HospitalInspections.org

Based on record review and interview the hospital lacked a system to provide patients who receives outpatient and emergency room services notification of their rights. The hospital failed to provide each patient or the patient's representative with their Patient Rights for 10 of 10 ER (Emergency Room) records reviewed (#1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) and for 2 of 2 Outpatient records reviewed (#32 and #33).

Findings included:

- Review of the hospital's Patient Rights revealed that patient's have the right to receive a written copy of their rights and responsibilities.

Review of 10 ER records revealed the following:

Patient #1 presented to the ER on 1/10/10 with status post fall with change in level of consciousness. Record review revealed the hospital lacked evidence staff provided the patient or the patient's representative with their Patient Rights.

Patient #2 presented to the ER on 12/26/09 with shortness of breath. Record review revealed the hospital lacked evidence staff provided the patient with their Patient Rights.

Patient #3 presented to the ER on 12/4/09 with unresponsiveness. Record review revealed the hospital lacked evidence staff provided the patient or the patient's representative with their Patient Rights.

Patient #4 presented to the ER on 9/26/09 with a rash. Record review revealed the hospital lacked evidence staff provided the patient with their Patient Rights.

Patient #5 presented to the ER on 11/8/09 due to a motor vehicle accident. Record review revealed the hospital lacked evidence staff provided the patient or the patient's representative with their Patient Rights.

Patient #6 presented to the ER on 10/2/09 with a child birth emergency. Record review revealed the hospital lacked evidence staff provided the patient or the patient's representative with their Patient Rights.

Patient #7 presented to the ER on 9/15/09 with a draining wound. Record review revealed the hospital lacked evidence staff provided the patient with their Patient Rights.

Patient #8 presented to the ER on 8/3/09 with suicidal threats. Record review revealed the hospital lacked evidence staff provided the patient or the patient's representative with their Patient Rights.

Patient #9 presented to the ER on 11/2/09 with chest pain. Record review revealed the hospital lacked evidence staff provided the patient with their Patient Rights.

Patient #10 presented to the ER on 1/16/10 with palpations (rapid heart rate) and anxiety. Record review revealed the hospital lacked evidence staff provided the patient with their Patient Rights.

Administrative staff B on 1/25/10 at 3:05pm verified that ER staff failed to provide Patient Rights to ER patients.

Patient #32 presented for outpatient services on 10/15/09 for an esophagogastroduodenoscopy (a procedure that allow the Physician to view the stomach with a scope). Record review revealed the hospital lacked evidence staff provided the patient with their Patient Rights.

Patient #33 presented for outpatient services on 1/27/10 for an esophagogastroduodenoscopy. Record review revealed the hospital lacked evidence staff provided the patient with their Patient Rights.

Administrative staff B on 1/27/10 at 9:45am verified staff failed to provide Patient Rights to patients being registered for outpatient services.

Based on document review and staff interview the hospital failed to develop and implement a policy and procedure for reporting adverse drug reactions.

Findings included:

- Interview during tour of the pharmacy on 1/26/10 at 9:00am with staff C and J acknowledged the hospital lacked a policy and procedure for reporting adverse drug reactions.

Review of the Nursing and Pharmacy policies and procedures on 1/28/09 at 9:30am revealed the hospital lacked a policy and procedure for reporting adverse drug reaction.

Interview on 1/28/10 at 9:00am with Administrative staff B verified the hospital lacked a policy and procedure for reporting adverse drug reactions.

1) Based on document review and interview, the hospital failed to assure clinical records include the "standing orders" (a set of provider's orders with standard treatments and medications for the treatment for certain medical conditions) on the clinical records of patients with the standardized orders. The hospital's failure to include standing orders effected 2 of 2 emergency room patients (#'s 3 and 9).

Findings included:

- Review of the clinical record for patient #3 revealed an emergency room visit on 12/26/09 with changes in mental status. The clinical record contained laboratory results and an electrocardiogram (EKG). Additional review of the record revealed the record lacked physician orders for the tests. Interview with staff A on 1/26/10 at 3:15pm acknowledged the record lacked documentation of the "standing orders". The hospital failed to assure all physician orders are included in the clinical record.

