HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure the provision of call lights in seven (7) of seven (7) emergency room bays to meet the needs of patients.

Findings Include:

Observation on 03/22/16 at 2:00 p.m. revealed the facility had no call lights in any of the seven (7) emergency room bays and no call light system was noted in the nursing station.

During an interview on 03/22/16 at 2:05 p.m. the Registered Nurse stated, "We have no call lights in the emergency room bays and no rule about how often to check on the patients in the bays, however we have two nurses and one triage nurse and we check on patients every 15 to 20 minutes."

Based on observation, staff interview, document review, Medical Staff Rules and Regulations review, Job Description Review, and policy and procedure review, the Governing Body failed to assume responsibility for the hospital's operation and is involved in the day-to-day operation of the hospital and is fully responsible for it operations.



Findings include:


Cross Refer to C200 for the facility's failure to ensure call lights are provided in all emergency room bays to ensure the safety of all patients.



Cross Refer to C276 for the facility's failure to ensure outdated medications were not available for patient use.


Cross Refer to C294 for the facility's failure to ensure the safety of their patients and pedestrians by failing to lock medication carts found on the medical-surgical hall unlocked with medications inside.

Cross Refer to C302 for the facility's failure to maintain complete clinical records.


Cross Refer to C386 for the facility's failure to provide medically related Social Worker (SW) services to their swing bed residents.

Based on observation, staff interview and policy review, the facility failed to ensure outdated medications were not available for patient use.

Findings Include:

On 03/22/16 at 10:50 a.m. observations were made on the nursing unit and the surgical unit:

The medication room contained three (3) outdated medications:
Humulin N Insulin with an expiration date of 02/2016;
Tuberculin PPD with an expiration date of 3/20/16; and
Silver Sulfadiazine cream with an expiration date of 02/2015.

The surgical unit contained:
three (3) 1000 ml (milliliter) IV (intravenous) bags containing Normal Saline with an expiration date of 11/2015;
Nine (9) 20 mg (milligram) vials of injectable Anectine with an expiration date of 06/2015;
two (2) 50 mg vials of Atracurium Besylate infectable with an expiration date of 12/2015; and
three (3) 30 mg. vials of injectable Marcaine with an expiration date of 03/01/2016.

An interview with the charge nurse and acting Director of Nurses (DON) on 03/22/16 at 11:30 a.m. confirmed the outdated medications. The acting DON stated the pharmacy checks medications once a month. The charge nurse stated that medications are checked by the nursing staff before administrating.

An interview on 03/22/16 at 11:50 a.m. with the Pharmacist revealed the crash carts and Med Selects (Automated Dispensing Systems) are checked monthly and if there is a medication expiring in the current or upcoming month it is pulled and discarded.

Review of the facility's "Pharmacy -Inventory Inspection for Expiration Dating" policy dated 11/2014 revealed: "...'expired products' will be pulled ...Pharmacy will perform routine (e.g. quarterly, monthly) inspections of drug area for expired drugs ....all Automated Dispensing Systems shall be inspected monthly, all expired or deteriorated stock will be removed ...".

Based on observation, staff interview, and document review, the facility failed to ensure the safety of their patients and pedestrians by failing to ensure medication carts are locked when not in use by nursing staff.

Findings Include:

On 03/22/16 at 11:15 a.m. observations made on the medical - surgical floor revealed an unlocked COW (computer on wheels) medication cart on the floor sitting beside the crash cart. Both drawers 138 and 139 contained medications. When floor staff was asked who was using the cart, no one claimed it. A Registered Nurse came forward and stated, "These patients were discharged yesterday." The medications were immediately removed from the cart by staff.

On 3/22/16 at 2:30 p.m. the interim Director of Nursing stated, "That cart has been broken and it won't lock. We took it off the floor." At that time the policy regarding the Computer on Wheels was requested and the inservices given to nurses instructing them how to use them.

On 3/22/16 at 4:00 p.m. the Quality Assessment Manager stated, "No policies can be found on COWs and no in-service documentation on using them is available. I'm sure we did them."

During an interview on 03/23/16 at 8:30 a.m. the Charge Nurse stated, "We are supposed to take the COWS off the floor if they will not lock. We are supposed to go get the medication for each patient and take it to their room, if the COWS are broken. It's been broken two months. We have turned in the proper paper work to get it fixed but he hasn't done it. If a patient is discharged, the nurse is supposed to take the medications to the pharmacy and if the nurse doesn't, the charge nurse is supposed to check each cart every change of shift to be sure no medications are in the COWs."

On 03/23/16 at 10:00 a.m. policies for Computer on Wheels and any in-services were requested again. None were submitted for review.

