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Based on observation, interview and review of documents from the life safety recertificaton survey performed September 14th, 2015 through September 16th, 2015, Amery Hospital and Clinic was found to be not in compliance. The hospital failed to be constructed, arranged, or maintained to ensure the safety of the patients. The cumulative effect of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients in 9 of the 9 smoke compartments. The Existing Health Care Occupancy chapter of the Life Safety Code (2000 Edition) [NFPA 101] was used for this survey.

Findings Include:
K-18: Corridor openings were not smoke tight.
K-27: Openings in Smoke Compartment were not smoke tight.
K-29: Hazardous areas were not enclosed with hourly rated fire barriers.
K-51: Fire Alarm system missing visible appliances
K-130: Means of egress requires two operations to leave a space.

Please refer to the specific K-tags for additional details.

Based on observation, record review and interview the facility failed to ensure equipment for patients are inspected and repaired prior to use in 1 of 10 areas observed (Cardiac Rehabilitation).

Findings include:

Per review of facility policy titled Equipment Management Plan (n.d.), it states under Inspection of New Equipment "All new equipment must be certified ready for use either by service personnel with vendor, our biomedical service person or Maintenance Department."

Per observation on 9/15/15 at 10:00 AM in the Cardiac Rehabilitation room, there are 2 treadmills, newly installed in 2/15 that has not been inspected for safety by the biomedical staff; and the seat on the stationary cycle is split exposing foam. These findings were confirmed in interview with Registered Nurse F at time of discovery, stating the machines should have been inspected and the seat needs to be replaced.

Based on observation, record review and interview the facility failed to ensure biologicals and sharps are secure and not available to patients, visitors or unauthorized staff in 2 of 10 areas observed (Family Practice Clinic, Medical/Surgical Unit).

Findings include:

Per review of hospital and facility policy titled Administration Offices for Environmental Services, last reviewed 1/09, the policy includes the Family Practice Clinic, it states under "End of Day" for PODS B, C and D "lock cupboards".

On 9/14/15 at 12:35 PM, observed supply draws containing needles, syringes, and pill cutters unlocked on the Medical/Surgical unit in rooms 100, 104, 105, 203 and 308. Per RN C, at the time of the observation, rooms 104, 105 and 308 had broken locks and rooms 100 and 203 were left unlocked.
This was confirmed with RN C who stated in interview all the drawers containing sharps should be locked.


Per observation of the Family Practice clinic on 9/15/15 between 7:05 AM and 7:35 AM the following examination rooms have unsecured Thin Prep and Formalin (fixatives for tissue samples): 1B, 2B, 3B, 4B, 5B, 6B, 7B, 8B, 9B, 10B, 11B and 12B. Room 12 B also had a spray bottle of germicidal cleaning spray on the counter, unsecured. This is confirmed in interview with Medical Assistant I on 9/15/15 at 7:30 AM, who also stated the items have never been secured, and all the C and D rooms have them as well. Medical Assistant I was unaware of a spill kit for the Formalin.

Per observation on 9/15/15 at 7:25 AM, Procedure Room B had unsecured Formalin, needles and syringes. This was confirmed in interview with Certified Medical Assistant H on 9/15/15 at 7:25 AM who stated "The cupboards are to be locked every night and I unlock them in the morning."

Per interview with Quality Director J on 9/16/15 at 7:47 AM, J stated there is no policy for securing Thin Prep, Formalin, needles or syringes.





18816

Based on observation, interview and review of documents from the life safety recertification survey performed September 14th, 2015 through September 16th, 2015, Amery Hospital and Clinic was found to be not in compliance. The hospital failed to be constructed, arranged, or maintained to ensure the safety of the patients. The cumulative effect of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients in 9 of the 9 smoke compartments. The Existing Health Care Occupancy chapter of the Life Safety Code (2000 Edition) [NFPA 101] was used for this survey.

Findings Include:
K-18: Corridor openings were not smoke tight;
K-27: Openings in Smoke Compartment were not smoke tight.
K-29: Hazardous areas were not enclosed with hourly rated fire barriers
K-51: Fire Alarm system missing visible appliances
K-130: Means of egress requires two operations to leave a space.

Please refer to the specific K-tags for additional details.

