HospitalInspections.org

Based on observation and interview, the hospital failed to ensure the psychiatric unit was maintained to assure a safe environment by: (1) having a wooden fence located in the patient outdoor recreation area with exposed nails (sharp pointed ends (8)) in 6 boards; (2) having shower heads screws that were not tamper resistant which had the risk for harm to all patient (8) currently admitted to the unit.
Findings:
Initial tour of the hospital conducted on 4/7/15 at 12:30 p.m. escorted by S15RN/Psych (Psychiatric) revealed the following:
(1) A six foot wooden fence was noted to have exposed nails (8) with sharp points on the inside of the fence
(2) Three shower stalls located in the common showering area was noted to have shower heads secured with screws that were were not tamper resistant.
In an interview on 4/7/15 at 12:30 p.m. S15RN/Psych confirmed the nails were exposed with sharp edges in the fence and the shower heads were secured with screws which were not tamper resistant. S15RN/Psych indicated both were a safety risk for all patients (8) who were currently admitted on the unit at the time of the observation.

Based on observation, record review and staff interview, the hospital failed to ensure that the environment was clean and neat as evidenced by: (a) ice & ice scoop stored in a dirty storage bin & ice container, (b) the presence of dirt/dust/grime buildup on the air conditioning vents (3 vents) located in the "Dining/Noisy" Room, (c) the refrigerator (patient) with large amount of food particles, dripping and dried substance, and (d) having patient care supplies stored in storage bins with visible accumulation of dust and hair.
Findings:
Initial tour of the Hospital's Psychiatric Unit, conducted on 4/7/15 at 12:30 p.m., escorted by S15RN/Psych (Psychiatric) revealed the following:
Observation of large green rolling ice bin filled with ice was not to be located in the nurses' station. The inner rim of the bin was noted to have strings of hair, trash, green, gray, brown particles which were removable when wiped with a paper towel by surveyor. The outside of the bin was noted to have white & gray drips of dried substance on the all 4 sides. The ice scoop was stored in a plastic container attached to the bin which contained a small amount of water which was noted to have an unidentified substance floating around in the water.
Observation of the Hospital's Psychiatric Dinning/Noisy Room revealed 3 large window unit air conditioners. The units were noted to have a large amount of dirt/dust/grime buildup on the vents.
Observation of the patient refrigerator (containing juices, milk, yogurt, mayonnaise, mustard, ketchup & sandwiches) and freezer (containing ice cream), located in Dinning/Noisy room, was noted to have a black substance on the insulated lining in the doors of the refrigerator and freezer. The shelves in the door and storage drawers and were all noted to have yellow, orange and red substances (dried). A hard, dark, reddish-orange substance was noted under the storage drawer. Freezer shelves were noted to have green, red & orange hard drip marks.
Observation of a room labeled "supplies" revealed 24 (21 small + 3 large) yellow storage bins were noted to have patients' hygiene supplies, patients' grooming items, medical supplies (dressings), and soft extremity restraints. The bins were all noted to have accumulation of visible dust & hair.
Review of the Hospital Policy titled "Ice Cart Cleaning Procedure" presented by S4RN/PsychMgr ( Psychiatric Manager) as current (01/08) read in part: Ice storage & dispensing: All ice must be dispensed with a conventional ice scoop that must be stored in the ice, handle up, or outside the ice container on a clean surface that is protected from contaminates. Cleaning will be performed by the CNAs (Certified Nursing Assistants) twice weekly and initial on the log form.
Review of the ice chart cleaning log presented by S4RN/ PsychMgr revealed a blank log (2015). There was no documented evidence that the ice machine had been currently cleaned by CNAs and or other staff members.
Review of a document presented by S4RN/PsychMgr, labeled as an air conditioner filter log check, revealed a document that indicated the air conditioners were cleaned and filter changed every 2 weeks. The document revealed the last cleaning & changing of the filter was 2/11/15.
In an interview on 4/7/15 at 12:50 p.m., S15RN/Psych confirmed the following observation. She indicated the supply room was a clean area and the supplies and items were for patient use. She indicated the hospital had no cleaning logs or records of cleaning the supply room.
In an interview on 4/7/15 at 12:55 p.m., S26MHT (Mental Health Technician) indicated the ice in the ice bin was served to the patients by the MHTs and/or staff. S26MHT indicated she was unable to recall if and when the ice bin was last cleaned.
In an interview on 4/7/15 at 1:05 p.m., S4RN/PsychMgr confirmed there was no documented evidence that the ice bin had been cleaned twice weekly, air conditioners cleaned every two weeks or cleaning of the refrigerator/freezer. She indicated logs were not maintained but should have been.

