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Based on record review, interview and policy review, the facility failed to provide patients with patient rights notification (see A117), failed to properly resolve patient grievences (see A118), failed to properly assess a restrained patient (see A167), failed to properly evalutate the need for restraints (see A187 and A188).

Based on record review and interview the facility failed to ensure that another important message was provided to the patient whose stay was more than 2 days after the first important message was delivered.

On 4/20/2011 at approximately 0810 a review medical records revealed that the second important message had not been delivered in 7 of 7 patients. Patient #22, #23, #36, # 37, #38, #39, and #40 did not have a second important message in the medical record.

On 4/20/2011 at approximately 1140, an interview with the Quality Assurance Manager took place at which time she confirmed the above findings.

Based on document review and policy and procedure review, the facility failed to establish a process for prompt resolution of patient grievances in 9 out of 16 (#41, #42, #46, #47, #49, #51, #54, #55, #56) filed.

Findings include:

During document review on 4/20/11 at approximately 0900 of the facilities complaint and grievance logs, it was found that the complaint log had 9 out of 16 incorrectly identified complaints that should have been documented and dealt with as a grievance based on the facilities policy and procedures.

During policy and procedure review on 4/20/11 at approximately 1030 the policy titled "Patient Complaint-Grievance Process" defines, "Grievance: A written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patients representative, regarding the patients care, abuse or neglect, issues related to the hospitals compliance with the CMS Hospital Condition of Participation, or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489. If the patient or the patient's representative requests their complaint to be handled as a grievance or requests a response front he health system the complaint is considered a grievance. Per CMS requirements, concerns regarding the following issues are automatically considered grievances: Written letters of complaint, Premature discharge, Patient rights, privacy, and safety of the patient, Confidentiality and access to patient records, Civil rights or issues of disability".

During complaint log review the following was found:

1. Patient #41 was filed in the complaint log, but this was a care related incident that needed further follow up action.
2. Patient #42 was filed in the complaint log,, but was done by phone communication that needed further follow up action.
3. Patient # 46 was filed in the complaint log, but was a care related incident that needed further follow up action.
4. Patient #47 was filed in the complaint log, but was done by phone communication that needed further follow up action.
5. Patient #49 was filed in the complaint log, but was a care related incident that needed further follow up action.
6. Patient #51 was filed in the complaint log, but was done by phone and a patient rights/privacy incident that needed further follow up action.
7. Patient #54 was filed in the complaint log, but was a care related incident that needed further follow up action.
8. Patient #55 was filed in the complaint log, but was done by phone and in person, it also needed further follow up action.
9. Patient #56 was filed in the complaint log, but was done by phone communication that needed further follow up action.

Based on medical record review and policy and procedure review, the facility failed to document in the medical record the patient's assessment of safe and appropriate restraints in 1 of 1 (#33) restraint patient's record.
Findings include:


During medical record review of patient #33 on 4/19/11 at approximately 1700 it was found that there are two time frames where the patient is not assessed every two hours as required per facility policy. The first one is an assessment at 1708 of the patient, then another assessment is not documented until 1955. the second instance is an assessment at 1955 of the patient, then another assessment is not documented until 2251.

During policy and procedure review on 4/20/11 at approximately 0830 it was found on the policy titled, "Restraint Use", under the procedure section, "10. The "Restraint Flow Sheet" is to be initiated. Every 2 hours, qualified nursing staff conduct a face-to-face assessment of the patient. The assessment shall include:".

Based on medical record review and policy and procedure review, the facility failed to document in the medical record the patient's condition or symptom that warranted the use of restraints in 1 of 1 (#33) restraint patient's record.
Findings include:

During medical record review of patient # 33, on 4/19/11 at approximately 1700 it was found that on the "Restraint Orders" form, under the section, "Purpose of Restraint", none of the boxes had been checked and the form was incomplete.

During policy and procedure review on 4/20/11 at approximately 0830 it was found on the policy titled, "Restraint Use", under the procedure section, "5. Alternative measures attempted, reason for initiating restraint and the physician's orders are recorded on the "Restraint Order Form"'.

Based on medical record review and policy and procedure review, the facility failed to document in the medical record the patient's response to the restraint usage, including rationale for continued use in 1 of 1 (#33) restraint patient's record.
Findings include:

During medical record review of patient #33 on 4/19/11 at approximately 1700 it was found that there is no documentation regarding the patient's response to the restraint usage or any reason for continued use of restraints.
During policy and procedure review on 4/20/11 at approximately 0830 it was found on the policy titled, "Restraint Use", under the procedure section, "10. The "Restraint Flow Sheet" is to be initiated. Every 2 hours, qualified nursing staff conduct a face-to-face assessment of the patient. The assessment shall include"...g. readiness for discontinuation of restraint".

