HospitalInspections.org

Based on review of facility documentation, observation and employee interviews (EMP), it was determined that the facility failed to follow its policy to ensure each patient, or patient representative was informed of the patient's rights, in advance of furnishing or discontinuing care in four of five hospital satellite locations.

Findings include:

Review of the Grove City Medical Center Administrative policy 1.06, "Patient Bill of Rights and Responsibilities," reviewed June 2013, revealed, "... V. Procedure A. Distribution of Information 1. The Patient Bill of Rights shall be posted and available upon request at each Grove City Medical Center main points of entry." The revision date of the Patient Bill of Rights and Responsibilities attached to Policy 1.06 was 2011.

1. Tour of the Pine Medical lab draw station on August 8, 2013, at 2:15 PM, revealed no posting of the hospital Patient Bill of Rights and Responsibilities nor any visible pamphlets. When asked at that time if the Bill of Rights was posted, EMP37 said it "was" but was unable to produce it. EMP37 further stated, "I don't know what happened to it."

2. Tour of the Hillcrest Avenue Speech Therapy Clinic waiting room on August 8, 2013, at 2:35 PM, revealed no posting of the hospital Patient Bill of Rights and Responsibilities in the main entrance/waiting area.

On August 8, 2013, at 2:36 PM, EMP30 confirmed there was no posting of the Patient Bill of Rights and Responsibilities, stating, "You are right. They [Patient Bill of Rights and Responsibilities] aren't [posted]." When asked if copies were available for patients upon request, EMP30 stated, "No. No one ever gave them to me. I'll have to get some."

3. Tour of the Hillcrest Avenue blood draw waiting room on August 8, 2013, at 3:20 PM, revealed no posting of the hospital Patient Bill of Rights and Responsibilities.

On August 8, 2013, at 3:21 PM, EMP4 confirmed there was no posting of the Patient Bill of Rights and Responsibilities in the main entry/waiting area.

On August 8, 2013, at 3:23 PM, a copy of the Patient Bill of Rights and Responsibilities was observed on the blood draw room wall. The posting was noted to be a February 2003 version of the rights, not the 2011 revision, as attached to administrative policy 1.06.

On August 8, 2013, at 3:25 PM, EMP30 confirmed there were no other postings or copies of patient rights for distribution to patients, stating, "No. I can copy you this one."

4. Tour of the Wound Clinic satellite on August 9, 2013, at 1:55 PM, revealed no posting of the Patient Bill of Rights and Responsibilities in the waiting area.

On August 9, 2013, at 2:00 PM, EMP36 confirmed there was no posted Patient Bill of Rights and Responsibilities at the clinic. When asked for a copy of the Patient Bill of Rights and Responsibilities, EMP36 was unable to provide one stating, "We will get some."

Based on review of facility documentation and employee interviews (EMP), it was determined that the facility failed to provide written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for two of three grievances reviewed.

Findings include:

Review of the facility Patient Rights and Responsibilities, dated 2011, revealed, "Complaints, Concerns, and Questions: You and your family/guardian have the right to: ... Seek review of quality of care concerns, coverage decisions, and concerns about your discharge. Expect a timely response to your complaint or grievance from the hospital. ..."

Review of Grove City Medical Center administrative Policy 1.37, "Process for Managing Patient Grievances," reviewed July 19, 2013, revealed, "DEFINITION: a. Grievance: A concern that is expressed to the hospital by a patient, or the patient's representative, when an issue cannot be resolved promptly by staff present. ... TEXT: ... A written acknowledgement of the grievance will be sent within 7 days to the patient or his/her representative ... A written follow-up letter will be generated by the Vice President of Marketing and Public Relations to the patient or his/her representative within 10 days of the Patient Satisfaction Committee review, which will include the steps taken on behalf of the patient to investigate the grievance, as well as any corrective action taken to ensure process improvement, and contact information for key hospital manager(s) involved in the resolution process."
1. Review of facility documentation revealed a grievance filed June 11, 2013, by a family member of a patient, regarding concerns about care received by the patient. Additional review of materials related to the grievance revealed no documentation that any correspondence was sent to the family member [complainant].

