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Based on record review and interview, the facility failed to ensure that 6 of 10 (#19, 24, 26, 27, 29, 35)medicare patients were provided with the Important Message from Medicare (IMM) within 48 hours of admission and/or discharge. Findings include:
During review of the medical record for patient #19 on 10/09/2012, revealed that the patient was admitted on 10/02/2012, staff LL was unable to locate an IMM in the medical record for the patient.
Patient #24 was admitted on 09/17/2012 and the IMM was completed at the time of admission. The patient was discharged on 09/24/2012, staff LL was unable to locate the 2nd IMM for the patient.
During review of the medical record for patient #26 on 10/08/2012, revealed that the patient was admitted on 10/06/2012, staff LL was unable to locate an IMM in the medical record for the patient.
During review of the medical record for patient #27 on 10/08/2012, revealed that the patient was admitted on 10/01/2012, staff LL was able to locate an IMM in the medical record for the patient; however the form was not signed.
During review of the medical record for patient #29 on 10/08/2012, revealed that the patient was admitted on 09/29/2012, staff LL was unable to locate an IMM in the medical record for the patient.
During review of the medical record for patient #35 on 10/08/2012, revealed that the patient was admitted on 09/28/2012, staff LL was unable to locate an IMM in the medical record for the patient.
During an interview with staff LL on 10/09/2012 at 1400, when queried as to what is the hospital's expectation in regards to the IMM she stated "they are supposed to be completed at the time of admission or within 48 hours of admission and again when the patients are discharged."
She also stated that "registration should be completing the first one and the case managers should be checking the record for it and if it is not completed should be completing it and case management should be completing the second one before discharge if one is needed."

Based on record review, interview and policy review the medical staff failed to enforce the bylaws of the facility in regards to the medical record content and the completion guidelines. Findings include:
During review of the document titled Physician Delinquency Report on 10/08/2012 at 1500, it revealed that the facility had 1346 open medical records of discharged patients that required some form of documentation from a physician to close them.
During an interview with staff S on 10/08/2012 at 1510, when queried as to the process for obtaining the needed documentation from the physicians to close out the open records she explained that the first step was to send the physician a letter titled Weekly Incomplete Record Notification, the second step was to send a Warning Letter and the third step was to send a Temporary Suspension Letter from the Chief Of Staff. When staff S was queried as to the results of the process she stated "it works for some physicians and not for others." When asked how many of the physicians that have delinquent records are suspended she stated "26." Further review of a document titled Physician Suspension Listing revealed a total of 26 physicians on suspension from 03/10/2011-10/05/2012.
A review of the medical staff bylaws on 10/09/2012 revealed that on June 22,2012 the bylaws were adopted. In section 4.2.11 of the bylaws it reads "Complete Medical Records Shall Prepare and complete in accordance with HIM Medical Record Content and Completion Guidelines Policy (108700-00-26) and Medical Staff Medical Record Delinquencies Policy (see Policy 108710-00-54) approved by the Medical Executive Committee for all patients admitted to or in any way provided care in the Medical Center."
A review of the policy titled Medical Record Delinquency #108710-00-54 issued 08/03/10 reads in the section titled Procedure
#1 "All records received within the HIM department will be analyzed for completeness, as defined in the policy "Medical Record Content and Completion Guidelines."
#2 "Records devoid of any elements required by the above policy, including dictations, signatures and/or dates will be marked as incomplete or deficient and entered into the chart deficiency system within the HIM department and will initiate the record count for completion of the record."
#3 "On a weekly basis {"Incomplete Record"} notices are generated and placed in the physician's mailbox. Any physicians having incomplete records will receive the incomplete record notification.
#4 "All incomplete records will be located/filed within the Incomplete File room and available for physician completion."
#5 "The attending physician, allied health professional and/or resident will have a total of thirty (30) days to complete his/her deficient/incomplete medical record before the record will be considered delinquent."
#6 As a courtesy, the HIM analyst will monitor the list of deficient/incomplete medical records and each Tuesday will provide weekly reminders to the physician. When deficient/incomplete records reach day 15, phone calls will be made to the appropriate offices to serve as reminders."
#7 "On the Tuesday after any deficient record reaches day 21, the HIM analyst will send a warning letter and contact the physician's incomplete medical record (s) and approaching 30 day deadline."
#8 Deficient/incomplete records will become delinquent on the 30 th day that the medical record was available for physician completion."
#9 "Physicians will have until 8 a.m. on the Thursday after a deficient/incomplete record is 30 days old before being placed on the suspension list."
#10 "Each Thursday, the VPMA and Chairperson of the applicable Department will be notified of any physicians having delinquent medical records. The HIM Department will notify the physician of the temporary suspension via a certified letter.
#15 "The Medical Executive Committee may take additional action to promote compliance in the event that a particular physician is consistently unable to complete his/her medical records in a timely manner.
During an interview with the COO on 10/09/2012 at 1115, when queried as to what was being done to get the physician's to complete their delinquent records and get off the suspension list he explained the same process with the letters and the temporary suspension. When asked if he thought that being on "temporary" suspension for 18+ months was working to get the records completed he stated "NO, we need to revisit this and make some changes to get the physicians to complete their records." He stated that "we have some physicians that see over a thousand patients a month and they can get their records completed and others who see a lot less patients don't get theirs completed. I think it has something to do with a better work ethic for some of them."