Based on interviews, observations and record reviews the Governing Body (GB) failed to ensure the Administrator and the Medical Executive Committee (MEC) were held accountable to the GB for the quality of care provided to patients as evidenced by patient medical records being delinquent for extended periods of time and physicians on suspension for extended periods of time (due to delinquent medical records) without any corrective plans of action being implemented by the GB, the Administrator or the MEC for 1 (S33MD) of 8 physicians on active medical staff and 1 (S34MD/Consult) of 5 physicians with consulting privileges.

Findings:
A review of the Governing Body (GB) By-Laws, as provided by S1CEO as the most current, revealed in part: The administrative powers of the hospital shall be vested in the Board of Commissions (GB) who shall have charge, control and management of the hospital ....in cooperation with the Administrator, as the duly authorized representative of the GB, in the active management and control of the hospital. The Administrator shall have full authority and responsibility for the administration of the hospital and he shall see that all policies of the GB, affecting the Medical Staff are followed. The Administrator will see that all orders for patient treatment are in writing and signed by the responsible physician. A further review of the GB By-Laws revealed in part: The GB shall appoint a professional (medical) staff composed of physicians. The GB shall see that the physicians are organized into responsible administrative units and shall make or approve By-Laws, rules and regulations for the control of their activities in the hospital as the GB deems to be for the best care of the patients of the hospital. A Chief of Staff (Medical Director) shall be elected by the GB and who shall have the authority to make recommendations for any changes to the medical staff/rules/regulations and present them to the GB.

A review of the GB meeting minutes from 2/4/14 to 3/24/15 revealed that the GB reviewed the following:
2/4/14- "Incomplete Chart" report for the month revealed 43 delinquent medical records and a plan of action would be required. (There was no evidence of a documented plan of action noted in the GB minutes).
3/25/14- S1CEO reported that there was no "Incomplete Chart" report from MEC (Medical Executive Committee) due to no MEC meeting in March.
4/22/14- There was no "Incomplete Chart" report noted.
5/27/14- "Incomplete Chart" report for the month revealed 23 delinquent medical records. No other report findings or plan of actions were noted.
6/24/14"- "Incomplete Chart" report for the month revealed 50 delinquent medical records. No other report findings or plan of actions were noted.
7/31/14- "Incomplete Chart" report for the month revealed 15 delinquent medical records. No other report findings or plan of actions were noted.
8/26/14- "Incomplete Chart" report for the month revealed 32 delinquent medical records. No other report findings or plan of actions were noted.
9/30/14- "Incomplete Chart" report for the month revealed 59 delinquent medical records. No other report findings or plan of actions were noted.
10/28/14- The GB minutes noted that there was no business to discuss under agenda item, "Incomplete Chart" report. No other report findings or plan of actions were noted
11/25/14- The GB minutes noted that there was no business to discuss under agenda item, "Incomplete Chart" report due to the new computer system conversion. No other report findings or plan of actions were noted
12/16/14- The GB minutes noted that there was no business to discuss under agenda item, "Incomplete Chart" report due to the new computer system conversion. No other report findings or plan of actions were noted
1/27/15- The GB minutes noted that there was no business to discuss under agenda item, "Incomplete Chart" report due to the new computer system conversion. No other report findings or plan of actions were noted
2/24/15- "Incomplete Chart" report for the month revealed 88 delinquent medical records. No other report findings or plan of actions were noted. S1CEO reported that the GB By-Laws had been reviewed with no revisions for the year 2015. S1CEO reported that the Medical Staff By-Laws had been reviewed with no revisions for the year 2015.
3/24/15- "Incomplete Chart" report for the month revealed 79 delinquent medical records. No other report findings or plan of actions were noted.

