HospitalInspections.org

Based on document review, observation, and staff interview, the hospital administrative staff failed to secure all medical records against unauthorized access in 1 of 1 area used to house medical records prior to shredding. The hospital administrative staff identified an average of 10 inpatients per day.

Failure to secure all medical records against unauthorized access could potentially result in an unauthorized staff member obtaining a patient's confidential medical information, or obtaining a patient's personal information, which could allow identity theft.

Findings include:

1. Review of the policy "Security and Safeguarding of Health and Hospital Information", revised 9/09, revealed in part, "... medical records and other information medium will be maintained in secure and restricted areas with access limited to those [hospital] staff members who have a 'need-to-access'..."

2. Observations during an environmental tour on 10/26/11 at 9:30 AM revealed the following:

a. A central shredding storage area with 6 locked shredding receptacle bins. Hospital staff had piled 11 clear plastic trash bags of confidential records on top of the shredding receptacle bins. Further observations revealed the bags contained confidential medical records that included the patient's name, date of birth, and personal medical information. The central shredding storage area also contained a storage area for oxygen cylinders.

b. A large box in the Medical/Surgical Unit labeled "Shredding". Further observation of the box revealed numerous pages of patients' medical records that included the patient's name, date of birth, and personal medical information.

c. A box in the Critical Care Unit labeled "Shred". Further observation of the box revealed staff had filled it about half full with pages from the patients' medical records that included the patient's name, date of birth, and personal medical information.

3. During an interview at the time of the tour, the Director of Facilities Management stated the housekeeping staff collected the confidential medical records from the Medical/Surgical Unit and Critical Care Unit, placed the records in the plastic bags, and transported the bags to the central shredding storage area. The Director of Facilities Management stated the housekeeping staff did not need to know the information contained in the medical records to perform their job duties.

The Director of Facilities Management acknowledged the central shredding storage area contained the hospital's extra oxygen cylinders. The Director of Facilities Management stated the maintenance staff unlocked the central shredding storage area when the oxygen supplier arrived to replace the empty oxygen cylinders. However, the maintenance staff did not remain in the storage area while the oxygen supplier replaced the oxygen cylinders. The Director of Facilities Management acknowledged the oxygen supplier had access to the confidential information in the plastic trash bags, and stated the oxygen supplier did not need to know the information contained in the medical records to perform their job duties.

Based on review of Medical Staff Bylaws, medical records, and staff interviews, the facility staff failed to ensure physicians signed dated and timed their entries in the patients' medical record for 3 of 5 Emergency Room (ER) closed records (Patients #9, 10, and 11) The hospital administration identified 556 ER visits from October 1, 2010 to September 30, 2011.

Failure to document date and time could potentially interrupt the sequence of events and continuity of patient interventions or assessment.

Findings included:

1. Review of Medical Staff Bylaws dated June 2007 revealed: " ...3. All patient medical record entries must be legible, complete, dated, timed and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided... "

2. Review of the following Patient Medical Records showed the following:

a. Patient #9 admitted to ER with complaints of wrist and ankle pain. The ER medical record revealed a handwritten Physician Progress Note that lacked a signature, date and time that identified when and who entered the progress note.

b. Patient #10 admitted to ER with complaints of chest pain. The ER medical record revealed a handwritten Physician Progress Note that lacked a signature, date and time that identified when and who documented the progress note.

c. Patient #11 admitted to ER with complaints of a persistent cough. The ER medical record revealed a handwritten Physician Progress Note that lacked a signature, date and time that identified when and who documented the progress note.

3. During an interview on 10/26/11 at 9:15 AM, Staff C, Registered Nurse-ER Manager, confirmed the findings and stated the Physicians used this Physician Progress Note template to document their visit with the patient. Staff C stated, the Physicians do not sign the Physician Progress Note template, but they are supposed to put the date and time of the patient examination in the provided area. Staff C stated, the ER Physicians who document on the Physician progress note template do not sign, date, and/or time this documentation.

Based on policy review, observation, document review, and staff interview, the hospital's pharmaceutical administrative staff failed to ensure anesthesia staff documented the shortened expiration date after removing paralytic medications from refrigerated storage in 3 of 3 operating room suites. The hospital's operating room administrative staff identified an average of 98 surgeries per month.

Failure to document a shortened expiration date after removing paralytic medications from the refrigerator could potentially result in staff using ineffective medications for patient care.

Findings include:

1. Review of Pharmacy policy "Medication Security", reviewed 10/10, revealed in part "... All drugs and biologicals are stored in accordance with manufacturer's directions and accepted professional principles. Opened multi-use medication vials will be timed and dated with date vial is opened".

2. Observations, during a tour of the Operating Rooms, on 10/24/11 at 1:30 PM, revealed 3 locked anesthesia carts that each contained 1 vial of Succinylcholine and 1 vial of Cisatracurium. The vials lacked documentation of the time or date anesthesia staff initially removed the vials from the Pyxis medication refrigerator.

