HospitalInspections.org

Based on review of facility documents, observation and staff interview (EMP), it was determined that the facility failed to follow their established practice for distribution of the Patient's Bill of Rights to all patients.

Findings include:

A review on March 9, 2010, of facility policy ADM-12 "Patient Rights and Responsibilities", last reviewed February 2010 revealed: "I. Purpose: To affirm the patient's rights in regards to his/her medical care including the decision to discontinue treatment to the extent permitted by law. II ... Prominent displays of Pennsylvania Bill of Rights are posted in every room and throughout Bloomsburg Hospital, and are available in patient handbooks."

1) Observation on March 9, 2010, of the hospital outpatient lab draw at the Elysburg location revealed that the Patient Bill of Rights were not displayed nor were there pamphlets available to patients.

2) An interview conducted on March 9, 2010, at 10:00 AM with EMP3 confirmed that there was no Patient Bill of Rights displayed nor were there pamphlets available to patients.

Based on a review of medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure that a restraint order was not written on an as needed basis (PRN) for three of four restraint medical records reviewed (MR17, MR18 and MR19).

Findings include:

A review conducted on March 10, 2010, of facility administrative policy "Restraint or Seclusion", last reviewed April, 2008, revealed: "... Orders for restraint or seclusion must never be written as a standing or on an as needed basis (PRN). **Nursing staff will refuse to accept a physician order for restraint or seclusion that does not meet the Medicare requirements."

1) A review on March 10, 2010, of MR17 revealed that there was a physician order for soft wrist restraints written on November 9, 2009. Further review of MR17 revealed that soft wrist restraints were not applied after November 8, 2009.

An interview conducted on March 10, 2010, at 10:00 AM with EMP1 confirmed that MR17 contained a physician order for soft wrist restraints, and that restraints were not used on the patient after November 8, 2009.

2) A review on March 10, 2010, of MR18 revealed that there was a physician order for soft wrist restraints written on December 27 and 28, 2009. Further review of MR18 revealed that there was no documentation the restraints were required by the patient or applied after December 26, 2009.

An interview conducted on March 10, 2010, at 11:00 AM with EMP1 confirmed that MR18 contained a physician order for soft wrist restraints written on December 27 and 28, 2009. Further review of MR18 revealed that there was no documentation the restraints were required by the patient or applied after December 26, 2009.

3) A review on March 10, 2010, of MR19 revealed that there was a physician order for soft wrist restraints, written on February 23-25, 2010. Further review of MR19 revealed that soft wrist restraints were not required by the patient or applied after February 22, 2010.

An interview conducted on March 10, 2010, at 11:30 AM with EMP1 confirmed that MR19 contained a physician order for soft wrist restraints, written on February 23- 25, 2010. Further review of MR19 revealed that soft wrist restraints were not required by the patient or applied after February 22, 2010.

Based on review of facility policies and staff interview (EMP), it was determined that facility medical staff failed to ensure a system for disciplinary action was enforced for physicians who had not completed medical records in a timely manner.

Review of the facility policy, "P&P#: MR-19.1 Physician Delinquency and Suspension List Process", last reviewed January 2010, revealed, "...Physician completion and authentication of medical records within 30 days post discharge is required by state and federal law.... Procedure: ... 4. Every Wednesday at 12:00 PM, a Suspension list will be distributed ... Suspension status carries the following restrictions: Surgeons No new surgeries can be scheduled. Scheduled surgeries will be cancelled, for the following day, if the surgeon appears on the suspension list after 12:00 PM. Medical No new admissions will be accepted. Physicians will not be permitted to treat their patients in the Emergency Department...."

1) An interview conducted on March 10, 2010, 9:00 AM with EMP10 revealed, "There are no suspensions. We send warning letters out to physicians with incomplete medical records 15 days after the patient's discharge." Further interview with EMP10 revealed 12% to 15% of discharged patient records were incomplete and the physician suspension policy had not been implemented.

