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Based on record review and interview, the facility failed to ensure Pts are asked if they have an AD, and/or offer information and assistance with developing an AD, in 4 of 17 MRs (2, 3, 4 and 6) of Pts 18 years old and over, out of a total of 20 MRs reviewed. This deficiency affects all 31 adults Pts treated at the facility during survey.

Findings include:

Review on 5/14/14 at 3 PM of facility P&P titled Advance Directives, dated 3/15/12, it states under Procedure 1. "...Patients will be asked by the nurse...if they have completed an Advance Directive...If the patient does not have an advance directive...document in the nursing notes any health care treatment preferences that are expressed...patient will be asked if they would like more information..."

Pt #2's MR review on 5/14/14 at 2:45 PM revealed staff did not document if Pt #2 has an AD, or offer information and assistance on developing an AD. This is confirmed in interview with Mgr B on 5/14/14 at 2:45 PM, adding the documentation should be in the MR.

Pt #3's MR review on 5/14/14 at 1:43 PM revealed staff did not document if Pt #3 has an AD, or offer information and assistance on developing an AD. This is confirmed in interview with Mgr B on 5/14/14 at 1:43 PM, adding the documentation should be in the MR.

Pt #4's MR review on 5/13/14 at 2:40 PM revealed staff did not document if Pt #4 has an AD, or offer information and assistance on developing an AD. This is confirmed in interview with Dir K on 5/13/14 at 2:40 PM, adding the documentation should be in the MR.

Pt #6's MR review on 5/13/14 at 2:20 PM revealed staff did not document if Pt #6 has an AD, or offer information and assistance on developing an AD. This is confirmed in interview with Dir K on 5/13/14 at 2:20 PM, adding the documentation should be in the MR.

Based on the tour of the facility from May 12th to May 13th with Staff M and Staff N; this surveyor observed that the hospital failed to be constructed, arranged, or maintained the building to ensure the safety of the patients. The cumulative effects of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients. The Existing Health Care Occupancy chapter of the Life Safety Code (2000 Edition) [NFPA 101] was used for this survey.

42 CFR 485.623: Condition of Participation: Physical Plant is NOT MET.

K-tags cited were as follows:
K-17: Corridors openings were not smoke-tight,
K-25: Smoke compartments doors were not smoke-tight,
K-27: Openings in Smoke compartments were not labeled, and
K-56: Sprinkler system was not installed per NFPA 13.

These deficiencies were confirmed at the time of discovery by a concurrent observation, record review and interview with Staff M and Staff N. Please refer to the individual K-tags for the full description of each deficient practice.

Based on observation and interview, this facility does not ensure that the physical environment is maintained in a way that protects patients, families, and visitors from harm in 3 of 13 departments observed (ED, M/S and Rehab). Failure to maintain a safe environment has the potential to affect all patients, families, and visitors in the facility including the 34 patients present throughout the course of the survey.

Findings include:

ED
Per observation in the ED was completed on 5/13/2014 from 7:30 a.m.-7:43 a.m. accompanied by EDM L. The following breeches in infection control were observed and confirmed by EDM L:

--The following rooms had unsecured needles/syringes that could be accessed by patients/families: Trauma room, Exam room 1, Exam room 2 (the procedure room was not observed as it was occupied).

M/S
Per observation in the M/S unit was conducted on 5/13/2014 from 10:35 a.m.-11:10 a.m. accompanied by DON K who confirmed the following finding:

--In the shower room, in an unlocked cabinet, there was a spray bottle of Oxivir, a chemical cleaning agent that should be out of reach of children. The cabinet door was not closed and the chemical cleaner could have been accessed by patients and/or visitors. In an interview with DON K during the tour, K stated this cabinet should have been locked.

Rehab:

Per observation in the Rehab Department with Dir P on 5/13/14 at 8:00 AM, the room used for Podiatry and Orthopedics had an unsecured drawer containing scalpels, needles and syringes. Per Dir P agreed during observation the items should be secured.

Based on the tour of the facility from May 12th to May 13th with Staff M and Staff N; this surveyor observed that the hospital failed to be constructed, arranged, or maintained the building to ensure the safety of the patients. The cumulative effects of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients. The Existing Health Care Occupancy chapter of the Life Safety Code (2000 Edition) [NFPA 101] was used for this survey.