During exit conference on 03/23/26 at 11:15 a.m. all evidence was presented. No further documentation was provided.

Based on record review, document review, Medical Staff Rules and Regulations review, and staff interview, the facility failed to maintain complete clinical records.

Findings Include:

Review of the facility's March 22, 2016 Incomplete and Delinquent Record Report revealed 140 closed patient records with delinquent (greater than 15 days) dictation or delinquent signatures.

Review of the facility's "Medical Staff Rules and Regulations", last amended 11/17/97, revealed: "...IV. Medical Records ...B. ...The record shall be completed within 15 days following discharge of the patient ...The medical records administrator will notify the physician in question when he has five (5) or more records not completed by 12 days after discharge. She will notify him of three(3) weekdays in which he has to complete the records ...At the end of 3 days, if the medical records are not complete and become delinquent, the president of the Medical Staff will notify the physician delinquent in records completion that his admitting privileges are being terminated until delinquent records have been properly completed ...".

Review of a document received from the Registered Health Information Technician (RHIT) on 3/22/16 at 11:10 a.m. revealed,
"Physician's Incomplete Charts -
The physician's incomplete records are counted each month before the Board Meeting and department managers meeting. These charts are found in the Medical Staff Room separated according to the attending physician. A chart is considered incomplete (a line was drawn through incomplete and delinquent was handwritten in) if the patient has been discharged for more than 15 days.
Three categories are checked for completeness: Emergency Room Records, (charts to be dictated had a line drawn through it), and charts to be signed (signed had a line drawn through it and locked was handwritten in). A letter is sent along with the incomplete chart count to each physician having delinquent records informing him of this. Copies of the incomplete chart count list are given to the administrator, chief of medical staff, hospital board members, and a copy is placed on the bulletin board in the Medical Staff Room. This incomplete chart count is also given to the Utilization Review/Medical Records Committee at their monthly meeting."

During an interview on 03/23/16 at 10:00 a.m. the RHIT confirmed the facility had 140 closed patient records with delinquent dictation or signatures.

Based on medical record review, policy and procedure review, and staff interview, the facility failed to ensure three (3) of 26 patients reviewed had properly executed informed consent forms and rights and responsibilities forms. Patient #15, #16 and #18.


Findings Include:


Record review for Patient #15, #16 and #18 revealed no documented evidence of signed and/or dated informed consent forms and/or rights and responsibilities forms.


During an interview on 03/23/16 at 10:00 a.m. the Registered Health Information Technician (RHIT) confirmed that the informed consent forms, and the rights and responsibilities forms were not signed or dated for Patients #15, #16 and #18.



Review of the facility's "Consent Policy", effective 7/21/00, revealed: "Policy - A. General consent is obtained at admission or registration and is valid for the duration of hospitalization or date of service. If the patient is coherent, the patient is responsible for signing the Consent form and the Rights and Responsibility form ... Responsibility Action - Admitting Clerk - 1. Consent form must be filled out completely. 2. Date, time, name of patient. 3. Patient signature, date (if patient is unable to sign and family member is available to sign, note on the consent."

Based on medical record review, staff interview and policy review, the facility failed to provide activities to two (2) of two (2) swing bed patients reviewed, Patient #23 and #24, based on their individual need and choice.

Findings Include:

Record review for Patients #23 and #24 revealed a standard nonspecific activity assessment. Both patients received a calendar of activities that were not individualized and contained no choices of activities.

An interview with the Activity Director on 03/23/16 at 9:15 a.m. confirmed that the activity calendar did not contain choices that enabled the patient to choose.

Review of the facility's "Swing Bed Policy-Patient Activities", approved 11/2014, revealed: "...the facility will provide a schedule of activities to accommodate the individual patient's needs and choices ...a patient will be provided a choice to participate ...The Activities Director will complete an initial evaluation of the resident's Activity needs and preferences ...the Activity Director will develop an individualized activities schedule ...".

Based on Job Description review, staff interview and policy review, the facility failed to provide medically related Social Worker (SW) services to their swing bed residents.

Findings Include:

Review of the Case Manager/Swing Bed Coordinator Job Description revealed no documented evidence of a qualified SW assessing residents needs or assisting in maintaining or improving their ability to manage their everyday needs.

Interview with the Activities Coordinator on 03/23/16 at 10:25 a.m. confirmed this. She stated that the facility has a qualified SW, but the SW but does not assess or provide services to the Swing Bed residents unless it is a need that she (the Activities Coordinator) cannot provide.

Review of the facility's "Swing Bed Policy-Social Services" policy, approved 11/2014, revealed: "...to identify the medically related social and emotional needs of each of its Swing Bed Patients ....this person provides services under the direction and guidance of a qualified and licensed social worker ...".