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Based on interview and record review the hospital failed to ensure the grievance record review had all the documentation related to the investigation and patients were informed of the results of the investigation related to all allegations for 3 (Patients #22, #57, and #58)

The findings include.

1. During record review on 12/06/11, the facility's Grievance Log noted 3 entries, dated 10/14/11, with the coding of "ED wait, tx, Attitudes." Review of these 3 grievances noted they involved Patients #22, #57 and #58.
Review of Patient #22's grievance revealed the patient had arrived in the Emergency Department (ED) on 10/05/11, around 15:30, and left the ED department around 21:00. Patient #22's wife filed the grievance with the Patient Relation (PR) office on 10/06/11. Written on a Complaint/Concern Form by Patient #22's representative stating her husband came to the ED on 10/05/11, around 14:20, with high blood pressure and high blood sugar. He never saw anyone, they just registered him. She stated as the day progressed she would tell the person at the desk about Patient #22's worsening symptoms. She stated he was beginning to experience pain down his left arm but "nobody cared." She stated at one point she was told "oh ma'am, I just came on ...he'll have to wait" by the associate working the desk around 1900. Patient #22's wife stated she left the ED department after talking with her son and went across the street where he was diagnosed with a blood clot to his brain and is currently in an intensive care unit.

The Complaint/Concern Form dated 10/06/11, at 0945, noted on 10/18/11 they spoke with Patient #22's wife, who was concerned about the wait time. The wife stated she told the front desk that Patient #22 was having a stroke and he was having numbness to their left shoulder. The PR wrote she told the wife Patient #22's care was being reviewed as well as our process. She wrote the wife seemed to be content with the statement, but that she further stated she did not want this to happen to anyone else. The last section 'Concern Resolved' was left blank.

A Risk Management (RM) letter dated 10/12/11, to Patient #22 and his wife was reviewed stating their concerns will be thoroughly investigated and appropriate action will be taken, if necessary.

Another letter dated 10/14/11, from RM to Patient #22 noted an investigation was conducted by the ED director and the Clinical Leader. The investigation concluded today and the results are as indicated:
1) We will be reviewing the flow from the ED to assure that patient's needs are addressed in a timely manner.
2) Ensure all staff has attended our customer service awareness training.
3) Staff will be educated on triage protocols.

The letter ends with thanking the complainants of voicing their concern.

The Risk Management reports documented the investigation was completed and resolved on 10/14/11. There are no further documents or notation in the RM reports related to any further investigation and/or resolution to the investigation.

2. Patient #57 filed a complaint with the PR office on 10/09/11, that on 10/08/11 she signed in at the front desk at the ED with her 22 month old sick daughter. Around 12:15 p.m., went to the desk to check on the status of how much longer she had to wait. She stated she was talked too very rudely by the staff at the front desk, because he thought the daughter was not sick. She ended her complaint by saying she should not have had to wait so long for service. She stated the ED staff had a bad attitude, and customer service should be at the top of the list and they were not just another ticket sitting around waiting to be seen.

RM sent a letter, dated 10/11/11, stating their concerns will be thoroughly investigated and appropriate action will be taken if necessary.

Another letter dated 10/14/11 from RM to Patient #57 stated an investigation was conducted by the ED director and the Clinical Leader. The investigation concluded today and the results are as indicated:
1) We will be reviewing the flow from the ED to assure that patient's needs are addressed in a timely manner.
2) Ensure all staff has attended our customer service awareness training.
The letter ends with thanking the complainants of voicing their concern.

The Risk Management reports documents the investigation was completed and resolved on 10/14/11. There are no further documents or notation in the RM reports related to any further investigation and/or resolution to the investigation.

3. The PR department received a letter from Patient #58 dated 10/03/11, that on 9/02/11 at approximately 5:00 p.m., while at the ED with her 2 year old son with a temperature of 105 degrees and complaining of abdominal pain. Upon entering the ED there was no one at the front desk. After a few minutes a male employee walked to the front desk and without asking a question stated "it's going to be a while, just so you know we have had people waiting here since 2:30 p.m., and they still haven't been seen." The letter noted he did not care that Patient #58's son was sick and rolled his eyes. The letter ended where they brought their son to another ED department were they were greeted and asked how they could help.

RM sent one letter in response to the complaint dated 10/14/11, stating the issues on 10/07/11 relates to the ED wait times were long and lack of compassion displayed by the staff. The second paragraph stated and investigation began on 10/10/11, by the ED director and the Clinical Leader. The investigation concluded today and the results are as indicated:
1) We will be reviewing the flow from the ED to assure that patient's needs are addressed in a timely manner.
2) Ensure all staff has attended our customer service awareness training.

The letter ends with thanking the complainants of voicing their concern.

The Risk Management reports documented the investigation was completed and resolved on 10/14/11. There are no further documents or notation in the RM reports related to any further investigation and/or resolution to the investigation.

Review of the 3 complaints reviewed by the RM department and sent letters on 10/14/11 of the facility resolution to each complaint. It was noted none of the letters had what was done by the facility related to the investigation. None of the RN reports noted all the employees involved in each complaint or written statements of each employee involved in each complaint. The final RM letters stated almost the same information for each complainant, Patients #22, #57, and #58 letters from RM was not individualize to each patients' complaints and/or issues related to their visit. None of the RM investigations has no follow-up notation related to patient flow in the ED, that all the ED staff involved in each incident were retrained/educated, attended customer service awareness training and were all educated on triage protocols in the ED as noted in the 10/14/11 letters.

12/07/11 at 11:30 p.m., interview with RM, ED Director (EDD) and Chief Nursing Officer (CNO) after reviewing Patients #22, #57, and #58 complaints confirmed the time frames noted earlier. The EDD stated she had done each investigation, then stated she does not have any written documentation related to what had happened in each incident and the names of all the employees involved in each incident. The EDD stated she has no written statement of employee interviewed related to each complaint.

The RM confirmed the 3 grievance investigations are completed as of this time. She confirmed the lack of documentation in each investigation of the hospital staff involved in each investigation, interviews done by RM and/or the EDD related to each investigation, the follow-up investigation to ensure all issues related to each complaint/grievances are still be address by the ED. She confirmed the letters sent to Patients #22, #57, and #58 does not address all concerns voice by the complainants in their phone call or letters. She stated the hospital uses a template and it does appears letters mailed on 10/14/11 are not individualized to each complaint and does not address all the issues voiced in the grievances.

The EDD stated the ED has regular daily and monthly meetings. She produced documentation of an ED staff Meeting for the month of October 2011 with staff sign-in sheet dated 10/25/11 and 10/28/11. Paragraph 6 notes the ED staff must be in the ED lobby at all times, make hourly rounds, and pay attention to how you are perceived by the patients. She confirmed the meeting held on 10/25/11 and 10/28/11 is not noted in the grievance investigation reports for Patient #22, #57, and #58. The EDD stated the ED staff meeting for October was done as part of the routine education for the ED staff and does not address the "patients wait times" in the ED.