A review of the Medical Staff By[Laws, Rules and Regulations as provided by S1CEO, as the most current, revealed in part: The active medical staff shall consist of physicians who admit more than 5 patients a year to the hospital and who assume all the functions and responsibilities of membership on the active medical staff. The consulting medical staff shall consist of physicians who qualified to the medical staff membership. Consulting medical staff members shall not be eligible to admit patients or vote or hold office in the medical staff organization. A further review revealed in part: The Medical Staff shall be responsible for assuring that all patient's medical records meet the highest standards of patient care usefulness and of historical validity. The MEC shall conduct a monthly review of currently maintained medical records...... and that they are sufficiently complete at all times so as to meet the criteria of medical comprehension of the patient. Each medical record shall be completed within 30 days of discharge or the medical record becomes delinquent. Chart count will be performed every Monday. Incomplete and delinquent medical records will be identified. Medical Records Department will notify the physician with a phone call and a 21 day notification letter noting the incomplete medical records. The letter will have a deadline date for the charts to be completed. If these medical records are not resolved (completed) on the ninth day following the 21 day notification letter, admitting privileges will be "automatic" suspended and the physician will be notified of his suspension. A notification of suspension memorandum will be sent to the appropriate hospital departments and posted in that department. Privileges will be restored by the Administrator and/or the Medical Director upon verification from the Medical Records Director when the delinquent medical records have been completed. "Automatic" suspension is the withdrawal of a physician's admitting privileges (meaning inpatient direct admits and elective surgeries), and will be effective until the medical records are completed.

A review of the monthly Medical Staff Executive Committee meeting minutes (MEC), as provided by S1CEO, from February 2014 to February 2015 revealed that S9MR/UR, Medical Records Director, reported monthly to the MEC the same "Incomplete Chart" reports regarding the monthly delinquent medical records that was reported to and revealed in the GB meeting minutes above. A further review of the MEC meeting minutes from February 2014 to February 2015 revealed no documented evidence in the MEC meeting minutes of any corrective actions or plans of corrections to be implemented by the Medical Staff. regarding physician medical record delinquencies.

A review of the Medical Records Department policy titled, "Medical Record Deficiency Check List Policy", as provided by S9MR/UR as the most current, revealed in part: Timely completion of medical records is important in order to be useful in a patient's care. A medical record is considered delinquent if it is not complete within 30 days after discharge. To ensure the completion of medical records, the medical records department will be responsible for "chart counting" every Monday. Incomplete medical records will be "flagged' for the physicians and physicians will be notified.

A review of the monthly "Incomplete Chart" reports from the Medical Records Department, provided by S9MR/UR, revealed in part: S33MD (active member of Medical Staff and Secretary of the MEC) had delinquent medical records over 30 days and had been on suspension since August 2014; S34MD/Consult (Consulting member of Medical Staff) had delinquent medical records over 30 days and had been on suspension since September 2013.

An observation on 4/9/15 of the nurse's station revealed a suspension memorandum dated September 12, 2013 indicating that S34MD/Consult was on suspension. A further observation on 4/9/15 of the nurse's station revealed a suspension memorandum dated August 13, 2014 indicating that S33MD was on suspension. The "Suspension of Admitting Privileges" form indicated that the following physicians' admitting privileges (except those through the emergency room) have been suspended until further notification from Medical Records/Administration.

