HospitalInspections.org

Based on review of hospital polices and procedures, and MR (medical record) review in 6 of 8 records reviewed of patients receiving Medicare benefits (#15, 18, 19, 20, 24, 29) out of a total of 29 MR reviewed, and interviews with facility staff by surveyor #13469, the hospital failed to ensure that each Medicare beneficiary is informed of his/her right to appeal discharge from the facility which became effective July 13, 2007 per S&C memorandum 07-28. The lack of a notification of these Medicare rights resulted in patient ' s #15, 18, 19, 20, 24, 29 inability to appeal discharge from the facility.

Findings include:
Per policy and procedure review, on 8/18/10 at 11:00 AM, the "Notification of Hospital Discharge Appeal Rights" policy #C0072 directs the following: Policy "1. Hospitals must notify Medicare beneficiaries who are hospital inpatients about their discharge appeal rights. IV. The Important Message from Medicare must be issued within 2 calendar days of admission. V. A signed follow up copy of the Message from Medicare must be delivered as far in advance of discharge as possible, but no more than 2 calendar days before discharge."

1. Per MR review, on 8/16/10 at 1:45 PM, patient #15 was seen in the ED and admitted on 7/9/10 for cellulitis and abscess of the hand. There was no evidence found in the MR that patient #15 received the Medicare discharge appeal rights information within two days of admission.

The above example was confirmed by Director of Patient Care Services (I) on 8/16/10 at 3:25 PM.

2. Per MR review, on 8/16/10 at 1:20 PM, patient #18 was seen in the ED and admitted on 6/11/10. Patient #18 was discharged from the hospital on 6/22/10. There was no evidence found in the MR that patient #18 received the Medicare discharge appeal rights information within two days of admission or within two days of discharge.

The above example was confirmed by Director of Patient Care Services (I) on 8/16/10 at 3:25 PM.

3. Per MR review, on 8/17/10 at 12 noon, patient #19 was admitted to Swing Bed on 6/6/10 for a fractured humerus. Patient #19 was discharged from the hospital on 6/22/10. There was no evidence found in the MR that patient #19 received the Medicare discharge appeal rights information within two days of admission or within two days of discharge.

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

4. Per MR review, on 8/18/10 at 9:40 AM, patient #20 was admitted to Swing Bed on 7/2/10 for shortness of breath and aspiration pneumonia. Patient #20 was discharged from the hospital on 7/24/10. There was no evidence found in the MR that patient #20 received the Medicare discharge appeal rights information within two days of admission or within two days of discharge.

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

5. Per MR review, on 8/18/10 at 10:10 AM, patient #24 was seen in the ED and admitted for a urinary tract infection on 6/5/10. Patient #24 was discharged from the hospital on 6/8/10. There was no evidence found in the MR that patient #24 received the Medicare discharge appeal rights information within two days of admission or within two days of discharge.

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

Per MR review, on 8/18/10 at 10:00 AM, patient #29 was seen in the ED and admitted on 6/5/10 for a subendo infarct. Patient #29 was discharged from the hospital on 6/8/10. There was no evidence found in the MR that patient #29 received the Medicare discharge appeal rights information within two days of admission or within two days of discharge.

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

Based on observation, staff interviews and review of maintenance documents, the facility did not construct and maintain the building systems to ensure a safe physical environment due to the cumulative effects of environment deficiencies and resulted in the hospital's inability to ensure a safe environment for the patients, which is a Condition of Participation. The facility did not have a facility free of life safety deficiencies. This deficiency occurred in all of the 10 smoke compartments, and had the potential to affect all of the 26 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 08/17/10 at 9:00 am surveyor #14105 observed that the facility had the following deficiencies:
K-17 (corridor walls)
K-18 (corridor doors),
K-29 (hazardous areas),
K-47 (exit signs),
K-51 (fire alarm appliances),
K-62 (fire alarm inspections),
K-147 (electrical code).
Please refer to the full description of the deficient practice at the cited K-tags: This observed situation was not compliant with CFR 482.41. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff K (Lead Engineer), and staff L (Engineer).

Based on observation, staff interviews and review of maintenance records, the facility did not construct, install and maintain the building systems to ensure a life safety environment in the building to meet the minimum requirements of the 2000 Edition of the Life Safety Code for "New Healthcare Occupancy" and "Existing Healthcare Occupancy" chapters of this code. The facility did not have a facility free of life safety deficiencies. This deficiency occurred in all of the 10 smoke compartments, and had the potential to affect all of the 26 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 08/17/10 at 9:00 am surveyor #14105 observed that the facility had the following life safety deficiencies:
K-17 (corridor walls)
K-18 (corridor doors),
K-29 (hazardous areas),
K-47 (exit signs),
K-51 (fire alarm appliances),
K-62 (fire alarm inspections),
K-147 (electrical code).
Please refer to the full description of the deficient practice at the cited K-tags: This observed situation was not compliant with CFR 482.41(b). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff K (Lead Engineer), and staff L (Engineer).

Based on two of two staff interviews, (C, D), by surveyor #13469, the hospital failed to ensure that a sample of mid-level practitioners outpatient records are reviewed at least every 2 weeks by a physician. The lack of periodic oversight of the mid-level staff by a physician could result in the lack of quality of care.