Based on interviews and record reviews the hospital failed to ensure all measurable improvement indicators are tracked with documentation of methods used to identify the improvement need, the analysis and tracking of the improvement needed, documentation of the action plan taken related to identified issues and the evaluation of the action plan.

The finding include:

On 11/07/11, at 10:00 a.m., during an interview with the Quality Manager (QM) related to how the facility measures, analyze and track all quality indicators throughout the hospital. She stated all the departments meet on a monthly basis and reviews the Safety Scorecard (SS) which totals all the percentages in key area being monitored by the hospital and gives them a score. The SS is color coded, (green, yellow, orange, and red) with green meaning they were in compliance and red mean are not in compliance. Review of the SS revealed multiple areas of red. One area was Aspiration Pneumonia Data noted 8 of 10 months (January through October) was color coded red. Patient INR greater than 2 with vitamin K listed as adverse drug reaction (ADR) noted 7 of 10 months were coded red.

The QM stated their last meeting was 11/18/11 and all departments received a colored copy of the SS report with all the concerns in their department. She stated not all departments report monthly, but they are required to be at the monthly meetings to discuss any trends noted on the SS report, address any concerns noted including patterns noted as in 7 of 10 months and 8 of 10 months being red i.e. out of compliance with the hospitals standards. She reviewed the meeting notes for 11/18/11 and stated there is no notation in the minutes the committee had addressed the Aspiration Pneumonia Data being out of compliance 8 of 10 months and the Patient INR reaction being out of compliance for 7 of 10 months. She stated those issues should have been addressed at the meeting and noted in the minutes.

Review of the section LWOT's (left without treatment) she stated means patient leaving the Emergency Room Department (ERD) without being seen by a physician was red for 9 out of 10 months. Review of the 11/18/11 meeting minutes noted the ED talked about the second quarter information January through June. The QM stated the ED representative was not ready for the meeting with the 3 quarter results so she had reported on the second quarter results. When asked if she had SS reports with all of the data from January through October in front of her at the time of the meeting, the QM stated "yes." She stated the ED manager had left her an action plan for the LWOT data on the SS report.

Review of the Recommendations/Actions Taken noted in the 3rd quarter section noted 'Will continue to monitor. LWOT rate has been dropping since implementation of new system.' When asked how the ED is monitoring for LWOT and what other actions the ED are taking to resolve the problem, the QM stated she does not know at this time and is all the ED has presented as their action plan for patients LWOT in the ERD.

On 11/07/11, at 12:30 p.m., an interview was held with the Pharmacy Department Head (PDH) who stated he attends all the monthly meeting and does receive a copy of the SS reports at each meeting. He confirmed Patient INR with an ADR was out of compliance 7 of 10 months. He stated he is responsible for reviewing this section and he had not noted the monthly report on the SS report was out of compliance 7 out of 10 months. He stated, "it must have been entered wrong and we all missed it." He confirmed the SS report of the Patient INR with an ADR should have been address at the quality meeting held with the QM.

Based on observation, record review, and interview, the medical history and evaluation did not reflect accurate documentation by the responsible provider who conducted the examination for 1 (Patient #53) of 7 patients reviewed.

The findings include:

Interview with the Operating Room Director on 12/06/11, at 9:40 a.m., revealed Patient #53 was a new case and was going to be operated on for an appendectomy. He stated the anesthesiologist (MD) was responsible for the oversight of the OR (Operating Room) of which his wife would be the CRNA (Certified Registered Nurse Anesthetist) responsible for administering anesthesia to Patient #53.

Observation on 12/06/11, at 10:00 a.m., revealed Patient #53 in the holding area of the hospital awaiting surgery. The patient's mother was at her bedside along with the circulating registered nurse (CRN), the holding room registered nurse (RN) and the CRNA. Observation revealed the CRNA completing a physical assessment and evaluation of Patient #53 before the induction of anesthesia to the patient and writing the responses of the patient and the mother on a form at the bedside table.

At 10:10 a.m., the MD was observed to have walked over to Patient #53 and after speaking to the patient's mother, walked over to the bedside table which was positioned near the CRNA and briefly documented on the same form that the CRNA was already writing on.

The MD exited the holding area and a copy of the form was requested. Observation revealed the information on the evaluation that was completed by the CRNA was not signed and dated as completed by the CRNA, rather, the MD signed and dated the form as having completed it.

A brief interview was conducted with the CNO (Chief Nursing Officer) on 12/07/11, at 8:40 a.m. who stated the hospital has policies and procedures which prohibit the direct supervision of family or spouse's over one another due to numerous reasons; however, "never thought about it from the physician standpoint" and wasn't sure there were any (policies) related to physicians in the hospital." She stated the anesthesia group practicing within the hospital was new and they were still formulating policies and procedures. She stated the hospital was currently conducting new audits on the documentation of the anesthesia group; however, was not aware of any current documentation issues by anesthesiology.

Interview with the MD on 12/07/11 at 2:00 p.m., confirmed he signed off on the anesthesia evaluation before it was completed by the CRNA and confirmed he was unaware of all that was documented on the form by the CRNA. He confirmed that by documentation of his signature on this form, it would appear that he signed off on it at the same time it was completed, which did not occur. He stated he should have dated and timed the form at the time when he had reviewed it. He was unaware that the CRNA did not sign her name as having completed the evaluation.

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Based on observation, interview, and record review, the hospital failed to ensure 1 (Patient #57) of 2 sampled patients with a diagnosis of End Stage Renal Disease (ESRD) and ordered to receive in-patient Hemo-Dialysis treatment was being properly assessed medically as it pertains to pre and post weights being recorded. The hospital failed to document when rounds were being made in the Emergency Room (ER) waiting room. The hospital failed to maintain oxygen tanks adequately for 2 of 10 crash carts surveyed.

The findings include:

1. Patient #57 was admitted on 12/05/2011 with a diagnosis, but not limited to End Stage Renal Disease (ESRD). Review of the clinical record on 12/7/11 documented a physician order dated 12/05/2011 for the patient to receive Hemo-Dialysis treatment 3 times weekly.

Review of the initial nursing assessment, dated 12/05/2011, and the nutritional assessment for Patient #57, dated 12/06/2011, indicated the recorded weight for the patient at 225 lb.,which was the only recorded weight completed for the patient since admission. Review of the Hemo-dialysis treatment sheet generated by the staff that preformed the Hemo-dialysis treatments did not demonstrate or document that patient weights were recorded pre and post treatment (pre and post weights on a dialysis patient are needed/essential to assess the amount of fluid gain that needs to be pulled off a patient during the dialysis treatment). Review of the dialysis flow sheet for 12/5/11 revealed a notation that reported no weight had been taken pre and post treatment. The sheet documented "UTW." The Hemodialysis Director reported this meant: "Unable to Weigh."

