HospitalInspections.org

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Based on observation, interview and document review, the hospital failed to:

1. Secure medications located in the OR (Operating Room) department to prevent access to them by unauthorized individuals.

2. Ensure medications dispensed to patients meet the general labeling requirements in accordance to state and federal laws

3. Remove expired medications from availability for use. Use of expired medications potentially placed patients at risk for receiving ineffective medications.

4. Monitor medication at the appropriate temperatures as specified by the manufacturer's recommendations and state regulations, when the facilities medication refrigerators' temperatures were found to be out of the safe temperature range. This failure had the potential to have significant impact on patient care since numerous medications have minimal tolerance for temperatures outside of a narrow range. The product may then be rendered less than optimally effective or ineffective.



Findings:


1. On 11/30/11 at 11:05 AM., during a tour of the OR (Operating Room) department, the entrance to the OR department was found unlocked. Inside the OR suite, various types of medications were found in a cabinet by the near back corner. Medications included Vancomycin (antibiotic) 1 gram, Cefazolin (antibiotic) 1 gram, Bupivacaine (local anesthetic agent) 0.5% (5 mg/ml) 10 ml, and Sensorcaine MPF (local anesthetic agent) 0.5% 30 ml. The medications were stored in an unlocked cabinet where anyone entering the room had access to them. On 11/30/11 at 11:08 AM, the DPH (Director of Pharmacy) acknowledged these medications should have been locked up in the cabinet. Unauthorized individuals could walk into the room and have access to all these medications.


2. On 11/29/11 at 3:10 PM, during an inspection of the Med/Surg (Medical Surgical) medication cart, a bottle of Pain Reliever Plus (medication for pain relief) was found inside a cassette bin for Patient 9. The pharmacy label contained information such as the complete patient's name, prescriber's name, quantity and direction etc. was found missing on the Pain Reliever Plus bottle. At 3:15 PM, when the DPH (Director of Pharmacy) was asked about the missing pharmacy label on the Pain Reliever Plus bottle, he stated the label on this bottle probably fell off. And he acknowledged it shouldn't be out in the patient care area without an appropriate pharmacy label.


3. On 11/30/2011 at 11:43 AM, during an inspection of the medication storage area of the Rural Health clinic with DPH (Director of Pharmacy) and RHCM (Rural Health Clinic Manager), a vial of 1 ml sterile diluent (for reconstitution with Measles, Mumps and Rubella vaccine) was found in the vaccine refrigerator. The diluent had an expiration of September 2010. During the interview with the DPH at 11:46 AM he acknowledged that this refrigerator was an area that was overlooked in the past during the regular monthly medication inspection.


4. On 11/30/11 at 11:43 AM, during an inspection of the medication storage refrigerator in the Rural Health clinic with DPH (Director of Pharmacy) and RHCM (Rural Health Clinic Manager), numerous temperature-sensitive vaccines and protein-based medications included Varicella (Chickenpox vaccine) and MMR (Vaccine that protects against Measles, Mumps and Rubella) were found inside. Review of the November 2011 temperature logs for this refrigerator revealed that temperature monitoring was not consistently carried out by the staff and indicated missing temperature records for the following dates: 11/5/11, 11/6/11, 11/12/11, 11/13/11, 11/19/11, 11/20/11, 11/24/11, 11/25/11, 11/26/11 and 11/27/11.

During interview with the RHCM on 11/30/11 at 11:55 AM, she acknowledged that medications which require storage under refrigeration was not consistently monitored especially during the time when the clinic was closed and to ensure acceptable storage conditions were met.

Based on interview and record review, the facility failed to ensure that nursing services met the needs for 1 of 10 sampled patients (Patient 4). The facility failed to ensure that nursing staff followed the facility practice of providing the patient with a discharge instructions sheet. This failure had the potential to result in the patient not having the information necessary to care of herself post-procedure.

Findings:

A review of the medical record for Patient 4 was conducted on 11/30/11. The review revealed that the patient was admitted to the facility on 11/17/11 for an out-patient procedure for a cataract extraction (removal). The medical record review revealed that the patient was discharged to her home on the same day. During the record review, it was noted that the facility form titled, "Patient Discharge Instructions" was not filled out.

