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Based on record review, policy review, observation and interview, it was determined:
The facility failed to inform patients of their rights in advance of furnishing patient care [See A117]
The facility failed to ensure patientw were informed of their right to file a grievance [See A118]
The facility failed to process an advance directive [See A132]
The facility failed to monitor and/or safeguard privileged patient information [See A147]
The facility failed to ensure that restraint orders were appropriately recorded/implemented [See A164]

Based on interview and record review, the facility failed to ensure that four of five patients were informed of their rights regarding the facility's privacy practices. Findings include:

According to the facility policy titled: "Notice of Privacy Practices of Ingham Regional Medical Center," dated 4/14/03, patients have a right to receive a paper copy of the notice of HIPAA (Health Insurance Portability & Accountability Act.)

0n 8/9/10, from 0900-1000, it was noted that four of five Emergency Department (ED) patients (#1, #2, #3, #4) at Campus A had blank spaces on the portion of the "Consent for Treatment for Inpatient and/Or Outpatient Services and Financial Authorization form" that indicated whether the patient "Received Today" or "Previously Received" the facility's Notice of Privacy Practices.

On 8/9/10 at approximately 1030, the ED Patient Care Manager and ED Patient Care Supervisor confirmed these findings.

Based on observation, interview and record review, the facility failed to ensure that patients on the in-patient psychiatric unit were informed of their right to file a grievance with the State agency. Findings include:

On 8/11/10 at 0750, of a tour of the inpatient psychiatric unit, it was noted that there was no posting or other notice to inform patients of their right to file a complaint with the State of Michigan.

Review of two out of three patient records (#77 and #78) revealed a lack of documentation of patient ' s inability or refusal to sign admission consent documents:

1. Patient #77 did not sign forms titled: Acknowledgement of Receipt of Notice of Privacy Practices, " " Consent For Treatment for Inpatient and/or Outpatient Services and Financial Authorization, " " An Important Message from Medicare, " or " Consent to Receive Psychotropic Medication(s). According to facility policy #958.3a, " Informed Consent for Use of Psychotropic Medications, " attempts will be made to obtain consent from all patients. Some of these forms were signed by a family member but there was no documentation to explain why the patient did not sign or legal documents to verify the family member ' s claim to have authority to consent for the patient. These findings were verified by the Director of Psychiatric Services.
2. Patient #78 signed some admission forms and not others. These were no documentation to indicate inability or refusal and documentation to document the authority to give consent on the forms that a family member signed. These findings were verified by the Director of Psychiatric Services.

Based on observation, interview and record review the facility failed to correctly honor/process the advance directive for one of ten patients. Findings include:

On 8/10/10 at approximately 1250, patient #43's clinical record was reviewed with the Compliance/HIPPA Officer. The patient's record indicated that patient #43 was admitted through the Emergency Department on 8/9/10 and had Full Code status. On 8/10/10 at approximately 1300 patient #43 was queried regarding her advanced directives. Patient #43 stated that she had requested DNR status upon admission and understood that it was in effect. Observation verified that patient #43 was not wearing a purple DNR bracelet, used by the facility to indicate DNR (Do Not Resuscitate) status, described in policy 200-116.

Further review of patient #43's clinical record revealed a form signed by the patient, dated 8/5/10, indicating the patient's desire for DNR status. A History and Physical (done 8/9/10) and Admission Progress Note (8/9/10) signed by the Emergency Department physician indicated that patient #43 had DNR code status. A form labeled "Resuscitation Order Form" with instructions to "Send original form with patient when transferred" was left blank. When asked to clarify why patient #43 did not have DNR status, the Compliance/HIPPA Officer stated that the Emergency Department physician should have written the DNR order.

Based on observation and interview the facility failed to supervise access to the protected health information of patients stored in unlocked wall cabinets ( " Wallaroos " ) throughout Campus A and on the orthopedic inpatient units on Campus B. Findings include:

During the initial tour of Campus A, on 8/9/10 from approximately 0800-1700, unsupervised medical records stored in Wallaroos were observed on all inpatient units. On 8/10/10 at approximately 1245 an open, unmonitored chart was observed outside room #623 and a closed unmonitored chart was observed outside room #624. These finding was confirmed by a Licensed Respiratory Therapist (employee #P).


