HospitalInspections.org

Based on review of medical records (MR) staff interviews, review of policy and procedures, in 1 of 1 interviews (N) the facility failed to ensure policies are in place to ensure the safety of all patients from fire during surgical procedures.

Findings include:

In 1 of 1 interviews the facility failed to ensure there is a policy for alcohol based skin prep that includes drying and prevention of fire. See tag C231.

In 5 of 7 surgical MR the facility failed to ensure there is documentation of the alcohol based skin prep is dry prior to draping. See tag C231.

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

Based on review of policy and procedures, review of medical records and interview with staff, in 5 of 7 surgical medical records (MR) (12, 13, 14 and 15, and 31), out of a total of 31 records, the facility failed to ensure there is documented time out including drying of skin preparation (prep), and there is a policy in place regarding alcohol based skin prep to prevent potential fire.

Findings include:

Facility policy titled Surgical Preparation of the Skin does not have instructions for alcohol skin prep including but not limited to: following manufacturer's instructions, surgical towels and linens are not soaked with the prep and if so removed, the prep is completely dry prior to draping to avoid potential fires.

Per interview with RN (P) on 8/4/10 at 12:55 PM after the alcohol is applied to the skin, a sterile towel is used to blot off excess alcohol in the umbilicus region.

SM (DS) provided a copy of the 2008 Perioperative Standards and Recommended Practices. The standard states on page 548 under VIII.d. "If pooling occurs, the excess solution should be wicked away..." SM (N) stated in interview on 8/4/10 at 12:55 PM the procedure to blot the alcohol is incorrect and should be wicked away.

Pt #12's MR review by surveyor 18816 on 8/4/10 at 10:35 AM revealed Pt #12 had a lap chole (laparoscopic gallbladder removal) on 2/16/10. The Physician Intraoperative Order Form (PIOF) indicated Alcohol for the skin prep. The Patient Identification and Surgical Site Verification Checklist (PISSVC) included under #5. "Prep site free from pooling". There is no documentation the alcohol prep is dry prior to draping. This is confirmed in interview with MGR N on 8/4/10 at 12:55 PM.

Pt #13's MR review by surveyor 18816 on 8/4/10 at 11:10 AM revealed Pt #13 had a lap chole on 7/19/10. The PIOF indicated Alcohol for the skin prep. The PISSVC (included under #5. "Prep site free from pooling". There is no documentation the alcohol prep is dry prior to draping. This is confirmed in interview with MGR N on 8/4/10 at 12:55 PM.

Pt #14's MR review by surveyor 18816 on 8/4/10 at 11:20 AM revealed Pt #14 had a Percutaneous Endoscopic Gastrostomy (PEG) tube placed on 2/10/10. The PIOF has no skin prep ordered. The PISSVC included under #5. "Prep site free from pooling". There is no documentation of what preps is used and if it should be dry prior to draping. This is confirmed in interview with MGR N on 8/4/10 at 12:55 PM.

Pt #15's MR review by surveyor 18816 on 8/4/10 at 12:35 PM revealed Pt #15 had an appendectomy on 11/7/09. The PISSVC included under #5. "Prep site free from pooling". There is no documentation the skin prep is dry prior to draping. This is confirmed in interview with MGR N on 8/4/10 at 12:55 PM.


26711

Findings include:

A medical record review was conducted on Pt. #31's closed medical record on 8/4/2010 at 9:07 a.m. Pt. #31 had isopropyl alcohol used as a skin preparation for surgery on 3/4/2010 for the removal of the gall bladder.

There is no documentation in the time out procedure that the alcohol was dry prior to starting surgery.

This finding was confirmed on 8/4/2010 at 1:30 p.m. with the Operating Room Mgr N.

Based on review of policy and procedures and interview with staff, in 1 of 1 interviews (VP A) the facility failed to ensure the facility documents providing information on an alleged assault.

Findings include:

Facility policy titled Victims of Sexual Assault, Including Rape dated 5/08 does not include the option of having an assault reported to law enforcement. This was confirmed in interview with VP A on 8/4/10 at approximately 11:00 AM.

Based on interview with staff, review of policy and procedures and review of the APIC position paper on injection practices, in 1 of 1 interview (P), the facility failed to ensure safe practices with multidose vials to prevent potential cross contamination.

Findings include:

Facility policy titled Multi-dose Vials dated 9/09 states "It is the policy of Our Lady of Victory Hospital to limit the use of multi-dose vials to where they may be used on only one patient. This is done to prevent contaminated vial from being used on several patients."

APIC (Association for Professionals in Infection Control and Epidemiology) position paper dated 2010 advises to not have multidose vials in patient care areas.

Per APIC position paper on Safe Injection infusion and Medication Vial Practices in Healthcare dated 2010, recommends using Multidose vials for single patient use whenever possible, and to keep away from immediate patient care area.

Per surveyor 18816 interview with MGR N on 8/4/10 at approximately 8:10 AM, multidose vials of Midazolam (amnesia medication) and Xylocaine (anesthetic) are used in the Operating Room, on the Anesthesia cart, for more than one patient.

Based on observations, policy/procedure review, review of professional standards of care, and staff interview, this facility was found to not have effective infection control practices in 6 of 12 departments observed (Nursing, Dietary, Laboratory, Rehabilitation, Operating Room, and Emergency Room), and to have equipment and/or structural integrity breeches in 3 out of 12 departments observed (Nursing, Rehabilitation, and Cardiac Rehabilitation). The ineffective infection control practices and breeches in structural integrity have the potential risk of contaminating all patients, staff, and visitors.

Findings include:

Facility policy/procedure titled, "Hand Hygiene," dated 3/2002 states that staff will follow CDC (Centers for Disease Control) guidelines for hand hygiene. The policy states, "Hands must be decontaminated after glove use....#7. [hands are to be decontaminated] After removing gloves with any patient or contaminated material contact."

Facility policy/procedure titled, "Accudata GTS Plus/GTS Glucose Analyzer," dated 9/2004 was reviewed on 8/4/2010 at 7:30 a.m. with QIS B. The policy does not give direction regarding cleaning of the glucose monitors. This was confirmed by QIS B.

Medical/Surgical Nursing unit:
A tour of the Medical/Surgical Nursing unit was completed on 8/3/2010 at 9:20 a.m. accompanied by Dir. Q. In a room marked "Soiled Utility" a hair dryer, curling iron, and hair trimmer designated for patient use, confirmed by Certified Nursing Assistant S as being clean items, were found in a drawer.

