HospitalInspections.org

Based on MR review and interview with staff, in 4 of 11 MR reviewed of Medicare beneficiaries admissions (Pt. # 9, 10, 21, and 23) out of a total of 32 MR reviewed, the facility failed to ensure that each Medicare beneficiary is informed of his/her right to appeal discharge from the facility according to the guidelines set by the Center for Medicare and Medicaid.

Findings include:

In an interview with RN AA on 10/13/2011 at 8:30 a.m., RN AA stated that patients get the discharge appeal notice on admission from the receptionist and if they are at the facility long enough the case management department tries to make sure they get the required second notice within 2 days of discharge. RN AA stated, "We try to catch them before they leave."

The facility did not have a policy for the Medicare Discharge Appeal notice when one was requested, however on 10/13/2011 at 8:40 a.m., CNO D provided a policy from the joint venture organization. CNO D stated, "We did not know this existed until now."

A MR review was completed on Pt. #9's closed MR on 10/13/2011 at 11:08 a.m. Pt. #9, 78 years (yrs) old, was admitted on 7/8/2011 and discharged on 7/12/2011. A Medicare discharge appeal notice was obtained on 7/9/2011, the second notice within 48 hours of discharge was not obtained.

A MR review was completed on Pt. #10's closed MR on 10/13/2011 at 11:20 a.m. Pt. #10, 59 yrs old, was admitted on 4/17/2011 and discharged on 4/26/2011. A Medicare discharge appeal notice was obtained on 4/17/2011, the second notice within 48 hours of discharge was not obtained.

These findings were confirmed by Mgr B at the time of discovery during the MR reviews on 10/13/2011.

Based on MR review in 4 of 4 MR reviewed of patients who had alcohol based skin preparations (Pt.'s #4, 8, 10, and 35), staff interviews, review of policy and procedures, the facility failed to ensure policies are in place to ensure the safety of all patients from fire during surgical procedures.

Findings include:
Per policy review the facility failed to ensure the policy includes alcohol based skin preparations
are dry prior to starting surgery. See tag C231. In 4 of 4 surgical MR the facility failed to ensure there is documentation of the alcohol based skin prep is dry prior to draping. See tag C231. Per observation of Pt. #35's surgical procedure the facility failed to ensure an alcohol based skin preparation was dry prior to starting surgery. See tag C231.

Based on observation, staff interviews, and review of maintenance records, the hospital failed to ensure the physical environment of the building met the minimum requirements of the NFPA 101 (2000 Edition of the Life Safety Code) for "Existing Healthcare Occupancy" and "New Healthcare Occupancy" chapters of this code.

The findings include for Building 01:
K-012 (building construction type),
K-017 (corridor walls)
K-018 (corridor doors)
K-019 (corridor windows)
K-020 (vertical openings)
K-022 (exit signage for exits)
K-027 (openings in smoke barrier)
K-029 (hazardous areas)
K-033 (exit enclosure)
K-034 (stairways)
K-038 (means of egress)
K-039 (corridor width)
K-045 (means of egress illumination)
K-046 (emergency lighting)
K-050 (fire drills)
K-051 (fire alarm systems)
K-056 (sprinkler installation)
K-062 (sprinkler system maintenance)
K-064 (portable fire extinguisher)
K-067 (ventilation)
K-069 (cooking facilities)
K-071 (laundry chutes)
K-074 (cubicle and shower curtains)
K-076 (medical gas storage)
K-077 (piped medical gas)
K-134 (emergency shower in laboratory)
K-144 (generator inspection)
K-147 (electrical wiring per NFPA 70)
K-154 (sprinkler outage)

The findings include for Building 02:
K-011 (occupancy separation)
K-017 (corridor walls)
K-025 (smoke compartments).
K-050 (fire drills)
K-062 (sprinkler system maintenance)
K-144 (generator inspection)
K-154 (sprinkler outage)

The findings include for Building 03:
K-130 (miscellaneous issues that included building construction type, hazardous areas, exit discharge illumination, sprinkler obstruction, sprinkler maintenance, ventilation and electrical wiring per NFPA 70)

The cumulative effect of these deficiencies indicates that the facility failed to provide a safe environment and reliable systems to ensure safety to all occupants, patients and staffs of this facility.

Based on observation, staff interviews , the facility did not construct, install and maintain a proper ventilation system. The facility did not have a ventilation system that was installed and maintained in accordance with state regulations and manufacturer recommendations. This deficiency occurred in 2 of the 12 smoke compartments, and had the potential to affect 15 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/10/2011 at 2:15 PM surveyor #18107 observed in the Three-3 smoke compartment on the 3rd floor in the Roof Air Handling Unit, that the ventilation to the space could not be confirmed to be compliant with accepted standards. The Roof Top Air Handing Unit (AHU) was not installed with the required 25'-0" distance between roof noxious and odor producing exhaust vents and the fresh air intake of the AHU per Facility Guidelines Institute for Design and Construction of Health Care Facilities. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

2. On 10/10/2011 at 2:25 PM surveyor #18107 observed in the Three-2 smoke compartment on the 3rd floor in the AHU-Intake , that the ventilation to the space could not be confirmed to be compliant with accepted standards. The Roof Top Air Handing Unit (AHU) was not installed with the required 25'-0" distance between roof noxious and odor producing exhaust vents and the fresh air intake of the AHU per the Facility Guidelines Institute for Design and Construction of Health Care Facilities. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (Safety Officer), staff F (Facilities Mgmt Supervisor) and staff G (Maintenance Supervisor).

