HospitalInspections.org

Based on interview and record review, the hospital failed to ensure that the Medical Staff was accountable to the Governing Body for the quality of care provided to patients. This had the potential to affect all patients in the hospital.
Findings include:
Review of the undated document titled " Cases for MSQC [Medical Staff Quality Committee] for 2015, " revealed the following significant concerns:
1). A physician failed to order a T&C (Type and Crossmatch) for a patient with sickle cell that required a blood transfusion. The MSQC members agreed to a rating of 4 (inappropriate care) for failing to follow the standard of care.
2). A physician was alleged to have overmedicated a patient during surgery. The MSQC members agreed to a rating of 4 (inappropriate care).
3). A physician was alleged to have reported patient findings to an attending physician without examining the patient. The MSQC team agreed to a rating of 5 (Inappropriate care-severe)
4). A physician was alleged to have inappropriately discharged an End Stage Renal Disease (ESRD) patient. The MSQC team agreed to a rating of 5 (Inappropriate care-severe)
During an interview on 12/8/15 at 1:00pm, Staff Person (SP) #1 who serves as the Medical Executive Committee (MEC) Director, stated that the MEC reports a summary of incidents to the Governing Body. When asked if any of the events noted above were referred to the Governing Body for recommended action, SP #1 stated that the Board has not made any recommendations as no cases have been presented to the board for recommendations. The board does not get involved unless recommended to do so by the MEC. SP #1 reported that the Governing Body has not made any recommendations for disciplinary actions to be taken against medical staff.
SP #1 was asked how the MEC determines when medical errors need to be presented to the board for recommended disciplinary action, and stated that the MEC " want[s] to develop a template of significant incidents. " SP #1 stated that this has not yet been developed.
During an interview on 12/9/15 at 1:00pm with SP #2, president of the Governing Body, stated that he is aware that the Governing Body must take a more active role in the oversight the concerns identified by the MEC. SP #2 confirmed that the hospital has no current objective guidelines for the situations that must be brought to the attention of the Governing Body.

Based on record review, interview, review of the directions for completing the informed consents, and policy review, the hospital failed to ensure that each patient, or their representative, was provided with information about the patient ' s health care needs, could make informed decisions and had signed the appropriate consents/documents. This had the potential to affect three (Patients #4, #7 and #24) of 31 sampled patients.

Findings include:

1. Interview with SP #3 on 12/8/15 at 3:00pm verified Patient #4 ' s " Emergency Room Record " lacked Patient #4 ' s signature or time and date. SP #3 confirmed that all consents are to be signed by the patient, family member or representative when the patient is admitted to the Emergency Room or as an inpatient.

Policy titled- " Inform Consent, SCOPE: (ALL PATIENT CARE SERVICES), EFFECTIVE DATE(s) PRIOR VERSIONS: November, 1, 2012 " directed staff to obtain and place in the patient medical record, a signed informed consent for all services provided in the hospital, including emergency service treatment.


2. Review of the medical record for Patient #7 revealed that the patient was admitted to this hospital on 11/2/15 with a diagnosis of a cerebral vascular accident (CVA- stroke).

Review of the " Physician's Order Form " dated 11/2/15 revealed that Patient #7 was to have the following procedures and tests performed during his/her stay at this hospital:
Vital signs every shift
Daily weight
Intravenous fluids (IVF) and medications (antibiotics)
Blood cultures
Urine Cultures
Daily blood draws
Carotid ultrasound
Echocardiogram
Speech Therapy
Social Services


Further review of the medical record for Patient #7 revealed that s/he lived alone, did not have any children and was unable to sign his/her own informed consents. Per the medical record, Patient #7 had a Power of Attorney (POA).

Review of the " Emergency Room Record " dated 11/2/15 revealed that the " General Consent for Treatment " remained blank and it had not been signed or dated by Patient #7 or the POA. In the middle of the document there was a handwritten note that read, " Patient is unable to sign. No relatives present at registration. " Review of the bottom of the document, revealed the directions for completing these consent. The directions read:

" If the patient cannot consent for him/herself, the signature of either the health care agent or legal guardian who is acting on behalf of the patient, or the patient ' s next of kin who is consenting to the treatment for the patient, must be obtained. "


Review of the " Conditions of Treatment " for Patient #7 revealed that neither s/he nor his/her POA dated or signed the document. At the bottom of the " Conditions of Treatment " document, there was a handwritten note that read, " Patient is unable to sign. "

Review of the document titled, " Acknowledgment and Receipt of Hospital Rights " for Patient #7 revealed that it was undated and unsigned by either the patient or his/her POA. Review of the " Remarks " section at the bottom of the document revealed the following information:
" Patient is unable to sign no relatives present at registration. "


Review of the document titled, " An Important Message from Medicare about Your Rights " revealed that it was unsigned by either the patient or his/her POA. At the bottom of the document, there was a hand written note that read, "Patient is unable to sign."

Review of the document titled, " Assignment of Benefits " for Patient #7 revealed that the form remained blank and it was signed by neither the patient nor his/her POA.

An interview with the Staff Person #4 on 12/8/15 at 9:45am confirmed that the hospital should have contacted Patient #7's POA to obtain consent for treatment. SP #4 stated that Patient #7's record was incomplete and the hospital could not ensure that Patient #7 or his/her POA had been informed of their rights, benefits or health care plan.

3. Review on 12/8/15 of inpatient Patient 24's "Emergency Room Record, dated 10/20/15 at 09:20am revealed the "General Consent For Treatment" lacked the patient's or a representative's signature at the time of admission.
Review of the hospital policy titled, "Inform Consent, SCOPE: (ALL PATIENT CARE SERVICES), EFFECTIVE DATE(s) PRIOR VERSIONS: November, 1, 2012" revealed that staff are directed to obtain and place in the patient's medical record a signed informed consent for all services provided in the hospital including emergency service treatment.
In an interview on 12/11/15 at 9:41am, SP #5, stated that if staff are unable to obtain consent at the time of entry to the hospital, the clerk documents that this is the case and speaks to the head nurse who is expected to contact the staff in patient access if the patient becomes available to consent or a family member presents at the hospital.

