HospitalInspections.org

Based on review of records and interviews, the medical records for 18 of 18 patients (Patients #6 through #9, Patients #11 through #14, Patients #16 through #19, Patient #22, and Patients #24 through #28), treated at the hospital after August 2010, were not complete in that the medical record entries were not dated, timed, and/or signed by the person responsible for providing hospital services to these 18 patients.

Findings included:

On the "Physician's Orders" physician and/or nurse signatures were not dated and/or timed for the following patients:

Patient #6 - Orders dated 12/12/10 not timed by physician.
Patient #7 - "Sliding Scale Orders Regular Insulin" dated 12/06/10 not timed by physician.
Patient #12 - Orders dated 01/05/11 not timed by physician.
Patient #13 - Orders noted by RN 02/17/11 at 9:20 PM physician's signature was not dated and timed. The "Sliding Scale Orders Regular Insulin (noted by the RN on 02/17/11 at 10:00 PM)" physician's signature was not dated and timed.
Patient #14 - The "Sliding Scale Orders Regular Insulin (noted by the RN on 09/28/10 at 07:30 PM)" physician's signature was not dated and timed.
Patient #16 - Orders noted by nurse 11/18/10 at 04:30 PM physician's signature was not dated and timed.
Patient #19 - Orders dated 02/03/11 not timed by physician.
Patient #22 - The "Sliding Scale Orders Regular Insulin (noted by nurse at 03:50 PM)" physician's signature was not dated and timed, and nurse's signature was not dated.

The Emergency Department's (ED) "Physician Orders" were not dated and timed by the physician for the following patients:

Patient #12 - Printed 01/05/11 at 09:14 AM (Orders included Zithromax).
Patient #25 - Printed 09/20/10 at 10:33 AM (Orders included pelvic tray set-up).
Patient #26 - Printed 02/14/11 at 10:21 AM (Orders included oxygen).
Patient #28 - Printed 02/01/11 at 08:37 AM (Orders included morphine).

The "ED Physician Notes" were not signed, dated, and/or timed by the physician for the following patients:

Patient #12 - Printed 01/05/11 at 09:14 AM, label triage date 01/05/11, not signed by physician with date and time of signature.
Patient #25 - "Pelvic Ultrasound Note" printed 09/20/10 at 10:33 AM, label triage date 09/20/10, physician's signature was not dated and timed.
Patient #26: Printed 02/14/11 at 10:21 AM, label triage date 02/14/11, not signed by physician with date and time of signature.
Patient #27 - Printed 01/20/11 at 12:57 PM, label triage date 01/20/11, not signed by physician with date and time of signature.

The "ED Course/Workup" physician's signature was not dated and/or timed for the following patients:

Patient #12 - Label triage date 01/05/11, "Care Assumed" at 11:25 AM - not dated and timed.
Patient #25 - Label triage date 09/20/10, "Completed" at 02:00 PM - not dated.
Patient #26 - Label triage date 02/14/11, "Completed" at 12:40 PM - not dated.
Patient #27 - Label triage date 01/20/11, "Completed" at 02:50 PM - not dated.
Patient #28 - Label triage date 02/01/11, "Completed" at 11:00 AM - not dated.

The ED nurse's report, that included vital signs, nurses' notes, patient disposition, and discharge information, Registered Nurse's (RN) signature was not dated and timed for the following patients:

Patient #12 - Printed 01/05/11 at 09:14 AM, "Time out of unit" 01:30 PM.
Patient #25 - Printed 09/20/10 at 10:33 AM, "Time out of unit" 03:10 PM.
Patient #26 - Printed 02/14/11 at 10:21 AM, "Time out of unit" 01:30 PM.
Patient #28 - Printed 02/01/11 at 08:37 AM, "Time out of unit" 11:30 AM.

The ED nurse triage assessment nurse's signature was not dated and timed for the following patients:

Patient #26 - Printed 02/14/11 at 10:21 AM - level 2.
Patient #28 - Printed 02/01/11 at 08:37 AM - level 3.

The "Physician Certification Statement for Ambulance Transportation" physician's signature was not dated and timed for the following patient:

Patient #26 - Transport date 02/14/11.

The "Med Reconciliation Form" physician's signature was not timed by the physician for the following patients:

Patient #6 - Signature dated 12/11/10.
Patient #8 - Signature dated 10/16/10.
Patient #13 - Signature dated 02/17/11.

