HospitalInspections.org

Based on medical record review and staff interview, the hospital failed to ensure that 4 of 30 patients (Pts.# 11, 13, 24, 27) had been informed of their Medicare Covered services on admission and upon discharge. This has the potential to affect the total inpatient population.

Findings include:

1) The 1/28/13 medical record review of 81 year old Patient #11 reflects that there is no signed documentation that this patient/ patient representative had been informed of medicare covered services and appeal rights contained in the "Important Message from Medicare about your Rights" document for the 4/11/12 through 4/14/12 Medicare hospital stay. This document contains Medicare information concerning covered services, care decision-making, reporting concerns to Quality Improvement organizations (with contact address and phone number) and discharge appeal rights.

2) The 1/28/13 medical record review of 98 year old Patient #13 reflects that there is no signed documentation that this patient/ patient representative had been informed of medicare covered services and appeal rights contained in the "Important Message from Medicare about your Rights" document for the 5/20/12 through 5/22/12 Medicare hospital stay.

3) The 1/28/13 medical record review of 75 year old Patient #24 reflects that there is no signed documentation that this patient/ patient representative had been informed of medicare covered services and appeal rights contained in the "Important Message from Medicare about your Rights" document for the 12/13/12 through 12/19/12 Medicare hospital stay.

4) The 1/28/13 medical record review of 79 year old Patient #27 reflects that there is no signed documentation that this patient/ patient representative had been informed of medicare covered services and appeal rights contained in the "Important Message from Medicare about your Rights" as of medical record review on 01/30/13 at 2:45 PM.

These findings found above were verified by Admissions Director Q and CNA/MRA (Certified nursing assistant/medical records assistant) M on 1/29/13 at approximately 3 p.m.

Based on observation, staff interviews, and review of maintenance records, the hospital failed to ensure the physical environment of the building met the minimum requirements of the 2000 Edition of the Life Safety Code for "New Healthcare Occupancy" and also "Existing Healthcare Occupancy" chapters of this code.

The findings include:
K11:The facility did not provide a common separation wall with rated wall construction.
K14: The facility did not provide corridor finishes with rated wall finish materials
K17: The facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with a smoke-tight corridor ceiling (in a sprinkled smoke zone), and rated walls in a non-sprinkled compartment. T
K18: The facility did not provide corridor separation doors with smoke-tight seals at meeting edges.
K25: The facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls that had sealed wall penetrations.
K29: The facility did not provide and maintain hazardous door assemblies that meet code requirements for hazardous areas with doors held-open with the required safe guards and the facility did not enclose hazardous rooms with rated doors and rated walls.
K48: The facility did not maintain a written evacuation plan that contained all the elements with staff trained on life safety procedures.
K51: The facility did not provide a fire alarm system that was installed in accordance with NFPA 72
K52: The facility did not maintain the fire alarm system according to NFPA 70 and 72 requirements.
K56: Sprinkler system did not meet all minimum requirements per NFPA 13.
K77: The facility did not provide medical gas piping as required by NFPA 99.
K130: The facility did not provide a code compliant environment with suite travel distance under the required limits
K144: The facility did not test the emergency electrical generator in accordance with the codes
with a complete test program for emergency generators and did not provide a battery warmer.
K145: The facility did not provide a Type I essential electrical system that was in accordance with the codes with a compliant type 1 emergency electrical system.
K147: Electrical system did not meet the minimum requirements per NFPA 70.

The cumulative effect of these deficiencies indicates that the facility failed to provide a safe environment and reliable systems to ensure safety to all occupants, patients and staff of this facility.

Based on observation, staff interviews and review of maintenance records, the facility did not construct, install and maintain a proper ventilation and temperature control system in pharmaceutical, food preparation, and other appropriate areas. The facility did not have a ventilation system that was installed and maintained in accordance with state regulations and manufacturer recommendations. This deficiency occurred in 2 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1) On January 28, 2013 at 1:25 pm, observation revealed on the 1st floor in the resp therapy clean utility room, that the ventilation to the space could not be confirmed to be compliant with accepted standards. The air flow was from dirty to clean. This observed situation was not compliant with 42 CFR 482.41(c)(4).

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Physical Plant Director).

2) On January 29, 2013 at 9:45 am, observation revealed on the lover level floor in the Surgery area, in the dirty Utility room, that the ventilation to the space could not be confirmed to be compliant with accepted standards. The air flow was from dirty to clean when the outside door to this suite was open to the corridor. This observed situation was not compliant with 42 CFR 482.41(c)(4).

3) On January 29, 2013 at 11:00 am, observation and review of records revealed on the lower level floor in the Operating rooms 1 and 2, that the ventilation to the space could not be confirmed to be compliant with accepted standards. The relative humidity in the Operating room 1 was below 30 % in the month of January on the 15, 22, 23, and 25th. It was below 19% on January 8th in OR 2. The require range for relative humidity is 30 to 60 %. This observed situation was not compliant with 42 CFR 482.41(c)(4). .

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Physical Plant Director).
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This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Physical Plant Director).
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Based on observation, staff interviews, and review of maintenance records, the hospital failed to ensure the physical environment of the building met the minimum requirements of the 2000 Edition of the Life Safety Code for "New Healthcare Occupancy" and also "Existing Healthcare Occupancy" chapters of this code.