An interview was conducted at the time of the record review on 11/30/11 at 10:30 AM, with the Informatics (Computer) Nurse, RN 2 (Registered Nurse 2). He stated that the facility required the nurse to complete a discharge instruction sheet for all patients being discharged from the facility.

An interview was conducted with the Chief Nursing Officer (CNO) on 11/30/11 at 2:00 PM. She stated that for all patients, in-patient or out-patient, the nurses are taught to complete a discharge instruction sheet. She acknowledged that for Patient 4 the sheet was not completed.

Based on interview and record review, the closed records of 3 of 4 post-surgical patients reviewed (4,5,7) contained entries that were incomplete. One chart (4) contained a Short Stay Admission Form and an Immediate Post Op note that lacked the time of entry. Also, the medication reconciliation form was not filled out. A second chart (5) had a History and Physical that only described a Head and Neck exam and no other systems. A third record (7) contained a Medication Reconciliation Form on which was written, "see attached." The next page was a typed list of the patient's medication but with no information on which medications would be continued or discontinued at discharge. This resulted in a failure of the hospital to be able to provide evidence that the undated, untimed entries occurred in a timely fashion. It also resulted in a failure of the hospital to provide evidence that the medications prior to admission were reviewed by the physician and any changes documented at the time of discharge. The lack of a complete H & P in patient 5 resulted in the possibility that surgery and sedation were performed without knowledge of the general health of the patient on the day of the surgery.

Findings:

1. A list of surgical procedures performed in the previous 2 months was obtained. Four records (4-7) were selected to represent the most common procedures and surgeons with higher volumes of cases. The records were reviewed from the electronic document system with the assistance of RN 2.

2. Patient Record 4 contained a History and Physical written on a Short Stay Admission Form. The form was filled out and signed by the physician. Next to the preprinted cue "Date/Time:" there was handwritten the date but not the time. There was no time of entry anywhere on the form. RN 2 confirmed that the date should have been present. A form entitled Immediate Post Operative Note was filled out and signed by the same physician but the DATE/TIME section was blank. A form labeled home Medication Reconciliation Form contained a list of medications but lacked the indication, dose, route, frequency and other information. That area of the form was crossed out with a large squiggly pen mark. The section "Continue on Discharge?", contained a column to circle yes or no, but contained no circles for any of the 9 medications listed.

3. A policy labeled Medication Profile Reconciliation-Continuum of Care (last reviewed 05/2011) was reviewed by the surveyor. It requires a history of all current medications, including drug name, strength, dose, route, frequency, reason for use and time dose last taken. Section 8 states that, "it will be the responsibility of the physician to either print (or request from nursing or pharmacy) and complete an accurate medication reconciliation form at the time of discharge." Section 11 goes on to state that, "On the day of discharge ...the Medication Reconciliation record ...will be printed and checked by the discharging physician or consulting physician to keep them updated on medication changes made in the hospital and improve patient safety."

4. Patient 5 underwent tonsillectomy and adenoidectomy by an Ear, Nose and Throat (ENT) surgeon. The record contained a dictated History and Physical. In the section entitled Physical exam was a detailed examination of the head, eyes, ENT (ears, nose and throat) and the neck. There was no documentation of examination of the heart, lungs, abdomen or other organ systems.

5. The Short Stay History and Physical Examination form was reviewed. RN 2 stated that this would be the minimum expected of a pre-op history and physical. The Physical Exam section contained areas to document vital signs, age, sex, General impression, skin, ears, eyes, nose and throat, chest and lungs, breasts, heart, abdomen, GU/Gyn, extremities and other.

6. A policy entitled Admission of Patient to Operating Room was reviewed. It states that " upon admission of the patient: II. The history, physical and lab results (if ordered) shall be completed and reports shall be attached to the chart. "

7. The record for patient 7 contained a Medication Reconciliation Form( a form filled out by the physician listing the home medications that the physician can mark yes or no for continue on discharge) on which was written " see attached. " The next page was a typed list of the patient ' s medication but with no information on which medications would be continued or discontinued at discharge.