42 CFR 485.623 (d)(1) Standard: Life Safety from Fire is NOT MET

K-tags cited were as follows:
K-17: Corridors openings were not smoke-tight,
K-25: Smoke compartments doors were not smoke-tight,
K-27: Openings in Smoke compartments were not labeled, and
K-56: Sprinkler system was not installed per NFPA 13.

These deficiencies were confirmed at the time of discovery by a concurrent observation, record review and interview with Staff M and Staff N. Please refer to the individual K-tags for the full description of each deficient practice.

Based on record review, observation and interview, the facility failed to ensure expired and/or open single use medications are not available for Pt use or unauthorized access, in 2 of 13 areas (OR and Rehab), and 1 of 8 staff (H) observed. This deficiency potentially affects all 34 Pts treated during survey.

Findings include:

Review on 5/14/14 at 3:00 PM of facility P&P titled Use of Multidose Vials, dated 5/26/11 does not state multidose vials may be "spiked".

Review on 5/14/14 at 3:00 PM of facility P&P titled Unit Inspection, dated 4/2/11, it states "Drugs shall be accessible only to responsible personnel designated by the hospital...Drugs shall not be kept in stock after the expiration date on the label"

Per review on 5/14/14 at 5:30 PM of APIC position paper: Safe injection, infusion, and medication vial practices in health care dated April 2010 states "Do not use spiking devices"

Example in OR:

On 5/12/14 at 12:46 PM, H H was observed mopping the OR floor, while a syringe of Propofol was unsecured and unattended on top of the Anes medication cart, allowing for unauthorized access.

Per interview with CRNA A on 5/13/14 at 8:00 AM, CRNA A acknowledged the syringe should not have been left on top of the cart.

Example in Rehab department:

Per observation in the Rehab Department with Dir P on 5/13/14 at 8:00 AM, the room used for Podiatry and Orthopedics had an unsecured drawer containing four sodium chloride inhalant solution expired 4/04.

In the storage room there is a black tray containing lumicain (hemostatic solution) expired 1/2010; Wound Wash Sterile Spray, labeled single use, approximately 1/2 empty; Formaldehyde expired 1/2012; Sterile Sodium Chloride bottle, open, with an expiration date of 9/2013.

The storage cabinet next to the treatment area contained 4 baggies with Dexamethasone for iontophoresis (electronic stimulation). In each baggy, there is one multidose vial of Dexamethasone "spiked" with a "luer" lock, allowing access without a needle. This practice allows for potential contamination of the medication.

Per interview with Dir P on 5/13/14 at 8:00 AM, the medications should not be expired, and single use should be discarded after first use. Dir P was not aware multidose vials could not be "spiked".

Based on observation, record review and interview, the facility failed to ensure there is a comprehensive infection control program to monitor and prevent potential infections and cross contamination, in 5 of 13 areas observed (OR, Decontamination, Rehab, ED and Lab), and in 7 of 8 staff (C, D, E, F, G, H and W) observed performing tasks. This deficiency potentially affects all 34 Pts treated at the facility during survey.

Findings include:

Per review on 5/14/14 at 3:00 PM of facility P&P titled Peripheral Intravenous Therapy, dated June 2013, it states under Site Selection and Preparation "Without touching cleansed insertion site, anchor the vein with the non-dominate hand..."

Per review on 5/14/1/4 at 3:00 PM of facility P&P titled Hand Hygiene, dated 7/12, it states under #3 "Hands will be washed...between every patient/client contact or contact with environmental surfaces...#8 Hands must be washed after removal of gloves."

Per review on 5/14/14 at 9:45 AM PM of facility P&P titled Aseptic Standards, dated 1/12, it states under II. Attire...Hair must be covered by surgical caps...VII. Skin "Prep" or "Scrub"...Scrub from the inner area, moving toward the outer aspect of the operative site...IX...All linen, soiled or clean, should be placed in a linen bags (sic) and sent to the laundry...XII. Cleaning instruments: Effective decontamination of instruments is essential...wash all instruments in an instrument soap and water, rinse, then to central supply room..."

