HospitalInspections.org

Hospital A

Based on medical record review, interview, and observation, the facility failed to educate regarding safety and security of infants for one patient (#A40) of two patients reviewed in Labor, Delivery, Recovery, and Post-partum (LDRP) of Hospital A.

The findings included:

Patient #A40 was admitted to the facility and gave birth to patient #A39 on May 30, 2011.

Interview with the Clinical Leader of LDRP on June 1, 2011, at 1:45 p.m., at the nursing station, revealed facility security procedures for protection of infants included application of identifying armbands for the mother and infant at birth, application of a monitor to the infant's leg which alarmed within five feet of the elevators, and educating all mothers to only allow staff wearing name badges with their titles in red lettering to take the infant.

Observation and interview on June 1, 2011, at 1:52 p.m., revealed patient #A40 was in the patient's room, holding patient #A39. Interview with patient #A40 confirmed the patient was aware of the facility's security measures of armbands identifying the infant and mother, and of a monitor placed on the infant's leg which alarmed when the baby was close to elevators. Further interview revealed the patient stated the infant could only be taken by a staff member, but was unaware the only hospital staff allowed to take the infant were indicated with the red lettering on the badge.

Medical record review of the patient's education and interview with the Clinical Leader on June 1, 2011, at 1:52 p.m., and 2:10 p.m., at the nursing station, confirmed there was no documentation the patient had been educated on safety and security measures.

Hospital A

Based on observation and interview, the facility failed to ensure patients' health information was secure for one of twelve inpatient units observed at Hospital A.

The findings included:

Observation of the third floor of the Women's Pavilion on June 1, 2011, at 12:55 p.m., revealed an alcove area towards the end of a hallway of patient rooms away from the nursing station, where the staff mailboxes (a wood case with divided open compartments) were located. Further observation revealed two of the open compartments contained clipboards with staff communication sheets which listed patient names, room numbers, diagnoses, and multiple other specifics related to patient care needs. Further obsrevation revealed traffic in the area included families, visitors, and maintenance staff.

Interviews with the Clinical Leader of the Women's Pavilion and with the Chief Nursing Officer on June 1, 2011, at 12:55 p.m., in front of the mailboxes, confirmed patients' confidential health information had not been secured from unauthorized persons.

Hospital B and Hospital C

Based on medical record review, observation, review of facility policy, and interview, the facility failed to ensure an order for the use of restraints was not written on an as needed (PRN) basis for one patient (#B7); failed to obtain an order for each episode of the use of restraints for one patient (#B7); and failed to ensure a physician's order was obtained for one patient (# C1) of six patients with restraints reviewed.

The findings included:

Patient #B7 was admitted to the Intensive Care Unit (ICU) of Hospital B on May 28, 2011, with diagnoses of Pneumonia and Alcohol Abuse.

Observation on June 1, 2011, at 2:38 p.m., revealed patient #B7 was in bed and both wrists were in soft restraints.

Medical record review of a Physician's telephone order dated May 30, 2011, at 4:30 a.m., revealed, "Use restraints as needed."

Review of the facility policy Restraints (un-numbered) revised February 7, 2011, revealed, "...4. All restraint use requires a physician's order. No PRN (as needed) orders will be utilized..."

Interview with the Clinical Leader of the ICU on June 1, 2011, at 3:02 p.m., outside the patient's room, confirmed the facility failed to ensure restraints were not ordered on a PRN basis.

Medical record review of the nursing notes revealed the soft wrist restraints were applied to patient #B7 on May 30, 2011, at 4:00 a.m., for pulling off the oxygen delivery system (Ventimask). Medical record review revealed the restraints were in use until 8:30 a.m., on may 30, 2011. Medical record review revealed at 8:30 a.m., the patient was calm, the son was at bedside, and the restraints were removed.

Medical record review revealed the patient was not restrained between May 30, 2011, at 8:30 a.m., and May 31, 2011, at 7:00 p.m., (over 24 hours) when the restraints were re-applied due to the patient pulling at tubes (facemask).

Medical record review revealed no documentation of a physician's order for the use of restraints on May 31, 2011.

Observation on June 1, 2011, at 2:38 p.m., revealed patient #B7 was in bed and both wrists were in soft restraints.

