HospitalInspections.org

Based on review of governing body minutes and interview, the hospital's governing body failed to provide evidence of the appointment of the Chief Executive Officer (CEO) to that position by the governing body.

The findings are:

On 04/03/14 at 12:50 p.m., review of the hospital's governing body minutes revealed there was no documentation of the appointment of the Chief Executive Officer (CEO). On 04/03/15 at 1:00 p.m., Patient Safety Officer (PSO) 1 verified there was documentation appointing the hospital's Chief Executive Officer to that position by the hospital's governing body.

Based on review of the hospital's Performance Improvement (PI) data, the hospital's Performance Improvement Committee failed to ensure oversight of the contracted dialysis services provided at the hospital.

The findings are:

On 04/03/15 from 10:30 a.m. - 11:35 a.m., review of the hospital's Performance Improvement (PI) data revealed there was no documentation of oversight for the quality of the services provided to patients receiving dialysis by the hospital's contracted dialysis services. On 04/03/15 at 1:45 p.m., Associate Vice President (AVP) 2 revealed, "the dialysis department information is relayed to the infection control nurse who reports to the hospital wide performance improvement committee once a year, and only reports information by exception. So there is no information for dialysis service".

Based on record review and interview , the hospital failed to ensure as part of its notification of patient rights that the telephone number and address for the state agency was provided to the patient or patient's representative for lodging a grievance with the state agency.


The findings are:


On 03/31/2015 at 2:20 p.m., review of the hospital's admission packet which included the patient's bill of rights and other information revealed that the only telephone listed for reporting a grievance in the hospital's admission packet was the telephone number for the complaint hotline for the Joint Commission at (800)994- 6610. There was no information that had the address and telephone number for the state agency for filing grievances. On 03/31/15 at 5:20 p.m., Patient Safety Officer 1 revealed, "the patient information packet provided to the patient has no listing for the address and telephone number for the state agency for patients to file their grievances."

Based on observation and interview, the hospital failed to provide patients with personal privacy when presenting to the the emergency department and/or waiting on results in room 26 that had 3 patients seated in reclining chairs.


The findings are:


On 03/30/15 at 3:00 p.m., observations of emergency room 26 revealed 6 recliners with one (1) curtain that could enclose the back right section and one (1) curtain that enclosed the entire 6 recliners in a space together. Further observations revealed four (4) persons occupied the space. Each recliner was separated by a side partition/divider, but there was no divider in the front of each recliner to provide the patients with privacy. On 03/30/15 at 3:15 p.m., observations of Registered Nurse 28 revealed the nurse walked into room 26 in the emergency department and verbally instructed Patient 10 on the medications that the patient was to receive and verbally instructed the patient that the patient could not have anything to eat and the reasons why. During this interval, room 26 had two other patients located north of the patient with a petition on the sides of each patient, but no partition was provided in the front of the two patients leaving a direct front view of the patients to others in the general area. All patients were able to hear the instructions provided by RN 28. On 03/30/15 at 3:25 p.m., Patient 10 who was located in room 26 stated that the location for treatment felt a little "claustrophobic and closed in".

On 03/31/15 at 10:15 a.m., Director 5 revealed that no patient information is discussed in front of patients in the room unless the patient consents. Director 5 stated that the recliners are divided by partitions. The recliners are placed to have one partition in the back and one partition in the front of the patient. Then, the patients turn the chairs themselves throughout the day.

Based on record review, interview, and review of hospital policy and procedure, the hospital failed to ensure documentation of restraint use for 1 of 13 closed patient chart reviewed. (Patient 1).

The findings are:

On 03/31/15 at 10:20 a.m., review of closed Patient 1's chart revealed the patient was admitted to the emergency department via emergency medical services (EMS). Review of the patient's chart showed nursing notes reflected restraint use, but there was no documentation per the "Daily documentation for continuous observation patients" form. On 04/01/15 at 12:15 p.m., Patient Safety Officer 1 verified the finding.

