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Based on record review, policies and procedures and interviews, the hospital failed to ensure the medical records contained physician discharge orders for 2 of 3 patients who had outpatient procedures (patient #16 and #17) and 1 of 2 swing bed patients who was transferred from acute care to swing bed (patient #1) in a total sample of 21. Findings:

1. Review of the closed medical record for sampled patient #16 revealed a tonsillectomy under general anesthesia was performed on 01/13/2011 as an outpatient procedure. Review of the physician orders failed to reveal orders to discharge patient #16 from the post anesthesia care unit to home (indicated on discharge instructions). Interview with S3 DON on 10/26/2011 at 11:00 AM confirmed the medical record did not contain an order for discharge following outpatient surgery for patient #16.

2. Review of the closed medical record for sampled patient #17 revealed a bilateral orchiectomy was performed in 02/08/2011 under general anesthesia as an outpatient procedure. Review of the physician orders failed to reveal orders to discharge patient #17 from the post anesthesia care unit to home (indicated on discharge instructions). Interview with S3 DON on 10/26/2011 at 11:00 AM confirmed the medical record did not contain an order for discharge following outpatient surgery for patient #17.

3. Review of the closed medical record for patient #1 revealed an acute hospitalization from 1/22/2011 to 1/26/2011 at which time the patient was discharged to swing bed. Review of physician orders revealed an order dated 1/28/2011 "Evaluate for Swing Bed". Further review failed to reveal a physician order to discharge patient #1 on 1/31/2011 from acute care. In an interview on 10/26/2011 at 11:40 AM S8 Case Manager confirmed the medical record did not contain a discharge order for patient #1.

Review of swing bed policy titled "Logistics of Transferring Patients from Acute Care to Swing Bed" revealed, "Patient is discharged from acute care and readmitted to the Swing Bed". Review of Medical Staff Rules and Regulations (8/30/2011) revealed, "Patients shall be discharged only upon the order of the attending physician".

Based on observation and interview with S6 RHIT (registered health information technician) the hospital failed to ensure medical records were completed within 30 days following patient discharge by having 80 incomplete medical records. Findings:

Observation of the medical records department on 10/24/2011 at approximately 11:00 AM revealed stacks of medical records with pages flagged for physician completion. On 10/25/2011 at 1:00 PM, S6 RHIT reported hospital physicians had 80 medical records that had not been completed within 30 days of patient discharge.

Based on observation, review of the Pharmacy Policy and Procedure manual and staff interview, the hospital failed to maintain a functioning alarm system for the pharmacy that was not staffed on a 24-hour basis to limit access to stored drugs and biologicals to unauthorized individuals. Findings:

On 10/24/11 at 11:00 AM, S1 pharmacy technician was asked to test the security alarm since the pharmacy was not staffed on a 24-hour basis. The alarm was set after all staff had exited the pharmacy. S1 explained the alarm would emit a sound indicating the alarm was set and when she opened the door to the pharmacy, an alarm would sound in the ED (Emergency Department). The alarm did not sound in the ED, so maintenance was notified. The maintenance worker examined the alarm box in the ED and discovered the wires were disconnected. S5 maintenance worker stated the wires should be connected with a wire end cap.

Review of the Pharmacy Alarm Policy and Procedure (effective date 4/14/2008) revealed the pharmacy alarm would be checked on a weekly basis. Review of the weekly Pharmacy Alarm Check Log revealed the last date the alarm was checked was 9/19/2011. S1 Pharmacy Tech confirmed on 10/24/11 at 11:15 AM that the log provided was the last date the alarm was tested.

Interview on 10/25/11 at 11:45 AM with S2 Director of Pharmacy Services confirmed the last date the alarm was tested was 9/19/11 and that when the alarm was dysfunctional, there was no way to ensure the security of the pharmacy and to limit access to stored drugs and biologicals to unauthorized individuals.

Based on review of the medical record, Anesthesia Policy and Procedures and staff interview, the hospital failed to complete and document a post anesthesia evaluation other than at the point of movement from the operative areas to the designated recovery area for 2 of 3 sampled surgical patients in a total sample of 21.
Findings:

Review of the closed medical record for sampled patient #16 revealed a tonsillectomy under general anesthesia was performed on 01/13/2011 as an outpatient procedure. Further review revealed documentation of an anesthesia evaluation at the point of movement from the operative area to the designated recovery area. Review of the post anesthesia note revealed no documented evidence of an anesthesia evaluation prior to discharge other than the CRNA signature which did not have a date or time.

Review of the closed medical record for sampled patient #17 revealed a bilateral orchiectomy was performed in 02/08/2011 under general anesthesia as an outpatient procedure. Further review revealed documentation of an anesthesia evaluation at the point of movement from the operative area to the designated recovery area. Review of the post anesthesia note revealed no documented evidence of an anesthesia evaluation prior to discharge other than the CRNA signature which did not have a date or time.

Review of the Anesthesia Policy and Procedure approved 12/20/2010 under Post-Op Care revealed "Recordings shall be made of postop visits that include at least one describing the presence or absence of anesthesia-related complications. Each postop note shall specify the date and time".

Interview with S3 DON on 10/26/11 at 11:00 AM confirmed, following review of the medical record for sampled patient #16 and #17, that there was no post anesthesia evaluation documented.

Interview with S7 CRNA (certified registered nurse anesthetist) on 10/16/11 at 11:45 AM confirmed there was only the evaluation of the patient at the point of transfer to the post anesthesia care unit. S7 confirmed he only placed his signature in the post anesthesia note area, did not date or time his signature and that this was his normal practice.