HospitalInspections.org

Based on review of records and interview, it was determined that the facility failed to inform each patient of their patient's rights in advance of furnishing care in 15 of 15 Outpatient records (Records: 1-15).

Findings:

York Hospital's Organizational wide policy titled Patient Rights stated, "I. Purpose: To describe how the York Hospital organization assures that patients are informed of their rights."

On December 4, 2018, outpatient records 1 - 12 were reviewed with the Practice Managers in each outpatient area. There was no documentation that these records contained documentation that the patient had been given their patient's rights in advance of furnishing care.

On December 6, 2018, outpatient records 12 -15 were reviewed with the Practice Managers in each outpatient area. There was no documentation that these records contained documentation that the patient had been given their patient's rights in advance of furnishing care.

On December 6, 2018, the Director of Practice Operations confirmed that the 15 outpatient records did not contain documentation that the patient had been informed of their patient's rights in advance of furnishing care.

Based on record review and interview, it was determined that the facility failed to document that each patient was asked if they had an advanced directive and/or did they want to execute one in 9 of 13 applicable Outpatient records. (Records: 4, 5, 6, 7, 8, 11, 12, 13 and 15)

Findings:

The York Hospital and All Off Sites policy titled Advance Directives stated, "York Hospital patients will be given information concerning their right to make decisions about medical care including the right to formulate advance directives and assistance in completing documents as requested."

On December 4 and 6, 2018, Outpatient records 4, 5, 6, 7, 8, 11, 12, 13 and 15 were reviewed with each Practice Manager. These records did not contain documentation that the patient had been asked about an advance directive.

On December 4, 2018, Practice Managers at Cardiovascular Care, Endocrinology, Pulmonology, Urology, Surgical Associates and Neurology (Records 4, 5, 6, 7, 8 and 11) confirmed that the patient's record did not contain documentation that the patient had been asked about an advanced directive.

On December 6, 2018, Practice Managers at York Family Practice, Wound Clinic and Psychiatry (Records 12, 13 and 15) confirmed that the patient's record did not contain documentation that the patient had been asked about an advanced directive.

Based on observation and interview, the hospital failed to ensure documentation on computer screens was kept confidential in the Ambulatory Surgical Unit (ASU) of Surgical Services.

Finding:

On 12/4/18 at 12:30 PM, during tour of Surgical Services, the surveyor and Director of Surgical Services observed 4 computer work station used by Surgical Services staff to document patient information in the corridor of the ASU. At the time of the observation and in an interview with the Director of Surgical Services, he/she confirmed unauthorized personnel cross through the corridor of the ASU. The surveyor requested the Director of Surgical Services access a patient record on one the computer workstations, the surveyor stood in the center of the corridor and was able to see the patient's name, demographic information and clinical information. At this time the surveyor confirmed the finding.

Based on 4 of 30 patient record reviews and interviews, (Patient #2, Patient #5, Patient #11, Patient #16), the facility failed to ensure that medications administered as ordered or documented according to hospital policy.

Findings:
1. Patient #2 had a physician order dated 11/26/18 for CO Q-10. There was no evidence the medication was administered on 11/27/18 through 12/5/18 at 9:00 A.M.

2. Patient #5 had a physician order dated 12/01/18 for Centrum Silver. There was no evidence this medication was administered on 12/1/18 through 12/4/18 at 9:00 A.M.

3. Patient #5 had a physician order dated 12/01/18 for Ocuvite. There was no evidence this medication was administered on 12/1/18 through 12/4/18 at 9:00 A.M. and 21:00.

4. Patient #11 had a physician order dated 12/02/18 for Acidophilus. There was no evidence this medication was administered on 12/3/18 through 12/4/18 at 9:00 A.M. and 21:00.

5. Patient #16 had a physician order dated 12/03/18 for Vitamin B-12. There was no evidence this medication was administered on 12/3/18 through 12/4/18 at 9:00 A.M.

An interview on 12/5/18 at approximately 1:00 P.M. with Registered Nurse #1 confirmed that the medications for Patient #2, Patient #5, Patient #11, Patient #16 were practitioner ordered, not administered because they were the patient's personal medications that the patient did not provide, and the pharmacy does not supply non-formulary medications.

Based on inpatient record reviews and interview, the hospital failed to ensure a patient's medical record entry indicated the time it was written for 1 of 30 inpatient records reviewed (Patient #30).

Finding:

Patient #30's record contained written documentation, dated 12/5/18, by a Physician. This documentation did not indicate the time the written note was made.

On 12/7/18 at 9:08 AM, the surveyor confirmed this finding with the Director of the Medical/Surgical Unit and a Registered Nurse.

