HospitalInspections.org

Based on observations as referenced in the Life Safety Report of survey completed 08/02/2010, the hospital leadership failed to have an effective governing body to ensure a safe environment for patients, staff, and visitors.

The findings include:

The hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

~cross refer to 482.41 Physical Environment Condition: Tag A0700

Based on policy and procedure review, grievance log review and staff interview the hospital failed to respond per policy to 3 of 6 patient grievances reviewed ( #71, 72 and 73).

The findings include:

Review of policy revised 9/2008 titled "NH-RE-RI-140 Complaints and Grievances - Patients" revealed "This policy applies to all ZZZ (name of hospital) hospitals and facilities operating under a ZZZ hospital Medicare provider number. The purpose of this policy is to establish a method for receiving, and responding to patient complaints and grievances...Send an acknowledgement letter to the patient within 7 days b. Investigate the grievance, develop and implement an action plan to resolve the grievance as appropriate c. Send a grievance response, in writing, to the patient within 7 days".

1. Review of Grievance Log # 71 revealed the grievance was received by the outpatient service on 1/19/2010. Review of the grievance revealed "Parent felt NP with help of MD missed ruptured ear drum on exam".

2. Review of Grievance Log # 72 revealed the grievance was received by the outpatient service on 2/15/2010. Review of the grievance revealed the patient complained of not receiving biopsy results.

3. Review of Grievance Log # 73 revealed the grievance was received by the outpatient service on 2/19/2010. Review of the grievance revealed the provider prescribed medication to the patient that the patient was allergic to. The patient had a reaction and went to Emergency Department.

Interview with administrative staff on 7/28/2010 at 1330 revealed all services under the hospital provider number follows the same patient's rights policy regarding grievance policy and procedure. The interview revealed a review of the grievance process had resulted in the identification that the outpatient services provided under a management group did not have information regarding the grievance process on the patient's Bill of Rights and the same did not follow the system wide policy for grievances. The interview revealed there was not a system or process in place to address the grievance policy and procedure in the outpatient services with the management group. The interview revealed there was no further documentation for the three grievances reviewed.

Based on the hospital's policy review, medical record review and staff interview, the hospital staff failed to obtain a time limited order for a patient restraint of up to 4 hours for an adult patient with self-destructive behavior in 1 of 2 sampled patients with documented self-destructive behavior (#1).

The findings include:

A review of the hospital's policy and procedure "Restraints and Seclusion" (effective date of 02/2009) revealed that for any violent or self-destructive behavior orders are time limited and expire 4 hours for adults 18 years of age and older." The policy further revealed "If restraint or seclusion needs to continue beyond the expiration of the time limited order, a new order must be obtained."

A closed medical record review on 07/27/2010 for patient #1, a 78 year old male, revealed that the patient was admitted to the hospital on 05/25/2010 through 06/18/2010 with a diagnosis of "Hyponatremia (low blood sodium level)." The review revealed that on 06/14/2010 at 2340 the patient was placed in a "vest" restraint by the hospital's nursing staff on the order of a hospital physician. The documentation revealed that the patient remained in the vest restraint until 06/16/2010 at 2220 (total of 46 hours and 40 minutes) when the patient was released from the vest restraint. The documentation in the patient's medical record revealed that the patient was placed in the restraint due to behaviors of "Getting out of bed, combative, trying to harm self and others, spitting, kicking, slapping, and swinging at staff (self-destructive/violent behavior). Chemical restraint unsuccessful." The review of the "restraint/seclusion physician order" form revealed that the restraint order was documented as "non-violent restraint order with time limits" that was documented as expiring every calendar day. The review revealed that no time limited order of up to 4 hours was obtained for the adult patient of 78 years old for the documented self-destructive behaviors by the hospital staff.

An interview with the hospital's administrative nursing staff on 07/27/2010 at 1348 revealed that the patient did have behavioral and self-destructive behaviors documented by the nursing staff on 06/14/2010. The interview also revealed that the patient should have had a time limited order for no longer than 4 hours since he was an adult patient.

Based on policy review, medical record review, and staff interview the hospital failed to ensure staff monitored a restrained patient per policy for 1 of 7 restrained patients sampled (#28).

The findings include:

Review of current hospital policy entitled "Restraints and Seclusion" dated 10/2007 revealed, "A. Application of Restraint...6. Monitoring...The following will be monitored and documented at least every 2 hours: Circulation; Skin condition; Correct application of the restraint; Patient position and range of motion; Nutrition; Hydration; Elimination needs; and Level of distress/agitation, mental status and cognitive functioning...."

Open medical record review on 07/28/2010 for Patient #28 revealed a 60 year old male admitted to the 9 General Unit (a medical surgical unit of the hospital) on 06/27/2010 for agitated dementia and a history of stroke. Record review revealed the patient was restrained in a vest restraint from 2300 on 06/27/2010 until 1738 on 06/28/2010 (18 hours 38 minutes). Record review revealed no documentation staff assessed the patient's circulation, skin condition, position and range of motion, nutrition and hydration status, elimination needs and level of distress/agitation, mental status and cognitive functioning on 06/28/2010 between 0405 and 0818 (4 hours and 13 minutes), 1216 and 1445 (2 hours and 29 minutes), and 1445 and 1738 (2 hours and 53 minutes).

Interview on 07/28/2010 at 1545 with the 9 General Unit Nurse Manager revealed nursing staff must assess restrained patients' circulation, skin condition, position and range of motion, nutrition and hydration status, elimination needs and level of distress/agitation, mental status and cognitive functioning at least every 2 hours. Interview confirmed there was no documentation available that staff assessed Patient #28's circulation, skin condition, position and range of motion, nutrition and hydration status, elimination needs and level of distress/agitation, mental status and cognitive functioning on 06/28/2010 between 0405 and 0818 (4 hours and 13 minutes), 1216 and 1445 (2 hours and 29 minutes), and 1445 and 1738 (2 hours and 53 minutes).

Based on policy review, medical record review, security incident report review, personnel file review, and staff interview the hospital failed to ensure staff that restrained a patient were trained annually in restraint application per policy for 1 of 7 restrained patients sampled (#28).

The findings include:

Review of current hospital policy entitled "Restraints and Seclusion" dated 10/2007 revealed, "C. Staff Training...1. Who must be trained -...All staff who implement restraint or seclusion orders must be trained and able to demonstrate competency in the application of restraints....2. Frequency of training - Training will occur as part of orientation and subsequently on an annual basis...."

