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Based on record review, policy and procedure review and staff interview the governing body failed to ensure an accurately written and complete medical record is securely maintained for each inpatient and outpatient treated; failed to ensure all entries/orders in the medical record contain a documented date, time and signature; consents are properly executed; and failed to ensure the medical record is promptly completed following patient discharge for Patients #1, #2, #4, #12, #16, #33, #36, #37, #38, #39, #41, #42, #43, #44, #45 and #47.



Findings include:


Cross Refer to A-431 for the governing body's failure to ensure an accurately written, complete medical record is securely maintained for each inpatient and outpatient treated; failure to ensure all entries/orders in the medical record contain a documented date, time and signature; failure to ensure consents are properly executed; and failure to ensure the medical record is promptly completed following patient discharge.

Based on record review, document review, policy and procedure review and staff interview, the facility failed to ensure an accurately written and complete medical record is securely maintained for each inpatient and outpatient treated; failed to ensure all entries/orders in the medical record contained a documented date, time and signature; and failed to ensure consents are properly executed. This effected Patients #1, #2, #4, #12, #16, #33, #36, #37, #38, #39, #41, #42, #43, #44, #45 and #47.


Findings include:


Cross Refer to A-438 for the facility's failure to ensure the medical record is promptly completed, properly filed and retained no later than 30 days following discharge.


Cross Refer to A-450 for the facility's failure to ensure all entries in Patients #36, #37, #38, #39, #41, #42, #44, #45 and #47's medical record contained documented dates, times and signatures.


Cross Refer to A-454 for the facility's failure to ensure all orders, including verbal orders, are dated, timed and authenticated by the ordering physician for Patients #33, #37, #38, #39 and #47.


Cross Refer to A-466 for the facility's failure to ensure a properly executed consent is documented in Patients #36, #38, #39 and #43's medical record.


Cross Refer to A-955 for the facility's failure to ensure a properly executed consent was documented prior to surgical procedure for Patients #36, #38 and #39.



On 3/03/14 at 11:00 a.m. the Medical Records Director was asked what the facility's process was for sending a medical record to be scanned. She stated, "Once the patient is discharged, the night clerk picks up the record and prepares it for shipping for scanning into the electronic medical record and the scanning service picks up each days' discharges at 2:00 a.m." At 3:45 p.m. the Medical Records Director was asked which documents in the medical record are on paper and sent for scanning. She stated, "Physician orders, physician progress notes, consults, history and physicals, and departmental forms... All discharged records are reconciled daily and placed into a hard plastic blue box and picked up at 2:00 a.m. each day by the scanning service." When asked if a copy of the original medical record was kept or made prior to releasing it to be scanned she stated, "No, it takes 12 to 24 hours to scan and be usable in the electronic medical record." When the Medical Records Director was asked if a list of documents was sent for scanning and maintained prior to the record leaving the facility for scanning she stated, "No." When asked if the facility had a check and balance for record she stated, "We would have to analyze physician orders to be sure documents are complete and audits are conducted on medical records once they are scanned."


On 3/05/14 at 9:50 a.m. the Medical Records Director was asked how the security and completeness of the medical record was maintained. She stated, "We scan in the discharged patient's label and receive a list of patient names per category (Inpatient, Outpatient, Same Day Surgery, Emergency Room and Clinics), and that is the documentation identifying the records that are sent for scanning into the Electric Medical Record at 2:00 a.m. each day." She confirmed the documentation sent for scanning is the original medical record document and that copies are not made of the medical record before it is sent for scanning. "139 medical records were sent for scanning on 3/4/14 and the documentation is the original paper record and no copies of the original paper record was obtained (made) prior to the medical record leaving the facility for scanning." She further stated, "Some portions are retrievable but not all of the paper record is retrievable." When asked if she could ensure none of the original documents sent for scanning were lost or misplaced, she stated, "No. We don't have enough staff to copy all of what is sent for scanning."


Review of the facility's "Record Reconciliation Summary" confirmed 139 original paper medical records, all for patients discharged on 3/4/14, were released to the scanning service at 2:00 a.m.


Review of the facility's "Medical Staff Rules & Regulations/Subject: Medical Records" policy revealed: "Policy: ...12. Records may be removed from the hospital's jurisdiction and safekeeping only in according with a court order, subpoena or statute. All records are the property of the hospital and shall not otherwise be taken away without permission of the Chief Executive Officer ...".


