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Based on record review, and staff interview, the governing body failed to function effectively including oversight of the Quality Assurance/Performance Improvement Committee, Medical Staff, Nursing and Medical Records.

Cross reference for specific details to:

482.13(d) (1) Patient Rights
482.21 Qapi;
482.22 Medical Staff;
482.23 Nursing Services and;
482.24 Medical Records

Based on observation, interview and job description, the facility failed to file and retain medical records to assure the patient's privacy was protected for two (2) of three (3) outpatient areas on campus.

Findings include:

Observation on 4/16/14 at 11:20 a.m. of the Outpatient Rehabilitation area of the facility, the active records were found in the lockable office of the department. The records were located in lockable file cabinets. The clerk confirmed that while the office door was locked at night, the file drawers were not locked and that housekeeping and security had keys to the office door after hours. The Department Manager and the clerk confirmed that the drawers should be locked at night and that they would resume doing so at close of business.

Observation on 4/16/14 at 1:10 p.m. of the Sleep Study Laboratory, located behind the main facility revealed that the medical records were kept in the office area which is locked after hours. The C.E.O. confirmed that the housekeeping and security departments had keys for entry when staff was not in the building.

Observation on 4/16/14 at 1:30 p.m. with the Supervisor of the Sleep Lab revealed at the end of a hall of patient bedrooms was an unlocked door. Upon opening the door, the room could not be entered because of a disarray of medical records (approximately 75-100) on the floor at a depth of six to eight (6-8) inches. There was a row of shelved medical records about 6 feet in height and 10 feet deep on the left hand wall. The Supervisor confirmed that this was inappropriate storage of records.

Review of the job description for the Health Information Management Manager (HIM) dated July 2010, revealed that HIM is to be responsible for coordinating all Health Information Management service across the Hospital including management of the HIM department and Associates and "Enforce all system and departmental privacy, record of care and information management policies and procedures..."

Based on record review, and staff interview, the Quality Assurance/Performance Improvement Committee failed to function effectively including oversight of the Medical Staff, Nursing and Medical Records.

Findings include:

Cross refer to:
482.13(d) (1) Patient Rights
482.21 Qapi;
482.22 Medical Staff;
482.23 Nursing Services and;
482.24 Medical Records

Based on policy and procedure review, and staff interview, the medical staff failed to assure physicians signed their orders within thirty (30) days after patient discharge for five hundred eighty three (583) orders.

Findings include:

Review of the physician chart audits from January 1, 2014 through April 14, 2014 revealed a document titled, "Deficiency Chart Total by Physician" dated April 2, 2014 with five-hundred-eighty-three (583) unsigned physician orders greater than thirty (30) days as follows:

· two hundred thirty two (232) unsigned physician orders greater than 30 days;
· sixty five (65) unsigned physician orders greater than sixty (60) days;
· thirty seven (37) unsigned physician orders greater than ninety (90) days and;
· two hundred forty nine (249) unsigned physician orders greater than one hundred twenty (120) days.

Review of the Medical Staff Bylaws, "Corrective Action for Failure to Complete a Medical Record" policy on page 16, section 10, physician privileges would be suspended when medical records were not complete 30 days after a patient is discharged.

Review of the Medical Executive Committee (MEC) meeting minutes dating from January 1, 2014 through April 14, 2014 revealed no evidence of suspension of physician privileges nor corrective actions for the 583 unsigned physician orders.

Interview on 4/16/2014 at 2:00 p.m. the Manager of Medical Records, confirmed the above findings.

Interview on 4/16/2014 the Senior Vice President confirmed the above findings stating the MEC was unaware of the 583 unsigned physician orders.

Based on a record review, policy and procedure, and staff interview, the hospital failed to provide nursing services and administer blood as ordered by the physician for one (1) patient (#15) of the sampled thirty-three (33) patients.

Findings include:

Cross refer to A409, for specific details

Review of the record for patient #15, revealed that the patient was admitted on April 11, 2014, with a diagnosis of Gastrointestinal Bleed, history of Peptic Ulcer Disease, smoker and drank alcohol. Review of the record revealed that patient #15 was actively bleeding, with clinical symptoms which caused a change in condition of the patient from a medical/surgical patient to an Intensive Care Unit patient. Over six (6) days the physician ordered a total of nine (9) units of Pack Red Blood Cell (PRBC), however despite the decline in the patient's condition, only six (6) units of PRBC were transfused.

