HospitalInspections.org

36293

Based on observations and interviews, the CAH failed to ensure the physical environment was maintained for the safety of the patients. This deficient practice is evidenced by failing to ensure the call bell feature worked on the patient's beds for 6 of 16 beds in the in-patient/swing-bed rooms.
Findings:

1) Observations on 08/08/2022 at 1:00 p.m. revealed the patient's hospital beds in rooms a, b, c, d, e and f were equipped with a nurse call function on the patient's bed. Further observation revealed this nurse call function was not connected to the call bell system and was non-functioning.

In an interview on 08/10/2022 at 8:50 a.m., S3MNT confirmed the call bell feature on the patient's beds in rooms a, b, c, d, e and f were non-functioning.

Based on review of the facility's policy/procedure, record review and interview, the CAH failed to maintain a clinical records system in accordance with its written policies and procedures.
Finding:

Review of the facility's policy 2.16 titled, "Suspension for Incomplete Medical Records" revealed in part: Medical Records are considered delinquent when they remain incomplete for 30 days following discharge.

Review of the facility's policy reference #4814 titled, "Discharge and Admission Orders-Swing Beds (CAH) revealed in part: A physician shall write discharge orders for the acute care inpatient services and subsequent admission orders for swing bed services.

Review of the facility's bylaws Medical Records 2.2 revealed in part: A complete admission History and Physical (H/P) will be recorded within twenty-four hours of admission.

Review of Patient #1's medical record on 08/08/2022 at 2:45 p.m. revealed in part: patient discharged on 07/08/2022. At the time of this review, there was not a signed discharge summary in the patient's chart.

In an interview at this time, S4HIM acknowledged Patient #1's chart was delinquent.

Review of Patient #2's medical record on 08/08/2022 at 2:50 p.m. revealed an admit of 08/02/2022 to a swing bed. Further review failed to reveal a completed H/P for Patient #2.

In an interview at this time, S4HIM acknowledged the H/P was not completed according to policy.

Based on observation and interview, the CAH failed to maintain a clean and sanitary environment as evidenced by having furniture with rips and tears in use in patient rooms, and having clean linen stored in an empty patient room with the window open to the outside, creating a warm, humid environment.
Findings:

On 08/08/22 at 1:00 p.m., observation of the inpatient rooms on the nursing unit revealed the following:
- Rooms a, c, and g contained reclining chairs that had rips and tears to the vinyl covering on the chair, exposing the foam cushioning underneath the covering.
- Room a contained an electronic blood pressure machine that had old, peeling tape on it.
- Room h contained 2 bins of clean linens. The door to the room was closed with the window open to the outside. The air in the room was warm and humid.
- All patient rooms had old used pieces of tape stuck on the doors.
- The therapy room had a large tear to the vinyl covering on the therapy table/bed.


On 08/09/22 at 1:30 p.m., an interview with S1CNO confirmed that the reclining chairs could not be cleaned and disinfected due to the tears in the vinyl, and that the clean linens should not be stored in a warm, humid environment.



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