Based upon interview and record review, the hospital failed to modify patient care plans to reflect the use of restraints for 1 patient in the sample of 31.
Findings include:
Review of Patient #26 ' s medical file revealed an order on 11/15/15 for the use of left and right upper extremity soft restraints. Review of the document titled, " Patient ' s Plan of Care " with a most recent revision date of 11/16/15, revealed no interventions addressing the use of restraints.
Review of the hospital policy titled, " Restraint and Seclusion " with an approval date of 7/6/15 revealed that " [t]he restrained or secluded patient ' s written care plan shall be modified to address appropriate interventions implemented to assure the patient ' s safety and encourage the prompt discontinuation of restraint. " (Page 3).
In an interview on 12/11/15 at 11:45am, Staff Person #6 stated that patient care plans need to reflect the patient ' s need for the use of restraint.

Based on record review and interview, the hospital failed to ensure that restraint orders were not written on an as needed basis for one patient (Patient #25) in the sample of 31.
Findings include:
Review of the document titled, " Physician ' s Order Form " maintained for Patient #25 on 10/22/15, revealed the following order, " Wrist restraints if pt [patient] attempts to pull out NG/IV [Nasogastric tube/Intravenous line] " .
Review of the hospital policy titled, " Restraint and Seclusion " with an approval date of 7/6/15 revealed that " PRN orders for restraint or seclusion shall not be used. Exceptions: Physician orders for restraint that are not used for the management of violent or self-destructive behavior shall remain in effect until ...[t]he end of the calendar day following the date of the order unless the order for restraint includes the specific indications for continuation and discontinuation. " (pp 1-2)
In an interview on 12/11/15 at 11:45am, Staff Person #6 stated that the hospital does not allow restraints to be ordered on an as needed basis and stated that the order as written appears to be a PRN (as needed) order for restraints.

Based on interview and record review, the hospital failed to demonstrate that a patient remained in restraints only for the period of time necessary to ensure his or her immediate safety for one patient (Patient #27) in the sample of 31.
Findings include:
Review of the document titled, " Restraint Order Non-Violent Patients " dated 11/30/15 revealed that Patient #27 was placed in bilateral wrist restraints at 8:25am. Review of the document titled, " Restraints Non Violent " dated 11/30/15 revealed that Patient #27 ' s right wrist restraint was removed at 12:00pm, but Patient #27 ' s left wrist remained in restraints until 6:00pm. Review of the documents titled " Nurse Notes " dated 11/30/15 revealed no documentation indicating why one wrist restraint was released while the other was not.
In an interview on 12/11/15 at 11:45am, Staff Person (SP) #6 confirmed that nursing documentation indicated that Patient #27 ' s right wrist was released from restraints on 11/30/15 at 12:00 but Patient #27 ' s left wrist remained in restraints. SP #6 stated that stated that she could identify no documentation indicating why Patient #27 required the single wrist restraint on 11/30/15. SP #6 confirmed that she expects that nursing staff would document why the left restraint was required at the time of removal of the right restraint.
Review of the facility policy titled, " Restraint and Seclusion " with an approval date of 7/6/15 revealed that " Restraint or seclusion shall be discontinued by the registered nurse once the behaviors or situation that served as the basis for the restraint are no longer present or the safety of the patient, staff members, or others may be assured through less restrictive means (pg. 3).

Based on interview and record review, the hospital failed to document monitoring assessments for patients in restraints as required by hospital policy for two patients (Patient #26 and Patient #9) in the sample of 31.
Findings include:
Review of the document titled, " Restraint Order Non-Violent Patients " dated 11/15/15 revealed that Patient #26 was placed in bilateral wrist restraints at 7:30am. Review of the document titled, " Nurse Notes " revealed that Patient #26 was placed in restraints on 11/15/15 at 7:30am and remained in restraints until his/her death on 11/19/15. Review of the documentation maintained to monitor Patient #26 while s/he was in restraints between 11/15/15 and 11/19/15 revealed that staff failed to document assessments indicating that Patient #26 continued to need the use of restraints to ensure his/her safety.
Review of the document titled, " Restraint Order Non-Violent Patients " dated 11/29/15 revealed that Patient #9 was placed in bilateral wrist restraints at 3:05am. Review of the document titled, " Nurse Notes " revealed that Patient #9 was placed in restraints on 11/29/15 at 3:05am and remained in restraints until the restraints were removed on 12/2/15 due to Patient #9's paralytic condition. Patient #9 expired 5 days later. Review of the documentation maintained to monitor Patient #9 while s/he was in restraints between 11/29/15 and 12/2/15, revealed that staff failed to document ongoing assessments indicating that Patient #9 continued to need the use of restraints to ensure his/her safety.
In an interview on 12/11/15 at 11:45am, Staff Person (SP) #6 stated that staff are to assess patients for the continued need for restraints every two hours. SP #6 confirmed that the records of Patient #26 and Patient #9 did not contain documentation every two hours that supported the continued need for the use of restraints. When asked where staff would document these assessments, SP #6 stated, according to hospital policy, staff are only expected to document once a shift.
Review of the hospital policy titled, " Restraint and Seclusion " with an approval date of 7/6/15 revealed the following facility requirement: " Non-Violent Behavior Restraint not used for the management of violent or self-destructive behavior that shall be subject to ongoing monitoring and assessment as specified in the patient's restraint care plan. Monitoring and assessments shall occur at least every 2 hours and documented (p. 2).

