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Based on record review and interview, the facility failed to ensure a history and physical was documented on the patient's record and/or an update to the history and physical prior to surgery and/or procedure on 17 (# 24, 25, 27, 29, 30, 31, 32, 33, 34, 39, 40, 41, 42, 43, 44, 45, and 46 ) of 24 records.
A review of the medical records revealed the following:
Findings:

A review of patient #24's medical record revealed the history and physical was completed at the physician's office on 12/3/2013. The History and Physical document on the medical record referred to the 12/3/2013 history and physical, in which physician documented "see attached H&P" which was 2 months old and the time was left blank of when the history and physical was completed. On 2/25/2014 a Left Power Port Placement & Right Open Breast Biopsy surgery was performed on this patient without a current history and physical.

A review of patient #25's medical record revealed a history and physical on the record by the admitting physician, but no history and physical or update from the surgeon. On 2/26/2014 an Appendectomy surgery was performed on this patient without a history and physical.

A review of patient #27's medical record revealed no history and physical on the record by the surgeon. On 2/25/2014 an Incision and Drainage procedure was performed on this patient without a history and physical.

A review of patient #29's medical record revealed a history and physical on the medical record from the admitting physician, but not signed. The surgeon performing the surgery had not documented a history and physical or an update to the record prior to surgery. On 2/25/2013 a Total Right Hip Replacement surgery was performed on this patient without an updated history and physical.

A review of patient #30's medical record revealed a history and physical on the record, but had not been signed or electronically signed, dated or timed by the physician. On 2/25/2014 a surgery was performed on this patient without a history and physical.

A review of patient #31's medical record revealed a history and physical on the record by the admitted physician, but no history and physical or update from the surgeon. On 2/21/2014 an Open Appendectomy surgery was performed on this patient without a history and physical from the surgeon.

An interview with staff member #15 and on 2/26/2014 at approximately 4:30 PM confirmed the above findings from surgical floor patient's medical record.

A review of patient #32's medical record revealed no history and physical on the record by the surgeon. On 2/25/2014 a Small Bowel Capsule Endoscopy procedure was performed on this 99 year old patient without a history and physical.
A review of patient #33's medical record revealed the history and physical was completed at the physician's office on 2/20/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was not timed to know when it occurred. On 2/25/2014 a Laparoscopic Bilateral Tubal Ligation surgery was performed on this patient without an updated history and physical.

A review of patient #34's medical record revealed the history and physical was completed at the physician's office on 2/18/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the procedure room. On 2/25/2014 an Endoscopy procedure was performed on this patient with the updated history and physical after the patient was in the procedure room.

A review of patient #39's medical record revealed the history and physical was completed at the physician's office on 2/10/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and surgery had started. On 2/25/2014 a Micro Suspension Laryngoscopy with Biopsy was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #40's medical record revealed the history and physical was completed at the physician's office on 2/19/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and surgery had started. On 2/25/2014 a Bilateral Myringotomy with ear tubes was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #41's medical record revealed the history and physical was completed at the physician's office on 2/19/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and surgery had started. On 2/25/2014 a Septoplasty was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #42's medical record revealed the history and physical was completed at the physician's office on 2/20/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and surgery had started. On 2/25/2014 a Direct Micro Laryngoscopy was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #43's medical record revealed the history and physical was completed at the physician's office on 2/24/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and surgery had started. On 2/25/2014 an Incision and Drainage Left Neck Abscess was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #44's medical record revealed the history and physical was completed at the physician's office on 2/13/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and the surgery was completed. On 2/25/2014 a Bilateral Myringotomy with ear tubes was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #45's medical record revealed the history and physical was completed at the physician's office on 2/13/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and the surgery was completed. On 2/25/2014 a Bilateral Myringotomy with ear tubes was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #46's medical record revealed the history and physical was completed at the physician's office on 2/13/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and the surgery was completed. On 2/25/2014 a Bilateral Myringotomy with ear tubes was performed on this patient with the updated history and physical after the patient was in the operating room.

An interview with staff member #17 and on 2/25/2014 at approximately 4:30 PM confirmed the above findings from the patient's medical record.

Based on record review and interview, the facility failed to ensure an updated history and physical was documented on the patient's record prior to surgery and/or procedure on 10 (#33, 34, 39, 40, 41, 42, 43, 44, 45, and 46 ) of 24 surgical records. The facility also failed to ensure that any changes made to the patient's condition was completed by a physician on 8 (#39, 40, 41, 42, 43, 44, 45,and 46) of 8 patient's records
A review of patient #33's medical record revealed the history and physical (H&P) was completed at the physician's office on 2/20/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was not timed to know when it occurred. On 2/25/2014 a Laparoscopic Bilateral Tubal Ligation surgery was performed on this patient without an updated history and physical.

