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Based on review of facility policy, observation and interview, the facility failed to separate undated supplies from current supplies. This practice affected all patients in the facility. The facility had a census of nine.

Findings included:

1. Review of the facility policy on 11/08/10 titled "Stocking/Outdates of Supplies" with a review date of 7/16/10 states in part:

* Adequate Supplies and Equipment shall be monitored by each individual department for quantity and outdates within Scotland County Memorial Hospital, but not limited to:
e. Operating Room/Ambulatory Surgery
* Purchasing will be responsible for restocking equipment and supplies as necessary pertaining to individual departments. (Restocking of supplies and equipment will be checked for outdates prior to restocking of such items.)
* Each department will be responsible to check quantity of equipment and outdates prior to usage.

During observation on 11/08/10 at 3:10 PM of Procedure room in the operating room (OR) showed the following outdated supplies:
4X4 dressings with an expiration (exp) date of 12/2008
2" kling dressing with an exp date of 09/2009
4 - Betadine solution bottles with an exp date of 03/06

During an interview on 11/08/10 at the time of the observation, Staff W, registered nurse said these supplies are no longer used and that the physician who used them is no longer at the facility.

Based on facility policy review, observation and interview the facility failed to ensure all patient use equipment received periodic preventive maintenance inspections, and failed to maintain equipment in safe operating condition to ensure patient safety in the Rehabilitation Department. The facility had a census of nine.

Findings included:

1. Observations during a tour of the facility conducted during the afternoon of 11/09/10 at 1:47 PM revealed two IV pumps, located in patient room 129, had not been inspected within the required time frames. The inspection tag on one IV pump showed it was due for inspection in April of 2010 and the inspection tag on the other IV pump showed it was due for inspection on October of 2010.

Staff U Physical Plant Director confirmed at that time both IV pumps were overdue for preventive maintenance inspections.


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2. Review of the facility policy titled, "Therapy Services - Safe Patient Environment," last reviewed 05/03/10, gave the following direction (in part): "Environmental rounds will be performed on a monthly basis. Any deficiencies will be immediately reported to the supervisor and corrective action taken and documented."

Review on 11/08/10 at 2:15 PM, of the 2010 temperature log for Paraffin Bath, Hot Pack Machine #1, Hot Pack Machine #2, and Freezer, showed the following (in part):
- No temperatures were recorded for the months of August, 2010 and September, 2010.
- Of the eight temperatures recorded for the Paraffin Bath, four were recorded outside the listed acceptable range.
- Of the eight temperatures recorded for the Freezer, seven were recorded outside the listed acceptable range.

During an interview on 11/08/10 at 3:00 PM, Staff B, Physical Therapy Supervisor, said, "There is probably not a policy of what to do if a temperature is outside the range." Staff B said that employees adjust the temperature to return the temperature to a normal range. Staff B was unable to provide evidence of corrective action and agreed that there was no evidence that the temperature was monitored until it returned to the appropriate temperature range.

Based on policy review, record review, observation and interview the facility failed to:
- ensure medications prepared in advance were labeled according to facility policy
- ensure multi-dose vials were discarded thirty days after opening per facility policy
- inspect patient's home medication when used for one (Patient #39) of one patient using home medication
- inspect drug storage areas monthly
- have documentation of pharmacy review of a patient medication profile for one patient (#42) of nine current records reviewed
- ensure there is restricted access to the pharmacy by authorizing all registered nurses employed by the facility to have pharmacy access. The facility employs 35 registered nurses (R.N.s)
- ensure that compounding, packaging, labeling and dispensing of medications were performed by or under the supervision of a pharmacist
- ensure that non-pharmacy personnel who compounded sterile medications in the Infusion Clinic and Oncology/Chemotherapy units were adequately trained, oriented to their area of new responsibility, and assessed for clinical competency
- ensure that medication orders in the Outpatient Clinic and Oncology/Chemotherapy unit were reviewed for appropriateness by the pharmacist
- ensure that all drugs and biologicals were stored in a manner to prevent access by unauthorized individuals
- ensure that the maximum stop date was consistently applied and
- ensure that safety equipment for medication preparation was kept in good working order

These failures have the potential to affect all patients accessing care at the facility, as well as staff preparing medications. The facility census was nine.