Based on interview and record review, the hospital failed to ensure that a Registered Nurse evaluated the need for additional care following the identification of an elevated blood sugar level for one patient (Patient #6) in the sample of 31.
Findings include:
1. Review of the document tiled " Insulin Sliding Scale Protocol " maintained for Patient #6 revealed the following:
Glucose level: Standard Sliding Scale Insulin Dose:
0-70mg/dl Carbohydrate Source + Call Prescriber
71-199mg/dl 0 Units
200-250mg/dl 3 Units
251-300 mg/dl 6 units
301-350 mg/dl 9 Units
351-400 mg/dl 12 units
Greater than 401 mg/dl 15 units and Call Provider
Review of the glucose level results revealed the following:
11/19/15 at 6:00am: 411mg/dl 15 units of insulin given.
Review of the glucose level results revealed the next blood glucose level was taken at 6:00pm.
Review of the glucose level monitoring worksheets used by staff revealed that blood glucose levels were taken at 6am and 6pm only on 11/19/15.
Review of the Nurse ' s Notes revealed on 11/19/15, no indication that the physician was contacted as indicated on the standard sliding scale protocol form and there was no documentation indicating that any additional blood glucose levels were measured by staff.
During an interview on 12/11/15, at 10:38am, Staff Person (SP) #7 confirmed that there was no documentation that indicated that the patient ' s physician was contacted. SP #7 stated that she would expect the staff nurse to use critical thinking and to recognize that the patient ' s physician should be notified after the glucose level was noted. SP #7 also stated that she would expect staff to recheck the patient ' s blood glucose level 30 minutes after administering the sliding scale insulin to ensure that the level had returned to normal. SP #7 confirmed this was not done.

Based on observation, interview and medical record review the hospital failed to ensure nursing staff assessed and administered prescribed blood pressure medication in a timely manner for one (1) of 31 sampled patients (Patient #11). Evidence includes the following:
2. Medical record review showed Patient #11 was admitted to the hospital on 12/6/15 after suffering a fall at home. His/her medical history included hypertension for which s/he was prescribed the blood pressure medication Lisinopril, 20 milligrams (mg.) daily.
Medical record review showed on 12/7/15 at 11:00 pm, the patient was transferred to the intensive care unit of the hospital after a brain scan earlier in the day showed a severe stroke and symptoms that included left-sided facial drooping and inability to move the right arm and leg. The patient ' s blood pressures between midnight and 6:00 am on 12/8/15 ranged from 157/89 to 154/102 (119/79 or lower is normal adult blood pressure). On 12/8/15 at 11:00 am, the patients' physician directed nursing staff to administer the blood pressure medication Vasotec 1.25 mg. intravenously every three (3) hours as necessary for systolic (the top number of the blood pressure reading) blood pressure greater than 160.
Observation of the patient on 12/8/15 at 3:30 pm showed a blood pressure reading of 184/102 on the bedside continuous cardiac monitor. At 3:53 pm the blood pressure reading showed 182/105. The bedside monitor also showed historical blood pressure readings on 12/8/15 of:
11:30 am-168/98
12:30 pm-178/99
2:36 pm-182/100
2:45 pm-175/103
3:12 pm-98/100
During an interview on 12/8/15 at 3:55 pm, the patients' nurse, Staff Person (SP) #16, said she had not yet administered any of the intravenous Vasotec blood pressure medication even though the patient ' s blood pressure had been significantly greater than 160 systolic for at least 4 ½ hours. After the interview concluded, SP #16 prepared and administered the Vasotec medication.

Based on record review, observation, and interview, the hospital failed to ensure that each patient's plan of care relative to swallowing difficulties and therapeutic diets were implemented. This deficient practice had the potential to affect one (Patient #7) of 31 sampled residents.


Findings include:

Review of the medical record for Patient #7 revealed that s/he was admitted to this hospital on 11/2/15 with a diagnosis of dysphagia (swallowing difficulties) due to a recent cerebral vascular accident (CVA- stroke).
Further review of the medical record revealed that Patient #7 had a physician ' s order dated 11/4/15 for a " thickened/pureed diet ", due to swallowing concerns and a risk of aspiration pneumonia. The physician also ordered a "Swallow Evaluation" and "Speech Therapy" consult.

Review of the admitting physician's, Staff Person #8 progress note, dated 11/4/15 at 12:03pm for Patient #7 revealed the following information:
" ...CVA- Physical Therapy to see, unfortunately Speech Therapy is not available. Will attempt to keed (sic) with thickened and see how it goes. "

Review of Patient #7 ' s care plan dated 11/3/15 revealed the following information:
" ...High Risk: Aspiration
May be related to: Neurological Deficits ... "
" ...Intervention
Optimal HOB (head of bed) placement
Feeding Assessment ... "

Review of the Registered Dietitian (RD) feeding assessment in the electronic medical record revealed the following information: On 11/14/15 at 12:29pm, " Swallowing difficulty related to CVA as evid (evidenced) by RN (Registered Nurse) observations ...improvement, but potential remains. "
" ...Intervention:.. "
" ...Continue w/(with) use of thickened beverages (Honey to Nectar thick)
Practice aspiration precautions. "

Observation of the lunch meal that the facility provided for Patient #7 on 12/7/15 at 11:30am revealed that his/her soup was placed in a bowl and had a "water-like" consistency. When interviewed, at that time, about why Patient #7's soup had a " water-like " consistency, the Director of Nutrition Services stated because the facility was " out of thickener. " The Director added that it was the facility policy to not thicken food in the kitchen. She stated that when a patient had an order for " thicken liquids ", the kitchen staff was to place a packet of thickener on each meal tray and the Certified Medical Assistants (CMA) would add the thickener to the liquids just before the patients ate.
An interview on 12/7/15 at 3:20pm with Staff Person #9 who was assigned to Patient #7, revealed that s/he (Patient #7) required assistance with feeding and s/he was ordered a puree diet with thickened liquids. SP #9 stated that the patient was not interviewable but he was able to communicate with him/her non-verbally. SP #9 added that Patient #7 received puree food for lunch and also received soup. However, the meal tray did not include a food thickening packet. Consequently, the patient was served soup that had a " water-like " consistency rather than a thickened consistency per physician order.