Open medical record review on 07/28/2010 for Patient #28 revealed a 60 year old male that was admitted to the 9 General Unit (a medical surgical unit of the hospital) on 06/27/2010 for agitated dementia and a history of stroke. Record review revealed the patient was restrained in a vest restraint from 2300 on 06/27/2010 until 1738 on 06/28/2010. Review of a nurse's note on 06/28/2010 at 1738 revealed, "...1200 - bed alarm ringing, went to room, found pt (patient) standing at bedside c (with) one side of his vest restraint unhooked from bed. While trying to get him back to (bed) he starts swinging and using profanity....we called security. Security arrives and helps pt back to bed. Vest restraint reapplied and wrist restraints added...."

Review of a Public Safety Department (security) incident report completed by Public Safety Officer #1 (PSO #1) and dated 06/28/2010 at 1251 revealed, "Date-Time of incident: 6/28/2010 12:07:46 PM....Incident: Patient Restraint....First Name: (Patient #28)....Officers Statement: On June 28, 2010 all officers were dispatched to room 9211 to assist with a patient that was being combative....(Patient #28) had released the clip on one side of his vest restraint and was sitting on the side of the bed trying to undo the other side....(Patient #28) swung the strap on his restraint at me and (PSO #2) and (PSO #3) took (Patient #28)'s arm and restrained him to the bed....Nursing staff received an order for wrist restraints and (PSO #2) and myself placed the restraints on (Patient #28) before clearing the scene at 1223 hours."

Review of personnel files for PSO #1, #2, and #3 revealed the last documentation of restraint application training for each officer was as follows: PSO #1 - 07/17/2008 (2 years ago); PSO #2 - 07/17/2008 (2 years ago); and PSO #3 - 04/28/2005 (5 years ago).

Interview on 07/30/2010 at 0900 with PSO #1 revealed Public Safety Officers routinely assist nursing staff with restraint of combative patients. Interview revealed, "We help hold the patient down while they apply restraints and also physically put restraints on." Further interview revealed on 06/28/2010 the officer and 4 other officers responded to assist nursing staff with Patient #28 because he was combative. Interview revealed the officers assisted with the restraint of the patient. Interview revealed, "The nurse came in and said she had an order for wrist restraints. He (the patient) really got combative then. Two officers held his legs and his arms were held by three officers. We (the officers) put the wrist restraints on him. I had the nurse tie the restraints to the bed, because I don't tie a good slip knot and it needed to be a slip knot." Further interview revealed the PSO received restraint training during his basic training when he was initially hired "about 3 years ago". Interview revealed the officer thought he had received an updated training "sometime last year", but couldn't remember the date. Interview revealed, "We haven't been able to do it (updated restraint training) here lately."

Based on policy review, staff interview and closed medical record review, the hospital failed to report by the close of business on the next business day, following knowledge of the patient's death, to the Centers for Medicare and Medicaid Services (CMS) the death of 2 of 2 sampled patients that died within 24 hours after removal of restraint (#21, #22)

The findings included:

Review of current hospital policy entitled "Reportable Situations" dated 08/09 revealed "Deaths occurring while a patient is restrained/secluded or within 24 hours after being restrained or secluded"
a. Situation- 1) any death that occurs while a patient is restrained or in seclusion; or 2) any death that occurs within 24 hours after the patient has been removed from restraint or seclusion.
b. Whose duty- hospitals.
c. Report to whom- Required reports shall be made by telephone to the Centers for Medicare and Medicaid Services ("CMS").
d. Information to be reported- The patient's name, date of death and type of restraint being used. The patient's medical record must include documentation of the date and time the death was reported to CMS.
e. Time limit for making report- the next business day following the knowledge of a patient's death.
f. Other- There is no duty to report injury resulting from restraints, only a duty to report death".

Interview on 07/28/10 at 1400 with the hospital's Accreditation Regulatory Manager revealed reporting patient deaths in restraints was the responsibility of the Nurse Manager of the patient's unit.

1. Closed medical record review for Patient #21 revealed a 71 year-old female admitted on 06/15/10 from the emergency department (ED) with abdominal pain, nausea and vomiting. Record review revealed the patient had a small bowel resection on 06/28/10, a thoracentesis (procedure to remove fluid from the space between the lungs and the pleural space) on 07/12/10 which resulted in placement of a chest tube. Record review revealed on 07/13/10 the patient had a subsequent surgery to remove a large left hemothorax (blood in chest cavity) and was transferred post-operatively to the Critical Care Unit (CCU) unresponsive, intubated and in critical condition. Record review revealed the patient's condition deteriorated and was subsequently made a "no code (do not resuscitate)" on 07/14/10. Record review revealed soft wrist restraints had been ordered and applied on 7/14/10 at 0130 and 0700 for safety. Record review revealed the soft wrist restraints were removed on 07/14/10 at 1200. Record review revealed the patient's condition continued to decline and she expired on 07/14/10 at 1535.
Review of the medical record on 07/27/10 revealed no documented evidence staff reported to CMS by the close of business on the next business day, following knowledge of the patient's death, the death of Patient #21 that occurred within 24 hours of restraint removal..

Interview on 07/28/10 at 1400 with the hospital's Accreditation Regulatory Manager revealed the unit Nurse Manager had not reported Patient #21's death that occurred within 24 hours of restraint removal to CMS as required.

2. Closed medical record review for Patient #22 revealed this 66 year-old female with a history of end stage renal disease was admitted on 06/28/10 from the ED with abdominal pain and vomiting for two weeks. Record review revealed the patient was admitted for perforated diverticulitis. Record review revealed the patient was transferred to the OR from the ED for surgical repair of the perforated bowel then admitted to Intensive Care Unit (ICU) post-operatively. Review revealed she remained in sinus rhythm per telemetry monitor and received hemodialysis in ICU. Review revealed the patient was alert but disoriented and on 07/03 at 0305 a vest restraint was ordered and applied for safety. Review revealed the patient's condition improved and she was transferred to the 6th floor from ICU on 07/03/10. Review revealed the vest restraint continued to be used for patient's safety. Review revealed on 07/05/10 the patient coded as hemodialysis was being initiated in the dialysis unit, was "cardio vented" by the rapid response team and sent back to ICU intubated. Record review revealed the patient's condition declined, the vest restraint was removed on 07/06/10 at 0630, and she expired on 07/06/10 at 2125 (14 hours and 55 minutes after vest restraint was discontinued).

Review of the medical record on 07/27/10 revealed no documented evidence staff reported to CMS by the close of business on the next business day, following knowledge of the patient's death, the death of Patient #22 that occurred within 24 hours of restraint removal..

