HospitalInspections.org

Based on staff interview, observation and policy review, the hospital failed to have equipment and supplies in readiness for use during an emergency on one (1) of two (2) days of survey.

Findings include:

On 03/12/2013 from 10:00 to 11:00 a.m. interview/observation with the Registered Nurse (RN) on the Acute Unit revealed that the Crash Cart had not been checked on a regular basis for outdated supplies which needed to be replaced. Observation of the Crash Cart contents revealed the following out-dated items:
1) Endotracheal tubes were all outdated as of 2010-03;
2) The stylet for the Endotracheal tube was outdated as of 2012-04;
3) Jelco IV (intravenous) catheters were outdated as follows: a) three (3) as of 2013-01, b) five (5) as of 2012-08, and c) five (5) as of 2012-10;
4) Sodium chloride injectible outdated as of 2012-01; and
5) Sterile wound dressing outdated as of 2009-05.

All supplies picked up and viewed were outdated. This included crash cart items other than the ones listed above. The Crash cart was located just inside the Nursing Station and was not locked. There were no pulls on the drawers. There was no adult ambu bag on the cart and there were no emergency drugs on the cart.

Observation of the Acute Unit's suction machine revealed that it was not in readiness (base and bottle separate with no tubing attached).

Review of the Crash Cart Daily Checklist revealed that it had only been signed by a nurse one (1) time during the month of March: on 03/07/13. During February 2013 the Checklist was signed by a nurse three (3) times: on 02/04/13, 02/13/13 and 02/18/13. A Licensed Practical Nurse (LPN) on the Unit stated, "When there's a Code called, the Crash Cart from the Emergency Room is brought to this Unit."

Review of the hospital's "Crash Carts" policy, effective date 03/12, revealed: "Policy: Emergency drugs and supplies...shall be immediately available at each patient care unit or service area. Emergency drugs for resuscitation shall be located in the emergency crash carts. The departments in which emergency carts are kept are as follows: ...Acute care."

Based on observations, staff interview and policy review, the hospital failed to properly store trash.


Findings include:


On 03/12/2013 initial tour began at approximately at 10:20 a.m., with maintenance personnel revealed Biohazardous Waste was improperly stored across from the nursing station.
1. The Biohazardous Waste room entrance was marked with a warning sign for storage of medical waste and a soiled linen storage sign. The entrance was unlocked thus not secure so as to prevent unauthorized access.
2. The soiled linen hamper contained soiled linen. The lid was not covering the container.
3. There was a covered container marked as Medical Waste next to the linen hamper.
4. The window in the Medical Waste room was open and had no screens, which meant there was no protection from rain or insects. There was a stuffed animal toy lying on the window ledge.


On 03/13/2012, a second tour beginning at approximately at 11:10 a.m., with maintenance personnel revealed the same concerns as on the initial tour.


Review of the facility's "Medical Waste Management Plan" policy, effective date 04/22/2009, revealed:
POLICY:
A. Storage and Containment of Infectious Medical Waste and Medical Waste.
1. Containment of infectious medical waste and medical waste shall be in a manner and location which affords protection from animals, rain and wind, does not provide a breeding place or a food source for insects and rodents, and minimizes exposure to the public...
4. Containment of infectious medical waste shall be separate from other wastes. Enclosures or containers used for containment of infectious medical waste shall be so secured as to discourage access by unauthorized persons and shall be marked with prominent labeling..."


On 03/13/2013 at 12:00 p.m. an interview with the housekeeper revealed, "They usually don't store medical waste in there."

485.627(a)


Based on documentation review, policy and procedure review and staff interview, the hospital failed to ensure that their Governing Body assume full legal responsibility for governing the facility's total operation.


Findings include:


Cross Refer to C300 for the Governing Body's failure to ensure all medical records are accurately documented, entries timed and dated, consents properly executed, and promptly completed following discharge.


Cross Refer to C336 for the Governing Body's failure to ensure ongoing quality monitoring, implementation, and evaluation of corrective actions.

Based on staff interview, observation and policy review, the hospital failed to meet the needs of the physicians, staff and patients.