There is a potential for cross-contamination of clean items stored in a soiled room.

In the medication room, enclosed in cases, Surveyor #26711 observed glucose monitors. Dir. Q was unable to produce evidence of cleaning of these multiple-patient use monitors.

The risk of cross-contamination between patients with the use of multiple-patient use glucose monitors is significant without evidence of the monitor being cleaned.

This was confirmed by Dir. Q at the time of discovery.

An observation of glucose monitoring with RN T was completed on 8/3/2010 at 11:05 a.m. After completing the procedure and discarding the used strip with a blood drop on it, RN T removed gloves, and proceeded to clean off the monitor with an alcohol wipe, then document the blood sugar before washing hands thereby potentially contaminating the monitor and the blood sugar log.

CDC guidelines and facility policy state to wash hands after removing gloves.

These findings were discussed on 8/4/2010 at 3:30 p.m. in the presence of VP A, QIS B, and Dir. Q.

An observation of wound care was completed on 8/4/2010 at 9:00 a.m. with RN R. After removing a wrap used for mild compression (ACE wrap), RN R did not wash hands prior to putting on clean gloves.

After removing the dressing which contained drainage, RN R removed gloves and then touched both pant legs and re-rolled the ACE wrap before washing hands thereby potentially contaminating R's clothing and re-contaminating the ACE wrap.

After applying a new dressing and the contaminated ACE wrap, RN R removed gloves and did not wash hands prior to putting the cover on the ointment used during wound care, thereby potentially contaminating the container.

CDC guidelines and facility policy state to wash hands after removing gloves.

These findings were discussed on 8/4/2010 at 3:30 p.m. in the presence of VP A, QIS B, and Dir. Q.

During a tour of the Medical/Surgical Nursing unit on 8/4/2010 at 9:15 a.m. accompanied by QIS B, Surveyor #26711 noted breeches in the integrity of the painted walls, exposing drywall underneath rendering the walls unable to be properly cleaned and free of potential contaminants to patients.

The following rooms (14 out of 18) were affected: 217, 214, 213, 210, 209, 208, 207, 206, 204, 203, 201, 205, and 212.

Also, in room 204 a reclining chair was found to have a tear in the vinyl exposing the absorbant inside of the stuffed arm. This breech in the integrity of the chair would render it un-cleanable and a potential risk of contamination to patients.

These findings were confirmed by QIS B during the time of discovery.




18816

Examples by surveyor 18816:
Dietary Department:
Facility policy titled Dresscode for Dietetic Services dated 11/06 states under #4. "Hair nets must be worn at all times. Longer hair must be pulled or clipped up and bangs need to covered by hair net."

On 8/3/10 between 7:40 AM and 8:03 AM surveyor 18816 observed the following in the Dietary Department with MGR F:

Cook G was observed preparing breakfast trays for patients, during this observation time Cook G changed her gloves at least 5 times without the benefit of washing her hands between changes.

At approximately 7:50 AM Cook G spilled coffee, picked up a rag stained with coffee and wiped the area, did not change gloves or wash hands and continued to set up trays.

When plating food, Cook G repeatedly wiped her fingers on a towel next to the steam bins, picking up toast with the same hand.

Cook G and MGR F did not have their bangs contained in the hair net.

Laboratory:
Facility policy titled Venipuncture Procedure states "Universal Precautions: Gloves should be worn and universal precautions observed when handling or processing all specimens. Specimens from any patient should be considered potentially infectious."

On 8/3/10 at 8:53 AM surveyor 18816 observed the following in the Laboratory with DIR J:

One of two lab chairs had a side table with a formica top that was not intact allowing for an uncleanable surface.

Phlebotomist H completed a lab draw on an outpatient, did not discard the tourniquet, and did not clean the Vacutainer holder leaving them both on the side table available for use on the next patient. Without washing and changing gloves, Phlebotomist H wrote on the label sheet, applied the patient label to the Vacutainer, removed her gloves and handled both the Vacutainer and label sheet, carried them to the counter next to the sink, washed, then pick up the sheet and Vacutainer and carried them in to the lab, without the benefit of gloves.

During the same observation, Medical Technician I came into the lab wearing her cover gown. Surveyor 18816 asked where she had been, and Medical Technician I stated she had been at the front desk, and confirmed she should not have been wearing her gown out of the lab.

Emergency Room :
On 8/3/10 between 10:30 AM and 11:00 AM surveyor 18816 toured and observed the following in the Emergency Room (ER) with DIR K:

The clean supply room, there is an open box of 16" Scopettes that were yellowed.

Trauma room 2 has Chux and cleaning cloths under the sink allowing for potential cross contamination.

Observation room 3 has toilet paper under the sink allowing for cross contamination.

Trauma room 1 has wash cloths, Chux, adult diapers and patient wipes under the sink allowing for potential cross contamination.

Major Med room has aprons, Chux and toilet paper under the sink allowing for potential cross contamination.

The Soiled room contained clean Personal Protective Equipment allowing for potential cross contamination.

Rehabilitation (Rehab) Department:
On 8/3/10 between 3:50 PM and 4:00 PM surveyor 18816 toured and observed the following in Rehab with DIR M:

The pediatric treatment room had cardboard boxes that did not have a cleanable surface allowing for potential cross contamination. There are stuffed animals used for therapy that do not have a cleanable surface allowing for potential cross contamination.

The Schwinn stationary bike had cracked spongy handles and are no longer a cleanable surface allowing for potential cross contamination.

Operating Room:
On 8/4/10 between 7:55 AM and 9:00 AM surveyor 18816 observed the following in the Operating Room (OR) with MGR N:

Facility policy titled Bloodborne Pathogens Exposure Control Plan states under #7. "All personal protective equipment must be removed prior to leaving the work area...10. Masks, Eye Protection and Face Shields: a. Mask in combination with eye protection devices, such as: 1) goggles 2) glasses with solid side shields 3) chin length face shields b. Must be worn whenever splashes, spray, splatters or droplets of blood or other potentially infectious materials may be generated and eye, nose or mouth contamination can be reasonably anticipated."

The Certified Registered Nurse Anesthetist did not have on a mask during a colonoscopy.

