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Based on policy and procedure, record review and staff interview it was determined in 1 of 2 (Pt. #3) surgical obstetric clinical records reviewed the Hospital failed to ensure patient rights policies were followed.
Findings include:

1. The policy dated 4/8/13, titled "Consent or Authorization for Surgical Treatment, Diagnostic and/or Therapeutic Procedure" was reviewed on 6/19/13. Under "VI. DOCUMENTATION 1.0 The consent form signed by the patient/agent and practitioner, and witnessed by the nursing staff... is placed in the medical record prior to surgery/procedure..."

2. The medical record of Pt. #3 was reviewed on 6/19/13. Documentation indicated Pt. #3 was admitted to the Obstetrics unit on 6/17/13 for a scheduled Caesarean Section. Documentation on "CONSENT TO OPERATION OR OTHER MEDICAL PROCEDURES" indicated the Practitioner failed to sign, date, and time that risks/benefits/alternatives of the procedure were explained to the patient and questions were answered.

3. During an interview with the Accreditation Compliance Coordinator on 6/19/13 at 10:30 AM, the Coordinator confirmed there was no Practitioner signature to verify the risks/benefits/alternatives of the procedure were explained to the patient and questions were answered.

Based on review of Hospital policy, observation and staff interview it was determined in 1 of 1 (Pt. #19) incarcerated patients observed, the Hospital failed to follow their policy related to incarcerated patients potentially affecting the safety of patients and staff.
Findings include:

1. Policy # SY-AD-022 Title "Prisoners" First created 8/15/12 was reviewed on 6/19/13. Documentation indicated under, Page 2 "V. Procedure 3.4 Prisoners are placed in a private room, if placed in a patient care unit. A. The door to the incarcerated patient's room remains closed."

2. During a tour of the ICU unit on 6/17/2013 at 2 PM, it was observed the door to Pt. #19's room was open. Pt. #19 was identified as an incarcerated patient. During the tour, the Accreditation Compliance Coordinator confirmed the door should have been closed. During a subsequent tour of the ICU unit on 6/19/13 at 2 PM, it was observed that Pt. #19's door remained open.

3. During staff interview conducted on 6/19/2013 at 2:30 PM, it was confirmed with the Accreditation Compliance Coordinator the door should have been closed.

Based on review of Hospital Policy and Procedure, record review and staff interview it was determined in 5 of 30 (Pt #11, Pt #14, Pt #18, Pt #29, Pt #30) records reviewed, the Hospital failed to ensure all verbal and/or telephone orders were signed within 72 hours after orders were given.
Findings include:

1. A review of Hospital policy titled "Medical Record Completion" last revised 03/21/13, was reviewed on 06/18/13. Under "Appendix A: Verbal/Telephone Order", it indicated "Dated/Timed/Signed within 72 hours after order given."

2. The medical record of Pt #11 was reviewed on 06/18/13 at 11:30 AM. It indicated Pt #11 was admitted on 04/19/13 with a diagnosis of Cardiac Arrest. Documentation on the Physician Orders sheet indicated telephone orders were given on 04/20/13 at 0219 and signed electronically by the Physician on 05/03/13, more than 72 hours after being given.

3. The medical record of Pt #14 was reviewed on 06/18/13. It indicated Pt #14 was admitted on 03/16/13 with a diagnosis of Cardiopulmonary Arrest. Documentation on the Physician Orders sheet indicated a telephone order was given on 03/16/13 at 1435 and signed electronically by the Physician on 03/28/13, more than 72 hours after being given.

4. The medical record of Pt #18 was reviewed on 06/18/13. It indicated Pt #18 was admitted on 05/30/13 with a diagnosis of Acute Hypoxic Hypercarbic Respiratory Failure. Documentation on the Telephone Orders sheet indicated telephone orders were given on 6/2/13 at 0455, 6/4/13 at 0545, and 6/11/13 at 1240. None of the telephone orders were signed electronically within 72 hours of being given.

5. The medical record of Pt #29 was reviewed on 06/20/13. It indicated Pt #29 was admitted on 05/03/13 with diagnoses of Congestive Heart Failure and Chronic Obstructive Pulmonary Disease and discharged on 05/15/13. Documentation on the Physician Orders sheet indicated a telephone order was given on 05/03/13 and signed electronically by the Physician on 05/14/13, more than 72 hours after being given.

6. The medical record of Pt #30 was reviewed on 06/20/13. It indicated Pt #30 was admitted on 06/04/13 with diagnoses of Sepsis, Dehydration and discharged on 06/05/13. Documentation on the Physician Orders sheet indicated a telephone order was given on 06/05/13 and signed electronically by the Physician on 06/10/13, more than 72 hours after being given.

7. During an interview with the Patients Relations Manager on 06/18/13 at 1:00 PM, it was confirmed the telephone orders were not signed by the Physician within 72 hours of being given and the Hospital policy required orders be signed within 72 hours of being given.