Based on observation, record review and interview staff at this facility failed to ensure 9 of 10 services provided in this hospital were provided in a safe and effective manner

Findings include:

1. Staff at this facility failed to ensure policies are reviewed once a year per facility policy, in 2 of 10 departments policies reviewed (Environmental Services, Nutritional Services).
(see C-272)

2. Staff at this facility failed to ensure there are records for dispensing sample medications and syringes are labeled and stored per policy in 1 of 10 areas observed (Family Practice Clinic). (See C-276)

3. Staff at this facility failed to follow it's policies and professional standards of practice for multiple dose medication vials in 2 of 10 departments observed (Operating Room, Radiology). (see C-0278)

4. Staff at this facility failed to follow its policies and procedures and the recommendations of nationally recognized professional standards of practice evidenced by failing to maintain an environment that was free from potential contaminants to patient, staff, and/or visitors in 8 out of 10 departments observed (Emergency Department, Surgical and Decontamination area, Medical/Surgical Unit, Behavioral Health Unit, Radiology Department, Kitchen, Birthday Suites, and Pulmonary Diagnostic Department). (see C-0278)

5. Staff at this facility failed to ensure that nursing plans of care are developed and updated in accordance with patient's individualized needs in 6 of 20 patient care plans out of a total of 20 MR reviewed (Patient # 1, 2, 3, 4, 5, 6). (see C-298)

The cumulative effect of these systematic failures has the potential to affect all patients who receive care at this facility including the 24 inpatients and the 18 patients in the Behavioral Health Unit at the time of this survey.







32670

Based on record review and interview the facility failed to ensure policies are reviewed once a year per facility policy, in 2 of 10 departments policies reviewed (Environmental Services, Nutritional Services).

Findings include:

Review of facility policy titled Policies and Procedures Review (n.d.) states "All departments will review policy and procedures on an annual basis."

During interview on 9/15/15 at 8:00 AM, Director of Nutrition Services Z stated most kitchen/dietary policies have not been reviewed and updated since 2011. Per Director of Nutrition Services Z, the goal is is to have all polices in compliance and added to their new system by the end of 2015.

Per review of facility policy titled Administration Offices for Environmental Services, it was last reviewed in 1/09. This is confirmed with Quality Director G on 9/16/15 at 9:44 AM who said most of the policies have not been reviewed in environmental services since 2009.

Per interview with Environmental Services Manager D on 9/14/15 at 3:10 PM Environmental Services Manager D said the department's policies have not been reviewed for two to three years.


18816

Based on observation, record review and interview the facility failed to ensure there are records for dispensing sample medications, and that syringes are labeled and stored per policy in 1 of 10 areas observed (Family Practice Clinic).

Findings include:

Per review of facility policy titled Sample Drugs (n.d.) it states under #7 "All medication removed from the cupboards are to be logged for tracking purposes."

Per review of facility policy titled Medication Labeling, reviewed 12/14, it states "All items are drawn up or prepared outside of the pharmacy department must be immediately labeled..."

Per observation on 9/15/1/5 at 7:35 AM there are sample medications in the Family Practice Clinic. There are empty bins labeled with the following medication names: Noxium, Spirivia, Flovent, Tudorza and Anoro. There is no record of a log verifying which patients were given these samples. These findings are confirmed in interview with Medical Assistant I on 9/15/15 at 7:35 AM, who said both nursing and medical staff are to place the patient sticker on the index card in the bins, Medical Assistant I confirmed there are no stickers on the index cards for the medications.

Per observation on 9/15/15 at 7:10 AM there is an unsecured syringe with a clear solution on the counter of Procedure Room B. This is confirmed in interview, at the time of observation, with Medical Assistant J adding, "I don't know who drew it up or what is in it."

Based on observation, record review, and interview, staff at this facility failed to maintain an environment free of potential contamination to patients and other staff by not adhering to infection prevention expectations of the facility and nationally recognized standards of practice in 8 out of 10 departments observed (Emergency Department, Surgical and Decontamination area, Medical/Surgical Unit, Behavioral Health Unit, Radiology Department, Kitchen, Birthday Suites, and Pulmonary Diagnostic Department) and 1 of 6 observations of care (Patient #22).