Based on 2 of 30 patient record reviews and interviews, (Patient #17 and Patient #9), the facility failed to ensure that verbal orders were timed on the date received.

Findings:

1. Patient #17 record on 12/4/18 had a telephone verbal order on 12/2/18 for a medication Acef. This order was not timed.

2. Patient #9 record on 12/4/18 had a telephone verbal order on 11/20/18 and 11/21/18 for a medication Xeralto. This order was not timed on the date received and these orders were not authenticated within 48 hours by the licensed practitioner.

An interview with Registered Nurse #1 on 12/5/18 at 1:42 P.M. confirmed Patient #17 and on 12/5/18 at 2:21 P.M. confirmed Patient #9 verbal orders were not timed on the date received.

The facility Revised 11/15 Verbal or Telephone Orders policy indicated, "Verbal or telephone orders must be dated, timed, and authenticated within 48 hours by the ordering practitioner or by another practitioner who is responsible for the care of the patient..."

Based on observations and interviews, the facility failed to store drugs and biologicals in a secure area in 2 of 13 departments of the hospital, including 2 of 7 pyxis machines.

Findings:

On 12/3/18 at 12:15 PM, on tour of the Emergency Department (ED) the surveyor and Director of the Emergency Department observed the medication area in the nurse station which contained a pyxis machine that required a user identification and password, but was not locked in an enclosed area designated for medication preparation and there was no camera for monitoring, thus in an unsecured area accessible to unauthorized personnel. At the time of the observation and in an interview with the Director of the Emergency Department, the surveyor inquired whether narcotics (schedule II-V) were stored in the pyxis machine and the Director of the Emergency Department confirmed narcotics were stored in pyxis. At this time, the surveyor confirmed the finding.

On 12/7/18 at 9:15 AM, two surveyors observed the Intensive Care Unit (ICU) which contained a pyxis machine behind the nurse station in an unsecured area accessible to unauthorized personnel and with no monitoring camera. At the time of the observation and in an interview with a Nurse Manager, the surveyors inquired whether narcotics (schedule II-V) were stored in the pyxis machine and the Nurse Manager confirmed narcotics were stored in pyxis. At this time, the surveyor confirmed the finding.

On December 7, 2018, at 11:55 AM, during a telephone interview with a hospital Pharmacist, she stated that an Emergency Department nurse could have access to the pyxis machine in the Intensive Care Unit, as an example, if the supervisor had approved it. Therefore other staff from other units could possibly access pyxis machines anywhere in the hospital with the supervisor's approval.

Based on observations and interviews, the facility failed to store Schedules II, III, IV, and V drugs in a secure area in 2 of 13 hospital departments, including 2 of 7 pyxis machines, per the Comprehensive Drug Abuse Prevention and Control Act of 1970 must be kept locked within a secure area.

Findings:

According to policy and procedure titled, "Controlled Drugs - Schedule 2, 3, 4, 5," section "3. Storage:" "In areas outside the Pharmacy, schedule 2 drugs will be stored securely under double lock and all controlled drugs will be stored in a secure manner. Only authorized personnel may access controlled drugs."

On 12/3/18 at 12:15 PM, on tour of the Emergency Department (ED) the surveyor and Director of the Emergency Department observed the medication area in the nurse station which contained a pyxis machine that required a user identification and password, but was not locked in an enclosed area designated for medication preparation and there was no camera for monitoring, thus in an unsecured area accessible to unauthorized personnel. At the time of the observation and in an interview with the Director of the Emergency Department, the surveyor inquired whether narcotics (schedule II-V) were stored in the pyxis machine and the Director of the Emergency Department confirmed narcotics were stored in pyxis. On 12/6/18 at 12:50 PM, the surveyor observed the Director of the Emergency Department log on to the pyxis machine in the ED and discovered a one minute delay for the pyxis machine to time-out, unless manual exit. At this time, the surveyor confirmed the finding with the Director of the Emergency Department.

On 12/7/18 at 9:15 AM, two surveyors observed the Intensive Care Unit (ICU) which contained a pyxis machine behind the nurse station in an unsecured area accessible to unauthorized personnel and with no monitoring camera. At the time of the observation and in an interview with a Nurse Manager, the surveyors inquired whether narcotics (schedule II-V) were stored in the pyxis machine and the Nurse Manager confirmed narcotics were stored in pyxis. During the interview, the surveyors inquired about any missing medications and the Nurse Manager confirmed more than one Ativan had gone missing and unaccounted for in March 2018. At the time of the interview, the surveyors confirmed the finding with Nurse Manager.

Based on observations and interviews, the hospital failed to ensure that crash carts were checked to ensure supplies were available in case of any emergency for 8 of 16 crash carts.