On August 5, 2013, at 10:45 AM, EMP6 stated that the parent [complainant] was not a power of attorney (POA), so a letter was not sent. When asked how it was confirmed that the parent [complainant] was not a POA, EMP6 stated, "I'm not sure. We didn't reach out to [him/her]."

2. Review of facility documentation revealed a grievance filed March 4, 2013, by a patient representative regarding care issues from an inpatient stay. Additional review of materials related to the grievance revealed no documentation that the grievance was reviewed by the Patient Satisfaction Committee or that any correspondence was sent to the patient representative.

On August 5, 2013, at 10:46 AM, when asked if a letter was sent to the patient representative in response to the March 4, 2013, grievance, EMP6 stated, "No. There was not."

On August 5, 2013, at 10:50 AM, EMP2 confirmed that there was no documentation that the March 4, 2013, grievance was reviewed by the Patient Satisfaction Committee stating, "I would not have known about that one."

Based on review of facility documents and employee interviews (EMP), it was determined that the governing body, medical staff, and administrative officials failed to ensure an ongoing program for quality improvement regarding facility processes.

Findings include:

Review of the, "Performance Improvement Plan," revised July 2013, revealed, "E. Performance Improvement Goals The primary goal of the Performance Improvement Plan is to systematically and collaboratively plan, design, measure, assess and improve performance of hospital-wide key functions and processes relative to patient care ... E. Scope of Performance Improvement Activities 1. The scope of Grove City Medical Center's Performance Improvement Process includes an overall assessment of the effectiveness of performance improvement activities with a focus on continually improving care provided, and patient safety practices conducted, throughout the hospital ... F. Organization/Framework: ... Board of Directors 1. Role: -To serve as the ultimate authority for the quality of patient care provided throughout the hospital ... 3. Responsibilities: -To evaluate the effectiveness of the performance improvement activities performed throughout the hospital and the Performance Improvement Process as a whole. -To review and evaluate quality reports relevant to the activities and the mechanisms for monitoring, assessing and evaluating patient safety practices and the quality of patient care, for identifying and resolving problems and for identifying opportunities to improve patient care and services or performance throughout Grove City Medical Center ... Medical Executive Committee 1. Role: -With authority delegated by the Board of Directors, the medical staff shall strive to improve and assure the provision of quality patient care through the monitoring, assessment and evaluation of performance measurement and outcome ... 3. Responsibilities: -To ensure compliance with accreditation and regulatory agency requirements as applicable to the medical staff ... -To identify opportunities for performance improvement through medical staff monitoring activities and the medical staff performance improvement process. -To develop corrective action plans and monitor effectiveness of actions taken ..."

Review of policy MR 5.23, "Temporary Suspension of Hospital Privileges due to Medical Record Delinquency," originating May 1, 1998, reviewed October 25, 2012, revealed, "III. Policy: It is the policy of Grove City Medical Center, pursuant to the Bylaws of the Medical staff to temporarily suspend a physicians' elective admitting and elective surgical privileges, for failure to complete medical records in the 30 day time frame required by the Department of Health and the Bylaws of the Medical Staff. IV. Text: A. Physicians are required by the Department of Health and the Bylaws of the Medical Staff to complete medical records by the 30th day post discharge. 1. For a medical record to be deemed complete it must contain all necessary dictation, required signatures, and other documentation as appropriate ... D. Failure to complete medical records will result in automatic suspension of a physicians' elective admitting and elective surgical privileges in accordance with section 7.3.3 of the Medical Staff Bylaws. V. Procedure/Protocol: A. On Monday morning, the Medical Records Director will send each physician a notice listing in detail all deficient records 20 days or greater ... B. On the following Wednesday, the Medical Records Director will send notice to the physicians with medical records that are 28 days delinquent noting the physician has until the following Monday morning to complete the delinquent medical records. C. On the Monday morning, following the letter mentioned in 'B' above, the Notice of Temporary Suspension of Elective Admitting and Surgical Privileges will be issued jointly by the Chief Executive Officer and the Chief of the Medical Staff for any delinquent medical records greater than 30 days. The temporary suspension will be effective at 8:00 a.m. on that date ..."