In an interview on 4/8/15 at 1:00 p.m. with S9MR/UR she indicated that the Medical Records Department was responsible for the "Chart Counts". S9MR/UR indicated that "Chart Counts" were performed on Mondays and the purpose of the "Chart Counts" were to "flag" patient's medical records for incomplete medical records, to determine monthly physician delinquencies and to determine Utilization Review data. S9MR/UR indicated that the Medical Records Department reported the physician's medical record delinquencies in a monthly "Incomplete Chart" report to the MEC at the MEC monthly meetings. S9MR/UR was asked if the MEC had directed the Medical Records Department to implement any corrective plan of actions regarding any physician's medical record delinquencies. S9MR/UR indicated, "no". S9MR/UR was asked about the suspension memorandums on the nursing units regarding the suspension of S33MD dated August 13, 2014 and the suspension of S34MD/Consult dated September 12, 2013. S9MR/UR indicated the memorandums were still current and that S33MD and S34MD/Consult had been on suspension since those dates. S9MR/UR indicated that the only penalty according to the Medical Staff By-Laws was that S33MD and S34MD/Consult were unable to "directly" admit patients, but patients could be "indirectly" admitted to them by the Emergency Room Physician or by the "on-call" physicians and physicians could still consult S34MD/Consult for their patient care needs. S9MR/UR indicated that S33MD had had many patients admitted to him since his suspension on August 13, 2014 and currently has patients in-house. S9MR/UR indicated that S34MD/Consult had only consulting privileges and did not admit patients. S9MR/UR indicated that S34MD/Consult was still being given patient consults through physician orders.

In a phone interview on 4/8/15 at 1:45 p.m. with S28MD/MedDir he indicated that he was the Medical Director for the hospital. S28MD/MedDir was asked about delinquent medical records and the suspension of S33MD and S34MD/Consult. S28MD/MedDir indicated that the "Incomplete Chart" reports were reported by S9MR/UR each month at the MEC meetings. S28MD/MedDir indicated that he (S28MD/MedDir) and Medical Records would simply remind S33MD and S34MD/Consult each month to complete their delinquent medical records. S28MD/MedDir further indicated that the Medical Staff had not implemented any other plan of corrections for the physicians who had delinquent medical records, except that they were not allowed to "direct" admit. S34MD/Consult had consulting privileges and did not admit patients. S28MD/MedDir indicated that the Medical Staff should probably initiate a more "strict" policy.

In an interview on 4/9/15 at 2:15 p.m. with S1CEO he indicated that he was a member of the GB. S1CEO was asked if the GB had recommended any plans of correction regarding the delinquent medical records and the suspension of S33MD and S34MD/Consult. S1CEO indicated that the "Incomplete Chart" reports were reported to the GB each month. S1CEO further indicated that the GB had not directed the Medical Staff/Medical Records Department to implement/initiate any plans of correction for the physicians who had continued delinquent medical records and who had been on continued suspension for several months.

