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Based on record review, policy review and interview, it was determined the facility failed to protect and promote the rights of patients as evidenced by: failure to provide patients with patient right information upon entry to the hospital (see A116), failure to inform each patient, or when appropriate, the patient's representative (as allowed under State law), of the patient's rights (see A117)..

Based on observation and interview the facility failed to ensure that each patient or patient's representative was informed of the patient's rights, in advance of furnishing or discontinuing patient care for patient #s 1-31 medical records reviewed out of a total of 31 medical records reviewed. Findings include:
During the tour of the Emergency Department on 1/29/13 at approximately 1400 it was found that the facility doesn't give out patient rights information to anyone, nor does it have any documentation within the medical records of patient records #s 1-31 of them receiving or being offered copies of such rights.
During this observation, staff A and J confirmed that the facility didn't furnish or document the availability of this information to patients or their representatives.

Based on observation and interview the facility failed to ensure that patients or their representatives receive information on patient rights of whom to contact within the facility to voice complaints or grievances and failed to give the contact address and phone number for the state complaint hotline. Findings include:

Review of the tri-fold pamphlet given to patients or their representatives revealed that the neither contact information for the State Agency or the facility, nor steps outlining how to file a grievance were written.

During the tour of the facility units, including Emergency Department, Obstetrics and Surgery on 1/29/13 and 1/30/13, it was revealed that multiple posted posters titled "Patient Rights" lacked contact information for the State Agency or who to contact, in the facility, to express a complaint or a grievance.

Staff D and G confirmed the above findings at the time of observation.


29774

On 1/30/13 at approximately 1100, a tour of the off-site physical therapy in Norway revealed a posted poster titled "Patient Rights" that lacked contact information for the State Agency or who to contact, in the facility, to express a complaint or a grievance. Staff F, manager of outpatient rehabilitation services said "There is a tri-fold pamphlet that is usually available for patients that does give that information, it looks like we are out of them right now." On 1/31/13 at approximately 1300 a review of the tri-fold pamphlet revealed that the contact information for the State Agency and the facility was not written on the pamphlet, and therefore the patient would not understand how to file a grievance or a complaint.

Based on documentation review and interview the facility failed to take action to reduce the numbers of medication errors and patient falls resulting the potential for patient harm for all patients served by the facility. Findings include:

On 1/30/13 at approximately 0845 a review of the 2012 Quality Assurance data for nursing revealed that for patient falls, the numbers of patient falls between second quarter and third quarter 2012 rose sharply. Additionally, the numbers of medication errors for the second and third quarters of 2012 were on an increasing trend. On 1/30/13 at approximately 1430 an interview with staff A, the Quality and Risk Manager, confirmed that the numbers of patient falls for the third quarter in 2012 did rise sharply however they had implemented a new database for monitoring which also included falls in home care and hospice. Staff A was asked whether this trend was analyzed for location, time of day, or other contributing factors, for the purposes of prevention of future falls, to which he replied that "nursing completes that analysis". Additionally staff A was asked about the increasing trend of medication errors for the second and third quarter of 2012, to which he replied "the pharmacy director tracks all those". When asked about analysis for medication errors to determine contributing factors, staff A indicated that nursing will provide those. Staff A indicated that he is "responsible for reporting the data.".

Staff G, the Director of Nursing, was interviewed on 1/30/13 between 0900 and 1000 on the topic of nursing services. When asked specifically for the nursing analysis and corrective action taken to reduce the numbers of patient falls and medication errors for the third and fourth quarters for 2012, Staff G said that the fourth quarter analysis for patient falls and medication errors is "not available". Staff G indicated that she would provide proof of analysis and corrective action. On 1/31/13 at approximately 1015 a review of the "proof" provided revealed; analysis of one overdose of coumadin and a line listing of each of the medication errors and near misses for third quarter 2012, and a "2005" document that revealed common days, times of day and personnel involved in patient falls. Interview with Staff G on 1/31/13 at approximately 1020, regarding analysis, corrective action and measuring impact of corrective actions on reducing patient falls and medication errors revealed that "I see that we could be more transparent with our analysis and action taken to reduce these (medication) errors and (patient) falls".