Per review on 5/14/15 at 5:30 PM of AORN SOPs it states under RP: Surgical Attire: II. "Clean surgical attire, including...jackets...should be worn in teh semirestircted and restricted areas...." RP: Patient Skin Antisepsis: IV.b.2. "...Hair removal should be performed...in a location outside of the operating or procedure room...minimizes the dispersal of loose hair and the potential for contamination of the sterile field and surgical wound...The clipper handle is contaminated with the Pt's skin flora..." RP: Sterile Technique: IV.a.8. "Only the top of a sterile, draped areas should be considered sterile. Items that fall below the sterile area should be considered contaminated." VI.g.3. "When solutions are dispensed to the sterile field, the entire contents of the container should be poured slowly into a solution receptacle that is placed near the sterile table's edge..." RP: Cleaning and Processing Endoscopes IX.a. "Flexible endoscopes should be stored in a closed cabinet with venting that allows air circulation around the flexible endoscopes..." RP: Environmental Cleaning: II.c.6. "Spray and misting methods should not be used to apply cleaning chemicals in the perioperative setting...spray mechanism may provide a route for airborne transmission of disease..." RP: Care of Instruments VI.a. "During transport to a decontamination area, soiled instruments must be contained in a manner to prevent exposure of patients or personnel.." X.a. ..."instruments received into the decontamination area should be rinsed with cold running water..." X.b.1. "...cleaning should be accomplished by submerging the instrument in warm water with an appropriate detergent followed by complete submersion of the instrument in rinse water..." XII.f. "Lumens...should be flushed with distilled demineralized, or sterile water before steam sterilization..." XIV.p. "An adequate inventory of instruments should be provided to allow for thorough instrument cleaning and sterilization."

Examples in the OR:

On 2/12/14 between 11:45 AM and 4:00 PM the following was observed:

At 11:45 AM RN D completed an IV site insertion. RN D palpated the site after cleaning, allowing for contamination of the insertion site.

At 12:05 PM endoscopes are observed hanging in an open corridor in the sub-sterile area of the OR suite. At 12:25 PM, ST E carried uncontained dirty linen, held against ST E's side, and irrigation IV bag with tubing, as well as dirty instruments, covered with a towel, and not contained to prevent spills, past the scopes. This storage method and practice of handling contaminated supplies allows for cross contamination of clean equipment.

At 12:11 PM ST E, CRNA C and RN F did not have all their hair incased in a bonnet, including sideburns, and nape of neck hair, allowing for potential contamination of the surgical site during procedures.

At 12:17 PM RN F did not wash between glove changes, allowing for potential cross contamination between tasks.

At 12:18 PM, chipped paint was noted along all four walls in the OR, making the surface unwashable.

The OR was cleaned between 12:25 PM and 12:52 PM, using a spray bottle of disinfectant, rather than a diluted solution with cleaning cloth to saturate the surfaces. The anes chair, anes cart and anes medication cart were not included with equipment cleaned.

At 12:46 PM, H H mopped the OR, did not have on a jacket to prevent sloughing of skin cells onto equipment. Used the same hand that maneuvered the mop bucket and mop ringer to move equipment out of the way for mopping and handled the door handles. This practice contaminated surfaces that were cleaned by staff for the next procedure. RN D entered the OR touching the door handles and did not wash prior to helping set up sterile instruments, picked up the strap to secure the Pt, and attached it to the OR table, potentially contaminating supplies and equipment. Per interview with Dir I on 5/13/14 at 8:00 AM, H H should have gone back and wiped down all surfaces touched with a disinfectant.

Between 1:09 PM and 1:11 PM the OR door was propped open with open sterile instruments on the table.

At 1:12 PM, RN F shaved the surgical site while Pt #1 is on the OR table. This practice allows for potential contamination of the surgical wound.

At 1:14 PM, RN F placed the used shaver on a stand with clean equipment, without discarding the blades, picked it up with ungloved hands and repositioned it on the table. This practice allows for contamination of clean supplies and hands.

At 1:20 PM, MD G entered the OR and assisted RN F with the surgical prep by pouring the Betadine solution in the sterile basin reaching over the basin and turning the bottle upside down. MD G had bare arms and did not have a sterile gown on. This practice allows for potential contamination of the sterile basin and solution.

At 1:21 PM, RN F began prepping the surgical site with Betadine. RN F did not start at the incision site, rather started wiping away from, and towards, the incision site. RN F repeated this process two more times with Betadine soaked gauze. This practice allows for reintroduction of potential contaminates at the incision site. Upon completion of the prep, at 1:23 PM, a sterile towel was immediately placed near the incision site, the prep was shiny, as though wet. This practice does not allow for complete effectiveness of the disinfectant. Per interview with DPCS A on 5/14/14 at 2 PM, the manufacturer states the Betadine should have a "matte" look when dry. At 1:25 PM the Pt was completely draped and time out was done, the prep was shiny as though wet. There was no verbal statement the skin prep was dry prior to draping.

