HospitalInspections.org

Based on review of records, hospital policies and meeting minutes, and interviews with staff, the hospital does not ensure that all patient grievances are identified, reviewed, investigated, resolved, and a written response, with the required information, sent to the complainant. Seven (#24, 25, 26, 27, 29, 30 and 31) of eight (#24, 25, 26, 27, 28, 29, 30 and 31) grievances/ complaints and incidents reviewed met the definition of a grievance but did not have evidence all required documentation or elements were completed. The hospital does not ensure all grievances and incidents are incorporated in the Quality Assessment and Performance Improvement (QAPI) process and data used to improve patient care.

Findings:

1. The surveyors reviewed the grievance and incident files for the past year.

2. Review of the incident reports identified incidents that required investigation of patient care complaints and should have been classified as grievances.

3. Staff C and D told the surveyors that incident reports were reviewed in Safety Committee, not in Quality or as part of the grievance review.

4. The surveyors reviewed the findings of the selected eight grievance and incident reports with Staff C and D. No additional information was provided.

5. The hospital does not ensure grievance data is incorporated in the hospital's Quality Assessment and Performance Improvement (QAPI) Program with analysis of the data and implementation of processes to improve patient care:
There was no evidence that grievance and complaint data was reviewed, trended and analyzed with implementation of corrective and/or process changes to improve patient care.

6. There was no evidence the Governing Body reviewed, trended, and analyzed incident, grievance, and incident data.

7. On 08/08/2012, the above findings were shared with administration during the exit conference. No further documentation/information was provided.

Based on review of medical records and personnel files, and interviews with hospital staff, the hospital failed to ensure staff, working on the mental health/psychiatric (psych) unit, were trained and kept current in the safe implementation in CPI (Crisis Prevention Intervention by Crisis Prevention Institute), the facility's approved method to hold/restrain patients, identify behaviors/circumstances that might trigger the use restraints, and deter the necessity to utilize restraints and seclusion, before patient care was assigned. This occurred for two of three (Staff J and L of Staff J, K, and L) geriatric psychiatric personnel files reviewed for CPI competency.

Findings:

1. On the afternoon of 08/08/2012, Staff C and M told the surveyors that the hospital used CPI as the hospital's approved method for identifying and managing potential aggressive situations, including methods to physically hold/restrain patients. This was confirmed by personnel file review.

2. State Licensure Chapter 667 Hospital Standards, Subchapter 33, 310:667-33-2(b)(2), stipulates, "All staff providing active treatment or monitoring patients shall be trained in facility methods approved to physically hold or restrain patients before patient care responsibilities are assigned. These staff members shall be reoriented regarding these policies annually or when policies are revised."

3. Two of three staff chosen for review did not have CPI training. Both staff, who did not have CPI training, had worked on the psychiatric unit within the last month. This was verified with administrative staff at the time of review on the afternoon of 08/08/2012.

Based on review of medical records and interviews with staff, the facility failed to enforce the required bylaws and ensure a history and physical examination was performed within 30 days of admission, or 24 hours after admission or prior to a procedure which required anesthesia. There was no evidence the facility enforced any bylaws enforcing medical record completion.

Findings:


1. Medical records 18 and 19 indicated a patient had been admitted for surgery, discharged and readmitted. Medical record 18 the first admission did not include a discharge summary. Admit orders were not timed. The history and physical was not timed. The patient was readmitted (record 19) to the intensive care unit three days later. There was no history and physical by the attending physician, no discharge summary, no progress notes by the attending physician, and none of the verbal orders were signed. The medical record was over 45 days old.

2. Patient #23's medical record indicated she initially presented to the facility in labor. According to the documentation the physician decided to perform a c-section because of non-reassuring fetal heart tones. The transfer report between obstetrics and surgery did not include any information on fetal heart tones. The physician did not dictate an operative note until two weeks post delivery. Verbal discharge orders were not signed by the physician. Two sets of c-section orders were in the closed medical record. Neither dated and timed for the date of the patient's c-section.