Based on record review, policy review and interviews, the facility failed to supervise staff when performing blood glucose meter calibration. Findings include:

During observations on the Med/Surg West and Med/Surg East units on 04/18/2011 at 1400 with staff G, this surveyor requested to see the log for documentation of the glucometer control logs. Staff G provided a document of previous blood sugars performed. Further explanation of wanting a log of the controls showing calibration of the machine by staff every night after midnight was discussed. Staff G stated that she would have them the next morning.
04/19/2011 Review of the meter QC log reports for the glucometer for both East and West units for February and March 2011 revealed that staff N and staff O had inaccurate documentation. See below:
On 02/03/2011 staff N documented on both units under comments "repeated test" however there is no documentation on the report of a repeat test being performed. On 02/05/2011 staff O documented on both units under comments "procedure error" however there is no documentation on the report of a repeat test being performed. On 02/07/2011 staff O documented on both units under comments "procedure error" however there is no documentation on the report of a repeat test being performed. On 02/09/2011 staff N documented on both units under comments "repeated test" however there is no documentation on the report of a repeat test being performed. The above findings continued throughout the months of February and March when ever staff N & O were performing the calibration of the meter.
Review of the St. Joseph Health Systems policy titled Blood Glucose Monitoring 01.10 revised 01/10 reads under Competency "All persons authorized to do blood glucose testing must demonstrate competency prior to performing patient testing and annually thereafter."
Discussion with the unit manager staff G and staff H Director of laboratory Services on 04/19/2011 at 0945, revealed that until 04/19/2011 the document titled QC lab report had never been printed prior to this surveyor requesting them. No one reviewed the documentation in regards to the blood glucose machine being calibrated correctly.

Based on record review, interview, and policy review, the facility failed to ensure that the nursing staff initiated nursing care plans timely in 2 of 6 (#1, #3) obstetrical charts reviewed. Findings include:

Review of the medical record with OB Nurse #R and the OB Nurse Manager on 4/18/11 at approximately 1430 revealed:

Patient #1 delivered her baby on 4/17/11 at 1633 and the care plan was initiated on 4/18/11 at 0747.

Patient #3 delivered her baby via C-Section on 4/14/11 at 1332 and the care plan was initiated on 4/15/11 at 0945.

Interview with the OB Nurse Manager at that time revealed that the care plans should have been initiated sooner. Review of the 'Postpartum Plan of Care' policy dated 0408 verified that the plan of care should have been initiated within six (6) hours after delivery. This had not been done.

Based on observation and interview the facility failed to protect patient health information. Findings include:
During observation of the medical/surgical unit on 04/18/2011 at 1030 with the unit manager, it was noted that in the hallways just outside of the patient's rooms were unsecured hanging file holders that contained patient health information.
The file holder outside of patient #26's room (134), contained information about the patient's code status and an education record related to a diagnosis of a heart attack.

The file holder outside of patient #34's room (135), contained information about the patient's code status.

The file holder outside of patient #35's room (136), contained information about the patient's code status, an education record related to a diagnosis of pneumonia and a document titled Pastoral Assessment.

The findings were discussed with the unit manager staff G during the observation who confirmed that the information was unsecured in these file holders. Next to the file folders on the walls were wall-a-roos that contained locks that could be used to store the patient information. When queried, the unit manager stated that they do not use them anymore.

Based on medical record review and interview the facility failed to ensure that all orders are dated, timed and authenticated by the ordering practitioner in 2 out of 2 (#28, #29) open surgical medical records. Findings include:

During medical record review of patient #28 on 4/19/11 at approximately 1145 it was found that on the "Preadmission & Preop Order Form", the physician failed to date and time the orders. During the same medical record review it was found that on the "Urology Pre-Operative Orders" sheet, the physician failed to time the orders.

During medical record review of patient #29 on 4/19/11 at approximately 1155 it was found that on the "Preadmission & Preop Order Form", the physician failed to authenticate, date and time the orders.

During an interview with staff K on 4/19/11 at approximately 1205, these findings were confirmed.

Based on open and closed record review, interview, and policy review, the facility failed to ensure that all verbal and telephone orders taken from the physician were authenticated by the next visit time frame for 1 of 2 closed records reviewed. Findings include:

Closed clinical record review on 04/19/2011 at 1600 revealed that staff had taken a verbal order for patient #31 on 03/19/11. The orders were for "Phenergan 12.5-25.0 mg IVP(inter-venous push) now". Additionally on 3/9/11 at 2000 a telephone order was taken for "D 5 and 0.45% Normal saline to run at 75/hr". As of 4/18/11 neither of these orders had been authenticated by the physician. Findings were confirmed by staff #B.