At 1:26 PM, RN F was told by MD G the cautery did not work RN F placed the grounding pad on Pt #1's leg. During this task, MD G held the drape up for access and touched underneath the drape with sterile gloved hands, allowing for contamination of the gloves. MD G did not change the sterile gloves and proceeded to begin the incision.

Examples from the Decontamination Room:

Per observation of ST E at 3:00 PM cleaning surgical instruments, ST E ran water in the sink, did not measure the water and squirted two and approximately 1/2 times of enzymatic cleaner into the water. When asked how much water and cleaner to use, ST E said "2 or 3 squirts, I never measure, just fill it." Per manufacturer's instruction for the Rapidzym cleaner it states "Presoak and manual cleaning...1) 1 fluid ounce per gallon of water...2) soak for 2-5 minutes." ST E made no comment when the instructions were read aloud. This practice allows for inconsistent concentration of enzymatic cleaner.

ST E began washing the unused instruments, that were in the procedure set, without a pre-rinse, scrubbing above the water line allowing for splatter. ST E rinsed the items and placed them on a towel next to the rinse sink to dry. ST E washed two rigid cystoscope shields with the enzymatic cleaner, using a syringe to squirt the cleaner through the lumens. ST E placed the shields in the rinse water, did not flush with clean water and placed the shields in a vertical position on the counter against the wall. ST E did not flush the lumens with air to ensure all moisture was removed. This practice prevents adequate rinsing of lumens and moisture in the lumens can prevent complete sterilization of the instrument.

ST E proceeded to wash the most recently used instruments and basins, that had been soaking in water with no enzymatic cleaner. ST E did not soak the items for the 2-3 minutes in the cleaner, as recommended by the manufacturer's instruction, and used a brush to scrub the items above the water level, allowing for splatter and potential contamination of clean instruments within 3 feet of the sink. One brush approximately 3 inches long had curled plastic bristles. When asked, during observation, if the brush could clean instruments, ST E stated "it still works", did not discard the brush. Use of this brush could prevent complete removal of bioburden on the instruments, potentially allowing for cross contamination.

Per interview with ST E at 3:00 PM the facility has two sets of eye instruments for cataract surgery. ST E states the facility usually schedules 5-8 cataract surgeries at a time. ST E stated the instruments need to be "flashed" or "immediate-use" sterilization to stay on schedule with the surgeries with a fifteen minute turnaround time. When asked about sterilizing any single use items, ST E pointed out there is a single use tourniquet that gets wiped down between use. The use of flash sterilizing does not allow adequate time fore the complete sterilization cycle.

Per interview with Mgr B on 5/12/14 at 2:00 PM, the OR department should follow the P&Ps, and AORN SOPs, for skin prep, PPE, cleaning/disinfecting and handwashing.

Examples in the Rehab Department:

Per observation in the Rehab Department Dir P on 5/13/14 at 8:00 AM, the room used for Podiatry and Orthopedics had an unsecured drawer containing two staple removers, one in a sterile package dated expired 10/26/02, another outside of packaging; and an unidentifiable instrument in sterile packaging dated expired 1/3/03.

The massage therapy room had uncovered linen on a bookcase.

In a storage room shared by the Rehab Department, Podiatry, and Orthopedics, there were ortho boots on floor, and a wooden cart had three containers with the disinfectant Mandacide, no expiration date. Dir P did not know what the Mandacide is used for, nor who or where it is used.

Examples of would care observation:

On 5/14/14 at 2:00 PM, RN W was observed assisting RN X with wound care for Pt #22. RN W picked up two packages of sterile sponges, while opening one, the other package touched the sterile sponge. This practice allows for contamination of sterile items.


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Examples in the ED:

Per observation in the ED on 5/13/2014 from 7:30 a.m.-7:43 a.m. accompanied by Mgr L. The following breeches in infection control were observed and confirmed by Mgr L:
--Under the sink in the room identified as the "Lab Draw Room" there were disposable washcloths, patient gowns and disposable paper pads. This is not a clean area to store patient supplies.

