HospitalInspections.org

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure that a physician ordered the No Code status for one of one applicable medical record reviewed (MR35).

Findings include:

Review of the facility "Code Level Order Sheet," no review date, revealed "... Only the attending physician of record (or covering physician assuming medico-legal responsibility for the patient's care) can change the code level. ... In addition to the order, a note must be written in the progress note(s) to reflect discussion with the patient or their representative / POA."

Review on June 8, 2011, of MR35 revealed the patient was admitted to the facility on September 28, 2010, as a full code (in the event the patient's heart and /or breathing stopped, cardiopulmonary resuscitation [CPR] would be initiated). On October 7, 2010, EMP3 changed MR35's code status from full code to No Code (CPR would not be administered). EMP2 confirmed that EMP3 was a physician assistant. Further review of MR35's physician progress notes revealed no documentation that MR35's attending physician discussed the change in MR35's code status with MR35's family.

Interview with EMP2 on June 8, 2011, at 11:00 AM confirmed that EMP3 changed MR35's code status from full code to no code. Further interview with EMP2 confirmed there was no documentation in MR35's physician progress notes indicating that MR35's attending physician discussed the change in the patient's code status with the patient's family.

Based on review of facility documents and staff interview (EMP), it was determined that the facility failed to ensure that blood spills, a potentially infectious material, were properly cleaned from patient medical records.

Finding include:

Review on June 7, 2011, of the facility's "Cleaning and Decontaminating Spills" policy, no review date, revealed "Policy: It is the policy of this facility that all spills or splashes of blood or body fluids are cleaned up and the spill or splash area is decontaminated as soon as practical. Procedure: 1. Surfaces and equipment contaminated with spills or splashes of blood or body fluids must be cleaned up as soon as practical. ... 5. Discard items contaminated with blood or body fluids. ..."

Review on June 7, 2011, of MR1 revealed a large red-brown-colored smear, measuring approximately four inches by two inches, on a paper in MR1's medical record. This paper contained documentation regarding MR1's medical treatment while an inpatient in the facility.

Interview with EMP2 on June 7, 2011, at the time of the observation confirmed that the red-brown-colored smear on MR1's medical record was dried blood.

Review on June 8, 2011, of MR36 revealed one large and five small droplets of a red-brown-colored material on a paper in MR36's medical record. This paper contained documentation regarding MR36's medical treatment while an inpatient in the facility.

Interview with EMP2 on June 8, 2011, at the time of the observation confirmed that the red-brown-colored material on MR36's medical record was dried blood. Further interview with EMP2 revealed that any paper containing blood should be placed in a bag to protect staff from contamination and photocopied. EMP2 revealed that the photocopied paper should be placed in the patient's medical record and the contaminated paper destroyed.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure that oral orders were signed, dated and timed by a practitioner within 24 hours for 14 of 41 medical records reviewed (MR3, MR4, MR9, MR10, MR20, MR29, MR30, MR32, MR33, MR34, MR35, MR37, MR40 and MR41).

Findings include:

Review on June 8, 2011, of the "Bucktail Medical Center Medical Staff Bylaws Rules and Regulations," approved June 28, 2000, revealed "Bucktail Medical Center Rules and Regulations of the Professional Staff, ... 7) All orders for treatment shall be in writing. An order shall be considered to be in writing if dictated to a licensed nurse or other authorized person, i.e., Physical Therapist, Surgeon, and signed by the ordering physician. Orders dictated over the telephone shall [sic] legible, complete and signed by the authorized person receiving the order as well as denoting the physician giving the verbal order. Within twenty-four (24) hours the ordering physician shall also sign, date and time said orders. ..."

Review on June 8, 2011, of MR3, MR4, MR9, MR10, MR20, MR29, MR30, MR32, MR33, MR34, MR35, MR37, MR40 and MR41 revealed oral orders not signed, dated and timed by a practitioner within 24 hours.

Interview with EMP2 on June 8, 2011, at 11:10 AM confirmed the oral orders for MR3, MR4, MR9, MR10, MR29, MR30, MR32, MR33, MR34, MR35 and MR37 were not signed, dated and timed by a practitioner within 24 hours.

Interview with EMP4 on June 8, 2011, at 11:20 AM confirmed the oral orders for MR20, MR40 and MR41 were not signed, dated and timed by a practitioner within 24 hours.

Based on review of facility documents, the facility quality assurance program and staff interview (EMP), it was determined that the facility failed to identify effective mechanisms for monitoring problem areas.

