HospitalInspections.org

Based on review of credentialing files, governing body meeting minutes, and medical staff bylaws the governing body failed to appoint and approve privileges for 5 out of 16 physicians.
Findings include:
During credentialing file review on 11/28/12 at approximately 10:00 a.m. 5 out of 16 physicians were not found to have been approved or appointed privileges as required under medical staff bylaws.
Review of governing body meeting minutes on 11/28/12 at approximately 11:00 a.m. revealed no evidence of the five physicians having been approved or appointed privileges.
Review of medical staff bylaws on 11/28/12 at approximately 11:30 a.m. revealed under section four " Terms and Conditions of Appointment " #5 states " Appointments to the medical staff shall confer upon the appointee only such privileges and responsibilities as have been granted by the governing board.

Based on medical record review and interview the facility failed to provide a copy of an "Important Message from Medicare" (IM) to 2 (Patients #1, #10) out of 2 patients, which could potentially deprive patients of the information necessary to exercise their rights. Findings include:

On 11/26/12 at approximately 1115 during record review for Patient #1 revealed that the "Important Message from Medicare" was not found on Patient #1's medical record. Staff E, the nursing supervisor was asked regarding their policy for completion of the Important Message from Medicare, to which she replied, "either the social worker, or the admitting person should have completed this". Staff E was unable to find a signed copy of the Important Message from Medicare for Patient #1.

On 11/26/12 at approximately 1530 during review of facility policy titled "Admitting #4.27 An Important Message from Medicare" revised 9/08 revealed "...During the admission process all Medicare patients including Senior Plans will be given the 'An Important Message from Medicare' letter....The admitting Department personnel will review with the patient or the person acting on the patients' behalf, 'An Important Message from Medicare' with Addendum. The staff will answer any questions and have the form signed and dated by the patient and sent to the Health Information Management Department for scanning."


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On 11/26/12 at approximately 1125 during record review for Patient #10 revealed that the "Important Message from Medicare" was not found on Patient #10's medical record. Staff E, the nursing supervisor was asked regarding their policy for completion of the Important Message from Medicare, to which she replied, "either the social worker, or the admitting person should have completed this". Staff E was unable to find a signed copy of the Important Message from Medicare for Patient #10.

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-709.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated November 26, 2012 for Life Safety Code.

Based on observation, interview and document review the facility failed to maintain a sanitary environment resulting in the potential for transmission of infectious agents to the eight patients receiving care in the facility. Findings include:

On 11/26/12 at approximately 1015, during facility tour found in an unoccupied room, 421 dust accumulation on the light over the patient bed and dust accumulation on the light over the bathroom sink. On 11/16/12 at approximately 1015, this was confirmed by Staff E.

On 11/16/12 at approximately 1545 a review of facility policy titled "Damp Dusting" dated 1/09 revealed "Begin dusting at the doorway and work way around the room. Always start at the top of an item and work down...". The policy failed to specify dusting frequency, nor evaluation of patient ready rooms when left unoccupied for prolonged periods.

On 11/16/12 at approximately 1545 a review of facility policy titled "Cleaning of the Patient Rooms Discharge or Transfer" dated 1/09 revealed "...wipe all fixtures, ledges and surfaces in the room above shoulder height. Begin at the door and work clockwise around the room...".

On 11/26/12 at approximately 1020 during the observational tour of the fourth floor revealed in a medication cart a screw-top type pill crusher with residual white powder remaining in the mechanism. This was confirmed by Staff E on 11/26/12 at approximately 1020, who said, "we are going to throw that out". Staff E was asked about the policy for cleaning the pill crusher, for which one could not be found, that specified cleaning protocols. Staff E said that "we will just (from now on) individually use these, one for each patient".


29955

On 11/26/2012 at approximately 10:30 am during the initial tour of the facility it was revealed the patient nourishment pantry had drawers with an accumulation of dust and crumbs. The nursing supervisor was asked which department was responsible for cleaning the pantry drawers. The nursing supervisor stated "housekeeping is responsible for keeping surfaces clean in the pantry area".