Findings include:
Per interview, on 8/11/10 at 11:10 AM with Nurse Practitioner (C), she is not aware of any MR (medical record) review of mid-level treatment and documention by a physician.

Per interview, with Quality Assurance Manager (D) on 8/16/10 at 9:00 AM, there is no policy or procedure for MR review of outpatient mid-level practitioner treatment and documentation by physicians.

Based on observation, policy and procedure review, and in 4 of 4 staff interviews (A, F, P, I), by surveyor #13469, the hospital failed to ensure that drugs and biologicals are secured from unauthorized access. The lack of proper control of all drugs and biologicals allows for removal, tampering, destruction or personal use.

Findings include:
Per hospital policy review on 8/18/10 in the AM, the policy "Medication, Security of #S1011 directs the following: All medication storage areas will be locked or otherwise secured in such a way that medications will be available to a patient when needed and will prevent access to medications by unauthorized persons, diversion of medications to unintended persons, and tampering."

1. Per observation while touring the ED (emergency department) on 8/11/10 at 11:10 with ED RN (registered nurse), two crash carts sitting next to patient gurneys in exam rooms #1 and #2 contained break-away locking devices to alert staff if someone had accessed the cart for use. The carts do not have a permanent locking device to ensure unauthorized access by patients, families and visitors.

Per interview with during the tour (A), patients, families and visitors are at times left unattended in the rooms with curtains drawn. As a result, the carts which contain drugs, biologicals and intravenous solutions could be accessed without staff knowledge.

2. Per observation, while touring the surgery department on 8/12/10 at 2:00 PM with Surgery Manager (F), it was noted that intravenous solutions and syringes with normal saline flushes found in the conscious sedation cart were not secured from unauthorized assess after the surgery staff leave. Per (F), housekeeping, maintenance and security have access to the department after hours and on weekends.

3. Per interview, with Therapy Department Manager (P) on 8/18/10 at 10:30 AM, a crash cart in the cardiac rehabilitation department has a break-away device to alert staff if someone had accessed the cart for use. The carts do not have a permanent locking device to ensure unauthorized access. The carts which contain drugs, biologicals and intravenous solutions could be accessed without staff knowledge by housekeeping, maintenance and security who have access to the department after hours and on weekends.

4. Per observation, while touring the medical nursing unit on 8/17/10 at 1:50 PM with Director of Patient Services Coordinator (I) it was noted that three tub/shower rooms on the unit had large bottles of Virex Disinfectant cleaning solution. The cleaning solutions are not secured from unauthorized access of patients, families and visitors who might accidentally or intentionally ingest the cleaning solutions.

Based on observations and interviews with facility staff by surveyor #13469, the hospital failed to ensure that the facility is kept clean, maintained, and arranged so as to provide a sanitary environment. In 2 of 4 observations clean and dirty are not kept separate. In 2 of 5 observations linen carts are not covered. In 1 of 2 observations surgical instruments are not cleaned with the proper concentrations of Enzymatic solution to water. The lack of using appropriate infection control practices allowed for the possible transfer of dust, debris and microorganisms, and communicable diseases to staff, patients and environmental surfaces. This affected all patients and staff in the facility during the survey between 8/11/10 and 8/18/10.

Findings include:
1. Per observation while touring the emergency department with RN (registered nurse) (A) on 8/11/10 at 11:15 AM, it was noted that a linen cart with 4 shelves was in a storage room with other patent care supplies, an ice machine, two coffee pots, and a hand washing sink. In addition the door to the room is always propped open. The linens on the cart were uncovered and not protected from dust and debris. Per (A) she is unsure how long some of the linen has been on the cart before it is used.

2. Per observation, while touring the nursing unit on 8/17/10 at 1:50 PM with Patient Services Coordinator (I), it was noted that a 4 shelf linen cart in a public hallway was uncovered and exposed to dust and debris. Per (I), the linen carts throughout the facility are supposed to be covered at all times.

3. Per observation while touring the emergency department with RN (A) on 8/11/10 at 11:15 AM, the dirty utility room with biohazard waste had 30 new sterile specimen cups stored on a shelf above a sink where dirty equipment is cleaned and hands are washed. The sterile specimen cups are exposed to cross contamination.

4. Per observation, clean and dirty are not kept separate, and food is not kept separate from patient supplies.

Per observation while touring the emergency department with RN (registered nurse) (A) on 8/11/10 at 11:15 AM, it was noted that a clean storage room contained the following items, a handwashing sink right next to a large coffee dispenser and an ice machine. Also in the room was a linen cart not covered, and orthopaedic cart with clean supplies. Per (A) the door to the room is always propped open.

Per interview with RN (A), the storage room has the potential for cross-contamination and dust and debris to the uncovered linens.

While in the room with RN (A), MD (B) entered the room and laid a patient medical record right next to the handwashing sink and proceeded to wash his hands. Visible spray and splash hit the medical record, coffee pot and ice machine. After drying his hands with a paper towel he used the same paper towel to wipe off the water/soap droplets that hit the medical record and then left the room. RN (A) confirmed that the observation was an breach of infection control practices.

