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Based on record review and interview the hospital failed to ensure the hospital policy regarding patient's written and/or verbal grievances contained a regulatory definition of what constituted a grievance to ensure all grievances were processed for 1 of 1 policy regarding grievances (Patient Complaints/Grievances, # RI-070 approved 9/01/2010). Findings:

Review of the hospital policy titled, "Patient Complaints/Grievances, # RI-070 approved 9/01/2010" presented by the hospital as current revealed in part, "Definitions: A grievance is only considered such when presented in writing or verbally communicated that the issue is to be considered a formal grievance necessitating a written response."

Review of the definition of a patient grievance as indicated in 42 CFR (Code of Federal Regulations) 489 revealed in part, "A patient grievance is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present, abuse or neglect, issues related to the hospital's compliance with the CMS Hospital conditions of Participation, or a Medicare beneficiary billing complaint related to rights and limitations. . . A written complaint is always considered a grievance. This includes written complaints from an inpatient, an outpatient, a released/discharged patient, or a representative regarding the patient care provided, abuse or neglect, or the hospital's compliance with Conditions of Participation. For the purposes of this requirement, an email or fax is considered written. "

During a face to face interview on 1/11/2012 at 2:20 p.m., Director of Quality Assessment Performance Improvement S5 confirmed the hospital's policy defining grievances failed to meet the Regulatory Definition of a Grievance. S5 further confirmed that all patients/representatives might not know to state/write that they want their complaint to be considered a formal grievance with a written response.

Based on record review and interview the hospital failed to ensure a patient's informed consent was complete by failing to include the specific risks for surgical procedures and only including general risks associated with a surgical procedure for 6 out 6 records reviewed for informed consents out of a sample of 30 ( #14, #20,#22, #23, #26, and #29). Findings:

Patient #14
Review of the medical record for Patient #14 revealed the patient was admitted to the hospital on 12/28/2011. Further review revealed a surgical consent dated 12/28/2011 at 1310 (1:10 p.m.) for "Incision and Drainage of right elbow with Hardware Removal". Review revealed "Specific to the planned procedure, my physician has explained the potential benefits, recognized risks, or side effects, including potential problems related to recuperation. the likelihood of achieving the expected treatment goals, reasonable possible results of not having the planned procedure and the relevant risks, benefits, and side effects related to alternatives, including the possible results of not having the planned procedure." Record review revealed a second consent was signed on 12/28/2011 at 1310 indicating, "My consent is given with the understanding that any operation of procedure involves risks and hazards. The more common risks include: infection, bleeding with the need for blood transfusion, never injury, blood clots, heart attack, stroke, allergic reaction, damage to teeth or bridgework, and pneumonia." Review of the entire medical record revealed no documented evidence to indicate the risks/benefits specific to the surgery being performed, the risks/benefits specific to not having the procedure, or the specific alternative options outside of surgery.

Patient #20
Review of the medical record for Patient #20 revealed the patient was admitted to the hospital on 12/28/2011 with diagnoses that included Dyspareunia. Further review revealed a surgical consent dated 12/28/2011 at 7:10 a.m. for "Laproscopic Assisted Vaginal Hysterectomy, Possible Open bilateral Salpihgo-oophorectomy, and Cystoscopy". Review revealed "Specific to the planned procedure, my physician has explained the potential benefits, recognized risks, or side effects, including potential problems related to recuperation, the likelihood of achieving the expected treatment goals, reasonable possible results of not having the planned procedure and the relevant risks, benefits, and side effects related to alternatives, including the possible results of not having the planned procedure." Record review revealed a second consent was signed on 12/28/2011 at 7:15 a.m. indicating, "My consent is given with the understanding that any operation of procedure involves risks and hazards. The more common risks include: infection, bleeding with the need for blood transfusion, never injury, blood clots, heart attack, stroke, allergic reaction, damage to teeth or bridgework, and pneumonia." Review of the entire medical record revealed no documented evidence to indicate the risks/benefits specific to the surgery being performed, the risks/benefits specific to not having the procedure, or the specific alternative options outside of surgery.

Patient #22
Review of the Consent for Surgical and Medical Procedure and Acknowledgement of Receipt of Information for Patient #22 dated 12/20/11 and timed 4:00 p.m. revealed she (#22) consented for a open reduction and internal fixation of right patella. Further review revealed no documented evidence the patient was informed of the specific risks or hazards of the procedure.

Patient #23
Review of the Consent for Surgical and Medical Procedure and Acknowledgement of Receipt of Information for Patient #23 dated 01/03/12 (no time dated) revealed she (#23) consented for a Cystoscopy with clot removal. Further review revealed no documented evidence the patient was informed of the specific risks or hazards of the procedure.

Patient #26
Review of the Consent for Surgical and Medical Procedure and Acknowledgement of Receipt of Information for Patient #26 dated 12/15/11 at 2:30 p.m. revealed she (#26) consented for a right total hip arthroplasty. Further review revealed no documented evidence the patient was informed of the specific risks or hazards of the procedure.

Patient #29
Review of the medical record for Patient #29 revealed the patient was admitted to the hospital on 12/12/2011 with diagnoses that included Diverticulitis. Further review revealed a surgical consent dated 12/12/2011 at 6:00 a.m. for "sigmoid colectomy". Review revealed "Specific to the planned procedure, my physician has explained the potential benefits, recognized risks, or side effects, including potential problems related to recuperation. the likelihood of achieving the expected treatment goals, reasonable possible results of not having the planned procedure and the relevant risks, benefits, and side effects related to alternatives, including the possible results of not having the planned procedure."Record review revealed a second consent was signed on 12/12/2011 at 6:25 a.m. indicating, "My consent is given with the understanding that any operation of procedure involves risks and hazards. The more common risks include: infection, bleeding with the need for blood transfusion, never injury, blood clots, heart attack, stroke, allergic reaction, damage to teeth or bridgework, and pneumonia." Review of the entire medical record revealed no documented evidence to indicate the risks/benefits specific to the surgery being performed, the risks/benefits specific to not having the procedure, or the specific alternative options outside of surgery.

