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Based on record review and interview the hospital failed to follow its policy and procedure for
authentication of entries into the medical record as evidenced by failure of the physicians to date and time orders for 5 of 18 medical records reviewed for orders out of a total sample of 20 medical records (#1, #4, #7, #8, #17). Findings:


Patient #1
Review of the medical record for Patient #1 revealed a 23 year old female admitted to the hospital on 11/21/11 for a Laproscopic Tubal Ligation under general anesthesia.. Review of the Admit Orders for Patient #1 dated 11/17/11 revealed no documented time the orders were written. Review of the Admit Orders to the PACU (Post Anesthesia Care Unit) for Patient #1 revealed no documented time the orders were written.

Patient #4
Review of the medical record for Patient #4 revealed a 27 year old female admitted to the hospital on 11/17/11 for Laproscopic Tubal Ligation under general anesthesia. Review of the Admit Orders to the PACU (Post Anesthesia Care Unit) for Patient #4 revealed no documented time the orders were written.

Patient #7
Review of the medical record for Patient #7 revealed a 23 year old female admitted to the hospital on 11/18/11 for a correction of a hallux limitus with cheilectomy and tendon lengthening of the left foot under general anesthesia. Review of the Admit Orders for Patient #7 revealed no documented date or the time the orders were written.

Patient #8
Review of the medical record for Patient #8 revealed a 16 year old female admitted to the hospital on 11/19/11 for an excision and drainage of an auricular cyst under general anesthesia. Review of the Admit Orders for Patient #8 revealed no documented time the orders were written

Patient #17
Review of the medical record for Patient #17 revealed a 45 year old male admitted to the hosptial on 09/27/11for a Rhizotomy of L3, L4 and L5. Review of the Anesthesia Orders dated 09/27/11 revealed no documented time the orders were written.

In a face to face interview on 02/07/12 at 3:30pm S1 CEO (Chief Operating Officer) indicated
the hospital had a change in physician staff since September 2011. Further S1 indicated the hospital was aware of the non-compliance in authentication of orders; however higher priority problems were addressed first.

Review of Policy No. IM-190 titled "Medical record Creation/Content and Distribution" and submitted as the one currently in use revealed..... "C. Proper Authentication: All clinical entries shall be accurately dated, times and authenticated by written signature or identifiable initials and professional title or initials indicating the professional title".

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Based on record review and interview the hospital failed to ensure all medical records of patients having a surgical procedure contained the original handwritten history & physical provided by the surgeon on the day of surgery for 10 of 18 medical records reviewed for History & Physicals prior to surgery (#1, #2, #5, #6, #7, #8, #9, #13, #16, #20) out of a total of 20 sampled patients. Findings:

Patient #1
Review of the medical record for Patient #1 revealed a 23 year old female admitted to the hospital on 11/21/11 for a Laproscopic Tubal Ligation under general anesthesia.. Review of the entire medical record revealed no documented evidence a History & Physical was completed and filed on the chart prior to the surgical procedure. Review of the Admit Record dated 11/21/11 revealed RN S15 circled "yes" in the space provided in the section titled History & Physical". Further documentation in the space revealed the word "dictated".

Patient #2
Review of the patient's record revealed the patient had a Laser Conization of the Cervix with general anesthesia as an outpatient on 01/25/12. Review of the History and Physical Report revealed that the report was dictated on 01/12/12. The form revealed the physician's signature with the date of 01/25/12 and 0645 (6:45 a.m.) hand written on the form. There was no documented evidence of an updated exam by the physician prior to surgery.

Patient #5
Review of the patient's record revealed the patient had a Hysteroscopy with a D&C (Dilation and Curettage) with general anesthesia as an outpatient on 11/29/11. Review of the record revealed no documented evidence of a History and Physical.

Patient #6
Review of the patient's record revealed the patient had a Right Bunionectomy with general anesthesia as an outpatient on 01/06/12. Review of the record revealed a hand written history documented by the physician on 01/05/12. The section of the form entitled, Physical Examination, was left blank. There was no documented evidence in the record of a Physical Examination of the patient prior to the surgery.

Patient #7
Review of the medical record for Patient #7 revealed a 23 year old female admitted to the hospital on 11/18/11 for a correction of a hallux limitus with cheilectomy and tendon lengthening of the left foot under general anesthesia. Review of the Outpatient Surgery History & Physical form dated 11/18/11 for Patient #7 revealed no documented evidence a physical examination
was performed prior to surgery. Further review revealed the section of the form titled "Physical Examination" was left blank.