After leaving the OR at 9:00 AM RN P was observed walking through the hospital lobby in full gown and mask. RN P had been a participating team member in the colonoscopy procedure observed

Cardiac Rehab:
On 8/4/10 at 9:00 AM surveyor 18816 toured and observed the following in Cardiac Rehab with DIR K:

The Schwinn stationary bike had cracked spongy handles and are no longer a cleanable surface allowing for potential cross contamination.

Based on observation and staff interview, this facility does not ensure that all food items that could be consumed by patients, visitor, or staff are clearly marked for date of delivery, opening, or expiration, posing potential health risks to all, in 2 of 12 departments (Nursing, Inpatient Rehabilitation).

Findings include:

A tour of the Inpatient Rehabilitation room was completed on 8/3/2010 with SW E at 1:10 p.m. In the kitchen area used by Occupational Therapy, Surveyor #26711 discovered a can of soup that expired in 2008 and an open container of lemonade mix that was undated.

Expired and/or undated opened food could pose a health risk to patients.

SW E confirmed these findings at the time of discovery.

A tour of the Medical/Surgical Nursing unit was completed on 8/3/2010 at 9:20 a.m. accompanied by Dir. Q. In the kitchen freezer individual ice cream servings (dixie cups) had been removed from the box that contains the expiration date on it and put in the freezer separately. The individual servings were not dated with either date of delivery or date of expiration.

In the kitchen refrigerator there were two cartons of milk that were opened and undated.

Undated and/or opened food could pose a health risk to patients.

Dir. Q confirmed these findings at the time of discovery.

Based on medical record review in 9 out of 31 medical records reviewed (Pts. #8, 12, 13, 14, 15, 23, 26, 27 and 28), staff interview, and policy/procedure review, this facility does not provide pain assessments according to the need of the patient or as depicted in the facility's policy.

Findings include:

Facility policy titled, "Standard of Care-Pain Management Adult", dated 10/2000 was reviewed on 8/3/2010 with Dir. Q. The policy states that the pain scale that depicts "Intensity rated on a scale of 0-10," is used for most patients.

The policy does not stipulate that more than one pain scale could be or should be used for an individual patient, and under what circumstances this could/should occur.

Dir. Q is in agreement that one pain scale should be used unless it is documented in the medical record why more than one is needed.

A medical record review was conducted on Pt. #23's closed medical record on 8/3/2010 at 1:23 p.m. Pt. #23, an 86 year old, was a Pt. in the facility from 3/19/2010-3/29/2010 with Pleurisy (an inflammation of the lining of the lung which is painful).

There are 3 different pain scales documented throughout the hospitalization without explanation by nursing staff as to why this is necessary.

During the time of the record review Dir. Q confirmed these findings.

A medical record review was conducted on Pt. #26's closed medical record on 8/4/2010 at 11:15 a.m. Pt. #26, an 81 year old, was a Pt. in the facility from 3/24/2010-3/29/2010 with Chronic Obstructive Pulmonary Disease.

There are 2 different pain scales documented throughout the hospitalization without explanation by nursing staff as to why this is necessary.

During the time of the record review Dir. Q confirmed these findings.

A medical record review was conducted on Pt. #27's closed medical record on 8/3/2010 at 1:23 p.m. Pt. #27, a 48 year old, was a Pt. in the facility from 4/6/10-4/10/10 with an infection in the blood and pain in the kidney region.

There are 2 different pain scales documented throughout the hospitalization without explanation by nursing staff as to why this is necessary.

During the time of the record review Dir. Q confirmed these findings.


A medical record review was conducted on Pt. #28's closed medical record on 8/3/2010 at 2:07 p.m. Pt. #28, a 76 year old, was a Pt. in the facility from 2/16/2010-2/23/2010 with a low blood count and weakness.

There are 2 different pain scales documented throughout the hospitalization without explanation by nursing staff as to why this is necessary.

During the time of the record review Dir. Q confirmed these findings.


18816

Examples by surveyor 18816:

Pt #8's MR review by surveyor 18816 on 8/4/10 at 9:55 AM revealed on 5/11/10 pain medication was given in the Emergency Room at 2:40 PM, there is no rating of pain or follow up on the effectiveness of the medication within one hour per DIR C. This is confirmed in interview with DIR Q on 8/4/10 at 2:45 PM.

Pt #12's MR review by surveyor 18816 on 8/4/10 at 10:35 AM revealed pain medication was given on 2/16/10 at 1:45 PM for pain rated at 7 on a scale of 1-10. There is no follow up to the effectiveness of the medication within one hour per DIR Q. On 2/17/10 at 2:10 AM medication was given for pain rated as 3. There is no follow up to the effectiveness of the medication within one hour. This is confirmed in interview with DIR Q. on 8/4/10 at 2:45 PM.

Pt #13's MR review by surveyor 18816 on 8/4/10 at 11:10 AM revealed pain medication was given on 7/16/10 at 6:13 PM for pain rated at 4 on a scale of 1-10. There is no follow up to the effectiveness of the medication within one hour per DIR Q. On 7/19/10 at 11:10 AM medication was given for pain rated as 4. There is no follow up to the effectiveness of the medication within one hour. This is confirmed in interview with DIR Q. on 8/4/10 at 2:45 PM.

Pt #14's MR review by surveyor 18816 on 8/4/10 at 11:20 AM revealed pain medication was given on 2/13/10 at 5:22 PM for unrated pain. There is no follow up to the effectiveness of the medication within one hour per DIR Q. On 2/13/10 at 8:55 PM medication was given for unrated pain. There is no follow up to the effectiveness of the medication within one hour. This is confirmed in interview with DIR Q. on 8/4/10 at 2:45 PM.

Pt #15's MR review by surveyor 18816 on 8/4/10 at 12:35 PM revealed pain medication was given on 11/14/10 at 7:01 PM for pain rated at 6 on a scale of 1-10. There is no follow up to the effectiveness of the medication within one hour per DIR Q. On 11/15/10 at 3:41 PM medication was given for pain rated as "mild". There is no follow up to the effectiveness of the medication within one hour. This is confirmed in interview with DIR Q. on 8/4/10 at 2:45 PM.

Based on medical record review of 4 out of 19 out of a total of 31 medical records reviewed (Pts. #13, 17, 24, and 31), and staff interview, this facility failed to develop nursing care plans that were current or pertinent to the each patient's reason for hospitalization.

