HospitalInspections.org

A. Based on a review of Hospital contracted services, a review of Governing Body minutes, a review of Quality Assurance (QA) minutes, and staff interview, it was determined the Hospital failed to evaluate contracted services to ensure care/services provided were performed in a safe and effective manner.

Findings include:

1. The list of contracted services, the Governing Body minutes for 2010, and the QA minutes for 2010 were reviewed on 12/1/10. There was no documentation to indicate that contracted services were evaluated to ensure care/services provided were performed in a safe and effective manner.

2. During a staff interview, conducted with the Director over laundry services on 11/29/10 at 10:20 AM, it was verbalized that laundry is provided by an off-site service. There was no documentation to indicate the service had been evaluated. During a staff interview, conducted with the Chief Financial Officer on 12/1/10 at 2:30 PM, the above finding was confirmed. There was no documentation to indicate that any of the contracted services were evaluated.

A. Based on a review of Hospital policy, medical record review, and staff interview, it was determined in 3 of 31 (Pts #9, #10, #11) medical records reviewed, the Hospital failed to ensure its Advanced Directives policy was followed.

Findings include:

1. The Hospital policy titled "Advanced Directives" was reviewed on 12/1/10. It indicated "2. At the time of admission, the staff inquires if the patient has made provisions for Advance Directives and may provide the patient with an informational brochure...if requested by the patient."

2. The medical record of Pt #9 was reviewed on 11/29/10. Pt #9 was admitted to the Hospital on 11/9/10 with the diagnosis Lumbar Spondylosis. There was no documentation to indicate whether or not Pt #9 had an Advanced Directive.

3. The medical record of Pt #10 was reviewed on 11/29/10. Pt #10 was admitted to the Hospital on 11/23/10 with the diagnosis Lumbar Spondylosis. There was no documentation to indicate whether or not Pt #10 had an Advanced Directive.

4. The medical record of Pt #11 was reviewed on 11/30/10. Pt #11 was admitted to the Hospital on 11/18/10 with the diagnoses Severe Spondylosis, Worsening Fatigue, and Dyspnea on Exertion. On 11/18/10, nursing documentation indicated Pt #11 did not have an Advanced Directive. There was no documentation to indicate that information was offered and/or if Pt #11 desired to complete one.

5. During an interview with the Quality Manager on 12/1/10 at 3:00 PM, the above findings were confirmed.

A. Based on medical record review and staff interview, it was determined that in 5 of 31 (Pts. #8, #11, #12, #23, #30) medical records reviewed, the Hospital failed to ensure all physician orders were carried out.

Findings include:

1. The medical record of Pt #8 was reviewed on 11/30/10. Pt #8 was admitted to the Hospital on 11/29/10 with the diagnosis Chest Pain and was discharged on 11/30/10. On 11/29/10, there was a physician's order "Consult Discharge Planning, Consult Cardiac Rehabilitation, and Consult Dietician, Adult." There was no documentation to indicate that these consults were completed and/or addressed.

2. The medical record of Pt #11 was reviewed on 11/30/10. Pt #11 was admitted to the Hospital on 11/18/10 with the diagnoses of Severe Spondylosis, Worsening Fatigue, and Dyspnea on Exertion. There was an Emergency Department order for a Urinalysis. Emergency nursing documentation indicated that a straight catheterization was performed to obtain the Urinalysis. There was no physician's order for the straight catheterization. On 11/18/10, there was a physician's order "Hemoccult Stool times three." There was no documentation to indicate that the order was completed and/or addressed.

3. The medical record of Pt #12 was reviewed on 11/30/10. Pt #12 was admitted to the Hospital on 11/25/10 for outpatient IV antibiotic therapy. On 11/25/10, there was a physician's order "Rocephin 1 gram IV for 6 days." There was no nursing assessment documentation on 11/26/10 thru 11/28/10.

