HospitalInspections.org

A. Based on observation and staff interview it was determined that the Hospital failed to ensure that confidentiality of patient records is maintained.

Findings include:

1. During a tour of the pain management clinic on 7/14/09 at 2:00 PM, it was observed that five patient medical records were laying on top of an open file cabinet which contained other patient records. The medical records were visible and accessible to the patient waiting room.

2. During an interview with the Nurse Manager on 7/14/09 at 2:00 PM, the above findings were confirmed.

A. Based on policy and procedure, record review and staff interview it was determined that in 1 of 3 (Patient (Pt.) #17) records reviewed with restraints the Hospital failed to ensure that a timely physician order was received according to Hospital policy.

Findings include:

1. The Hospital policy titled, " Restraints, Use of" under "Protective Restraints-2 Point Only" "1. The order must originate from the physician...nurse. The physician must be notified within 12 hours...order."

2. The medical record of Pt. #17 was reviewed on 7/15/09. Pt. #17 was admitted to the Hospital on 2/18/09 with the diagnosis of Altered Mental Status. Documentation indicated that Pt. #17 was "restless"and was in a Geriatric chair on 2/19/09 at 0900. Documentation indicated a physician order dated 2/20/09 at 1430 was signed by the physician in the wrong area on the restraint form with no time or date.

3. During an interview with the Nurse Manager on 7/15/09 at 3:00 PM, the above findings were confirmed.

A. Based on medical record review and staff interview, it was determined that in 4 of 5 (Pt #'s 10, 19, 21 & 23) of patients with orders for Nasal Swabs for MRSA (Methicillin Resistant Staph Aureus), the Hospital failed to ensure that all orders were authenticated promptly by the ordering physician.

Findings include:

1. The medical record of Pt #10 (Patient) was reviewed on survey date 07/15/09. Pt #10 was admitted to the Intensive Care Unit (ICU) on 04/17/09 with diagnoses of Acute Alcohol Abuse, Multi- Drug Abuse and Bi-Poplar Disorder. An order for a nasal swab for MRSA was initiated on 04/17/09. Documentation failed to indicate that the order was authenticated by the ordering physician.

2. The medical record of Pt #19 was reviewed on survey date 07/15/09. It indicated that Pt #19 was admitted to the ICU on 03/18/09 with the diagnoses of Sepsis, Malaise & Diarrhea. An order for a nasal swab for MRSA was initiated on 03/18/09. Documentation failed to indicate that the order was authenticated by the ordering physician.

3. The medical record of Pt #21 was reviewed on 07/15/09. It indicated that Pt #21 was admitted to the ICU on 05/06/09 with a diagnosis of Pneumonia. An order for a nasal swab for MRSA was initiated on 05/06/09. Documentation failed to indicate that the order was authenticated by the ordering physician.

4. During an interview conducted on 07/15/09 at 3:30 PM with the Director of Medical Surgical Services, the above findings were confirmed.
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B. Based on record review and staff interview, it was determined that in 4 of 31 ( Pt #13, 14,18, 28) records reviewed, the Hospital failed to ensure that all orders including verbal orders, are dated, timed, and authenticated promptly by the ordering physician.

Findings include:

1. The medical record of Pt #13 was reviewed on survey date 7/14/09. Pt #13 was admitted on 7/12/09 with diagnosis of Term Labor. Documentation failed to indicate that orders for Admission dated 7/12/09 and Obstetrical/Gynecological orders dated 7/12/09 were authenticated by the ordering physician.

2. The medical record of Pt#14 was reviewed on survey date 7/14/09. Pt#14 was admitted on 7/13/09 at 0:44 with diagnosis of Normal Newborn Delivery. Documentation failed to indicate that Newborn Nursery orders dated 7/13/09 were authenticated by the ordering physician.

3. The medical record of Pt#18 was reviewed on survey date 7/15/09. Pt #18 was admitted on 4/8/09 with diagnoses of Senile Dementia and Confusion. Documentation indicated that a telephone order for "Xanax 0.25 mg p.o...." was signed by the physician but there was no date or time. documentation indicated that on Pt#18's discharge medical orders there was no date or time.

4. The medical record of Pt #28 was reviewed on survey date 7/15/09. Pt #28 was admitted to the Day Surgery Department on 3/19/09 with a diagnosis of Abdominal Pain. Pt #28 underwent a Laparoscopic Cholecystectomy with general anesthesia. Documentation failed to indicate that orders for Pre and Post- Op Anesthesia were authenticated by the ordering practitioner.

5. During an interview conducted on 07/15/09 at 3:30 PM with the Director of Medical Surgical Services, the above findings were confirmed.


C. Based on medical record review and staff interview, it was determined that in 8 of 14 (Pt #'s 2, 3, 8, 16, 18, 20, 24 & 25) medical records reviewed in which patients were treated in the ED (Emergency Department), the Hospital failed to ensure that all orders were dated, timed and authenticated by the physician in a timely manner.

Findings include:

1. The medical record of Pt #2 was reviewed on 07/15/09. It indicated that Pt #2 was admitted to the ED on 04/27/09 with a chief complaint of MVA (Motor Vehicle Accident) patient vs. car. Documentation indicated that the "Time of Initial Orders:" area on the ED physician's order form was not completed.

