HospitalInspections.org

Based on a review of facility documents, medical records (MR) and staff interview (EMP), it was determined that the facility failed to comply with Federal Regulations.

The facility was found to be non-compliant with the following Federal Regulation:

482.13 (a)(1) Patient Rights: Notice of Rights. A hospital must inform each patient, or when appropriate, the patient's representative (as allowed under State law), of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible.

This is not met as evidenced by:

Based on a review of facility documentation, medical records (MR) and staff interview (EMP), it was determined that the facility failed to provide the patient or the patient's representative a copy of the Important Message from Medicare no more than 2 days prior to discharge for 9 of twenty-one medical records reviewed (MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR10 and MR11).

Findings include:

A review on August 20, 2018, of facility policy "Important Message from Medicare And Patient Appeal Rights last reviewed 6/13 revealed, "...IV. PROCEDURE: CRM staff Responsibilities: A copy of the IM is delivered to and reviewed with the patient with other discharge information (not more than 2 calendar days prior to discharge: A. The IM is signed by the patient or representative to be retained by the hospital; a second form is given to the patient or their records [sic]. B. The original signed notice placed in the paper medical record [sic]."


A review of MR2 on August 21, 2018, revealed the patient was admitted on July 25, 2018 and discharged on August 4, 2018. A copy of the admission IMM was noted on MR2. There was no discharge IMM noted on MR2.

A review of MR3 on August 21, 2018, revealed the patient was admitted on May 1, 2018 and discharged on May 13, 2018. A copy of the admission IMM was noted on MR3. There was no discharge IMM noted on MR3.

A review of MR4 on August 21, 2018, revealed the patient was admitted on May 16, 2018, and discharged on May 25, 2018. A copy of the admission IMM was noted on MR4. There was no discharge IMM noted on MR4.

A review of MR5 on August 21, 2018, revealed the patient was admitted on May 15, 2018, and discharged on May 30, 2018. A copy of the admission IMM was noted on MR5. There was no discharge IMM noted on MR5.

A review of MR6 on August 21, 2018, revealed the patient was admitted on May 23, 2018, and discharged on June 4, 2018. A copy of the admission IMM was noted on MR6. There was no discharge IMM noted on MR6.

A review of MR7 on August 21, 2018, revealed the patient was admitted on July 18, 2018, and discharged on July 22, 2018. A copy of the admission IMM was noted on MR7. There was no discharge IMM noted on MR7.

A review of MR8 on August 21, 2018, revealed the patient was admitted on June 11, 2018, and discharged on June 18, 2018. A copy of the admission IMM was noted on MR8. There was no discharge IMM noted on MR8.

A review of MR10 on August 21, 2018, revealed the patient was admitted on June 8, 2018, and discharged on June 15, 2018. A copy of the admission IMM was noted on MR10. There was no discharge IMM noted on MR10.

A review of MR11 on August 21, 2018, revealed the patient was admitted on June 9, 2018, and discharged on June 13, 2018. A copy of the admission IMM was noted on MR11. There was no discharge IMM noted on MR11.

An interview with EMP1 on August 21, 2018, confirmed there was no documentation on MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR10, and MR11 regarding the second IMM.

Based on review of facility documentation, facility tour, and employee interviews (EMP), it was determined that the facility failed to ensure drugs under the control of the pharmacist, which are unlabeled, or inadequately labeled shall be identified by the pharmacist and shall be disposed of in compliance with applicable State and Federal law and regulations for seventeen out of seventeen syringes in the anesthesia workroom.

Findings include:

Review on August 21, 2018, of facility policy OR-450 "LABELING OF FLUIDS AND MEDICATIONS IN THE OPERATING ROOM" revised 6-21-18 revealed ..."POLICY: ..."This policy gives guidelines in regards to labeling fluids and medication that are removed from their original container in the perioperative area. B. Method ... 1. Labeling occurs when any medication or solution is transferred from the original packaging to another container. 4. Label all medications and solutions as soon as they are prepared, unless they are immediately administered...7. Discard of all used and open solutions at the end of each case..."

Observation of the anesthesia workroom on August 20, 2018, at approximately 11:15AM revealed under a wooden panel in a file drawer the following syringes:

(6) Phenylephrine (used to treat hypotension) syringes dated 8/19 2330
(2) Phenylephrine (used to treat hypotension) syringes dated 8/19 0700
(4) Lidocaine syringes (used to treat arrhythmias) 1.5% dated 8/19 0700
(1) Glycopyrrolate (can decrease salivary secretions) 0.2mg/ml no date
(1) Ephedrine (used to treat hypotension) 5mg/5ml prepackaged syringe with expiration date 8/17/18
(1) Neosynephrine (used to treat arrhythmias) 0.1mg/ml in a bag of 100ml Normal Saline dated 8/19 0700
(2) Neosynephrine (used to treat arrhythmias) dated 8/19 0700

Interview on August 20, 2018 at approximately 11:34AM with EMP3 revealed that "if meds aren't used after cases we put them in here to use for others, if we don't hand them off." Further interview revealed that EMP3 had been employed for approximately 10 years and "we've been doing it like that since I've been here".