Findings include:

During the interview with Infection Preventionist V, Vice President of Patient Care Services A, and Quality Director G on 9/16/2015 between 8:00 AM and 8:30 AM, Infection Preventionist V stated that staff at the facility are to adhere to the standards of practice for infection control, surgical services, and decontamination/sterilization from the following organizations: The Association of Professionals for Infection Control, Centers of Disease Control, The Association of peri-Operative Registered Nurses, and The Association for Advancement in Medical Instrumentation.

Standard of Practice:

Association of peri-Operative Registered Nurses Peri-operative Standards and Recommended Practices, 2013 Edition: "Masks should not be worn hanging down from the neck because the filter portion of a surgical mask harbors bacteria collected from the nasopharyngeal airway. The contaminated mask may cross-contaminate the surgical attire top."

Association of peri-Operative Registered Nurses recommended practices, Recommendation IV 2012:
All personnel should cover their head and facial hair when in the semirestricted and restricted areas. Hair coverings should cover facial hair, sideburns, and the nape of the neck. Perioperative nurses can help minimize the risk of surgical site infections by covering head and facial hair, which prevents skin squames and hair shed from the scalp from falling onto the sterile field.

Centers of Disease Control Safe Injection Practices 2007:
Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer's recommendations.

Centers of Disease Control Flash (Immediate Use) Sterilization 2008:
Flash sterilization should not be used for reasons of convenience, as an alternative to purchasing additional instrument sets, or to save time.

Emergency Department Observation on 9/14 /2015:

A tour of the Emergency Department was conducted on 9/14/2015 between 1:00 PM and 1:30 PM accompanied by Quality Director G. The following observations were made:
At 1:10 PM Registered Nurse P was observed exiting room 2 with gloves on and carrying a specimen cup containing a patient's urine. The specimen cup was not in a bio-hazard bag. After handing off the specimen cup to the Emergency Department Technician, Registered Nurse P removed gloves but did not perform hand hygiene.

Surgical and Decontamination area observations on 9/15/2015:
A tour of the High Level Disinfection area was conducted on 9/15/2015 at 7:15 AM accompanied by Surgery Coordinator Q. The following observation was made:
In a vented cabinet within the endoscope processing room the clean scopes are hung until used for the next procedure. This finding was discussed with and confirmed by Infection Preventionist V, Vice President of Patient Care Services A, and Quality Director G in an interview on 9/16/2015 at 8:15 AM. Infection Preventionist V agreed that the clean scopes should not be stored in the same room that dirty scopes are processed.

At 7:37 AM Certified Registered Nurse Anesthetist S entered the pre-operative area with a surgical mask tied around S's neck. The face portion of the mask was laying on S's chest which had exposed chest hair at the V of the scrub top. Certified Registered Nurse Anesthetist S did not perform hand hygiene upon entering or exiting Patient #22's pre-operative room. This finding was discussed with and confirmed by Infection Preventionist V, Vice President of Patient Care Services A, and Quality Director G in an interview on 9/16/2015 at 8:15 AM. Infection Preventionist V stated that education on hand hygiene is annual and S did not follow the expectations of the facility for hand hygiene or surgical attire.

At 7:50 AM in Operating Room 2 Certified Registered Nurse Anesthetist S was observed to have multiple dose vials of medication open in the anesthesia cart (Lidocaine 1%, Neostigmine 10 milligrams per 10 milliliters). Per interview with Certified Registered Nurse Anesthetist S at the time of the observation, S stated that syringes of the medications are drawn up prior to the procedure and put in the top drawer (several marked syringes were drawn up for Patient #22's pending operation). If more is needed during the procedure the vials would be accessed in the operating room. This finding was discussed with and confirmed by Infection Preventionist V, Vice President of Patient Care Services A, and Quality Director G in an interview on 9/16/2015 at 8:15 AM. Infection Preventionist V was unaware that multiple dose vials were being accessed in the operating room.

The facility's policy titled, "Safe Injection, Infusion and Medication Vial Practice," dated 4/11, states in part, "Keep multi-dose vials away from the immediate patient environment."