Review of the electronic progress notes revealed a note dated 12/5/15 at 2:35pm that was written by the facilities RD. The following information was obtained from that note:
Continues to do well with puree textures
Nutrition services is currently out of thickener
" Diet-puree, thickener (as above, not sending thickener at this time) "

An interview with Patient #7 ' s attending physician Staff Person (SP) #10 on 12/8/15 at 11:00am confirmed that Patient #7 required thickened liquids and a puree diet due to aspiration precautions. SP #10 stated that she was unaware that the facility had not provided thickened liquids to Patient #7, she was unaware that the facility was out of thickener and they did not attempt an alternative.

An interview with the RD on 12/10/15 at 10:00am confirmed that the hospital was "out of thickener" and the kitchen staff prepared soup for Patient #7 that had a "water-like" consistency, which was contraindicated per his/her feeding assessment and plan of care.

Based in interview and record review, the hospital failed to administer sliding scale insulin as ordered by a physician, for one (1) of 31 sampled patients (Patient #6).
Findings include:
1. Review of the document titled " Insulin Sliding Scale Protocol " maintained for Patient # 6 revealed the following:
Glucose level: Standard Sliding Scale Insulin Dose:
0-70mg/dl Carbohydrate Source + Call Prescriber
71-199mg/dl 0 Units
200-250mg/dl 3 Units
251-300 mg/dl 6 units
301-350 mg/dl 9 Units
351-400 mg/dl 12 units
Greater than 401 mg/dl 15 units and Call Provider
Review of the glucose level results revealed the following:
11/23/15: 216mg/dl; 0 units of insulin given
Review of the Nurse's Notes dated 11/23/15 revealed no documentation indicating why insulin was not given.
Review of the document titled, " Summary of Medication Error Reports involving LA/SA (lookalike/sound alike) Medications for 2014 " revealed no identified insulin-related errors for November, 2015.
During an interview on 12/11/15, at 10:38am, Staff Person (SP) #7 confirmed that there was no documentation that indicated why insulin was not given on 11/23/15. SP #7 confirmed that insulin was a high risk medication and stated that she expected her staff to identify these errors when they conduct the daily review every morning.
During an interview on 12/10/15 at 2:42pm, SP #11 stated that she was not aware of any insulin-related errors for the month of November, 2015. SP #11 stated that a patient who did not receiving insulin as ordered would be an omission error. SP #11 stated that the hospital currently has no formal process to identify these errors of omission.
Review of the document titled, " High Alert Medications " with an effective date of March 2004 and a revision date of October 2012 revealed that Insulin was identified by the hospital as a high risk medication. The document states " High alert medications are drugs that have an increased risk of causing significant harm to a patient when used in error. Because the consequences of an error associated with use of these medications can result in significant patient injury, special precautions will be employed with their overall management throughout the institution "

Based on medical record review and interview the hospital nursing staff failed to ensure patient medications were administered in accordance with accepted standards of practice and hospital policy and procedure for one (1) of 31 sampled patients (Patient #29).
Evidence includes the following:
2. Review of the hospital pharmacy policy and procedure for, Patient ' s Own Medication (usage) " , revised 10/2012, showed the following instructions:-Medications brought in by the patient to be utilized during their stay must meet the following conditions:
-Drugs have been ordered by a person permitted by law and license to give such an order, ...The order must be entered in the patient ' s medical record, i.e., the physician ' s order must indicate that the " patient may use own medications. "
-The contents of the containers have been examined, positively identified and the integrity evaluated by the patient ' s physician and/or the hospital ' s Pharmacist.
-A patient may utilize his/her medication on the written order of the attending physician ...when all of the following conditions are met: patient ' s own medication may be used, name of drug, strength of drug and route, dose schedule, rationale for drug use.
-Medications must be inspected by the pharmacist for positive identification, integrity and correct labeling.
-The Pharmacist will attach a label to the container to indicate that it has been checked, properly identified and integrity evaluated.

Medical record review showed Patient #29 was brought to the hospital ' s emergency department on 11/18/15 with chronic lymphocytic leukemia and sepsis (bacterial infection in the bloodstream or body tissues). At 2:30 pm that afternoon the patient complained of severe pain at a level of 10 (a numeric rating scale for patient self-reporting of pain with 0 being no pain and 10 being severe pain) and requested nursing staff allow him/her to self-medicate with prescribed oral morphine medication s/he had brought with him/her from home and that s/he routinely consumed at this time of day. Documentation showed nursing staff contacted the patient ' s physician and verbal permission was given for the patient to self-administer his/her morphine. Nursing notes showed the patient self-administered the morphine. However, review of the patient ' s medical record on 12/10/15 showed no written physician ' s order authorizing the patient to self-medicate with morphine, and the medication administration record (MAR) showed no nursing documentation of the morphine, including the amount and time that it was self-administered. The medical record contained no nursing or pharmacy services documentation showing the morphine had been inspected by a hospital pharmacist prior to its consumption by the patient.
During an interview on 12/11/15, Staff Person (SP) #11 confirmed that patient medication brought in from home may not be self-administered by the patient until the medication has been inspected and approved by the hospital pharmacy. She said patients in the emergency department should be receiving their prescribed medications through the hospital pharmacy. She was unaware that Patient #29 brought medications from home to the emergency department and was allowed to self-medicate with morphine without first sending the morphine to the hospital pharmacy for inspection. After reviewing the patient ' s medical record, Staff Person #11 confirmed there was no written physician order for the patient to self-medicate with the morphine s/he had brought in from home. SP #11 also confirmed nursing staff did not follow accepted standards of practice by failing to document on the patient ' s MAR the drug name, dose, route, and time that s/he self-medicated with the morphine.

