HospitalInspections.org

Based on record review and staff interview it was determined in 1 of 33 patient (Pt #20) medical records reviewed, the Hospital failed to ensure Advance Directives were addressed per policy. This has the potential to affect all patients receiving services.

Findings include:

1. The Hospital policy reviewed on 1/26/14 titled, "Advance Directives" was reviewed on 10/7/15. The policy indicated under "III. GUIDELINES/PROCEDURES B. At the time of the admission, the staff inquires if the patient has made provisions for Advance Directives... 1. The admitting nurse notes on the Admission Form if there is or isn't an Advance Directive in force".

2. The medical record of Pt #20 was reviewed on 10/6/15. Pt #20 was admitted to the ARC (Advanced Rehabilitation Care) unit on 9/23/15 with diagnosis of sacral osteomyelitis. There was no documentation that Advance Directive information was addressed in the electronic or paper medical record at the time of admission.

3. An interview was conducted on 10/7/15 at 3:30 PM with Rehabilitation Program Director (E#17). E#17 reviewed Pt #20's electronic and paper record and confirmed the Advance Directives was not addressed.

Based on hospital policy, document review and staff interview, it was determined in 1 of 7 Intensive Care Unit (ICU) patient (Pt #17), the nurse failed to include the name of the medication when writing a verbal/telephone order for medication administration. This failure has the potential to affect all patients receiving medications in the ICU.

Findings include:

1. A review of the policy titled Medication Management, revision date 07/14, was reviewed on survey date 9/8/15 at 9:00 AM. The policy indicates under "B. Medication Order Process, c. To be considered complete, a medication order must contain: i. Drug name......"

2. A review of Pt #17's clinical record was completed on 10/5/15 at 2:30 PM. Pt #17 was admitted to the ICU on 9/30/15 with diagnoses of acute diastolic heart failure, thrombophlebitis of right upper extremity and diabetes mellitus. A review of verbal and telephone orders indicated an order dated 10/2/15 at 1:00 PM for "2 mg IVP now". The order did not include a medication name. In review of the medication administration record it was noted Morphine Sulfate 2 mg was given on 10/2/15 at 3:30 PM.

3. During an interview with Quality Facilitator (E#2) at the time of the record review, E#2 observed the order and agreed the order was not complete and missing the medication name. An interview was conducted with Pharmacy Director (E#5) on 10/8/15 at 10:50 AM. E#5 stated "If an order is received without all components, the physician is to be called to verify the order. This was not done so the nurse was not notified and no correction was made."

Based on policy, record review and staff interview it was determined in 1 of 1 patient (Pt #20) admitted to the ARC (Acute Rehabilitation Care) unit, the Hospital failed to ensure the initial nursing assessments was completed per policy. This has the potential to affect all patients admitted to the ARC unit.

1. The policy revision date 3/26/12, titled, "SMD Assessment/Reassessment Guidelines for Patients" was reviewed on 10/6/15. The policy indicated under "III. GUIDELINES/PROCEDURES C. Time Frame for Completion of Initial Assessment: ...The assessment of the patient is initiated according to the following time frames:.. ARC within 1 hour and completed within 4 hours".

2. The medical record of Pt #20 was reviewed on 10/6/15. Pt #20 was admitted on 9/23/15 at 1:39 PM with diagnoses of motor vehicle accident and sacral osteomyelitis. The initial nursing assessment was completed on 9/23/15 at 7:15 PM, over the 4 hour time frame.

3. An interview was conducted an 10/6/15 at 3:30 PM with the Acute Rehabilitation Manager (E#17). E#17 reviewed the medical record of Pt #20 and confirmed the initial assessment was not completed per policy.

Based on document review and interview, it was determined in 4 of 33 patients (Pt #4, Pt #5, Pt #7, Pt #17) clinical records, the Hospital failed to ensure the medical records were completed per Hospital policy. This has the potential to affect all patients receiving services.

Findings include:

1. On 10/7/2015 at approximately 1:00 PM the Hospital policy titled "Physician's Order" (approved by Med Exec. 8/11/2015) was reviewed. The policy required, " It is the physician's responsibility to sign telephone/verbal orders within 48 hours."