2. The medical record of Pt #3 was reviewed on 07/15/09. It indicated that Pt #3 was admitted to the ED on 06/10/09 with a chief complaint of Fever & Sore Throat. Documentation indicated that the "Exam Time: & Time of Initial Orders:" areas on the ED physician's order form were not completed.

3. The medical record of Pt #8 was reviewed on 07/15/09. It indicated that Pt #8 was admitted to the ED on 01/18/09 with a chief complaint of Cerebral Vascular Accident and Urinary Tract Infection. Documentation indicated that the "Disposition Time:" area on the ED physician's order form was not completed.

4. The medical record of Pt #16 was reviewed on 7/15/09. It indicated that Pt. #16 was admitted to the ED on 4/5/09 with a chief complaint of Malaise and Fatigue and Transischemic Attack. Documentation indicated that the "Disposition Time:" area on the ED physician's order form was not completed.

5. The medical record of Pt #18 was reviewed on 7/15/09. It indicated that Pt. #18 was admitted to the ED on 4/7/09 with a diagnosis of "Senile Dementia and Confusion". Documentation indicated that the ED physician's initial order form was not complete.

6. The medical record of Pt #20 was reviewed on 07/15/09. It indicated that Pt #20 was admitted to the ED on 06/24/09 with a chief complaint of Hypoglycemic Reaction. Documentation indicated that the "Disposition Time: & Time of Initial Orders:" areas on the physician's order form were not completed.

7. The medical record of Pt #24 was reviewed on 7/15/09. It indicated that Pt. #24 was admitted to the ED on 4/23/09 with the chief complaint of Fever. Documentation indicated that the "Disposition Time:" area on the ED physician's order form was not completed.

8. The medical record of Pt #25 was reviewed on 7/15/09. It indicated that Pt. #25 was admitted to the ED on 4/16/09 with the chief complaint of Fever. Documentation indicated that the "Disposition Time:" area on the ED physician's order form was not completed.

9. During an interview conducted on 07/15/09 2:00 PM with the Quality Services Coordinator, the above findings were confirmed.


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A. Based on medical record review and staff interview, it was determined that in 1 of 20 (Pt # 29) in which the patient had surgical procedures, the Hospital failed to ensure that all informed consents for procedures and treatments were signed, dated and timed by the physician prior to the procedure being performed.

Findings include:

1. The medical record of Pt #29 was reviewed on 07/16/09. It indicated that Pt #29 was admitted to the Hospital on 03/17/09 for a Cesarean Section. Documentation indicated that a form titled, "Consent for Surgical and/or Special Procedures" and the form titled, "Consent and Release for Shared Cesarean Birth Experience" was not signed, dated or timed by the physician.

2. During an interview conducted on 07/16/09 at 10:00 AM with the Quality Resources Coordinator, the above finding was confirmed.

A. Based on record review and staff interview, it was determined that in 3 of 20 closed records, the hospital failed to ensure that discharge summaries were completed.

Findings include:

1. The medical record of Patient (Pt) #10 was reviewed on survey date 7/15/09. Pt #10 was admitted to the facility on 4/17/09 with diagnoses of Acute Alcohol Abuse, Multi- Drug Abuse and Bi-Poplar Disorder. Pt #10 was discharged to home on 4/20/09. Documentation failed to indicate that a discharge summary was completed.

2. The medical record of Pt #28 was reviewed on survey date 7/15/09. Pt #28 was admitted to the Day Surgery Department on 3/19/09 with a diagnosis of Abdominal Pain. Pt #28 was discharged the same day after out-patient surgery. Documentation failed to indicate that a discharge summary was completed.

3 .The medical record of Pt #30 was reviewed on survey date 7/16/09. Pt #30 was admitted to the Day Surgery Department on 3/23/09 with diagnosis of Benign Prostatic Hypertrophy. Pt #30 was discharged the same day after an out-patient surgical procedure. Documentation failed to indicate that a discharge summary was completed.

4. During an interview on 7/15/09 at 3:30 PM with the Director of Medical Surgical Services, the above findings were confirmed.

A. Based on a review of the Medical Staff Bylaws, Rules and Regulations, a review of the incomplete records report and staff interview, it was determined that the Hospital failed to ensure that all discharged medical records were completed in a timely manner.

Findings include:

1. The Hospital Bylaws, Rules and Regulations were reviewed on 07/15/09. It indicated under, "Medical Records...all records of discharged patients must be completed within 15 days of the date the patient is discharged, and signed within 30 days of discharge."

2. The number of incomplete records past 30 days after discharge was 35, as of July 16, 2009.

3. During an interview conducted on 07/16/09 at 9:00 AM with the Quality Services Coordinator, the above finding was confirmed.

A. Based on Hospital policy, observation and staff interview, it was determined that the Hospital failed to provide patient safety by failing to ensure that drugs and biologicals are maintained in accordance with applicable standards of practice, consistent with Federal and State law.