A review of patient #34's medical record revealed the history and physical was completed at the physician's office on 2/18/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the procedure room. On 2/25/2014 an Endoscopy procedure was performed on this patient with the updated history and physical after the patient was in the procedure room.

A review of patient #39's medical record revealed the history and physical was completed at the physician's office on 2/10/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and surgery had started. On 2/25/2014 a Micro Suspension Laryngoscopy with Biopsy was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #40's medical record revealed the history and physical was completed at the physician's office on 2/19/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and surgery had started. On 2/25/2014 a Bilateral Myringotomy with ear tubes was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #41's medical record revealed the history and physical was completed at the physician's office on 2/19/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and surgery had started. On 2/25/2014 a Septoplasty was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #42's medical record revealed the history and physical was completed at the physician's office on 2/20/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and surgery had started. On 2/25/2014 a Direct Micro Laryngoscopy was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #43's medical record revealed the history and physical was completed at the physician's office on 2/24/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and surgery had started. On 2/25/2014 an Incision and Drainage Left Neck Abscess was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #44's medical record revealed the history and physical was completed at the physician's office on 2/13/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and the surgery was completed. On 2/25/2014 a Bilateral Myringotomy with ear tubes was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #45's medical record revealed the history and physical was completed at the physician's office on 2/13/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and the surgery was completed. On 2/25/2014 a Bilateral Myringotomy with ear tubes was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #46's medical record revealed the history and physical was completed at the physician's office on 2/13/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and the surgery was completed. On 2/25/2014 a Bilateral Myringotomy with ear tubes was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of the medical records #39 through #46 revealed the writing on the stamped "H&P Update (Prior to procedure)" form, was not the same writing as physician #25. The times on the updated H&P had been marked out and changed.
An interview with staff member #17 and on 2/25/2014 at approximately 4:30 PM confirmed the above findings from the patient's medical record.
Staff #17 was asked why there was a difference in the handwriting and why the times were marked out on the history and physical updates on patient's records #39 through #46. She stated, "She is the physician's employee (#7) from his office. She came and changed the times when we told her the surveyor had noted the times were after the patient had gone to surgery." When asked what her title was, she stated, "I don't know." When asked was she credentialed to write on the charts, she stated, "I don't know."
A review of physician's employee #7 credentialing file revealed employee #7 is a medical assistant. The "Delineation of Privileges" noted the following requirements: "This category of physician's employees may work in the Hospital only under the direct supervision of the physician employer. (Direct supervision is defined as "in the presence of the physician employer.")
Further review of the "Delineation of Privileges" noted in the "Orders" section the following requirements: "Serve as a scribe for the sponsoring physician by recording notes in the Physician Progress Notes (for immediate signature by the physician)."
An interview with staff member #1 and on 2/26/2014 at approximately 3:30 PM confirmed physician's employee #7 should not have been documenting in the medical record without the physician present.

Based on interview and record review the facility failed to ensure 1 of 1 patients received a thorough skin evaluation and turning and repositioning as required (Patient #18).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:
Review of "Nurse's Notes" revealed Patient #18 was a 71 year old female who presented to the Emergency Department (ED) on 02/24/2014 at 5:51 p.m. with a diagnosis of gangrene-left leg. According to documentation in the ED "Nurses notes" at 7:45 p.m., Patient #18 had the following skin breakdown:
*Decubitus located on coccyx approximately 7.6 cm to 10 cm is draining moderate amount of malodorous, serosanguinous.
*Decubitus located on the left shin approximately 2.6 cm to 7.5 cm is draining moderate amount of malodorous, serosanguinous.
At 9:48 p.m. .....pictures were taken of decubitus sores on the left leg and coccyx.
On 02/25/2015 at 00:15 a.m., Patient #18 was admitted to the floor and at 1:12 a.m. she left the ED.
Review of an "Adult Admission Physical Assessment" dated 02/25/2014 at 6:55 a.m. revealed the following:
"On admission, ALL dressings must be removed, wound assessed and appropriate wound protocol placed on the chart "
Review of the "Adult Admission Physical Assessment" dated 02/25/2014 at 6:55 a.m.; revealed Patient #18's first wound was a Stage IV to the coccyx which had tunneling, undermining, odor and drainage. There was documentation there was no photos on the chart. The second wound was described as a stasis ulcer and there was documentation it was not assessed because a dressing was in place. The third wound was on the left heel and it was not assessed because a dressing was in place. According to the Braden Risk Assessment Scale the patient was at high risk for skin breakdown. This was the first documentation of the heel wound and there was no detailed documentation of an assessment.
Review of the "Pressure Ulcer Prevention Protocol" dated 02/25/2014 revealed a nurse initiated the protocol at 11:00 a.m. (the next day after admission). The portion addressing dressing selection for pressure ulcers revealed no documentation of initiation.
Review of the "Patient Flow sheet Report" revealed the following turning/repositioning for 02/25/2014:
2:00 a.m. on right side;
4:00 a.m. on back (on breakdown surface);
6:00 a.m. on left side;
8:00 a.m. patient able to turn self (no documentation of which side patient on);
10:00 a.m. on right side;
11:53 a.m. nothing documented;
2:00 p.m. patient able to turn self (no documentation of which side patient on);
4:00 p.m. on left side;
6:00 p.m. on back (on breakdown surface);
8:00 p.m. on back (on breakdown surface);
10:00 p.m. on left side;
12 midnight on back (on breakdown surface);
Review of the facility "Pressure Ulcer Prevention Protocol" revealed staff was to initiate appropriate turning/repositioning guidelines,
Turn patient every 1-3 hours
Avoid positioning patient on breakdown surfaces if possible..
During an interview on 02/25/014 after 4:00 p.m. and 02/26/2014 after 8:30 a.m., Staff #15 confirmed the admission protocol condition and the problems with turning.

