HospitalInspections.org

A. Based on clinical record review and staff interview, it was determined that the Facility failed to ensure all treatments were provided as ordered by the physician. This was evident in 1 (Pt. #18) of 2 records reviewed where patients were restrained.

Findings include:

1. Pt. #18 was admitted to the Hospital on 12/24/10 with the diagnoses of suicidal ideation and depression. Pt. #18 was restrained without a physician's order during an examination in the ED (Emergency Department).

2. The above finding was verified with the DON (Director of Nursing) and CNO (Chief Nursing Officer) on 04/21/11 at 2:00pm.

A. Based on clinical record review, a review of the Hospital's infection control (IC) data/program and staff interview, it was determined that the Facility failed to ensure all measures for an active IC surveillance program existed. This was evident in 3 of 5 (Pt.s #8, #9 & #12) clinical records reviewed with IC issues.

Findings include:

1. Pt. #8 was admitted to the Hospital on 02/23/11 with the diagnoses of Urinary Tract Infection, Sepsis and Anemia. Lab results indicated Pt. #8 was positive for Clostridium difficele and urinary pseudomonas while hospitalized. The IC coordinator did not have patient data logged and could not provide any documentation to indicate specific measures had been utilized to identify, track or evaluate these infections and prevent further IC issues.

2. Pt. # 9 was admitted to the Hospital on 03/14/11 with the diagnoses of Sepsis, Urinary Tract infection and Gastrointestinal hemorrhage. Laboratory data indicated Pt. #9 had two positive blood cultures for Escherichia coli and a positive urine culture with the same organism. The IC Coordinator could not provide documentation that these cultures had been evaluated, monitored or documented to identify or assess any of these infections.

3. The medical record of Pt #12 was reviewed on 04/21/11. It indicated that Pt #12 was admitted to the Hospital on 02/17/11 with the diagnoses of Pneumonia and Sepsis. Lab results from blood cultures obtained from Pt #12 on 02/17/11 had positive results for MRSA. The IC Coordinator could not provide documentation that these cultures had been utilized to identify, track or evaluate the infection and prevent further IC issues.

4. During an interview with the IC Coordinator on 04/21/11, she indicated that she did not previously keep accurate recordings of IC data. The IC coordinator indicated the infection control incidence for the last year was 0%, although mechanisms for a complete, active infection control program for identifying, investigating, and reporting infections did not exist.

B. Based on Hospital policy, observation, a tour of the Hospital, and staff interview it was determined that the Facility failed to ensure IC surveillance mechanisms were maintained to prevent sources of contamination and transmission of contagions.

Findings include:

1. The Hospital policy titled "IV procedure and daily care,"indicates intravenous (IV) site dressings must be labeled with RN/LPN/CRNA/Xray tech who started IV device, preferably the label supplied with the IV start kit should be used.

2. During an interview with Pt. #6 on 04/20/11 at 10:00 am, it was noted that Pt. #6's left antecubital IV site was not labeled with the date or who started the IV.

3. During a tour of the Hospital, the clean holding area of the Rehabilitation unit had patient care items (cold/ice packs) and Hospital personnel frozen foods comingled in the same freezer unit.

4. During a tour of the Hospital it was noted that none of the housekeeping carts had labeled their carts containing clear liquids in basins that were used for cleaning.

5. The above findings were verified with the Chief Nursing Officer (CNO) and Director of Nursing (DON)on 04/20/11 at 11:00am.

A. Based on Hospital policy, clinical record review and staff interview it was determined the Hospital failed to ensure licensed staff personnel notified the physician of all critical lab values. This was evident in 1 (Pt. #15) of 20 records reviewed.

Findings include:

1. The policy titled "Reporting of Critical Tests and Critical Values" was reviewed on 04/21/11 at 1055am. It indicated under "Procedure: All critical tests as defined above and all tests with critical values will be called to the physician by a licensed staff person. The above testing reports must be reported to the patient's physcian immediately upon notification."

2. Pt. #15 was admitted on 11/24/10 with diagnosis of Leukemia. On 11/24/10 thru 12/1/10 there were 4 critical lab values called to the licensed staff person who failed to report the critical values to the patient's physician immediately upon notification.

3. The above findings were confirmed with the DON and CNO on 04/21/11 at 1055.

A. Based on clinical record review and staff interview, it was determined the Hospital failed to ensure all nursing care plans were initiated and kept current as required. This was evident in 1 (Pt. #10) of 15 clinical records reviewed.

Findings include:

1. Pt. # 10 was admitted to the CAH on 03-09-11 with the diagnoses of Gastrointestinal Hemorrhoids, Acute Kidney Failure, and Urinary Tract Infection. The pt. care plan failed to ensure learner methods and outcomes were discussed.

2. The above finding was verified with the DON and CNO on 04-21-11 at 10AM.

A. Based on Facility policy, a written statement regarding delinquent medical records and staff interview, it was determined the Facility failed to ensure all medical records were completed in a timely manner.

Findings include:

1. Facility policy indicates: "An inpatient medical record remaining incomplete by the attending physician seven days following discharge is delinquent."

2. On 04/20/11, the Medical Records department coordinator presented a statement that 5 medical records were delinquent as of April 20th, 2011.

3. The above findings were verified with the Chief Nursing Officer (CNO) and Director of Nursing on 04/20/11.

A. Based on clinical record review and staff interview, it was determined the Hospital failed to ensure all medical records were maintained and contained all required information. This was evident in 3 of (Pt. #9, #10, #15) 20 clinical records reviewed.

Findings include:

1. Pt. # 9 was admitted to the Hospital on 03/14/11 with the diagnoses of Diabetes and Sepsis. Pt. #9 received 3 units of Packed Red Blood Cells during his hospitalization. Documentation did not include a witness signature on the blood consent.

2. Pt. # 10 was admitted to the Hospital on 03/09/11 with the diagnoses of Gastrointestinal Hemorrhoids, Acute Kidney Failure and Urinary Tract Infection. Pt. #10 received a blood transfusion on 03/09/11. The pt.'s temperature was not obtained at 30 minutes after the transfusion started or post transfusion.

3. Pt. #15 was admitted to the Hospital on 11/24/10 with the diagnosis of Leukemia. Pt. #15 received 4 units of Packed Red Blood Cells and 3 units of Platelets during her hospitalization. Documentation did not include an employee signature, date or time on the blood consent form, dated 11/24/10. There was no witness signature on the blood consent form dated 11/25/10.

4. The above findings were verified with the DON and CNO on 04/21/11 at 10:30am.

A. Based on a review of medical records and staff interview, it was determined that in 1 of 17 (Pt #17) medical records reviewed in which the patient was treated in the Emergency Department, the Facility failed to ensure that documentation contained all pertinent patient information and was incorporated in the patient's medical record.

Findings include:

1. The medical record of Pt #17 was reviewed on 04/21/11. It indicated that Pt #17 was admitted to the Hospital through the Emergency Department on 04/09/11 with an admitting diagnoses of Chronic Obstructive Pulmonary Disease Exacerbation, Hypotension and Dehydration. A two part physician's examination sheet titled, "Emergency Department QualChart" was reviewed. There was no documented time of physician's examination on page 1 of 2. There was no documentation on page 2 of 2, which included the continuation of the medical screening examination, discharge diagnosis, time of discharge, physician's signature, reports of treatments or medications, patient's progress or response to treatments and documentation of consulting with admitting physician.

2. During an interview conducted on 04/21/11 at 1:30 PM with the Director of Nursing Services, the above findings were confirmed.