Based on observation, staff interviews the facility did not maintain overall hospital environment in a manner to ensure the safety and well being of patients. The facility did not have walls free of damage. This deficiency occurred in 1 of the 12 smoke compartments, and had the potential to affect 5 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 10/11/2011 at 6:35 PM surveyor #18107 observed in the One-1 smoke compartment on the 1st floor in the Surgery Equipment Room, that a portion of a wall was damaged and in need of repair. Damaged wall at door caused by carts. This damage renders this surface porous and non-cleanable. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Plant Operations Manager), staff G (Maintenance Supervisor), staff E (Safety Officer), and staff F (Facilities Mgmt Supervisor).

Based on review, interview and observation the hospital failed to ensure the safety from fire in the OR
(operating room) by not performing a Time Out for dry skin preparation (prep). This occurred in 4
of 4 records reviewed where alcohol based skin preparations were used. Pt.'s #4, 8, 10, and 35.
Findings by Surveyor #26390 include:

On 10-12-11 at 2:00 p.m. a review of the P&P titled, Identification of correct person, procedure
and site, dated April 2011 was completed. Under section H, #7, "The time out documentation
addresses the following:

a. Correct patient identity.
b. Confirmation that the correct side and site are
marked.
c. An accurate procedure consent form.
d. Correct patient position.
e. Relevant images and results are properly
labeled and appropriately displayed.
f. Agreement on the procedure to be done.
g. The need to administer antibiotics or fluids for
irrigation purposes.
h. Safety precautions based on patient history or
medication use."

The P&P does not address skin prep dry time. Pt. #35's closed MR was reviewed on 10-13-11
at 11:40 a.m. Pt. #35 had right carpal tunnel surgery and the skin prep used was Chloroprep.
There is no documentation in the MR that the skin prep was dry prior to starting surgery.
Observation of pt. #35's surgery on 10-12-11 at 8:20 a.m. revealed a Time Out that did not
include dry time of skin prep. On 10-11-11 at approximately 9:30 a.m. an
interview with Surgery Mgr., V and RN BB revealed the hospital does not conduct a time out
for dry time of alcohol based skin prep nor do they document that the skin prep is dry prior to
surgery.

Findings by Surveyor #26711:
MRs were reviewed by Surveyor #26711 on 10/13/2011 between 8:51 a.m. and 11:55 a.m.
accompanied by Mgr B. Pt. #4's closed in-patient MR was reviewed at
10:15 a.m. Pt. #4 had hip surgery and the prep used was Chloroprep, an alcohol based surgical
skin prep. There is no documentation in the MR that the skin prep was dry prior to starting
surgery. Pt. #8's closed in-patient MR was reviewed at 11:00 a.m. Pt. #8 had a Cesarean Section and
the skin prep used was Duraprep, an alcohol based surgical skin prep. There is no documentation in the MR that the skin prep was dry prior to starting surgery. Pt. #10's closed in-patient MR was reviewed at 11:20 a.m. Pt. #10 had abdominal surgery and the skin prep used was Chloroprep. There is no
documentation in the MR that the skin prep was dry prior to starting surgery. These findings were confirmed by Mgr B at the time of discovery during record review.

Based on observation, staff interviews, and review of maintenance records, the hospital failed to ensure the physical environment of the building met the minimum requirements of the NFPA 101 (2000 Edition of the Life Safety Code) for "Existing Healthcare Occupancy" and "New Healthcare Occupancy" chapters of this code.

The findings include for Building 01:
K-012 (building construction type),
K-017 (corridor walls)
K-018 (corridor doors)
K-019 (corridor windows)
K-020 (vertical openings)
K-022 (exit signage for exits)
K-027 (openings in smoke barrier)
K-029 (hazardous areas)
K-033 (exit enclosure)
K-034 (stairways)
K-038 (means of egress)
K-039 (corridor width)
K-045 (means of egress illumination)
K-046 (emergency lighting)
K-050 (fire drills)
K-051 (fire alarm systems)
K-056 (sprinkler installation)
K-062 (sprinkler system maintenance)
K-064 (portable fire extinguisher)
K-067 (ventilation)
K-069 (cooking facilities)
K-071 (laundry chutes)
K-074 (cubicle and shower curtains)
K-076 (medical gas storage)
K-077 (piped medical gas)
K-134 (emergency shower in laboratory)
K-144 (generator inspection)
K-147 (electrical wiring per NFPA 70)
K-154 (sprinkler outage)

The findings include for Building 02:
K-011 (occupancy separation)
K-017 (corridor walls)
K-025 (smoke compartments).
K-050 (fire drills)
K-062 (sprinkler system maintenance)
K-144 (generator inspection)
K-154 (sprinkler outage)

The findings include for Building 03:
K-130 (miscellaneous issues that included building construction type, hazardous areas, exit discharge illumination, sprinkler obstruction, sprinkler maintenance, ventilation and electrical wiring per NFPA 70)

The cumulative effect of these deficiencies indicates that the facility failed to provide a safe environment and reliable systems to ensure safety to all occupants, patients and staffs of this facility.