Hospital policy, titled, "Restraint Use For Management Of Violent Or Self-Destructive Behavior", reads, "....Assessment/Orders/Documentation....4. a registered nurse will assess the patient in restraints at the initiation of restraint and every 15 minutes thereafter, or sooner as indicated based on assessment of the patient. The registered nurse will document this on the Restraint/Safety Devices clinical form for the Violent or Self-destructive Patient....6. The use of restraints will be reflected in the nursing notes....".

Based on review of patient record, interview, and review of hospital policy and procedure, the hospital failed to ensure a physician's order for a patient restraint was obtained for 1 of 13 closed charts reviewed. (Patient 1)

The findings are:

On 03/31/15 at 10:20 a.m., review of closed Patient 1's chart revealed the patient was admitted to the emergency department via Emergency Medical Services (EMS) on 02/04/15. Review of the patient's chart revealed the patient had been transported with restraints that were removed to transfer the patient onto a stretcher in the emergency room at 9:56 a.m.. Documentation in the patient's chart showed the patient's restraints were re-applied at 5:00 p.m. in the emergency department until 5:40 p.m. when the patient was transferred. There was no physician order for the restraint.
On 04/01/15 at 12:15 p.m., Patient Safety Officer 1 verified there was no physician order for the restraints.

Hospital policy, titled, "Restraint Use For Management of Violent Or Self-Destructive Behavior", reads, "A LIP (licensed independent practitioner) or physician's order is required for ALL patient behaviors that necessitate the use of restraints at GHS. A. A physician or LIP order should be obtained prior to the initiation of restraints using the Violent or Self-Destructive Patients Order form (available on formsfast) and entered into meditech as appropriate. B. During an emergent situation, if a physician or other licensed independent practitioner is not available to issue a restraint order, it is initiated by a registered nurse based on an assessment of the patient. C. The registered nurse, or designee, is responsible to contact the treating physician or LIP at the time of restraint application or within a few minutes after the restraint has been applied....".

Based on review of patient records, interview, and review of hospital policy and procedure, the hospital failed to document the date and time when a one hour face to face was conducted for 1 of 13 closed patient charts reviewed. (Patient 2).

The findings are:

On 03/31/15 at 2:20 p.m., review of closed patient chart 2 revealed a "Provider's Orders & Signature" form for violent or self-destructive patient restraints/safety device with a physician's signature, but no date or time by the signature. On 04/03/15 at 11:15 a.m., Patient Safety Officer 1 verified the order form contained only a physician signature with no date or time.

Hospital policy, titled, "Restraint Use For Management of Violent Or Self-Destructive Behavior", reads, "....Assessment/orders/documentation: 7. When restraints are used to manage violent or self-destructive behavior there must be documentation in the patient's medical record physician, or LIP (licensed independent practitioner), of the one-hour face-to-face medical and behavioral evaluation that includes: A. A description of the patient's behavior and the intervention used, B. Alternatives or other less restrictive interventions have been attempted (as applicable), C. The patient's condition or symptom (s) that warranted the use of the restraint. D. The patient's response to the intervention (s) used, including the rationale for continued use of the intervention....".

Based on interview and review of submitted data, the facility failed to ensure the hepatitis immunizations of dialysis patients were being monitored.

The findings are:

On 4/2/15 at 11:25 AM, the Infection Control Officer stated, "I don't have any knowledge who is hepatitis positive on dialysis. I do not track or monitor those labs. The dialysis staff is responsible for keeping up with that themselves. The only thing I watch for in that unit is MRSA."

Based on review of hospital Performance Improvement (PI) data and interview, the hospital failed to ensure that 2 of 2 adverse events reviewed contained completed documentation and follow-up information from the events.

