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Based on policy and procedure review, document review, and staff interview, the facility failed to implement its hospital-wide infection control program per policy and procedure related to screening for immunization status and/or history for twenty of twenty-three (P3-P12, #S20-24, 26-28, #S8-9) personnel health records reviewed.

Findings:
1. Policy titled, "Employee Immunizations" reviewed at 9:00 AM on 2/3/10 indicated:
a. on pg. 1, under Procedure section, "The following immunizations are to be given...to employees: influenza, hepatitis B, and MMR (measles, mumps, rubella) vaccine."
b. on pg. 2, under MMR vaccine, point j., "Return form to Infection Control Nurse who will file it with employee's health records."

2. Review of personnel health records at 11:11 AM on 2/2/10 indicated:
a. Personnel P3, P4, P5, P7, and P9 lacked documentation of immunization status and/or history for Rubeola and Varicella.
b. Personnel P8, P11, and P12 lacked documentation of immunization status and/or history for Rubella, Rubeola, and Varicella.
c. Personnel P6 lacked documentation of immunization status and/or history for Rubeola, Varicella, and hepatitis B.
d. Personnel P10 lacked documentation of immunization status and/or history for Rubella, Rubeola, Varicella, and hepatitis B.

3. Review of personnel files on 2-3-10 indicated:
a. #S20 personnel file lacked documentation of immunity or documented disease history for Rubeola and Varicella.
b. #S21 personnel file lacked documentation of immunity or documented disease history for Varicella; immunity to Hepatitis B.
c. #S22 personnel file lacked documentation of immunity or documented disease history for Varicella; immunity to Hepatitis B.
d. #S23 personnel file lacked documentation of immunity or documented disease history for Varicella.
e. #S24 personnel file lacked documentation of immunity or documented disease history for Rubella, Rubeola and Varicella; immunity to Hepatitis B.
f. #S26 personnel file lacked documentation of immunity or documented disease history for Rubella, Rubeola and Varicella; immunity to Hepatitis B.
g. #S27 personnel file lacked documentation of immunity or documented disease history for Rubella, Rubeola and Varicella.
h. #S8 personnel file lacked documentation of immunity or documented disease history for Rubella, Rubeola and Varicella.
i. #S9 personnel file lacked documentation of immunity or documented disease history for Rubella, Rubeola and Varicella.
j. #S28 personnel file lacked documentation of immunity or documented disease history for Rubella, Rubeola and Varicella; immunity to Hepatitis B.

4. Interview with #S3 on 2-3-10 at 1520 hours indicated the findings were accurate. Additional documents were requested; none were provided prior to exit.

5. Personnel P20 was interviewed on 2/3/10 at 10:06 AM, and confirmed documentation of the immunization status and/or history was lacking as described for the above-mentioned personnel.


27548

Based on policy and procedure review, medical record review, and staff interview, the facility failed to ensure identification data as required by facility policy and procedure for five of nine (N4, N5, N6, N7 and N9) closed patient medical records reviewed.

Findings:

1. Policy No. HIS-07, titled "Medical Record Content", reviewed on 2/3/10 at 1:15 PM, indicated under Procedure section, point 3. Identification, "Labels have been developed to satisfy identification and should be used and placed on each page of the record. The labels should not obscure any documentation in the medical record. Where labels are not available, each page must contain sufficient patient identification to distinguish the page for that particular date of service."

2. Review of patient closed medical records on 2/3/10 at 11:16 AM, indicated:
A. patient N4, N6, N7 and N9, per General Condition of Admission forms dated 2/2/10, 2/2/10, 1/13/10, and 11/9/09, respectively, lacked an identification label and/or medical record number.
B. patient N5, per Progress Notes, lacked an identification label.

3. Personnel P15 was interviewed on 2/3/10 at 12:30 PM and confirmed, the above-mentioned medical record forms are lacking patient identification labels and/or medical record numbers as required per facility policy and procedure.

Based on document review, medical record review, and staff interview, the medical staff failed to ensure authentication of physician orders as required by facility policy and procedure for five of nine (N1-N5) closed patient medical records reviewed.

Findings:

1. Review of Medical Staff Rules and Regulations on 2/4/10 at 10:00 AM, on pg. 3, under Medical Records section, point a., "Orders for treatment shall be in writing...and signed by the attending physician."

2. Policy No. 05, titled "Providers' Orders", reviewed on 2/3/10 at 1:00 PM, indicated under Procedure section, point 3., "The provider may write and sign orders. The date/time is to be recorded..."

3. Review of patient closed medical records on 2/3/10 at 11:16 AM, indicated:
A. patient N1, per Emergency Department Physician Record, lacked date and time on physician order.
B. patient N2, per Emergency Department Physician Record, lacked physician authentication and time on physician order.
C. patient N3, per Physician Orders Induction Orders, lacked physician authentication date and time on physician order.
D. patient N4, per Physician Orders Newborn Orders, lacked physician authentication date and time on physician order.
E. patient N5, per Routine Post-Partum Orders, lacked physician authentication date and time on physician order.

4. Personnel P15 was interviewed on 2/3/10 at 12:30 PM and confirmed, the above-mentioned physician orders are lacking either physician authentication, date, and/or time as required per facility Medical Staff Rules and Regulations and policy and procedure.