During a face to face interview on 1/11/2012 at 11:10 a.m., Registered Nurse Supervisor S2 indicated patients often sign a generic surgery consent form with no specific risk/benefits for surgery or other alternative treatment options listed. S2 indicated there were some physicians that used more detailed consents specific to the procedure and medical history of the patient and others that used the generic consents. S2 confirmed the above listed consents did not contain patient specific information.

Review of Louisiana Statute LSA-R.S. 40:1290.40 revealed.... (6) Consent to medical care that appears on the secretary's list requiring disclosure shall be considered effective under this Subsection, if it is given by the patient or a person authorized to give consent and by a competent witness, and if the consent specifically states, in such terms and language that a layman would be expected to understand, the risks and hazards that are involved in the medical care or surgical procedure in the form and degree required by the secretary under Paragraph (4) of this Subsection".

Review of the hospital policy titled, "Ethics, Rights and Responsibilities, Consent and Disclosure, #RI-020 "presented by the hospital as current revealed in part, "Properly executed informed consent contains at least the following. . . 2. Name of Procedure. . . 4. Risks, 5. Alternative procedures and treatments. . ."



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26351

Based on record review and interview the hospital failed to ensure a policy and procedure was developed regarding allegations or suspicion of abuse occurring within the hospital to include how the hospital would screen, protect, investigate, or respond to the allegations/suspicion for 2 of 2 policies reviewed regarding abuse. Findings:

Review of the hospital's Policy titled, "Abuse/Family Violence or Neglect, approved 9/01/2010" revealed in part, "Grievances that may be cases of employee suspected patient/client abuse shall be treated as occurrences. All such incidents shall be immediately reported to the CEO (Chief Executive Officer), CNO (Chief Nursing Officer), and/or immediate supervisor." Review of the entire policy revealed no documented evidence to indicate how the hospital would screen, protect, investigate, or respond to allegations or suspicions of abuse within the hospital.

Review of the hospital's Policy titled, "Ethics, Rights and Responsibilities, approved 9/01/10" presented by the hospital as current revealed in part, "The right to expect a reasonable safe environment free from mental, verbal, sexual and physical abuse and which safeguards the patient's belongings at the patient's request. In the event the hospital determines it is unable to provide for safety of the patient and/or the staff, the hospital may transfer or discharge the patient when medically appropriate. The right to expect that, within its capacity and policies, the hospital will make reasonable response to the request of a patient for appropriate and medically indicated care and services." Review of the entire policy revealed no documented evidence to indicate how the hospital would screen, protect, investigate, or respond to allegations or suspicions of abuse within the hospital.

Review of Louisiana Revised Statute Title 40. Chapter 11. 2009.20 revealed in part, "Department shall mean the Department of Health and Hospitals. . .Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, licensed practical nurse, nurse's aide, home and community based service provider employee or worker, personal care attendant, respite worker, physician's assistant, physical therapist, or any other direct caregiver having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. . ."

Review of a Louisiana Health Standards Section Memo addressed to "All Licensed Hospitals" from the "Department of Health and Hospitals, Health Standards Section, Hospitals Program Desk" dated October 27, 2010 regarding "Reporting Allegations of Abuse/Neglect" revealed in part "The purpose of this memorandum is to clarify the process to be used by hospitals when self-reporting allegations of abuse and/or neglect so that the information submitted may be processed in an efficient and timely manner by the Hospitals Program Desk. Effective immediately, all hospital self-reports allegations of abuse and/or neglect submitted to the Department of Health and Hospitals Health Standards Section must be faxed to (phone number) within 24 hours of the facility having knowledge of the allegations. The facility is free to determine which of its personnel will be responsible for initial notification, but it must be sent via facsimile. The preliminary report must contain all of the information required in the Abuse/Neglect Initial Report form, including, but not limited to: 1. Name and DOB of the patient, 2. The patient's admission and discharge dates, 3. Patient's admitting and pertinent diagnoses, 4. Nature and specific description of the alleged event, including any details available, 5. Date, time, and specific location of the alleged event, 6. How and when the incident was discovered, 7. Whether patient sustained injuries or adverse effects, 8. Name and title of the alleged perpetrator, 9. Alleged perpetrator's professional license number or social security number if unlicensed, 10. Alleged perpetrator's date of hire, 11. Whether or not there is video surveillance of the location involved, 12. If video surveillance existed, is it the type that records? If so, how long does it maintain the recording?, 13. Was the video reviewed relative to the incident? If so, by whom; what were the findings?, 14. Date and time facility administration became aware of the allegation, 15. Name and title of administrative personnel first notified, 16. Actions taken by the facility to safeguard the patient(s), 17. To whom the facility has reported the incident (including physician, family member, police dept, licensing board, protective services, etc.)".

During a face to face interview on 1/11/2012 at 2:20 p.m., Director of Quality Assurance Performance Improvement S5 confirmed the hospital had no policy outlining the procedure for allegations or suspicion of abuse within the hospital to include how the hospital would prevent abuse/neglect through screening of employees, protect the patient (identified victim) during an investigation of reported allegations/suspicion of abuse, investigate the allegation/suspicion, respond to allegations/suspicion of abuse, and report allegations of in-house abuse/neglect to the police and/or Department of Health and Hospitals.