Review of the March 28, 2011, "Medical Staff Bylaws, Rules & Regulations," Section 7.3.3, revealed, "Medical Records An automatic suspension of a practitioner's admitting privileges shall, after warning of delinquency, be imposed jointly by the Chief of Staff and CEO for failure to complete medical records in a timely fashion. Such suspension shall continue until such records are completed unless the practitioner satisfies the Chief of Staff and the CEO ... Grove City Medical Center Rules and Regulations ... 24 ... The medical record of each patient shall be completed by the thirtieth (30th) day following discharge of the patient from the hospital. Failure to do so shall result in a suspension of elective admitting, and elective surgical privileges until the medical record is completed. Suspension letters will be sent out after thirty days by the Chief of Staff ..."

1. Review of facility documentation on August 6, 2013, at approximately 11:45 AM, revealed that there were 115 medical records that were not completed as of August 6, 2013, that were over 30 days after the patients' discharges. Nine physicians were currently suspended from "elective" admissions and surgeries. Additional information revealed three physicians had medical records that were incomplete over 60 days (including CF11). The suspension of physicians prevented "elective admissions," only. For example, CF11 was suspended from elective admissions and surgeries between December 3, 2012, and June 6, 2013, but admitted 143 patients during that same time frame. CF11 currently is suspended, with 20 medical records over 30 days from date of discharge and four medical records over 60 days after discharge. When asked, at the time of the review, if CF11 had admitted any patients after the admitting privileges were suspended, EMP18 stated, "Yes. Only elective admissions are suspended."

2. Review of additional facility documentation revealed that periodically the Medical Executive Committee were made aware of the staff that were suspended and that even though there had been phone calls, faxes, and letters sent out several times, some physicians "chose to remain non-compliant with the Department of Health Regulations..."


3. Review of credential files for CF11, CF12, and CF13 (physicians with current medical record delinquencies over 60 days) on August 9, 2013, at approximately 11:45 AM, revealed the physicians had been on the medical staff since 1994 and 2001. Upon hiring and recredentialing, each physician signed statements that included, "In making this application for appointment to the medical staff of this hospital, I acknowledge that I have received and read the by-laws of the hospital ... and the bylaws, rules and regulations of the medical staff of this hospital ... I agree to be bound by the terms thereof if I am granted membership or clinical privileges ... I further agree to abide by such hospital and staff rules and regulations as may be from time to time enacted ..."

4. Interview on August 9, 2013, at approximately 12:00 PM, with EMP1, when asked if it was possible, for example, a physician's documentation would be incomplete 27 days after discharge on Wednesday, would not receive a 28 day notice until the following Wednesday, when the record was 34 days after discharge, and the physician was not suspended until the following Monday (39 days after patient discharge) was correct, EMP1 agreed. When asked if the medical staff rules and regulations were effective for completion of medical records within 30 days, EMP1 confirmed that they were not and that, "most patients [admitted under a physician that was suspended] would come through the ED, so they would not be elective [admissions]." EMP1 further confirmed that wording of the Medical Staff Bylaws, Rules & Regulations and the Medical Records policy do not agree (one noting admissions suspended and one noting elective admissions being suspended) and that physicians were being suspended at 6:00 PM rather than 8:00 AM which was required by policy.

5. On August 9, 2013, at 2:50 PM, EMP2 confirmed there was currently no quality monitoring of the medical records delinquency or delinquency process.

