HospitalInspections.org

Based on observation and review of a patient's medical record and interview of the hospital nursing staff and the Patient Registration Supervisor, it was determined that one of 46 inpatients reviewed had not received the required standardized "Important Message from Medicare" (IM), within the 2 days of their admission to the hospital.
The findings were:
Patient #2 was 84 years old and was admitted to the hospital on 01/25/13 for elective surgery for a total shoulder replacement. Observation and review of the patient's medical record on 01/28/13 revealed that the IM was not signed by the patient or other designated patient representative (wife). Interview of the 6 East licensed nursing staff on 01/28/13 between 12-12:45 PM revealed that the staff was unsure why the form was not signed. Interview of the Patient Registration Supervisor at 12:45 PM on 01/28/13 confirmed that the IM had not been signed by the patient or other designated representative as required within the 2 day time frame of the patient's admission. Further review of the patient's medical record on 01/30/13 in the Medical Records Department at 3:15 PM indicated that the IM was signed by the patient's wife on 01/28/13 at 2:50 PM, which was 3 days after admission and after surveyor intervention.

Based on review of hospital policy and bylaws, the Governing Body has delegated the review and resolution of grievances to the patient advocate who chairs the grievance committee, but has not done so in writing.
Review of the hospital policy " Patient Grievances and Complaints " (revised 11/2012), reveals an Organizational Chart revealed that the Patient Advocate chairs the Grievance Committee and reports to the Director of Performance Improvement. The Director of Performance Improvement reports to the Vice President, Medical Affairs/Chief Medical Officer. However, review of the Hospital Bylaws and other documentation revealed that there is no document that indicates that the Governing Body has delegated the responsibility of the grievance process to the hospital's Grievance Committee.

Based on review of hospital policy and patient complaint files, the hospital, does not meet the average expected length of time for resolution of grievances, nor does the hospital convey detailed grievance process information to complainants.

A review of the hospital's policy "Hospital Patient Grievances & Complaints" reveals, in part, that the expectation is that all grievances will be resolved within 30 days. This regulation requires the prompt resolution of complaints with an expectation that resolution and written response will be on average, a time frame of 7 days for the provision of the response.

" We do not require that every grievance be resolved during the specified timeframe although most should be resolved. "

Review of hospital grievance files for the time period of December 1, 2012 through January 31, 2013 revealed 23 resolved files . Resolution of these complaints was noted to be between 1 - 30 days, with an average resolution time frame of 7.43 days. Additionally, 14 of the 23 (61%) were resolved within the 7-day average timeframe. Nine of 23 complaints were not resolved within 7 days .

While the hospital was close to resolving complaints within the required timeframes , the hospital's policy and procedure did not reflect the time frames required for resolution and requiring the required written response within 7 days.

Based on observation and review of a patient's medical record and interview of the hospital nursing staff, it was determined that a patient who had executed an Advanced Directive did not have a copy of their Advanced Directive in the medical record. This was evident for 1 of 46 sampled inpatient reviews.
The findings were:
Patient #2 was 84 years old and was admitted to the hospital on 01/25/13 for elective surgery for a total shoulder replacement. The patient had other multiple medical conditions, which included pancreatic cancer.

Observation and review of the patient's 3-ring flip binder medical record and electronic medical record on 01/28/13, revealed that the printed Patient Assessment-Advanced Directive had the following printed statement: "Advance Directive available on current medical record: Y, on chart/packet given". Further medical record review (both hard copy and electronic) revealed that a copy of the patient's Advanced Directive was not on the patient's chart.