Based on record review and interview the hospital failed to ensure nursing staff implemented the plan of care for performing accuchecks for 2 of 2 patients reviewed for accuchecks out of a total sample of 30 (Patient #16, #24). Findings:

Review of Patient #16's medical record revealed the patient was admitted to the hospital on 1/06/2012 with diagnoses that included gangrene of the foot. Further review revealed physician's orders dated 1/06/2012 at 1435 (2:35 p.m.) for Blood Glucose Monitoring before meals and at Bedtime. Review of Patient #16's entire medical record revealed no documented evidence of Blood Glucose Monitoring before lunch or dinner on 1/07/2012.

Review of Patient #24's medical record revealed the patient was admitted to the hospital on 12/12/2011 with diagnoses that included Left Shoulder Arthroscopy and Diabetes. Further review revealed physician's orders dated 12/12/2011 at 1540 (3:40 p.m.) for Accuchecks (Blood Glucose Monitoring) before meals and every hour sleep. Review of Patient #24's entire medical record revealed no documented evidence of Blood Glucose Monitoring before breakfast on 12/13/2011 or before lunch or at hour sleep on 12/14/2011.

During a face to face interview on 1/12/12 at 8:15 a.m., Registered Nurse Supervisor S8 confirmed the failure to follow physician orders for Accuchecks on Patient #16 and #24 as outlined above. S8 indicated she had reviewed the medical records for both patients and the patients had been on the unit; therefore, she could find no reason why the accuchecks for blood glucose monitoring had not been done as ordered. S8 further indicated she had spoken with Registered Nurse S14 regarding the incidents after she had reviewed the medical records for Patient #16 and #24 with the surveyor. S8 indicated it had been the same Registered Nurse involved in both patient's missed accuchecks (S14). S8 indicated with Patient #16 it had appeared to be a documentation error; however, with Patient #24 it could not be determined if the accuchecks had ever been done as ordered. S8 indicated Patient #16 and #24 should have had accuchecks performed as ordered and documented in the patient's medical record.

Based on record review and interview the hospital failed to ensure all entries into the Medical Record were not timed for 11 of 30 sampled patients (#12, #14, #15, #20, #21,#22, #24, #25, #26, #27, #29). Findings:


Review of Preoperative Evaluation Forms for Patients #12 (1/09/2012) , #14 (1/09/2012), #15 (1/09/2012), #20 (12/28/2011), #21(12/23/2011), #24 (12/12/2011), and #29's (12/12/2011) revealed no documented time of the entry.

Review of Postoperative Evaluations for Patients #12 (1/09/2012),#22 (12/21/11), #24 (12/12/2011), and #26 (12/19/11) revealed no documented time of the entry.


Patient #25
Review of the medical record for Patient #25 revealed an 56 year old male admitted to the hospital for a Left Total Knee Arthroscopy under general anesthesia. Review of the verbal Physician's Orders for Patient #25 revealed no documented date and time the orders were received by the nurse. Review of the physician's Admit Orders dated 11/21/11 and the Pain Management Orders dated 12/12/11 for Patient #25 revealed no documented time the orders were signed.

Patient #27
Review of the medical record for Patient #27 revealed a 40 year old female admitted to the hospital for a Laparoscopic Sleeve Gastronomy dated 12/15/11. Review of the Bariatric Screening Orders and Bariatric Pre-op Orders for Patient #27 revealed no date or time ordered by the physician. Review of the Post-Op Laproscopic Sleeve Gastronomy Orders dated 12/15/11 and the Progress Note dated 12/16/11 for Patient #27 revealed no documented evidence of the time of entry were written.

Patient #30
Review of the medical record for Patient #30 revealed a 51 year old male admitted to the hospital for a Left Partial Amputation of Foot with Tendo Achilles Lengthening performed with the use of a block and Propofol. Review of the Anesthesia consent dated 12/09/11 revealed no documented evidence of the date or time the physician signed the consent.

During a face to face interview on 1/11/2012 at 11:10 a.m., S2Vice President of Clinical Services confirmed the findings listed above and indicated all entries in patient's medical records were to be dated, timed, and authenticated.

Review of the hospital's policy for Adequate Documentation of Medical Record, Policy No. IM-030 revealed in part, "... B. All entries are authenticated. According to the Federal Regulations 482.24 (c)(1) all entries in the medical record must be timed, dated, and authenticated, and a method established to identify the author.."




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26351

Based on record review and interview the hospital failed to follow their policy for authenticating verbal orders as evidenced by failure to sign, date and/or sign the orders with 72 hours for 3 of 30 sampled medical records (#23, #25,#30). Findings:

Patient #23
Review of the medical record for Patient #23 revealed an 83 year old male admitted to the hospital for a Cystoscopy with clot removal on 01/04/12. Review of the verbal admit orders dated/timed 01/04/12 at 10:00 am, verbal order dated/timed 01/04/12 at 1300 (1:00pm), verbal order dated/timed 01/04/12 at 1305 (1:05pm), verbal order dated/timed 01/05/12 at 0000 (12:00am), verbal order dated/timed 01/05/12 at 11:25am, and verbal order dated/timed 01/08/12 at 1300 (1:00pm), revealed no documented evidence the date or time authenticated by the physician.

Patient #25
Review of the medical record for Patient #25 revealed an 56 year old male admitted to the hospital on 12/12/11 for a Left Total Hip Arthroscopy under general anesthesia. Review of the verbal Physician's Orders for Patient #25 (which had no documented date and time received by the nurse) revealed no documented evidence the verbal orders were authenticated by the physician (dated/timed/signed by the physician).