5. Per interview, while touring the central sterile supply processing department on 8/12/10 at 2:30 PM with Processing Technician (E) it was revealed that the mixture of Enzymatic cleaning solution to water mixture to clean bioburden from used surgical instruments prior to the sterilization process is not mixed per manufacturers directions. Per Technician (E), she pours an unmeasured amount of water into a blue container and pumps 3 squirts of Enzymatic cleaning solution into the water and then places the contaminated instruments into the solution. Per review of the bottle of Enzymatic cleaning solution instructions, the correct mixture of the solution is one ounce per gallon water. Per (E), she is not sure if she is mixing the correct concentration as she is not measuring the water or the cleaning solution.

Based on observation and interview with one of one dietary staff (H), by surveyor #13469, the hospital does not ensure that dietetic services personnel are competent with regard to the handling of food. The lack of protecting food from contaminates, identifying the contents of food containers, and dating food when opened does not ensure the safety and quality of food served to patients and staff and increases the risk of food allergies.

Findings include:
1. Per observation, while touring the dietary department on 8/16/10 at 12:30 PM with Dietary Manager (H), dietary staff are not consistently identifying containers as to their contents, nor the date they were opened.

Examples include: Five 1.5 pound partially used Jello packets were not dated when opened. A cake in the freezer was not labeled as to the the type of cake and the date it was made. In another freezer, 6 large packages of a stew meat and 4 large packages of hamburger were not labeled as to the type of stew meat and the date it was removed from the package of the outside vender. One large Zip Lock bag contained what appeared to be chicken pieces that was not labeled as to the contents or when the chicken was placed into the bag. A cupboard contained a large tub of yellow food. Upon question of (H) it was determined that it was butter. The container was not labeled as to it's contents or when the butter was placed in the container from it's original container. Per interview with (H) it was determined that all food containers should be identified as to their contents and dated when opened for proper disposal if not used in the allotted time.

2. Per observation during the department tour it was noted that the door between the food prep area and the public cafeteria is always propped open. As a result dust and debris are allowed to enter the food prep area on a consistent basis.

3. Per observation, during the department tour with (H) it was noted that the food and supply storage room had boxes of dietary supplies for patient use resting directly on the floor allowing for contamination and preventing the storage room to be properly cleaned.

4. Per interview, while touring the dietary department on 8/16/10 at 12:30 PM with Dietary Manager (H), the nursing unit has Healthy Choice frozen dinners for late admission or diet changes after the dietary department is closed. Per (H), there is no policy or procedure in place to date the dinners when placed in the nursing floor freezer or a practice to replace the dinners to ensure freshness and integrity. Per (H), she is not sure how long the frozen dinners have been in the freezer.

Per observation, while touring the nursing unit on 8/17/10 at 1:50 PM with Director of Patient Care Services (I) it was noted that the nourishment freezer contained 3 Healthy Choice Meals that were not labeled as to the date they were placed in the freezer for use. Per (I), she is not sure how long the dinners have been in the freezer.

Based on MR (medical record) review, medical staff rules and regulations review, and interviews with facility staff by surveyor #13469, in 7 of 11 MR reviewed of admitted patients (#9, 12, 15, 18, 19, 20, 27) out of a total of 29 MR reviewed, the hospital failed to ensure that all telephone/verbal orders are authenticated within 48 hours of receipt. The lack of physician validation of telephone/verbal orders within 48 hours could result in inaccurate and inappropriate medication administration and treatment of patients.

Findings include:
Per review of medical staff rules and regulations dated 5/24/10 the rules direct the following: "L.3 Orders - Verbal orders must be signed by the practitioner or practitioners responsible for care of the patient within 48 hours of receipt."

1. Per MR review, on 8/12/10 at 12:15 PM, patient #9 was seen in the ED and admitted on 5/8/10 for chest pain. T.O. (telephone orders) dated 5/8/10 and 5/10/10 do not include a MD (medical doctor) countersignature within 48 hours of the order being received.

The above example was confirmed by Quality Manager (D) on 8/12/10 at 1:50 PM.

2. Per MR review, on 8/16/10 at 2:00 PM, patient #12 was seen in the ED and admitted on 6/1/10 for diverticulitis. V.O (verbal orders) dated 6/3/10 do not identify the date or the time the MD countersigned the orders. The exclusion of a date or time with the MD countersignature does not identify if the V.O. were countersigned within 48 hours.

T.O. dated 6/1/10 do not identify the date or the time the MD countersigned the orders. The exclusion of a date or time with the MD countersignature does not identify if the T.O. were countersigned within 48 hours.

The above example was confirmed by Director of Patient Care Services (I) on 8/16/10 at 3:25 PM.

3. Per MR review, on 8/16/10 at 1:45 PM, patient #15 was seen in the ED and admitted on 7/9/10 for cellulitis and abscess of the hand. T.O. dated 7/11 and 7/9/10 do not identify the date or the time the MD countersigned the orders. The exclusion of a date or time with the MD countersignature does not identify if the T.O. were countersigned within 48 hours.

The above example was confirmed by Director of Patient Care Services (I) on 8/16/10 at 3:25 PM.