At 8:05 AM Medical Doctor/Surgeon T entered Patient #22's pre-operative room. Medical Doctor T did not perform hand hygiene upon entering or exiting the room. In an interview with Surgery Coordinator Q on 9/15/2015 at 8:08 AM regarding this observation, Q stated that the surgery department is the last to receive new foam hand sanitizer dispensers that will be put on the inside and outside of the rooms which will make it more accessible to staff.

At 8:10 AM Certified Registered Nurse Anesthetist S was observed assisting to transport Patient #22 to the operating room and tied the surgical mask that was laying on S's chest up over S's face.

Between 8:12 AM and 8:30 AM the following staff were observed in the Operating Room while the sterile field was being established, to have surgical bouffant style hair coverings tucked behind their ears, exposing the ear to the sterile arena: Registered Nurse X, Medical Doctor T, and Certified Registered Nurse Anesthetist S. This finding was discussed with and confirmed by Infection Preventionist V, Vice President of Patient Care Services A, and Quality Director G in an interview on 9/16/2015 at 8:15 AM. Infection Preventionist V stated that the staff did not follow the expectations of the facility for surgical attire.

At 9:04 AM an interview and tour of the Decontamination/Sterilization Department was conducted with Surgery Coordinator Q and Certified Surgical Technician U. Regarding the immediate use sterilizer and reasons for use, Technician U stated immediate use sterilization, "Is done a couple times per week to turn over instruments quickly if something is needed and we do not have enough." When asked for examples of equipment that would be immediate-use sterilized, Technician U stated, "Arthroscopy trays. We only have two and sometimes have more than two of those cases in a day."

A review of the logs, received on 9/16/2015 at 7:40 AM, for the immediate use sterilizer between 3/2/2015-9/14/2015 indicate that the 5 top immediate use sterilized equipment at this facility for the reason of quick turn around times, or more than one case and not enough equipment were: 1. eye instruments-56 times, 2. total knee instruments 13 times, 3. total hip instruments 8 times, 4. sinus scopes 7 times, and 5. McGlamry elevators (or foot instruments) 4 times.

This finding was discussed with and confirmed by Infection Preventionist V, Vice President of Patient Care Services A, and Quality Director G in an interview on 9/16/2015 at 8:15 AM. Infection Preventionist V and Vice President of Patient Care Services A both stated they were aware that immediate use sterilization for lack of equipment was not an acceptable reason.

At 9:33 AM Certified Registered Nurse Anesthetist S was observed wearing a pair of gloves to assist transferring Patient #22 to the bed after the surgical procedure. With these same gloves Certified Registered Nurse Anesthetist S used sani-wipes to clean the anesthesia machine and wires/cords of the anesthesia equipment, thereby re-contaminating them by wearing soiled gloves. Certified Registered Nurse Anesthetist S then exited the Operating Room, removing and discarding the gloves and did not perform hand hygiene. This finding was discussed with and confirmed by Infection Preventionist V, Vice President of Patient Care Services A, and Quality Director G in an interview on 9/16/2015 at 8:15 AM. Infection Preventionist V stated that Certified Registered Nurse Anesthetist S did not follow the expectations of the facility for glove changes and hand hygiene.

At 9:47 AM Registered Nurse R was observed removing a multidose vial of Lidocaine 1% that was used during the surgical procedure (accessed at 8:10 AM by Registered Nurse R and Surgical Technician Y in the Operating Room) and taking it out of the Operating Room, putting it into a drawer in the Accu-Dose medication dispensing machine. Per interview with Registered Nurse R at 9:47 AM, when the Lidocaine is needed for the next patient, staff would come in, remove the vial and take it to the operating room, take what they need and return it to the machine after surgery until it is empty. This finding was discussed with and confirmed by Infection Preventionist V, Vice President of Patient Care Services A, and Quality Director G in an interview on 9/16/2015 at 8:15 AM. Infection Preventionist V stated that this is not the expectation for multiple dose vials for this facility.

At 10:15 AM, accompanied by Certified Registered Nurse Anesthetist S and Surgery Coordinator Q, the Anesthesia carts in Operating Rooms 1 and 3 were inspected. Operating Room 1's Anesthesia Cart contained the following opened multiple dose vials: Lidocaine 1% and Dexamethasone.

