HospitalInspections.org

Based on tour of 3 of the 5 hospital satellite practices and observation during tour of the hospital Emergency Room it was determined that the hospital failed to meet rules for the storage, handling and administration of drugs and biologicals.

Findings include:

During tour of the hospital Emergency Room with Staff H (Registered Nurse) on 7/31/12 at approximately 11:00 a.m. showed three individual mobile treatment carts stored in front of the emergency room nurse's station desk. These three mobile treatment carts each had a key protruding from each individual lock at the top section of each mobile cart allowing access to each cart by unauthorized individuals. These three mobile carts are stored by the nurse's station outer desk area which is adjacent to a main Emergency Room hallway utilized by individuals employed or not employed, patients, visitors, etc. within the hospital Emergency Room.

At the time of this tour Staff H confirmed that the three mobile treatment carts, containing multiple medications, needles and syringes, are stored in this area of the hallway on the outer side of the nurse's Emergency Room station with the keys protruding from the three individual mobile treatment carts.

Further observation during the Emergency Room tour with Staff H revealed that the wall mounted upper cabinets in Trauma Room 102 containing multiple medications, needles and syringes were unlocked and unattended.




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During tour of the facility satellites on 8/1/12 with Staff E (Director of Outpatient Clinics) it was confirmed through observation and interview that three practices failed to properly store and administer medications the findings are as follows:

1) When touring Internal Medicaine Associates it was observed in exam room #4 keys that were left in the cabinet door. When opening the door it was found to have needles and syringes. This key also was used on exam room #3 which also opened the cabinet doors. Exam rooms 1 and 2 had patients and were not able to be checked. Staff E observed findings and removed the key and returned key to staff.

2) When touring Winnipesaukee Family Medicine it was observed under the sink of the room where laboratory functions occur was a wash basin, within the wash basin were 14 vials of multi dose Lidocaine, 8 vials of multi dose bicarbonate, and serval multi dose vials of saline. Staff E questioned staff nurse of the practice why they were under the cabinet unsecured and staff nurse said they are to be sent back to pharmacy.

3) When touring Pediatrics it was observed within the medication refrigerator that there were two syringes that were drawn up with medication with no date, time, dose, and initials for the nurse who drew it up.

Based on record review and interview the facility failed to obtain a written physicians order to administer medications for 1 patient in a sample size of 40 patients. (Patient identifier #1)

Findings include:

During review of Patient #1's record it shows an admission date of 7/26/12 due to status post fall. On 8/1/12 an X ray was performed due to spine pain, part of the radiologist findings states "Frontal projection shows large amount stool consistent with constipation..." On 8/1/12 Staff A (Registered Nurse) was asked if Patient #1 has received any bowel medication or had any bowel movents since admission. Staff A stated that over the weekend on 7/29/12 17 gm of Miralax was given with no results.

On review of the Medication Records there was no order written for administering 17 gm of Miralax. This information was shown to Staff A who stated that medication was taken from another patient who had refused it earlier that day for a discard bin. Staff A did state that the medication that was given was told to the physician at time of administering the medication which the physician OKed, but the order was written for Milk of Magnesia 10 ML and not Murelax 17 gm's.

Based on record review and interview it was determined that the hospital failed to ensure that the patients' medical record is complete and accurate. (Patient identifiers are #36, #44, #45, #46, #47, #48, #49, #50, #51, and #53.)

Findings include:

Record review on 8/2/12 of the "TRANSFER CERTIFICATION" patient records revealed the following sections were not completed:

Patient #36 (dated 6/16/10) showed that section "Consent to Transfer", the section for the "Ambulance Service" and section for "nursing report to..." was not completed and there was no documentation of a patient identifier on this form.

Patient #44 (dated 1/10/12), Patient #45 (dated 4/2/12), Patient #46 (dated 7/13/12), Patient #47 (dated 7/21/12), Patient #48 (dated 6/2/12), Patient #49 (dated 6/27/12, Patient #50 (dated 1/8/12), Patient #50 (dated 7/11/12), Patient #52 (dated 6/21/12) and Patient #53 (dated 6/30/12) showed no documentation of a patient identifier on this form.

Patient #46 showed "Consent to Transfer" section and the section for "nursing report to..." was not completed.