Interview on 07/28/10 at 1400 with the hospital's Accreditation Regulatory Manager revealed the unit Nurse Manager had not reported Patient #22's death that occurred within 24 hours of restraint removal to CMS as required.

Based on policy review, medical record review, observation, and staff interview the hospital's nursing staff failed to supervise and evaluate patient care by failing to monitor 1 of 2 sampled behavioral health patients per physician's orders (#28); failed to provide the dialysate flow rates (DFR) as ordered by the physician for 3 of 4 hemodialysis patients sampled (#22, #26, #25); and failed to assess a patient within 2 hours of arrival on a nursing unit for 1 of 1 nursing unit to nursing unit transfers sampled (#51).

The findings include:

1. Review of current hospital behavioral health policy entitled "Precaution and Observation Levels" dated 06/2008 revealed, "A. The physician shall order required precautions/observations....F. The following precaution/observation levels may be ordered:...7. 1:1: Requires 1:1 patient-staff ratio. Staff member will remain within 3-6 feet of the patient....Level of observation is documented on the observation sheet as 1:1. This level of observation is reviewed with the attending physician or their designee daily. An order is required to maintain a patient on a 1:1 observation status...."

Open medical record review on 07/28/2010 at 1200 for Patient #28 revealed a 60 year old male that was admitted to a medical surgical unit of the hospital on 06/27/2010 for agitated dementia and a history of stroke. Review of admission nursing documentation revealed the patient had an unsteady gait, was at high risk for falls, and falls prevention protocol was implemented. Record review revealed a sitter (either hospital staff or a family member) stayed with the patient most of the time from 06/29/2010 at 1500 until 07/05/2010 at 1230. Review of nurse's notes on 07/05/2010 at 0910 revealed, "Patient fell on the floor while trying to step on the chair and tried to jump on the window...." Record review revealed the patient's significant other was present in the room when the patient fell. Record review revealed a sitter (hospital staff) was placed with the patient on 07/05/2010 from 1000 until 1230, at which time the patient was transferred to the behavioral health unit (Med/Psych Unit). Review of behavior health physician's admission orders dated 07/05/2010 at 1615 revealed the patient was placed on Assault and Escape Precautions (every 15 minute checks by staff). Review of the behavioral health unit admission nursing assessment revealed the patient was at high risk for falls. Review of nurse's notes dated 07/10/2010 at 1900 revealed, "Pt. (patient) in room slamming drawers, closet and attempting to break off metal handle on a recliner. This and all other items removed from pt's room. Pt. is loud an cursing and continues to attempt to manipulate sill of window breaking away pieces of the plaster....Pt. had broken the entire window ledge away from the wall...." Review of the attending psychiatric physician's orders (Physician A) dated 07/11/2010 at 1200 revealed, "1:1 for safety." Review of physician's orders dated 07/18/2010 at 1715 revealed, "DC (discontinue) 1:1." Record review revealed no documentation the patient was monitored 1:1 by staff on 07/12/2010 from 0700-1500 and 07/17/2010 from 0700-1900 (2 of 21 shifts reviewed). Review of nurse's notes dated 07/22/2010 at 1443 revealed, "Pt came out of his room stating he leaned over in the closet and hit his head in the closet. Noted 3" laceration X 1/2 cm (centimeter) depth. Dr. called....Surgeon...stated he would come around 5 p.m. and bring supplies...." Record review revealed a plastic surgeon saw the patient on 07/22/2010 at 1815 and sutured the patient's scalp laceration. Review of Physician A's order dated 07/26/2010 at 0900 revealed, "1:1 for pt's safety." Record review revealed no physician's order to discontinue 1:1 monitoring of the patient or documentation staff discussed the patient's observation level with the physician after he ordered 1:1 monitoring on 07/26/2010 for the patient's safety. Record review revealed no documentation the patient was monitored 1:1 by staff on 07/26/2010 from 0700-1500, 1500-2300, and 2300-07/27/2010 at 0700; on 07/27/2010 from 0700-1500; and 07/28/2010 from 0700-1200 (5 of 7 shifts reviewed).

Observation during tour of the behavioral health unit (Med/Psych Unit) on 07/28/2010 at 1120 revealed Patient #28 was in Recreation Therapy group. Observation revealed at 1130 RN #1 rolled Patient #28 into the hall in a wheelchair and parked him beside the surveyor (adjacent to the nurse's station and across from the patient's room. Observation revealed the nurse left the patient beside the surveyor with no staff member within arms reach of the patient. Further observation at 1132 revealed the patient slowly rolled himself into his room across the hall unaccompanied by staff. Observation revealed at 1201 the patient rolled back out into the hall and proceeded to roll down the hall (away from the nurse's station) unaccompanied by staff.

Interview with RN #1 on 07/28/2010 at 1205 during the observation revealed the nurse was assigned to Patient #28 and 5 other patients. Interview revealed, "He's (Patient #28) not on one to one today." Interview confirmed there was no documentation available of a physician's order to discontinue 1:1 monitoring of the patient.

Interview on 07/28/2010 at 1230 with the behavioral health Nurse Manager confirmed nursing staff were not monitoring Patient #28 1:1 at the time of the observation. Interview revealed the patient was initially placed on 1:1 for aggressive behavior. After the Manager reviewed the physician's order date 07/26/2010, interview revealed, "It's probably for the safety of other patients, staff, and his safety." Further interview revealed, "The doctor is not supposed to write the order for one to one. It's a nursing process in this hospital."

Interview on 07/28/2010 at 1700 with Physician A revealed the physician ordered for the patient to be monitored 1:1 by staff because he had a very unsteady gait. Interview revealed, "He was leaning to the side, had an unsteady gait, and a history of getting a gash on his head." Interview revealed the physician had not ordered to discontinue 1:1 monitoring of the patient. Interview revealed the process at the hospital was that staff continually re-evaluate the need for 1:1 monitoring and they decide when to stop it. Interview revealed, "It's up to the nurse's discretion. They don't call me with their evaluation to discuss it." Further interview revealed the physician evaluated the patient on the morning of 07/28/2010. Interview revealed, "He is still leaning and has an unsteady gait. That is why I consulted a neurologist today. I feel like he still needs to be on one to one for safety."

Further interview on 07/29/2010 at 1200 with the behavioral health Nurse Manager confirmed there was no documentation available that staff monitored Patient #28 1:1 on 07/12/2010 from 0700-1500; on 07/26/2010 from 0700-1500, 1500-2300, and 2300-07/27/2010 at 0700; on 07/27/2010 from 0700-1500; and on 07/28/2010 from 0700-1200. Interview revealed, "We should have had him on one to one."