The attending physician for Patient #57, a Nephrologist, was present when the patient's clinical record was being reviewed on 12/07/2011, at 10:21 a.m. The staff nurse from the Medical Unit and assigned to the patient's care was present. The physician and the nurse were questioned in reference as to why Patient #57's weights were not assessed pre and post dialysis treatments. The nurse replied, "We do not have anyway of weighing the patient, there is no scale in the room." The physician was questioned on how the patient is assessed and whether a fluid loss is achieved during treatment. The physician replied, "The staff usually record the amount of fluid pulled off post treatment." When the physician asked if this was an acceptable means of assessment, the physician said that this is a problem and would like to see the patient's weighed pre and post treatment.

During Hemo-Dialysis treatment for Patient #57, on 12/7/11, at 2:00 p.m., the dialysis nurse was observed to ask the patient what the "dry" weight (the term "dry weight" means the amount of body mass (weight) without extra fluid (water) and the dry weight is used to calculate the ultrafiltration (UF) volume and rates for each dialysis treatment) and what was today's weight. Patient #57 replied that the "dry" weight was 99 Kg. The patient reported that today's weight was 225 lbs. The patient added the Medical Unit staff took the weight on the "standing" scale that morning. Review of the clinical record failed to demonstrate any documentation of a weight having been taken on 12/6/11 and 12/7/11. Patient #57 was lying on a bed with a built-in scale, which was capable of weighing the patient daily and pre and post dialysis treatments. This finding was again observed and confirmed on 12/8/2011 at 9:30 a.m.

In an interview on 12/7/11, at approximately 3:00 p.m., with the Medical Unit Director, Director of the shared hemodialysis staff and Facility Director of ICU/IMCU/Dialysis Unit, the lack of a recorded weight for 12/7/11 was confirmed. The Medical Unit Director was asked if there was any documentation available and was given a opportunity to provide documentation of a weight being taken for 12/7/11 with none submitted during the survey process.

Review on 12/8/11, of the Facility's Policy and Procedure entitled "Assessment of Dialysis Patient" Policy No: Nur 2500 DI304 revealed the procedure documented the following: 1. The pre and post dialysis assessment will include evaluation of the hand-off report data, the physical assessment and results of diagnostic studies. These include, but not limited to: a. weight...etc.; 2. All assessment findings are documented on the dialysis flow sheet.
2. On 12/7/11, at 9:15 a.m., the crash cart on the Post-Partum Unit of the facility was observed to have an Oxygen tank that was ¼ level of pressure. The Pharmacy Technician that was on tour at that time verified the Oxygen tank was ¼ full. She was unable to say at what level oxygen tanks were changed on the crash carts.

On 12/7/11 at 9:40 a.m., one of the two crash carts on the ICU Unit was observed to have an oxygen tank at ¼ level of pressure.

An interview was conducted with the charge nurse of the ICU unit at 9:42 a.m., on 12/7/11. She stated she would change the oxygen tank on the crash cart if it was ¼ full or less.

At 10:40 a.m., on 12/7/11, an interview was conducted with the Director of Respiratory Therapy. She stated, "I would want those oxygen tanks to be full on the crash carts. I would not want them at a ¼ of a tank during a code." She stated, "It is a nursing responsibility to monitor the oxygen on the crash carts daily and then either replace the tanks when they have low pressure or notify pharmacy to replace them."

A record review was completed of the crash cart check flow sheets for the post-partum unit and the ICU unit. The records showed the tanks were ¼ levels since 12/1/11 and were not changed until the day of survey.

Based on observation, record review, and interview, surgical procedures failed to reflect medical entries that were accurately dated, timed, and authenticated for 1 (Patient #53) of 7 medical records reviewed. The CRNA (Certified Registered Nurse Anesthetist) failed to sign and date an anesthesia evaluation she had completed while the overseeing anesthesiologist signed and dated the same anesthesia form before she completed the evaluation; the anesthesiologist signed a "blank" post anesthesia evaluation form that the recovery room nurse completed after he signed the form and left the recovery room.

The findings include:

Interview with the Operating Room Director on 12/06/11 at 9:40 a.m., revealed Patient #53 was a new case and was going to be operated on for an appendectomy. He stated the anesthesiologist (MD #1) was responsible for the oversight of the OR (Operating Room) of which his wife would be the CRNA (Certified Registered Nurse Anesthetist) responsible for administering anesthesia to Patient #53.

Observation on 12/06/11 at 10:00 a.m., revealed Patient #53 in the holding area of the hospital awaiting surgery. The patient's mother was at her bedside along with the circulating registered nurse (CRN), the holding room registered nurse (RN), and the CRNA.

Observation revealed the CRNA completing a physical assessment of the patient before the induction of anesthesia to the patient, and writing the responses of the patient and the mother on a form at the bedside table.

At 10:10 a.m., MD #1 was observed to have walked over to the patient and after speaking to the patient's mother, walked over to the bedside table which was positioned near the CRNA and wrote on the same form that the CRNA was writing on.

The MD exited the holding area and a copy of the form was requested. Observation revealed the information on the form, that was completed by the CRNA, was not signed and dated as completed by the CRNA, rather, the MD signed and dated the form as having completed it.

The patient returned to the recovery room at 12:05 p.m. The CRNA was present and was observed documenting on the anesthesia record at the patient's bedside. As the recovery room nurse was assisting the patient to a comfortable level, observation revealed post-operative orders by MD #1 dated 12/06/11 and timed "1010" being followed by the recovery room nurse; however, MD #1 was not in the recovery room at the time of the patient's arrival to the recovery room. The post operative orders were given "pre-operatively" for the patient by MD #1.

Observation at 12:08 p.m., revealed the CNRA remaining at the patient's bedside due to the patient complaining of difficulty breathing post surgery. A different anesthesiologist (MD #2) came to the patient's bedside and 4 mg. of Decadron was intravenously administered to the patient due to complaints of difficulty breathing and "inspiratory stridor." It was also during this time observation revealed the anesthesia record had already been signed by MD #1, who was not present in the recovery room.

The CRNA continued to document on this anesthesia record. At 12:10 p.m., the CRNA signed off on the record which had already been previously signed off by MD #1, who had not seen the patient post surgery.

Observation at 1:00 p.m., 55 minutes after the patient entered the recovery room, MD #1 entered, observed the patient, and signed the post operative surgery/procedure orders discharging the patient from the recovery room. In addition, MD #1 dated and signed a "blank" post anesthesia evaluation form located at the patient's bedside.

On this form, the following items included: "The patient identified below has received an anesthesia care provider evaluation postoperatively that includes, but is not necessarily limited to the following: vital signs, mental status, airway and respiratory function, cardiovascular function, pain control, nausea and vomiting control, and postoperative hydration." The MD placed a check mark next to the following documentation: "I find the above criteria are as expected for this patient and the procedure and that no anesthetic related complications are apparent." However, there were no evaluations next to the "above criteria" on behalf of the patient; the criteria listed were left blank.

The MD discharged the patient from the recovery room at 1:00 p.m., and he left with the patient remaining in the room.