Findings include:

A medical record review was conducted on 8/3/2010 at 10:40 a.m. on Pt. #17's open medical record. Pt. #17 was admitted to the facility on 8/2/2010 for observation with a diagnosis of Hypoglycemic (low blood sugar) Episode.

Pt. #17's nursing care plan contains two goals for the blood sugar. One states to keep the blood sugar over 60. One states to keep the blood sugar between 70-150.

Dir. Q agreed,at the time of the record review, that there should be one set of parameters for the patient's blood sugar.

A medical record review was conducted on 8/3/2010 at 1:34 p.m. on Pt. #24's closed medical record. Pt. #24 was admitted to the facility on 5/31/2010 with Dehydration. The nursing care plan for Pt. #24 does not address the primary reason for hospitalization.

Dir. Q agreed, at the time of the record review, that the care plan does not reflect Pt. #24's reason for hospitalization and should have.

A medical record review was conducted on 8/4/2010 at 9:07 a.m. on Pt. #31's closed medical record. Pt. #31 was admitted to the facility on 3/3/2010 for Gall bladder surgery. The nursing care plan for Pt. #31 does not address the primary reason for hospitalization. There are no goals related to Pt. 31's surgical procedure.

Dir. Q agreed, at the time of the record review, that the care plan does not reflect Pt. #31's surgical procedure or interventions for after surgery as it should have.




18816

Examples by surveyor 18816:

Pt #13's MR review by surveyor 18816 on 8/4/10 at 11:10 AM revealed there is no care plan for Pt #13 admitted for gall bladder surgery. This is confirmed in interview with DIR Q on 8/4/10 at 2:45 PM.

Based on review of medical records (MR), review of policy and procedures and interview with staff, in 3 of 5 death records (1, 2 and 4) out of a universe of 30 records, the facility failed to ensure compete documentation of contacting the Organ Procurement Organization including contact name, time of contact and reference number.

Findings include:

Examples by surveyor 18816:

Facility policy titled Tissue, Eye and Organ Donation revised 4/10 states under 2. "Complete Mandatory Death Reporting Log with information required by OPO prior to calling the OPO. The policy does not include documenting OPO contact, contact reference number and time of contact in the medical record (MR).

Per Interview with Dir of OPO K on 8/3/10 at 10:20 AM revealed the Mandatory Death Reporting Log is not kept at part of the MR, but in a separate log book for monitoring.

Pt #1's MR reviewed on 8/3/10 at 1:30 PM revealed there is no documentation of the OPO contact name and reference number upon Pt #1's death on 12/20/09. This is confirmed in interview with QIS B on 8/4/10 at 1:40 PM.

Pt #2's MR reviewed on 8/3/10 at 2:00 PM revealed there is no documentation of the OPO contact name and reference number upon Pt #2's death on 1/11/10. This is confirmed in interview with QIS B on 8/4/10 at 1:40 PM.

Pt #4's MR reviewed on 8/3/10 at 2:00 PM revealed there is no documentation of the OPO contact name, time of contact and reference number upon Pt #2's death on 1/11/10. This is confirmed in interview with QIS B on 8/4/10 at 1:40 PM.

Findings include:
Based on medical record review, policy/procedure review, and staff interview, this facility failed to maintain complete, properly authenticated medical records in the following areas:
discharge summaries not dated or timed: 13 out of 19 out of a total of 31 eligible records (Pt.s #3, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, and 30);
blood product consent, 1 out of 2 out of a total of 5 eligible records (Pt. #22);
and in 1 of 1 medical records (Pt. #9), the facility failed to ensure patients are provided emergency contraception (EC) upon request.

Findings include:

Medical Staff Rules and Regulations, dated 6/17/2009, state on page 49, #2. "The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient."

On page 50, #8. "All clinical entries in the patient's medical record shall be accurately dated, timed and authenticated with a signature."

On page 51, #16. "The medical record shall be complete at the time of discharge...If the record still remains incomplete thirty (30) days following discharge...the chief of staff shall notify the practitioner..." and #C 1, "A general "Consent Form", signed by or on behalf of every patient admitted to the hospital, must be obtained at the time of admission."

Facility policy and procedure titled "Delinquent Medical Records Procedure" dated 7/2005 states, "A record is considered delinquent if it has not been completed within 31 days after the patient's discharge."

VP A, QIS B, and President L all agreed on 8/4/2010 at 7:30 a.m. the policy should read "30 days."

Discharge Summaries:
During medical record reviews conducted between 8/3/2010 starting at 10:40 a.m.-2:40 p.m. and 8/4/2010 starting at 7:55 a.m.-11:15 a.m., it was discovered that the following Pt. records, which were over 30 days of being discharged, did not have a properly authenticated Discharge Summary:

Pts. # 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, and 30 had discharge summaries that were not dated or timed by the physician.

The delinquency of the proper authentication for these documents does not correspond with the facility's Medical Staff Rules and Regulations or policy.

These findings were confirmed with VP A on 8/4/2010 between 1:57 p.m. and 2:25 p.m.

Pt. #3's medical record review by surveyor #18816 on 8/3/2010 at 2:30 p.m. revealed the discharge summary dictated on 5/20/2010 is not authenticated by the MD (Medical Doctor) with a date and time. This is confirmed in interview with QIS B on 8/4/2010 at 1:40 p.m.

Consents:
A medical record review was completed on 8/3/2010 at 1:15 p.m. on Pt. #22's closed medical record. Pt. #22 was discharged from the facility on 4/26/2010. There is a consent for receiving blood products which was not signed, dated or timed by a witness, such as the RN who would have been responsible for obtaining the consent.

These findings were confirmed on 8/4/2010 with VP A between 1:57 p.m. and 2:25 p.m.





18816

Findings include:

Facility policy titled Victims of Sexual Assault, Including Rape dated 5/08 states under Discharge: "...If the patient chooses to prevent conception and it has been determined by pregnancy test that the patient is not pregnant, the physician may offer emergency treatment to prevent conception per standing order. If the medication requires more than one dosage, the hospital will provide all subsequent dosages to the victim for later self-administration."

Pt #9's MR review on 8/4/10 at 10:45 AM revealed Pt #9 arrived in the Emergency Room (ER) on 4/29/10 requesting EC following an alleged sexual assault. Per the MR there is no documentation, a pregnancy test was offered or ordered, and there is no documentation the EC was offered and dispensed. This is confirmed in interview with QIS B on 8/4/10 at 1:40 PM.