- Review of the clinical record for patient #9 revealed an emergency room visit on 11/2/09 with complaint of chest pain. The clinical record contained the results of laboratory tests and an electrocardiogram (EKG). Additional review of the record lacked physician orders for the tests. Interview with staff A on 1/26/10 at 3:15pm acknowledged the record lacked documentation of the "standing orders". The hospital failed to assure all physician orders are included in the clinical record.

- The Medical Staff's "Rules and Regulations" directed "all orders for treatment shall be in writing...".

The hospital failed to assure all provider's orders are written and included in the clinical record.

2) Based on document review and interview, the hospital failed to assure the clinical record contained complete physician orders for tests and treatments provided. This failure to assure documentation of the physician orders affected 2 of 10 sampled Emergence Room (ER) patient's records (#'s 1 and 4).

Findings included:

- Review of the clinical record for patient #1 revealed an emergency room visit on 1/10/10 following a fall. Review of the clinical record revealed radiology results for a spinal x-ray. Additional review of the record revealed the record lacked a physician's order for the test. Interview with staff A on 1/26/10 at 12:05pm confirmed the record lacked a physician's order for the test.

- Review of the clinical record for patient #4 revealed an emergency room visit on 9/26/09 for a skin rash. The physician's order states "Acyclovir" (an oral antiviral medication) as a treatment for the patient. Review of the nurses notes revealed the patient received Acyclovir 400mg (milligrams) 2 tablets orally. Interview with staff A on 1/26/10 at 3:30pm confirmed the physician's order lacked the dose of the medication and route of administration. Staff A acknowledged the incomplete physician's order.

The Medical Staff's "Rules and Regulations" directed "all orders for treatment shall be in writing...".

The hospital failed to assure physician's orders are complete, in writing and included in the clinical record.

Based on record review and interview the hospital failed to ensure physicians dated and timed all entries into the medical record when they authenticated those entries on 25 of 33 active and closed records reviewed (#'s 2, 4, 5, 6, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 23, 24, 25, 27, 28, 29, 30 and 31).


Findings included:

- Review of the clinical record for patient #2 revealed an emergency room (ER) visit on 12/26/09. The signed ER record lacked the date and time when the physician authenticated the record.

- Review of the clinical record for patient #11 revealed an inpatient admission date of 1/12/10 and discharge date of 1/15/10 for child birth services. The clinical record included signed history and physical, progress notes, 6 verbal/telephone orders, procedure notes, surgical report and discharge summary which lacked the date and time of authentication.

- Review of the clinical record for patient #12 revealed an inpatient admission date of 11/6/09 and discharge date of 11/10/09 for child birth services. The clinical record included signed labor care orders, surgical standing orders, emergency surgical standing orders, admission orders, anesthesia orders, post-partum orders, progress note dated 11/7/09, 11/8/09 11/9/10 and 11/10/09, 5 telephone/verbal orders and a discharge summary which lacked the date and/or time authenticated.

- Interview with staff F on 1/27/10 at 2:15pm confirmed knowledge of all entries in the clinical record require the date and time of authentication. Staff F further acknowledged the medical staff "Rules and Regulations" fail to address the requirement to date and time all entries in a clinical record.

This deficient practice also affected clinical records for patients #'s 4, 5, 6, 9, 10, 13, 14, 15, 16, 17, 18, 19, 20, 21, 23, 24, 25, 27, 28, 29, 30 and 31.

Based on document review and interview, the hospital failed to assure clinical records are completed within 30 days following the patient's discharge. This deficient practice affected 5 of 11 inpatient closed records (#'s 17, 18, 21, 29 and 30).

Findings included:

- Review of the clinical record for patient #17 revealed an inpatient admission date of 10/19/09 with diagnoses including gastrointestinal bleeding, congestive heart failure and diabetes with a discharge date of 10/21/09. The physician dictated the discharge summary on 11/25/09- 33 days after discharge with transcription on 11/30/09- 39 days after discharge.

- Review of the clinical record for patient #18 revealed an admit date of 8/16/09 for the treatment of atrial fibrillation (a heart irregularity) and pneumonia with a discharge date of 8/17/09. The physician dictated the discharge summary on 10/11/09- 55 days after discharge with transcription on 10/13/09- 57 days after discharge.

