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Based on facility policy review, record review, and interview, the facility failed to provide written grievance resolution within a reasonable timeframe to patients and/or families filing a complaint/grievance for three (Patients #67, #68 and #69) of seven grievances reviewed. The facility census was 239.

Findings Included:

1. Review of the facility policy titled "Patient Rights and Responsibilities," approved 11/19/09, showed the following (in part): "The patient has the right to: Voice concerns without discrimination regarding quality of care or services, and to expect those concerns to be addressed immediately according to the hospital grievance policy, or to be referred to the appropriate state agency."

Review of the facility policy titled "Patient Grievance Policy," showed the following (in part):
- "Patient and Visitor Relations will send the patient a letter or return e-mail within two business days acknowledging the grievance, explaining the process/steps, time frames and alternatives for resolving the grievance."
- "After reviewing the grievance process with the patient, the Patient and Visitor Relations Department will, whenever possible, resolve the issue immediately by providing information/answers. If this cannot happen, a written summary of the grievance will be prepared by Patient and Visitor Relations and forwarded for follow-up to the appropriate department manager/administrator within two business days of receiving it."
- "The department(s) or individual(s) named in the grievance usually will have three business days to respond in writing to Patient and Visitor Relations with their findings and action plans. For more complicated issues, departments may request additional time, in which case Patient and Visitor Relations will contact the patient in writing to advise of and extended date of completion."
- "The patient will be notified by Patient and Visitor Relations of the findings or recommended action plan by letter within two business days of receiving the response."

2. Review on 05/20/10 at 10:55 a.m. of a grievance filed by Patient # 67 showed the following:
- Patient #67 filed a complaint/grievance with the facility on 04/26/10 by email.
- The Director of Patient and Visitor Relations staff TT contacted the patient on 04/26/10 to discuss the allegations.
- The appropriate manager completed an investigation on 04/29/10.
- A resolution letter was sent on 05/04/10, eight days after the complaint/grievance was lodged.

Review on 05/20/10 at 11:00 a.m. of a grievance filed by Patient # 68 showed the following:
- Patient #68 filed a complaint/grievance with the facility on 04/18/10 by mailing a letter to the CEO of the hospital.
- The Director of Patient and Visitor Relations staff TT was forwarded the complaint after approximately twenty-three days, and contacted the patient on 05/12/10.
- The complaint was still under investigation on 05/20/10, thirty-three days after the complaint/grievance was lodged.
- There is no evidence that the patient was notified of a delay in the investigation process.

Review on 05/20/10 at 11:15 a.m. of a grievance filed by Patient # 69 showed the following:
- Patient #69 filed a complaint/grievance with the facility on 04/26/10.
- The appropriate manager completed an investigation on 04/26/10, however the manager investigated only one of two allegations.
- A resolution letter was sent on 05/11/10, sixteen days after the complaint/grievance was lodged.

3. During an interview on 05/20/10 at 11:30 a.m., Director of Patient and Visitor Relations staff TT said the following:
- There was a delay in receiving the written complaint for Patient #68 because it went to the CEO rather than being forwarded to the appropriate office for a response.
- When complaints are assigned to managers for investigation, staff TT expects "a timely response," but there is no mechanism in place to assure that investigations and responses are completed within the guidelines specified by policy.
- There was a delay in providing a written response to Patient #69 due to other obligations that took priority over this task.

Based on observation, interview, and record review, the facility failed to ensure signs were posted to inform the public of the usage of one of two Physician Assistants sampled (Staff QQ) in the hospital owned clinic and failed to ensure informed consent was obtained prior to the procedure for two (Patient #42 and Patient #35) of five patients' records reviewed for informed consent. The hospital census was 239.
Findings included:
Review of the facility policy titled, "Informed Consent", revised 07/09, gave direction, in part, to include the following:
"The performing physician is responsible for obtaining the patient's informed consent prior to the treatment or procedure."
"Elements of Informed Consent for treatment or procedure:"
"Date and time of the patient, witness and physician signature."
"It is the legal responsibility of the physician performing the procedure to make certain the Consent Form is accurately completed, signed, dated and timed and initialed by the patient, witness and physician."
"Members of the Department of Anesthesia are responsible for explaining the risks, benefits, and alternatives for anesthesia any time a member of this department is assigned care of a patient. This is documented on the consent form in the Anesthesia declaration and the patient/patient representative signature, date and time is obtained. The Anesthesia physician then signs, dates and times in acknowledgement."

Review of the facility policy titled, "Patient Rights and Responsibilities", reviewed 08/09, gave direction, in part, to include the following:
"The patient has the right to:" "Information necessary for the patient or authorized representative to give informed consent before any procedure or treatment."

During an observation on 05/18/10 at 10:05 A.M. at the hospital owned Gastroenterology, Hematology, and Transplant clinic there is no sign found to inform patients the clinic utilizes physician assistants.
During an interview on 05/18/10 at 9:30 A.M. Gastroenterology, Hematology, and Transplant clinic Practice Manager said the clinic utilizes the services of two Physician Assistants.
Review of the collaborative agreement for Physician's Assistant (PA), Staff QQ, showed the following requirement in section 3.6-Physician Assistant (PA) shall not be used in any office of a physician or in a clinic or hospital unless a notice stating that a physician assistant is utilized is posted in a prominent place in such office, clinic, or hospital.







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Review of current Patient #42's medical record showed a document titled, "Special Informed Consent to Surgery or Other Procedure - Electroconvulsive Therapy (ECT [electric shock therapy used for some psychiatric conditions]) - Up to 24 Treatments". The physician and anesthesiologist's signatures were dated 05/05/10 but were not timed making it impossible to determine if the physician and anesthesiologist signed before or after the procedure. Additional record review showed the patient had ECT on 05/05/10, 05/07/10, 05/12/10, and 05/17/10.


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Review of current Patient #35's medical record on 05/18/10 at 11:45 a.m. showed a document titled, "Special Informed Consent for Endoscopy Procedure Esophagogastroduodenoscopy (EGD)". (A diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract up to the duodenum). The physician and anesthesiologist signatures were dated 0512/10, but were not timed. It is not possible to tell if the physician and anesthesiologist signed before or after the procedure.

Based on facility policy review, observation, and interview, the facility failed to protect patient's rights to privacy by placing patient names in public view on twelve patient care units of twenty patient care units. The facility census was 239.
Findings included:

1. Review of the facility's policy titled, "Patient Rights and Responsibilities", reviewed 08/09, gave direction, in part, to include the following:
"Confidentiality of all clinical records and communication to the extent permitted or required by law."

Review of the facility's policy titled, "Confidentiality - Use and Access of Information", reviewed 11/08, gave direction, in part, to include the following:
"Purpose
To protect confidentiality and proprietary information from breach, misuse, invasion of privacy or mishandling by a person inside or outside the organization."
"Confidential information includes, but is not limited to the following:
a. Patient's name, if restricted, diagnosis, records, test results, medical procedures, bills, knowledge of litigation, or like information."

2. Observation on 05/17/10 at 2:30 P.M. in the Cardiology ICU (Intensive Care Unit), 9 ICU, showed a white eraser board at the nurses' station and was positioned where it could be viewed by the public. The board contained the last names and room number of all 10 patients in the unit.

3. Observation on 05/17/10 at 3:25 P.M. in the Neurological ICU, 5 ICU, showed a white eraser board at the nurses' station and was positioned where it could be viewed by the public. The board contained the last names and room number of all 13 patients in the unit. At 3:45 P.M. in the same unit, a second white eraser board was noted at a nurses' station at the other end of the unit. The second board also contained the last names and room number of all 13 patients in the unit and was positioned where it could be viewed by the public. An observation on 05/18/10 at 10:27 A.M. in the same unit showed the two white eraser boards with the first three letters of the patients' last names and their room number. This affected 13 patients in the unit.

4. Observation on 05/18/10 at approximately 1:45 P.M. in the Adult Psych unit, 4 West, showed a white eraser board in the hallway across from the nurses' station and was positioned where it could be viewed by the public. The board contained the first name and room number of all 20 patients on the unit.

5. Observation on 05/19/10 at 9:40 A.M. in the Physical Medicine and Rehabilitation department showed a clipboard at the counter next to the entrance door for outpatients to sign upon arrival. The sign-in sheet showed the first and last name of two patients.

During an interview with the Director of Physical Medicine and Rehabilitation, staff FF, confirmed the sign-in sheet showing the names of two patients should have been removed or covered to protect the names of patients.


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6. Observation on 05/17/10 at 2:30 p.m. of the Orthopedic unit, 6 South, showed patient last names visible on medical charts lying on counters in the nursing station and in the chart rack. The names were easily readable from 15 feet away to any patients or visitors to that unit.
7. Observation on 05/19/10 at 8:35 a.m. of the Medical Intensive Care Unit, 8 ICU, showed a white board listing the last names of all nine patients on that unit. The white board was visible to any patients or visitors to that unit.
8. Observation on 05/19/10 at 9:30 a.m. on the Abdominal Transplant unit, 7 North, showed patient last names visible on medical charts lying on counters in the nursing station and in the chart rack. The names were easily readable from 15 feet away to any patients or visitors to that unit.
9. Observation on 05/19/10 at 09:45 a.m. on the Neurology/ENT unit, 5 North, showed a white board listing the first three letters of patient last names who were on that unit. The white board was visible to any patients or visitors to that unit. Additionally, patient last names were visible on medical charts lying on counters in the nursing station and in the chart rack. The names were easily readable from 15 feet away to any patients or visitors to that unit.
10. Observation on 05/19/10 at 10:30 a.m. on the Neurosurgery floor showed patientlast names visible on medical charts lying on counters in the nursing station and in the chart rack. The names were easily readable from 15 feet away to any patients or visitors to that unit.


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11. Observation on 05/18/10 at 10:00 a.m. on 9 North showed patient charts with the patient's last name lying on counters in the nursing station and in the chart rack. The names were readable from the nursing station to patients and visitors.
12. Observation on 05/17/10 at 2:10 p.m. on 8 North showed patient charts with the patient names lying on counters in the nursing station and in the chart rack. The names were readable from the nursing station to patients and visitors.
13. Observation on 05/17/10 at 2:10 p.m. on 8 South showed patient charts with the patient names lying on counters in the nursing station and in the chart rack. The names were readable from the nursing station to patients and visitors.

Based on facility policy review, observation and interview facility staff failed to ensure patient medical information was secured to prevent unauthorized access for patients in the mammography (X-ray exam of breast tissue to investigate lumps in the breast) unit, and for patients on the 8 North and 9 North nursing units (Patients #3, #35, #36, #37, #38). The facility census was 239 patients.

Findings included:

1. Review of the facility's policy titled, "Patient Rights and Responsibilities", reviewed 08/09, and gave direction, in part, to include the following:
"Confidentiality of all clinical records and communication to the extent permitted or required by law."

Review of the facility's policy titled, "Confidentiality - Use and Access of Information", reviewed 11/08, and gave direction, in part, to include the following:
"Purpose
To protect confidentiality and proprietary information from breach, misuse, invasion of privacy or mishandling by a person inside or outside the organization."
"Confidential information includes, but is not limited to the following:
a. Patient's name, if restricted, diagnosis, records, test results, medical procedures, bills, knowledge of litigation, or like information."

2. Observation on 05/17/10 at 4:30 P.M. in the Mammography Unit showed Open bins above physician work area containing file folders of previous mammograms, with the radiology report, patient name and patient date of birth. Housekeeping personnel observed in the unit during observation.

3. During an interview on 5/17/10 at 4:30 P.M. with the Staff M Director of Imaging, Staff M confirmed the observation of the unsecured X-ray folders.


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4. Observation on 05/18/10 at 11:00 a.m. on 8 North showed an Intake and Output record in a folder on the outside of Patient #3's door. This document included the patient's full name and birth date, and was accessible to anyone on the nursing unit.
On 05/18/10 at 11:15 a.m. Staff H, Registered Nurse Manager confirmed that these records are kept on the patient doors.
5. Observation on 05/18/10 at 1:00 p.m. on 9 North showed Intake and Output records placed in a folder on the outside of the door of the bathroom in the patient rooms for Patient #35, #36, #37, and #38. This document included the patients' full name and birth date, and was accessible to anyone on the nursing unit.
On 05/18/10 at 1:30 p.m. Staff WW, Registered Nurse Manager confirmed that these records are kept on the patient doors.

Based on observation, record review and interview, the facility failed to ensure physician orders were obtained for the use of restraints on three (Patient #18, #19, and #20) of six patients observed in restraints. The facility census was 239.

Findings included:

1. Review of the facility's policy titled, "Restraints", revised 04/09, gave direction, in part, to include the following:
"Each patient has the right to receive care in a safe setting which provides protection for the patient's emotional health and safety as well as his/her physical safety."
"Documentation (All actions taken regarding restraint and/or seclusion must be documented in the patient's medical record)."
"Authorization for restraint application and relevant orders for use."
"Restraint is initiated only upon the order of a physician. The order is time-limited not to exceed 24 hours and includes the specific reason for the intervention."
"If restraint continues to be clinically justified, continued use of restraint beyond the first 24-hours must be authorized by the physician. Restraint orders must be renewed on a daily basis not to exceed 24 hours."
"Restraint orders must be dated and timed when signed by physician ..."

Review of the facility's policy titled, "Patient Rights and Responsibilities", revised 08/06, gave direction, in part, to include the following:
"The patient has the right to:"
"Be free from any medically unnecessary restraints or seclusion."

2. Observation on 05/17/10 at 3:30 P.M. showed Patient #18 in bed with a soft wrist restraint on his/her left wrist.

Review of Patient #18's medical record on 05/17/10 at 3:35 P.M. showed the following documents titled, "Non-behavioral Restraint Order":
- On 05/11/10, the physician signed and dated the order but the signature was not dated.
- On 05/12/10, no physician order was found.
- On 05/13/10, the physician signature was not dated or timed.
- On 05/14/10, the physician signature was not dated or timed.
- On 05/15/10, the physician signature was not dated or timed.
- On 05/16/10, no physician order was found.

During an interview on 05/17/10 at 3:45 P.M., Nurse Manager, staff R, confirmed the above and stated that Patient #18 had restraints on since 04/24/10. Staff R stated they obtain their orders for restraints at 11:30 P.M.

3. Review of current Patient #19's medical record on 05/18/10 at 9:35 A.M. showed that the patient was wearing soft wrist restraints to both wrists. The document titled, "Non-behavioral Restraint Order", dated 05/17/10 by the RN (Registered Nurse) was signed by the physician but the signature was not dated or timed.

Observation of Patient #19 on 05/18/10 at 10:25 A.M. showed the patient in bed with soft wrist restraints to both wrists.

During an interview on 05/18/10 at approximately 9:40 A.M., Nurse Manager, staff R, stated that Patient #19 had been in restraints since he/she returned from surgery on 05/17/10.

4. Observation of Patient #20 on 05/18/10 at 10:30 A.M. showed the patient with a bulky mitten on his/her right hand. The bulky mitten prevented the patient from using his/her right hand.

Review of Patient #20's medical record on 05/18/10 at approximately 10:45 A.M. showed a document titled, "Non-behavioral Restraint Order", signed by the nurse on 05/17/10 at 7:00 P.M. The physician signature was dated 05/17/10 but was not timed. Nursing documentation showed that Patient #20's restraint was removed on 05/17/10 at 3:00 A.M. and re-applied at 7:00 P.M.

Based on record review and interview, the facility failed to ensure one of three patients (#33) sampled with skin breakdown received photographic documentation of wounds in a timely manner; the facility failed to to follow the facility's internal policy regarding peripheral intravenous catheter maintenance for two patients (Patient #6, and Patient #37), and failed to follow the facility policy regarding central venous catheter maintenance care for one patient (Patient #3). The hospital census was 239.

