HospitalInspections.org

Based on observation, employee interviews, policy review, review of hospital documents and staff interview, it was determined that for 3 of 12 (25%) outpatient service departments in the sample, the hospital failed to provide patients with a copy of the patient rights. Findings include:

The hospital policy entitled "Patient Rights and Responsibilities" stated, "...Outpatient service departments will make the 'Patient Rights and Responsibilities' document available to the patient..."

The hospital document entitled "Conditions for Treatment" given to patient's at admission/registration stated, "Notification and Acknowledgement of Patient Rights and Privileges". The document contained the statement "I have had the opportunity to receive and review Christiana Care Health Services Notice of Privacy Practices" with a place for initials. Below this statement was a patient signature line and date.

During a tour of the hospital outpatient areas on 1/21/11, the following was identified:

A. During the tour of the hospital Outpatient Surgery Center at 10:10 AM, Surveyor C questioned Registration Clerk B about the registration process for patients coming for surgical procedures. Registration Clerk B stated that the patient was given the "Conditions for Treatment" form and the "Notice of Privacy Practices" and the "Notice of Privacy Summary" but not the brochure containing the rights and responsibilities. Brochures for "Patient's Rights and Responsibilities" were on the counter.

This finding was confirmed by the Vice President of Peri-Operative Services during the tour.

B. During an interview at 1:20 PM in the Heart and Vascular Intervention Services unit with the clerk at the registration desk, Clerk A stated the "Patient's Rights and Responsibilities" pamphlets were on the counter but not handed to the patients at the time of registration. In addition, patient's rights were not posted in the waiting room or elsewhere.

This finding was confirmed at the time of the interview with Nurse Manager R.

C. During an interview at 1:50 PM in the Nuclear Medicine area with the clerk at the registration desk, Clerk C stated that only the "Privacy Practices" were given to the patient's and not the "Patient's Rights and Responsibilities". In addition, patient's rights were not posted in the waiting room or elsewhere.

This finding was confirmed with Director of Patient Care Services A at 1:50 PM on 1/21/11.

Based on observation, policy review and staff interview, it was determined that for 5 of 27 (18%) Christiana Hospital inpatient units in the sample, staff failed to ensure confidentiality of patient medical records (Patient #'s 26, 110, 111, 112, 113, 114 and 115). Findings include:

The hospital policy entitled "Information Security - Information Confidentiality and Security" stated, "...Confidential - Protected Health Information...Individually identifiable health information (electronic, paper)...any health information that includes one of the following...Name...Any Dates...Medical record numbers..."

The hospital policy entitled "Information Security - Computer Workstation Use and Security" stated, "...User Responsibilities...Position the screen away from unauthorized users...Unacceptable workstation use...Leaving private or confidential information out in the open or unsecured..."

Survey activities included patient care observations for inpatient and outpatient units and departmental tours. The following issues related to patient confidentiality were identified during these observational activities:

I. Christiana Hospital - 3D - District 2

A. Chart spines visible to unauthorized individuals - 1/20/11 at 12:45 PM
- While passing through the main thoroughfare, Surveyor C and Nurse Manager X observed two medical records laying on the ledge of the district desk. The spine of the charts, visible to unauthorized individuals, contained the first and last names for Patient #'s 26 and 115.

Nurse Manager V, present at the time of discovery, confirmed this finding.

II. Christiana Hospital - 6 B - District 3

A. Open computer screen - 1/21/11 at 8:47 AM
- While passing through the main thoroughfare, Surveyor A and Director of Patient Care Services A observed an unlocked computer screen that was unmanned. The computer screen, facing the general public, contained personal and medical information belonging to Patient #114.

Director of Patient Care Services A, present at the time of discovery, confirmed this finding.

III. Christiana Hospital - 2 D - District 3

A. Open computer screen and unsecured medical record - 1/21/11 at 9:55 AM
- While passing through the main thoroughfare, Surveyor A and Nurse Manager V observed an unlocked computer screen that was unmanned. The computer screen, facing the general public, contained personal and medical information belonging to Patient #113. In addition, Patient #113's medical record was laying unsecured on the same work table.

Nurse Manager V, present at the time of discovery, confirmed that the medical records were not secure and that the expectation would be that the medical records would not be accessible or readable to unauthorized individuals.

IV. Christiana Hospital - 4 A - Central Desk

A. Chart spine visible to unauthorized individuals - 1/21/11 at 1:05 PM
- While passing through the main thoroughfare, Surveyor A and Director of Patient Care Services B observed three medical records laying on the ledge of the central desk. The spine of one chart, visible to unauthorized individuals, contained Patient #112's first and last names.

Director of Patient Care Services B, present at the time of discovery, confirmed this finding.

V. Christiana Hospital - 6 B - Central Desk

A. Chart spine visible to unauthorized individuals - 1/24/11 at 10:26 AM
- While passing through the main thoroughfare, Surveyor A and Director of Patient Care Services A observed a medical record laying on the ledge of the central desk. The spine of the chart, visible to unauthorized individuals, contained Patient #110's first and last names.

Director of Patient Care Services A, present at the time of discovery, confirmed this finding.

B. Open computer screen and unsecured medical record - 1/24/11 at 10:30 AM
- While passing through the main thoroughfare, Surveyor A and Director of Patient Care Services A, observed an unlocked computer screen that was unmanned. The computer screen, facing the general public, contained personal and medical information belonging to Patient #111. In addition, Patient #111's medical record, which was open, was laying unsecured on the same work table.

Director of Patient Care Services A, present at the time of discovery, confirmed this finding.

Based on medical record review, policy review and staff interview, it was determined that for 2 of 5 (40%) restrained patients in the sample (Patient #'s 36 and 88), a physical restraint intervention was utilized without a physician's order. Findings include:

The hospital policy entitled "Restraints and Seclusion, Guidelines for Use" stated, "...Authority to initiate...Restraint and Seclusion...In an emergency situation only, the Registered Nurse (RN) may initiate Restraint...in order to protect the safety of the patient...A verbal or written order will be obtained from the physician or designee immediately (within a few minutes) after the initiation of the emergency intervention..."

A. Patient #36
Review of the "Order Information for: Restraints Renew, Med/Surg (Medical/Surgical)" revealed a physician's order for 2 point restraints to be applied on 1/15/11 at 6:11 AM.

Review of the "Patient Care Flowsheet" documentation revealed that Patient #36 was initially restrained on 1/14/11 at 7:00 PM. Review of the medical record (paper and electronic) failed to support evidence of a physician's order for the 1/14/11 restraint application.

Interview with Nurse Manager G and RN B on 1/21/11 at 9:45 AM confirmed this finding. Nurse Manager G reported that the restraints remained on "through the night".

B. Patient #88
Review of the "Nursing Care Flowsheet" documentation revealed that Patient #88 was initially restrained on 1/24/11 at 12:05 AM. Review of the medical record (paper and electronic) failed to support evidence of a physician's order for the 1/24/11 restraint application.

Interview with RNs C and D on 1/28/11 at 2:40 PM confirmed this finding.