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During the observation tour of the facility on 8/9/2010 at 0900 hours it was observed the facility's use of closable wall containers located outside each patient's room, to house each inpatient's clinical record. The wall containers were not all visible from each units nursing station and were not locked or otherwise secure when not used.

Also; during the observation tour of the facility's outpatient "Sports Medicine" facility on 8/11/2010, it was observed closed clinical records being stored in a storage room that had 2 doors, neither of which were locked. An interview with the facility's Director of Outpatient Services AA, confirmed that the doors to the storage room were not routinely locked at night.

Based on record review and interview the facility failed to ensure restraint orders for patients are completed according to policy for 2 of 2 (#10, #11) patients. Findings include:

On 8/9/10 at approximately 1015 during a tour of the unit identified as the Surgical Intensive Care Unit (SICU) patient #10's medical record was reviewed and was found to have a form titled "Physician Order Medical/Surgical Restraints" that consisted of a restraint order dated 8/9/10 but without a time indicating when the physician signed the order. Underneath the physician's signature line it is written "MUST BE SIGNED WITHIN 1 HOUR OF INITIATION." Staff #G was queried regarding the time of the physician's signature and she took the form down the hall to ask the nurse that was responsible for the patient at that time and the form came back with the time of 0800. Staff #G was queried about the time written in and stated "I wrote that in after I spoke with the nurse." Staff #G was then queried if that time was to be written and indicated by the physician signing the form and staff #G stated "I guess you're right, that is for the physician."

On 8/9/10 at approximately 1015 during a tour of the unit identified as the Surgical Intensive Care Unit (SICU) patient #11's medical record was reviewed and was found to have a form titled "Physician Order Medical/Surgical Restraints" that was absent of a physician's order that indicated the placement of restraints (which extremity to apply) and the time limit (either 24 hours or a specified time in hours). Staff #G was queried regarding the incomplete physician's order and stated "that should have been identified, that is part of the physician's order."

On 8/10/10 at approximately 0830 review of the facility's policy and procedure titled "Restraint Use" it is written under the section title "II. Policy" under the eighth bullet point "Orders are time-limited; this does NOT mean that restraints must be applied for the entire length of time the order in in effect." Under the section titled "IV. Procedure 4. d." it is written "A written order utilizing the Restraint Physician Order, Medical/surgical Restraints (see Attachment A), will be completed. NOTE: Do not use regular physician order forms; use the Physician Order, Medical/Surgical Restraints. i. The order must include the following elements: Reason for the restraint; Type of restraint; Placement of restraint; Length of time the restraint is authorized for in hours, not to exceed 24 hours.





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Review of the facility policy titled "Restraint Use" (#200-1, revised 7/10) revealed the following statements under A. Medical and Surgical Guidelines for Restraints" that do not provide a clear definition of when restraints may be applied.

3b. "If the patient's presenting behavior is usual for the patient and they are not a threat to themselves or others, restraints will not be utilized. If restraints are used for patients in these situations, the physician and/or RN may determine..."

4b. "If restraints are instituted emergently based on a significant change in the patient's condition, the physician will be notified immediately and an order obtained."

Based on observation, interview, and record review the facility failed to ensure registered nurses supervised the nursing care for 2 of 3 (#13, #15) patients. Findings include:

On 8/9/10 at approximately 1345 patient #13 had a note posted outside her room that she is to be turned every two hours. Patient #13 was observed to lying on her back and the last documented repositioning was 1200. By 1420 no staff had entered the room to turn the patient. On 8/9/10 at approximately 1630 upon return to the unit, patient #13 was observed to be in the same position they were in at 1545. Patient #13's daughter was in the room and was queried about how long she had been present and she stated "for at least a couple hours", the she was queried if staff had been in to turn or reposition patient #13 and she stated "No they haven't, apparently they're supposed to huh?" Review of the nursing notes revealed that no documentation had been completed since 1300 regarding the positioning of the patient. Patient #13 was observed to be in the same position she was in at 1345. These finding were confirmed by staff #J at the time of the findings.