Based on medical record review, review of Medical Staff Rules and Regulations, policy/procedure review, and in 3 of 3 staff interviews, (Staff A, B, and L), this facility does not ensure that there are properly authenticated reports by the responsible practitioner in the medical record in the following areas: History and Physical and Diagnostic reports.

Findings include:
Medical Staff Rules and Regulations, dated 6/17/2009, state on page 49, #2. "The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient."

On page 50, #8. "All clinical entries in the patient's medical record shall be accurately dated, timed and authenticated with a signature."

On page 51, #16. "The medical record shall be complete at the time of discharge...If the record still remains incomplete thirty (30) days following discharge...the chief of staff shall notify the practitioner..."

Facility policy and procedure titled "Delinquent Medical Records Procedure" dated 7/2005 states, "A record is considered delinquent if it has not been completed within 31 days after the patient's discharge."

VP A, QIS B, and President L all agreed on 8/4/2010 at 7:30 a.m. the policy should read "30 days."

History and Physicals:
During medical record reviews conducted between 8/3/2010 starting at 10:40 a.m.-2:40 p.m. and 8/4/2010 starting at 7:55 a.m.-11:15 a.m., it was discovered that the following Pt. records, which were over 30 days of being discharged, did not have a properly authenticated History and Physical (H&P):

Pts. # 18, 19, 22, 23, 24, 25, 26, 28, 30, and 31 had H&Ps that were not signed or dated by the Physician.

Pt. # 20 had an H&P that did not include a time for the Physician's dated signature.

Pt. #21 had an H&P that was not signed, dated or timed by the Physician.

The delinquency of the proper authentication for these documents does not correspond with the facility's Medical Staff Rules and Regulations or policy.

These findings were confirmed with VP A on 8/4/2010 between 1:57 p.m. and 2:25 p.m.

Diagnostic reports:
During medical record reviews conducted between 8/3/2010 starting at 10:40 a.m.-2:40 p.m. and 8/4/2010 starting at 7:55 a.m.-11:15 a.m., it was discovered that the following Pt. records, which were over 30 days of being discharged, did not have a properly authenticated Diagnostic Reports:

Pts. # 20, 22, 23, 24, 27, 28, and 30 had diagnostic reports that were not dated or timed by the physician.

Pt. #21 had a diagnostic report that was not dated, signed, or timed by the physician.

The delinquency of the proper authentication for these documents does not correspond with the facility's Medical Staff Rules and Regulations or policy.

These findings were confirmed with VP A on 8/4/2010 between 1:57 p.m. and 2:25 p.m.

Based on medical record review, review of Medical Staff Rules and Regulations, and staff interview, this facility failed to ensure there were properly documented physician orders written for medications, laboratory tests, and x-rays and that verbal orders are authenticated within 48 hours by the physician in 18 out of 31 medical records reviewed (Pts. #1, 2, 3, 5, 6, 7, 8, 10, 12, 13, 14, 15, 17, 21, 22, 23, 24, and 26)

Findings include:

Medical Staff Rules and Regulations, dated 6/17/2009, state on page 50, #8. "All clinical entries in the patients's medical record shall be accurately dated, timed and authenticated with a signature."

In an interview with Dir. of Health Information C on 8/2/2010 at 1:30 p.m., C stated that, "Verbal orders are to be authenticated within 48 hours."

A medical record review was completed on 8/3/2010 at 10:40 a.m. on Pt. #17's open inpatient/observation record. Pt. #17 was admitted to the hospital on 8/2/2010 through the Emergency Department (ED). At 6:12 p.m. the ED RN inserted a saline lock (capped intravenous [IV] line) and at 6:14 p.m. the ED RN gave D-50 (concentrated sugar solution) through the IV.

The ED Physician (Medical Doctor- MD) did not write an order for the saline lock or the D-50. The ED MD did not indicate a time that laboratory tests or X-rays were ordered.

These findings were confirmed by Dir. of Patient Care Q on 8/3/2010 at 11:00 a.m.

A medical record review was completed on 8/3/2010 at 1:05 p.m. on Pt. #21's closed medical record. Pt. #21 was admitted to the hospital on 5/11/2010 through the ED.

The ED MD did not indicate a time that laboratory tests or X-rays were ordered. The ED record (page 4 of 4) was not signed, dated or timed by the RN or the MD.

These findings were confirmed by VP A on 8/4/2010 between 1:57 p.m. and 2:25 p.m.

A medical record review was completed on 8/3/2010 at 1:15 p.m. on Pt. #22's closed medical record. Pt. #22 was admitted to the hospital on 4/19/2010 through the ED.

The ED MD did not indicate a time that laboratory tests or X-rays were ordered.

These findings were confirmed by VP A on 8/4/2010 between 1:57 p.m. and 2:25 p.m.

A medical record review was completed on 8/3/2010 at 1:23 p.m. on Pt. #23's closed medical record. Pt. #23 was admitted to the hospital on 3/19/2010 through the ED.

The ED MD did not indicate a time that laboratory tests or X-rays were ordered.

These findings were confirmed by VP A on 8/4/2010 between 1:57 p.m. and 2:25 p.m.

A medical record review was completed on 8/3/2010 at 1:34 p.m. on Pt. #24's closed medical record. Pt. #24 was admitted to the hospital on 5/31/2010 through the ED.

The ED MD did not indicate a time that laboratory tests or X-rays were ordered.

These findings were confirmed by VP A on 8/4/2010 between 1:57 p.m. and 2:25 p.m.

A medical record review was completed on 8/4/2010 at 11:15 a.m. on Pt. #26's closed medical record. Pt. #26 was admitted to the hospital on 3/24/2010 through the ED.

The ED RN inserted an IV and administered IV solution to Patient #26, however the ED MD did not write an order for them. The ED MD did order a "DuoNeb" (medication administered through inhalation for breathing problems), however dose and route are not specified. This order is incomplete.

The ED MD did not indicate a time that laboratory tests or X-rays were ordered.

These findings were confirmed by VP A on 8/4/2010 between 1:57 p.m. and 2:25 p.m.