Based on observation, policy review and staff interview, it was determined that for 4 of 27 (15%) inpatient units at Christiana Hospital, nursing staff failed to follow the hospital policy for hand hygiene. Findings include:

The hospital policy entitled "Hand Washing/Alcohol Hand Gel Procedure" stated, "...Handwashing/alcohol hand gels will be used for the following...Before donning and after removing gloves and other PPE...When moving from a contaminated body site to a clean body site during patient care...After contact with excretions, secretions, blood, body fluids, mucous membranes, non-intact skin, or contaminated objects whether or not gloves are worn or visibly soiled. Hands must be washed with soap and water..."

The hospital policy entitled "Glove Selection and Use" stated, "...Hands will be washed after removing gloves...Gloves will be changed during care on a single patient when moving from a more contaminated area to a less contaminated area..."

The hospital policy entitled "Standards of Nursing Practice" stated, "The RN/LPN assumes responsibility and accountability for assuring that a stated level of quality is maintained as it relates to individual patients on a specific unit. The RN/LPN also contributes to maintaining hospital wide standards for quality of nursing care. This is evidenced by...Incorporating principles of infection control in the implementation of nursing care..."

A. On 1/20/11 at 11:15 AM, Surveyor C observed the following wound care and suctioning provided by registered nurse (RN) E to Patient #116:

- sanitized hands and applied gloves
- assembled supplies
- opened supplies
- opened normal saline solution and poured a small amount into a gauze packet
- removed old dressing that was saturated with serosanguineous (bloody, serous) drainage
- cleansed the sacral wound with the saline soaked gauze
- patted the wound dry with clean gauze
- removed a new gauze pad from the package, applied santyl (a medication that removes dead tissue) to the gauze and placed it on the wound
- applied Tegaderm (a self adhesive barrier)
- removed right glove, took pen from pocket with right hand and noted the date and time of the dressing change on the tape border
- donned a new right glove and applied the tape border to the dressing
- replaced and adjusted sheet protector pad under the patient
- repositioned Patient #116 onto her right side and raised the head of the bed
- reapplied the bunny boot to the patient's right leg
- propped pillows under legs
- reapplied tubing to the patient's compression boots
- touched the IV pump
- readjusted the pillow under the patient's head
- opened a suction kit
- removed gloves
- donned new sterile gloves from the suction kit
- suctioned the patient 3 times
- removed gloves and washed hands

During Patient #116's care, RN E failed to:
- Remove gloves and perform hand hygiene when moving from a contaminated area to a clean area during wound care and after performing wound care
- Sanitize hands prior to suctioning the patient

During an interview with Director of Patient Care Services B and Nurse Manager Q on 1/20/11 at 11:40 AM, it was confirmed that RN E failed to follow nursing standards and handwashing and glove use policies.

B. During an observational tour of the obstetrical/gynecologic triage unit on 1/19/11 at 8:30 AM, Surveyor A and Nurse Manager B observed RN G, with gloves on, leaving Room 1937 with a used supply wrapping in one hand and a clear-colored laboratory slide in the other hand. RN G took the items in her hands to another room and immediately returned to the main desk area with gloves still on. RN G checked the patient chart on the desk with the same gloved hands.

RN G failed to:
- Remove gloves after handling contaminated objects and perform hand hygiene

Nurse Manager B confirmed that this witnessed observation was an infection control issue and was unacceptable.

During an interview with Infection Prevention Manager A and Infection Preventionist A on 1/25/11 at 3:00 PM, Infection Preventionist A reported that the entire hand hygiene program was based upon CDC (Centers for Disease Control) guidelines and that nurses should be following the guidelines. The observation of 1/19/11 at 8:30 AM, was discussed and Infection Preventionist A confirmed that the nurse failed to follow hand hygiene protocol.

C. Patient #10 - Unit 3A
During a medication administration observation on 1/19/11 at 12:05 PM, RN H was observed checking Patient #10's identification bracelet prior to administering medication.

RN H administered the medication, left the room and charted on Patient #10's medical record.

RN H failed to:
- Perform hand hygiene after physical contact with Patient #10's wrist and before accessing the patient's medical record

Nurse Manager B, present at the time of observation, confirmed that this was an infection control issue and that RN G failed to perform hand hygiene between activities.

The above observation was discussed with Infection Prevention Manager A and Infection Preventionist A on 1/25/11 at 3:00 PM. Infection Preventionist A reported that the nurse should have used a hand sanitizer after making contact with the patient's skin.

D. Patient #27 - Unit 4C

On 1/20/11 at 12:15 PM, Surveyor A observed the following wound care provided by RN I to Patient #27:

- Cleansed hands, donned gloves, removed tape and blood saturated gauze from chest tube insertion site
- Disposed of soiled dressing in red isolation bag
- Removed gloves
- Set-up clean field (opened sterile gloves, gauze package, drain sponge)
- Donned sterile gloves
- Performed wound care
- Removed gloves
- Disposed of trash; dated and timed dressing; tied patient gown
- Moved chest tube drainage cannister
- Cleansed hands

RN I failed to perform hand hygiene:
- After removal of gloves; and
- Before donning sterile gloves

On 1/20/11 at 1:40 PM, Surveyor A reviewed the wound observation findings with Nurse Manager E. Nurse Manager E reported that the expectation would have been that RN I would have performed hand hygiene after the removal of gloves and prior to donning sterile gloves.

During an interview with Infection Prevention Manager A and Infection Preventionist A on 1/25/11 at 3:00 PM, Infection Prevention Manager A reported that the nurse was "going from dirty to clean" and should have sanitized her hands after glove removal and at completion of the "dirty process".

Based on review of active and closed medical records, policy and procedure review and staff interview, it was determined that for 3 of 65 (5%) inpatients in the sample whose care plans were reviewed (Patient #'s 7, 13 and 45), staff failed to develop and/or revise the plan of care. Findings include:

The hospital policy entitled "Standards of Practice" stated, "...The development of a written, individualized, plan of care, based upon problem identification and outcome goals collaboratively developed with patient/family and other health care providers...Implementation of the plan of care is necessary to achieve desired outcomes...The RN (registered nurse) reviews & documents the appropriateness and completeness of the plan of care at least once each 24 hours..."

The hospital document entitled "Provision of Patient Care Plan" stated, "...The ongoing assessment and reassessment of patients allows for the care plan process to be initiated. The goal of planning care is to provide individualized safe and patient centered care in settings responsive to specific patient needs...Care goals and plans are...revised based on the individual patient needs..."

A. Patient #7 - Headache
On 1/19/11 at 10:17 AM, Surveyor A interviewed Patient #7. During the interview, Patient #7 reported that she had been having symptomatic headaches since having an epidural on 1/17/11 and was resting in bed due to a persistent headache.

1. Medical record entries provided evidence of physician's orders and specific interventions related to complaints of headache. However, nursing staff failed to update/revise the plan of care to address the headache when identified at the following times:

a. Review of the Anesthesia "Consultation" dated 1/18/11 at 5:00 PM revealed that a consult was ordered on 1/17/11 to rule out "spinal headache". The consult revealed that Patient #7 had an "incidental dural puncture" during the insertion of an epidural for labor analgesia on 1/17/11.

b. Review of the "Medication Administration Record (MAR)" revealed a 1/17/11 order for Tylenol every 4 hours as needed for headache. Documentation on the MAR revealed that Patient #7 was medicated for a headache at the following times:

- 1/17/11 at 6:40 PM
- 1/18/11 at 2:20 AM and 10:15 AM
- 1/19/11 at 4:35 AM

Review of the "Maternal Plan of Care" failed to provide evidence that Patient #7's care plan was revised to address/include the patient's complaints of headache, treatment interventions or goals.