According to facility policy titled Verbal Orders/Telephone Orders, "...the responsible physician shall sign, date and time the (telephone or verbal) orders at the next visit". The facility's policy is inconsistent with federal regulations which stipulate that the timeframe for authentication of verbal orders is within 48 hours.

During the tour of the surgical area on 4/19/11 at approximately 1000 the following observations were made:
1. Anesthesia Cart #4
a. One 1milligram epinephrine single use syringe with an expiration date of 4/1/11
b. One 1milliliter vial of Atropine with no open or expiration date
c. One 10 milliliter bottle of Rocuronium with no open or expiration date
d. One 20 milliliter bottle of Lidocaine-2% with no open or expiration date

These findings were confirmed by staff K during the tour and observation.



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Based on observation, interview and policy review, the facility failed to discard medications that had exceeded their manufacturers expiration date. Findings include:

On 4/18/11 at approximately 1410 during a tour of the main pharmacy, found Hydrophor oil with a manufacturers expiration date of February 2011. Also during the pharmacy tour while counting controlled substance type medications, found Demerol 100 mg injectable unopened package of 10 syringes with a manufacturers expiration date of March 1, 2011. These findings were confirmed with staff staff L, who took these medications out of availability for patient use.

Review of policy titled Unit Inspections on 4/18/11 at 1600 reveals that "all drug storage areas in the hospital will be inspected once every two months by an assigned pharmacy to ensure proper storage conditions proper inventory, formulary compliance and evaluation of expiration dating...remove and replace expired/expiring medications...".

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-709.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors, the facility does not comply with the applicable provisions of the Life Safety Code.

See the K-tags on the CMS-2567 dated May 19, 2011 for Life Safety Code.

Based on observation and interview the facility failed to ensure supplies and equipment were maintained at an acceptable level of safety and quality.
Findings include:
During the tour of the surgical area on 4/19/11 at approximately 1000 the following observations were made:

1. Anesthesia Room
a. Two 24 gauge intravenous catheters with an expiration date of 06/08
b. One 22 gauge intravenous catheter with an expiration date of 09/09
2. Anesthesia Cart #2
a. One 14 gauge intravenous catheter with an expiration date of 09/04
3. Anesthesia Cart #3
a. One 18 gauge intravenous catheter with an expiration date of 4/09
4. Anesthesia Cart #4
a. One 22 gauge intravenous catheter with an expiration date of 11/10
b. Two purple top blood collection tubes with an expiration date of 06/05
c. One green top blood collection tube with an expiration date of 10/00
d. One lavender top blood collection tube with an expiration date of 06/10
e. One blue top blood collection tube with an expiration date of 10/03

During observation, tour and interview on 4/19/11 , staff K confirmed these findings.

Based on observation, interview and policy review the facility failed to discard food intended for use by patients that had exceeded the manufacturers expiration dates. Findings include:

On 4/18/11 at approximately 1130 during a tour of the medical/surgical/pediatric unit's pantry found the following food that was available for patient use:
1. A box of Infant Rice Cereal (opened) with a manufacturers expiration date of April 7 2007
2. A box of Cream of Wheat Cereal (opened) with a manufacturers expiration date of August 12, 2010.

Staff G confirmed the presence of the two opened boxes of cereal and discarded each of them into the trash.

Review of facility's policy titled Patient Food Storage in Clinical Areas fails to specify how the facility monitors for and removes from service expired food.

Based on medical record review and interview, the facility failed to ensure that a complete, updated history and physical, including any changes in patient's condition within 24 hours of admission on 2 of 2 (#28, #29) open surgical medical records. Findings include:

During medical record review of patient # 28 on 4/19/11 at approximately 1145 it was found that the physician failed to update the patients medical history and physical prior to surgery.
During medical record review of patient # 29 on 4/19/11 at approximately 1155 it was found that the physician failed to have a complete medical history and physical in the patient's chart prior to surgery.

During an interview with staff K on 4/19/11 at approximately 1205, these findings were confirmed.

Based on medical record review, policy and procedure review and interview, the facility failed to ensure a properly executed informed consent form for the operation in 1 out of 2 (#28) open surgical medical records.
Findings include:

During medical record review of patient #28 on 4/19/11 at approximately 1145 it was found that the physician failed to sign, date and time the "Consent to Surgery or Other Procedures" form.

During policy and procedure review on 4/19/11 at approximately 1600 it was found on the policy titled, "Informed Consent/Forms", states, "3. The physician must sign the form affirming that he/she discussed the nature, reasonably expected risks, benefits and alternatives of the procedure with the patient, patient's relatives or other persons".

During interview with staff K on 4/19/11 at approximately 1205 the above findings were confirmed.