Based on observations and staff interviews, the hospital failed to ensure that drugs and biologicals kept in 2 of 2 crash carts in the emergency department (ED) are secured from unauthorized access. Failure to secure the crash carts had the potential to affect the 3 patients who were in the ED at the time of the survey.

Findings include:

Per observation, by surveyor #29963 while touring the ED on 10/12/11 at 2:00 PM with ED Mgr R and CNO D, it was noted that two crash carts, which contain drugs and biologicals, were stored in alcoves. The carts do not have a permanent locking device to ensure unauthorized access by patient, families and visitors.

Per interview with ED mgr R and CNO D on 10/12/11 at 2:05 PM, the carts are left unattended and out of the staff's view. As a result, the crash carts, which contain drugs, biologicals, and intravenous solutions could be accessed without staff knowledge resulting in tampering, destruction, or removal of crash cart contents.

These crash carts were observed to be unattended during the 45 minutes Surveyors #26390 and 29963 were in the ED.

Findings were confirmed at time of observation with Mgr R and CNO D.

Based on observations, staff interviews, policy review, and the Dietary Food Code guidelines, this facility failed to ensure measures were taken to control and prevent infections and avoid cross contamination of patient equipment and supplies in 7 of 8 departments observed (OB-Obstetrics, ER-Emergency Room, MED/SURG-Medical/Surgical, Surgery, Outpatient Therapy, Kitchen, and Laundry). These findings had the potential to affect all 13 patients present during the time of the survey.
Also, the Outpatient Therapy department failed to develop and follow a system for the identifying, and reporting communicable diseases. These findings had the potential to affect all 5 patients present at the time of the survey.


Findings include:
According to the 2009 FDA (Food and Drug Administration) Food Code: Observations should be made to determine whether practices are in place to eliminate the potential for contamination of utensils, equipment, and single-service items by environmental contaminants, employees, and consumers.
The 2009 FDA Food Code also addresses shipping containers (cardboard boxes) in the kitchen area in the following guidance: 2009 FDA Food Code Preventing 3-302.11 Packaged and Unpackaged Food - Protection Food and Separation, Packaging, and Segregation. Ingredient. Contamination Food that is inadequately packaged or contained in damaged packaging could become contaminated by microbes, dust, or chemicals introduced by products or equipment stored in close proximity or by persons delivering, stocking, or opening packages or overwraps. Packaging must be appropriate for preventing the entry of microbes and other contaminants such as chemicals. These contaminants may be present on the outside of containers and may contaminate food if the packaging is inadequate or damaged, or when the packaging is opened. The removal of food product overwraps may also damage the package integrity of foods under the overwraps if proper care is not taken.
On 10-12-11 at 3:00 p.m. a review of the P&P titled, Laundry Infection Control was completed. Under the section titled, Engineering is the following, " Water used in the laundry comes from the city of Shawano. Water temperatures are maintained at 140-160 degrees. " The P&P does not address dryer temperatures.
An interview with RN Y regarding the facility's infection control program was conducted on 10/10/2011 at 2:10 p.m. by Surveyor #26711. Mgr O also attended. During the interview it was determined that RN Y is collecting an adequate amount of data. RN Y stated however that Y is not documenting in a fashion where the information can be turned into a useful tool for tracking of infections and surveillance of the facility. This was also discussed with CNO D on 10/11/2011 at approximately 11:00 a.m.

A tour of the kitchen was conducted on 10/11/2011 at 8:00 a.m. by Surveyor #26711, accompanied by CFO L and Mgr K.

The floor of the walk in freezer was visibly dirty with debris (dust, dirt, pieces of ripped off labels from food cartons) on the floor. Mgr K stated that the floor is swept regularly and it was on a cleaning schedule.

On a wire rack shelving unit in the food preparation area, cardboard delivery boxes were noted to be on the shelf with paper product supplies (for example Styrofoam cups and lids). Cardboard shipping containers are a source of potential contamination to food, staff, and products stored in the vicinity (refer to FDA guidelines regarding contaminants on containers). Mgr K confirmed that these boxes are the original shipping containers from the truck.

In an interview regarding cardboard shipping containers and surveillance in the kitchen with RN Y on 10/11/2011 at 2:30 p.m., RN Y stated that the kitchen staff had been tracking cardboard boxes in the kitchen. RN Y stated Y was aware of the boxes in the dry storage area off the back hallway (not an area that would be of concern with the shipping containers) but was not aware there were cardboard shipping containers in the kitchen. RN Y stated' "Boxes should not be in clean areas."

A tour of the Maternity unit was conducted on 10/11/2011 at 11:15 a.m. by Surveyors #26711 and #29963 accompanied by CNO D and Mgr U.

In a room identified as "Soiled Utility" a bottle of Cidex (a chemical cleaning agent ) was under the sink. The door to this room was unlocked, as well as the cabinet the cleaning agent was in, making this room and its contents accessible to any visitor or patient who may enter it. Access to this room by unauthorized personnel has the potential for contamination of microorganisms from trash and laundry, and injury from chemicals.

In a storage room on the Maternity unit Surveyor #26711 discovered a box of bottle nipples that expired on 5/30/2011. Mgr U agreed they were expired and should have been discovered by staff when they were checking stock for outdates.

These findings were confirmed at the time of discovery by CNO D and Mgr U.