Interview of the licensed nursing staff and the Nurse Manager of 6 East and 6 West on 01/28/13 between 11:30 AM-12:45 PM revealed that they could not explain why the patient's Advanced Directive was not on the patient's chart and nor were they able to recall what the patient's Advanced Directives specifically entailed. In addition, further interview of the nursing staff revealed that they were unable to electronically retrieve/see in the patient's electronic portion of the medical record, where an Advanced Directive may have been scanned into the medical record. Interview of the 6 East/6 West Nurse Manager a second time on 01/29/13 at 2:35 PM regarding the patient's Advanced Directives revealed: 1) the patient did have an Advanced Directive that was scanned into the patient's electronic medical record by another department, 2) the staff are getting a copy of the patient's Advanced Directive to place on the patient's chart, and 3) the direct care staff do not have access/cannot see the Advanced Directive information when it is scanned in from the "other department" because the electronic medical record view they currently use does not show this.

Failure of the nursing staff to have the patient's Advanced Directives on the patient's chart potentially placed the patient at risk for either: 1) receiving care against their wishes, or 2) not receiving care specified in their Advanced Directive. Advanced Directives serve as an instrument by which patients can provide an outline of their wishes/ instructions about their medical care in the event they become unable to communicate.

Based on observations and review of policies, procedures, the hospital failed to provide care in a safe setting as evident by the following:
1. The inpatient psychiatric unit has an East and West hallway with patient bedrooms, bathrooms, showers, and tub rooms on each hallway. The unit began installing the anti-ligature plumbing and washroom fixtures including door knobs, door hinge, faucets, shower and tub room faucet heads, toilets, safe bars, and replacement of suspended tile ceilings. The patient bedrooms, bathrooms, shower and tub rooms were in varying degrees of completion, for example bathrooms with anti-ligature toilets and ceilings but regular faucets. The shower and tub rooms have the anti-ligature safe bars and faucet heads but regular water valve to turn the shower head off and on. Some of the bathrooms had anti-ligature toilets but regular faucets and others have regular toilet plumbing and anti-ligature faucets. There was a suspended tile ceiling in the men ' s bathroom and regular door hinges on the west hallway. The bedrooms had wardrobes with hinged doors and closet shelves that could be used by the patient to harm-self or others. In addition, on the east hallway the patient bathrooms had vanity shelves and regular faucet plumbing. Although the hospital makes every fifteen minute rounds on their patients, there is the potential risk of harm. This unit was also surveyed by the environmental surveyor on January 28, 2013 . After noting the fixtures that were not anti-ligature, the department head for the unit was interviewed and she stated that the staff were aware of which areas are safe for patients at risk for suicide and had in place methods to protect these patients. These methods included: 1. Assessment for risk, beginning in the ED and when admitted; 2. 24 hour sitter, 3. 15 minute checks of all patients; and that patients at risk for self harm are not put in rooms with bathrooms, making it less likely that they could easily access plumbing that might be loopable.

The hospital did perform a risk assessment of the unit which indicated that some structural changes were needed to ensure patient safety. The inpatient psychiatric unit was toured by two nurse surveyors on January 28, 2013 and February 1, 2013 and by the sanitarian on January 28, 2013. It was during the tour that above stated concerns were noted. The hospital had switched 50% of the plumbing and bathroom fixtures to anti-ligature fixtures The anti-ligature fixtures are designed with a minimum number of ligature points and breakaway fail safes to eliminate potential suicide risks . The devices are designed to be in compliance with the suicide resistant codes written in the Americans with Disabilities Act Accessibility Guidelines and the National Association of Psychiatric Health Guidelines. Compliance will provide a safer environment in which to provide care to patients with suicidal ideations.


2. Based on review of one of one record where a patient had been placed in seclusion, it is revealed the hospital took one and half hours after the physician's order was written to transfer a patient who was in seclusion on the behavioral health unit to telemetry where the patient's medical needs could be met .

Patient #1 is a 44-year-old patient admitted to the behavioral health unit for management of depression and alcohol dependence. Patient #1 has a history of hallucinations and alcohol withdrawal seizures.

Patient #1 was begun on an alcohol detoxification protocol which included medications and Alcohol Withdrawal Assessments (AWA). The AWA has nine areas of assessment ranging from 0-7 where 7 is the greatest prevalence of symptoms, and one assessment area with a range of 0-4. A maximum score of 67 could be assessed for all areas combined. Additionally, patient #1 was placed on fall precautions.