Interview with the registered nurse (RN #B1) assigned the care of patient #B7, revealed the patient was in wrist restraints (both wrists) at 7:00 a.m., "when my shift started and I first saw (the patient)." Continued interview with RN #B1 revealed, "I called to remind the physician to write an order for the restraint."

Medical record review of the Restraint Order revealed the pre-printed order was marked for the use of wrist restraints for pulling out necessary tubes. Review of the order revealed the order was not dated and was not timed by the nurse or the physician. (Medical record review of additional orders written by the attending physician revealed the physician did write orders on additional pages and were dated June 1, 2011, and timed 12:45 p.m., (five hours and 45 minutes after RN #B1 noted the patient being in restraints.)

Review of the facility's policy Restraints (un-numbered) revised February 7, 2011, revealed, "...In an emergency situation where there is imminent risk of patient harm and RN may implement a restraint intervention without a physician's order; however, an order from a physician must be obtained either during the emergency application of the restraint or immediately (within) a few minutes after the restraint has been applied. The failure to obtain an order immediately is viewed as the application of restraint without an order..."

Interview with the Clinical Leader of the ICU on June 1, 2011, at 3:02 p.m., outside the patient's room, confirmed the facility failed to obtain an order for each episode of the application of restraints.




21160


Patient # C1 was admitted to hospital C on May 22, 2011 with diagnoses to include Pneumonia, Acute Respiratory Failure, Tracheostomy, Septic Shock, and Encephalopathy.

Medical record review of the Restraint Flow Sheet dated May 23, 2011, at 7:02 a.m., revealed the patient was placed in bilateral wrist restraints. Continued review of the medical record revealed the Physician's Order, dated May 23, 2011, by the nurse, was not dated and timed when signed by the physician. Continued medical record review of the Restraint Flow Sheet, dated May 24, 2011, at 4:00 p.m., revealed the patient was placed in bilateral wrist restraints. Continued medical record review of the Physician's orders revealed there was no documentation of a Physician's Order for May 24, 2011.

Review of the facility policy Restraints, dated as last revised February 7, 2011, (no policy number) revealed "...Policy...4. All restraint use requires a physician's order...Procedure...9. A physician must examine and write an order...within 24 hours of the initiation of the restraint..."

Interview at the nurse's station of the ICU on May 31, 2011 at 4:20 p.m., with the Manager of the ICU confirmed the facility policy for physician's orders for the use of restraints was not followed.

Hospital B and Hospital C

Based on medical record review, facility policy review and interview, the facility failed to ensure the condition of a restrained patient was monitored on an ongoing basis at hospital C for one patient (# C1); and one patient at hospital B (#B7) of six patients with restraints reviewed.

The findings included:

Patient # C1 was admitted to hospital C on May 22, 2011 with diagnoses to include Pneumonia, Acute Respiratory Failure, Tracheostomy, Septic Shock, and Encephalopathy.

Medical record review of the Restraint Flow Sheet dated May 23, 2011, at 7:02 a.m., revealed the patient was placed in bilateral wrist restraints. Continued review of the Restraint Flow Sheet revealed the next documentation on the Restraint Flow Sheet of the patient's condition on was documented on May 23, 2011, at 10:18 a.m. (3 hours and 16 minutes later). Continued medical record review of the Restraint Flow Sheet, dated May 25, 2011, revealed the patient's condition was not documented as monitored from 8:00 a.m. until 12:00 p.m. (4 hours later) and 4:00 p.m. until 8:00 p.m. (4 hours later).

Review of the facility policy "Restraints, dated as last revised February 7, 2011, (no policy number), revealed "...Procedure...11. Clinical staff with demonstrated restraint competency will observe the patient and note any changes in the patient's clinical condition at a minimum of every two hours..."

Interview at the nurse's station of the Intensive Care Unit (ICU) on May 31, 2011 at 4:20 p.m., with the Manager of the ICU confirmed the facility policy for documentation for monitoring the condition of a patient in restraints was not followed.



21161

Patient #B7 was admitted to the Intensive Care Unit of Hospital B on May 28, 2011, with diagnoses of Pneumonia and Alcohol Abuse.

Medical record review revealed wrist restraints were applied on May 30, 2011, at 4:30 a.m., removed on May 30, 2011, at 8:30 a.m., and re-applied on May 31, 2011, at 7:00 p.m., due to pulling at tubes (facemask).