Findings included:
Review of the facility policy titled "Skin Care: Tissue and Pressure Ulcer Assessment and Management", dated as effective 1/10, states in part the following: ...Obtain photo documentation of any new wound (s) and/or change in existing wound (s) and place on Photographic Wound Documentation form. Photograph wound (s) at discharge and document on the Photographic Wound Documentation form.
Medical record review for Patient #33, age 48, showed admission to the hospital on 04/30/10 after a motor vehicle accident. Review of the initial nursing assessment did not show any skin breakdown and the Braden score is documented as 10 (18 or less=at risk for skin breakdown).
Left coccyx fold:
Review of the document titled "Nursing Wound Care Flowsheet" (used by nursing to document skin breakdown) showed the following skin breakdown:
05/05/10-Wound type-0, length 4"x width 6", no stage, Periwound Tissue (wound edges) described as series of blisters popped and unpopped. No photo taken.
05/06/10-Nothing documented
05/07/10- Wound type-0, , no measurement, no stage, Periwound Tissue (wound edges) described as open blisters. No photo taken.
05/08/10-Wound type-0, length 4"x width 6", ? stage, Periwound Tissue (wound edges) described as popped blisters. No photo taken.
05/09/10-Wound type-0, length 4"x width 6", ? stage, Periwound Tissue (wound edges) described as same. No photo taken.
05/10/10-Wound type-P (Pressure ulcer), length 4"x width 6", stage II (Stage II is defined as the skin blisters or forms an open sore. The area around the sore may be red and irritated), Periwound Tissue (wound edges) described as series of blisters popped and unpopped. Photo taken by the wound nurse.
Right buttocks/hip:
05/07/10-Wound type-Excoriation and blisters that are redden, length 6 centimeters (c.m.) x width 0.5c.m., ? stage, Periwound Tissue (wound edges) described as inflamed and macerated. No photo taken.
05/08/10- Wound type-Excoriation and blisters that are redden, length 6 centimeters (c.m.) x width 0.5c.m., ? stage, Periwound Tissue (wound edges) described as inflamed and macerated. No photo taken.
05/09/10- Wound type-Excoriation and blisters that are redden, length 6 centimeters (c.m.) x width 0.5c.m., ? stage, Periwound Tissue (wound edges) described as inflamed and macerated. No photo taken.
05/10/10- Wound type-Excoriation and blisters that are redden, length 6 centimeters (c.m.) x width 0.5c.m., ? stage, Periwound Tissue (wound edges) described as inflamed and macerated. Photo taken by the wound nurse.
During an interview on 05/17/10 at 3:00 P.M. Registered Wound Care Nurse said pictures are to taken on admission if there is skin breakdown, pictures at discharge if there is skin breakdown, and pictures whenever there is a change in the skin condition or new skin breakdown. Registered Wound Care Nurse said that he/she did not see Patient #33 until 05/10/10 due to the patient not being in the room when he/she visited. Based on the fact the patient had blisters/excoriation he/she would probably have taken pictured when the wounds were discovered.




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The facility policy titled, "Intravenous Therapy: Vascular Access Device Care and Maintenance", effective date February 2007 and last revised 04/10 states on page 10 under the heading of peripheral catheters, "Place date and time of dressing change and size and gauge of catheter directly on dressing". The policy states on page 13 under the heading of central venous catheters, "Place date and time of dressing change and size of and guage of catheter directly on dressing".

An interview with Patient #37 on 05/18/10 at 9:00 a.m. on 9 North showed a peripheral intravenous (a catheter placed into a peripheral vein in order to administer fluids and/or medications) dressing with no date or time in the patient's right arm.

An interview with Patient #6 on 05/17/10 at 2:30 p.m. on 8 South showed a peripheral intravenous dressing with no date or time in the patient's left arm.

An interview with Patient #3 on 05/17/10 at 3:30 p.m. on 8 North showed a central venous catheter (a catheter placed into a large vein in the neck, chest, or groin used to administer medications and/or fluids) dressing with no date or time in the patient's upper left chest.

Staff H, Registered Nurse Manager on 8 North said during an interview on 05/17/10 at 4:00 p.m. that it is facility policy to date and time the dressings on peripheral and central line dressings.

Based on policy, record review, and interview, the facility failed to identify and/or update the nursing plan of care for two (Patient #17 and #19) of 28 current patients' medical records reviewed. The facility census was 239.

Findings included:

1. Review of the facility's policy titled, "Care Planning", revised 06/09, gave direction, in part, to include the following:
"The RN (Registered Nurse) retains the ultimate responsibility for initiating, developing, evaluating, and revising each patient's care plan."
"A Patient Care Plan is printed and signed every 12 hours."

2. Review of current Patient #17's medical record on 05/17/10 showed he/she was admitted on 05/15/10 for a stroke. The initial nursing assessment identified him/her as being high risk for falls. Review of the document titled, "Patient Plan of Care", showed no care plan for the risk of falls.

During an interview on 05/17/10 at 2:40 P.M., Nurse Manager, 9 ICU (Intensive Care Unit), staff VV, stated that he/she would expect to see Patient #17's plan of care to include risk for falls. Nurse Manager, staff O, confirmed there was a care plan option that could have been selected for potential injury from falls.

3. Review of current Patient #19's medical record on 05/18/10 showed he/she was admitted on 05/13/10. Review of the patient's plan of care showed only one review completed on 05/16/10.

During an interview on 05/17/10, Nurse Manager, staff O, stated that the plan of care is updated every 12-hour shift.

Based on observation, facility policy review and interview, facility staff failed to follow facility policy with regard to administering medication via Intravenous (a line directly into a vein) push (IVP) for one (Patient #43) of one patient observed receiving medication via IVP. The census at the time of the survey was 239 patients.

Findings include:

1. The facility medication guideline states:
DOSAGE AND ADMINSTRATION
The recommended adult dose is either 20 or 40 milligrams (mg) esomeprazole (Nexium-treatment for esophagitis - inflammation of the tube from the back of the mouth to the stomach) given once daily by IVP injection (no less than 3 minutes).

2. During observation of medication administration to Patient #43 on 05/19/10 at 09:30 A.M., showed staff Y, Registered Nurse (RN) administer IVP Nexium 40 mg in 15 seconds.

Interview with Staff Y after the medication administration revealed, believe gave over at least 30 seconds.

Based upon record review, interview, and review of policies, the nursing staff failed to have complete record content in regards to documentation of weight documentation for one (#50) of one reviewed for weight documentation; and for intake of nutritional supplements for one (#50) of one case reviewed for nutritional supplement consumption The facility census was 239.
Finding included:
1. During interview on 05/18/10 at 3:30 P.M., the Nurse Manager for the contracted service for dialysis, Employee XX stated the policy for the contracted services for dialysis by the DaVita Corporation expect the staff to weigh each patient before and after dialysis treatments.
2. Record review for Patient #50, showed on the dialysis treatment sheet for 05/14/10 documentation that the patient weight recorded before treatment on 05/14/10 was documented as " bed " ; and the weight after the same treatment was recorded as " no scale " .
3. Record review for patient #50, currently admitted since 04/19/10, showed the physician order sheet to require provision of Nova Source Renal nutritional supplement. The graphic documentation by nursing staff for meals indicated a meal intake range of 30-50% of meals.
On 05/06/10, the Registered Licensed Dietitian documented recommendation of a change to Boost supplement to be served three times per day. Further review of this same medical record showed no documentation of the amount of nutritional supplements consumed.

Based on policy and record review, the facility failed to ensure physicians and patients dated and timed consents for the administration of blood and blood products for three of sixteen sampled patients (current patient #33 and discharged patient #22 & #26). The facility census was 239.

Findings Included:

Review of the facility policy titled "Informed Consent", dated as revised 7/09, states in part the following instructions: The elements a valid informed consent include disclosure of the following information: #9-Date and time of the patient, witness, and physician signature.

Current patient #33 record review, age 48, showed a surgical procedure of Application of an External Fixator right upper extremity on 05/02/10. The form titled "Informed Consent for the Transfusion of Blood and/or Blood Components is dated 05/01/10, but not timed by the physician. Without a time it is unknown if the form was completed prior to the patient's procedure.

Discharged record review for patient #22, age 53, showed a surgical procedure for removal of Gallbladder on 04/13/10. Review of the form titled "Informed Consent for the Transfusion of Blood and/or Blood Components is undated and untimed by the patient and physician. Without a time it is unknown if the form was completed prior to the patient's procedure.

Discharged record review for patient #26, age 39, showed a surgical procedure of Left Nephrectomy (removal of a kidney) on 04/14/10. Review of the form titled "Informed Consent for the Transfusion of Blood and/or Blood Components is undated and untimed by the patient. Without a time it is unknown if the form was completed prior to the patient's procedure.

Based on record review, the facility failed to ensure physicians authenticated orders and order sets with date and time for nine of sixty-nine patients (patient #21, #22, #23, #25, #26, #27, #29, #30, #32) sampled as required by facility policy. The facility census was 239.
Findings included:
1.Review of the policy titled " Chart Completion " (Hospital), " B. Hospital Implementation states in part the following: 1. It is the responsibility of any clinicians/ staff members / individuals who make a chart entry, dictate a report for transcription, or give a verbal order to authenticate that item within the medical record within a timely manner. If an individual other than the attending physician dictates a report, the report must identify the person providing the dictation, the dictating party is not required to sign the report (e.g. " dictated by John Hones for William Smith, MD " ). Authentication requirements are not restricted to physicians. These requirements apply to all individuals making entries in the medial record (e.g., physical therapists, recreational therapists, nursing staff.) "
2. Discharged record review for patient #21, age 48, showed a surgical procedure of Excision of left breast cyst and possible right breast cyst excision on 03/29/10. Review of the physician's order set titled "Ambulatory Care Unit Post-Op (operative) Orders" (order set used in the post anesthesia care unit area), "Surgical Prophylaxis Orders" (used to order prophylaxis antibiotics), and Post Anesthesia Care Unit Orders all showed the physician signed the orders, however, there was no date or time to indicate when the physician signed the three order sets.
Discharged record review for patient #22, age 53, showed a surgical procedure for removal of Gallbladder on 04/13/10. Review of the physician's order set titled "Intravenous Patient Controlled Analgesia (PCA) Order Form" (order set used to order pain medication for patient controlled pump), "Ambulatory Care unit Admission Orders" (order set used in the post anesthesia care unit area), "Surgical Prophylaxis Orders" (used to order prophylaxis antibiotics), and Post Anesthesia Care Unit Orders all showed the physician signed the orders, however, there was no date or time to indicate when the physician signed the four order sets.
Discharged record review for patient #23, age 31, showed a surgical procedure for Bilateral Tympanostomy with tube placement (is a small tube inserted into the eardrum in order to keep the middle ear aerated for a prolonged period of time, and to prevent the accumulation of mucus in the middle ear) on 04/13/10. Review of the physician's order set titled "Ambulatory Care Unit Post-Op (operative) Orders" (order set used in the post anesthesia care unit area) showed the physician signed the orders, however, there was no date or time to indicate when the physician signed the order set.
Discharged record review for patient #25, age 39, showed a surgical procedure of Wide Excision of Right Scapula (shoulder blade) Melanoma (cancer), Lymph Node Dissection on 04/13/10. Review of the physician's order set titled "Surgical Prophylaxis Orders" (used to order prophylaxis antibiotics) showed the physician signed the orders, however, there was no date or time to indicate when the physician signed the order set.
Discharged record review for patient #26, age 39, showed a surgical procedure of Left Nephrectomy (removal of a kidney) on 04/14/10. Review of the physician's order set titled "Surgical Prophylaxis Orders" (used to order prophylaxis antibiotics), and Post Anesthesia Care Unit Orders all showed the physician signed the orders, however, there was no date or time to indicate when the physician signed the two order sets.
Discharged record review for patient #27, age 48, showed a surgical procedure of Excision of right hip mass on 04/13/10. Review of the physician's order set titled "Ambulatory Care Unit Post-Op (operative) Orders" (order set used in the post anesthesia care unit area) showed the physician signed the orders, however, there was no date or time to indicate when the physician signed the order set.
Discharged record review for patient #29, age 60, showed a surgical procedure of Left Cataract Removal with Lens implanted on 04/13/10. Review of the physician's order set titled "IV (intravenous) and Medication Order Sheet" and "Outpatient Surgery Physician Discharge Orders" showed the physician signed the orders, however, there was no date or time to indicate when the physician signed the two order sets.
Discharged record review for patient #30, age 58, showed a surgical procedure of Right Arthroscopic Should Repair on 04/15/10. Review of the physician's order set titled "Ambulatory Care Unit Post-Op (operative) Orders" (order set used in the post anesthesia care unit area), "Surgical Care Infection Prevention (SCIP) Orders" (used to order prophylaxis antibiotics), and Post Anesthesia Care Unit Orders all showed the physician signed the orders, however, there was no date or time to indicate when the physician signed the three order sets.
Discharged record review for patient #31, age 32, showed a surgical procedure of Left Arthroscopic Shoulder Repair on 04/15/10. Review of the physician's order set titled "Surgical Prophylaxis Orders" (used to order prophylaxis antibiotics), and Post Anesthesia Care Unit Orders all showed the physician signed the orders, however, there was no date or time to indicate when the physician signed the two order sets.

Based on the facility's Rules and Regulations and record review, the facility failed to ensure telephone and verbal orders were signed by a physician with 48 hours for two patient (Patient #8 and Patient #3) of 69 medical records reviewed. The facility census was 239.
Findings included:
1. Review of the facility's policy titled "Verbal/telephone Order Read-Back Verification," approved 01/28/10, showed the following (in part): "The physician/physician assistant/nurse practitioner giving the verbal/telephone orders reviews and countersigns them within 48 hours of giving the orders."
2. Review of current Patient #8's medical record on 05/18/10 at 10:15 a.m. showed a physician order dated 05/15/10 stating "OK to use DHT (for meds)." {The meaning of DHT is uncertain.} order is signed by the physician, but not dated or timed.



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3. Review of current Patient #3's medical record on 05/17/10 at 3:45 p.m. showed a physician order dated 05/05/10 that said to change the PCA settings to PCA dose = 0.5 mg., rate = 2mg. an hour, lockout = ten minutes with one hour limit = 3mg. (Dosage for pain medication through an infusion pump). The order is signed by the physician, but not dated or timed.

Staff H, Registered Nurse Manager confirmed this at the time of the medical record review.

Based on facility policy review and record review, the facility failed to ensure staff properly documented informed consent prior to a blood transfusion for one patient (Patient #1) of 20 medical records reviewed for consent for blood transfusion. The facility census was 239.
Findings included:
1. Review of the facility policy titled, "Transfusion of Blood Components," last revised 04/09, showed the following (in part):
- "Signed written informed consent for transfusion of blood components must be obtained from the patient or the patient's representative (if the patient is not able to give consent)."
- "The physician should explain the risks and alternatives of transfusion to the recipient or responsible family member and document in the medical that this has been done."
- "The nurse caring for the patient is responsible for ensuring that the appropriate consent form is completed, signed, and placed in the patient's medical record."

Review of the facility policy titled, "Informed Consent," approved 09/24/09, showed the following (in part):
- "Elements of Informed Consent for treatment or procedure: Date and time of the patient, witness and physician signature."
- "Written informed consent is required for inpatients and outpatients having diagnostic and/or therapeutic interventions, to include, but not limited to: Invasive and surgical procedures, use of investigational drugs, emergency department treatment, administration of blood and/or blood components, chemotherapy agents, ambulatory care, anesthesia, conscious or moderate sedation, unless otherwise specified in this policy."
- "The consent form spaces and/or boxes will be completed, legibly using black or blue ink. The patient's first and last name shall be on the consent form."
- "For inpatients receiving recurrent and/or successive planned treatments/therapy/procedures (e.g., blood/blood component transfusions, hemodialysis, chemotherapy, etc.), the consent form is valid for the entire hospitalization unless the patient or patient's representative revokes the consent.
- "It is the legal responsibility of the physician performing the procedure to make certain the Consent form is accurately completed, signed, dated and timed and initialed by the patient, witness and physician."