In the early morning of the third day of admission, patient #1 was noted to have severe alcohol withdrawal called delirium tremens which despite multiple interventions, continued to progress throughout the night. By 0830 patient #1 had progressed from an Alcohol Withdrawal Assessment (AWA) score of 9 at 0200 to a score of 33, (7) for pacing and thrashing about, (7) for continuous visual disturbances, (4) for disorientation to person and place, (4) for moderately severe visual disturbances, (4) for moderately severe anxiety, (4) for moderate tremor with arms extended, and (3) for moderate itching, where the highest possible score is a 67.

At 0950, a physician progress note states " Pt seen and evaluated, case reviewed (with) staff. Pt has been delirious since yesterday afternoon (alcohol withdrawal + UTI (urinary tract infection)). Has auditory and visual hallucinations. She is disoriented. She is restless and fidgety. " He noted patient #1 as "Grossly Psychotic" and she received haldol and an increase in benzodiazepines. Patient #1' s care plan revealed the physician problem addition of "Delirious/DT s" and the goal of "Pt will remain safe in hospital."

Patient #1 continued to deteriorate until, per a 1224 nursing note, "Pt is scoring 33 W/D (withdrawal) this AM, Pt having hallucinations; visual and tactile. Pt is disorganized, delirious, speech garbled and not understandable, is not oriented to situation, place or time, does respond to her name .... " and "Pt attempting to enter others room this AM, stating 'Looking for my husband I know he is in there with Ronnie.' Pt requested to return to her RM, became agitated, had removed mattress on bed and blocked door with chair, as this person tried to enter to speak to pt, pt pushed and demanded to ' Let me go find ( ___). Pt was requested to come to quiet rm, required assistance from staff, then resulted in LDS (locked door seclusion). Please see LDS process note for info."

The patient was placed in seclusion at 1015. At 1030, a nursing note of 1030 reveals that patient #1 was "pacing intermittently + standing at door. Talking to self, speech nonsensical " At 1100 a nurse writes "Moving around the room banging on door yelling "Let me the F__ out of here! "

Patient #1 was seen by a hospitalist who at 1140 wrote multiple orders, that included transferring the patient to telemetry. The hospitalist note of 1209 states in part, "Unfortunately, her condition is declining. The patient became delirious. She became combative. She is very confused. Yesterday I saw this patient and had a chance to examine her today. Today her condition is definitely declining. The patient is completely confused, and she will be transferred to the telemetry unit." Under the note discussion, the physician writes "The patient is presenting delirium, probably secondary to the alcohol withdrawal. As part of differential diagnosis, we need to rule out an infection. We need to rule out intracranial bleeding or mass ...the patient will be transferred to the telemetry unit. She should be considered a high-risk patient ...at this moment because of combativeness; she will require 2-point restraint."

Nursing documentation revealed that following the hospitalist-identified medical decline of patient #1, the need to rule out multiple potential etiologies, and the telemetry transfer order of 1140 , staff continued patient #1 in seclusion until 1315.

At 1305, still while maintained in seclusion, it was noted that patient #1 had developed acrocyanosis (acrocyanosis may manifest as peripheral limb mottling, and may be a sign of central cyanosis, infection, toxicities and other serious medical problems), and orders were changed to send patient #1 to the Intensive Care Unit instead of telemetry. Additionally, a continuation order for seclusion timed at 1310 is found in the record, indicating the staff intent to continue patient #1 in seclusion until transfer to ICU at 1315.

Thus, patient #1's condition continued to decline while she was kept behind the door of seclusion, where documentation revealed that for the last 45 minutes, patient #1 was alternately found to be quiet and sleeping. The hospital failed to provide patient #1's right to receive care in a safe setting when it maintained patient #1's seclusion and failed to transfer patient #1 in a timely way.