Patient #48 showed "Consent to Transfer" section and "ambulance Service.." section not completed.

Patient #49 showed the section for "nursing report to..." not completed.

Patient #50 showed the section for "ambulance Service ..." not completed.

Patient #51 showed the section "Patient-Initiated Request for Transfer" and the section for "nursing report to" not completed.

Patient #53 showed the sections "NOTICE OF RISKS AND BENEFITS OF TRANSFER ... Physician's Certificate of Transfer... Consent to Transfer" not completed.

During interview with Staff G (Director of Health Information) on 8/2/12 at approximately 11:50 a.m. after Staff G reviewed the above listed patient record findings, Staff G confirmed that the "TRANSFER CERTIFICATION" forms did not have a patient identifier name and were not filled out completely as shown in the above findings.

Based on record review and interview the facility failed to maintain a patient record that includes properly executed informed consent on 1 of 16 patients in a surgical survey sample of 16. (Patient identifier is #12); and facility failed to have dated pre-operative history and physicals in 4 of 16 patients in a surgical survey sample of 16 patients. (Patient identifiers are #2, #4, #5, and #12).

Findings include:

Patient #12
Review of surgical records on 8/1/12 revealed a surgical consent for Patient #12 that was signed by the patient and witnessed by staff however the procedure to be performed was not indicated on the consent form.

Interview with Staff F,( RN Utilization/Risk Management), on 8/3/12 at 12:30 pm confirmed the informed consent for the procedure to be performed did not indicate the name of the procedure to be performed. The patient had signed the consent and the signature witnessed.

Review of surgical records for Patient #2, #4, #5, and #12 on 8/1/12 revealed pre-operative history and physicals were signed by the physician but not dated. Interview with Staff F confirmed the lack of a dated signature. Since the signature was not dated a determination of compliance with the history and physical within 30 days of surgery could not be validated.

Based on record review, interview and review of the hospital policy and procedure it was determined that the hospital failed to maintain effective monitoring of the progress in response to treatment for the administration of a bowel management medication for 1 inpatient in a survey sample of 20 inpatients, failed to have admission to swing physician order for 1 patient and it was determined that the hospital failed to complete a comprehensive pain assessment and reassessment following the administration of pain medications for 3 emergency room patients in a survey sample of 8 emergency room patients. (Patient identifiers are #1, #17, #39, #41 and #43.)

Findings include:

Review of the hospital policy and procedure titled "Pain Assessment (Acute and Chronic)" dated "May 2011" provided at the time of survey revealed the following:
"Policy Statement:
It is the policy of ... for patients to receive the best level of pain control that can safely be provided.
... has separate specific specific policies and protocols regarding ischemic chest pain and immediate postoperative surgical pain in the PACU (postanesthesia care unit).

Definitions:

Pain: is whatever the experiencing patient says it is, existing whenever she/he says it does. Self-report is the preferred indicator of pain, and behavior/physiological indicators are used only when the patient is unable to self report.

Self rating pain scale: ... uses a self-rating 0-10 scale to evaluate pain. 0 indicates no pain 10 indicates worse pain imaginable. A faces pain scale is available as a visual analogue scale for patients unable to utilize the numeric rating scale.

Unrelieved, non-ischemic pain: defined as a pain scale intensity rating of equal to or greater then 4, causes the patient distress, is unacceptable to the patient, or limits the patient's physical, cognitive or psychological function.

Pain relief: the alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient.

Procedure:
1. The assessment for the presence of pain will be done on initial assessment of all admitted patients and with routine vital signs. The appropriate ... flowchart will be utilized. This assessment will be escalated if the patient, RN (Registered Nurse), or care team deems that more frequent assessment is needed...
4. If the patient indicates Yes assessment and documentation will progress to
. Origin of pain
. Pain scale
. Pattern of pain
. Character of pain
. Aggravating factors
. Alleviating factors
. Interventions done
. Evaluation of effectiveness of intervention
5. Administer pain-relieving medications as ordered...
14. Re-assess pain intensity after each pain management intervention (pharmacological and non-pharmacological) once a sufficient time has elapsed for the treatment to reach peak effect (general guidelines: 30 minutes for IV, 60 minutes for PO/IM and 15-60 minutes for non-pharmacological)... "

Patient #39.
Record review on 8/1/12 of the "EMERGENCY DEPARTMENT ASSESSMENT" for Patient #39 dated "7/31/12" revealed that Patient #39 "Chief Complaint: c/o (complained of) abdominal pain R (right) upper quadrant...". In the section titled "Pain: ... 1-10 Scale 8...".

