HospitalInspections.org

Based on review of the Quality Assurance/Performance Improvement Plan (QA/PI), review of data collection, and QA/PI minutes, the hospital failed to ensure that quality improvement projects are conducted.


Findings include:


There was no documentation available for review to show that the hospital had performed a quality improvement project, or that it had outlined any project that will be conducted in the future.

Based on review of the Quality Assurance/Performance Improvement Plan, the hospital failed to delineate executive responsibilities and accountability for Quality Assurance/Performance Improvement activities.


Findings include:


The Quality Assurance/Performance Improvement Plan did not specify the entity responsibility and accountable for the ongoing program for quality improvement.

Based on review of the Quality Assurance/Performance Improvement Plan (QA/PI), review of data collection, and QA/PI minutes, the hospital failed to ensure an ongoing program for quality improvement has been maintained.


Findings include:


There was no documentation available for review, prior to May, 2011, to show that the hospital was performing Quality Assurance/Performance Improvement.

Based on patient diet cards review, staff interview, and policy manual review, the facility failed to implement policies that address the Dietary Communication form which is to be used between dietary and nursing service when patients are admitted and when changes are made for dietary concerns.
Findings include:
Observation during the noon meal on 08/10/2011 at 11:45 a.m., revealed that two (2) of four (4) patient diet cards had the wrong patient room number on them.

During an interview, the Dietary Manager (DM) confirmed the findings. When asked what role dietary had in assuring correctness, the DM stated that nursing service was to use the Dietary Communication form to show changes and then send them to dietary.

Nursing policy and procedure manual review revealed no documented evidence of a policy for the Dietary Communication form.

An interview with the Chief Nursing Officer revealed that there was no policy that addressed the use of the Dietary Communication form.

Based on staff interview, review of Medical Staff Rules and Regulations, review of employee credentials, and review of medical records, the hospital failed to ensure that the medical record service is administratively responsible for medical records.


Findings include:


Cross Refer to A0432 for the hospital's failure to ensure that the medical record service was organized and staffed with trained personnel.

Cross Refer to A0438 for the hospital's failure to ensure 10 of 10 medical records reviewed were promptly completed

Cross Refer to A450 for the hospital's failure to ensure 10 of 10 medical records reveiwed had all entries dated and times and signed by the person responsible.

Cross Refer to A0458 for the hospital's failure to ensure that 10 of 10 medical records reviewed contained a history and physical exam documented within 24 hours of admission.

Cross Refer to A0464 for the hospital's failure to ensure that 10 of 10 medical records reviewed contained a psychiatric evaluation within 60 hours of admission.

Cross Refer to A0469 for the hospital's failure to ensure that records of discharged patients are completed within 15 days of discharge.

Based on staff interview and review of employee credentials, the hospital failed to ensure that it had provided adequate orientation and training of the medical record personnel, and failed to ensure that the department maintained a Patient Index, Diagnostic Index and Physician Index.


Finding include:

Cross Refer to A0440 for the hospital's failure to maintain a diagnostic index or physician index in the Medical Record Department.

1. Review of employee credentials revealed that the hospital employed a person to work in the Medical Record Department that has had no prior medical record experience. She began her employment with the hospital on 01-19-11, and she is the only employee in the department. The company that manages the hospital employs a Registered Health Information Administrator (RHIA). On interview with the hospital administrator and employee, it was revealed that the RHIA had not made any visits to provide guidance to this employee, and to ensure that the department was complying with the requirements of the Federal Regulations for Hospitals.

2. During an interview on 08/11/11, the Administrator stated that the only training the employee was provided was three (3) days in the medical record department of another hospital run by the same management company.

3. There was not a Medical Record Policy and Procedure Manual available for review. Interview with the Medical Records employee revealed that she had been functioning without one.

4. The Medical Record Department does not maintain a Patient Index. A list of the patients admitted to the facility, the medical record number issued them along with the date of admission and their date of birth had been maintained since 01-19-11. This list only contained the date of admission that the medical record number was issued, and not subsequent admissions.

Based on review of Medical Staff Rules and Regulations and review of medical records, the hospital failed to ensure that 10 of 10 medical records reviewed were promptly completed.

