HospitalInspections.org

Based on observation, staff interview, document review and policy review, the facility failed to ensure that all defibrillators are checked daily.


Findings include:


On 10/29/13 at 1:40 p.m. observation of the "Crash Cart/Monitor/Defib" check-list for Lifepak 20, located in the Emergency Department, revealed that from October 1, 2013 through October 29, 2013 the sections for monitor and defibrillator check had "No Test Plug" documented. Interview with Registered Nurse (RN) #1 at that time revealed that there was no test plug to check the defibrillator. The Director of Nurses (DON) stated, "We have it ordered."


On 10/29/13 at 1:50 p.m. observation of the defibrillator check sheet for Lifepak 9, located in the Emergency Department, revealed no documented evidence of checks being performed on 8/29/13, 9/2/13, 9/5/13, 9/6/13, 9/8/13, 9/10/13, 9/13/13, 9/20/13, 10/6/13 or 10/28/13. Interview with RN #1 at that time revealed that the defibrillator was not checked on the days with no documentation. She stated, "If there is a patient in the room, sometimes we forget to check it."


Review of the facility's "Code II Procedure" policy (review date March 13, 2012) revealed, "Equipment ...The RN in charge is responsible for checking emergency equipment daily. Equipment check includes: 1) The defibrillator ...".


Observation in the surgical department with the DON on 10/30/13 at 10:00 a.m. revealed that there was no defibrillator in the surgery suite. Interview with the DON revealed, "We bring one from the ER (emergency room)."

Based on record review, staff interview and policy review, the facility failed to ensure all clinical records are complete:
1. Three (3) of six (6) patient records reviewed had history and physicals (H&P) which were not signed by the physician within 24 hours;
2. 137 patient records were found to be incomplete for over 30 days; and
3. Bylaws and policies are not being followed regarding delinquencies of physicians who fail to complete records in a timely manner.

Findings include:

Review of the facility's medical staff bylaws revealed, "A History and Physical must be performed by a practitioner who has been granted privileges to do so within 30 days prior to, or within 24 hours after, inpatient admission or registration."

Closed record review for Patients #4, #5 and #6 revealed that the patient's physicians failed to complete the H&P within 24 hours.

Record review revealed that 137 medical records were incomplete/over 30 days delinquent. There was no documented evidence they followed their by-laws addressing delinquent records. These bylaws stated, "... a. Timeliness of completion of records: The patient's medical record shall be managed and completed in a timely manner. b. Records should be complete at the time of discharge, including progress notes, final diagnosis, and the discharge summary. Where this is not possible, the patient's chart should be completed within fifteen days. c. If the record still remains incomplete after 15 days, the Director of Medical Records, shall notify the practitioner of the incomplete records and request they be completed promptly. d. Records are considered delinquent after 30 days past discharge. A list of all practitioners with records more than 30 days past discharge shall be presented to the Medical administrative Committee. The Medical Administrative Committee shall issue a letter placing the practitioner on probation. e. The Medical Administrative Committee may, at its discretion, may suspend the privileges of the practitioner who is delinquent medical records are more than 60 days late."

During an interview on 10/30/13 at 10:15 a.m. the Director of Medical Records stated that she did not have a paper trail, and had made calls and e-mailed, but had not documented these actions. She stated she had also reviewed the list of delinquent medical records out loud in Medical Staff. She also revealed that she did not have a copy of the Medical Staff bylaws.

On 10/30/13 at 12:30 p.m. the Administrator stated that the issues discussed with the Director of Medical Records would be taken care of and that he would see that the new Medical Records Director has all the documents she needs.

These issues were presented in exit conference on 10/30/13. No further documentation was provided.