HospitalInspections.org

A. Based on review of the Medical Staff Rules and Regulations, clinical record review and staff interview, it was determined that in 1 of 10 (Pt. #1) clinical records reviewed, the Hospital failed to ensure daily patient assessments was conducted by a physician in accordance with the Hospital's Medical Staff Rules and Regulations (R&R).

Findings include:

1. On 1/4/10 at 1:00PM, the Hospital's Medical Staff Rules and Regulations approved 7/7/09 were reviewed. The R &R included, " I. A. ...professional staff physician on a daily basis shall see all patients, with appropriate progress notes written. Sufficient documentation shall be provided commensurate with the severity of illness, intensity of service, and the projected treatment plan."

2. The clinical record for Pt. #1 was reviewed on 1/4/10 at approximately 11:00AM Pt. #1, an 81 year old male, was admitted to the Emergency Department (ED) from home on 12/1/09 at approximately 9:48AM with complaints of shortness of breath. Triage vital signs on 12/1/09 at 10:05 AM were: B/P 104/54, temp 97.5, pulse 80, and respirations 22 with oxygen saturation of 94%. Pt. #1 was admitted to unit southwest on 12/01/09 at 2:41 PM with a diagnoses of Shortness of Breath/ Chronic Obstructive Pulmonary Disease (COPD)/ and GI Bleed. Pt. #1 was discharged on 12/9/09 at approximately 12:00PM. The clinical record failed to contain a daily patient assessment with progress note on 12/8/09 or 12/9/09.

3. The above finding was confirmed by the Director of Patient Care Services during an interview on 1/04/10 at approximately 11:30 AM..

B. Based on a review of Medical Staff Rules and Regulations, clinical record review and staff interview, it was determined in 1 of 5 (Pt. #1) closed records reviewed, the physician failed to ensure complete discharge orders were written.

Findings include:

1. On 1/04/10 at approximately 2:00PM, the Hospital's Rules and Regulations were reviewed. The Regulations page 9, included, "...Physician orders: A discharge order must be recorded by the physician..."

2. The clinical record for Pt. #1 was reviewed on 1/4/10 at approximately 11:00 AM Pt. #1, an 81 year old male, was admitted to the Emergency Department (ED) from home on 12/1/09 at approximately 9:48 AM with complaints of shortness of breath. The ED physician ordered a "Foley" (urinary drainage catheter and drainage bag) on 12/1/09 at 1:45 PM. Pt. #1 was hospitalized for 8 days with a Foley catheter. The clinical record contained a telephone order dated 12/9/09 at 11:15 PM that read, " Discharge home today. Resume home nurse/PT." The physician failed to include an order to either discontinue or continue Pt. #1's Foley catheter. As a result, Pt. #1 was discharged home on 12/09/09 at approximately 12:00 PM with a urinary catheter in place.

3. The above finding was confirmed by the Director of Patient Care Services during an interview on 1/04/10 at approximately 11:30 AM..

A. Based on clinical record review, review of laboratory recommendations and staff interview, it was determined that in 1 of 10 (Pt#1) clinical records reviewed, the Hospital failed to ensure Medical Staff was accountable for patient quality of care by evaluating Pt. complaints of persistent diarrhea prior to discharge.

Findings include:

1. The clinical record for Pt. #1 was reviewed on 11/04/10 at approximately 10:00 AM. Pt. #1 was admitted to the ED from home on 12/1/09 at approximately 10:49 AM. The ED history and physical, dated 12/01/09 at 10:49 Included, " Course in the emergency room: ...the Pt. is being treated for CHF (congestive heart failure). He is going to receive basic labs, chest Xray, and obstructive series..." The radiology report, dated 12/1/09 indicated, " Colon dilated up to 10cm involving the entire colon up to the region of the rectosigmoid. Possibility of obstruction at the rectosigmoid area is suggested" On 12/01/09 at approximately 2:41 PM the Pt. was admitted to room 3372 in stable condition. On 12/3/09 at 9:40 PM, the physician ordered "stool for C-diff". The final laboratory result, dated 12/4/09, was "negative". The laboratory result included, "A single negative test may not rule out C Difficile. If symptoms persist, repeat testing is recommended" The clinical record contained nursing documentation that Pt. #1 continued to have frequent liquid stool in large amounts on 12/4/09, 12/7/09 and 12/8/09. There was no documentation that a repeat test was ordered by the physician as recommended. The nurse documented on 12/9/09 at 10:11 AM "patient does have loose watery tarry/grey like stools, condition is stable except for the loose stools. Magnesium held." On 12/09/09 at 12:15 PM, the nurse documented, "Trace ambulance here to take patient home. Extreme amount of grey liquid stool from shoulders to just below the knees same as this morning...instructed to hold magnesium. When Dr called back...informed him of the diarrhea. Asked if he wanted to see the Pt. in a week, and Dr. response was that he would see the Pt. at home" On 12/10/09 at 3:17 AM ( less than 24 hours later), Pt. #1 was readmitted to the Hospital by ambulance with complaints of diarrhea. Triage vital signs were documented as: Temp 99.9, pulse 108, resp 20 without pain. The admission history and physical dated 12/10/09, included, "Diarrhea could be secondary to Clostridium difficile. Will start on Flagyl..." A laboratory result, dated 12/11/09 indicated, " C Diff toxin A& B positive" Pt. #1 was admitted with a diagnosis of Dehydration, treated and discharged home on 12/16/09 (six days later) in stable condition.