Based on medical record review and interview, the hospital failed to ensure nursing staff followed hospital policy and procedures for patient self-administration of prescribed medications brought in from home. Nursing staff failed to ensure the medical record for one (1) of 31 sampled patients (Patient #29) included written physician orders for the self-administered medication and failed to document the administration of the medication in the patient ' s medical record. Evidence includes the following:
Medical record review showed Patient #29 was brought to the hospital ' s emergency department on 11/18/15 with chronic lymphocytic leukemia and sepsis (bacterial infection in the bloodstream or body tissues). At 2:30 pm that afternoon the patient complained of severe pain at a level of 10 (a numeric rating scale for patient self-reporting of pain with 0 being no pain and 10 being severe pain) and requested nursing staff allow him/her to self-medicate with prescribed oral morphine medication s/he had brought with him/her from home, and that s/he routinely consumed at this time of day. Documentation showed nursing staff contacted the patient ' s physician and verbal permission was given for the patient to self-administer his/her morphine. Nursing documentation showed the patient self-administered the morphine. However, review of the patient ' s medical record on 12/10/15 showed no written physician order authorizing the patient to self-medicate with morphine, and the medication administration record showed no nursing documentation of the morphine, including the amount and time that was self-administered.
Review of the hospital pharmacy policy and procedure for, " Patient's Own Medication (Usage) " , showed: medications brought in by the patient to be utilized during their stay must meet the following conditions - the contents of the containers have been examined, positively identified and the integrity evaluated by the patient's physician and/or the hospital's pharmacist; medications must be inspected by the pharmacist for positive identification, integrity and correct labeling.

During an interview on 12/11/15, Staff Person #11 confirmed that patient medication brought in from home may not be self-administered by the patient until the medication has been inspected and approved by the hospital pharmacy. She said patients in the emergency department should be receiving their prescribed medications through the hospital. She was unaware that Patient #29 brought medications from home to the emergency department and was allowed to self-medicate with morphine without first sending the morphine to the hospital pharmacy for inspection.

Based on interview and record review the hospital failed to have a medical record system that ensured the prompt completion of all patient medical records by the responsible physician. The hospital did not follow their policy and procedure for implementing monetary fines or suspension of privileges when a physician ' s patient medical records are delinquent 30 days or more post patient discharge. Evidence includes the following:
During an interview on 12/10/15 at 10:20 am, Staff Person (SP) #21 provided a document titled, " Incomplete/Delinquent Records " , that showed a listing of 38 hospital physicians and the numbers of incomplete and/or delinquent patient medical records each physician currently had. Delinquent medical records included those that were incomplete 30 days or longer after the patients' discharge from the hospital. The document showed the 38 physicians had a total of 182 incomplete and/or delinquent patient medical records. SP #21 said her department had tried multiple methods in an effort to ensure the hospital physicians completed their patient medical records in a timely manner, including taking the records to medical staff meetings to have the physicians complete, sending weekly faxes to physicians notifying them they had incomplete and/or delinquent patient medical records, keeping the medical records department open and staffed after normal business hours so physicians with incomplete and or delinquent patient medical records could come in late to complete them. She said her department follows the hospital policy/procedure for incomplete/delinquent medical records by sending letters to the physicians on the 7th and 15th day post patient discharge. If patient medical records remain incomplete and/or delinquent on the 15th day post patient discharge the letter sent to the physicians will state that they will be suspended in 15 days unless their records have been completed. A copy of this letter of suspension is also submitted to President of the Medical Staff. SP #21 said if a physician ' s patient medical record remains incomplete/delinquent 21 days after the patient has been discharged from the hospital the President of the Medical staff, by policy, is to inform the physician in a letter that he or she will lose admitting, consultative and surgical privileges unless the incomplete medical records are completed immediately. In addition, the hospital policy says if the physician has not completed the delinquent patient medical record by the 30th day post patient discharge, the loss of privileges will commence. The hospital policy also shows that in lieu of suspension, economic sanctions may be imposed by the hospital Medical Executive Committee upon physicians who are sole providers or who serve understaffed departments in order to minimize further reduction in services. Fines of $50.00 per patient chart will be automatically instituted in lieu of suspension. However, SP #21 said since at least 2012, no physician has been fined or had privileges suspended because of delinquent medical records.
During an interview on 12/10/15 at 12:15 pm, Staff Person #22 confirmed the accuracy of the current list of 38 hospital physicians with incomplete and/or delinquent patient medical records. He said he discusses the requirements for prompt completion of patient medical records at medical staff meetings and in private meetings with physicians in his office. Staff Person #22 also confirmed that he did not enforce the hospital suspension or monetary fine policies for physicians with delinquent patient medical records.

Based on record review, interview and review of directions for document completion, the hospital failed to ensure that each patient ' s medical record was complete and accurate. The hospital did not ensure that each patient ' s consent forms were complete with a signature and a date from either the patient or their representative. This potential had the potential to affect four (Patients #4, #7, #24 and #31) of 31 sampled patients.

Findings include:

1. Review on 12/8/15 of inpatient Patient #4 ' s " Emergency Room (ER) Record, " dated 11/30/15 at 11:44am revealed the patient was admitted to the ER with a diagnosis of Left Foot Gangrene and Occlusion of the Left Femoral Artery. The ER " General Consent For Treatment " lacked the patient's or a representative's signature at the time of admission.
Interview with Staff Person #3 on 12/8/15 at 3:00pm, verified Patient #4 ' s " Emergency Room Record " lacked Patient #4 ' s signature or time and date. Nursing staff #31 confirmed that all consents are to be signed by the patient, family member or representative when the patient is admitted to the ER.