On 8/9/10 at approximately 1350 patient #15's present nursing notes were reviewed and there was no documentation since the 0700 time regarding turning the patient every 2 hours according to sign posted outside of the patient #15's room. Staff # LL stated "I will have to get staff #MM to document the turns" then staff #MM was queried about the absence of documentation regarding patient #15's turns every 2 hours and stated " I wasn't personally in there to flip him." After speaking with staff #MM that staff #LL stated performed the turns, the surveyor went back to make a copy of the nursing notes that were absent of documentation of care regarding the turning and staff #LL had filled in the times. On 8/9/10 at approximately 1630 returned to the floor and patient #15 was still in the same position that she was at 1400 and no documentation had been completed since 1300 regarding the positioning of the patient. These findings were confirmed by staff #J at the time of the findings.

On 8/12/10 at approximately 1230 review of the facility's policy and procedure titled "Pressure Ulcer Prevention" under the section "5. (O)" it is written "Turn and position clients every 2 hours if consistent with care goals.

Based on record review and interview the facility failed to ensure physician's orders were complete, dated, timed, and authenticated in 7 of 28 (#10, #11, #28, #29, #35, #83, #91) patient's medical records. Findings include:

On 8/9/10 between the hours of 1100 and 1200 patient #10's medical record was reviewed and the following was noted:
1) A form titled "DVT/PE RISK ASSESSMENT SCREENING AND ORDERS" without a physician's or nurse's signature completing assessment, did not have marked if physician was contacted, no indication of orders marked as being completed and no physician's signature, date, or time.
2)A form titled "Physician's Orders" two telephone orders dated 8/6/10 were not authenticated by a physician.
These findings were confirmed by staff #G.

On 8/9/10 between the hours of 1100 and 1200 patient #11's medical record was reviewed and the following was noted:
1)A form titled "Physician Orders" a telephone order dated 8/4/10 was not authenticated by a physician.
This finding was confirmed by staff #G.

On 8/10/10 between the hours of 1000 and 1100 during the tour of the surgical areas on Campus A patient #28's medical record was reviewed and the following was noted:
1)A form titled "BETA-BLOCKER PROTOCOL SCREENING AND ORDERS/PLACE WITH ANESTHESIA RECORDS" under the section titled "PREOPERATIVE ANESTHESIA ORDERS" was blank.
This finding was confirmed by staff #K.

On 8/10/10 between the hours of 1000 and 1100 during the tour of the surgical areas on Campus A patient #29's medical record was reviewed and the following was noted:
1)1)A form titled "BETA-BLOCKER PROTOCOL SCREENING AND ORDERS/PLACE WITH ANESTHESIA RECORDS" under the section titled "PREOPERATIVE ANESTHESIA ORDERS" had only a physician's signature without indicating a specific order and was without a date and time.
This finding was confirmed by staff #K.


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Record #35: During the 8-10-10 review of the patient record, it was noted that the following verbal and telephone orders had not been authenticated/signed by the physician as of 8-11-10 at 09:15: order for Versed and Fentanyl, dated 8-1-10; order for nephrology and wound nurse consults, dated 8-1-10; order for stat hemodialysis, dated 8-1-10; order for BUN/Creatinine draw, Vancomycin, dated 8-6-10; order for rectal tube and Foley catheter, dated 8-6-10; order for Vicodin, dated 8-6-10; and doppler, dated 8-5-10. The above findings were verified by the Patient Care Manager (staff N) during an interview on 8-11-10 at 09:15.