Findings include:

Review on June 8, 2011, of the "Facility-Wide Quality Assurance Program" last revised May 27, 1998, revealed "The Bucktail Medical Center, through the Board of Directors, Medical Staff and Administration, is dedicated to the provision of quality of care to all its patients/residents. In order to ensure that quality of care is provided, an ongoing QA program has been establish [sic]. The program includes an effective mechanism for monitoring patient/resident care and responding to problem areas in an appropriate and timely manner. Purpose: the Bucktail Medical Center QA plan is designed to fulfill the facility's responsibility to its patients, residents, community and staff, in accordance with the Department of Health Code and the policies and procedures of other regulatory agencies. The QA plan will coordinate and integrate all QA and Risk Management activities throughout the facility, thereby providing an effective mechanism for the identification of opportunities to improve care, within the limitation of the available resources to the facility. Goals: To develop appropriate standards for the provision of patient/resident care. To develop appropriate standards for the performance of professional and support staff. To monitor and evaluate systematically the quality and appropriateness of patient resident care. To identify trends and patterns of care through the use of generic indicators. To ensure appropriate ongoing staff development for all disciplines. ... Objectives: A. To ensure the provision of high-quality patient care through objective care evaluation and other QA activities. B. To ensure coordination and integration of all QA activities by establishing a QA committee as the focal point through which all QA information will be exchanged and monitored. C. To identify and correct patient/resident care problems by assessing their cause and scope and implementing actions to resolve them. D. To prioritize identified problems so that those directly affecting patient/resident care can be resolved in a timely manner. ... Responsibilities: 1. Assist in the ongoing monitoring or screening of patient /resident care and clinical performance. 2. Assists in the identification / assessment of problem areas. 3. Determines priorities for both investigating and resolving problems. 4. Review finding of QA activities performed by department and/or services. ... 6. Plan / monitors corrective action designed to resolve problems or improve clinical performance. ... 8. Annually evaluates the effectiveness of the QA program. ..."

Review on June 8, 2011, of "Bucktail Medical Center Medical Staff Bylaws Rule and Regulations," last approved June 28, 2000, revealed "... Article II - Purpose and Responsibilities ... Section 2 - Responsibilities The responsibilities of the Medical Staff are to : A. Account to the Board for the quality and efficiency of patient care provided by all practitioners authorized to practice in the hospital through the following measures: 1. Review and evaluation of the quality of patient care through the use of and participation in the facility wide Quality Assurance Program. ..."

Review on June 8, 2011, of the facility's Quality Assurance committee meeting minutes from July 2009 to June 2011 revealed no documentation reflecting the facility's continued monitoring of compliance of the following areas: 1) obtaining all three of the required background checks for employees with significant likelihood of regular contact with children for all employees hired after July 1, 2008; 2) reporting of infrastructure failures and hospital acquired infections to the Patient Safety Authority or the Department of Health; 3) compliance with the facility's patient complaint and grievance policy with timely review of the patient compliant and providing written notification regarding the facility's investigation and outcome to the complainant; 4) authentication of verbal orders by the ordering physician within 24-hours; 5) countersigning of orders written by a physician assistant by the supervising physician within 72-hours; 6) activity evaluation for swing bed patients were completed; 7) that swing bed patient preferences were honored; 8) that patients on swing bed status were offered activities.

Interview with EMP1 and EMP5 on June 8, 2011, at approximately 11:45 AM confirmed that the facility's quality assurance program did not include a mechanism to identify effective mechanisms for monitoring problem areas and to identify trends and patterns that required further review.

Based on review of facility meeting minutes and staff interview (EMP), it was determined that the Infection Control Committee failed to periodically review antibiotic usage of patients in the hospital.

Findings include:

Review on June 7, 2011, of the facility's "Medical Staff Bylaws Rules and Regulations," approved June 28, 2000, revealed " ... Infection Control Function The duties involved in preventing, investigating, and controlling hospital-acquired infections are to : ... E. Coordinate action on finding on findings for the Medical Staff's review of the clinical use of antibiotics. ..."

Review of the facility's Infection Control Committee meeting minutes from July 2009 through May 2011 revealed no documentation that the infection control committee reviewed the antibiotic usage of hospitalized patients.

Interview with EMP2 on June 7, 2011, at approximately 11:45 AM confirmed that the infection control committee did not review antibiotic usage of hospitalized patients.