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2. Medical record review for patient #22 revealed this 66 year old female had been admitted on 06/28/2010 for a perforated bowel. Record review revealed this patient had a medical history that included end stage renal disease and during her hospital stay she received hemodialysis on 06/28, 06/29, 06/30, 07/02 and 07/05/2010. Record review revealed a 06/28/2010 physician order that instructed staff to dialyze this patient with a 600 cc/minute DFR. Review of the hemodialysis flow sheet documentation revealed this patient's DFR was not provided as ordered on 06/29 (DFR provided at 500 cc/minute), 06/30 (DFR provided at 500 cc/minute), 07/02 (DFR provided at 500 cc/minute), and 07/05 (DFR provided at 500 cc/minute).

Interview with the hemodialysis Nurse Manger on 07/28/2010 at 1130 revealed the hemodialysis machines will revert to the "standard" DFR which is 500 cc/ minute if staff forgets to enter the DFR as ordered by the physician. Interview revealed the DFR for patient #22 had not been provided as ordered, respectively.

3. Medical record review for patient #26 revealed this 85 year old male had been admitted on 07/20/2010 with hypertension and generalized weakness. Record review revealed this patient had a medical history that included end stage renal disease and during her hospital stay he received hemodialysis on 07/21-07/28/2010. Record review revealed a 07/21/2010 physician order that instructed staff to dialyze this patient with a 600 cc/minute DFR. Review of the hemodialysis flow sheet documentation revealed this patient's DFR was not provided as ordered on 07/22 (DFR provided at 500 cc/minute).

Interview with the hemodialysis Nurse Manger on 07/28/2010 at 1130 revealed the hemodialysis machines will revert to the "standard" DFR which is 500 cc/ minute if staff forgets to enter the DFR as ordered by the physician. Interview revealed the DFR for patient #26 had not been provided as ordered, respectively.

4. Medical record review for patient #25 revealed this 43 year old female had been admitted to behavioral health on 07/13/2010 due to suicidal ideation. Record review revealed this patient had a medical history that included end stage renal disease and during her hospital stay he received hemodialysis on 07/15, 07/16, 07/19, 07/21, 07/23, 07/26 and 07/28/2010. Record review revealed a 07/13/2010 physician order that instructed staff to dialyze this patient with a 600 cc/minute DFR. Review of the hemodialysis flow sheet documentation revealed this patient's DFR was not provided as ordered on 07/23 (DFR provided at 500 cc/minute).

Interview with the hemodialysis Nurse Manger on 07/28/2010 at 1130 revealed the hemodialysis machines will revert to the "standard" DFR which is 500 cc/ minute if staff forgets to enter the DFR as ordered by the physician. Interview revealed the DFR for patient #26 had not been provided as ordered, respectively.


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5. Review of a facility policy entitled "Assessment/re-assessment of Patient and Referral Criteria" dated May 2010, states "The patient's initial assessment consisting of vital signs and systems assessment (content of which is defined in the unit specific documentation) is completed within 2 hours of arrival to the unit."

Medical record review of patient #51 revealed the patient had been admitted to the hospital, from the Emergency Department, on 7/20/2010, after being treated for a head laceration as a result of a fall at home. The patient was admitted with diagnosis of fall with laceration, dehydration with acute renal failure and rhabdomyolysis, with plan to detox the patient in TICU. On 7/22/2010 at 0955 the physician had given an order to transfer the patient to the Cardio Telemetry Unit. A Nursing Transfer Summary indicated the time of transfer was 1230 with the transferring nurse signature as 1215. The receiving nurse signature was at 1530. A cardiac rhythm strip dated and timed 7/22/2010 at 13:33:53 was run. Nurse staff interview on 7/29/2010 at 1315 indicated this was the time of transfer. Vital signs had been recorded at this time. Further review of the patient medical record revealed no further documentation of an assessment being conducted until 2030 by the next shift.

Interview with the unit staff nurse on 7/29/2010 at 1615 indicated there were no other unit policies regarding assessments upon transfer. Interview with the Director of Nurses on 7/30/2010 at 0900 revealed a systems assessment should have been conducted when the vital signs were obtained and that a policy would need to be developed addressing the issue.

Based on hospital policy review, medical record review and staff interview, the nursing staff failed to monitor vital signs as required for patients receiving blood transfusions for 4 of 10 patients reviewed that received blood transfusions (#61, #62, #21, #22).

The findings included:

Review of the hospital policy titled "Blood and Blood Product Administration" dated July 2010 revealed "J. Blood Administration Monitoring 1. Monitor vital signs, patient's tolerance and observe for possible transfusion reaction. Monitor vital signs (at a minimum):
Immediately prior (within 30 minutes) to initiating infusion. 15 minutes after blood has reached the patient. 1 hour after the transfusion is initiated. When the transfusion is completed 1 hour following completion of the infusion...10. Begin the transfusion slowly and observe the patient for adverse transfusion reactions. Qualified personnel should remain with the patient to closely observe for at least the first 15 minutes of the blood or blood product infusion".

1. Open medical record review of patient # 61 revealed the patient was admitted on 7/27/2010 for a blood transfusion. Record review revealed the blood transfusion started at 1120. Record review revealed the vital signs were taken before the transfusion at 0925 (1 hour 55 minutes prior to transfusion start).

Interview with administrative staff on 7/27/2010 at 1500 revealed the blood pressure prior to the start of the transfusion should be no greater than 30 minutes before the start. The interview did not reveal why the staff did not take the vital signs per the policy.

2. Open medical record review of patient # 62 revealed the patient was admitted on 7/27/2010 for a blood transfusion. Record review revealed the transfusion was started at 1325. Record review revealed the vital signs were checked at 1350 (25 minutes after start of transfusion).

Interview with administrative staff on 7/27/2010 at 1500 revealed the staff are to stay with the patient for the first 15 minutes of the infusion starting and check the patient's vital signs after 15 minutes of the infusion. The interview did not reveal why the staff did not take the vital signs per the policy.


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3. Closed medical record review for Patient #21 revealed this 71 year-old female was admitted on 06/15/2010 from the ED with abdominal pain, nausea and vomiting. Record review revealed the patient had a small intestine perforation and received a unit of packed red blood cells (PRBC) on 07/04, 7 units of PRBC on 07/13 and one unit of PRBC on 07/14/2010. Record review revealed staff did not monitor this patients vital signs as required during her transfusions on 07/04 and 07/13/2010. Record review revealed on 07/04 the transfusion was competed at 1530. Record review revealed no documented evidence that this patient vital signs were taken at 1630 (1 hour post transfusion).