Based on medical record review and interview the facility failed to ensure that orders for drugs are given under the orders of the physician responsible for the patients' care in 3 out of 3 (#12, #13 and #14) surgical patients' medical records reviewed. Findings include:

During medical record review on 1/30/13 at approximately 1400 it was found that patient #12 had received 2 milligrams (mg) of Versed in the Pre-Operative area, prior to surgery, without the order of a physician. During review of the "Pre-Op Orders" form, there was not an order for the Versed on the form signed by the physician. Further review of the medical record showed no order for the Versed by the physician.

During medical record review on 1/30/13 at approximately 1430 it was found that patient #13 had received 2 milligrams (mg) of Versed in the Pre-Operative area, prior to surgery, without the order of a physician. During review of the "Pre-Op Orders" form, there was not an order for the Versed on the form signed by the physician. Further review of the medical record showed no order for the Versed by the physician. There was also a verbal order written for the patient to receive 5 mg of Labetalol, which was given, but no physician signature had been obtained.

During medical record review on 1/30/13 at approximately 1500 it was found that patient #14 had received 2 milligrams (mg) of Versed and a 0.1 mg Scopolamine patch in the Pre-Operative area, prior to surgery, without the order of a physician. During review of the "Pre-Op Orders" form, there was not an order for the Versed or the Scopolamine patch on the form signed by the physician. Further review of the medical record showed no order for either of the medications by the physician.

During an interview with staff H on 1/31/13 at approximately 0900, the medical records above were reviewed by staff H and no orders could be found and the findings were confirmed.

Based on medical record review and interview the facility failed to ensure the medical records had orders that were timed (see 0450); the facility failed to ensure telephone/verbal orders were authenticated by the physician resulting in the potential for patient harm from physicians not authenticating and verifying patient orders (see 0457); and the facility failed to ensure medical records were closed within 30 days of the patient discharge from the hospital (see 0469).

Based on document review and interview, the facility failed to ensure that all medical orders were timed for eight out of ten medical records ( Patient #s 2, 3, 5, 6, 7, 12, 13, and 14) reviewed resulting in the potential for medical errors and patient harm for all patients served by the facility. Findings include:

On 1/29/13 from 1400 through 1630 a review of open medical records revealed that Patient #2 had medical orders dated 1/24/13, 1/25/13, 1/26/13, 1/27/13, 1/28/13, and 1/29/13 that lacked time that the order was written. Staff D confirmed that these orders lacked a time written. Staff D was asked whether their policy stipulates that a time of order needed to be documented in the medical record, to which she replied "yes".

On 1/29/13 from 1400 through 1630 a review of open medical records revealed that Patient #3 had medical orders dated 1/29/13 that lacked time that the order was written. Staff D confirmed that this order lacked a time written.

On 1/29/13 from 1400 through 1630 a review of open medical records revealed that Patient #5 had medical orders dated 1/27/13, 1/28/13 and 1/29/13 that lacked time that the orders were written. Staff D confirmed that these orders lacked a time written.

On 1/29/13 from 1400 through 1630 a review of open medical records revealed that Patient #6 had medical orders dated 1/24/13, 1/25/13, 1/27/13, 1/26/13, and 1/29/13 that lacked time that these orders were written. Staff D confirmed that these orders lacked a time written.

On 1/29/13 from 1400 through 1630 a review of open medical records revealed that Patient #7 had medical orders dated 1/19/13, 1/20/13, 1/21/13, and 1/22/13 that lacked time that these orders were written. Staff D confirmed that these orders lacked a time written.

According to the Dickinson County Healthcare System's "Rules and Regulations of the Medical Staff" article iv, Orders, E. "verbal orders and/or telephone shall be signed by the person receiving such, along with the name of the physician. All verbal and/or telephone orders must be dated, timed and countersigned within twenty-four (24) hours."