Based on interview and record review the facility failed to ensure admission paperwork, skin assessments, skin protocols, venous thromboembolic protocols, turning schedules, blood sheets, medication orders and restraint orders were complete, accurate and legible in 7 of 46 sampled patients (Patient #s' 13, 14, 15, 18, 19, 20, and 21).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:
Review of "Nurse's Notes" revealed Patient #18 was a 71 year old female who presented to the Emergency Department (ED) on 02/24/2014 at 5:51 p.m. with a diagnosis of gangrene-left leg. According to documentation in the ED "Nurses notes" at 7:45 p.m., Patient #18 had the following skin breakdown:
*Decubitus located on coccyx approximately 7.6 cm to 10 cm is draining moderate amount of malodorous, serosanguinous.
*Decubitus located on the left shin approximately 2.6 cm to 7.5 cm is draining moderate amount of malodorous, serosanguinous.
At 9:48 p.m. .....pictures were taken of decubitus sores on the left leg and coccyx.
On 02/25/2015 at 00:15 a.m., Patient #18 was admitted to the floor and at 1:12 a.m. she left the ED.
Review of an "Adult Admission Physical Assessment" dated 02/25/2014 at 6:55 a.m. revealed the following:
"On admission, ALL dressings must be removed, wound assessed and appropriate wound protocol placed on the chart "
Review of the "Adult Admission Physical Assessment" dated 02/25/2014 at 6:55 a.m.; revealed Patient #18's first wound was a Stage IV to the coccyx which had tunneling, undermining, odor and drainage. There was documentation there was no photos on the chart. The second wound was described as a stasis ulcer and there was documentation it was not assessed because a dressing was in place. The third wound was on the left heel and it was not assessed because a dressing was in place. According to the Braden Risk Assessment Scale the patient was at high risk for skin breakdown. This was the first documentation of the heel wound and there was no detailed documentation of an assessment.
Review of the "Pressure Ulcer Prevention Protocol" dated 02/25/2014 revealed a nurse initiated the protocol at 11:00 a.m. (the next day after admission). The portion addressing dressing selection for pressure ulcers revealed no documentation of initiation.
Review of the "Patient Flow sheet Report" revealed the following turning/repositioning for 02/25/2014:
2:00 a.m. on right side;
4:00 a.m. on back (on breakdown surface);
6:00 a.m. on left side;
8:00 a.m. patient able to turn self (no documentation of which side patient on);
10:00 a.m. on right side;
11:53 a.m. nothing documented;
2:00 p.m. patient able to turn self (no documentation of which side patient on);
4:00 p.m. on left side;
6:00 p.m. on back (on breakdown surface);
8:00 p.m. on back (on breakdown surface);
10:00 p.m. on left side;
12 midnight on back (on breakdown surface);
Review of the facility "Pressure Ulcer Prevention Protocol" revealed staff was to initiate appropriate turning/repositioning guidelines,
Turn patient every 1-3 hours
Avoid positioning patient on breakdown surfaces if possible..
During an interview on 02/25/014 after 4:00 p.m. and 02/26/2014 after 8:30 a.m., Staff #15 confirmed the admission protocol condition and the problems with turning.