3. During an interview, at the time of the tour, the Director of Surgical Services stated anesthesia staff keeps the medications in the locked anesthesia carts until needed for use. The Director of Surgical Services stated that hospital policy instructed staff to date all paralytic medication multi-dose vials with the date of removal from the Pyxis refrigerator. The Director of Surgical Services acknowledged that anesthesia staff did not follow hospital policy.

4. Review of the manufacturer's directions for Succinylcholine, revised 5/04, revealed in part, "... vials are stable for up to 14 days at room temperature without significant loss of potency".

5. Review of the manufacturer's directions for Cisatracurium, revised 11/10, revealed in part, "Upon removal from refrigeration to room temperature storage conditions ... use [Cisatracurium] within 21 days, even if refrigerated".

6. During an interview on 10/25/11 at 3:55 PM, the Director of Pharmacy stated that the pharmacy policy requires anesthesia staff to date multi-dose vials of Succinylcholine and Cisatracurium if the vials are going to be stored in the anesthesia carts.

Based on review documents, observation and staff interviews, the nursing staff failed to test the defibrillators unplugged from the AC power to ensure the battery's functioning capabilities. Concerns identified with 5 of 7 defibrillators. The administrative staff identified an average daily census of 10.

Failure to test the defibrillators unplugged from the AC power could potentially result the battery of the defibrillator malfunctioning during an emergency causing a loss of time in providing immediate life saving emergency care.

Findings included:

1. Review of the "General Maintenance and Testing for Defibrillators/Monitors" revealed:

a. LifePak 20 Defibrillator/Monitor Operator's Checklist revealed in part, "...Inspection and testing of this defibrillator on a daily basis is recommended...6. Disconnect the defibrillator from AC power, wait 2 seconds, press ON..."

b. LifePak 20 Defibrillator/Monitor Operator's Checklist revealed in part, "...Inspection and testing of this defibrillator on a daily basis is recommended...5. With the Battery installed, disconnect the defibrillator from AC power...wait 2 seconds, press ON..."

c. A policy "Crash Cart Checks" reviewed on 4/10 lacked instruction to disconnect the defibrillator/monitor prior to the daily check.

2. Observations made during department tours revealed:

a. Tour of the Medical Surgical unit on 10/24/11 at 8:30 AM, with Staff F, Registered Nurse-Med/surgical manager, revealed a crash cart with the defibrillator plugged into an outlet in the wall. Review of the Crash cart log revealed a daily check of the defibrillator. Staff F stated the nursing staff checked the defibrillator while plugged into the electrical outlet in the wall. Staff F stated, "We [nursing staff] don't check it [defibrillator] to make sure the battery is functioning, I guess we should."

b. A tour of the Critical Care Unit on 10/24/11 at 8:55 AM, with Staff F, revealed a crash cart with the defibrillator plugged into an outlet in the wall. Review of the Crash cart log revealed a daily check of the defibrillator. Staff F, Registered Nurse, stated the nursing staff checked the defibrillator while plugged into the electrical outlet in the wall. Staff F stated, "We [nursing staff] will start to check it [defibrillator] unplugged to make sure the battery is functioning correctly."

c. Tour of the Surgical Recovery Department on 10/24/11 at 1:30 PM, with Staff E, Registered Nurse, revealed a crash cart with the defibrillator plugged into an outlet in the wall. Review of the Crash cart log revealed a daily check of the defibrillator. Staff E stated the nursing staff checked the defibrillator while plugged into the electrical outlet in the wall. Staff E stated, "I guess it [defibrillator] should be checked with the battery to make sure th battery is charged and working."

d. Tour of the Emergency Department on 10/26/11 at 10:30, Staff D stated the nursing staff were told the defibrillator did not have to be unplugged during the daily check. Staff D acknowledged the nursing staff did not unplug the defibrillator to assure the battery is charged and working.

e. During a tour of the Obstretical Department (OB) on 10/26/11 at 10:00 AM, Staff A, Registered Nurse, stated the nursing staff checked the LifePak 20 defibrillator daily. Staff A confirmed the nursing staff did not unplug the defibrillator when doing the daily check.

3. During an interview on 10/25/11 at 2:00 PM, Staff B, BioMed technician, provided the "General Maintenance and Testing for Defibrillators/Monitors" document and stated he checked the battery function twice a year. Staff B acknowledged the manufacture recommended staff check the Defibrillators/Monitors daily, unplugged to ensure the battery is charged and functioning correctly. Staff B stated the hospital utilized 7 Defibrillators and was unaware how the department staff checked the defibrillators.

Based on review of Medical Staff Rules and Regulations, policy/procedures, open/ closed surgical records, and staff interview, the hospital administration failed to ensure that qualified staff completed and documented a pre-anesthesia evaluation of surgical patients in 2 of 2 open surgical records (Patients #1 and 2) and 6 of 6 closed surgical records (Patients #3, 4, 5, 6, 7, and 8). The Director of Surgical Services identified an average of 98 surgeries per month.