The findings are:

On 04/3/15 at 12:15 p.m., review of the hospital's adverse event log revealed an incident dated 06/20/14 and the hospital developed a plan of action, but there was no documentation related to the implementation of the plan of action and/or monitoring of its effectiveness related to the incident.
On 04/03/15 at 12:20 p.m., Manager 2 revealed the hospital had no additional documentation related to the adverse event.

On 04/03/15 at 12:15 p.m., review of the hospital's adverse event logs revealed an incident dated 09/08/14, but there was no evidence that the hospital developed a plan of action, implementation of any plan of action, and/or any associated monitoring related to the adverse event.

On 04/03/15 at 12:20 p.m., interview with Manager 2 revealed no additional documentation related to the incident.

Based on review of patient medical records, interview, and review of the hospital policy and procedures, the hospital failed to ensure physician orders were provided for tasks performed on 1 of 30 concurrent open patient medical records (Concurrent Inpatient 15 ) and 6 of 6 concurrent outpatient medical records reviewed. (Outpatient 4, 5, 6, 7, 8, and 9)

The findings are:

On 3/31/15 at 11:08 a.m., review of concurrent Inpatient 15's medical record revealed the patient was admitted on 3/21/15 and a urinary catheter was inserted, but there was no physician's order for a urinary catheter. The findings were verified with RN 9 and RN 12 on 3/31/15 at 12:05 p.m..

On 4/1/15 at 11:00 a.m., review of Outpatient 4's surgical record revealed the patient had a cataract removal on the right eye on 4/1/15 and documentation showed the patient had an intermittent venous (INT) catheter, but there was no physician order for the placement of an intermittent venous (INT) catheter. The findings were verified with RN 14 at 11:00 a.m. on 4/1/2015.

On 4/1/15 at 1:25 p.m., review of Outpatient 7's surgical record revealed the patient had a left excision of a mucus cyst on 4/1/15, and an intermittent venous (INT) catheter was placed, but there was no physician order for the placement of an intermittent venous (INT) catheter.

On 4/1/15 at 1:50 p.m., review of Outpatient 5's surgical record revealed the patient had a right carpal tunnel release on 4/1/15, and an intermittent venous (INT) catheter was placed, but there was no physician order for the placement of an intermittent venous (INT) catheter.

On 4/1/15 at 2:06 p.m., review of Outpatient 6's surgical record revealed the patient had a right distal ulna resection on 4/1/15, and an intermittent venous (INT) catheter was placed and Lactated Ringers intravenous solution was being administered, but there was no physician order for the placement of an intermittent venous (INT) catheter or the Lactated Ringers solution.

On 4/1/15 at 2:44 p.m., review of Outpatient 8's surgical record revealed the patient had a right arthroscopic knee on 4/1/15, and an intermittent venous (INT) catheter was placed, but there was no written order for the placement of an intermittent venous (INT) catheter.

On 4/1/15 at 3:00 p.m., review of Outpatient 9's surgical record revealed the patient had a laparascopic cholecystectomy on 4/1/15, and an intermittent venous (INT) catheter was placed, but there was no written order for the placement of an intermittent venous (INT) catheter.

On 4/1/2015 at 3:00 p.m., RN 14 verified the findings.


Hospital policy, titled, "Saline Lock, Care of", reads, "....1. Obtain and verify a physician'/mid-level provider's order prior to initiating a saline lock....".

Hospital policy, titled, "Intravenous Therapy", reads, ".... POLICY : 1. Before administering any intravenous therapy, a physician's order must be obtained and verified....".

Based on review of the patient medical records and interview, the hospital failed to ensure its staff documented patient assessments and findings in the patient's records for 1 of 30 concurrent open patient records, (Patient 9) and 1 of 1 closed patient record reviewed for capturing the dialysis patient's hepatitis status. (Closed Patient 7)


The findings are:


On 03/31/15 at 2:35 p.m., review of Patient 9's medical record revealed the patient had an intravenous needle placed on 03/22/15, but there was no documentation that the intravenous needle site was changed as of 03/31/2015, or a physician's order not to change the intravenous needle site. The findings were verified by Clinical Informatic Specialist (CIS) 1.