Review of orders dated 02/24/2014 revealed Patient #15 was a 24 year old female admitted for an induction of pregnancy.
Review of admission orders dated 02/24/2014 revealed one of the patient's listed medications was crossed out on the form. There was no indication as to who crossed out the medication or when.
Review of an "Admission Home Medication List" revealed "this list should never have medications added to it after the initial completion by the admitting nurse. If there is a blanket order by the Physician to continue home medications, this list must be reviewed with the Physician prior to initiating home medications." The list was left completely blank by the admitting nurse. The physician had pre-signed the form and left off the medications to be continued, date and time.
There was also a pre-certification physician order for Inpatient status which was not dated or timed by the physician in the admission papers.


Review of an admission record dated 02/24/2014 revealed Patient #13 was a 27 year old female admitted for a repeat Cesarean section.
The "Post Anesthesia Assessment" dated 02/24/2014 revealed the anesthesiologist signed off at 1:40 p.m... There was documentation of someone writing over the time and changing it to 3:40 p.m. There was no indication as to who wrote over the numbers or when.
Review of the "Adult Risk Stratification of VTE(venous thrombus embolus) and Prophylaxis (RSVP) Order Set" for Patient #13 revealed it had not been completed by nursing or the physician nor signed off. According to instructions on the form pharmacological methods were contraindicated for recent or anticipated neuraxial anesthesia (epidural or spinal anesthesia): risk of spinal or epidural hematoma and subsequent paralysis. This risk information had not been completed for this patient who had an epidural.

Review of a "Blood and Blood Component Flow sheet" dated 02/19/14 revealed Patient #14 was admitted on 02/18/2014. Review of the flow sheet revealed Patient #14 received a unit of blood on 02/19/2014 and staff failed to document the transfusion start time on the form.
During an interview on 02/25/2014 at 1:09 p.m., Staff #14 confirmed the documentation problems on Patient # s' 13, 14 and 15.

Review of a "Blood and Blood Component Flow sheet" dated 02/25/2014 revealed Patient #19 was admitted on 02/24/2014. According to the medication administration record dated 02/25/2014 Patient #19 received a dose of Benadryl 25 milligrams at 10:22 am. Review of the physician orders and the nurse' s notes revealed no documentation as the reason the medication was administered.

Review of the "Blood and Blood Component Flow sheet" dated 02/25/2014 revealed Patient #19 received a unit of blood 5 hours later at 3:20 p.m. Review of the blood flow sheet revealed two staff verified the order for blood administration, but one of the staff failed to document their credentials. One of the times for documentation of vital signs taken was scratched through and not legible.
During an interview on 02/26/2014 after 8:30 a.m., Staff #15 confirmed not knowing the reason for the administration of Benadryl early in the morning and the documentation problems on the blood sheet.

Review of a "Physician Restraint Order sheet for Non-Violent, Non-Self Destructive Restraint" on Patient #21 revealed she was an 86 year old female admitted on 02/17/2014. The following was documented on the restraint orders:
One order for elbow immobilizers dated 02/19/2014 was timed as being ordered at 4:50 p.m. and signed by the nurse. Underneath the nurse signature was a place for the physician to sign, date and time the orders. The date 2/19/2014, at 4:00 p.m. was originally written by the physician. The date 02/19/2014 was written over and the date 02/20/2014 was written in. There was no indication as to who wrote over the date. The physician's signature was written with a black marker which was totally different from the pen used for the date and time on the order next to his name.
The next order written for elbow immobilizers was ordered on 02/24/2014. The time of the order was 12 midnight and signed off by the nurse. The physician signed and dated the order with a black marker. The time on the order next to the physician' s signature was written in the same color pen as the nurse's information.

The next order written for elbow immobilizers was ordered 02/25/14. The time of the order was 12 midnight and signed off by the nurse. The physician signed and dated the order with a black marker for 2/24/2014 (the day prior). The time on the order next to the physician' s signature was written in the same color pen as the nurse' s information.

Review of a "Physician Restraint Order sheet for Non-Violent, Non-Self Destructive Restraint" on Patient #20 revealed he was a 61 year old male admitted on 02/7/2014. An order was received for elbow immobilizers on 02/14/2014 and the time ordered was written over. There was no way to tell what time they were ordered.
During an interview on 02/26/2014 after 2:00 p.m., Staff #16 confirmed the orders were pre dated by nursing.


