HospitalInspections.org

Based on observation and employee interview, the facility failed to maintain a safe physical plant to ensure patient safety.


Findings Include:


Observation on 1/06/15 at 10:45 a.m., accompanied by a maintenance worker who acknowledged the findings, revealed four (4) of 10 oxygen tanks were stored without a restraint mechanism and the outside Bio Hazard storage shed had approximately 4 inch wide by 4 inch long holes in the outside siding.



A tour of the Laboratory on 1/06/15 at 11:00 a.m. revealed a Medical Waste container with medical waste inside did not have a tight-fitting lid.

Based on observation, record review, policy and procedure review and staff interview, the facility failed to ensure:
1. the governing body, or individual that assumes full legal responsibility, ensured that the policies and procedures are administered by employees to provide quality health care in a safe environment; and
2. that 10 of 27 patient's records reviewed (Patient #11, #12, #13, #15, #18, #20, #21, #22, #23 and #24) were complete and accurately documented, contained outpatient surgery physician orders and entries contained a documented date, time and signature.


Findings Include:


Cross Refer to C221 for the facility's failure to maintain a safe physical plant.


Cross Refer to C270 for the facility's failure to ensure the provision of services were provided in a safe and effective manner.


Cross Refer to C278 for the facility's failure to ensure a system for identifying, reporting, investigating and controlling infections and communicable diseases.


Cross Refer to C297 for the facility's failure to ensure all drugs, biological, and intravenous medications are administered by or under the supervision of a Registered Nurse (RN), a doctor of medicine, osteopathy or physician assistant in accordance with written and signed orders.


Cross Refer to C300 for the governing body's failure to ensure the medical record was complete, accurately documented, contained outpatient surgery physician orders and entries contained a documented date, time and signature for Patient #11, #12, #13, #15, #18, #20, #21, #22, #23 and #24.






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Based on record review, staff interview and policy review, the facility's governing body (or responsible individual) failed to ensure that the medical staff is accountable to the governing body (or responsible individual) for the quality of care provided to patients.


Findings include:


Cross Refer to C221 for the facility's failure to maintain a safe physical plant.


Cross Refer to C270 for the facility's failure to ensure the provision of services were provided in a safe and effective manner.


Cross Refer to C278 for the facility's failure to ensure a system for identifying, reporting, investigating and controlling infections and communicable diseases.


Cross Refer to C297 for the facility's failure to ensure all drugs, biological, and intravenous medications are administered by or under the supervision of a Registered Nurse (RN), a doctor of medicine, osteopathy or physician assistant in accordance with written and signed orders.


Cross Refer to C302 for the facility's failure to ensure all medical records are complete, accurately documented and all entries contain a documented date, time and signature.


Cross Refer to C306 for the facility's failure to ensure all outpatient surgery medical records contained physician's orders.


Cross Refer to C345 for the facility's failure to ensure all deaths are reported to the organ recovery agency within one (1) hour.

Based on observation, medical record review, policy and procedure review and staff interview, the facility failed to ensure that the provision of services was provided to the patients in a safe and effective manner.

Findings Include:



Cross Refer to C278 for the facility's failure to ensure that it had a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.


Cross Refer to C297 for the facility's failure to ensure that all drugs, biological, and intravenous medications must be administered by or under the supervision of a registered nurse, a doctor of medicine, osteopathy or physician assistant in accordance with written and signed orders.

Based on observation, policy and procedure review, record review and staff interview, the facility:
a) failed to ensure the control of infections and communicable diseases of patients and personnel by failing to appropriately store and protect Medical Waste and oxygen tanks.
b) failed to have and implement a plan to have specific measures in place to prevent infection in the surgery suite.
c) failed to ensure that it had a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.

Findings Include:

Cross Refer to C221 for the facility's failure to ensure Medical Waste and oxygen tanks are stored appropriately and safely.

Review of the personnel record for the employee identified by the Administrator as the Infection Control Officer revealed no documented evidence of a job description for Infection Control Officer. There was no documented evidence of education or training regarding infection control in the personnel file.

On 1/06/15 at 11:30 the designated Infection Control Officer was asked what type of education or training she had in infection control. She stated, "I am the a lab technician and the lab manager, but I do not have any formal education or training in infection control."

Review of the facility's "(Facility name) Infection Preventionist" policy revealed, "Special Requirements: Membership in a professional organization. Training in infection prevention and control through APIC (Association for Professionals in Infection Control and Epidemiology)."


On 1/07/15 at 9:15 a.m. observation was made of Registered Nurse (RN) #2 providing bilateral foot wound care for Patient #14. After donning gloves RN #2 removed the soiled dressings from both feet. She then removed her dirty gloves and put on clean gloves. She failed to wash her hands prior to donning the clean gloves. Wound care was completed on the patient's right foot and a clean dressing was applied. Her hands were not washed and gloves were not changed prior to wound care and dressing application to the patient's left foot.