Findings included:
1. Review of the facility policy on 11/10/10 titled "Labeling Standards", last reviewed 06/08/09, states (in part):
All drug containers shall be labeled and drug labels must be clear, consistent, legible and in compliance with state and federal requirements.
* For individualized medications prepared for multiple specific patients, or when the individual preparing the medication does not administer the medication, the medication shall be labeled with the label including, at a minimum:
? Generic drug name and manufacturer's name
? Amount of drug in the dosage form unit
? Directions for use (dose, frequency and conditions if applicable)
? Cautionary remarks, i.e., refrigeration required, IM use only
? Expiration date (if over 24 hours) and time (if under 24 hours)
During observation on 11/9/10 at 2:30 PM in the obstetrical (OB) operating room 3 syringes were observed on the anesthesia machine. Syringe #1 had no label. The syringe contained 3 milliliters (ml) of clear liquid. Syringe #2 had a label stating Zofran (medication for nausea) and contained no other information. Syringe #3 had a label Glycopyrrolate/Neostigmine (used to decrease oral secretions and assist in intubation - assist with air-way maintenance for anesthesia); syringe had no other labeling information and contained 3 ml of clear liquid.
Staff P, operating room (OR) manager verified the lack of labeling on the 3 syringes. Staff P said the last OR case completed in this room was on 11/03/10.
2. Review of facility policy on 11/10/10 titled "Multi-dose Medication Vials in Clinical Areas" with an approval date of 07/20/09 states in part under Procedure:
2. Place the expiration date on the opened vial. The expiration date is 30 days after the vial is opened or the manufacturer's recommended expiration date (whichever comes first) and discard at time of expiration.
During observation on 11/10/10 at 11:30 AM of the respiratory therapy (RT) work room, Staff R, certified respiratory therapist (CRT) stated drugs are kept in the Pyxis (a secure cabinet to dispense medication) with the exception of Albuterol (used for pulmonary function tests). Observation of the cabinet revealed a 20 ml vial of Albuterol. The vial was dated 9/15/10.
During an interview on 11/10/10 at 2:30 PM, Staff R said he/she has to dispose of multi-dose vial because it is over the 30 days of usage.
3. Review of facility policy on 11/10/10 titled "Patient's Own Medication (Usage)" with an approval date of 11/09/10 states in part:
POLICY:
* The contents of the containers have been examined, positively identified and the integrity evaluated by the patient's physician and/or the hospital's pharmacist.
Procedure:
* A patient may utilize his/her medication on the written order of the attending physician or other licensed independent practitioner permitted by law by the organization to prescribe medications when all of the following conditions are met:
? Medications are ordered by the patient's physician or other licensed independent practitioner and the order is entered on the patient's chart, indicating:
*Patient's own medication may be used
*Name of drug
*Strength of drug and route
*Dose schedule
*Rationale for drug use
? Medications have been examined by the ordering physician or pharmacist for positive identification, integrity and correct labeling.
? The pharmacist or ordering physician will attach a label to the container to indicate that it has been checked properly identified and integrity evaluated.
During medication observation on 11/10/10 at 9:15 AM, Staff S administered B-6 (a vitamin) 50 milligram (mg) and Acyclovir (antiviral) medication 400 mg to Patient #39. Staff S said Patient #39 wrote for the patient to take his/her home medication. Review of medication failed to document physician/pharmacist verification of the medication.
During an interview on 11/10/10 at 2:30 PM Staff T, physician stated "No, I did not look at the pills".
4. Review of facility policy on 11/10/10 titled "Unusable and Outdated Drugs" with an effective date of 7/20/09 states in part under Procedure:
* All drug storage areas of the hospital will be inspected, including surgery and other patient care unit stock areas if applicable, for outdated drugs, contaminated drugs, improperly stored drugs and containers with worn, illegible or missing labels. The licensed staff member conducting the inspection will remove all these types of drugs from the area. The inspection will be conducted monthly.
During observation of the OR, ambulatory care unit and OB OR unit on 11/09/10 at, Staff P, OR manager said drug supplies are checked by nurses, pharmacy does not check drug supplies.