Review of the policy named "Correcting Entries in Patient Paper and/or Electronic Record" revealed the following:
To establish guidelines for correcting information in the medical record, errors and omissions in the medical record should be corrected to accurately reflect the care and condition of the patient. All corrections made in a medical record must be done by the following procedures. Care must be taken to insure that no documentation is completely obliterated from the patient medical records.
The person who made the error shall be the one to correct it.
Process
Correcting the Paper Record -
Handwritten entries
A single line shall be drawn through the mistaken entry. Write in the correct information as close to the original entry as possible. The correction is to be initialed, dated and timed.
If a medical record form is completed erroneously, an "X" is marked through the entire form or a single line drawn diagonally; Error is clearly indicated, initialed, dated and timed. A new form is completed. If the error is noted any time after initial completion of the form, the erroneously completed form is maintained as a permanent part of the patient' s record with the corrected form.

Based on record review and interview, the facility failed to ensure a history and physical was documented on the patient's record and/or an update to the history and physical prior to surgery and/or procedure on 17 (# 24, 25, 27, 29, 30, 31, 32, 33, 34, 39, 40, 41, 42, 43, 44, 45, and 46 ) of 24 records. The facility also failed to follow their own policy on history and physical being completed on the patient's record.
A review of the medical records revealed the following:
Findings:

A review of patient #24's medical record revealed the history and physical was completed at the physician's office on 12/3/2013. The History and Physical document on the medical record referred to the 12/3/2013 history and physical, in which physician documented " see attached H&P " which was 2 months old and the time was left blank of when the history and physical was completed. On 2/25/2014 a Left Power Port Placement & Right Open Breast Biopsy surgery was performed on this patient without a current history and physical.

A review of patient #25's medical record revealed a history and physical on the record by the admitting physician, but no history and physical or update from the surgeon. On 2/26/2014 an Appendectomy surgery was performed on this patient without a history and physical.

A review of patient #27's medical record revealed no history and physical on the record by the surgeon. On 2/25/2014 an Incision and Drainage procedure was performed on this patient without a history and physical.

A review of patient #29's medical record revealed a history and physical on the medical record from the admitting physician, but not signed. The surgeon performing the surgery had not documented a history and physical or an update to the record prior to surgery. On 2/25/2013 a Total Right Hip Replacement surgery was performed on this patient without an updated history and physical.

A review of patient #30's medical record revealed a history and physical on the record, but had not been signed or electronically signed, dated or timed by the physician. On 2/25/2014 a surgery was performed on this patient without a history and physical.

A review of patient #31's medical record revealed a history and physical on the record by the admitted physician, but no history and physical or update from the surgeon. On 2/21/2014 an Open Appendectomy surgery was performed on this patient without a history and physical from the surgeon.

An interview with staff member #15 and on 2/26/2014 at approximately 4:30 PM confirmed the above findings from surgical floor patient's medical record.

A review of patient #32's medical record revealed no history and physical on the record by the surgeon. On 2/25/2014 a Small Bowel Capsule Endoscopy procedure was performed on this 99 year old patient without a history and physical.
A review of patient #33's medical record revealed the history and physical was completed at the physician's office on 2/20/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was not timed to know when it occurred. On 2/25/2014 a Laparoscopic Bilateral Tubal Ligation surgery was performed on this patient without an updated history and physical.

A review of patient #34's medical record revealed the history and physical was completed at the physician's office on 2/18/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the procedure room. On 2/25/2014 an Endoscopy procedure was performed on this patient with the updated history and physical after the patient was in the procedure room.

A review of patient #39's medical record revealed the history and physical was completed at the physician's office on 2/10/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and surgery had started. On 2/25/2014 a Micro Suspension Laryngoscopy with Biopsy was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #40's medical record revealed the history and physical was completed at the physician's office on 2/19/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and surgery had started. On 2/25/2014 a Bilateral Myringotomy with ear tubes was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #41's medical record revealed the history and physical was completed at the physician's office on 2/19/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and surgery had started. On 2/25/2014 a Septoplasty was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #42's medical record revealed the history and physical was completed at the physician's office on 2/20/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and surgery had started. On 2/25/2014 a Direct Micro Laryngoscopy was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #43's medical record revealed the history and physical was completed at the physician's office on 2/24/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and surgery had started. On 2/25/2014 an Incision and Drainage Left Neck Abscess was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #44's medical record revealed the history and physical was completed at the physician's office on 2/13/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and the surgery was completed. On 2/25/2014 a Bilateral Myringotomy with ear tubes was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #45's medical record revealed the history and physical was completed at the physician's office on 2/13/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and the surgery was completed. On 2/25/2014 a Bilateral Myringotomy with ear tubes was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #46's medical record revealed the history and physical was completed at the physician's office on 2/13/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and the surgery was completed. On 2/25/2014 a Bilateral Myringotomy with ear tubes was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of record titled, "Medical Record Department, MRD .02.01.0004, Initial Assessment of the Patient (Components History and Physical Examination)" revealed the following:
"The medical history and physical examination is to be completed and documented no more than 30 days before or 24 hours after admission or registration, but for cases involving surgery or procedure requiring anesthesia services, prior to the surgery or procedure. The medical history and physical examination must be placed in the patient ' s medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services."
An interview with staff member #17 and on 2/25/2014 at approximately 4:30 PM confirmed the above findings from the patient's medical record.