On 4/3/15 at 10:00 a.m., review of the closed chart for Patient 7 revealed the patient was admitted on 1/5/15 and dialyzed on 1/8/15 on continuous renal replacement therapy (CRRT), and there was never a hepatitis level drawn on the patient. The findings were verified with RN 7 on 4/3/15 at 11:00 a.m..

Based on record review and interview, the hospital failed to ensure the nursing care plan was reviewed and updated for 3 of 30 patient records reviewed for care plans. (Patient 6, 18, and 19)

The findings include:

On 03/31/2015 at 2:45 p.m., review of Patient 6's clinical record revealed the patient was admitted to 3 east inpatient medical surgical unit on 03/26/2015. Review of the patient's plan of care showed the patient's plan of care was not reviewed and updated every 24 hours on 03/28/2015 and 03/29/2015. The registered nurse clinical informatic specialist verified the findings on 03/31/2015 at 3:05 p.m..

On 04/01/2015 at 11:00 a.m., review of Patient 18's clinical record revealed the patient was admitted to 3 east inpatient medical surgical unit on 03/13/15. Review of the patient's plan of care showed the patient's plan of care was not reviewed and updated every 24 hours on 03/15/2015. The finding was verified by the registered nurse clinical informatic specialist on 04/01/2015 at 11:30 a.m.

On 04/01/2015 at 1:35 p.m., review of Patient 19's clinical record revealed the patient was admitted to 3 west inpatient medical surgical unit on 03/18/2015. Review of the patient's plan of care showed the patient's plan of care was not reviewed and updated every 24 hours from 03/18/2015 to 03/25/2015 The finding was verified by the Director of the 3 west unit on 04/01/2015 at 1:50 p.m.

Review of hospital policies and procedures, titled, "...PLAN OF CARE, PATIENTS..Effective 04/2014, reads, "...POLICY: ...5. The Plan of Care must be evaluated daily by an RN (registered nurse)...".

Based on observation and interview, 1 of 1 Registered Nurses (RN 23) failed to disinfect the septum of a medication vial and the injection port prior to the administration of a medication.

The findings are:

On 4/2/15 at 10:06 a.m., observations in the critical care unit revealed RN 23 failed to wipe the medication septum on the vial prior to withdrawing medications from the vial with a syringe, and failed to wipe the injection port of the patient's intermittent (INT) intravenous catheter prior to administering the medication.

Based on interview and patient record review, the facility failed to ensure all entries were dated and timed for 1 of 30 concurrent inpatient records and 4 of 9 outpatient records. (Concurrent Inpatient 16, Outpatient 4, 5, 6, and 7)

The findings are:

On 4/1/15 at 11:00 a.m., review of Outpatient 4's surgical record revealed a set of pre-op and post-op orders with no date and time documented.
On 4/1/15 at 1:25 p.m., review of Outpatient 7's surgical record revealed a set of pre-op orders with no date and time documented.
On 4/1/15 at 1:50 p.m., review of Outpatient 5's surgical record revealed a set of pre-op orders with no date and time documented.
On 4/1/15 at 2:06 p.m., review of Outpatient 6's surgical record revealed a set of pre-op orders with no date and time documented.
On 4/1/15 at 3:32 p.m., review of Inpatient 16's surgical record revealed a set of pre-op orders with no date and time documented.
On 4/1/2015 at 3:32 p.m., the findings were verified with RN 14 at the time of the review.

Based on record review and interview, the hospital failed to ensure informed consents were signed for 1 of 30 inpatient records reviewed. (Concurrent Inpatient 14)


The findings are:

On 3/31/15 at 2:20 p.m., review of concurrent Inpatient 14's medical record revealed the patient was admitted on 3/26/15, but there was no signed consent for treatment on the patient's chart. The findings were verified with RN 10 and Patient Access Representative 1 at 2:20 p.m. on 3/31/2015.