Interview with Nurse Manager A on 1/19/11 at 9:50 AM confirmed this finding. Nurse Manager A reported that there should have been a care plan because the "headaches were a problem with interventions".

B. Patient #13 - History of Seizures
1. The 2011 Lippincott Williams & Wilkins document utilized by the hospital entitled "Seizure Management" stated, "...Document that the patient requires seizure precautions and record all precautions taken..."

The "Supplemental Plan of Care - Neurologic Status" stated, "Seizure Precautions...Prevention or minimization of potential injuries sustained by a patient with known seizure disorder...Refer to seizure management nursing procedure...patient will not sustain injury related to seizure activity..."

2. Review of the medical record revealed nursing staff failed to update/revise the plan of care to address seizures when identified at the following times:

a. "Admission Referral Process" completed 11/24/10 at 9:02 PM indicated that Patient #13 had a history of seizures.

b. "Nursing Profile Form" documented by the RN daily from 11/24 until discharge on 12/3/10 noted seizure precautions.

c. "Orders" report 11/25/10 at 6:45 PM stated, "Gabapentin (a seizure medication) 300 mg cap"

d. "Scheduled Meds" list documented administration of gabapentin 300 mg twice a day beginning 11/25/10 at 7:13 PM until discharge on 12/3/10

e. "Pre-Procedure Anesthesia Evaluation" completed on 11/29/10 at 11:00 AM stated, "seizures...per mom - 6/10 last"

f. "Patient Care Flowsheet Medical/Surgical 5 Day" dated 11/29/10, first noted "seizure precautions"

Interview with Nurse Manager E on 1/25/11 at 3:20 PM confirmed that Patient #13's seizure precautions should have been added to the care plan.

C. Patient #45 - Constipation
On 1/24/11 at 9:05 AM, Surveyor A interviewed Patient #45. Patient #45 reported having concerns about constipation at least three times during the 20 minute conversation. Patient #45 reported that constipation had also been a problem at home and that he had been receiving medication for constipation since admission.

1. Review of the medical record revealed nursing staff failed to update/revise the plan of care to address constipation when identified at the following times:

a. "History and Physical" - Documented the use of stool softeners at home; At the time of assessment, Patient #45 reported that his last bowel movement was two days previously.

b. "Interdisciplinary Patient Progress Record" - 1/24/11 at 9:20 AM - Physician documented that Patient #45 was "very constipated...very nauseous...very physically distressed...Severe constipation...Has not had significant relief despite enema, suppository/lactulose...Plan...D/C (discontinue) enema & try suppository daily..."

c. "Medication Administration Record (MAR)" - Patient #45 received the following medications to relieve constipation:

1/20/11 - Senokot S tablets (2 tablets); Lactulose 30 milliliters (ml) (1 dose)

1/21/11 - Colace capsules (1); Senokot S tablets (4 tablets)

1/22/11 - Colace capsules (4); Senokot S tablets (4 tablets); Lactulose 30 ml (1 dose)

1/23/11 - Colace capsules (3); Senokot S tablets (4 tablets); Lactulose 30 ml (1 dose); Dulcolax suppository (1)

1/24/11 - Colace capsules (1); Senokot S tablets (2 tablets); Lactulose 30 ml (1 dose); Fleet enema (1)

d. "Current Orders Report" - 1/20/11 - Nursing - "Constipation Assessment"

e. "Initial Nutrition Assessment and Progress Record" - Assessment by the dietitian on 1/21/11 at 9:00 AM revealed that staff was to ensure that an "aggressive" bowel regime was maintained.

Review of the "Plan of Care and Education Record" failed to provide evidence that Patient #45's care plan was revised to address/include the patient's complaints of constipation, treatment interventions or goals.

Interview with Nurse Manager K on 1/24/11 at 9:25 AM confirmed this finding. Nurse Manager K reported that Patient #45 should have had a care plan for constipation since he had been on a "constipation protocol since admission".

Based on medical record review, policy review and staff interview, it was determined that for 42 of 109 (39%) patients (Patient #'s 5, 9, 10, 11, 12, 13, 16, 17, 18, 19, 20, 21, 27, 28, 36, 37, 38, 39, 41, 42, 43, 44, 45, 46, 59, 61, 62, 68, 69, 73, 75, 76, 77, 82, 84, 86, 87, 88, 90, 92, 93 and 103) in the sample, the medical record entries failed to contain the required elements. Findings include:

The hospital policy entitled "Documentation in the Medical Record" stated, "...Guidelines...Date, time (military) and sign entries...Write or print legibly...Make entries that are timely, consistent and avoid contradictions..."

The Medical-Dental Staff Rules stated, "...A minimal history and physical shall be accurate...Orders will be dated and timed...Verbal orders shall be signed, dated and timed...no later than 48 hours after the transmission of the verbal order. Verbal orders shall be authenticated...within forty-eight (48) hours...Telephone orders shall be signed, dated and timed...no later than 48 hours after the transmission of the telephone order and authenticated...within forty-eight (48) hours..."

Review of medical records revealed that entries lacked the following required information:

1. Patient #5
1/18/11
A. "Doctor's Order Sheet" - Failed to include the date and time of physician authentication

Interview with Nurse Manager A on 1/19/11 at 9:50 AM confirmed this finding.
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2. Patient #9
1/16/11
A. "OB/GYN (Obstetrics/Gynecology) Triage Orders" - Failed to include the time of order entry
B. "Doctor's Order Sheet" documentation
1. Physician failed to authenticate the verbal order
2. Diagnostic imaging failed to include time of medical record entry
3. Failed to include time of order entry (2 entries)

1/17/11
A. "Doctor's Order Sheet" - Failed to include time of order entry
B. "Doctor's Order Sheet" - Failed to include time and year of order entry
C. "Interdisciplinary Patient Progress Record" - Failed to include the year of entry (5 entries)

1/19/11
A. "Interdisciplinary Patient Progress Record" - Failed to include the time of entry

Interview with Patient Care Coordinator A on 1/19/11 at 11:30 AM confirmed these findings.
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3. Patient #10
1/14/11
A. "Doctor's Order Sheet" - Failed to include time of order entry (2 entries)

1/17/11
A. "Doctor's Order Sheet" - Failed to include time of order entry

Interview with Nurse Manager B on 1/19/11 at 2:07 PM confirmed these findings.
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4. Patient #11
1/8/11
A. "Progress Record - Neonatal Intensive Care Unit (NICU)" - Failed to include the time of entry

Interview with Nurse Manager C on 1/19/11 at 3:25 PM confirmed this finding.
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5. Patient #12
1/18 and 1/19/11
A. "Progress Record - Neonatal Intensive Care Unit (NICU)" - Failed to include the time of entry

Interview with Nurse Manager C on 1/19/11 at 3:28 PM confirmed this finding.
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6. Patient #13
11/26, 11/27, 11/29, 11/30, 12/2 and 12/3/10
A. "Interdisciplinary Patient Progress Record" - Failed to include the time of entry (10 entries)

