HospitalInspections.org

Based on document review and medical record review and staff interviews, the hospital failed to ensure the nursing staff follows hospital policy and procedure regarding the use of siderails as restraints in ten (10) out of ten (10) medical records (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) reviewed. This has the potential to negatively impact all patient care by creating an unsafe patient care environment. Findings include:

1. Charleston Area Medical Center, Inc. (CAMC) Patient Care Manual policy, Restraining a Patient, TX 480.00, last revised 2/2009, states in part "...Definitions: Restraint - Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely..."

2. Review of the medical records for Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10 revealed documented evidence of inconsistent use of all four (4) siderails in the up position at various times during their admissions, by various nursing staff members.

3. During interviews with the Unit Manager and Clinical Management Coordinator in the afternoon of 2/17/10 and the Unit Manager in the afternoon of 2/18/10, the medical records were reviewed and they agreed with the above findings.

Based on document review, medical record review and staff interviews, the hospital failed to ensure the nursing staff follows hospital policy regarding the prevention of pressure ulcers in one (1) of five (5) closed medical records (Patient #1) reviewed. This has the potential to negatively impact all patient care by not preventing pressure ulcers in patients more susceptible or preventing worsening of already present pressure ulcers. Findings include:

1. Charleston Area Medical Center (CAMC) Nursing Manual policy, Procedure for Assessment and Prevention of Pressure Ulcers, 1912, last revised 4/2008, states in part "...3. Initiate Nursing Interventions based on patient assessment..."

2. Review of the medical record for Patient #1 revealed inconsistent documented turning of the patient by the nursing staff on every day of the patient's stay. Some of the documentation was self-turning by the patient, some was the actual position the staff turned the patient, but the majority was no documented evidence of any turns at all.

3. During an interview with the Unit Manager (UM) in the afternoon of 2/18/10, the medical record was reviewed and the UM agreed with the above findings.

Based on document review and staff interviews, the hospital failed to ensure the nursing staff has an effective and adequate policy and procedure for the administration of medications to patients. This has the potential to negatively impact all patient care by creating an institution-wide opportunity for medication errors. Findings include:

1. Charleston Area Medical Center (CAMC) Patient Care Manual policy, Procedure for Administration of Medications, TX 320.00, last revised 10/2009, states in part "...15. Scheduled doses missed may be administered: A. When less than 1/2 of the dosing interval has elapsed (e.g., 3 hours when administered every 8 hours), missed dose should be given and the next regularly scheduled dose given as scheduled. B. When greater than 1/2 of the dosing interval elapsed since the dose was missed (e.g., 6 hours when administered every 8 hours) wait until the next scheduled dose to continue therapy..."

2. During a telephone interview at 1510 on 2/16/10 with the Director of the Nursing Standards and Practice Department, the medication administration policy was reviewed, in particular the above mentioned section. When asked what Standard of Practice was used to support this policy, the Director stated "it was a collaboration with hospital personnel and pharmaceutical personnel based on the pharmacological parameters and physiologic kinetics of a medication and the patient." She then referred the surveyor to speak with a pharmacist at CAMC-Memorial Division for further information.

3. The PharmD. was interviewed at 1530 on 2/16/10 regarding the medication administration policy, particularly the above mentioned section. When asked what Standard of Practice was used to support this policy, the pharmacist stated the same thing the Director of the Nursing Standards and Practice Department had stated earlier and it's based on the half-life principle. After much discussion regarding the safety of such medication administration practices (i.e., possible overdosing or underdosing of medication), the pharmacist then stated the policy was "actually written for those patients that are off the floor for a procedure during the scheduled time of medication administration." The policy in finding #1 above does not state that part.

Based on surveyor observations, the hospital failed to ensure the medical records department provided five (5) of five (5) requested patient medical records (Patients #1, 2, 3, 4, 5) to the State Surveyors in a timely fashion and/or in their entirety (Patient #1) as requested. This has the potential to negatively impact all patient care by impeding the survey process by unnecessarily delaying access to the medical records. Findings include:

1. Charleston Area Medical Center (CAMC) uses a paper charting system. Once the patient is discharged, the medical record is scanned into the computer system and maintained in the central medical records department so that if the patient presents at one of the other three (3) divisions, an old medical record can be printed at the current division.

2. The State Surveyors entered Charleston Area Medical Center - Memorial Division (CAMC) on 2/16/10 at 1005 and immediately requested the complaint record (Patient #1) in it's entirety. The medical record was not received until 1200. When the medical record was received, it was not the complete record. The patient was admitted 12/22/09 and discharged 1/11/10. The initial medical record received did not contain any nursing documentation from 12/26/09 through the patient's discharge to home on 1/11/10 nor did it contain any of the Medication Administration Record or any of the Physician Progress Notes. When this was brought to Administration's attention, the complete medical record was not received until 1600.

2. The State Surveyors chose four (4) random closed medical records (Patients #2,3,4,5), for review, from the admitting log of the complaint unit and submitted the list to Administration for retrieval from the medical records department at 1230 on 2/16/10. These medical records were not received from the medical records department until 0900 2/17/10.

3. In the morning of 2/17/10, the Administration Secretary agreed with the above findings.

Based on surveyor observations, the hospital failed to ensure patients' medical records are kept secure at all times. This has the potential to negatively impact all patient care by unauthorized individuals gaining access to and altering patient records. Findings include:

1. Upon entering 5-South on 2/17/10 at 0915 to begin medical record reviews and a tour of the unit, a female was observed by the surveyor to be standing in the hallway, alone, wearing a long black coat, holding purse and with no hospital name badge identifiable and holding a medical record.

2. While walking through the unit, it was observed the facility uses chart boxes in the hallway outside each patient room to hold each patient medical record. The surveyor opened several different boxes to find complete patient medical records inside.

3. During interviews with the Unit Manager (UM) and Clinical Management Coordinator (CNM) in the morning of 2/17/10, the CNM stated the female noted earlier was with the Social Worker. The surveyor explained the female had no identifiable name badge and was alone in the hallway. During the same interview, the UM and CNM agreed the chart boxes are not locked throughout the facility or kept free from unauthorized access.