2. The above findings were discussed with the Performance Improvement Coordinator during an interview on 1/05/10 at approximately 9:15 AM.

Based on Hospital Directive and policy review, clinical record review, observations, and staff interview, it was determined that the Hospital failed to protect and promote each patient's rights (115); failed to ensure advance directives were addressed with the patient (A132); failed to ensure patient safety by providing protective clothing during transport from the Hospital to home (A144-A); failed to fully implement the Falls Prevention Protocol for all patients at risk for falls, based on the fall screening protocol (A144-B); failed to ensure physician's restraint orders were written and complete (A168); failed to ensure restraint orders were renewed in accordance with Hospital Directive #111 (A173); and failed to ensure patients were monitored and reassessed in accordance with Hospital Directive #111 (A175). The cumulative effect of these systemic practices resulted in the hospital's inability to protect and promote patients rights and to ensure patients' safety.

A. Based on a review of Hospital Directive, clinical record review, and staff interview, it was determined that, for 1 of 10 (Pt. #6) clinical records reviewed, the Hospital failed to ensure advance directives were addressed with the patient.

Findings include:

1. Hospital Directive #23, Board approved 9/2/03, entitled, "Patient Rights and Responsibilities," was reviewed on 1/4/10 at approximately 1:00 P.M. The Directive requires, "As a patient... have the right to... Have information regarding Advance Directives concerning treatment or a designated surrogate decision maker."

2. The clinical record of Pt. #6 was reviewed on 1/4/10. This was a 79-year-old male, admitted 12/25/09 with a diagnosis of Right Hip Fracture. The record lacked documentation to indicate that advance directives were addressed with the patient.

3. The above finding was confirmed during an interview with the Assistant Unit Supervisor of the Southwest Unit and Performance Improvement Coordinator, on 1/4/10 at approximately 12:00 P.M.

A. Based on, a review of "Accu/Weather .com" information, clinical record review and staff interview, it was determined that in 1 of 5 (Pt. #1)closed records reviewed, the Hospital failed to ensure patient safety by providing protective clothing during transport from the Hospital to home.

Findings include:

1. On 1/05/10 at approximately 9:20 AM, "AccuWeather .com " weather reports were reviewed. The weather temperature on 12/9/09 was 36 degree F.

2. The clinical record for Pt. #1 was reviewed on 1/4/10 at approximately 11:00 AM. Pt. #1, an 81 year old male, was admitted to the Emergency Department (ED) from home on 12/1/09 at approximately 9:48 AM with complaints of shortness of breath. Triage vital signs on 12/1/09 at 10:05 AM were: B/P 104/54, temp 97.5, pulse 80, and respirations 22 with oxygen saturation of 94%. Pt. #1 was admitted on 12/01/09 at 2:41 PM with a diagnoses of Shortness of Breath/ Chronic Obstructive Pulmonary Disease (COPD)/ and GI Bleed. Vital signs on 12/9/09 at 7:30 AM were: Temp 97.8, pulse 88, resp 20 and an oxygen saturation of 99%. Pt. #1 was discharged home by ambulance on 12/9/09 at approximately 12:00 PM with a weather temperature of 36 degrees F.