18816

Examples by surveyor 18816:

Pt #1's MR review by surveyor 18816 on 8/3/10 at 1:30 PM, revealed there are emergency medications documented as given in the ED on 12/30/09 and no written orders to match. This is confirmed in interview with QIS B on 8/4/10 at 1:40 PM.

Pt #2's MR review by surveyor 18816 on 8/3/10 at 2:00 PM revealed there are emergency medications documented as given in the ED on 1/11/10 and no written orders to match. This is confirmed in interview with QIS B on 8/4/10 at 1:40 PM.

Pt #3's MR review by surveyor 18816 on 8/3/10 at 2:30 PM revealed there are telephone and verbal orders written between 4/13/10 and 5/3/10 that are not authenticated by the MD with a signature, date and/or time. This is confirmed in interview with QIS B on 8/4/10 at 1:40 PM.

Pt #5's MR review by surveyor 18816 on 8/4/10 at 7:15 AM revealed there are emergency medications documented as given in the ED on 6/27/10 and no written orders to match. This is confirmed in interview with QIS B on 8/4/10 at 1:40 PM.

Pt #6's MR review by surveyor 18816 on 8/4/10 at 9:20 AM revealed there are emergency medications documented as given in the ED on 8/2/10 and no written orders to match. There are ED orders for lab and X-ray that are not timed when written on 8/2/10. This is confirmed in interview with QIS B on 8/4/10 at 1:40 PM.

Pt #7's MR review by surveyor 18816 on 8/4/10 at 9:45 AM revealed there are discharge medications documented as given in the ED on 7/30/10 and no written orders to match. This is confirmed in interview with QIS B on 8/4/10 at 1:40 PM.

Pt #8's MR review by surveyor 18816 on 8/4/10 at 9:55 PM revealed there are emergency medications documented as given in the ED on 5/11/10 and no written orders to match. There are ED orders for lab and X-ray that are not timed when written on 5/10/10. This is confirmed in interview with QIS B on 8/4/10 at 1:40 PM.

Pt #10's MR review by surveyor 18816 on 8/4/10 at 9:55 PM revealed there are ED orders for lab and X-ray that are not timed when written on 1/27/10. This is confirmed in interview with QIS B on 8/4/10 at 1:40 PM.

Pt #12's MR review by surveyor 18816 on 8/4/10 at 10:35 AM revealed there are standing orders that are not written as standing orders by the RN on 2/16/10. This is confirmed in interview with QIS B on 8/4/10 at 1:40 PM.

Pt #13's MR review by surveyor 18816 on 8/4/10 at 11:10 AM revealed an Intravenous line was placed and normal saline was given without a corresponding order on 7/19/10. This is confirmed in interview with QIS B on 8/4/10 at 1:40 PM.

Pt #14's MR review by surveyor 18816 on 8/4/10 at 11:20 AM revealed there are ED orders for lab and X-ray that are not timed and a medication Levaquin (antibiotic) was given without a corresponding order on 2/7/10. This is confirmed in interview with QIS B on 8/4/10 at 1:40 PM.

Pt #15's MR review by surveyor 18816 on 8/4/10 at 12:35 PM revealed there are ED orders for lab and X-ray that are not timed when written on 11/7/09. This is confirmed in interview with QIS B on 8/4/10 at 1:40 PM.

Based on medical record review, review of the facility's Medical Staff Rules and Regulations, policy/procedure review, and staff interview this facility fails to ensure that reports are properly authenticated by the responsible professional in 11 out of 31 medical records reviewed (Pts. #3, 5, 8, 10, 11, 14, 15, 18, 19, 23, and 28).

Findings include:

Medical Staff Rules and Regulations, dated 6/17/2009, state on page 49, #2. "The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient."

On page 50, #8. "All clinical entries in the patient's medical record shall be accurately dated, timed and authenticated with a signature."

On page 51, #16. "The medical record shall be complete at the time of discharge...If the record still remains incomplete thirty (30) days following discharge...the chief of staff shall notify the practitioner..."

Facility policy and procedure titled "Delinquent Medical Records Procedure" dated 7/2005 states, "A record is considered delinquent if it has not been completed within 31 days after the patient's discharge."

VP A, QIS B, and President L all agreed on 8/4/2010 at 7:30 a.m. the policy should read "30 days."

Progress Notes:
During medical record reviews conducted between 8/3/2010 starting at 10:40 a.m.-2:40 p.m. and 8/4/2010 starting at 7:55 a.m.-11:15 a.m., it was discovered that the following Pt. records, which were over 30 days of being discharged, did not have a properly authenticated Progress Notes:

Pts # 18, 19, 23, and 28 had physician progress notes in the medical record that did not include a time they were written by the physician.

Without a time of the documented entry a chronological event line cannot be established.

These finding were confirmed on 8/4/2010 between 1:57 p.m. and 2:25 p.m. with VP A.


18816

Examples by surveyor 18816:

Pt #3's MR review by surveyor 18816 on 8/3/10 at 2:30 PM revealed the H & P completed by the Physician Assistant on 4/10/10 is not authenticated by the MD with a date and time to ensure the record is complete in 30 days. This is confirmed in interview with QIS B on 8/4/10 at 1:40 PM.

Pt # 5's MR review by surveyor 18816 on 8/4/10 at 7:15 AM revealed the Emergency Room/Urgent Care Report dictated on 6/27/10 is not authenticated by the MD with a date and time. This is confirmed in interview with QIS B on 8/4/10 at 1:40 PM.

Pt # 8's MR review by surveyor 18816 on 8/3/10 at 9:55 AM revealed the Emergency Room/Urgent Care Report dictated on 5/11/10 is not authenticated by the MD with a signature, date and time. This is confirmed in interview with QIS B on 8/4/10 at 1:40 PM.

Pt # 10's MR review by surveyor 18816 on 8/3/10 at 10:15 AM revealed the Emergency Room/Urgent Care Report dictated on 1/27/10 is not authenticated by the MD with a signature, date and time. This is confirmed in interview with QIS B on 8/4/10 at 1:40 PM.

Pt # 11's MR review by surveyor 18816 on 8/3/10 at 10:25 AM revealed the Emergency Room/Urgent Care Report dictated on 3/3/10 is not authenticated by the MD with a signature, date and time. This is confirmed in interview with QIS B on 8/4/10 at 1:40 PM.