Record #83: On 8-12-10 at 08:00, registered nurse (staff FF) was observed taking a telephone order from a physician for the administration of Morphine. It was noted that the registered nurse (FF) did not read back and verify the verbal orders given by the physician. Agency policy #200-103 states "Verbal orders and critical results will be written and read back..." This observation was confirmed by the Director of Patient Care Services (staff EE).

Based on record review and interview the facility failed to ensure informed consent forms were properly executed for procedures and treatments for 3 of 9 (#11, #28, #29) patient's. Findings include:

On 8/9/10 between the hours of 1100 and 1200 patient #11's medical record was reviewed and the following was noted:
1)On the form titled "CONSENT FOR PERIPHERALLY INSERTED CENTRAL CATHETER [PICC] and PERIPHERALLY INSERTED CATHETER [PIC] PLACEMENT" dated 8/3/10 under item "1." did not contain the physician's name on who ordered the insertion; and the witness's signature did not indicate the date.
2)On the form titled "CONSENT TO SURGERY AND OTHER PROCEDURES" dated 7/21/10 did not have a witness's signature.
3)On the form titled "CONSENT TO SURGERY AND OTHER PROCEDURES" dated 7/21/10 did not have the patient's name, the ordering physician's name, or a witness's signature.
4)On the form titled "REQUEST AND CONSENT TO ANESTHESIA" dated 7/27/10 did not have the informant's (physician) signature, date, or time.
These findings were confirmed by staff #G.

On 8/10/10 between the hours of 1000 and 1100 during the tour of the surgical areas on Campus A patient #28's medical record was reviewed and the following was noted:
1)On the form titled "CONSENT TO SURGERY AND OTHER PROCEDURES" dated 8/10/10 did not have a date and time at the top of the form in the space indicated or a date of explanation after the physician's signature.
2)On the form titled "REQUEST AND CONSENT TO ANESTHESIA" dated 8/10/10 did not have the informant's (physician) signature, date, or time.
These findings were confirmed by staff #K.

On 8/10/10 between the hours of 1000 and 1100 during the tour of the surgical areas on Campus A patient #29's medical record was reviewed and the following was noted:
1)On the form titled "CONSENT TO SURGERY AND OTHER PROCEDURES" dated 8/10/10 did not have the time on the top of the form in the space indicated.
This finding was confirmed by staff #K.

On 8/10/10 at approximately 1700 upon review of the facility's policy and procedure titled "Consent for Surgery and other Procedures, Guidelines for All Patient Care Units" under the section titled "Procedure:" "2. Section 'A' shall be completed by RN/LPN or technologist (in non-nursing departments) with the patient's legal name and current date/time." and "3. Section 'B' is filled in with the name of the physician performing the procedure or under whose guidance it is being performed."

Based on document review and staff interview, it was determined the facility failed to ensure that all discharged records were complete within 30 days of discharge. Findings include:

During the 8-11-10 review of the "Chart Aging Summary", printed on 8-11-10, and confirmed by the Director of Health Information Management (staff interview U) during an interview on 8-11-10 at approximately 10:40, it was identified that there were 482 incomplete patient records beyond 30 days following the patient's discharge from the facility.

Based on observation, interview, and policy review the facility failed to ensure medications that were unusable due to being potentially expired or expired were not available for patient use. Findings use:

On 8/9/10 between the hours of 0900 and 0945 during a tour of the Emergency Department with staff #A and staff #B the following medications were found to be outdated and/or unusable:
1) A single use vial a sterile water was noted in the cupboard in the room 1 was found open and undated.
2)Fifteen 4 ounce bottles of 5% Glucose water for infants was found stocked in the clean supply room with an expiration date of 7/1/09.
3)A bottle of Hydrogen Peroxide 16 ounces was found in the front medication station open and not dated.
These findings were confirmed by Staff #A and #B at the time of the finding.