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Record review for Patient #2 and #4 revealed no documented evidence of a physician's signature on the anesthesia consents. In an interview on 3/04/14 around 11:00 a.m. the lead anesthesiologist stated, "We have to sign at least eight (8) times and we ask that they pull out what we sign and place on the front of the chart."

Review of surgical records for Patient #1, #12 and #16 revealed that the physician authenticated five (5) to 10 days after the surgery in which a CRNA(Certified Registered Nurse Anesthetist) performed the anesthesia. In an interview on 3/04/14 at 11:30 a.m. the Quality Manager of the facility stated, "The anesthesiologist should sign behind the CRNA within 24 hours."

All findings were presented at exit conference on 3/05/14 at 12 noon. No further documentation was provided.

Based on document review, policy and procedure review and staff interview, the facility failed to ensure the medical record is promptly completed following discharge.


Findings include:


During an interview on 3/3/14 at 11:05 a.m. the Medical Records Director stated "There are 95 delinquent medical records."


Review of the "Deficiency Chart Total by Physician" revealed that 46 physicians have medical records greater than 30 days delinquent. The dates range from April 27, 2013 through January 28, 2014 and include: physician orders, consultation reports, respiratory therapy reports, discharge summary, history and physicals, operative reports, emergency department physician records, progress notes, holter monitor reports, and echocardiogram reports.


Review of the facility's "Medical Staff Bylaws" revealed: " ...6. Article Six: Corrective Actions ...6.6.5 Medical Records: A medical record is considered to be delinquent when it has not been completed for any reason within thirty (30) calendar days following a patient's discharge ...".


Review of the facility's "Medical Staff Rules & Regulations/Subject: Medical Records" revealed: "Policy: 1. The attending practitioner shall be responsible for the preparation of a complete ...medical record for each patient ... ".


Review of the facility's "Medical Record Delinquency Reporting" policy revealed: "...Policy: ...Delinquent charts are defined as those charts that include at least one deficiency and have not been completed within 30 calendar days of the patient discharge or date of service. This also includes charts that are 30 calendar days or older that have not been analyzed due to a backlog ...".

Based on record review, policy and procedure review and staff interview, the facility failed to ensure all entries in the medical record were accurately written, complete and contained a documented date, time and signature for nine (9) of 13 patients reviewed, Patient #36, #37, #38, #39, #41, #42, #44, #45 and #47.


Findings include:


Record review for Patient #36, #38 and #39 revealed the surgical and anesthesia procedure consents were incomplete. This included dates, times, type of anesthesia, patient name and physician signature.


Record review for Patient #36, #37, #38, #39, #41, #42, #44, #45, and #47 revealed the physician orders and/or progress notes were not dated or timed when written into the medical record. This included orders written by the physician, verbal and/or telephone orders taken by the nurse and routine order sheets placed on the medical record.


Record review for Patient #36 revealed the only physician progress note stated, "I'm dictated" and there was no documented evidence of a physician signature.


Record review for Patient #36 and #37 revealed no documented evidence that the "Master Anesthesia Record" contained a documented "Post Anesthesia Care Vital/Notes" or that the "Anesthesia Pre and Post Anesthetic Evaluation" contained a documented "Post-op Note".


Review of the facility's "Medical Staff Rules & Regulations/Subject: Medical Records" policy revealed: "Policy ...7. All clinical entries in the patient's medical record shall be legible, accurately dated and authenticated ... ".


Review of facility's "Informed Consent (Medical and Surgical Procedures)" policy revealed: "..Policy: The patient's Informed Consent for a medical or surgical procedure must be obtained and documentation placed in the patient's medical record prior to a medical or surgical procedure ...Obtaining the patient's Informed Consent is the physician's responsibility and cannot be delegated to anyone else ...3) Name of the specific procedure or other type of medical treatment for which consent is being given; 4) Name of the responsible practitioner who is performing the procedure or administering the medical treatment; ...7) Date and time the informed consent is signed ...Informed Consent is required for: moderate to deep sedation, general anesthesia, surgical procedures ...Procedure: The physician obtains and documents the patient's Informed Consent ...and places the documentation in the medical chart ...If the signature is obtained from anyone other than the patient, two licensed staff members will witness the signature ...A properly executed consent must be placed in the patient's chart prior to the procedure..."