Interview with the Manager of Patient Safety and Accreditation A on 1/25/11 at 4:05 PM confirmed this finding.
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7. Patient #16
1/10 - 1/18/11
A. "Interdisciplinary Patient Progress Records" - Failed to include the time of entry (13 entries)

Interview with Nurse Manager W on 1/19/11 at 11:05 AM confirmed this finding.
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8. Patient #17
1/19/11
A. "Interdisciplinary Patient Progress Record" - Was illegible and failed to include the time of entry

Interview with Nurse Manager Y on 1/19/11 at 1:05 PM confirmed this finding.
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9. Patient #18
January 2011
A. "Interdisciplinary Patient Progress Record" - Failed to include the day of entry and time (2 entries)

1/15, 1/16 and 1/18/11
A. "Interdisciplinary Patient Progress Record" - Failed to include a time (4 entries)

Interview with Nurse Manager Y on 1/19/11 at 11:05 AM confirmed this finding.
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10. Patient #19
1/18/11A. "Interdisciplinary Patient Progress Record" - Failed to include a time

Interview with Nurse Manager W on 1/19/11 at 11:05 AM confirmed this finding.
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11. Patient #20
January 2011
A. Gauze sponge "Count Record" - Failed to include the day of entry

1/18/11
A. "...Epidural Analgesia Orders..." - Failed to include the time of order entry
B. "...Post Partum Orders..." - Failed to include the time of order entry
C. "...History and Physical" - Failed to include time of examination
D. "Obstetrical Record Page IV" - Failed to include date and time of entry

1/19 - 1/20/11
A. Obstetrical Record Page V - Failed to include time of entry

Interview with Patient Care Coordinator A on 1/20/11 at 10:30 AM confirmed these findings.
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12. Patient #21
1/17/11
A. "Doctor's Order Sheet" - Failed to include time of order entry
B. "...Anesthesiology Epidural Orders" - Failed to include time of order entry

1/18/11
A. "Doctor's Order Sheet" - Failed to include time of order entry (3 entries)

1/19/11
A. "Doctor's Order Sheet" - Failed to include time of order entry
B. Dictated "Operative Report" for 1/17/11 procedure - Age of patient inaccurate (patient 16 years old, not 60)
C. "Pre-Procedure Anesthesia Evaluation" - Failed to include time of evaluation
D. "...Post Anesthesia Care Unit" orders - Failed to include time of entry

Interview with Nurse Manager D on 1/20/11 at 9:55 AM confirmed these findings.
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13. Patient #27
1/18/11
A. "Interdisciplinary Patient Progress Record" - Failed to include the time of entry (2 entries)
B. "Interdisciplinary Patient Progress Record" - Failed to include the year of entry
C. Dictated "History and Physical (H&P)" - Site of pleural effusion (fluid in chest/lungs) and hemothorax (collection of blood in the chest) were inaccurate; Documentation for "Principal Diagnosis" and "Brief Admission Summary" on the H&P identified the affected side as being on the right. During a wound care observation, Patient #27 was observed to have a left-sided chest tube.

Interview with Nurse Manager E on 1/20/11 at 1:30 PM confirmed these findings.

In response to the H&P inconsistency, Physician A was notified and "reviewed the radiographs and the clinical case" of Patient #27 and confirmed that the patient had a left-sided pleural effusion. Director of Patient Safety and Accreditation A presented Surveyor A with the written clarification on 1/21/11 at 3:47 PM.
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14. Patient #28
A. "...Post Anesthesia Care Unit" orders - Failed to include time and year of entry on pages 1 and 2

1/18/11
A. "Interdisciplinary Patient Progress Record" - Failed to include the year of entry (diagnostic studies)
B. "Interdisciplinary Patient Progress Record" - Failed to include year and time of entry (3 entries)

1/19/11
A. "Pre-Procedure Anesthesia Evaluation" - Failed to include time of evaluation

1/20/11
A. "Interdisciplinary Patient Progress Record" - Failed to include time of entry

Interview with Nurse Manager F on 1/20/11 at 3:10 PM confirmed these findings.
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15. Patient #36
1/13/11
A. "History and Physical" - Failed to include year (Dictated document was not in electronic record at time of review)

1/14, 1/15, 1/17, 1/18 and 1/19/11
A. "Interdisciplinary Patient Progress Record" - Failed to include time and year of entry

1/15 and 1/16/11
A. "Progress Record - Surgical Critical Care" - Failed to include time of entry

1/15, 1/17, 1/18, 1/19 (2 entries), 1/20 and 1/21/11
A. "Interdisciplinary Patient Progress Record" - Entries were only partially legible

1/21/11
A. "Wound Packing Communication Log" - Inaccurate number documented for "Total of Item in Wound" (1)

Review of the "Wound Packing Communication Log" documentation dated 1/21/11 at 5:45 AM revealed that Patient #36's wound had been packed with one (1) 4x4 gauze sponge. On 1/21/11 at 8:10 AM, Surveyor A observed wound care provided to Patient #36. Registered nurse (RN) J removed not one gauze as documented, but two (2) gauze sponges from the open abdominal wound.

Interview with Nurse Manager G on 1/21/11 at 8:33 AM confirmed these findings.
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16. Patient #37
A. "H&P" - No time or date of entry (Document was not in electronic record at time of review)

Interview with RN B on 1/21/11 at 11:25 AM confirmed this finding.
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17. Patient #38
1/12/11
A. "Interdisciplinary Patient Progress Record" - Failed to include time of entry and year of entry was incorrect (2010)

January 14
A. "Interdisciplinary Patient Progress Record - Procedure Note" - Failed to include year of entry

1/15/11
A. "Interdisciplinary Patient Progress Record" - Failed to include time of entry

1/17/11
A. "Progress Record - Trauma Service/Critical Care" - Failed to include time of entry

1/19/11
A. "Progress Record - Trauma Service/Critical Care" - Failed to include time and year of entry by confirming attending physician (2 entries)

Interview with Nurse Manager H on 1/21/11 at 11:00 AM confirmed these findings.
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18. Patient #39
1/18/11
A. "Pre-Procedure Anesthesia Evaluation" - Failed to include time of evaluation
B. "...Post Anesthesia Care Unit" orders - Failed to include time of entry on pages 1 and 2
C. "Trauma History and Physical" - Age of patient inaccurate (patient 27 years old, not 19)

Interview with Director of Patient Care Services B on 1/21/11 at 3:30 PM confirmed these findings.
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19. Patient #41
1/19/11
A. "Interdisciplinary Patient Progress Record" - Year of doppler study entry was inaccurate (2010)

1/20/11
A. "Interdisciplinary Patient Progress Record" - Failed to include time of entry (2 entries)

Interview with Director of Patient Care Services B on 1/21/11 at 2:45 PM confirmed these findings.
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20. Patient #42
1/21/11
A. "Interdisciplinary Patient Progress Record" - Failed to include time of entry
B. "Carotid Wet Reading" - Failed to include time of entry