Review of hospital restraint and seclusion policy reveals the definition is not consistent with the CMS definition of a chemical restraint as evidenced by :
Review of the hospital policy " Restraint and Seclusion " definition for chemical restraint revealed the hospital's definition states:
" Chemical restraint is when the use of a drug or medication is clearly outside the standard for a patient or a situation, or a medication is not medically necessary but is used for patient discipline or staff convenience; or the use of a medication that results in restricting the patient ' s freedom of movement. Chemical restraint is not the use of pharmacological treatment for patients who are suffering from serious mental illness and who need therapeutic doses of both standing and /or prn medication to improve their level of functioning so that they can more actively participate in their treatment. "
The hospital definition includes a reference and linkage to mental illness in its definition As chemical restraints may be used on patients who do not have a mental illness and may be medicated for medical or psychiatric diagnosis or purposes , the hospital's definition is not consistent with this regulation. Therefore, the hospital must revise its definition of a chemical restraint .

Based on review of one of one record of patients that were placed in seclusion, it was revealed that staff did not attempt the use of all least restrictive interventions when they secluded patient #1.
Patient #1 is a 44-year-old patient admitted to the behavioral health unit for management of depression and alcohol dependence. Patient #1 has a history of hallucinations and alcohol withdrawal seizures.

Patient #1 was begun on an alcohol detoxification protocol, which included medications and Alcohol Withdrawal Assessments (AWA). The AWA has nine areas of assessment ranging from 0-7 where 7 is the greatest prevalence of symptoms, and one assessment area with a range of 0-4. A maximum score of 67 could be assessed for all areas combined. Additionally, patient #1 was placed on fall precautions.

On the first two days of admission, patient #1 received IV fluids, multivitamins, haldol, and benzodiazepines to ease withdrawal symptoms. Additionally, the patient received Cipro for a urinary track infection.

In the early morning of the third day, patient #1 became irritable, and began to exhibit psychosis " referencing individuals who were not there." An IV giving her multivitamins (banana bag) was stopped due to agitation and attempts to pull out the IV. Psychosis progressed until patient #1 began going in and out of other patient rooms, in the belief that the patient's spouse was in the " hotel. "

Patient #1 continued to deteriorate until at 0546 and the RN wrote " Patient seems to be decompensating a bit R/T (related to) delirium/Psychosis, seeing dead bodies outside her hospital room window, refusing to stay in bed, increased mood lability. Concerned that her symptoms may be the result of alcohol withdrawal and with the knowledge that she has a history of DT s (delirium tremens) and seizures R/T same I called the on call PA (physician assistant) to review my concerns with him. He will be down to assess patient shortly. Close monitoring of patient continues. "

The PA saw patient #1 and at 0630, ordered patient #1's standing dose of metoprolol be given "for its anxiolytic (anti-anxiety) properties."

By 0830 patient #1 had progressed from an AWA score of 9 at 0200 to 33, (7) for pacing and thrashing about, (7) for continuous visual disturbances, (4) for disorientation to person and place, (4) for moderately severe visual disturbances, (4) for moderately severe anxiety, (4) for moderate tremor with arms extended, and (3) for moderate itching.

At 0950, a physician progress note states "Pt seen and evaluated, case reviewed (with) staff. Pt has been delirious since yesterday afternoon (alcohol withdrawal + UTI (urinary tract infection)). Has auditory and visual hallucinations. She is disoriented. She is restless and fidgety." He noted patient #1 as "Grossly Psychotic" and she received haldol and an increase in benzodiazepines. Patient #1's care plan revealed the physician problem addition of "Delirious/DT s" and the goal of "Pt will remain safe in hospital."

Patient #1 continued to deteriorate until, per a 1224 nursing note "Pt is scoring 33 W/D (withdrawal) this AM, Pt having hallucinations; visual and tactile. Pt is disorganized, delirious, speech garbled and not understandable, is not oriented to situation, place or time, does respond to her name .... " and, " Pt attempting to enter others room this AM, stating 'Looking for my husband I know her is in there with Ronnie.' Pt requested to return to her RM, became agitated, had removed mattress on bed and blocked door with chair, as this person tried to enter to speak to pt, pt pushed and demanded to ' Let me go find ( ___). Pt was requested to come to quiet rm, required assistance from staff, then resulted in LDS (locked door seclusion). Please see LDS process note for info. " The seclusion progress note reveals staff did not attmept to use a sitter as a less restrictive intervention.