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5. Review of facility policy, Pharmaceutical Services approved 07/20/09 showed in section 3.1, "A copy of all written orders will be faxed to the licensed pharmacist upon receipt of the order from the healthcare provider. The pharmacist will create a patient profile for each patient based on available medication history, current therapy and shall include allergies and/or sensitivities."Further review of the policy showed in section 3.2, "The pharmacist will conduct an ongoing review of the patient's medication regimen for any potential interactions or incompatibilities within 24 hours of accessing the new medications for a patient."

Review of patient medication profiles on 11/08/10 at 2:40 PM showed no documentation of a pharmacy review for medication ordered for Patient #42 on 11/03/10.

During an interview on 11/08/10 at 2:40 PM pharmacy technician Staff J said that the pharmacist is in the facility when needed and reviews the patient medication profiles electronically. Staff J said that after the review the pharmacist's name is added to the review section of the medication profile.

During a telephone interview on 11/09/10 at 3:30 PM pharmacist Staff M said that he/she thinks there is something wrong in the electronic system that deleted his/her name from the review of the patient medication profile. Staff M said that he/she thinks if an order is recreated, due to a time or dosage change, the reviewer of the medication profile is deleted.

6. Review of facility policy, Authorized Access to Pharmacy approved 07/20/09, showed the policy is to prevent unnecessary entry to the pharmacy, locked supply of routinely used medication shall be available for access by authorized personnel when the pharmacist is unavailable. The policy showed authorized personnel, when the Pharmacist or Pharmacy Personnel not available shall include: the charge nurse on duty or the director of nurses along with another licensed signature for witness. Further review of the policy showed the authorized person shall log onto the Pharmacy Entry Log and complete. A licensed witness signature will accompany the entry log upon retrieval of medication or entry into the pharmacy.
Review of the Pharmacy System Allowed Access Report showed forty one staff members have access to the pharmacy by using a badge to swipe a control box to gain entry. Employees allowed access are the 35 registered nurses, four licensed practical nurses who have been trained as pharmacy technicians, the full time pharmacy technician and the Director of Pharmacy.
Review of the Pharmacy Quality Improvement (QI) Report for entries into the pharmacy showed for September 2010 there were 19 logged entries with six entries not logged onto the pharmacy entry log for a total of 25 entries into the pharmacy. For October the report showed 15 logged entries with one no witness entry, three entries not logged onto the pharmacy entry log and one staff member used another nurse's ID badge to gain entry for a total of 20 entries into the pharmacy.
During an interview on 11/09/10 at 2:15 PM the Director of Nursing, Staff H said that the facility has approximately 30 nurses and they all need access to the pharmacy after hours because they are all trained to be charge nurses. Staff H said there is no nursing supervisor for the facility and if the pharmacy isn't open the charge nurses go to pharmacy to get any needed medication. Staff H said that he/she did not know why someone would use anyone else's ID badge to gain access into the pharmacy. Staff H said that he/she did not know until he/she reviewed the QI report that anyone had used another staff member's ID badge to gain entrance into the pharmacy.
During a telephone interview on 11/09/10 at 3:50 PM the Director of Pharmacy, Staff M said that he/she would like to limit the number of staff members who have access to the pharmacy. Staff M said that the access now is practically unlimited. Staff M said that he/she does not review the access control system history report so he/she has no idea how many times a month there is access into the pharmacy.


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7. During an interview on 11/08/10 at 3:20 PM, Staff C, Infusion Nurse, said that on Mondays and Tuesdays, the facility provides an Outpatient Infusion Clinic and patients come to the clinic to receive intravenous medications for rheumatoid arthritis (an inflammatory process that destroys joint tissue and leads to loss of function). Staff C said that nurses prepare the intravenous solutions in the Infusion Clinic and immediately administer them to patients.

During an interview on 11/08/10 at 3:50 PM, Staff A, Oncology Supervisor, said that on Tuesdays, unit employees routinely prepare and administer a variety of medications, including chemotherapy (medications used to treat cancer), for outpatients. Nurses in the unit determine what medications will be needed in the upcoming week based on which patients are expected to report for therapy, request the medications from the pharmacy, and prepare the necessary infusions within a hood when the patient has met all the pre-infusion criteria. Prepared infusions are labeled with the name of the medication and are immediately administered to patients.