Interview outside the patient's room with the registered nurse (RN #B1) assigned to the care of patient #B7, on June 1, 2011, at 2:45 p.m., revealed the patient was in wrist restraints (both wrists) at 7:00 a.m., "when my shift started and I first saw (the patient)."

Medical record review revealed no documentation for the monitoring of the patient condition while in restraints on June 1, 2011, between 3:00 a.m., and 2:45 p.m., almost a 12 hour period.

Interview with the Clinical Leader of the ICU on June 1, 2011, at 3:02 p.m., outside the patient's room, confirmed the facility failed to ensure the condition of the restrained patient was documented every two hours.

Hospital A and Hospital C

Based on medical record review, interview, and review of facility policy, the facility failed to maintain complete medical records for four patients (#A4, #A5, #A19, #A27) at Hospital A and one patient (#C7) at Hospital C of sixty-one sampled patients.

The findings included:

Patient #A4 presented to Hospital A's Emergency Room (ER) on May 30, 2011. Medical record review of an Emergency Provider Record dated May 30, 2011, revealed, "Time Seen: 8:40 a.m...chief complaint: ...here for repeat US (ultrasound)...seen 5/28 for 2 days pelvic/vag (vaginal) pain..."

Medical record review of an Emergency Department (ED) Nursing Record dated May 30, 2011, at 2:00 p.m., revealed, "...awaiting consult...Remains awake alert."

Medical record review of an Emergency Provider Record dated May 30, 2011, revealed, "...2:52 (p.m.) Pt (patient) updated Dr. (name deleted) delayed with emergent C sec (section)..."

Medical record review of an ED Nursing Record dated May 30, 2011, at 3:00 p.m. revealed, "Report received. Assumed care. Pt not in room." Medical record review of an ED Nursing Record dated May 30, 2011, at 3:50 p.m., revealed, "...no longer in...room and was unable to locate pt anywhere...notified Dr. (name deleted) about elopement..."

Medical record review of an Emergency Provider Record dated May 30, 2011, revealed no documentation regarding disposition (destination/arrangement for care following the ER visit) of the patient.

Interview with the Chief Quality Officer on May 31, 2011, at 1:58 p.m., in a conference room, confirmed the facility had failed to document the disposition of Patient #A4 in the medical record.

Medical record review revealed Patient #A5 presented to Hospital A's ER on May 30, 2011. Medical record review of an Emergency Provider Record dated May 30, 2011, revealed, "Time Seen: 9:30 a.m...chief complaint: out of dilantin (seizure medication)..."

Medical record review of an ED Nursing Record dated May 30, 2011, revealed, "...11:10 (a.m.) upon entering room to draw blood. Pt not in room...(11:25 a.m.) cont (continues) to not be found in room. not in lobby, premises..."

Medical record review of an Emergency Provider Record dated May 30, 2011, revealed, "Disposition Order Time 12:00 p.m. Disposition home...elopement...stable."

Interview with the Chief Quality Officer on May 31, 2011, at 2:10 p.m., confirmed the facility failed to accurately document the disposition of Patient #A5 on May 30, 2011.

Patient #A19 presented to Hospital A's emergency room on May 30, 2011. Medical record review of an Emergency Provider Record dated May 30, 2011, revealed,"...chief complaint: suicidal thoughts..."

Medical record review of a consent to treat revealed the patient's signature and no witness signature and/or date/time.

Interview with the Chief Quality Officer on June 1, 2011, at 11:37 a.m., in a conference room, confirmed the facility failed to complete the consent to treat for Patient #A19 on May 30, 2011.

Medical record review revealed patient #A27 was admitted to Hospital A on May 18, 2011, after normal birth. Continued medical record review revealed the Routine Newborn Admission Orders were not dated, timed, signed by the physician, or signed by the nurse as being activated. Further medical record review revealed there were no other orders in the record.

Interview on May 31, 2011, at 10:30 a.m., in the medical records department, the Vice President of Nursing confirmed the orders had not been completed.

Patient # C7 was admitted to the Emergency Department of Hospital C on May 29, 2011, with Chief Complaint of Left Hand Sprain.