Based on review of facility documents and medical records (MR), and employee interviews (EMP), it was determined that the facility failed to ensure that all orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner for 12 of 18 MR (MR1, MR2, MR6, MR8, MR9, MR10, MR11, MR12, MR13, MR15, MR18, and MR28).

Findings include:

Review of the "Grove City Medical Center, ... Medical Staff Bylaws, Rules, & Regulations, Fair Hearing Plan," reviewed March 28, 2011, revealed, "... Rules and Regulations ... C. Medical Records ... 5. The attending physician shall countersign all orders, ... when they have been recorded by an intern, resident physician or physician's assistant. ... 9. All clinical entries in the patients [sic] medical record shall be accurately dated and authenticated. ... D. General Conduct of Care 1. All orders for treatment shall be in writing. ... All orders dictated over the telephone shall be dictated by the practitioner and shall be signed by the appropriately authorized person to whom dictated with the name of the practitioner per his or her own name. The responsible practitioner shall authenticate such order within twenty-four hours ... ."

Review of Policy ADMIN. 5.26, "Medical Record Documentation Guidelines," reviewed/revised November 2012, revealed, "... IV. Text: ... A. Legal Documentation Guidelines ... 3. Date and Time of Entries: Every entry in the medical record must include a complete date - month, day and year and have a time associated with in. ..."

Review of Policy ADMIN 5.45, "Physician Orders," reviewed July 2009, revealed, "... IV. Text: ... C. Standard Procedure for Recording on the Physician's Order Sheet: ... 3. Enter the time order was received and reduced to writing. ... 5. The physician must sign all verbal or telephone orders at the earliest possible time, not to exceed 24 hours. The physician will date the order when it is signed off. ..."

Review of Policy NURS 4.0; PHARM 3.10, "Medication Administration - General Principles," revised January 2012, revealed, "... V. Procedure/Protocol: A. Medication Orders ... 2. All medication orders must include the date and time, ... ."

1. Review of MR1, on August 6, 2013, at approximately 11:00 AM, "Physician's Orders," revealed three orders written by physicians on May 12, 2013, May 15, 2013, and May 16, 2013, which did not have the time of the order documented.

Further review of the "Physician's Orders," revealed telephone and/or verbal orders taken on May 12, 2013, at 1:10 PM; May 13, 2013, at 11:20 AM; May 13, 2013, at 1:30 PM; May 16, 2013, at 6:00 PM; and May 16, 2013, at 12:05 PM, which did not have dates and/or times of the physicians' counter signature documented.

Additional review revealed a telephone order taken on May 12, 2013, at 1:10 PM, which did not have a physician counter signature.

Review of the "Medication Reconciliation Report," did not reveal a time of the physician's signature for the form on May 16, 2013.

At approximately 1:45 PM on August 9, 2013, EMP2 confirmed the above findings.

2. Review of MR2, on August 6, 2013, at approximately 11:50 AM, "Physician's Orders," revealed an order titled, "Standing Orders for Telemetry/ICU/Chest Pain;" an order from March 22, 2013; an automatic stop reorder for Zosyn; and an order written on March 27, 2013, with no documentation of the time of the order.

Further review of the "Physician's Orders," revealed telephone and/or verbal orders taken on March 20, 2013, at 9:35 AM; March 20, 2013, at 11:55 AM; March 21, 2013, at 8:15 AM; March 21, 2013, at 11:10 AM; March 21, 2013, at 12:10 PM; March 22, 2013, which was untimed upon receipt; March 22, 2013, at 1:30 PM; March 23, 2013, at 10:30 AM; March 25, 2013, at 7:35 PM; March 27, 2013, at 12:10 AM; March 26, 2013, at 5:04 PM; March 26, 2013, at 11:43 PM; March 27, 2013, which was untimed upon receipt; March 27, 2013, at 1:56 AM; March 27, 2013, at 9:50 AM; March 27, 2013, at 9:55 AM; March 27, 2013, at 6:25 PM; March 27, 2013, at 10:50 PM; March 28, 2013, at 11:45 AM; March 28, 2013, at 9:20 AM; March 28, 2013, at 11:30 AM; March 28, 2013, at 11:40 AM; March 28, 2013, at 2:00 PM; March 28, 2013, at 4:00 PM; March 29, 2013, at 9:15 AM; and March 29, 2013, at 10:30 AM. Review of the documentation of the counter signatures for the identified telephone and/or verbal orders did not reveal documentation of date and/or time.