Staff A said the pharmacist does not review the physician orders for the infusions that are administered in either the Outpatient Infusion Clinic or the Oncology/Chemotherapy unit; is not involved in interpreting the order, dispensing the medication from the pharmacy, compounding the medication, or labeling it; and does not oversee any part of this process.

8. Review of personnel files on 11/09/10 at 1:30 PM showed no evidence of orientation or competency evaluation when Staff A, Oncology Nurse, Staff X, Oncology Nurse, or Staff C, Infusion Nurse, were given new job assignments and responsibilities.

During an interview on 11/10/10 at3:05 PM, Staff H, Director of Nursing, said that Staff A, Staff X, and Staff C received training on mixing and administering chemotherapy, and became certified as part of that training. No additional training was done at the facility, and their competency was not assessed at any time by facility staff. Staff H also said that these three nurses perform a variety of duties within the facility, including working on the nursing floor, and confirmed that they were not oriented to the Infusion Clinic or Oncology/Chemotherapy Outpatient areas of the facility when their job duties changed.

9. Observation on 11/10/10 at 9:25 AM showed a jar of cream on the bedside table of Patient #14 labeled "Cleaver Cream."

Review of Patient #14's medical record on 11/10/10 at 12:05 PM showed an order dated 11/06/10 to apply the cream to Patient #14's buttock BID prn (twice daily, as needed). There was no indication that the medication was to be left at the bedside for application by the patient.

During an interview on 11/10/10 at 12:10 PM, Staff F, Licensed Practical Nurse (LPN) said medications were not left at the bedside unless there was an order to do so from the physician. Staff F said the medication was not supposed to be at Patient #14's bedside.

10. Review of the facility policy titled, "Automatic Stop Orders," effective 7/20/09, gave the following direction (in part):
- The hospital shall limit the duration of drug therapy in the absence of the prescriber's specific indication of duration of drug therapy or other circumstances defined by the Pharmacy and Therapeutics Committee and the medical staff by-laws.
- All medication orders of unspecified length of treatment are subject to automatic discontinuation.
- Established automatic stop times are as follows, unless the chart order indicates the exact number of doses or specifies the length of time such therapy shall be administered.
- All other medications, 21 days.

A. Review of the medical record for Patient #10 on 11/09/10 at 1:55 PM showed the following (in part):
- A pre-printed form titled, "Physician Orders for Orencia (used to reduce the pain and swelling of joints caused by rheumatoid arthritis)," which listed the physician's orders for Orencia administration. Instructions on the form included the following (in part):
- A line at the top of the form shows the date 11/08/10, however the physician's signature at the bottom of the form is dated 1/11/10.
- A hand written note in the left margin of the form shows, "11/08/10 Orders noted 10:27 AM" and a Registered Nurse signature.
- "Orencia Dose at weeks 0,2,4, and then Q (every) 4 weeks." An end date is not specified. The order indicates a dose of 750 mg (milligrams, a unit of measure) Orencia = 3 vials.
- Administer pre-medication if ordered: "Solu-Medrol (decreases the body's natural defense system and relieves swelling and allergic-type reactions) IV (intravenous) 80 mg, Benadryl (antihistamine) 25 mg po (by mouth), Ranitidine (used to treat and prevent ulcers in the stomach and intestines) 150 mg po, and also give Toradol (analgesic - used to reduce pain, fever and inflammation) 30mg IVP (IV push) after each infusion" were hand-written on the form. The hand-written entries were not dated, timed, or signed to indicate whether they were part of the original order on 1/11/10 or were written at a later date.
- A form titled, "Progress Notes," lists notes from 8/30/10 to 11/08/10.
- A note dated 11/1/10 at 10:40 AM states, "Pt (patient) here for Orencia but not sure if she can get it d/t (due to) not feeling well. Has head congestion. No sore throat, no fever. V.O. (verbal order) (physician name) Z-pack (Zithromycin, an antibiotic) and 1 g (gram) Rocephin (antibiotic). Orencia rescheduled for next week." The note indicates the Rocephin was "Given IM (intramuscular)."
- A note dated 11/08/10 at 10:30 AM states, "Orencia," indicating the medication was administered.