Based on record review and interview, the facility failed to ensure an updated history and physical was documented on the patient's record prior to surgery and/or procedure on 10 (#33, 34, 39, 40, 41, 42, 43, 44, 45, and 46 ) of 24 surgical records.
A review of patient #33's medical record revealed the history and physical was completed at the physician's office on 2/20/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was not timed to know when it occurred. On 2/25/2014 a Laparoscopic Bilateral Tubal Ligation surgery was performed on this patient without an updated history and physical.

A review of patient #34's medical record revealed the history and physical was completed at the physician's office on 2/18/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the procedure room. On 2/25/2014 an Endoscopy procedure was performed on this patient with the updated history and physical after the patient was in the procedure room.

A review of patient #39's medical record revealed the history and physical was completed at the physician's office on 2/10/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and surgery had started. On 2/25/2014 a Micro Suspension Laryngoscopy with Biopsy was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #40's medical record revealed the history and physical was completed at the physician's office on 2/19/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and surgery had started. On 2/25/2014 a Bilateral Myringotomy with ear tubes was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #41's medical record revealed the history and physical was completed at the physician's office on 2/19/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and surgery had started. On 2/25/2014 a Septoplasty was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #42's medical record revealed the history and physical was completed at the physician's office on 2/20/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and surgery had started. On 2/25/2014 a Direct Micro Laryngoscopy was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #43's medical record revealed the history and physical was completed at the physician's office on 2/24/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and surgery had started. On 2/25/2014 an Incision and Drainage Left Neck Abscess was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #44's medical record revealed the history and physical was completed at the physician's office on 2/13/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and the surgery was completed. On 2/25/2014 a Bilateral Myringotomy with ear tubes was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #45's medical record revealed the history and physical was completed at the physician's office on 2/13/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and the surgery was completed. On 2/25/2014 a Bilateral Myringotomy with ear tubes was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #46's medical record revealed the history and physical was completed at the physician's office on 2/13/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and the surgery was completed. On 2/25/2014 a Bilateral Myringotomy with ear tubes was performed on this patient with the updated history and physical after the patient was in the operating room.

An interview with staff member #17 and on 2/25/2014 at approximately 4:30 PM confirmed the above findings from the patient's medical record.

Based on observation and interview, the facility failed to ensure patient care items were stored in a manner to protect them from becoming wet and soiled when the floors are mopped or if a spill occurs. Nine (9) boxes of patient care items were found stored on the floor in the facility' s central supply area.

Findings include:

During a tour of the central supply building on 2/25/14 at 10:00a.m., nine boxes of patient care items were found stored on the floor. Staff #6 confirmed this finding during the tour.

Based on record review, observation, and interview, the facility failed to

A. monitor the results of the biological test indicators.

A review of the record titled, "Daily Biological Test Control Sheet " revealed the 7 of 14 days were not read or recorded with the initial of the staff member.

A review of the policy titled, "Surgery, SURG.00.00.0046, Guide Lines for Gas Plasma Sterilization (Sterrad)" revealed the following:

"5. All items to be sterilized will be recorded on log book; along with: load sticker
(lot #), status of internal indicator (pass/fail), the results of the biological testing, and operator's initials."

A review of the manufacture guidelines, "Attest Biological monitoring System" recommends the following:

"When examining the processed indicator at regular intervals such as 8, 12, 18, 24 and 48 hours, also examine the control indicator for a color change toward yellow (evidence of bacterial growth). Record results and discard indicators in accordance with your healthcare facility's policy. The Attest (Trademark) monitoring system provides separate color coded vials for steam indicators. This one spore per vial system provides the user with the best assurance of sterility. If both indicator organisms are on the same spore strip (e.g., as in a two spores per vial system), a positive growth control could be obtained if incorrect incubation conditions existed (e.g., incubator not functioning, or vials inadvertently incubated at wrong temperature). If the test biological indicator came from a cycle with a sterilization process failure, a false positive control and false negative test would result."

An interview with staff #18 and #23 on 2/26/2014 at approximately 10:00 AM confirmed the above findings.

