HospitalInspections.org

Based on a review of clinical records and interview, the hospital failed to ensure that two of two patient's (#6,#7) in the endoscopy clinic, had a history and physical (H&P) completed within 30 days prior to the procedure. The findings include:

a. Review of Patient #6's clinical record identified that the patient underwent a screening colonoscopy by MD #1 on 11/12/14, for which the patient received anesthetic medication. Although MD #1 documented a "pre-anesthesia assessment" on the procedure record, the endoscopy record failed to include an H&P completed within the last 30 days. Additionally, the cardiovascular evaluation identified that the patient was "normal" rather than what MD #1 heard when the patient's heart sounds were auscultated (regular vs irregular). During interview on 11/12/14 at approximately 11:15 AM, the Director of the Outpatient Clinics stated that she was unaware that the H&P was required to be on the record.

b. Review of Patient #7's clinical record on 11/13/14 identified that the patient underwent an EGD (esophagealendoduodenoscopy) by MD #1 on 11/12/14, for which the patient received anesthetic medication. Review of the record reflected that the patient had undergone an H&P on 10/1/14; greater than 30 days prior to the procedure. A pre-anesthetic assessment was completed by MD #1 on the procedure record, documenting heart and lung sounds prior to the procedure. Additionally, the patient had an "unconfirmed" allergy to Latex on nursing documentation but failed to reflect substantiation in the physician documentation.

Based on clinical record review and interviews for 2 (P#3, P#5) of 5 patients reviewed on observation every 15 minutes and 2 (P#3, P#12) of 5 patients on weekly weights, the facility failed to carry out the interventions according to the physician's orders and patient plan of care (PCP). The findings include:

Patient (P) #3 was admitted to the hospital on 10/29/14 with diagnoses that included severe depression. A PCP and physicians orders dated 10/29/14 indicated P#3 was to be observed every 15 minutes for safety checks and weekly weights. The medical record lacked documentation that 15 minute checks were completed on 11/1/14 from 4:30 AM through 6:30 AM and 11/8/14 at 3:30 PM. In addition the medical record indicated P#3 was weighed on 11/2/14 and 11/12/14. The medical record lacked documentation P#3 had been weighed on admission and weekly thereafter.

P#5 was admitted to the hospital on 10/27/14 with diagnoses that included dementia with increased agitation, aggression, and behavioral disturbances. A PCP and physicians orders dated 10/27/14 indicated P#5 was to be observed every 15 minutes for safety checks. The medical record lacked documentation that 15 minute checks were completed on 10/29/14 9:00 PM through 10:30 PM, 11/2/14 6:00 AM through 6:30 AM and 11/6/14 10:00 AM through 3:00 PM.

P#12 was admitted to the hospital on 11/7/1414 with diagnoses that included dementia with behavioral disturbances and premorbid schizophrenia. A PCP and physicians orders dated 11/7/14 indicated P#12 was to be weighed weekly. The medical record indicated P#12 was not weighed on admission due to combative behaviors. P#12 was weighed on 11/12/14. The medical record lacked documentation explaining why P#12 had not been weighed between 11/7/14 and 11/12/14.


During an interview with the Vice President of Nursing on 11/13/14 at 1:00 PM, the Vice President of Nursing indicated 15 minute checks should be completed every 15 minutes and weights should be documented weekly according to physician orders.


Facility Weight Monitoring policy indicated patients would be weighed on admission and as determined by the physician. Additionally the facility policy for the Geriatric Psychiatric Program Individual Behavioral Checklist indicated all patients would be admitted on 15 minute checks and progression of check status would be made by the Physician or Licensed Individual practitioner (LIP).

Based on observation and interview, the hospital failed to ensure that sanitary practices were consistently observed within the tray line. The findings include:

a. Observation of the tray line production on 11/12/14 at approximately 12:05 PM with the Director of Food Services, identified that the person ladling out the main course, while having adequate head covering that completely covered the hair on his head, failed to cover the hair of his beard which was approximately one inch long. During interview with the Director of Food Services, identified that all hair should be covered when working the tray line. Additionally, two tray line participants one who set the tray with eating utensils and another who added dessert to each tray: each left the tray line to open the door of the refrigerator during tray line to obtain additional supplies without hand sanitation and/or changing gloves. One participant, near the end of tray line, took additional supplies from a cart and obtained additional warming plates without hand sanitation/changing of gloves.