The findings include:
K11:The facility did not provide a common separation wall with rated wall construction.
K14: The facility did not provide corridor finishes with rated wall finish materials
K17: The facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with a smoke-tight corridor ceiling (in a sprinkled smoke zone), and rated walls in a non-sprinkled compartment. T
K18: The facility did not provide corridor separation doors with smoke-tight seals at meeting edges.
K25: The facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls that had sealed wall penetrations.
K29: The facility did not provide and maintain hazardous door assemblies that meet code requirements for hazardous areas with doors held-open with the required safe guards and the facility did not enclose hazardous rooms with rated doors and rated walls.
K48: The facility did not maintain a written evacuation plan that contained all the elements with staff trained on life safety procedures.
K51: The facility did not provide a fire alarm system that was installed in accordance with NFPA 72
K52: The facility did not maintain the fire alarm system according to NFPA 70 and 72 requirements.
K56: Sprinkler system did not meet all minimum requirements per NFPA 13.
K77: The facility did not provide medical gas piping as required by NFPA 99.
K130: The facility did not provide a code compliant environment with suite travel distance under the required limits
K144: The facility did not test the emergency electrical generator in accordance with the codes with a complete test program for emergency generators and did not provide a battery warmer.
K145: The facility did not provide a Type I essential electrical system that was in accordance with the codes with a compliant type 1 emergency electrical system.
K147: Electrical system did not meet the minimum requirements per NFPA 70.

The cumulative effect of these deficiencies indicates that the facility failed to provide a safe environment and reliable systems to ensure safety to all occupants, patients and staff of this facility.

Based on interview, record review (refrigerator temperature logs) and observation the facility did not store medications in a safe and secure manner. Medications were being stored in two refrigerator/freezer units in the pharmacy which were monitored only once a day for proper temperature and were left unmonitored for up to 20 hours each weekend day. Medications also were stored in one radiology exam room which was not locked. Medications were also stored in patient care area in surgery.

This is evidenced by:

Example #1: On January 29th 2013 11:00 a.m.-12:15 p.m. during interview and tour with Pharmacy Director F, two residential kitchen refrigerator/freezer units were observed in the pharmacy. These units were a freezer on top and a refrigerator below.

In an interview on January 29th, 2013 between 11:00a.m.-12:15p.m. with Pharmacy Director F, Pharmacy Director F indicated the units contained refrigerated and frozen pharmaceuticals. The units are monitored for temperature each morning. A log of temperatures was reviewed for current month of January 2013 with no out of range temperatures noted. Pharmacy Director F indicated the refrigerator/freezers are on back up power supply. Pharmacy Director F indicated there however is no alarm to indicate if refrigerator/freezer units go out of temperature range and for how long.

Per interview with Pharmacy Director F on January 29th, 2013 between 11:00 a.m.-12:15 p.m., the pharmacy is open weekdays from 7 a.m.-4 p.m. and on weekends from 8 a.m.-noon. Pharmacy Director F indicated there are vaccines in the units which may become unusable if the vaccines are exposed to room temperature for less than 12 hours.
Based on this interview, the refrigerators can be unmonitored on weekends for up to 20 hours during which times the temperature for vaccines may be compromised and ineffective without pharmacy knowledge.

Example #2: During tour and interview on January 29th at 7:38-8:05 a.m. with Radiology Manager E Radiology Exam Room Two containing a Computed Tomography (CT) machine was observed. Exam Room Two was across and down the hall from the radiology reception desk. The door could only be directly observed through a bubble mirror in the hall at the reception desk. Radiology Manager E entered room without a key as door was unlocked. Within the room an unlocked cabinet containing intravenous contrast media and a tackle box with emergency medications was observed. In interview at 7:38-8:05a.m., Radiology Manager E indicates the exam room remains unlocked during the day when the radiology department is staffed. At 9:35 a.m. on January 29th exam room two door was observed unlocked and no staff present at radiology desk. At 10:15 a.m. on January 29th exam room two door was observed unlocked and no staff present at radiology desk. The medications stored in this room are not secured when staff is not present.



26711

According to the Centers for Disease Control, (CDC) Safe Injection Practices 2007, regarding multidose vials: IV.H.7. Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer's recommendations; discard if sterility is compromised or questionable 453, 1003. Category IA.
During a tour of the surgical area on 1/30/2013 at 8:45 a.m. accompanied by Director B, it was noted that in a closed cabinet in the Operating Room (OR) several multi-dose vials were noted to be pre-spiked with a device that would allow entry and withdrawal of the medication. The spiked medications were: Bupivicaine 0.5% (3 vials), Marcaine with Epinephrine 0.5% (1 vial), Lidocaine 1% with Epinephrine (1 vial).
During the observation of the room set-up for Pt. #26's surgical procedure on 1/30/2013 at 10:45 a.m., Surgical Technician K and Registered Nurse T were observed preparing a syringe of Bupivicaine 1/4%, which was pre-spiked, in the OR adjacent to the sterile field.
Multidose vials are not to be kept or accessed in patient care areas.
This finding was discussed on 1/30/2013 at 4:30 p.m. in the presence of Chief Executive Officer O and Director of Nursing H.

