Director of Oncology indicated needles should not be accessible to the public.

In a face-to-face interview on 08/13/10 at 10:25am, Senior Director of Quality/Case Management/Registration/Education S17 indicated the hospital did not currently have a policy regarding the storage of sharps.

3) Expired IV start kits:
Observations made on 8/12/10 at 9:30 am revealed two Intravenous (IV) start kits located in the crash cart in Radiology had expired 2/2005.

An interview was held with S1, Director of Radiology on 8/12/10 at 9:30 am. She indicated the two IV start kits located in the crash cart in Radiology had been expired since 2/2005.

4) Psychiatric Unit:
Observations on 8/11/10 at 10:15 a.m. of the hospital's adult psychiatric unit revealed sections of mold/mildew in the showers of three patient rooms (Patient Room #204, #205 & #209) and sections of loose and/or missing molding (baseboard and corner) in Patient Room #205.

In an interview on 8/11/10 at 10:15 a.m., the Senior Director of Nursing (S3) confirmed the presence of mold/mildew in the showers of these patient rooms and the sections of loose and/or missing molding.

5) Kitchen:
Observations on 8/12/10 at 11:50 a.m. of the hospital's kitchen revealed sections of broken, cracked and/or missing ceramic tiles in the food preparation and storage areas, sections of baseboard and corner molding and stainless steel separating and/or missing from the walls in the food preparation and storage areas, sections of the drop ceiling frame with rust and/or mildew in the dish washing area, and sections of dirt/grime buildup on the walls near one of the hand washing sinks and on the vents in the coolers.

In an interview on 8/12/10 at 11:50 a.m., the General Manager of Food Services (S18) confirmed the presence of broken, cracked and/or missing ceramic tiles in the food preparation and storage areas, confirmed the sections of baseboard and corner molding separating and/or missing from the walls in the food preparation and storage areas, confirmed the rust and mildew on the frame of the drop ceiling, and confirmed the dirt/grime buildup on the walls near one of the hand washing sinks and vents in the coolers.