Based on observations, interviews and record reviews the hospital failed to provide continuous telemetry monitoring assessment for 2 of 2 (#3, #4) patients who had physician orders for telemetry (cardiac) monitoring. This failed practice was evidenced by no nursing staff/ monitor technician assigned to monitor the patient telemetry monitors for the patients with physician orders for cardiac monitoring.
Findings:
A review of the policy titled, "Telemetry Monitoring", as provided by S2DON/QA as the most current, revealed in part: There is a telemetry monitor located at the nurse's station and the ER which continuously shows all monitored beds. The hospital does not have a designated telemetry technician. All nursing staff have telemetry competency. The nursing staff views the monitors directly to asses any possible arrhythmias. Rhythm strips are posted in the patient's chart every 4 hours and as needed in the case of abnormal events.
Patient #3
A review of Patient #3's medical record revealed that the patient presented to the ER on 4/7/15 with a chief complaint of chest pain. The patient had had chronic sternal pain for a week. The patient had a history of coronary artery disease, a history of a "minimal blockage" 8 years ago and a self-diagnosed history of reflux. S31MD/ER ordered cardiac monitoring for Patient #3 while in the ER.
An observation of the telemetry monitors at the nurse's station in the ER on 4/7/15 revealed that Patient #3 was on a telemetry monitor. A further observation of the telemetry monitors at the nurse's station in the ER revealed that there was no nursing staff/telemetry technician monitoring the telemetry monitors.
In an interview on 4/7/15 at 2:30 p.m. with S5RN/ED Mgr she was asked about the monitoring of the patients on the telemetry monitors. S5RN/ED Mgr indicated that there was no staff assigned to the telemetry monitoring. S5RN/ED Mgr indicated that nursing staff would check the monitors on and off and run a patient strip every 4 hours for the patient's medical record. S5RN/ED Mgr indicated that the monitors were set to alarm if there were any unusual arrhythmias. S5RN/ED Mgr was asked if the telemetry monitors were set for all unusual arrhythmias. S5RN/ED Mgr indicated that not all unusual arrhythmias were able to be set on the telemetry monitors. S5RN/ED Mgr further indicated that the nurses mostly depended upon the alarms "going off " on the telemetry monitors for patient arrhythmias. S5RN/ED Mgr indicated that the patients on telemetry on the acute unit could also be viewed on the telemetry monitors in the ER and that the nursing staff on the acute units would monitor those patients on telemetry.
Patient #4
A review of Patient #4's medical record revealed that the patient presented to the ER on 4/7/15 with a chief complaint of shortness of breath. The ER physician notes revealed that Patient #4 had a history of congestive heart failure, hypertension, diabetes, coronary artery disease and chronic obstructive pulmonary disease. The ER physician admitted Patient #4 to the hospital under S33MD. The ER physician wrote orders for Patient #4 to be on cardiac monitoring in the ER and on the acute unit.
An observation of the telemetry monitors at the nurse's station on the acute unit on 4/8/15 revealed that Patient #4 was on a telemetry monitor. A further observation of the telemetry monitors at the nurse's station on the acute unit revealed that there was no nursing staff/telemetry technician monitoring the telemetry monitors.
In an interview on 4/8/15 at 9:50 a.m. with S14RN she indicated that she was the charge nurse for the acute unit today (4/8/15). S14RN she was asked about the monitoring of the patients on the telemetry monitors. S14RN indicated that there was no staff assigned to monitor the telemetry monitors. S14RN indicated that the charge nurse each day would mostly be responsible for "keeping an eye" on the telemetry monitors when patients were ordered to be on telemetry monitoring. S14RN indicated that the charge nurse or other nursing staff would check the monitors frequently and run a patient strip every 4 hours for the patient's medical record. S14RN indicated that the monitors were set to alarm if there were any unusual arrhythmias. S14RN was asked if the telemetry monitors were set for all unusual arrhythmias. S14RN indicated that not all unusual arrhythmias were able to be set on the telemetry monitors. S14RN further indicated that the nurses mostly depended on the alarms "going off " on the telemetry monitors for patient arrhythmias. S14RN indicated that the acute patients on telemetry monitoring could also be viewed on the telemetry monitors in the ER by the ER staff and that someone in the ER might also be watching the telemetry monitors.
In an interview on 4/8/15 at 11:15 a.m. with S2DON/QA she was asked about the monitoring of telemetry patients in the ER and on the acute unit. S2DON/QA indicated that the hospital did not assign a staff person to continuously monitor the telemetry monitors for the patients who had physician orders for telemetry monitoring. S2DON/QA indicated that staff mostly depended upon the telemetry monitor's alarms for patient arrhythmias. S2DON/QA indicated that the hospital should have assigned staff for telemetry monitoring.