3. Patient #16 was admitted for two surgical procedures. The closed medical record did not contain a dictated operative note for one of the procedures. There was not an updated history and physical in the record. The record was greater than 45 days old.

4. Patient #17 was admitted for an infection of a recently placed peg tube. There was no discharge summary. The record contained illegible handwriting by the attending physician. The medical record was greater than 45 days old.

5. Review of the Utilization Review and Medical Records Committee meeting minutes does not indicate records are reviewed for completion. There was no evidence delinquent medical record information was presented to the Medical Staff and Governing Body for action as required by the facilities bylaws. This finding was confirmed with Staff G on 8/8/2012.

Based on record review and interviews with hospital staff, the hospital does not ensure that all drugs are administered to patients according to the orders of the practitioner and hospital policy. One (#14) of one patient's record reviewed did not follow the hospital's policy for dose range orders specifying that the dose administered depends on the pain assessment. This assessment is to be documented on the medical record. Documentation of the patient's pain assessment was not consistently documented in the medical record.

Findings:

1. The dose range order policy states that the nurse will assess the patient's pain and document it on the medical record. If the patient's pain assessment is between 0-5 on the numeric pain scale then the lower of the two dose options will be given. If the patient's pain is between 6-10 on the numeric scale then the higher dose will be given.

2. The physician's order was for Morphine 5-10 mg (milligrams) IV (intravenous) every 6 hours prn (as needed) pain.

3. Three of five Morphine doses administered to patient # 14 for pain did not have evidence of a pain assessment documented in the MAR (medical administration record) or patient care notes justifying the dose given

4. Hospital staff verified that the pain assessments were not documented.

Based on review of policies and procedures and medical records and interviews with hospital staff, the hospital failed to develop and ensure medical records were complete, readily accessible/retrievable.

Findings:

1. The hospital's medical records are comprised of dictated, handwritten and electronic orders and charting. The surveyors were told by Staff C that the computerized charting portion is comprised of four different systems, with emergency services (ER), obstetrics, surgical services, and medical/surgical and psychiatric units all on different systems. The systems were accessed separately.

2. The hospital's policy, "Medical Record Content", listed all the components of what comprised medical records, but did not designate/detail:
a. In what form (dictated, handwritten, or electronic) the different components/documents were acceptable;
b. Where each portion of the medical record would be kept/retained and in what form (printed or computerized);
c. How staff would access and provide patients and other staff with a complete medical record.

3. Records #2, 3 and 5 contained documentation by the nursing staff that the physician gave verbal orders for medications. The surveyors were told by Staff C, F and G that ER medical records provided for surveyor review were complete and kept in "hard copy". The records did not contain physician signatures authorizing all the medications administered. These finding were reviewed and verified with Staff C and D on 08/08/2012 at 1045 and 1150 and with Staff G on the afternoon of 08/08/2012. Staff C stated this had occurred because the physician completed the electronic record before the nurse, and therefore all medications administered were not identified for the physician to view/sign.

4. After review of the printed medical record on the afternoon of 08/08/2012, one surveyor spent over 25 minutes with hospital staff trying, unsuccessfully, to review the computerized medical record. The individual assigned to help the surveyor called other staff, who were also unsuccessful in accessing the records. Staff told the surveyors that the inability to access records occurred often.

5. Medical records 18 and 19 indicated a patient had been admitted for surgery, discharged and readmitted. Medical record 18 the first admission did not include a discharge summary. Admit orders were not timed. The history and physical was not timed. The patient was readmitted to the intensive care unit three days later. There was no history and physical by the attending physician, no discharge summary, no progress notes by the attending physician, and none of the verbal orders were signed. The medical records were over 45 days old.