Review of "Physician's Orders," revealed entries by the physician's assistant on March 21, 2013, at 7:00 AM; March 21, 2013, at 7:15 AM; March 21, 2013, at 8:15 AM; and March 25, 2013, at 7:30 AM, which were counter signed by the physician without documentation of the date and time of the counter signature.

At approximately 1:46 PM on August 9, 2013, EMP2 confirmed the above findings.

3. Review of MR6, on August 6, 2013, at approximately 3:10 PM, "Physician's Orders," revealed an order written by the physician on August 4, 2013, which did not have documentation of the time of the order.

Review of "Physician's Orders," revealed telephone and/or verbal orders taken on August 5, 2013, at 11:20 AM; August 6, 2013, at 6:45 AM; August 5, 2013, at 11:30 PM; August 5, 2013, at 12:57 PM; and August 4, 2013, at 3:08 PM. Review of the documentation of the counter signatures for the identified telephone and/or verbal orders did not reveal documentation of date and/or time of the counter signatures.

Review of "Physician's Orders," revealed an entry by the physician's assistant on August 5, 2013, at 8:30 AM, which was not counter signed by the physician.

At approximately 1:47 PM on August 9, 2013, EMP2 confirmed the above findings.

4. Review of MR8, on August 6, 2013, at approximately 1:30 PM, revealed Emergency Department Physician Orders that were signed and not dated or timed.

5. Review of MR9, on August 6, 2013, at approximately 2:00 PM, revealed Emergency Department Physician Orders that were signed and not dated or timed.

6. Review of MR10, on August 6, 2013, at approximately 2:20 PM, revealed Emergency Department Physician Orders that were signed and not dated or timed.

7. Review of MR11, on August 6, 2013, at approximately 2:45 PM, revealed Emergency Department Physician Orders that were signed and not dated or timed.

8. Review of MR12, on August 6, 2013, at approximately 2:50 PM, revealed Emergency Department Physician Orders that were signed and not dated or timed.

On August 9, 2013, at approximately 2:45 PM, EMP2 confirmed the missing dates and times of signatures on MR8, MR9, MR10, MR11, and MR12.

9. Review of MR13, on August 7, 2013, at approximately 10:30 AM, revealed telephone and/or verbal orders taken on August 6, 2013, at 6:00 PM; August 7, 2013, at 8:20 AM; and August 6, 2013, at 5:05 PM. Review of the documentation of the counter signatures for the identified telephone and/or verbal orders did not reveal documentation of date and/or time of the counter signatures.

At approximately 1:48 PM on August 9, 2013, EMP2 confirmed the above findings.

10. Review of MR15, on August 7, 2013, at approximately 11:22 AM, "Medication Reconciliation," revealed the order to have been implemented on June 3, 2013. Review of the documentation did not reveal a time of the physician signature.

Review of "Physician's Orders," revealed orders on June 3, 2013, at 3:00 PM; June 4, 2013, at 9:00 AM; and an undated CHF documentation tool, which did not have documentation of date and/or time of the physician signatures.

Review of "Physician's Orders," revealed telephone and/or verbal orders taken on June 3, 2013, at 5:26 PM; June 4, 2013, at 8:18 AM; June 4, 2013, at 1:30 PM; June 4, 2013, at 1:45 PM; and "Medication Reconciliation Report," from June 4, 2013, at 8:17 AM, which did not have dates and/or times of the physician counter signatures.