4. Per MR review, on 8/16/10 at 1:20 PM, patient #18 was seen in the ED and admitted on 6/11/10. T.O. dated 6/19/10 and V.O. dated 6/19/10 do not identify the date or the time the MD countersigned the orders. The exclusion of a date or time with the MD countersignature does not identify if the T.O. were countersigned within 48 hours.

The above example was confirmed by Director of Patient Care Services (I) on 8/16/10 at 3:25 PM.

5. Per MR review, on 8/17/10 at 12 noon, patient #19 was admitted to Swing Bed on 6/6/10 for a fractured humerus. T.O. dated 6/22/10, 6/16/10, 6/17/10 and V.O. dated 6/21/10 and 6/15/10, do not identify the date or the time the MD countersigned the orders. The exclusion of a date or time with the MD countersignature does not identify if the T.O. were countersigned within 48 hours.

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

6. Per MR review, on 8/18/10 at 9:40 AM, patient #20 was admitted to Swing Bed on 7/2/10 for shortness of breath and aspiration pneumonia. T.O. dated 7/21, 7/23, 7/14, 7/7, 7/12, 7/5, and 7/6/10 do not identify the date or the time the MD countersigned the orders. The exclusion of a date or time with the MD countersignature does not identify if the T.O. were countersigned within 48 hours.

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

7. Per MR review on 8/17/10 at 3:15 PM, patient #27 was admitted to Swing Bed on 7/16/10 for a leg ulcer. T.O. dated 7/17, 7/28 and 8/6/10 and V.O. dated 7/16/10 and 8/12/10, do not identify the date or the time the MD countersigned the orders. The exclusion of a date or time with the MD countersignature does not identify if the T.O. were countersigned within 48 hours.

The above example was confirmed by Director of Patient Care Services (I) on 8/17/10 at 3:30 PM.

Based on MR (medical record) review, and interviews with facility staff by surveyor #13469, in 11 of 22 records reviewed requiring discharge instructions ( #1, 3, 4, 5, 9, 10, 12, 15, 16, 21, 22) out of a total of 29 MR reviewed, the hospital did not ensure that nursing staff provide each patient/representative relevant information concerning continuing health care needs at the time of discharge. The lack of complete written discharge instructions failed to specify actions the patient should take in the immediate post-discharge period to promote their recovery from the surgery to include warning signs of complications.

In 28 of 29 MR reviewed requiring a consent for treatment (#1 through 23 and #25 through 28) out of a total of 30 MR reviewed, the consents do not identify the time the consent was signed by the patient/representative nor a witness signature. The lack of a properly executed informed consent affected all 28 patient MR reviewed.

Findings include:

1. Per MR review, on 8/11/10 at 1:30 PM, patient #1 had a knee arthroscopy on 5/3/10. The discharge instructions found in the MR do not include what signs and symptoms of infection (pain, drainage, redness, swelling, fever) the patient is to watch for and report to the physician.

The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The above examples were confirmed by Quality Manager (D) on 8/11/10 at 2:50 PM.

2. Per MR review, on 8/11/10 at 2:00 PM, patient #2 had a colonoscopy on 5/6/10. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The above examples were confirmed by Quality Manager (D) on 8/11/10 at 2:50 PM.

3. Per MR review on 8/11/10 at 3:20 PM, patient #3 had a ventral hernia repair on 6/1/10. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The discharge instructions found in the MR do not include what signs and symptoms of infection (pain, drainage, redness, swelling, fever) the patient is to watch for and report to the physician.

The above examples were confirmed by Quality Manager (D) on 8/12/10 at 10:20 AM.

4. Per MR review, on 8/12/10 at 9:10 AM, patient #4 had a removal of a right knee lipoma on 6/8/10. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

There was no evidence found in the MR that patient #4 received discharge instructions.

The above examples were confirmed by Quality Manager (D) on 8/12/10 at 10:20 AM.

5. Per MR review, on 8/12/10 at 9:25 AM, patient #5 had a right eye cataract on 6/9/10. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The discharge instructions found in the MR do not include what signs and symptoms of infection (pain, drainage, redness, swelling, fever) the patient is to watch for and report to the physician.

The above examples were confirmed by Quality Manager (D) on 8/12/10 at 10:20 AM.

6. Per MR review, on 8/17/10 at 10:40 AM, patient #6 was seen in the ED (emergency department) on 5/1/10 for a fractured radius. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

7. Per MR review, on 8/17/10 at 11:50 AM, patient #7 was seen in the ED and transferred on 5/3/10 for abdominal pain. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

8. Per MR review, on 8/17/10 at 10:50 AM, patient #8 was seen in the ED for a closed head injury. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

9. Per MR review, on 8/12/10 at 12:15 PM, patient #9 was seen in the ED and admitted on 5/8/10 for chest pain. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The discharge instructions found in the MR of patient #9 do not include the signs and symptoms of cardiac chest pain (chest pressure, jaw or neck pain, nausea, sweating, arm tingling or numbness, irregular pulse rate) to watch for and return to the ED.

The above example was confirmed by Quality Manager (D) on 8/12/10 at 1:50 PM.

10. Per MR review, on 8/16/10 at 1:20 PM, patient #10 was seen in the ED and discharged on 5/8/10 for a hand laceration. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The discharge instructions found in the MR do not include what signs and symptoms of infection (pain, swelling, fever) the patient is to watch for and report to the physician.