B. ensure the immediate use steam sterilization autoclave #1, #2, #3, and #4 were being used only for carefully selected clinical situations, such as a dropped instrument or no replacement instrument available. Also the facility failed to complete and record the "Flash Sterilization Log" record per the facility policy.

A review of the record titled, "Flash Sterilization Log" for autoclave #1, #2, #3, and #4 revealed staff members were not placing patient identification stickers on the log. The staff members were filling the log out inconsistently. The log indicated that complete instrument sets were being sterilized in the immediate use autoclave.

A review of the policy titled, "Surgery, SURG.00.00.0046, Guidelines for Immediate Use Sterilization" revealed the following:

"Immediate -Use Steam Sterilization (formerly known as flash sterilization) implies that an item is not wrapped, and will be used during the procedure for which it was sterilized.
a. Should only be used in carefully selected clinical situations, such as a dropped instrument and there is no replacement available.
b. Instruments sterilized using this process are not to be stored for future use.
c. Immediate Steam Sterilization for Use should not be performed on implants, single -use items, devices that have not been validated with the specific cycle employed, and instruments used on patients who may have Creutzfeldt-Jakob disease or similar disorders. Please see AAMI ST79.Annexes for Processing CJD-contaminated patient care items.
d. Gravity sterilizers ran for immediate use sterilization; operate at 270°F/ 32°C for 3 mm and 10 mm with zero or 1 mm dry time."

According to "Perioperative Standards and Recommended Practices, For Inpatient and Ambulatory Settings, (AORN (Association of periOperative Registered Nurses) - 2012 Edition); "Recommendation IV ", page 550:
"Use of flash sterilization should only be kept to a minimum. Flash sterilization should be used only in selected clinical situations and in controlled manner. Flash sterilization should be used only when there is insufficient time to process by the preferred wrapped or container method. Flash sterilization should not be used as a substitute for sufficient instrument inventory."
An interview with staff #19 and #20 on 2/26/14 at approximately 2:00 PM stated, "We are flashing full instrument sets, because we don't have enough sets for some of the surgeons working at the facility."
C. ensure a history and physical was documented on the patient's record and/or an update to the history and physical prior to surgery and/or procedure on 17 (# 24, 25, 27, 29, 30, 31, 32, 33, 34, 39, 40, 41, 42, 43, 44, 45, and 46 ) of 24 records. The facility also failed to follow their own policy on history and physical being completed on the patient's record.
Refer to A0952- History and Physical

Based on record review and interview, the facility failed to ensure a complete history and physical on 1 (# 27) of 15 surgical inpatients' record.
A review of the medical records revealed the following:
Findings:

A review of patient #27's medical record revealed the history and physical was completed at the physician's office on 12/11/2013. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was left blank. On 12/17/2013 a Total Right Knee Replacement surgery was performed on this patient without an updated history and physical.

An interview with staff member #26 on 12/18/2013 at approximately 4:00 PM confirmed the findings from above.



During the follow-up visit on 2/25-26/2014 the history and physical for surgical patients were still found to be out of compliance.


Based on record review and interview, the facility failed to ensure a history and physical was documented on the patient's record and/or an update to the history and physical prior to surgery and/or procedure on 17 (# 24, 25, 27, 29, 30, 31, 32, 33, 34, 39, 40, 41, 42, 43, 44, 45, and 46 ) of 24 records. The facility also failed to follow their own policy on history and physical being completed on the patient's record.
A review of the medical records revealed the following:
Findings from the surgical floor:

A review of patient #24's medical record revealed the history and physical was completed at the physician's office on 12/3/2013. The History and Physical document on the medical record referred to the 12/3/2013 history and physical, in which physician documented " see attached H&P " which was 2 months old and the time was left blank of when the history and physical was completed. On 2/25/2014 a Left Power Port Placement & Right Open Breast Biopsy surgery was performed on this patient without a current history and physical.

A review of patient #25's medical record revealed a history and physical on the record by the admitting physician, but no history and physical or update from the surgeon. On 2/26/2014 an Appendectomy surgery was performed on this patient without a history and physical.

A review of patient #27's medical record revealed no history and physical on the record by the surgeon. On 2/25/2014 an Incision and Drainage procedure was performed on this patient without a history and physical.

A review of patient #29's medical record revealed a history and physical on the medical record from the admitting physician, but not signed. The surgeon performing the surgery had not documented a history and physical or an update to the record prior to surgery. On 2/25/2013 a Total Right Hip Replacement surgery was performed on this patient without an updated history and physical.