4. The medical record of Pt #23 was reviewed on 11/30/10. It indicated that Pt #23 was admitted on 11/22/10 with a diagnoses of Neck Pain and C-Spine Mass. Documentation indicated that there were physician orders for stool specimens to be collected for analysis for C-Diff on 11/29 at 04:30, 11/29 at 09:10, 11/29 at 22:20 and on 11/30 at 13:35. A nursing note, dated 11/30/10 at 21:35, indicated the patient had a bowel movement. As of survey date 12/1/10, there was no documentation that a specimen was sent to the lab for analysis.

5. The medical record of Pt #30 was reviewed on 12/1/10. Pt #30 was admitted to the Hospital on 11/20/10 for outpatient IV antibiotic therapy. On 11/22/10, there was a physician's order "Continue Invanz 1 gram IV daily thru 11/29/10." There was no documentation for 11/25/10, 11/27/10, 11/28/10, or 11/29/10. On 11/26/10, there was documentation that Pt #30 had received services; however, there was no documentation to indicate the IV was given. It further indicated that Pt #30 had received IVs on 11/30/10 and 12/1/10; however, there was no physician's order.

6. During an interview with the Quality Manager on 12/1/10 at 3:00 PM, the above findings were confirmed.

A. Based on Hospital policy, medical record review and staff interview, it was determined that in 1 of 4 (Pt #21) medical records reviewed in which patient's received blood transfusions, the nurse failed to administer blood transfusions in accordance with the Hospital policies.

Findings include:

1. The Hospital policy titled, "Blood Components- Typing and Crossmatching, Administration, Documentation, Reaction and Consent" under Part IV "Blood components-Record Utilization, 1. The Blood Administration/Utilization Record form is used on all patients receiving any type of transfusion. After the blood transfusion this completed form is placed..."

2. The medical record of Pt. #21 was reviewed on 12/01/10. Pt. #21 was admitted to the hospital on 11/24/10 with diagnoses of Neutropenic Fever, Sepsis, and Dehydration. Documentation indicated a physician order dated 11/25/10 was for "type and cross for 2 U PRBC ( units of packed red blood cells) ; transfuse each over 3 hrs." Documentation on the blood bank record indicated 2 units were released to the nurse, #40GT 69728 on 11/25/10 at 1340 and #40GT 69726 on 11/26/10 at 0000. During an interview with the Medical-Surgical Supervisor on 12/01/10 at 9:30 AM, she verified that Pt. #21 did receive the 2 units of blood per physician orders. There was no documentation to indicate that either of the 2 units of blood had been transfused.

3. During an interview with the Medical-Surgical Supervisor conducted on 12/01/10 at 9:30 AM, the above finding was confirmed.


B. Based on Hospital policy, medical record review and staff interview, it was determined that in 1 of 4 (Pt #21) in which patients who had received blood, the nurse failed to follow the hospital policy to obtain consent for blood administration.

Findings include:

1. The Hospital policy titled, "Blood Components-Typing and Crossmatching, Administration, Documentation, Reaction and Consent" under Part IV "Blood Components- Utilization Record, 2. A signed Authorization and Consent for Blood/Blood Products Transfusion is obtained or verified before beginning transfusion."

2. The medical record of Pt. #21 was reviewed on 12/01/10. Pt. #21 was admitted to the hospital on 11/24/10 with diagnoses of Neutropenic Fever, Sepsis, and Dehydration. Documentation indicated a physician order dated 11/25/10 was for "type and cross for 2 U PRBC ( units of packed red blood cells) ; transfuse each over 3 hrs." During an interview with the Medical-Surgical Supervisor on 12/01/10 at 9:30 AM, she verified that Pt. #21 did receive the 2 units of blood per physician orders. Documentation indicated that there was no signed consent for the administration of the blood.

3. During an interview with the Quality Manager conducted on 12/01/10 at 4:00 PM, the above finding was confirmed.

A. Based on policy, record review, and staff interview it was determined that in 10 in 31 (Pts #1, #2, #8, #11, #16, #17, #19, #21, #22, #27) records reviewed, the Hospital failed to ensure that all physician orders were signed, dated, and timed.

Findings include:

1. The Hospital policy titled, "Physician's Order" under "General Information: VIII. Orders will be written legibly and include date, time, and signature." was reviewed on 11/30/10.