Based on 1 of 3 observations of patient care (Pt. #26, Staff S), policy and procedure review, Nationally accepted standards of practice, manufacturer recommendations, and 2 of 2 staff interviews (Staff G and U), the facility does not ensure that standards of practice are followed and that patients are protected from potential contaminants. Failure to follow standards of practice and protect patients from contaminants has the potential to affect all patients receiving care in the facility

Findings include:

Nationally accepted Standard of Practice, October 12, 2007, Center for Disease Control (CDC): IV.A.3. The preferred method of hand decontamination is with an alcohol-based hand rub. Alternatively, hands may be washed with an antimicrobial soap and water.

Facility policy titled, "Hand Washing," dated 10/1/10, was reviewed on 1/30/2013 at 2:30 p.m. The policy states in part, hands are to be washed, using either soap and water or alcohol based hand gel, "Before each patient encounter...Before applying gloves and inserting peripheral vascular catheters...Always after removing gloves." This policy also has a procedure with directions on how to wash hands using the antimicrobial soap.

In an interview with the Infection Control Officer, also the Director of Medical/Surgical (G) on 1/29/2013 at 1:55 p.m., G stated the minimum expectation for hand washing is upon entry and exit from a patient's room. Depending on what staff is doing in the room will depend on the frequency of hand washing.

An interview with RN U was conducted in the high level disinfection area of the facility on 1/30/2013 at 9:05 a.m. RN U explained the process of cleaning endoscopes and that the dirty scope is placed in a bin and carried to the adjacent disinfection room. RN U states U then, "Puts 2 pumps of Endozime [high level disinfecting cleaning agent] to however many gallons it takes to cover the scope...I don't know, maybe 3 or 4." RN U confirmed the bins are not marked with a line indicating the water level.

According to the manufacturer recommendations for Endozime provided on 1/30/2013 at 1:13 p.m., the dilution concentration is 1/4 ounce [oz] per gallon. On this same paper is hand written by the facility, "1 pump = 1 oz and Container maximum capacity 8 gallons."

Director B was present during the interview of RN U.

An observation of Pt. #26's intravenous (IV) placement was completed on 1/30/2013 at 9:40 a.m. Certified Registered Nurse Anesthetist (CRNA) S entered Pt. #26's room and applied gloves without washing hands to insert the IV. Upon completion of the IV insertion, CRNA S removed gloves and used the antimicrobial soap, as if it was alcohol based hand gel, without using water or paper towel to wash hands prior to exiting the room.

Registered Nurse (RN) N confirmed the container that CRNA S used contained soap and not hand gel.

During the surgical procedure (1/30/2013 at 11:15 a.m.) CRNA S was observed to enter a port in the IV line of Pt. #26 with numerous medications and did not clean the hub of the port with an alcohol swab between each of the medications. An alcohol swab was used prior to the initial syringe insertion but not between each successive insertions. This happened several times throughout the surgical procedure when more than one medication was given.

Director B was present during the surgical observation.

Based on observations, medical record review, dietary contract review and staff interview, the hospital failed to provide dietary consultation in a timely manner to 1 of 2 patients (Patient #9), identified as having a medical order for dietary consultation. The dietary department did not operate in accordance with recognized dietary practices based on food items being improperly stored. The totality of the issues has the potential to negatively affect all in-house patients.

Findings include:

Interview with Medical Surgical Director G while reviewing Patient #9's in-patient record, on 1/28/13 at approximately 3 p.m. verifies that this patient has a medical order for a dietary consult with a dietitian.

Further medical record review on 1/30/13 with CNA/MRA (Certified nursing assistant/medical records assistant) M at approximately 1:40 p.m. reflects that Patient #9 had been discharged from the hospital. Review of this closed record reflects that no dietary consult could be found to be completed before hospital discharge.

Interview with Nursing Director H on 1/30/13 at approximately 2 p.m. reflects that the registered dietitian comes to the facility one day per week, and states that this patient was admitted and discharged between dietary consultation weekly visits. Nursing Director H stated that there is no one in the hospital to perform a dietary consultation when the dietitian is not there. Nursing Director H verified that this patient did not receive the medically ordered dietary consult.

The 1/30/13 review of the dietary contract with signed 1/23/13 by hospital CEO (Chief Operating Officer) O and RD (Registered Dietitian) BB documents the following: "Terms of Agreement- ...it is anticipated the RD will provide approximately 4 hours per week of service to the facility....Weekly consultation visits will be provided unless otherwise agreed upon by Administrator or Food Service Supervisor and Consultant...".


20878


According to the Wisconsin Food Code, food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold or discarded, based on the temperature and time combination of 5oC (41oF) or less for a maximum of 7 days.

On 01/30/2013, 11:45 a.m. in the walk-in cooler, the following observations were made: items past discard date: partially used gallon of milk (01/26), 8 1/2 pint cartons of 2% milk (01/28).

The above observations were verified by Kitchen Manager L.