30172

Based on observations, interviews and record reviews the hospital; 1) failed to ensure that the Physician Standing Order medication choices were ordered by a physician prior to the nursing staff initiating the Physician Standing Orders for 2 (#1, #4) of 3 (#1, #3, #4) patient medical records reviewed for Physician Standing Orders, and 2) failed to ensure that all patient medication orders were documented and placed in the medical record for 1 (#5) of 7 (# 1, #2, #3, #4, #5, #11, #12) patient medical records reviewed for medication management.
Findings:
1) failed to ensure that the Physician Standing Order medication choices were ordered ,by a physician prior to the nursing staff initiating the Physician Standing Orders for 2 (#1, #4) of 3 (#1, #3, #4) patient medical records reviewed for Physician Standing Orders,
A review of the hospital policy titled, "Physician Standing Orders", provided by S2DON/QA as the most current, revealed in part: Commonly, nurses note problems with their patients (temperature elevation, constipation, headaches, minor aches/pains, indigestion, rash, increased respiratory secretions). When these problems occur, the nurse is to take into consideration the patient's diagnosis, current condition and past medical history before deciding to initiate a Physician's Standing Order sheet. Nurse are to use great caution in this decision making process in order to be aware of possible contraindications of medicines or treatments in certain types of patients. Physician Standing Orders can be initiated by the ER physician, the attending physician or by the nurse.
Patient #1
A review of Patient #1's medical record revealed that the patient presented to the ER on 4/5/15 with a chief complaint of left leg pain and increased swelling of her left leg. The patient was a post-operative total knee replacement. The ER physician admitted Patient #1 to the hospital under the care of S28MD/MedDir. The ER physician wrote orders to initiate S28MD/MedDir's Physician Standing Orders.
A review of S28MD/MedDir's Physician Standing Orders revealed in part: for a patient temperature of 101 degrees or more, the nurse can choose either Acetaminophen or Ibuprofen; for a patient's indigestion, the nurse can choose either Maalox or Mylanta; for a patient rash, the nurse can choose either Mycostatin or Nystatin; for a patient's constipation, a nurse can choose either Milk of Magnesia or Dulcolax; for a patient's diaper rash/irritation, a nurse can choose either A&D ointment, Desitin or Boudreaux's butt paste. A further review of S28MD/MedDir's Physician Standing Orders revealed no indication that either the ER physician or S28MD/MedDir had checked off any of the blocks where medication acute choices on the Physician Standing Orders were available.
In an interview on 4/9/15 at 10:45 a.m. with S16RN she indicated that she was the nurse caring for Patient #1. S16RN was asked about S28MD/MedDir's Physician Standing Orders that was initiated for Patient #1. S16RN indicated that the ER physician ordered S28MD/MedDir's Physician Standing Orders to be initiated for the patient upon admit to the acute unit. S16RN further indicated that it was the nurse's or the patient's choice of medications when choices were available on the Physician Standing Order sheets. S16RN further indicated that there were 3 physicians who utilized Physician Standing Orders that allowed medication choices to be made by the nurse/patient. S16RN indicated that after a medication was given, they (the nurses) would check the choice and the physician would sign the choice on the order sheet when the physician made rounds on the patient.
Patient #4
A review of Patient #4's medical record revealed that the patient presented to the ER on 4/7/15 with a chief complaint of shortness of breath. The ER physician notes revealed that Patient #4 had a history of congestive heart failure, hypertension, diabetes, coronary artery disease and chronic obstructive pulmonary disease. The ER physician admitted Patient #4 to the hospital under the care of S33MD. The ER physician wrote orders to initiate S33MD's Physician Standing Orders.
A review of S33MD's Physician Standing Orders revealed in part: for a patient temperature of 101 degrees or more, the nurse can choose either Acetaminophen or Ibuprofen; for a patient's indigestion, the nurse can choose either Maalox or Mylanta; for a patient rash, the nurse can choose either Mycostatin or Nystatin; for a patient's constipation, a nurse can choose either Milk of Magnesia or Dulcolax; for a patient's diaper rash/irritation, a nurse can choose either A&D ointment, Desitin or Boudreaux's butt paste. A further review of S33MD's Physician Standing Orders revealed no indication that either the ER physician or S33MD had checked off any of the blocks where medication choices on the Physician Standing Orders were available.
In an interview on 4/8/15 at 10:00 a.m. with S14RN she indicated that she was the nurse caring for Patient #4. S14RN was asked about S33MD Physician Standing Orders that was initiated for Patient #4. S14RN indicated that the ER physician ordered S33MD's Physician Standing Orders to be initiated for the patient upon admit to the acute unit. S14RN further indicated that it was the nurse's or the patient's choice of medications when choices were available on the Physician Standing Orders. S14RN further indicated that there were 3 physicians who utilized Physician Standing Orders that allowed medication choices by the nurse/patient. S14RN indicated that after a medication was given, they (the nurses) would check the medication choice and the physician would sign the choice on the order sheet when the physician made rounds on the patient.
In an interview on 4/9/15 at 11:00 a.m. with S2DON/QA she was asked about the Physician Standing Order sheets that were utilized by 3 (S28MD/MedDir, S33MD, S35MD) of the hospital's physicians. S2DON/QA indicated that Physician Standing Orders could be initiated by the ER physician, the attending physician or by the nurse. S2DON/QA indicated that after a medication was given by the nurse, the nurse would check the choice on the Physician Standing Order sheet and the physician would sign the order when the physician made rounds on the patient. S2DON/QA indicated that it was probably not acceptable professional practice for the nurses to make those medication choices and that the physician should be responsible for patient medication decisions when choices were available. .