The above example was confirmed by Director of Patient Care Services (I) on 8/16/10 at 3:25 PM.

11. Per MR review, on 8/16/10 at 1:20 PM, patient #11 was seen in the ED and discharged for a crushing hand injury. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The above example was confirmed by Director of Patient Care Services (I) on 8/16/10 at 3:25 PM.

12. Per MR review, on 8/16/10 at 2:00 PM, patient #12 was seen in the ED and admitted on 6/1/10 for diverticulitis. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The discharge instructions found in the MR do not include what signs and symptoms of diverticulitis to watch for and report to the doctor.

The above example was confirmed by Director of Patient Care Services (I) on 8/16/10 at 3:25 PM.

13. Per MR review, on 8/16/10 at 2:10 PM, patient #13 was seen in the ED and transferred on 6/1/10 for vaginal bleeding. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The above example was confirmed by Director of Patient Care Services (I) on 8/16/10 at 3:25 PM.

14. Per MR review, on 8/16/10 at 1:50 PM, patient #14 was seen in the ED and transferred on 6/2/10 for edema. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The above example was confirmed by Director of Patient Care Services (I) on 8/16/10 at 3:25 PM.

15. Per MR review, on 8/16/10 at 1:45 PM, patient #15 was seen in the ED and admitted on 7/9/10 for cellulitis and abscess of the hand. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The discharge instructions found in the MR do not include what signs and symptoms of cellulitis (fever, swelling, itching, pain, fever) to watch for and report to the doctor.

The above example was confirmed by Director of Patient Care Services (I) on 8/16/10 at 3:25 PM.

16. Per MR review, on 8/12/10 at 11:15 AM, patient #16 was seen in the ED and admitted on 7/10/10 for syncope. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The discharge instructions found in the MR do not include what signs and symptoms of infection (pain, drainage, redness, swelling, fever) the patient is to watch for and report to the physician.

The above example was confirmed by Quality Manager (D) on 8/12/10 at 1:50 PM.

17. Per MR review, on 8/16/10 at 11:40 AM, patient #17 was seen in the ED and transferred on 7/6/10 for a foreign body in the stomach. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The above example was confirmed by Director of Patient Care Services (I) on 8/16/10 at 3:25 PM.

18. Per MR review, on 8/16/10 at 1:20 PM, patient #18 was seen in the ED and admitted on 6/11/10. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The above example was confirmed by Director of Patient Care Services (I) on 8/16/10 at 3:25 PM.

19. Per MR review, on 8/17/10 at 12 noon, patient #19 was admitted to Swing Bed on 6/6/10 for a fractured humerus. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

20. Per MR review, on 8/18/10 at 9:40 AM, patient #20 was admitted to Swing Bed on 7/2/10 for shortness of breath and aspiration pneumonia. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

21. Per MR review, on 8/17/10 at 12:25 PM, patient #21 was seen in the ED and discharged on 12/2/09 for sexual assault. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The discharge instructions found in the MR do not include what signs and symptoms of infection (pain, drainage, redness, swelling, fever) the patient is to watch for and report to the physician.

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

22. Per MR review, on 8/17/10 at 12:10 PM, patient #22 was seen in the ED and discharged on 4/25/10 for sexual assault. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The discharge instructions found in the MR do not include what signs and symptoms of infection (pain, drainage, redness, swelling, fever) the patient is to watch for and report to the physician.

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

23. Per MR review, on 8/18/10 at 10:10 AM, patient #24 was seen in the ED and admitted for a urinary tract infection on 6/5/10. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

24. Per MR review, on 8/17/10 at 2:50 PM, patient #25 was seen in the ED and admitted on 8/16/10 for pancreatitis. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The above example was confirmed by Director of Patient Care Services (I) on 8/17/10 at 3:30 PM.

25. Per MR review, on 8/17/10 at 3:05 PM, patient #26 was seen in the ED and admitted on 8/16/10 for a fractured rib. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The above example was confirmed by Director of Patient Care Services (I) on 8/17/10 at 3:30 PM.

26. Per MR review on 8/17/10 at 3:15 PM, patient #27 was admitted to Swing Bed on 7/16/10 for a leg ulcer. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The above example was confirmed by Director of Patient Care Services (I) on 8/17/10 at 3:30 PM.

27. Per MR review, on 8/18/10 at 9:55 AM, patient #28 was seen in the ED and discharged on 6/5/10 for an elbow dislocation. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

28. Per MR review, on 8/18/10 at 10:00 AM, patient #29 was seen in the ED and admitted on 6/5/10 for a subendo infarct. The general consent for treatment found in the MR does not identify the time the consent was signed or identify the name of the person who reviewed the consent with the patient.

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

Based on MR (medical record) review and interviews with facility staff by surveyor #13469, in 29 of 29 MR reviewed (#1 through 29) the hospital failed to ensure that all entries into the medical record are complete, timed, dated and authenticated. The lack of a complete record with timing, dating and authenticating entries into the MR does not provide a chronological picture of the patient's progress to delineate the course of treatment.

Findings include:
1. Per MR review, on 8/11/10 at 1:30 PM, patient #1 had a knee arthroscopy on 5/3/10. The hand written operative note found in the MR does not identify the date or the time the note was entered into the MR.