- Review of the clinical record for patient #21 revealed an inpatient admission on 5/20/09 for child birth and a discharge date of 5/21/09. The physician dictated the discharge summary on 6/23/09- 33 days after discharge with transcription on 6/24/09-34 days after discharge.

- Review of the hospital's Medical Staff "Rules and Regulations" #15 directed "Within 21 days of the discharge date, the attending physician shall complete and sign the record"'. The "Rules and Regulations continue "If the record is incomplete at the end of the 21 days..., the physician will be sent a letter signed by the administrator allowing them a 7 day grace period to complete the record. On the 28th day the administrator... will notify...(the physician) privileges have been suspended until the records are completed".

Interview with staff F on 1/27/10 acknowledged the delinquent discharge summaries and further confirmed letters have not been sent to the physicians. Staff F acknowledged the hospital failed to assure discharge summaries are completed within 30 days of the patient's discharge.

This deficient practice also effected patients' records #'s 29 and 30.

Based on document review and staff interview the hospital failed to follow their pharmacy policy and procedure to develop a formulary (a list of drugs available in the hospital) and update it annually.

Findings included:

- Interview on 1/26/10 at 8:45am with staff J acknowledged the hospital lacked a formulary developed by the medical staff and reviewed periodically.

Review of the pharmacy policy and procedure manual on 1/27/10 revealed under the letter E titled "Formulary: Mercy Hospital shall have a drug formulary which shall be updated yearly..."

The hospital reported a census of two acute patients, two swing bed patients, two newborns and a respite patient. Based on observations, staff interview and document review, the hospital's infection control officer failed to ensure hospital personnel followed basic infection control practices during 8 of 15 random observations.

Findings included:

- Observation on 1/25/10 at 1:40pm in the ER (Emergency Room) revealed an open Yankauer suction tip in ER #1 and one on the ER crash cart with the covering package partially open.

Administrative staff A on 1/25/10 at 1:40pm acknowledged the open Yankauer suction tips.

- Observation on 1/26/10 at 8:00am in the LDR (Labor/Delivery Room) revealed an open Yankauer suction tip in LDR #1 and LDR #2 with the covering package partially open.

Administrative staff A on 1/26/10 at 8:00am acknowledged the open Yankauer suction tips.

- Observation on 1/25/10 at 4:10pm revealed staff H entered the hallway with their hands full of soiled linens from room #119. Staff H failed to place the soiled linens inside a linen bag to carry the linens through the hallway to the Utility room. Therefore, this action by staff potentially could transmit the infectious microorganisms from the bed linens and could be carried to other areas of the hospital.

Staff G on 1/25/10 at 4:10pm verified staff H carried unbagged soiled linens through the hallway.

- Observation on 1/26/10 at 7:15am revealed staff C performed blood glucose testing on patient #33. Staff C removed the glucometer (a machine used to test blood sugar) and supplies needed to test the patient's blood sugar from a white box sitting on the bedside table. Staff C, wearing gloves, completed the blood sugar test. Staff C removed the test strip from the glucometer then laid the glucometer on the bedside table without a protective barrier. Staff C disposed of their gloves and the test strip, picked up the glucometer and placed the glucometer back into the white box. Staff C failed to clean the glucometer after use and failed to wash their hands after they performed the blood test. At 7:20am staff C returned the white box containing the glucometer and testing supplies to a drawer at the nurses station without cleaning the white box or the glucometer.

Administrative staff A acknowledged the glucometer and white box should be cleaned after each use and the facility failed to have a policy directing staff on how to clean the glucometer.

- Observation during cleaning of the scope room in the Operating Suite on 1/26/10 at 11:25am revealed staff D, using "Virex 256" cleaning solution, wet wiped the cabinets, medication cart, monitors, trash cans, lights and equipment. These areas remained wet for a contact time of less than one minute. While cleaning the cabinets, staff D wet wiped the glass areas then immediately dried the surface. At 12:01pm staff D began to wet mopped the floor using "Virex 256" cleaning solution. The floor remained wet for a contact time of only 5 minutes not the required 10 minutes for disinfection.

The "Virex 256" container's label with manufacturer's guidelines for disinfection instructed staff to allow surfaces to remain wet for 10 minutes to assure disinfection.