At approximately 1:50 PM on August 9, 2013, EMP2 confirmed the above findings.

11. Review of MR18, on August 7, 2013, at approximately 1:30 PM, revealed a "Medication Reconciliation," from March 10, 2013, which did not have a time of the physician signature.

Review of the "Physician's Orders," revealed telephone and/or verbal orders taken on March 10, 2013, at 3:05 PM; and March 11, 2013, at 2:50 AM. Review of the documentation did not reveal a time of the physician signatures.

Review of the "Emergency Department Physician Orders," did not reveal a date and time of the entry.

At approximately 1:51 PM on August 9, 2013, EMP2 confirmed the above findings.

12. Review of MR28, on on August 7, 2013, at approximately 3:00 PM, revealed a verbal order on August 6, 2013, at 12:30 AM, that was signed by the physician but did not include the date and time of the physician's signature. A telephone order on August 6, 2013, at 1:35 AM, was not yet signed by the physician. The lack of documentation was confirmed by EMP2 on August 9, 2013, at approximately 2:00 PM.



*Cross Reference With: 482.24 (c) (1) (iii) Verbal Orders Authenticated Based on Law

Based on review of facility documents and medical records (MR), and employee interviews (EMP), it was determined that the facility failed to ensure that all verbal orders must be authenticated based upon Federal and State law for 7 of 18 MR (MR1, MR2, MR6, MR13, MR15, MR18, and MR28).

Findings include:

Review of the "Grove City Medical Center, ... Medical Staff Bylaws, Rules, & Regulations, Fair Hearing Plan," reviewed March 28, 2011, revealed, "... Rules and Regulations ... D. General Conduct of Care 1. ... All orders dictated over the telephone shall be dictated by the practitioner and shall be signed by the appropriately authorized person to whom dictated with the name of the practitioner per his or her own name. The responsible practitioner shall authenticate such order within twenty-four hours ... ."

Review of Policy ADMIN 5.45, "Physician Orders," reviewed July 2009, revealed, "... IV. Text: ... C. Standard Procedure for Recording on the Physician's Order Sheet: ... 3. Enter the time order was received and reduced to writing. ... 5. The physician must sign all verbal or telephone orders at the earliest possible time, not to exceed 24 hours. The physician will date the order when it is signed off. ..."

Review of Policy NURS 4.0; PHARM 3.10, "Medication Administration - General Principles," revised January 2012, revealed, "... V. Procedure/Protocol: A. Medication Orders ... 2. All medication orders must include the date and time, ... ."

1. Review of MR1, on August 6, 2013, at approximately 11:00 AM, "Physician's Orders," revealed telephone and/or verbal orders taken on May 12, 2013, at 1:10 PM; May 13, 2013, at 11:20 AM; May 13, 2013, at 1:30 PM; May 16, 2013, at 6:00 PM; and May 16, 2013, at 12:05 PM, which did not have dates and/or times of the physicians' counter signature documented.

Additional review revealed a telephone order taken on May 12, 2013, at 1:10 PM, which did not have a physician counter signature.

At approximately 1:45 PM on August 9, 2013, EMP2 confirmed the above findings.

2. Review of MR2, on August 6, 2013, at approximately 11:50 AM, "Physician's Orders," revealed telephone and/or verbal orders taken on March 20, 2013, at 9:35 AM; March 20, 2013, at 11:55 AM; March 21, 2013, at 8:15 AM; March 21, 2013, at 11:10 AM; March 21, 2013, at 12:10 PM; March 22, 2013, which was untimed upon receipt; March 22, 2013, at 1:30 PM; March 23, 2013, at 10:30 AM; March 25, 2013, at 7:35 PM; March 27, 2013, at 12:10 AM; March 26, 2013, at 5:04 PM; March 26, 2013, at 11:43 PM; March 27, 2013, which was untimed upon receipt; March 27, 2013, at 1:56 AM; March 27, 2013, at 9:50 AM; March 27, 2013, at 9:55 AM; March 27, 2013, at 6:25 PM; March 27, 2013, at 10:50 PM; March 28, 2013, at 11:45 AM; March 28, 2013, at 9:20 AM; March 28, 2013, at 11:30 AM; March 28, 2013, at 11:40 AM; March 28, 2013, at 2:00 PM; March 28, 2013, at 4:00 PM; March 29, 2013, at 9:15 AM; and March 29, 2013, at 10:30 AM. Review of the documentation of the counter signatures for the identified telephone and/or verbal orders did not reveal documentation of date and/or time.