Record review revealed on 07/13 this patient received her 6th unit of PRBC from 1455-1530. Review revealed no documented evidence that staff obtained this patients vital signs 15 minutes into the transfusion or at the completion of this transfusion as required by policy. Review revealed vital signs were not obtained until 1605 at the initiation of her next unit of blood.

Record review revealed on 07/13 this patient received her 8th unit of PRBC from 1635-1735. Review revealed no documented evidence that staff obtained this patients vital signs at the completion of this transfusion as required by policy.

Interview on 07/28/2010 at 1525 with the hospital's Accreditation Regulatory Manager revealed staff is required to document per hospital policy. Interview revealed the medical record did not include documentation by staff that this patient had been monitored during blood administration as required.

4. Closed medical record review for Patient #22 revealed this 66 year-old female with a history of end stage renal disease was admitted on 06/28/2010 from the ED with abdominal pain and vomiting for two weeks. Record review revealed the patient was admitted for perforated diverticulitis and received a unit of PRBC on 07/02. Record review revealed staff did not monitor this patients vital signs as required during her transfusion. Record review revealed on 07/02 the transfusion was competed at 1724. Review revealed staff did not obtain this patients pulse or blood pressure as required at the one hour post transfusion interval. Review revealed only staff only documented the patients temperature.

Interview on 07/28/2010 at 1525 with the hospital's Accreditation Regulatory Manager revealed staff is required to document per hospital policy. Interview revealed the medical record did not include documentation by staff that this patient had been monitored during blood administration as required.

Based on observation and staff interview the hospital failed to ensure Controlled Drugs were locked within a secure area for 2 of 2 outpatient surgical facilities (#1 and #2).

The findings include:

1. Observation during tour on 07/29/2010 at 1330 of Outpatient Surgery Facility #1 revealed a room labeled "Clean Storage" in an unsupervised corridor outside the sterile core of the operating room. Observation revealed the room was unlocked. Observation further revealed 2 plastic boxes with tamper evidence plastic tags on each of the boxes. Observation revealed the boxes contained drugs, including Midazolam HCl (Versed) and Fentanyl (both scheduled controlled substances).

Interview on 07/29/2010 at 1345 with administrative staff revealed the courier delivers the drugs to the facility between 0930 and 1000. Interview revealed the pharmacy technician comes between 1500 and 1530 and places the drugs in the Pyxis (secured automated drug dispensing machine). Interview further revealed the drugs are placed in the unlocked storage room and are not supervised constantly by authorized staff.

Interview on 07/30/2010 at 0900 with the hospital's pharmacy staff revealed "all scheduled drugs need to be locked". Interview confirmed the controlled drugs that are delivered to the outpatient surgery facilities are not locked between delivery by the courier and placement in the Pyxis by the pharmacy technician.

2. Observation during tour on 07/29/2010 at 1450 of Outpatient Surgery Facility #2 revealed a room labeled "Clean Storage" in an unsupervised corridor outside the sterile core of the operating room. Observation revealed the room was unlocked. Observation further revealed 1 plastic box with a tamper evidence plastic tag on the box. Observation revealed the box contained drugs, including Midazolam HCl (Versed) and Fentanyl (both scheduled controlled substances).

Interview on 07/29/2010 at 1455 with administrative staff revealed the courier delivers the drugs to the facility "around 11 o'clock". Interview revealed the pharmacy technician comes between 1130 and 1200 and places the drugs in the Pyxis (secured automated drug dispensing machine). Interview further revealed the drugs are placed in the unlocked storage room and are not supervised constantly by staff.

Interview on 07/30/2010 at 0900 with the hospital's pharmacy staff revealed "all scheduled drugs need to be locked". Interview confirmed the controlled drugs that are delivered to the outpatient surgery facilities are not locked between delivery by the courier and placement in the Pyxis by the pharmacy technician.

Based on hospital policy review, observation during tour, document review and staff interviews the hospital failed to ensure medications on the malignant hyperthermia cart in the operating room were not outdated.

The findings include:

Review of hospital policy, "Medication Expiration and Beyond Use Dating", revised 01/2008, revealed "...II. Policy Beyond-use dates are based on current literature and professional judgment, and in accordance with federal and state laws and regulations. ...Surveillance of Expired Medications A. Identification of Expired Meds 1. Pharmacy technicians and technician assistants are assigned to check for expiration dates on a monthly basis...".

Review of hospital policy, "Emergency Code Blue Carts and Kits", revised 10/2008, revealed "I. Scope/Purpose The purpose of this policy is to have available the necessary medication, supplies, and equipment required in an emergency situation and for the utilization and maintenance of Code Blue Carts, emergency trays, emergency bags, and/or kits. ...II. Policy C. It is the responsibility of clinical staff to monitor the Emergency Code Blue Carts and/or Kits while they are in the patient care areas. ...3. Once a month, a complete check of the equipment, expiration dates, and medications will be completed and documented. ...V. Procedure ...2. Units that Do Not participate in the exchange procedure are listed below: ...Main OR/Anesthesia (Hyperthermia cart...)...".

Observation during tour on 07/28/2010 at 1050 of the main operating room revealed a malignant hyperthermia cart. Observation revealed a tamper evidence plastic tag on the cart. Observation of the contents of the cart revealed 17 vials of Dantrolene expired 05/2010, 18 vials of Dantrolene expired 10/2009, (4) Calcium Chloride expired 06/01/2010, (1) Lidocaine 2% expired 09/01/2009, (6) 8.4% Sodium Bicarbonate expired 06/01/2009, (6) 8.4% Sodium Bicarbonate expired 07/01/2009, (10) Lasix 20 mg (milligrams) expired 01/01/2010, (1) Procainamide 2 ml (milliliters) expired 05/01/2009 and (3) MgSO4 (magnesium sulfate) 1 gram/2ml expired 01/31/2010.

Review of the malignant hyperthermia log located on the top of the cart revealed the cart had been checked on 07/20/2010.

Interview on 07/28/2010 at 1055 with operating room staff revealed the cart is checked monthly by the operating room staff. Interview revealed the monthly check consists of verifying the number on the tamper evidence plastic tag with what is documented on the check sheet. Interview revealed the pharmacy is responsible for checking the cart for outdated drugs. Interview confirmed the drugs were outdated and were available for patient use in the case of malignant hyperthermia.

