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Based on document review and interview, it was determined for 2 of 28 (Pts #4, #21) patients, the Hospital failed to ensure physician written and telephone orders were dated and timed as to when the orders were written and/or when the orders were authenticated. This has the potential to affect all patients being serviced by the Hospital.

Findings include:

1. The "Medical Staff Rules and Regulations" (revised 05/2015) were reviewed on 8/26/2015 at 1:00 PM. The rules and regulations indicated under, "3.2 Authentication of Entries: All clinical entries of the patient's medical record should be accurately dated, timed...".

2. Pt #4's record was reviewed on 8/24/2015 at approximately 1:00 PM. Pt #4 was admitted to the Day Surgery Unit with the diagnosis of Gastric/Espohagitis. The physician order titled "Pre Anesthesia Assessment/Consent and Post Anesthesia Assessment/Consent", dated 8/24/2015, lacked the time they were written.

3. Pt #21's record was reviewed on 8/25/15 at approximately 1:30 PM. Pt #21 was admitted to the Hospital on 8/18/15 with the diagnosis Acute Upper Gastrointestinal Bleed. Between 8/18/15 and 8/23/15, there were thirteen out of thirteen telephone, verbal or standing orders which lacked the date and time as to when the physician authenticated them.

4. An interview was conducted with the Assistant Vice Present of Revenue Cycle (E#6) on 8/26/2015 at approximately 2:45 PM. E#6 stated "the expectation is that all patient medical record entries are to be dated, timed and authenticated" at the time they are written.

Based on document review and interview, it was determined for 6 of 28 (Pts #5, #6, #7, #8, #21 and #23) patients, the Hospital failed to ensure all entries into the medical record, whether written or electronic, were accurately authenticated with date, time and signature, in accordance with its' Bylaws. This has the potential to affect all patients being serviced by the Hospital.

Findings include.

1. The "Medical Staff Rules and Regulations" (revised 05/2015) were reviewed on 8/26/2015 at approximately 1:00 PM. The rules and regulations stated under, "3.2 Authentication of Entries: All clinical entries of the patient's medical record should be accurately dated, timed..."... 3.18.1 Requirements for Timely Completion of Medical Records: e. An Inpatient Progress Note must be recorded and authenticated by the attending physician, or designated practitioner, at the time of each encounter, and on a daily basis."

2. Pt #5's record was reviewed on 8/24/15 at approximately 4:30 AM. Pt #5 was admitted to the Hospital's Day Surgery on 8/24/15 with the diagnosis Right Cataract. The pre-anesthesia assessment lacked the time as to when it was conducted.

3. Pt #6's record was reviewed on 8/24/15 at approximately 4:00 PM. Pt #6 was admitted to the Hospital's Day Surgery on 8/24/15 with diagnosis Penile Lesion. Both the pre-anesthesia and post-anesthesia assessments lacked the times as to when they were conducted. The pre-anesthesia assessment lacked the time as to when it was conducted.

4. Pt #7's record was reviewed on 8/25/15 at approximately 7:00 AM. Pt #7 was admitted to the Hospital's Day Surgery on 8//24/15 with the diagnosis Right Renal Calculi. The pre-anesthesia assessment lacked the time as to when it was conducted. The intra-operative anesthesia record stated Pt #7 was taken to the post anesthesia recovery room at 12:30 PM, however, the post-anesthesia assessment stated the assessment was conducted at 12:20 PM, prior to the patient leaving the surgery suite.

5. Pt #8's record was reviewed on 8/25/2025 at approximately 2:00 PM. Pt #8 was admitted to the Intensive Care Unit on 8/20/2015 with a diagnosis of Hypercardia Chronic Obstructive Pulmonary Disease. As of 8/25/15, the physician electronic progress notes dated 8/22/2015, and 8/23/2015 had not been authenticated by the attending physician..

6. Pt #21's record was reviewed on 8/25/15 at approximately 1:30 PM. Pt #21 was admitted to the Hospital on 8/18/15 with the diagnosis Acute Upper Gastrointestinal Bleed and underwent an Esophagogastroduodenoscopy on 8/22/15. The "Combined Home Medication and Inpatient Medication Reconciliation Order Form" and the Standing Orders titled "Anesthesia Pre-operative Orders/ Anesthesia Post-Operative Orders" both lacked the dates and times they were ordered. Both the pre and post-anesthesia assessments lacked the time as to when they were conducted.

7. Pt #23's record was reviewed on 8/25/25 at approximately 2:45 PM. Pt #23 was admitted to the Hospital on 8/25/15 to undergo a Right Total Knee Arthroplasty. The post-anesthesia assessment lacked the time as to when it was conducted.

8. An interview was conducted with the Assistant Vice President of Revenue Cycle (E#6) on 8/26/2015 at 2:40 PM. E#6 stated "All records are to be signed."

9. An interview was conducted with E#6 on 8/27/15 at approximately 10:30 AM with the Director of Education (E#2) present. E#6 stated once the physician dictates a note, they have 30 days to sign (authenticate) the transcription. E#6 was not aware the authentication of the medical record as a whole, inclusive of electronic authentication of transcribed dictations section of the Bylaws did not match the authentication of daily progress notes section.