Review of the facility's "Medical Staff Rules & Regulations/General Rules Regarding Surgical Care" policy revealed: "1. Written, signed, informed, surgical consent shall be obtained prior to the invasive procedure ...5. The anesthetist shall maintain a complete anesthesia record to include evidence of peri-anesthetic ( ...immediately post anesthesia) evaluation ...post-anesthetic ( ...discharge from recovery area) following-up of the patient's condition ..."


Review of facility's "Guidelines of Peri-Operative Anesthesia Practice" policy revealed: "Policy: ...Guideline III Post-Operative Guidelines of Care: A ...5. Documents patient condition on appropriate form."


Review of the facility's "Medical Staff Rules & Regulations/General Conduct of Care" policy revealed: "Policy: 1. A general consent form, signed by or on behalf of every patient admitted to the hospital, must be obtained at the time of admission ...2. All orders for treatment shall be in writing. A verbal order shall be considered to be in writing if dictated to a health care professional and signed by the responsible practitioner. All verbal orders shall be signed and dated by the appropriately authorized person to who dictated with the name of the practitioner per his or her own name ...The responsible practitioner shall authenticate such verbal orders no later than 48 (forty-eight) hours after the order is given ...".

Based on medical record review, policy and procedure review and staff interview, the facility failed to ensure all orders, including verbal orders, were dated, timed and authenticated by the ordering physician for five (5) of 13 patients reviewed, Patient #33, #37, #38, #39 and #47.


Findings include:


Cross Refer to A-0450 for the facility's failure to ensure all orders, including verbal orders, were dated, timed and authenticated by the ordering physician according to facility policy for Patient #33, #37, #38, #39 and #47.
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Based on medical record review and policy and procedure review, the facility failed to ensure a properly executed consent was documented for four (4) of 13 patients reviewed, Patient #36, #38, #39 and #43.


Findings include:


Record review for Patient #36 revealed the anesthesia consent form did not contain a documented date, time, type of anesthesia or timely physician signature; and the surgical procedure consent did not contain a documented date or time.


Record review for Patient #38 revealed the anesthesia consent did not contain a documented date, time or timely physician signature; and the surgical procedure consent did not contain a documented time or physician signature.


Record review for Patient #39 revealed the anesthesia consent did not contain a documented date or time.


Record review revealed Patient #43 was admitted on 3/3/14 but did not sign the facility document "Conditions of Admissions and Consent for Outpatient Care" until 3/4/14 at 4:42 p.m.

Based on record review, current dietary list review and staff interview, the facility failed to ensure therapeutic diets were prescribed by the practitioner or practitioners responsible for the care of Patient #1 and #2, two (2) of 10 patients reviewed for diets.


Findings include:


On 03/04/2014 at approximately 9:21 a.m. the facility's dietary staff provided a copy of the facility's "Current Diet" list which contained the names of current patients and their current diet.


Record review for Patient #1, with assistance of nursing unit staff, revealed no documented evidence of a diet order. The Current Diet list stated that the patient was on an "ADA Diet". In the Special Notification sections of the Current Diet list, the Number Of Calories was specified to be 1800. Facility staff on the nursing unit was asked how this specific diet order was provided to Dietary. A staff member stated, She told us that this is the diet she was on at home." There was no documented evidence of this conservation with Patient #1. At approximately 10:40 a.m. a copy of Patient #1's current diet order was provided by staff.


Record review, with assistance of the staff on the nursing unit, revealed Patient #2 was receiving a Lactose Free Diet. There was no documented evidence regarding this patient's allergy to milk. Staff stated that the patient told them that she was allergic to milk, but this was not documented in the medical record. This information was later entered on the patient's allergy list.

Based on observation, staff interview, and policy review, the facility failed to ensure that equipment was maintained to ensure acceptable level of safety and quality.


Findings include:


On 3/3/14 at 1:30 p.m. observation in Room #27 of the facility's Intensive Care Unit (ICU) revealed the room had been cleaned for reuse. A tube feeding pump and a pump used with sequential hose was found stored in the room's closet. The tube feeding pump had visible white substance on the screen. When asked if the substance could be removed, the Registered Nurse (RN) used a Sani-Wipe to clean the substance from the pump. When asked to explain the process of cleaning the ICU rooms after patient discharge, the RN stated, "The techs (technicians) are responsible for cleaning the equipment when the rooms are cleaned."


Review of the facility's "Cleaning and Disinfection Guidelines for Non-Critical Items/Equipment" policy (effective date 09/2010; Policy Number IC05.02; page #3 of 7) revealed, "Terminal cleaning includes: ...equipment removed from the room by nursing staff and placed in the soiled utility room to be cleaned by designated personnel."

