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Based on interview, policy review and medical record review, the facility failed to monitor and evaluate Patient 29's heart rhythm according to facility policy, and failed to monitor Patient 29 for constipation. The sample size was 51 patients, the census was 156 patients.
Findings:

The medical record review for Patient 29 was completed on 11/15/11. The medical record review revealed that the 96-year-old patient was admitted to the facility on 11/10/11 and had a history and physical dated 11/10/11 that stated that the patient had congested heart failure, schizophrenia, second degree atrial/ventricular block, dementia, diabetes, and atrial fibrillation that was new.
The medical record review revealed a physician's order dated 11/10/11 at 4:30 P.M. that stated the patient's heart was to be monitored with telemetry.
The medical record review revealed a telemetry strip reading had not been documented for the 7:00 AM to 3:00 PM shift. The medical record review revealed telemetry strips dated 11/11/11 at 4:24 AM, 11/11/11 at 1:22 PM, 11/11/11 at 9:48 PM, 11/12/11 at 4:20 AM, 11/12/11 at 3:03 PM, 11/12/11 at 9:44 PM, 11/13/11 at 4:22 AM, 11/13/11 at 3:43 PM, and 11/13/11 at 9:47 PM.
The medical record review did not reveal where the floor telemetry nurse read the telemetry strip from 11/12/11 at 11:00 PM to 11/13/11 at 11:00 PM.
On 11/14/11 from 3:00 PM to 11:00 PM the floor nurse had interpreted the patient's heart rhythm as simply atrial fibrillation in the nursing note (and not on the timed and dated strip). The ICU staff had interpreted the rhythm on the strip of 11/14/11 at 9:34 PM as sinus arrhythmia with premature ventricular contractions. The medical record review did not reveal where the ICU staff and the floor nurse discussed the discrepancy.
On the morning of 11/15/11 the surveyor was presented with two policies regarding telemetry: one that was last reviewed 01/11 and one that was last reviewed 01/09. The 01/09 policy stated both ICU staff and the telemetry floor nurse are to document the patient's rate and rhythm on the strip. It stated if there were any discrepancy, the ICU staff would call the floor nurse to discuss it.
The 01/11 telemetry policy stated ICU staff (ICU RN/Monitor Clerks) were to document the patient's rhythm every shift. (It does not direct the floor telemetry nurse to assess the rhythm.)Neither the 01/09 or 01/11 policies have an effective date listed.
On the afternoon of 11/15/11, a third telemetry policy was presented. This policy had a review date of 11/11 that stated the telemetry floor had a central monitoring station for visual monitoring only and the ICU staff would provide basic rhythm strip interpretation for each shift.
When the 01/11 telemetry policy was presented, Staff M stated it was still in the process of being approved.
On 11/15/11 at 9:55 AM in an interview, Staff N stated that the rhythm strips for the day shift were traced and recorded on the night shift because " If we waited to 7:00 AM we couldn't get strips on people. " He/she said " It's a busy time. " He/she explained at that time strips are being taken for the ICU patients, and there isn't time to take tracings of the telemetry floor patients.
The medical record review revealed that the patient was admitted on 11/10/11 from a local extended care facility. The medical record review did not reveal where a bowel movement had been documented either in the extended care facility prior to the patient's admission to the facility, or at any time during the patient's hospital stay.
On 11/15/11 at 10:45 AM in an interview, Staff O stated he/she did not know the last time the patient had had a bowel movement.
After surveyor queries into the patient's bowel movements, the medical record review revealed a physician's order dated 11/15/11 at 10:45 AM that stated to give the patient an enema before discharge on 11/15/11 and to call if there weren't any results.
The medical record review revealed a nursing note dated 11/15/11 at 3:05 PM noting that the patient stated he/she had had a bowel movement the evening of 11/14/11 and was refusing the enema.
The medical record review revealed that the patient had been assessed on 11/15/11 from 3:00 PM to 11:00 PM as having an unsteady gait and needing assistance with ambulation. The medical record review revealed that the patient had been assessed on 11/15/11 from 11:00 PM to 11/16/11 at 7:00 AM as needing assistance with ambulation.

Based on interview and clinical record review, the facility failed to ensure that a medication order for Patient 35 included dosages for titration. The sample size was 51 patients, the census was 156 patients.