Medical record review of the nursing Triage Note dated May 29, 2011, at 12:30 a.m., revealed the patient's pain scale was documented as"9-10 unbearable". Continued medical record review of the Emergency Physician Record, dated May 29, 2011, at 12:35 a.m., revealed "severity of pain" documented as "moderate". Review of the Discharge Instruction, no date or time noted, revealed "...medicines prescribed...Ultram (analgesic) 50 mg (milligrams) one every 4 hours PRN (as needed) for pain..." Continued medical record review of the Emergency Department Nursing Record, dated May 29, 2011, at 1:45 a.m., revealed the "...ace wrap to L left hand/wrist...discharge instructions given..." Continued medical record review of the Emergency Department Nursing Record, dated May 29, 2011, at 1:45 a.m., revealed the area for "discharge vital signs and pain" was blank.

Interview with the Chief Clinical Officer in the conference room on June 1, 2011, at 12:25 p.m., confirmed the medical record was incomplete for discharge vital signs and pain assessment.

Hospital B and Hospital C

Based on observation, review of manufacturer's instructions, interview, and review of American Diabetic Association recommentations, the facility failed to ensure unusable drugs were not available for patient use in one of three warmers used in the Operating Rooms of Hospital C, and in the computer-controlled medication dispenser on the 4th floor of Hospital B.

The findings included:

Observation on May 31, 2011 at 11:00 a.m., of the warmer located between Operating room 5 and 6 revealed the temperature of the warmer was 104 degrees Fahrenheit. Continued observation revealed located within the warmer was one 22 gm (gram) tube of Mupirocin (antibacterial) Ointment 2%.

Review of the Manufacturer's instructions revealed "...How Supplied...store at 20 - 25 degrees Centigrade (68 - 77 degrees Fahrenheit)...controlled room temperature...).

Interview with the Chief Clinical Officer in the conference room on May 31, 2011 at 3:10 p.m., confirmed the pharmacist indicated the medication was not to be stored in the warmer at 104 degrees Fahrenheit; and the medication was available for patient use.



21689

HOSPITAL B
Observation of the 4th floor of Hospital B on June 1, 2011, at 10:30 a.m., revealed in the medication room was a computer-controlled medication dispenser for the storage of medications. Observation of one drawer of medications revealed a bottle of Humalog Insulin U-100 (100 units per milliliter) ? empty; opened and undated.

Review of the American Diabetic Association recommendation revealed once an insulin vial is accessed it should be discarded after 28 days.

Interview with the Clinical Leader of the 4th floor in the medication room on June 1, 2011, at 10:32 a.m., confirmed the facility failed to ensure the medication was used prior to the 28 days expiration date.

Hospital A and Hospital C

Based on observation and interview, the facility failed to ensure patient supplies were not available beyond the expiration date for one of two crash carts and the sterile supply room in the Surgery Department at Hospital A and for one of six operating rooms in the Surgery Department at Hospital C.

Observation of the Surgery Department at Hospital A on May 31, 2011, at 12:50 p.m., revealed the operating room (OR) had two crash carts for emergency resuscitation. Observation of the top drawer of one crash cart revealed three packages of defibrillator pads with one package labeled with an expiration date of April, 2011.

Interviews with the Director and the Manager of the operating room on May 31, 2011, at 12:50 p.m., confirmed the defibrillator pads available for use during emergency resuscitation were beyond the expiration date.

Observation of the Sterile Supply room in the Surgery Department of Hospital A on May 31, 2011, at 1:50 p.m., revealed a suture cart with the following expired sutures: seven packs of 3-0 Vicryl J838D, expired January, 2010; one full unopened box and one half full box of 6-0 PDS 883G, expired January, 2010; one unopened box PDO 1 2XT9, expired February, 2011; two full boxes PDO 1 1059Q expired December, 2010; and Monoderm 2-0 YA1024Q, three packs expired February, 2011, and two packs expired January, 2011.

Interview with Clinical Leader of the Sterile Supply and the Chief Nursing Officer on May 31, 2011, at 1:50 p.m., in the Sterile Supply room, confirmed the sutures were available for patient use beyond the expiration dates.




21160

Observation with the Manager of Surgery and the Chief Clinical Officer in the Cardiac Operating Room of Hospital C on May 31, 2011 at 10:50 a.m., revealed a box of Prolene 5-0 sutures with sixteen sutures dated expired January 2011 and one suture dated expired July 2010.