2. Review of current Patient #1's medical record on 05/17/10 at 4:05 p.m. showed a form titled, "Informed Consent for the Transfusion of Blood and/or Blood Components." The consent was signed by the patient, but there is no documentation of date or time. At the bottom of the consent form there is a statement: "I certify that I have explained to the above individual the nature, purpose, risks and potential benefits of the above procedure and I have answered any questions that have been raised." The physician signed the statement, but did not date or time the signature.

Based upon record review and interview, the physician discharge summary of acute admissions failed to be completed within the required time frame of 30 days past discharge for three (#14, 13, 56) of seven cases reviewed. The current census in the hospital was 239.
Finding included:
1. Record review for Patient #14, admitted from 01/30-01/02/10, showed the recorded physician discharge summary signed by the dictating Fellow (student) physician on 03/09/10; and by the attending physician on 03/12/10, which is more than the required 30 day past discharge limitation for record completion.
2. Record review for Patient #13, admitted from 03/17-03/18/10, showed the recorded physician discharge summary signed by the attending on 04/29/10, which is more than the required 30 day past discharge limitation for record completion.
3. Record review for Patient #56, admitted 03/15-03/18/10, showed the recorded physician discharge summary signed by the attending physician on 04/23/10, which is more than the required 30 day past discharge limitation for record completion.
4. During interview on 05/18/10 at 10:00 A.M., the Director of Medical Records, Employee AAA, stated that the delinquent chart count is about 21%.

Based upon observation, interview and review of facility documents, the facility failed to have:
-specific policies for the meal service to outpatients kept overnight at Anheuser-Bush Institute (ABI) ; cross refer to A620.
-quality monitoring for the meal service to outpatients kept overnight at ABI; cross refer to A620.
-nutritionally adequate menu plans, including menu nutrient analysis for the meal service to outpatients kept overnight at ABI; cross refer to A628.
-staff with knowledgeable access to the approved diet manual for the meal service to outpatients kept overnight at ABI; cross refer to A620.
-safe and sanitary practices for food production and service at the main kitchen to include:
-hair covering.
-policy and process to check surface temperature of items to be sanitized by the dishmachine.
At the ABI kitchen:
-clean floors.
-stove, grill and hood area free of excess grease collection; cross refer to A620.

The cumulative results of these findings resulted in the overall non-compliance with CFR 482.28, Condition of Participation: Food and Dietetic Services.

Based upon observation, interview and review of facility documents, the facility failed to:
-have consistent hair covering for employees at the main campus kitchen.
-have adequate system in place to monitor the sanitizing hot water temperature for the dishwasher at the main campus kitchen.
-had no policy to provide detail instructions for the procedure of serving patients at the ABI Outpatient Surgery area.
-maintain safe and sanitary practices for food production and service at the Anheuser Busch Institute (ABI) cafeteria kitchen, which serves any patient needing to stay overnight for recovery.
-had no quality assurance, performance improvement monitors in place for the preparation and service of patient meals at the ABI.
The current census at the hospital was 239; and the total number of patients who were kept overnight at the ABI since 01/01/10 has been 15 patients.
Finding included:
During the kitchen tour at the main hospital kitchen on 05/17/10 at 2:00 P.M., and on 05/19/10 at 11:00 A.M. the following observations were made:
-the dishwasher employee who loaded the dishmachine, Employee YY, had shoulder length hair; and had a hairnet covering only the top crown of his/her head.
-the trayline hot beverage server employee, Employee ZZ, had very short hair; and had no hairnet to cover.
-Registered, Licensed Dietitian, Employee EE, had hair extending beyond the hairnet covering.
-Food Service Retail Manager, Employee E , had hair extending beyond the hairnet covering.
-Observation on 05/17/09 at 2:30 P.M., showed the process of testing the dishwasher with a temperature sensitive test tape produced negative results. The test was repeated with the second test run through the dishmachine four times. Neither test tape turned color, as would be the indication of adequate dish sanitation at 160 degrees Fahrenheit (F).
During interview on 05/17/09 at 2:30 P.M., the Chef, Employee D, stated the kitchen procedure was to record the temperatures on a clip-board log as indicated by the temperature dials on the dishmachine. Review of the temperature log showed complete data with all temperature readings at appropriate levels. Employee D stated that the facility did not use a system to test the water temperature at the surface level of each item being washed.
During interview on 05/18/10 at 11:00 A.M., Employee D stated that the machine had been checked by the maintenance employees and was found to have had clogged rinse water jets, which delayed the ejection of the hot rinse water and allowed the water to cool below sanitation levels.
During observation on 05/19/10 at 2:00 P.M., the kitchen tour at the Anheuser-Busch Institute (ABI) kitchen revealed the following:
-the floor in the serving area, and near the stove /grill was extremely slippery with grease.
-the hood over the stove/grill had a very heavy accumulation of grease, to the point of dripping.
-the floors, especially at the edges of doorways, were very dirty.
During interview on 05/20/10 at 10:30 A.M., the Director of Food Service, Employee UU, stated that the policies for food service would be the same as the policies for the main kitchen. Employee UU also stated that there was no quality assurance monitoring for the food service at the ABI kitchen.




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During an interview on 05/20/10 at 9:00 A.M. Anheuser-Busch Institute (ABI), Staff KK said:
-That there is no diet manual.
-The Food Service Director comes over to the Anheuser-Busch Institute (ABI) weekly, but only checks on employee food supplies. The Food Services Director does not check on patient food.
-Nursing staff would inform the kitchen if a patient has any special dietary needs, and Staff KK would call the main hospital if the Anheuser-Busch Institute (ABI) kitchen does not have the special foods.
-Staff KK said there is no Quality Data related to foods served at the Anheuser-Busch Institute (ABI) location.
-The nurses know when a patient will be staying overnight at the Anheuser-Busch Institute (ABI) location and come and get food before the kitchen closes. Staff KK said he/she does not know what happens to the food once it leaves the kitchen. He/she does not know how or where it is stored.
During an interview on 05/20/10 at 10:00 A.M. Registered Nurse (ABI) Staff MM said that he/she retrieves the food at 1:30 P.M. and brings it up to the nursing unit to store in the refrigerator. Staff MM said he/she heats the food up in the microwave, however, does not have the means to check the temperature of the food.
Staff MM said that Jello is stored in the refrigerator for patient use, however, regular temperature checks are only done on the refrigerator when patients are on the unit, not daily.
During an observation on 05/20/10 at 10:00 A.M. a penny on an ice cube in a Styrofoam cup is observed in the refrigerator freezer. Staff MM said that this is used to make sure the temperature did not get low enough to allow for the ice cube melting. Review of the form titled "Daily Refrigerator Temp Checks", showed from 05/1/10 to 05/20/10 only four refrigerator temperature checks were done.

Based upon review of facility documents and interview, the facility failed to have a menu to adequately meet the nutritional needs of the outpatients who are kept overnight at the Anheuser-Bush Institute (ABI), outpatient surgical center. This applied to all patients who were served meals as they were kept in observation overnight. The total number of patients who have stayed overnight at ABI since 01/01/10 has been 15. The current inpatient census of the hospital was 239.
Finding included:
Review of the menu options given to patients who stay overnight included lunch and dinner options for sandwich and / or soup and applesauce and garden salad with Ranch dressing. No breakfast menu was given to the patients.
During interview on 05/19/10 at 2:30 P.M., the Lead Cook, Employee KK stated that the patients who stay overnight would get a breakfast muffin and a serving of solid fruit, such as pineapple chunks or something.
During interview on 05/19/10 at 2:15 P.M., the Nurse in the Outpatient area, Employee PP provided the copied sheet of menu options and stated that the nursing department would have access to breakfast items such as juice, milk and instant oatmeal. If a patient would need a special diet, the ABI nursing staff would call the dietitian at the hospital for guidance.
During interview on 05/20/10 at 10:30 A.M., the Lead Dietitian, Employee EE for the hospital stated that the ABI menu had not been reviewed for nutritional adequacy.

Based upon interview and observation, the facility at the Aneuser-Busch Institute (ABI) for Outpatient Surgery failed to have knowledge and access to a current Diet Manual. This applied to all patients who were served meals as they were kept in observation overnight. The total number of patients who have stayed overnight at ABI since 01/01/10 has been 15. The current inpatient census of the hospital was 239.
Finding included:
During interview on 05/19/10 at 2:00 P.M., the Outpatient Nurse, Employee DD stated that the facility did not have a diet manual for their reference.
During interview on 05/20/10 at 10:30 A.M., the hospital lead dietitian, Employee EE stated that all nurses receive training upon hire about how to access the facility Diet Manual online.

Based upon observation, review of facility documents, and interview, the dishwasher in the main kitchen failed to reach adequate temperature to sanitize dishes. This applied to all patients, staff and visitors. The current inpatient census was 239.
Finding included:
Observation on 05/17/09 at 2:30 P.M., showed the process of testing the dishwasher with a temperature sensitive test tape produced negative results. The test was repeated with the second test run through the dishmachine four times. Neither test tape turned color, as would be the indication of adequate dish sanitation at 160 degrees Fahrenheit (F).
During interview on 05/17/09 at 2:30 P.M., the Chef, Employee D, stated the kitchen procedure was to record the temperatures on a clip-board log as indicated by the temperature dials on the dishmachine. Review of the temperature log showed complete data with all temperature readings at appropriate levels. Employee D stated that the facility did not use a system to test the water temperature at the surface level of each item being washed.
During interview on 05/18/10 at 11:00 A.M., Employee D stated that the machine had been checked by the maintenance employees and was found to have had clogged rinse water jets, which delayed the ejection of the hot rinse water and allowed the water to cool below sanitation levels.

Based on policy, interview, and observation, the facility failed to maintain a clean environment in the surgical services areas where procedures are performed; failed to maintain a clean environment for two current patients (Patient #40 and Patient #38); and the facility failed to implement appropriate infection control policies and procedures to prevent the risk of transmission of organisms for one patient (Patient #46) out of 44 current patients observed during nursing care procedures.

The facility census was 239.
Findings included:
1. Review of the facility policy titled "Cleaning Procedure: Surgical Suite, In-depth, dated as reviewed 4/2010, states in part the following cleaning instructions: Damp wipe equipment (except biomedical and electrical0, open horizontal surfaces, including ledges, counters, wall fixtures, vents, ceiling lights, fire extinguishers, linen hampers, waste receptacles, and clocks.
2. Review of the facility policy titled "Environmental Cleaning and Sanitation" (Department-Operating Room), dated as revised 07/09, states in part the following procedure to staff: The patient should be provided a clean, safe environment .... D. All horizontal surfaces in the OR (eg, furniture, surgical lights, booms, equipment) should be damp dusted before the first scheduled surgical procedure of the day. .....B. Cleans all flat surfaces ...
3. Review of the facility signage titled "Daily Routine For OR (Operating Room) Staff" posted in the surgical procedure rooms at the Anheuser-Busch Institute (ABI) outpatient surgical area states in part the following instructions to staff: .....make sure countertops and other working surfaces are clean and free of clutter. ....
4. During an observation on 05/18/10 at 2:15 P.M. , operating room known as #8 is found to have a very dusty prep stand in need of cleaning. Also, the anesthesia administration cart top is very dusty and in need of cleaning. The Registered Nurse Educator said this room was used at approximately 1:30 P.M. today.
During an interview on 05/18/10 at 2:20 P.M. the Registered Nursing Educator for the operating room said that the prep stand should be cleaned daily.
During an interview on 05/18/10 at 2:30 P.M. the Registered Nurse Director of Surgical Services said that the Anesthesia Technicians are responsible for cleaning the anesthesia carts daily.
5. During an observation on 05/18/10 at 2:35 P.M. , operating room known as operating room #12 is found to have an anesthesia administration cart top very dusty and in need of cleaning.
6. During an observation on 05/18/10 at 2:35 P.M. , operating room known as operating room cysto room is found to have an anesthesia administration cart top and the top of the x-ray light box very dusty and in need of cleaning. Also, the operating room table patient pad is found to have tears exposing the foam core (it is not possible to clean the pad since it has holes, making it an infection control hazard). The Registered Nurse Educator said this room was used approximately one week ago.
7. During an observation on 05/19/10 at 1:45 P.M. at the Anheuser-Busch Institute (ABI) outpatient surgical area operating room known as #3 the top of the anesthesia administration cart top very dusty and in need of cleaning. On 05/19/10 at 2:04 P.M. the Operating Room Interim Registered Nursing Manager said that room #3 was not used today, but was used for two cases yesterday. Also, he/she said that it is the operating room staff and housekeeping staff responsibility shared to ensure the cleaning is done.


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8. Observation of medication administration to Patient 40 on 05/18/10 at 9:15 a.m. showed blood on the floor in the patient's room and on the pole holding the intravenous pump due to the patient's intravenous line in the right hand had come loose and resulted in bleeding from the site.

9. Observation of Patient #40's room on 05/18/10 at 2:00 p.m. showed blood on the floor. Staff WW, Registered Nurse Manager said the patient had been taken to dialysis, (the process to remove liquid and chemicals from the blood that the kidneys would normally remove if they were functioning) along with the pole holding the intravenous pump.

10. Observation of patient care to Patient #38 on 05/18/10 at 9:35 a.m. showed what appeared to be dried blood on the foot board of the bed.

11. Observation of Patient #38's room on 05/18/10 at 2:00 p.m. showed what appeared to be dried blood remained on the foot board.





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12. Review of the facility policy titled, "Hand Hygiene," approved 09/24/09, showed the following (in part):
- "Decontaminate hands before having direct contact with patients."
- "Decontaminate hands after contact with a patient's intact skin, e.g., when taking a pulse or blood pressure, and lifting a patient."
- "Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled."
- "Decontaminate hands if moving from a contaminate-body site to a clean-body site during patient care."
- "Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient."

13. Review of the facility policy titled "Intravenous Therapy: Vascular Access Device Care and Maintenance," approved 05/28/09, showed the following (in part):
- "Follow Scrub the Hub and Save the Line Practice Protocol for all intravenous lines. Refer to Addendum C.
- Hand Hygiene and Aseptic Technique during insertion and care
- Vigorous friction to hub with hospital approved CHG swab for 30 seconds then let dry 30 seconds before accessing the line every time."
- "Prior to flushing a vascular access device, slowly aspirate until positive blood return to confirm catheter patency."

14. Review of the Practice Guideline titled, "Medication Administration: Intravenous Bolus," used for nursing education classes within the facility, showed the following (in part):
- "Perform hand hygiene."
- "Apply clean gloves."
- "Prepare flush solutions."
- "Clean lock's injection port with antiseptic swab. Allow to dry."
- "Insert syringe with 0.9% sodium chloride through injection port of IV lock."
- "Pull back gently on syringe plunger, and check for blood return."
- "Flush IV site with 0.9% sodium chloride by pushing slowly on plunger."
- "Remove saline-filled syringe."
- "Clean lock's injection port with antiseptic swab. Allow to dry."
- "Insert syringe containing prepared medication through injection port of IV lock."
- "Inject medication within amount of time recommended."
- "After administering medication, withdraw syringe."
- "Clean lock's injection port with antiseptic swab. Allow to dry."
- "Flush injection port."