Interview on 07/28/2010 at 1100 with an anesthesiologist (Physician B) revealed there is only one malignant hyperthermia cart in the main operating room. Interview revealed pharmacy is responsible for maintaining drugs on the cart.

Interview on 07/28/2010 at 1115 with pharmacy staff revealed the operating room staff is responsible for checking the malignant hyperthermia cart. Interview revealed "we thought they were checking for expired drugs, too".

Interview on 07/28/2010 at 1145 with administrative pharmacy staff revealed "there is absolutely no excuse for having expired drugs anywhere in this place. We will take on the malignant hyperthermia cart today and it will never happen again going forward".

Based on observations during tour and staff interviews the hospital dietary staff failed to carry out their respective duties in a competent manner to ensure a clean and sanitary environment for the safe handling, preparation, and storage of food and equipment.

The findings include:

1. Observations during the dietary departmental tour on 07/27/2010 at 1100 revealed a cart holding coffee thermoses was dirty, a warming cabinet's wire shelves were dirty, a food preparation sink where vegetables were being washed and a container/cabinet holding cookies and buns was dirty. Interview with the dietary manager during tour confirmed this was inappropriate dietary practice.

2. Observation during the dietary departmental tour on 07/27/2010 at 1115 revealed in the dry food storage room, 2 dented cans of tomato paste and in the dairy freezer, one dented can of banana pudding. Review of current facility dietary policy, revised 8/2009, revealed "Products must be checked to detect unacceptable items, i.e. dented, swollen or rusted cans, thawed or refrozen, crushed cases, etc." Interview with the dietary manager during tour confirmed this was inappropriate dietary practice.

3. Observation during the dietary departmental tour on 07/27/2010 at 1120 revealed three refrigerators: (1) the meat box, (2) the dairy refrigerator, and (3) the produce box. Further review revealed the dairy (milk and juice box) refrigerator temperature registered 42 to 43 degrees Farenheit (F). Further observation during tour of the dietary department on 7/27/2010 at 1315 revealed the dairy (the milk and juice box) refrigerator temperature continued to register 42 to 43 degrees F. Further observation revealed the temperature of a carton of milk registered 42 F degrees when tested. Review of current facility dietary policy, revised 8/2009, revealed "Refrigeration equipment temperature of 40 F or below and freezer equipment temperature of 0 F must be maintained during stable times." Review of a current XXX health system policy dated 6/10 revealed "Refrigerators shall be maintained at a safe temperature; 40 degrees F or below." Interview with the dietary manager during tour confirmed this was inappropriate dietary practice.

4. Observation during the dietary departmental tour on 07/27/2010 at 1130 of the serving line revealed cold pudding and apple sauce being served at a temperature of 43 degrees F. Review of current facility policy, revised 8/2009, revealed "All potentially hazardous foods must meet the following temperature requirements during preparation, display, service, and transportation...Cold foods: Hold foods at 40 F or below." Interview with the dietary manager during tour confirmed this was inappropriate dietary practice.

5. Observation during the dietary departmental tour on 07/27/2010 at 1125 revealed in the refrigerator where bread products were being stored, the trays the bread products were on were dirty and moldy. Interview with the dietary manager during tour confirmed this was inappropriate dietary practice.

6. Observation during the dietary departmental tour on 07/27/2010 at 1140 revealed a container of cut tomatoes and cut cucumbers with not dated or labeled when placed into the refrigerator. Further observation revealed containers of food products that had been opened and not dated and labelled when opened. Review of current facility policy, revised 8/2009, revealed "All foods prepared in operation must be covered and labeled as to contents and date of preparation prior to storage in refrigerators and freezers." Interview with the dietary manager during tour confirmed this was inappropriate dietary practice.

Based on observations as referenced in the Life Safety Report of survey completed 08/02//2010 the hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

The findings include:

The hospital failed to ensure the safety and well-being of patients.

~cross-refer to 482.41(b) Physical Environment Standard Tag A0701.

Based on observations as referenced in the Life Safety Report of survey completed 08/02/2010, the hospital failed to ensure the safety and well-being of patients.

The findings include:

1. Observations and staff interview during the tour on 7/27/2010 onward to 8/2/2010 the following items were noncompliant, the specific findings include for Building 1:
a. Doors in the following locations did not close and latch to prevent the passage of smoke: 9152, 9165 , 5164, 5163, 5324, 5318, 4702, 4319, 3318, 3537, 1st floor kitchen stock entrance from dock, 1st floor left door for tray line entrance.
b. Soiled Utility Room #3455 had tape over the keeper hardware not allowing the door to latch.
c. Bathroom by elevator #17 & #18 was missing a strike plate and had a throw latch.
d. Dutch doors next to 2555 in behavioral health had an air gap between the top and bottom doors.
Building 2
Observation on 07/27/2010 the door to the break room opens on to an egress corridor and had tape over the keeper so the door could not latch.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0018.

2. Observations and staff interview during the survey on 7/27/2010 onward to 8/2/2010 the following items were noncompliant, specific findings include for Building 1: There are unsealed penetrations in rated wall assemblies in the following locations:
a. above the cross corridor doors near the nurses station on the 7th floor East
b. above the cross corridor doors near the nurses station on the 6th floor East
c. above the ceiling in the bathroom area at the elevator vestibule where HVAC construction was halted
d. above the ceiling near room 6118 unsealed penetrations in the rated wall assembly.
e. above the ceiling in Central Supply.
f. in the HVAC space which is inside the main penthouse complex

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0025.

3. Observation on 07/27/2010 the following items were noted as noncompliant for Building 1: a. fire doors on the sixth floor near room 6127 did not close smoke tight
b. smoke doors near the fire alarm room on the fourth floor did not close smoke tight along with other smoke doors in the facility.
c. The right leaf of fire doors near room 5324 did not close and latch.
d. There was a gap in the smoke doors next to nourishment room 4697.
e. The fire doors next to the 3rd floor stairwell and near elevators #17 & #18 did not close and latch tightly in it's frame.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0027.

4. Observation of Building 1, on 07/27/2010 there were hazardous areas located through out the facility that the corridor door did not close and latch to maintain the one hour rating of the space. These rooms included but are not limited to soiled linen rooms, storage rooms, and other hazardous areas. Observation of Building 8 on 07/27/2010 the door to the soiled linen room did not have a closer.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0029.

5. Observations and staff interview during the tour on 7/27/2010 onward to 8/2/2010 the following item was noncompliant for Building 1: the code requirement was not met for exiting at the loading dock as there was a drop off of more than 30 inches with no handrail present.