Findings include:

1. Six (6) medical records were randomly selected from a list of discharges from the hospital since 01-19-11, and reviewed along with four (4) inpatient medical records for a total of 10 medical records.

2. Review of four (4) of four (4) inpatient medical records, revealed, the history and physical examination had not been documented in the record. The patients had been admitted on 07-25-11, 07-27-11, 08-03-11 and 08-04-11.

3. Review of four (4) of four (4) inpatient medical records, revealed, verbal orders had not been signed by the physician within 48 hours.

4. The psychiatric evaluation had not been documented on one (1) of four (4) inpatient medical records reviewed. It had not been performed within 60 hours of admission on one (1) of the three (3) records that contained documentation of a psychiatric evaluation. The psychiatric evaluation was absent on one (1) of six (6) discharged records reviewed. It had not been performed within 60 hours of admission on one (1) of the five (5) records that contained a psychiatric evaluation, and had not been dated on another.

5. The patient's name and medical record number had not been recorded on all pages of the medical record on 10 of 10 medical records reviewed.

Based on interview with medical record staff and administration, the hospital
failed to ensure that it has a system of coding and indexing medical records to allow for timely retrieval of patient records by diagnosis and procedures.


Findings include:


Interview with the medical record staff on 08/11/11, revealed that the department does not maintain a diagnostic index and/or a physician index and no one at the hospital codes the final diagnoses.

Interview with the Administrator on 08/11/11 revealed that a hospital run by the same management company coded all discharged records for the facility. This was accomplished by the hospital faxing copies of certain pages of the medical record to the other hospital in order for them to code the discharged records.

Based on interview with medical record staff and administration, the hospital failed to ensure that the medical record department was operating with a Policy and Procedure Manual containing policies and procedures regarding confidentiality of patient medical records.

Findings include:

Interview with the administrator and the medical records person on 08/11/11, revealed neither were aware of a Policy and Procedure Manual for the medical record department that included policies and procedures for release of information and confidentiality of medical records.

Based on Medical Staff Rules and Regulations review and review of medical records, the hospital failed to ensure that all entries are dated and timed and signed by the person responsible on 10 of 10 medical records reviewed.

Findings include:

Cross Refer to A0469 for the hospital's failure to to ensure that all medical records belonging to discharged patients were complete. Hospital personnel that provide care and write in the medical record, other than the physician, have not signed their entries.

1. Six (6) medical records were randomly selected from a list of discharges from the hospital since 01-19-11, and reviewed along with four (4) inpatient medical records for a total of 10 medical records.

2. Verbal orders had not been signed by the physician within 48 hours on four (4) of four (4) inpatient records reviewed and on one (1) of six (6) discharged records reviewed.

3. Review of 10 of 10 medical records revealed all dictated reports did not include the time of dictation, nor did the reports contain the time the reports were transcribed.

Based on Medical Staff Rules and Regulations review and review of medical records, the hospital failed to ensure that 10 of 10 medical records reviewed contained a history and physical exam documented within 24 hours of admission.

Finding include:

1. Six (6) medical records were randomly selected from a list of discharges from the hospital since 01-19-11, and reviewed along with four (4) inpatient medical records for a total of 10 medical records.

2. On four (4) of four (4) inpatient medical records reviewed, the history and physical exam was absent. These records belonged to patients who had been in the facility from two (2) weeks to six (6) days.

3. Review of three (3) of six (6) discharged medical records revealed, the history and physical had been documented four (4) to six (6) days after the patient's admission to the facility.

Based on Medical Staff Rules and Regulations review and review of medical records, the hospital failed to ensure that 10 of 10 medical records reviewed contained a psychiatric evaluation within 60 hours of admission.

Findings include:

1. Six (6) medical records were randomly selected from a list of discharges from the hospital since 01-19-11, and reviewed along with four (4) inpatient medical records for a total of 10 medical records.

2. Medical Record review revealed that the psychiatric evaluation had not been documented on one (1) of four (4) inpatient medical records reviewed. It had not been performed within 60 hours of admission on one (1) of the three (3) records that contained documentation of the psychiatric evaluation. The psychiatric evaluation was absent on one (1) of six (6) discharged records reviewed. It had not been performed within 60 hours of admission on one (1) of the five (5) records that contained the psychiatric evaluation, and had no been dated on another.