Patient #8
Review of the medical record for Patient #8 revealed a 16 year old female admitted to the hospital on 11/19/11 for an excision and drainage of an auricular cyst under general anesthesia. Review of the Outpatient History & Physical form for Patient #8 revealed an incomplete physical was performed which failed to include the required assessment of vital signs. Further review of the form revealed no documented date the physical was performed.

Patient #9
Review of the patient's record revealed the patient was a 57 year old male that had a Resection of the Metatarsal Head of the right first toe with general anesthesia as an outpatient on 10/21/11. Review of the record revealed a progress note from the physician's office dated 10/18/11. The progress note revealed only a physical exam of the patient's feet. There was no documented evidence of an updated physical exam prior to the survey.

Patient #13
Review of the patient's record revealed the patient was a 56 year old female that had a Right Shoulder Arthroscopy with a Rotator Cuff Repair general anesthesia on 10/28/11. Review of the record revealed an office visit note from the physician dated 10/12/11. Review of the record also revealed a Preoperative History & Physical, dictated on 10/31/11. Review of the Admit Record documented by the RN revealed yes was circled indicating the history and physical was present on the record. Review of the record revealed no documented evidence of an updated physical exam done prior to surgery.

Patient #16
Review of the patient's record revealed that the patient was a 68 year old male who had been admitted on 11/02/11 and again on 12/14/11 for cataract surgery on each eye. Review of the record revealed a Phacoemulsification of cataract with a lens implant of the right eye was done on 11/02/11, and the left eye was performed on 12/14/11. Review of the Anesthesia Records revealed the patient received regional anesthesia for the right eye procedure, and Monitored Anesthesia Care (MAC) for the left eye procedure.

Review of the record revealed that a Preoperative Medical Consultation Request was documented on 02/24/11 and 11/18/11. The record also revealed a History & Physical Addendum form on the record of the admit on 11/02/11. This form was left blank.

There was no documented evidence on the patient's record of an updated physical exam prior to the surgery for either procedure.

Patient #20
Review of the medical record for Patient #20 revealed a 46 year old male admitted to the hospital on 09/30/11 for a repair of a rotator cuff under general anesthesia. Review of the dictated Pre-Operative History & Physical for Patient #20 revealed it was dictated on 10/31/11 and transcribed 10/31/11 which was 30 days after the surgery was performed.

Review of 3 medical records for patients waiting in the holding area by the survey team revealed all three medical records contained handwritten physicals in the medical record. Review of the Admit Record dated 11/21/11 for Patient #20 revealed RN S15 circled "yes" in the space provided in the section titled History & Physical".

In a face to face interview on 02/07/11 at 1:40pm RN S9 Director of Nurses (after review of the medical records with missing history and physicals) indicated she was the pre-op nurse on several of the patients and she would not have circled yes on the Admit form if the H&P would not have been on the chart. Further S9 indicated it is common practice for the physicians to bring in either a handwritten or typed H&P from his/her office. S9 indicated she did not know what happened to the H&P after the chart left the Post Anesthesia when the patients were discharged.

In a face to face interview on 02/07/11 at 4:00pm S13 Director of Medical Records indicated he did not know what happened to the handwritten history and physicals. Further S13 indicated the only ones he receives are the one dictated in-house by the physicians.

Review of the Medical Staff Rules and Regulations submitted as the ones currently in use revealed.... "D. Medical Records: 4. Medical History and Comprehensive Physical b. Except in an extreme emergencies, an appropriate history and physical examination and the pre-operative diagnosis shall be recorded in the medical record prior to the performance of the surgery".

Review of the hospital's policy and procedure entitled Preoperative Requirements, revealed the following:
5. History and Physical (H & P)
1. The H&P must be dictated and a hard copy must be placed in the patient's medical record prior to sending the patient to the operating room.
2. If a H&P has been completed within 30 days prior to an elective surgical procedure or elective admission, it may be used in lieu of a new H&P provided that a note is documented in the patient's chart to the effect that:
a. The previous H&P is still current.
b. The patient has been assessed within the previous 7 days and the proposed plan of care continues to be necessary.
c. The patient's condition has not changed since the original H&P was completed.

Based on record review and interview, the hospital failed ensure the effective implementation of accountability procedures relating to the control and disposition of narcotics resulting in the hospital's inability to identify narcotic diversion in a timely manner. Findings:

Review of DEA Form 106, completed by the hospital's contracted pharmacist (S16) on 1/23/12, revealed the following controlled substances were lost or stolen:
-Clonazepam: Sixteen (16) 0.5mg tablets.
-Hydrocodone-APAP 10-500: Nine (9) tablets.
-Demerol 50mg/ml: Twelve (12) ampuls.
-Meperidine 25mg/ml: Fifty-two (52) vials.
-Morphine 8mg/ml: Nineteen (19) milliliters.