2. The clinical record of Pt #4 was reviewed on 10/5/2015 at approximately at 1:00 PM.
Pt #4 was admitted with a diagnosis of pneumonia. Nursing documentation included (8) telephone orders and (1)verbal order dated 9/28/2015 thru 10/1/2015 which were not authenticated by the physician as of 10/5/2015.

3. The clinical record of Pt #5 was reviewed on 10/5/2015 at approximately 1:30 PM. Pt #5 was admitted with a diagnosis of post concussive syndrome and multiple contusions. Nursing documentation included (3) telephone orders and (1)verbal order dated 10/2/2015 thru 10/3/2015 which was not authenticated by the physician as of 10/5/2015.

4. The clinical record of Pt #7 was reviewed on 10/5/2015 at approximately 2:00 PM. Pt #7 was admitted with a diagnosis of sepsis effecting skin. Nursing documentation included (1) telephone order dated 10/1/2015 which was not authenticated by the physician as of 10/5/2015.

5. An interview was conducted with the Director Medical Advanced Rehabilitation (E #10) at approximately 2:15 PM on 10/5/2015. E#10 stated the physician should have signed the orders within 48 hours.

6. The clinical record of Pt #17 was reviewed on 10/5/15 at 2:30 PM. Pt #17 was admitted to the ICU on 9/30/15 with diagnoses of acute diastolic heart failure, thrombophlebitis of right upper extremity and diabetes mellitus. The record included (5) telephone orders dated 9/30/15 through 10/1/15 not authenticated by the physician as of 10/5/15.

7. An interview was conducted during the review of the record with the Quality Facilitator (E#2) on 10/5/15. E#2 observed the orders and agreed all orders should be signed within 48 hours, which was not done.

Based on document review and staff interview it was determined in 1 of of 33 patient (Pt #31), the physician failed to complete a history and physical (H/P) within 24 hours and ensure it was signed within 30 days. This has the potential to affect all patients receiving services.

Findings include:

1. A request for a policy regarding time requirements for completion of the history and physical was made to the Chief Nursing Officer (E #8) on 10/8/15 at 10:30 AM. E#8 stated "There is no written policy, but it is a known policy all H/P's are to be completed within 24 hours."

2. A review of Pt #31's clinical record was completed on 10/7/15 at 2:30 PM. Pt #31 was admitted to the facility on 3/29/15 with a diagnosis of fractured right femur. The history and physical was dictated and transcribed on 9/1/15 and signed on 9/2/15, over 4 months past the required time frames.

3. During an interview with the Project Accountability (E#4) on 10/8/15 at 11:50 AM, the H/P was reviewed and E#4 agreed the document was not completed per the known verbal policy, including dictation and signature.

Based on hospital Bylaws, record review and staff interview, it was determined in 1 of 33 patient ( Pt #31), the physician failed to complete the discharge summary within 14 days of discharge and failed to sign the summary within 30 days of discharge. This has the potential to affect all patients receiving services.

Findings include:

1. A review of the hospital Bylaws was completed on 10/8/15. The ByLaws indicate under
"1. Discharge Summaries: Discharge Summaries are to be dictated within fourteen(14) days of discharge. The medical record must be complete, including signatures, within thirty (30) days of discharge."

2. A review of Pt #31's medical record was completed on 10/7/15 at 2:30 PM. Pt #31 was admitted to the facility on 3/29/15 with a diagnosis of fractured right femur and discharged on 4/1/15. The discharge summary was dictated and transcribed on 9/1/15 and signed on 9/2/15, over 4 months past the required time frames.

3. During an interview with the Project Accountability (E#4) on 10/8/15 at 12:15 PM, E#4 reviewed the record and agreed the discharge summary was not completed within the required time frame.

Based on document review, observation and staff interview, it was determined the Hospital failed to ensure the pharmacy performed and resolve medication discrepancy reports. This has the potential to affect all patients receiving services.
Findings Include:

1. On 10/7/15 at 1:00 PM, Hospital policy "Automated Dispensing System " (7/2014), was reviewed. The policy read under "Verify Count: the charge nurse must request a discrepancy report at the end of each shift and reconcile all open discrepancies ".

