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Based on interview and record reviews, the hospital failed to protect and promote the rights of each patient. The following deficient practices were identified:

1. The hospital failed to ensure that their grievance process was implemented and adhered to for 4 of 30 sampled patients (Refer to A 0122).

2. The hospital failed to ensure that the written notices for grievance resolution contained the required elements for 5 of 30 sampled patients (Refer to A 0123).

3. The hospital failed to ensure that for 1 of 30 sampled patients, the patient had the right to participate in the implementation of the plan of care (Refer to A 0130).

4. The hospital failed to ensure that for 1 of 30 sampled patients, the patient was provided the information needed to make an informed decision prior to undergoing an procedure (Refer to A 0131).

5. The hospital failed to adhere to the patient's wishes for 1 of 30 sampled patients as documented on the advance directive provided that noted that the patient did not want to be resuscitated. (Refer to A 0132).

The cumulative effect of these systemic problems resulted in the hospital's inability to be in compliance with the Condition of Participation for Patient Rights.

Based on interview and document review, the hospital failed to ensure that their grievance process timeframe for review and response were implemented and adhered to, for 4 of 30 sampled patients (Patient's 14, 15, 16 and 17) who submitted grievances to the hospital. The hospital failed to follow-up on the substantiated grievances for 2 of 30 sampled patients (Patient's 14 and 15) . These failures had the potential for all patients to not have their grievances investigated thoroughly and timely to prevent future occurrences in a universe of 104 patients.

1. For Patient 14, the hospital failed to notify the patient within 7 days (per the hospital's policy and procedure (P&P) titled, "Grievance/Complaint Process", dated August 2012,) that there was a delay in their investigation. The hospital also failed to follow-up on the patient's substantiated grievance regarding a left forearm injury.

2. For Patient 15, the hospital failed to notify the patient within 7 days (per the hospital's (P&P) titled, "Grievance/Complaint Process", dated August 2012,) that there was a delay in their investigation. The hospital also failed to follow-up on the patient's substantiated grievance regarding a missed physician order for breathing treatments (a medication given to ease breathing difficulty, like wheezing or shortness of breath).

3. For Patient 16, the hospital failed to notify the patient within 7 days (per the hospital's (P&P) titled, "Grievance/Complaint Process", dated August 2012,) that there was a delay in their investigation of the patient's grievance regarding the bill that the patient received for services that were not provided by the hospital.

4. For Patient 17, the hospital failed to notify the patient within 7 days (per the hospital's (P&P) titled, "Grievance/Complaint Process", dated August 2012,) that there was a delay in their investigation of the patient's grievance regarding the condition of the patient upon return to the hospital Emergency Department.

Findings:

On August 21, 2013, a review of the hospital's (P&P) titled, "Grievance/Complaint Process", dated August 2012, was conducted and included the following:

a. The hospital shall maintain a process for the prompt resolution of a patient grievance regarding an alleged violation of patient rights as mandated by the Center for Medicare/Medicaid Services (CMS).

b. A patient (the term patient also includes parent, spouse, family member, significant other, surrogate decision-maker, appointed guardian, conservator, etc.) who perceives that a right has been violated may submit a written or verbal grievance to the hospital.

c. If the issue is unable to be resolved immediately, or within 24 hours, the patient will be notified within seven (7) business days following submission of the grievance.

1. On August 21, 2013, a review of Patient 14's submitted grievance, dated February 7, 2013, was conducted. Patient 14's spouse alleged that upon discharge from the hospital, the registered nurse (RN) ripped off the tape that secured the patient's left forearm's (LFA) intravenous (catheter inserted into a vein for medication administration) site. As a result, the patient sustained a quarter sized skin tear that oozed blood. The documentation noted that the Patient Experience Coordinator (PEC) suggested that the patient be evaluated by their primary care physician or an urgent care physician.