Operating Room 3's Anesthesia Cart contained the following opened multiple dose vials: Lidocaine 1%, 2 vials of Rocuronium Bromide 10 milligrams per milliliter, Neostigmine 10 milligrams per 10 milliliters, and on top of the cart, unlocked, was an opened vial of Lidocaine 1%. Per previous interview with Certified Registered Nurse Anesthetist S, these vials would be accessed in the Operating Room, a patient care area, until empty.

This finding was discussed with and confirmed by Infection Preventionist V, Vice President of Patient Care Services A, and Quality Director G in an interview on 9/16/2015 at 8:15 AM. Infection Preventionist V stated that this is not the expectation for multiple dose vials for this facility.

Observation on the Medical/Surgical Unit:

On 9/14/15 at 1:30 PM, observed one wheelchair leg and two battery packs stored on the floor of the supply room on the Medical/Surgical unit. RN C confirmed at the time of discovery that the items should be placed on the shelves and not on the floor.

Per Quality Director G the facility does not have a policy related to storing clean items off the floor.

During the interview with Infection Preventionist V, Vice President of Patient Care Services A, and Quality Director G on 9/16/2015 between 8:00 AM and 8:30 AM, Infection Preventionist V stated it is not acceptable practice to store clean items on the floor.

Observations on the Behavioral Health Unit:

On 9/15/15 at 9:00 AM, observed one large black patient mat and one small blue patient mat stored on the floor of the supply room in the Behavioral Health Unit. Director of Behavioral Health AA confirmed at the time of discovery that the items should not be stored on the floor.

Radiology Department:

During interview on 9/15/15 with Director of Radiology BB, mulitdose vials of Lidocaine are used in the radiology department. The lidocaine is stored in a locked medication cart in the procedure room. Per Director of Radiology BB, the lidocaine is drawn up in the procedure room (patient care area) and then returned to the locked cart for use on the next patient.

Kitchen:

Per review of facility policy titled "Infection Control" dated 4/11, it states "wash temperature for dishwashing should be sufficient to clean and disinfect: Dishwasher: 150 degrees F was temp" and "Refrigerator and freezer temperatures should be monitored and documented on a daily basis."

Per review of dishwasher temperature and sanitizer logs the wash temperatures the dishwasher temperatures did not reach 150 degrees on 9/3/15, 9/5/15, 9/10/15, and 9/11/15.

Per review of "refrigerator/freezer temperature/cleaning monitoring Log" on 9/16/15 the refrigerator temperatures were not monitored or recorded on two refrigerators in the Medical/Surgical unit on 9/1/15, 9/2/15, 9/8/15, 9/9/15, 9/13/15 and 9/14/15.

Per interview with Director of Nutritional Services Z on 9/16/15, the facility contacted the manufacturer and a representative will be sent to reprogram the dish machine so the wash temperature is above 150 degrees. Director of Nutritional Services Z stated fridge and freezer temperatures should be monitored on a daily basis.

Observations in the Birthday Suites:

Per review of facility policy titled Medication Administration General Statements, revised 5/15, it states #14 "...Pill cutters should be cleaned after each use..."

Per review of facility policy titled Rotation/Outdate of Supplies, revised 2/09, it states "All departments are responsible for monitoring their fixed/secondary storage area and are to return all outdated items to the Materials Management Department..."

Per observation on 9/14/15 at 1:05 PM in the Birthday Suites, there is a pill cutter with a white power on the blade and stabilizing reservoir. At 1:37 PM in the nursery there are 8 boxes of baby formula, each containing 6 bottles, and one box containing 2 bottles that expired 9/1/15. These findings were confirmed in interview with Registered Nurse B at time of discovery, stating the pill cutter should be cleaned between use and the formula should be disposed of once expired.

Observations in the Pulmonary Diagnostic Room:

Per observation on 9/14/15 at 2:50 PM in the Pulmonary Diagnostic Room, a Fit Test Mister (sprays bitter solution to confirm the fit of a hepa mask) had a white powdery residue at the seal. This is confirmed in interview with Respiratory Therapist W, at time of observation, who stated the mister should be cleaned between use.


















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18816

Based on record review and interview the facility failed to ensure Patient Care Plans are timely and individualized to the patient needs and goals in 6 of 20 medical records reviewed (1, 2, 3, 4, 5, 6).