Based on review of facility documents, observation and interview with staff (EMP), it was determined that the facility failed to ensure privacy to a patient receiving treatment in the physical therapy department.

Findings include:

Review on June 7, 2011, of the facility's policy "Patient's Bill of Rights," no date of review, revealed "Policy: Bucktail Medical Center is committed to delivering quality medical care to their patients. Patients/Families/Surrogates will be made aware of their individual rights afforded them under applicable law and regulation. ..."

Review on June 7, 2011, of the facility's document "Patient Rights and Responsibilities," no date of review, revealed "As a patient of this hospital, or as a family member or guardian of a patient at this hospital, we want you to know the rights you have under federal and Pennsylvania state law as soon as possible in your hospital stay. We are committed to honoring your rights, and want you to know that by taking an active role in your health care, you can help your hospital caregivers meet your needs as a patient or family member. That is why we ask that you and your family share with us certain responsibilities. Your Rights, As a patient you or your legally responsible party have the right to receive care without discrimination due to age, sex, race, color, religion, sexual orientation, income, education, national origin, ancestry, marital status, culture, language, disability, gender identity, or who will pay your bill. As our patient, you have the right to safe, respectful, and dignified care at all times. ... Care Delivery, Your Rights ... You have the right to: ... Receive kind, respectful, safe, quality care delivered by skilled staff. ... Privacy and Confidentiality, You have the right to: ... Be interviewed, examined, and discuss your care in places designed to protect your privacy. ..."

Tour of the physical therapy department at 9:30 AM on June 7, 2011, revealed a patient receiving physical therapy treatment on a treatment table. The patient was visible to the surveyor.

Interview with EMP1 at the time of the observation revealed that the privacy curtain should have been pulled to provide privacy to the patient receiving physical therapy treatment. Further interview with EMP1 revealed that it is the facility's practice to post a sign on the entry door indicating that a treatment is in progress. EMP1 confirmed that there was no sign posted on the entry door indicating that a patient was receiving treatment.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined that the facility failed to provide an ongoing activity program to meet the needs of eight of 14 swing bed medical records reviewed (MR2, MR4, MR29, MR30, MR33, MR34, MR35 and MR40).

Findings include:

Review on June 7, 2011, of the facility's "Recreational Therapy Director (Activities Director)" job description, no review date, revealed "Job summary: Plans, coordinates and directs all Recreational Programs and Volunteer services for the ... swing Bed units. ... Duties: ... 9. Maintains various records regarding programs and participants, prepares periodic and / or special reports as required. ... 13. Evaluates programs and participation. ..."

Review on June 7, 2011, of the facility's "Therapeutic Recreation Programming" policy, no review date, revealed "Policy: Recreational Therapy group programs will be offered to all BMC SBU (swing bed unit) patients unless contraindicated in writing on the chart by the admitting physician. Procedure: A. All new admission to BMC SBU will be offered an initial leisure assessment with the TR director and be encouraged to attend scheduled recreational programs. B. Patients have the option to refuse the initial leisure assessment to focus on their rehab services with proper documentation provided by the TR Director. ..."

Review on June 7, 2011, of the facility's "Activities Evaluation" form, no review date, revealed the facility used the form to obtain information from the resident through interview questions of current and past activity interests. These activities included: "animal/pets, arts/crafts, beauty/barber, bingo, board games, cards, community outings, computer, cooking/baking, creative writing, cultural events, current events/news, dominoes, educational programs, exercise, family/friend visits, gardening, group discussion, knit, crochet, movies, music, radio, reading, religious services, religious studies, resident council, shopping, sing-alongs [sic], social/parties, sports, television, volunteering, walking and writing."

Review on June 7, 2011, of MR2, MR4, MR29, MR30, MR33, MR34, MR35 and MR40 revealed no documentation that the facility completed an initial activities evaluation upon admission to the swing bed program. Further review of MR2, MR4, MR29, MR30, MR33, MR34, MR35 and MR40 revealed no documentation that activities were offered or that the patients refused participation in activities while in the swing bed program.

Interview with EMP2 and EMP6 on June 7, 2011, at approximately 1:15 PM confirmed that MR2, MR4, MR29, MR30, MR33, MR34, MR35 and MR40 were admitted to the swing bed program and that the facility did not complete an initial activities evaluation upon admission to the swing bed program. Further interview with EMP2 and EMP6 confirmed there was no documentation in MR2, MR4, MR29, MR30, MR33, MR34, MR35 and MR40 that activities were offered or that the patients refused participation in activities while in the swing bed program.