At approximately 1:46 PM on August 9, 2013, EMP2 confirmed the above findings.

3. Review of MR6, on August 6, 2013, at approximately 3:10 PM, "Physician's Orders," revealed telephone and/or verbal orders taken on August 5, 2013, at 11:20 AM; August 6, 2013, at 6:45 AM; August 5, 2013, at 11:30 PM; August 5, 2013, at 12:57 PM; and August 4, 2013, at 3:08 PM. Review of the documentation of the counter signatures for the identified telephone and/or verbal orders did not reveal documentation of date and/or time of the counter signatures.

At approximately 1:47 PM on August 9, 2013, EMP2 confirmed the above findings.

4. Review of MR13, on August 7, 2013, at approximately 10:30 AM, revealed telephone and/or verbal orders taken on August 6, 2013, at 6:00 PM; August 7, 2013, at 8:20 AM; and August 6, 2013, at 5:05 PM. Review of the documentation of the counter signatures for the identified telephone and/or verbal orders did not reveal documentation of date and/or time of the counter signatures.

At approximately 1:48 PM on August 9, 2013, EMP2 confirmed the above findings.

5. Review of MR15, on August 7, 2013, at approximately 11:22 AM, "Physician's Orders," revealed telephone and/or verbal orders taken on June 3, 2013, at 5:26 PM; June 4, 2013, at 8:18 AM; June 4, 2013, at 1:30 PM; June 4, 2013, at 1:45 PM; and "Medication Reconciliation Report," from June 4, 2013, at 8:17 AM, which did not have dates and/or times of the physician counter signatures.

At approximately 1:50 PM on August 9, 2013, EMP2 confirmed the above findings.

6. Review of MR18, on August 7, 2013, at approximately 1:30 PM, "Physician's Orders," revealed telephone and/or verbal orders taken on March 10, 2013, at 3:05 PM; and March 11, 2013, at 2:50 AM. Review of the documentation did not reveal a time of the physician signatures.

At approximately 1:51 PM on August 9, 2013, EMP2 confirmed the above findings.

7. Review of MR28, on on August 7, 2013, at approximately 3:00 PM, revealed a verbal order on August 6, at 12:30 AM, that was signed by the physician but did not include the date and time of the physician's signature. A telephone order on August 6, 2013, at 1:35 AM, was not yet signed by the physician. The lack of documentation was confirmed by EMP2 on August 9, 2013, at approximately 2:00 PM.



*Cross Reference With: 482.24 (c) (1) Orders Dated and Signed

Based on observation and employee interviews (EMP), it was determined that the facility failed to lock and secure a mobile medication cart in the pain clinic area.

Findings include:

Review of facility policy RX MM 02-021, "Storage of Medications in Patient Care Areas," reviewed July 2013, revealed, "PROCEDURE General Medication Storage Requirements for Patient Care Areas ... Medications that are not securely locked must be under constant surveillance. Mobile nursing medication carts, anesthesia carts, epidural carts and other medication carts containing drugs or biologicals are locked in a secure area when not in use or under surveillance."

1. Tour of the facility pain management area on August 7, 2013, at 10:40 AM, revealed an unattended, open, and unlocked room containing an unlocked medication cart. Five ampules of lidocaine and three ampules of Sensorcaine were observed on top of the cart. The storage drawers of the cart were unlocked with the key remaining in the lock. The drawers contained multiple doses of depo-medrol and Kenalog. A pad of blank prescriptions were also included in the unlocked drawer.