Based on record review, review of medical staff rules and regulations, facility policy, and interview with staff in 6 of 30 records (# 2,15,16,17,18,27) the facility failed to ensure all verbal and telephone orders were authenticated by the MD with a signature, date and time within 48 hours of being written.

Findings include:

Rules and Regulations of the Medical Staff dated 03/12 states: "Telephone orders will be signed by the ordering physician within 48 hours. Orders may be signed by another physician as designated by the attending physician when the ordering physician is not available."

Facility policy entitled: "Identification of authors/authentication of signatures" (#16-48) states: "All entries must be legible, timely, meaningful, and complete and must be authenticated and dated and timed by the person (identified by name and title) who is responsible for ordering, providing, or evaluating the service furnished."

Pt. #2's clinical record was reviewed on the afternoon of 01/30/13, it revealed two telephone orders written on 08/04/12 which were signed without title and were not dated or timed. These findings were confirmed per interview with Medical Records clerk D on 01/30/13 at 2:40 PM.

Pt. #27's clinical record was reviewed on the afternoon of 01/30/13, it revealed a telephone order and a verbal order written on 01/28/13 which were signed without title and were not dated or timed. These findings were confirmed per interview with Medical Records clerk D on 01/30/13 at 2:40 PM.



26711


MR (medical record) reviews for Pt.s #15-19 were completed on 1/29/2013 in the presence of Registered Nurse (RN) C between 7:50 a.m. and 3:45 p.m.

In Pt. #15's closed Same Day Stay (SDS) MR, there is a VO (verbal order) taken by an RN on 12/19/2012 which is signed but not dated or timed by the provider.

In Pt. #16's closed SDS MR there is a VO taken by an RN on 11/20/2012 which is signed but not dated or timed by the provider.

In Pt. #17's closed SDS MR there is a pre-printed standing order sheet for pre-operative knee surgery that is marked by an RN as being verbal orders taken on 11/9/2012 for surgery on 11/20/2012 which are signed but not dated or timed by the provider. There is a VO taken by an RN on 11/20/2012 which is signed but not dated or timed by the provider.

In Pt. #18's closed SDS MR there is a pre-printed standing order sheet which contains pre and post operative colonoscopy orders. The pre-operative section is signed off by an RN as a verbal order from the physician on 1/16/2013 and the physician did not date, time or sign these orders pre-procedure. The post-procedure orders are signed and dated by the physician but a time is not indicated.

These findings were confirmed at the time of the MR review by RN C.

Based on 6 of 30 medical records reviewed (#15,16,17,18,19 and 30), staff interview and facility policy the hospital failed to develop patient centered care plans.

Findings include:


26711

The facility policy titled "Care Plans" dated 10-06-08 was reviewed on 1/30/2013 at 2:30 p.m. The policy purpose states, "To ensure the development of a plan of care, treatment and services which is individualized and appropriate to the patient's needs, strengths, limitations, and goals."

This policy also states, "The Plan of Care will be individualized to meet the unique needs and circumstances of the patient."

And, under Procedure, #2, "Unit specific protocols and standards may be used. These are individualized according to patient needs, Additional patient's-specific issues will be identified and goals and interventions developed to meet the identified patient's needs."

MR reviews for Pt.s #15-19 were completed on 1/29/2013 in the presence of Registered Nurse (RN) C between 7:50 a.m. and 3:45 p.m.
MR review for Pt. # 30 was completed on 1/30/2013 in the presence of Certified Nursing Assistant (CNA) M at 1:33 p.m. CNA M was assigned to assist in chart navigation as M is a facility resource in the medical record.

Patient #15 had a gall bladder removal on 12/19/2012.
Patient #16 had a pacemaker generator replacement on 11/20/2012.
Patient #17 had knee surgery on 11/20/2012.
Patient's #18 had a colonoscopy on 1/18/2013.
Patient #19 had an upper endoscopy on 12/5/2012.
Patient #30 had an upper endoscopy on 8/19/2012.

All of these patients have a surgical care plan that is identical and is not individualized to the patient's specific needs. The surgical care plans relate to pre and post-operative (op) care and reflect two goals that are for nursing to meet and do not reflect the patient. These goals are: "Nursing will meet standards of care for SDS [same day stay] post-op," and "Nursing will meet standards of care for SDS pre-op."

All of the interventions on the care plan are related to what nursing must do, such as what should be documented, tasks to be completed, assessments to be completed, etc.

In an interview with RN C during the MR review, RN C confirmed that the goals were not patient centered but were nursing centered.

In an interview with CNA M on 1/30/2013 at 1:00 p.m., CNA M stated M spoke to the health information staff who informed M that the same day stay surgical patients all have the same goals because they are only in the hospital for a short time.

In a phone interview with RN N on 1/30/2013 at 2:45 p.m., RN N, who is the pre and post-operative nurse, confirmed that there were no patient centered goals on the standardized patient care plans for surgical patients.

The MR findings were confirmed at the time of the MR review with RN C and CNA M.

Based on medical record review and staff interview, the hospital failed to ensure that 6 of 30 medical records reviewed (Pts.# 10,15,17,19,29 and 30) were readily accessible for review. This has the potential to affect the total inpatient population.