Pt #14's MR review by surveyor 18816 on 8/4/1 at 11:20 AM revealed the Operating Report dictated on 2/11/10 is not signed by the MD within 30 days. This is confirmed in interview with QIS B on 8/4/10 at 1:40 PM.

Pt # 15's MR review by surveyor 18816 on 8/4/10 at 12:20 AM revealed the Emergency Room/Urgent Care Report dictated on 11/07/09 is not authenticated by the MD with a signature date and time. This is confirmed in interview with QIS B on 8/4/10 at 1:40 PM.

Based on observation, policy/procedure review, and staff interview, this facility does not ensure that medical records are secured from unauthorized access in 2 of 6 departments observed (Health Information department-to include garage storage-and outpatient rehabilitation). There is a potential for unauthorized persons to access the confidential medical records of all inpatients, and discharged patients, from this facility.

Findings include:

Facility policy titled, "Security of Medical Records;" dated 11/2003 states, "Areas housing medical record information shall be restricted to authorized personnel."
"Medical records shall not be left unattended in areas accessible to unauthorized individuals."
"All progress notes and continuing therapy notes located in the Rehab Department. These are maintained within the department in a locked storage area until the patient is done with treatment and then they are sent to Health Information for filing."
"Each department is responsible for safeguarding the medical record...Maintenance night staff will routinely check all doors on their routine security checks and report any deviation from this practice to the Safety Committee through regular reports. These departments include X-ray, Lab, Rehab, Cardiac Rehab, Respiratory Therapy and Health Information."

A tour of the Health Information department was conducted on 8/2/2010 at 1:30 p.m. with Dir. of Health Information (DHI) C.

Within the medical records department it was discovered that a Medicare certified Rural Health Clinic (RHC) files are stored in the Hospital medical records department. Both the RHC and the Hospital have separate staff, according to DHI C, and access by either staff to all of the records is possible.

Discharged medical records are stored in a storage garage on the hospital property. Both Hospital Health Information staff and RHC medical records staff have access to this storage garage and the medical records contained inside. There are no physical barriers separating the medical records to secure from unauthorized use from either staff.

These findings were confirmed by DHI C during the time of the observations.




18816

Example by surveyor 18816:

Per surveyor 18816 tour and interview with DIR M on 8/3/10 at 3:50 PM, outpatient medical records for the next day's patients were in cubbyholes and unsecured. There is a rolling cart that contained outpatient medical records that are unsecured. Per DIR M, housekeeping does not clean the office where medical records are stored when staff are present.

Based on review of medical records (MR), review of Medical Staff Rules and Regulations, and interview with staff, in 6 of 7 surgical MR (12, 13, 14, 15 and 16, and 28) out of a total of 31 records, the facility failed to ensure the surgical consent includes the risks and benefits of the procedure and signature of the surgeon that explained the procedure.

Findings include:

Medical Staff Rules and Regulations, dated 6/17/2009, state on page 54, #6, "The risks/benefits associated with a surgical procedure are discussed with the patient prior to documenting informed consent..."

Pt #12's MR review by surveyor 18816 on 8/4/10 at 10:35 AM revealed Pt #12 had a lap chole on 2/16/10. There is no documentation on the surgical consent of the risks and benefits of the procedure, and no signature of the surgeon. This is confirmed in interview with MGR N on 8/4/10 at 12:55 PM.

Pt #13's MR review by surveyor 18816 on 8/4/10 at 11:10 AM revealed Pt #13 had a lap chole on 7/19/10. There is no documentation on the surgical consent of the risks and benefits of the procedure, and no signature of the surgeon. This is confirmed in interview with MGR N on 8/4/10 at 12:55 PM.

Pt #14's MR review by surveyor 18816 on 8/4/10 at 11:20 AM revealed Pt #14 had a PEG tube placed on 2/11/10. There is no documentation on the surgical consent of the risks and benefits of the procedure, and no signature of the surgeon. This is confirmed in interview with MGR N on 8/4/10 at 12:55 PM.

Pt #15's MR review by surveyor 18816 on 8/4/10 at 12:35 AM revealed Pt #15 had an appendectomy on 11/7/10. There is no documentation on the surgical consent of the risks and benefits of the procedure, and no signature of the surgeon. This is confirmed in interview with MGR N on 8/4/10 at 12:55 PM.

Pt #16's MR review by surveyor 18816 on 8/4/10 at 12:40 AM revealed Pt #16 had a colonoscopy on 8/4/10. There is no documentation on the surgical consent of the risks and benefits of the procedure, and no signature of the surgeon. This is confirmed in interview with MGR N on 8/4/10 at 12:55 PM.

The result of this deficiency affects the 2 surgical patients seen at the facility during the survey as well as future surgical patients.



26711

Findings include:

A medical record review was conducted on Pt. #28's closed medical record on 8/3/2010 at 2:07 p.m. Pt. #28 had a colonoscopy (guided camera tube inserted through the intestine) during this hospitalization. There is no indication in the medical record that risks and benefits were discussed or what they were prior to consent being obtained.

These findings were confirmed by VP A on 8/4/2010 between 1:57 p.m. and 2:25 p.m.

Based on medical record review, review of Medical Staff Rules and Regulations, policy/procedure review, and staff interview in 5 out of 7 Surgical medical records (Pt. #12, 14, 15, 16, and 31) out of a total of 31 medical records reviewed, this facility fails to ensure that a proper post-anesthetic evaluation is completed and documented before being discharged.

Findings include:

Medical Staff Rules and Regulations, dated 6/17/2009, state on page 54, #7. "Every surgical patient shall have...post-anesthesia follow-up examination, with findings recorded within 48 hours after surgery."

Facility policy titled Post Anesthesia Evaluation dated 7/03 states under #1 "The initial post anesthesia evaluation must be made: a. after the patient has left the PACU (Post Anesthesia Care Unit) b. within forty-eight (48) hours post-op."

A medical record review was conducted on Pt. #31's closed medical record on 8/4/2010 at 9:07 a.m. Pt. #31 had general anesthesia on 3/4/2010 for the removal of the gall bladder. The date and time of the post anesthesia evaluation, which is difficult to read due to legibility, is 3/18/2010 at 13:[45] (1:45, however the '45' is not legible).

In an interview with CRNA O on 8/4/2010 at 1:30 p.m., O stated this was an evaluation that O did not document after surgery. It was discovered by the medical record department during a review of the discharge chart and CRNA O went to the medical record department on 3/18/2010 to complete the documentation.