On 8/9/10 between the hours of 1300 and 1400 during a tour of Units 3 South and 3 North with staff #II the following medications were found to be outdated and/or unusable:
A) Unit 3 South
1)Medication Room
a)A bottle of Hydrogen Peroxide 16 ounces was open and not dated
b)A bottle of Isopropyl Alcohol 16 ounces was open and not dated
c)A patient's medication phenytoin from pharmacy without an expiration date.
d)A patient's medication Calcium Carbonate from pharmacy without an expiration date.
e)A patient's medication multivitamin from pharmacy without an expiration date.
f)A patient's medication lactulose from pharmacy without an expiration date.

B)Unit 3 North
1)Medication Room
a)Two bottles of Nitroglycerin 0.4mg sublingual tablets 100 count was open and not dated.
b)A patient's medication drawer labeled 305-1 contained a medication dispensing cup with a green tablet.
These findings were confirmed by Staff #II at the time of the findings.

On 8/9/10 at approximately 1545 during a tour on Unit 6 North with staff #J the following medication was found to be outdated and/or unusable:
A)Medication Room
1)A bottle of Nitroglycerin 0.4 mg sublingual tablets 100 count was open and not dated.
This finding was confirmed by Staff #J at the time of the finding.

On 8/10/10 between the hours of 0900-1030 during a tour of the surgical areas with staff #K and staff #L on Campus A the following medications were found to be outdated and/or unusable:
A)Operating Room 1
1)A bottle of Isopropyl alcohol 16 ounces was open and not dated.
This finding was confirmed by Staff #K and staff #L at the time of the finding.

On 8/10/10 between the hours 1300 and 1500 during a tour of the surgical areas on Campus B with staff #K and staff #JJ the following medication was found to be outdated and/or unusable:
A)Preoperative Area Crash Cart
1)Two 250ml intravenous bags of Dextrose 5% solutions that expired in 3/10.
2) One liter bag of intravenous fluid of Sodium Chloride 0.9% that expired in 7/10.
These findings were confirmed by Staff #K and staff #JJ at the time of the findings.

On 8/12/10 at approximately 1200 upon review of the facility's policy titled "Expiration Dating of Multiple Dose Containers" under the section titled "Policy (1)" it is written " The beyond use date for multiple dose containers, is 28 days from the date and time the container is initially opened (needle-punctured), unless otherwise stated by the manufacturer."

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-710.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on August 10-11, 2010, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated August 11, 2010 for Life Safety Code.

Based upon observation and record review, the facility failed to routinely test and maintain equipment that protects the potable water supply at Campus B. Findings include:

On 8/11/10 between 10am and 12pm during the physical plant walk through at Campus B in the surgical suite it was observed that the facility had 2 reduced pressure principle backflow (RPZ) assemblies installed upstream of 2 Neptune Waste Management System disposal units. During the record review of the maintenance records it was discovered that the 2 RPZ ' s where not listed on the preventative maintenance schedule and were not being tested annually as required.


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Based on observation, interview, and policy review the facility failed to ensure supplies were maintained to an acceptable level of quality for patient use. Findings include:

On 8/10/10 between the hours of 1000 and 1100 during the tour of the surgical areas on Campus A the following supplies were noted to be expired:
A)Clean storage area
1)A box of Prolene 2-0 sutures expired in 7/10.

B)OR Room 1
1) A 20ml syringe open and lying on anesthesia cart.
2)A box of Ethibond Excel suture that expired in 1/10.

The above findings were confirmed by staff #K.

On 8/10/10 between the hours of 1300 and 1430 during a tour of the surgical areas and the Endoscopy Unit on Campus B the following was found:
A)Preoperative area crash cart
1)Thirteen packages of sterile gloves expired on 12/31/09.

B)OR Supply Room
1)One box of cobalt bone cement expired in 6/10.

C)Postoperative Recovery Area (PACU)
1)The current glucometer controls were noted to have expired on 8/4/10.

D)Endoscopy Unit Crash Cart
1)Four packages of sterile gloves were found that expired on 12/31/09.
2)Three packages of sterile 4x4 gauze pads had expired in 11/09.
3)Two central line kits were found in which one had expired in 4/09 and the other expired in 5/09.