Interview with Director of Patient Care Services B on 1/21/11 at 2:20 PM confirmed these findings.
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21. Patient #43
1/19/11
A. "Interdisciplinary Patient Progress Record" - Failed to include time of entry (2 entries - ultrasound and vascular lab)

1/23/11
A. "Interdisciplinary Patient Progress Record" - Failed to include year of entry

Interview with Director of Patient Care Services A on 1/21/11 at 8:35 AM confirmed these findings.
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22. Patient #44
1/24/11
A. "Interdisciplinary Patient Progress Record" - Failed to include time of entry; Page 2 of entry, which was not dated or timed, was not identified as a continuation of the 1/24/11 medicine note

Interview with Nurse Manager J on 1/24/11 at 11:30 AM confirmed these findings.
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23. Patient #45
January 21
A. "Interdisciplinary Patient Progress Record" - Failed to include time and year of entry (diagnostic studies)

1/22 and 1/23/11
A. "Interdisciplinary Patient Progress Record" - Failed to include time of entry

Interview with Director of Patient Care Services A on 1/24/11 at 10:00 AM confirmed these findings.
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24. Patient #46
1/23/11
A. "Emergency Department Interdisciplinary Continuation Notes" - Failed to include year of entry
B. "Interdisciplinary Patient Progress Record" - Failed to include year of entry (2 entries)
C. "History and Physical" - Allergy information was inaccurate; Review of the "Emergency Physician Record" and "Assessment/Patient Care Flowsheet" revealed documentation to support that Patient #46 was allergic to Penicillin (antibiotic) and Vasotec (used to treat high blood pressure and heart failure). The allergy section of the "History and Physical" dictated on 1/23/11 at 1:13 PM, contained the statement "She has no known allergies".

Interview with Nurse Manager L on 1/24/11 at 12:05 PM confirmed these findings.
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25. Patient #59
1/25/11
A. "Emergency Department Intake and Interdisciplinary Record" - Year of entry was inaccurate (2012)

Interview with Nurse Manager M on 1/25/11 at 9:15 AM confirmed this finding.
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26. Patient #61
1/6/11
A. "Referral/Request for Anatomical Donations" - Documentation was inconsistent; The "Outcome of Consent" on the referral revealed that consent was "Granted" and a "check mark" identified that there was "Next of kin opposition". Review of "Donor Operative Report" documentation revealed that Patient #61's liver and kidneys were harvested. At the time of medical record review, there was no documentation in the medical record to support that consent had been obtained for the removal of Patient #61's body organs.

As a result of the above finding, Director of Patient Care Services B contacted the Gift of Life Program on 1/25/11 at 11:20 AM. The Director was able to obtain a copy of the consent for donation. Review of the "Consent for Organ and/or Tissue Donation" supported that consent was given to the Gift of Life by Patient #61's sister on 1/5/11 at 11:30 PM.

B. "Patient Care Flowsheet" - Failed to include a date (An entry timed at 11:15 PM documented "Brain Death Exam")

Interview with Director of Patient Care Services B on 1/25/11 at 11:20 AM confirmed these findings.
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27. Patient #62
12/20/10
A. "Interdisciplinary Patient Progress Record" - Month of entry was inaccurate (10/20/10 - Brain Death Clinical Exam completed); The "Protocol for the Certification of Brain Death" was dated 12/21/10 at 2:10 AM.

Interview with Director of Patient Care Services B on 1/25/11 at 12:45 PM confirmed this finding.
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28. Patient #68
A. "Admission/Visit Summary" - Failed to include time or date of entry

Interview with Patient Care Coordinator B on 1/26/11 at 1:10 PM confirmed this finding.
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29. Patient #69
A. "Admission/Visit Summary" - Failed to include time or date of entry

Interview with Patient Care Coordinator B on 1/26/11 at 1:10 PM confirmed this finding.
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30. Patient #73
1/25/11
A. "Emergency Physician Record" - Inconsistent documentation (Physician circled no known allergies, but documented a list of three (3) allergies)

Interview with Nurse Manager I on 1/31/11 at 10:25 AM confirmed these findings.
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31. Patient #75
1/27/11
"Attending Emergency Physician Notes" - Entry only partially legible

Interview with Nurse Manager I on 1/28/11 at 12:55 PM confirmed this finding.
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32. Patient #76
1/27/11
"Attending Emergency Physician Notes" - Entry only partially legible

Interview with Nurse Manager I on 1/28/11 at 12:55 PM confirmed this finding.

33. Patient #77
1/27/11
"Attending Emergency Physician Notes" - Entry only partially legible

Interview with Nurse Manager I on 1/28/11 at 12:55 PM confirmed this finding.
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34. Patient #82
1/26/11
"H & P update note" - Failed to include time of entry

Interview with the Vice President of Perioperative Services on 1/26/11 at 9:30 AM confirmed this finding.
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35. Patient #83
1/26/11
"Department of Anesthesiology Post Anesthesia Care Unit" order sheet - Failed to include time of entry

Interview with the Vice President of Perioperative Services on 1/26/11 at 10:10 AM confirmed this finding.
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36. Patient #84
1/25/11
Discharge instructions - Failed to include time of entry

Interview with the Vice President of Perioperative Services on 1/26/11 at 11:20 AM confirmed this finding.
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37. Patient #86
1/26/11
A. "Pre-Procedure Anesthesia Evaluation" - Failed to include time of entry
B. "Department of Anesthesiology Post Anesthesia Care Unit" order sheet - Failed to include time of entry

Interview with the Vice President of Perioperative Services on 1/26/11 at 9:55 AM confirmed this finding.
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38. Patient #88
1/23/11
"History and Physical" - Dictated report was inaccurate (Documentation referred to a total hip arthroplasty, however, there was nothing in the medical record to support the statement). Physician B and RNs C and D reviewed the medical record and confirmed this finding.

Physician B contacted Physician C, the dictating physician, on 1/28/11 at 2:40 PM to report the finding.
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39. Patient #90
1/26/11
A. "Pre-Procedure Anesthesia Evaluation" - Failed to include time of entry
B. "Consent for Gastrointestinal Endoscopy" - Failed to contain the signature of the physician

1/25 - 1/28/11
A. "Interdisciplinary Patient Progress Record" - Failed to include time of entry (7 entries)

Interview with Nurse Manager P on 1/28/11 at 11:55 AM confirmed this finding.
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40. Patient #92
A. "Interdisciplinary Patient Progress Record" note for a late entry of blood transfusion - Failed to include the date and time

1/21 - 1/23/11
A. "Interdisciplinary Patient Progress Record" - Failed to include the time of entry (4 entries)

Interview with Nurse Manager O on 1/26/11 at 11:55 AM confirmed this finding.
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41. Patient #93
1/24 - 1/26/11
A. "Interdisciplinary Patient Progress Record" - Failed to include the time of entry (3 entries)

Interview with Nurse Manager O on 1/26/11 at 11:55 AM confirmed this finding.
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42. Patient #103
1/15 - 1/21/11
A. "Interdisciplinary Patient Progress Record" - Failed to include the time of entry (3 entries)

Interview with Nurse Manager AA on 1/28/11 at 11:35 AM confirmed this finding.