Failure to ensure qualified staff complete and document preanesthesia evaluations has the potential to put surgical patients at risk for anesthesia complications or death during surgical procedures.

Findings included:

1. Review of Medical Staff Rules and Regulations, dated June 2007, revealed the following:

"3. ...All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided...".

"20. Pre-operative and post-operative visits shall be recorded on all surgery patients".

2. Review of hospital policy "Anesthesia documentation" reviewed 10/10, revealed "... The preoperative anesthesia documentation will include: Anesthesia evaluation, to be performed within 48 hours prior to surgery".

3. Review of hospital policy "Certified Registered Nurse Anesthetists (CRNA) qualifications and responsibilities" reviewed 10/06, revealed "... Responsibilities of the CRNA included: 1. Preoperative, intra-operative, and post-operative anesthesia assessment and documentation".

4. Review of Patient #1's open medical record showed a surgery date of 10/23/11 for a tubal ligation. The patient's medical record lacked evidence of a timed preoperative evaluation.

5. Review of Patient #2's open medical record showed a surgery date of 10/22/11 for a C-Section. The patient's medical record lacked evidence of a dated and timed preoperative evaluation

6. Review of Patient #3's closed medical record showed a surgery date of 8/31/11 for a reversal of a colostomy. The patient's medical record lacked evidence of a dated and timed preoperative evaluation.

7. Review of Patient #4's closed medical record showed a surgery date of 9/6/11 for a left total knee arthroplasty. The patient's medical record lacked evidence of a dated and timed preoperative evaluation.

8. Review of Patient #5's closed medical record showed a surgery date of 9/16/11 for a repeat C-Section. The patient's medical record lacked evidence of a dated and timed preoperative evaluation.

9. Review of Patient #6's closed medical record showed a surgery date of 10/4/11 for a C-Section. The patient's medical record lacked evidence of a dated and timed preoperative evaluation.

10. Review of Patient #7's closed medical record showed a surgery date of 10/16/11 for repair of a fractured left femur. The patient's medical record lacked evidence of a dated and timed preoperative evaluation.

11. Review of Patient #8's closed medical record showed a surgery date of 10/17/11 for a cystoscopy under anesthesia. The patient's medical record lacked evidence of a dated and timed preoperative evaluation.

12. During an interview on 10/26/11 at 1:10 PM, Staff G, the Vice President of Inpatient Services, confirmed the open and closed surgical records for Patients #1, 2, 3, 4, 5, 6, and 7 lacked evidence of a completed preoperative anesthesia evaluation (including date and time). Staff G indicated that the CRNA's are responsible for completion and documentation of the preoperative anesthesia evaluation.

Based on review of Medical Staff Rules and Regulations, policy/procedures, open/ closed surgical record, and staff interview, the hospital administration failed to ensure that qualified staff completed and documented a post-anesthesia evaluation of surgical patients in 1 of 2 open surgical records (Patient #1) and 3 of 6 closed surgical records (Patients #3, 4, and 7). The Director of Surgical Services identified an average of 98 surgeries per month.

Failure to ensure qualified staff completed and documented post anesthesia evaluations could result in an inability to ascertain if complications occurred during post-anesthesia recovery.

Findings included:

1. Review of the Medical Staff Rules and Regulations, dated June 2007, revealed the following:

"3. ...All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided...".

"20. Pre-operative and post-operative visits shall be recorded on all surgery patients".

2. Review of hospital policy "Anesthesia documentation", reviewed 10/10, revealed "...With respect to inpatients, a postanesthesia follow-up report will be written for each patient within 48 hours after surgery containing the items specified above".

3. Review of hospital policy "Certified Registered Nurse Anesthetists (CRNA) qualifications and responsibilities", reviewed 10/06, revealed "Responsibilities of the CRNA include: 1. Pre-operative, intra-operative, and post-operative anesthesia assessment and documentation...".

4. Review of Patient #1's open medical record showed a surgery date of 10/23/11 for a tubal ligation. The patient's medical record lacked evidence of a timed post-operative evaluation.

5. Review of Patient #3's closed medical record showed a surgery date of 831/1 for a reversal of a colostomy. The patient's medical record lacked evidence of a post-operative evaluation.

6. Review of Patient #4's closed medical record showed a surgery date of 9/6/11 for a left total knee arthroplasty. The patient's medical record lacked evidence of a dated and timed post-operative evaluation.

7. Review of Patient #7's closed medical record showed a surgery date of 10/16/11 for repair of a fractured left femur. The patient's medical record lacked evidence of a dated and timed post-operative evaluation.

8. During an interview on 10/26/11 at 1:10 PM, Staff G, the Vice President of Inpatient Services, confirmed the open and closed surgical records for Patients #1, 3, 4, and 7 lacked evidence of a completed post-operative anesthesia evaluation (including date and time). Staff G indicated that the CRNA's are responsible for completion and documentation of the post-operative anesthesia evaluation.