Findings include:

Patient #10's 1/29/13 medical record reflects the pt. came into the hospital's emergency department on 2/6/12 by ambulance in cardiac arrest with no pulse or respirations. "Page 2 of 2" of the physician summary notes "syncope/near syncope" by Emergency physician W written on 2/6/12 at 4:55 p.m. states under "re-evaluation: see code sheet-asystole/agonal...".

Review of this medical record reflects that no "code sheet" could be found for this patient. This code sheet would have details of the care and treatment Patient #10 received during resuscitation efforts.

These findings were verified by RN (Registered Nurse) C and CNA/MRA (Certified nursing assistant/medical records assistant) M on 1/29/13 at approximately 10:55 a.m.


20878




26711


While reviewing the Operating Room ledger for selection of patients on 1/29/2013 it was noted that 3 of the 5 selected patients (Pt. #15, 18,. and 19) had their birthdates incorrectly entered in the ledger making this information inaccurate.

Registered Nurse C confirmed this finding on 1/29/2013 at 3:30 p.m.

MR reviews for Pt.s #15-19 were completed on 1/29/2013 in the presence of Registered Nurse (RN) C between 7:50 a.m. and 3:45 p.m.
MR review for Pt. # 30 was completed on 1/30/2013 in the presence of Certified Nursing Assistant (CNA) M at 1:33 p.m. CNA M was assigned to assist in chart navigation as M is a facility resource in the medical record.

The MR for Pt.s 15-19 did not contain evidence that patients were informed of their rights and responsibilities in the facility. In an interview with RN C during the MR reviews, C stated that C is unaware of anything the patient would sign that is part of the MR since the facility now has a laminated copy of the patient rights in the rooms. This change took place approximately 6 months prior to the survey according to RN C's recollection.

Pt. #15's MR contained an Operating Room (OR) nurses note that did not include the time a time out for surgery was completed, and was incomplete in 7 out of 10 sections on the first page of the note and 4 out of 5 sections on the second page of the note.

Pt. #17's MR contained a Operative Report dictated by the physician on 11/20/2012 that remains unsigned by the physician at the time of the MR review (1/29/2013).

Pt. #19's MR contained a pre-anesthesia evaluation form that does not indicate the time the anesthesia provider completed the pre-anesthesia examination.

Pt. #29's MR contained an "Acknowledgement Receipt of Patient Rights and Responsibilities" form that does not include a date or time it was signed.

Pt. #30's MR contained a transfer form (Pt. #30 was transferred from this facility to a facility that could provide more intensive services) that is incomplete. The form, which is signed by Pt. #30, does not indicate the medical condition, reason for transfer, risks and benefits of the transfer and mode of transportation. The provider signed the form but did not time or date it. There is no time or date of Pt. #30's signature. There is a pre-anesthesia evaluation form that contains documentation from a Certified Registered Nurse Anesthetist (CRNA) that is illegible and the time of the pre-anesthesia evaluation can not be determined by RN C or Medical Records Clerk D at the time of the MR review.

These findings were confirmed by RN C and CNA M at the time of the MR reviews.

Based on medical record review and staff interview, the hospital failed to ensure that 19 of 30 patients (Pts.# 2, 4, 5, 8, 9, 12, 13, 15, 16, 17, 18, 19, 23, 24, 25, 27, 28, 29 and 30) reviewed had properly executed consents for treatment and documentation to ensure that they had been informed of their patient rights. This has the potential to affect the total inpatient population.

Findings include:

1) The 1/28/13 medical record review of Patient #8 reflects that there is no signed consent for hospital treatment received. This alert and oriented patient was admitted under observation status on 1/27/13 at 11:10 p.m. This 1/28/13 review of "Consent for Services" form provides information on:
1) routine and emergency treatment,
2) release of personal property responsibility,
3) release of medical records,
4) medicare authorization,
assignment of insurance and other benefits,
5) guarantee of account/responsibility of payment.

2) The 1/28/13 medical record review of Patient #9 reflects that there is no signed consent ("Consent for Services") for hospital treatment received. This 88 year old patient was admitted to the hospital on 1/27/13 at approximately 12 p.m. accompanied by her daughter.

3) The 1/28/13 medical record review of Patient #12 reflects that there is no documentation of the notification of patient rights and responsibilities signed by this patient. The "Acknowledgement Receipt of Patient Rights and Responsibilities" states that the patient has received a copy of these rights and responsibilities.

4) The 1/28/13 medical record review of Patient #13 reflects that there is no documentation of the notification of patient rights and responsibilities signed by this patient. The "Acknowledgement Receipt of Patient Rights and Responsibilities" states that the patient has received a copy of these rights and responsibilities.

5) The 1/28/13 medical record review of Patient #23 reflects that there is no documentation of the notification of patient rights and responsibilities signed by this patient. The "Acknowledgement Receipt of Patient Rights and Responsibilities" states that the patient has received a copy of these rights and responsibilities.

6) The 1/28/13 medical record review of Patient #24 reflects that there is no documentation of the notification of patient rights and responsibilities signed by this patient. The "Acknowledgement Receipt of Patient Rights and Responsibilities" states that the patient has received a copy of these rights and responsibilities.