Findings:

According to the hospital's policy and procedure titled "Emergency Resucitation Services - Code Blue under section D. Checking Supplies and Equipment" "1. Nursing staff members are responsible for checking and documenting code cart lock number, top and side contents (including defribrillator functionality) on the code cart check sheet every day."

1. On 12/7/18 from 11:30 AM to 1 PM, a review of the "Crash Cart Checklist" for each of the following crash carts was conducted: Specials, Birthing, Interventional Radiology, Cardiology, Cath Lab [Cardiac Catheter Laboratory], CT Scan, PACU [Post Anesthesia Care Unit], and BWing. The months of November and December 2018 were reviewed. The following was identified:

a. Specials November 2018 checklist was missing checks on all weekends, and November 22 - 25, 2018. December 2018 checklist was missing December 1 and 2, 2018.

b. Birthing November 2018 checklist was missing a check for November 20, 2018. December 2018 checklist was missing a check for December 3, 2018.

c. Interventional Radiology November 2018 checklist was missing a check for November 24, 2018.

d. Cardiology November 2018 checklist was missing checks for all weekends, and November 22 - 25, 2018. December 2018 checklist was missing December 1 and 2, 2018.

e. Cath Lab November 2018 checklists was missing checks for all weekends and November 24, 2018.

f. CT Scan November 2018 checklist was missing checks for November 26 and 27, 2018.

g. BWing November 2018 checklist was missing a check for November 17th, 2018.

h. PACU November 2018 checklist was missing checks for November 3, 4, 5, 11, 17, 22 - 25, and 29 - 30, 2018. December 2018 checklist was missing a check for December 2, 2018.

On December 7, 2018, at approximately 1:15 PM, the Director of Pharmacy confirmed the above findings at the time of discovery.


28881

Based on record review and interviews, the hospital failed to maintain temperatures within acceptable standards within 5 of 5 anesthetizing locations (Operating Rooms 1, 2, 3, 4, and 5).

Finding:

On 12/06/2018 a 6 month sample of the York Hospital Surgery Temperature & Humidity Logs were reviewed.

The Log indicated that their recommended temperature range was 70 to 75 degrees Fahrenheit. The recorded temperatures were out of the log's stated recommended range on 93.8 % of the records (111 of 126 days in Operating Room (OR) 1, on 126 of 126 days in OR 2, on 102 of 126 days in OR 3, on 126 of 126 days in OR 4, and 123 of 123 days in OR 5).

On 12/06/2018 at 8:00 AM, these out of range temperatures were confirmed with the Surgical Services/Infection Control Director.

On 12/06/2018 at 2:40 PM, the Surgical Services/Infection Control Director stated that they have no policies/procedures in place for recording or maintaining OR temps.

Based on observations and interviews, the hospital failed to have a system in place to ensure that the facility maintained a sanitary environment in 6 of 14 areas (Kitchen, Intensive Care Unit, Emergency Department, Surgical Services, Birthing, and Medical/Surgical).

Findings:

1. Four ice machines were observed to be lacking air gaps thus creating on opportunity for the back flow of waste water into the ice machine. The observations were as follows:

On 12/03/2018 at 12:10 PM, the kitchen ice machine was observed to drain into a floor drain. The floor drain has an approximate 4-inch high wall completely around it and the end of the ice machine drain was below the lip of the wall around the drain, thus there was no air gap. This finding was confirmed with the Food Service and Housekeeping Director at the time of the observation.

On 12/04/2018 at 11:00 AM, the ice machine on the Medical/Surgical Biewind Wing was observed to be lacking the required air gap. This finding was confirmed with the Plant Operations Director at the time of the observation.

On 12/04/2018 at 12:30 PM, the ice machine on the Medical/Surgical Strater Wing was observed to be lacking the required air gap. This finding was confirmed with the Plant Operations Director at the time of the observation.

On 12/04/2018 at 1:05 PM, the ice machine on the Birthing Unit was observed to be lacking the required air gap. This finding was confirmed with the Plant Operations Director at the time of the observation.

2. Non-intact surfaces, creating surfaces that cannot be easily cleaned and sanitized were observed as follows:

On 12/04/2018, at 6:45 AM, as areas of chipped paint on many areas of the eye tower in Operating Room # 2. This finding was confirmed with the Head Anesthesiologist and Medical Director of Surgical Services at the time of the observation.

On 12/04/2018 at 7:15 AM, on the vinyl covering of the stool seat in Endoscopy Procedure Room 3 and at 7:20 AM, on the vinyl covering on the stool seat in Endoscopy Procedure Room 5. These findings were confirmed with the Head Anesthesiologist and Medical Director of Surgical Services at the time of the observations.