15. Observation of medication administration to Patient #46 on 05/19/10 at 08:35 a.m. showed the following:
- Registered Nurse (RN) staff Z, entered the room and placed the medications for administration on the patient's overbed table. Hand hygiene was not preformed prior to applying gloves. RN staff Z roused the patient through touch, then unwrapped the oral medication and administered it to the patient. Without changing gloves, RN staff Z then administered a subcutaneous medication into the patient's abdomen. Next, without changing gloves, RN staff Z examined the patients intravenous (IV) site in the right arm. During palpation, the patient complained of tenderness at the site. Without changing gloves, RN staff Z then moved to the other side of the bed and palpated the IV site in the left arm and determined that the IV medication would be given in this site. Without changing gloves, RN staff Z went to a cabinet in the room and removed a pre-filled syringe, then went back to the bedside. The IV catheter hub was swiped with an alcohol pad, and the pre-filled syringe was attached to the hub. RN staff Z then pushed approximately half of the pre-filled syringe into the IV catheter, explaining that the reason the catheter wasn't checked for a blood return was because this had been done "a little while ago and there was a good blood return." RN staff Z then removed the pre-filled syringe and laid it on the overbed table. There was no protective barrier on the overbed table. Without changing gloves, RN staff Z then returned to the room cabinet and removed a second pre-filled syringe, squirted half of it into the trashcan, attached it to the medication vial containing the medication to be administered, and withdrew the medication. Returning to the bedside, without changing gloves, RN staff Z swiped the catheter hub with an alcohol pad, attached the syringe containing medication, and administered it over the course of approximately two minutes. RN staff Z then removed the empty syringe from the hub, swiped it, reattached the partially filled syringe that had been placed previously on the overbed table, and pushed what remained of that solution into the IV catheter. RN staff Z did not change gloves at any point during the medication administration process. When all medications had been given, RN staff Z removed the gloves and washed with soap and water at the sink in the patient's room.

During an interview on 05/19/10 at 2:55 p.m., Director of Nursing Practice staff Q and Clinical Educator staff GG agreed that RN staff Z should have performed hand hygiene before donning gloves, should have changed gloves and performed hand hygiene multiple times during the medication process, and did not follow proper procedure for administering IV medications.

Based on policy review, record review, and interview, the facility failed to ensure physicians and patients properly completed and documented informed surgical consent with date and time for ten of seventeen sampled patients (current Patient #33 and #1; and discharged Patient #21, #23, #25, #27, #29, #30, #32, #65, & #66 ). The facility census was 239.

Findings Included:

1. Review of the facility policy titled, "Informed Consent," approved 09/24/09, showed the following (in part):
- "Elements of Informed Consent for treatment or procedure: Date and time of the patient, witness and physician signature."
- "It is the legal responsibility of the physician performing the procedure to make certain the Consent form is accurately completed, signed, dated and timed and initialed by the patient, witness and physician."
- "Members of the Department of Anesthesia are responsible for explaining the risks, benefits, and alternatives for anesthesia any time a member of this department is assigned care of a patient. This is documented on the consent form in the Anesthesia declaration and the patient/patient representative signature, date and time is obtained. The Anesthesia physician then signs, dates and times in acknowledgement."

2. Current patient #33 record review, age 48, showed a surgical procedure of Application of an External Fixator right upper extremity on 05/02/10. Review of the document titled "Special Informed Consent to Surgery or Other Procedure" , reveals the section for the physician's signature is dated, however, the consent is not timed. Without a time it is unknown if the form was completed prior to the patient's procedure.

Discharged record review for patient #21, age 48, showed a surgical procedure of Excision of left breast cyst and possible right breast cyt excision on 03/29/10. Review of the document titled "Special Informed Consent to Surgery or Other Procedure" , reveals the section for the physician's signature is dated, however, the consent is not timed. Without a time it is unknown if the form was completed prior to the patient's procedure.

Discharged record review for patient #23, age 31, showed a surgical procedure for Bilateral Tympanostomy with tube placement (is a small tube inserted into the eardrum in order to keep the middle ear aerated for a prolonged period of time, and to prevent the accumulation of mucus in the middle ear) on 04/13/10. Review of the document titled "Special Informed Consent to Surgery or Other Procedure" , reveals the section for the patient and physician's signature is dated, however, the consent is not timed. Without a time it is unknown if the form was completed prior to the patient's procedure.

Discharged record review for patient #25, age 39, showed a surgical procedure of Wide Excision of Right Scapula (shoulder blade) Melanoma (cancer), Lymph Node Dissection on 04/13/10. Review of the document titled "Special Informed Consent to Surgery or Other Procedure" , reveals the section for the patient and physician's signature is dated, however, the consent is not timed. Without a time it is unknown if the form was completed prior to the patient's procedure.

Discharged record review for patient #27, age 48, showed a surgical procedure of Excision of right hip mass on 04/13/10. Review of the document titled "Special Informed Consent to Surgery or Other Procedure" , reveals the section for the patient and physician's signature is dated, however, the consent is not timed. Without a time it is unknown if the form was completed prior to the patient's procedure.

Discharged record review for patient #29, age 60, showed a surgical procedure of Left Cataract Removal with Lens implanted on 04/13/10. Review of the document titled "Special Informed Consent to Surgery or Other Procedure" , reveals the section for the patient's signature is dated, however, the consent is not timed. Without a time it is unknown if the form was completed prior to the patient's procedure.

Discharged record review for patient #30, age 58, showed a surgical procedure of Right Arthroscopic Should Repair on 04/15/10. Review of the document titled "Special Informed Consent to Surgery or Other Procedure" , reveals the section for the physician's signature is dated, however, the consent is not timed. Without a time it is unknown if the form was completed prior to the patient's procedure.

Discharged record review for patient #32, age 28, showed a surgical procedure of Right bunionectomy (removal of bony formation on the toe area) on 04/15/10. Review of the document titled "Special Informed Consent to Surgery or Other Procedure" , reveals the section for the patient's signature is dated, however, the consent is not timed. Without a time it is unknown if the form was completed prior to the patient's procedure.

Discharged record review for patient #65, age 36, showed a surgical procedure of Right Knee Reconstruction on 05/18/10. Review of the document titled "Special Informed Consent to Surgery or Other Procedure" , reveals the section for the patient's signature is dated, however, the consent is not timed. Without a time it is unknown if the form was completed prior to the patient's procedure.

Discharged record review for patient #66, age 36, showed a surgical procedure of Right Knee Arthroscopic examination on 02/02/10. Review of the document titled "Special Informed Consent to Surgery or Other Procedure" , reveals the section for the physician's signature is dated, however, the consent is not timed. Without a time it is unknown if the form was completed prior to the patient's procedure.


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3. Review of current Patient #1's medical record on 05/17/10 at 4:00 p.m. showed a form titled, "Special Informed Consent to Surgery or Other Procedure" for a "Irrigation and debridement (cleaning wound and removing dead tissue), external fixation (of right wrist fracture) placement (alignment) of right distal radius. The consent was signed by the patient on page two of the form, but there is no documentation of date or time. Beneath the patient's signature is a "Physician Statement" segment stating, "I explained the above statements, and answered all the patient's questions." The physician signed the form, but there is no documentation of date or time. Beneath that portion of the consent form is a segment giving consent for anesthesia. The patient signed that section of the form, and there is a date of 05/05/10, but no documentation of time. At the bottom of the consent form there is a statement: "I certify that I have explained to the above individual the nature, purpose, risks and potential benefits of the above procedure and I have answered any questions that have been raised, and the patient/representative agrees to proceed." The physician signed and dated the statement, but did not time the signature.

Review of current Patient #1's medical record on 05/17/10 at 4:10 p.m. showed a form titled, "Special Informed Consent to Surgery or Other Procedure" for a "Irrigation and debridement (cleaning wound and removing dead tissue), possible closure (of the wound), possible VAC change (wound vacuum, which accelerates healing), possible external fixation adjustment/revision of right wrist (fracture), and all other indicated procedures. Page two of the form indicates the intended surgery is "I&D (irrigation and debridement) Right Wrist," without mention of the "possible closure, possible VAC change, possible external fixation adjustment/revision of right wrist, and all other indicated procedures" which were documented on page one of the form. Page two of the consent was signed by the patient, and there is a date of 05/15/10, but there is no documentation of time. Beneath the patient's signature is a "Physician Statement" segment stating, "I explained the above statements, and answered all the patient's questions." The physician signed and dated the form, but there is no documentation of time. The consent to anesthesia portion of that form is blank, and the consent is documented on a separate (identical) form. The name of the procedure on this (third) page of the form is "I&D (irrigation and debridement) Right Wrist," without mention of the "possible closure, possible VAC change, possible external fixation adjustment/revision of right wrist, and all other indicated procedures" which were documented on page one of the form. The patient signed that section of the form, and there is a date of 05/14/10, but there is no time. At the bottom of the consent form there is a statement: "I certify that I have explained to the above individual the nature, purpose, risks and potential benefits of the above procedure and I have answered any questions that have been raised, and the patient/representative agrees to proceed." The physician signed and dated the statement, but did not time the signature.
During an interview on 05/17/10 at 4:30 p.m., Inpatient Nursing Director, staff W said the multi-page consent form is computer generated and printed, and the multiple pages are matched by the patient identification at the bottoms of the forms.
Review of the identifiers at the bottoms of the forms for the above example showed that the identification matched for pages 1 and 2 of the form signed 05/15/10. However, the consent for anesthesia form provided as evidence of obtaining consent for surgery on 05/15/10 (signed and dated 05/14/10) does not match the patient identification found on pages 1 and 2 of the form.

Based on policy, interview, and record review, the facility failed to provide post anesthesia evaluations for ten of sixteen surgical patients sampled (current patient #33 & #34 and discharged #24, #25, #26, #28, #31, #32, #63, & #64), within 24 hours after receiving a general anesthesia; and the facility failed to provide post anesthesia evaluations for two of two current psychiatric patients sampled (Patient #42 and #58), within 24 hours after receiving a general anesthesia for ECT (Electroconvulsive Therapy [electric shock therapy used for some psychiatric conditions]). The hospital census was 239.

Findings included:

Review of the medical staff rules and regulations, unknown date of approval, Section I-e states the following in part: ... ...Post-anesthesia evaluation completed within 24 hours after surgery. Evaluation includes: Date and time ... ...

During an interview on 05/19/10 at 10:20 A.M. the Anesthesia Services Medical Director said that Medical Records is responsible for tracking post-anesthesia evaluations not completed and that he/she does not remember any notification by the Medical Records department informing him/her of any incomplete evaluations.

Current patient #33 record review, age 48, showed a surgical procedure of Application of an External Fixator right upper extremity on 05/02/10; and Adjustment of External Fixator on 05/06/10. Review of the document titled "Anesthesia Perioperative Record" (also used to document the anesthesia post-operative visit at the bottom of the form), reveals the section for the post-operative evaluation is signed and dated 05/14/10 by the anesthesiologist, however, the assessment was not timed. Without a time it is unknown if the patient was assessed within the twenty-four hour time period.

Current patient #34 record review, age 47, showed a surgical procedure of Right percutaneous nephrolithotomy (removal of kidney stone) on 05/13/10. Review of the document titled "Anesthesia Perioperative Record" (also used to document the anesthesia post-operative visit at the bottom of the form), reveals the section for the post-operative evaluation is signed and dated 05/14/10 by the anesthesiologist, however, the assessment was not timed. Without a time it is unknown if the patient was assessed within the twenty-four hour time period.

Discharged record review for patient #24, age 46, showed a surgical procedure of Incision and Drainage of an Abscess with Possible Dental Extractions on 04/10/10. Review of the document titled "Anesthesia Perioperative Record" (also used to document the anesthesia post-operative visit at the bottom of the form), reveals the section for the post-operative evaluation is signed and dated by the anesthesiologist (using electronic stamping), however, the assessment section documenting the patient's condition was blank.

Discharged record review for patient #25, age 39, showed a surgical procedure of Wide Excision of Right Scapula (shoulder blade) Melanoma (cancer), Lymph Node Dissection on 04/13/10. Review of the document titled "Anesthesia Perioperative Record" (also used to document the anesthesia post-operative visit at the bottom of the form), reveals the section for the post-operative evaluation is signed and dated by the anesthesiologist, however, the assessment section documenting the patient's condition was blank.

Discharged record review for patient #26, age 39, showed a surgical procedure of Left Nephrectomy (removal of a kidney) on 04/14/10. Review of the document titled "Anesthesia Perioperative Record" (also used to document the anesthesia post-operative visit at the bottom of the form), reveals the section for the post-operative evaluation is signed and dated by the anesthesiologist (using electronic stamping), however, the date of the stamp is 05/01/10 at 11:07 P.M. and the assessment section documenting the patient's condition was blank.

Discharged record review for patient #28, age 14, showed a surgical procedure of Left Tendon Repair on 04/13/10. Review of the document titled "Anesthesia Perioperative Record" (also used to document the anesthesia post-operative visit at the bottom of the form), reveals the section for the post-operative evaluation is signed and dated by the anesthesiologist, however, the assessment section documenting the patient's condition was blank.

Discharged record review for patient #31, age 32, showed a surgical procedure of Left Arthroscopic Shoulder Repair on 04/15/10. Review of the document titled "Anesthesia Perioperative Record" (also used to document the anesthesia post-operative visit at the bottom of the form), reveals the section for the post-operative evaluation was blank. There is no documentation of a post-operative anesthesia evaluation.

Discharged record review for patient #32, age 28, showed a surgical procedure of Right bunionectomy (removal of bony formation on the toe area) on 04/15/10. Review of the document titled "Anesthesia Perioperative Record" (also used to document the anesthesia post-operative visit at the bottom of the form), reveals the section for the post-operative evaluation is signed and dated by the anesthesiologist (using electronic stamping), however, the date of the stamp is 04/21/10 at 11:42 A.M. and the assessment section documenting the patient's condition was blank.

Discharged record review for patient #63, age 27, showed a surgical procedure of Enecleation (removal) of Right Eye with Implant on 05/18/10. Review of the document titled "Anesthesia Perioperative Record" (also used to document the anesthesia post-operative visit at the bottom of the form), reveals the section for the post-operative evaluation is signed by the anesthesiologist, however, the assessment was not dated or timed. Without a date and time it is unknown if the patient was assessed within the twenty-four hour time period.

Discharged record review for patient #64, age 44, showed a surgical procedure of Left Arthroscopic Knee Repair on 05/18/10. Review of the document titled "Anesthesia Perioperative Record" (also used to document the anesthesia post-operative visit at the bottom of the form), reveals the section for the post-operative evaluation is blank. There was no documentation of a post-operative anesthesia evaluation.


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Review of current Patient #42's medical record on 05/18/10 at 2:20 P.M. showed that he/she had ECT (Electroconvulsive Therapy [electric shock therapy used for some psychiatric conditions]) on 05/05/10. Review of the document titled, "Anesthesia Perioperative Record" (also used to document the anesthesia post-operative visit at the end of the form), showed the section for the post-operative evaluation was blank. On 05/07/10, the ECT was repeated and the section for the post-operative evaluation was blank. On 05/12/10, the ECT was repeated and the section for the post-operative evaluation was blank. On 05/17/10, the ECT was repeated and anesthesia finished at 11:09 A.M. Review of the document titled, "Anesthesia Perioperative Record" showed the section for the post-operative evaluation was blank.

Review of current Patient #58's medical record on 05/18/10 at 3:35 P.M. showed that he/she had ECT (Electroconvulsive Therapy [electric shock therapy used for some psychiatric conditions]) on 05/10/10. Review of the document titled, "Anesthesia Perioperative Record" (also used to document the anesthesia post-operative visit at the end of the form), showed the section for the post-operative evaluation was blank. On 05/12/10, the ECT was repeated and review of the document titled, "Anesthesia Perioperative Record", showed the section for the post-operative evaluation was blank. On 05/17/10, the ECT was repeated and anesthesia finished at 10:35 A.M. Review of the document titled, "Anesthesia Perioperative Record" showed the section for the post-operative evaluation was blank.