Based on document review and interview, it was determined for 1 of 1 (Pt #20) patient, in which a medication ordered was also listed as an allergy, the Hospital failed to ensure medication orders identified as an allergy were clarified to prevent potential adverse reactions. This has the potential to affect all patients being serviced by the hospital.

Findings include:

1. Pt #20's record was reviewed on 8/25/15 at approximately 12:15 PM. Pt #20 was admitted to the Hospital on 8/22/15 with the diagnosis Pubic Granis Fracture. On 8/22/15, the "Home Medication Reconciliation Order Form" stated Pt #20 was allergic to Morphine and listed nausea as the allergy. On 8/22/15 at 9:50 PM, there was a telephone order for Morphine 2 milligrams (MG) intravenous push (IVP) every one hour as needed. An undated and untimed subsequent telephone order for Zofran 4 mg IVP every 4 hours as needed. There was no documentation of either Nursing and/or Pharmacy contacting the physician to clarify the Morphine order to prevent the known adverse reaction of nausea for Pt #20.

2. An interview was conducted with the Director of Medical (E#3) on 8/25/15 at approximately 12:25 PM, during the record review. E#3 stated "Someone should have caught that ... (Pt #20) was allergic to Morphine" and clarified whether the patient was to have the medication or not due to the listed allergy with nausea as the reaction.

Based on observation and interview it was determined the hospital failed to secure medications. This has the potential to affect all patients and visitors.

Findings include:
1. An observational tour was conducted on 8/25/2015 between approximately 11:40 AM and 1:15 PM on the Intensive Care Unit with a registered nurse (E #5). It was observed in the Intensive Care unit an unlocked refrigerator with the following unsecured medications: 1 (one) 10 milligram vial Succinycholine (a neuromuscular blocker) 200 milligrams (20 milligrams/milliliter) and 1 (one) 10 milligram vial Amidate (a general anesthetic) 20 milligrams/10 milliliters (2 milligrams/milliliter).

2. An interview was conducted on 8/26/2015 at approximately 11:00 AM with E #4 (Pharmacist). E #4 stated the medication should have been locked up and should be stored in the crash cart as the medications are considered an emergency medication.

Based on observation and interview, it was determined the Hospital failed to ensure patient care equipment underwent initial and/or ongoing preventive maintenance. This has the potential to affect all patients serviced by the Hospital.

Findings include:

1. During observational tours, conducted 8/25/15 thru 8/26/15, the following patient care equipment was observed to have not been checked for initial and/or ongoing preventive maintenance:
a. On 3 South: in the Physical Therapy room- one Nu Step machine; in Storage Room- one Health-O-Meter scale; in the Pediatric Storage Room- one Infant Scale
b. On 2 South: in the Equipment Room- one Pediatric Scale; in the Storage Room- two Health-O-Meter scales

2. An interview was conducted with the Biomed Technician (E#36) on 8/25/15 at approximately 3:30 PM. E#36 stated the Nu Step, the three Health-O-Meters, the Infant Scale, and the Pediatric Scale had not been put on the preventive maintenance schedule and should have been.

C. Based on observation and interview, it was determined the Hospital failed to ensure hand hygiene products were available and utilized in the surgical suites. This has the potential to affect all patients serviced and all staff in the surgical department.

Findings include:

1. An observation of Regional Anesthesia administration and preparation for surgery for Pt #23 was conducted on 8/25/15 at approximately 7:45 AM. The following breaches in infection control were observed:
a. There was no hand hygiene gel available in the surgical suite.
b. The Certified Registered Nurse Anesthetist was observed to don and remove gloves without performing hand hygiene before, between or afterwards.
c. The Registered Nurse (E#29) was observed to pick up an item off the floor with bare hand, throw the item away, went to Pt #23's bedside, donned a sterile glove, and held Pt #23's right leg up. Another Registered Nurse (E#30) was observed to don sterile gloves , performed surgical scrub of Pt #23's right leg, removed gloves, charted on computer, donned sterile gloves, zipped the scrub technician's sterile hood/gown, removed gloves, charted on the computer, checked items on desk area with hands, donned sterile gloves, zipped the surgeon's sterile hood/gown, removed gloves, charted more on computer, donned sterile gloves, zipped the sterile hood/gown of the Physician Assistant, removed gloves and continued with activities at computer and in room. At no time did either E#29 or E#30 perform hand hygiene before, between, or after glove donning/removal.

2. An interview was conducted with E#30 on 8/25/15 at approximately 8:35 AM. E#30 stated "If we need it (to perform hand hygiene), it's outside the room. We don't have any in the room (surgical suite). There's only one patient so we don't have to. If we need it, it's outside the room."

3. An interview was conducted with the Director of Surgical Services (E#28) on 8/25/15 at approximately 8:40 AM. E#28 stated "We use to have hand gel in the ORs (operating rooms), but they would outdate and were wasted. We're in the mind set of being with one patient and not that we are touching the computer or anything else."