On August 7, 2013, at 10:45 AM, EMP22 confirmed that the medications and prescription pad were unlocked and unattended stating, "It's locked when there is no pain clinic."

On August 8, 2013, at 10:46 AM, EMP20 confirmed the medications and prescription pad were unlocked and unattended stating, "It all [medication room and medication cart] should have been locked."

Based on review of facility documentation and medical records (MR), and employee interview (EMP), it was determined that the facility failed to follow established policies and procedures to reduce the risk of fire associated with alcohol based skin preparations for five of five peripheral catheter diagnostic procedures (MR19, MR20, MR21, MR22 and MR23).

Findings include:

Review of an exception letter dated May 1, 2007, revealed the facility was granted an exception to 28 PA. Code 123.25(2) regulation to regulations for control of anesthetic explosion hazards. The letter revealed, "You have completed the process established by the department for requesting an exception to this regulation and agreed to the following: ... The facility shall ensure the skin preparation solutions, that contain combustible agents, do not soak into the patient's hair or linens. The facility shall ensure the skin preparation solution is completely dry prior to draping and shall inspect the prepped area to confirm it is dry prior to draping. The facility shall document in the patient's medical record that the above has occurred prior to the surgical procedure."

Review of policy SSD 3.34 "Use of Alcohol-Based Antiseptic Solutions (Example: DuraPrep)" revealed, "A. Alcohol-based antiseptic solutions are skin preparations that are used on patients to prepare the skin prior to procedures ... B. Although these agents have benefits in reducing risk of surgical site infection, they increase the risk of surgical fire... E. After applying solution: 1. To reduce risk of fire, wait until solution is completely dry (generally 3 minutes on skin.) ... 1. A second 'time out' will be used to verify the prepped skin site is dry ... 2. Document in the OR record that this has been verified..."

Review of facility Policy M.I. 1.12, "Infection Control in Medical Imaging Department," revised January 2012, revealed, "B. Invasive Procedures ... 2. Site preparation ... g. Chlorhexidine gluconate containing scrub shall be performed for a minimum of 30 seconds. ... Allow to air dry for 3 minutes. ... h. Isopropyl alcohol scrub ... Allow to air dry for 3 minutes. ..."

1. Review of MR19 revealed a procedural report dated August 7, 2013, "Right groin was prepped with ChloraPrep then draped in usual sterile fashion." Further review of MR19 revealed no documentation that the prepped area was inspected to ensure the solution was dry prior to draping.

2. Review of MR20 revealed a procedural report dated June 28, 2013, "Right groin was prepped with Chloraprep-prep then draped in usual sterile fashion." Further review of MR20 revealed no documentation that the prepped area was inspected to ensure the solution was dry prior to draping.

3. Review of MR21 revealed a procedural report dated June 28, 2013, "Left groin was prepped with Chloraprep-prep then draped in usual sterile fashion." Further review of MR21 revealed no documentation that the prepped area was inspected to ensure the solution was dry prior to draping.

4. Review of MR22 revealed a procedural report dated June 27, 2013, "Right groin was prepped with Chloraprep-prep then draped in the usual sterile fashion." Further review of MR22 revealed no documentation that the prepped area was inspected to ensure the solution was dry prior to draping.

5. Review of MR23 revealed a procedural report dated June 27, 2013, "Right groin was prepped with Chloraprep-prep then draped in the usual sterile fashion." Further review of MR23 revealed no documentation that the prepped area was inspected to ensure the solution was dry prior to draping.

6. On August 8, 2013, at 10:00 AM, EMP23 confirmed that MR19, MR20, MR21, MR22, and MR23 had no documentation that the prepped area was inspected to ensure the solution was dry prior to draping. EMP23 stated, "We don't (document inspection of drying of solution prior to draping). We document its use but not the rest."