Based on facility policy review, record review, and interview, the facility failed to provide written grievance resolution within a reasonable timeframe to patients and/or families filing a complaint/grievance for three (Patients #67, #68 and #69) of seven grievances reviewed. The facility census was 239.

Findings Included:

1. Review of the facility policy titled "Patient Rights and Responsibilities," approved 11/19/09, showed the following (in part): "The patient has the right to: Voice concerns without discrimination regarding quality of care or services, and to expect those concerns to be addressed immediately according to the hospital grievance policy, or to be referred to the appropriate state agency."

Review of the facility policy titled "Patient Grievance Policy," showed the following (in part):
- "Patient and Visitor Relations will send the patient a letter or return e-mail within two business days acknowledging the grievance, explaining the process/steps, time frames and alternatives for resolving the grievance."
- "After reviewing the grievance process with the patient, the Patient and Visitor Relations Department will, whenever possible, resolve the issue immediately by providing information/answers. If this cannot happen, a written summary of the grievance will be prepared by Patient and Visitor Relations and forwarded for follow-up to the appropriate department manager/administrator within two business days of receiving it."
- "The department(s) or individual(s) named in the grievance usually will have three business days to respond in writing to Patient and Visitor Relations with their findings and action plans. For more complicated issues, departments may request additional time, in which case Patient and Visitor Relations will contact the patient in writing to advise of and extended date of completion."
- "The patient will be notified by Patient and Visitor Relations of the findings or recommended action plan by letter within two business days of receiving the response."

2. Review on 05/20/10 at 10:55 a.m. of a grievance filed by Patient # 67 showed the following:
- Patient #67 filed a complaint/grievance with the facility on 04/26/10 by email.
- The Director of Patient and Visitor Relations staff TT contacted the patient on 04/26/10 to discuss the allegations.
- The appropriate manager completed an investigation on 04/29/10.
- A resolution letter was sent on 05/04/10, eight days after the complaint/grievance was lodged.

Review on 05/20/10 at 11:00 a.m. of a grievance filed by Patient # 68 showed the following:
- Patient #68 filed a complaint/grievance with the facility on 04/18/10 by mailing a letter to the CEO of the hospital.
- The Director of Patient and Visitor Relations staff TT was forwarded the complaint after approximately twenty-three days, and contacted the patient on 05/12/10.
- The complaint was still under investigation on 05/20/10, thirty-three days after the complaint/grievance was lodged.
- There is no evidence that the patient was notified of a delay in the investigation process.

Review on 05/20/10 at 11:15 a.m. of a grievance filed by Patient # 69 showed the following:
- Patient #69 filed a complaint/grievance with the facility on 04/26/10.
- The appropriate manager completed an investigation on 04/26/10, however the manager investigated only one of two allegations.
- A resolution letter was sent on 05/11/10, sixteen days after the complaint/grievance was lodged.

3. During an interview on 05/20/10 at 11:30 a.m., Director of Patient and Visitor Relations staff TT said the following:
- There was a delay in receiving the written complaint for Patient #68 because it went to the CEO rather than being forwarded to the appropriate office for a response.
- When complaints are assigned to managers for investigation, staff TT expects "a timely response," but there is no mechanism in place to assure that investigations and responses are completed within the guidelines specified by policy.
- There was a delay in providing a written response to Patient #69 due to other obligations that took priority over this task.

Based on observation, interview, and record review, the facility failed to ensure signs were posted to inform the public of the usage of one of two Physician Assistants sampled (Staff QQ) in the hospital owned clinic and failed to ensure informed consent was obtained prior to the procedure for two (Patient #42 and Patient #35) of five patients' records reviewed for informed consent. The hospital census was 239.
Findings included:
Review of the facility policy titled, "Informed Consent", revised 07/09, gave direction, in part, to include the following:
"The performing physician is responsible for obtaining the patient's informed consent prior to the treatment or procedure."
"Elements of Informed Consent for treatment or procedure:"
"Date and time of the patient, witness and physician signature."
"It is the legal responsibility of the physician performing the procedure to make certain the Consent Form is accurately completed, signed, dated and timed and initialed by the patient, witness and physician."
"Members of the Department of Anesthesia are responsible for explaining the risks, benefits, and alternatives for anesthesia any time a member of this department is assigned care of a patient. This is documented on the consent form in the Anesthesia declaration and the patient/patient representative signature, date and time is obtained. The Anesthesia physician then signs, dates and times in acknowledgement."

Review of the facility policy titled, "Patient Rights and Responsibilities", reviewed 08/09, gave direction, in part, to include the following:
"The patient has the right to:" "Information necessary for the patient or authorized representative to give informed consent before any procedure or treatment."

During an observation on 05/18/10 at 10:05 A.M. at the hospital owned Gastroenterology, Hematology, and Transplant clinic there is no sign found to inform patients the clinic utilizes physician assistants.
During an interview on 05/18/10 at 9:30 A.M. Gastroenterology, Hematology, and Transplant clinic Practice Manager said the clinic utilizes the services of two Physician Assistants.
Review of the collaborative agreement for Physician's Assistant (PA), Staff QQ, showed the following requirement in section 3.6-Physician Assistant (PA) shall not be used in any office of a physician or in a clinic or hospital unless a notice stating that a physician assistant is utilized is posted in a prominent place in such office, clinic, or hospital.







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Review of current Patient #42's medical record showed a document titled, "Special Informed Consent to Surgery or Other Procedure - Electroconvulsive Therapy (ECT [electric shock therapy used for some psychiatric conditions]) - Up to 24 Treatments". The physician and anesthesiologist's signatures were dated 05/05/10 but were not timed making it impossible to determine if the physician and anesthesiologist signed before or after the procedure. Additional record review showed the patient had ECT on 05/05/10, 05/07/10, 05/12/10, and 05/17/10.


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Review of current Patient #35's medical record on 05/18/10 at 11:45 a.m. showed a document titled, "Special Informed Consent for Endoscopy Procedure Esophagogastroduodenoscopy (EGD)". (A diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract up to the duodenum). The physician and anesthesiologist signatures were dated 0512/10, but were not timed. It is not possible to tell if the physician and anesthesiologist signed before or after the procedure.

Based on facility policy review, observation, and interview, the facility failed to protect patient's rights to privacy by placing patient names in public view on twelve patient care units of twenty patient care units. The facility census was 239.
Findings included:

1. Review of the facility's policy titled, "Patient Rights and Responsibilities", reviewed 08/09, gave direction, in part, to include the following:
"Confidentiality of all clinical records and communication to the extent permitted or required by law."

Review of the facility's policy titled, "Confidentiality - Use and Access of Information", reviewed 11/08, gave direction, in part, to include the following:
"Purpose
To protect confidentiality and proprietary information from breach, misuse, invasion of privacy or mishandling by a person inside or outside the organization."
"Confidential information includes, but is not limited to the following:
a. Patient's name, if restricted, diagnosis, records, test results, medical procedures, bills, knowledge of litigation, or like information."

2. Observation on 05/17/10 at 2:30 P.M. in the Cardiology ICU (Intensive Care Unit), 9 ICU, showed a white eraser board at the nurses' station and was positioned where it could be viewed by the public. The board contained the last names and room number of all 10 patients in the unit.

3. Observation on 05/17/10 at 3:25 P.M. in the Neurological ICU, 5 ICU, showed a white eraser board at the nurses' station and was positioned where it could be viewed by the public. The board contained the last names and room number of all 13 patients in the unit. At 3:45 P.M. in the same unit, a second white eraser board was noted at a nurses' station at the other end of the unit. The second board also contained the last names and room number of all 13 patients in the unit and was positioned where it could be viewed by the public. An observation on 05/18/10 at 10:27 A.M. in the same unit showed the two white eraser boards with the first three letters of the patients' last names and their room number. This affected 13 patients in the unit.

4. Observation on 05/18/10 at approximately 1:45 P.M. in the Adult Psych unit, 4 West, showed a white eraser board in the hallway across from the nurses' station and was positioned where it could be viewed by the public. The board contained the first name and room number of all 20 patients on the unit.

5. Observation on 05/19/10 at 9:40 A.M. in the Physical Medicine and Rehabilitation department showed a clipboard at the counter next to the entrance door for outpatients to sign upon arrival. The sign-in sheet showed the first and last name of two patients.

During an interview with the Director of Physical Medicine and Rehabilitation, staff FF, confirmed the sign-in sheet showing the names of two patients should have been removed or covered to protect the names of patients.


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6. Observation on 05/17/10 at 2:30 p.m. of the Orthopedic unit, 6 South, showed patient last names visible on medical charts lying on counters in the nursing station and in the chart rack. The names were easily readable from 15 feet away to any patients or visitors to that unit.
7. Observation on 05/19/10 at 8:35 a.m. of the Medical Intensive Care Unit, 8 ICU, showed a white board listing the last names of all nine patients on that unit. The white board was visible to any patients or visitors to that unit.
8. Observation on 05/19/10 at 9:30 a.m. on the Abdominal Transplant unit, 7 North, showed patient last names visible on medical charts lying on counters in the nursing station and in the chart rack. The names were easily readable from 15 feet away to any patients or visitors to that unit.
9. Observation on 05/19/10 at 09:45 a.m. on the Neurology/ENT unit, 5 North, showed a white board listing the first three letters of patient last names who were on that unit. The white board was visible to any patients or visitors to that unit. Additionally, patient last names were visible on medical charts lying on counters in the nursing station and in the chart rack. The names were easily readable from 15 feet away to any patients or visitors to that unit.
10. Observation on 05/19/10 at 10:30 a.m. on the Neurosurgery floor showed patientlast names visible on medical charts lying on counters in the nursing station and in the chart rack. The names were easily readable from 15 feet away to any patients or visitors to that unit.


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11. Observation on 05/18/10 at 10:00 a.m. on 9 North showed patient charts with the patient's last name lying on counters in the nursing station and in the chart rack. The names were readable from the nursing station to patients and visitors.
12. Observation on 05/17/10 at 2:10 p.m. on 8 North showed patient charts with the patient names lying on counters in the nursing station and in the chart rack. The names were readable from the nursing station to patients and visitors.
13. Observation on 05/17/10 at 2:10 p.m. on 8 South showed patient charts with the patient names lying on counters in the nursing station and in the chart rack. The names were readable from the nursing station to patients and visitors.

Based on facility policy review, observation and interview facility staff failed to ensure patient medical information was secured to prevent unauthorized access for patients in the mammography (X-ray exam of breast tissue to investigate lumps in the breast) unit, and for patients on the 8 North and 9 North nursing units (Patients #3, #35, #36, #37, #38). The facility census was 239 patients.

Findings included:

1. Review of the facility's policy titled, "Patient Rights and Responsibilities", reviewed 08/09, and gave direction, in part, to include the following:
"Confidentiality of all clinical records and communication to the extent permitted or required by law."

Review of the facility's policy titled, "Confidentiality - Use and Access of Information", reviewed 11/08, and gave direction, in part, to include the following:
"Purpose
To protect confidentiality and proprietary information from breach, misuse, invasion of privacy or mishandling by a person inside or outside the organization."
"Confidential information includes, but is not limited to the following:
a. Patient's name, if restricted, diagnosis, records, test results, medical procedures, bills, knowledge of litigation, or like information."

2. Observation on 05/17/10 at 4:30 P.M. in the Mammography Unit showed Open bins above physician work area containing file folders of previous mammograms, with the radiology report, patient name and patient date of birth. Housekeeping personnel observed in the unit during observation.

3. During an interview on 5/17/10 at 4:30 P.M. with the Staff M Director of Imaging, Staff M confirmed the observation of the unsecured X-ray folders.


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4. Observation on 05/18/10 at 11:00 a.m. on 8 North showed an Intake and Output record in a folder on the outside of Patient #3's door. This document included the patient's full name and birth date, and was accessible to anyone on the nursing unit.
On 05/18/10 at 11:15 a.m. Staff H, Registered Nurse Manager confirmed that these records are kept on the patient doors.
5. Observation on 05/18/10 at 1:00 p.m. on 9 North showed Intake and Output records placed in a folder on the outside of the door of the bathroom in the patient rooms for Patient #35, #36, #37, and #38. This document included the patients' full name and birth date, and was accessible to anyone on the nursing unit.
On 05/18/10 at 1:30 p.m. Staff WW, Registered Nurse Manager confirmed that these records are kept on the patient doors.

Based on observation, record review and interview, the facility failed to ensure physician orders were obtained for the use of restraints on three (Patient #18, #19, and #20) of six patients observed in restraints. The facility census was 239.

Findings included:

1. Review of the facility's policy titled, "Restraints", revised 04/09, gave direction, in part, to include the following:
"Each patient has the right to receive care in a safe setting which provides protection for the patient's emotional health and safety as well as his/her physical safety."
"Documentation (All actions taken regarding restraint and/or seclusion must be documented in the patient's medical record)."
"Authorization for restraint application and relevant orders for use."
"Restraint is initiated only upon the order of a physician. The order is time-limited not to exceed 24 hours and includes the specific reason for the intervention."
"If restraint continues to be clinically justified, continued use of restraint beyond the first 24-hours must be authorized by the physician. Restraint orders must be renewed on a daily basis not to exceed 24 hours."
"Restraint orders must be dated and timed when signed by physician ..."

Review of the facility's policy titled, "Patient Rights and Responsibilities", revised 08/06, gave direction, in part, to include the following:
"The patient has the right to:"
"Be free from any medically unnecessary restraints or seclusion."

2. Observation on 05/17/10 at 3:30 P.M. showed Patient #18 in bed with a soft wrist restraint on his/her left wrist.

Review of Patient #18's medical record on 05/17/10 at 3:35 P.M. showed the following documents titled, "Non-behavioral Restraint Order":
- On 05/11/10, the physician signed and dated the order but the signature was not dated.
- On 05/12/10, no physician order was found.
- On 05/13/10, the physician signature was not dated or timed.
- On 05/14/10, the physician signature was not dated or timed.
- On 05/15/10, the physician signature was not dated or timed.
- On 05/16/10, no physician order was found.

During an interview on 05/17/10 at 3:45 P.M., Nurse Manager, staff R, confirmed the above and stated that Patient #18 had restraints on since 04/24/10. Staff R stated they obtain their orders for restraints at 11:30 P.M.

3. Review of current Patient #19's medical record on 05/18/10 at 9:35 A.M. showed that the patient was wearing soft wrist restraints to both wrists. The document titled, "Non-behavioral Restraint Order", dated 05/17/10 by the RN (Registered Nurse) was signed by the physician but the signature was not dated or timed.

Observation of Patient #19 on 05/18/10 at 10:25 A.M. showed the patient in bed with soft wrist restraints to both wrists.

During an interview on 05/18/10 at approximately 9:40 A.M., Nurse Manager, staff R, stated that Patient #19 had been in restraints since he/she returned from surgery on 05/17/10.

4. Observation of Patient #20 on 05/18/10 at 10:30 A.M. showed the patient with a bulky mitten on his/her right hand. The bulky mitten prevented the patient from using his/her right hand.

Review of Patient #20's medical record on 05/18/10 at approximately 10:45 A.M. showed a document titled, "Non-behavioral Restraint Order", signed by the nurse on 05/17/10 at 7:00 P.M. The physician signature was dated 05/17/10 but was not timed. Nursing documentation showed that Patient #20's restraint was removed on 05/17/10 at 3:00 A.M. and re-applied at 7:00 P.M.

Based on record review and interview, the facility failed to ensure one of three patients (#33) sampled with skin breakdown received photographic documentation of wounds in a timely manner; the facility failed to to follow the facility's internal policy regarding peripheral intravenous catheter maintenance for two patients (Patient #6, and Patient #37), and failed to follow the facility policy regarding central venous catheter maintenance care for one patient (Patient #3). The hospital census was 239.