The 1/28/13 medical record review of Patient #24 reflects that there is no signed consent ("Consent for Services") for hospital treatment received. This 75 year old patient was admitted to the hospital on 12/13/12 with Renal Failure, and discharged on 2/19/12.

7) The 1/28/13 medical record review of Patient #25 reflects that there is no documentation of the notification of patient rights and responsibilities signed by this patient. The "Acknowledgement Receipt of Patient Rights and Responsibilities" states that the patient has received a copy of these rights and responsibilities.

These findings found above were verified by Admissions Director Q and CNA/MRA (Certified nursing assistant/medical records assistant) M on 1/29/13 at approximately 3 p.m.



20878


Hospital policy # 05-02-02 entitled: "Admission and Registration Process" states: "Patient must read and sign Consent for services form, Patient Rights and Responsibilities, and HIPPA need to be signed and that date is to be entered into HMS. This verifies patient has received them."

8) Per record review patient #2 received an acknowledgement form indicating understanding of swing bed charges and Patient Rights and responsibilities. It was dated 08/04/12 but was not timed. This was confirmed per interview with Medical Records Clerk D on 01/30/13 at 2:40 PM.

9) Per record review patient #4 received an acknowledgement form indicating understanding of swing bed charges and Patient Rights and responsibilities. It was dated 08/30/12 but was not timed. This was confirmed per interview with Medical Records Clerk D on 01/30/13 at 2:40 PM.

10) Per record review patient #5 received an acknowledgement form indicating understanding of swing bed charges and Patient Rights and responsibilities. It was dated 08/31/12 but was not timed. This was confirmed per interview with Medical Records Clerk D on 01/30/13 at 2:40 PM.

11) Per record review patient #22's POA signed a consent for services on 01/28/13, it was not timed nor was there a witness signature. This was confirmed per interview with Medical Records Clerk D on 01/30/13 at 2:40 PM.

12) Per record review patient #27 received an acknowledgement form indicating understanding of swing bed charges and Patient Rights and responsibilities. It was dated 01/28/13 but was not timed. A consent for services in pt. #27's medical record was not signed or dated by the patient or the witness. These findings were confirmed per interview with Medical Records Clerk D on 01/30/13 at 2:40 PM.

13) Per record review patient #28 signed a consent for services on 01/29/13, it was not timed nor was there a witness signature. This was confirmed per interview with Medical Records Clerk D on 01/30/13 at 2:40 PM.


26711

Surgical Consents
The facility policy titled, "Consent Form for Operation," dated 9/15/2004, was reviewed on 1/30/2013 at 5:56 a.m. This form is used for surgical procedures and endoscopy procedures.
The policy statement states, " A properly executed informed consent form for the operation must be in the patient's chart before surgery, except in emergencies."
Regarding what the completed consent form will contain, the policy indicates, in part, these items:
"1.e. Date and time consent is obtained; f. Signature and professional designation of person witnessing the consent; 2. The OR [operating room] Nurse transporting the patient to surgery will review the patient's chart for a signed consent before the patient is brought to surgery and document same on "pre-op" check list."

An interview with the Director of Surgical Services (Dir) B was conducted on 1/28/2012 at 1:30 p.m. Dir. B stated that instead of a phone call, most of the time patients come to the hospital for a face to face pre-operative meeting with one of the surgical nurses to discuss events related to the surgery and their instructions. The consent for surgery is often signed at this meeting.

14) An observation of Pt. #26's pre-surgical admission was conducted on 1/30/2013 from approximately 9:00 a.m. until 9:50 a.m. Registered Nurse (RN) N was observed getting Pt. #26's signature on the informed consent form at 9:00 a.m., which RN N also signed at this time. The Medical Doctor (MD) V entered the room at 9:32 a.m. After spending approximately 5 minutes with Pt. #26, MD V signed the consent form. MD V did not indicate the time V signed the consent.

Medical Record (MR) reviews for Pt.s #15-19 were completed on 1/29/2013 in the presence of RN C between 7:50 a.m. and 3:45 p.m.
MR review for Pt. # 30 was completed on 1/30/2013 in the presence of Certified Nursing Assistant (CNA) M at 1:33 p.m. CNA M was assigned to assist in chart navigation as M is a facility resource in the medical record.

15) Pt. #18 had a colonoscopy on 1/18/2013. The surgical consent does not include a date or time that the patient or witness signed the form and the physician did not sign the form at all.

16) Pt. #15 had 15's gallbladder removed on 12/19/2012. The consent form is dated 12/13/12 at 9:20 a.m., thought to be the time and date Pt. #15 came in for the pre-operative meeting with the nurse. There is no indication next to the signature of the patient, witness, or physician to verify that they all signed the form at the same time on the same date.

17) Pt. #16 had a pacemaker generator replacement on 11/20/2012. The consent form is dated 11/14/12 at 1400 (2:00 p.m.), thought to be the time and date Pt. #16 came in for the pre-operative meeting with the nurse. There is no indication next to the signature of the patient, witness, or physician to verify that they all signed the form at the same time on the same date.

18) Pt. #19 had an upper endoscopy on 12/5/2012. The consent form is dated 11/28/12 at 1455 (2:55 p.m.), thought to be the time and date Pt. #19 came in for the pre-operative meeting with the nurse. There is no indication next to the signature of the patient, witness, or physician to verify that they all signed the form at the same time on the same date.