At 1:10 p.m., observation revealed the recovery room nurse completing the "blank" post anesthesia evaluation form that MD #1 already signed off on. She completed the vital signs, mental status, airway and respiratory function, cardiovascular function, pain control, nausea and vomiting control, and postoperative hydration of the patient. The MD was unaware the nurse had completed the form.

At 1:18 p.m., the patient complained of nausea and pain. She was medicated by the recovery room nurse. MD #1, though signing off on the patient as "stable" and having no post anesthesia complications 18 minutes earlier, was unaware of the patient's condition.

The patient was subsequently stabilized and discharged from the recovery room at 1:42 p.m., 42 minutes after MD #1 cleared her for discharge and who was also unaware of the complication of nausea and pain after signing the blank anesthesia form which indicated there were no "apparent" anesthetic complications.

An interview was conducted with the nurse who was in charge of the recovery room on 12/06/11 at 1:30 p.m. She was asked when a patient should receive post surgery orders. She stated that after a patient returns from the OR and enters the recovery room, the anesthesiologist should be writing post procedure orders. She confirmed they should not be writing post operative orders "pre-operatively."

A brief interview was conducted with the CNO (Chief Nursing Officer) on 12/07/11 at 8:40 a.m., who stated the hospital has policies and procedures which prohibit the direct supervision of family or spouse's over one another; however, "never thought about it from the physician standpoint" and wasn't sure there were any related to physicians in the hospital." She stated the anesthesia group practicing within the hospital was new and they were still formulating policies and procedures. She stated the hospital was currently conducting new audits on the documentation of the anesthesia group; however, was not aware of any current documentation issues by anesthesiology.

Interview with MD #1 on 12/07/11 at 2:00 p.m., revealed he usually always orders "post-op" orders preoperatively for his patients. He stated he is usually covering a large area of the hospital, feels comfortable in knowing his patients' outcomes and what's anticipated and thought it was in the best interest of the patient. He confirmed the orders were not specifically "tailored" to meet each individual patient's needs; confirmed he would have no way of knowing the patient's outcome post procedure unless the symptoms presented "post-operatively."

The MD confirmed he signed off on the anesthesia record before it was completed by the CRNA and confirmed he was unaware of all that was documented on the form by the CRNA. He confirmed that by the appearance of his signature on this form, it would appear that he signed off on it at the same time it was completed, which did not occur. He stated he should have dated and timed the form at the time when he had reviewed it.

The MD stated he signed off on the post-anesthesia evaluation at 1:00 p.m., on 12/06/11 because after looking at the patient, felt she was safe for discharge from the unit. He was unaware the recovery room RN completed the evaluation after he signed the document and left the unit. He confirmed he had no idea what was entered on the form after he signed it. He stated he felt she was safe for discharge and was not aware that the patient was medicated twice for nausea after his departure. He stated the evaluation should not have been completed by the recovery room RN.

Based on observation and interview the facility failed to ensure stored medications were being maintained at a proper temperature thereby failing to assure safe distribution and efficacy of medications.

The findings include:

A tour of the pharmacy was conducted on 12/5/11. In observing the refrigerators throughout the facility, it was noted there were two thermometers in every refrigerator that held medications. One thermometer was hanging outside the refrigerator with a wire running internally attached to a small green plastic probe. The second thermometer was hanging internally. It was gray in color and digitally controlled. It was noted the internal hanging thermometer held a memory of a daily temperatures leading back to September of 2011. Both thermometers in the Pharmacy refrigerators were registering within normal range of 36 to 46 degrees.

An interview was conducted with the Director of the Pharmacy on 12/5/11 at 11:00 a.m. He stated he had installed the gray hanging thermometer to see if they might be a better way to keep track of the refrigerator temperatures. He stated he was not tracking the data of the gray thermometers at this time. He was still just tracking the temperatures from the external thermometers. He did not acknowledge why he was not tracking both thermometers in the refrigerators. It was noted that this was the practice throughout the hospital.

On 12/7/11 at 10:25 a.m., a tour was conducted in the ER (Emergency Room). It was observed the documentation from the gray hanging thermometer revealed the temperatures were out of range for the last seven days. The following temperatures were in the memory of the gray internal thermometer:
12/1/11- 50.2;
12/2/11- 50.9;
12/3/11- 50.2;
12/4/11- 50.9;
12/5/11-50.9;
12/6/11-50.7;
12/7/11-48.0.

A copy of the pharmacy's recorded temperatures for the month of December was obtained. All were recorded within normal range. On 12/7/11 at 11:10 a.m., the findings were reported that the ER internal gray thermometer was recording temperatures out of range to the Director of Pharmacy.

At 11:20 a.m., on 12/7/11 it was verified with the Director of Pharmacy using a hand held laser thermometer that the ER refrigerator temperature was not within normal range of 36 to 46 degrees. Both the internal and external thermometers were registering 47.0 degrees. The hand held laser thermometer was registering 50.0 degrees. At this time the Director of Pharmacy stated he would have to replace the refrigerator.

On 12/7/11/ at 3:00 p.m., an interview was conducted with the Director of Pharmacy. When asked what he was going to do with the medications in the ER refrigerator he stated, "I will swap them out when I get another refrigerator."

On 12/8/11 at 9:40 a.m., a copy of the daily refrigerator temperatures was obtained from Pharmacy. The ER refrigerator was recorded at 47.0 degrees.

On 12/8/11 at 4:10 p.m., an interview was conducted with the Director of Pharmacy. He stated he had not yet swapped out the refrigerator.

Based on observation and interview the facility failed to remove outdated medication; and stored medications were being maintained at improper temperature thereby failing to assure safe distribution and efficacy of medications.

The findings include:

During the tour of the pharmacy on 12/5/11 at 1:55 p.m., 5 tablets labeled "Naprosyn 250 Mg" were pulled from the pharmacy shelf. The tablets had an expiration date of 9/5/11.

An interview was conducted with the director of Pharmacy at that time. After verifying the medication had expired he stated, "Somebody screwed up."

A tour was conducted of the pharmacy on 12/5/11. In observing the refrigerators, it was noted there were two thermometers in every refrigerator that held medications. One thermometer was hanging outside the refrigerator with a wire running internally attached to a small green plastic probe. The second thermometer was hanging internally; it was grey in color and digitally controlled. It was noted that the internal hanging thermometer held a memory of a daily temperatures leading back to September of 2011. Both thermometers in the Pharmacy refrigerators were registering within normal range of 36 to 46 degrees.

An interview was conducted with the Director of the Pharmacy on 12/5/11 at 11:00 a.m. He stated he had installed the grey hanging thermometer to see if they might be a better way to keep track of the refrigerator temperatures. He stated he was not tracking the data of the grey thermometers at this time. He was still just tracking the temperatures from the external thermometers. He did not acknowledge why he was not tracking both thermometers in the refrigerators. It was noted this was the practice throughout the hospital.