2. The medical record of Pt #1 was reviewed on 11/30/10. It indicated that Pt #1 was admitted on 11/22/10 with diagnoses of Neck Pain/C-Spine Mass. A review of the electronic signature for a physician indicated that there were 4 unsigned orders from 11/27/10 and 1 from 11/30/10.

3. The medical record of Pt #2 was reviewed on 11/30/10. It indicated that Pt #2 was admitted on 11/30/10 with diagnoses of Dehydration and Fever. Documentation indicated that there were several orders not dated or timed.

4. The medical record of Pt #8 was reviewed on 11/30/10. Pt #8 was admitted to the Hospital on 11/29/10 with the diagnosis Chest Pain. As of 11/30/10, 4 out of 8 physician orders failed to include a time as to when written.

5. The medical record of Pt #11 was reviewed on 11/30/10. Pt #11 was admitted to the Hospital on 11/30/10 with the diagnosis of Severe Spondylosis. As of 11/30/10, 5 out of 16 physician orders failed to include a time as to when written.

6. The medical record of Pt. #16 was reviewed on 11/29/10. Pt. #16 was admitted on 11/11/10 with the diagnosis of Critical Illness Myopathy. Documentation indicated that multiple orders written during the hospital stay were not timed by the physician.

7. The medical record of Pt. #17 was reviewed on 11/30/10. Pt. #17 was admitted on 11/17/10 with the diagnosis of Infection Left Knee Replacement. Documentation indicated that multiple orders written during the hospital stay were not timed by the physician

8. The medical record of Pt. #19 was reviewed on 11/30/10. Pt. #19 was admitted on 11/22/10 with the diagnosis of Psychosis. Documentation indicated that the admission orders written on 11/22/10 were signed by the physician but there was no time.

9. The medical record of Pt. #21 was reviewed on 12/1/10. Pt. #21 was admitted on 11/24/10 with the diagnosis of Neutropenic Fever. Documentation indicated that multiple orders written during the hospital stay were not timed by the physician.

10. The medical record of Pt. #22 was reviewed on 12/1/10. Pt. #22 was admitted on 7/7/10 with the diagnosis of Pancreatic Cancer. Documentation indicated that multiple orders written during the hospital stay were not dated and timed by the physician.

11. The medical record of Pt. #27 was reviewed on 12/1/10. Pt. #27 was admitted on 8/13/10 with the diagnosis of Subdural Hematoma. Documentation indicated that multiple orders written during the hospital stay were not dated and timed by the physician.

12. During an interview with the Quality Manager on 12/1/10 at 3:00 PM, the above findings were confirmed.

A. Based on policy, record review, and staff interview it was determined that in 2 of 31 (Pts. #22, #27) medical records reviewed the Hospital failed to ensure that verbal/telephone orders are signed per policy.

Findings include:

1. The Hospital policy titled, "Physician's Order" under "General Information: II. It is the physician's responsibility to sign telephone/verbal orders within 48 hours." was reviewed on 12/1/10.

2. The medical record of Pt. #22 was reviewed on 12/1/10. Pt. #22 was admitted on 7/7/10 with the diagnosis of Pancreatic Cancer. Documentation indicated that a physician telephone order written on 7/10/10 was signed by the physician on 9/10/10, over the 48 hour timeframe.

3. The medical record of Pt. #27 was reviewed on 12/1/10. Pt. #27 was admitted on 8/13/10 with the diagnosis of Subdural Hematoma. Documentation indicated that a physician telephone order written on 8/16/10 was signed by the physician on 9/16/10, over th 48 hour timeframe.

4. During an interview with the Quality Manager on 12/1/10 at 3:00 PM, the above findings were confirmed.

A. Based on a review of the Medical Staff Rules and Regulations, medical record review and staff interview, it was determined that in 3 of 31 (Pt #'s 14, 23 & 28) medical records reviewed, the Hospital failed to ensure the history an physical were always completed within the required time frames.