19) Pt. #30 had an upper endoscopy on 8/19/2012. The consent form is dated 8/19/12 10:22 a.m. There is no indication next to the signature of the patient, witness, or physician to verify that they all signed the form at the same time.

In an interview with RN C during the time of the MR reviews, RN C indicated that the date on the top of the consent form is considered to be the date and time the form was signed by everyone. RN C could not say that all parties are signing the form at the same time on the same date after reviewing the MRs.

These findings were confirmed with RN C during the MR reviews.

Consent for Blood
Pt. #30 has a consent to obtain blood products. This consent does not indicate a time the consent was signed.

These findings were confirmed with CNA M during the MR reviews.

General Consent for Care
In an interview with the Director of Admissions (Q), on 1/29/2013 in the afternoon, Dir. Q stated that on the patient's face sheet in the MR, the initials of the admitting clerk is the person who witnessed the patient's signature on the consent for care.

Pt. #15's Consent for Services form was signed dated and timed by Pt. #15 on 12/13/2012 for a surgical date of 12/19/2012. The witness signature line indicates "On file" with no date or time.

Pt. #16's Consent for Services form does not indicate a date or time Pt. #16 signed the form and the witness signature line indicates "On file" with no date or time.

Pt. #17 was signed in to the facility for knee surgery on 11/20/2012 at 8:28 a.m. by an admitting clerk with the initials of SRO. Pt. #17's Consent for Services form is signed by Pt. #17 on 11/14/2012 at 8:21 a.m. and the witness signature line indicates "Signature on File" with no date or time.

Pt. #18's Consent for Services is signed by the patient and a witness and dated, but there is no time to indicate when this form was signed.

Pt. #29's Consent for Services form is signed by the patient but there is not a date or time to indicate when this was done and the witness signature line indicates "On file" with no date or time.

These findings were confirmed with RN C and CNA M during the MR reviews.

Based on medical record review, facility policy review and staff interviews, the hospital failed to ensure that 5 of 30 medical records reviewed (Pts.#4, 11,12,13 and 16 )had timely completion of admission physical and medical history reports. This has the potential to affect all inpatients.

Findings include:

The 1/30/13 review of the Rules and Regulations of the Medical Staff revised March 2012 states: "A comprehensive admission History and physical shall be recorded for every inpatient within 24 hours of admission."

1) Patient #4 was admitted on 08/31/12, per record review pt. #4 was discharged on 09/03/12, a swing bed history and physical was not dictated until 09/07/12 it was not signed by the physician until 09/29/12.

These findings were confirmed per interview with Medical Records clerk D on 01/30/13 at 2:40 PM.

2) Patient #11 was admitted to the hospital on 2/21/12 with diagnosis of Lung Cancer and discharged on 2/23/12. The 1/29/13 medical record review reflects that no history and physical could be found for this patient stay.

These findings were verified by RN (Registered Nurse) C and CNA/MRA (Certified nursing assistant/medical records assistant) M on 1/29/13 at approximately 10:55 a.m.

3) Patient #12 was admitted to the hospital on 4/11/12 with diagnosis of Lung Cancer and discharged on 4/14/12. The 1/29/13 medical record review reflects that no history and physical could be found for this patient stay.

These findings were verified by RN (Registered Nurse) C and CNA/MRA (Certified nursing assistant/medical records assistant) M on 1/29/13 at approximately 11:15 a.m.

4) Patient #13 was admitted to the hospital on 5/20/12 with diagnosis of Cardiovascular Disease and discharged on 5/22/12. The 1/29/13 medical record review reflects that no history and physical could be found for this patient stay.

These findings were verified by RN (Registered Nurse) C and CNA/MRA (Certified nursing assistant/medical records assistant) M on 1/29/13 at approximately 10:55 a.m.

5) Pt. #16's Medical Record (MR) review was completed on 1/29/2012 at 9:40 a.m. in the presence of Registered Nurse (RN) C.
Pt. #16 had surgery for a pacemaker generator replacement on 11/20/2012. The physician did a same day History and Physical, which does not include the time it was completed, and the top half of the form which includes chief complaint, past history if applicable, present medications, family history as applicable and vital signs is blank.

This finding was confirmed by RN C at the time of the MR review.


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Based on observation, interview and review of facility policy the hospital failed to ensure security of medical records. This could affect all patients of this hospital.

Findings include:

Hospital policy # 50-20-03 entitled: "Clean Desk and Closed Door" governs security of medical records. The policy states: "All staff shall take appropriate action to protect confidential information in their work area by removing sensitive documents from view or by closing and locking the office door when leaving the area for extended periods of time."

During a tour of the hospital with Environmental Services Director A on 01/28/2013 at 1:00 PM the following was observed; the door to the old medical records room was wide open. Five, floor to ceiling, double sided, rolling files containing hundreds of medical records were unsecured and readily accessible to anyone entering this room. Env. Svcs Dir. A confirmed this observation at the time of the tour.