Observation on 07/27/2010 for Building 8 there were three rooms in the facility that required more than one motion of the hand to exit the room.

Observation on 07/27/2010 of Building 9 there were three rooms in the facility that required more than one motion of the hand to exit the room.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0032.

6. Observations and staff interview during the survey on 7/27/2010 onward to 8/2/2010 the following items were noncompliant with Building 1: The facility has electromagnet locking mechanisms and systems in several locations. These special locking arrangements being utilized must comply with NFPA 101 Delayed-Egress Locks[7.2.1.6.1] or NCSBC Special Locking Arrangements [1003.3.1.8.5] specific findings include:
a. The kill switch at the door leading from endoscopy to behavioral health does not meet either requirement as it automatically relock after a few seconds after the door is closed. The door must relock only by manual means.
b. In some areas you must pass through more than one delayed egress in order to exit the facility.
c. One door did not release when pressure was applied to the release device.
d. Where N.C. Special Locking was used in some areas there were no master release switches, one master release switch failed to release the doors.
e. Some staff interviewed did not know about the door master release switch.
f. Delayed egress doors on the 9th floor would relock without being manually reset.
g. In the E.D. Blue Zone keyed electromagnetic locks were being used and the staff did not carry keys on them, the key was in a drawer on a key ring with other keys.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0038.

7. Observations and staff interview during the tour on 7/27/2010 onward to 8/2/2010 for Building 1 the following item was noncompliant, specific findings include a single bulb fixture at the 1st floor radiology imaging exit.

Observations and staff interview during the survey dated 7/27/2010 onward to 8/2/2010 The following exit discharge illumination for Building 8 was observed as noncompliant as the specific findings include: No exit discharge lighting leading from the stairwell next to the elevators to the public way.

Observations and staff interview during the survey of Building 10 dated 7/27/2010 onward to 8/2/2010 The following exit discharge illumination was observed as noncompliant as the specific findings include: No exit discharge lighting leading from the stairwell next to the elevators to the public way.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0045.

8. Observations and staff interview during the tour of Building 1 on 7/27/2010 onward to 8/2/2010 the following item was noncompliant; the exit stairwell light in south general next to room 4324 was not functioning properly.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0046.

9. Observations and staff interview during the survey of Building 1 on 7/27/2010 onward to 8/2/2010 the following exit directional signage was noncompliant, specific findings include: The exit directional sign leading from the end of the South hall near room 4327 directs persons to the elevator vestibule and not the egress stairwell

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0047.

10. Observations and staff interview during the tour on 7/27/2010 onward to 8/2/2010 of Building 1 the following item was noncompliant, Whitaker building did not have a Fire Department Connection (FDC) Sign at the fire department connection point.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0056.

11. Observation on 07/27/2010 of Building 1 the following was found noncompliant:
a. The back-flow preventers for the sprinkler systems that did not have tamper alarms installed on the control valves located in pits on the out side of the building along with the P.I.V. located at the loading docks. b. The dry sprinkler system at the loading dock has a valve located up stream of the pressure operated flow switch . this valve has the handle removed but it must be electrically supervised.

Observation on 07/27/2010 for Building 2 the following was found to be noncompliant: there were no electrically supervised tamper alarms on the main sprinkler valves located in the pit at the street.

Observation of Building 9 on 07/27/2010 the control valves for the sprinkler back - flow preventer located in the pit in the front of the facility did not have electrically monitored tamper alarms installed on them.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0061.

12. Observation of Building 2 on 07/27/2010 the following was found to be noncompliant:
a. There were no access doors for the duct detectors in the basement equipment room.
b. The air handlers did not shut down upon activation of the fire alarm when duct detector was tested.

Observations and staff interview during the tour of Building 3 on 7/27/2010 onward to 8/2/2010 the following item was noncompliant; there was not a available shut down switch for the air handling units (AHU) at a manned station.

Observations and staff interview during the tour of Building 4 on 7/27/2010 onward to 8/2/2010 the following item was noncompliant, a. there was not a available shut down switch for the three air handling units (AHU) at a manned station. b. The AHU on the 2nd floor outside the break area did not shut down with fire alarm activation.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0067.

13. Observations and staff interview during the tour on 7/27/2010 onward to 8/2/2010 of Building 1 the following items were noncompliant: a. soiled linen chute in room 3130, 5108, 4733 did not close and latch automatically when tested b. trash chute in room 5109, 3109 did not close and latch automatically when tested

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0071.

14. Observations and staff interview during the tour on 7/27/2010 onward to 8/2/2010 of Building 1 the following items were noncompliant,
There are doors that open into the egress corridor that do not open 180 degrees or have door closures to keep the doors closed after being opened. These locations are noted:
a. 9th floor East linen closet and electrical room in front of the nurse ' s station
b. 8th floor East linen closet
c. 7th floor East electrical room in front of the nurse ' s station
d. 5th floor East electrical room and telecommunications in front of the nurse ' s station
e. Storage room next to room 5555
f. Storage room 4674A
g. 4th floor East clean linen and electrical room in front of the nurse ' s station
h. Environmental services door 3605
i. food cart stored unattended near room 9117
j. throughout the facility there wall mounted charting cabinets that did not retract when not in use
k. 2nd floor of Whitker had wall mounted cabinets near rooms 2603, 2607, 2615, 2619 that did not swing 180 degrees.
l. OR had items stored in the required exit areas.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0072.

15. Observations and staff interview of Building 1 during the survey dated 7/27/2010 onward to 8/2/2010 The following items were observed as noncompliant as the specific findings include: a. The compressed gas room number 2 in the blood lab did not have its cylinders individually secured.
b. oxygen storage on the North 5th floor had a mix of full and empty cylinders in the same storage rack.
c. oxygen cylinders stored at the loading dock area were not individually secured
d. the oxygen storage in the Whitaker Building had had a mix of full and empty cylinders in the same storage rack

Observations and staff interview of Building 10 during the survey dated 7/27/2010 onward to 8/2/2010 The following was observed as noncompliant as the specific findings include:
a. The oxygen storage room on the exterior of the building did not have its cylinders individually secured.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0076.

16. Observations and staff interview during the tour of Building 1 on 7/27/2010 onward to 8/2/2010 the following item was noncompliant, the pixus unit in the OR Supply room was plugged into normal power.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0130.


17. Observations and staff interview during the survey of Building 1 on 7/27/2010 onward to 8/2/2010 the following item was found was noncompliant, specific findings include: a. The ground fault circuit interrupter receptacle (GFCI) did not work properly when tested in the beauty parlor located in the Whitaker building. b. there was a 4x4 junction box with no cover above the ceiling tile near room 6123 that had wires that were not terminated properly.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0147.