During an interview on 11/09/10 at 2:10 PM, Staff O, Medical Records Director, said that there were no physician orders in the medical record that corresponded to the date of service 11/08/10 with the exception of the "Physician Orders for Orencia" form dated 1/11/10 as noted above.

B. Review of the medical record for Patient #41 on 11/10/10 at 9:00 AM showed the following documentation (in part):
- A form titled, "Oncology Orders, Avastin - Colon" showed an order for Avastin 592 mg. In the column marked "Cycle Length" was written "14 days." At the bottom of the form was a physician signature (initials) dated 10/27/09, plus the signatures of two Registered Nurses, both dated 10/27/09.
- A form titled, "Oncology Orders, XelOx (Xeloda-Oxaliplatin Combination - a type of chemotherapy) - Dose Dense (terminology for spacing chemotherapy treatment close together)" showed an order for Xeloda 2310 mg and Oxaliplatin 196 mg. In the column marked "Cycle Length" was written "14 days." In the section titled, "Premedications:" were orders for Decadron (a medication that reduces inflammation and allergic response) 20 mg and Aloxi (used to prevent nausea and vomiting) 0.25 mg. At the bottom of the form was a physician signature (initials) dated 10/27/09, plus the signatures of two Registered Nurses, both dated 10/27/09.
- A form titled, "Oncology Clinic," dated 10/26/10 showed the following:
- Under the section titled, "Physician's Report," was the following notation: Continue Avastin (chemotherapy) q (every) 2 weeks.
- There were no other medications listed in the note.
- The bottom of the form was initialed, but there was no signature or title, and no date or time necessary to constitute a valid physician order.
- A form titled, "Oncology Flowsheet," had columns with dates ranging from 7/27/10 to 11/09/10. Four medications were hand-written on the form, with start and stop times indicated in the column corresponding to the date of service.
- Notations in the 11/09/10 column showed that on that date, Patient #41 received the following medications:
- Decadron 20mg IV, end time 10:30 AM
- Aloxi 0.25 mg IV, end time 10:32 AM
- Avastin 592 mg IV q (every) 14 days, end time 11:25 AM.
- Oxaliplatin 196 mg IV q 14 days. There is a note that his medication was stopped 8/10/10 and all but the 7/27/10 column are crossed through with a large X. A corresponding physician order to discontinue the medication was not found in the medical record.

During an interview on 11/08/10 at 4:00 PM, Staff A, Oncology Nurse, said that it was understood by staff that orders for chemotherapy continued until discontinued by the physician, and was unsure whether this was in conflict with the facility policy on stop orders. Staff A said all orders, including pre-medication orders, were considered to be "ongoing" and "valid," and that the original orders written 10/27/09 were used to determine which meds to give during each chemotherapy visit. Staff A said that the "Oncology Clinic" form was considered the "updated" source of physician orders for each episode of chemotherapy care because it documented the patient's most recent visit with their physician, and that an order to "continue Avastin" meant continue giving the medication every two weeks until the next physician visit.

11. Observation on 11/09/10 at 10:30 AM showed an eye wash station in the Oncology/Chemotherapy medication room. The apparatus was independent of a water source, and included a bottle of solution that would be used to flush eyes in the event of splash injury to the eyes. The expiration date on the bottle was 9/2010.

During an interview on 11/09/10 at 4:10 PM, Staff A, Oncology Nurse, agreed that the bottle of solution was expired.

Based on policy review, record reviews and interviews, the facility failed to follow their policy on medication errors by not reporting the errors to the patient's physician for three medication errors of 11 medication errors reviewed. The facility had a census of nine.
Findings included:
Review of facility policy, Medication Errors dated 07/20/09 showed the person who discovered the error shall report this information to the attending physician or physician on-call as soon as possible.
Review on 11/09/10 at 11:15 AM of medication error reports showed the following:
- the wrong route of administration of mucomyst (a medication that destroys or dissolves mucus) on 07/11/10. The error report showed no notification to the patient's physician of the error.
- bactrim pediatric solution (an antibiotic) given to the wrong patient on 07/14/10. The error report showed no notification to the patient's physician of the error.
- the wrong dosage of Lisinopril (used to treat high blood pressure) to a patient on 07/15/10. The error report showed no notification to the patent's physician of the error.