Based on closed medical record review, "Medical-Dental Staff Rules" review and staff interview, it was determined that for 1 of 11 (9%) discharged patients (Patient #13) in the sample, staff failed to ensure that the medical record was completed within 30 days of discharge. Findings include:

The "Medical-Dental Staff Rules" stated, "...A medical record is expected to be completed within thirty (30) days of a patient's discharge..."

Review of the medical record for Patient #13 revealed that Patient #13 was discharged on 12/3/10. The discharge summary was not dictated and transcribed until 1/20/11, 48 days after discharge.

Interview with the Manager of Patient Safety and Accreditation on 1/25/11 at 4:05 PM confirmed this finding.

Based on review of medical records, pharmacy documents, policy review and staff interview, it was determined that nursing staff failed to maintain accurate documentation for controlled substances for 3 of 5 (60%) emergency department patients (Patient #'s 72, 78 and 117) in the sample. Findings include:

The hospital policy entitled "Wasting Medications" stated, "...If all or part of a medication originally taken from the Station has been wasted, it will be documented at the Station by using the Waste option under procedures. Two nurses will be required to waste a controlled substance to document a witness. The wasted medication is to be documented at the time the medication is wasted..."

A. Patient #72 - Waste amount discrepancy

1. Review of the medication administration record (MAR) revealed an order for the controlled anti-anxiety drug, Ativan to be administered intravenously (IV) once.

Nurse documented administration of: Ativan 0.5 milligrams (mg) on 1/26/11 at 6:34 AM

2. Review of the "AcuDose" medication waste system document revealed:

- Inventory Dispensed: Ativan 2 mg/1ml (milliliter)
- Waste documented: Ativan 1mg

Interview with Pharmacist B and Nurse Manger I on 1/26/11 at 2:33 PM confirmed that the wasted amount of medication was inaccurate. Pharmacist B reported that the nurse should have documented the Ativan waste as 1.5 mg.

B. Patient #78 - Waste amount not documented

1. Review of the MAR revealed an order for the controlled pain medication, Dilaudid, to be administered intravenously (IV) every 4 hours as needed.

Nurse documented administration of: Dilaudid 0.3 mg on 1/25/11 at 4:40 AM

Review of the "AcuDose" medication system document revealed:

- Inventory Dispensed: Dilaudid 1mg/ml
- Waste documented: None
- Waste unaccounted: Dilaudid 0.7 mg

Interviews with Pharmacist B and Nurse Manger I on 1/28/11 at 9:45 AM and with Pharmacist A on 1/31/11 at 10:50 AM, confirmed that the nurse failed to document the wasted amount of Dilaudid medication. Pharmacist A and B reported that the nurse should have documented the Dilaudid waste as 0.7 mg.

C. Patient #117 - Medication removed from inventory - No evidence of physician's order; No evidence that medication removed for patient was given or wasted

1. Review of the "AcuDose" medication waste system document revealed:

- Inventory Dispensed: Ativan Vial 2 mg/1ml (milliliter)
- Waste documented: No evidence of waste

Interview with Pharmacist A on 1/31/11 at 10:56 AM, confirmed that a 2 mg vial of Ativan was removed from inventory on 1/26/11 at 6:29 PM for Patient #117's use and that there was no documentation that the medication had been wasted.

On 1/31/11 at 11:13 AM, Surveyor A and Nurse Manager I reviewed Patient #117's Emergency Department medical record. Nurse Manager I confirmed that even though the vial of Ativan had been dispensed under Patient #117's name, there was no evidence in the paper or electronic medical record to support that an order was obtained for the IV administration of Ativan or that Patient #117 received IV Ativan.

Based on observation, staff interview and policy review, it was determined that the hospital failed to maintain environmental surface cleanliness in a manner to assure patient safety in 22 of 67 (33%) patient care/support areas toured. Findings include:

The hospital policy entitled "Infection Prevention Policy" stated, "Environmental Services Department's Infection Prevention Policy is intended to minimize the risk of infections in patients and employees by adherence to...procedures as outlined...in the...Department Policy Manual."

The Environmental Services/Infection Prevention Department policy entitled "Standard 10-Step Cleaning Procedure" stated, "...Sanitize all horizontal surfaces: Using a cleaning rag...wipe high touch surfaces with the hospital approved disinfectant solution. Spot clean walls, doors, partitions and glass...using a germicidal solution..."

During tours conducted on 1/18, 1/19, 1/20, 1/21 and 1/25/11, the following environmental observations of a lack of surface cleanliness in patient care and patient service areas were made:

Christiana Hospital

1/18/11, 1:30 PM -- Unit 7 E -- tape, adhesive residue and paper signs posted with tape on doors, refrigerators, walls in hallways and patient rooms, counter tops, windows
1/18/11, 2:05 PM -- Unit 6 E -- paper signs posted with tape on refrigerator doors
1/18/11, 2:45 PM -- Unit 6 D -- signs posted with tape; tape and tape residue on windows and cabinets
1/18/11, 3:00 PM -- Unit 6 C -- 13 paper signs posted with tape in the Physical Therapy Gym
1/18/11, 3:15 PM -- Unit 6 B -- tape on lounge window

The above findings were confirmed by the Corporate Director, Facilities Engineering at the times of observation.

1/19/11, 8:45 AM -- Operating (OR) Room Core E -- tape on doors, refrigerators, countertops; tape and tape residue on 2 OR tables
1/19/11, 9:15 AM -- OR Core D -- taped sign; tape and tape residue on warming cabinet
1/19/11, 9:45 AM -- Patient Prep and Holding, Post Anesthesia Care Unit (PACU) -- tape and tape residue on cabinets, counter tops and stairway doors
1/19/11, 10:43 AM -- Unit 5 E -- tape and tape residue on medication room refrigerator
1/19/11, 11:00 AM -- Unit 4 E -- adhesive and adhesive residue on medication refrigerator; signs posted with tape in nutrition room
1/19/11, 11:35 AM -- Unit 4 C -- tape on medication refrigerator

The above findings were confirmed by the Corporate Director, Facilities Engineering at the times of observation.

1/19/11, 1:05 PM -- Unit 3 E (Medical Intensive Care Unit) -- peeling plastic coating on exterior of medication refrigerator; tape and tape residue on medication refrigerator door; spotted and smeared windows
1/19/11, 1:38 PM -- Unit 3 D -- tape on door of nourishment room

The above findings were confirmed by the Vice President of Facilities and Services A at the times of observation.

1/20/11, 8:55 AM -- Special Care Nursery -- tape and tape residue on doors of two refrigerators; paper signs taped on doors; paper signs taped on milk bank freezer
1/20/11, 9:35 AM -- Unit 2 D, TSU (Transitional Surgical Unit) -- excessive tape on door; tape on windows; tape residue on window; dirty floor in family waiting area for the neuro intensive care unit; stained caulk around hand washing sink; hand gel drips on wall below dispenser
1/20/11, 11:25 AM -- Radiology -- adhesive tape remaining on x-ray table after observed cleaning; locking mechanism on CT core area door taped to prevent latching
1/20/11, 3:05 PM -- Surgical and Procedure Unit -- damaged ceiling tile

The above findings were confirmed by Vice President of Facilities and Services A and the Corporate Director, Facilities Engineering at the times of observation.