6. Patient #23's medical record indicated she initially presented to the facility in labor. According to the documentation the physician decided to perform a c-section because of non-reassuring fetal heart tones. The transfer report between obstetrics and surgery did not include any information on fetal heart tones. The physician did not dictate an operative note until two weeks post delivery. Verbal discharge orders were not signed by the physician. Two sets of c-section orders were in the closed medical record. Neither dated and timed for the date of the patient's c-section.

7. Patient #16 was admitted for two surgical procedures. The closed medical record did not contain a dictated operative note for one of the procedures. There was not an updated history and physical in the record. The record was greater than 45 days old.

8. Patient #17 was admitted for an infection of a recently placed peg tube. There was no discharge summary. The record contained illegible handwriting by the attending physician. The medical record was greater than 45 days old.

9. Review of the Utilization Review and Medical Records Committee meeting minutes does not indicate records are reviewed for completion. There was no evidence delinquent medical record information was presented to the Medical Staff and Governing Body for action as required by the facilities bylaws. This finding was confirmed with Staff G on 8/8/2012.

Based on review of medical records and interviews with hospital staff, the hospital failed to ensure verbal orders were signed and dated by the ordering practitioner. Three of five (Records #2, 3 and 5 of Records #2, 3, 4, 5, and 6) emergency room (ER) only medical records reviewed did not contain handwritten or electronic signatures of verbal orders received by the ER nurse.

Findings:

1. The hospital has medical records comprised of both handwritten and electronic orders and charting.

2. Records #2, 3 and 5 contained documentation by the nursing staff that the physician gave verbal orders for medications. The surveyors were told by Staff C, F and G that ER medical records were complete and kept in "hard copy". The records did not contain physician signatures authorizing all the medications administered.

Records #18,19, and 23 contained documentation by the nursing staff that the physician gave verbal orders for medications. The records did not contain physician signatures authorizing all the medications administered.

3. These finding were reviewed and verified with Staff C and D on 08/08/2012 at 1045 and 1150 and with Staff G on the afternoon of 08/08/2012. Staff C stated this had occurred because the physician completed the electronic record before the nurse, and therefore all medications administered were not identified for the physician to view/sign.

4. Staff F and G stated on the morning of 08/08/2012 that ER medical record review for completeness did not occur.

Based on record review and interviews with hospital staff, the hospital does not ensure that scheduled drugs are tracked from point of entry into the hospital to the point of departure either through administration to the patient, destruction or return to the manaufacturer. Narcotic administration records for PCA (patient controlled analgesia) showing each dose administered and wastage were unavailable for surveyor review when requested. This was verified by pharmacy staff during a tour of the pharmacy department on 08/08/12.

Based on record review and interviews with hospital staff the hospital does not ensure that drug orders are administered to patients as ordered and are clearly discontinued when the physician makes a dosage change in a previous order to assure patient safety and minimize medication errors. One (#14) of one patient records reviewed did not have the original orders discontinued and documented before initiating changed orders.

Findings:

1. Morphine 5 - 10 mg (milligrams) IV (intravenous) every 6 hours as needed for pain was ordered on 07/09/12 at 1532. Another order for Morphine 4 mg IV every 6 hours as needed for pain on 07/11/12 at 1430. There was no documentation that the first Morphine order was discontinued before the second order was implemented.

2. The first ordered doses of Morphine were administered five times ( two on 07/09/12, three on 07/10/12 ) according to documentation on the MAR (medication administration record). The second ordered doses of Morphine were administered two times on 07/11/12. A written order to discontinue the first Morphine order was not documented in the patient's record.

3.Zofran 4 mg (milligrams) IV (intravenous) every 6 hours as needed for nauses was ordered on 07/09/12 at 1532. Another order for Zofran 4 - 8 mg IV every 6 hours as needed for nausea and vomiting on 07/11/12 at 1532. There was no documentation that the first Zofran order was discontinued before the second order was implemented.