Findings include:

Per review of facility policy titled Documentation of Nursing Care and Plan of Care (n.d.) it states under C. "Each patient will have an individualized and interdisciplinary plan of care that will include documentation throughout the EHR (Electronic Health Record)..."

Patient #1's medical record review revealed Patient #1 was admitted on 9/10/15 with pneumonia. The History and Physical completed on 9/10/15 at 5:01 PM stated "...(patient) has bilateral rib cage pain on the lower rib cage area, left more than right." Review of Patient #1's care plan revealed a plan to address Patient #1's pain is listed as "Chronic" not initiated until 9/13/15. These findings were confirmed in interview with Director of Nursing K on 9/15/15 at 12:45 PM, stating the plan should be individualized and should have been initiated upon admission.

Pt #2's medical record review revealed Patient #2 was admitted on 9/14/15 with Gastrointestinal Bleeding. Review of Patient #2's care plan under "Care Plan Documentation" has no individualized plan, with patient specific preferences, goals and interventions. These findings were confirmed in interview with Registered Nurse L on 9/15/15 at 1:15 PM who stated the care plan is to be individualized based on patient preferences, goals and interventions.

Pt #3's medical record review revealed Patient #3 was admitted on 6/30/15 to deliver a baby. Review of Patient #3's care plan under "Care Plan Documentation" has no individualized plan, with patient specific preferences, goals and interventions. These findings were confirmed in interview with Registered Nurse L on 9/15/15 at 2:50 PM who stated the care plan is to be individualized based on patient preferences, goals and interventions.

Pt #4's medical record review revealed Patient #4 was admitted on 7/1/15 to deliver a baby. Review of Patient #4's care plan under "Care Plan Documentation" has no individualized plan, with patient specific preferences, goals and interventions. These findings were confirmed in interview with Registered Nurse L on 9/15/15 at 2:15 PM who stated the care plan is to be individualized based on patient preferences, goals and interventions.

Pt #5's medical record review revealed Patient #5 was admitted on 7/1/15 as a newborn. Review of Patient #5's care plan under "Care Plan Documentation" has no individualized plan, with patient specific preferences, goals and interventions. These findings were confirmed in interview with Registered Nurse L on 9/15/15 at 2:45 PM who stated the care plan is to be individualized based on patient preferences, goals and interventions.

Pt #6's medical record review revealed Patient #6 was admitted on 7/3/15 with as a newborn. Review of Patient #6's care plan under "Care Plan Documentation" has no individualized plan, with patient specific preferences, goals and interventions. These findings were confirmed in interview with Registered Nurse L on 9/15/15 at 3:15 PM who stated the care plan is to be individualized based on patient preferences, goals and interventions.

Based on record review and interview, staff at this facility failed to maintain a complete and accurate record by failing to 1. Ensure transfer forms are completed in 1 of 1 patient transfer records (Patient #10) out of a total of 20 medical records reviewed.
2. Ensure Emergency Department records include the time the physician was notified of a new patient to be seen in 4 of 4 Emergency Patient medical records (Patient # 2, 10, 11, and 12) out of a total of 20 medical records reviewed.
3. Ensure that emergency cart checks are documented as per facility expectation in 2 of 3 departments with emergency carts (Emergency Department, Medical/Surgical Unit )

Findings include:

The facility's policy titled, "Patient Transfer Policy," #65 which is undated, states in part, "The provider must then document on the transfer certification form that the medical benefits to be received from the transfer outweigh the risks."

Patient #2's medical record review revealed Patient #2 arrived in the Emergency Department on 9/10/15 at 12:38 PM with possible Gastrointestinal Bleeding. Review of the Emergency Department record does not include the time the Medical Doctor is notified the patient has been triaged and is ready to be seen. This is confirmed in interview with Registered Nurse L on 9/15/15 at 1:15 PM who added the Medical Doctor is usually there and knows when patients arrive, and they do not document notifying the doctor.

Patient #10's closed Emergency Department/Transfer medical record revealed that Patient #10 arrived at the Emergency Department on 8/25/2015 at 1:46 PM. There is no documentation regarding when the physician was notified of a new patient to see.