Seclusion for patient #1 began at 1015. At 1030, a nursing note of 1030 reveals that patient #1 was " pacing intermittently + standing at door. Talking to self, speech nonsensical, " At 1100 a nurse writes, " Moving around the room banging on door yelling, " Let me the F__ out of here! "

Patient #1 was seen by a hospitalist who at 1140 wrote multiple orders, to include, transfer to telemetry. The hospitalist note of 1209 states in part, "Unfortunately, her condition is declining. The patient became delirious. She became combative. She is very confused. Yesterday I saw this patient and had a chance to examine her today. Today her condition is definitely declining. The patient is completely confused, and she will be transferred to the telemetry unit." Under the note discussion, the physician writes "The patient is presenting delirium, probably secondary to the alcohol withdrawal. As part of differential diagnosis, we need to rule out an infection. We need to rule out intracranial bleeding or mass ...the patient will be transferred to the telemetry unit. She should be considered a high-risk patient ...at this moment because of combativeness; she will require 2-point restraint."

It was noted that patient #1 was exhibiting acrocyanosis (acrocyanosis may manifest as peripheral limb mottling, and be a sign of central cyanosis, infection, toxicities and other serious medical problems). Therefore, orders were changed to transfer patient #1 to the Intensive Care Unit (ICU). Patient #1 was transferred to the ICU at 1356 via stretcher with two staff and a sitter.

While patient #1 exhibited behavior that ranged from hallucinations to combativeness, these behaviors were clearly caused by a delirium having a medical etiology. Therefore, the use of an intervention such as seclusion which is used for violent behaviors was no more appropriate for patient #1's care than would seclusion be for a patient with metabolic encephalopathy. Additionally, the potential for patient #1 who was on fall precautions to have been injured while in seclusion was high. Some other interventions such verbal intervantion, quiet room, and medication were tried prior to placing the patient in seclusion. patient #1's medical status, and provided closer monitoring than can be provided behind a locked door. Considering patient #1's medical status, and the need for close monitoring, there is no indication that the staff considered using a locking tabletop chair, non-violent 2-point soft restraints or 1:1 staffing (which ultimately was successfully provided after her transfer to ICU). The hospital failed to use the least restrictive intervention for patient #1.

Based on review of the hospital policy "APC 3" related to restraint and seclusion, the hospital's policy failed to address the timely acquisition of the order for restraint or seclusion prior to its application of restraints or seclusion or in emergency application situations.
The policy review revealed under "IV. Indications for Use, D. An RN can initiate the use of restraint and should receive an order from the licensed independent practitioner, nurse practitioner or physician assistant promptly". The regulation requires the physician order to be obtained prior to the application of restraint or seclusion. Under " section VI, Use for Violent or self-destructive behavior, B." the policy states "if the registered nurse has initiated the order for restraint or seclusion in an emergency situation for violent or self-destructive behavior a verbal or written order must be acquired within one hour from a licensed independent practitioner, nurse practitioner or physician assistant. " In recognition that a restraint or seclusion intervention may occur so quickly that an order cannot be obtained prior to the application of restraint or seclusion, the regulation states that in these emergency application situations, the order must be obtained either during the emergency application of restraint or seclusion, or immediately (within a few minutes) after the restraint or seclusion has been applied.
The hospital policy has not met the regulatory requirements since it does not address the process the need for an immediate acquisition of restraint and seclusion in its restraint and seclusion policy and procedure.