Based on interview and observation, the hospital failed to remove/discard expired supplies from current patient stock.

The findings are:

On 03/31/15 at 3:55 p.m., random observations of the pediatric emergency crash cart revealed (1) central venous catheter tray expired on 10/2014.
On 03/31/15 at 3:55 p.m., Director 3 revealed the nursing staff checks the crash cart for expired supplies.

On 04/02/15 from 9:00 a.m.- 9:30 a.m., observations of medication administration by Registered Nurse (RN) 26 revealed RN 26 placed 4 syringes in a plastic bag and placed the plastic bag in his/her lab coat jacket. On 04/02/15 at 9:30 a.m., Director 15 revealed, "syringes should not be placed in the nurse's lab coat jacket and transported into patient rooms.".

Based on interview and review of hospital policy and procedures, the hospital failed to ensure the shielding used to protect patients during radiology procedures was inspected annually.

The findings include:

On 04/01/2015 at 9:20 a.m., the System Director for radiology at the outpatient imaging facility revealed the lead shielding to protect the patient during the radiology procedures in the outpatient facility had not been inspected since 03/13/2014. The System Director verified the finding on 04/01/2015 at 10:00 a.m..

Review of the hospital policies and procedures, titled, "...Integrity of Lead Shielding...Effective 01/2015", reads, "...PROCEDURE: ... 1. Visually inspect the aprons, gloves, and shields for possible defects. 2. Using a permanent marker, number the apron/shields in sequence for identification purposes. Beside the number of the lead apron, in permanent marker, write the month/year that the first survey and/or each subsequent annual survey is done...".

Based on interview, review of the "Key Performance Indicators-Utilization Management", "Utilization Management Committee" meeting minutes, and review of the hospital policy and procedures, the hospital failed to include review of Medicare and Medicaid admissions with respect to the medical necessity of admissions, duration for stays, and the professional services furnished to include drugs and biologicals.

The findings are:

On 04/02/15 at 1:40 p.m., review of the hospital's "Key Performance Indicators-Utilization Management" dated April 2014 through February 2015 and the hospital's "Utilization Management Committee" meeting minutes dated February 18, 2015 failed to include any review of admission data for necessity of admission criteria. On 04/02/15 at 1:55 p.m., Director 12 revealed admission rates are not listed and reviewed at the Utilization committee meetings or in the data. The only admissions that are reviewed are the outlier cases related to extended stays.

Hospital policy, titled, "Utilization Management Plan", reads, "....The Utilization Management Program strives for appropriate allocation of the hospital's resources by provision of quality patient care in the most cost effective manner. It provides for timely review of the medical necessity for admissions, continued stays and services rendered....".

Based on interview, review of the Utilization Review Department's "Key Performance Indicators-Utilization Management", "Utilization Management Committee" meeting minutes, and review of hospital policy and procedures, the hospital failed to ensure a review and oversight of its professional services which includes aspect of care rendered by its laboratory personnel, physical therapist, nurses and medical staff.


The findings are:


On 04/02/15 at 1:40 p.m., review of the Utilization Review Department's "Key Performance Indicators-Utilization Management" dated April 2014 through February 2015, and review of the "Utilization Management Committee" meeting minutes dated February 18, 2015 showed both failed to include its professional services in its review processes. On 04/02/15 at 1:55 p.m., Director 12 revealed that ancillary (professional) services providers are not listed and reviewed at the Utilization committee meetings or in the data.

Hospital policy, titled, "Utilization Management Plan", reads, "....The Utilization Management Program strives for appropriate allocation of the hospital's resources by provision of quality patient care in the most cost effective manner. It provides for timely review of the medical necessity for admissions, continued stays and services rendered....".

Based on observation and interview, the hospital failed to ensure the environment was safe for patients related to accumulated dust in the electrical rooms on 2 East, emergency department, and the main electrical room.