3. The Nurse (E#1), who cared for Pt. #1 at the time of discharge, was interviewed on 1/4/10 at approximately 11:30AM. E#1 stated that Pt. #1 was placed in a hospital gown instead of street clothes that were available prior to discharge, because Pt. #1 was incontinent of stool. By wearing a hospital gown, Pt. #1's street clothes would be protected from future potential contamination. E#1 also stated that Pt.#1 was lying on a sheet and covered with a blanket prior to transport.

4. The above finding was confirmed by the Director of Patient Care Services during an interview on 1/04/10 at approximately 11:30 AM..



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B. Based on a review of Hospital policy, clinical record review, observation, and staff interview, it was determined that for 5 of 8 (Pt. #s 4, 5, 6, 7, and 8) patients observed or reviewed for fall screening, the Hospital failed to fully implement the Falls Prevention Protocol for all patients at risk for falls, based on the fall screening.

Findings include:

1. Hospital policy #PCS-615 entitled, "Falls Prevention Protocol," was reviewed on 1/4/10 at approximately 2:00 P.M. The policy requires, "The nurse identifies the patient at risk for falls via the fall screening. Patient is to be placed on Fall Prevention if: Two or more questions are answered yes in the Adult Database... When the nurse identifies a patient at risk for falls... Place wrist band on patient... Place fall prevention sticker on patient chart... Place fall prevention sign on patient door frame... Orient patient to room and call light... document Q 2 hourly checks on Fall Prevention Protocol Intervention..."

2. The clinical record for Pt. #4 was reviewed on 1/4/10. This was a 75-year-old male, admitted 12/26/09 with a diagnosis of Lower Gastrointestinal Bleed. The Adult Database dated 12/28/09 included a fall screening with 3 "yes" responses for this patient: Acute elimination needs; Postural instability; and > 65 years old, indicating the patient was at risk for falls.

3. On 1/4/10 a tour of the South West Unit was conducted from approximately 9:45-11:15 A.M. Pt. #4 was not wearing a fall risk wrist band. In addition, the call light was not within the patient's reach.

4. The clinical record for Pt. #5 was reviewed on 1/4/10. This was an 88-year-old male, admitted 12/29/09 with a diagnosis of Dyspnea; Bronchospasm. The Adult Database dated 12/29/09 included a fall screening with 2 "yes" responses for this patient: Postural instability; > 65 years old, indicating the patient was at risk for falls. The patient chart did not include a fall prevention sticker.

5. On 1/4/10 a tour of the South West Unit was conducted from approximately 9:45-11:15 A.M. Pt. #5 was not wearing a fall risk wrist band. In addition, the call light was not within the patient's reach.

6. The clinical record of Pt. #6 was reviewed on 1/4/10. This was a 79-year-old male, admitted 12/25/09 with a diagnosis of Right Hip Fracture. The Adult Database dated 12/29/09 included a fall screening with 3 "yes" responses for this patient: Have you fallen recently; Acute generalized weakness; > 65 years old, indicating the patient was at risk for falls.

7. On 1/4/10 a tour of the South West Unit was conducted from approximately 9:45-11:15 A.M. Pt. #6 was not wearing a fall risk wrist band.

8. The clinical record of Pt. #7 was reviewed on 1/4/10. This was a 78-year-old female, admitted 1/3/10 with diagnoses of Abdominal Pain, Colitis, and Impaction. The Adult Database dated 12/29/09 included a fall screening with 3 "yes" responses for this patient: Acute generalized weakness; Postural instability; > 65 years old, indicating the patient was at risk for falls. The patient chart did not include a fall prevention sticker.

9. On 1/4/10 a tour of the South West Unit was conducted from approximately 9:45-11:15 A.M. Pt. #7 was not wearing a fall risk wrist band, and there was no fall prevention sign on the door frame.

10. The clinical record of Pt. #8 was reviewed on 1/5/10. This was an 85-year-old female, admitted 10/30/09 with multiple diagnoses, including: Severe Anemia, Dehydration, and Diarrhea. The Adult Database dated 10/30/09 included a fall screening with 1 "yes" response for this patient: Have you fallen recently? The fall screening failed to include a "yes" response for "> 65 years old" even though the patient was 85 years old. The two "yes" responses would indicate that the patient was at risk for falls. The record lacked fall prevention documentation every 2 hours on 11/4/09 at 10:00 P.M. and 11/5/09 at 12:00 A.M.

11. The above findings were confirmed during an interview with the Assistant Unit Supervisor of the Southwest Unit and Performance Improvement Coordinator, on 1/4/10 at approximately 12:00 P.M., and again with the Performance Improvement Coordinator on 1/5/10 at approximately 1:30 P.M.