2. On 10/7/15 at 3:00 PM, Hospital policy "Controlled Substances - Local System Hospitals" effective 10/1/15 was reviewed. Under "5.1.1" it reads "The Director of Pharmacy, .....or designee will monitor and review all discrepancies to ensure appropriate resolution."

3. On 10/5/15 at 12:00 PM, a tour of the 4th floor, Medical Surgical Unit was conducted with the Director of Medical/Advanced Rehabilitation (E#10). During the tour the Automated Dispensing System discrepancy report was obtained for 10/5/2015 at 12:37 PM, and the following discrepancies were unresolved:

oxycodone/acetaminophen 5/325 mg (milligram) one tablet- documented discrepancy on 9/25/2015
tramadol 50 mg (milligram) one tablet - documented discrepancy 9/18/2015
lorazepam 0.5 mg (milligram) one tablet - documented discrepancy 9/19/2015

4. On 10/5/15 at 2:30 PM an interview with the Director of Pharmacy (E#5) was conducted. E#5 verified the discrepancies were not cleared and verbalized "The Automated Dispensing System should have had the discrepancy report run and the discrepancies resolved at the end of the shift."

A. Based on document review, observation, and staff interview, it was determined in 1 of 1 patient (Pt #13), receiving care in the Emergency Department (ED), and transferred via ambulance, the Hospital failed to maintain accurate records and distribution of all scheduled drugs. This has the potential to affect all patients transferring from the ED.
Findings Include:
1. On 10/6/15 at 9:45 AM, the clinical record of Pt #13 was reviewed. Pt #13 presented to the ED on 10/5/15 at 4:10 AM with a complaint of abdominal and shoulder pain. The "ED Patient Record" dated 10/5/15 at 10:30 AM indicated "Morphine 4 MG/ML (milligram/milliliter) syringe was dispensed under Pt #13's name with a note that reads "see documentation". The "Patient Audit Trail" dated 10/5/15 at 10:30 AM, read "4 mg of morphine sent with paramedic to give to patient in case of pain en route." There was no documentation in the medical record to indicate if the patient received the morphine that was given to the ambulance personnel.
2. On 10/7/15 at 3:00 PM, the policy "Controlled Substances - Local System Hospitals" (effective 10/1/15) was reviewed. Under "Diversion of Controlled Substances 1)" it reads "No prescription drug or controlled substance may be sold, transferred, or otherwise distributed, except as allowed by law, and as authorized by written policy..." There was no documentation in the policy that allowed for the transfer of controlled substances to ambulance personnel.
3. During a tour of the Pharmacy Department on 10/6/15 at 9:30 AM, an interview with the Director of Pharmacy (E#5) was conducted. E#5 verbalized "It is not our policy to provide ambulance personnel with medications. The ambulances are equipped with medication boxes that contain the medication (morphine) and the medication from the ambulance box should have been used on the patient during the transfer.
4. On 10/7/15 at 3:40 PM, a phone interview with ED registered nurse (E#7) was conducted. E#7 indicated she gave the morphine syringe to ambulance personnel and it was supposed to be used for Pt #13's pain while in route to the accepting Hospital.
B. Based on document review, observational tour and staff interview, it was determined on the 4th floor, Medical Surgical Unit, the Hospital failed to ensure discrepancy reports were performed and open discrepancies were resolved at the end of each shift. This has the potential to affect all patients receiving care on the 4th Floor, Medical Surgical Unit.
Findings Include:

1. On 10/7/15 at 1:00 PM, the policy "Automated Dispensing System" (7/2014), was reviewed. The policy required under "Verify Count: the charge nurse must request a discrepancy report at the end of each shift and reconcile all open discrepancies".