While leaving the Maternity floor accompanied by CNO D (10/11/2011, 11:50 a.m.) , Surveyor #26711 discovered that the route for Cesarean Section (C-Section) moms and babies to go to the operating room and return after delivery is through a section of hallway which houses Medical/Surgical patients. On 10/11/2011 it was noted that one of the Medical/Surgical patients in this section of hallway was on infection control precautions.

The route taken by C-Section moms and babies has a potential for cross contamination of microorganisms for this specialized population. The hospital does not currently have a policy depicting the protection of these moms and babies during transfers through a potentially contaminated environment.

CNO D confirmed these findings at the time of discovery.

Findings by Surveyor #18107:

Surveyor #18107, a Life Safety Code Surveyor, toured the building on 10/10/2011 from 10:30 a.m. to 6:00 p.m., on 10/11/2011 from 8:00 a.m. to 7:00 p.m. and on 10/12/2011 from 8:00 a.m.-3:30 p.m. accompanied by Safety Officer (S.O.) E, Supvr F, Supvr G and Mgr C. The following are a result of these tours and were confirmed by the accompanying facility personnel at the time of discovery:

On 10/11/210 from 3:04 p.m. through 3:15 p.m., Surveyor #18107 made the following finding:
** In the Laundry the return air vent was dirty (build up of lint and dust) and dusty.

On 10/11/2011 between 5:39 p.m. and 7:00 p.m. in the Surgery area Surveyor #18107 made the following findings:
** There is no exhaust vent for the two steam sterilizers.
** In Operating Rooms A, B, and C there were breaches in the integrity of the walls exposing the porous dry wall underneath rendering the surface un-cleanable for all microorganisms.
** In the sterile clean storage room there were damaged (holes in them) and stained ceiling tiles.
**The surgery equipment room had damage to the walls (breaches in the integrity of the dry wall) and door making the surfaces non-smooth and porous and unable to be cleaned properly.


26390

Findings by Surveyor #26390 include:

On 10-11-11 at 3:15 p.m. a tour of the hospitals outpatient therapy location was conducted with Mgr. S and surveyor #29963. Mgr. S explained that it is not part of their process to monitor patients for signs or symptoms of communicable diseases, nor do they have a process for reporting infections or possible communicable diseases to the hospital.

On 10-11-11 at 7:34 am a interview with Mgr. W was completed along with a tour of the laundry. Mgr. W explained that all of the laundry for the hospital and offsite location is processed at the hospital.

Inside the laundry Coordinator (Coor.), X explained the process for washing and drying linens, scrubs, gowns and isolation textiles. It was demonstrated how soiled textiles get to the scale and then to the washing machines. The soiled textiles are in large rolling carts without covers and not bagged. The carts are rolled past and in close proximity to large rolling carts of clean laundry, also not covered or bagged. This does not demonstrate the separation of clean and dirty for linens in the laundry area.

Coor. X explained that the washing machines and dryers are set to certain temperatures but there is not a process to check and log the temperatures. Coor. X could not tell the surveyor if the washing machines and dryers were hot enough to kill bacteria and spores.

On 10-13-11 at 9:30 am Maintenance Mgr. C confirmed the hospital does not have a tracking system for washing machine or dryer temperatures.


29963

Findings by surveyor #29963 include:

Per observation surveyor #29963 toured Obstetrics Unit on 10/11/11 at 11:20 AM and noted a bottle of Virex 256 (a chemical cleaning agent with directions stating to keep out of reach of children) being stored in an unlocked cabinet in the kitchenette used by staff, patients and visitors. These findings were confirmed with RN U and RN D at 11:20 AM during tour.

Per observation surveyor # 29963 toured Outpatient therapy treatment area on 10/11/11 at 3:00 PM and noted a bottle of Virex 256 left out on the countertop in a treatment room utilized by patients throughout the day. These findings were confirmed with Manager of Outpatient Therapy S at 3:00 PM during the tour.

Based on observation in one of one kitchen, and 3 of 3 staff interviews (staff K, M, and N), this facility does not ensure that all food items that could be consumed by patients are clearly marked for the date of opening, or expiration. Failure to clearly mark food items had the potential to affect the 13 patients in the facility during the time of the survey.

Findings include:

A tour of the kitchen was conducted on 10/11/2011 at 8:00 a.m. by Surveyor #26711, accompanied by CFO L and Mgr K.

In an interview with Mgr K during the tour, K confirmed that all food containers that are opened are marked with the date they are opened and good for a period of seven days, with the exception of frozen foods which could be good for longer than seven days.

The following food items were found to be opened and undated:
*Refrigerator: toffee chips used for baking.
*Dry Storage: three pudding mixes, one jello mix, and a box of rice krispies.
*Freezer: hash brown sticks, tater sticks, blueberries, and corn.

These findings were confirmed by Mgr K, and kitchen staff M and N at the time of discovery, who all confirmed these food items should be dated when opened.

Based on record review, staff interview and review of facility's standard of practice, the hospital failed to individualize care plans on 30 of 30 medical records reviewed (#1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 33, and 34).

Findings include:

Per review of Hospitals Standards of Care section IV. states "Every patient can expect an individualized plan of care based on identified patient and family needs".

The Nursing care plans on all patients are computer generated care plans that are in a standardized format. The care plans are not personalized to address interventions related to an individual's diagnoses related to their hospitalization. These care plans are initiated on the day of admission and not updated, or kept current, to the changes in the patient's condition throughout hospitalization.