Based on interview and record review, the hospital failed to ensure that in 2 out of 4 (4,5) post-surgical closed records that a complete History and Physical was documented. The record for patient (4) contained a Short Stay admission form that had no documentation of date or time. This resulted in the inability to ensure that the form was completed within the time frame specified in regulation and in the facility policy. The Regulation requires the H & P either within 30 days before surgery with an update on the day of surgery OR completed on the day of surgery. The hospital policy (Physician Medical Record Guidelines reformatted 1/2009) is within 7 days, with an update of the day of surgery. This also made it impossible to ascertain if the information on the form was current, up-to-date and accurate. The medical record for patient (5), a patient admitted for tonsillectomy/adenoidectomy, contained a physical exam by the physician that included only the head and neck. Facility policy and community standards require a complete physical examination before a procedure in which sedation or anesthesia is to be used. This resulted in the possibility that surgery and anesthesia would be performed on a patient with an intercurrent illness or medical problem that might make such a procedure higher risk.

Findings:

1. Patient Record 4 contained a History and Physical written on a Short Stay Admission Form. The form was filled out and signed by the physician. Next to the preprinted cue "Date/Time:" was handwritten the date but not the time. There was no time of entry anywhere on the form. RN 2 confirmed that the date should have been present.

2. Patient 5 underwent tonsillectomy and adenoidectomy by an Ear, Nose and Throat surgeon. The record contained a dictated History and Physical. In the section entitled Physical exam was a detailed examination of the head, eyes, ENT (ears, nose and throat) and the neck. There was no documentation of examination of the heart, lungs, abdomen or other organ systems.

3. The Short Stay History and Physical Examination form was reviewed. RN 2 stated that this would be the minimum expected of a pre-op history and physical. The Physical Exam section contained areas to document vital sign s, age, sex, General impression, skin, ears, eyes, nose and throat, chest and lungs, breasts, heart, abdomen, GU/Gyn, extremities and other.

4. A policy entitled Admission of Patient to Operating Room (last revised 3/99) was reviewed. It states that "upon admission of the patient: II. The history, physical and lab results (if ordered) shall be completed and reports shall be attached to the chart."

5. A policy entitled Physician Medical Record Guidelines (last reformatted 1/2009) was reviewed. The section marked Procedures states, " 2. History and Physical Examination ...must include the following:
* Physical examination to include inventory of body systems and vital signs.

Based on interview and record review, the hospital failed to ensure that all entries to the medical record were signed, dated and timed. One chart (4) of 4 post-surgical closed records reviewed contained a Short Stay Admission Form and an Immediate Post Op note that lacked the time and date of entry. This resulted in a failure of the hospital to be able to provide evidence that the undated, untimed entries occurred in a timely fashion.

Findings:

1. Patient Record 4 contained a History and Physical written on a Short Stay Admission Form. The form was filled out and signed by the physician. Next to the preprinted cue "Date/Time:" was handwritten the date but not the time. There was no time of entry anywhere on the form. RN 2 confirmed that the date should have been present.

2. The record for patient 4 also contained a form labeled Immediate Post-Operative Note. The form was filled out and signed but the section on top labeled DATETIME was blank.

Based on observation, interview and record review, the facility failed to ensure that each patient had the right to personal privacy. The facility failed to ensure that their policy and procedures regarding the use of camera monitoring in the medical surgical unit clearly defined the process to ensure the evaluation of the necessity for camera monitoring, the timeframe for camera monitoring and consent for camera monitoring. This failure had the potential to result in a violation of personal privacy for a universe of potentially 8 patients (4 rooms with camera monitoring capability, with 2 beds each).

Findings:

On 11/29/11 at 10:30 AM, an observation was conducted on the medical/surgical unit of the facility. At the nurse's station there was a monitor that was used for displaying the video from camera monitoring in the patient rooms. The monitor was visible to the staff in the nurse's station. There were 4 rooms, 2 beds in each room, with the potential for camera monitoring.

An interview was conducted, at the time of the observation with RN 1 who works on the medical surgical unit. She stated that the cameras are used for patients who present a fall or safety risk.