The findings include:

On 03/30/2015 at 2:30 p.m. a tour of the physical environment revealed an electrical room on 2 east and the main electrical room had a very large accumulation of dust in each of the rooms. Additional observation in the emergency department revealed in 2 of the main electrical rooms there was moderate to large accumulation of dust observed. The Plant Operations Director verified the findings on 03/30/3015 at 3:30 p.m..

Based on observation and interview, the hospital failed to ensure the safety of patients on the pediatric unit in that there were no electric outlet covers in 11 of 11 pediatric rooms located on the second floor west. (202- 212)

The findings include:

On 03/30/2015 at 2:30 p.m., a tour of the second floor west pediatric unit revealed there were no electrical outlet covers in patient rooms 202-212. The Director of the second west unit verified the finding on 03/30/2015 at 3:30 p.m..

Based on interview, review of personnel records, and review of governance minutes, the hospital governing body failed to designate in writing an infection control officer and the Infection Control had no active infection control monitoring of staff practices in the renal dialysis unit.

The findings are:

On 3/30/15 at 2:30 p.m., RN 18 (Infection Control Officer) verified that he/she was the hospital's Infection Control Officer for eight (8) years.
On 4/2/15 at 3:15 p.m., review of RN 18's personnel file revealed there was no documentation of the designation of RN 18 as the Infection Control Officer by the governing body. On 4/3/15 at 9:45 a.m., PSO 1 verified the finding.

On 4/2/15 at 11:25 a.m., the Infection Control Officer (RN 18) revealed that he/she maintains no oversight of infection control surveillance in the inpatient dialysis unit. The Infection Control Officer reported, "They do their own thing up there. I get a report if there are any MRSA(Methicillin Resistant Staphylococcus Aureus) patients who will be on dialysis, because they have to go into the isolation room to have dialysis. I have not done any infection control audits there. The only information I receive from dialysis is their monthly water cultures if they are out of limit."

Based on observation, interview, review of hospital policy and procedures, 2 of 29 Registered Nurses (RN 20 and 29),1 of 1 Emergency Technicians (ED Technician 1), and 1 of 1 Nurse Practitioners (NP 1) observed in the treatment area failed to perform hand hygiene appropriately to prevent potential transmission of infectious agents in the hospital setting; 1 of 29 Registered Nurse (RN 5) failed to transport a lab specimen appropriately; 1 of 29 Registered Nurses failed to handle dirty linen appropriately(RN 20); 2 of 29 Registered Nurse (RN 23 and 26) failed to disinfect equipment appropriately; 1 of 29 Registered Nurse (RN 7) failed to don appropriate personal protective equipment (PPE); and hospital staff failed to ensure that staff and/or visitors did not consume food at the nurse station for 2 of 7 physicians (Physician 3 and 4) observed.

The findings are:

On 03/30/15 at 3:00 p.m., random observations in the emergency department revealed RN 20 carried soiled linen with his/her bare hands. On 03/30/15 at 3:50 p.m., RN 20 revealed linen should be transported by bunching the linen together. RN 20 revealed that "gel-in and gel-out or hand washing if soiled" should be performed after glove removal and exiting a patient's room.

On 03/30/15 at 3:05 p.m., random observations in the emergency department revealed Nurse Practitioner (NP) 1 exited patient examination room 26, walked over to phone, but failed to perform hand hygiene after exiting room 26.

On 03/30/15 at 3:05 p.m., random observations in the emergency department revealed Emergency Department Technician 1 walked out of patient room 26 wearing gloves, removed the gloves, started removing items out of a cart, but failed to perform hand hygiene after removing the gloves worn in patient room 26.

On 03/31/15 at 10:35 a.m., observations in the emergency department revealed RN 29 removed gloves, wrote on stickers to label patient's blood, donned clean gloves, but failed to perform hand hygiene after removal of the soiled gloves.