In an interview by surveyor #29963 on 10/10/11 at 10:00 AM with Nurse Mgr D and CNO D, confirmed that interventions are not personalized to the patient's on the care plans. Nurse Mgr D and CNO D stated that the computer system allowed for individualized interventions to be added to the care plan but staff does not utilize that capability.

These findings by surveyor # 26711 were confirmed on patients #3-12 on 10/13/2011 between 8:30 AM and 11:50 AM with Nurse Mgr B.

Findings by surveyor #29963 on patient #13 and 16 on 10/11/11 between 11:50 AM - 12:10 PM confirmed by RN Z.

Findings by surveyor #29963 on patients #14, 15, 17, and 18 on 10/12/11 between 4:00 PM - 5:15 PM confirmed by Nurse Mgr U.

Findings by surveyor #29963 on patient # 19, 20, and 21 on 10/12/11 between 10:30 AM - 11:15 AM confirmed by Nurse Mgr B.

Findings by surveyor #29963 on patient # 33-34 on 10/13/11 between 9:00 AM- 9:45 AM confirmed by RN H.

Findings by surveyor # 26390 on patient #1 on 10/10/11 at 2:08 PM, confirmed by RN H.

Findings by surveyor # 26390 on patient # 22-29 on 10/10/11 between 10:18 AM - 3:15 PM, confirmed by CNO B.

Based on MR review, review of the Medical Staff Rules and Regulations, and staff interview the hospital failed to maintain complete medical records by not having documentation for 1 of 1 sexual assault pt. records (pt. #30), and not having History and Physicals (H&Ps) for 2 of 6 surgical pt. records (pt.'s #8 & 35), and 1 of 1 Swing Bed MR (Pt. #3) out of a total of 32 MR reviewed.

Findings by Surveyor #26390 include:

A review of the Medical Staff Rules and Regulations, dated May 2006, was completed on 10/12/2011 at 10:30 a.m. by Surveyor #26711. On page 17, F. 2. History and Physical states, "A complete admission history and physical examination shall be recorded or dictated within 24 hours of admission."
On page 20, #17. states in part, "Emergency Care Records, A medical record shall be kept on every individual seeking emergency medical care..."

On 10-12-2011 at 2:40 p.m. a review of medical record for pt. #30 was completed with RN Mgr, S. The record contained a single form that showed pt. #30 arriving at the hospital Emergency Department (ED) at 8:34 am. At that time the pt. was assessed for physical injury. The record showed pt. #30 was not suffering from any injury. The SANE (sexual assault nurse examiner) saw pt. #30 at 9:35 am. When asked about documentation for the SANE examination and the disposition of the pt. RN Mgr. S explained, "I don't know where pt. #30 went. We don't keep SANE nurse documentation in the record." "They (sexual assault pt's) come to the ED just for the sexual assault. We don't really see them, the SANE nurses do everything."

On 10-12-2011 at 4:00 p.m. CNO D, confirmed all documentation for sexual assault patients must be in the medical record.

On 10-13-2011 at 11:40 am a review of the record for pt. #35 was completed. The record showed pt. #35 was admitted on 10-12-11 for carpal tunnel surgery. The anesthesia record dated 10-12-11 shows pt. #35 had surgery under MAC (monitored anesthesia care). The H&P update form shows a check mark in the box next to "No Changes". This section states further, "H&P was reviewed and the patient was examined. No changes have occurred in the patient's condition since the H&P was completed."
At 11:45 am Dir., J referred surveyor to a single page in pt. #35's record titled HPI details, dated 9-27-2011. The single paragraph page states in part, " the patient is 15 days status post left carpal tunnel release. Her hand it no longer is numb and tingly." This document was reviewed with Dir. J who confirmed, "not a complete H&P".


26711

Findings by Surveyor #26711:

A MR review of Pt. #3's closed Swing Bed record was completed on 10/13/2011 at 8:51 a.m. On 7/21/2011 Pt. #3 was discharged from acute inpatient status and admitted to Swing Bed on 7/21/2011. There is no update to the H&P from the acute care admission for the Swing Bed admission, and a new H&P was not completed.

A MR review of Pt. #8's closed Maternity record was completed on 10/13/2011 at 11:00 a.m. Pt. #8 was admitted to the hospital on 3/25/2011 and had a Cesarean Section on 3/26/2011. There is no H&P in the MR.

These findings were confirmed at the time of discovery by Mgr. B during record review on 10/13/2011.

Based on MR review, review of the facility's Medical Staff Rules and Regulations, policy/procedure review, and staff interview this facility fails to ensure that MD orders and reports are properly authenticated by the responsible professional in 10 out of 32 MRs reviewed (Pts. #3, 4, 5, 7, 9, 10, 12, 19, 21, and 33).

Findings by Surveyor #26711 include:

The facility's Medical Staff Rules and Regulations (R&Rs), dated May 2006, were reviewed on 10/12/2011 at 10:30 a.m. On page 2, #9 states in part, "The ordering practitioner must sign all verbal orders within 48 hours (with exception of standing orders)."
On page 4 of the R&Rs #18 states in part, "All orders must be written clearly, legibly, and completely."
On page 18 of the R&Rs, #6 states, "All clinical entries in the patient's medical record shall be accurately dated, timed, and authenticated.
On page 19 of the R&Rs, #16 states, "If a medical record is not completed within 30 days of discharge the record will be permanently recorded as delinquent."