On 12/7/11 at 10:25 a.m., a tour was conducted in the ER (Emergency Room). It was observed the documentation from the grey hanging thermometer revealed the temperatures were out of range for the last seven days. The following temperatures were in the memory of the grey internal thermometer:
12/1/11- 50.2;
12/2/11- 50.9;
12/3/11- 50.2;
12/4/11- 50.9;
12/5/11-50.9;
12/6/11-50.7;
12/7/11-48.0.

A copy of the pharmacy's recorded temperatures for the month of December was obtained. All were recorded within normal range. On 12/7/11 at 11:10 a.m., the findings were reported that the ER internal grey thermometer was recording temperatures out of range to the Director of Pharmacy.
At 11:20 a.m., on 12/7/11 it was verified with the Director of Pharmacy using a hand held laser thermometer that the ER refrigerator temperature was not within normal range of 36 to 46 degrees. Both the internal and external thermometers were registering 47.0 degrees. The hand held laser thermometer was registering 50.0 degrees. At this time the Director of Pharmacy stated that he would have to replace the refrigerator.

On 12/7/11/ at 3:00 p.m., an interview was conducted with the Director of Pharmacy. When asked what he was going to do with the medications in the ER refrigerator he stated, "I will swap them out when I get another refrigerator."

On 12/8/11 at 9:40 a.m., a copy of the daily refrigerator temperatures was obtained from Pharmacy. The ER refrigerator was recorded at 47.0 degrees. At that time the director of Pharmacy stated, "I misunderstood what you were asking yesterday. I'm going to replace all the medication when I replace the refrigerator."

On 12/8/11 at 4:10 p.m., an interview was conducted with the Director of Pharmacy. He stated he had not yet swapped out the refrigerator yet. "I've got to get time to go get one."

On 12/8/11 at 4:15 p.m., an inventory of the medications in the ER refrigerator was completed. The following medications and there storage temperatures were noted:
Bicillin- 36-46 degrees; Tuberculin PPD- 36-46 degrees; Novolin R-36-46; degrees; Novolin N-36-46 degree; Levimir-36-46 degrees; Methylergonovine maleate- store below 77 degrees; Fosphenytoin-36-46 degrees; Diltiazim-36-46 degrees; Digoxin-59-86 degrees; Pancuronium-36-46 degrees; Lantus Insulin-36-46 degrees; Rabies Vacine-36-46 degrees; Influenza vaccine-35-46 degrees; Tetanus vaccine-35-46 degrees; Crotalidae-36-46 degrees; and Antivenin-36-46 degrees.

At 4:30 p.m., on 12/8/11 the COO (Chief Operating Officer) was contacted to let him know the concerns for the efficacy of the medications in the ER refrigerator. He stated he would have the medications removed from the refrigerator in 15 minutes. At 4:45 p.m., on 12/8/11 the director of Pharmacy confirmed he had removed the medications.

Based on observation, interview, and record review the facility failed to ensure the physical environment of the facility was in good condition. As evidenced by broken floor tiles in the kitchen, observation of a black fussy substance on the exterior walls of the freezer, with a musty smell observed permeating throughout the kitchen.

The findings include:

1. The initial tour of the kitchen, on 12/05/2011, at 9:30 a.m., with the Director of Dietary (DD) revealed the walk in freezer; the interior chamber of the freezer had icicles and large clumps of ice on the ceiling. On the floor of the freezer was a "Caution" sign. When the DD was asked what the sign was for, he said we have been having a moisture problem in the freezer, and the signs are posted for staff safety. Observed underneath the sign was a large clump of ice. The threshold of the freezer door was observed to a significant amount of accumulated dirt as well.

The tour continues to the side of the hot food preparation area where the steam kettles and steam jacket were located. The equipment was observed to be visibly dirty with a coating/film of food debris dirt, and grease. The metal grated on the floor hat metal slits that presented with a black appearing substance on the slits. The tile on the floor, located in the same area, had numerous tiles, which were missing and cracked. The tiles that were missing exposed the old flooring underneath, which was of a brick material. The DD was questioned on the condition of the tiles. The DD said due to the moisture in the area of the steam equipment it causes the tiles to loosen, and left off the floor. The DD also said the tiles in the kitchen were not intended for a commercial kitchen floor.

On 12/07/2012 at 1:15 p.m., a follow-up tour of the kitchen was conducted with the DD, COO (Chief Operations Officer), DM (Director of Maintenance), and the Fire Life Safety surveyors. The tour was conducted in the freezer in regards to the moisture problem, causing ice build-up. The freezer again presented with a significant ice build, noted to be entering from a seam in the fabrication of the ceiling wall. It was confirmed by the facility staff that there was a moisture problem. Upon exiting the walk-in refrigeration unit, there was a very strong musty order.

Further review revealed the odor was coming from to air vents. The air vents were located on the right and left hand side of the exterior of the walk in refrigeration units. The Fire Life Safety surveyor proceeded to take the vent cover off. Observed in the space was a small crawl space area. On one side was the exterior wall of the kitchen, and the other side was the metal wall of the freezer. Observed on the metal wall of the freezer was a black furry appearing substance. The DD, COO, and the DM, also observed the smell, and validated it was a strong musty smell. After surveyor intervention, the two vents were covered over as to prevent the musty smell to permeate the kitchen.

The tour continued to the area where there were missing, and cracked tile. The COO and the DM confirmed they were aware of the concern with the flooring. They also confirmed the tile was not appropriate for commercial use, and the moisture from the steam kettles, and jackets was causing the tiles to left up off the floor.

2. Observation of the kitchen at 1:15 p.m., on 12/7/11, revealed there was an addition to the building at some point to house the walk-in coolers and freezers. Inspection of the space between the original exterior wall and the metal walls of the freezer, which is approximately 2 ½ feet wide, is accessed from inside the kitchen thru an opening fitted with an air conditioning hinged transfer grill, revealed there was a strong musty odor in the space. Further review revealed the walls and freezer walls were discolored with mold and mildew. There were further observations of moisture and in this space. The odors and the mold and mildew buildup were acknowledged by the Facilities Director, the Chief Operating Officer, and the Associate Administrator.

The Facilities Director contracted with a Licensed Remediation Company to remediate this issue that evening once all food operations were completed. Inspection of theses spaces were conducted at 2 p.m., on 12/8/11. The space was observed to be cleaned and repainted. The facilities director advised the surveyors that the source of the problem was identified as water from the kitchen floor getting through the wall and onto the floor into that space. To remedy the issue, the remediation company used marine class product to seal and isolate the wall in the kitchen to that space. This is intended to prevent the water intrusion thereby eliminating the moisture source and deny the life cycle of the mold and mildew.

Negative Air Pressure in the Kitchen - Inspection of the kitchen on 12/7/11 at 2:15 p.m., revealed there was a noticeable negative pressure between the open kitchen space and the corridor that leads to the kitchen. Both the Florida Administrative Code and the Florida Building Code require the pressure relationship for a kitchen to a corridor be neutral to prevent any contaminated air from entering the kitchen and open food preparation. The negative air in this particular situation was strong enough to deny a kitchen door to the corridor open by air pressure even though the door is equipped with a hydraulic door closer. The surveyors verified the kitchen hood exhaust, make up air were functional as well as the regular ventilation and air conditioning for the kitchen. This issue was verified and acknowledged by the Facilities Director and the Chief Operating Officer. The problem causing the negative pressure was not identified prior to the end of the survey.