Policy titled- " Inform Consent, SCOPE: (ALL PATIENT CARE SERVICES), EFFECTIVE DATE(s) PRIOR VERSIONS: November, 1, 2012 " directed staff to obtain and place in the patient ' s medical record a signed informed consent for all services provided in the hospital including emergency service treatment.

2. Review of the medical record for Patient#7 revealed that s/he was admitted to this hospital on 11/2/15 with a diagnosis of a cerebral vascular accident (CVA- stroke). Per Patient #7 ' s medical record, s/he lived alone, did not have any children and was unable to sign his/her own informed consents. However, s/he had a Power of Attorney (POA). Patient #7 remained in the hospital until 12/7/15 when s/he was discharged home after receiving his/her physician-ordered treatments and plan of care.


Review of Patient #7 ' s closed medical record on 12/8/15, after s/he was discharged from the hospital, revealed that his/her consent forms and benefit documents remained undated and unsigned by either the patient or the POA. The following information was obtained from Patient #7 ' s closed medical record:


Review of the " Emergency Room Record " dated 11/2/15 revealed that the " General Consent for Treatment " remained blank and it had not been signed or dated by Patient #7 or his/her POA. In the middle of the document there was a handwritten note that read, "Patient is unable to sign. No relatives present at registration." Review of the bottom of the document, revealed the directions for completing these documents. The directions read:

" If the patient cannot consent for him/herself, the signature of either the health care agent or legal guardian who is acting on behalf of the patient, or the patient ' s next of kin who is consenting to the treatment for the patient, must be obtained. "


Review of the " Conditions of Treatment " for Patient #7 revealed that neither s/he nor his/her POA dated or signed the document. At the bottom of the " Conditions of Treatment " document, there was a handwritten note that read, " Patient is unable to sign. "

Review of the document titled, " Acknowledgment and Receipt of Hospital Rights " for Patient #7 revealed that it was undated and unsigned by either the patient or his/her POA. Review of the " Remarks " section at the bottom of the document revealed the following information:
" Patient is unable to sign no relatives present at registration. "


Review of the document titled, " An Important Message from Medicare about Your Rights " revealed that it was unsigned by either the patient or his/her POA. At the bottom of the document, there was a hand written note that read, " Patient is unable to sign. "


Review of the document titled, " Assignment of Benefits " for Patient #7 revealed that the form remained blank and it was signed by neither the patient nor his/her POA.

An interview with the SP #4 on 12/8/15 at 9:45am confirmed that Patient#7 ' s closed record was incomplete. She added that it was the facility's policy to obtain the appropriate signatures on each consent form either before treatment or before the patients were discharged from the facility.

3. Review on 12/8/15 of inpatient Patient 24's "Emergency Room Record, dated 10/20/15 at 09:20am revealed the "General Consent For Treatment" lacked the patient's signature or a representative at the time of admission.
Review of the hospital policy titled, "Inform Consent, SCOPE: (ALL PATIENT CARE SERVICES), EFFECTIVE DATE(s) PRIOR VERSIONS: November, 1, 2012" revealed that staff are directed to obtain and place in the patient's medical record a signed informed consent for all services provided in the hospital including emergency service treatment.
In an interview on 12/11/15 at 9:41am, SP #5 stated that if staff are unable to obtain consent at the time of entry to the hospital, the clerk documents that this is the case and speaks to the head nurse who is expected to contact the staff in patient access if the patient becomes available to consent or a family member presents at the hospital.

4. Review on 12/8/15 of Patient #31 ' s " Cesarean Section Informed Consent " , dated 11/23/15, revealed the signature and title of the witness that observed Patient #33 sign the consent, a nursing employee) was dated on 12/4/15 or 11 days after the patient signed the consent.
Interview with SP #12 on 12/8/15 at 3:30pm verified Patient #31 signed the consent during a visit to the fast track clinic on 11/23/15, and the witness (a nursing employee) signed the consent on 12/4/15 after the employee returned for another appointment. Staff #3 confirmed the hospital policy requires the witness to sign and date at the same time the patient signs the informed consent form.

Policy titled. " Inform Consent, SCOPE: (ALL PATIENT CARE SERVICES), EFFECTIVE DATE(s) PRIOR VERSIONS: November, 1, 2012 " revealed the following information under,
"C. Informed Consent Form ...7. The witness (an employee) shall witness the signature. The signature of the witness indicates that this person saw the patient sign the consent form ..."

Based on observation, interview, record review and review of the " Nutrition Care Manual, " the hospital failed to: 1) Prepare physician ordered therapeutic diets, 2) develop therapeutic preplanned menus, 3) utilized standardized recipes, and 4) ensure that each patient who had swallowing concerns such as dysphagia, received the appropriate modified food consistency and texture. During the survey, the hospital's average daily census was approximately 66. Twenty-nine of the 66 patients, approximately 44%, were affected by this deficient practice. The patients affected included: Patients #1, #2 #3, #4, #6, #7 #8, and #18, of the 31 sampled patients and 21 non-sampled patients.

Findings include:

Observation of the kitchen on 12/7/15 at 11:30am revealed that the patients ' lunch meal was prepared and ready for service. The meal included: Red Pea Soup, Roast Turkey, Rice, Green Beans and Gravy. Observation of the steam table and the prepared foods revealed that there was no differentiation between the regular foods and the therapeutic foods. In addition, the pureed foods were lumpy in texture and the pureed soup and gravy had a " water like " consistency.