The facility's policy titled, "Medical Record Documentation," dated 9/2009, was reviewed on 10/12/2011 at 10:45 a.m. On page 1, the policy states, "All entries must be legible and complete, and must be authenticated and dated promptly of the person (identified by name and discipline) who is responsible for ordering, providing, or evaluating the service furnished."
On page 2 of 3, under Authentications, #2 states, "Progress notes and orders shall have signatures, dates, and times as defined by the medical staff rules."

MRs were reviewed by Surveyor #26711 on 10/13/2011 between 8:51 a.m. and 11:55 a.m. accompanied by Mgr B.

Pt. #3's closed Swing Bed record was reviewed at 8:51 a.m. Pt. #3 had one verbal order from 7/22/11 that was not co-signed by the MD until 8/11/11 and three verbal orders on 7/23/11 that were not co-signed by the MD until 8/11/11.

Pt. #4's closed in-patient MR was reviewed at 10:15 a.m. Pt. #4's MR had MD Progress notes from 5/31/11 and 6/3/11 that did not indicate a time they were written; two MD orders that did not indicate a time they were written (6/3/11 and 6/4/11); on verbal order not signed within 48 hours (taken 6/1/11, not signed until 6/15/11); and a hand written post-operative note on 6/1/11 that did not include a time.

Pt. #5's closed in-patient MR was reviewed at 10:35 a.m. Pt. #5 had two orders that did not include the year on the date (6/1/11 and 6/2/11); and three MD Progress notes that did not include a year with the date (5/31/11, 6/1/11, and 6/2/11).

Pt. #7's closed in-patient Pediatric MR was reviewed at 10:50 a.m. Pt. #7 had admitting orders from the Emergency Room that did not include a time on 8/14/11.

Pt. #9's closed in-patient MR was reviewed at 11:08 a.m. Pt. #9 had one MD progress note that did not include a time it was written (7/8/11) and four MD progress notes that did not include a year with the date (7/9/11, 7/10/11, 7/11/11, and 7/12/11).

Pt. #10's closed in-patient MR was reviewed at 11:20 a.m. Pt. # 10 had one MD progress note that did not have a year for the date or the time it was written (4/22/11); two MD progress notes that did not have a date or time at all, and could have potentially been continuations on another page but this is not indicated anywhere, and two pages of standing MD orders for Alcohol Withdrawal that do not include the time for the MD signature.

Pt. #12's closed in-patient MR was reviewed at 11:38 a.m. Pt. #12 had one verbal order taken by an RN on 4/22/11 that does not indicate the time it was received, one verbal order on 4/22/11 that does not indicate the time the MD signed the order, one MD order that does not have a time (4/22/11); and one MD order that does not have a date or a time on the same page as the 4/22/11 orders, along with several tests that are crossed out and different tests ordered.

These findings were confirmed by Mgr B at the time of discovery during record review on 10/13/2011.


29963

Findings by Surveyor #29963 include:

Per open medical record review patient #19, had a physician order written on 10/10/11 with no indication of what time the order was written.

Per open medical record review patient #21 had a telephone order documented with no indication of a date or time the order was written.

Above findings were confirmed by Mgr B on 10/12/11 at 11:20 AM.

Per closed- death medical record review patient #33, had 3 physician orders written on 1/30/11 with no indication of what time the orders were written. Findings were confirmed with RN Spvr T on 10/13/11 at 9:15 AM.
Record review by surveyor #29963 on 10/13/11 at 9:00 AM revealed patient #33 with an admission date of 1/30/11 and a discharge date of 2/4/11. History and Physical was dictated on 1/30/11 and was not signed by the MD until 3/12/11. A time period of more than 30 days.
These findings were confirmed by RN T on 10/13/11 at 9:15 AM.

Based on policy and procedure review, tour of the MR department, and 1 of 1 staff interview (staff J), the hospital failed to ensure that patients records were kept confidential from unauthorized staff. Failure to secure MR from unauthorized staff has the potential to affect all 13 of the current patients in the facility, as well as all previous patients who received care at this facility.

Findings include:

Facility policy titled, "Patient Rights, Responsibilities, Complaint Procedure," dated 11/2010, was reviewed by Surveyor #26711 on 10/13/2011 at 8:15 a.m. On page 1, under Patient Rights, #3. states, "[All patients have the right:] To confidentiality of all treatment records."

In an interview by surveyor #29963 on 10/10/11 at 2:35 PM with Dir J, Dir J stated housekeeping cleans the medical record storage room 1 time a week in the evening. The housekeeper is allowed to clean the MR room unsupervised by medical records staff. This room houses all of the MR for patients who received care in this facility and are not in locked cabinets.

Housekeeping staff are not authorized to have access to MR and should not be in the MR departments without MR staff.

These findings were discussed with and confirmed by CNO D on 10/11/2011 at 4:30 p.m.

Based on record review, standards of practice from the Association for Operating Room Nurses, policy and procedure review, interview and observation the hospital failed to ensure patient's safety from fire in the OR (operating room) by not performing a Time Out for dry skin preparation (prep). This occurred in 4 of 4 records reviewed where alcohol based skin preparations were used (Pt.'s #4, 8, 10, and 35) and 1 of 1 observation (Pt. #35).