Based on review of QAPI (Quality Assurance Performance Improvement) indicators and staff interview, the hospital failed to ensure that it had an effective quality assurance program that collected data for all contracted services (laundry, housekeeping, kitchen and dietary services), and compiled aggregate data of adverse occurrences to identify high risk and/or problem-prone trends and patterns. This occurred in 3 of 3 quality assurance interviews conducted (Staff J, L and I), and has the potential to affect the total patient population.

Findings include:

1) Review of the hospital's "Occurrence /Event Report Forms" and the "Occurrence Report Summaries for the year of 2012" on 1/29/13 reflects that information is logged by month. There is no informational analysis documentation of trends or patterns for occurrence category types that are listed to identify problem-prone or high risk occurrences.

This was verified in interview with Quality Director I on 1/30/13 at approximately 3 p.m.


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2) An interview with Assistant Administrator (Admin) J was conducted on 1/29/2013 at 1:09 p.m. Admin J oversees the Environmental Services Director and was interviewed regarding the Housekeeping and Laundry functions in this facility. Laundry service is contracted out to a service in the same building but separate from the facility.

Admin J states that data is collected for the laundry service however this data has not been compiled together and forwarded to the Quality department to include this contracted service in the overall quality plan for the facility.

3) Interview with Assistant Administrator (Admin) J was conducted on 1/29/2013 at 1:09 p.m. Admin J stated that Housekeeping services, which are provided by the facility, are not currently involved in quality assurance activities.

4) Per interview with Kitchen Manager L on 01/30/13 at 11:00 AM their department is not involved in any quality assurance initiatives and has not submitted data to the QA program of the hospital. Dietary services are contracted out to a service in the same building but separate from the facility.

5) The hospital uses a contracted Registered Dietitian for professional nutritional services and patient assessments. Per interview with Quality Director I on 1/30/13 at approximately 3 p.m., there is no quality assurance data submitted or reviewed for contract dietary services to show that the terms of agreement are met. (reference C279)

Based on closed medical record review and staff interview, the hospital failed to have documentation of OPO (Organ procurement organization)contact in 1 of 6 patient (Patient #13) deaths reviewed.

Findings include:

The 1/29/13 closed medical record review of Patient #13's death record reflects admission on 5/20/12, and death as an in-patient on 5/22/12 at 6:30 p.m. Full medical record review reflects that no "Organ Procurement Organization" form could be found to reflect death notification and potential for tissue, eye or organ donation.

These findings found above were verified by Admissions Director Q and CNA/MRA (Certified nursing assistant/medical records assistant) M on 1/29/13 at approximately 3 p.m.

Based on closed medical record review and staff interview, the hospital failed to ensure that a trained designated requestor was utilized when inquiries were made for eye, tissue and organ donation. This occurred in 5 of 6 patient (Pts. 10, 11, 12, 14 and 23) deaths reviewed.

Findings include:

Interview with Nursing Director H on 1/29/13 at approximately 10 a.m. reflects that there is one 1 hospital staff member that has taken the OPO designated coursework to be a "designated requestor". Nursing Director states that is Social Worker P, who works regular business hours.

The 1/29/13 closed medical record review was conducted for the following patients:

1) The "nursing record" documents that "CPR (resuscitation efforts) were stopped" at 4:55 p.m. on 2/6/12 for Patient #10, with Emergency Physician pronouncing death at 4:55 p.m. on 2/6/12.

Review of the OPO (Organ Procurement Organization) form dated 2/6/12 at 6:25 p.m. for Patient #10 reflects that RN (Registered Nurse) X approached the family about donation and contacted the OPO after the death. RN X is not a OPO trained designated requestor.

2) The "progress notes" documents on 2/23/12 at 5:32 a.m. that Patient #11 is "declared dead".

Review of the OPO (Organ Procurement Organization) form dated 2/23/12 at 5:45 a.m. for Patient #11 reflects that the RN signature is illegible. This RN documents that contact was made with the family about donation, and made the OPO suitability telephone call. This is not the signature of Social Worker P.

3) Medical Record review reflects that Patient #12 was pronounced dead on 4/14/12 at 6:37 a.m. by the physician.

Review of the OPO (Organ Procurement Organization) form dated 4/14/12 at 6:52 a.m. for Patient #12 reflects that RN (Registered Nurse) Y contacted the OPO after the death. There is no documentation to reflect that family or significant others were approached by a designated OPO requestor for potential donation.

4) The 6/20/12 "emergency code sheet" timed at 9:20 a.m. reflects that resuscitation was stopped at 9:41 a.m. for Patient #14.

Review of the OPO (Organ Procurement Organization) form for Patient #14 (not dated) at 9:41 a.m. reflects that RN Z contacted the OPO after the death. There is no documentation to reflect that family or significant others were approached by a designated OPO requestor for potential donation.

5) Review of the OPO (Organ Procurement Organization) form for Patient # 23 dated 12/3/12 at 11:02 a.m. reflects "time of death at 10:40 a.m.". RN AA contacted the OPO after the death. There is no documentation to reflect that family or significant others were approached by a designated OPO requestor for potential donation.

These findings found above were verified by Nursing Director H and CNA/MRA (Certified nursing assistant/medical records assistant) M on 1/29/13 at approximately 3 p.m.