During an interview on 11/09/10 at 10:35 AM the Director of Quality Improvement and Risk Management, Staff I said that the physician should be notified when there is a medication error.

Based on interview and review of related policy/procedures, the facility failed to have a physician assessment for one patient (Patient #39) of one post partum (after birth) record reviewed, prior to the administration of Pitocin/Oxytocin (labor inducting medications). The facility had a census of nine.

Findings included:

1. Review of facility policy "Oxytocin for Induction or Augmentation of Labor" with a review date of 07/28/10 on 11/10/10 at 9:00 AM revealed in part the following:

Procedure:
a. Physician must assess and examine patient immediately prior to ordering and starting Oxytocin.

2. Record review of Patient #39 on 11/10/10 at 9:10 AM revealed a physician history and physical dated 11/08/10 at 11:29 AM, physician documents Pelvic exam. Record further documents intravenous (IV) infusion of Pitocin (Oxytocin) at 7:37 AM.

During an interview on 11/10/10 at 2:30 PM Staff T, Patient #39's physician states "I did not do a vaginal examination of the patient prior to the Pitocin induction".

Based on review of medical staff by laws, record review and interview the facility failed to ensure staff obtained an order for medication administered to one patient (#33) of four medications reviewed. Eight closed and one open ED (Emergency Department) records were reviewed. The facility census was nine.
Findings included:
1. Facility Medical Staff Bylaws section I and J adopted July 23, 2009 states in part, "All inpatient and observation orders for treatment, drugs or biological shall be legible, complete, dated, timed and authenticated in written or electronic form by the ordering practitioner responsible for the care of the patient and authorized to write orders". In addition, "Verbal orders must be used infrequently, and only to meet the care needs of the patient when it is impossible or impractical for the ordering practitioner to write the order or enter it into a computer or electronic prescribing system without delaying the treatment. Verbal orders shall immediately be recorded in the patient chart and signed by the individual receiving the order. . . the ordering practitioner responsible for the care of the patient. . .shall authenticate such orders within 24 hours".
2. Closed record review on 11/10/2010 at 10:20 AM of Patient #33's record, date of service 11/6/2010, identified that staff administered Morphine (a narcotic pain killer), 4 mg (milligrams, a unit of measure) IVP (intra venous push, delivering medication via a syringe into a port established in the patient for such use) at 12:55 PM. No such order was entered by the physician or staff on the physician order sheet relating to that visit.
3. During an interview on 11/10/2010 at 3:05 PM Staff E, ER Supervisor, said that all orders should be recorded on the physician order sheet.

Based on record review and interview, the facility failed to ensure that an individualized nursing care plan was developed and kept current for two (Patients #16 and #14) of two medical records reviewed for care planning. The facility census was nine.

Findings included:

Review of the medical record for Patient #16 on 11/10/10 at 11:00 AM showed Patient #16 was admitted from the Emergency Department to acute care on 9/11/10 for respiratory distress with hypoxia (a condition where oxygen levels fall below what is necessary to sustain life). On 9/16/10 Patient #16 was transferred to the swing bed program. During the course of these hospitalizations, additional disease processes were identified, including: history of myocardial infarction (heart attack), history of renal (kidney) failure, Congestive Obstruction Pulmonary Disease (COPD), alcoholic cirrhosis with acute withdrawal from daily consumption (described as "heavy") of beer, withdrawal from cigarettes (several packs per day), paraplegia (paralysis of the lower extremities), confusion, and multiple open pressure wounds. Review of the care plan for Patient #16 showed only one disease process had been identified for care planning - impaired skin integrity.