Interview with the Manager of Surgery and the Chief Clinical Officer in the Cardiac Operating Room on May 31, 2011 at 10:50 a.m., confirmed the sutures had expired and were available for patient use.

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Hospital A and Hospital B

Based on observation, interview, review of Centers for Disease Control and Prevention (CDC) website Frequently Asked Questions (FAQs) regarding Safe Practices for Medical Injections, review of the Healthcare Infection Control Practices Advisory Committee (HICPAC) 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings Safe Injection Practices, 2007, and review of facility policy, the facility failed to ensure safe injection practices were followed for one of one pain management rooms observed at Hospital A; failed to ensure a sanitary environment for one of one operating rooms in the Women's Pavilion observed at Hospital A and two of two trauma rooms observed at Hospital B; and failed to use hand hygiene in one of one Intensive Care Unit (ICU) at Hospital B.

The findings included:

Observation of a procedure room in the Pain Management Center of Hospital A on June 1, 2011, from 10:10 a.m., until 10:35 a.m., revealed Certified Registered Nurse Anesthetist (CRNA) #A1 was in the room at 10:10 a.m., preparing for the next procedure.

Observation and interview with CRNA #A1 on June 1, 2011, at 10:10 a.m., in the procedure room, confirmed the CRNA had a box of anesthesia medications which included two vials of Propofol 50 ml (milliliters) to be used on multiple patients throughout the day. Continued observation revealed the labels on the Propofol indicated the vials were Propofol 1% 10 mg/ml (milligrams per milliliter) and were "single-patient infusion vial." Continued interview revealed CRNA #A1 stated the vials were "multi-dose patient use," the CRNA would draw up 10 ml in a syringe when the patient came to the room, and would use the vials on multiple patients.

Observation on June 1, 2011, at 10:15 a.m., in the procedure room, revealed patient #A23 was brought to the room, positioned face-down on the procedure table, and CRNA #A1 drew up 10 ml of Propofol and administered it to the patient intravenously. Continued observation revealed, at 10:25 a.m., the CRNA accessed the Propofol vial again with a new syringe and needle, drawing 10 ml of medication to administer to the patient. Continued observation revealed the procedure ended at 10:30 a.m., and the remaining medication was put back into the CRNA's medication box for use on the next patient.

Interview with CRNA #A1 on June 1, 2011, at 10:32 a.m., in the procedure room, confirmed the CRNA would administer up to 5 doses of 10 ml each from each 50 ml vial to multiple patients.

Review of the CDC website FAQs regarding Safe Practices for Medical Injections revealed, "Vials that are labeled as single-dose or single-use should be used for a single patient and single case/procedure/injection. There have been multiple outbreaks resulting from healthcare personnel using single-dose or single-use vials for multiple patients. Even if a single-dose or single-use vial appears to contain multiple doses or contains more medication than is needed for a single patient, that vial should not be used for more than one patient nor stored for future use on the same patient."

Review of the HICPAC 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings revealed "Safe Injection Practices...Whenever possible, use of single-dose vials is preferred over multiple-dose vials, especially when medications will be administered to multiple patients..."

Interview with the Clinical Leader for the Pain Management Center on June 1, 2011, at 10:30 a.m., in the procedure room, confirmed the Propofol vials were labeled for single patient use and were not multi-dose vials, and the pain management center had been utilizing the single-use vials for multiple patients.

Interview with the Director of Pharmacy on June 1, 2011, at 3:00 p.m., in the Executive Offices Conference Room, confirmed the 50 ml vials were for single patient use and the facility had not followed safe injection practices.

Observation of OR #1 in the Women's Pavilion of Hospital A on June 1, 2011, at 1:04 p.m., revealed the mattress on the operating room table had multiple perforations in the vinyl covering of the foam mattress. Continued observation revealed both sides of the mattress were covered with a foam tape down the length of each side of the mattress.

Interviews with the Women's Center Clinical Leader and the Chief Nursing Officer on June 1, 2011, at 1:04 p.m., in OR #1, confirmed the mattresses were not sanitary and in need of replacement.




21161

Observation of the Emergency Department (ED) of Hospital B with the Director of the ED on June 1, 2011, at 9:30 a.m., revealed the Trauma rooms contained two stretchers separated by a pulled curtain. Observation revealed both stretchers were covered with linens and available for use.