Findings included:
Review of the facility policy titled "Skin Care: Tissue and Pressure Ulcer Assessment and Management", dated as effective 1/10, states in part the following: ...Obtain photo documentation of any new wound (s) and/or change in existing wound (s) and place on Photographic Wound Documentation form. Photograph wound (s) at discharge and document on the Photographic Wound Documentation form.
Medical record review for Patient #33, age 48, showed admission to the hospital on 04/30/10 after a motor vehicle accident. Review of the initial nursing assessment did not show any skin breakdown and the Braden score is documented as 10 (18 or less=at risk for skin breakdown).
Left coccyx fold:
Review of the document titled "Nursing Wound Care Flowsheet" (used by nursing to document skin breakdown) showed the following skin breakdown:
05/05/10-Wound type-0, length 4"x width 6", no stage, Periwound Tissue (wound edges) described as series of blisters popped and unpopped. No photo taken.
05/06/10-Nothing documented
05/07/10- Wound type-0, , no measurement, no stage, Periwound Tissue (wound edges) described as open blisters. No photo taken.
05/08/10-Wound type-0, length 4"x width 6", ? stage, Periwound Tissue (wound edges) described as popped blisters. No photo taken.
05/09/10-Wound type-0, length 4"x width 6", ? stage, Periwound Tissue (wound edges) described as same. No photo taken.
05/10/10-Wound type-P (Pressure ulcer), length 4"x width 6", stage II (Stage II is defined as the skin blisters or forms an open sore. The area around the sore may be red and irritated), Periwound Tissue (wound edges) described as series of blisters popped and unpopped. Photo taken by the wound nurse.
Right buttocks/hip:
05/07/10-Wound type-Excoriation and blisters that are redden, length 6 centimeters (c.m.) x width 0.5c.m., ? stage, Periwound Tissue (wound edges) described as inflamed and macerated. No photo taken.
05/08/10- Wound type-Excoriation and blisters that are redden, length 6 centimeters (c.m.) x width 0.5c.m., ? stage, Periwound Tissue (wound edges) described as inflamed and macerated. No photo taken.
05/09/10- Wound type-Excoriation and blisters that are redden, length 6 centimeters (c.m.) x width 0.5c.m., ? stage, Periwound Tissue (wound edges) described as inflamed and macerated. No photo taken.
05/10/10- Wound type-Excoriation and blisters that are redden, length 6 centimeters (c.m.) x width 0.5c.m., ? stage, Periwound Tissue (wound edges) described as inflamed and macerated. Photo taken by the wound nurse.
During an interview on 05/17/10 at 3:00 P.M. Registered Wound Care Nurse said pictures are to taken on admission if there is skin breakdown, pictures at discharge if there is skin breakdown, and pictures whenever there is a change in the skin condition or new skin breakdown. Registered Wound Care Nurse said that he/she did not see Patient #33 until 05/10/10 due to the patient not being in the room when he/she visited. Based on the fact the patient had blisters/excoriation he/she would probably have taken pictured when the wounds were discovered.




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The facility policy titled, "Intravenous Therapy: Vascular Access Device Care and Maintenance", effective date February 2007 and last revised 04/10 states on page 10 under the heading of peripheral catheters, "Place date and time of dressing change and size and gauge of catheter directly on dressing". The policy states on page 13 under the heading of central venous catheters, "Place date and time of dressing change and size of and guage of catheter directly on dressing".

An interview with Patient #37 on 05/18/10 at 9:00 a.m. on 9 North showed a peripheral intravenous (a catheter placed into a peripheral vein in order to administer fluids and/or medications) dressing with no date or time in the patient's right arm.

An interview with Patient #6 on 05/17/10 at 2:30 p.m. on 8 South showed a peripheral intravenous dressing with no date or time in the patient's left arm.

An interview with Patient #3 on 05/17/10 at 3:30 p.m. on 8 North showed a central venous catheter (a catheter placed into a large vein in the neck, chest, or groin used to administer medications and/or fluids) dressing with no date or time in the patient's upper left chest.

Staff H, Registered Nurse Manager on 8 North said during an interview on 05/17/10 at 4:00 p.m. that it is facility policy to date and time the dressings on peripheral and central line dressings.

Based on policy, record review, and interview, the facility failed to identify and/or update the nursing plan of care for two (Patient #17 and #19) of 28 current patients' medical records reviewed. The facility census was 239.

Findings included:

1. Review of the facility's policy titled, "Care Planning", revised 06/09, gave direction, in part, to include the following:
"The RN (Registered Nurse) retains the ultimate responsibility for initiating, developing, evaluating, and revising each patient's care plan."
"A Patient Care Plan is printed and signed every 12 hours."

2. Review of current Patient #17's medical record on 05/17/10 showed he/she was admitted on 05/15/10 for a stroke. The initial nursing assessment identified him/her as being high risk for falls. Review of the document titled, "Patient Plan of Care", showed no care plan for the risk of falls.

During an interview on 05/17/10 at 2:40 P.M., Nurse Manager, 9 ICU (Intensive Care Unit), staff VV, stated that he/she would expect to see Patient #17's plan of care to include risk for falls. Nurse Manager, staff O, confirmed there was a care plan option that could have been selected for potential injury from falls.

3. Review of current Patient #19's medical record on 05/18/10 showed he/she was admitted on 05/13/10. Review of the patient's plan of care showed only one review completed on 05/16/10.

During an interview on 05/17/10, Nurse Manager, staff O, stated that the plan of care is updated every 12-hour shift.

Based on observation, facility policy review and interview, facility staff failed to follow facility policy with regard to administering medication via Intravenous (a line directly into a vein) push (IVP) for one (Patient #43) of one patient observed receiving medication via IVP. The census at the time of the survey was 239 patients.

Findings include:

1. The facility medication guideline states:
DOSAGE AND ADMINSTRATION
The recommended adult dose is either 20 or 40 milligrams (mg) esomeprazole (Nexium-treatment for esophagitis - inflammation of the tube from the back of the mouth to the stomach) given once daily by IVP injection (no less than 3 minutes).

2. During observation of medication administration to Patient #43 on 05/19/10 at 09:30 A.M., showed staff Y, Registered Nurse (RN) administer IVP Nexium 40 mg in 15 seconds.

Interview with Staff Y after the medication administration revealed, believe gave over at least 30 seconds.

Based upon record review, interview, and review of policies, the nursing staff failed to have complete record content in regards to documentation of weight documentation for one (#50) of one reviewed for weight documentation; and for intake of nutritional supplements for one (#50) of one case reviewed for nutritional supplement consumption The facility census was 239.
Finding included:
1. During interview on 05/18/10 at 3:30 P.M., the Nurse Manager for the contracted service for dialysis, Employee XX stated the policy for the contracted services for dialysis by the DaVita Corporation expect the staff to weigh each patient before and after dialysis treatments.
2. Record review for Patient #50, showed on the dialysis treatment sheet for 05/14/10 documentation that the patient weight recorded before treatment on 05/14/10 was documented as " bed " ; and the weight after the same treatment was recorded as " no scale " .
3. Record review for patient #50, currently admitted since 04/19/10, showed the physician order sheet to require provision of Nova Source Renal nutritional supplement. The graphic documentation by nursing staff for meals indicated a meal intake range of 30-50% of meals.
On 05/06/10, the Registered Licensed Dietitian documented recommendation of a change to Boost supplement to be served three times per day. Further review of this same medical record showed no documentation of the amount of nutritional supplements consumed.

Based on policy and record review, the facility failed to ensure physicians and patients dated and timed consents for the administration of blood and blood products for three of sixteen sampled patients (current patient #33 and discharged patient #22 & #26). The facility census was 239.

Findings Included:

Review of the facility policy titled "Informed Consent", dated as revised 7/09, states in part the following instructions: The elements a valid informed consent include disclosure of the following information: #9-Date and time of the patient, witness, and physician signature.

Current patient #33 record review, age 48, showed a surgical procedure of Application of an External Fixator right upper extremity on 05/02/10. The form titled "Informed Consent for the Transfusion of Blood and/or Blood Components is dated 05/01/10, but not timed by the physician. Without a time it is unknown if the form was completed prior to the patient's procedure.

Discharged record review for patient #22, age 53, showed a surgical procedure for removal of Gallbladder on 04/13/10. Review of the form titled "Informed Consent for the Transfusion of Blood and/or Blood Components is undated and untimed by the patient and physician. Without a time it is unknown if the form was completed prior to the patient's procedure.

Discharged record review for patient #26, age 39, showed a surgical procedure of Left Nephrectomy (removal of a kidney) on 04/14/10. Review of the form titled "Informed Consent for the Transfusion of Blood and/or Blood Components is undated and untimed by the patient. Without a time it is unknown if the form was completed prior to the patient's procedure.

Based on record review, the facility failed to ensure physicians authenticated orders and order sets with date and time for nine of sixty-nine patients (patient #21, #22, #23, #25, #26, #27, #29, #30, #32) sampled as required by facility policy. The facility census was 239.
Findings included:
1.Review of the policy titled " Chart Completion " (Hospital), " B. Hospital Implementation states in part the following: 1. It is the responsibility of any clinicians/ staff members / individuals who make a chart entry, dictate a report for transcription, or give a verbal order to authenticate that item within the medical record within a timely manner. If an individual other than the attending physician dictates a report, the report must identify the person providing the dictation, the dictating party is not required to sign the report (e.g. " dictated by John Hones for William Smith, MD " ). Authentication requirements are not restricted to physicians. These requirements apply to all individuals making entries in the medial record (e.g., physical therapists, recreational therapists, nursing staff.) "
2. Discharged record review for patient #21, age 48, showed a surgical procedure of Excision of left breast cyst and possible right breast cyst excision on 03/29/10. Review of the physician's order set titled "Ambulatory Care Unit Post-Op (operative) Orders" (order set used in the post anesthesia care unit area), "Surgical Prophylaxis Orders" (used to order prophylaxis antibiotics), and Post Anesthesia Care Unit Orders all showed the physician signed the orders, however, there was no date or time to indicate when the physician signed the three order sets.
Discharged record review for patient #22, age 53, showed a surgical procedure for removal of Gallbladder on 04/13/10. Review of the physician's order set titled "Intravenous Patient Controlled Analgesia (PCA) Order Form" (order set used to order pain medication for patient controlled pump), "Ambulatory Care unit Admission Orders" (order set used in the post anesthesia care unit area), "Surgical Prophylaxis Orders" (used to order prophylaxis antibiotics), and Post Anesthesia Care Unit Orders all showed the physician signed the orders, however, there was no date or time to indicate when the physician signed the four order sets.
Discharged record review for patient #23, age 31, showed a surgical procedure for Bilateral Tympanostomy with tube placement (is a small tube inserted into the eardrum in order to keep the middle ear aerated for a prolonged period of time, and to prevent the accumulation of mucus in the middle ear) on 04/13/10. Review of the physician's order set titled "Ambulatory Care Unit Post-Op (operative) Orders" (order set used in the post anesthesia care unit area) showed the physician signed the orders, however, there was no date or time to indicate when the physician signed the order set.
Discharged record review for patient #25, age 39, showed a surgical procedure of Wide Excision of Right Scapula (shoulder blade) Melanoma (cancer), Lymph Node Dissection on 04/13/10. Review of the physician's order set titled "Surgical Prophylaxis Orders" (used to order prophylaxis antibiotics) showed the physician signed the orders, however, there was no date or time to indicate when the physician signed the order set.
Discharged record review for patient #26, age 39, showed a surgical procedure of Left Nephrectomy (removal of a kidney) on 04/14/10. Review of the physician's order set titled "Surgical Prophylaxis Orders" (used to order prophylaxis antibiotics), and Post Anesthesia Care Unit Orders all showed the physician signed the orders, however, there was no date or time to indicate when the physician signed the two order sets.
Discharged record review for patient #27, age 48, showed a surgical procedure of Excision of right hip mass on 04/13/10. Review of the physician's order set titled "Ambulatory Care Unit Post-Op (operative) Orders" (order set used in the post anesthesia care unit area) showed the physician signed the orders, however, there was no date or time to indicate when the physician signed the order set.
Discharged record review for patient #29, age 60, showed a surgical procedure of Left Cataract Removal with Lens implanted on 04/13/10. Review of the physician's order set titled "IV (intravenous) and Medication Order Sheet" and "Outpatient Surgery Physician Discharge Orders" showed the physician signed the orders, however, there was no date or time to indicate when the physician signed the two order sets.
Discharged record review for patient #30, age 58, showed a surgical procedure of Right Arthroscopic Should Repair on 04/15/10. Review of the physician's order set titled "Ambulatory Care Unit Post-Op (operative) Orders" (order set used in the post anesthesia care unit area), "Surgical Care Infection Prevention (SCIP) Orders" (used to order prophylaxis antibiotics), and Post Anesthesia Care Unit Orders all showed the physician signed the orders, however, there was no date or time to indicate when the physician signed the three order sets.
Discharged record review for patient #31, age 32, showed a surgical procedure of Left Arthroscopic Shoulder Repair on 04/15/10. Review of the physician's order set titled "Surgical Prophylaxis Orders" (used to order prophylaxis antibiotics), and Post Anesthesia Care Unit Orders all showed the physician signed the orders, however, there was no date or time to indicate when the physician signed the two order sets.

Based on the facility's Rules and Regulations and record review, the facility failed to ensure telephone and verbal orders were signed by a physician with 48 hours for two patient (Patient #8 and Patient #3) of 69 medical records reviewed. The facility census was 239.
Findings included:
1. Review of the facility's policy titled "Verbal/telephone Order Read-Back Verification," approved 01/28/10, showed the following (in part): "The physician/physician assistant/nurse practitioner giving the verbal/telephone orders reviews and countersigns them within 48 hours of giving the orders."
2. Review of current Patient #8's medical record on 05/18/10 at 10:15 a.m. showed a physician order dated 05/15/10 stating "OK to use DHT (for meds)." {The meaning of DHT is uncertain.} order is signed by the physician, but not dated or timed.



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3. Review of current Patient #3's medical record on 05/17/10 at 3:45 p.m. showed a physician order dated 05/05/10 that said to change the PCA settings to PCA dose = 0.5 mg., rate = 2mg. an hour, lockout = ten minutes with one hour limit = 3mg. (Dosage for pain medication through an infusion pump). The order is signed by the physician, but not dated or timed.

Staff H, Registered Nurse Manager confirmed this at the time of the medical record review.

Based on facility policy review and record review, the facility failed to ensure staff properly documented informed consent prior to a blood transfusion for one patient (Patient #1) of 20 medical records reviewed for consent for blood transfusion. The facility census was 239.
Findings included:
1. Review of the facility policy titled, "Transfusion of Blood Components," last revised 04/09, showed the following (in part):
- "Signed written informed consent for transfusion of blood components must be obtained from the patient or the patient's representative (if the patient is not able to give consent)."
- "The physician should explain the risks and alternatives of transfusion to the recipient or responsible family member and document in the medical that this has been done."
- "The nurse caring for the patient is responsible for ensuring that the appropriate consent form is completed, signed, and placed in the patient's medical record."

Review of the facility policy titled, "Informed Consent," approved 09/24/09, showed the following (in part):
- "Elements of Informed Consent for treatment or procedure: Date and time of the patient, witness and physician signature."
- "Written informed consent is required for inpatients and outpatients having diagnostic and/or therapeutic interventions, to include, but not limited to: Invasive and surgical procedures, use of investigational drugs, emergency department treatment, administration of blood and/or blood components, chemotherapy agents, ambulatory care, anesthesia, conscious or moderate sedation, unless otherwise specified in this policy."
- "The consent form spaces and/or boxes will be completed, legibly using black or blue ink. The patient's first and last name shall be on the consent form."
- "For inpatients receiving recurrent and/or successive planned treatments/therapy/procedures (e.g., blood/blood component transfusions, hemodialysis, chemotherapy, etc.), the consent form is valid for the entire hospitalization unless the patient or patient's representative revokes the consent.
- "It is the legal responsibility of the physician performing the procedure to make certain the Consent form is accurately completed, signed, dated and timed and initialed by the patient, witness and physician."