Findings include:

1. The Hospital Medical Staff Rules and Regulations were reviewed. They indicated under, "MEDICAL RECORDS 2. A legible, complete admission history and physical examination shall be recorded within twenty-four (24) hours of admission by the attending physician."

2. The medical record of Pt #14 was reviewed on 11/30/10. It indicated that Pt #14 was admitted on 11/11/10 with the diagnoses of TIA (Transient Ischemic Attack) and Parkinson's Disease. Documentation indicated that the history and physical for Pt #14 was completed on 11/13/10, making it over 24 hours of admission.

3. The medical record of Pt #23 was reviewed on 12/1/10. It indicated Pt #23 was admitted on 11/29/10 with a diagnosis of Sepsis. There was no documentation that indicated a history and physical had been written or dictated as of survey date 12/1/10.

4. The medical record of Pt #28 was reviewed on 12/01/10. It indicated that Pt #28 was admitted on 07/23/10 with the diagnoses of CHF (Congestive Heart Failure) and Acute Renal Failure. Documentation indicated that the history and physical was completed on 07/26/10, making it over 24 hours of admission.

5. During an interview with the Quality Manager, conducted on 12/1/10 at 10:45 AM, the above findings were confirmed.

A. Based on medical record review and staff interview, it was determined that in 4 of 31 (Pts #1, #9, #11, #23) medical records reviewed, the Hospital failed to ensure documentation was accurate and complete.

Findings include:

1. The medical record of Pt #1 was reviewed on 11/30/10. It indicated Pt #1 was admitted on 11/22/10 with diagnoses of Neck Pain and C-Spine Mass. The physicians history and physical (H & P) dictated on 11/22/2020 at 09:01, indicated Pt #1 was allergic to Bactrim, Crestor, and Metformin. The computer profile indicated that the drug allergy of Pt #1 was "Sulfa".

2. The medical record of Pt #9 was reviewed on 11/29/10. Pt #9 was admitted to the Hospital on 11/9/10 with the diagnosis of Lumbar Spondylosis and underwent a Monitored Anesthesia Care (MAC) procedure. On 11/9/10, the Post Operative Progress Note indicated that it was completed at 11:05 AM. The Anesthesia Administration record indicated the time of admission to operating room as 11:26 AM and induction time as 11:35 AM. It further indicated "Medications: Cymbalta." The nursing medication list and the medication data sheet both indicated "Norco" and failed to include Cymbalta.

3. The medical record of Pt #11 was reviewed on 11/30/10. Pt #11 was admitted to the Hospital on 11/18/10 with the diagnoses Spondylosis, Worsening Fatigue, and Dyspnea on Exertion and was discharged on 11/25/10 with the IV for outpatient IV antibiotic therapy. It was unable to be determined whether Pt #11 had one or two sites, where the sites were, or when they were changed. There was no documentation to indicate Pt #11 was educated on care of the IV site prior to discharge.

4. The medical record of Pt #23 was reviewed on 12/1/10. It indicated Pt #23 was admitted on 11/29/10 with a diagnosis of Sepsis. Documentation indicated that Pt #23 was allergic to Ticarcillin Disodium, Nitrofurantoin Macrocrystal, Ciprofloxacin HCl, Cefadroxil Hydrate, Sulfa, Potassium Clavulanate, Nitrofurantoin, Ciprofloxacin, and Pregabalin. The allergy sticker on the front of the chart (to alert staff to the patient's allergies) was blank.

5. During an interview with the Quality Manager conducted on 12/1/10 at 2:45 PM, the above findings were confirmed.

A. Based on observation, a review of Hospital policy, and staff interview, it was determined the Hospital failed to ensure outdated drugs and biologicals were not available for patient use.