A review of Patient 14's acknowledgement letter, dated February 18, 2013, eleven (11) days after the submission of the grievance, was conducted. The acknowledgement letter did not address Patient 14's specific allegations. The letter noted that hospital's investigation was delayed and that the patient would receive the results of the investigation in approximately two weeks.

On August 22, 2013 at 4:10 PM, an interview was conducted with Director of Medical Surgical Department (DMSD). When asked what steps she had taken on behalf of Patient 14 to investigate the allegation, the DMSD stated that she discussed the incident with the registered nurse involved. When asked what measures she implemented to prevent future occurrences, the DMSD stated that she verbally counseled the registered nurse involved. The DMSD confirmed that the patient went to an urgent care to have the LFA injury evaluated. The DMSD stated that she did not follow-up with the patient to determine the extent of the LFA injury.

On August 23, 2013 at 11 AM, an interview was conducted with the Director of Performance Improvement (DPI). The DPI stated that Patient 14 was seen in the hospital's urgent care department. She confirmed that the DMSD investigation did not include the extent of Patient 14's injury.

2. On August 21, 2013, a review of Patient 15's submitted grievance, dated February 5, 2013, was conducted. Patient 15 alleged that on February 4, 2013, the patient did not receive breathing treatments (medications) and alleged that the physicians were rude.

A review of Patient 15's acknowledgement letter, dated February 12, 2013, nine (9) days after the grievance was submitted, was conducted. The acknowledgement letter did not address the patient's specific allegations. The letter noted that hospital's investigation was delayed and that the patient would receive the results of the investigation in approximately two weeks.

On August 23, 2013 at 9:25 AM, an interview and document review were conducted with the Respiratory Therapy Supervisor (RTS). The RTS stated that her investigation results showed that the patient did not receive the breathing treatments as ordered by the physician on February 4, 2013. She stated that the computerized physician order entry was not received in the Respiratory Department, as a result the respiratory therapist did not know that the patient had a physician order for breathing treatments.

On August 23, 2013 at 11 AM, an interview was conducted with the DPI. The DPI confirmed that Patient 14's allegation for the missed breathing treatment was substantiated. She also stated that a missed dose of medication was considered a medication error and should have been reported. The DPI stated that the missed medication was not reported as medication error, but should have been. She also stated the hospital did not follow-up on the physician order for the breathing treatments that the Respiratory Department did not receive.

3. On August 21, 2013, a review of Patient 16's submitted grievance, dated June 14, 2013, was conducted. Patient 16 alleged that she left the Emergency Department without being seen, but received a bill for services that were not provided.

A review of Patient 16's acknowledgement letter, dated on June 24, 2013, ten (10) days after the submission of the grievance, was conducted. The acknowledgement letter did not address the patient's specific allegations. The letter noted that hospital's investigation was delayed and that the patient would receive the results of the investigation in approximately two weeks.

4. On August 21, 2013, a review of Patient 17's spouse's grievance, dated July 12, 2013 was conducted. The grievance noted that the patient was transported via bed from the Emergency Department (ED) to the Radiology Department (area in the hospital, like x-rays of the chest were performed). When the patient returned to the ED, he was soaked with urine from his waist down.

The hospital did not send an acknowledgement letter to the patient noting that their investigation was delayed.

On August 22, 2013 at 3:10 PM, concurrent interviews and reviews of the grievance and the P&P were conducted with the PEC and the DPI. When asked of the hospital's timeframe for resolving patient grievances, they stated that the hospital's practice was to resolve the grievances and/or notify the patients that the investigations were delayed within seven (7) business days, not calendar days. The DPI and PEC acknowledged that the hospital provided patient services 24 hours a day, 365 days a year. They confirmed that for Patient 14, 16 and 17 that the hospital did not meet the seven day timeframe.

During the same interview, the PEC stated that submitted grievances were forwarded to the specific department directors to conduct the investigations. The PEC also stated that at the conclusion of the investigations the resolution letters were sent to the patients' via certified mail.