Based on hospital policy review, observation and staff and physician interview, the hospital failed to maintain a functional malignant hyperthermia cart to ensure the safety of surgical patients.

The findings include:

Review of hospital policy, "Medication Expiration and Beyond Use Dating", revised 01/2008, revealed "...II. Policy Beyond-use dates are based on current literature and professional judgment, and in accordance with federal and state laws and regulations. ...Surveillance of Expired Medications A. Identification of Expired Meds 1. Pharmacy technicians and technician assistants are assigned to check for expiration dates on a monthly basis...".

Review of hospital policy, "Emergency Code Blue Carts and Kits", revised 10/2008, revealed "I. Scope/Purpose The purpose of this policy is to have available the necessary medication, supplies, and equipment required in an emergency situation and for the utilization and maintenance of Code Blue Carts, emergency trays, emergency bags, and/or kits. ...II. Policy C. It is the responsibility of clinical staff to monitor the Emergency Code Blue Carts and/or Kits while they are in the patient care areas. ...3. Once a month, a complete check of the equipment, expiration dates, and medications will be completed and documented. ...V. Procedure ...2. Units that Do Not participate in the exchange procedure are listed below: ...Main OR/Anesthesia (Hyperthermia cart...)...".

Observation during tour on 07/28/2010 at 1050 of the main operating room revealed a malignant hyperthermia cart. Observation revealed a tamper evidence plastic tag on the cart. Observation of the contents of the cart revealed 17 vials of Dantrolene expired 05/2010, 18 vials of Dantrolene expired 10/2009, (4) Calcium Chloride expired 06/01/2010, (1) Lidocaine 2% expired 09/01/2009, (6) 8.4% Sodium Bicarbonate expired 06/01/2009, (6) 8.4% Sodium Bicarbonate expired 07/01/2009, (10) Lasix 20 mg (milligrams) expired 01/01/2010, (1) Procainamide 2 ml (milliliters) expired 05/01/2009 and (3) MgSO4 (magnesium sulfate) 1 gram/2ml expired 01/31/2010.

Review of the malignant hyperthermia log located on the top of the cart revealed the cart had been checked on 07/20/2010.

Interview on 07/28/2010 at 1055 with operating room staff revealed the cart is checked monthly by the operating room staff. Interview revealed the monthly check consists of verifying the number on the tamper evidence plastic tag with what is documented on the check sheet. Interview revealed the pharmacy is responsible for checking the cart for outdated drugs. Interview confirmed the drugs were outdated and were available for patient use in the case of malignant hyperthermia.

Interview on 07/28/2010 at 1100 with an anesthesiologist (Physician B) revealed there is only one malignant hyperthermia cart in the main operating room. Interview revealed pharmacy is responsible for maintaining drugs on the cart. Interview revealed "I will make the anesthesia staff aware that our drugs on the cart are expired and are being replaced".

Interview on 07/28/2010 at 1115 with pharmacy staff revealed the operating room staff is responsible for checking the malignant hyperthermia cart. Interview revealed "we thought they were checking for expired drugs, too".

Interview on 07/28/2010 at 1145 with administrative pharmacy staff revealed "there is absolutely no excuse for having expired drugs anywhere in this place. We will take on the malignant hyperthermia cart today and it will never happen again going forward".

Based on review of medical staff rules and regulations, medical records and staff interviews, the hospital failed to ensure the completion of an operative report immediately following surgery for 6 of 12 surgical records reviewed (#48, #73, #49, #42, #47 and #46).

The findings include:

Review of the hospital's medical staff rules and regulations, revised 06/08/2010, revealed "...B. Medical Records...6. ...A handwritten note or signed report relating specific basic details must be recorded in the medical record by a surgeon immediately following any operative procedure. Operative progress notes must be dated and timed and include the following: findings/description; post-operative diagnosis; procedure(s) performed; name of surgeon and assistant; specimens removed; and estimated blood loss...".

1. Open medical record review of Patient #48 revealed a 50 year-old admitted 07/26/2010 with cancer of the bile duct. Record review revealed Patient #48 had a percutaneous transhepatic cholangiogram under general anesthesia 07/26/2010. Record review revealed no documented evidence of an operative report written by the physician immediately after the surgical procedure.

Interview on 07/26/2010 with administrative staff revealed an operative report should be documented in the patient's medical record immediately after a surgical procedure. Interview confirmed there was no documented evidence of an immediate operative note/report written for Patient #48's procedure 07/26/2010.

2. Open medical record review of Patient #73 revealed a 40 year-old admitted for a right knee arthroscopy 07/29/2010. Record review revealed an operative report, with no documented evidence of time completed by the surgeon.

Interview on 07/29/2010 at 1400 with administrative staff revealed the immediate operative report should be timed by the surgeon. Interview confirmed the operative report for Patient #73 was not timed by the surgeon.

3. Open record review of Patient #49 revealed a 42 year-old admitted 07/26/2010 for a cervical discectomy and fusion of cervical vertebrae 5 and 6. Record review revealed an operative report, with no documented evidence of time completed by the surgeon.

Interview on 07/29/2010 at 1400 with administrative staff revealed the immediate operative report should be timed by the surgeon. Interview confirmed the operative report for Patient #49 was not timed by the surgeon.

4. Closed record review of Patient #42 revealed a 60 year-old admitted 05/28/2010 with a perforated acute sigmoid diverticulitis and had an anterior resection of the colon and appendectomy 06/02/2010. Record review revealed an operative report, with no documented evidence of time completed by the surgeon.

Interview on 07/29/2010 at 1400 with administrative staff revealed the immediate operative report should be timed by the surgeon. Interview confirmed the operative report for Patient #42 was not timed by the surgeon.

5. Closed record review of Patient #47 revealed a 7 year-old admitted for a tonsillectomy 07/08/2010. Record review revealed an operative report, with no documented evidence of time completed by the surgeon.

Interview on 07/29/2010 at 1400 with administrative staff revealed the immediate operative report should be timed by the surgeon. Interview confirmed the operative report for Patient #47 was not timed by the surgeon.

6. Closed record review of Patient #46 revealed a 48 year-old admitted 07/06/2010 for a right shoulder arthroscopy with rotator cuff repair. Record review revealed an operative report, with no documented evidence of time completed by the surgeon.

Interview on 07/29/2010 at 1400 with administrative staff revealed the immediate operative report should be timed by the surgeon. Interview confirmed the operative report for Patient #46 was not timed by the surgeon.