Examples in the Lab:

Per observation in the Lab on 5/12/2014 from 3:25 p.m.-3:45 p.m. accompanied by MLT O. The following breeches in infection control were observed and confirmed by MLT O:
--There were two live plants planted in soil within the confines of the lab on the clean side. Plants harbor dust and the soil could potentially harbor microorganisms.
--There was a build up of dust along the back edge of the counters between and behind the Lab equipment in the Coagulation area, Blood Gas area, and the Clean area of the Lab.
In an interview with MLT O during the tour, MLT O stated that housekeeping cleans the floors in the Lab but the Lab staff are responsible for cleaning the counters.

An interview regarding the infection control program was conducted on 5/14/2014 at 8:45 a.m. with DQ R and IP Q. IP Q stated that this facility follows the recommendations for infection control from APIC, CDC, and AORN.

IP Q stated that Q has started looking in the computer at surgical patients for any infection related complications after their surgery and has spoken to the OR Manager B to have physicians contact IP Q for any patients who may develop infections, but does not currently have an effective tracking or logging system for SSIs.

Based on observation and interview, the facility failed to ensure there are no single use or undated open food items available to Pts, in 2 of 13 areas (Nursery and M/S). This deficiency potentially affects all newborns at the facility.

Findings include:

Per observation in the Nursery on 5/13/14 at 10:00 AM there is an open bottle of glucose water given to infants on a pacifier for comfort during circumcisions. Per interview with Dir K during the observation, the glucose is for single patient use, and should have been discarded.


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Per observation in the M/S unit was conducted on 5/13/2014 from 10:35 a.m.-11:10 a.m. accompanied by DON K who confirmed the following finding:
--In the kitchenette there was an open undated container of Thickit (product to thicken liquids for patients who have difficulty swallowing regular liquids) that was half gone. In an interview during the observation, DON K stated that this should have been dated when it was opened.

Based on record review and interview, the facility failed to ensure P&Ps are reviewed on an annual basis, in 2 of 13 departments (Respiratory and OR) reviewed. This deficiency potentially affects all 34 Pts treated during survey.

Findings include:

Per interview with DPCS A on 5/13/14 at 8:00 AM, DPCS stated there are approximately a dozen P&Ps regarding Respiratory Therapy, that were due for review in December 2013, that he is unable to determine if they are up to date.

Per interview with Mgr B on 5/14/14 at 11:00 AM, Mgr B recently started as the Mgr of the OR, and has not been able to review all P&Ps that are due as yet. Per review of a sample of P&Ps for the OR, there are 3 P&P that are not reflecting current SOPs for ORs: Aseptic Standards does not address new SOPs such as: covering all hair, wearing jackets, hair removal, and cleaning instruments. The P&P for Draping, has no revision date since 1999, does not address documenting and verbalizing the skin prep is dry prior to draping. The P&P Surgical Preps has no revision date since 1999, and does not address alcohol based skin preps.

Based on observation, record review and interview, the facility failed to ensure medication administration is performed aseptically, in 1 of 2 staff observed doing medication administration (C). This deficiency potentially affects all 34 Pts treated at the facility during survey.

Findings include:

Per review on 5/14/14 at 3:00 PM of facility Medication Labeling in Perioperative & Procedural Settings, dated 1/3/06, it states under Procedure 3."Labeling must include:...b. Strength of medication or solution...c. Date the medication was transferred to another container d. Initials of the person preparing the label." This P&P does not require the medication to be timed when prepared.

Per review on 5/14/14 at 3:00 PM of facility P&P titled Peripheral Intravenous Therapy, dated June 2013, it states under Peripheral Site Maintenance...Vigorously scrub the hub to be accessed for a minimum of 15 seconds with a 70% alcohol prep."

Per review on 5/14/14 at 5:30 PM of APIC position paper: Safe injection, infusion, and medication vial practices in health care dated April 2010 states "Disinfect IV ports and vial stoppers by wiping and using friction with a sterile 70% isopropyl alcohol"

At 12:40 PM, CRNA C took out a predrawn syringe of Propofol from the Anes Medication Cart. The syringe was not labeled with dose, date, time and who drew up the medication. When questioned, at time of observation, CRNA C said the medication was drawn up before the last Pt was brought into the OR.

At 1:03 PM, CRNA C drew up fentanyl without the benefit of wiping the septum, and turned the vial of Versed upside down to rub on an alcohol wipe, failing to completing clean the septum.

At 1:11 PM, CRNA C cleaned Pt #1's IV port for sedation medication reusing one alcohol wipe between all three medications, placing the wipe on Pt #1 skin when not being used. This practice allows for recontamination of the IV port.