Hospital policy, titled, "Linen Policy", reads, "....Dirty Linen:...Handle, transport, and process used linen soiled with blood, body fluids, secretions, or excretions in a manner that prevents skin and mucous membrane exposure and contamination of clothing, and that avoids transport of microorganisms to other patients and environment....".

Hospital policy, titled, "Hand Hygiene and Infection Control (Non-Patient and Patient Care Areas)", reads, "2....hands shall be cleaned before and after patient care within 10 seconds of entering the room, hands shall be cleaned after removing gloves....".






30011

On 04/02/15 from 9:00 a.m.- 9:30 a.m., observations of medication administration by Registered Nurse (RN) 26 revealed RN 26 transported the computer on wheels with paper forms laid on top of the computer into a patient room. The patient was diagnosed with C-difficle. Although the nurse cleaned the computer, the computer exited the patient's room with the extra sheets of paper forms on top it. On 04/02/15 at 9:30 a.m., Director 15 revealed, "papers shouldn't be taken into the patient's room because what goes in should stay in".

Hospital policy, titled, "Equipment Cleaning, Purpose: To assure that reusable bio-medical patient care equipment is adequately cleaned and disinfected after patient use to prevent cross-transmission of microorganisms. Policy: 1. It is the responsibility of the care nurse/designated assistant/or environmental services to clean all pieces of equipment when a.) notably contaminated b.) after patient use or upon patient discharge....".


31672

On 3/31/15 at 10:58 a.m., observations in the critical care unit revealed RN 5 transported a bloody sputum specimen out of a patient's room prior to placing the specimen in a biohazard specimen bag. On 3/31/15 at 11:05, RN 5 confirmed the finding and stated, "I shouldn't have brought it out of the room without placing it in a bag first."

On 3/31/15 at 3:15 p.m., observations at the 3 east nursing station revealed Physician 4 eating a piece of fried chicken. The findings was verified at the time of the observation(3/31/2015 at 3:15 p.m.) with PSO(Patient Safety Officer) 1 who stated,"We have told them before that there is no eating in any area where patient care is conducted."

On 3/31/15 at 3:39 p.m., observations in the inpatient dialysis unit revealed RN 7 wore the same PPE from the dialysis water treatment room into the dialysis treatment room. On 3/31/15 at 3:55 p.m., observations in the inpatient dialysis unit revealed two (2) staff members bringing a patient into the dialysis unit and the staff members were not given PPE to wear although another patient was being initiated for dialysis.

On 4/1/15 at 1:20 p.m., an observation in the Post Anesthesia Care Unit (PACU) revealed Physician 3 eating at the nurse station. The findings was verified with RN 13 and RN 14 at 1:20 p.m. on 4/1/2015.

On 4/2/15 at 10:16 a.m., an observation in the critical care unit revealed RN 23 rolled the medication cart out of a patient's room and did not wipe the medication cart down.

Based on record review, interview, and review of hospital policy, the hospital failed to ensure that 1 of 30 concurrent inpatients reviewed had a discharge plan completed in the appropriate time frame. (Inpatient 15)
The findings are:

On 3/31/15 at 11:08 a.m., review of Inpatient 15's medical record revealed there was no initiation of discharge planning completed by case management. On 3/31/15 at 2:15 p.m., Registered Nurse 5 verified the findings, and stated, "Anyone can consult case management, not just the doctor. The whole interdisciplinary team makes rounds on the patients, but case management never offered their services for this patient. He is very critical and will definitely benefit from case management. It should have already been addressed."

Based on review of patient medical records and interview, the hospital failed to ensure its staff documented pertinent information in the patient's discharge planning evaluation for 2 of 3 concurrent patient medical records related to discharge (Patient 31 and 32) and 1 of 2 closed patient medical record related to discharge. (Patient 11)

The findings are:

On 04/02/15 at 3:15 p.m., review of Patient 31's concurrent medical record revealed Patient 31's discharge planning evaluation did not contain information regarding self-care/activities of daily living (ADLs).