A. Based on a review of Hospital Directive #111, clinical record review, and staff interview, it was determined that for 3 of 4 (Pt. #s 8, 9, and 10) clinical records reviewed for patients with medical restraints, the Hospital failed to ensure physician's restraint orders were written and complete.

Findings include:

1. Hospital Directive #111, Board approved 10/4/05, entitled, "Use of Restraints For Medical Purposes," was reviewed on 1/5/10 at approximately 12:30 P.M. The Directive requires, "Physician Orders... An RN may initiate the restraint... The physician must be notified within 12 hours of initiation, and a phone order or written order obtained... Within 24 hours of initiating the restraint, the physician must examine the patient and provide a written order for restraint use... A renewal order is required each calendar day. The decision to continue restraints must be based on a physician examination... This cannot be a phone order..."

2. The clinical record of Pt. #8 was reviewed on 1/5/10. This was an 85-year-old female, admitted 10/30/09 with multiple diagnoses, including: Severe Anemia, Dehydration, and Diarrhea. The record included documentation that Pt. #8 was in restraints from 10/30/09-11/1/09. The original restraint order of 10/30/09 at 7:00 P.M. was incomplete for date and time of physician signature, and therefore it could not be determined whether or not the patient was examined within the required 24 hours of initiation of restraints.

3. The clinical record of Pt. #9 was reviewed on 1/5/10. This was a 71-year-old male, admitted 8/18/09 with a diagnosis of Urosepsis. The record included documentation that Pt. #9 was in restraints from 8/20/09-8/24/09. The original restraint order of 8/20/09 (untimed) was incomplete for date and time of physician signature, and therefore it could not be determined whether or not the patient was examined within the required 24 hours of initiation of restraints.

4. The clinical record of Pt. #10 was reviewed on 1/5/10. This was a 48-year-old male, admitted 8/7/09 with a diagnosis of Respiratory Failure. The record included documentation that Pt. #10 was in restraints from 8/8/09-8/22/09. The record lacked documentation of physicians' restraint orders for 8/8, 8/9, 8/18, 8/19, and 8/21/09. In addition the restraint order dated 8/22/09 lacked documentation of the type of restraint to be used, as well as the reason for the medical restraint.

5. The above findings were confirmed during an interview with the Performance Improvement Coordinator, on 1/5/10 at approximately 1:30 P.M.

A. Based on a review of Hospital Directive #111, clinical record review, and staff interview, it was determined that for 3 of 4 (Pt. #s 8, 9, and 10) clinical records reviewed for patients with medical restraints, the Hospital failed to ensure restraint orders were renewed in accordance with Hospital Directive #111.

Findings include:

1. Hospital Directive #111, Board approved 10/4/05, entitled, "Use of Restraints For Medical Purposes," was reviewed on 1/5/10 at approximately 12:30 P.M. The Directive requires, "Physician Orders... A renewal order is required each calendar day. The decision to continue restraints must be based on a physician examination... This cannot be a phone order..."

2. The clinical record of Pt. #8 was reviewed on 1/5/10. This was an 85-year-old female, admitted 10/30/09 with multiple diagnoses, including: Severe Anemia, Dehydration, and Diarrhea. The record included documentation that Pt. #8 was in restraints from 10/30/09-11/1/09. The restraint renewal orders for 10/31/09 and 11/1/09 lacked the date and time of the physician's signature, and therefore it could not be determined that physician examination was timely.

3. The clinical record of Pt. #9 was reviewed on 1/5/10. This was a 71-year-old male, admitted 8/18/09 with a diagnosis of Urosepsis. The record included documentation that Pt. #9 was in restraints from 8/20/09-8/24/09. The restraint renewal orders for 8/21, 8/22, 8/23, and 8/24/09 lacked the date and time of the physician's signature, and therefore it could not be determined that physician examination was timely.

4. The clinical record of Pt. #10 was reviewed on 1/5/10. This was a 48-year-old male, admitted 8/7/09 with a diagnosis of Respiratory Failure. The record included documentation that Pt. #10 was in restraints from 8/8/09-8/22/09. The restraint renewal orders for 8/11/09-8/17/09, 8/20/09, and 8/22/09 lacked the date and time of the physician's signature, and therefore it could not be determined that physician examination was timely. In addition, the restraint renewal order dated 8/22/09 lacked documentation of the type of restraint to be used, as well as the reason for the medical restraint.