Per interview with Mgr B on 5/12/14 at 2:00 PM, the facility follows APIC SOPs.

Based on record review and interview, the facility failed to ensure properly corrected errors and complete documentation 4 of 7 MRs (11, 13, 14 and 15) out of a total 20 MRs reviewed. This deficiency potentially affects all ED Pts that arrive at the facility.

Findings include:

The facility's policy titled, "Corrections to the Paper Medical Record," dated February 2014, was reviewed on 5/14/2014 at 3:41 p.m. The policy states in the last bullet point, "The use of white-out is prohibited."

The facility's policy titled, "Standards of Care in the Emergency Department," dated September, 2011, was reviewed on 5/14/2014 at 3:44 p.m. The policy states in part on page 2, "Standard 5...A medical record shall be kept for every patient receiving emergency service. It shall become an official hospital record. This specifies that the medical record for every patient shall contain...2) time of arrival, means of arrival, and by whom transported...."

A MR review for Pt. #11 was conducted on 5/13/2014 at 3:25 p.m. accompanied by Mgr L who confirmed the following finding: Pt. #11's sexual assault history form, a paper document, had an area of white out (obstructive correction tape) and Pt. #11's name was written over the white out.

MR reviews for Pt.s #13, 14, and 15 were conducted on 5/13/2014 from 2:30 p.m.-3:00 p.m. accompanied by Mgr L. Pt.s #13, 14, and 15 were all patients who presented to the ED. It was noted during the MR review that the time the patient arrived to the ED, if the patient does not arrive by ambulance, is not documented.

In an interview with Mgr L regarding the documentation of arrival time at 2:40 p.m. on 5/13/2014, L stated that on the electronic form arrival time is the time the patient is triaged. Admit time is the time they are taken to a room in the ED.

Mgr L stated that the facility is not capturing the time patients come to the department if they come through the front doors of the facility. Without capturing the time patients arrive at the department, if they are not arriving by ambulance, the ED is unable to capture a complete chronological time line of events for the patient.

Based on record review and interview, the facility failed to ensure the consents for anesthesia are complete with a signature, date and time, in 4 of 4 MRs (1, 2, 3 and 4) out of a total of 20 MRs reviewed. This deficiency potentially affects all 34 Pts treated at the facility during survey.

Findings include:

Per review on 5/14/14 at 3:00 PM of facility P&P titled Informed Consent it states "The date and time of witnessing the signature is completed."

Pt #1's MR review on 5/14/14 at 12:55 PM revealed Pt #1 had surgery on 5/12/14. The consent for Anes is not dated and timed by the CRNA indicating the risks and benefits were discussed prior to surgery. This is confirmed in interview with Mgr B on 5/14/15 at 12:55 PM, adding there should be a date and time.

Pt #2's MR review on 5/14/14 at 2:45 PM revealed Pt #2 had surgery on 1/20/14. The consent for Anes is not dated and timed by the CRNA indicating the risks and benefits were discussed prior to surgery. This is confirmed in interview with Mgr B on 5/14/15 at 2:45 PM, adding there should be a date and time.

Pt #3's MR review on 5/14/14 at 1:43 PM revealed Pt #3 had surgery on 5/12/14. The consent for Anes is not dated and timed by the CRNA indicating the risks and benefits were discussed prior to surgery. This is confirmed in interview with Mgr B on 5/14/15 at 1:43 PM, adding there should be a date and time.

Pt #4's MR review on 5/13/14 at 2:40 PM revealed Pt #4 had surgery on 2/12/14. The consent for Anes is not dated and timed by the CRNA indicating the risks and benefits were discussed prior to surgery. This is confirmed in interview with Mgr B on 5/13/15 at 2:40 PM, adding there should be a date and time.

Based on record review and interview, the facility failed to ensure all VO, TO and SO are authenticated by the MD, in 6 of 20 MRs reviewed (4, 5, 6, 16, 17 and 20). This deficiency potentially affects all 34 Pts treated at the facility during survey.

Findings include:

Review on 5/14/14 at 11:00 AM of the facility Medical Staff Rules and Regulations, dated 2/11, it states under #4 "...all verbal and telephone orders shall be authenticated (signed), dated and timed by a physician who is authorized to write orders by hospital policy within forty-eight hours of receipt."