Wilmington Hospital

1/25/11, 10:30 AM -- Main OR -- tape on warmer between ORs 5 and 6
1/25/11, 1:05 PM -- Intensive Care Unit -- tape and tape residue on windows
1/25/11, 2:28 PM -- Unit 3 East Surgical -- tape on nutrition room refrigerator; tape on medication refrigerator
1/25/11, 2:45 PM -- Unit 3 West Psychiatry (District 2) -- tape and tape residue on nurses station windows and glass door
1/25/11, 2:55 PM -- Eye Clinic -- chipped laminate; damaged wallboard outside exam room 1

The above findings were confirmed by the Corporate Director, Facilities Engineering at the times of observation.

Based on observation, it was determined that the hospital failed to maintain all locations of the hospital in a manner to ensure patient safety. The hospital failed to meet the applicable provisions of the 2000 edition of the Life Safety Code (LSC) of the National Fire Protection Association (see the four attached CMS-2567s referencing LSC deficiencies).

Based on observation, review of documentation, guideline review, policy review and staff interview, it was determined that the hospital failed to maintain supplies and equipment in 32 of 67 (48%) patient care and support areas. Findings include:

I. Based on observation, review of daily crash cart check logs, guideline review and staff interview, it was determined that staff failed to perform daily crash cart checks and weekly defibrillator checks as required. Findings include:

Review of the "Guidelines for Use: Emergency Equipment Checklist" stated, "...Document equipment checks every 24 hours...Your signature confirms that you have verified equipment is present...Perform defibrillator check every Monday..."

During tours of individual hospital units at Christiana and Wilmington Hospitals, crash carts were examined to ensure that staff was performing daily crash cart checks as required. Review of the "Emergency Equipment Checklist" revealed crash carts at Christiana Hospital were not checked daily and defibrillators were not checked weekly on the following dates:

1. Unit 2 A
Crash cart - 1/27, 11/14 and 11/15/10

On 1/21/11 at 11:50 AM, Surveyor A, Patient Care Coordinator C and registered nurse (RN) B reviewed the crash cart documentation and confirmed that the daily crash cart check had not always been performed. Patient Care Coordinator C reported that the task was assigned to the 11:00 PM - 7:00 AM shift charge nurse.

2. Unit 3 B/C
Crash cart - 1/22, 1/23, 1/24, 1/25, 1/26, 1/27, 1/28, 1/29/10, 4/4, 4/14, 4/15, 4/16, 4/22, 4/23, 5/20, 5/21, 5/22, 5/23, 9/29, 9/30, 10/2, 10/27, 10/29, 10/30/10, 1/15 and 1/16/11

Defibrillator - 1/25, 10/11 and 10/18/10

On 1/19/11 at 10:30 AM, Surveyor A and Nurse Manager U reviewed the crash cart documentation and confirmed that the daily crash cart check and/or weekly defibrillator checks had not always been performed. Nurse Manager U reported that the task was assigned to the 11:00 PM - 7:00 AM shift and was to be performed following the Code Blue policy - Addendum I - "Guidelines for Use: Emergency Equipment Checklist".

3. Unit 4 B
Crash cart - 5/3 and 5/14/10

On 1/19/11 at 11:30 AM, Surveyor A and Patient Care Coordinator A reviewed the crash cart documentation and confirmed that the daily crash cart check and/or weekly defibrillator checks had not always been performed. Patient Care Coordinator A reported that the task was assigned to the 11:00 PM - 7:00 AM shift.

4. Unit 4 C
Crash cart - 1/16, 2/26, 3/7, 3/20, 6/20, 8/29, 9/18 and 11/30/10

Defibrillator - 6/14, 6/28, 8/5/10

On 1/20/11 at 2:10 PM, Surveyor A and Nurse Manager E reviewed the crash cart documentation and confirmed that the daily crash cart check and/or weekly defibrillator checks had not always been performed. Nurse Manager E reported that the task was assigned to the 11:00 PM - 7:00 AM charge nurse.

5. Unit 2 D -- TSU (Transitional Surgical Unit)
a. Crash cart #28 - 3/6, 3/15, 3/20, 3/21, 3/27, 6/4, 6/10, 10/12, 10/14, 10/24, 11/11, 11/14, 11/18, 11/22, 11/27 and 11/28 /10

b. Crash cart #64 - 3/28, 4/2, 4/5, 4/10, 4/11, 4/16, 4/27, 4/29, 5/12, 5/13, 5/20, 5/28, 5/29 and 5/30/10

c. Crash cart # 71 - 6/4 and 6/10/10

Defibrillator - 6/21/10

d. Crash cart #9 - 6/24, 6/30, 7/18, 8/5, 8/14, 8/15, 8/27, 9/5, 9/18, 9/19 and 12/24/10

Defibrillator - 6/20/10

e. Crash cart #39 - 7/28, 8/5, 8/14, 8/15, 8/27, 10/14, 10/23, 10/24, 10/29, 11/13, 11/14, 11/22, 11/23, 12/24, 12/25 and 12/30/10

Defibrillator - 12/20/10

On 1/21/11 at 10:10 AM, Surveyor A and Nurse Manager H reviewed the crash cart documentation for crash carts and confirmed that the daily crash cart check and/or weekly defibrillator checks had not always been performed. Nurse Manager H reported that the task was assigned to the 7:00 AM - 3:00 PM charge nurse.

6. Unit 5 C
Defibrillator - 1/25, 9/27, 10/4 and 10/25/10

On 1/20/11 at 3:10 PM, Surveyor A and Nurse Manager F reviewed the crash cart documentation and confirmed that the weekly defibrillator checks had not always been performed. Nurse Manager F reported that the task was assigned to the 11:00 PM - 7:00 AM charge nurse.

II. Based on observation, staff interview and policy review, it was determined that the hospital failed to ensure an acceptable level of safety and quality with respect to the cleanliness and condition of patient care equipment and supplies. Findings include:

The hospital document entitled "Equipment cleaning check sheet" stated the following:

- "...Blood glucose monitor; Responsible department, Nursing (inside with bleach); Cleaning agent, Bleach or Alcohol wipe; Frequency, after use..."
- "...code cart; Responsible department, Environmental/Equipment room; Cleaning agent, Wexcide; Frequency, weekly..."
- "...isolation cart; Responsible department, Environmental/Equipment room; Cleaning agent, Wexcide; Frequency, daily..."
- "...immobilizer chair; Responsible department, various; Cleaning agent, Bleach or Alcohol wipe; Frequency, daily..."
- "...rolling computer; Responsible department, Nursing-tops/Environmental- bottoms; Cleaning agent, Bleach or Alcohol wipe; Frequency, after use/daily..."
- "...stretcher; Responsible department, Escort; Cleaning agent, Bleach or Alcohol wipe; Frequency, after use..."
- "...visitor chairs; Responsible department, Environmental; Cleaning agent, Wexcide; Frequency, daily..."