Based on record review, and interview the facility failed to ensure that the nursing staff keeps current nursing care plans in 1 of 14 charts reviewed.(Patient # 44) Findings include:

Patient #44's care plan did not contain current updates during the hospitalization, especially after the patient sustained a fall on 10/06/12.

On 10/08/12 at approximately 1100 during record review it was determined that patient #44 was admitted on 09/15/12. The patients physician documented on 10/04/12 that "he states "concerns with ambulating". Patient #44's chart did not contain changes in the care plan, no reassessment was found on the chart in regards to the "concerns with ambulation".

Staff DD confirmed that the facility did not update the care plan in between 09/15/12 and the date of the patient's fall on 10/06/12.

Based on record review and interview the facility failed to ensure that medical record documentation was completed for 8 of 8 records reviewed. Findings include:
During review of the medial record for patient #13 on 10/09/2012, it revealed that the patient was given discharge instructions by the RN and discharged from the hospital on 09/24/2012. The physician order was not completed and signed by the physician until 10/04/2012. There was no documentation of a telephone order from the RN on 09/24/2012.
Review of medical records for patients #21, 22 and 23 did not contain any documentation of a physician's order to discharge the patients.
During an interview with staff B on 10/09/2012 at 1700, he confirmed the findings and stated that "all the records should have a discharge order on them. "
Review of the medical records for patients #36 and 37 on 10/08/2012 revealed that the document titled Patient Health History were incomplete. The sections that are filled out by the patient were complete but the 3rd an 4 th pages that were supposed to be completed by the RN were not complete.
During an interview with staff LL at the time of the findings she stated "the patient fills out the first two pages and the nurse is supposed to complete the other two pages." She also confirmed the incomplete documentation on the forms.
Review of the medical records for patients #21, 22, 23,and 34 revealed incomplete physician orders for the use of restraints.
The restraint order for patient #21 was obtained on 10/01/2012 per a telephone order, at the time of the record review on 10/09/2012 the order had not yet been signed by the physician.
The restraint orders for patient #22 was obtained on 09/15/2012 and 09/16/2012 per telephone orders, at the time of the record review on 10/09/2012 the orders had not yet been signed by a physician.
The restraint order for patient #23 was obtained on 09/30/2012, the form does not identify the type of order or a physician's name identifying who the order was obtained from. At the time of record review on 10/09/2012, the order has not been signed by a physician.
During an interview with staff B on 10/09/2012 at 1630, when queried as to what is the expectations for having the restraint orders signed, he stated "the expectation is that the physician would sign the order within 24 hours since he had to see the patient to evaluate the use of the restraints."