Review of the preplanned written lunch menu for Monday, 12/7/15, revealed that there was no differentiation between the Roast Turkey, Rice, Green Beans, or Gravy that were prepared for those patients who were on a " regular " diet and those who were ordered a therapeutic diet such as a low sodium or a low fat/cholesterol.

An interview with the Staff Person (SP) #13, on 12/7/15 at 11:45am revealed that she had prepared all of the food for the patients ' lunch meal. SP #13 stated that she did not utilized standardized recipes and she prepared all of the food the same way; without regard for calories, sodium, fat, cholesterol or texture. When interviewed about how the hospital could ensure that the patients who were ordered a 2 gram (gm)/low sodium diet and those that were ordered a low cholesterol/cardiac diet received the appropriate foods, SP#13 stated she was uncertain. In addition, SP #13 stated that the hospital did not thicken pureed soups or gravy. She stated that when a patent required " thickened liquids " the hospital would provide a packet of thickener on the patients ' meal tray and staff on the nursing unit would add the thickener to the appropriate foods. When interviewed about how the staff on the nursing unit would know how much thickener to add to each food to ensure that the food would be thickened appropriately, SP #13 stated she did not know.

Review of the " ...Current Diets ... " dated 12/7/15 revealed the following information:

Patient #1 had a physician ordered renal pureed diet.
Patients #2 and #7 were ordered pureed foods and Patient #7 also had a " thickened liquids " order.
Patients #3, #4, #6, #8 and #18 had a 2 gram (gm)/low sodium physician ordered diet.

There were 21 non-sampled patients who had physician-ordered therapeutic diets; 16 were ordered a 2 gm/ low sodium diet and five were ordered a low cholesterol/cardiac diet. In addition, some of these patients also had a physician ' s order for a calorie-specific diet in addition to their sodium and fat restrictions.

An interview with SP #14 on 12/7/15 at 11:30am, revealed that the hospital updated the list of " ...Current Diets ... " daily. She added that each patient should receive the diet that their physician ordered.

An interview with the SP #15 on 12/8/15 at 10:15am revealed that the hospital utilized the " online " version of the " Nutrition Care Manual. " Staff Person #15 confirmed that the kitchen staff was required to follow the Nutrition Care Manual when preparing the patient ' s meals to ensure that they received the appropriate physician ordered diets relative to modified consistency and therapeutic foods.

Review of the online undated " Nutrition Care Manual " revealed that pureed foods should have a " pudding-like " smooth texture for safe swallowing, a 2 gm low sodium diet and a low cholesterol/cardiac diet should be prepared appropriately to ensure that the patients do not obtain and retain water, salt and fat unnecessarily.

An interview with SP #14 on 12/7/15 at 12:00pm confirmed that the hospital did not utilized standardized recipes. When interviewed about how the hospital knew how to prepare the patient ' s meals without recipes, SP #14 stated that the cooks would " google " the internet for the recipes. SP #14 added that the hospital could not ensure that the patients were receiving the appropriate therapeutic diets per physician order.

An interview with SP #15 on 12/10/15 at 10:00am revealed that the hospital previously utilized standardized recipes and menus that corresponded with a " Nutrition Analysis " of each food. However, SP #15 stated that the hospital no longer utilized those recipes and menus; they were utilizing different menus that did not have a corresponding recipe or a nutritional analysis. When interviewed about how the hospital could ensure that the patients had received the appropriate amount of calories, sodium, cholesterol, and fat per their physician ' s therapeutic diet order, if they did not utilize the recipes and menus that had a corresponding nutritional analysis; SP #15 stated " we cannot. "

Based on observation, interview, review of hospital maintenance records and record review, the hospital failed to maintain hospital equipment and furniture to ensure an acceptable level of safety and quality, failed to ensure that their equipment and environment was well-maintained, safe, and free of the potential spread of infection. This deficient practice had the potential to affect all of the patients who frequented this hospital.

Findings include:
1. Observations conducted on all days of the survey and in multiple patient care locations showed the following:
-Multiple wheeled stretchers in emergency department rooms, including Rooms 14, 15, 11, 10, 7, showed numerous areas where the paint/finish had chipped or worn off, exposing rusted bare metal;
-Multiple beds in patient rooms on the medical-surgical units showed large areas where the paint/finish was chipped off, exposing bare, rusted metal;
-Multiple over-bed tables located throughout the hospital showed significant amounts of rust on their metal base and support arm;
-Room 3 in the Fast Track outpatient clinic showed a patient exam table with multiple areas of chipping paint and torn upholstery that exposed the underlying wood frame;
-Patient room 3090 showed a chair with ripped upholstery on the upper, mid- back cushion and on the right corner of the seat cushion that exposed the inner foam. Another chair in the room showed a tear in the upholstered seat cushion that exposed the inner padding;
-Patient #12's room showed a long metal drapery rod across the window that was rusted across its entire length. The metal housing on the over-bed light fixture showed rust along the outer edges and across the front. Rust coated the metal legs and framework of the patient room chair and the upholstered seat cushion was torn, exposing the inner padding.
During an interview on 12/10/15 at 3:00 pm, Staff Person #17 said staff are to place a plant operations work order for patient beds with chipped paint and his staff will remove the bed from patient use and sand, prime, and repaint the bed. He said the four or five staff he has in his department cannot keep up with the maintenance needs of the whole hospital. He said patient chairs with torn upholstery should be reported to his department and the chair will be removed from use and replaced. He said if his staff pulled every chair in the hospital that contained torn upholstery they would not have any chairs left for patient use. Review of plant operations/maintenance work orders for August, September, October and November, 2015 showed no requests for removal and repainting of any patient beds.