Findings include:

On 03/13/13 at 9:45 a.m., an interview was held with the contract Pharmacist. She stated that she did not have a Job Description or a list of duties, and that they did not have a Formulary.

Review of the hospital's Policy and Procedure Manual revealed that the manual was reviewed and signed on 03/28/12. The Manual was not signed by the Director of Nurses or the Administrator.

Observation in the Emergency Department (ED) and on the Acute Unit on 03/13/2013 at 11:35 a.m. revealed standing water in the medication refrigerators. The staff stated that the night shift had decided to defrost the refrigerators. All boxes that contained the medications were wet. The temperature of the refrigerators was unknown.

Based on review of the Staffing Schedule and staff interview, the hospital failed to ensure that Registered Nurses (RNs) were scheduled to meet the needs of patients.

Findings include:

Review of the hospital's Staffing Schedule dated February 24, 2013 through March 23, 2013 revealed that one (1) RN was scheduled to work 60 hours straight without a day off. This included 02/28/2013 - 7:00 a.m. to 7:00 p.m.; 03/01/2013 - 7:00 a.m. to 7:00 p.m.; 03/03/2013 - 7:00 a.m. to 7:00 p.m.; and 3/4/13 - 7:00 a.m. The RN had a similar schedule for March 14 through March 18, 2013.

The Staffing Schedule did not include the location where the staff was to work except for the Behavioral Health Unit (through March 2, 2013).

On 03/12/13 at 2:50 p.m. the RN who staffs the Acute Unit was asked how he covered this unit as well as the Emergency Department. He stated that the Acute Unit had a Licensed Practical Nurse (LPN).

Based on medical record review, policy and procedure review and staff interview, the hospital failed to ensure all medical records are accurately documented, entries timed, consents properly executed, and promptly completed following discharge.


Findings include:


A total of 30 medical records (inpatient and discharged) were reviewed, representing acute, swing bed and outpatient records.


17 of the records reviewed did not contain a properly executed general admissions/treatment consent. These consents either did not contain documentation concerning power of attorney, organ donation, authorization for communicable disease testing, authorization for photograph (if applicable), receipt of privacy rights, or a patient identifier (label).

16 of the records reviewed did not contain documented times on all entries on the physician "Progress Reports".

Six (6) of the records reviewed did not contain documented times on all entries on the patient "Orders".

Two (2) of the records reviewed had no documented evidence of discharge planning.

Eight (8) of the records did not contain documented times on the physical exam (history and physical). One (1) record had no documented date on the physical exam (history and physical).

Two (2) of the records reviewed contained an incomplete "Patient Assessment Profile (Nursing Assessment)".


Review of the Delinquent Medical Records document submitted by the Medical Records Director (MRD) revealed there were five (5) incomplete physician records ranging from July 2012 through February 3, 2013. On 03/12/13 at 11:20 a.m. the MRD confirmed the number of delinquent records, "There are five (5) delinquent physician records greater than 30 days after discharge."


On 3/12/13 at 1:30 p.m., in an interview concerning delinquent physician records, the MRD stated, "Our internal policy was to try and complete within fifteen days but we do not consider a record delinquent until thirty days after discharge... No physician has been sent any letters or suspended for not completing records...We only have one physician most of the time and if we suspend him we would have to close the facility."


On 3/13/13 at 10:30 a.m. the MRD was asked about dates and times for entries into the medical record. She stated, "Dates and times should be on entries."


Review of the hospital's "Medical Record Guideline for Physicians" undated policy revealed, "...Procedure: General Outlines: All entries must be timed, dated and authenticated. ....History and Physical Examinations: Shall be completed within the first 48 hours of admission ...Progress Notes: Must be timed and dated ..."


Review of the hospital's "Medical Records Guidelines for Entries" policy (Effective: March 01, 2002) revealed, "Policy: All entries must be legible and complete, ...and dated promptly... Procedure: All entries must be timed, dated (complete date) and authenticated."