Findings include:

Per policy review the facility failed to ensure the policy includes alcohol based skin preparations are dry prior to starting surgery.

In 4 of 4 surgical MR the facility failed to ensure there is documentation of the alcohol based skin prep is dry prior to draping.

Per observation of Pt. #35's surgical procedure the facility failed to ensure an alcohol based skin preparation was dry prior to starting surgery.

The cumulative effect of these environmental deficiencies results in the hospital's inability to ensure a safe environment for all patients, staff and visitors.

Findings by Surveyor #26390 include:

On 10-12-11 at 2:00 p.m. a review of the P&P titled, Identification of correct person, procedure and site, dated April 2011 was completed. Under section H, #7, "The time out documentation addresses the following:
a. Correct patient identity.
b. Confirmation that the correct side and site are marked.
c. An accurate procedure consent form.
d. Correct patient position.
e. Relevant images and results are properly labeled and appropriately displayed.
f. Agreement on the procedure to be done.
g. The need to administer antibiotics or fluids for irrigation purposes.
h. Safety precautions based on patient history or medication use."

The P&P does not address skin prep dry time.

The Association for Operating Room Nurses (AORN) Perioperative Standards and Recommendations, 2008 Edition indicate:
IX.d.1. Waterless, brushless, surgical-scrub solutions should be allowed to dry completely to decrease the potential to produce ignition by static electricity or sparks.
IX.d.3. Provide adequate time for the flammable surgical prep solution to dry completely and any fumes to dissipate before applying surgical drapes, using an active electrode or laser, or activating a fiber-optic light cable.
IX.d.5. Drapes should not be applied until prep solutions are dry, to prevent the accumulation of volatile fumes beneath them.

Pt. #35's closed MR was reviewed on 10-13-11 at 11:40 a.m. Pt. #35 had right carpal tunnel surgery and the skin prep used was Chloroprep. There is no documentation in the MR that the skin prep was dry prior to starting surgery.

Observation of pt. #35's surgery on 10-12-11 at 8:20 a.m. revealed a Time Out that did not include dry time of skin prep.

On 10-11-11 at approximately 9:30 a.m. an interview with Surgery Mgr., V and RN BB revealed the hospital does not conduct a time out for dry time of alcohol based skin prep nor do they document that the skin prep is dry prior to surgery.


Findings by Surveyor #26711:

MRs were reviewed by Surveyor #26711 on 10/13/2011 between 8:51 a.m. and 11:55 a.m. accompanied by Mgr B.

Pt. #4's closed in-patient MR was reviewed at 10:15 a.m. Pt. #4 had hip surgery and the prep used was Chloroprep, an alcohol based surgical skin prep. There is no documentation in the MR that the skin prep was dry prior to starting surgery.

Pt. #8's closed in-patient MR was reviewed at 11:00 a.m. Pt. #8 had a Cesarean Section and the skin prep used was Duraprep, an alcohol based surgical skin prep. There is no documentation in the MR that the skin prep was dry prior to starting surgery.

Pt. #10's closed in-patient MR was reviewed at 11:20 a.m. Pt. #10 had abdominal surgery and the skin prep used was Chloroprep. There is no documentation in the MR that the skin prep was dry prior to starting surgery.

These findings were confirmed by Mgr B at the time of discovery during record review.

Based on MR review, staff interview, policy and procedure (P&P) review, review of the Medical Staff Rules and Regulations this facility failed to ensure proper evaluations for anesthesia recovery were completed in 6 of 6 (Pt.'s #4, 8, 10, 23, 24, 35) surgical MRs out of a total of 32 MR reviewed.

Findings by Surveyor #26390 include:

The Medical Staff Rules and Regulations, dated May 2006, were reviewed on 10/12/2011 at 10:30 a.m. On page 12, #4, Anesthesia Record states, "Anesthetists shall maintain a complete anesthesia record to include evidence of anesthetic follow up of the patient's condition."

On 10-12-11 at 4:33 p.m. a review of the P&P titled Post-anesthetic note was completed with CNO D. The P&P was reviewed last in October 2011. The Policy states, "A post anesthetic visit and note is made by anesthesia personnel. Notation is made as to time and date, also included are references to anesthetists recovery,(ie., good recovery from anesthesia or anesthetic complication). NOTE: Effort is made to place remark on chart in all cases." CNO D, confirmed the P&P is insufficient.

On 10-11-11 at 9:05 am a review of pt. #23 ' s record was completed with Surgery Mgr., V and RN BB. The record showed pt. #23 was admitted on 9-14-11 for a sigmoid colon obstruction. The anesthesia record dated 9-15-11 shows anesthesia was started at 1235 and stopped at 1600. The section titled Post Anesthesia Summary is timed as 1555. The evaluation was completed prior to the completion of anesthesia.

On 10-11-11 at 9:30 am a review of pt. #24 ' s record was completed with Surgery Mgr., V and RN BB. The record showed pt. #24 was admitted on 10-5-11 for a acute cholecystitis. The anesthesia record dated 10-6-11 shows anesthesia was started at 1000 and stopped at 1242. The section titled Post Anesthesia Summary is not timed. A note in the remarks section states, " 1240 extubated awake with out comp, VSS [vital signs stable] to PACU [Post Anesthesia Care Unit] " . The evaluation was completed prior to the completion of anesthesia.