MD (medical doctor) orders dated 5/3/10 do not identify the time the orders were entered int the MR.

The adult PII (pneumococcal influenza immunization) order protocol dated 5/3/10 does not identify the time the orders were entered into the MR.

Anesthesiology post-operative orders dated 5/3/10 do not identify the time the orders were entered into the MR.

Anesthesia intra-operative notes do not identify the times medications were given. Examples include Propofol, Lidocaine, Fentanyl, and Versed.

The above examples were confirmed by Quality Manager (D) on 8/11/10 at 2:50 PM.

2. Per MR review, on 8/11/10 at 2:00 PM, patient #2 had a colonoscopy on 5/6/10. Anesthesia intra-operative notes do not identify the times medications were given. Examples include Propofol and Lidocaine.

The moderate sedation record dated 5/6/10 does not identify who entered the notes into the MR. Initials AD are recorded without a full name or signature sheet found in the record.

Post procedure notes found in the MR do not indicate the date or time the notes were entered into the MR nor the identity of the person completing the notes.

The pre-procedure preparation worksheet dated 5/6 does not identify the year or the identity of the persons completing the notes.

The above examples were confirmed by Quality Manager (D) on 8/11/10 at 2:50 PM.

3. Per MR review on 8/11/10 at 3:20 PM, patient #3 had a ventral hernia repair on 6/1/10. Anesthesia intra-operative notes do not identify the times medications were given. Examples include Propofol, Lidocaine, Succinylcholine, Fentanyl, and Rocuronium.

Post-operative progress notes dated 6/1/10 do not identify the time the notes were entered into the MR.

MD post-operative orders dated 6/1/10 do not identify the time the orders were written.

The adult PII order protocol dated 6/1/10 does not identify the time the orders were entered into the MR.

Post anesthesia nursing notes timed 9:35 AM found in the MR do not identify the date or identity of the person completing the notes.

The above examples were confirmed by Quality Manager (D) on 8/12/10 at 10:20 AM.

4. Per MR review, on 8/12/10 at 9:10 AM, patient #4 had a removal of a right knee lipoma on 6/8/10.
Post-operative progress notes dated 6/8/10 do not identify the time the notes were entered into the MR.

Pre-printed anesthesia orders found in the MR do not identify the name of the person who entered the orders into the MR or the time and date the orders were given to nursing staff.

MD pre-operative orders dated 5/7/10 and postoperative orders dated 6/8/10 do not identify the time the orders were written.

The adult PII order protocol dated 6/4/10 does not identify the time the orders were entered into the MR.

Anesthesia intra-operative notes do not identify the times medications were given. Examples include Propofol, Lidocaine, Succinylcholine, Fentanyl, Zofran, and Robinul.

The above examples were confirmed by Quality Manager (D) on 8/12/10 at 10:20 AM.

5. Per MR review, on 8/12/10 at 9:25 AM, patient #5 had a right eye cataract on 6/9/10. Anesthesia intra-operative notes do not identify the times medications were given. Examples include: Versed.

MD Pre and post-operative orders found in the MR do not include the time or the date the orders were entered into the MR.

The adult PII order protocol dated 6/9/10 does not identify the time the orders were entered into the MR.

The above examples were confirmed by Quality Manager (D) on 8/12/10 at 10:20 AM.

6. Per MR review, on 8/17/10 at 10:40 AM, patient #6 was seen in the ED (emergency department) on 5/1/10 for a fractured radius. The MD notes do not identify the time the patient was seen by the MD nor the time the notes were entered into the MR.

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

7. Per MR review, on 8/17/10 at 11:50 AM, patient #7 was seen in the ED and transferred on 5/3/10 for abdominal pain. The MD notes do not identify the time the patient was seen by the MD nor the time the notes were entered into the MR.

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

8. Per MR review, on 8/17/10 at 10:50 AM, patient #8 was seen in the ED for a closed head injury. The MD notes do not identify the time the patient was seen by the MD nor the time the notes were entered into the MR.

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

9. Per MR review, on 8/12/10 at 12:15 PM, patient #9 was seen in the ED and admitted on 5/8/10 for chest pain. The MD notes do not identify the time the patient was seen by the MD nor the time the notes were entered into the MR.

The above example was confirmed by Quality Manager (D) on 8/12/10 at 1:50 PM.

10. Per MR review, on 8/16/10 at 1:20 PM, patient #10 was seen in the ED and discharged on 5/8/10 for a hand laceration. The MD notes do not identify the time the patient was seen by the MD nor the time the notes were entered into the MR.

The above example was confirmed by Director of Patient Care Services (I) on 8/16/10 at 3:25 PM.

11. Per MR review, on 8/16/10 at 1:20 PM, patient #11 was seen in the ED and discharged for a crushing hand injury. The MD notes do not identify the time the patient was seen by the MD.

The above example was confirmed by Director of Patient Care Services (I) on 8/16/10 at 3:25 PM.

12. Per MR review, on 8/16/10 at 2:00 PM, patient #12 was seen in the ED and admitted on 6/1/10 for diverticulitis. MD orders dated 6/1/10, 6/2/10, 6/3/10 and 6/4/10 do not identify the time the orders were written.

