HospitalInspections.org

Based on record review it was determined that the governing board had not reviewed and approved the medical staff bylaws.

Findings include:

A review of the medical staff bylaws was completed on 8/1/2013. There was no documented evidence that the governing board had approved the bylaws.

A review of the last two years of governing board meeting minutes was completed on 8/1/2013. There was no documentation in the minutes that the bylaws had been approved.

Based on record review it was found that 5 of 26 patient charts did not have a medical history and physical (H&P) examination within 30 days prior to, or within 24 hours after admission or registration. (Pt. identifiers; 18,23,25,26,28)

Findings included:

1. A total of 5 Medical Records of 26 reviewed did not meet the 30 day time frame for completion.

a. On review of the medical records, 3 of 26 did not have an H&P. (Patient identifiers; 18,26 and 28)

b. On review of the medical records, 2 of 26 charts had physicals that were done outside of the required time frames. The first patient was admitted 9/30/09 and the H&P was done on 7/30/09. The second patient was admitted on 1/5/12 and the H&P was done 2/8/13. (Patient identifiers; 23 and 25)

Based on observation and interview it was determined that the facility was not monitoring temperature and humidity in 2 of 2 operating rooms.

Findings include:

A tour of the 2 operating rooms was completed on 8/1/2013. There were no devices for monitoring temperature and humidity visible in the operative areas.

A telephone interview was held with the nurse that was responsible for the operating rooms. She stated that they did not monitor temperature and humidity in the operating rooms or the core.

Based on record review and interview it was found that the Hospital did not have an ongoing system for identifying, reporting, investigating and controlling infections and communicable diseases of surgical patients.

Findings included:

1. Review of documentation provided by the Infection Control Officer (ICO) showed there were no infections documented for post operative wounds.

2. An interview was done on 08/02/13 with the ICO. She stated that no followup was conducted regarding post operative wound infections. The only time post operative infections were identified was if a patient presented to the emergency room with an infection but nothing was documented or tracked.

Based on record review it was found that 2 of 5 surgical charts did not meet the requirement for a medical history and physical examination within 30 days before or 24 hours after admission or registration. Patient identifier 6 and 7.

Findings include:

A review of 5 surgical medical records was completed on 8/1/2013. In two of the 5 medical records, there was no history and physical present in the record which is required to be on the chart prior to a surgical procedure.

Based on review of the operating room log it was found that the log lacked 3 of the 10 required elements.

Findings included:

A review of the operating room log was completed on 7/31/2013. It was found that the log was missing the documentation for the age of the patient, the patient's hospital identification number and pre and post operative diagnosis.