Based on a review of hospital Restraint and Seclusion policy, the hospital policy indicates that training in CPR and first aid was not required for staff who may have the training as part of their professional practice .
Review of hospital policy " Restraint and Seclusion " reveals that " Staff receives education and training in the use of first aid techniques and cardiopulmonary resuscitation (when it is not an inherent part of their professional education and training). Based on this policy there is no requirement that all hospital staff who are involved in the application of seclusion or restraint with the exceptions of physicians, receive education and training in the use of first aid techniques as well as training and certification and recertification in the use of cardiopulmonary resuscitation.

Based on review of the hospital ' s policy regarding " Restraint and Seclusion " Policy number APC3, specifically under section VIII, it was determined that the policy states that the policy fails to specify :
1. That a log will be maintained for two point soft wrist restraints
2. That the required report will be forwarded to CMS after report deaths related to seclusion and restraints.
Review of the hospital policy revealed that a the hospital will maintain a log for all deaths that occur while a patient is " 2 point limb restraint. " The requirement is that a log be maintained for 2 point soft wrist restraints. The policy as written would also include other types of 2 point limb restraints such as e.g. hard restraints, soft restraint, leg restraints all of which constitute limb restraints.
In addition, the policy fails to incorporate the requirements that the hospital not only telephone CMS with reports of death related to the application of seclusion and restraint but file the required written report form required by CMS. Hospitals are required to not only report by telephone but must complete the required reporting form to CMS for all deaths related to seclusion and restraint that occur:
1. While a patient is in restraint or seclusion,
2. Within 24 hours after the patient has been removed from restraint or seclusion, or
3. Within 1 week after restraint or seclusion, where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to the patient's death.

The hospital's policy did reflect appropriate time frames for reporting to CMS and did reflect that the death reports to CMS would be recorded in the medical records as required by this standard.

Based on a review of the patient handbook and the hospital visiting policy, the hospital 's policy does not clearly outline the patient's visitation rights including any clinical restriction or limitation on visitation rights and the right, subject to his or her consent, to receive the visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner, another family member, or a friend, and the patient's right to withdraw or deny such consent at any time. The policy also fails to indicate that the patient can designate a support person or patient's representative of their choosing and that this information must be documented in the patient's records

The findings are:

Review of the Hospital policy "Patient Rights to Communication/Visiting" revealed that the patient has the right to "Receive visitors, telephone calls and mail ... " The policy also states "Visitors can be good therapy for patients. Family members and friends are welcome to visit ... " However, the policy fails to specify any clinical reasons or other circumstances where visitation would not be permitted or would be limited. Additionally, the policy does not reflect that the patient is informed of his/ her right to have or deny visitation by the persons of their choosing. The hospital obtains the name of the patient's contact person but fails to specify that the contact person can act in the capacity of the patient's support person.

Based on review of the hospital's policy and patient right's booklet, it was revealed that the hospital's visitation policy does not state that visitation privileges are allowed regardless of the visitor or patient's race, color, national origin, religion, sex, gender identity, sexual orientation, or disability of the visitor.

The findings are:

Review of the Hospital policy "Patient Rights to Communication/Visiting" revealed the patient has the right to "Receive visitors, telephone calls and mail ... " The policy also states "Visitors can be good therapy for patients. Family members and friends are welcome to visit ... " However, the policy and the patient admission booklet fail to specify that visitation will be allowed regardless of the visitor's race, color, national origin, religion, sex, gender identity, sexual orientation, or disability of the visitor and in accordance with the patient's expressed preferences. Therefore, the hospital failed to provide patients and their support persons (as appropriate) with details concerning the rights of visitations.

Based on interviews with staff and review of the medical staff bylaws, rules and regulations, and the credentialing policy on January 30, 2013, it was determined that the hospital's mechanism for granting temporary privileges to physicians not on the hospital's medical staff does not specify that the provider must be approved by the hospital's governing body. The hospital has granted temporary privileges in only one case in the past 12 months. That provider was approved for temporary privileges by the vice president of the medical staff.

Based on review of the hospital's bylaws and rules and regulations for the medical staff on February 1, 2013, it was determined that the hospital has failed to specify which types of providers are considered to be allied health who must be credentialed and privileged by the medical staff. In the bylaws, the allied health providers are divided into dependant and independent practitioners without specifying which job titles or professional designations fit into each category.