The delinquency of this documentation does not coincide with the Medical Staff Rules and Regulations.

This finding was confirmed by the Operating Room Mgr. N and CRNA O at the time of the interview.



18816

Examples by surveyor 18816:

Pt #12's MR reviewed by surveyor 18816 on 8/4/10 at 10:35 AM revealed Pt #12 had gall-bladder surgery on 2/16/10. Pt #12's surgery finished at 9:35 AM, the post anesthesia note is written at 9:38 AM not allowing sufficient time to evaluate recovery from anesthesia medications. This is confirmed in interview with MGR N on 8//10 at 12:55 PM.

Pt #14's MR reviewed by surveyor 18816 on 8/4/10 at 11:20 AM revealed Pt #14 had a PEG tube (percutaneous endoscopic gastrostomy tube) placed on 2/11/10. The post anesthesia note states "Pt in room-t (temperature), BP (Blood Pressure), P (pulse) as per pre-(illegible) surgery lever as per preop-(illegible). This does not constitute a complete post anesthesia note including Cardiopulmonary status, level of consciousness, follow up care, observations and complications. This is confirmed in interview with MGR N on 8//10 at 12:55 PM.

Pt #15's MR reviewed by surveyor 18816 on 8/4/10 at 12:35 AM revealed Pt #15 had an appendectomy on 11/2/09. Pt #12's surgery finished at 8:45 AM, the post anesthesia note is written at 8:46 AM not allowing sufficient time to evaluate recovery from anesthesia medications. This is confirmed in interview with MGR N on 8//10 at 12:55 PM.

Pt #16's MR reviewed by surveyor 18816 on 8/4/10 at 12:40 PM revealed Pt #16 had a colonoscopy on 8/4/10. The post anesthesia note states "Pt in room-t, BP, P as per pre-op (illegible). This does not constitute a complete post anesthesia note including Cardiopulmonary status, level of consciousness, follow up care, observations and complications. This is confirmed in interview with MGR N on 8//10 at 12:55 PM.

Based on review of Quality Assurance (QA) meeting minutes, and staff interview, this facility does not incorporate contracted services (1 out of 3 reviewed-laundry) into its QA surveillance plans for tracking, trending, and data analysis. By not including the laundry service into the QA plan and determining its effectiveness and cleanliness, there is a potential for all patients who are served by the hospital to be exposed to contaminants.

Findings include:

Per interview with the Dir. of Plant Operations (DPO) D on 8/2/2010 at 2:00 p.m., it was determined that this facility contracts with another facility for laundry services.

DPO D is not aware of any involvement of the laundry service into this facility's QA plan.
A review of the QA program meeting minutes was completed on 8/3/2010 at approximately 1:30 p.m. There is no evidence of data tracking, trending, or analysis for the laundry or that the laundry service is incorporated into the facility's QA plan.

An interview regarding the QA program was conducted on 8/3/2010 at 2:20 p.m. with VP A, QIS B, and President L.

Surveyor #26711 asked what assurance this facility has in regards to knowing that the service this facility is contracting with for laundry is performing in a safe and appropriate manner and delivering a safe product for patients.

President L stated, "There is no assurance other than they are our partner and they do what they are supposed to do."

QIS B concurred that laundry services have not been included in the facility QA plan.

Based on medical record review of 3 out of 3 Swing Bed Pts. out of a total of 31 records reviewed, (Pts. #18, 19 and 29) and staff interview, this facility does not have an Activity program that is designed in such a way as to keep patients engaged and active in their environment while recuperating from illness.

Findings include:

An interview was conducted with SW E on 8/2/2010 at 12:50 p.m. regarding the Swing Bed (program for acute care patients who no longer require acute care but need further treatment for their illness/disease process).

SW E, who is also the Activities Program Director, describes the activity program as a cart with movies, puzzle books, puzzles, cards, and other solitary activities. Also included as an activity are Chaplain visits.

SW E stated that patients are informed of the availability of the activities on admission and are approached on a daily basis, by SW E, to determine if they are interested in any of the activities on the cart however, "We don't have many group activities due to our population."

SW E stated that on occasion, weather dependent, there will be opportunities to go outside. Also, during football season there could be an occasional football party.

SW E states, "We do not have an activity calender."

Dir. of Patient Care E, stated during a conversation on 8/3/2010 at 12:10 p.m. that, "there is no activity calender...there are no planned activities," when asked how families might know when activities are planned and if they would be interested in joining the patient.

A medical record review was conducted on 8/4/2010 at 7:55 a.m. on Pt. #29's open medical record. Pt. #29 is an 84 year old who was admitted to the Swing Bed program on 7/21/2010 for therapy after an insertion of a pacemaker for an irregular heart beat.

Pt. #29's activity attendance record indicates the following activities: watching television, 1:1 SW visit, family friend visit. Visits from facility staff are not an activity and there are no planned activities recorded that would keep the patient engaged and involved while hospitalized.

These findings were confirmed by VP A on 8/4/2010 between 1:57 p.m.-2:25 p.m.

A medical record review was conducted on 8/3/2010 at 12:10 p.m. on Pt. #18's closed medical record. Pt. #18 is a 79 year old with dementia (a disorder that affects memory) who was cared for on the Swing Bed unit from 6/10/201-6/17/2010 for recovery from an infection.

Pt. #18's activity attendance record indicates the following activities: watching television, 1:1 SW visit, care giver visits, and Chaplain visits. Visits from facility staff are not an activity and there are no planned activities recorded that would keep the patient engaged and involved while hospitalized.

These findings were confirmed by VP A on 8/4/2010 between 1:57 p.m.-2:25 p.m.

A medical record review was conducted on 8/3/2010 at 12:50 p.m. on Pt. #19's closed medical record. Pt. #19 is an 81 year old who was cared for on the Swing Bed unit from 3/31/2010-4/8/2010 for recovery after recent Pneumonia.

Pt. #19's activity activity attendance record indicates the following activities: watching television, puzzle books, reading, 1:1 SW visits, family/friend visits, and Chaplain visits. Visits from facility staff are not an activity and there are no planned activities recorded that would keep the patient engaged and involved while hospitalized.

These findings were confirmed by VP A on 8/4/2010 between 1:57 p.m.-2:25 p.m.