The ED MD notes do not identify the time the patient was seen by the MD nor the time the notes were entered into the MR. In addition, the MD did not sign his/her notes.

The above example was confirmed by Director of Patient Care Services (I) on 8/16/10 at 3:25 PM.

13. Per MR review, on 8/16/10 at 2:10 PM, patient #13 was seen in the ED and transferred on 6/1/10 for vaginal bleeding. The MD notes do not identify the time the patient was seen by the MD nor the time the notes were entered into the MR

The above example was confirmed by Director of Patient Care Services (I) on 8/16/10 at 3:25 PM.

14. Per MR review, on 8/16/10 at 1:50 PM, patient #14 was seen in the ED and transferred on 6/2/10 for edema. The MD notes do not identify the time the patient was seen by the MD nor the time the notes were entered into the MR

The above example was confirmed by Director of Patient Care Services (I) on 8/16/10 at 3:25 PM.

15. Per MR review, on 8/16/10 at 1:45 PM, patient #15 was seen in the ED and admitted on 7/9/10 for cellulitis and abscess of the hand. MD orders dated 7/9, 7/10, and 7/11/10 do not identify the time the orders were entered into the MR.

The above example was confirmed by Director of Patient Care Services (I) on 8/16/10 at 3:25 PM.

16. Per MR review, on 8/12/10 at 11:15 AM, patient #16 was seen in the ED and admitted on 7/10/10 for syncope. Cardiac admission orders dated 7/10/10 do not identify the time the MD wrote the orders.

The adult PII order protocol dated 6/9/10 does not identify the time the orders were entered into the MR.

Hand Off communication notes found in the MR do not identify the date or time the notes were entered into the MR, nor the identify of the person who completed the notes.

The above example was confirmed by Quality Manager (D) on 8/12/10 at 1:50 PM.

17. Per MR review, on 8/16/10 at 11:40 AM, patient #17 was seen in the ED and transferred on 7/6/10 for a foreign body in the stomach. The MD notes do not identify the time the patient was seen by the MD nor the time the notes were entered into the MR. In addition, the MD did not sign his/her notes.

The above example was confirmed by Director of Patient Care Services (I) on 8/16/10 at 3:25 PM.

18. Per MR review, on 8/16/10 at 1:20 PM, patient #18 was seen in the ED and admitted on 6/11/10. MD orders dated 6/20, 6/21, and 6/19/10 do not identify the times the orders were entered into the MR.

MD notes dated 6/18/10 do not identify the time the notes were entered into the MR.

The adult PII order protocol dated 6/9/10 does not identify the time the orders were entered into the MR.

Progress notes dated 6/10, 6/15, 6/16, 6/17, 6/18, and 6/21/10 completed by OT (occupational therapy) do not identify the time the notes were entered into the MR.

The above example was confirmed by Director of Patient Care Services (I) on 8/16/10 at 3:25 PM.

19. Per MR review, on 8/17/10 at 12 noon, patient #19 was admitted to Swing Bed on 6/6/10 for a fractured humerus. MD orders dated 6/22, 6/18, 6/19, 6/20, 6/15, 6/16/10 do not identify the times the orders were entered into the MR.

PT (physical therapy) and OT notes dated 6/7, 6/8, 6/9, and 6/10/10 do not identify the times the notes were entered into the MR.

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

20. Per MR review, on 8/18/10 at 9:40 AM, patient #20 was admitted to Swing Bed on 7/2/10 for shortness of breath and aspiration pneumonia. MD orders dated 7/23, 7/13, 7/12, 7/2, 7/3, and 7/6/10 do not identify the times the orders were entered into the MR.

The adult PII order protocol dated 6/9/10 does not identify the time the orders were entered into the MR.

OT and PT notes dated 7/6, 7/7, and 7/5/10 do not identify the times the notes were entered into the MR.

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

21. Per MR review, on 8/17/10 at 12:25 PM, patient #21 was seen in the ED and discharged on 12/2/09 for sexual assault. The MD notes do not identify the time the patient was seen by the MD nor the time the notes were entered into the MR

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

22. Per MR review, on 8/17/10 at 12:10 PM, patient #22 was seen in the ED and discharged on 4/25/10 for sexual assault. The MD notes do not identify the time the patient was seen by the MD nor the time the notes were entered into the MR

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

23. Per MR review, on 8/17/10 at 12:40 PM, patient #23 was seen in the ED and died on 6/7/10. The MD notes do not identify the time the patient was seen by the MD.

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

24. Per MR review, on 8/18/10 at 10:10 AM, patient #24 was seen in the ED and admitted for a urinary tract infection on 6/5/10. The MD notes do not identify the date or time the patient was seen by the MD nor the time the notes were entered into the MR. In addition, the MD did not sign his/her notes.

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

25. Per MR review, on 8/17/10 at 2:50 PM, patient #25 was seen in the ED and admitted on 8/16/10 for pancreatitis. The MD notes do not identify the date or time the patient was seen by the MD nor the time the notes were entered into the MR.

The above example was confirmed by Director of Patient Care Services (I) on 8/17/10 at 3:30 PM.