Based on record review, policy and procedure review, and staff interview the facility failed to administer packed red blood cells (PRBC) as ordered by the physican to one (1) patient (#15) of the thirty three (33) sampled patients.

Findings include:

Record review for patient #15 revealed the following:

1. April 11, 2014-
Patient #15 was admitted from the Emergency Department (ED) on April 11, 2014 at 7:07 p.m. to the Medical/Surgical Unit with a diagnosis of Gastrointestinal Bleed (GI) Bleed and a previous history of Peptic Ulcer Disease, smoker-one (1) pack a day for twenty (20) years, and alcohol use- a six (6) pack a week.

Review of the ED assessment revealed that labortory assessments were completed including a Complete Blood Count (CBC). The CBC is a labortory test that assesses the Hemoglobin and Hematocrit (H/H), which is used to determine if a patient has a loss of blood (normal range of hemoglobin of 13.5-17.5 and hemacrit of 39-50).

Review of the CBC results of April 11, 1014 at 5:11 p.m. in the ED revealed that patient #15 had an abnormal H/H of 8.4/26.0.

Review of a physician's order dated April 11, 2014, at 7:08 p.m. revealed two (2) units of packed red blood cells (PRBC) were to be transfused STAT (stat-means immediately).

Review of a physician's order dated April 11, 2014 at 7:34 p.m. revealed to transfuse one (1) additional unit of PRBC. Review of the problem list per the physician revealed, acute blood loss anemia (a condition in which the body does not have enough red blood cells which carries oxygen to the major body organs).

Review of the Transfusion form (a form that is used during transfusion of blood products), dated April 11, 2014 at 7:55 p.m. one (1) unit of PRBC had been administered. Based on the time of the physician's order, this was one (1) of the two units of PRBC to be administered STAT, and the only unit that was transfused to patient #15, of the three (3) units ordered to stabilize the patient's acute blood loss.

Based on the above, three (3) units of PRBC were ordered to treat patient #15, and only one (1) was administered, despite physician orders and the abnormally low H/H.

2. April 12, 2014-
Review of the CBC dated April 12, 2014 at 7:37 a.m. revealed that patient #15, H/H were 7.9/25.0, reflecting continuous bleeding, and only one (1) of the three (3) units of PRBC were administered.

Review of the record revealed patient #15 received one (1) unit of PRBC on April 12, 2014 at 9:15 a.m.

Review of the physician orders dated April 12, 2014 at 9:25 a.m. revealed an order to transfuse two (2) units of PRBC.

Continued review of the record revealed patient #15, was transferred from a Medical/Surgical Unit to the Intensive Care Unit (ICU) on April 12, 2014 at 10:18 a.m., after vomiting large amounts of blood with severe dizziness and a near syncope episode.

After arriving to the ICU one (1) unit of PRBC was administered at 11:30 a.m.

In addition, after arrival to the ICU, an Esophagogastroduodenoscopy (EGD) and a Colonoscopy was completed. (An EGD is the process in which a scope (tube) is passed through the mouth to examine the gastrointestinal tract, the Colonoscopy, is the process in which the scope examines the lower gastrointestinal tract).

Based on the above, a total of five (5) units of PRBC were ordered to treat patient #15, and only a total of three (3) were administered, despite physician orders, the abnormally low H/H, the transfer to a higher level of care from Medical/Surgical Unit into an ICU, and obvious signs of active bleeding.


3. April 13, 2014-
Review of the CBC dated April 13, 2014 at 5:58 a.m. revealed that patient #15, H/H were 7.2/22.0, reflecting continuous bleeding.

Based on the above, a total of five (5) units of PRBC were ordered to treat patient #15, and only a total of three (3) were administered, despite physician orders, the transfer to a higher level of care from Medical/Surgical Unit into an ICU, obvious signs of active bleeding and a continued drop in the H/H.


4. April 14, 2014-
Review of the CBC dated April 14, 2014 at 8:16 a.m. revealed that patient #15, H/H were 6.9/21.0.

Review of the physician orders dated April 14, 2014 at 8:55 a.m. revealed an order to transfuse one (1) units of PRBC.

Review of the record revealed patient #15 on April 14, 2014 at 9:15 a.m. one (1) unit of PRBC was administered.

Review of the CBC dated April 14, 2014 at 10.40 p.m. revealed that patient #15, H/H were 8.8/27.0.