On August 23, 2013 at 2:30 PM, an interview was conducted with the PEC and Chief Executive Officer (CEO). The CEO confirmed that the hospital's P&P was to resolve grievances or notify the complainants that their grievance investigations were delayed, within seven business days, not calendar days.

Based on interview and document reviews, the hospital failed to provide grievance resolution letters that contained the steps taken on behalf of the patient to investigate the grievances, the results of the grievance process, and the investigation completion dates for 5 of 30 sampled patients (Patient 14, 15, 16, 17 and 18). These failures created a risk for all patients to not be satisfied with the actions taken on their behalf. These failures also had the potential to contribute to unresolved grievances for a universe of 104 patients.

Findings:

On August 21, 2013, a review of the hospital's grievance process resolution letters was conducted. The letters did not elaborate on the steps taken by the hospital on behalf of the patient to investigate the grievance or the specific concerns. The letters did not contain the results of the grievance process or the investigation completion dates.

1. On August 21, 2013, a review of Patient 14's spouse's grievance, dated February 7, 2013, was conducted and noted that upon Patient 14's discharge from the hospital, the registered nurse (RN) ripped off the tape that secured the patient's left forearm's (LFA) intravenous (catheter [tube] inserted into a vein for medication administration) site. As a result, Patient 14 sustained a quarter sized skin tear that oozed blood. The documentation noted that the Patient Experience Coordinator (PEC) suggested that the patient be evaluated by their primary care physician or an urgent care physician.

A review of the resolution letter, dated March 11, 2013 was conducted. The letter did not include the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process or the date that the investigation was completed.

2. On August 21, 2013, a review of Patient 15's grievance, dated February 5, 2013, was conducted. The allegations indicated that Patient 15 perceived that the physicians were rude, and that the patient did not receive physician ordered breathing treatments.

A review of the resolution letter, dated March 8, 2013 was conducted. The letter did not include, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process or the date that the investigation was completed.

3. On August 21, 2013, a review of Patient 16's grievance, dated June 14, 2013, was conducted. The allegations indicated that the patient left the Emergency Department without being seen and received a bill for services that were not provided.

A review of the resolution letter, dated July 18, 2013, was conducted. The letter did not include, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process or the date that the investigation was completed.

4. On August 21, 2013, a review of Patient 17's grievance, dated July 12, 2013, was conducted. The allegations indicated that Patient 17 was soaked in urine from the waist down upon return to the Emergency Department from the Radiology Department.

A review of the resolution letter, dated July 22, 2013, was conducted. The letter did not include, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process or the date that the investigation was completed.

5. On August 21, 2013, a review of Patient 18's grievance, dated March 8, 2013, was conducted. The allegations indicated that the patient was left lying in urine for four (4) days.

A review of the resolution letter, dated March 14, 2013, was conducted. The letter did not include, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process or the date that the investigation was completed.

On August 21, 2013, a review of the hospital's policy and procedure (P&P) titled, "Grievance/Complaint Process, dated August 2012, was conducted. The indicated that the notification shall include: the steps taken on behalf of the patient to investigate the grievance, the date the investigation was completed and the results for the investigation and the subsequent outcome.

On August 23, 2013 at 11:45 AM, an interview and document reviews were conducted with the Director of Performance Improvement (DPI). She reviewed the grievance resolution written notices that were sent to Patients 14, 15, 16, 17 and 18, as well as the hospital's Grievance/Complaint Process policy and procedure. She stated that the hospital's resolution letters did not include the steps taken on behalf of the patients to investigate the grievance and the investigation completion date. The DPI stated that the hospital's grievance letters should have contained the required elements. The DPI further stated that the hospital's practice was to not disclose the outcome of the grievance process.

On August 23, 2013 at 3 PM, an interview was conducted with the CEO and Patient Experience Coordinator. The CEO stated that the hospital's grievance letters should contain a more detailed account of the actions taken by the hospital to investigate and resolve the grievances submitted.