Review of the medical record for Patient #14 on 11/10/10 at 12:05 PM showed Patient #14 was admitted on 11/6/10 from the Emergency Department for Congestive Heart Failure (CHF), weakness and wheezing. During the course of this hospitalization, additional disease processes were identified, including: impaired skin integrity due to a wound on his buttock, arthritis, a history of pacemaker implantation, left pleural effusion (a buildup of fluid between the layers of skin that line the lungs and chest) affecting oxygenation, and urinary tract infection. Patient #16 was also identified as being at risk of falling when out of bed. Review of the care plan for Patient #16 showed only one disease process had been identified for care planning - excess fluid volume.

During an interview on 11/10/10 at 2:00 PM, Staff H, Director of Nursing, said nurses are told to initiate a care plan upon admission to the facility, but there isn't a policy on how many issues to identify for care planning. Staff H agreed that nurses should have added to the care plan to ensure a patient's needs were comprehensively addressed.

Based on record review and interview, the facility failed to have completed discharge summaries for two (#21, 24) of six patients reviewed for discharge summaries. The facility had a census of nine.
Findings included:
Record review for Patient #21, admitted 8/6-30/10 to the Swing Bed Program for rehabilitation, left humerus fracture after a fall prior to admission, showed the record failed to have a discharge summary.
Record review for Patient #24, admitted 9/1-13/10 to the Swing Bed Program for rehabilitation after pneumonia, showed the record failed to have a discharge summary.
During an interview on 11/10/10 at 10:00 AM, the Director of Medical Records, Staff O, stated that the discharge summaries were sometimes hard to get from the physicians.

Based on record review and interview, the facility failed to ensure that a history and physical was completed for each episode of care and within 24 hours of admission for two (Patient #16, #22) of two records reviewed for transfer from acute care to swing bed. The facility census was nine.

Findings included:

Review of the medical record for Patient #16 on 11/10/10 at 11:05 AM showed Patient #16 was admitted to acute care on 9/11/10. On 9/16/10, Patient #16 was discharged from acute care and transferred to the swing bed program. A document titled "Interim History and Physical" was identified, written on 9/16/10, the date Patient #16 transferred to the swing bed program.

During an interview on 11/10/10 at 11:15 AM, Staff H, Director of Nursing, said that based on a review of the electronic medical record and a review of the medical records for both the 9/11/10 admission and the 9/16/10 admission, there was no evidence of a history and physical for the 9/11/10 admission.




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Record review of Patient #22, admitted 8/6-30/10 for rehabilitation for a left humerus fracture after a fall, prior to admission, showed the record failed to have documentation of a physician's History and Physical Examination.

Based on record review the facility failed to ensure that the medical record contained reports of treatments, orders, notes, and other pertinent information that were authenticated with signature, date and time for two (Patients #10 and #16) of 13 medical records reviewed for care. The facility census was nine.

Findings included:

Review of the medical record for Patient #10 on 11/9/10 at 1:55 PM showed the following (in part):
- A form titled, "Progress Notes," lists notes from 8/30/10 to 11/08/10.
- A note dated 11/01/10 at 10:40 AM states, "Pt (patient) here for Orencia but not sure if she can get it d/t (due to) not feeling well. Has head congestion. No sore throat, no fever. V.O. (verbal order) (physician name) Z-pack (Zithromycin, an antibiotic) and 1 g (gram) Rocephin (antibiotic). Orencia rescheduled for next week." The note indicates the Rocephin was "Given IM (intramuscular)." The note is initialed, but not signed with name and title.
- A note dated 11/08/10 at 10:30 AM states, "Orencia," and is initialed, but not signed with name and title.

Review of the medical record for Patient #16 on 11/10/10 at 11:20 AM showed a form titled, "Progress Notes," with the following entries:
- "10/20/10 Phone call to Scotland Co (County) Hm (Home) Health - Jinny M. They'll go in initially for skilled care needs of catheter care et (and) treatment, pressure ulcer prevention." The entry was not timed or signed.
- "10/20/10 Premier contacted - Info reviewed. They'll call back." The entry was not timed or signed.
- "10/20/10 Premier called back. They would need to hire someone who could do advanced personal care, they would come out to hospital to do assessment." The entry was not timed or signed.

Based on observation and interview, the facility failed to protect the confidentiality and unauthorized access of all patients' medical records in one decentralized record storage location. The facility had a census of nine.