Based on review of Hospital Policy and Procedure, record review and staff interview it was determined in 3 of 30 (Pt #11, Pt #14, Pt #29) records reviewed, the Hospital failed to ensure all Discharge Summaries were completed per policy.
Findings include:

1. A review of Hospital policy titled "Medical Record Completion" last revised 03/21/13, was reviewed on 06/18/13. Under "Appendix A: Discharge Summary, Completion Timeframe" it indicated "Dictated/Handwritten within 10 days following inpatient discharge."

2. The medical record of Pt #11 was reviewed on 06/17/13. It indicated Pt #11 was admitted on 04/19/13 with a diagnosis of Cardiac Arrest and expired on 04/26/13. Documentation on the Discharge Summary indicated it was dictated on 05/17/13 and authenticated by the Physician on 05/18/13, more than 10 days following discharge.

3. The medical record of Pt # #14 was reviewed on 06/17/13. It indicated Pt #14 was admitted on 03/16/13 with a diagnosis of Cardiopulmonary Arrest and expired on 03/17/13. Documentation on the Discharge Summary indicated it was dictated on 04/12/13 and authenticated by the Physician on 04/23/13, more than 10 days following discharge.

4. The medical record of Pt #29 was reviewed on 06/20/13. It indicated Pt #29 was admitted on 05/03/13 with diagnoses of Congestive Heart Failure and Chronic Obstructive Pulmonary Disease and discharged on 05/5/13. Documentation on the Discharge Summary indicated it was dictated on 05/22/13 and authenticated by the Physician on 05/28/13, more than 10 days following discharge.

5. During an interview with the Patient Relations Manager on 06/18/13 at 1:00 PM, it was confirmed that all Discharge Summaries need to be completed within 10 days following inpatient discharge.

A. Based on Hospital policy, observation and staff interview, it was determined that the Hospital failed to ensure the Dietary Supervisor managed Dietary Services according to their policies to ensure the quality and safety of food storage and prevention of food borne illnesses. This has the potential to affect 100% of the patients served by the dietary department.
Findings include:

1. The Hospital policy titled, "Infection Control, Applies to: Food and Nutrition Services," last revised 06/23/2010, was reviewed on 06/18/13. Under 11., it indicates "Foods taken out of the original container or case will be labeled with a date and time. Frozen foods will be used within 6 months of that date and refrigerated items will be used within 7 days or discarded."

2. During a tour of the Dietary Department on 06/17/13 at 12:15 PM, it was observed, in the Food Freezer, 7 containers of unidentified food that did not contain labels identifying the food, date the food was opened, or a use by date.

3. During an interview with the Food and Services Manager on 06/17/13, at 09:00 AM, it was confirmed that all food stored in the Dietary Department freezer should have been labeled with a date that the food was opened and used by date.

B. Based on policy and procedure, observation and staff interview it was determined the Hospital failed to ensure expired food/drink was not available for patient usage, potentially affecting 100% of the patients on the obstetric unit.
Findings include:

1. The Hospital policy dated 6/23/10, titled "Infection Control" was reviewed on 6/18/13. Documentation indicated under "I. POLICY The proper purchasing, storage, handling service and disposal of foods is essential...foods free from contaminations and infections."

2. During a tour of the Post Partum unit on 6/17/13 at 2:25 PM, it was observed in the patient nourishment refrigerator, one carton of whole milk had expired 6/14/13. During a tour of the Labor and Delivery on 6/17/13 at 2:55 PM, it was observed in the patient nourishment refrigerator, two cartons of chocolate milk had expired 6/16/13.

3. During an interview with the Charge Nurse on 6/17/13 at 2:30 PM, the Charge Nurse confirmed the milk was expired and should have been discarded.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Medicare Sample Validation Survey conducted on June 17 - 19, 2013, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Medicare Sample Validation Survey conducted on June 17 - 19, 2013, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated June 19, 2013.

Based on observation and staff interview it was determined the hospital failed to ensure all sterile supplies used in radiological patient procedures are maintained in a sterile manner. This has the potential to affect 100% of all patients receiving radiological procedures.

1. A tour of the Radiology Department was conducted on 6/18/2013 2:30 PM. In the CT Procedure room three 60" T Connector and Prime Tubes were observed to be removed from sterile kits and laying in the supply cart and available for use in patient procedures.

2. During a staff interview on 6/18/2013 at 2:30 PM the radiology technician verbalized that if a syringe is needed from a kit then the sterile kit is opened and the remaining capped tubing is saved and used when needed for sterile procedures.

3. During a staff interview on 6/20/2013 at 08:30 AM with the Interim Manager of Radiology this surveyor was informed of the decision to order individual sterile packaged 60" Connector and Prime Tubing and that he was conducting staff education regarding the change. The Interim Manager confirmed that staff should not be saving and using the tubing from sterile kits for sterile procedures.