A review of patient #30's medical record revealed a history and physical on the record, but had not been signed or electronically signed, dated or timed by the physician. On 2/25/2014 a surgery was performed on this patient without a history and physical.

A review of patient #31's medical record revealed a history and physical on the record by the admitted physician, but no history and physical or update from the surgeon. On 2/21/2014 an Open Appendectomy surgery was performed on this patient without a history and physical from the surgeon.

An interview with staff member #15 and on 2/26/2014 at approximately 4:30 PM confirmed the above findings from surgical floor patient's medical record.

Findings from the Day Surgery Unit:

A review of patient #32's medical record revealed no history and physical on the record by the surgeon. On 2/25/2014 a Small Bowel Capsule Endoscopy procedure was performed on this 99 year old patient without a history and physical.
A review of patient #33's medical record revealed the history and physical was completed at the physician's office on 2/20/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was not timed to know when it occurred. On 2/25/2014 a Laparoscopic Bilateral Tubal Ligation surgery was performed on this patient without an updated history and physical.

A review of patient #34's medical record revealed the history and physical was completed at the physician's office on 2/18/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the procedure room. On 2/25/2014 an Endoscopy procedure was performed on this patient with the updated history and physical after the patient was in the procedure room.

A review of patient #39's medical record revealed the history and physical was completed at the physician's office on 2/10/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and surgery had started. On 2/25/2014 a Micro Suspension Laryngoscopy with Biopsy was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #40's medical record revealed the history and physical was completed at the physician's office on 2/19/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and surgery had started. On 2/25/2014 a Bilateral Myringotomy with ear tubes was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #41's medical record revealed the history and physical was completed at the physician's office on 2/19/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and surgery had started. On 2/25/2014 a Septoplasty was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #42's medical record revealed the history and physical was completed at the physician's office on 2/20/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and surgery had started. On 2/25/2014 a Direct Micro Laryngoscopy was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #43's medical record revealed the history and physical was completed at the physician's office on 2/24/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and surgery had started. On 2/25/2014 an Incision and Drainage Left Neck Abscess was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #44's medical record revealed the history and physical was completed at the physician's office on 2/13/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and the surgery was completed. On 2/25/2014 a Bilateral Myringotomy with ear tubes was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #45's medical record revealed the history and physical was completed at the physician's office on 2/13/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and the surgery was completed. On 2/25/2014 a Bilateral Myringotomy with ear tubes was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of patient #46's medical record revealed the history and physical was completed at the physician's office on 2/13/2014. The History and Physical documentation on the medical record was stamped with a stamp that was written, "H&P Update (Prior to procedure)", but the stamp was timed after the patient was in the operating room and the surgery was completed. On 2/25/2014 a Bilateral Myringotomy with ear tubes was performed on this patient with the updated history and physical after the patient was in the operating room.

A review of record titled, "Medical Record Department, MRD .02.01.0004, Initial Assessment of the Patient (Components History and Physical Examination)" revealed the following:
"The medical history and physical examination is to be completed and documented no more than 30 days before or 24 hours after admission or registration, but for cases involving surgery or procedure requiring anesthesia services, prior to the surgery or procedure. The medical history and physical examination must be placed in the patient ' s medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services."
An interview with staff member #17 and on 2/25/2014 at approximately 4:30 PM confirmed the above findings from the patient's medical record.

A review of the medical records #39 through #46 revealed the writing on the stamped "H&P Update (Prior to procedure)" form, was not the same writing as physician #25. The times on the updated H&P had been marked out and changed.
An interview with staff member #17 and on 2/25/2014 at approximately 4:30 PM confirmed the above findings from the patient's medical record.
Staff #17 was asked why there was a difference in the handwriting and why the times were marked out on the history and physical updates on patient's records #39 through #46. She stated, "She is the physician's employee (#7) from his office. She came and changed the times when we told her the surveyor had noted the times were after the patient had gone to surgery." When asked what her title was, she stated, "I don't know." When asked was she credentialed to write on the charts, she stated, "I don't know."
A review of physician's employee #7 credentialing file revealed employee #7 is a medical assistant. The "Delineation of Privileges" noted the following requirements: "This category of physician's employees may work in the Hospital only under the direct supervision of the physician employer. (Direct supervision is defined as "in the presence of the physician employer.")
Further review of the "Delineation of Privileges" noted in the "Orders" section the following requirements: "Serve as a scribe for the sponsoring physician by recording notes in the Physician Progress Notes (for immediate signature by the physician)."
An interview with staff member #1 and on 2/26/2014 at approximately 3:30 PM confirmed physician's employee #7 should not have been documenting in the medical record without the physician present.