29313

During medical record review on 1/30/13 at approximately 1400 it was found that patient #12 had the form, "Immediate Post Operative/Procedural Progress Notes", that was not completed, signed, dated or timed. On the form, "Pre-Op Orders", and "Post-Op Orders, ACU", the forms at the top states, "All Orders With a (box) Must Be Checked To Be Initiated", none of the boxes were checked to be completed on either form and the orders failed to have a time when the physician signed.

During medical record review on 1/30/13 at approximately 1430 it was found that patient #13 had the form, "Pre-Op Orders" the form at the top states, "All Orders With a (box) Must Be Checked To Be Initiated", not all of the boxes were checked to be completed on the form and the orders failed to have a time when the physician signed.

During medical record review on 1/30/13 at approximately 1500 it was found that patient #14 had the form, "Immediate Post Operative/Procedural Progress Notes", that was not dated or timed. On the form, "Pre & Post-Op ACU OB/GYN", the form at the top states, "All Orders With a (box) Must Be Checked To Be Initiated", not all of the boxes were checked to be completed on the form and the orders failed to have a date and time when the physician signed.

During an interview with staff H on 1/31/13 at approximately 0900, the medical records above were reviewed by staff H and these findings were confirmed.

Based on document review and interview, the facility failed to ensure that telephone and verbal orders were authenticated by the physician for three ( Patient #s 6, 7, and 24) of ten medical records reviewed resulting in the potential for medical errors and patient harm for all patients served by the facility. Findings include:

On 1/29/13 at approximately 1600 a review of medical record for Patient #6 revealed, "TORB" (telephone orders read back) on 1/25/13 and 1/26/13 that lacked authentication by the physician. This was confirmed by Staff D, who was asked what their policy was for authentication of verbal and telephone orders, who replied "they should have been signed by the doctor within twenty-four hours".

On 1/31/13 at approximately 1000 during record review for Patient #7 revealed "TORB" (telephone orders read back) on 1/21/13 and 1/22/13 that lacked authentication by the physician. This was confirmed by Staff A on 1/31/13 at approximately 1025.

According to the Dickinson County Healthcare System's "Rules and Regulations of the Medical Staff" article iv, Orders, E. "verbal orders and/or telephone shall be signed by the person receiving such, along with the name of the physician. All verbal and/or telephone orders must be dated, timed and countersigned within twenty-four (24) hours."


29955

On 1/29/2013 at approximately 11:40 am during medical record review, it was revealed orders were not verified and signed by the physician for one of one patients (patient #24). On 1/21/2013 the following verbal orders were not verified by the physician for patient #24:

1/21/2013 1800 IV fluids to keep vein open.
2115 Lasix 40 mg IV at midnight.
2140 Ok to give above Lasix now
Bipap per RT

1/22/2013 0930 Change general diet with decaf coffee
1200 Discontinue amiodarone drip
1350 Metoprolol ER 12.5 mg by mouth x 1 now
1500 Change to IMC status
EKG now

1/23/2013 1620 PT and INR now, If INR under 2 give 5 mg po coumadin
Schedule TEE with cardioversion in OR for Friday 1/25/2013
1730 Ok to give coumadin 5 mg with INR result of 2.05
Give Digoxin 250 mcg IV x 1 now

1/25/2013 0810 Esmolol 5 mcg/kg/min IV drip titrate to maintain heart rate less than 100 bpm
0855 Clarification Esmolol 50 mcg/kg/min IV drip titrate to maintain heart rate less than 100 bpm
1600 Fentanyl 50 mcg IVP x 1 now
Versed 1mg IVP x 1 now
Oxygen to maintain sats greater than 92% intaprocedure
EKG post cardioversion
1630 discontinue benadryl
discontinue haldol
discontinue morphine
Ativan 1mg IVP every 4 hours prn agitation
Fentanyl 25 mcg IVP every 4 hours for pain
Continue esmolol drip at 100 mcg/kg/min
If heart rate less than 60 bpm, titrate down

1/26/2013 0925 Ramazicon 0.2 mg IVP x 1 now Narcan 0.4 mg IVP x 1 now
0940 Discontinue restraints
1040 Ramazicon 0.2 mg IVP at 1100
Narcan 0.4. mg IVP at 1100
1245 Ramazicon 0.2 mg IVP at 1300
Narcan 0.4 mg IVP at 1300
1335 Xanax 1 mg po x 1 at 1700
1800 May titrate esmolol to maintain heart rate below 100 bpm
1920 Discontinue Advair

1/27/2013 1440 Increase amiodarone drip to 1 mg/min
Decrease esmolol to 100 mcg/min


An interview with staff C verified the findings on 1/29/2013 at 1155 am.