Based on interview and record review, the hospital failed to ensure that 1 of 30 sampled patients (Patient 7), had the right to participate in the implementation of their plan of care. For Patient 7, the hospital failed to reassess for pain relief after the patient was medicated with intravenous morphine sulfate (a pain medication administered directly into the vein) after the patient complained of pain. This failure had the potential to contribute to Patient 7 not having needs met by not being appropriately medicated for pain.

Findings:

A record review and concurrent interview with Registered Nurse (RN) 6 were conducted on August 22, 2013 at 11 AM, of Patient 7's medical record. The record revealed that the patient was admitted on August 18, 2013 with dementia (prolonged and possibly progressive confusion), urinary tract infection and hematuria (blood in the urine). On August 19, 2013 at 7:19 AM, Patient 7 complained of pain and rated it a '5' on a 0 to 10 scale (0 is no pain experienced with 10 being the most severe pain ever experienced). According to RN 6, the hospital's practice was to reassess the patient after administering an intravenous pain medication to ensure that the medication was effective. RN 6 stated that there was no documented evidence that Patient 6 was reassessed.

On August 22, 2013, a record review of the hospital policy titled, "Pain Management, revised on March 2012" was conducted. The policy revealed the following: "(Hospital Name) licensed staff shall do an initial assessment and reassessment of pain on all patients, which shall include patient perception of, quality, radiation, severity and time of pain, in order to effectively manage their pain...The patient shall be reassessed...30 minutes after intravenous/intramuscular medications..."

Based on interview and record review, the facility failed to ensure that 1 of 30 sampled patients (Patient 1) in a universe of 104, was provided the information needed to make an informed decision prior to receiving an insertion of an Ash Catheter [A catheter surgically inserted into patients who have kidney damage and require dialysis (a process of removing toxic materials in the blood)]. This failure had the potential to result in the violation of Patient 1's rights to make an informed decision regarding the care and treatment which was provided.

Findings:

A record review and a concurrent interview were conducted on August 19, 2013 at 2 PM, with the Director of Performance Improvement. The record revealed that Patient 1 was admitted to the hospital on April 24, 2012 when the patient was admitted for kidney failure (Diminished function of the kidney). The admitting Medical Doctor (MD) ordered and requested that a kidney specialist evaluate Patient 1. Physician orders also included to insert an Ash Catheter for dialysis. A surgeon, (MD 1), performed the procedure on April 26, 2012.

A review of MD 1's operative report was conducted on August 19, 2013 at approximately 2 PM. The operative report of the Ash Catheter insertion, performed on April 26, 2012 revealed the following: "...the left subclavian vein (a blood vessel in which blood flows toward the heart) was cannulated (insertion of a cannula/Ash Catheter guidewire) by a single puncture. The guidewire was advanced through the localizing needle. However, it was impossible to advance the guidewire beyond approximately 15 centimeters (5.9 inches). The needle was removed and following a second attempt and a third attempt being unsuccessful to pass the guidewire through the needle into the subclavian system, the left subclavian approach was abandoned (removed). Then the right subclavian vein was cannulated...successful..."

On August 19, 2013 at approximately 2:15 PM, a review of an informed consent (A legal document obtained prior to an invasive procedure/surgery, which ensures that a patient was made aware by the physician, of all the potential risks and benefits of an invasive procedure, prior to having the procedure/surgery performed), dated April 25, 2012, was conducted. The informed consent contained an electronically signed signature from the surgeon, who inserted the Ash Catheter however; the signature was dated May 15, 2012 (19 days after the procedure was performed).

On August 19, 2013 at approximately 12 PM, a record review was conducted of the hospital's "Medical Staff General Rules and Regulations, approved by the hospital on December 12, 2012." The document revealed the following: "...INFORMED CONSENT: It shall be the practitioners responsibility to obtain an informed consent for all procedures identified in the (Hospital Name) procedure on consents, including blood and blood components. The practitioner shall document evidence of an informed consent in the medical record ..."