2. Review of current Patient #1's medical record on 05/17/10 at 4:05 p.m. showed a form titled, "Informed Consent for the Transfusion of Blood and/or Blood Components." The consent was signed by the patient, but there is no documentation of date or time. At the bottom of the consent form there is a statement: "I certify that I have explained to the above individual the nature, purpose, risks and potential benefits of the above procedure and I have answered any questions that have been raised." The physician signed the statement, but did not date or time the signature.

Based upon record review and interview, the physician discharge summary of acute admissions failed to be completed within the required time frame of 30 days past discharge for three (#14, 13, 56) of seven cases reviewed. The current census in the hospital was 239.
Finding included:
1. Record review for Patient #14, admitted from 01/30-01/02/10, showed the recorded physician discharge summary signed by the dictating Fellow (student) physician on 03/09/10; and by the attending physician on 03/12/10, which is more than the required 30 day past discharge limitation for record completion.
2. Record review for Patient #13, admitted from 03/17-03/18/10, showed the recorded physician discharge summary signed by the attending on 04/29/10, which is more than the required 30 day past discharge limitation for record completion.
3. Record review for Patient #56, admitted 03/15-03/18/10, showed the recorded physician discharge summary signed by the attending physician on 04/23/10, which is more than the required 30 day past discharge limitation for record completion.
4. During interview on 05/18/10 at 10:00 A.M., the Director of Medical Records, Employee AAA, stated that the delinquent chart count is about 21%.

Based upon observation, interview and review of facility documents, the facility failed to have:
-specific policies for the meal service to outpatients kept overnight at Anheuser-Bush Institute (ABI) ; cross refer to A620.
-quality monitoring for the meal service to outpatients kept overnight at ABI; cross refer to A620.
-nutritionally adequate menu plans, including menu nutrient analysis for the meal service to outpatients kept overnight at ABI; cross refer to A628.
-staff with knowledgeable access to the approved diet manual for the meal service to outpatients kept overnight at ABI; cross refer to A620.
-safe and sanitary practices for food production and service at the main kitchen to include:
-hair covering.
-policy and process to check surface temperature of items to be sanitized by the dishmachine.
At the ABI kitchen:
-clean floors.
-stove, grill and hood area free of excess grease collection; cross refer to A620.

The cumulative results of these findings resulted in the overall non-compliance with CFR 482.28, Condition of Participation: Food and Dietetic Services.

Based upon observation, interview and review of facility documents, the facility failed to:
-have consistent hair covering for employees at the main campus kitchen.
-have adequate system in place to monitor the sanitizing hot water temperature for the dishwasher at the main campus kitchen.
-had no policy to provide detail instructions for the procedure of serving patients at the ABI Outpatient Surgery area.
-maintain safe and sanitary practices for food production and service at the Anheuser Busch Institute (ABI) cafeteria kitchen, which serves any patient needing to stay overnight for recovery.
-had no quality assurance, performance improvement monitors in place for the preparation and service of patient meals at the ABI.
The current census at the hospital was 239; and the total number of patients who were kept overnight at the ABI since 01/01/10 has been 15 patients.
Finding included:
During the kitchen tour at the main hospital kitchen on 05/17/10 at 2:00 P.M., and on 05/19/10 at 11:00 A.M. the following observations were made:
-the dishwasher employee who loaded the dishmachine, Employee YY, had shoulder length hair; and had a hairnet covering only the top crown of his/her head.
-the trayline hot beverage server employee, Employee ZZ, had very short hair; and had no hairnet to cover.
-Registered, Licensed Dietitian, Employee EE, had hair extending beyond the hairnet covering.
-Food Service Retail Manager, Employee E , had hair extending beyond the hairnet covering.
-Observation on 05/17/09 at 2:30 P.M., showed the process of testing the dishwasher with a temperature sensitive test tape produced negative results. The test was repeated with the second test run through the dishmachine four times. Neither test tape turned color, as would be the indication of adequate dish sanitation at 160 degrees Fahrenheit (F).
During interview on 05/17/09 at 2:30 P.M., the Chef, Employee D, stated the kitchen procedure was to record the temperatures on a clip-board log as indicated by the temperature dials on the dishmachine. Review of the temperature log showed complete data with all temperature readings at appropriate levels. Employee D stated that the facility did not use a system to test the water temperature at the surface level of each item being washed.
During interview on 05/18/10 at 11:00 A.M., Employee D stated that the machine had been checked by the maintenance employees and was found to have had clogged rinse water jets, which delayed the ejection of the hot rinse water and allowed the water to cool below sanitation levels.
During observation on 05/19/10 at 2:00 P.M., the kitchen tour at the Anheuser-Busch Institute (ABI) kitchen revealed the following:
-the floor in the serving area, and near the stove /grill was extremely slippery with grease.
-the hood over the stove/grill had a very heavy accumulation of grease, to the point of dripping.
-the floors, especially at the edges of doorways, were very dirty.
During interview on 05/20/10 at 10:30 A.M., the Director of Food Service, Employee UU, stated that the policies for food service would be the same as the policies for the main kitchen. Employee UU also stated that there was no quality assurance monitoring for the food service at the ABI kitchen.




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During an interview on 05/20/10 at 9:00 A.M. Anheuser-Busch Institute (ABI), Staff KK said:
-That there is no diet manual.
-The Food Service Director comes over to the Anheuser-Busch Institute (ABI) weekly, but only checks on employee food supplies. The Food Services Director does not check on patient food.
-Nursing staff would inform the kitchen if a patient has any special dietary needs, and Staff KK would call the main hospital if the Anheuser-Busch Institute (ABI) kitchen does not have the special foods.
-Staff KK said there is no Quality Data related to foods served at the Anheuser-Busch Institute (ABI) location.
-The nurses know when a patient will be staying overnight at the Anheuser-Busch Institute (ABI) location and come and get food before the kitchen closes. Staff KK said he/she does not know what happens to the food once it leaves the kitchen. He/she does not know how or where it is stored.
During an interview on 05/20/10 at 10:00 A.M. Registered Nurse (ABI) Staff MM said that he/she retrieves the food at 1:30 P.M. and brings it up to the nursing unit to store in the refrigerator. Staff MM said he/she heats the food up in the microwave, however, does not have the means to check the temperature of the food.
Staff MM said that Jello is stored in the refrigerator for patient use, however, regular temperature checks are only done on the refrigerator when patients are on the unit, not daily.
During an observation on 05/20/10 at 10:00 A.M. a penny on an ice cube in a Styrofoam cup is observed in the refrigerator freezer. Staff MM said that this is used to make sure the temperature did not get low enough to allow for the ice cube melting. Review of the form titled "Daily Refrigerator Temp Checks", showed from 05/1/10 to 05/20/10 only four refrigerator temperature checks were done.

Based upon review of facility documents and interview, the facility failed to have a menu to adequately meet the nutritional needs of the outpatients who are kept overnight at the Anheuser-Bush Institute (ABI), outpatient surgical center. This applied to all patients who were served meals as they were kept in observation overnight. The total number of patients who have stayed overnight at ABI since 01/01/10 has been 15. The current inpatient census of the hospital was 239.
Finding included:
Review of the menu options given to patients who stay overnight included lunch and dinner options for sandwich and / or soup and applesauce and garden salad with Ranch dressing. No breakfast menu was given to the patients.
During interview on 05/19/10 at 2:30 P.M., the Lead Cook, Employee KK stated that the patients who stay overnight would get a breakfast muffin and a serving of solid fruit, such as pineapple chunks or something.
During interview on 05/19/10 at 2:15 P.M., the Nurse in the Outpatient area, Employee PP provided the copied sheet of menu options and stated that the nursing department would have access to breakfast items such as juice, milk and instant oatmeal. If a patient would need a special diet, the ABI nursing staff would call the dietitian at the hospital for guidance.
During interview on 05/20/10 at 10:30 A.M., the Lead Dietitian, Employee EE for the hospital stated that the ABI menu had not been reviewed for nutritional adequacy.

Based upon interview and observation, the facility at the Aneuser-Busch Institute (ABI) for Outpatient Surgery failed to have knowledge and access to a current Diet Manual. This applied to all patients who were served meals as they were kept in observation overnight. The total number of patients who have stayed overnight at ABI since 01/01/10 has been 15. The current inpatient census of the hospital was 239.
Finding included:
During interview on 05/19/10 at 2:00 P.M., the Outpatient Nurse, Employee DD stated that the facility did not have a diet manual for their reference.
During interview on 05/20/10 at 10:30 A.M., the hospital lead dietitian, Employee EE stated that all nurses receive training upon hire about how to access the facility Diet Manual online.

Based upon observation, review of facility documents, and interview, the dishwasher in the main kitchen failed to reach adequate temperature to sanitize dishes. This applied to all patients, staff and visitors. The current inpatient census was 239.
Finding included:
Observation on 05/17/09 at 2:30 P.M., showed the process of testing the dishwasher with a temperature sensitive test tape produced negative results. The test was repeated with the second test run through the dishmachine four times. Neither test tape turned color, as would be the indication of adequate dish sanitation at 160 degrees Fahrenheit (F).
During interview on 05/17/09 at 2:30 P.M., the Chef, Employee D, stated the kitchen procedure was to record the temperatures on a clip-board log as indicated by the temperature dials on the dishmachine. Review of the temperature log showed complete data with all temperature readings at appropriate levels. Employee D stated that the facility did not use a system to test the water temperature at the surface level of each item being washed.
During interview on 05/18/10 at 11:00 A.M., Employee D stated that the machine had been checked by the maintenance employees and was found to have had clogged rinse water jets, which delayed the ejection of the hot rinse water and allowed the water to cool below sanitation levels.

Based on policy, interview, and observation, the facility failed to maintain a clean environment in the surgical services areas where procedures are performed; failed to maintain a clean environment for two current patients (Patient #40 and Patient #38); and the facility failed to implement appropriate infection control policies and procedures to prevent the risk of transmission of organisms for one patient (Patient #46) out of 44 current patients observed during nursing care procedures.

The facility census was 239.
Findings included:
1. Review of the facility policy titled "Cleaning Procedure: Surgical Suite, In-depth, dated as reviewed 4/2010, states in part the following cleaning instructions: Damp wipe equipment (except biomedical and electrical0, open horizontal surfaces, including ledges, counters, wall fixtures, vents, ceiling lights, fire extinguishers, linen hampers, waste receptacles, and clocks.
2. Review of the facility policy titled "Environmental Cleaning and Sanitation" (Department-Operating Room), dated as revised 07/09, states in part the following procedure to staff: The patient should be provided a clean, safe environment .... D. All horizontal surfaces in the OR (eg, furniture, surgical lights, booms, equipment) should be damp dusted before the first scheduled surgical procedure of the day. .....B. Cleans all flat surfaces ...
3. Review of the facility signage titled "Daily Routine For OR (Operating Room) Staff" posted in the surgical procedure rooms at the Anheuser-Busch Institute (ABI) outpatient surgical area states in part the following instructions to staff: .....make sure countertops and other working surfaces are clean and free of clutter. ....
4. During an observation on 05/18/10 at 2:15 P.M. , operating room known as #8 is found to have a very dusty prep stand in need of cleaning. Also, the anesthesia administration cart top is very dusty and in need of cleaning. The Registered Nurse Educator said this room was used at approximately 1:30 P.M. today.
During an interview on 05/18/10 at 2:20 P.M. the Registered Nursing Educator for the operating room said that the prep stand should be cleaned daily.
During an interview on 05/18/10 at 2:30 P.M. the Registered Nurse Director of Surgical Services said that the Anesthesia Technicians are responsible for cleaning the anesthesia carts daily.
5. During an observation on 05/18/10 at 2:35 P.M. , operating room known as operating room #12 is found to have an anesthesia administration cart top very dusty and in need of cleaning.
6. During an observation on 05/18/10 at 2:35 P.M. , operating room known as operating room cysto room is found to have an anesthesia administration cart top and the top of the x-ray light box very dusty and in need of cleaning. Also, the operating room table patient pad is found to have tears exposing the foam core (it is not possible to clean the pad since it has holes, making it an infection control hazard). The Registered Nurse Educator said this room was used approximately one week ago.
7. During an observation on 05/19/10 at 1:45 P.M. at the Anheuser-Busch Institute (ABI) outpatient surgical area operating room known as #3 the top of the anesthesia administration cart top very dusty and in need of cleaning. On 05/19/10 at 2:04 P.M. the Operating Room Interim Registered Nursing Manager said that room #3 was not used today, but was used for two cases yesterday. Also, he/she said that it is the operating room staff and housekeeping staff responsibility shared to ensure the cleaning is done.


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8. Observation of medication administration to Patient 40 on 05/18/10 at 9:15 a.m. showed blood on the floor in the patient's room and on the pole holding the intravenous pump due to the patient's intravenous line in the right hand had come loose and resulted in bleeding from the site.

9. Observation of Patient #40's room on 05/18/10 at 2:00 p.m. showed blood on the floor. Staff WW, Registered Nurse Manager said the patient had been taken to dialysis, (the process to remove liquid and chemicals from the blood that the kidneys would normally remove if they were functioning) along with the pole holding the intravenous pump.

10. Observation of patient care to Patient #38 on 05/18/10 at 9:35 a.m. showed what appeared to be dried blood on the foot board of the bed.

11. Observation of Patient #38's room on 05/18/10 at 2:00 p.m. showed what appeared to be dried blood remained on the foot board.





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12. Review of the facility policy titled, "Hand Hygiene," approved 09/24/09, showed the following (in part):
- "Decontaminate hands before having direct contact with patients."
- "Decontaminate hands after contact with a patient's intact skin, e.g., when taking a pulse or blood pressure, and lifting a patient."
- "Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled."
- "Decontaminate hands if moving from a contaminate-body site to a clean-body site during patient care."
- "Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient."

13. Review of the facility policy titled "Intravenous Therapy: Vascular Access Device Care and Maintenance," approved 05/28/09, showed the following (in part):
- "Follow Scrub the Hub and Save the Line Practice Protocol for all intravenous lines. Refer to Addendum C.
- Hand Hygiene and Aseptic Technique during insertion and care
- Vigorous friction to hub with hospital approved CHG swab for 30 seconds then let dry 30 seconds before accessing the line every time."
- "Prior to flushing a vascular access device, slowly aspirate until positive blood return to confirm catheter patency."

14. Review of the Practice Guideline titled, "Medication Administration: Intravenous Bolus," used for nursing education classes within the facility, showed the following (in part):
- "Perform hand hygiene."
- "Apply clean gloves."
- "Prepare flush solutions."
- "Clean lock's injection port with antiseptic swab. Allow to dry."
- "Insert syringe with 0.9% sodium chloride through injection port of IV lock."
- "Pull back gently on syringe plunger, and check for blood return."
- "Flush IV site with 0.9% sodium chloride by pushing slowly on plunger."
- "Remove saline-filled syringe."
- "Clean lock's injection port with antiseptic swab. Allow to dry."
- "Insert syringe containing prepared medication through injection port of IV lock."
- "Inject medication within amount of time recommended."
- "After administering medication, withdraw syringe."
- "Clean lock's injection port with antiseptic swab. Allow to dry."
- "Flush injection port."

