HospitalInspections.org

Based on policy/procedure review, open and closed medical record review, and staff interview, the hospital Administrative staff failed to ensure all physicians dated and timed each medical record entry in accordance with facility policy. Problems identified with documentation in 2 of 2 open skilled patient records (Patients # 1 and #2), 5 of 6 open acute patient records (#5, #6, #7, #8, and #9), and 3 of 3 open Emergency Room (ER) patient records (#10, #11, and #12) . The hospital reported a skilled patient census of 2 patients, an acute patient census of 6, and approximately 10 ER visits per day.

When physicians fail to document the date and/or time of all entries into the medical record there is a potential to disrupt the timeliness for further therapeutic actions, assessments, and delay patient treatment.

Findings include:

1. Review of Medical Staff Rules and Regulations, approved by the Medical Staff and Board of Trustees on 3/22/2010 revealed: "II. Medical Records A. General Requirements #2: All entries should be dated and authenticated by the physician". The Medical Staff Rules and Regulations lacked a requirement for timing all entries in the medical record.

2. Review of hospital policy titled, "Legal Medical Record Standards- Section VI" effective dated 6/2010, revealed: "C. All medical record entries are to be dated, the time entered, and signed".

3. Review of open skilled patient medical records On 3/15/11, revealed the following:

a. Review of Patient #1's medical record showed the physician admitted the patient to the skilled unit for antibiotic therapy on 3/8/12. Six of 8 physician progress notes lacked the time the physician entered the progress note into the medical record.

b. Review of Patient #2 ' s medical record showed the physician admitted the patient to the skilled unit on 3/1/11 for physical therapy following surgery. Review of the 3/2/11 physician history and physical showed the physician had failed to document the time he/she entered the history and physical into the patient ' s medical record.

4. Review of open acute patient medical records On 3/15/11, revealed the following:

a. Review of Patient #5's medical record showed the physician admitted the patient to the acute nursing unit on 3/12/11 for weakness, nausea/vomiting, and dehydration. Review of the physician progress notes showed the physician failed to document the time that he/she entered the progress notes into the patient's medical record on 2 of 2 progress notes.

b. Review of Patient #6's medical record showed the physician admitted the patient to the acute nursing unit on 3/10/11 for acute renal failure. Medical record review showed the physician failed to document the time he/she entered 3 of 3 physician progress notes and 1 (of 1) history and physical into the patient's medical record.

c. Review of Patient #7's medical record showed the physician admitted the patient to the acute nursing unit on 3/9/11, for pneumonia. Medical record review showed the physician failed to document the time he/she entered 2 of 6 physician progress notes and 1 (of 1) history and physical into the patient's medical record.

d. Review of Patient #8's medical record showed the physician admitted the patient to the acute nursing unit on 3/12/11 for congestive heart failure. Medical record review showed the physician failed to document the time he/she entered the history and physical and physician consultation into the patient's medical record.

e. Review of Patient #9's medical record showed the physician admitted the patient to the acute nursing unit on 3/12/11 for a small bowel obstruction. Medical record review showed the physician failed to document the time he/she entered the history and physical and 2 of 6 physician progress notes in the patient's medical record.

5. Review of open Emergency Room (ER) patient medical records On 3/16/11, revealed the following:

a. Review of Patient #10's medical record showed the patient presented to the ER on 3/16/11 and requested treatment following a physical assault. Medical record review showed the physician failed to document the time he/she entered 1 (of 1) physician progress note in the patient's medical record.

b. Review of Patient #11's medical record showed the patient presented to the ER on 3/16/11 and requested treatment for a knee infection. Medical record review showed the physician failed to document time he/she entered 1 (of 1) progress note in the patient's medical record.

c. Review of Patient #12's medical record showed the patient presented to the ER on 3/16/11 requesting treatment for depression. Medical record review showed the physician failed to document the time he/she entered 2 of 2 physician progress notes in the patient's medical record.

6. During an interview, on 3/14/11 at 3:30 PM, the Nurse Manager of the Medical/Surgical Unit acknowledged that physicians were not consistently timing all entries in the medical records. The Nurse Manager also verified that the medical records for Patient ' s 1, 2, 5, 6, 7, 8, and 9 lacked evidence that physicians had timed each of their entries. According to the Nurse Manager, the hospital ' s policy is that all staff must date, time and sign each entry in the medical record.

13. During an interview, on 3/16/11 at 10:45 AM, the Vice President of Operations reported the administrative staff was aware that physicians were not consistently timing all entries in the medical records. She stated that administrative staff is working with the medical staff to increase physician compliance.