An interview was conducted on August 20, 2013 at 2:45 PM with MD 1 (the surgeon who had performed the procedure). He stated that he could not recall why the consent was signed 19 days post procedure.

Based on interview and record review, the hospital failed to ensure that the 'do not resuscitate' (DNR - instructs health care providers to not perform cardiopulmonary resuscitation [CPR]/life saving measures if breathing stops or if the heart stops beating) wishes for 1 of 30 sampled patients (Patient 2) was followed. This failure had the potential to contribute to patients seeking care in the hospital to not have their end of life wishes complied with.

Findings:

On August 19, 2013, a review of Patient 2's medical record was conducted with the Intensive Care Unit (ICU) Charge Nurse. The medical record indicated that Patient 2 was admitted to the hospital on August 16, 2013 with diagnoses that included jaundice (yellowing of the skin and eyes). Patient 2 also had a history of Alzheimer's disease (an ongoing, prolonged brain disorder that affects a person's ability to carry out daily activities).

A review of the "Patient Rights Acknowledgement," form, dated August 16, 2013 at 5:31 PM was conducted. It noted that the patient had an executed advance directive (AD-legal documents that allows the patient to spell out their decisions about end-of-life care prior to hospital treatment) and that a copy of the AD was submitted to the hospital personnel.

A review of the Power of Attorney (POA- a power of attorney gives specific instructions, prepared in advance, intended to direct medical and/or financial care of the patient), dated July 19, 2003, was conducted. The POA agent's (authorized to enforce the patient's end of life wishes) name was noted.

A review of the "Emergency Medical Services Prehospital Do Not Resuscitate," document dated June 7, 2007, was conducted.

A review of the physician order (PO), dated August 17, 2013, was conducted. It revealed a full code status (in the event of respiratory or cardiac arrest every possible measure available will be used to resuscitate the patient) PO.

A review of the physician progress notes, dated August 17, 2013, was conducted. It noted that Patient 2 was a full code.


A review of the nurses notes, dated August 17, 2013 at 2:30 AM, was conducted. It noted that the patient had an Advance Directive and that a family member was the POA. The documentation also noted that the patient resuscitation status was a full code.

On August 19, 2013, a review of the Patient 2's medical record indicated that on June 10, 2007 the patient's wishes were not to be resuscitated (DNR). However, a physician order and progress note, dated August 17, 2013, indicated that Patient 2 had a full code status.

On August 19, 2013 at 2:20 PM, an interview was conducted with the Intensive care Unit (ICU) Charge Nurse with regard to the inconsistencies between the patient's documented DNR wishes and the physician order for a full code status. The ICU Charge Nurse stated that the admitting physician must have spoken with the POA agent prior to writing the full code status order. The ICU Charge Nurse was unable to locate documented evidence that showed that the physician spoke with the POA agent regarding the change of Patient 2's code status from DNR to a full code.

On August 19, 2013 at 2:30 PM, an interview was conducted with the patient's family. The family member stated that the patient's wishes were not to be resuscitated.

On August 19, 2013 at 3:15 PM, an interview was conducted with the POA agent. The POA agent stated that when she submitted the advance directive documents on August 16, 2013, she believed that the hospital was going to implement and comply with the patient's wishes to not be resuscitated.

On August 19, 2013 at 3:30 PM, an interview and record review were conducted with Registered Nurse (RN) 4 that was assigned to provide care and services for Patient 2. RN 4 indicated that the electronic medical record reflected that the patient had a full code status and that the paper portion of the medical record noted that the patient had an AD that indicated a DNR status. When asked to provide documented evidence that the physician was notified of the patient's DNR wishes, RN 4 was unable to locate documented evidence to show that the physician was informed of the patient's wishes to not be resuscitated.

