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Tag No.: A0395
Based on clinical record review, interviews and review of hospital documentation for one of three sampled patients (Patient #66) with complaints of pain, the clinical record lacked documentation of a comprehensive assessment. The findings include:
Patient # 66 was seen in the Emergency Department on 12/6/11 at 9:10 PM following two days of nausea, vomiting and diarrhea. Past medical history includes congestive heart failure and hypertension. Physician orders dated 12/6/11 at 9:53 PM directed to administer Tylenol 650 milligrams by mouth. Review of the Emergency Department Record identified that the patient had no complaints of pain upon admission, however, subsequent pain assessment at 10:15 PM identified a pain rating as severe 7/8 on a rating scale of 0-10. Further review of the clinical record identified that pain assessments were completed every 30 minutes between 10:15 PM and 12:30 AM with a continued pain rating of 7/8, however the clinical record failed to provide evidence of medications and /or interventions that were attempted to decrease the patient's level of pain. A review of the hospital pain assessment and management policy identified that documentation of the assessment and management of the pain will be included in the nursing documentation of every clinical area, either in electronic or written form. This documentation would include time, pre intervention assessment, dose administered, route, and reassessment post intervention. Interview and review of the clinical record with Registered Nurse(RN) #12 on 12/14/11 at 2:20 PM identified that Tylenol was administered for complaints of pain, but was not documented in the clinical record . RN#12 further identified that narcotic medications and/or alternative methods could not be utilized for pain control due to the patients unstable condition.
Tag No.: A0441
Based on observation and interview, the facility failed to ensure that patient health records were secured. The finding includes:
During a tour of the Diagnostic Imaging Department, on 12/13/11 from 2:05 P.M. to 2:25 P.M., the clinical records of approximately one hundred patient's was observed to be stored in an unsecured room that opened into the patient waiting area. Interview with the Director of Diagnostic Imaging, on 12/13/11 during the tour, identified that the room has never had a means to be secured.
Tag No.: A0502
Based on observations and interviews, the facility failed to ensure that medications stored in emergency carts were secured and/or access to medications was restricted. The findings include:
a. During tour of the same day surgery area, on 12/13/11 from 9:10 A.M. to 10:40 A.M., an unlocked emergency cart that contained five vials of medications (Nitroprusside, Naloxone, Adrenaline, Adenosine and Amiodarone) was observed to be stored in an unsecured storage area located in a private patient care room. Interview with the Nurse Director of Surgery, on 12/13/11 at 10:15 A.M., identified that the emergency cart should be locked.
b. During a tour of the central sterile department, on 12/13/11 from 10:43 A.M. to 11:25 A.M., identified that on arrival staff was not present in the department and the office door was ajar. Located in the office was an unlocked emergency cart containing a medication tray including multiple vials of Adenosine, Amiodarone, Benadryl, Dobutamine, Epinephrine, Etomidate, Vasopressin, Magnesium Sulfate, Lopressor, Naloxone, Nitroprusside, Norepinephrine and Flumazenil. Unlicensed central supply technicians had access to these medications during the cart re-stocking process. Interview with the Nurse Director of Surgery, on 12/13/11 at 11:00 A.M., identified that the office door and the emergency cart should be locked, however, unlicensed staff routinely had access to the medications located in the emergency carts during the re-stocking process.
Tag No.: A0959
Based on a review of clinical records, interview and review of documentation for two of six patients (Patients # 86 and 88) that had a procedure, the facility failed to ensure that the medical provider completed an operative note. The findings include:
a. Patient #86 was admitted on 12/14/11 for a colonoscopy procedure. Review of the clinical record failed to reflect that the physician had completed an operative report after completing the procedure.
b. Patient #88 was admitted on 12/14/11 for an esophagogastroduodenoscopy and colonoscopy procedures. Review of the clinical record failed to reflect that the physician had completed an operative report after completing the procedure.
Interview with the Nurse Manager, on 12/14/11 at 10:28 A.M., identified that operative reports for these patients were not present in the clinical records.
Review of the Medical Staff By-Laws Rules and Regulations, adopted 11/3/10, identified that a brief note to summarize the operative procedure is completed after the procedure/surgery.