2. On 10/5/15 at 12:00 PM a tour of the 4th floor Medical Surgical Unit was conducted with the Director of Medical/Advanced Rehabilitation (E#10). During the tour the Automated "Discrepancy Transaction Report Devise: ...4 West" was obtained for 10/5/2015 at 12:37 PM, and the following discrepancies were unresolved:

oxycodone/acetaminophen 5/325 mg (milligram) one tablet- documented discrepancy on 9/25/2015
tramadol 50 mg (milligram) one tablet - documented discrepancy 9/18/2015
lorazepam 0.5 mg (milligram) one tablet - documented discrepancy 9/19/2015

3. On 10/5/15 at 1:00 PM, an interview with the Manager 4th floor Medical/Surgical Unit (E#12) was conducted. E#12 stated "The Automated Dispensing System should have had the discrepancy report run and the discrepancies resolved every day."

A. Based on observational tour, document review and interview, it was determined the Hospital failed to ensure the dietary staff followed established policies and procedures to maintain safe food service practices and sanitary food service environment. This has the potential to affect all patients, staff and visitors receiving dietary food services in the hospital.

Findings include:

1. On 10/7/15 between 11:00 AM and 12: 00 PM an observational tour was conducted with the Dietary Manager (E#19). The Hospital's Dietary Sink Sanitizer Log Sheet for the month of October 2015 was reviewed on 10/10/8/15 at approximately 9:15 AM. The log lacked documentation of sanitizer solution sample testing on 10/6/15.

2. Review of Dietary Supervisor's daily "Opening Checklist" provided by Dietary Manager (E#19) on 10/8/15 at approximately 12:30 PM indicated that Dietary Supervisors are expected to ...... record daily sink sanitizer check in the log... Also, review of "Receiving and Storing" employee procedures also provided by E#19 on 10/8/15 at 12:30 PM stated... employees are expected to date products for proper rotation and keep products in original package or in tightly covered, clearly labeled container

3. During a tour of the kitchen, six cans of Bay Valley Liquid Cheddar Cheese Sauce (6 lbs, 11 0z) and five cans of Lindsey Black Olives (55 oz) were found in a walk in cooler with no documentation of date of delivery or out of use date.

4. During the tour of the kitchen, thirty-six apple, carmel frozen cookies had been prepared to bake at a later time were found covered with plastic, unidentified or dated.

5. The Dietary Manager (E#19) stated during an interview on 10/8/15 at approximately 12:15 PM, "The employee who helps with stocking the food deliveries should have dated these cans." E #19 stated the sink sanitizer check and log should be checked daily. E#19 also reported the cookies should by identified and dated.


32822

Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety portion of a full survey due to complaint conducted on October 5-6, 2015 the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety portion of a full survey due to complaint conducted on October 5-6, 2015 the surveyors find that the facility does not comply with the applicable provisions of the 2000 edition of NFPA 101 Life Safety Code.

See the life safety code deficiencies identified with K-tags on the CMS form 2567, dated October 6, 2015.

Based on document review, observation, and interview it was determined the Hospital failed to ensure the 4th floor Medical Surgical Unit patient refrigerator was taken out of service after the refrigerator temperature was not maintained. This has the potential to effect all patients on the 4th floor Medical Surgical Unit.

Findings include:

1. On 10/7/2015 at approximately 1:00 PM the Hospital policy titled "Refrigerator and Freezer Monitoring" (reviewed 12/5/2013) was reviewed. The policy required "If temperatures were not maintained, remove items from the refrigerator or freezers, discard, and notify facilities."
2. On 10/5/2015 at approximately 12:00 PM an observational tour of the 4th floor Medical Surgical Unit was conducted with the Director of Medical/Advance Rehabilitation (E#10). The patient refrigerator daily monitoring log was reviewed and the log indicated the refrigerator temperature was out of range on October 2nd, 3rd, 4th and 5th, 2015. The log indicated no action was taken.

3. E#10 stated during an interview conducted on 10/5/2015 at approximately 12:15 PM, the refrigerators should have been taken out of service and maintenance notified.

Based on record review, observation, and interview it was determined for 1 of 5 patient (Pt #6) in isolation on the 4th floor Medical Surgical unit and 1 of 1 patient (Pt #28) in isolation on the Pre-Operative Surgical Unit, the Hospital failed to ensure staff and visitors followed infection control policies and procedures related to personal protective equipment (PPE) and established "Safe Zone" areas. This has the potential to affect all patients, staff, and visitors of the Hospital.

