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Based on record review, policy and procedure review, and staff interview, the facility failed to maintain documented evidence in Patient #6, #7, #8, and #9's medical record (four [4] of 24 patient records reviewed) of issuance of the written notice of the facility's Advance Directive policies.

Findings Include:

Record review for Patient #6 (closed record), #7, #8 and #9 revealed no documented evidence that the patient or patient's representative was given information concerning Advance Directives. The blank forms were located on the patient charts but were not signed.

During an interview on 11/01/16 at 2:05 p.m. the Director of Nursing (DON) confirmed there was no documented evidence to show whether or not Patient #6, #7, #8 and #9 had completed an Advance Directive or had been given information regarding Advance Directives.

Review of the facility's "Advance Directives" policy (effective 10/01/2010) revealed: "Policy: It is the policy of (Hospital) to respect and encourage patient self-determination. Patients will be encouraged and assisted to be active participants in the decision making process regarding their care through education, inquiry and assistance as requested. Patients will be encouraged to communicate their desires in regard to advance directives to their significant others, to allow for guidance of significant others and healthcare providers in following the patient's wishes should the patient become incapacitated, rendering them unable to make decisions ...Procedure: An inquiry will be made by the Admitting Department during the admissions process of the patient, or if the patient is incapacitated, to the patient ' s significant other, as to whether or not the patient has completed an advance directive ...Admitting Department personnel will document in the medical record whether the patient has completed an advance directive and that information concerning advance directives has been given to the patient/significant other during the admission process. In the event that the patient bypasses the routine admissions process due to nature or severity of illness, and is admitted directly to the patient care units, the responsibility to inquire about advance directives and provide necessary information as outlined above, will rest with the nursing staff. The Admitting Department will notify the nursing staff of the need for advance directive follow-up ...".

Based on observation and staff interview, the facility failed to provide call lights in six (6) of six (6) emergency exam rooms to meet the needs of patients in a safe manner during one (1) of two (2) days of survey.

Findings include:

Observation on 10/31/16 at 11:25 a.m. revealed no call lights, or any other way to notify staff if a problem occurred, in all six (6) emergency exam rooms. No call light system was observed in the nursing station in the Emergency Department.

During an interview on 10/31/16 at 11:30 a.m. the Emergency Department Director stated, "The emergency room has never had call lights in the exam rooms."

No policy and procedure was submitted for review.

Based on observation, staff interview, and manufacturer guideline review, the facility failed to ensure the hospital environment was maintained for the safety of patients during one (1) of two (2) days of survey.

Findings Include:

Observation at 12:20 p.m. on 10/31/16 revealed four (4) of the six (6) exam rooms in the Emergency Department had oxygen nipple adapters attached to the oxygen flow meter.

Observation at 1:00 p.m. on 10/31/16 revealed that six (6) out of 25 patient rooms had oxygen nipple adapters attached to the oxygen flow meter.

During an interview on 10/31/16 at 1:15 p.m. the Respiratory Therapist stated, "We use the oxygen nipple adapters for mult-patient use." At 1:30 p.m. the Respiratory Director stated, "The oxygen nipple adapters should be mult-patient use. I will have to call my supplier and have them email me that information."

Review of Manufacturer Guidelines revealed that oxygen nipple adapters are for single patient use only.

The facility failed to submit a policy regarding oxygen nipple adapters.

Based on facility report review, policy and procedure review, and staff interview, the facility failed to maintain complete, accurately documented clinical records.

Findings Include:

Review of the facility's "Deficiency Report by Physician" revealed a total of 82 delinquent closed clinical records, greater than 15 days past discharge. The deficiencies included incomplete or missing Physician signatures or history and physicals and involved four (4) different physicians.

Review of the facility's "Medical Record Guideline for Physician Policy" revealed, "Records shall be completed and authenticated within 15 days following patient discharge...."

Interview with the Medical Record Director on 11/01/16 at 10:55 a.m. confirmed the 82 incomplete clinical records. The Medical Record Director also stated that warning letters had been sent to each physician with delinquent records.

Interview with the Hospital Administrator on 11/01/16 at 2:50 p.m. confirmed that four (4) physicians were delinquent on signatures and history and physicals and that a warning letter had been sent to each physician involved. The Hospital Administrator stated that the facility plans to update the policy to extend the delinquent time to 30 days.

Based on record review and staff interview, the facility failed to maintain a record for each patient receiving health care services that included evidence of a properly executed informed consent form. This involved four (4) of 24 patients reviewed, Patient #6 (closed record), #7, #8, and #9.

Findings Include:

Record review for Patient #6, #7, #8 and #9 revealed no documented evidence of a properly executed, informed consent form for admission and treatment.

During an interview on 11/01/16 at 2:05 p.m. the Director of Nursing (DON) confirmed these findings.

Based on observation, review of the high-level disinfectant test strip documentation log, review of the manufacturer technical information, staff interview, and policy and procedure review, the facility failed to ensure the surgical staff documented each date the high-level disinfectant solution was changed.

Findings Include:

Observation of the Central Sterile Supply Room on 10/31/16 at 2:10 p.m. revealed a container containing blue fluid with no documented evidence on the container of what the blue fluid was, the date the blue fluid was placed in the container, and/or the name of the staff member who poured the blue fluid into the container. During the observation Surgical Technician #1 stated that the blue fluid was a High-Level Disinfectant that was used to sterilize surgical instruments and endoscopy dilators. She stated, "I just pulled the label off the container and have not put a label back on."

Review of the High-Level Disinfectant test strips results log revealed the last documented date the solution was changed was on 6/26/16 by Surgical Technician #2.

Review of the Manufacturer Technical Information revealed: "...Solution is a High-Level Disinfectant (HLD) for use in reprocessing heat-sensitive medical devices ...Directions For Use ...Solution Usage ...Record the date the solution was poured out of the original container into a secondary container in a log book ...on label affixed to the secondary container. The solution in the secondary container can be used for a period of 14 days. The product must be discarded after 14 days even if the ...test strip indicates a concentration above the Minimum Effective Concentration (MEC) ... ".

During an interview on 10/31/16 at 2:25 p.m. Surgical Technician #2 stated that she had been changing the High-Level Disinfectant solution every 14 days, but failed to document the date the solution was changed on the facility log.

During an interview on 10/31/16 at 4:35 p.m. the Surgical Director confirmed that the date the High-Level Disinfectant was changed should be documented on the test strip results log.

Review of the facility's "Ortho-Phthalaldehyde (OPA)" policy (revised: 10/31/16) revealed: "Purpose: To assure an effective concentration of the OPA (High-Level Disinfectant) ...used ...To provide immediate information and documenting proof of acceptable solution strength of cold sterilant ...Procedure: Prepare solution, per manufacturer's instructions ... ".

Based on record review and staff interview, the facility failed to maintain documented evidence that Patient #6, #7, #8, and #9 were informed of his or her rights and responsibilities. This was four (4) of 24 patient records reviewed.

Findings Include:

Record review revealed Patient #6, #7, #8 and #9 had no documented evidence that the patient was informed of his or her rights and responsibilities.

During an interview on 11/01/16 at 2:05 p.m. the Director of Nursing (DON) confirmed these findings.