Patient #30
Review of the medical record for Patient #30 revealed a 51 year old male admitted to the hospital for a Left Partial Amputation of Foot with Tendon Achilles Lengthening performed with the use of a block and Propofol. Review of the verbal orders dated 12/09/11 at 1700 (5:00pm) revealed no documented evidence of a physician's signature. Review of the verbal order dated/times 12/09/11 at 1800 (6:00pm) revealed no documented evidence the date and time the physician signed the order.

In a face to face interview on 01/12/12 at 2:00pm S2 Vice President of Clinical Services indicated all verbal orders must be signed, dated, and timed.

Review of the Medical Staff Rules and Regulations, no date of revision and submitted as the one currently in use revealed.... "3. Verbal and Telephone Orders:...... the ordering physician or LIP (Licensed Independent Practitioner) shall authenticate such orders within 72 hours or within the timeframe required by the state and federal law and regulation".

Based on record review and interview the hospital failed to ensure accurate records were kept for the receipt and distribution of scheduled drugs contained in Anesthesia boxes that were picked up and returned to pharmacy at the start and close of surgery days. Findings:

Review of 3 anesthesia Narcotic Administration Records for Anesthesia Boxes picked up and returned to pharmacy on the date of 1/11/2012 revealed no documented evidence of reconciling the drug count at the time pharmacy released the medications to Anesthesia or at the end of the surgical day when the Narcotics were returned to pharmacy.

Review of the hospital policy titled, "Controlled Drugs: Storage and Distribution and Accountability, #PCS-09-01" presented by the hospital as current revealed in part,"Accountability of Controlled Drugs, The Director of Pharmacy is responsible for determining that all records for controlled drugs are accurate and correct and that an account of all controlled drugs is maintained and recorded.

During a face to face interview on 1/12/2012 at 9:40 a.m., Pharmacy Director S13 indicated the Pharmacy had not always consistently documented reconciliation of Narcotics in the Anesthesia Narcotic Boxes when Anesthesia picked up the narcotic medications in the morning or returned the narcotic medications at the close of surgery days. S13 indicated there should be a signature of two staff; one from pharmacy and one from Anesthesia, indicating a count of narcotics had been made and was accurate during pick up and delivery of narcotics from Pharmacy to Anesthesia and upon return at the close of the day.

Based on record review and interview the hospital's Radiology Department failed to develop and implement a policy regarding evaluation of employees' cumulative radiation exposure at the time of hire and/or for employees that work at more than one location resulting in 1 of 1 new hire having no Radiation Exposure Report obtained at the time of hire (S4). Findings:

Review of the Environmental Regulatory Code Title 33, Part XV, S 414 revealed in part, "Determination of Prior Occupational Dose: For each individual who is likely to receive, in a year, an occupational dose requiring monitoring in accordance with LAC 33:XV.431, the licensee or registrant shall: 1. determine the occupational radiation dose received during the current year; and 1. attempt to obtain the records of lifetime cumulative occupational radiation dose. B. Prior to permitting an individual to participate in a planned special exposure, the licensee or registrant shall determine: 1. the internal and external doses from all previous planned special exposures; and 2. all doses in excess of the limits, including doses received during accidents and emergencies, received during the lifetime of the individual. . . ."

Review of Radiology Tech S4's personnel file revealed no documented evidence of a cumulative radiology exposure report obtained from prior employment prior to being hired by the hospital on 11/30/2011.

This finding was confirmed by Imaging Director S3 in a face to face interview on 1/11/2012 at 1:05 p.m. S3 indicated the hospital had no policy on obtaining cumulative radiation exposure reports on new hires or for employees that worked at more than one facility. S3 confirmed Environment Regulatory Code required Radiology Departments of the hospital to monitor pre-hire exposure and cumulative exposure of employees working at more than one facility. S3 indicated the hospital had not been monitoring pre-hire exposure or cumulative exposure of employees that worked at more than one facility as they should have been.

26351


Based on record reviews and interviews the hospital: 1) failed to ensure the Center of Disease Control guidelines for Tuberculosis (TB) screening were followed as evidence by 4 out 4 physicians TB skin test results reviewed and 1 out 7 employee's TB skin test reviewed were not timed when they were administered or timed when they were read ensuring the 48 to 72 hour CDC guidelines were followed, and
2) failed to maintain a sanitary environment in the decontamination area as evidenced by: a) having a large yellow "Flammable" box/container with a dirty biohazard sharps container with a Laproscopic suction tip and a K-Wire that extended approximately 2 and 1/2 inches past the tip of the container and approximately eight (8) inches above the container's designated fill line that was located less than one (1) foot from the clean cart holding about ten (10) clean instrument trays that was located less than one (1) foot from the dirty sink area with dirty rectal and cystoscopy instruments located on the countertop with no distinct separation between the dirty and clean area(s) in the room; and b) failing to maintain aseptic technique during the decontamination process of the rectal and/or cytoscopy instruments by S12, Sterile Processing Supervisor as evidenced by: 1) failing to ensure the rectal and/or cytoscopy instruments soaked in the enzymatic (Prolystica) solution for a minimal of 2 to 5 minutes as per the manufacturer's recommendations, 2) failing to inspect the instruments (rectal and/or cytoscopy) for contamination during the decontamination process as per policy, and 3) failing to remove dirty gloves, perform hand washing and don clean gloves after the decontamination process of the dirty instruments (rectal and/or cytoscopy) and prior to beginning the clean process of the instruments and prior to exiting the decontamination area.
Findings:

1)
Review of the personnel records for physicians S9MD, S15MD, S16MD, and S17MD revealed the TB (tuberculosis) skin tests were not timed on administration or when the result was read. Review of the personnel record for S10RN revealed the TB skin test was not read on administration or timed when the result was read.

