HospitalInspections.org

Based on document review and staff interview, it was determined the hospital failed to adequately investigate and subsequently resolve possible systemic problems in one (1) of four (4) grievances reviewed. This has the potential to adversely impact the hospital's grievance process if all components of a grievance are not adequately investigated. Findings include:

1. A grievance had been filed on behalf of patient #1 (via letter mailed to the hospital on 6/17/10). The hospital mailed a written notice of their findings to the complainant on 6/23/10. The letter to the complainant indicated the information in the grievance would be relayed to the Nurse Managers of the Emergency Department (ED) and the Fifth Floor for their review.

2. Review of the hospital's investigation indicated the Risk Manager had discussed the issues with the Nurse Manager of the 5th Floor, but there was no mention of any discussion with the Nurse Manager of the ED. The Risk Manager was not available for interview during the week of the survey.

3. The Director of Quality Resource Management was interviewed on 7/19/10 in the afternoon. She reviewed the Risk Manager's notes in the grievance file of patient #1 and agreed there was no indication the ED component of the grievance had been investigated.

4. The ED Nurse Manager was interviewed in the afternoon of 7/20/10. She said although she might have, she did not specifically recall reviewing patient #1's ED record at the request of the Risk Manager. She acknowledged she had no documentation indicating she had reviewed the ED record of patient #1 relative to a grievance.

5. The ED Staff Nurse who was mentioned in the grievance letter was interviewed in the late morning of 7/21/10. He said no one from the hospital had previously asked him anything about patient #1 relative to his remembrance of having cared for the patient. He said when he was interviewed by surveyors this was the first time anyone has asked him any questions about a complaint filed on behalf of patient #1.

Based on document review, medical record review and staff interview, it was determined the hospital failed to generate incident reports in two (2) of five (5) closed medical records reviewed (patient #1 and #4). This has the potential to cause unnecessary harm to the hospital's patients if all medical errors and adverse patient events are not being captured. Findings include:

1. The "Occurrence/Incident Reporting " policy (contained in the hospital's "Risk Management Plan") states (in part): "Any happening out of the ordinary which results in a potential for or actual injury to a patient, visitor, employee, or damage to facility property or reputation will be reported through completion of an occurrence/incident report."

2. Review of the medical record of patient #1 revealed a physician's order dated 6/3/10 at 1715 stating "Patient may take home seizure medications if brand name not available in pharmacy" and review of the Medication Administration Record (MAR) revealed a note stating "All seizure medications are at bedside. Patient cannot take generic. Must be brand name which are at bedside." However, staff cannot confirm whether patient did or did not receive his own home medications or the hospital's generics.

3. Review of the medical record of Patient #1 revealed on 6/3/10 the 0600 dose of Lamictal was documented as given at 1000 and the 1400 dose of Trileptal was documented as given at 1500.
Review of the medical record of Patient #4 revealed on 6/14/10 the 0600 dose of Nexium was documented as given at 0900. During an interview with the Chief Nursing Officer (CNO) in the afternoon of 7/21/10 the medical records were reviewed and the CNO agreed with the findings.

4. Review of the hospital's occurrence\incident reports for the month of June 2010 revealed no occurrence report had been filled out for patient #1 or patient #4.

5. The Nurse Manager of the 5th Floor was interviewed in the afternoon of 7/19/10. She said the alleged fall patient #1 said he had suffered, should have generated an occurrence/incident report.

Based on medical record review and staff interview, the hospital failed to ensure the nursing staff properly completes all medical record documentation when noting-off physician orders in nine (9) of ten (10) medical records (Patient #1, 3, 4, 5, 6, 7, 8, 9, 10) reviewed. This has the potential to negatively impact all patient care by not providing an accurate timeline of when orders were received and care provided. Findings include:

1. Review of the medical record for Patient #1 revealed documented evidence of nursing staff noting-off physician orders without a date and/or time a total of thirteen (13) times during admission 6/2/10 - 6/4/10 and no documented evidence of Admission Medication Orders on 6/2/10 and Discharge Orders on 6/6/10 being noted-off at all.

2. Review of the medical record for Patient #3 revealed documented evidence of nursing staff noting-off physician orders without a date and/or time a total of nine (9) times during admission 6/4/10 - 6/10/10, no documented evidence of a total of four (4) orders being noted-off at all and an order written on 6/7/10 without a time, signature or what type of order (telephone or verbal).