Based on observation, interview, and record review the facility failed to ensure that vital kitchen equipment was clean and in good working repair. The facility also failed to ensure Oxygen (O2) tanks were stored in a safe manner.

The findings include:

1. The initial tour of the kitchen, on 12/05/2011, at 9:30 a.m., with the Director of Dietary (DD) revealed the walk in freezer; the interior chamber of the freezer had icicles and large clumps of ice on the ceiling. On the floor of the freezer was a "Caution" sign. When the DD was asked what the sign was for, he said we have been having a moisture problem in the freezer, and the signs are posted for staff safety. Observed underneath the sign was a large clump of ice. The threshold of the freezer door was observed to a significant amount of accumulated dirt as well. The tour continued to the hot food preparation area. The exhaust hood above the ranges, ovens, and steam equipment presented with a film, that appeared to be grease, dirt, and dust. The DD was asked how often the exhaust hood is cleaned, and said every 3 months, we have a company who cleans the hoods.

Further observation of the grill revealed there was a significant amount of burnt on food particles that had accumulated on the grill slots. The shelf under the grill had an accumulation of grease and food debris, and the side of the range had baked on food particles and numerous splatters of an unidentified substance.

The tour continues to the side of the hot food preparation area, where the steam kettles and steam jacket were located. The equipment was observed to be visibly dirty with a coating/film of food debris, dirt, and grease. The metal grated on the floor hat metal slits that presented with a black appearing substance on the slits. The tile on the floor located in the same area had numerous tiles which were missing and cracked. The tiles that were missing exposed the old flooring underneath, which was of a brick material. The DD was questioned on the condition of the tiles. The DD said due to the moisture in the area of the steam equipment it causes the tiles to loosen, and left off the floor. The DD also said the tiles in the kitchen were not intended for a commercial kitchen floor.

Further observation during the tour, revealed a column located across were food production takes place. The column had 2 metal cabinets, which incased the fire equipment for the exhaust good. The outside surface of the cabinet was dirty, and the top of the cabinets had a large accumulation of unidentified debris.

Follow-up visit to the kitchen, on 12/06/2011, at 11:00 a.m., during noon tray line service, revealed the following; the pot rack above the tray line preparation counter, had a significant accumulation of dust and grease. There were 4 knobs located on the steam table that present with an accumulation of cake on dirt, and debris on and around the knobs. The "utensil cabinet" located in the serving area, had numerous food splatters located on the exterior of the cabinet doors.

Further observation revealed the fryer holding frozen food in the fryer basket. The deep fryer is located above the exhaust hood that was observed to have a significant amount of dirt and grease in the interior of the hood. Also observed were the sides of the deep fryer that had an accumulation of buildup grease and grime.

On 12/07/2012 at 2:00 p.m., a follow-up tour of the kitchen was conducted with the DD, COO (Chief Operations Officer), DM (Director of Maintenance), and the Fire Life Safety surveyors. The tour was conducted in the freezer in regards to the moisture problem, causing ice build-up. The freezer again presented with a significant ice build, noted to be entering from a seam in the fabrication of the ceiling wall. It was confirmed by the facility staff that there was a moisture problem. Upon exiting the walk-in refrigeration unit, there was a very strong musty order.

Further review revealed the odor was coming from to air vents. The air vents were located on the right and left hand side of the exterior of the walk in refrigeration units. The Fire Life Safety surveyor proceeded to take the vent cover off. Observed in the space was a small crawl space area. On one side was the exterior wall of the kitchen, and the other side was the metal wall of the freezer. Observed on the metal wall of the freezer was a black furry appearing substance. The DD, COO, and the DM, also observed the smell and validated it was a strong musty smell. After surveyor intervention, the two vents were covered over as to prevent the musty smell to permeate the kitchen.

The tour continued to the area where there were missing and cracked tile. The COO and the DM confirmed they were aware of the concern with the flooring. They also confirmed the tile was not appropriate for commercial use, and the moisture from the steam kettles, and jackets was causing the tiles to left up off the floor.


2. Observation of the kitchen at 1:15 p.m., on 12/7/11, revealed there was an addition to the building at some point to house the walk-in coolers and freezers. Inspection of the space between the original exterior wall and the metal walls of the freezer, which is approximately 2 ½ feet wide, is accessed from inside the kitchen thru an opening fitted with a air conditioning hinged transfer grill, revealed there was a strong musty odor in the space.

Further review revealed the walls and freezer walls were discolored with mold and mildew. There were further observations of moisture and in this space. The odors and the mold and mildew buildup were acknowledged by the Facilities Director, the Chief Operating Officer, and the Associate Administrator.

The Facilities Director contracted with a Licensed Remediation Company to remediate this issue that evening once all food operations were completed. Inspection of theses spaces were conducted at 2 p.m., on 12/8/11. The space was observed to be cleaned and repainted. The facilities director advised the surveyors that the source of the problem was identified as water from the kitchen floor getting through the wall and onto the floor into that space. To remedy the issue, the remediation company used marine class product to seal and isolate the wall in the kitchen to that space. This is intended to prevent the water intrusion thereby eliminating the moisture source and deny the life cycle of the mold and mildew.

Negative Air Pressure in the Kitchen

Inspection of the kitchen, on 12/7/11 at 2:15 p.m., revealed there was a noticeable negative pressure between the open kitchen space and the corridor that leads to the kitchen. Both the Florida Administrative Code and the Florida Building Code require the pressure relationship for a kitchen to a corridor be neutral to prevent any contaminated air from entering the kitchen and open food preparation. The negative air in this particular situation was strong enough to deny a kitchen door to the corridor open by air pressure even though the door is equipped with a hydraulic door closer. The surveyors verified the kitchen hood exhaust make up air was functional as well as the regular ventilation and air conditioning for the kitchen. This issue was verified and acknowledged by the Facilities Director and the Chief Operating Officer. The problem causing the negative pressure was not identified prior to the end of the survey.

3. On 12/7/11 at 0915 a.m., it was observed the crash cart on the Post-Partum Unit of the facility had an Oxygen tank that was ¼ level of pressure. The Pharmacy Technician that was on tour at that time verified the Oxygen tank was ¼ full. She was unable to say at what level oxygen tanks were changed on the crash carts.

On 12/7/11 at 0940 a.m., it was observed that one of the two crash carts on the ICU unit had an oxygen tank at ¼ level of pressure. An interview was conducted with the charge nurse of the ICU unit at 0942 a.m., on 12/7/11. She stated she would change the oxygen tank on the crash cart if it was ¼ full or less.

At 10:40 a.m., on 12/7/11, an interview was conducted with the Director of Respiratory Therapy. She stated, "I would want those oxygen tanks to be full on the crash carts. I would not want them at a ¼ of a tank during a code." She stated, "It is a nursing responsibility to monitor the oxygen on the crash carts daily and either replace the tanks when they have low pressure or notify pharmacy to replace them."

