HospitalInspections.org

Based on observation, it was determined that the hospital failed to ensure that the patient areas were maintained in a safe and sanitary manner.

Findings were:
? 2 public/patient restrooms in the patient care area did not have emergency pull cords
? 1 patient bathing area did not have an emergency pull cord
? 1 patient restroom situated between 2 patient rooms did not have an emergency pull cord
? A 4 inch step was noted immediately in behind a door that led into a patient/public restroom. This step created a fall hazard.
? 2 plinth tables in the Physical Therapy Department had small tears in their vinyl coverings. These tears make disinfection impossible and cross contamination likely.

In an interview with the Facility Administrator on 5/19/10, the above patient safety concerns were acknowledged.

Based on review of documentation, it was determined that the facility failed to ensure that telephone/verbal orders were dated, timed and authenticated with in 48 hours by the prescriber.

Findings were:

Review of medical records revealed the following unsigned physician orders:
? Patient # 9, unsigned order dated 9/21/09
? Patient # 13, unsigned order dated 10/11/09
? Patient # 18, unsigned order dated 11/12/09
? Patient # 20, unsigned EKG report dated 11/18/09
? Patient # 21, unsigned Emergency Record, dated 12/24/09
? Patient # 22, had 2 unsigned orders dated 4/22/10
? Patient # 23, had 5 unsigned orders dated 4/28/10

In an interview with the Facility Administrator on 5/19/10, the above unsigned physician ' s orders were acknowledged.

Based on review of documentation, it was determined that the facility failed to maintain complete and accurate medical records.

Findings were:

Facility policy entitled " Swing Bed Program " stated " Evaluation should clearly indicate that the patient is not too acute for swing bed care. The admit note should include goals of patient care and rehabilitative potential if any. "
The same policy continued under " Psychosocial Evaluation " stated that an evaluation will be " preformed by the licensed Social Worker or Social Services Designee. "

Review of Swing Bed medical records revealed Patients # 6, 26 and 27 did not have " Swing Bed Certification Statement " completed.

6 of 6 Swing Bed charts reviewed had no Psychosocial Evaluation in the patient record.

In an interview with the Facility Administrator on 5/19/10, the above incomplete medical records were confirmed.

Based on observation, it was determined that the hospital failed to provide confidentiality of patient records.

Tour of the facility on 5/19/10, revealed an unlocked file cabinet filled with patient medical records. This file cabinet was located in the " old " (under construction) nurse ' s station and was left opened and unguarded. These records were easily accessible to passersby.

In an interview with the Facility Administrator on 5/19/10, the unsecured patient records were confirmed.

Based on review of facility policy and procedure manuals, it was determined that the facility failed to annually evaluate departmental policy and procedures.

Findings were:

? Nursing policy and procedure manual had not been reviewed and/or updated since 7/08.
? Pharmacy policy and procedure manual had not been reviewed and/or updated since 12/02.

In an interview with the Facility Administrator on 5/19/10, it was confirmed that the hospital had not reviewed the Nursing and Pharmacy policy and procedure manuals annually.