Based on medical record review, interview and document review, the facility failed to ensure a history and physical (H&P) was completed on 2 of 12 patients (#4, #6) resulting in the potential for for medical errors due to incomplete patient information. Findings include:

On 10/8/12 at approximately 1200 during open record review for Patient #6 revealed a document titled "History and Physical" that only contained a brief history but no physical. A review of the progress notes with Staff #I revealed no other hand written or typed history and physical in the medical record.

On 10/8/12 at approximately 1100 during open record review for Patient #4 revealed a document titled "History and Physical" dated 8/23/12. The Physician initialed the H&P as an update on 9/26/12. This was beyond the 30 days allowed for an initialed update. Further review of the record with Staff #G revealed no other comprehensive current H&P.

Interview with the Director of Regulatory and Medical Staff Affairs, on 10/8/12 at approximately 1400, revealed that the Medical Staff Bylaws endorsed the Policy & Procedure titled "Medical Record Content and completion Guidelines". This Policy & Procedure dated 6/9/11, specified "History and Physical Examination - The required History and Physical (H&P) may be completed up to 30 days prior to or within 24 hours after inpatient admission."

Based on record review, interview and policy review the facility failed to ensure that medical records are completed for all patients within 30 days of discharge. Findings include:
During review of the document titled Physician Delinquency Report on 10/08/2012 at 1500, it revealed that the facility had 1346 open medical records of discharged patients that required some form of documentation from a physician to close them.
During an interview with staff S on 10/08/2012 at 1510, when queried as to the process for obtaining the needed documentation from the physicians to close out the open records she explained that the first step was to send the physician a letter titled Weekly Incomplete Record Notification, the second step was to send a Warning Letter and the third step was to send a Temporary Suspension Letter from the Chief Of Staff. When staff S was queried as to the results of the process she stated "it works for some physicians and not for others." When asked how many of the physicians that have delinquent records are suspended she stated "26." Further review of a document titled Physician Suspension Listing revealed a total of 26 physicians on suspension from 03/10/2011-10/05/2012.
A review of the medical staff bylaws on 10/09/2012 revealed that on June 22,2012 the bylaws were adopted. In section 4.2.11 of the bylaws it reads "Complete Medical Records Shall Prepare and complete in accordance with HIM Medical Record Content and Completion Guidelines Policy (108700-00-26) and Medical Staff Medical Record Delinquencies Policy (see Policy 108710-00-54) approved by the Medical Executive Committee for all patients admitted to or in any way provided care in the Medical Center."
A review of the policy titled Medical Record Delinquency #108710-00-54 issued 08/03/10 reads in the section titled Procedure
#1 "All records received within the HIM department will be analyzed for completeness, as defined in the policy "Medical Record Content and Completion Guidelines."
#2 "Records devoid of any elements required by the above policy, including dictations, signatures and/or dates will be marked as incomplete or deficient and entered into the chart deficiency system within the HIM department and will initiate the record count for completion of the record."
#3 "On a weekly basis {"Incomplete Record"} notices are generated and placed in the physician's mailbox. Any physicians having incomplete records will receive the incomplete record notification.
#4 "All incomplete records will be located/filed within the Incomplete File room and available for physician completion."
#5 "The attending physician, allied health professional and/or resident will have a total of thirty (30) days to complete his/her deficient/incomplete medical record before the record will be considered delinquent."
#6 As a courtesy, the HIM analyst will monitor the list of deficient/incomplete medical records and each Tuesday will provide weekly reminders to the physician. When deficient/incomplete records reach day 15, phone calls will be made to the appropriate offices to serve as reminders."
#7 "On the Tuesday after any deficient record reaches day 21, the HIM analyst will send a warning letter and contact the physician's incomplete medical record (s) and approaching 30 day deadline."
#8 Deficient/incomplete records will become delinquent on the 30 th day that the medical record was available for physician completion."
#9 "Physicians will have until 8 a.m. on the Thursday after a deficient/incomplete record is 30 days old before being placed on the suspension list."
#10 "Each Thursday, the VPMA and Chairperson of the applicable Department will be notified of any physicians having delinquent medical records. The HIM Department will notify the physician of the temporary suspension via a certified letter.
#15 "The Medical Executive Committee may take additional action to promote compliance in the event that a particular physician is consistently unable to complete his/her medical records in a timely manner.
During an interview with the COO on 10/09/2012 at 1115, when queried as to what was being done to get the physician's to complete their delinquent records and get off the suspension list he explained the same process with the letters and the temporary suspension. When asked if he thought that being on "temporary" suspension for 18+ months was working to get the records completed he stated "NO, we need to revisit this and make some changes to get the physicians to complete their records." He stated that "we have some physicians that see over a thousand patients a month and they can get their records completed and others who see a lot less patients don't get theirs completed. I think it has something to do with a better work ethic for some of them."