Pt #4's MR review on 5/13/14 at 2:40 PM revealed there is a SO, written on 2/14/14, that is not timed by the MD, and there is a TO written on 2/14/14 that is not authenticated by the MD, and VOs written on 2/14/14 that are authenticated by the MD on 3/28/14, more than 30 days after discharge. This is confirmed in interview with Dir K on 5/14/14 at 2:40 PM, adding the MDs should authenticate within 48 hours.

Pt #5's MR review on 5/13/14 at 4:25 PM revealed there is a TO written on 2/15/14 that is authenticated on 3/28/14 by the MD, more than 30 days after discharge. This is confirmed in interview with Dir K on 5/13/14 at 4:25 PM adding the MDs should authenticate within 48 hours.

Pt #6's MR review on 5/13/14 at 2:20 PM revealed there are VOs written on 2/15/14 at 1:55 PM that are authenticated on 2/16/14 at 3:30 PM, beyond the 24 hours of being written. This is confirmed in interview with Dir K on 5/14/14 at 2:20 PM, adding the MDs should authenticate within 48 hours.


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A MR review was conducted on Pt. #16's closed MR on 5/14/2014 at 12:20 p.m. accompanied by Mgr L who confirmed these findings during the MR review. Pt. #16 had 9 TOs from 3/2/2014 (admission orders) that were not signed by the physician until 3/7/2014. This time frame exceeds 24 hours.

A MR review was conducted on Pt. #17's closed MR on 5/14/2014 at 1:16 p.m. accompanied by EDM L who confirmed these findings during the MR review. Pt. #17 had one TO from 4/1/2014 that was not signed by the physician until 4/20/2014. This time frame exceeds 24 hours.

A MR review was conducted on Pt. #20's open SB record on 5/14/2014 at 2:30 p.m. accompanied by EDM L who confirmed these findings during the MR review. Pt. #20 has two TOs from 5/6/14, three TOs from 5/7/14, and one TO from 5/9/14 that are not authenticated within 24 hours by the provider.

Based on record review and interview, the facility failed to ensure all entries are signed, dated and timed, in 3 of 20 MRs reviewed (2, 4 and 7). This deficiency potentially affects all 34 Pts treated at the facility during survey.

Findings include:

Per review on 5/14/14 at 11:00 AM of the Medical Staff R&R dated 11/11, it states under #5. "...All entries into the medical record must be properly authenticated to include the time and date of each entry."

Pt #2's MR review on 5/14/14 at 2:45 PM revealed Pt #2 was discharged on 1/21/14, the OP dictated on 1/20/14, is not authenticated with a date and time. This is confirmed in interview with Mgr B on 5/14/14 at 2:45 PM.

Pt #4's MR review on 5/13/14 at 2:40 PM revealed the Newborn Exam is not dated and timed, making this an incomplete MR after 30 days. This is confirmed in interview with Dir K on 5/14/14 at 2:40 PM.

Pt #7's MR review on 5/13/14 at 4:40 PM revealed the Newborn Exam is not dated and timed, making this an incomplete MR after 30 days. This is confirmed in interview with Dir K on 5/14/14 at 4:40 PM.

Based on record review and interview, the facility failed to ensure there documentation of contacting the OPO upon Pt death, in 2 of 2 closed death MRs (8 and 9) out of a total 20 MRs reviewed. This deficiency directly affects the potential donors Pts 8 and 9 and all future Pts that my die at the facility.

Findings include:

Per interview with SW J on 5/14/14 at 10:30 AM, SW J stated staff are to document the following in MRs of a Pt that has died: Date, time, reference number and name of contact at the OPO. In review of the facility's policy titled, "Organ, Tissue and Eye Procurement, " dated October, 2011, was reviewed on 5/14/2014 at 10:15 a.m. The policy does not indicate that staff are to document the name of the OPO as per the facility's expectation. The policy does not include actions to take when there is immanent death.

A MR review was conducted on Pt. #8's closed death record on 5/14/2014 at 2:46 p.m. accompanied by Mgr L who confirmed these findings at the time of the interview. The documentation of OPO notification does not include the name of the OPO representative contacted.

A MR review was conducted on Pt. #9's closed death record on 5/14/2014 at 2:54 p.m. accompanied by Mgr L who confirmed these findings at the time of the interview. The documentation of OPO notification does not include the name of the OPO representative contacted.

In an interview with Mgr L during the MR reviews, Mgr L stated that L would document the name of the OPO contact because, "That's the way we were taught."