HospitalInspections.org

A. Based on a letter of attestation and staff interview it was determined that the Hospital failed to ensure completion of medical records 30 days after discharge.

Findings include:

1. A letter of Attestation was presented by the Director of Health Information Management (HIM) on 6/25/09 at 12:50 AM. The letter indicated that as of June 25, 2009, there were 22 incomplete records, 30 days after discharge.

2. The above finding was conveyed to the Director of HIM on 6/25/09, at 12:50 AM during interview.





19840

A. Based on a review of the manufacturer's guidelines, observation, and staff interview, it was determined, that the Hospital Pharmacy failed to ensure unusable biologicals were not available for use.

Findings include:

1. A correspondence from the Hospira Manufacturer was reviewed on 6/25/09. The document included: "... how long Hospira large volume parenteral solutions in LifeCare flexible containers can be stored out of the overwrap... Once the overwrap is removed, moisture escapes from the bag at a faster rate... Continuous water evaporation causes the content of the bag to become progressively more concentrated... We recommend that PVC LifeCare containers with fill volumes greater than 25 mL, out of their overwrap, be used within (30) days. LifeCare containers with 25 mL fill volumes should be used within twenty one (21) days after removal from the overwrap... This recommendation applies to the following Hospira products... General I.V. Solutions... ADD-Vantage Partial-Fill and LifeCare Partial-Fill Solutions..."

2. On 6/25/09, at 11:15 AM, a tour of the Pharmacy was conducted. A 100 ml bag of 0.9 NS solution had been removed from the overwrap and was available for use, without a label to include the date of expiration for the solutions.

3. The above findings were conveyed to the Director of Pharmacy during an interview on 6/25/09 at approximately 11:30 AM.



19840

A. Based on review of Hospital policy, review of memorandum, laboratory culture log review, and staff interview, it was determined that the Hospital failed to ensure that the laboratory culture log book was completed, as required.

Findings:

1. On survey date 6/25/09 at 1:00 PM a memorandum on the subject of "Microbiology log-book" dated 4/1/09, was reviewed. The Memo required, "...Effective today, when a specimen is set-up in Microbiology all data must be recorded for each specimen. Data are: Date and time, time receiving, time set-up, plates set-up. Follow standard procedures to set-up. Log sheet is ready to record all data. All information is essential for the processing and interpretation of culture's results."

2. On survey date 6/25/09 at 1:45 PM, policy No. 51.0019.8, titled: Specimen Receipt and Accessioning was reviewed. The policy required: "C. Procedure... 3.Document the time specimen was received. Register the specimen with all the information in the laboratory log book..."

3. The culture log book was reviewed on 6/25/09 at 12:45 PM The culture log book lacked a received time for 20 of 30 specimens on 6/13, and 6/14/09.

4. The Laboratory Manager was interviewed on 6/25/09. at 1:00 PM. The Manager stated all specimens are plated within an hour of receipt. The findings were conveyed to the Laboratory Manager during the interview.



19843

A. Based on review of Hospital policy, clinical record review and staff interview, it was determined that in 2 of 2 (Pt. #1 and 2) clinical record reviewed in the Medical Detoxification Unit, the Hospital failed to ensure orders for dietary consult were completed.

Findings include:

1. The Hospital policy reviewed on 6/25/09 at 3:00 PM, titled "Food Delivery System-Diet Orders" required, "It is Policy of this facility that all patients will be provided with a diet as ordered by the physician...diet consult and communication are done via computer."

2. The clinical record of Pt. #1 was reviewed on 6/25/09 at 10:30 AM. Pt. #1 was a 56 year old female admitted on 6/23/09 with diagnoses of Medical Detoxification, History of Drug Use, and Symptoms of Withdrawal. The Medical Substance Abuse Unit Standing orders for Substance Abuse protocol dated 6/23/09, included a dietary consultation. The record lacked documentation that a dietary consult was done.

3. The clinical record of Pt. #2 was reviewed on 6/25/09 at 10:45 AM. Pt. #1 was a 43 year old male admitted on 6/23/09 with diagnoses of Medical Detoxification, History of Drug Use, and Symptoms of Withdrawal. The Medical Substance Abuse Unit Standing orders for Substance Abuse protocol dated 6/23/09, included a dietary consultation. The record lacked documentation that a dietary consult was done.

4. The Hospital Dietician was interviewed at 10:30 am on 6/25/09. The Dietician stated that she does not review the physicians order that required a dietary consult.

5. The above finding was conveyed to the Nursing Educator, during an interview on 6/25/09 at 11:00 AM


19843