The hospital's "FFConsent" form signatures were not timed by the hospital's appointed witness for the following patients:

Patient #6 - Witness signed 12/11/10.
Patient #7 - Witness signed 12/06/10.
Patient #9 - Witness signed 12/06/10.
Patient #11 - Witness signed 09/07/10.
Patient #12 - Witness signed 01/05/11.
Patient #13 - Witness signed 02/17/11.
Patient #14 - Witness signed 09/28/10.
Patient #19 - Witness signed 02/06/11.
Patient #22 - Witness signed 01/16/11.
Patient #24 - Witness signed 12/30/10.
Patient #26 - Witness signed 02/14/11.

The "Disclosure and Consent...Transfusion" form signature was not timed by the hospital's appointed witness for the following patient:

Patient #14 - Witness signed 10/01/10.

The "Memorandum of Transfer" physician's signature was not dated and timed for the following patients:

Patient #25 - Transferred 09/20/10.
Patient #26 - Transferred 02/14/11.

The "Progress Note" physician's signature was not dated and/or timed for the following patients:

Patient #7 - Visit 12/07/10, 09:01 AM - signature not dated and timed.
Patient #8 - Visit 10/17/10, 10:37 AM - signature not dated and timed.
Patient #14 - Visit 09/29/10, 10:06 AM - signature not dated and timed.
Patient #16 - Visit 11/20/10, 07:31 AM - signature not dated and timed.
Patient #18 - Visit 10/22/10, 08:23 AM - signature not dated and timed.
Patient #19 - Visit 02/07/11, - signature not dated and timed.
Patient #22 - Visit 01/18/11, 07:56 AM - signature not dated and timed.
Patient #24 - Visit 12/31/10, 11:10 AM - signature not dated and timed.

The "Progress Record" physician's signature was not timed for the following patient:

Patient #13 - Dated 02/19/11.

The "Pediatric Admission Assessment Record" was not authenticated by the nurse with a signature that was dated and timed for the following patient:

Patient #18 - Date/Time of Arrival 10/21/10 at 06:05 PM.

The laboratory reports were not authenticated with a signature dated and timed by the person who provided the laboratory information to the hospital for the following patients:

Patient #8 - "Microbiology" final report released on 10/17/10 at 04:07 PM noted "...escherichia coli." This report was dated 10/18/10 at 08:59 AM.
Patient #11 - "Microbiology" final report released on 09/09/10 at 08:00 AM included "...escherichia coli." This report was dated 09/09/10 at 08:01 AM.
Patient #14 - "Hematology," "Chemistry," and "Glomerular Filtration Rate" test date 10/01/10 05:25 AM. This report was as of 10/01/10 at 07:30 AM.
Patient #16 - "Hematology," "Chemistry," and "Glomerular Filtration Rate" test date 11/21/10 05:15 AM. This report was as of 11/21/10 at 06:46 AM.
Patient #17 - "Urinalysis" test date 09/29/10 10:15 PM. This report was as of 09/29/10 at 10:37 PM.
Patient #19 - "Urinalysis" test date 02/08/11 08:15 AM. This report was as of 02/08/11 at 09:30 AM.

The "Radiology Report" interpreting physician's approved electronic signatures were not timed for the following patients:

Patient #8 - Chest x-ray report transcribed 10/17/10, 01:12 PM, physician did not time his 10/18/10 signature and "CT Scan" of the head without contrast report transcribed 10/18/10, 09:02 AM, physician did not time his 10/18/10 signature.
Patient #13 - "CT Scan" of the head with and without contrast report transcribed 02/18/11, 11:58 AM, physician did not time his 02/18/11 signature.

The "Echocardiographic Evaluation" Technologist's signature was not dated and timed for the following patient:

Patient #12 - Date of evaluation 01/06/11.

On 03/30/11 at approximately 02:00 PM, the Chief Nursing Officer (Personnel #2) and Medical/Surgical Manager (Personnel #6) reviewed the above medical records of Patients #6 through #9, Patients #11 through #14, Patients #16 through #19, Patient #22, and Patients #24 through #28 and agreed that the medial record entries were missing authentication information that included signatures, dates of signatures, and/or times of signatures.

The hospital's "General Medical Record Policy and Procedure" dated 11/11/10 noted, "All entries must be legible and complete and must be authenticated and dated and timed by the person making the entry."