Based on interview and record review, the facility failed to reconcile accuracy of controlled medications records when picked up by the Reverse Distributor Company. Finding include:

Interview with the Director of Pharmacy, on 10/9/12 at approximately 1100, revealed that expired controlled medications were picked up quarterly by a Reverse Distributor Company. A review of the documents of the last pick up dated 7/9/12 revealed that three (3) additional vials of meperidine 10 mg/ml had not been initially documented by the Reverse Distributor Company. Further interview with the Pharmacy Director revealed that Pharmacy Staff #N kept the paperwork for the expired medication pick up. After further inquiry of the Pharmacy Director, Manager and Staff #N, it was determined that no one actually reconciled pharmacy expired controlled medications with the Reverse Distributor Company. The Pharmacy Manger stated "We can begin doing that..."

Based on observations the facility failed to ensure an acceptable level of safety as evidenced by the following:
1. Emergency medical (crash) cart, equipped with medications that allow for immediate access, was found at 11:26 a.m. on October 9, 2012 to be stored beyond line of sight that allows for continuous control by staff on the 5 North inpatient nursing unit. As such it could not be ensured that supplies and medications would always be available for emergent patient needs.
2. No disposable hand towel dispenser was found at 11:30 a.m. on October 9, 2012 at handwashing facility in pathology. As such proper hand hygiene was not facilitated.
3. No disposable hand towel dispenser was found at 11:34 a.m. on October 9, 2012 at handwashing facility in blood bank. As such proper hand hygiene was not facilitated.
4. A jacket, two purses, and a wooden shipping pallet were found at 11:36 a.m. on October 9, 2012 in the general chemistry work area of the lab. Each of these items represent possible harborage of vermin and contamination as they were not cleaned by hospital staff.
5. Emergency medical (crash) cart, equipped with medications that allow for immediate access, was found at 1:50 p.m. on October 9, 2012 to be stored beyond line of sight continuous control of staff in the neuro progressive care staff lounge nursing unit. As such it could not be ensured that supplies and medications would always be available for emergent patient needs.
6. A wooden shipping pallet was found at 1:55 p.m. on October 10, 2012 in the clean supply room of material management. This represents possible harborage of vermin and contamination as it could not be properly cleaned.

Adequate levels of artificial illumination was not provided as measured at the high density storage units in central sterile processing. Only 9 footcandles of illumination was measured versus the required 15 footcandles needed to ensure staff can identify supplies and properly clean the area.

Based on observation and interview the facility failed to monitor compliance with infection control measures related to hospital contract workers including dialysis and housekeeping, this has the potential to impact all patients seen at this facility.

Findings include:

On 10/8/2012 at approximately 1500 (3:00 pm) during tour of the in-patient dialysis unit discontinuation of treatment for 2 patients ( #47 & #48) was observed. Staff #K was preparing to discontinue patient #47, 1) wearing no face shield, 2) one pair of gloves worn- touched dialysis machine, then open sterile 2x2's, walked across room to put on faceshiled that was hanging on the wall, then removing needles from the fistula, with bloody gloves still on tearing tape from a reusable roll of tape. Staff J came to turn off the alarm on the machine during the discontinuation procedure and only put one glove partially on the right hand. Staff J was interviewed at approximately 1530 (3:30 pm) if this was acceptable practice, stated "NO".
At 1515 (3:15 pm) during continued observation in the in-patient dialysis unit Staff J was observed discontinuing patient #48 with a permacath while the privacy curtain was hanging over the entire stretcher and resting on patient #48s railing to provide the third patient privacy while using the bedpan. Staff J had to move a 4 th dialysis machine from in front of the sink with dirty hands in order to wash hands after removing gloves. Patient #48 was subsequently examined by 3 doctors- when asked to sit up the privacy curtain was resting on the patients head. Staff #B & #DD verbalized knowledge "not good infection control practice".

