HospitalInspections.org

I. Based on review of contracted services, medical record review and interview with the CNO, the government body failed to ensure contracted agreements complied with standards of services as evidenced by not addressing the time frames in the agreement for the delivery of blood to the surgical hospital that resulted in the nurse administering blood to 1 of 1 patients (patient #7) in a total sample of 39 eleven hours and 10 minutes after the order for blood was taken off by the nurse. Finding:

Review of the closed medical record revealed patient #7 was a 69 year- old who was admitted on 11/11/2011 with the chief complaint of osteoarthritis in the right knee. Further review revealed on 11/11/2011 a right total knee arthroplasty was performed.

Review of a physician orders dated 11/12/2011 (no time documented by the physician) revealed an order to transfuse 2 units of packed red blood cells (PRBC). Further documentation revealed this order was signed off at 1:00 PM on 11/12/2011. Review of the blood administration record revealed the nurse administered the first unit of PRBC at 11/13/2011 at 12:10 AM (11 hours and 10 minutes after the order was taken off by the nurse).

Review of the contracted agreement with a blood center failed to address frames for the delivery of blood to the surgical hospital. In a face to face interview on 01/05/2012 at 1:00 PM S1 CNO confirmed that the hospital's contract with a blood center did not stipulate times for providing blood for the hospital. She also confirmed that the blood should have been administered sooner than 11 hours.


II. Based on review of contracted services, and interview with S15, CEO (Chief Executive Officer), the government body failed to adhere to the contracted agreement between the hospital and S16, RHIA (Registered Health Information Administrator) by not providing documented evidence that the contractor provided services addressed within the contract. Findings:

Review of the contracted agreement between Fairway Medical Surgical Hospital revealed the S16, RHIA, signed the agreement on 9/28/2009 and the S15 CEO signed the agreement on 9/22/2009. Further review revealed the quarterly duties of the RHIA was to "review 15 charts for completeness and to ensure that policies and procedures are being followed. Following this review, a consultation meeting will be scheduled with the Chief Financial Officer and Business Office Manager to discuss the findings. A written report of the review finds will be presented to the Chief Financial Officer and Business Office Manager. This is estimated at 3 hours per quarter". Fairway Medical Surgical Hospital failed to provide the survey team with documentation proving that S16 was providing over site of the medical records department.

In a face to face interview on 01/05/12 at 4:11 PM S15 CEO (Chief Executive Officer) indicated the hospital had a contract for medical record services with S16 but she has been gone for 4 or 5 months. He further stated that as of 12/11/2011 the medical records department is being supervised by S17 RHIT (Registered Health Information Technician).

Review of the RHIT's contract with Fairway Medical Surgical Hospital revealed S15 CEO signed the agreement on 12/01/2011 and S17 RHIT signed the agreement on 1/05/2012 (during this validation survey).

Based on record review and interview the hospital failed to follow their policy for providing a written notice of its decision as evidenced by written correspondence to a patient which failed to include the final result of the grievance or the date of grievance completion for 1 of 1 reviewed grievances (R1). Findings:

Review of the letter from the hospital to Random Patient R1 dated 08/31/11 revealed the action taken on her (R1) behalf was to share the concerns with the appropriate managers and the Chief Clinical Officer. Further the events of her care would be presented to the Medical Executive Committee for review and recommendation (no dates documented as to the date).

In a face to face interview on 01/05/12 at 4:00pm RN S17 Director of Quality Management indicated she felt the letter included the actions taken. Further S17 indicated that because the patient told the nurse she (R1) did not want to be contacted, S17 felt the patient should contact the facility to initiate any further action.

Review of the Grievance Log for 2011 revealed a grievance submitted on 08/30/11(via the follow-up post-op phone call) by Random Patient R1 revealed she (R1) was upset after not being able to produce a urine sample for a pregnancy test on the day of surgery, having to have her surgery delayed to receive additional intravenous fluids and then having to experience an in and out catherization to obtain the specimen.

Based on record review and interview the hospital failed to follow their policy and procedure for informed consents as evidenced by consents without documentation of the name of the surgeon authorized to perform the procedure, therapeutic alternatives and the risks of such alternatives and/or the condition/diagnosis for which the procedure was being performed for 4 of 39 sampled medical records (#1, #3, #5, #6). Findings:

Patient #1
Review of the Informed Consent for Treatment form dated 11/22/11 revealed Patient #1 had a Left Knee Arthroscopy. Further review revealed no documented evidence Patient #1 was informed of the name of the physician authorized to perform the procedure.

Patient #3
Review of the Informed Consent for Treatment form revealed Patient #3 had a Colonoscopy/ Ileoscopy performed on 01/03/12. Further review revealed no documented evidence Patient #3 was informed of the condition and/or diagnosis for which the procedure was being performed or the name of the physician authorized to perform the procedure.