Based on Medical Staff Rules and Regulations and review of medical records, the hospital failed to ensure that all medical records were completed with 15 days of discharge.

Findings include:

1. Medical Staff Rules and Regulations require that charts are completed no more than 14 days after discharge. Charts will be considered deficient if not completed in 15 days.

2. On 08-11-11, a count of incomplete discharge medical records, revealed there were 44 incomplete medical records dating back to February, 2011. Most of these records lacked signatures from physicians and other health care professionals. Since 01-19-11, there have been 74 admissions to the facility.

3. There were 35 outpatient medical records incomplete over 15 days that dated back to September, 2010.

Based on pharmacy inspection and staff interview, the hospital failed to ensure that outdated drugs and biological were not available for patient use.

Findings include:

On 08/10/2011 at 2:07 p.m., inspection of the Pharmacy Department with the Chief Nursing Officer (CNO) revealed the following expired intravenous (IV) medications housed on the shelves with in date medications:

Four (4) vials of IV Lasix 20 milligrams (mg)/2 milliliters (ml) expired 04/2011;
One (1) ampule of IV Metoprolol 5 mg/5 ml expired 09/2009;
Six (6) prefilled syringes of IV 50% (percent) Dextrose 50 ml expired 07/2011; and
Six (6) prefilled syringes of Epinephrine 1 mg/10 ml expired 05/2011

The CNO confirmed all of the aforementioned findings during the observation.

Based on dietary inspection and staff interview, the hospital failed to ensure that all foods are stored safely.

Findings include:

On 08/11/2011, at 9:30 a.m., a dietary tour revealed a 64 ounce bottle of teriyaki sauce housed on an open shelf with an open date of 04/20/2011. The label notes to refrigerate after opening. During the dietary tour the Dietary Manager (DM) was asked about the refrigeration after the teriyaki sauce bottle is open. The DM stated that it did not need refrigeration but upon reading the label noted that she was in error.

Inspection of the refrigeration unit revealed a flat of raw eggs (30 eggs) stored on the top shelf over a shelf of juice and a shelf of sealed cheese. Interview with the DM confirmed that the eggs should not be housed on the top shelf due to the possible bacterial contamination concern.

Based on observation and document review, the facility failed to ensure the building was constructed, arranged and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community during one (1) of one (1) day of survey.

Findings include:

Cross Refer to A701 for the hospital's failure to ensure the building was maintained to ensure the safety of the patient and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community.

Based on observation and document review, the hospital failed to ensure the condition of the physical plant and the overall hospital environment was developed and maintained in such a manner that the safety and well-being of patients are assured during one (1) of one (1) day of survey.

Findings include:

Observation on 08/11/11 between 10:00 a.m. and 11:45 a.m.
revealed:
1. Smoke barrier doors located next to the office area failed to close when the fire alarm was activated.
2. The smoke barrier wall located near the office area had an unsealed penetration around electrical conduits and sprinkler piping.
3. The Laundry Room had two (2) small penetrations around electrical conduit.
4. The Boiler Room had numerous unsealed penetrations in the wall that connects with the hospital.
5. The Central Supply Storage Room had unsealed penetrations around the sprinkler piping.

Based on observation, the hospital failed to provide a properly installed, tested and maintained fire alarm system in their Senior Care Unit.

Findings include:

Observation on 08/11/11 revealed there was no fire alarm horn/strobe in the hospital's Senior Care Unit.

Based on documentation review, the hospital failed to ensure proper testing and maintenance of their fire alarm system.

Findings include:

The hospital failed to provide documented evidence that they had performed quarterly tests on their sprinkler system. The maintenance supervisor was unaware that tests had to be performed quarterly.

Based on Infection Control Committee policy review, minutes of meetings review and Chief Nursing Officer (CNO) interview, it was determined that the hospital infection control committee failed to conduct quarterly meetings as facility policy notes.


Findings include:


On 08/10/2011, at 3:05 p.m., review of the Infection Control Committee minutes revealed meetings documented on 09/15/2010, 12/15/2010, 01/15/2011, 06/03/2011 and 08/09/2011.


Infection Control manual review revealed a policy revised 06/09/2011, noting that the Infection Control Committee will hold quarterly meetings.


Interview with the CNO confirmed that the policy was not being followed for quarterly meetings.