Patient #10 was transferred to an acute care facility for more advanced care. The transfer form does not specify the medical benefits or risks that are individualized to this patient. The transfer form does not indicate the time the provider spoke to the receiving facility's provider regarding the transfer. The Nursing section of the form does not indicate the time the patient arrived at the emergency department or what time the nurse spoke to the receiving facility's nurse. The Patient section of the form does not indicate why the transfer is needed. These findings were confirmed per interview with Emergency Department Coordinator N on 9/15/2015 at 2:47 PM who agreed that the form was not complete. Coordinator N also stated that the documentation of physician notification of a patient in the department used to be on the paper forms, but with the computer system that seems to have gone away.

Patient #11's closed Emergency Department/Transfer medical record revealed that Patient #11 arrived at the Emergency Department on 3/8/2015 at 10:40 AM. There is no documentation regarding when the physician was notified of a new patient to see.
These findings were confirmed per interview with Emergency Department Coordinator N on 9/15/2015 at 3:14 PM who agreed that physician notification was not documented.

Patient #12's closed Emergency Department/Transfer medical record revealed that Patient #12 arrived at the Emergency Department on 6/9/2015 at 10:48 AM. There is no documentation regarding when the physician was notified of a new patient to see. These findings were confirmed per interview with Emergency Department Coordinator N on 9/15/2015 at 3:24 PM who agreed that physician notification was not documented.



Facility document titled "Crash Cart Inspection" undated, states "For all areas, the crash carts need to be checked one time per 24 hour period."

The Emergency Department's check sheet for the emergency cart's for July, August, and September were received on 9/16/2015 at 9:40 AM. There are 2 days in August the checks were not documented (August 1 and 2) and one day in September (September 6). This was confirmed in with Quality Director G on 7/16/15 at 11:10 AM.

The emergency and supply equipment check sheets on the Medical/Surgical unit shows blanks for the dates of 8/4/15, 8/20/15 8/29/15, 9/7/15 and 9/11/15. Quality Director G confirmed these finding on 9/16/15 at 11:10 AM and stated the carts should have been checked on a daily basis.



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18816

Based on record review and interview, staff at this facility did not ensure that the time the surgeon signed the surgical consent form was documented on the consent form prior to surgery in 2 of 3 surgical consents out of a total of 20 medical records reviewed (Patient #7 and 8).

Findings include:

The medical staff rules and regulations, dated March 2015, state in part on page 51, "All clinical entries in the patient's medical record shall be accurately dated, timed, and authenticated."

Patient #7's closed surgical medical record revealed that Patient #7, a witness, the medical doctor, and the nurse anesthetist all signed and dated the surgical consent of 8/12/2015. The medical doctor and nurse anesthetist did not indicate the time they signed the consent.

This finding was confirmed per interview with Director of Nursing K on 9/15/2015 at 11:22 AM, who stated that the finding was correct, no time was indicated by either staff.

Patient #8's closed surgical medical record revealed that Patient #8, a witness, and the medical doctor signed and dated the surgical consent of 7/6/2015. The medical doctor did not indicate the time the consent was signed. This finding was confirmed per interview with Surgery Coordinator on 9/15/2015 at 12:20 PM, who stated that the finding was correct, no time was indicated by medical doctor.

Based on record review and interview the facility failed to include patients assets or strengths as part of the psychiatric evaluation in 3 of 3 (#15, 15, 17) psychiatric MR's reviewed out of a total of 20 MR reviewed. This has the potential to affect all 18 patients on the Behavioral Health Unit during this survey.

Findings include:

Review of facility policy titled "Written Plan of Service - older Adult Psychiatric Inpatient Unit" dated 12/1/08 states under assessment and evaluation "2. The psychiatric evaluation includes: ...patients assets..."

Review of Pt # 17's MR on 9/15/15 revealed the Psychiatric Evaluation does not contain assets or strengths as part of the evaluation.

Review of Pt # 16's MR on 9/15/15 revealed the Psychiatric Evaluation does not contain assets or strengths as part of the evaluation.

Review of Pt # 15's MR on 9/15/15 revealed the Psychiatric Evaluation does not contain assets or strengths as part of the evaluation.

During an interview on 9/15/15 at 10:30 AM, VP of Care A confirmed the psychiatric evaluation did not include patients assets.