Findings:

The medical record review for Patient 35 was completed on 11/15/11. The medical record review revealed the 63-year-old patient was admitted to the facility on 11/10/11 and had a history and physical dated 11/10/11 that stated the patient was found not to be awake in the morning by her/his neighbor. The history and physical stated the patient had a medical history of diabetic ketoacidosis, brittle diabetes, hypertension, coronary artery disease, and hypothyroidism. The history and physical stated the patient was diagnosed with an alteration in mental status, respiratory failure, and diabetic ketoacidosis.
The medical record review revealed the patient came to the ICU on 11/10/11 at 12:45 PM and on 11/10/11 at 3:00 PM had a heart rate of 142 beats per minute, and a blood pressure of 99/51 millimeters mercury.
The medical record review revealed a physician's order dated 11/10/11 at 3:20 PM that stated: " IV levophed titrate to keep blood pressure greater than 90/60 and heart rate greater than 65. " The order did not indicate the starting dose, the maximum dose, or by what amounts the nurse could titrate the medication.
On 11/15/11 at 2:50 PM in an interview, Staff M stated they did not have a policy dictating the amount by which the drug could be titrated. He/she said her/his staff knows how to titrate the drug.
On 11/17/11 at 11:00 AM in an interview, Staff P stated that the order should have been transcribed to the medication administration record with the starting dose and intervening titration doses. He/she confirmed that that was not done.

Based on observations and staff interviews, the facility failed to ensure that all medical records were completed within 30 days following discharge.

Findings include:

During tour of the medical records area on Wednesday, 11/16/11 with the Director of Medical Records, it was learned during interview that there were 36 delinquent medical records over 30 days following discharge. There was currently 1 physician on suspension due to his/her delinquent records.

Based on the life safety code inspection conducted 11/14/11 thru 11/17/11, it was determined that this facility was not maintained in a manner safe from fire. This has a potential to affect patients, visitors and staff members. The facility census at the beginning of the survey was 156.

Findings include:


This facility failed to ensure all doors in exit passageways and smoke/fire barriers were held open only by devices which would allow release of the door upon activation of the fire alarm, smoke detection or sprinkler systems. Additionally, this facility failed to ensure all like doors would close and latch properly with two sets of doors leaving a gap greater than one eighth inch between the door leafs when in the closed position. Please refer to Life Safety Code deficiency tag K-21.

This facility failed to ensure all exits and exit passageways were marked with readily visible signs which could be viewed from all areas of the room or corridor which the exit exists. Please refer to Life Safety Code deficiency tag K-22.

This facility failed to ensure the medical gas storage location light switches and receptacles were mounted either outside of the room or mounted greater than five feet from the floor if located within the room. Additionally, this facility failed to ensure all medical gasses in storage were stored within the one hour fire rated room. Please refer to Life Safety Code deficiency tag K-76.

This facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors and to ensure all smoke detectors were sensitivity tested as required by the National Fire Protection Association (NFPA) 72 Chapter 7-3.2.1. Please refer to Life Safety Code deficiency tag K-130.

Based on the life safety code inspection conducted 11/14/11 thru 11/17/11, it was determined that this facility was not maintained in a manner safe from fire. This has the potential to affect patients, visitors, and staff members. This facility census at the beginning of the survey was 156.


Findings include:

K-21 This facility failed to ensure all doors in exit passageways and smoke/fire barriers were held open only by devices which would allow release of the door upon activation of the fire alarm, smoke detection or sprinkler systems. Additionally, this facility failed to ensure all like doors would close and latch properly with two sets of doors leaving a gap greater than one eighth inch between the door leafs when in the closed position.

Facility tour took place with staff J on the days of 11/14/11 through 11/17/11. During tour of the first and third floor smoke/fire barriers observation was made of doors failing to close and latch properly and doors which were propped open using unapproved devices. These doors were observed in the following locations:

First Floor:
* The smoke/fire barrier door in room 1155 was observed to be propped open with a chair.
* The smoke/fire barrier door in the specialty department room was observed to be propped open with a trash container.
* The smoke/fire barrier door located at the north section of the cardiac catheterization lab failed to close and latch properly.
* The smoke/fire barrier door located at the north section of the medical office building failed to close and latch properly.

Third Floor:
*The double smoke barrier doors near rooms 353 and 355 was observed to have a gap greater than one eighth inch between the door leaves when in the closed position.

Fifth Floor:
*The smoke barrier door was observed to have a gap greater than one eighth inch between the door leaves when in the closed position.