An interview was conducted with S5QAPI (Quality Assurance Performance Indicators) Director on 1/12/12 at 10 a.m. and she indicated the tuberculosis screening were not timed on administration or when the results were read.

Review of the Hospital's policy on Employee Health Screening, Pre-employment and Annual, Policy Number IC-060 revealed in part,"...Tuberculosis screening should be administered as follows:..The responses should be read in 48-72 hours (by the Employee Health nurse or his/her designee) after injection."

Review of the CDC Guidelines revealed: "Tuberculin skin test: A diagnostic aid for finding M. tuberculosis infection. A small dose of tuberculin is injected just beneath the surface of the skin (in the United States by the Mantoux method), and the area is examined for induration by palpation 48--72 hours after the injection..."

2)
a)
During a tour of the decontamination process on 01/12/12 from 9:35am through 10:20am with S2VP of Clinical Services, this area was observed with a large yellow box/container labeled, "Flammable" containing about eighteen (18) surgical solutions (hydrocloric acid, citranox, eosin-y, phenol liquid, lugols, flexible collidian, formaldehyde, bluing rinse, methyl alcohol, vinegar, monsel's solution, hematoxylin 7211, ETOH, Reagent alcohol, and xylene). Further observation revealed on the top of this container/box was a biohazard sharps container with a laparoscopic suction tip and a K-wire that both extended approximately two (2) and half (1/2) inches out of the tip of the container. The laparoscopic suction tip and the K-wire were both approximately ten (10) inches above the designated fill line noted of the sharps container. Further observation revealed less than one (1) foot from the "Flammable" box/container was a large metal cart containing about twenty (20) clean metal instrument trays. Further observation also revealed less than one (1) foot from the large metal cart was the dirty sink area. On top of the dirty sink area was a dirty rectal and cystoscopy instrument set(s).

b)
During the same tour of the decontamination process on 01/12/12 from 9:35am through 10:20am with S2VP of Clinical Services, S12Sterile Processing Supervisor confirmed there were two (2) sinks. Sink #1 had two (2) squirts of "Prolystica" solution in it and Sink #2 had clear water. Both Sink #1 and Sink #2 were observed about half (1/2) filled. At 9:35am, S12 was observed removing the rectal instrument set from the countertop and placed it into sink #1 (the enzymatic solution). At 9:36am, S12 moved the instruments from sink #1 to sink #2 (the clear water). Further observation revealed S12Sterile Processing Supervisor did not visually inspect the rectal instruments during the decontamination process. There was no clock noted in the decontamination area. S12Sterile Processing Supervisor did not have a wrist watch noted on either wrist. S12Sterile Processing Supervisor did not remove her dirty gloves, perform hand washing and/or don clean gloves after she placed the decontaminated rectal instruments into Sink #2-the clean area. At 9:37am, S12 began removing the rectal instruments from sink #2 and placed them on a metal tray that was located on the right side of the sink. At 9:38am, S12 put the rectal instrument set onto the clean Steris area. There was no degloving, hand washing performed and/or doning of clean gloves noted by S12 at this time. At 9:38am, S12Sterile Processing Supervisor placed the cystoscopy instrument set from the dirty countertop area into Sink #1. At 9:39am, S12 brushed the cystoscopy instruments with no visual inspection of the instruments for contamination during the decontamination process and placed them into Sink #2-the clean sink. There was no degloving, hand washing and/or doning of gloves noted by S12 at this time. At 9:40am, S12 removed the cystoscopy instruments from Sink #2. At 9:41am, S12 walked and got a clean instrument tray from a metal rack that contained about twenty (20) clean instrument trays. S12 walked back to the clean area and placed the cystoscopy instruments into the clean tray. At 9:42am, S12 brought the cystoscopy instruments to the clean Steris area. Further observation revealed there was no degloving and/or hand washing performed at this time. At 9:43am, S12Sterile Process Supervisor exited the decontamination area and went to the sink that was located outside the room. She degloved and performed hand washing at this time. During this same observation, S12Sterile Process Supervisor indicated she only visually inspects instruments that are contaminated. S12 confirmed she did not visually inspect the rectal and/or cystoscopy instruments during the decontamination process. Further S12 indicated the enzymatic cleaner "Prolystica" does not have a dwell/soaking time. S12 verified there was no clock in the decontamination area. Further S12 verified she did not have a wrist watch on either wrist. At this time, S12 read the manufacturer's label on the "Prolystica". S12 indicated the "Prolystica" label read, "...Soak minimal of 2 to 5 minutes...". S12 stated she failed to follow the manufacturer's recommendations for the instruments to soak for a minimal of 2 minutes during the decontamination process of the rectal and/or cystoscopy instruments. S12 confirmed she failed to deglove, perform hand washing and/or don gloves after the decontamination process of the rectal and/or cystoscopy instrument(s). S12 indicated this area is dirty. Further S12 indicated there was no sink available in the decontamination area to perform hand washing. S12 stated the closest sink to perform hand washing is located outside the decontamination area. S12 confirmed the door knob on the decontamination area is dirty. S2VP of Clinical Services and S11ORCN both confirmed the above findings during the observation of the decontamination process from 9:35am through 10:20am on 01/12/12.

Review of the "Prolystica" enzymatic solution label read, "soak for a minimal of 2 to 5 minutes".

