HospitalInspections.org

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Based on observation and interview the facility failed to ensure 1 medication syringe, ready for patient use, was labeled with the name of the medication. This failed practice created a risk for a medication error. Findings:

Observation on 5/31/16 during the initial tour of the Specialty Clinic exam rooms revealed 1 syringe, dated 5/26/16 and labeled with Patient #18's name, filled with 4 cc's of clear liquid, was found in the orthopedic room. Medical Assistant #1 stated the syringe was filled with a medication used by a Provider to numb Patient #18's wrist. The syringe was not labeled with the name of the medication.

Review of Patient #18's medical record, on 6/1-3/16, revealed the Patient was seen 5/26/16 in the clinic for wrist pain. The record revealed "...I [Provider] injected the radial side of the left wrist-superficial radial nerve. This made [Patient #18] numb..."

During an interview on 6/2/16 at 4:10 pm the Specialty Clinic Manager said the medication that was in the syringe for Patient #18's 5/26/16 office visit was Bupivacaine (a numbing medicine).
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Based on interview the facility failed to ensure radiology services had policies and procedures: 1) specifying criteria for ensuring patients and staffs safety from radiation hazards and 2) for which studies and/or films require tele-radiology services interpretation. Failure to have these policies and procedures in place has the potential to place patients and staff at risk for increased radiation doses and has the potential for delays with patients' studies/films being interpreted. Findings:

During an interview on 6/1/16 at 11:10 am the Radiology Manager (RM) was asked for policies and procedures on patient and staff safety from radiation hazards and which studies and/or films are read in house and which must be sent out. The RM said there were no policies or procedures.

Based on record review, interview and policy review the facility failed to ensure complete and accurate documentation in medical records for 3 patients (#s 18, 19, and 24). This failed practice created an incomplete portrayal of the care and services provided to the patients. Findings:

Patient #18

Record review on 6/2-3/16 revealed Patient #18 was seen in the Specialty Clinic on 5/26/16 with diagnosis of persistent left wrist pain.

Continued review of the medical record revealed "...I [Provider] injected the radial side of the left wrist-superficial radial nerve. This made [Patient #18] numb..." The medical record did not have documention of what the medication was or the dosage the Patient had received.

During an interview on 6/2/16 at 3:33 pm, the Specialty Clinic Manager said he would expect the standard of care to be followed, which would including writing the name and the amount of the medication the Patient received, when documenting in the Patients chart.

Patient #19

Record review on 6/2/16 revealed Patient #19 was admitted to the facility on 6/2/16 at 8:00 am for an outpatient procedure.

During an observation on 6/2/16 at 8:00 am the Nurse Manager for Perioperative Services (Nurse Manager) and RN #1 prepped the Patient for the procedure. RN #1 first gave Patient #19 an injection of lidocaine (a numbing medication) to the back of the Patient's right hand, then inserted the needle cannula (flexible plastic tube) into a vein and connected it to the IV (intravenous-within the vein) fluid. The Patient stated the IV cannula was causing a painful shooting down his fingers. As the RN continued to adjust the IV, the Patient stated he was nauseous and dizzy. The Nurse Manager lowered the Patient's head and a cool cloth was placed on the Patient's forehead. RN #1 removed the IV from the Patients right hand. The Nurse Manager obtained an ice bag and placed it on the back of the Patient's right hand.

At 8:20 am, after the Patient stated he felt better, RN #1 placed an IV in the back of the Patient's left hand.

Review of the medical record on 6/2/16 revealed at 8:20 am "Location: metacarpal vein (top of hand), left Device/Lot Number: over-the-needle catheter system Gauge/Length: 20 gauge Pain Prevention/ Patient Tolerance..." There was no documentation about the prior IV start on the right hand and the resulting pain, nausea and dizziness.

During an interview on 6/2/16 at 5:00 pm, the Quality Support Specialist was unable to find a record of the failed IV start in the Patient's right hand.

During an interview on 6/3/16 at 12:30 pm, when asked about the documentation, the Nurse Manager was unable to locate the documentation in the record. The Nurse Manager stated she would expect an event like that to be documented.