On August 21, 2013 at 2:15 PM, an interview was conducted with the Chief of Staff (CS). The CS stated that the admitting physician should have reviewed the advance directive (AD)documentation that was contained in the patient's medical record and then discussed the patient's AD wishes with the designated POA agent. He stated that the physician's order should have been consistent with the patient's do not resuscitate (DNR) wishes. The CS stated that the physician should have completed the hospital's "Code Status Form/ Comfort Care/Palliative Care Treatment Physician Orders," to ensure that the hospital complied with the patient's DNR wishes.

On August 21, 2013 at 3:05 PM, an interview was conducted with the Admitting Department Director (ADD) in the presence of the Director of Performance Improvement. The ADD reviewed Patient 2's "Patient Rights Acknowledgement, " form, dated August 16, 2013 at 5:31 PM. The ADD stated that a copy of the POA and DNR forms were obtained and placed in the patient's medical record. The ADD stated that it was not the Admitting Department staff's responsibility to inform the RN or the physician that Patient 2 had an executed advance directive for healthcare.

During the same interview, the ADD stated that the Admitting Department's responsibility was to scan the Advance Directives into the hospital's HPF (archive) system and place a copy of the AD in the patient's medical record for review. When asked if the licensed nurses and the physicians had access to the HPF system, the Director of Performance Improvement and the ADD stated that they were unsure.

On August 23, 2013 at 4:15 PM, the Quality Assessment and Performance Improvement interview was conducted with the Chief Executive officer (CEO), the Chief of Staff (CS) and the Director of Performance Improvement. The CS stated that the HPF (archive) system was only accessible to the physicians after the patients were discharged. The CS stated that the physician were responsible for reviewing and having the staff implement and comply with the patient's AD wishes for end of life care.

A review of the hospital's policy and procedure (P&P) titled, "Advance Directives," dated April 2013, was conducted. The P&P indicated that during the initial admission assessment, the licensed staff shall ask every patient 18 years and older if he/she has an Advance Directive. This information shall be documented in the patient's medical record. When a patient is admitted and does have a copy of his/her existing Advance Directive, the copy shall be placed in the patient's medical record. A sticker "Advance Directive" shall be placed on the Patients Chart. The physician shall be notified that the patient has an Advance Directive. When the patient's wishes are known, the physician shall be notified to provide verbal or telephone orders that are consistent with the patient's wishes.

On August 21, 2013, a review of the P&P titled, "Grievance/Complaint Process," dated August 2012, was conducted. It indicated that patients have the right to formulate advance directives (inpatients only) and have the hospital staff and practitioners who provide care comply with these directives.

Based on interview and record review, three physicians from the hospital's contracted Radiologic Services (Radiologists 1, 2 & 3) failed to identify, on three (3) occasions, that a fractured (broken or sheared piece) guidewire (a steel wire or cable used to guide the insertion of an Ash Catheter [A catheter surgically inserted into patients who have kidney damage and require dialysis]) was not left inside 1 of 30 sampled patients (Patient 1) after a physician attempted to insert an Ash Catheter. This failure had the potential to increase the risk of harm to all patients who seek treatment at the hospital.

Findings:

A record review and a concurrent interview were conducted on August 19, 2013 at 2 PM, with the Director of Performance Improvement. The record revealed that Patient 1 was admitted to the hospital on two (2) different occasions. The first admission was on April 24, 2012 when the patient was admitted for kidney failure. The admitting Medical Doctor (MD) ordered for and requested that a kidney specialist evaluate Patient 1. Medical Physician orders also included to insert an Ash Catheter for dialysis. A surgeon, (MD 1), performed the procedure on April 26, 2012.

A review of MD 1's operative report was conducted on August 19, 2013 at approximately 2 PM. The operative report of the Ash Catheter insertion, performed on April 26, 2012 revealed the following: "...the left subclavian vein (a vessel in which blood flows toward the heart) was cannulated (insertion of a cannula/Ash Catheter guidewire) by a single puncture. The guidewire was advanced through the localizing needle. However, it was impossible to advance the guidewire beyond approximately 15 centimeters (5.9 inches). The needle was removed and following a second attempt and a third attempt being unsuccessful to pass the guidewire through the needle into the subclavian system, the left subclavian approach was abandoned (removed). Then the right subclavian vein was cannulated...successful..."