Findings include:

1. The hospital policy titled "IC Guidelines- General Isolation" was reviewed on 10/7/2015 at 3:00 PM. Under section c. Contact Precautions "When possible, dedicate the use of non-critical patient-care equipment to a single patient...Safe Zone in Contact Precautions: The intent of the "Safe" Zone is to allow staff to communicate with the patient from a designated areas in the patient's isolation room with no PPE use...Red tape will be placed on the floor to designate the entry allowed without PPE."

2. Pt #6's clinical record was reviewed on 10/5/2015 at 1:00 PM. The record noted Pt #6 was admitted with a diagnosis of infection internal knee prosthesis on 10/3/2015. Pt #6 was placed on contact isolation on 10/3/2015 for precautionary measures.

3. During an observational tour with the Director Medical Advanced Rehabilitation (E #10) on 10/5/2015 at 12:15 PM, there was no identified "Safe Zone" red tape indicating the designated "Safe Zone" area in Pt #6's room. E #10 agreed there was no identified "Safe Zone" area.

4. Pt #28's clinical record was reviewed on 10/6/2015 at 11:00 AM. The record noted Pt #28 was admitted with a diagnosis of left knee chondral lesion meniscal tear on 10/6/2015. Pt #28 was placed on precautionary contact isolation for a history of VRE (Vancomycin Resistant Enterococcus).

5. During an observational tour with Director medical Advanced Rehabilitatioan (E #10) on 10/6/2015 at 10:30 AM, (3) three family members entered and exitied Pt #28's isolation room and entered the waiting room for the Pre Operative area without following contact isolation precautions (wearing and discarding PPE). Also observed, was the omission of the "Safe Zone" red tape indicating the designated safe zone area in Pt #28's room. E #10 agreed with the findings.

6. During an interview conducted with Pt #28 on 10/6/2015 at 10:30 AM, Pt #28 stated "Neither I or my husband received any education regarding VRE and the precautions."

Based on Hospital policy, document review and staff interview, it was determined in 1 of 33 patient (Pt #32), the Registered Nurse failed to include an initial screening for discharge planning as part of the initial assessment. This has the potential to affect all patients receiving services.

Findings include:

1. A review of the hospital policy titled "Assessment/Reassessment Guidelines, revision 07/14" was completed on 10/6/15 at approximately 3:30 PM. The policy indicates under "B. Referral Screening at Admission 3. Discharge Planning".

2. A review of the clinical record for Pt #32 was completed on 10/7/15 at 3:30 PM. Pt #32 was admitted to the facility on 3/30/15 with diagnoses of chest pain, anemia and hypoglycemia. Documentation indicates the Registered Nurse failed to assess Pt #32 for needs at discharge in order to initiate a referral for discharge planning if needed.

3. An interview with Project Accountability (E#4) was conducted on 10/8/15 at 12:45 PM. E#4 stated "We are unable to locate any documentation of the assessment screening for discharge planning." E#4 agreed the screening should have been completed.

Based on document review and staff interview in 1 of 5 patient (Pt#8) clinical records reviewed on the Medical Surgical Unit, it was determined anesthesia failed to ensure all pre operative assessments were authenticated. This has the potential to affect all patients receiving services.

Findings include:

1. The hospital policy titled "Pre-Anesthesia Assessment" (reviewed 02/2014) on 10/7/2015 at 4:00 PM. Under III. Guidelines/Procedures it was indicated "The attending anesthetist and anesthesiologist will perform and document a preanethesia assessment ...Documentation will include date and time".

2. The clinical record of Pt #8 was reviewed on survey date 10/5/2015 at 3:40 PM.
Pt. #8 was admitted to the Hospital on 10/5/2015 with a diagnosis of cervical stenosis radiculopathy. The pre anesthesia assessment lacked authentication (date and time) of the pre anesthesia assessment.

3. During an interview with the Manager of 4th floor Medical/Surgical Unit (E#12) on 10/5/2015 at 4:00 PM, it was confirmed anesthesia was not following hospital policy and should have indicated a date and time.