Patient #5
Review of the Informed Consent for Treatment form revealed Patient #5 had a Right Pytosis Repair performed on 12/14/11. Further review revealed no documented evidence Patient #5 was informed of the therapeutic alternatives, the risks associated with such alternatives, or the name of the physician authorized to perform the procedure.

Patient #6
Review of the Informed Consent for Treatment form revealed Patient #6 had an Esophagogastroduodenoscopy on 11/30/11. Further review revealed no documented evidence Patient #6 was informed of the condition and/or diagnosis for which the procedure was being performed or the name of the physician authorized to perform the procedure.

In a face to face interview on 01/04/12 at 10:30am RN S1 Chief Nursing Officer indicated most of the consents are sent from the physicians' offices and are not witnessed by the hospital staff.

Review of the Medical Staff Rules and Regulations last reviewed 01/22/10 and submitted as the ones currently in use, revealed.... " G. Informed Consents: The attending physician, or procedure list is responsible for providing the patient with all information regarding the proposed treatment or procedure necessary for the patient to understand the risks and potential benefits of the proposed treatment or procedure in order to be able to make an informed decision, for documenting the informed consent discussion, and for obtaining the patient's signature on consent forms".

Based on record review and interview the hospital failed to follow their policy on prevention of abuse/neglect as evidenced by failing to perform background checks on all employees hired for 2 of 2 employee files reviewed (#4, #6). Findings:

Review of the personnel files for Housekeeper S4 (Date of Hire 06/11/09), Pharmacy Facilitator S6 and Operating Room Tech S11 (Date of Hire 09/18/06) revealed no documented evidence a background check was performed prior to being hired.

In a face to face interview on 01/04/12 at 3:00pm S1 Chief Nursing Officer verified background checks for criminal records are not presently being performed on newly hired employees. Further S1 indicated the Human Resources Department was in the process of revising the hiring process to include criminal background checks; however the checks (criminal background) would apply only to those employees whose job description included handling of money.

Review of the policy titles "Abuse, Neglect or Exploitation" last reviewed 08/10/11 and submitted as the one currently in use, revealed.... "Screen: Persons with a criminal record of abuse or neglect should not be hired or retained as employees".

Based on record review and interview the hospital failed to ensure a complete history and physical was performed on all patients before having a surgical procedure for 3 of 39 sampled medical records (#1, #3, #6). Findings:


Patient #1
Review of the medical record for Patient #1 revealed a 65 year old female admitted to the hospital on 01/03/12 for a left arthroscopy and repair of a left medial meniscus tear under general anesthesia. Further review of the medical record revealed Patient #1 had a history of obesity, increased cholesterol and hypertension.

Review of the History and Physical for Patient #1 dated/timed 01/03/12 at 7:00am revealed no documentation a physical examination was performed as evidenced by blanks left next to the lines for the assessment of Mental Illness, HEENT (head, eyes, ears, nose, throat), heart, lungs, abdomen, neuro and airway exam.


Patient #3
Review of the medical record for Patient #3 revealed a 71 year old female admitted to the hospital on 01/03/12 for Colonoscopy/Ileoscopy under IV (Intravenous) conscious sedation.
Further review of the medical record revealed Patient #3 had a history of diarrhea, weight loss and COPD (chronic obstructive pulmonary disease).

Review of the History and Physical for Patient #3 dated/timed 01/03/12 at 7:30am revealed no documented evidence a physical examination pertinent to the chief complaint was performed or an admitting diagnosis was determined and documented.


Patient #6
Review of the medical record for Patient #6 revealed a 61 year old female admitted to the hospital on 12/13/11 for a Total Knee Arthoscopy Revision under general anesthesia.

Review of the History and Physical for Patient #6 dated/timed 01/03/12 at 11:00am revealed no documented evidence a physical examination pertinent to the chief complaint was performed or an admitting diagnosis was determined and documented.

In a face to face interview on 01/04/12 at 10:30am RN S1 Chief Nursing Officer indicated physicians not completing History and Physicals are an ongoing problem.

Review of the Medical Staff Rules and Regulations last revised 01/22/10 and submitted as the one currently in use, revealed.... C. History and Physical (H&P) 1. Content of the H&P: a. Patient's name; b. Patient's medical number; c. Dictating physician; d. Attending physician; e. Date; f. Chief Complaint; g. Allergies; i. Detail of Present Illness; j. Inventory of Body Systems; k. Physician Examination (Vital Signs, General Description, HEENT, Chest and Lungs, Heart, Abdomen, Extremities, Neurological); l. Impression; m. Plan; n. Signature of Attending Physician.

