HospitalInspections.org

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Based on medical staff credentialing records and interview the facility failed to ensure 3 providers had current background checks as required by Alaska State law. Failure to ensure background checks were current placed patients at risk for abuse. Findings:

Review of the medical staff credentialing files on 4/5/17 at 2:28 pm revealed 2 physicians and 1 physician's assistant did not have current background checks.

During an interview on 4/5/17 at 2:45 pm the Medical Staff Director confirmed the 2 physicians and 1 physician's assistant did not have current background checks.
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Based on record review and interview the facility failed to ensure documentation was accurate for 4 patients (#s 23; 24; 29; and 30). Specifically: 1) 1 patient (#23) was admitted to the emergency department and the disposition had conflicting documentation of whether the patient was discharged or transferred to another hospital; 2) the facility failed to ensure 1 patient (#24) had signed a consent for treatment in the emergency department prior to treatment; and 3) 2 patients (#s 29 and 30) had documentation of communications with the organ/tissue procurement center upon their death, These failed practices created a risk for an inaccurate medical record.
Findings:

Patient #23

Record review from 4/4-6/17 revealed Patient #23 was admitted to the emergency department on 10/3/16 at 2:11 am for diagnoses that included unspecified abdominal pain and nausea.

Further review of the medical record revealed:

"...04:55 Discharge ordered by MD...05:22 Discharged to home ambulatory, with significant other, Patient to go POV [personal vehicle] to Providence Oncology..."

"05:24 Patient left the ED."

"10/04/2016 17:04 [5:04 pm] Addendum: Urine: a result faxed to Prov-pt [patient] was direct admit."

"Encounter Summary ...Outcome: Discharge ...Location: Hospital via POV...Go straight to Providence 4 North".

Review of the discharge instructions for Patient #23 Revealed "...Diagnosis: Small bowel [bowel] obstruction ...

[Providence Hospital physician] When: Today is Recommended; Reason; Now...Go straight to Providence 4 North".

During an interview on 4/4/17 at 2:15 pm the Director of Quality/Risk (DQR) was asked about Patient #23's leaving the emergency department. The DQR said it was not an appropriate transfer because it looked like a discharge not a transfer. There was also no documentation that medical records were sent or how.

Patient #24

Record review on 4/4-6/17 revealed Patient #24 was admitted to the emergency department on 3/31/17 at 6:00 am with a diagnosis that included gastrointestinal hemorrhage.

Continued review of the medical record revealed the Patient did not sign consent for treatment in the emergency department, but the Patient did sign a "consent to and authorize the transfusion or administration of blood or blood components ..." at 10:27 am.

During an interview on 4/4/17 at 2:03 pm, the Director of Quality/Risk confirmed the consent to treat in the emergency department for Patient #24 was not signed

Patient #s 29 and 30

Record review on 4/5/17 revealed Patient #29 died in the facility on 12/9/2016. The medical record contained no documentation Life Center Northwest (the organ/tissue perocurement was notified of the death.

Record review on 4/6/17 revealed Patient #30 died in the facility on 12/14/16. The medical record had no documentation Life Center Northwest was notified of the death.

Review of a "Quality Death Worksheet", dated 12/14/16, revealed Patient #30 had died 12/14/16 at 6:52 pm and Life Center Northwest had been contacted. The worksheet had "Not a Part of Patient's Record" at the bottom of the page.

During an interview on 4/6/17 at 12:20 pm, the Chief Quality Officer confirmed there was no documentation Life Center Northwest had been contacted in either Patient's medical record.

Review of the facility's policy "CM #23 Death Checklist", revised 1/2017, revealed "Life Center Northwest ...Record the reference # and the name of the person you spoke with in the patient record and on the Quality Death Worksheet."


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Based on observation, interview, record and policy review the facility failed to maintain medical records (MR) in manner to prevent access to unauthorized individuals and monitor access to medical records by facility staff and providers. This failed practice created a risk for missing and/or inaccurate MR through loss and/or theft and potential altering of the MR. Findings:

The facility used a "hybrid" system for documentation in patient's medical records. Some of the medical record was stored in the electronic medical record system and some documentation was stored in a paper (soft) chart.

Observations on 4/6/17 at 1:45 pm revealed soft charts for the emergency department (ED) patients and Outpatient (OP) patients on open shelves in the health information management (HIM) department. The door accessing the department was unlocked. Other inpatient records were stored in a locked room inside the HIM department.

During an interview on 4/6/17 at 1:45 pm, when asked who had access to the medical record area, the Director of HIM stated facility staff and the environmental services (EVS) staff came in during the day to vacuum. In addition, EVS came in at night, unattended by MR staff, to pick up the trash. The Director of HIM confirmed there were no MR staff in the area after 7:30 pm.

During an interview on 4/6/17 at 2:05 pm, the Chief Quality Officer (CQO) stated s/he was unaware EVS staff had access to the HIM department after 7:30 pm.