Findings included:

Observation on 11/09/10 at 2:25 PM showed the corridor door into the chemotherapy administration room open and unlocked. No personnel were observed in the room. Two unsecured medication records were located on a shelf just inside the door. The records contained patient identification information and were accessible to anyone entering the room. A closet located in the room had an open door. Inside the closet was an unlocked file cabinet containing numerous medical records with patient identification information.

Observation at 2:30 PM showed two maintenance employees enter the unlocked room. The employees said that they had been working on the sink in the room and needed to leave to obtain equipment. They said they did not have a key to the room so they left the door open and unlocked.

During an interview on 11/09/10 at 2:35 PM registered nurse (R.N.) Staff A said that there are approximately 60 patient records in the unlocked file cabinet in the open closet. Staff A confirmed that the patient records were left unsecured.

Based on record review, facility policy review and interview the facility failed to provide physician oversight for three (Patient #7, Patient #6 and Patient #3) of seven surgical patients records reviewed. The facility had a census of nine.

Findings included:

1. Review of facility Bylaws on 11/10/10 under Section "O" states in part:
All patients undergoing surgery or other procedures at Scotland County Memorial Hospital, when a C.R.N.A. (certified registered nurse anesthetist) administers anesthesia, the CRNA shall be under the supervision of the physician, dentist or podiatrist performing the procedure.

Review of the facility policy on 11/10/10 titled "Duties & Responsibilities - Certified Registered Nurse Anesthetist (C.R.NA.) states in part:
The C.R.N.A. works in collaboration with the Operating Physician.

Record review for Patient #7 on 11/09/10 revealed no physician oversight for anesthesia was found on Patient #7's record.

Record review for Patient #6 on 11/09/10 revealed no physician oversight for anesthesia was found on Patient #6's record.

Record review for Patient #3 on 11/09/10 revealed no physician oversight for anesthesia was found on Patient #3's record.

During interview with Staff P, surgery manager, on 11/09/10, Staff P verified lack of anesthesia oversight by the surgeon. Staff P said surgeon usually signs on the C.R.N.A.'s anesthesia record.

Based on record review and interview, the facility's Periodic Review failed to state clearly the number of patient admissions for the past fiscal year, and the average length of stay in hours. This applied to all patients. The facility had a census of nine.
Finding included:
Review of the facility Periodic Review for Fiscal Year, 2009, showed the report failed to clearly document the total number of inpatients served and the average length of stay in hours.
During an interview on 11/10/10 at 12:00 PM, Staff G, Administrator, stated that the number of patients served and the average length of stay in hours, could be calculated by the data that was contained in the report.

Based on record review and interview, the facility failed to ensure that a Criminal Background Check (CBC) and a check for the Missouri Employee Disqualification List (EDL) was performed upon the new hire of employees and intermittently (at least annually). This affected all patients who accessed care at the facility. The swing bed census was three, and the acute bed census was six.
Findings included:
1. Review of the personnel records for the following employees, showed the following:
-Staff Y, Dietary Manager, hired 1/29/91. No EDL, no CBC.
-Staff Z, Dietitian, contracted 2/18/08. No EDL, No CBC.
-Staff AA, Dietary Aide, hired 10/6/08. No EDL.
-Staff A, Oncology/Chemotherapy RN, hired 3/20/91. No EDL.
-Staff X, Oncology/Chemotherapy RN, hired 12/13/99. No EDL.
- Staff C, Infusion RN, hired 1/26/89. No EDL, No CBC.
- Staff DD, Occupational Therapy/Physical Therapy Aide, hired 12/5/98. No EDL since 2/01.
- Staff E, Emergency Department Manager, hired 2003. No EDL, No CBC.
- Staff B, Physical Therapist, hired 8/23/96. No EDL since 2/01.
- Staff EE, Physical Therapy Assistant, hired 6/13/08. No EDL.
During an interview on 11/10/10 at approximately 2:00 PM, Staff V, Human Resources Director, said all new hires get a criminal background check, but the facility did not plan to ensure that all current staff had them. Staff V also said there wasn't a process to obtain EDL background checks at hire or annually.