Based on a review of facility policy, medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure that verbal orders were countersigned by the practitioner within 24 hours for four of 40 medical records reviewed (MR12, MR14, MR19 and MR20).

Findings include:

A review on March 10, 2010, of the "Bloomsburg Hospital Medical Staff Rules and Regulations" revealed, " ... and shall be countersigned within twenty-four (24) hours by the Practitioner or Allied Health Professional who gave the verbal order."

1) A review on March 9 and 10, 2010, of MR12, MR14, MR19 and MR20 revealed that each medical record contained verbal orders that were not signed, dated and/or timed within 24 hours by the physician.

2) Interviews conducted on March 9 and 10, 2010, with EMP2 confirmed that there were verbal orders that were not signed, dated and/or timed within 24 hours by the physician.

The facility could not provide documentation that the verbal orders listed above were countersigned by the practitioner within 24 hours.

Based on review of facility policy, observation and interview with staff (EMP), it was determined the facility failed to store medical records in a secure manner.

Findings include:

A review conducted on March 9, 2010, of facility policy MR-6, "File Systems and Storage", last reviewed July 2009 revealed, "...All files areas shall remain in a physically secure area at all times and be restricted to authorized personnel only"

1) Observation on March 9, 2010, of the hospital outpatient lab draw satellite at the Elysburg location revealed that medical records were stored in a file cabinet in the reception area. The area was accessible after hours to the housekeeping staff in the adjacent physician ' s office. Further observation revealed that the file cabinet could not be locked.

An interview conducted on March 9, 2010, at 10:00 AM with EMP3 confirmed that the medical records were kept in a file cabinet that was not secure and accessible to unauthorized personnel. Further interview with EMP3 revealed that the staff was unable to locate a key for the file cabinet.

2) Observation on March 9, 2010, of the hospital outpatient physical therapy satellite at the Central Road location revealed that the medical records were stored in the reception area of the adjoining physician's office. Further observation of the area revealed that the physician's office staff had access the medical records.

An interview conducted on March 9, 2010, at 11:00 AM with EMP5 confirmed that the medical records were stored in the reception area of the adjoining physician's office. The physician's staff had access to the medical records.

Based on review of and medical records (MR) and interview with staff (EMP) it was determined the facility failed to ensure that all entries in the medical record were authenticated, dated and timed for six of 43 medical records reviewed ( MR15, MR36, MR37, MR38, MR40, and MR41).

Findings include:

A review conducted on March 10, 2010, of the Bloomsburg Hospital Health Information Management Services, Administrative Policy and Procedure P&P#: MR- 3.2 Creating Legal Documentation, last revised September 2009, revealed "Creating Documentation Entries Documentation Should be timely, accurate and authenticated by the author..."

1) A review conducted on March 10, 2010, of MR15, MR36, MR37, MR38, MR40, and MR41 revealed that the records contained Preoperative check lists and/or PACU (post anesthesia care unit) records that were not authenticated by the person making the entries.

2) An interview conducted on March 10, 2010, at 10:40 AM with EMP6 confirmed that MR36, MR37, MR38, MR40, and MR41 contained Preoperative check lists and/or PACU records that were not authenticated by the person making the entries.

Based on review of medical records (MR), facility documents and staff interview (EMP), it was determined that the hospital failed to ensure that medical records were completed within 30 days following discharge for four of 44 medical records reviewed (MR15, MR16, MR20 and MR35).

Findings include:

Review of the facility policy, "P&P#: MR-19.1 Physician Delinquency and Suspension List Process", last reviewed January 2010, revealed, "Physician completion and authentication of medical records within 30 days post discharge is required by state and federal law.... Procedure: ... 4. Every Wednesday at 12:00 PM, a Suspension list will be distributed ... Suspension status carries the following restrictions: Surgeons No new surgeries can be scheduled. Scheduled surgeries will be cancelled, for the following day, if the surgeon appears on the suspension list after 12:00 PM. Medical No new admissions will be accepted. Physicians will not be permitted to treat their patients in the Emergency Department...."