Interview of Staff #B &#DD regarding in patient dialysis "this service is contracted with outside agency".


15195

During tour of the 3rd floor Neurological Progressive Care Unit on 10/8/12 at approximately 1145, it was noted that the Medication Room Counter had built up dirty grime. Nurse #I was queried at that time about who was responsible for cleaning the counter, and she stated "Housekeeping had to be let in the Med Room for cleaning or the Nurse can do it". The cleaning wipes were not available in the Medication Room. Nurse #I then left the Medication Room and retrieved the cleaning wipes, returned and cleaned the Medication Room counter.


27408

On 10/08/2012 at approximately 1045 during observations on 5 South it was revealed that the refrigerator located in the stock room was not being cleaned by housekeeping or patient care staff. The lower shelf inside the refrigerator contained a yellow-brown dried substance that had been spilled and not cleaned up. The counter under the window, where the coffee pot and sink were located, contained several coffee spills that were dried and needed cleaned up. The room also contained numerous small bins that contained clean patient supplies such as dressings, bath supplies, and speciality items for certain medical procedures, that contained dust and debris and needed to be cleaned.


28273

During observations on 4 South with Staff LL on 10/08/2012 at 1000, it revealed that the refrigerator located in the stock room needed to be cleaned. The lower compartments inside the refrigerator contained a yellow dried substance that had been spilled and not cleaned up. The coffee pot and area surrounding the coffee pot located in the same stock room was very dusty and contained several coffee spills that needed cleaned up. The room also contained numerous small bins that contained patient supplies (dressing supplies, bath supplies and supplies used for procedures), that contained dust and debris and needed to be cleaned.
During further observation with staff LL on 4 North, it was noted that the stock room also contained small bins for patient supplies that also were dusty and needed to be cleaned.
The findings were confirmed by staff LL at the time of the observations. Staff LL stated that "the refrigerator is supposed to be cleaned by dietary, the coffee pot would be Nursing's responsibility to clean and I think the bins would be material supply's responsibility."

Based on record review and interview the facility failed to ensure that 3 of 7 (#18, 19,20) Anesthesia consents are completed by the CRNA prior to having the patient sign the form Findings include:
During review of the medical record for patient #18 on 10/09/2012, revealed that the patient had a surgical procedure performed on 10/04/2012. The document titled Consent For Anesthesia/Moderate Sedation lacked documentation of the type of anesthesia that would be used on the patient such as: General, Spinal/Epidural, Major/Minor Nerve Block or Moderate Sedation.
Review of the medical record for patient #19 on 10/09/2012, revealed that the patient had a surgical procedure performed on 10/02/2012. The document titled Consent For Anesthesia/Moderate Sedation lacked documentation of the type of anesthesia that would be used on the patient such as: General, Spinal/Epidural, Major/Minor Nerve Block or Moderate Sedation. The document also lacked documentation as to who the MD/CRNA was that would provide the anesthesia to the patient.
Review of the medical record for patient #20 on 10/09/2012, revealed that the patient had a surgical procedure performed on 10/02/2012. The document titled Consent For Anesthesia/Moderate Sedation lacked documentation of the type of anesthesia that would be used on the patient such as: General, Spinal/Epidural, Major/Minor Nerve Block or Moderate Sedation.
During a review of the documentation with the Director of Surgical Services and the Chief CRNA on 10/09/2012 at 1300, they confirmed the findings and stated that the documents should include both the name of the provider filled in at the top and the type of anesthesia being used identified on the document.