Findings include:

1. During a tour of the Hospital, conducted 11/29/10 thru 11/30/10, the following outdated drugs were observed in patient care areas, available for patient use. In the Pain Clinic, Room #2, one 16 ounce Hydrogen Peroxide expired 8/09, one open 16 ounce Isopropyl Alcohol with no date as to when opened, and one 15 ml Hibiclens packet expired 12/05. In the Pain Clinic, Room #3, one open 16 ounce Hydrogen Peroxide dated as opened 11/09 and one open Isopropyl Alcohol with no date as to when opened. In the Surgery department anesthesia crash cart, one Percutaneous Sheath Introducer Kit expired 9/10. In the Surgery Malignant Hyperthermia emergent cart, one light green top Vacutainer expired 10/10, one blue top Vacutainer expire 9/10, and two 10 ml 0.9% Sodium Chloride expired 11/1/10. In the Surgery department Intubation Kit, 1 light green top Vacutainer expired 10/10 and 1 blue top Vacutainer expired 5/10. In the Wound Clinic, one 30 ml vial of Lidocaine 1% 10 mg/ ml expired 4/1/10.

2. The Hospital policy titled "Storage of Medications" was reviewed on 11/30/10. It indicated "3. Pharmacy areas and all patient care areas with medications... are checked monthly by Pharmacy staff." There was no policy to address outdated biologicals.

3. During an interview with the Quality Manager on 12/1/10 at 3:00 PM, the above findings were confirmed.

A. Based on Hospital policy, observation and staff interview, it was determined that the hospital failed to ensure that the dietary supervisor managed dietary services according to their policies.

Findings include:

1. The Hospital policy titled, "Food Donations to Good Samaritan" under #5, "Food will be stored in the freezer. The letters 'SMH', the date and contents will be written on each bucket." During an interview with the Production Manager on 12/01/10 at 4:00 PM, it was reported that it is a verbal policy that all opened food items are to be labeled with the "use by date."

2. During a tour of the dietary department on 11/30/10 at 10:00 AM, it was observed that 5 plastic cartons containing food were in an area for transport outside of the hospital and were not identified with contents, date or time. Also during the tour, it was observed that the following items were opened with no use by date: 2 bags of vegetables, 1 package of gravy mix, and 1 angel food cake.

3. During an interview with the Quality Manager conducted on 11/30/10 at 11:00 AM, the above findings were confirmed.

B. Based on a review of Hospital policy, a review of refrigerator temperature logs, and staff interview, it was determined the Hospital failed to ensure refrigerator temperatures were maintained within acceptable ranges and action was taken, in accordance with Hospital policy.

Findings include:

1. The Hospital policy titled "Refrigerator and Freezer Monitoring/Cleaning" was reviewed on 12/1/10. It indicated "5. If the temperature is out of acceptable range as noted on the temperature log, notify Facilities Management. Food and medications may not be used when the refrigerator and freezer temperatures are not within the appropriate range."

2. The "Refrigerator Daily Monitoring" logs for August thru November 2010 for 4th and 6th floors were reviewed on 12/1/10. On the 4th floor, there was no documentation of temperatures 7 out of 21 days documented in August, 16 out of 30 days in September, and no documentation for October. Out of the documented temperatures, 3 in August and 1 in November were above the 40 degree mark. On the 6th floor, there was no documentation of refrigerator temperatures 8 out of 31 days in August, 7 out of 30 days in September, 8 out of 31 days in October, and 6 out of 30 days in November. Of the documented temperatures 18 in September, 21 in October, and 21 in November were over the 40 degree mark. There was no documentation to indicate that action was taken and/or that Facilities Management was notified.

3. During an interview with the Quality Manager on 12/1/10 at 3:00 PM, the above findings were confirmed

A. Based on a review of the Hospital Medical Staff Rules and Regulations, a review medical records and staff interview, it was determined that in 1 of 10 (Pt #9) medical records reviewed in which patients had surgical procedures, the Hospital failed to ensure that a complete history and physical was recorded by a physician and placed into the medical record prior to surgery.

Findings include:

1. The Hospital's Medical Staff Rules and Regulations was reviewed on 11/29/10. It indicated under, "Department of Surgery 2. Elective b. A complete history and physical must be recorded on the chart on all patients undergoing surgery prior to transferring the patient to the operating room..."