Policy no. MS10, Surgical Assistants Requirements, dated 12/2012, was reviewed on 2/1/13 along with minutes from December 2012 and January 2013 meetings of the Medical Executive Committee (MEC) related to changes to the bylaws. The MEC approved, in December 2012, changes to the bylaws specifying that surgical assistants will have privileges delineated by the medical staff, competence assured by the Chief of Surgery, and be under the direct supervision of the attending surgeon while performing approved surgical procedures in the operating room. In reviewing the medical staff bylaws on 2/1/13, it was determined that although the MEC had approved the by-law changes those by-law changes had not been approved by the hospital's Governing Body and were not yet reflected in the by-laws.

Based on review of 46 open patient medical records, it was determined that in two of 46 open records reviewed : 1. open record had an order that the pharmacist inappropriately corrected by scratching through a part of the order , and 2. that entries on one ED chart were illegible to the surveyor as well as to ED staff . The findings include:

1. Open record for patient # 3 had an antibiotic order written by the pharmacist on 1/28/13 at 6:45 AM with the drug name, dosage and a bracket with 25 mg/kg written above something that had been scratched out by the pharmacist which cannot be read. In addition, the correction was not dated, timed and initialed by the pharmacist. The hospital policy NR 12, documentation guidelines under correction of the paper medical record stated " neatly draw one thin line through the error, leaving the incorrect material legible. Initial, date, and time the new entry so it will be obvious that it was a corrected mistake.

The error was not corrected by the pharmacist per hospital policy and could potentially be misread or misinterpreted.

2. Patient #5 is a female who arrived at the hospital's Emergency Department (ED) with a chief complaint of having been hit in the head which resulted in patient #5 having a 0.5cm contusion to the back of the head. Patient #5 was also feeling pressure behind the right eye. Patient #5 was subsequently triaged and a medical screening examination was performed by the ED physician. However, on review of the medical screening examination it was determined that some of the entries in the medical screening were illegible. During the review of the ED on January 29, 2013, the ED Department Manager and another RN were asked by the surveyor to review the entries to determine if they were able to read and clarify the entries; however they were also unable to clarify illegible entries.

Based on observation and review of a patient medical record and interview of the licensed nursing staff, it was determined that verbal and telephone orders were not being signed by the physician within 48 hours as required. This was evident for 1 of 46 sampled inpatient reviews.

The findings were:

Patient #4 admitted on 01/24/13 to 6 East for sepsis, urinary tract infection, fever, back pain, osteomyelitis, and an epidural abscess.

Observation and review of the patient ' s medical records on 01/28/13 between 11:30AM-12:45AM revealed that (3) verbal/telephone orders given by the physician/physician assistant staff (PA) from 01/24/13-01/25/13, were not signed. Interview of the 6 East/6 West charge nurse and review of the patient's "Prescribed Order Sheets" with the charge nurse confirmed that the physician(s)/ PA who gave the orders (verbal/telephone orders) had not signed the orders as required. This finding was evidenced by the lack of medical staff's notation or written signature by the order indicating their review. Further, while verbal orders may be given, the verbal orders must be signed promptly. Four or more days after an orer is given is not considered to be prompt or timely.

Based on the observations during a tour of the hospital and interviews with staff it was determined that the following facilities and equipment were not maintained at an acceptable level of safety and quality .
The findings include:
1. While touring the 5 West and 2 Center units, the surveyor observed the tubing and cords to the sequential compression devices (designed to limit the development of Deep Vein Thrombosis) dangling loose at the foot of the bed onto the floor with the potential for trips and falls from the tubing and electrical cord.

2. On January 28 2013 at 2:45 PM, a nicotine patch was observed stuck on the wall of a common shower in 5 west. Staff were notified and indicated " I'll take care of it. " About 10:30 am on January 29, 2013 , the surveyor returned to the shower room and observed that the nicotine patch was still on the wall.