Based on observation, document review and staff interviews, chemotherapy nursing staff failed to secure medications stored the clean utility room cabinets. The administrative staff identified a monthly average of 20 inpatients and 25 outpatients for the chemotherapy infusion center.

Failure to secure medications could result in unauthorized access, use, and/or diversion of medications.

Findings include:

1. Observations during a tour of the chemotherapy infusion center on 3/15/11 at 10:30 AM revealed the following medications stored in an unlocked cabinet located in an unsecured clean utility room.

a. 10 blister packs of Diphenhydramine HCL, 25 milligrams (mg)
b. 9 - vials of Magnesium Sulfate 50 mg
c. 1 - vial of Venofer (Iron Sucrose) 5 ml
d. 105 tablets of Acetaminophen 325 mg
e. 1 vial of Methylprednisolone sodium succinate 125 mg
f. 2 vials of Ceftriaxone 1 gram
g. 1 vial Vancomycin Hydrochloride 500 mg
h. 4 Diphenhydramine HCL 50 mg Carpojet
i. 4 - intravenous bags of Magnesium Sulfate
j. 11 - vials of Furosemide 40 mg
k. 2 vials of Aloxi (Palonestron HCL)

2. During an interview, at the time of the observation, the Assistant Vice President stated maintenance staff removed the lock from the door and verified the cabinets lacked a locking mechanism. The Assistant Vice President stated, "This room is not monitored by chemotherapy infusion staff, this is a public hallway so anyone could have access to these medications."

During an interview, at the time of the observation, Staff B, Pharmacist, acknowledged the unsecured medications and stated, "I'll take these medications back to the pharmacy until we are able to secure them."

During an interview on 3/15/11 at 10:50 AM, Staff C, Registered Nurse (RN) stated, "There's never been a lock on the door or cupboard."

During an interview on 3/16/11 at 9:05 AM, the Pharmacy Director said the medications should always be secure. The Pharmacy Director verified that he/she was aware that the door and cabinet in the clean utility room needed a locking mechanism but had not done anything about it yet.

3. Review of hospital policy titled "Medication Security" revised 8/08 revealed in part, "...All drugs stored in this hospital shall be accessible only to authorized personnel ...All drugs ...will be stored in lockable containers or areas. Medications ...diagnostic areas will be stored in locked cabinets or drawers."

Based on observation, review of hospital documents and staff interviews, the hospital Dietitian failed to ensure dietary staff washed their hands after handling dirty dishes in the dish room. The Dietitian reported a daily average of 112-120 meals produced a day.

The hospital dietary staff's failure to wash their hands after handling dirty dishes and utensils could potentially spread bacteria and food debris to clean dishes and utensils and passed on to the patients.

Findings include:

1. Observation, during the initial kitchen tour, on 3/14/11 at 1:20 PM revealed Staff A, Dietary Aide, picked up dirty dishes, cups, and silverware and rinsed them over the sink. Staff A handled the water sprayer and dirty dishes with bare hands. Staff A placed the dirty dishes, cups and silverware in the washing rack and pushed the rack into the dishwasher. After rinsing and stacking the dirty dishes, cups and silverware, Staff A walked to the clean side of the dishwasher and picked up clean serving equipment from the clean drying rack.

Staff A did not wash his/her hands prior to picking up the clean serving equipment.

Staff A took the clean serving equipment and walked out of the kitchen. Staff A returned to the kitchen, the Dietician asked Staff A if he/she washed their hands prior to picking up the clean serving equipment. Staff A responded, "No, I usually do, I just forgot. I know I was suppose to wash my hands, I just forgot."

Staff A moved to the clean dishes in the drying rack and picked up clean dishes. Staff A did not wash their hands after returning to the kitchen or prior to picking up the clean dishes. The Dietitian immediately stopped Staff A from removing the clean dishes and instructed Staff A to wash their hands.

2. Review of the hospital documents revealed:

a. In-service sign in sheet dated January 27, 2009 revealed Staff A attended the in-service education that reviewed of hand washing and the 2005 Food Code.

b. The 2005 Iowa Food Code Section 2-301.14 stated in part, "...Food employees shall clean their hands...(E) After handling soiled EQUIPMENT OR UTENSILS..."

c. Sanitation and the Food Service Area document stated in part, "...The person working the dirty dish area should not handle any clean dishes without...washing his/her hands..."

d. Evaluation dated and signed by Staff A on 2/17/11 stated in part, "...[Staff A] is well aware of our sanitation policies..."

3. During an interview on 3/15/11 at 1:20 PM, the Dietitian acknowledged Staff A's orientation included the Sanitation and Food Service Area document review.