Findings include:

1. The Hospital policy titled, "Crash Cart Check List, sentence #2, Crash carts in all department except ICU (see specific policies) are checked every 24 hours for the following: 1) Drawers locked..."

2. During a tour of the Obstetrical (OB) unit on 07/14/09 at 1:30 PM with an OB nurse, it was observed that the crash cart located in the Caesarean Section (C-section) suite was unlocked.

3. During an interview with the OB nurse, it was reported that the pharmacy staff had recently checked the cart and replaced medications but had not placed a lock on the cart. On 07/15/09 at 3:30 PM during an interview with the Director of Medical Surgical Services, the above finding was confirmed.

A. Based on observation and staff interview it was determined that the Hospital failed to ensure that all medical supplies are safe for patient usage.

Findings include:

1. During a tour of the operating room suite, day surgical unit, and intensive care unit on 7/14/09 at 10:00 am, it was observed that the emergency cart contained several supplies that were outdated.

2-14 French catheter and glove kit-expired 5/07
1-14 French catheter and glove kit-expired 11/06
1 14 French catheter and glove kit-expired 9/06
1-Central venous catheter kit-expired 6/08
2 packages of electrodes -expired 2/03
2-blue top blood collection tubes-expired 3/09
2-yellow top blood collection tubes-expired 6/09
1-red top blood collection tubes-expired 5/09

2. During an interview with the Nurse Manager on 7/14/09 at 10:30 am, the above findings were confirmed.

A. Based on policy, observation, and staff interview it was determined that the Hospital failed to ensure that infection control policies and procedures were followed to prevent the spread of infection.

Findings include:

1. The Hospital policy titled, "Food Service Uniform Policy" under "Uniform Policy", "Clean working attire-head coverings...worn. They must be clean with no holes and cover the head from the forehead to the nape of the neck."

2. During a tour of the dietary department on 7/14/09 at 2:00 PM, it was observed that one of the staff did not have hair completely covered.

3. During an interview with the Nurse Manager on 7/14/09 at 2:30 PM, the above findings were confirmed.

A. Based on observation, policy and procedure, and staff interview it was determined that the Hospital failed to ensure that staff followed surgical attire policies.

Findings include:

1. During a tour of the surgical suites on 7/14/09 at 9:30 am, it was observed that six staff were observed to be wearing jewelry while in restricted areas.

2. The Hospital policy titled, "Operating Room Attire" Policy: " No jewelry allowed" revised 12/08.

3. During an interview with the Nurse Manager on 7/14/09 at 10:00 am, the above findings were confirmed.

A. Based on Hospital policy, medical record review and staff interview, it was determined that in 5 of 11 (Pt #'s 22, 26, 28, 30 and 31) records of patients who received anesthesia , the hospital failed to ensure that a post-anesthesia evaluation was completed and documented by an individual qualified to administer anesthesia, no later than 48 hours after the surgery or procedure requiring anesthesia.

Findings include:

1. The Hospital policy titled, "Patient Care Policies, Anesthesia Department, under #7, A post-anesthetic visit should be performed and recorded accordingly on the patient's chart within 24 hours after completion of the anesthetic course. The post-anesthesia visit documentation should include the date and time, presence or absence of complications, status of the patient..."

2. The medical record of Pt #22 was reviewed on survey date 07/15/09. Pt #22 was admitted to the facility with diagnoses of Osteoarthritis, Hypertension and Right Total Knee Replacement. Pt #22 underwent surgery for a knee replacement on 03/10/09 with general anesthesia. Documentation failed to indicate that a post anesthesia evaluation was completed.

3. The medical record of Pt #26 was reviewed on survey date 07/15/09. Pt #26 was admitted to the facility on 02/26/09 with diagnoses of Colon Cancer and Chronic Obstructive Pulmonary Disease. Pt #26 required a Laparoscopic Colon Resection on 02/26/09 with general anesthesia. Documentation failed to indicate that a post anesthesia evaluation was completed.

4. The medical record of Pt #28 was reviewed on survey date 07/15/09. Pt #28 was admitted to the Day Surgery Department on 03/19/09 with a diagnosis of Abdominal Pain. Pt #28 underwent a Laparoscopic Cholecystectomy with general anesthesia on the same day (03/19/09). Documentation failed to indicate that a post anesthesia evaluation was completed.

5. The medical record of Pt #30 was reviewed on survey date 07/16/09. Pt #30 was admitted to the Day Surgery Department on 03/23/09 with diagnosis of Benign Prostatic Hypertrophy. Pt #30 underwent a Cystography with Laser Transurethral Resection on 03/23/09 under spinal anesthesia. Documentation failed to indicate that a post anesthesia evaluation was completed.

6. The medical record of Pt #31 was reviewed on survey date 07/15/09. Pt #31 was admitted on 04/28/09 with diagnoses of Gastrointestinal Bleeding, and Possible Mass/Pancreas. Pt #31 underwent an Esophagogastroduodenoscopy with a neck biopsy requiring anesthesia services on 04/30/09. Documentation failed to indicate that a post anesthesia evaluation was completed.

7. During an interview conducted on 07/15/09 at 3:30 PM with the Director of Medical Surgical Services, the above findings were confirmed.