Observation revealed beneath the stretcher mattress of Trauma Room #1 was a moderate amount of dried material dark red/brown in color. Continued observation revealed the material was easily removed with a cleaning cloth by the ED Director.

Observation of the right full side rail revealed a smear of dried dark red/brown material. Observation revealed the material was easily removed with a cleaning cloth by the ED Director.

Observation of the overhead spot light in Trauma Room #1 revealed a thick build-up of dust on the upper surface of the structure. Observation of the light revealed a small amount of dried dark red/brown material on the handle. Observation revealed the material was easily removed with a cleaning cloth by the ED Director.

Observation of the overhead spot light in Trauma Room #2 revealed a thick build-up of dust on the upper surface of the structure.

Observation revealed beneath the stretcher mattress of Trauma Room #2 was a small amount of dried material dark red/brown in color. Observation revealed the material was easily removed with a cleaning cloth by the ED Director.

Interview with the Director of the ED on June 1, 2011, at 9:42 a.m., verified the material was "probably blood" and confirmed the facility failed to ensure the stretchers and lights were thoroughly cleaned after each use.

Observation of the Intensive Care Unit (ICU) at Hospital B on June 1, 2011, at 2:38 p.m., revealed a registered nurse (RN #B1) in the room of patient #7. Observation revealed the nurse was administering a medication via the port of an intravenous (IV) line. Continued observation revealed the nurse was not wearing gloves. Continued observation revealed the nurse pulled the covers back onto the patients arm before disposing of garbage and supplies in the sharps box. Continued observation revealed the nurse exited the room; pulled the door closed; and with both hands moved the computer on wheels (COW, device for documentation) without washing or sanitizing the hands.

Interview with the RN #B1 outside the room on June 1, 2011, at 2:41 p.m., verified the hands were not washed or sanitized prior to leaving the room and touching the door or COW.

Review of the facility policy Infection Control- Hand Hygiene (un-numbered) revised June 10, 2010, revealed, "If hands are not visibly soiled, use an alcohol-based hand rub for decontaminating hands in all other clinical situation. Examples included...f. after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient."

Interview with the Clinical Leader of the ICU at the nurses' desk on June 1, 2011, at 2:48 p.m., confirmed the facility failed to ensure infection prevention guidelines were followed.

Hospital A and Hospital C

Based on medical record review, review of Medical Staff Rules and Regulation, and interview, the facility failed to ensure an updated History and Physical was completed before an outpatient surgical procedure was performed at Hospital A for one patient (#A22) and at Hospital C for one patient (# C6) of sixty-one medical records reviewed.

The findings included:

Patient #A22 was admitted to Hospital A on June 1, 2011, for a Left Hip Steroid Injection.

Observation on June 1, 2011, at 10:00 a.m., revealed the patient was lying in bed in the pain management center recovery area, awake and alert, after the procedure.

Review of the medical record revealed the procedure was performed with a Certified Registered Nurse Anesthetist (CRNA) administering Propofol (anesthetic medication), and no documentation of the history and physical examination was available in the medical record.

Interview with the Medical Director of the Pain Management Center on June 1, 2011, at 10:05 a.m., in the pain management center recovery area, confirmed a complete history and physical examination had not been documented prior to the procedure.




21160

Patient # C6 was admitted to Hospital C on May 31, 2011 for outpatient surgery to include Endoscopic Retrograde Cholangio Pancreatography (ERCP) with possible Sphincterotomy (excision of a circular muscle of an orifice).

Medical record review revealed the physician's History and Physical present in the medical record was dated as dictated and transcribed May 5, 2011. Continued medical record review revealed the History and Physical had not been updated and no documentation present indicating the patient was assessed for changes prior to surgery.

Review of the Medical Staff Rules and Regulations, no date or number, revealed "...Section III Medical Records...Content of the Medical Record 1...e. history and physical examination should be completed and documented no more than thirty (30) days before or twenty-four hours after admission, but prior to surgery or a procedure requiring anesthesia services. When performed prior to admission, an updated addendum, including any changes in the patient's condition, must be performed...prior to surgery..."

Interview with the Manager of the Recovery Room and Chief Clinical Officer at the Recovery Room nursing station on May 31, 2011 at 11:35 a.m., confirmed the History and Physical had not been updated prior to the patient having surgery and the Medical Staff Rules and Regulations had not been followed.