15. Observation of medication administration to Patient #46 on 05/19/10 at 08:35 a.m. showed the following:
- Registered Nurse (RN) staff Z, entered the room and placed the medications for administration on the patient's overbed table. Hand hygiene was not preformed prior to applying gloves. RN staff Z roused the patient through touch, then unwrapped the oral medication and administered it to the patient. Without changing gloves, RN staff Z then administered a subcutaneous medication into the patient's abdomen. Next, without changing gloves, RN staff Z examined the patients intravenous (IV) site in the right arm. During palpation, the patient complained of tenderness at the site. Without changing gloves, RN staff Z then moved to the other side of the bed and palpated the IV site in the left arm and determined that the IV medication would be given in this site. Without changing gloves, RN staff Z went to a cabinet in the room and removed a pre-filled syringe, then went back to the bedside. The IV catheter hub was swiped with an alcohol pad, and the pre-filled syringe was attached to the hub. RN staff Z then pushed approximately half of the pre-filled syringe into the IV catheter, explaining that the reason the catheter wasn't checked for a blood return was because this had been done "a little while ago and there was a good blood return." RN staff Z then removed the pre-filled syringe and laid it on the overbed table. There was no protective barrier on the overbed table. Without changing gloves, RN staff Z then returned to the room cabinet and removed a second pre-filled syringe, squirted half of it into the trashcan, attached it to the medication vial containing the medication to be administered, and withdrew the medication. Returning to the bedside, without changing gloves, RN staff Z swiped the catheter hub with an alcohol pad, attached the syringe containing medication, and administered it over the course of approximately two minutes. RN staff Z then removed the empty syringe from the hub, swiped it, reattached the partially filled syringe that had been placed previously on the overbed table, and pushed what remained of that solution into the IV catheter. RN staff Z did not change gloves at any point during the medication administration process. When all medications had been given, RN staff Z removed the gloves and washed with soap and water at the sink in the patient's room.

During an interview on 05/19/10 at 2:55 p.m., Director of Nursing Practice staff Q and Clinical Educator staff GG agreed that RN staff Z should have performed hand hygiene before donning gloves, should have changed gloves and performed hand hygiene multiple times during the medication process, and did not follow proper procedure for administering IV medications.

Based on policy review, record review, and interview, the facility failed to ensure physicians and patients properly completed and documented informed surgical consent with date and time for ten of seventeen sampled patients (current Patient #33 and #1; and discharged Patient #21, #23, #25, #27, #29, #30, #32, #65, & #66 ). The facility census was 239.

Findings Included:

1. Review of the facility policy titled, "Informed Consent," approved 09/24/09, showed the following (in part):
- "Elements of Informed Consent for treatment or procedure: Date and time of the patient, witness and physician signature."
- "It is the legal responsibility of the physician performing the procedure to make certain the Consent form is accurately completed, signed, dated and timed and initialed by the patient, witness and physician."
- "Members of the Department of Anesthesia are responsible for explaining the risks, benefits, and alternatives for anesthesia any time a member of this department is assigned care of a patient. This is documented on the consent form in the Anesthesia declaration and the patient/patient representative signature, date and time is obtained. The Anesthesia physician then signs, dates and times in acknowledgement."

2. Current patient #33 record review, age 48, showed a surgical procedure of Application of an External Fixator right upper extremity on 05/02/10. Review of the document titled "Special Informed Consent to Surgery or Other Procedure" , reveals the section for the physician's signature is dated, however, the consent is not timed. Without a time it is unknown if the form was completed prior to the patient's procedure.

Discharged record review for patient #21, age 48, showed a surgical procedure of Excision of left breast cyst and possible right breast cyt excision on 03/29/10. Review of the document titled "Special Informed Consent to Surgery or Other Procedure" , reveals the section for the physician's signature is dated, however, the consent is not timed. Without a time it is unknown if the form was completed prior to the patient's procedure.

Discharged record review for patient #23, age 31, showed a surgical procedure for Bilateral Tympanostomy with tube placement (is a small tube inserted into the eardrum in order to keep the middle ear aerated for a prolonged period of time, and to prevent the accumulation of mucus in the middle ear) on 04/13/10. Review of the document titled "Special Informed Consent to Surgery or Other Procedure" , reveals the section for the patient and physician's signature is dated, however, the consent is not timed. Without a time it is unknown if the form was completed prior to the patient's procedure.

Discharged record review for patient #25, age 39, showed a surgical procedure of Wide Excision of Right Scapula (shoulder blade) Melanoma (cancer), Lymph Node Dissection on 04/13/10. Review of the document titled "Special Informed Consent to Surgery or Other Procedure" , reveals the section for the patient and physician's signature is dated, however, the consent is not timed. Without a time it is unknown if the form was completed prior to the patient's procedure.

Discharged record review for patient #27, age 48, showed a surgical procedure of Excision of right hip mass on 04/13/10. Review of the document titled "Special Informed Consent to Surgery or Other Procedure" , reveals the section for the patient and physician's signature is dated, however, the consent is not timed. Without a time it is unknown if the form was completed prior to the patient's procedure.

Discharged record review for patient #29, age 60, showed a surgical procedure of Left Cataract Removal with Lens implanted on 04/13/10. Review of the document titled "Special Informed Consent to Surgery or Other Procedure" , reveals the section for the patient's signature is dated, however, the consent is not timed. Without a time it is unknown if the form was completed prior to the patient's procedure.

Discharged record review for patient #30, age 58, showed a surgical procedure of Right Arthroscopic Should Repair on 04/15/10. Review of the document titled "Special Informed Consent to Surgery or Other Procedure" , reveals the section for the physician's signature is dated, however, the consent is not timed. Without a time it is unknown if the form was completed prior to the patient's procedure.

Discharged record review for patient #32, age 28, showed a surgical procedure of Right bunionectomy (removal of bony formation on the toe area) on 04/15/10. Review of the document titled "Special Informed Consent to Surgery or Other Procedure" , reveals the section for the patient's signature is dated, however, the consent is not timed. Without a time it is unknown if the form was completed prior to the patient's procedure.

Discharged record review for patient #65, age 36, showed a surgical procedure of Right Knee Reconstruction on 05/18/10. Review of the document titled "Special Informed Consent to Surgery or Other Procedure" , reveals the section for the patient's signature is dated, however, the consent is not timed. Without a time it is unknown if the form was completed prior to the patient's procedure.

Discharged record review for patient #66, age 36, showed a surgical procedure of Right Knee Arthroscopic examination on 02/02/10. Review of the document titled "Special Informed Consent to Surgery or Other Procedure" , reveals the section for the physician's signature is dated, however, the consent is not timed. Without a time it is unknown if the form was completed prior to the patient's procedure.


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3. Review of current Patient #1's medical record on 05/17/10 at 4:00 p.m. showed a form titled, "Special Informed Consent to Surgery or Other Procedure" for a "Irrigation and debridement (cleaning wound and removing dead tissue), external fixation (of right wrist fracture) placement (alignment) of right distal radius. The consent was signed by the patient on page two of the form, but there is no documentation of date or time. Beneath the patient's signature is a "Physician Statement" segment stating, "I explained the above statements, and answered all the patient's questions." The physician signed the form, but there is no documentation of date or time. Beneath that portion of the consent form is a segment giving consent for anesthesia. The patient signed that section of the form, and there is a date of 05/05/10, but no documentation of time. At the bottom of the consent form there is a statement: "I certify that I have explained to the above individual the nature, purpose, risks and potential benefits of the above procedure and I have answered any questions that have been raised, and the patient/representative agrees to proceed." The physician signed and dated the statement, but did not time the signature.

Review of current Patient #1's medical record on 05/17/10 at 4:10 p.m. showed a form titled, "Special Informed Consent to Surgery or Other Procedure" for a "Irrigation and debridement (cleaning wound and removing dead tissue), possible closure (of the wound), possible VAC change (wound vacuum, which accelerates healing), possible external fixation adjustment/revision of right wrist (fracture), and all other indicated procedures. Page two of the form indicates the intended surgery is "I&D (irrigation and debridement) Right Wrist," without mention of the "possible closure, possible VAC change, possible external fixation adjustment/revision of right wrist, and all other indicated procedures" which were documented on page one of the form. Page two of the consent was signed by the patient, and there is a date of 05/15/10, but there is no documentation of time. Beneath the patient's signature is a "Physician Statement" segment stating, "I explained the above statements, and answered all the patient's questions." The physician signed and dated the form, but there is no documentation of time. The consent to anesthesia portion of that form is blank, and the consent is documented on a separate (identical) form. The name of the procedure on this (third) page of the form is "I&D (irrigation and debridement) Right Wrist," without mention of the "possible closure, possible VAC change, possible external fixation adjustment/revision of right wrist, and all other indicated procedures" which were documented on page one of the form. The patient signed that section of the form, and there is a date of 05/14/10, but there is no time. At the bottom of the consent form there is a statement: "I certify that I have explained to the above individual the nature, purpose, risks and potential benefits of the above procedure and I have answered any questions that have been raised, and the patient/representative agrees to proceed." The physician signed and dated the statement, but did not time the signature.
During an interview on 05/17/10 at 4:30 p.m., Inpatient Nursing Director, staff W said the multi-page consent form is computer generated and printed, and the multiple pages are matched by the patient identification at the bottoms of the forms.
Review of the identifiers at the bottoms of the forms for the above example showed that the identification matched for pages 1 and 2 of the form signed 05/15/10. However, the consent for anesthesia form provided as evidence of obtaining consent for surgery on 05/15/10 (signed and dated 05/14/10) does not match the patient identification found on pages 1 and 2 of the form.

Based on policy, interview, and record review, the facility failed to provide post anesthesia evaluations for ten of sixteen surgical patients sampled (current patient #33 & #34 and discharged #24, #25, #26, #28, #31, #32, #63, & #64), within 24 hours after receiving a general anesthesia; and the facility failed to provide post anesthesia evaluations for two of two current psychiatric patients sampled (Patient #42 and #58), within 24 hours after receiving a general anesthesia for ECT (Electroconvulsive Therapy [electric shock therapy used for some psychiatric conditions]). The hospital census was 239.

Findings included:

Review of the medical staff rules and regulations, unknown date of approval, Section I-e states the following in part: ... ...Post-anesthesia evaluation completed within 24 hours after surgery. Evaluation includes: Date and time ... ...

During an interview on 05/19/10 at 10:20 A.M. the Anesthesia Services Medical Director said that Medical Records is responsible for tracking post-anesthesia evaluations not completed and that he/she does not remember any notification by the Medical Records department informing him/her of any incomplete evaluations.

Current patient #33 record review, age 48, showed a surgical procedure of Application of an External Fixator right upper extremity on 05/02/10; and Adjustment of External Fixator on 05/06/10. Review of the document titled "Anesthesia Perioperative Record" (also used to document the anesthesia post-operative visit at the bottom of the form), reveals the section for the post-operative evaluation is signed and dated 05/14/10 by the anesthesiologist, however, the assessment was not timed. Without a time it is unknown if the patient was assessed within the twenty-four hour time period.

Current patient #34 record review, age 47, showed a surgical procedure of Right percutaneous nephrolithotomy (removal of kidney stone) on 05/13/10. Review of the document titled "Anesthesia Perioperative Record" (also used to document the anesthesia post-operative visit at the bottom of the form), reveals the section for the post-operative evaluation is signed and dated 05/14/10 by the anesthesiologist, however, the assessment was not timed. Without a time it is unknown if the patient was assessed within the twenty-four hour time period.

Discharged record review for patient #24, age 46, showed a surgical procedure of Incision and Drainage of an Abscess with Possible Dental Extractions on 04/10/10. Review of the document titled "Anesthesia Perioperative Record" (also used to document the anesthesia post-operative visit at the bottom of the form), reveals the section for the post-operative evaluation is signed and dated by the anesthesiologist (using electronic stamping), however, the assessment section documenting the patient's condition was blank.

Discharged record review for patient #25, age 39, showed a surgical procedure of Wide Excision of Right Scapula (shoulder blade) Melanoma (cancer), Lymph Node Dissection on 04/13/10. Review of the document titled "Anesthesia Perioperative Record" (also used to document the anesthesia post-operative visit at the bottom of the form), reveals the section for the post-operative evaluation is signed and dated by the anesthesiologist, however, the assessment section documenting the patient's condition was blank.

Discharged record review for patient #26, age 39, showed a surgical procedure of Left Nephrectomy (removal of a kidney) on 04/14/10. Review of the document titled "Anesthesia Perioperative Record" (also used to document the anesthesia post-operative visit at the bottom of the form), reveals the section for the post-operative evaluation is signed and dated by the anesthesiologist (using electronic stamping), however, the date of the stamp is 05/01/10 at 11:07 P.M. and the assessment section documenting the patient's condition was blank.

Discharged record review for patient #28, age 14, showed a surgical procedure of Left Tendon Repair on 04/13/10. Review of the document titled "Anesthesia Perioperative Record" (also used to document the anesthesia post-operative visit at the bottom of the form), reveals the section for the post-operative evaluation is signed and dated by the anesthesiologist, however, the assessment section documenting the patient's condition was blank.

Discharged record review for patient #31, age 32, showed a surgical procedure of Left Arthroscopic Shoulder Repair on 04/15/10. Review of the document titled "Anesthesia Perioperative Record" (also used to document the anesthesia post-operative visit at the bottom of the form), reveals the section for the post-operative evaluation was blank. There is no documentation of a post-operative anesthesia evaluation.

Discharged record review for patient #32, age 28, showed a surgical procedure of Right bunionectomy (removal of bony formation on the toe area) on 04/15/10. Review of the document titled "Anesthesia Perioperative Record" (also used to document the anesthesia post-operative visit at the bottom of the form), reveals the section for the post-operative evaluation is signed and dated by the anesthesiologist (using electronic stamping), however, the date of the stamp is 04/21/10 at 11:42 A.M. and the assessment section documenting the patient's condition was blank.

Discharged record review for patient #63, age 27, showed a surgical procedure of Enecleation (removal) of Right Eye with Implant on 05/18/10. Review of the document titled "Anesthesia Perioperative Record" (also used to document the anesthesia post-operative visit at the bottom of the form), reveals the section for the post-operative evaluation is signed by the anesthesiologist, however, the assessment was not dated or timed. Without a date and time it is unknown if the patient was assessed within the twenty-four hour time period.

Discharged record review for patient #64, age 44, showed a surgical procedure of Left Arthroscopic Knee Repair on 05/18/10. Review of the document titled "Anesthesia Perioperative Record" (also used to document the anesthesia post-operative visit at the bottom of the form), reveals the section for the post-operative evaluation is blank. There was no documentation of a post-operative anesthesia evaluation.


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Review of current Patient #42's medical record on 05/18/10 at 2:20 P.M. showed that he/she had ECT (Electroconvulsive Therapy [electric shock therapy used for some psychiatric conditions]) on 05/05/10. Review of the document titled, "Anesthesia Perioperative Record" (also used to document the anesthesia post-operative visit at the end of the form), showed the section for the post-operative evaluation was blank. On 05/07/10, the ECT was repeated and the section for the post-operative evaluation was blank. On 05/12/10, the ECT was repeated and the section for the post-operative evaluation was blank. On 05/17/10, the ECT was repeated and anesthesia finished at 11:09 A.M. Review of the document titled, "Anesthesia Perioperative Record" showed the section for the post-operative evaluation was blank.

Review of current Patient #58's medical record on 05/18/10 at 3:35 P.M. showed that he/she had ECT (Electroconvulsive Therapy [electric shock therapy used for some psychiatric conditions]) on 05/10/10. Review of the document titled, "Anesthesia Perioperative Record" (also used to document the anesthesia post-operative visit at the end of the form), showed the section for the post-operative evaluation was blank. On 05/12/10, the ECT was repeated and review of the document titled, "Anesthesia Perioperative Record", showed the section for the post-operative evaluation was blank. On 05/17/10, the ECT was repeated and anesthesia finished at 10:35 A.M. Review of the document titled, "Anesthesia Perioperative Record" showed the section for the post-operative evaluation was blank.