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Based on observation and interview, the hospital failed to ensure used intravenous materials were removed from one of 24 (Room # 104) patient rooms.

This failed practice had the potential for a patient to harm themselves by swallowing, choking or hanging using the intravenous materials.

Findings:

Room # 104

On 06/13/18 at 11:30 am, the surveyor observed a bag of intravenous fluids, with the used tubing still attached, hanging from a pole. The tubing was still connected to the bag of intravenous fluids. At the end of the tubing, the intravenous catheter which had been in a patient's arm was laying on the floor. The intravenous materials had been laying on the floor for approximately 12-14 hours after nurse removed it from patients arm.

On 06/13/18 at 11:40 am, Staff V stated he/she took out the intravenous catheter on 06/12/18 at 5:00 pm.

On 06/14/18 at 12:20 pm, Staff T stated the intravenous materials should have been discarded.

Based on record review and interview the hospital failed to ensure Staff D (Attending Physician), followed hospital policies, rules and regulations for documentation of orders. 21 of 21 records reviewed, lacked the physician's order verification with signature, date and time.
This failed practice resulted in 21 delinquent medical records.

Findings:
I. A policy, "Physician Orders" issued 10/15 showed:
A. All orders will be completed in accordance with the Medical Staff Bylaws, Rules and Regulations.
B. Physician orders are required to comply with the following guidelines:
1. The complete medication order shall be written on the "Physician Order Form" and include: Physician's/APRN's signature.
2. Telephone orders shall be signed by a staff physician as soon as possible, but not later than 72 hours
3. Verbal orders may only be used in emergencies and must be signed as soon as possible following the emergency (prior to the physician leaving the unit).
II. Rules and Regulations of the Medical Staff of Rolling Hills Hospital, effective 05/14/17 showed:
A. The practitioner shall provide the required documentation as stipulated in this document and hospital policy. All practitioners are to follow the guidelines for medical record documentation.
B. All entries to the medical record must be legibly signed, dated, timed and authenticated.
C. Any verbal orders dictated over the telephone shall be limited to emergency situations.
III. 21(#1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21) of 21 patient records reviewed showed:
A. Staff D had not written, (all orders were verbal/telephone) dated, or timed any orders.
B. seven (#1,3,4,5,7,13,21) of 21, Staff D had not written, dated, or timed admission orders (all were verbal/telephone orders).
C. 41 of the verbal/telephone orders were unsigned, dated, or timed by Staff D.
IV. On 06/14/18 at 10:30 am, Staff B (RN), stated he/she thought the policy stated that physicians should sign orders every 24 hours. He/she stated Staff D did not sign orders daily.
On 06/14/18 at 1:00 pm, Staff C (RN), stated Staff D was on the unit three times a week, that he/she "signed orders on weekends if nursing staff had flagged them".
On 06/18/18 at 2:00 pm, Staff K (DON), stated he/she had noticed orders were not signed within 24 hours.
On 06/18/18 at 2:30 pm, Staff J (MR Director) stated "Staff D should be writing more orders", and "we should decrease the verbal orders".
On 06/14/18 at 12:00 pm surveyors observed as Staff H reviewed the medical records of patients #11 and 12. He/she confirmed Staff D had not signed multiple orders in the records.

Based on record review and interview the hospital failed to ensure discharge summaries were completed by Staff D, MD, (the attending physician) in accordance with hospital policies, rules and regulations for medical records in five (#1,6,7,9,13) of 13 medical records reviewed. This failed practice resulted in five delinquent medical records.

Findings:
A document, "Rules and Regulations of the Medical Staff" effective 05/15/17 showed:
1. The Practitioner shall provide the required documentation as stipulated in this document and hospital policy. All Practitioners are to follow the guidelines for medical record documentation.
2. All discharge summaries and other medical record documentation shall be completed within thirty (30) days following the patient's discharge.

A review of closed medical records with discharge dates from 03/24/18 to 05/15/18 showed as of 06/19/18, five (#1, 6, 7, 13, 19) of 13 records did not contain a discharge summary written by Staff D within 30 days of the discharge date.

On 06/14/18 at 2:30 pm, Staff J stated the discharge summaries should be charted within 30 days.