A review of the facility policy titled, "Patient Room(s) Camera Monitoring", dated 9/2011, revealed that the reason for the monitoring was to "Insure patient safety for those who may be at risk in the hospital setting." The policy documented that the nurse would "assess the patient for potential safety risk" upon admission to the hospital and orient the patient to the reason for the camera, the location of the equipment. The policy also documented that the patient can "agree or disagree" to the camera monitoring on the "Conditions of Admission" form.

A review was conducted, on 11/29/11 at 1:00 PM, of the log book that listed all of the patients that were admitted to the medical surgical unit. The log also tracked which patients were being monitored by the use of the camera. Since September 2011, there were three patients that were monitored with the use of the camera. A medical record review was conducted on two of the three patients, Patients 1 and 2. The following were noted:

Patient 1:

Patient 1 was admitted to the hospital on 10/6/11 for follow up care for pneumonia and rehabilitation.

A physician's order for the camera monitoring, dated 9/24/1, stated "Camera Monitoring". The order did not specify a timeframe for the monitoring or a reason for camera monitoring.

The nurse's admission assessment, dated 10/6/11, contained a "fall risk assessment"; however, there was no area on the form for a "safety assessment". The fall risk assessment identified the patient as a high risk for falls.

On the general admission information, completed by the nurse on 10/6/11, there was an area for orientation to room and "camera if applicable". This area was check as "yes".

The nurse's narrative notes, dated 9/28/11 at 8:20 PM, documented "Notified pt (patient) of camera monitoring."

The facility form "Conditions of Admission", dated 9/23/11 at 5:39 PM, had an area for "Consent to Video Camera Monitoring" that stated that the hospital may be recording you through the use of a video surveillance system throughout the internal and external structure, including hospital rooms. The form directed the patient or family to the policy for camera monitoring for further information. There was an area for an initial from the patient or the patient's representative. This form was initialed by the patient's representative. There was no area for the patient to agree or disagree.

Patient 2:

Patient 2 was admitted to the hospital on 9/8/11 with diagnoses that included kidney failure and an abdominal abscess (collection of fluid and pus in the belly area).

A physician's order for "camera monitoring and personal alarm" was written on 9/8/11. The order did not specify a timeframe for the monitoring or a reason for camera monitoring.

The nurse's admission assessment, dated 9/8/11, contained a "fall risk assessment"; however, there was no area on the form for a "safety assessment". The fall risk assessment identified the patient as a high risk for falls.

On the general admission information, completed by the nurse on 9/8/11, there was an area for orientation to room and "camera if applicable". This area was check as "yes".

The nurse's narrative note, dated 9/8/11, documented that the patient was on "camera monitoring" and that the patient was notified.

The facility form "Conditions of Admission", dated 9/23/11 at 5:39 PM, had an area for "Consent to Video Camera Monitoring" that stated that the hospital may be recording you through the use of a video surveillance system throughout the internal and external structure, including hospital rooms. The form directed the patient or family to the policy for camera monitoring for further information. There was an area for an initial from the patient or the patient's representative. This form was initialed by the patient's representative. There was no area for the patient to agree or disagree.


On 11/30/11 a review was conducted of the facility policy titled "Fall Assessment and Prevention", dated 6/2010. The policy did not include the criteria for placing the patient under camera monitoring.

An interview was conducted with the facility's Chief Nursing Officer (CNO) on 11/30/11 at 11:00 AM. The CNO acknowledged that camera monitoring could be an invasion of a patient's personal privacy. She acknowledged that the nursing assessment did not include a safety assessment. The CNO stated that the facility was using the camera monitoring for patients who present as a fall risk. She acknowledged that the facility's polices, camera monitoring and fall risk, did not identify the criteria for camera monitoring or give a reassessment timeframe. She confirmed that the physician's orders for Patient 1 and Patient 2 did not identify the reason for the camera monitoring or give a time limit for reassessment. She stated that there should be a clear reason and a clear reassessment timeframe. The CNO stated that the nursing documentation should be clear that the patient/patient representative was informed and educated regarding the use of the camera. She acknowledged that the consent for the use of the camera should make it clear that the patient/patient's representative had agreed to the use of camera monitoring in the patient room and that the facility's present consent did not meet that criteria.













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