HospitalInspections.org

Based on interview and record review the hospital failed to ensure 1 of 4 Psychiatrists (ID# 4) promptly completed their medical records per Medical Rules and Regulations.

Findings include:

Record review of the Medical Rules and Regulations (no date) stated "Medical Records: 7. A discharge summary shall be completed by the attending physician within fifteen days after discharge of the patient. this summary shall be transcribed, signed and made a part of the patient's permanent medical record within thirty days of the discharge, at which time any deficiencies in the medical record shall have been completed..."

Record review of a document provided by the Health Information Director (ID# 16) titled "Physician Delinquencies" revealed Psychiatrist ID# 4 had 789 signatures that were delinquent greater than 90 days in closed records.

The Director for Heath Information Management (HIM) acknowledged that physician ID# 4 was delinquent on signatures. The HIM Director stated that physician ID# 4 has the highest admission rate at the hospital. The Director stated the hospital does not have a policy to suspend a physician related to delinquent medical records.

Based on observation, interview, and record review the facility failed to have systems in place to give a prompt accounting of all schedule 2, 3, and 5 drugs stored in the pharmacy. The facility failed to include inventory and reconciling of schedule drugs in their Pharmacy policy/procedure.

Findings:

Observation in the facility's pharmacy on 5/28/2013 at 9:45 am revealed that pharmacy stored multiple containers and packets of schedule drugs.

The Surveyor asked the Pharmacist to show documentation for Hydrocodone 5/500 milligram tablets that was stored in the pharmacy. The Pharmacist was unable to tell from record how many tablets were in the container or how many was received and dispensed and what the balance was.

During the interview on 5/28/2013 at 11:15 am with the Pharmacist Staff( #10) he stated he did not keep a perpetual inventory for any drug except for the C 4 drugs stored in the pharmacy.
According to the Pharmacist he had no perpetual inventory for any schedule drugs nor for the Class 2,3 and 5 drugs stored in the facility and no documentation of reconciliation of those drugs.
Staff (#10) stated he was not aware it was required for schedule drugs to be on inventory.

Observation and review of pharmacy records and policies revealed there was no systems in place to account for any of the more than 12 different types of schedule 2,3 and 5 drugs in multiple dosage forms stored in the facility from entry into the pharmacy through dispensing. There was no way to tell what was dispensed and what should be remaining.

Based on observation, interview and record review the facility failed to enforce their infection control policy to ensure staff wash their hands when contaminated and prior to handling patient medication. This failed practice had the potential for the spread of infection to all patients and staff. Citing two random observations staff #s (19, 25).

Findings:

Observation on 5/30/2013 at 2:10 pm on Unit 2 revealed Staff (25) RN was sitting at the desk in the nurses station handling patient's medical records. The Staff was coughing in the palm of her hands and continued her task without sanitizing her hands. Staff # (25) repeatedly cough in the palm of her hands, then took a bunch of keys to the medication room, handled the keys and handed then to another Nurse (# 11) who had observed the the hand contamination. The nurse took the keys and handled them for an extended period of time. Hand washing was not done by either staff nor sanitizing of the keys.

Further observation on Unit 2 revealed instructions posted with visuals on the proper way to cover your cough and sneeze and instructions to sanitize hands afterwards.

On 5/29/2013 at 9:15 am in the pharmacy Staff (19) Pharmacy Technician was seen going to the door to talk to someone with a pair of gloves on her hands. The staff went back to her station and was observed with the same pair of gloves sorting loose pills and containers. The Staff was sorting and packaging and moving from the clean preparation area to the storage area and back to the clean area with the same pair of gloves on. The Staff did not change gloves and wash her hands after moving from the storage area to the clean preparation area. The practice was repeated several times.

During an interview on 5/29/2013 at 9:35 am with Staff (10) Pharmacist he stated staff wear gloves to prevent contamination of the medication when sorting or packaging pills.

Review of the facility's hand hygiene policy dated February 2012 include the following information:

Hand hygiene is the cornerstone of our infection control program that plays an integral role in reducing and preventing cross transmission of nosocomial pathogens to susceptible patients. Hand hygiene compliance is an intervention designed to eliminate the spread of infection. Rational indications and techniques for hand hygiene will be identified.

Hand Hygiene is to be performed when contaminated hands are contaminated with proteinaceous material, or are visibly soiled with blood or other body fluids. Wash hands with either a non-antimicrobial soap and water or any antimicrobial soap and water."