Based on observation and interview, the hospital failed to utilize electrical equipment in a safe manner for one (1) patient in the sample of 31 (Patient #11).
Findings include:
2. During an observation on 12/9/15 at 9:00am, Patient #11 was observed prior to receiving a CAT scan. During the observation, Patient #11 ' s bed was placed next to the CAT scan platform and the patient ' s bed was plugged into a wall outlet with an extension cord in order to raise the bed to the level of the CAT scan platform.
In an interview on 12/11/15 at 1:00pm, Staff Person (SP) #2 stated that the facility is not to use extension cords for patient beds.

3. Observation of the kitchen on 12/7/15 from 9:39-11:45am revealed that the kitchen environment was not maintained in a clean and safe fashion. The following observations were made during that time:

The tile floor was cracked in places and missing some tiles.
The walls had holes, missing paint, and in general need of repair.
The floor drains were rusted, cracked and missing in some locations.
The seal on the freezer door was not sealing properly which caused a build- up of ice and water around the surrounding area.
Two ceiling tiles just outside the kitchen area in the hallway that lead to the garbage receptacles were covered with black fuzzy debris and water marks.

An interview with the SP #14 on 12/7/15 at 12:00pm confirmed that the kitchen and the surrounding environment were in need of repair. She added that the Maintenance Department had been aware of the freezer door but it had not yet been fixed. Review of the repair order #9584 for the freezer door revealed that the order was placed on 4/16/15, approximately 8 months prior to survey.

Based on observation, interview and record review the hospital failed to ensure that acceptable standards of infection control practices were maintained by nursing staff in the emergency department when cleaning a blood spill, and in the acute care dialysis unit by nursing staff when sanitizing a dialysis station after patient use.
Evidence includes the following:
1. Observation on 12/7/15 at 11:30 am in emergency department patient room 14 showed several drops of blood fall onto the floor and onto the patient ' s over-bed table during placement of an intravenous catheter. Staff Person #18, gloved, sprayed the blood droplets on the floor with a bottle labeled, " Clorox bleach germicidal cleaner " , waited approximately 10 seconds and wiped the blood off the floor with a paper towel. The nurse then sprayed the blood droplets on the over-bed table with the Clorox cleaner and immediately wiped the area with a paper towel. Directions for use on the bottle of Clorox cleaner directed staff to spray the affected surface and let stand for one (1) minute before wiping with a clean paper towel. Staff failed to allow the Clorox cleaner to stand on the blood spills for one (1) minute before wiping with the paper towel.
2. Observation on 12/8/15 at 9:40 am showed Patient #14 receiving dialysis treatment in the hospital acute care dialysis unit. The outer side panels of the chair the patient sat in were splattered with small, dried on, white particles. Later that day at 1:40 pm, observation showed Staff Person (SP) #19 cleaning the chair Patient #14 sat in during his/her dialysis treatment with Sani-Cloths (a germicidal, disposable wipe). When the technician finished wiping the chair, observation showed the numerous dried on, white particles remained on both outer side panels of the chair. During an interview at 1:50 pm, SP #19 said she had used the Sani-Cloth wipes on both side panels. After the surveyor pointed out the white, dried-on splatters on both side panels, SP #19 wiped the outer side panels with the Sani-Cloths and the white splatters disappeared. When interviewed, the technician said she had not opened the chairs side panels and cleaned the inner sides. When asked by the surveyor to open the side panels, the inner metal supports were observed to be heavily soiled with dust, crumbs and grime. SP #19 said she did not know when the side panels had last been opened and cleaned.
Review of the hospital hemodialysis policy and procedure titled, " Cleaning Workstations ", revised on 4/2011 showed the following instructions: At the end of each dialysis treatment the workstation will be cleaned with a bleach solution or hospital-approved disinfectant. The areas to be cleaned include, but are not limited to, all external surfaces of the dialysis machine, ....chair, ....

3. Observation of the kitchen on 12/7/15 at 11:30am revealed that the patients' lunch meal was prepared and ready for service. The meal included: Red Pea Soup, Roast Turkey, Rice, Green Beans and Gravy.
An interview with Staff Person (SP) #13, on 12/7/15 at 11:45am revealed that she had prepared all of the food for the patients' lunch meal and she was ready to take and record the food temperatures. SP #13 calibrated the stem of a digital thermometer and then donned a pair of gloves. SP #13 used an alcohol pad to sanitize the probe of the thermometer; then she laid the thermometer probe on the metal counter while she removed the prepared foods from the heat source. SP #13 used her gloved hand to open the oven door, obtain a pair of tongs, remove the tin foil from the pan and retrieve the thermometer probe from the metal counter. She held the probe with her gloved hand, then inserted the probe into the food without first re-sanitizing it. SP #13 was observed inserting the digital thermometer deep into the food and the yellow plastic housing, which was unclean and unsanitized, came in contact with the ready-to-eat foods. These unsafe practices had the potential to create a cross-contamination situation and food borne illness.

An interview with the Director of Nutrition Services on 12/7/15 at 11:55am confirmed that SP #13 had not followed good safety food techniques while taking the food temperatures on 12/7/15 at 11:45am. The Director stated that she had completed in-service training relative to taking and recording food temperatures without cross contamination which included not touching the sanitized probe before inserting it into the ready to eat food and not allowing the unclean yellow housing to come in contact with the food.

4. Observation of the Laboratory on 12/9/10 at 9:55am and again on 12/10/15 at 9:15am revealed that the chair that was used for drawing blood samples was not maintained in a safe fashion. The arm rest, the one that is extended for the patients to place their arm palm side up for blood draws, was cracked in several places and the underling white permeable foam padding was exposed. The arm rest could not be cleaned and sanitized effectively.
An interview with Staff Person #20 on 12/10/15 at 9:15am confirmed that the arm chair in the laboratory was cracked and the underlying material was exposed. The Laboratory Supervisor stated that the hospital had sent out their other chair for repair and until that chair returned to the hospital, they could not send this one out for repair. She was unable to confirm a repair date at this time.