1) Review on March 90-10, 2010, of MR15, MR16, MR20 and MR35 revealed the medical records were not completed within 30 days after the patients discharge.

2) An interview with EMP10 on March 10, 2010, 9:00 AM confirmed that MR15, MR16, MR20 and MR35 were not completed within 30 days of discharge.

Based on review of facility policy, observation and interview with staff (EMP), it was determined the facility failed to ensure drug storage areas must be administered in accordance with accepted professional principles when they failed to dispose of expired medications and properly label open multi-dose vial in the surgical suite.

Findings include:

A review conducted on March 9, 2010 of facility policy "2.28 Injectables - Single Dose & Multi-dose" last reviewed November 2009, revealed " ...Multi-dose vials of injectable drugs containing preservative shall be discarded if not used within thirty (30) days after initial use or sooner according to manufactures package insert.... The first time a vial is used, write on the label the date and time of opening. Partially used vials not used within the time limits specified above must be discarded...."

1) Observation on March 8, 2010, at 2:15 PM, revealed an opened multi use vial in the anesthesia medication cart in operating room five within the main hospital surgical suite. The open vial was Neostigmine 1:1000 1 milligram per milliliter (mg/ml ), 10 ml, labeled "multiple dose vial". The multiple dose vial was not labeled with the date and time it was opened.

An interview conducted on March 8, 2010, at 2:15 PM, with EMP 9 confirmed that the opened multiple dose vial was not labeled with the date and time it was opened.

2) Observation on March 8, 2010, at 2:15 PM, revealed an outdated vial in the anesthesia medication cart in operating room five within the main hospital surgical suite. The outdated medication was Ondansetron 4 mg/2ml with an expiration date of December 2009.

An interview conducted on March 8, 2010, at 2:15 PM, with EMP9 confirmed that the Ondansetron 4 mg/2ml expired December 2009.

A review on March 9, 2010, of facility policy "2.28 Injectables - Single Dose & Multi-dose" last reviewed November 2009, stated " ... All single dose ampoules and vials shall be used once and discarded .... "

3) Observation on March 8, 2010, at 2:15 PM, revealed two opened single use vials in the anesthesia medication cabinet in operating room five within the main hospital surgical suite. The open vials were Reglan Injection 50 mg/10 ml and Midozolam 5 mg/5 ml. The manufacturers' label for each vial stated " Single dose vial".

An interview conducted on March 8, 2010, at 2:15 PM, with EMP9 confirmed that the medications should have been discarded after one use and that the anesthesia staff did use the single dose Reglan and Midozolam for more than one patient

Based on review of facility documentation and interview with staff (EMP), it was determined the facility failed to ensure that the overall hospital environment was maintained when they failed to ensure quarterly fire drills were conducted at all off-site outpatient locations.

Findings include:

1) A review on March 10, 2010, of facility documentation of fire drills conducted in 2009 revealed that quarterly fire drills were not conducted in any of the following locations: Benton Laboratory Services, Berwick Laboratory Services and Elysburg Laboratory Services.

2) An interview conducted on March 10, 2010, at 11:00 AM with EMP7 confirmed that quarterly fire drills were not performed on the three outpatient locations in 2009.

Based on review of facility policy, observation and staff interview (EMP), it was determined that the facility failed to ensure that disposable syringes and needles were maintained in a location which provides adequate security, with access available only to authorized personnel.

Findings include:

A review conducted on March 9, 2010, of facility policy GN44, "Needles and Syringes", last reviewed November 2009, revealed, "Disposable syringes and needles are secured in the medication cart on every unit and are available to authorized personnel only."

1) Observation on March 9, 2010, of the Medical/Surgical nursing unit revealed that there were unsecured syringes and intravenous start kits on a counter in the nurses' station.

2) An interview conducted on March 9, 2010, at 1:30 PM with EMP8 confirmed that unsecured syringes and intravenous start kits were kept on a counter in the nurses' station. Further interview with EMP8 revealed that the area was not under constant surveillance and could be accessible to unauthorized personnel.