Based on observation, interview, and record review, the hospital did not maintain their medical supplies to ensure an acceptable level of safety and quality in that 6 of 11 female urinary catheterization kits in the medical/surgical nursing supply room had expired dates and were available for patient use.

Findings included:

During a tour of the medical/surgical nursing unit at approximately 03:45 PM on 03/29/11, the nursing central supply room adjacent to the nursing desk was randomly checked for expired supplies. The surveyor observed 6 of 11 female catheterization kits with gloves and swabs that had the following "use by" dates on the packaging: March 2010 - 5 kits and April 2010 - 1 kit. These 6 female catheterization kits were available for patient use.

During an interview at approximately 03:50 PM on 03/29/11, the Director of Central Supply (Personnel #23) was shown the 6 outdated female catheterization kits and agreed that the 6 kits should have been taken off the shelf.

The materials management "Outdated, Damaged or Recalled Items" policy 675-04-06 approved 08/06/10 noted, "...To protect the patients and staff from the consequences of using contaminated or possible non-sterile supplies...expiration dates are monitored on a continuous basis...Dates are checked for expiration...Any product that has expired will be removed from the shelf and returned to the Material Management Department..."

Based on record review and interview, the facility did not promote the rights of 1 of 2 Swing Bed patients (Patient #4), in that they did not provide the patient with information of her rights to include a dignified existence, self determination, contact with persons inside and outside the facility, the right to refuse treatment or to refuse to participate in experimental research, the right to formulate an Advanced Directive, the right to choose a physician, to be fully informed about treatment, to personal privacy. and the right to retain and use personal possessions.

Findings Included:

1) Review of the medical record for Patient #4 did not include a copy of her Swing Bed Patient Rights.

2) In an interview with the surveyor on 03/30/11 at 10:00 AM the CEO (Personnel #1) was asked to review Patient #4's record for Swing Bed Patient Rights. She confirmed there were no patient rights in the record.

3) Facility Policy, dated 07/19/10 included: "Swing Bed Program Policies and Procedures - SWB 17 - Swing Bed Admission Procedures...Procedure...3. Nurses will review SWB patient rights with the patient and/or family member. Patient/family member will sign and nurse will witness. The original form will be maintained in the patient's medical record. A copy will be given to the patient."

Based on review of records and interview, the facility had not informed, in writing, one of one residents (Patient #5) who was entitled to Medicaid benefits of those services that were or were not covered by Medicaid.

Findings included:

1) Review of the Swing Bed record for Patient #5 who received Medicaid coverage, did not include information or written notification of services that were provided by the facility indicating what charges were covered by Medicaid and what was not covered.

2) In an interview with the surveyor on 03/30/11 at 10:00 AM the CEO (Personnel #1) was asked to review the record for notification to the patient of services provided and either paid for or not paid for by Medicaid. She confirmed there was no notification of services and if the services were paid for or were not paid by Medicaid.

Based on record review and interview, the hospital had not ensured that an ongoing program of activities was directed by an activities professional, to meet the interests, and the physical, mental, and psychosocial well-being of each patient for 2 of 2 Swing Bed patients (Patients #4 & #5).

Findings included:

Review of 2 of 2 discharged Swing Bed patients' (Patients #4 and #5) medical records did not include documentation of activities to meet the interests, and the physical, mental, and psychosocial well-being of each patient.

In an interview with the surveyor at 10:00 AM on 03/30/11 the CEO (Personnel #1) was asked if the facility had a Swing Bed Activity professional. She stated that the facility had not had a qualified activities professional since 06/15/09. She provided documentation that the facility had provided Swing Bed care for 42 patients since June of 2009 until the date of the survey with an average length of stay of 7 days per patient. She was asked, if at the time of this survey, if there were any Swing Bed patients. She stated there were no Swing Bed patients. She provided the file of Personnel #7 that included the employee was enrolled in and completing courses in an Activity Director program at a local college. She was asked if Personnel #7 had provided any activities to Patients #4 and #5. She stated Personnel #7 was not providing services at the time of this survey. She confirmed that Patients #4 and #5 had not been offered activities.

Review of the hospital's "Swing Bed Program, Patient Activities Policy and Procedure," dated 07/19/10 included at SWB 16, "Quality of Life...Procedure...3..4 Activity Therapist for Social Stimulation..."