3.. A baby scale was observed in labor and delivery labeled with a 11/12 maintenance sticker for preventative maintenance. Staff were asked by the surveyor to determine why the scale had not received its required preventive maintenance (PM).

On January 29, 2013 at 11:00 am, surveyor interviewed the interim manager for bio-medical equipment maintenance. He verified that when equipment due for PM can not be located by maintenance staff within 60 days of the preventive maintenance date, the equipment is removed from the schedule. When the equipment cannot be located initially and after 30 days, a memo is sent to department managers to let them know that a piece of equipment requiring preventive maintenance could not be located. After 60 days, the equipment is removed from active status. There is no further follow through to ensure that equipment is not used or that staff continue trying to locate it. For the baby scale in question, the surveyor received a printout that demonstrated that it had been removed from the schedule effective 12/31/12, although the scale was found in a patient area. Further, while investigating the maintenance history of the scale, nursing came into the room requesting to use the scale.
The hospital preventive maintenance system failed to have an effective process to locate missing equipment.

Based on a observations during a tour of the nuclear medicine area on January 29, 2013, it was observed that staff failed to dispose of a catheter in a disposal container. Additionally staff failed to maintain equipment for patient use within the manufacturer's expiration dates.
The findings include :
During a tour of the nuclear medicine area at 9:50 AM on January 29, 2013, the surveyor observed in Procedure Room 1, five 24 gauge IV catheters that had expired in June 2011, and one that expired in May 2011. Once expired the integrity of the packaging and sterility of the catheters can be questioned.

At 10:00 am that same date , in procedure room one of the Nuclear Medicine department, a used catheter needle was observed left on a table next to a patient chair. Staff were informed by the surveyor . The department manager was interviewed verifying that the catheter needle should have been disposed of into a sharps box. The manager did verify that the catheter did not require special handling as radioactive waste. Incorrect disposal of blood contaminated patient care items poses a risk of infection to staff and other patients.

Based on a review of the hospital policy "Emergency Response" (revised 11/2012) and interview with outpatient nursing staff, it was determined that on-campus outpatient services for medical emergencies : 1. are limited to calling 911 during a medical emergency; 2. lacks specific interventions for the management and life sustaining treatment of the individual in crisis; and 3. lacks the disposition of the individual after 911 activation.

Review of the hospital policy " Emergency Response " revealed that the main hospital has a system to access the Emergency Response Team. The policy states "All other events on the medical center grounds utilize the community based emergency response system by dialing 9-911. EMS notification is encouraged for non-main hospital occurrences to facilitate treatment and transportation to appropriate medical facility for additional care." This hospital's policy fails to identify that the hospital's staff will provide medical care and services or deploy hospital staff capable of providing emergency medical care to the outpatient area when needed. Based on the fact that the building is on hospital grounds, the hospital is required to provide an immediate emergency response to the outpatient area.

On January 31, 2013 , the surveyor interviewed the nurse manager and observed that the outpatient building had emergency equipment including emergency carts, medications, an automated external defibrillators (AED), and staff who are well trained to perform codes. However, the hospital's policy does not reflect the availability or use of the equipment or the availability of trained staff to use the equipment .

Further, the outpatient clinic is located in a office building located on the opposite side of the parking garage from the main hospital. Further interviews with nurse manager revealed that the hospital does not have a private ambulance by which to transport patients from the outpatient area to the hospital ED. Therefore, 911 is called to obtain ambulance service to transport patients from the clinics as indicated in hospital policy. Hospital policy states that patients are treated and given "transportation to appropriate medical facility for additional care." The policy does not identify that the patient must be transported to the hospital's emergency department. The policy fails to address that the hospital will have the patient transported to its own ED.

The hospital's policy addressing medical emergencies occurring in the on-campus outpatient facilities :
1. Does not describe or direct the medical services provide by hospital staff at on-campus outpatient locations; and
2. Does not identify that the patient will be taken to the hospital's emergency department for further treatment and stabilization.