Based on review of infection control data, surveillance activities, and meeting minutes, and hospital documents, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner (ICP) developed and maintained a comprehensive system for reporting, analyzing and controlling infections and communicable diseases among patients and staff and ensuring a sanitary environment.

Findings:

1. The surveyors reviewed meeting minutes and surveillance activities provided for October 2011 through July 2012 containing Infection Control.

2. Meeting minutes containing infection control, did not reflect the program contained review and analysis with plans of action and follow-up of monitoring:
a. While Employee Health did track employee illness, it did not analyze the data to ensure transmissions between staff and patients did not occur;
b. Infections and communicable diseases - Meeting minutes documented nosocomial/hospital acquired infections occurred to patients in the hospital. The meeting minutes and documents provided did not demonstrate an analysis had occurred to identify if corrective actions, or policies and procedures or protocols revision need to occur or follow-up to ensure any corrective actions/revisions taken were effective. The modes of possible transmission between individuals (patients and staff) with analysis of measures taken to contain and prevent transmission and whether they were effective.
c. Except for handwashing and environmental rounds/spot checks, monitoring in all areas of the hospital to ensure that staff followed established policies and procedures and standards of practice to prevent and control infections and maintain a sanitary environment.

3. The infection control program did not contain a review of staff immunization history. Meeting minutes did not demonstrate immunization histories were reviewed and discussed. Review of eight of eight physician and one of one CRNA (certified registered nurse anesthetist) files did not contain complete immunization histories as as required by Oklahoma State Hospital Licensure Standards and recommended by Centers for Disease Control (CDC) and its Advisory Committee on Immunization Practices (ACIP).

4. Monitoring activities, provided for review, did not include active surveillance of the practices, to ensure staff adhered to the policies to avoid possible transmission of infections throughout the hospital, including the proper application of disinfectants.
a. The ICP has not monitored the application of disinfectants to ensure they were applied according to the manufacture's guidelines in all department of the hospital.
b. Surgical practices - June and July autoclave tapes were reviewed. Surgical staff routinely used shortened cycle/"flash" autoclave cycles to sterilize eye, plastic, lipo, and some knee instruments during this period. The ICP has not monitored the surgical practices to ensure current manufacture and current sterilization practice guidelines were followed. The infection control program has not analyzed the uses of shortened/"flash" cycles to identify if surgical case scheduling changes or if purchase of additional instruments needed to occur to limit and reduce the use of shortened/"flash" cycles.
c. The infection control plan documented a plan to monitor gown/glove and other protective equipment compliance in isolation rooms. This activity has not occurred.

4. These findings were reviewed with Staff with hospital administrative staff during the exit conference on the afternoon of 08/08/2012. No additional information was provided.

Based on review of medical records and interviews with hospital staff, the hospital failed to provide ongoing activities to swingbed patients that were based on a comprehensive assessment performed by a qualified activity coordinator/professional. This occurred in two of two (Patients #11 and 12) swingbed patients, whose medical records were reviewed.

Findings:

1. Administrative staff identified Staff H as the swingbed activities coordinator on 08/07/2012.

2. Although Staff H met the qualifications for swingbed activities coordinator, review of Staff H's personnel file did not contain a job description for swingbed activities coordinator. This finding was reviewed and confirmed with Staff C and M on the afternoon of 08/08/2012.

3. Swingbed Patient #11 did not have a comprehensive activity assessment documenting the patients interests and physical, mental and psychosocial needs. This was confirmed with Staff C and I on 08/08/2012 at 1800.

4. Patient #11, swingbed admission 06/18 through 22/2012 - The medical record did not contain evidence activities were provided to the swingbed patient. This was confirmed with Staff C and I on 08/08/2012 at 1800.

5. Patient #12, swingbed admission 06/12 through 20/2012 - The medical record did not contain evidence activities were provided to the swingbed patient over the weekend of 06/16 and 17/2012 or on 06/19 and 20/2012. This was confirmed with Staff C and I on 08/08/2012 at 1800.