HospitalInspections.org

Based on observation, it was determined the hospital failed to maintain essential electrical and patient care equipment in a safe functional condition for patients, visitors and staff.

Findings include:

1. During a tour of the hospital for a survey conducted from 04/11/11 to 04/14/11 the following conditions were observed:

a. Light shield missing on light located in clean utility room #233;

b. Light shield missing on light located in the stairwell near the nurse station;

c. Light shields missing on the lights in the sprinkler riser room;

d. Light shield missing on the light in the kitchen dish washing room;

e. Light shield missing on the light in the dietary storage room;

f. The mobile Magnetic Resonance Imaging trailer located a considerable distance from the hospital does not have a shelter access route to protect patients from the elements of the weather when traveling between the hospital and the mobile unit; and

g. There was no current temperature log for the Hydrocollator located at the outpatient physical therapy.

Based on observation, it was determined the hospital failed to store all biohazardous medical waste in a secure location. This failure has potential for access by unauthorized individuals.

Findings include:

1. On 04/11/11 at approximately 11:15 a.m., an inspection of the soiled utility room located on the med surge unit was conducted. At this time, biohazardous medical waste storage was observed in this unsecured room. Biohazardous medical waste storage must be in a secure location with access by only trained authorized personnel.

A. Based on medical record review and staff interview, it was determined the hospital failed to ensure the Emergency Department (ED) medical staff recorded the time of the medical screening exam (MSE) in three (3) of six (6) ED medical records (Patients #1, 5 and 6) reviewed. This has the potential to negatively impact all ED patient care by not establishing a timeline of events. Findings include:

1. Review of the medical record for Patient #1 revealed the patient was Triaged at 2005, taken to the exam room at 2015 and discharged to home at 2125. There is no documented evidence of the physician recording the time of the MSE.

2. Review of the medical record for Patient #5 revealed the patient was Triaged at 1930, taken to the exam room at the same time and discharged to home at 2210. There is no documented evidence of the physician recording the time of the MSE.

3. Review of the medical record for Patient #6 revealed the patient was Triaged at 1920, taken to the exam room at 2032 and left the facility Against Medical Advice (AMA) at 2042. There is no documented evidence of the physician recording the time of the MSE.

4. During an interview with the Director of Nursing (DON) in the afternoon of 4/12/11, the medical records were reviewed and the DON agreed with the above findings.

B. Based on medical record review and staff interview, it was determined the hospital failed to ensure the medical staff authenticates medical records with a date and time, in eight (8) of twelve (12) inpatient medical records (Patients #7, 8, 10, 12, 15, 17, 18 and 19) reviewed. This has the potential to negatively impact all patient care by not establishing a timeline of events. Findings include:

1. Review of the medical record for Patient #7 revealed the patient was admitted 12/30/10 and expired on 1/1/11. The electronic printed History and Physical (H&P) was dictated 12/31/10 and authenticated with no evidence of a date and/or time of signature. Review of the medical record revealed no documented evidence of a Discharge Summary and only one (1) physician Progress Note dated 12/31/10, which also was not timed. Further review of the medical record revealed a physician order written 12/30/10 not timed, telephone orders (T.O.) and/or verbal orders (V.O.) written 12/30/10 at 2215, 12/31/10 at 1030 and 1/1/11 at 0245 all authenticated by the physician without a date and/or time.

2. Review of the medical record for Patient #8 revealed the H&P and Discharge Summary were both authenticated by the physician without a date and/or time. Physician progress notes dated 1/15/11 and 1/16/11 were not timed. Further review of the medical record revealed a physician order written on 1/15/11 and 1/16/11 was not timed. Also, T.O. orders written 1/15/11 at 2145 and 1/16/11 at 0630 were authenticated without a date and/or time.

3. Review of the medical record for Patient #10 revealed the H&P and Discharge Summary were both authenticated by the physician without a date and/or time. A dictated physician progress note dated 3/10/11 was authenticated without a date and/or time. Admission orders were written by the physician with no documented evidence of a date and/or time of when written. A T.O. written 3/9/11 at 1500 was authenticated without a date and/or time.

4. Review of the medical record for Patient #12 revealed the swing admission orders were written by the physician with no documented evidence of a date and/or time.

5. Review of the medical record for Patient #15 revealed dictated physician progress notes on 4/8/11, 4/10/11, 4/11/11 and 4/12/11 were all authenticated by the physician with no documented evidence of a date and/or time. Further review of the medical record revealed V.O. on 4/7/11 at 0845, 4/8/11 at 1130 and 4/9/11 at 2005 all authenticated by the physician without a date and/or time. A V.O. on 4/10/11 at 1300 had no documented evidence of physician authentication at the time of record review on 4/14/11.

6. Review of the medical record for Patient #17 revealed pre-printed admission orders instituted by the ED physician without a date and/or time and handwritten physician admission orders dated 4/13/11 were not timed. The review also revealed a physician's progress note dated 4/14/11 with no documented evidence of time.

7. Review of the medical record for Patient #18 revealed a physician's progress note dated 4/14/11 with no documented evidence of time and V.O. dated 4/13/11 at 2150 and 4/14/11 at 0710 in which both were authenticated by the physician without a date and/or time.

8. Review of the medical record for Patient #19 revealed the H&P to be authenticated without a date and/or time. Also dictated physician progress notes dated 4/6/11 and 4/7/11 had no documented evidence of time of note and were authenticated by the physician without a date and/or time. Further review of the medical record revealed V.O. written 4/4/11 at 1544, 4/5/11 (not timed) and 4/5/11 at 1736 all authenticated by the physician without a date and/or time.

9. During interviews with the DON in the mornings of 4/13/11 and 4/14/11, the medical records were reviewed and the DON agreed with the above findings.