Further review in the section titled "Ongoing Assessment" for Patient #39 revealed that "Fentanyl 50 mcg IV (intravenous) - pain scale 8" was given to Patient #39 at "1600" and "Fentanyl 50 mcg IV for continued RUQ pain" was given at "1730". No documented evidence of a pain assessment could be found for the effectiveness of the Fentanyl administered to Patient #39 during the Emergency Room visit through discharge on 7/31/12.

Patient #41.
Record review on 8/1/12 of the "EMERGENCY DEPARTMENT ASSESSMENT" for Patient #41 dated "7/31/12" revealed that Patient #41 "Chief Complaint: ...back pain around to ...(lower) abd (abdomen) if you touch hip." In the section titled "Pain: ... 1-10 Scale 10/10..".

Further review in the section titled "Ongoing Assessment" for Patient #41 revealed that "Dilaudid 4 mg IM (Intramuscular) and Norflex 60 mg IM" were given to Patient #41 at "0550 and 0555". No documented evidence of a pain assessment could be found for the effectiveness of the Dilaudid and Norflex administered to Patient #41 during the Emergency Room visit through discharge on 7/31/12.

Patient #43.
Record review on 8/1/12 of the "EMERGENCY DEPARTMENT ASSESSMENT" for Patient #43 dated "7/31/12" revealed that Patient #43 "Chief Complaint: Headache started this morning. Areas of my temples radiating into the back of my head - some nausea - photosensitive...". In the section titled "Pain: 1-10 Scale 8-9..."

Further review in the section titled "Ongoing Assessment" for Patient #43 revealed that "Reglan 10 mg IV... Benadryl 35 mg po ... DHE 1 mg IV" were given to Patient #43. No documented evidence of a pain assessment could be found for monitoring the effectiveness of the above listed medications administered to Patient #43 during the Emergency Room visit through discharge on 7/31/12.

During interview with Staff H (Registered Nurse) on 8/1/12 at approximately 11:40 a.m., after Staff H reviewed the above listed patient Emergency Room records, Staff H confirmed that there was no documented evidence of a pain assessment for the effectiveness of the medications administered to Patients' #39, #41 and #43 during their Emergency Room visits as listed in the above findings.



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Patient #1
During review of patient #1's record it shows an admission date of 7/26/12 due to status post fall. On 8/1/12 an X ray was performed due to spine pain, part of the radiologist findings states "Frontal projection shows large amount stool consistent with constipation..." On 8/1/12 Staff A (Registered Nurse) was asked if Patient #1 has received any bowel medication or had any bowel movents since admission. Staff A stated that over the weekend on 7/29/12 17 gm of Miralax was given with no results.

Staff A was interviewed on 8/1/12 and asked since admission on 7/26/12 has Patient #1 had a bowel movement since it has been six days. Staff C (Registered Nurse) reviewed the computer for Staff A and confirmed that since admission on 7/26/12 until 8/1/12 Patient #1 has not had a bowel movement. On 8/2/12 Staff D (VP of Nursing) confirmed that Patient #1 did have a bowel movent later that evening on 8/1/12.

(Cross reference C 297)



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Patient #17

Review of medical record on 8/1/12 revealed a physician order on 1/29/12 to admit patient to Observation. Patient was changed to swing bed status later on 1/29/12 however, a physician order to admit to swing bed status was not obtained.

Interview with Staff F, (RN Utilization/Risk Management), confirmed that Patient #17 had an order to be admitted to Observation however, did not have an order to admit to swing. Patient was transferred to swing without an order from a physician.

Based on record review and interview it was determined that the facility failed to have comprehensive care plans to include measurable objective and timetables to meet residents medical and psychosocial needs on patient records.

Findings include:

During review of twenty inpatient records it was found that the facility's software program completed goal oriented charting, but failed to meet the regulatory requirements for a comprehensive plan of care by not having written, measurable objectives for a specified period of time. Interview with Staff B (Director of Information Technology) confirmed that the software program is unable to do a complete comprehensive care plan at this time.