K-22 This facility failed to ensure all exits and exit passageways were marked with readily visible signs which could be viewed from all areas of the room or corridor which the exit exists.

Findings include:

Facility tour took place with staff J on the days of 11/14/11 through 11/17/11. During tour of the second floor observation was made of two exit access doors which had illuminated exit signs but they failed to be mounted in a position which were readily visible to all those utilizing these areas. They were located in the following locations:

*At the south wing medical surgery department, stairwell C.
*Within the recovery room of the surgery department near room 1202.


K-76 This facility failed to ensure the medical gas storage location light switches and receptacles were mounted either outside of the room or mounted greater than five feet from the floor if located within the room. Additionally, this facility failed to ensure all medical gasses in storage were stored within the one hour fire rated room.

Findings include:

Facility tour took place with staff J on the days of 11/14/11 through 11/17/11. During tour of the medical gas storage room observation was made within the room of one light switch and one receptacle mounted approximately four feet from the floor.
Additionally, tour of the surgical area reveals three H tanks of argon and 4 H tanks of helium along with two E tanks of nitrogen, two E tanks of oxygen, four E tanks of carbon dioxide, two E tanks of compressed air and two E tanks of nitrous oxide stored in an unprotected room which also housed medical equipment. This room was labeled as an equipment room and lacked any sign indicating medical gasses were stored within the room.


K-130 This facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors and to ensure all smoke detectors were sensitivity tested as required.

Findings include:

Facility tour took place with staff J on the days of 11/14/11 through 11/17/11. During tour observation was made of several smoke detectors which were located near air flow devices in the following areas:

Ground Floor:
*Within the housekeeping room near the receiving area.
*Within the MRI waiting area and the control room.
*At the entrance of the cafeteria.
*Within the IT department data center and director's office.

First Floor:
*Within the hyperbaric room.
*Within room 1129 outside the cardiac catheterization lab.
*Within the radiology department corridor by the smoke barrier doors on the same side as the CAT scan room and by room 0164.
*By room 1169
*Within room 0150
*Within the emergency department rooms 1101, 1103, 12, 1126, 1162, 1164, 0169, at the ambulance entrance and operations room of the registration area.

Second Floor:
*Beside the return vent near room 0253 of the south wing medical surgery area.
*Within the ICU by bed 8.
*Within the north wing medical surgery area rooms 0218, 0220 and 0221.
*Within the surgery and recovery areas in rooms 1202, 1206, 1208, 1209, 1222, 1214, 1215, 1216 and two smoke detectors within the waiting area.

Third Floor:
*Within the laser room 0365.
*Just outside the delivery suites.
*Near the nurses station.
*Within the nursery room 0343.
*Within the clean utility room 0360.
*Within the physician's sleep room 0345.
*Within lab rooms 0382, 0383, 0384 and four smoke detectors within the open lab area.

Fourth Floor:
*Within the endoscopy waiting room.
*Within rooms 0414, 0417, 0424, 0425 and 0450.

Fifth Floor:
*Within rooms 0509, 0520, 0523 and 0534.

Documentation review for the fire alarm system for both surveyed off-sites took place on 11/16/11. Documentation verifies there was no sensitivity testing of the smoke detectors.

Staff J validated all the above findings during the survey process.

Based on interview and medical record review, the facility failed to ensure Patient 39's consent form was properly executed. The sample size was 51 patients, the census was 156 patients.

Findings:

The medical record review of Patient 39 was completed on 11/15/11. The clinical record review revealed the patient presented to the facility on 11/14/11 for surgery for a laparoscopic cholecystectomy or possible standard procedure.
The medical record review revealed that there was a surgical consent signed and dated by the patient at 11/14/11 at 11:00 AM. The form stated: " I have discussed the content of this consent form with my physician or his/her designee. I have had all my questions answered. I have read this form (or have had it read to me) and, of my own free will, consent and agree to the above." Above this, the form reads: PHYSICIAN'S ATTESTATION/I have discussed the above with the patient or his/her representative. " Below this statement is a place for the physician to sign, date, and time the form. The form did not show a physician's signature.
On 11/14/11 at 12:45 PM in an interview, Staff Q stated the surgeon was not yet in the building.
The medical record review revealed that a history and physical dated 11/14/11 had been dictated at 12:18 PM and stated: " The patient is scheduled for laparoscopic, possibly open, cholecystectomy. The risks, benefits and complications were discussed. The patient consented for surgery. "