5. April 15, 2014-
Review of the CBC dated April 15, 2014 at 4.29 a.m. revealed that patient #15, H/H were 8.0/24.0.

Review of the physician orders dated April 15, 2014 at 9:21 a.m. revealed an order to transfuse two (2) units of PRBC.

Review of the record revealed patient #15 on April 15, 2014 at 10:55 p.m. one (1) unit of PRBC was administered.

Based on the above, a total of eight (8) units of PRBC were ordered to treat patient #15, and only a total of five (5) were administered, despite physician orders.

6. April 16, 2014-
Review of the physician orders dated April 16, 2014 at 7:52 a.m. revealed an order to transfuse one (1) units of PRBC.

Review of the medical record revealed that on 4/16/14
at 10:30 a.m., patient #15, received one (1) unit of PRBC.

Review of the CBC dated April 16, 2014 at 3.05 p.m. revealed that patient #15, H/H were 11.3/33.0.

Based on the above, a total of nine (9) units of PRBC were ordered to treat patient #15, and only a total of six (6) were administered, despite physician orders.

Review of hospital policy # MU-10-01 revealed an incident report would be completed for any blood administration errors, or adverse events, however there was no evidence of incident reports for the three (3) units of PRBC ordered for patient #15.

Interview on 4/17/2014 at 10:00 a.m. the Director of Quality, and Chief Nursing Officer confirmed the findings.

Based on observation, interview, and record review, the hospital failed to assure that pateint medical records were complete 30 days after patient discharge.

Findings include:

Cross Refer to 482.22 (A338) Medical Staff for specific details.

Review of the physician chart audits from January 1, 2014 through April 14, 2014 revealed a document titled, "Deficiency Chart Total by Physician" dated April 2, 2014 with five-hundred-eighty-three (583) unsigned physician orders greater than thirty (30) days as follows:

· two hundred thirty two (232) unsigned physician orders greater than 30 days;
· sixty five (65) unsigned physician orders greater than sixty (60) days;
· thirty seven (37) unsigned physician orders greater than ninety (90) days and;
· two hundred forty nine (249) unsigned physician orders greater than one hundred twenty (120) days.

Based on record review, policy and procedure review, and staff interview, it was determined that the hospital failed to appropriately complete patient medical records, evidenced by a review of chart audits which were incomplete as of the survey date 4/14/2014. The records remained incomplete, and delinquent missing necessary physician signatures for 583( five hundred eighty three ) orders greater than 30 days post discharge.

Findings include:

Review of the physician chart audits from January 1, 2014 through April 14, 2014 revealed a document titled, "Deficiency Chart Total by Physician" dated April 2, 2014 with five-hundred-eighty-three (583) unsigned physician orders greater than thirty (30) days as follows:

· two hundred thirty two (232) unsigned physician orders greater than 30 days;
· sixty five (65) unsigned physician orders greater than sixty (60) days;
· thirty seven (37) unsigned physician orders greater than ninety (90) days and;
· two hundred forty nine (249) unsigned physician orders greater than one hundred twenty (120) days.

A review of the hospital policy and procedure revealed the medical record policy # RC-01-06 10 titled Procedure for Medical Record Completion that indicated Physician orders must be signed within 30 days of discharge.

Interview on 4/16/2014 at 2:00 p.m. the Manager of Medical Records, confirmed the above findings.

Based on observation, interview, and work order the facility failed to ensure a system was in place in bathrooms that patients use in two (2) of three (3) outpatient departments toured: The Radiology Department and Outpatient Therapy Department. Each area is a high risk area increasing the likelihood of injury and/or harm to patients using the two (2) areas.

Findings include:

Observation on 4/15/14 at 9:30 a.m. in the Radiology department revealed the patient emergency call system in two (2) of (3) patient restrooms were not functioning. The third restroom could not be surveyed because of patient occupancy.

The Department Manager concurred that this needed to be corrected and asked someone to call in a work order.

A work order dated 4/17/14 stated that the problem had been called in on 4/15/14 at 10:15 am and validated that the problem involved all three of the restrooms due to a bad power supply. The repair was reported completed at 7:00 pm on 4/17/14.

Observation on 4/15/14 at 12:45 p.m. in the Outpatient Registration area revealed no emergency call system in the patient restrooms. The restrooms were located out of visual and auditory observation of the facility staff. A second surveyor verified the finding.