Staff D on 1/26/10 at 12:15pm acknowledged they learned earlier in the day the "Virex 256" cleaner required a contact time of 10 minutes to achieve disinfection. Staff D verified the surfaces on the equipment in the scope room and the floor failed to remain wet for the 10 minutes required for disinfection.

Review on 1/27/10 at 11:30am of the hospital's policy titled "Infection Surveillance, Nosocomial and Acute" with Administrative staff A, acknowledged the policy failed to include surveillance of environmental cleaning and staff practices. Review of the policies for cleaning of patient rooms, birthing rooms and operating rooms failed to instruct staff on the required time surfaces need to remain wet to assure disinfection.


21996

- Observation on 1/26/10 at 10:15am revealed staff E cleaned room #119. Staff E, wearing gloves, cleaned the outside of the toilet bowl with a cloth taken from a small bucket of water that contained "Virex" (a disinfectant). Staff E then applied "Clinging Toilet Bowl" (a liquid disinfectant) from a squirt bottle into the water in the toilet bowl, brushed the inside of the toilet bowl with a toilet bowl brush and flushed the toilet. Staff E then cleaned the sink and counter in the patient room with a cloth taken from a second small bucket of water that contained "Virex", rinsed the inside of the sink with water and immediately dried the sink and counter top with a paper towel. Staff E mopped the floor using "Virex" cleaner which dried with in 3-4 minutes of the initial contact time.

Staff E failed to allow the "Virex" cleaning solution to remain on surfaces for 10 minutes in the patient room to achieve the desired disinfection of the sink, counter and floor. Staff E failed to remove the water from the toilet bowl before cleaning the toilet with "Clinging Toilet Bowl" cleaner to achieve the desired disinfection of the toilet bowl.

Review on 1/26/10 of the directions on the "Clinging Toilet Bowl" directed, "...Remove water from bowl....pour 1 ounce of product onto applicator...scrub entire unit especially under the rim at water outlet wait 1 minute, then flush."

Review on 1/26/10 of the directions on the One -Step Disinfectant Cleaner and Deodorant bottle directed, "Virex...for disinfection, all surfaces must remain wet for 10 minutes.

Interview on 1/26/10 at 10:15am with staff E acknowledged they were unaware the "Virex" cleaner required a contact time of 10 minutes to achieve disinfection and they needed to remove the water from the toilet bowl before applying "Clinging Toilet Bowl" ,the disinfectant, wait one minute and then flush the toilet.

- Observation during the terminal cleaning of a patient room on 1/26/10 revealed staff E wearing gloves, cleaning the patient bed, bedside stand, over-bed table, and counter tops in the room with a cloth taken from a bucket of water that contained the disinfectant "Virex". The cleaned surfaces remained wet for 3-5 minutes after the application of the disinfectant solution not the required 10 minutes for disinfection.

Interview on 1/26/10 at 11:00am with staff E acknowledged the surfaces dried in less than 10 minutes as required by the manufacturer to achieve disinfection of the surfaces.

- Observation on 1/26/10 at 8:00am of the clean utility room revealed an uncover ice scoop lying on the ice machine. Two intravenous (IV) pumps sat directly on the floor of the utility room. The open ice scoop and IV pumps on the floor had the potential for contamination.

Interview on 1/26/10 at 8:10am with staff A acknowledged the uncovered ice scoop and IV pumps on the floor were no longer considered clean.

Based on interview and record review the facility failed to provide a qualified professional to direct the activities program and failed to provide evidence of activities for 5 of 5 sampled swing bed residents (#'s 27, 28, 29, 30 and 31).

Findings included:

- Record review on 1/25/10 and 1/26/10 for swing bed patients #'s 27, 28, 29, 30 and 31 revealed the records lacked evidence of a care plan addressing activities, scheduled activities for each resident or documentation activities were conducted.

Interview on 1/26/10 at 2:10pm with Administrative staff B acknowledged the medical records for patient #27 and #28 lacked evidence the care plan included activities or documentation of on-going activities. Staff B acknowledged the hospital no longer employed an Activities Director and the Social Service Designee had assumed those duties.

Interview on 1/26/10 at 2:25pm with staff I confirmed they were responsible for activities for swing bed residents. Staff I acknowledged they did not have an Activities Director certification and lacked knowledge of the need to care plan or provided organized activities for swing bed residents.