Patient #24

Record review on 6/3/16 revealed Patient #24 was seen in the Specialty Clinic on 5/19/16 for right thumb pain. Continued review of the medical record revealed "PLAN: The patient would like a right thumb CMC [carpometacarpal] injection...We will proceed with the injection..." The Physician's documentation did not state if the injection was done, and if done what the medication and dosage was for the injection.

Review of the facility policy "Medication Administration" number 951.169, last revised 9/14, provided by the Specialty Clinic Manager, revealed "This policy outlines standards for safe medication administration and a consistent method for documentation of medications...requires that qualified personnel [which includes physicians] obtain, administer, monitor and document all medications given to patients..."

Review of the facility "MEDICAL STAFF RULES AND REGULATIONS...Adoptions: January 21, 2014", revealed "...PATIENT CARE DOCUMENTATION The attending practitioner shall be responsible for the preparation of a complete medical record for each patient...Each medical record should include...medical...treatment..."
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Based on document review and interview the facility failed to ensure a periodic evaluation of their services was completed and utilized to guide quality assurance issues. Therefore, the CAH was unable to meet the Condition of Participation of Periodic Evaluation & QA Review at CFR 485.641. The cumulative effect of this created a risk for the facility's inability to maintain effective quality assurance processes in order to ensure provision of quality health care. Findings:

C331- The facility failed to conduct an annual evaluation of the its total program at least once a year.

C332-The facility failed to perform an annual review of the utilization of the facility's volume of services.
C333-The facility failed to ensure a sample of open and closed records was completed as part of a yearly program evaluation.

C335- The facility failed to have an annual program evaluation that determined whether the utilization of services was appropriate and used for the review of facility practices and procedures.
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Based on record review and interview the facility failed to conduct an annual review of their total program. As a result, there was no documented evidence of an evaluation that included determining appropriateness of utilization of services and drove changes in facility practices. Without sufficiently identifying or adequately addressing and communicating about the facility's scope and services, systemic improvement cannot be achieved and maintained throughout the facility. Findings:
Review of the facility's quality assurance program and Governing Body meeting minutes on 6/2-3/16 revealed no provided evidence of the hospital's annual program review.

During a interview on 6/2/16 at 2:00 pm, when asked about the facility's annual review the Chief Executive Officer (CEO) stated she would have to check.

During a second interview on 6/3/16 at 8:05 am, the CEO stated the facility had not completed an annual review of their program.
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Based on record review and interview the facility failed to perform an annual review of the utilization of the facility's volume of services. The failure to perform the annual review denied the facility the opportunity to improve the quality, utilization, and value of hospital services. Findings:


Review of the quality assurance program on 6/2-3/16 revealed no evidence the number of patients and volume of services were reviewed annually.


During an interview on 6/2/16 at 2:00 pm, when asked about the facility's annual review the Chief Executive Officer (CEO) stated she would have to check.

During a second interview on 6/3/16 at 8:05 am, the CEO stated the facility had not completed an annual review of their program.
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Based on record review and interview the facility failed to ensure a sample of open and closed records was completed as part of a yearly program evaluation. Without sufficiently identifying or adequately addressing and communicating about areas of deficient practice, systematic corrections cannot be achieved and maintained throughout the facility. Findings:

Review of the facility's Governing Body meeting minutes and quality improvement program on 6/2-3/16 revealed no evidence 10% of patient records and been reviewed as part of the annual program review.

During an interview on 6/2/16 at 2:00 pm, when asked about the facility's annual review the Chief Executive Officer (CEO) stated she would have to check.

During a second interview on 6/3/16 at 8:05 am, the CEO stated the facility had not completed an annual review of their program.

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Based or record review and interview the facility failed to have an annual program evaluation that determined whether the utilization of services was appropriate and used for the review of facility practices and procedures.

Review of the Governing Body meeting minutes and the quality assurance program on 6/2-3/16 revealed no evidence an annual review of the hospital's program had been evaluated.

During a interview on 6/2/16 at 2:00 pm, when asked about the facility's annual review the Chief Executive Officer (CEO) stated she would have to check.

During a second interview on 6/3/16 at 8:05 am, the CEO stated the facility had not completed an annual review of their program.
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