On 12/04/ 2018 at 9:45 AM, on an unsealed cork board in Room 7 and at 9:50 AM on the seat of a stool (torn/open seam) in Room D of the Emergency Department. These findings were confirmed with the Plant Operations Director at the time of the observations.

On 12/06/2018 at 9:00 AM, as areas of chipped paint on the base of a stool in Room 2, on the surface of the covering on the exam table in Room 5 (a puncture and a missing piece on the vinyl), wood head board with 3 areas of ½-3/4 inch damaged in the wood head board also in Room 5 Of the Emergency Department. These findings were confirmed with the Plant Operations Director at the time of the observations.

3. An accumulation of dust, indicating areas that had not been cleaned and sanitized, was observed as follows:

On 12/04/2018, during a tour of Surgical Services, at 7:00 AM, on window sills, of Bays 1, 2, 3, 4, and 5 of the Post Anesthesia Care Unit and at 7:10 AM, on the window sills and picture frames in Bays 2, 4, and 10 of the Ambulatory Care Unit. These findings were confirmed with the Head Anesthesiologist and Medical Director of Surgical Services at the time of the observations.

0n 12/04/2018, during a tour of the Intensive Care Unit, at 8:10 AM, on the top surface of the wall-hung, over-bed light, on the top surface of cabinet doors, and on the top of the over-sink cabinet in Room 1 and on top surface of the cabinet doors in Room 2. These findings were confirmed with the Plant Operations Director at the time of the observations.

On 12/04/2018, during a tour of the Emergency Department that began at 9:45 AM, on the top surface of the cabinet door in Room 7, on top of the cabinet door and on the stretcher frame in Room 6, on stretcher frame and head board in Room 3, on the top edge of the white board in Room 8, on the stretcher frame in Room A, and on the stretcher frame and the top of the cabinet door in Room D. These findings were confirmed with the Plant Operations Director at the time of the observations.

On 12/04/2018, during a tour of the Medical/Surgical Biewind Wing, that began at 10:00 AM, on the bed frame and on the wall-hung light over bed in Room 206, on top of the cabinet in Room 210, on top of the cabinet door in Room 211, Biewind wing tour continues, on the top of the cabinet and on the bed frame in Room 214, on top of the cabinet and on the top surface of the bathroom light in Room 216, 217, 218 OK, on the top edge of the bathroom mirror in Room 220. These findings were confirmed with the Plant Operations Director at the time of the observations.

On 12/04/2018, during a tour of the Medical/Surgical Strater Wing, that began at 12:30 PM, on the bed frame and on the top of the wall-hung light over the bed in Room 252, on top of the cabinet in Room 257, on top of the cabinet and on the top surface of the bathroom light in Room 258, on top of the cabinet in Room 264, and on the top surface of the bathroom light in Room 263, on top. These findings were confirmed with the Plant Operations Director at the time of the observations.

On 12/04/2018, during a tour of the Birthing Center, that began at 12:55 PM, on the top surface of the bathroom light in Room 1 and on the top of the bathroom cabinet in Room 9. These findings were confirmed with the Plant Operations Director at the time of the observations.

Based on record reviews and interviews, the hospital failed to ensure a list of home health agencies was presented to the patient for 2 of 3 records reviewed of patients who have been discharged and determined in need of home health agency services (Discharge Patient #2 and Discharge Patient #3). In addition, the facility failed to ensure that a list of the Home Health Agencies was presented to 1 of 30 patients (Patient #19) who it was determined in need of home health services and were awaiting discharge.

Findings:

1. Documentation in Discharge Patient #2's record indicated that this patient was in need of home health services upon discharge. There was no evidence in the patient's medical record that a list of home health agencies that served his/her geographical area was presented to the patient.

On 12//48/18 at 10:30 AM, the surveyor confirmed this finding with the Registered Nurse (RN) Case Manager/Interim Director and the Denial Appeal RN.

2. On 12/4/18 between 12:30 PM and 1:30 PM, the record of Discharge Patient #3 was reviewed with hospital staff. During the review, it was noted that the patient had home health services prior to this hospitalization and a list of home health agencies that served his/her geographical area was not presented to the patient during this admission. The Denial Appeal RN indicated that the patient had home health agency services prior to hospitalization; therefore, a list was not given to the patient.

3. Patient #19 record did not include evidence of a list of Home Health Agencies and there was no documentation that this list was offered.

An interview on 12/5/18 at 11:30 A.M. with Registered Nurse #1 indicated that the family and Patient #19 wanted to have the Home Health Agency he/she had utilized in the past so the Home Health Agency list was not provided.



30015