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Tag No.: C0222
Based on observation, interview and document review the facility failed to ensure preventive maintenance (PM) was provided
Findings included:
On 7/16/13, at 9:35 a.m., observation in patient room #1 indicated there was no indication of PM having been completed on the wall suction machine. The portable nebulizer device in the room had a PM sticker that indicated the PM was due in April 2013.
On 7/16/13, at 9:05 a.m., Exam Room #1 had a wall mounted otoscope with a sticker that indicated the last PM was completed in October 2005. The wall suction in the same room had a sticker that indicated the last PM was completed in January 2012.
On 7/16/13, at 9:10 a.m., during tour of the Labor and Delivery area, the wall suction had a sticker that indicated the last PM was completed in January 2012.
The maintenance director (MD) was interviewed on 7/16/13, at 10:55 a.m., and stated the current contract for PM was dated May 2010 through May 2012. There were multiple specific pieces of medical equipment listed on the contract along with a category of unspecified "clinical equipment." The MD contacted the contracted PM company; however, there was no further information provided.
Tag No.: C0304
Based on interview and document review, the facility failed to obtain informed consent for treatment for 1 of 5 patients (P32) whose emergency department records were reviewed.
Findings include:
P32 was admitted to the emergency department (ED) 7/6/13 with diagnoses that included concussion and rib fracture. The facility did not obtain informed consent for treatment that included blood work, urinalysis, x-rays and a computed tomography (CT scan).
On 7/17/13, at 1:30 p.m., the director of nursing (DON) was interviewed and verified informed consent needs to be obtained prior to treatment.
The facility medical staff bylaws, undated, directs a general consent form, signed by or on behalf of every patient admitted to the hospital must be obtained at the time of admission.
Tag No.: C0305
Based on interview and document review, the facility failed to complete a history and physical (H&P) for 1 of 20 patients (P16) whose records were reviewed.
Findings include:
P16 was admitted to the facility 1/2/13, and discharged 1/4/13. The medical record lacked an H&P.
On 7/17/13, at 1:30 p.m. the director of nursing (DON) was interviewed and verified an H&P needs to be completed on all patients admitted to the hospital.
The medical staff bylaws, undated, direct a comprehensive, current physical assesment with a medical history be recorded within twenty-four hours of admission.
Tag No.: C0306
Based on interview and document review, the facility failed to complete a timely discharge summary for 4 of 20 patients (P15, P16) whose records were reviewed.
Findings include:
P15 was admitted to the facility 1/2/13, and was discharged on 1/4/13. The discharge summary was dictated by the physician on 3/17/13, and signed 4/13/13.
P16 was admitted to the hospital on 1/2/13, and was discharged on 1/4/13. The discharge summary was dictated by the physician on 3/17/13, and signed 4/13/13.
P4 was admitted on 2/15/13, and died on 2/22/13. The discharge summary was dictated on 3/24/13, and signed on 3/27/13.
P5 was admitted on 1/26/13, and died on 1/27/13. The discharge summary was dictated on 2/171/3 and signed on 6/9/13.
On 7/17/13, at 1:30 p.m., the director of nursing (DON) was interviewed and verified a discharge summary should be completed within 30 days of discharge.
The medical staff bylaws, undated, direct a discharge summary note shall be dictated on all patients hospitalized, and should be completed by thirty days from the date of discharge.
Tag No.: C0307
Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure that physician signatures were timed and dated for 4 of 4 outpatients records (P22, P23, P24, P25) reviewed.
Findings include:
P22 was admitted on 7/16/13, for a colonoscopy procedure with conscious sedation. The conscious sedation standing orders were signed and dated by physician (phy A); however the document lacked the time of signature. Order #8 of the 10 orders indicated: "Procedure medications given per verbal order by attending physician." Review of the nurse's procedure record indicated that medications (Versed 3 mg intravenous (IV) at 8:09 a.m. and 1 mg IV at 8:25 a.m. (used for sedation) ; and Fentanyl 100 mcg IV at 8:11 a.m. and 50 mcg IV at 8:20 a.m. (used for pain control). The verbal orders were not signed by the physician.
P23 was admitted on 6/18/13, for a colonoscopy procedure with conscious sedation. The conscious sedation standing orders were signed and dated by physician (phy A); however the document lacked the time of signature. Order #8 of the 10 orders indicated: "Procedure medications given per verbal order by attending physician." Review of the nurse's procedure record indicated that medications (Versed 3 mg intravenous (IV) at 9:26 a.m.; and Fentanyl 100 mcg IV at 9:28 a.m. and 50 mcg IV at 9:36 a.m..). The verbal orders were not signed by the physician.
P24 was admitted on 6/18/13, for a colonoscopy procedure with conscious sedation. The conscious sedation standing orders were signed and dated by physician (phy A); however the document lacked the time of signature. Order #8 of the 10 orders indicated: "Procedure medications given per verbal order by attending physician." Review of the nurse's procedure record indicated that medications (Versed 2 mg intravenous (IV) at 9:14 a.m.; and Fentanyl 100 mcg IV at 9:15 a.m.. The verbal orders were not signed by the physician.
P25 was admitted on 5/14/13, for a colonoscopy procedure with conscious sedation. Review of the nurses procedure record indicated that verbal orders were not signed by phy-A. The registered nurse (RN)-A documented administration of Versed 2 mg intravenous (IV) at 13:02 a.m. and 1 mg IV at 13:27 a.m.; and Fentanyl 100 mcg IV at 13:04 a.m. and 50 mcg IV at 13:12 a.m. and 25 mcg IV at 13:23 a.m..
The director of nurses (DON), interviewed on 7/17/13, at 1:20 p.m., stated the problem of undated/untimed orders had been identified. The DON stated the colonoscopy standing orders lacked the time of signature for all four patients reviewed, and that physicians were not signing verbal orders for medications administered during the procedures.
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