Environmental tours conducted at Christiana and Wilmington Hospitals revealed the following observations:

Christiana Hospital

1/18/11, 1:30 PM -- Unit 7 E -- tops of crash carts dusty; Welch Allyn blood pressure monitors had dusty rolling bases; chair arm with damaged vinyl; adhesive residue on stretcher mattress
1/18/11, 1:45 PM -- Unit 6 E -- multiple isolation carts with sticker adhesive residue on medication boxes; soiled cleaning cloth at sink in patient nourishment room; roll of paper toweling stored beneath sink in the patient nourishment room; computers on wheels had dusty/dirty bases; Welch Allyn blood pressure monitors had dusty/dirty bases; dusty/dirty base of Hausted immobilizer chair and tape residue on upholstery of chair; crash carts had dusty/dirty top and bases; clean items stored beneath sink in nourishment substation
1/18/11, 3:15 PM -- Unit 6 B -- blood pressure monitors had dusty/dirty bases

The above findings were confirmed by the Corporate Director, Facilities Engineering at the times of observation.

1/19/11, 8:45 AM -- Operating (OR) Room Core E -- tape on case carts; stretcher mattress had torn vinyl covering; stained ceiling tile
1/19/11, 9:15 AM -- OR Core D -- tape residue on difficult airway cart; top surface of code cart was dusty/dirty; several stained ceiling tiles
1/19/11, 10:10 AM -- Unit 5 B -- damaged vinyl upholstery on Lumex immobilization chair
1/19/11, 10:15 AM -- Unit 5 D -- Physical Therapy Room 5D21-- rust and calcified areas on Hydrocollator (hot pack) unit
1/19/11, 10:35 AM -- Unit 5 E -- adhesive residue on isolation cart medication boxes; top surfaces of crash carts were dusty/dirty
1/19/11, 11:00 AM -- Unit 4 E -- adhesive and adhesive residue on isolation carts; dust on crash cart suction machine
1/19/11, 11:35 AM -- Unit 4 C -- adhesive residue on isolation carts
1/19/11, 11:40 AM -- Unit 4 B Maternity -- paper adhered to and not properly removed from the bottom shelf of Scaletronix infant scale
1/19/11, 11:50 AM -- Unit 4 A -- reclining exam chair (near 4 A elevator bank) had dusty/dirty base

The above findings were confirmed by the Corporate Director, Facilities Engineering at the times of observation.

1/19/11, 1:05 PM -- Unit 3 E (Medical Intensive Care Unit) -- adhesive residue on isolation carts; computer on wheels had dusty/dirty base; soiled wash cloth on counter top in nourishment room; couch, three (3) soiled fabric-upholstered seats; stained ceiling tile
1/19/11, 1:38 PM -- Unit 3 D -- tape and adhesive residue on isolation carts
1/19/11, 2:45 PM -- Unit 3 A -- damaged vinyl armrest on reclining chair; day room recliner with split seam in back rest

The above findings were confirmed by the Vice President of Facilities and Services at the times of observation.

At 1:38 PM on 1/19/11, interview with the Director of Materials Management revealed that hospital-owned equipment that moves from place to place was distributed by the equipment room and then returned to the equipment room for cleaning before reuse. Isolation carts, infusion pumps, intravenous fluid delivery support poles and crash carts were supposed to be cleaned and readied for reuse by staff in the equipment room.

1/20/11, 8:50 AM -- Ronald McDonald Room -- paper towels stacked on counter top
1/20/11, 8:55 AM -- Special Care Nursery -- dirty, portable C-arm x-ray machine with apparent heat damage to plastic pieces
1/20/11, 9:15 AM -- Unit 2 C (Ortho/Neuro Trauma) -- stained fabric upholstery in family waiting area; adhesive residue on isolation carts
1/20/11, 9:35 AM -- Unit 2 D (TSU) -- tape on isolation carts, adhesive residue on top of code cart; room 2D35 vacated 2 days ago had not been terminally cleaned; two (2) black reclining chairs had dirty bases, tape and residue on upholstery
1/20/11, 10:20 AM -- Unit 2 E -- adhesive residue on isolation carts, adhesive labels on crash cart; two (2) damaged/delaminated step stools; two boxes (for doppler units) with dark gray open cell foam lining soiled with dried ultrasound gel residue
1/20/11, 11:25 AM -- Radiology -- one (1) Steris and one (1) Hausted "vest" chairs used for fluoroscopic swallowing studies with dirty bases and white-colored dried drips
1/20/11, 2:10 PM -- Magnetic Resonance Imaging (MRI) -- damaged mattress on MRI treatment table

The above findings were confirmed by the Vice President of Facilities and Services A and the Corporate Director, Facilities Engineering at the times of observation.

1/24/11, 11:40 AM -- Unit 5 E -- large amount of dried debris observed in the fold/crease of the hard plastic box containing glucose testing strips, alcohol swab packets, cotton balls and Gluco-Chlor packets (used to clean blood glucose monitoring unit after use).

Nurse Manager L, present at the time of the observation, confirmed this finding.

Wilmington Hospital

1/25/11, 10:30 AM -- Main Operating Room (OR) -- covering of padded arm support (for surgery) damaged; long-handled flowered tote bag hanging in OR 6
1/25/11, 10:45 AM -- Hallway between OR's and Special Procedure Unit -- nine (9) stretchers with fresh linen, three (3) with dirty bottom shelves
1/25/11, 11:20 AM -- Post Anesthesia Care Unit -- clean supplies stored on shelving in utility room with a flushing rim sink. The flushing rim sink was used throughout the day according to Nurse Manager Z.
1/25/11, 1:05 PM -- Intensive Care Unit -- labels and adhesive on respiratory and crash carts
1/25/11, 1:17 PM -- Acute Care for the Elderly -- crash carts with stickers and residue; black adhesive residue on top of medication cart
1/25/11, 1:45 PM -- Clean Utility Room 4206 -- space was shared between equipment and clean supplies
1/25/11, 2:53 PM -- Eye Center -- stickers and tape on emergency drug box; soiled fabric-upholstered seats, Exam Room 3 and 4

The above findings were confirmed by the Corporate Director, Facilities Engineering at the times of observation.

1/26/11, 1:45 PM -- Center for Rehabilitation -- paraffin (hot wax for heat therapy) -- fuzzy lint balls and dirt suspended in the molten wax

Director of Patient Care Services A, present at the time of observation, confirmed this finding.

1/28/11, 1:20 PM -- Emergency Department -- 3 electrocardiogram machines found with tape and tape residue

This finding was confirmed by Corporate Director, Facilities Engineering at the time of observation.

Based on record review, Medical-Dental Staff Rules review and staff interview, it was determined that hospital staff failed to document a history and physical within 30 days of the surgical procedure for 1 of 13 (8%) surgical outpatients (Patient #29) whose records were reviewed. Findings include:

The "Medical-Dental Staff Rules" stated, "...The history and physical of a patient shall be performed within (30) days prior to admission...If a history and physical was performed within thirty (30) days prior to admission, a durable, legible copy of this report may be used provided the report is made current, dated and authenticated by an attending physician...before surgery..."

Patient #29

Review of the medical record revealed that Patient #29 was admitted to the hospital outpatient surgical center on 1/21/11 for a surgical procedure. The record contained a history and physical done on 8/9/10 by a surgeon, printed on 1/20/11 and countersigned by the surgeon performing the procedure on 1/21/11.

Interview with the Vice President of Perioperative Services on 1/21/11 at 10:30 AM confirmed that the record failed to contain a history and physical done within 30 days of the procedure.