On 04/03/15 at 9:45 a.m., review of Patient 32's concurrent medical record revealed Patient 32's discharge planning evaluation did not contain information regarding self-care/activities of daily living (ADL).

On 04/02/15 at 10:15 a.m., review of Patient 11's closed medical record revealed Patient 11's discharge planning evaluation did not contain information regarding self-care/activities of daily living (ADL).

On 04/02/15 at 4:00 p.m., Assistant Vice President 1 revealed the social workers, registered nurses, or case managers who perform the discharge evaluation rely on the documentation of the patient's ADL/self care from other disciplines.

Hospital policy, titled, "Discharge Planning", reads, ".... PROCEDURE: ....It is the responsibility of each discipline assessing discharge planning needs to document associated assessment findings within the medical records....".

Based on medical records review and interview, the hospital failed to ensure its staff documented the transfer of pertinent information to the transferred facility for 1 of 2 closed patient medical records reviewed related to discharge planning. (Patient 11).

The findings are:

On 04/03/15 at 10:50 a.m., review of Patient 10's closed medical record revealed Patient 10 was transferred to a hospice house, but there was no documentation that the patient's discharge instructions transferred to the hospice house. On 04/03/15 at 11:00 a.m., Associate Vice President (AVP) 1 revealed the discharge section was not completed for Patient 11.

Based on record review and interview, the hospital did not ensure all patient care staff received annual updated education related to the organ procurement organization, tissue bank, and eye bank. (Nursing Staff except staff located in the Intensive Care Unit and the Emergency Department)

The findings include:

On 04/02/2015 at 2:10 p.m., review of random staff orientation records revealed there was no annual training for all staff related to Organ Procurement policies and procedures. On 4/02/2015 at 2:20 p.m., the Director of Staff Development revealed patient care staff received education related to the organ procurement organization (OPO) only at the employee's orientation at hire. The Staff Director reported the OPO conducts periodic updates, but those are only for Intensive Care Unit staff and Emergency Department staff and not through staff development and revealed no patient care staff received annual education related to the hospital's policies and procedures related to OPO processes. The Director of Staff Development verified the findings on 04/02/2015 at 2:20 p.m..

Based on patient medical record review, interview, and review of the hospital's policy and procedures, the hospital failed to ensure a history and physical (H&P) was in the patient's medical record for 1 of 30 concurrent patient medical charts reviewed (Patient 27) and failed to ensure a follow up history and physical was completed for 1 of 30 concurrent patient medical charts reviewed. (Patient 23)

The findings are:

On 04/02/15 at 10:15 a.m., review of Patient 23's medical record revealed the patient had surgery on 04/01/15, but the patient's record had no documentation in the "Provider Pre-Procedure Review Notes" section on the "Pre/Post Procedure Progress Notes" that had an update of the patient's condition for any changes or no changes since the patient's history and physical was completed prior to the patient's surgery date. The findings were verified by CIS 3 on 4/15/2015 at 10:15 a.m..

Hospital policy, titled, "History and Physical Examinations", reads, "....History and physicals must be performed within 30 days (Joint Commission Standard) prior to scheduled admission date with an update of the patient's condition at the time of admission (CMS(Centers for Medicare and Medicaid Services) states 24 hours); or if the history and physical was completed within 30 days prior to admission, there must be an update of the patient's condition in the medical record within 24 hours after admission but prior to surgery. Whenever the history and physical is performed before arrival for admission or registration, there must be an update within 24 hours after admission or registration and before surgery occurring within the first 24 hours (CMS requirement).




30011

On 04/02/15 at 3:00 p.m., review of concurrent Patient 27's chart revealed the patient was admitted on 03/30/15 from outpatient surgery to the floor, but there was no documentation of the patient's history and physical. On 04/02/15 at 4:00 p.m., Associate Vice President (AVP 3) revealed the operating room was unable to locate the patient's history and physical from the day of the surgery.