2) failed to ensure that all patient medication orders were documented and placed in the medical record for 1 (#5) of 7 (# 1, #2, #3, #4, #5, #11, #12) patient medical records reviewed for medication management.
Patient #5
An observation on 4/9/15 at 12:15 p.m. revealed S17RN (Registered Nurse) administered Novolin R insulin 4 units SQ (Subcutaneous) to Patient #5.
Record review on 4/9/2015 at 12:30 p.m. revealed Patient #5 was admitted on 4/6/15 with a diagnosis of Bilateral Pneumonia. Further review revealed here were no orders for Novolin R. S17RN stated that the orders were taken from S33MD's Physician Standing Orders. S17RN could not find documentation of the medicine in the patient's physician's orders. Further review of the MAR (Medication Administration Record) for Patient #5 revealed Insulin Regular per sliding scale: less than 200=0 units, 200-250= 4 units, 251-300= 6 units, 301-350= 8 units, 351-400= 10 units, and BS (Blood sugar) > (less than) 400= 10 units and call MD. S17RN further stated that the orders are faxed to the pharmacy on admission and were on the Patient #5's MAR, but could not explain why the Physician Standing Orders for Sliding Scale insulin were not on the medical record.
Interview on 4/9/15 at 1:05 p.m. with the S2DON/QA confirmed the orders should have been on the Patient #5 ' s record. The nurses do 24 hour chart checks and should have caught the missing order.
Review of the hospital policy titled Transcription of Medication Orders on New Admission and Inpatients, Number 89.0, revised January 8, 2008 revealed in part: ... 3. Send copies of physician orders to pharmacy. 4. Interpret the order and place on the MAR and kardex... 11. Written orders must specify date and time of order; also must specify drug, dosage, route, and time intervals; must be signed by prescribing physician.

Based on observation, interview and record reviews, the hospital failed to ensure that patient's medical records were stored in a manner where the medical records were protected from damage from water. This failed practice was evidenced by patient medical records being stored in the Medical Records Department on open shelving racks in rooms that had a sprinkler system.

Findings:
A review of the hospital policy titled "Storage of Records", provided by S9MR/UR, as the most current, revealed in part: All primary hardcopy medical records shall be housed in physically secure areas under the control of the Medical Records Department. All medical records will be maintained and retained in accordance with federal and state laws and regulations.

An observation on 4/8/15 at 12:20 p.m. in the presence of S9MR/UR, of the Medical Records Department, revealed the following: approximately 12 (twelve) open ended shelving racks (8 feet by 2 feet and 7 feet by 2 feet) with multiple shelves, containing over 3000 patient medical records that were stored on the open ended shelving racks in rooms were an overhead sprinkler system was in place.

In an interview on 4/8/15 at 12:45 p.m. with S9MR/UR, she indicated that she was responsible for the patient's medical records in the Medical Records Department. S9MR/UR indicated that all the patient medical records in the Medical Records Department were the original hardcopies that had not been scanned into the hospital's EMR (electronic medical record) system yet. S9MR/UR was asked how the patient's medical records in the Medical Record Department were protected from water damage in the event that the sprinkler system was activated. S9MR/UR indicated that they (Medical Records personnel) would probably contact maintenance who could provide them with plastic covering material. S9MR/UR further indicated that there was no readily available water protection covering in the Medical Records Department at present. S9MR/UR indicated that the Medical Records Department was not opened 24 hours a day and if the sprinkler system was activated after hours, the patient medical records in the Medical Records Department would be subjected to water damage.