According to the Dickinson County Healthcare System's "Rules and Regulations of the Medical Staff" article iv, Orders, E. "verbal orders and/or telephone shall be signed by the person receiving such, along with the name of the physician. All verbal and/or telephone orders must be dated, timed and countersigned within twenty-four (24) hours." Staff C confirmed the rules and regulations were not followed.

Based on document review and interview the facility failed to ensure that 738 of 738 medical records were closed within 30 days of patients' discharge from the facility resulting in incomplete medical records.

On 1/30/2013 at approximately 3:30 pm during document review of open medical records it was revealed 738 medical records were open beyond 30 days. The document showed 152 records beyond 30 days, 93 records beyond 60 days, 38 records beyond 90 days, and 455 records beyond 120 days.

An interview with staff E on 1/30/2013 at approximately 3:45 pm was conducted. Staff E confirmed the number of open records and stated physicians were kept aware of open records and showed multiple attempts of communication.

According to the facility's "rules and regulations of the medical staff", article xii, completed medical record, d. "physician will be notified on a weekly basis on incomplete charts. Charts not completed within fourteen (14) days shall be considered delinquent. Physicians not completing charts with thirty (30) days shall have their admitting privileges suspended. Their admitting privileges will be reinstated immediately upon completion of their medical record."

When asked if privileges had been suspended for the physicians with outstanding records, Staff E responded "no".

Based on observation and interview the facility failed to ensure that outdated and unusable drugs and biologicals were not available for patient use. Findings include:

During the tour of the Emergency Department on 1/29/13 at approximately 1400 it was found that 5 bottles of Iodoform packing strips were open and once open the sterility is lost and can't be used on other patients. Staff J agreed and confirmed this finding.

During the tour of the Surgical Department on 1/30/13 during the hours of 0900-1200 the following was found:
Anesthesia Cart #3
1. One 1 ml single dose vial of Hydralazine in drawer for use on multiple patients, labeled as single use, the vial should be discarded after the procedure on that specific patient is completed
2. One 10 ml single dose bottle of Esmolol opened and in drawer for use on multiple patients, labeled as single use, the vial should be discarded after the procedure on that specific patient is completed

These findings were confirmed at the time of observation by staff G and H

Anesthesia Cart #4
1. One 10 milliliter (ml) vial of single dose sterile water opened and being used on multiple patients, labeled as single use, the vial should be discarded after the procedure on that specific patient is completed
2. One 6 ml syringe with 5 ml of Epinephrine with no date, time or initials on the label
3. One 1 ml single dose vial of Phenylephrine in the medication drawer to be used on multiple patients, labeled as single use, the vial should be discarded after the procedure on that specific patient is completed
4. One 10 ml bottle of Ketamine opened with no open/expiration date

Based on observation and interview, the facility failed to provide and maintain a safe environment for patients and staff. This is evidenced by the Life Safety Code deficiencies identified. See K-tags for results.

Based upon observation and interview with the Director of maintenance, the facility failed to maintain a safe hospital environment. Findings include:

1. During the tour of second floor at approximately 10:00 AM on 1/30/13 the housekeeping closet near the ICU was observed to have a water connection from the mop sink faucet to a chemical dispenser. There was a shutoff valve downstream of the atmospheric vacuum breaker (AVB) without benefit of a wasting tee or other arrangement to prevent damage to the AVB and subsequent possible backflow of hazardous chemicals into the hospital potable water supply which could harm all building occupants.

2. During the building tour of second floor at approximately 9:00 AM on 1/30/13, the clean supply room across from Room 259 had an accumulation of dust on the flat top of the storage unit.