5. The above findings were confirmed during an interview with the Performance Improvement Coordinator, on 1/5/10 at approximately 1:30 P.M.

A. Based on a review of Hospital Directive #111, clinical record review, and staff interview, it was determined that for 3 of 4 (Pt. #s 8-10) clinical records reviewed for patients with medical restraints, the Hospital failed to ensure the patients were monitored and reassessed in accordance with Hospital Directive #111.

Findings include:

1. Hospital Directive #111, Board approved 10/4/05, entitled, "Use of Restraints For Medical Purposes," was reviewed on 1/5/10 at approximately 12:30 P.M. The Directive requires, "Every two (2) hour assessment and care of the patient as indicated... Skin/circulation... Fluid and meals... Toileting... Reassessment for continued need and alternatives tried..."

2. The clinical record of Pt. #8 was reviewed on 1/5/10. This was an 85-year-old female, admitted 10/30/09 with multiple diagnoses, including: Severe Anemia, Dehydration, and Diarrhea. The record included documentation that Pt. #8 was in restraints from 10/30/09-11/1/09. The record lacked documentation of assessment of skin/circulation, fluid and meals offered, toileting, and reassessment for continued need of restraints on 11/1/09 from 12:00 A.M.- 7:42 A.M.

3. The clinical record of Pt. #9 was reviewed on 1/5/10. This was a 71-year-old male, admitted 8/18/09 with a diagnosis of Urosepsis. The record included documentation that Pt. #9 was in restraints from 8/20/09-8/24/09. The record lacked documentation of the following assessments:
*8/21/09 at 8:00 P.M. and 10:00 P.M. and 8/23/09 from 12:00-6:00 A.M. (skin/circulation, fluid and meals offered, toileting, and reassessment for continued need of restraints)
*8/22/09 from 12:00-6:00 A.M. (lacked assessment of skin/circulation)

4. The clinical record of Pt. #10 was reviewed on 1/5/10. This was a 48-year-old male, admitted 8/7/09 with a diagnosis of Respiratory Failure. The record included documentation that Pt. #10 was in restraints from 8/8/09-8/22/09. The record lacked documentation of the following assessments:
*8/8/09 at 4:00 P.M., 8/10/09 at 12:00 A.M., and 8/11/09 at 4:00 A.M. (skin/circulation, fluid and meals offered, toileting, and reassessment for continued need of restraints)

5. The above findings were confirmed during an interview with the Performance Improvement Coordinator, on 1/5/10 at approximately 1:30 P.M.

A. Based on Hospital policy "Standards of Care" review, clinical record review and staff interview, it was determined that in 1 of 10 (Pt. #1) clinical records reviewed, the Hospital failed to ensure nursing communicated and documented abnormal findings to the physician in accordance with the Hospital's "Standards of Care" policy.

Findings include:

1. On 1/05/10 at approximately 9:00 AM, the Hospital's "Standards of Care" Hospital review date 1/7/07 were reviewed. Standard 11 included, "The RN documents and communicates assessment data to appropriate members of the health care team"

2. On 1/04/10 at approximately 10:00 AM the clinical record for Pt. #1 was reviewed. Pt. #1, an 81 year old male, was admitted to the Emergency Department (ED) from home on 12/1/09 at approximately 9:48 AM with complaints of shortness of breath. Triage vital signs on 12/1/09 at 10:05 AM were: B/P 104/54, temp 97.5, pulse 80, and respirations 22 with oxygen saturation of 94%. Pt. #1 was admitted on 12/01/09 at 2:41 PM with a diagnoses of Shortness of Breath/ Chronic Obstructive Pulmonary Disease (COPD)/ and GI Bleed Nursing documentation on 12/3/09, 12/04/09 and 12/7/09 indicated that Pt. #1 was having large amounts of involuntary stool and these findings were not documented that the physician was notified/informed. A review of the physician notes from 12/3/09 to 12/7/09 failed to include documentation of loose stools or abnormal GI symptoms.

Nursing clinical documentation of Pt. #1's intake and out put examples were:

12/3/09 three large stools, 12/4/09 four stools, 12/7/09 six stools , 12/8/09 one large liquid stool.

3. The above findings were discussed with the Performance Improvement Coordinator during an interview on 1/05/10 at approximately 9:15 AM.