D. Based on observation and interview, it was determined for 1 of 1 Emergency Department (ED) patient transport stretchers, the Hospital failed to ensure the stretcher mattresses were clean to prevent the potential for cross contamination. The has the potential to affect all patients requiring transport via stretcher into the ED.

Findings include:

1. An observational tour of the ED was conducted on 8/25/15 at approximately 11:30 AM with the Director of Critical Care Services (E#1). A stretcher with a mattress with tape residue (which would compromise the cleaning process) was observed parked in the entryway to the ED and was available for patient care use.

2. An interview was conducted with E#1 on 8/25/15 at approximately 11:45 AM. E#1 had observed the tape residue on the stretcher mattress. E#1 agreed the stretcher mattress should not be available for patient care use.


32822

A. Based on document review, observation, and interview it was determined that for 1 of 2 (Pt #8) patient, observed in isolation, the Hospital failed to ensure staff followed infection control policies and procedures related to personal protective equipment (PPE) and dedicated equipment to prevent the potential for cross contamination. This has the potential to affect all visitors, staff, and patients being serviced by the Hospital.

Findings include:

1. The policy titles "Isolation" (effective 10/1997) and the "Contract Precaution" signage were both reviewed on 8/26/2015 at approximately 3:15 PM. Both indicated the following: Wear gloves when entering the room; Wear gown when entering patient room if you anticipate that your clothing will have substantial contact with patient...; Dedicate the use of noncritical patient-care equipment to a single patient;

2. Pt #8's record was reviewed on 8/25/2015. The record noted, Pt #5 was admitted to the Hospital on 8/20/2015 with diagnosis of Hypercardia Chronic Obstructive Pulmonary Disease and History of Methocillian Resistant Staphylococcus Aureus of the right leg. Pt #5 was placed in contact isolation on 8/23/2015 at 11:16 AM.

3. A tour of the of the Intensive Care Unit was conducted on 8/25/2015 at approximately 1:00 PM with the Director of Education (E #2). Room #4 was observed to have signage for contact isolation. A registered nurse (E #5) entered Room #4 without donning gloves or a gown. E#5 then assisted Pt #8 on and off the bedside commode, assisted Pt #8 back to bed, opened the curtains, removed gloves, and then performed hand hygiene prior to exiting the room. Gloves and gowns were not observed to be available for E#5 before entering Pt #8's room.

4. An interview was conducted on 8/25/2015 with E#5. E#5 stated they use a temporal thermometer on all patients in the intensive care unit and then it is cleaned after each use. "We do not have disposable thermometers on this unit."

5. An interview was conducted with E #2 on 8/25/2015 at 1:30 PM. E #2 stated the infection control policy was not being followed.

B. Based on document review and interview, it was determined for 5 of 8 {Medical Doctor} (MD)#5, MD#6, MD#11, MD#12, MD#14) physicians, credentialed to provide services, the Hospital failed to ensure infection control education was provided. This has the potential to affect all patients being provided care by indicated physicians.

Findings include:

1. MD #5's credential file was reviewed on 8/27/2015 at approximately 11:00 AM. MD# 5 was reappointed to medical staff thru 7/6/2017. The file lacked documentation of infection control education.

2. MD #6's credential file was reviewed on 8/27/2015 at approximately 11:00 AM. MD #6 was reappointed to medical staff thru 10/31/2016. The file lacked documentation of infection control education.

3. MD #11's credential file was reviewed on 8/27/2015 at approximately 11:00 AM. MD #11 was reappointed thru 10/31/2017. The file lacked documentation of infection control training.

4. MD #12's credential file was reviewed on 8/27/2015 at approximately 11:00 AM. MD #12 was reappointed thru 9/20/2018. The file lacked documentation of infection control training.

5. MD #14's credential file was reviewed on 8/27/2015 at approximately 11:00 AM. MD #14 was reappointed thru 7/31/2018. The file lacked documentation of infection control training.

6. During an interview with an Director of Education (E #2), conducted on 8/27/2015 at approximately 2:00 PM, E#2 stated that there was no documentation that the physician's received infection control training.

Based on document review, observation and interview it was determined the Hospital failed to ensure the Malignant Hyperthermia (MH) policy was followed. This has the potential to effect all patients serviced by the Surgical Department.

Finding:

1. The policy titled "Malignant Hyperthermia Box" (revised 8/2015) was reviewed on 8/27/2015 at approximately 2:00 PM. The policy indicated "The Surgical Services Department will have a cart stocked for the management of malignant hyperthermia at all times". Examples of equipment the policy stated the cart would contain were items such as a temperature probe, equipment needed for arterial line, 3-way Foley catheter, rectal tubes of various sizes, peritoneal lavage tray, Dantrolene- 36 vials (20 milligram vials), etcetera.

2. An observational tour of the Surgery Department was conducted on 8/25/2015 at approximately 11:00 AM with the Director of Education (E #2). The MH Cart was observed to contain only the Dantrolene. E #2 verified the cart lacked all the items listed on the Malignant Hyperthermia policy.

3. An interview was conducted with the Director of Anesthesia Services (E #7) on 8/25/2015 at approximately 11:30 AM. E #7 verbalized the MH Cart did not have all the necessary equipment to treat a MH emergency.