26. Per MR review, on 8/17/10 at 3:05 PM, patient #26 was seen in the ED and admitted on 8/16/10 for a fractured rib. The MD notes do not identify the date or time the patient was seen by the MD nor the time the notes were entered into the MR.

The above example was confirmed by Director of Patient Care Services (I) on 8/17/10 at 3:30 PM.

27. Per MR review on 8/17/10 at 3:15 PM, patient #27 was admitted to Swing Bed on 7/16/10 for a leg ulcer. MD orders dated 7/16/10, 8/7, 8/12, 8/10, and 8/6/10 do not identify the times the orders were entered into the MR.

The above example was confirmed by Director of Patient Care Services (I) on 8/17/10 at 3:30 PM.

28. Per MR review, on 8/18/10 at 9:55 AM, patient #28 was seen in the ED and discharged on 6/5/10 for an elbow dislocation. The MD notes do not identify the date or time the patient was seen by the MD nor the time the notes were entered into the MR.

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

29 Per MR review, on 8/18/10 at 10:00 AM, patient #29 was seen in the ED and admitted on 6/5/10 for a subendo infarct. The MD notes do not identify the date or time the patient was seen by the MD nor the time the notes were entered into the MR.

The above example was confirmed by Director of Patient Care Services (I) on 8/18/10 at 11:40 AM.

Based policy review, on tour of the facility with staff, and interviews in two of two staff (O, J), by surveyor #13469, the facility failed to ensure that MR (medical records) are secure from unauthorized access. The deficiency allows for possible loss, destruction or unauthorized use of patient medical records.

Findings include:
Per policy review on 8/18/10 in the AM, policy "Confidentiality and Security Information" policy #A0003 directs the following: "Definitions VI. Confidential Information is private or otherwise sensitive information that must be restricted to those with a legitimate business need for access. Unauthorized disclosure of this information to people without a business need for access may be against laws and regulations."

Per tour of the medical records department on 8/16/10 at 2:30 PM with MR Manager (O) it was thought that the department is cleaned after hours by housekeeping when MR staff are not present allowing for unauthorized access to the MR.

It was confirmed in interview with Facilities Manager (J) on 8/18/10 at 9:20 AM that housekeeping staff do clean the MR department after the MR staff have left for the day allowing access to patient MR by the housekeeping staff.

Based on MR (medical record) review and interview with facility staff by surveyor #13469, in 5 of 5 surgery records reviewed (#1, 2, 3, 4, 5) out of a total of 29 MR reviewed, the hospital failed to ensure that the pre- and post-operative examinations are complete. In 5 of 5 MR reviewed (#1, 2, 3, 4, 5), the pre-anesthesia exam lacks a time and/or date. In 5 of 5 MR reviewed, ((#1, 2, 3, 4, 5) the post-anesthesia exam does not include the cardiopulmonary status with blood pressure, pulse and respiration, level of consciousness, if there were any complications during the post-anesthesia recovery period, or if there is any follow-up care and or observations to be done. The lack of pre- and post-anesthesia information does not delineate the course of treatment and patient response for all 5 MR reviewed.

Findings include:
1. Per MR review, on 8/11/10 at 1:30 PM, patient #1 had a knee arthroscopy on 5/3/10. The pre-anesthesia exam does not include the date or the time the exam was done.

The post-anesthesia exam notes completed at 8:55 AM do not include include the cardiopulmonary status with blood pressure, pulse and respiration or level of consciousness.

The above examples were confirmed by Quality Manager (D) on 8/11/10 at 2:50 PM.

2. Per MR review, on 8/11/10 at 2:00 PM, patient #2 had a colonoscopy on 5/6/10. The pre-anesthesia exam does not include the date or the time the exam was done.

The post-anesthesia exam notes completed at 1326 PM do not include include the cardiopulmonary status with blood pressure, pulse and respiration or level of consciousness. The notes do not identify if there were any complications during the post-anesthesia recovery period nor if there are any follow-up care and or observations.

The above examples were confirmed by Quality Manager (D) on 8/11/10 at 2:50 PM.

3. Per MR review on 8/11/10 at 3:20 PM, patient #3 ventral hernia repair on 6/1/10. The pre-anesthesia exam does not include the time the exam was done.

The post-anesthesia exam notes completed at 1:00 PM do not include include the cardiopulmonary status with blood pressure, pulse and respiration or level of consciousness.

The above examples were confirmed by Quality Manager (D) on 8/12/10 at 10:20 AM.

4. Per MR review, on 8/12/10 at 9:10 AM, patient #4 a removal of a right knee lipoma on 6/8/10. The pre-anesthesia exam does not include the time the exam was done.

The post-anesthesia exam notes completed at 12:45 PM do not include include the cardiopulmonary status with blood pressure, pulse and respiration or level of consciousness.

The above examples were confirmed by Quality Manager (D) on 8/12/10 at 10:20 AM.

5. Per MR review, on 8/12/10 at 9:25 AM, patient #5 had a right eye cataract on 6/9/10. The pre-anesthesia exam does not include the time the exam was done.

The post-anesthesia exam notes completed at 8:50 AM do not include the cardiopulmonary status with blood pressure, pulse and respiration or level of consciousness.

The above examples were confirmed by Quality Manager (D) on 8/12/10 at 10:20 AM.