Review of the policy titled, "Medical Device Cleaning, Disinfecting, and Sterilization", Approved date of 9/01/10 with no reviewed and/or revised date(s), presented as the hospital's current "Sterilization/Decontamination Process" policy on 01/11/12 at 10:45am by S1Administrator. The policy indicated its purpose was to provide clean, disinfected and/or sterile equipment for safe patient care and prevent and control the potential risk of cross contamination/infection with reusable medical devices (patient care equipment). Medical devices will be appropriately reprocessed after use. The definition of cleaning is the physical removal of organic material (blood/body fluids) or soil from objects by using water with or without detergent. The definition of disinfection is the removal of many or all pathogenic microorganisms with the exception of bacterial spores. The definition of sterilization is the complete elimination/destruction of all forms of microbial life. The procedure for the items to be reprocessed should be placed into three (3) categories according to the risk of infection to the patient. Non-critical items, Semi-critical items and Critical items. The Critical items are items that enter sterile tissue or the vascular system such as surgical instruments. After use, all items should be thoroughly cleaned to remove foreign material before disinfecting or sterilizing. Cleaning medical instruments should be centralized. The instruments should be soaked in disinfectant. Some of the products approved for cleaning of instruments should be used according to the manufacturer's suggestions. High level disinfection and/or sterilization may be accomplished by the use of chemical germicides according to manufacturer's directions. Chemical germicide's efficacy should be stated in the manufacturer's written instructions. Critical items should be thoroughly rinsed with sterile water after the required contact time.

Based on record review and interview the hospital failed to follow their policy and procedure for performing History and Physicals as evidenced by: 1) failed to perform an H&P within 30 days of admit resulting in using an H&P performed 150 days prior to surgery (#27); 2) failing to update a the H&P when performed greater than 24 hours prior to surgery (#30); and 3) failed to assess the vital signs as required on the H&P form (#23) for 3 of 30 surgical patients reviewed. Findings:

1) failed to perform an H&P within 30 days of admit resulting in using an H&P performed 150 days prior to surgery.

Patient #27
Review of the medical record for Patient #27 revealed a 40 year old female admitted to the hospital for a Laparoscopic Gastrectomy/Gastric Sleeve under general anesthesia. Review of the History and Physical (H&P) dated 12/15/11 (no time documented) and signed by the physician revealed ... " See H&P 07/15 " . Further review of the H&P form revealed a check in the box indicating the physician had reviewed the H&P and there were " No changes from above. The form was signed, dated, and timed 12/15/11 at 0800am.

Review of the History and Physical contained in the medical record for Patient #27 was dated 07/15/11, which was performed five months prior to the surgery on 12/15/11.

2) failing to update a the H&P when performed greater than 24 hours prior to surgery.

Patient #30
Review of the medical record for Patient #30 revealed a 51 year old male admitted to the hospital for a Left Partial Amputation of Foot with Tendon Achilles Lengthening performed with the use of a block and Propofol on 12/05/11 (no date/time documented). Review of the History & Physical, handwritten on the hospital's form and dated 12/09/11 revealed an assessment of the left foot was performed. The H&P form was signed by the MD, but there was no documented evidence of the date or time the assessment of the limb was performed. Further review of the form revealed the physician had signed the section used for updating the H&P; however there was no documented evidence of an assessment and the date and/or time performed.

3) failed to assess the vital signs as required on the H&P form.

Patient #23
Review of the medical record for Patient #23 revealed an 56 year old male admitted to the hospital for a Cystoscopy with removal of clots under general anesthesia

Review of the History and Physical form for Patient #23 dated/timed 01/04/12 at 11:00am revealed no documentation the blood pressure, pulse, or respirations were assessed as evidenced by a blank in the spaced provided for the information on the form.

In a face to face interview on 01/12/12 at 2:00pm S2 Vice-President of Clinical Services indicated the hospital was aware of the problem with the physicians not completing the history and physicals. Further S2 indicated it was difficult because many of the physicians used their own forms and completed the assessments at his/her office.

Review of the Medical Staff Rules and Regulations (no date of revision) submitted as the one currently in use, revealed ..... "4. Medical History and Comprehensive Physical: a. A complete admission history and physical examination, including all update notes when applicable, done by a Physician shall be recorded within 24 hours of admission. This report should include all pertinent findings resulting from an assessment of all the systems of the body. In lieu of this, if a complete history has been recorded and a physical examination performed within 30 days prior to the patient's admission to the Hospital, a legible copy of these reports may be used in the patient's Hospital medical record, providing these reports were recorded by a Staff Member. In such instances, an interval admission note, which should include a physical examination to update the patient's current medical status, shall be completed within 7 days prior to, or within 24 hours after admission " .

Based on record review and interview the hospital failed to follow their policy and procedure for performing post-anesthesia evaluation as evidenced by failing to include a cardiopulmonary status, level of consciousness, follow-up care/observations, complications occurring in the post-anesthesia/recovery phase and any follow-up care needed for 13 of 30 sampled medical records of surgery patients (#12, #14, #15, #20, #21, #22, #23, #24, #25, #26, #27, #29, #30). Findings:

Patient #12
Review of the medical record for Patient #12 revealed the patient was admitted to the hospital on 1/09/2012 with diagnoses that included Right Hip Degenerative Joint Disease. Further record review revealed the patient had surgery on 1/09/2012. Review of the Post-Operative Evaluation by anesthesia for Patient # 12 revealed the date 1/09/2012; (no documented time); a check next to the box indication "No anesthesia complications" and the signature of anesthesia. Further review revealed no documented evidence of a cardiopulmonary status, level of consciousness, follow up care/observations, complications occurring in the post-anesthesia/recovery phase and any follow up care that was performed.