In an interview on 2/06/12 at 1:50 p.m., the contracted pharmacist (S16) confirmed that the above documented controlled substances were lost or stolen. S16 indicated that a registered nurse (S15) had self-reported the narcotic diversion to the hospital's Director of Nursing (S9) on 1/23/12 during an internal investigation relating to a patient's missing home medications of Clonazepam. S16 indicated that an internal investigation is in process relating to the extent of the narcotic diversion by S15. S16 indicated that the Director of Nursing (S9) and the Quality Director (S14) were conducting the internal investigation.

In an interview on 2/06/12 at 2:00 p.m., the Quality Director (S14) confirmed that an internal investigation is in process relating to the specifics of S15's diversion of narcotics.

In an interview on 2/06/12 at 2:10 p.m., the Director of Nursing (S9) confirmed S15 had self-reported on 1/23/12 that she had been diverting narcotics. S9 indicated that S15 informed her that she had been taking the narcotics after going into the Pyxis machine under a patient name and documenting the removal of the narcotics under the patient's name making it appear as though she (S15) was removing the narcotics to administer to the patient. S9 indicated that S15 primarily worked on the pre-operative unit of the hospital but would remove the narcotics from the Pyxis machine on the inpatient unit. When asked about specific details relating to the patient's who S15 involved in this narcotic diversion in an effort to determine if S15's narcotic diversion resulted in patients experiencing unnecessary pain due to withholding ordered pain medication, S9 indicated that an internal investigation was currently in process regarding the specific details relating to the patients.

Review of Pyxis reports for four (4) randomly selected days in January of 2012 (1/09/12, 1/10/12, 1/11/12, 1/12/12) and review of the medical records of the patients identified on the Pyxis reports revealed the following inconsistencies in regards to S15's withdrawal of narcotics from the Pyxis unit:

-For the date of 1/09/12
Documentation on the Pyxis report revealed S15 removed Four (4) One (1) ml vials of Meperidine HCL 25mg/1ml for Patient #R1. Review of the medical record of Patient #R1 revealed that Meperidine was not even ordered for Patient #R1. Further review revealed no documentation to indicate that Meperidine was administered to Patient #R1.
Documentation on the Pyxis report revealed S15 removed Four (4) One (1) ml vials of Meperidine HCL 25mg/1ml for Patient #R2. Review of hospital documentation revealed that Patient #R2 did not receive any services in the hospital on 1/09/12 and was not a patient in the hospital on 1/09/12 as his scheduled surgery was canceled.

-For the date of 1/10/12
Documentation on the Pyxis report revealed S15 removed Two (2) One (1) ml vials of Meperidine HCL 50mg/1ml for Patient #R3. Review of the medical record of Patient #R3 revealed that Meperidine was not even ordered for Patient #R3. Further review revealed no documentation to indicate that Meperidine was administered to Patient #R3.

-For the date of 1/12/12
Documentation on the Pyxis report revealed S15 removed Two (2) One (1) ml vials of Meperidine HCL 50mg/1ml for Patient #R5 at 10:18 a.m. and Two (2) additional One (1) ml vials at 11:35 a.m. for a total of Four (4) 50mg/1ml vials. Review of Patient #R5 revealed that Meperidine was not even ordered for Patient #R5. Further review revealed no documentation to indicate that Meperidine was administered to Patient #R5.

In an interview on 2/06/12 between 2:10 p.m. and 2:30 p.m., the contracted pharmacist (S16) and the Director of Nursing (S9) confirmed that the hospital should have implemented better accountability procedures relating to the control and disposition of narcotics in the hospital. Both confirmed that narcotics being withdrawn from the inpatient unit Pyxis machine by a nurse assigned to the pre-operative unit for patients who were either not in the hospital or who did not have orders for the narcotics that were withdrawn from the Pyxis machine should have alerted pharmacy administration and nursing administration of a problem.

Based on record review and interview, the hospital failed to implement a system that ensures all medication orders (except in emergency situations) are reviewed for appropriateness by a pharmacist before the first dose is dispensed. This resulted in there being no pharmacist review for the therapeutic appropriateness of a patient's medication regimen; duplication in the patient's medication regimen; appropriateness of the drug, dose, frequency, route and method of administration; real or potential medication-medication, medication-food, medication-laboratory test and medication-disease interactions; real or potential allergies or sensitivities; variation from organizational criteria for use; and/or other contraindications prior to first dose administration to patients. Findings:

Review of the hospital's process for ordering, reviewing, and administering medications revealed no evidence to indicate that medication orders are reviewed by a pharmacist before the first dose is dispensed.