Based on observation, staff interview and policy and procedure review, the facility failed to ensure that a system was developed and implemented for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel during three (3) of three (3) days of survey.


Findings include:


Observation of nursing staff in the facility's Intensive Care Unit on 3/3/13 at 1:30 p.m. revealed Employee #6 sitting at the nursing station with a face mask under her chin (not covering her face or nose). When asked why she was wearing the face mask she stated, "I did not take the flu shot." An interview with this same employee on 3/4/14 at 3:40 p.m., while she was working on Telemetry Hall A, revealed that she was supposed to wear a face mask while in contact with patients and visitors. "I come in to work, put on my mask prior to seeing patients." At the time she was standing in the hallway in front of the nursing station and did not have a face mask on. Visitors were present in the hallway.


Review of the facility's "Influenza Vaccination Program" policy, effective date1992; policy number Sect. 4. #2; page 2 of 2, revealed," Unvaccinated healthcare personnel will wear a surgical mask in the following areas: Direct Patient care activities including patient transport. Patient care areas where contact and/or exposure may occur such as hallways in patient care areas, holding areas, or waiting rooms. Locations where patient and person interactions may have exposures occur such as nursing stations, patient transport hallways accessing ...".


Observation on 3/5/14 at 9:30 p.m. revealed Employee #7 walking from the nursing unit hallway to the nursing station, where the medication administration system was located. Employee #7 did not wash his hands prior to removing medication from the system. He then took the medications and went to Patient #32's room and assessed patient without washing his hands.


Review of the facility's "Hand Hygiene Guidelines" policy revealed, "D. Indication for hand hygiene:
1. Before and after each patient contact
2. Before and after touching wounds/non-intact skin, whether surgical, traumatic, or associated with an invasive device.
3. Before preparing medication or diagnostics agents ..."

Based on record review, policy and procedure review and staff interview, the facility failed to ensure a properly executed consent was documented prior to surgical procedure for Patients #36, #37, #38, #39, #41, #42, #43, #44, #45 and #47.



Findings include:


Cross Refer to A-466 for the facility's failure to ensure a properly executed surgical and anesthesia consent was documented for Patient #36, #38, #39 and #43.



Cross Refer to A-450 for the facility's failure to ensure surgical and anesthesia consents were properly executed for Patient #36, #37, #38, #39, #41, #42, #44, #45 and #47.
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Based on record review, document review, policy and procedure review and staff interview, the agency failed to provide post anesthesia assessments for Patients #1, #4, #12 and #16, four (4) of six (6) surgical patients reviewed.

Findings include:

Record review for Patients #1, #4, #12, and #16 revealed no documented evidence that the post anesthesia portion of these records was completed.

Review of the facility's "Post operative Guidelines of Care" policy revealed:
"1. Give patient's name, type of surgery, physical limitations, and pre-op level of consciousness.
2. Explain any problems arising during surgery.
3. Communicates necessary equipment needs.
4. Assure patient stability and safety before leaving the recovery room.
5. Documents patient condition on appropriate form."

In an interview on 3/04/14 at 2:00 p.m. the Quality Manager stated, "They feel like they are documenting it other places."

In exit conference on 3/05/14 at 12:00 noon no further documentation was presented.

Based on observation, staff interview and policy and procedure review, the facility failed to ensure the safety of rehabilitation (rehab) equipment by failing to monitor the temperature on two (2) of two (2) hydroculators in the rehabilitation center.

Findings include:

During a tour of the facility's rehab center at 9:30 a.m. on 3/05/14, it was observed there was no documentation of temperatures for two (2) of the two (2) hydroculators or hot pack warmers.

During an interview on 3/05/14 at 10:00 a.m., the managing Physical Therapist stated, "In 2011 Joint Commission told me we had to do this monitoring for a year, but did not have to do it anymore... I look at the temperature every time I use a hot pack."

Review of the facility's "Temperature Checks" policy, adopted on 05/2001, revealed, "All temperature modalities will be monitored and kept at the correct temperatures to prevent burns or injuries to patients."

On 3/05/14 at 11:00 a.m. the Physicial Therapist presented logs developed by the facility's Physical Therapy Department to begin fixing the problem.

These findings were discussed during exit conference on 3/05/14 at 12:00 p.m.