Review of the hospital's "Delinquent Medical Records" undated policy revealed:
"Policy: It is the policy of the Health Information Management Department to notify a practitioner of suspension when he/she has delinquent medical records.
Procedure: Physicians will be notified on a weekly basis of their number of incomplete charts through a letter until the charts are complete or the physician is on suspension. All deficiencies are noted, by responsible physician, on the chart deficiency computer system. Deficient records are then placed in the Physician's File Drawer...Should the Health Information Management Department not receive a physician response to complete his/her medical records within 7 days of the first notice, the physician will be notified with a second reminder letter. Should the medical record(s) remain incomplete on the 15th day after patient discharge, the Health Information Management Department will notify the physician...that his/her admitting privileges have been suspended until his/her medical records have been completed...A copy of all suspension letters mailed are placed in the physician's peer review file...Any patient remaining in the hospital more than 24 hours shall require a discharge summary."

Review of hospital's undated "Governing Bylaws of ...Hospital" revealed: "...Definitions: ...3. 'Governing Body' means the governing authority appointed by the corporation ...
1. ARTICLE 1 GENERAL SCOPE:... 7. Responsibilities: ...The responsibilities and obligations of the board shall include: ...Assuming responsibility for Medical Staff oversight ...Subject to recommendations from the Medical Staff and review and concurrence of the Corporation, approving the Bylaws, Rules and Regulations and Fair Hearing Plan of the Medical Staff and appointing, suspending or removing any practitioner from the Medical Staff, following the provisions of these bylaws and the Medical Staff Bylaws. ... Assisting the CEO in establishing medical record policies ..."

Review of the hospital's "Medical Staff Bylaws" (reviewed July 27, 2012) revealed:
"Article III The Medical Staff -
3.10 The Medical Staff shall see that there is adequate documentation ...to ensure that medical records meet the required standards of completeness, clinical pertinence, and promptness or completion of following discharge: Article VIII: Corrective Action
7.3.3 Medical Records Default: In the event a Practitioner fails to complete all required medical record within 15 days of a patient discharge he will be notified by the Medical Record Supervisor. Upon notification the Practitioner will have an additional 15 days to complete the records. If the records are not complete at the end of this periods, the Practitioner's admitting privileges shall be suspended upon notification by the Medical Record Administrator.
Article XI: Committees
11.3 Medical Records Committee: The Medical Records Committee shall be responsible for assuring that all medical records meet the appropriate standards of patient care...The committee shall conduct at least quarterly review...It shall also conduct a review of records of discharged patients to determine the promptness, pertinence, adequacy and completeness thereof."

Based on medical record review, policy and procedure review and staff interview, the hospital failed to ensure all medical records reviewed were complete and accurately documented.


Findings include:


Cross Refer to C300 for the facility's failure to ensure all medical records are complete and accurately documented.

Based on medical record review, policy and procedure review and staff interview, the hospital failed to ensure consent forms are properly executed.


Findings include:


Cross Refer to C300 for the hospital's failure to ensure consents are properly executed.

Based on medical record review and staff interview, the hospital failed to ensure that all entries in the medical records were timed and dated.


Findings include:


Cross Refer to C300 for the hospital's failure to ensure all entries contain a documented time and date of entry.

Based on document review, policy and procedure review and staff interview, the hospital failed to ensure ongoing quality monitoring, implementation, and evaluation of corrective actions.


Findings include:


Review of the departmental "Monthly Performance Improvement Report(s)" revealed that the latest date submitted was September 2012 and included only one (1) of the facility departments. Review of the Quality Assurance/Performance Improvement Committee Monthly Meeting minutes revealed the latest meeting was held on August 8, 2012.


On 03/13/13 at 10:30 a.m. the hospital's Quality Assurance Program was discussed with the Medical Records Director. She stated, "The quality information is in the manuals that were provided." No further documentation was submitted.


Review of facility's undated "Governing Bylaws of ... County Hospital" revealed: "Definitions: 3. 'Governing Body' means the governing authority appointed... 7. Responsibilities... The responsibilities and obligations of the Board shall include:... Establishing, maintaining and supporting, through the CEO and the Medical Staff and its designated committees, hospital-wide program for quality assessment and improvement, receiving reports of quality improvement information on a regular basis from the Medical Staff, and assuring that all aspects of the program are performed appropriately... Designating particular individuals or departments responsible for evaluating and monitoring quality of care in particular patient services..."