The hospital's contracted pharmacist (S16) was interviewed on 2/06/12 at 1:50 p.m. S16 reported there is a pharmacist on site on Monday, Wednesday, and Friday from 8:00 a.m. till 12:00 noon and indicated that medication orders are reviewed by a pharmacist during these hours. When asked if medication orders are reviewed for appropriateness by a pharmacist before the first dose is dispensed, S16 indicated that medication orders are not routinely reviewed by a pharmacist before the first dose is dispensed. S16 indicated that the hospital has not implemented a system to ensure a pharmacist review for the therapeutic appropriateness of a patient's medication regimen prior to first dose administration to patients.

Based on observation and interview, the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by:

1. Failing to ensure the functionality of a call button labeled "Nurse Call" located on the handrails of the beds on the inpatient unit. Findings:

Observations were made on the inpatient unit of the hospital on 2/06/12 between 10:00 a.m. and 10:30 a.m. A button labeled "Nurse Call" was noted to be on the handrail of the beds on 10 of 10 inpatient beds. The button was noted to be non- functional as it failed to activate any type of nurse call system.

The Unit Charge Nurse (S2) was interviewed at the time of this observation. S2 confirmed that the button labeled "Nurse Call" located on the handrails of the inpatient beds was not functioning when pressed. S2 indicated that the hospital does have a nurse call system which includes a cord with a button and reported that patients are instructed to use this call system. When asked if it would be possible for a patient who may be sedated and/or confused to press the button on the handrail of the bed labeled "Nurse Call" thinking they are calling for assistance without the nursing staffs knowledge due to the call button not working, S2 indicated yes that would be possible.


2. Failing to ensure the handrails were free of tape (including sections of sticky residue from tape) resulting in the inability to have a smooth wipable surface for disinfection. Findings:

Observations were made on the inpatient unit of the hospital on 2/06/12 between 10:00 a.m. and 10:30 a.m. Tape (including sections of sticky residue from tape) were noted on the handrails of 4 of 10 inpatient beds ( 2 beds in Patient Room #103, 1 bed in Patient Room #104, and 1 bed in Patient Room #106) observed resulting in the inability to have a smooth wipable surface to ensure for disinfection.

The Unit Charge Nurse (S2) was interviewed at the time of this observation. S2 confirmed the presence of tape and the presence of the sticky residue on the inpatient beds in Patient Room #103, Patient Room #104, and Patient Room #106. S2 indicated that nursing staff have been instructed not to put tape on the handrails of the beds.

Based on record review and interview the hospital failed to ensure all patients administered anesthesia received a post-anesthesia evaluation within 48 hours after surgery which included assessment of respiratory function, cardiovascular function, mental status, temperature, pain, presence of nausea and vomiting and post-op hydration according to the current standards of anesthesia care for 17 of 17 patients having medical procedures involving anesthesia (#1, #2, #3, #4, #5, #6, #7, #9, #11, #12, #13, #14, #15, #16, #17, #20) out of a total of 20 sampled medical records. Findings:

Review of the Anesthesia Record used by the anesthesiologist or his/her designee revealed a section titled "Postoperative" which included a space for the date, time, and other. Further review revealed a check box next to the following: no apparent anesthetic complication by patient or surgeon; day surgery patient released without apparent complications; discharge of patient by surgeon without apparent complications; complications/comments; cardiopulmonary status; level of consciousness; follow-up care/observations; and signature.

Review of the Anesthesia Record of Patients #1, #2, #3, #4, #5, #6, #7, #9, #11, #12, #13, #14, #15, #16, #17 and #20 revealed a check was made in the box next to the statement indicating "no apparent anesthetic complication by patient or surgeon". Further review of all of the medical records revealed no documented evidence an assessment of respiratory function, cardiovascular function, mental status, temperature, pain, presence of nausea and vomiting and post-op hydration was performed.

Review of the Medical Staff Rules and Regulations submitted as the ones currently in use revealed.... " F. General Conduct of Surgical Care: 4. Anesthesia: The Anesthesiologist or the anesthetist shall maintain a complete anesthesia record to include evidence of pre-anesthesia evaluation and post-anaesthetic follow-up of the patient's condition". Further review of the Medical Staff Rules and Regulations revealed no documented evidence

In a face to face interview on 02/07/12 at 3:45pm S19 Chief of Anesthesia indicated he was newly contracted for anesthesia services to the hospital and had no input into the development of the current Medical Staff Rules and Regulations or forms. Further S19 indicated he was aware of the the requirements of the post-anesthesia evaluations because he (S19) practices in other facilities). S19 indicated changes would be made to meet the requirements.



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