2. The medical record of Pt #9 was reviewed on 11/29/10. It indicated that Pt #9 was admitted on 11/09/10 with the diagnoses of Lumbar Spondylosis, Pain and Bilateral Lumbar Radiofrequency L3, L4 & L5. Documentation indicated on 11/09/10, Pt #9 had undergone a scheduled surgery to the Lumbar region under MAC. There was no documentation indicating a history and physical had been completed, recorded and placed in the medical record prior to the surgical procedure.

3. During an interview conducted on 11/29/10 with the Quality Manager, the above finding was confirmed.

A. Based on a review of policy, observation, medical record review,and staff interview it was determined that in 5 of 10 (Pts. #9, 10, #27, #32, #33) surgical records reviewed that the Hospital failed to ensure that post-anesthesia evaluations are completed per policy.

Findings include:

1. The Hospital policy titled, "Pre and Post Anesthesia Evaluation" under "Procedure:" bullet 3, "All patients receiving anesthesia or sedation...shall have post anesthesia evaluation...no later than 48 hours after surgery..." was reviewed on 12/1/10.

2. The medical record of Pt #9 was reviewed on 11/29/10. Pt #9 was admitted to the Hospital on 11/9/10 with the diagnosis of Lumbar Spondylosis and underwent an outpatient MAC procedure. There was no documentation of a post-anesthesia evaluation.

3. The medical record of Pt #10 was reviewed on 11/29/10. Pt #10 was admitted to the Hospital on 11/23/10 with the diagnosis of Lumbar Spondylosis and underwent an outpatient MAC procedure. There was no time as to when the post-anesthesia evaluation was completed.

4. The medical record of Pt. #27 was reviewed on 12/1/10. Pt. #27 was admitted on 8/13/10 with the diagnosis of Subdural Hematoma. Documentation indicated that Pt. #27 had Gastrostomy tube placement on 8/25/10. There was no documentation to indicate a post-anesthesia evaluation was completed.

5. During a tour of the Pre-operative area, conducted on 11/30/10 at 1:00 PM, it was observed that the Anesthetist documented both the pre-anesthesia (with time) and post-anesthesia (without time) evaluations on Pts #32 and #33. During a staff interview, conducted with the Anesthetist and the Executive Director of Perioperative Services, the above findings were confirmed.

6. During an interview with the Quality Manager on 12/1/10 at 3:00 PM, the above findings were confirmed.

A. Based on a review of policy, observation, medical record review,and staff interview it was determined that in 5 of 10 (Pts. #9, 10, #27, #32, #33) surgical records reviewed that the Hospital failed to ensure that post-anesthesia evaluations are completed per policy.

Findings include:

1. The Hospital policy titled, "Pre and Post Anesthesia Evaluation" under "Procedure:" bullet 3, "All patients receiving anesthesia or sedation...shall have post anesthesia evaluation...no later than 48 hours after surgery..." was reviewed on 12/1/10.

2. The medical record of Pt #9 was reviewed on 11/29/10. Pt #9 was admitted to the Hospital on 11/9/10 with the diagnosis of Lumbar Spondylosis and underwent an outpatient MAC procedure. There was no documentation of a post-anesthesia evaluation.

3. The medical record of Pt #10 was reviewed on 11/29/10. Pt #10 was admitted to the Hospital on 11/23/10 with the diagnosis of Lumbar Spondylosis and underwent an outpatient MAC procedure. There was no time as to when the post-anesthesia evaluation was completed.

4. The medical record of Pt. #27 was reviewed on 12/1/10. Pt. #27 was admitted on 8/13/10 with the diagnosis of Subdural Hematoma. Documentation indicated that Pt. #27 had Gastrostomy tube placement on 8/25/10. There was no documentation to indicate a post-anesthesia evaluation was completed.

5. During a tour of the Pre-operative area, conducted on 11/30/10 at 1:00 PM, it was observed that the Anesthetist documented both the pre-anesthesia (with time) and post-anesthesia (without time) evaluations on Pts #32 and #33. During a staff interview, conducted with the Anesthetist and the Executive Director of Perioperative Services, the above findings were confirmed.

6. During an interview with the Quality Manager on 12/1/10 at 3:00 PM, the above findings were confirmed.