Patient #14
Review of the medical record for Patient #14 revealed the patient was admitted to the hospital on 1/09/2012 with diagnoses that included Prostate Cancer. Further record review revealed the patient had surgery on 1/09/2012. Review of the Post-Operative Evaluation by anesthesia for Patient # 14 revealed the date 1/09/2012; time 1700 (5:00 p.m.); a check next to the box indication "No anesthesia complications" and the signature of anesthesia. Further review revealed no documented evidence of a cardiopulmonary status, level of consciousness, follow up care/observations, complications occurring in the post-anesthesia/recovery phase and any follow up care that was performed.

Patient #15
Review of the medical record for Patient #15 revealed the patient was admitted to the hospital on 1/09/2012 with diagnoses that included Degenerative Joint Disease. Further record review revealed the patient had surgery on 1/09/2012. Review of the Post-Operative Evaluation by anesthesia for Patient # 15 revealed the date 1/09/2012; time 11:42 a.m.; a check next to the box indication "No anesthesia complications" and the signature of anesthesia. Further review revealed no documented evidence of a cardiopulmonary status, level of consciousness, follow up care/observations, complications occurring in the post-anesthesia/recovery phase and any follow up care that was performed.

Patient #20
Review of the medical record for Patient #20 revealed the patient was admitted to the hospital on 12/28/2011 with diagnoses that included Dyspareunia. Further record review revealed the patient had surgery on 12/28/2011. Review of the Post-Operative Evaluation by anesthesia for Patient # 20 revealed the date 12/28/2011; time 11:20 a.m.; a check next to the box indication "No anesthesia complications" and the signature of anesthesia. Further review revealed no documented evidence of a cardiopulmonary status, level of consciousness, follow up care/observations, complications occurring in the post-anesthesia/recovery phase and any follow up care that was performed.

Patient #21
Review of the medical record for Patient #21 revealed the patient was admitted to the hospital on 12/23/2011 with diagnoses that included Left Foot pain. Further record review revealed the patient had surgery on 12/23/2011. Review of the Post-Operative Evaluation by anesthesia for Patient #21 revealed the date 12/23/2011; time 1333 (1:33 p.m.); a check next to the box indication "No anesthesia complications" and the signature of anesthesia. Further review revealed no documented evidence of a cardiopulmonary status, level of consciousness, follow up care/observations, complications occurring in the post-anesthesia/recovery phase and any follow up care that was performed.

Patient # 22
Review of the medical record for Patient #22 revealed a 73 year old female admitted to the hospital on 12/21/11 with an Open Reduction Internal Fixation (ORIF) of her right knee performed on the same day of her admission, 12/21/11. Review of the Anesthesia Preoperative Evaluation Form dated 12/21/11 revealed the anesthetic administered during the procedure was general. Further review of the Postoperative Evaluation timed and dated 12/21/11 at 1603 (4:03 p.m.) revealed no anesthesia complications checked off and the signature of the physician. There was no documentation of an evaluation of the patient's respiratory function, cardiovascular function, mental status, pain, nausea and vomiting, and hydration status in the postoperative anesthesia/recovery stage.


Patient #23
Review of the medical record for Patient #23 revealed an 56 year old male admitted to the hospital for a Cystoscopy with removal of clots under general anesthesia. Review of the Intra-op Report revealed surgery was started on 01/04/12 at 11:45am and ended at 12:00pm. Review of the Post-Operative Evaluation by anesthesia for Patient #23 revealed the date 01/04/12; time: 12:10pm; a check next to the box indication " No anesthesia complications " and the signature of anesthesia. Further review revealed no documented evidence a cardiopulmonary status, level of consciousness follow-up care/observations, complications occurring in the post-anesthesia/recovery phase and any follow-up care was performed.

Patient #24
Review of the medical record for Patient #24 revealed the patient was admitted to the hospital on 12/12/2011 with diagnoses that included Degenerative Joint Disease. Further record review revealed the patient had surgery on 12/12/2011. Review of the Post-Operative Evaluation by anesthesia for Patient #24 revealed the date 12/12/2011; (no documented time); a check next to the box indication "No anesthesia complications" and the signature of anesthesia. Further review revealed no documented evidence of a cardiopulmonary status, level of consciousness, follow up care/observations, complications occurring in the post-anesthesia/recovery phase and any follow up care that was performed.

Patient #25
Review of the medical record for Patient #25 revealed an 83 year old male admitted to the hospital for a Left Total Knee Arthroscopy under general anesthesia. Review of the Intra-op Report revealed surgery was started on 12/12/11 at 7:43am and ended at 09:35am. Review of the Post-Operative Evaluation by anesthesia for Patient #25 revealed the date 12/12/11; time: 10:18am; a check next to the box indication " No anesthesia complications " and the signature of anesthesia. Further review revealed
no documented evidence a cardiopulmonary status, level of consciousness follow-up care/observations, complications occurring in the post-anesthesia/recovery phase and any follow-up care was performed.

Patient #26
Review of the medical record for Patient # 26 revealed a 77 year old female admitted to the hospital on 12/19/11 and had a Right total hip anthroplasty surgical procedure performed on the same day. Review of the Anesthesia Preoperative Evaluation Form dated 12/19/11 revealed the anesthetic administered during surgery was general. The Postoperative Evaluation was not dated or timed, there was no documentation indicating if there were any anesthesia complications. Further review revealed no documentation of an assessment of respiratory function, cardiovascular function, mental status, pain, nausea and vomiting, and hydration status in the postoperative anesthesia/recovery stage.

Patient #27
Review of the medical record for Patient #27 revealed a 40 year old female admitted to the hospital for a Laparoscopic Gastrectomy/Gastric Sleeve under general anesthesia. Review of the Intra-op Report revealed surgery was started on 12/15/11 at 08:50am and ended at 09:55am. Review of the Post-Operative Evaluation by anesthesia for Patient #27 revealed the date 12/15/11; time: 10:10am; a check next to the box indication " No anesthesia complications " and the signature of anesthesia. Further review revealed no documented evidence a cardiopulmonary status, level of consciousness follow-up care/observations, complications occurring in the post-anesthesia/recovery phase and any follow-up care was performed.

