HospitalInspections.org

Based on observation and interview, it was determined that the facility failed to provide a safe and sanitary environment for its patients and staff.

The findings include:

Tour of the facility on 2/12/14 revealed the following:
? Swollen and uneven floor tile in the Emergency Department which made cleaning of the floor impossible.
? Chipped linoleum counter tops at the nurses' station in the Emergency Department which made thorough cleaning of the floor impossible.
? Paint and a frying pan stored under a sink in a patient exam room in the Emergency Department.
? Radiology Department had old tile that had gaps in the seams on the edge which also made cleaning of the flooring impossible.
? Stretcher mattresses in the Emergency Department were wet, having been cleaned without being allowed to air dry before the bed was remade. This practice could lead to cross contamination.
? A dripping water dispenser was observed in the Medication Room in the Emergency Department. The dispenser drain was noted to be clotted with hard water build up which indicated improper maintenance of the machine.

In an interview with the Director of Nurses on 2/12/14, the above infection control issues were confirmed.

Based on credentialing file review, review of governing body bylaws, and staff interview, the facility failed to ensure facility policies were followed in regard to approving clinical privileges for practitioners. 5 of 6 physician credentialing files did not have delineation of privileges documented as approved by the governing body in the physician file.

The findings include:

Review of credentialing files for physicians on 2/12/14 at 11:30 a.m. revealed physicians #2, 3, 4, 5, and 7 did not have documentation of approved delineation of privileges by the governing board of the facility. The facility form titled "Delineation of Privileges Checklist" has a section that states "Board of Managers Approval: This Board has reviewed all documentation and the foregoing recommendations considered. The Delineation of privileges is hereby: [] Approved [] Not Approved." Neither the box for approved or not approved is marked on the form.

Facility policy titled "Clinical Privileges and Functions" states, in part "Each staff member shall be reviewed for reappointment and renewal of clinical privileges every 2 years." "Every practitioner who is permitted by law and by the Board to provide patient care services independently in the Hospital shall be entitled to exercise only those clinical privileges specifically granted to him or her in accordance with these Bylaws."

The above findings were confirmed on 2/12/14 at 2:00 p.m. by the Administrator and the Director of Nurses.

Based on review of documentation and interview, it was determined that the facility failed to always document procedures and incidents in the patient medical record.

Findings were:

On 10/14/13, Patient # 1 was evaluated in the Emergency Room of Ward Memorial Hospital. An IV was initiated in the patient's right forearm without an MD order or mention in the nursing progress notes. The patient was discharged later in the day with the heplock still intact. This was not mentioned in the nursing progress notes. An Occurrence Report was not initiated nor was the incident reported to the Safety Committee.

In interviews with Staff Member # 9 (ER Room RN) and the Director of Nurses on 2/12/14, the lack of documentation in the above incident was confirmed.

Based on medical record review and staff interview the facility failed to ensure all entries in the medical record were timed, dated, and authenticated by the physician. 2 of 9 discharge summaries and history and physicals were inaccurate in date, time, and authentication by the physician.

The findings include:

Review of medical records for patients #6 and #8 revealed the discharge summary and the history and physical were authenticated by the physician as correct prior to the time of transcription of the document. The discharge summary and the history and physical for patient #6 and #8 had blank areas for the physician to complete.

In an interview with the director of nurses at 2:15 p.m he confirmed the physician had not authenticated and completed the documents after reviewing for completeness and accuracy after being transcribed.

Based on review of credentialing files, governing body bylaws, and physician files the physician performing surgery in the facility did not have a delineation of surgical procedures he was approved to perform in the facility.

The findings include:

Review of credentialing files for physicians on 2/12/14 at 11:30 a.m. revealed physician #3 did not have current documentation of approved delineation of surgical privileges he could perform in the facility by the governing board of the facility. The facility form titled "Delineation of Privileges Checklist" has a section that states "Board of Managers Approval: This Board has reviewed all documentation and the foregoing recommendations considered. The Delineation of privileges is hereby: [] Approved [] Not Approved." Neither the box for approved or not approved is marked on the form.

Facility policy titled "Clinical Privileges and Functions" states, in part "Each staff member shall be reviewed for reappointment and renewal of clinical privileges every 2 years." "Every practitioner who is permitted by law and by the Board to provide patient care services independently in the Hospital shall be entitled to exercise only those clinical privileges specifically granted to him or her in accordance with these Bylaws."

The above findings were confirmed on 2/12/14 at 2:00 p.m. by the Administrator and the Director of Nurses.

Based on review of documentation and interview, it was determined that the facility failed to always report and track adverse events in the facility.

Findings were:

Ward Memorial Hospital Safety Program stated its purpose: "The purpose of Ward Memorial Hospital's Safety Program is to improve healthcare safety and reduce risk to patients, visitors, contract staff and employees through an environment that encourages:
? Recognition and reporting of risks to patient safety and medical/health errors
? Review of reported risks to identify underlying causes and system changes needed to reduce the likelihood of recurrence
? The initiation of actions to reduce these risks
? The internal reporting of what has been found and actions taken
? A focus on processes and systems
? Minimization of individual blame or retribution for involvement in a medical/health care error
? Prospective analysis of selected health care services before an adverse event occurs to identify system redesign that will reduce the likelihood of error
? Organizational learning about medical/health care errors
? Support of the sharing of that knowledge to effect behavioral changes in itself and other healthcare organizations

The scope of Ward Memorial Hospital's Safety Program includes an ongoing assessment, using internal and external knowledge and experience, to prevent error occurrence, maintain and improve healthcare safety. Safety occurrence information from aggregated data reports and individual incident occurrence reports will be reviewed by the Safety Officer, the Risk Manager, and the Safety Committee to prioritize organizational safety activity efforts. The aggregate resource information comes from, but not limited to the following:
? Occurrence Reports
? Medication Errors
? Adverse Drug Reactions
? Transfusion Reactions
? Sentinel Events
? Near Misses

The scope of the hospital wide Safety Program encompasses the patient population, visitors, volunteers, contract staff, physicians and employees. The program addresses maintenance and improvement in healthcare safety issues in every department throughout the facility. It is the responsibility of Administration, Department Directors/Managers and Supervisors to ensure full compliance with this program. There will be emphasis on important functions of:
? Patient Rights
? Assessment of Patients
? Care of Patients
? Patient/Family Education
? Continuum of Care
? Leadership
? Improving Organizational Performance
? Management of Information
? Management of Human Resources
? Management of Environment of Care
? Surveillance, Prevention and Control of Infection."

On 10/14/13, Patient # 1 was evaluated in the Emergency Room of Ward Memorial Hospital. During the time in the ER, Patient # 1 experienced a fall without injury. An IV was initiated in the patient ' s right forearm without an MD order or mention in the nursing progress notes. The patient was discharged later in the day with the heplock still intact. This was not mentioned in the nursing progress notes. An Occurrence Report regarding the patient fall and the removal of the heplock was not initiated nor was the incident reported to the Safety Committee.

In interviews with Staff Member # 9 (ER Room RN) and the Director of Nurses on 2/12/14, the lack of reporting adverse occurrences per hospital policy in the above incident was acknowledged.