A tour was conducted with the Director of Respiratory Therapy to show her the low oxygen tanks. At that time the tanks had been exchange for full tanks.

A record review was completed of the crash cart check flow sheets for the post-partum unit and the ICU unit. The records showed the tanks were ¼ levels since 12/1/11 and were not changed until the day of survey.



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4. Observation on 12/05/11, at 9:40 a.m., during the tour of the third floor in the presence of the clinical manager and charge nurse of the medical/surgical unit revealed the following:

*crash cart outside of the nurse's station contained a suction canister that was coated with dust. The tubing connected to the canister was coated with a black stick residue.

*inside shelf of the "wallaroo" next to room 304 was coated with brown and black stains as well as dust and dirt. A nurse was observed documenting on top of this shelf and was unaware she was resting her arms on top of the dirt.

*inside of the medication room refrigerator revealed a black foam tray containing vials of insulin. Black particles disintegrating from the foam were observed coating the shelf; a slimy rust colored residue could be observed on the side of the shelf as well.

*the handles to the medication refrigerator were coated with a blackish gray residue.

*the bottom of the plastic bins holding IV (intravenous) solutions in the medication room were coated with brown particles, dust and dirt.

*the fluorescent light cover in the ceiling in the medication room was stained brown.

*the counters in the medication room were covered with a white powdery unidentifiable substance.

*the top of the nursing treatment cart located inside of the nurses station was coated with a black sticky residue while the bottom of the cart was coated with rust, dust and dirt. The inside shelves which contained IV and laboratory supplies were coated with dust and dirt.

*the bottom shelf of the refrigerator in the clean utility room was coated with unidentifiable debris.

*the inside bottom of the bins holding patient supplies in the clean utility room were coated with dust, dirt and debris. Large brown flakes of an unidentifiable substance was observed on the bottom of the bins holding IV tubing and syringes.

*the caulking behind the sink in the clean utility room was crusted and peeling away from the wall. The caulking itself was stained with a black and pink fuzzy residue.

*the tops of the bins holding cookies and crackers in the clean utility room were covered with dust, dirt and lint. The inside of the shelves holding patient snacks were covered with a light brown unidentifiable powdery residue.

*the top of the nursing treatment cart outside of Room 323 was covered with a black, sticky residue.

*the bins inside the pyxis machine located near the nurses station were lined with dust and lint.

Interview with the clinical manager and charge nurse on 12/05/11 at 11:30 a.m. revealed it is a "joint" effort between environmental services, nursing and nutritional services to ensure the areas identified are clean. They could not confirm who specifically covered each area to ensure cleanliness was maintained.

The tour continued to the "same day surgery" area where observations in the presence of the OR (Operating Room) director and charge nurse revealed the refrigerator holding patient's snacks with a blackish brown furry substance lining the top inside refrigerator gasket. The bottom cupboards of the sinks were coated with large, black unidentifiable substances and brown staining was also observed on the bottom shelves.

Observation on 12/05/11 at 12:10 p.m. in the recovery room in the presence of the OR Director and charge nurse revealed white unidentifiable residue on the insides of the bins holding IV supplies. The inside of the cupboard doors which contained patient food was coated with a brown, dried substance. The bottom cupboard shelf under the emergency eye wash station was coated with large black dried particles and the bottom of the shelf was stained brown. The small bins holding test tubes were coated with dust.

Observation of OR "6" at 12:30 p.m., on 12/05/11 in the presence of the OR director revealed a clear, slimy residue on the outside glass doors of the cupboard holding OR supplies. Rust was observed on the metal of the container holding the biohazard bags. The foot pedal alcove to the x-ray machine was coated with dust.

The tour continued to OR "5" which revealed a bean bag (used for positioning) which was coated with a greenish gray unidentifiable substance. The arm board attached to the operating table was torn and the front of the ENT cart was rusted. Chipped paint could be observed on the metal slats on the ceiling above the operating table. In OR "8" chipped pain could be observed on a portion of the metal slats surround the light above the operating table. The front of the anesthesia cart had a small amount of rust and the front of the door to enter the operating room had a large metal strip peeling away from the door.

Interview with the OR director on 12/05/11 at 12:45 p.m., revealed it is the role of the nurses to ensure the same day surgery, recovery room and operating rooms are clean in conjunction with environmental services.

Based on observation, record review, and interview, the hospital failed to ensure policies and procedures delineating the responsibilities of anesthesiologists and associated certified practitioners to perform anesthesia services were in place and tailored to meet each patient's specific needs during surgical procedures.


The findings include:

Interview with the operating room director on 12/06/1,1 at 9:40 a.m., revealed Patient #53 was a new case and was going to be operated on for an appendectomy. He stated the anesthesiologist (MD #1) was responsible for the oversight of the OR (Operating Room) of which his wife would be the CRNA (Certified Registered Nurse Anesthetist) responsible for administering anesthesia to Patient #53.

Observation on 12/06/11 at 10:00 a.m., revealed Patient #53 in the holding area of the hospital awaiting surgery. The patient's mother was at her bedside along with the circulating registered nurse (CRN), the holding room registered nurse (RN) and the CRNA. Observation revealed the CRNA completing a physical assessment of the patient before the induction of anesthesia to the patient and writing the responses of the patient and the mother on a form at the bedside table.

At 10:10 a.m., MD #1 was observed to have walked over to the patient and after speaking to the patient's mother, walked over to the bedside table which was positioned near the CRNA and wrote on the same form that the CRNA was writing on.

The MD exited the holding area and a copy of the form was requested. Observation revealed the information on the form that was completed by the CRNA was not signed and dated as completed by the CRNA, rather, the MD signed and dated the form as having completed it.

The patient returned to the recovery room at 12:05 p.m. The CRNA was present and was observed documenting on the anesthesia record at the patient's bedside. As the recovery room nurse was assisting the patient to a comfortable level, observation revealed post-operative orders by MD#1 dated 12/06/11 and timed "1010" being followed by the recovery room nurse; however, MD#1 was not in the recovery room at the time of the patient's arrival to the recovery room. The post operative orders were given "pre-operatively" for the patient by MD#1.

Observation at 12:08 p.m., revealed the CNRA remaining at the patient's bedside due to the patient complaining of difficulty breathing post surgery. A different anesthesiologist (MD #2) came to the patient's bedside and 4 mg. of Decadron intravenously was administered to the patient due to complaints of difficulty breathing and "inspiratory stridor." It was also during this time observation revealed the anesthesia record had already been signed by MD#1, who was not present in the recovery room.

The CRNA continued to document on this anesthesia record. At 12:10 p.m., the CRNA signed off on the record which had already been previously signed off by MD #1 who had not seen the patient post surgery.

Observation at 1:00 p.m., 55 minutes after the patient entered the recovery room, MD #1 entered, and observed the patient and signed the post operative surgery/procedure orders discharging the patient from the recovery room. In addition, MD #1 dated and signed a "blank" post anesthesia evaluation form located at the patient's bedside.

