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Based on record review and interview, the registered nurse failed to ensure that complete orders were obtained from the physician that included the name, dose, route, and frequency of the drug to be administered prior to the administration of all drugs and biologicals. This was noted in the medical record of 1 of 7 sampled patients (Patient #6).
Findings:

Patient #6: Medical record review revealed that the patient was admitted to the hospital on 1/13/10. The patient's medical diagnoses included left knee degenerative arthritis. According to the medical record, the patient underwent an operative procedure (Left total knee replacement with a rotating platform prosthesis) on 1/13/10. Review of the medication administration record for the date of 1/14/10 revealed that 24 mcg of Amitiza was administered to the patient on 1/14/10 at 10:00 a.m. and 10:00 p.m., 0.25 mg of Mirapex was administered to the patient on 1/14/10 at 10:00 p.m., 120 mg of Verapamil was administered to the patient on 1/14/10 at 10:00 p.m., and 10 mg of Zolpidem was administered to the patient on 1/14/10 at 10:00 p.m. Documentation revealed an order dated 1/13/10 at 4:06 p.m. to "Resume home meds in AM". There was no documentation to indicate that the orders included the name, dose, route, and frequency of the above documented medications prior to their administration.
In an interview with S13, Quality Coordinator, RN, on 3/26/10 at 9:55 a.m., the Quality Review Coordinator confirmed that the orders did not include the name, dose, route and frequency of the above documented medications prior to their administration.

Based on record review and interview, the hospital failed to ensure that all entries in the medical record were complete and/or accurate in relation to 1) incomplete physician orders for 1 of 7 sampled patients (Patient #6), 2) inaccurate operative report for 1 of 7 sampled patients (Patient #6).
Findings:

1) Incomplete physician orders.

Patient #6: Medical record review revealed that the patient was admitted to the hospital on 1/13/10. The patient's medical diagnoses included left knee degenerative arthritis. According to the medical record, the patient underwent an operative procedure (Left total knee replacement with a rotating platform prosthesis) on 1/13/10. Review of the medication administration record for the date of 1/14/10 revealed that 24 mcg of Amitiza was administered to the patient on 1/14/10 at 10:00 a.m. and 10:00 p.m., 0.25 mg of Mirapex was administered to the patient on 1/14/10 at 10:00 p.m., 120 mg of Verapamil was administered to the patient on 1/14/10 at 10:00 p.m., and 10 mg of Zolpidem was administered to the patient on 1/14/10 at 10:00 p.m. Documentation revealed an order dated 1/13/10 at 4:06 p.m. to "Resume home meds in AM". There was no documentation to indicate that the orders included the name, dose, route and frequency of the above documented medications prior to their administration.

In interview on 3/26/10 at 9:55 a.m., S13, Quality Coordinator, RN, confirmed that the orders did not include the name, dose, route and frequency of the above documented medications prior to their administration.


2) Inaccurate operative report.

Patient #6: Medical record review revealed that the patient was admitted to the hospital on 1/13/10. The patient's medical diagnoses included left knee degenerative arthritis. According to the medical record, the patient underwent an operative procedure (Left total knee replacement with a rotating platform prosthesis) on 1/13/10. Review of the anesthesia record revealed documentation indicating that Regional Anesthesia was administered to the patient at 11:11 a.m. on 1/13/10. Review of the operating room nursing notes confirmed that Regional Anesthesia was administered to the patient on 1/13/10. Review of the operative report revealed documentation indicating that General Anesthesia was administered to the patient on 1/13/10.

In interview on 3/25/10 at 1:50 p.m., S1, Vice President of Nursing Services, reviewed the medical record and reported that it appeared as though the operative report was not accurate in relation to the type of anesthesia administered to the patient on 1/13/10.

Based on record review and interview, the hospital failed to ensure that all entries in the medical record were timed when written. This was noted in the medical record of 4 of 7 sampled patients (#4, #5, #6, #7).
Findings:

Patient #4
Review of the medical record for Patient #4 revealed physician's orders dated 01/26/10, 01/23/10, 01/24/10, and 01/26/10 that were not timed.

Patient #5
Review of the medical record for Patient #5 revealed physician's orders dated 01/27/10, 01/28/10, 01/29/10, and 02/01/10 that were not timed.

Patient #6
Review of the medical record for Patient #6 revealed progress notes dated 01/14/10, 01/15/10, 01/16/10 and 01/17/10 that were not timed and physician's orders dated 1/13/10, 01/14/10 and 01/15/10 that were not timed.

Patient #7
Review of the medical record for Patient #7 revealed the Consent for Surgery for the Right Total Hip replacement had no date the physician signed the consent, no date the physician signed the Blood Consent, no date and time the physician signed the Anesthesiology Pre-Operative orders, no date and time the physician signed the Home Medication Reconcilliation form, no time on physician orders dated 01/14/10, no time on 3 of 5 physician orders written on 01/15/10, no time on the physicians orders for "Post-Op Hip Surgery Day 2" orders on 01/16/10, no time on orders written on 10/16/10, no time on 2 of 2 orders written on 01/17/10, and no time on 3 of 5 physician orders for 01/18/10.


In an interview on 03/26/10 at 10:00 a.m. S13, Quality Coordinator, RN, confirmed that the orders were not timed when written.

Based on record review and interview the hospital failed to ensure all medical records for discharged patients included a discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care for 1 of 7 medical records reviewed (Patient #4).
Findings:

Review of the medical record for Patient #4 revealed the patient was discharged home on 01/26/10. Review of the entire medical record revealed no documented evidence that a discharge summary was completed.

In interview on 03/26/10 at 9:40 a.m. S13, Quality Coordinator, RN, indicated the physician failed to complete a discharge summary. S13 further indicated the physician would be contacted and instructed to complete the required discharge summary.

Based on observations and interview, the hospital failed to ensure that all facilities, supplies, and/or equipment were maintained in a manner to ensure the safety and well being of patients and/or maintained in a manner to ensure quality assurance. Findings:

An observation was made on 3/25/10 at 3:00 p.m. of a patient care room "a" that was reported to be clean and ready for a new admission. The unit charge nurse (S5) was present at the time of this observation. This observation revealed the following:

Patient Room "a" was reported to be clean and ready for a new admission. The bed in this room was noted to be neatly made. Three (3) reddish colored stains were noted to be on the side of the frame of this bed and a sticky residue was noted to be on one (1) of the rails of this bed. The reddish stains were wiped with a damp cloth by S5 at the request of the surveyor. The stains were noted to be easily removed from the bed with minimal pressure. S5 reported that she could not identify the source of the stains and reported that the stains should have been removed during the cleaning and disinfecting of the bed prior to indicating that the room was ready for a new admission.