Review of the facility's "Standard Precautions" policy (revised date August 2007) revealed, "When using protective gloves, follow the guidelines listed below: #1 Wash your hands before and after using protective gloves, and remember to remove all hand jewelry to prevent tearing of gloves."



Observation of the surgical suite on 1/07/15 at 10:30 a.m. revealed four (4) scopes, for use in gastro-intestinal procedures, were hanging in the surgical suite unprotected.

During an interview on 1/07/15 at 10:30 a.m. the Director of Surgery stated, "I have wanted a cabinet. They have always been hanging like this since 1995." When asked if the three (3) are cleaned after one is used in a procedure, she stated, "No." When asked if all are cleaned during terminal cleaning she stated, "No."

There was no documented evidence of notes regarding infection found in the facility's Infection Control Minutes. The Director of Surgery stated, "This is reported, just not included in the minutes." She stated they knew of no infections.

Review of the facility's undated "Protection of Personnel in Endoscopy Department" revealed, "All instruments and equipment used are cleaned and packaged for sterilization by Endoscopy Personnel." There was no documented evidence of a policy for packaging or covering scopes once cleaned.

During the Exit Conference on 1/07/15 these findings were discussed. The parent company had provided photographs of a cabinet being sent to cover the scopes and also remove them from the surgical suite. No further documentation was provided.






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Based on record review, employee interview, observation, and review of policy and procedures, the facility failed to ensure that all drugs, biological, and intravenous medications are administered by or under the supervision of a Registered Nurse (RN), a doctor of medicine, osteopathy or physician assistant in accordance with written and signed orders.


Findings Include:


Record review for Patients #11, #12 and #13 revealed that these patients had been admitted to the surgery department for an outpatient procedure. Documentation in the records revealed that the procedure had been performed and the patients discharged home. The medical records contained no documented evidence of physician orders for pre operative, post operative, or discharge.


On 01/06/15 at 1:30 p.m. observation of the facility's telemetry monitors revealed that Patient #15 was on the cardiac telemetry monitor. Review of the medical record for Patient #15 revealed no documented evidence of a physician's order for the patient to be monitored. During review of the electronic medical record for Patient #15, RN #3 was asked to show the physician's order for Patient #15 to be placed on a cardiac monitor. She stated, "There is no order."


During an interview on 1/07/15 at 10:30 a.m. RN #4 revealed that there were no physician's orders on Patient #11, #12 or #13's medical records. She stated, "We have always done it this way. We don't have physician orders on the record."


Review of the facility's "Preparing A Patient For Surgical Procedure" policy (effective date 1/01/02) revealed, "Preoperative Care - #5. Obtain and perform preoperative orders including appropriate prep."

Based on record review, policy and procedure review and staff interview, the facility failed to ensure the medical record is complete, accurately documented, contains outpatient surgery physician orders and entries contain a documented date, time and signature for 10 of 27 patients reviewed. (Patient #11, #12, #13, #15, #18, #20, #21, #22, #23 and #24)


Findings Include:


Cross Refer to C297 for the facility's failure to ensure that all drugs, biological, and intravenous medications are administered by or under the supervision of a Registered Nurse (RN), a doctor of medicine, osteopathy or physician assistant in accordance with written and signed orders for Patient #11, #12, #13 and #15.



Cross Refer to C302 for the facility's failure to ensure the medical record is complete, accurately documented and entries contain a documented date, time and signature.


Cross Refer to C306 for the facility's failure to ensure the medical record contains outpatient surgery physician's orders.

Based on medical record review, policy and procedure review and staff interview, the facility failed to ensure the medical record is complete, accurately documented and entries contain a documented date, time and signature for Patient #11, #12, #13, #15, #18, #20, #21, #22, #23 and #24, 10 of 27 patients reviewed.


Findings Include:


Cross Refer to C306 for the facility's failure to ensure the medical record contained outpatient surgery physician's orders for Patients #11, #12, #13, #22, #23 and #24.


Record review for Patient #18 revealed no documented evidence that a physician signed a 12/31/14 verbal order.


Record review for Patient #20 revealed the "Swing Bed Weekly Progress Toward Goals" contained incomplete documentation for Physical Therapy (PT) and Speech Therapy (ST):
11/11/14 - PT failed to document
11/18/14 - PT failed to document
Record review for Patient #20 revealed the patient's 11/21/14 "Discharge Summary on Swing Bed Patients" contained no documentation for PT and ST.


Record review for Patient #21 revealed the 5/28/14 "Discharge Summary on Swing Bed Patients" contained no documentation for PT and ST.