On this form, the following items included: "The patient identified below has received an anesthesia care provider evaluation postoperatively that includes, but is not necessarily limited to the following: vital signs, mental status, airway and respiratory function, cardiovascular function, pain control, nausea and vomiting control, and postoperative hydration." The MD placed a check mark next to the following documentation: "I find the above criteria are as expected for this patient and the procedure and that no anesthetic related complications are apparent." However, there were no evaluations next to the "above criteria" on behalf of the patient; the criteria listed were left blank.

The MD discharged the patient from the recovery room at 1:00 p.m., and he left with the patient remaining in the room.

At 1:10 p.m., observation revealed the recovery room nurse completing the "blank" post anesthesia evaluation form that MD #1 already signed off on. She completed the vital signs, mental status, airway and respiratory function, cardiovascular function, pain control, nausea and vomiting control and postoperative hydration of the patient. The MD was unaware the nurse had completed the form.

At 1:18 p.m., the patient complained of nausea and pain. She was medicated by the recovery room nurse. MD #1, though signing off on the patient as "stable" and having no post anesthesia complications 18 minutes earlier, was unaware of the patient's condition.

The patient was subsequently stabilized and discharged from the recovery room at 1:42 p.m., 42 minutes after MD #1 cleared her for discharge and who was also unaware of the complication of nausea and pain after signing the blank anesthesia form which indicated there were no "apparent" anesthetic complications.

An interview was conducted with the nurse who was in charge of the recovery room on 12/06/11 at 1:30 p.m. She was asked when a patient should receive post surgery orders. She stated that after a patient returns from the OR and enters the recovery room, the anesthesiologist should be writing post procedure orders. She confirmed they should not be writing post operative orders "pre-operatively."

A brief interview was conducted with the CNO (Chief Nursing Officer) on 12/07/11 at 8:40 a.m., who stated the hospital has policies and procedures which prohibit the direct supervision of family or spouse's over one another for many reasons; however, "never thought about it from the physician standpoint" and wasn't sure there were any (policies) related to physicians in the hospital. She stated the anesthesia group practicing within the hospital was new and they were still formulating policies and procedures. She stated the hospital was currently conducting new audits on the documentation of the anesthesia group; however, was not aware of any current documentation issues by anesthesiology.

Interview with MD #1 on 12/07/11 at 2:00 p.m., revealed he usually always orders "post-op" orders preoperatively for his patients. He stated he is usually covering a large area of the hospital, feels comfortable in knowing his patients' outcomes and what's anticipated and thought it was in the best interest of the patient. He confirmed the orders were not specifically "tailored" to meet each individual patient's needs; confirmed he would have no way of knowing the patient's outcome post procedure unless the symptoms presented "post-operatively."

The MD confirmed he signed off on the anesthesia record before it was completed by the CRNA and confirmed he was unaware of all that was documented on the form by the CRNA. He confirmed that by the appearance of his signature on this form, it would appear that he signed off on it at the same time it was completed, which did not occur. He stated he should have dated and timed the form at the time when he had reviewed it.

The MD stated he signed off on the post-anesthesia evaluation at 1:00 p.m., on 12/06/11, because after looking at the patient, felt she was safe for discharge from the unit. He was unaware the recovery room RN completed the evaluation after he signed the document and left the unit. He confirmed he had no idea what was entered on the form after he signed it. He stated he felt she was safe for discharge and was not aware that the patient was medicated twice for nausea after his departure. He stated the evaluation should not have been completed by the recovery room RN.

Interview with the CNO on 12/07/11, at 1:00 p.m., confirmed there were no specific policies and procedures delineating between when pre operative and post operative orders should be written by the anesthesiologists.

Based on observation, record review, and interview, the hospital failed to ensure 1 (Patient #53) of 7 surgical records reviewed contained a post-anesthesia evaluation which was completed by a qualified individual authorized to provide anesthesia services.

The findings include:

Interview with the operating room director on 12/06/11, at 9:40 a.m., revealed Patient #53 was a new case and was going to be operated on for an appendectomy.

Observation on 12/06/11, at 10:00 a.m., revealed Patient #53 in the holding area of the hospital awaiting surgery. The patient went into surgery at 11:00 a.m., and returned from the operating room at 12:05 p.m. The CRNA (Certified Registered Nurse Anesthetist) was present and was observed documenting on the anesthesia record at the patient's bedside.

Observation at 1:00 p.m., 55 minutes after the patient entered the recovery room, an anesthesiologist entered, observed the patient and signed the post operative surgery/procedure orders discharging the patient from the recovery room. In addition, the MD dated and signed a "blank" post anesthesia evaluation form located at the patient's bedside.

On this form, the following items included: "The patient identified below has received an anesthesia care provider evaluation postoperatively that includes, but is not necessarily limited to the following: vital signs, mental status, airway and respiratory function, cardiovascular function, pain control, nausea and vomiting control, postoperative hydration." The MD placed a check mark next to the following documentation: "I find the above criteria are as expected for this patient and the procedure and that no anesthetic related complications are apparent." However, there were no evaluations next to the "above criteria" on behalf of the patient; the criteria listed were left blank.

The MD discharged the patient from the recovery room at 1:00 p.m., and left while the patient remained in the recovery room.

At 1:10 p.m., observation revealed the recovery room nurse completing the "blank" post anesthesia evaluation form that the anesthesiologist had previously signed and dated. She documented information regarding the patient's vital signs, mental status, airway and respiratory function, cardiovascular function, pain control, nausea and vomiting control and postoperative hydration of the patient. The MD was unaware the nurse had completed the form.

At 1:18 p.m., the patient complained of nausea. She was medicated by the recovery room nurse. The MD though signing off on the patient as "stable" and having no post anesthesia complications 18 minutes earlier, was unaware of the patient's condition.

The patient was subsequently stabilized and discharged from the recovery room at 1:42 p.m., 42 minutes after the MD cleared her for discharge and who was also unaware of the complication of nausea after signing the blank anesthesia form which indicated there were no "apparent" anesthetic complications.

A brief interview was conducted with the CNO (Chief Nursing Officer) on 12/07/11, at 8:40 a.m., who stated the anesthesia group practicing within the hospital was new and they were still formulating policies and procedures. She stated the hospital was currently conducting new audits on the documentation of the anesthesia group; however, was not aware of any current documentation issues by anesthesiology.

Interview with the anesthesiologist on 12/07/11 at 2:00 p.m., revealed he signed off on the post-anesthesia evaluation at 1:00 p.m., on 12/06/11 because after looking at the patient felt she was safe for discharge from the unit. He was unaware the recovery room RN completed the evaluation after he signed the blank document and left the unit. He confirmed he had no idea what was entered on the form after he signed it. He stated he felt she was safe for discharge and was not aware that the patient was medicated twice for nausea after his departure. He stated the evaluation should not have been completed by the recovery room RN.