3. During the building tour at approximately 11:00 AM on 1/30/13, the mold room had splattering of alloy on the walls and around the melting pot. Staff had not sufficiently cleaned the mold room of the debris from the alloy which could be hazardous.

Based upon observation during facity tour at 4:00 PM on 1/30/2013, the facility failed to provide appropriate ventilation. Findings include:

1. There was no discernible air flow between the Central Sterile Room and Decontamination room in the direction of clean to the "dirty" decontamination room.

2. The Central Sterile Room was under a net negative pressure to the corridor.

Based on observation and interview the facility failed to ensure that a sanitary environment is maintained to prevent and control infections of patients and personnel.
Findings include:


During the tour of the Surgical Department on 1/30/13 during the hours of 0900-1200 the following was found:
Anesthesia Cart #3:
1. One size 7.0 Endotracheal Tube (ET) opened with the syringe attached and placed on top of the cart

Anesthesia Cart #4:
1. One size 6.0 ET tube open with stylette and syringe in place on top of the cart
2. One size 6.5 ET tube open with stylette and syringe in place on top of the cart
3. One size 7.0 ET tube open with stylette and syringe in place on top of the cart
4. One size 7.0 ET tube open with stylette open and placed back in drawer of cart
5. Three tongue depressors that expired 3/2012
6. Three tongue depressors open in the drawer
7. Seven 22 gauge spinal needles that expired 10/2011
8. Seven 22 gauge spinal needles that expired 4/2012
9. Two 24 gauge intravenous catheters that expired 1/2011, 8/2010 respectively
10. One 16 gauge intravenous catheter that expired 2/2007

Pediatric Anesthesia Cart:
1. One pediatric size 4 ET tube open and placed back into the cart
2. One 10 french suction catheter open and placed back into the cart

Anesthesia Room Cart:
1. One size 7.0 ET tube open with the syringe and placed back into the cart drawer
2. One size 7.5 ET tube open with the syringe and placed back into the cart drawer

During the observational tour staff G and H confirmed these findings at the time of observation.


29774

On 1/29/13 at approximately 1105 during facility tour found in the soiled utility on the second floor, floor storage of two closed trash bags and one full trash bag stored on top of the covered bin. Additionally, under the hand hygiene sink, in the soiled utility room, found a large silver bucket with about three inches of turbid brown water accumulated, that was positioned under the pipes of the sink, which when water was turned on, leaked fluid into the bucket. The above observations were confirmed by Staff D, who said that "there should be nothing stored under the sink, I will let the facilities guys know about this". Regarding the accumulated trash bags, Staff D said "they should be picking up trash soon".

On 1/29/13 at approximately 1110 during facility tour found in the pediatric examination room a covered linen cart that had clean fitted bottom sheets that were spilling over onto the floor. Staff D was asked whether those sheets would be used for a patient to which she replied, "no, I am going to put these into the soiled linen cart".

On 1/30/13 at approximately 1045 during a tour of the off-site physical therapy facility found, in both treatment rooms, floor storage of patient care equipment and undersink storage of clean linen. This was confirmed by Staff F, who said that "we may need some shelving or additional cabinets (installed) for storage in these rooms, I will ask the landlord...".

An interview with Staff C on 1/31/13 between 0900 and 1000, regarding responsibilities to monitor infection control practices revealed that they "monitor hand hygiene, and do environmental rounds from time to time, but perhaps not often enough and not in the off-site rehab area".

Based on medical record review and interview the facility failed to ensure that a medical history and physical examination was completed and documented within 30 days before surgery in 1 out of 3 (#13) surgical medical records reviewed. Findings include:

During medical record review on 1/30/13 at approximately 1430 it was found that patient #13 had a surgical procedure on 1/30/13 and that the most current history and physical in patient #13's medical record was from 12/18/12, outside the required timeframe of the thirty-day requirement.
During an interview with staff H on 1/31/13 at approximately 0900, the medical records above were reviewed by staff H and no more current history and physical could be found and the findings were confirmed.