During an interview on 1/07/15 at 1:55 p.m. the Medical Record Director and Medical Record Technician both confirmed the number of delinquent (greater than 30 days after discharge) medical records was 37. This number included both acute and swing beds. The delinquent count ranged from January 2014 to present day and included nursing documentation, physician orders, nutrition and cardiopulmonary sheets, and physical, speech and occupational therapy weekly progress and discharge notes.


Review of the facility's "Delinquent Medical Records" policy, revealed " ...A medical record is considered delinquent when it has not been completed within 30 days of the patient's discharge ...".


Review of the facility's "Discharge Planning" policy revealed: " ...Policy: Discharge planning is a multi-disciplinary process initiated on admission ...Referrals are made to other disciplines ...rehab services ...will have discharge needs and progress assessed by the interdisciplinary team during their weekly meeting ...Planning for Inpatient's Discharge ...2. Within 24 hours: For patients identified as high risk ...Discharge Care Plan is initiated within 24 hours by ...appropriate disciplines..For patients not identified as high risk goals for planning ...are identified within 24 hours ...".


Review of the facility's "Rules and Regulations of the Medical Staff" revealed: "...Section II: Medical Records: A medical record is initiated and maintained for every individual assessed or treated ...A. Complete and Legible medical record: The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient...K. Orders for Treatment ...A verbal (i.e. telephone) order shall be considered to be in writing if dictated to a duly authorized person functioning within his sphere of competence and signed, dated and timed by the responsible practitioner ...O. Dating, Timing, and Signing of all Clinical Entries: All clinical entries in the patient's medical record shall be dated, timed, and authenticated ...Y. Timeliness of Completion of Records: The patient's medical record shall be managed and completed in a timely manner ...Records should be complete at the time of discharge, including progress notes ...If the records still remains incomplete after fifteen (15) days, the Director of the Medical Records Department shall notify the practitioner of the incomplete records and request that they be completed promptly. Records are considered delinquent after 30 days past discharge. A list of any practitioners with delinquent records (i.e. records more than 30 days past discharge) shall be presented to the Medical Administrative Committee... Z. Signature Requirements: All clinical entries in the patient's medical record must be accurately dated, timed and individually authenticated ...".

Based on medical record review, policy and procedure review and staff interview, the facility failed to ensure the outpatient surgery record contained physician's orders for Patient #11, #12, #13, #22, #23 and #24, six (6) of 27 patients reviewed.


Findings Include:


Record review for Patient #11, #12, #13, #22, #23 and #24 revealed no documented evidence of signed outpatient surgery physician's orders prior to medical treatment.


During an interview on 1/07/15 at 11:35 a.m. the Surgery Director confirmed there was no further documentation of orders other than what had already been submitted for review. She stated, "We have never had any other orders other than what you have in the record now." No further documentation was submitted for review.


Review of the facility's "Outpatient Report" policy revealed, "Procedure: Outpatient admissions and orders are received ...daily. The reports are checked against a register log from the previous day to ensure all orders are present ...Outpatient surgery records are handled much in the same manner as inpatients ...".


Review of the facility's "Rules and Regulations of the Medical Staff" revealed: "Section I: Admission and Discharge: A ...The hospital shall accept for care and treatment any patient who admission to the hospital is ordered by a member of the Medical staff ... B. A member of the Medical Staff with admitting privileges shall be responsible for the medical care and treatment of each patient ...Section II. Medical Records ...K. Orders for Treatment: All orders for treatment shall be in writing ...".

Based on documentation review, staff interview and policy and procedure review, the facility failed to notify the organ recovery agency of two (2) patient deaths in a timely manner.


Findings Include:


Review of the facility's "2014 Tissue Donation Report" revealed: "April ...all reported in a timely manner except one (1) ...it (death) was called in well after the one (1) hour time of cardiac arrest ...July ...there was one (death) called in late ...".


During an interview on 1/06/15 at 2:55 p.m. the Director of Nursing (DON) confirmed that when a patient death occurs the nurse assigned to care for the patient is the responsible for placing the call to the organ recovery agency in a timely manner.


Review of the facility's "Organ & Tissue Donation Cooperative Agreement" revealed: " ...Whereas, the purpose of this agreement is to ensure that the organ and tissue donation program ...is in full compliance with all the relevant federal and state laws or regulations ...III. Responsibilities of facility: A.7. Timely referral of all expired patients, within one hour of cardiac death, to the ...referral line ...".


Review of the facility's "Organ/Tissue Donation/Routine Referral Process" policy revealed: "Policy: ...All patient deaths are referred ...Procedure: Notification/Referral..The nurse supervisor or their designee will call ...within 30 minutes after any and all deaths that occur in the hospital ...".