A record review of Patient 1's medical record also revealed that during the first admission and after the insertion of the Ash Catheter, two (2) chest x-rays were obtained. The first x-ray was read by Radiologist 1 and the second one was read by Radiologist 2. Both times, the placement of the Ash Catheter was verified however, there was no documentation from Radiologist 1 or Radiologist 2 that they had identified that there was a piece of fractured guidewire that was left in Patient 1. Further record review revealed that on April 27, 2012, Patient 1 was discharged from the hospital.

A record review and a concurrent interview were conducted on August 19, 2013 at 2 PM, with the Director of Performance Improvement. According to the admission history and physical, Patient 1's second admission to the hospital was May 29, 2012 for severe low back pain; rule out urinary tract infection, renal disease among others.

Review of the discharge summary revealed that during Patient 1's admission, the patient developed a "worsening left eye infection with blurred vision" (endophthalmitis). During the hospitalization and due to the worsening eye infection, Patient 1 received orders to transfer to another hospital for a higher level of care. Prior to discharge, on June 10, 2012, Patient 1 received a chest x-ray. There was no documented evidence that the radiologist who viewed the chest x-ray and wrote the report (Radiologist 3), identified that there was a fractured piece of guidewire left in Patient 1 after MD 1 unsuccessfully attempted to insert an Ash Catheter into the left subclavian on April 26, 2012. On June 14, 2012, Patient 1 was discharged from the hospital and transferred to a second hospital.

During an interview, on August 19, 2013 at 2 PM, with the Director of Performance Improvement, she stated that on June 29, 2012 she received a telephone call from the hospital that Patient 1 was transferred to. The caller informed her that after they obtained a chest x-ray, their radiologist identified that Patient 1 had a retained fractured guidewire. The Director of Performance Improvement stated that after the hospital conducted their own investigation and had Patient 1's chest x-rays' re-read by the Director of Radiology, they identified the fractured guidewire and determined that "It was our fault." The addendum (an addition) to the initial chest x-ray, obtained on April 26, 2012 revealed the following: "Upon review of the chest radiograph from April 26, 2012, there is a linear metallic density overlying the aortic knob measuring approximately 4 centimeters in length...represents a fracture guidewire from an attempted placement of a central line catheter (referring to the Ash Catheter) on the left side..."

Based on staff interview and record review, the hospital failed to ensure the medical history and physical examination (H&P) report was completed, as per the hospital policy for 1 of 30 sampled patients (Patient 8). This failure had the potential to affect the planned course of treatment that may require additional interventions to reduce the risk of harm to the patient.

Findings:

During a review of Patient 8's medical record on August 20, 2013 at approximately 10:30 AM, it was revealed that Patient 8 was admitted to the hospital on August 9, 2013 for a complaint of pain to the right knee. The right knee x-ray report completed on August 9, 2013 at 12:35 PM, stipulated that there was a right hemiarthroplasty (a partial knee replacement, in which one joint surface is replaced with an artificial material, usually metal) present.

Further review of the medical record revealed that the "Pre-Operative or Short Form History and Physical" form was completed and signed by the physician but was not dated and timed.

During an interview with Registered Nurse (RN) 2 on August 20, 2013 at 10:35 AM, RN 2 was asked what the hospital policy indicated regarding what was required for a physician's entry that required a signature, RN 2 confirmed and stated that it should contain the date and time.

The hospital policy and procedure titled "General Documentation Guidelines" revised June 2012 indicated, "All health records of (hospital name) patients shall be documented in an accurate, complete and consistent manner to facilitate patient care and foster continuity of care among providers. The procedure under the "General Documentation Guidelines" 1.4 stipulated, "All entries shall be dated and timed appropriately."