Patient #29
Review of the medical record for Patient #29 revealed the patient was admitted to the hospital on 12/12/2011 with diagnoses that included Diverticulitis. Further record review revealed the patient had surgery on 12/12/2011. Review of the Post-Operative Evaluation by anesthesia for Patient #29 revealed the date 12/12/2011; time 1010 (10:10 a.m.); a check next to the box indication "No anesthesia complications" and the signature of anesthesia. Further review revealed no documented evidence of a cardiopulmonary status, level of consciousness, follow up care/observations, complications occurring in the post-anesthesia/recovery phase and any follow up care that was performed.

Patient #30
Review of the medical record for Patient #30 revealed a 51 year old male admitted to the hospital for a Left Partial Amputation of Foot with Tendon Achilles Lengthening performed with the use of a block and Propofol. Review of the Intra-op Report revealed surgery was started on 12/09/11 at 15:22(3:22pm) and ended at 16:13 (4:13pm). Review of the Post-Operative Evaluation by anesthesia for Patient #30 revealed the date 12/09/11; time: 1631 (4:31pm); a check next to the box indication " No anesthesia complications " and the signature of anesthesia. Further review revealed no documented evidence a cardiopulmonary status, level of consciousness follow-up care/observations, complications occurring in the post-anesthesia/recovery phase and any follow-up care was performed.

In a face to face interview on 01/12/12 at 2:00pm S2 Vice-President of Clinical Services indicated the hospital recognized the problem with anesthesia not documenting the post-anesthesia evaluations.

Review of Policy No. AA-180 Subject: Pre-Anesthesia and Post-Anesthesia Evaluation last
revised 12/15/11 and submitted as the one currently in use revealed ... .... " C. Post-Anesthesia
Evaluation 2. The post-anesthesia/sedation evaluation will include: a. Cardiopulmonary status; b.
Level of Consciousness; c. Any follow-up care and/or observations; d. Any complications
occurring during post-anesthesia/sedation recovery; e. Any follow-up care needed or patient
instructions given"




26351

Based on record review and interview the hospital failed to ensure the evaluation and plan of care for occupational therapy included the type, amount, frequency and duration, and diagnosis for 5 of 5 sampled patients with orders for occupational therapy (#12, #15, #21, #24, #25) out of a total of 30 sampled medical records. Findings:

Patient #12
Review of the medical record for Patient #12 revealed the patient was admitted to the hospital on 1/09/2012 with diagnoses that included right hip Degenerative Joint Disease. Review of the Occupational Therapy Evaluation and Care Plan revealed no documented evidence the Occupational Therapist had documented the diagnosis of Patient #12 or the type, frequency and duration of treatment. Review of the Physical Therapy Evaluation and Care Plan revealed no documented evidence the Physical Therapist had documented the diagnosis of Patient #12 or the type, frequency, and duration of treatment

Patient #15
Review of the medical record for Patient #15 revealed the patient was admitted to the hospital on 1/09/2012 with diagnoses that included Degenerative Joint Disease. Review of the Occupational Therapy Evaluation and Care Plan revealed no documented evidence the Occupational Therapist had documented the diagnosis of Patient #15 or the type, frequency and duration of treatment. Review of the Physical Therapy Evaluation and Care Plan revealed no documented evidence the Physical Therapist had documented the diagnosis of Patient #15 or the type, frequency and duration of treatment

Patient #21
Review of the medical record for Patient #21 revealed the patient was admitted to the hospital on 12/23/2011 with diagnoses that included Left foot pain. Review of the Occupational Therapy Evaluation and Care Plan revealed no documented evidence the Occupational Therapist had documented the diagnosis of Patient #21 or the type, frequency and duration of treatment.

Patient #24
Review of the medical record for Patient #24 revealed the patient was admitted to the hospital on 12/12/2011 with diagnoses that included Degenerative Joint Disease of the Left Shoulder. Review of the Occupational Therapy Evaluation and Care Plan revealed no documented evidence the Occupational Therapist had documented the diagnosis of Patient #24 or the type, frequency and duration of treatment. Review of the Physical Therapy Evaluation and Care Plan revealed no documented evidence the Physical Therapist had documented the diagnosis of Patient #24 or the type, frequency and duration of treatment

Patient #25
Review of the medical record for Patient #23 revealed an 83 year old male admitted to the hospital for a Left Total Knee Arthroscopy under general anesthesia. Review of the Occupational Therapy Evaluation and Care Plan revealed no documented evidence the Occupational Therapist had documented the diagnosis of Patient #25 or the type, frequency and duration of treatment.

During a face to face interview on 1/11/2012 at 8:10 a.m., Physical Therapist S6 and Occupational Therapist S7 indicated they had not been differentiating between long and short term goals for patients they had evaluated for Physical and/or Occupational Therapy in the hospital nor had they documented the type, frequency or duration of treatment needed. S6 and S7 had further indicated that patients at the hospital were typically there for a very short duration and with the initiation of electronic medical records there had been an oversight in determining short term goals, long term goals, treatment type, treatment frequency, and duration of treatment for the patients' plan of care. S6 and S7 further indicated there was no hospital policy for Physical or Occupational Therapy Services.

Review of the hospital's contract for Physical and Occupational Care Services revealed in part, "Therapist shall prepare, or cause to be prepared, timely, accurate, complete and legible medical patient records, and other records relating to the delivery of Services by Therapists under this Agreement that are customary in the field of physical therapy. . ."