On 10-13-11 at 11:40 am a review of pt. #35 ' s record was completed. The record showed pt. #35 was admitted on 10-12-11 for a right carpal tunnel surgery. The anesthesia record dated 10-12-11 shows anesthesia was started at 0815 and stopped at 0850. The section titled Post Anesthesia Summary is not timed, and is not complete. Nurse Mgr. B confirmed the findings at 11:52 am.

During record reviews Surgery Mgr., V and RN BB explained anesthesia brings the patients to PACU, gives report to the nurse and then leaves, they do not return to evaluate prior to discharge. Surgery Mgr., V stated,"we are trying to get them to come back and see the patients again."



26711

Findings by Surveyor #26711:

A MR review was completed on Pt. #4's closed MR on 10/13/2011 at 10:15 a.m. Pt. #4 had spinal anesthesia for surgery on 6/1/2011. The surgical procedure started at 9:55 a.m. and ended at 10:50 a.m. Pt. #4 was transferred to the PACU at 11:00 a.m. Anesthesia completed a post-anesthesia summary note at 11:00 a.m. This is not a sufficient time to determine appropriate recovery from anesthesia.

A MR review was completed on Pt. #8's closed MR on 10/13/2011 at 11:00 a.m. Pt. #8 had spinal anesthesia for a Cesarean Section on 3/26/2011. The surgical procedure started at 6:23 p.m. and ended at 7:00 p.m. There is no indication of the time Pt. #8 was transferred to the PACU. Anesthesia completed a post-anesthesia summary note which is not timed and consists of vital signs and the statement, "No apparent complications." This note is incomplete and does not contain sufficient information to determine appropriate recovery from anesthesia.

A MR review was completed on Pt. #10's closed MR on 10/13/2011 at 11:20 a.m. Pt. #10 had general anesthesia for abdominal surgery on 4/16/2011. The surgical procedure started at 10:13 p.m. and ended at 12:18 a.m. Pt. #10 was transferred to PACU at 12:25 a.m. Anesthesia completed a post-anesthesia summary note which is not timed and consists of vital signs and the statement, "To PACU, VSS, Pt. awake." This note is incomplete and does not contain sufficient information to determine appropriate recovery from anesthesia.

These findings were confirmed by Mgr B at the time of discovery during record review on 10/13/2011.

Based on interview and 1 of 1 policy and procedure review the hospital failed to include a definition of imminent death in the policy and failed to include notification to the OPO (Organ Procurement Organization) as part of the procedure.

Findings include:

On 10-11-2011 at 7:04 am an interview with CNO, D and Spvr, Q was completed. A review of the facility policy titled, "Organ, Tissue, and Eye Donation," dated October 2011, was reviewed at this time as well.

Spvr. Q, explained the procedure for calling the OPO after a death had occurred.

RN Spvr. Q stated staff do not call the OPO for imminent death.

CNO D, confirmed after review of the P&P that a definition of imminent death is not included in the policy nor does the P&P contain information to call the OPO for an imminent death.

Based on review of facility's Patient Rights and Responsibilities for Swing Bed, and 4 of 4 staff interviews ( Staff Q, O, B, and D), this facility fails to inform patients of their right to choose a personal physician.

Findings include:

Patient Rights and Responsibilities for Swing Bed patients, which is undated, were reviewed on 10/11/2011 at 8:30 a.m. The document did not include the right to choose a personal physician.

This finding was confirmed in a group interview on 10/11/2011 at 10:15 a.m. with Supvr Q, Mgr O, Mgr B, and CNO D.

Based on review of facility's Patient Rights and Responsibilities for Swing Bed, and 4 of 4 staff interviews ( Staff Q, O, B, and D), this facility fails to inform patients of their right to share a room with their marital partner if both partners were in the Swing Bed program at the same time. This deficiency will afffect all future swing bed patients to enter this facility.

Findings include:

The "Patient Rights and Responsibilities" statement for Swing Bed patients, which is undated, were reviewed on 10/11/2011 at 8:30 a.m. The patient rights statement is missing information regarding the right for married couples to share a room with their marital partner if both partners were in the Swing Bed program at the same time and they were both agreeable to the arrangement.

This finding was confirmed in a group interview on 10/11/2011 at 10:15 a.m. with Supvr Q, Mgr O, Mgr B, and CNO D.

Based on review of the facility's Swing Bed Rights and Responsibilities, and 4 of 4 staff interviews ( Staff Q, O, B, and D), this facility does not ensure that Swing Bed patients have the required information needed at the time of transfer or discharge. This deficiency will afffect all future swing bed patients to enter this facility.

Findings include:

The facility's Swing Bed Rights and Responsibilities, which is undated, were reviewed on 10/11/2011 at 8:30 a.m. by Surveyor #26711.

The facility has not developed a notice for transfer or discharge that contains language that would inform the patient of the right to know the reason, effective date, nor where they would be discharged or transferred should this occur.

The facility also does not give the patient information about the Long Term Care Ombudsman, or include information regarding who to contact for patients with developmental disabilities or mental illness, since this would be located on the transfer/discharge notice.

This finding was confirmed in a group interview on 10/11/2011 at 10:15 a.m. with Supvr Q, Mgr O, Mgr B, and CNO D. All agreed that the facility does not have a transfer/discharge notice for Swing Bed patients.