The above findings were confirmed by staff #K.

On 8/12/10 at approximately 1215 during review of the facility's policy and procedure titled "Perishable Products Handling Hospital and Affiliates" under the section titled "III. Procedure 3." it is written "Stock items located in the keep fill areas shall checked by the distribution staff to make sure they have not reached expiration." Upon review of the facility's policy and procedure titled "Crash Cart, SPD Quality Assurance, Semi Annual &Annual Checks" under the section titled "Procedure: B Annual Check each December (1) (b) it is written "Internal supplies for dates on dated solutions, and supplies, i.e., catheter kits, betakine, suture, etc. KEYPOINT: Dates should be through the following December."

Based on observation, interview, and record review the facility failed to ensure the infection contol officer had a developed an effective system for controlling infections. Findings include:

On 8/9/10 at approximately 1345 while touring Unit 6 South, patient #16's room had a respiratory and contact isolation sign posted outside of the room. A visitor was observed inside the room at the bedside and had not donned the appropriate personal protective equipment. Staff #J stated that the visitors are educated regarding wearing the personal protective equipment and was asked where that would be documented in the medical record. The education form used in the nurses notes was absent of any documented education to visitors.

On 8/12/10 at approximately 1215 review of the facility's policy and procedure titled "Isolation Managment of Patients" under the section titled "III. Procedure (H)" it is written "Instruct the patient's visitors regarding performance of the isolation procedures."

On 8/12/10 at approximately 1215 review of the facility's policy and procedure titled "Droplet Isolation Precautions" under the section titled "III. Isolation Procedure and Patient Care J." it is written "Visitors should be given surgical masks and instructed in their use and proper disposal."

On 8/10/10 between the hours of 0900 and 1030 while touring the surgical area on Campus A, in operating room #10 where open heart surgery is performed a black backpack was noted sitting by the anesthesia cart. Staff #L was queried and stated "It's the anesthesia residents bag". Staff #NN was queried regarding if the bag was clean or from the outside and he stated "I bring this bag in, I carry my books and my equipment in it, yes from home." Staff #K was queried about the bag and stated "They shouldn't have those in the OR."

On 8/10/10 between the hours of 0900 and 1030 while touring the surgical area on Campus B, while standing in the hall outside of a clean supply room near operating room #9 with staff #K and staff #L, it was observed that staff #OO came out of OR #9 with gloves on during a patient emergency, went to the clean supply room, retrieved a supplies and returned to OR #9 with the gloves still on his hands. Staff #K was queried regarding infection control practices and staff #K stated "staff should always remove their gloves as they leave the patient's room."

Based on observation, interview, and record review the facility failed to ensure that a post-anesthesia evaluation was completed and documented by the individual qualified to administer anesthesia on 7 of 7 (#28, #29, #30, #62, #63, #64, #65) post-surgical patients. Findings include:

On 8/10/10 at approximately 1025 while touring, making observations, and reviewing medical records in the recovery area and post anesthesia care unit on Campus A. No documentation was noted that a post surgical anesthesia evaluation was being completed in patient's(#28, #29, #30, #62, #63, #64, #65) medical records. Staff #K was queried and stated "the nurse evaluates per the protocol and will contact anesthesia if needed."

On 8/10/10 at approximately 0515 review of the facility's policy and procedure titled "Guideline for the Delivery of Anesthesia Care" under the section titled "II Procedure, C." under the fourth bullet it is written "An Anesthesia Provider usually sees his/her patients in PACU during some point of their recovery. The RN caring for the patient in PACU discharges the patietn according to pre-established discharge criteria which have been approved by the Anesthesia Department." Under the fifth bullet it is written "The Anesthesia Provider must be available to see the patient if there are any postoperative anesthesia complications in the PACU. The Anesthesia Provider is responsible for all preoperative and postoperative care given to patients as related to anesthesia. The PACU nurse, the Nurse Manager or the Director of Patient Care Services areas is responsible for informing the Anesthesia Provider of any untoward effects that the patient may have."