3. Review of the medical record for Patient #4 revealed documented evidence of nursing staff noting-off a 6/15/10 0730 physician order without a date and/or time and a 6/15/10 1830 physician order not noted-off until 2355.

4. Review of the medical record for Patient #5 revealed documented evidence of nursing staff noting-off physician orders without a date and/or time a total of nineteen (19) times during admission 6/14/10 - 6/25/10 and no documented evidence of a total of four (4) orders being noted-off at all.

5. During an interview with the Chief Nursing Officer (CNO) in the afternoon of 7/21/10, the above medical records were reviewed and the CNO agreed with the above findings.

6. Review of the medical record for Patient #6 in the afternoon of 7/21/10 revealed documented evidence of the nursing staff noting-off physician orders without a date and/or time a total of five (5) times since admission on 7/20/10.

7. Review of the medical record for Patient #7 in the afternoon of 7/21/10 revealed documented evidence of the nursing staff noting-off the 7/20/10 1820 order without a date and/or time.

8. Review of the medical record for Patient #8 in the afternoon of 7/21/10 revealed documented evidence of the nursing staff noting-off two (2) 7/20/10 physician orders without a date and/or time.

9. Review of the medical record for Patient #9 in the afternoon of 7/21/10 revealed documented evidence of the nursing staff noting-off physician orders without a date and/or time a total of three (3) times since admission on 7/20/10.

10. Review of the medical record for Patient #10 in the afternoon of 7/21/10 revealed documented evidence of the nursing staff noting-off physician orders without a date and/or time a total of eight (8) times since admission on 7/17/10 and no documented evidence of two (2) physician orders being noted-off at all.

11. During an interview with the Shift Coordinator (SC) in the afternoon of 7/21/10, the above medical records were reviewed and the SC agreed with the above findings.

Based on document review, medical record review and staff interview, the hospital failed to ensure the Emergency Department (ED) nursing staff follows hospital policy and obtains patients' lists of home medications during Triage in five (5) of five (5) closed medical records (Patient #1, 2, 3, 4, 5) reviewed. This has the potential to negatively impact all ED patient care by not providing all the necessary information for the physician to prescribe appropriate medications for treatment or to prevent an adverse reaction to prescribed medications. Findings include:

1. Logan Regional Medical Center Triage Policy, last revised 11/5/08, states in part "...A. Triage evaluation includes at minimum: ... 5. Current medication..."

2. Review of the medical record for Patient #1 revealed the patient was Triaged at 1031 with documentation of home medications at 1546.

3. Review of the medical record for Patient #2 revealed the patient was Triaged at 1200 with documentation of home medications at 2040.

4. Review of the medical record for Patient #3 revealed the patient was Triaged at 1230 with documentation of home medications at 1245.

5. Review of the medical record for Patient #4 revealed the patient was Triaged at 0333 with documentation of home medications at 0433.

6. Review of the medical record for Patient #5 revealed the patient was Triaged at 1330 with no documented evidence of the home medication list.

7. During an interview with the Chief Nursing Officer (CNO) in the afternoon of 7/21/10, the medical records were reviewed and the CNO agreed with the above findings.

Based on review of documents and interview the hospital failed to have less than one hundred (100) hospital beds. This makes the hospital ineligible for use of swing beds. Findings include:

1. During medical record review it was observed that the hospital is operating swing bed service. The hospital is licensed for one hundred forty (140) beds; this total numberof beds currently includes twelve (12) swing beds.

2. The facility has been providing the swing bed service since 12/2006 based on approval from the Centers for Medicare and Medicaid Services (CMS) Regional Office through a letter dated 1/29/07 and received by LRMC on 2/1/07.

3. During an interview with the Chief Nursing Officer (CNO) in the afternoon of 7/21/10 the CNO stated when the swing bed program was started, the Administration understood the CCU beds, OB/GYN beds, Recovery Room beds, Rehab Unit beds and Newborn Nursery beds could be deducted from the total number of beds which put the facility at ninety-nine (99) total beds.

4. The above findings were discussed and verified on 7/22/10 between the State Agency and Regional Office.