Review of the "Access Level: Medical Records" information, provided by the Director of Human Resource, revealed a list of 67 staff and non-staff who had full access to both doors in the HIM department. The list included administrative staff; physicians; medical coders; EVS; previous employees; and at least 1 staff who didn't work in the hospital building but had full access to the medical records. In addition, 32 employees had limited access to the HIM department from 9:00 am to 5:00 pm. This information was all confirmed by the Director of Human Resources.

Review of the employees that had badged in after hours revealed EVS had entered the department unsupervised on the night shifts on 4/1-4/17. The Director of Human Resources stated security staff can access the records anytime.

During an interview on 4/6/17 at 3:00 pm, the CQO stated so many people with unsupervised access to the HIM department was a concern.

Review of the facility's policy, "Viewing: Location and Security of Medical Records Policy", revised 1/2017, revealed "Medical records will be maintained within the Health Information Management Department and the HIM department will remained locked 24 hours a day for security purposes...Access to the HIM department during off hours by facility staff and physicians with be granted by assigning restricted access responsibility to certain key individuals, such as a nursing supervisor or a designated individual in the emergency department."


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Based on observations, interview, and policy review the facility failed to ensure the kitchen was maintained and organized in an acceptable manner according to the FDA (US Food and Drug Administration) standards. Specifically, the facility failed to ensure: 1) food was stored in a manner to prevent contamination; and 2) kitchen floors, drawers and areas under cooking appliances were clean and free from debris accumulation. These failed practices placed all patients receiving food from the facility at risk for food borne illnesses and/or infestation from vermin. Findings:

1) Food Storage


Observations of the Central Kitchen cold and dry food storage on 4/2-5/17 revealed:


- 1 - box of frozen cheese sticks open to air;
- 1 - container of peeled garlic that had a use by date of 3/30/17;
- 1 - container of peeled garlic that had a use by date of 3/12/17; and
- 1 - container of prepped mashed potatoes, asparagus and cut potatoes were in a serving line cooler uncovered.
- 1 - employee straw and cup were located within the serving line cooler that contained uncovered cut vegetables and other read to eat foods.


During random interviews from 4/2-5/17 the Dietary Manager (DM) stated food items shouldn't be open to air and food items past their used-by date should be discarded.


Review of the US Food and Drug Administration Food Code, dated 2013, revealed "Preventing Contamination from the Premises 3-305.11 Food Storage ...FOOD shall be protected from contamination by storing the food...in a clean ...location ...Where it is not exposed to splash, dust or other contamination ..."
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2) Kitchen Sanitation


Random observations from 4/2-6/17 revealed multiple areas on the kitchen floor, serving line drawer storage and under non-mobile cooking appliances contained a dried buildup of blackened dust, grease, and/or debris.


During an interview on 4/6/17 the DM stated the area was covered in grease build up and should have been cleaned. In addition, the DM stated the cooking appliances, located with a deep-fat fryer, did not contain wheels which made it difficult to clean under them.


Review of the US Food and Drug Administration Food Code, dated 2013, revealed "Cleanability 4-202.16 Nonfood-Contact Surfaces ...designed and constructed to allow easy cleaning and to facilitate maintenance.


Review of the facility's policy "Infection Control for Nutrition Services", revised 10/12, revealed " "All floors in the kitchen are mopped in the evening by the EVS [environmental service] staff."

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Based on record review, interview and policy review the facility failed to ensure residents' had an activities program designed to meet the individualized needs of 3 swing bed status (SB-a hospital bed used to furnish skilled level of care) residents (#s 31, 32, and 33), based on a comprehensive assessment and the interests, mental and psychosocial well-being of each resident. This failed practice placed residents at risk for not receiving meaningful activities designed to enhance their quality of life. Findings:

Resident #31

Record review on 4/6/17 revealed Resident #31 was admitted to SB status on 3/20/17. Further review revealed the Resident's record did not contain an activity assessment that addressed the Resident's activity preferences, lifestyle patterns and hobbies.

The Resident's record revealed no care plan for activities that identified goals and interventions for meaningful activities.

Resident #32

Record review on 4/6/17 revealed Resident #32 was admitted to SB status on 3/23/17. Further review revealed the Resident's record did not contain an activity assessment that addressed the Resident's activity preferences, lifestyle patterns and hobbies.

The Resident's record revealed no care plan for activities that identified goals and interventions for meaningful activities.

Resident #33

Record review on 4/6/17 revealed Resident #33 was admitted to SB status on 4/5/17. Further review revealed the Resident's record did not contain an activity assessment that addressed the Resident's activity preferences, lifestyle patterns and hobbies.

Further review of the Resident's record revealed no care plan for activities that identified goals and interventions for meaningful activities.

During an interview on 4/6/17 at 2:00 pm, the Case Management Director (CMD) was asked about the activity program and how the facility determined what to provide to residents. The CMD stated the only activities that were done was 3 times a week when volunteers take a cart with DVDs, movies, magazines and books around to residents rooms. The CMD further stated there were no activity assessments or activity care plans.

Review of the facility policy, "Swing Bed Policy", revised 1/17, revealed no mention of an activity program for residents residing in the facility.
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