Based on record review and interview the hospital failed to: 1) follow their policy and procedure for assessing and reassessing patients with a change in condition (#3, #6) for 2 of 2 medical records reviewed for a change in condition out of a total sample of 39 medical records; 2) follow the sliding scale for administration of insulin (#3) for 1 of 1 patients with an elevated blood sugar out of 39 totaal sampled medical records; and 3) failed to ensure the duties related to the stocking, storage, wastage, monitoring of medications and identification of patients' home medications was not delegated to an unlicensed staff member as evidenced by the RN delegating those duties to an employee with the title of Pharmacy Facilitator and the job duties of a licensed Pharmacy Tech. Findings:

1) follow their policy and procedure for assessing and reassessing patients with a change in condition
Patient #3
Review of the medical record for Patient #3 revealed a 71 year old female admitted to the hospital on 01/03/12 for a Colonoscopy/Ileoscopy. Further review revealed Patient #3 had a history of COPD (chronic obstructive pulmonary disease).

Review of the "Hand-Off Communication" used to document the pre-op stay of Patient #3 dated/timed 01/03/12 at 0615 (6:15 am) revealed....... "BP (blood pressure) 111/68, SAO2 (oxygen saturation) 88%, Pulse 88, Resp (respirations) 18 and Temp (temperature) 97.9 degrees Fahrenheit, Comments - Registered high as 95% low as 74%". Review of the medication section revealed Patient #3 received Xopenex 1.25 mg Resp. (respiratory) TX (treatment) as ordered at 0625 (6:25 am). Further review revealed no documented evidence an assessment of the patient's respiratory status including an assessment of the patient's lung fields had been performed.

Patient #6
Review of the medical record for Patient #6 revealed a 61 year old male admitted to the hospital on 11/30/11 for an Esophagogastroduodenoscopy. Review of the History & Physical dated 11/30/11 at 11:00 am revealed Patient #6 had no previous history of hypertension or cardiac problems.

Review of the "Hand-Off Communication" form dated/timed 11/30/11 at 10:45 am revealed the vital signs for Patient #6 were as follows: BP (blood pressure) 151/100, SAO2 (oxygen saturation) 96%, Pulse 85, Resp (respirations) 16 and Temp (temperature) 98.4 degrees Fahrenheit. Further review of the form revealed no documented evidence the physician was notified or that Patient #6's blood pressure had been re-assessed before being sent for the procedure at 11:15am.

Review of the Anesthesia Record dated/timed 11:25am revealed Patient #6 was placed on a cardiac monitor and had a "slightly irregular heartbeat". Review of the Cardiology Consult dated 11/30/11 at 12:15pm revealed Patient #6 had new onset atrial fibrillation with a rapid ventricular response and a transfer was ordered to a higher level of care.

In a face to face interview on 01/05/12 at 3:00pm RN S2 Director of Inpatient and Outpatient Services indicated the nurse should have re-assessed the patient's vital signs and notified the MD of the elevated blood pressure.


2) follow the sliding scale for administration of insulin
Review of the medical record for Patient #3 revealed a 71 year old female admitted to the hospital on 01/03/12 for a Colonoscopy/Ileoscopy. Further review revealed Patient #3 had a history Diabetes Mellitus.

Review of the Glucose form for Patient #3 dated 01/03/12 revealed 0620 (6:20 am) blood sugar of 133 and 0753 (7:53 am) blood sugar of 206. Further review revealed no documented evidence the physician had been notified for orders to withhold the standing orders.

Review of the Standing Insulin Orders revealed for a blood sugar of 201-250 ---- 4 units of insulin.


3) failed to ensure the duties related to the stocking, storage, wastage, monitoring of medications and identification of patients' home medications was not delegated to an unlicensed staff member
Review Record review of the Job Description of the Pharmacy Facilitator S6 revealed..... "2) Remove expired/discontinued/slow moving/overstocked drugs throughout the facility assuring medication from stock is rotated, returned or exchanged as needed; 4) Participate in bi-annual hospital inventory; 5) Keep labels updated and medicine packages stored safely; 6) Maintain inventory controls/audits of narcotics and stock meds; 7) Order drugs and supplies for the stockroom; stock shelves; maintain storage closet; 9) Receive drugs from courier; match purchase orders to packing slip and shipment; 13) Use Identi-Drug to verify patient's home meds; 14) Prepare MARS for inpatient unit; check MARS after patient is discharged; prepare billing by adding quick codes and quantity; and 17) Other duties as assigned by supervisor.
Further review of S6's job description revealed this job is under the supervision of the Outpatient Director. On pg 3, National Certification, and Valid Louisiana state pharmacy technician registration were listed under Regulatory Requirements.

Review of the personnel file for S6 Pharmacy Facilitator revealed no documented evidence S6 had a current license as a Pharmacy Technician.

In a face to face interview on 1/3/12 at 1:30pm S6 Pharmacy Facilitator indicated she reviews patient home medications and uses the Identi-System, which is a medication identifier software, to identify the home medications.

In a telephone interview on 1/4/12 at 10:00am S14 Consulting Pharmacist indicated because S6 Pharmacy Facilitator is not a licensed Pharmacy Tech, S6 cannot work under her (S14)'s supervision. Further S14 indicated S6 performs the duties of checking the stock cabinets for expired drugs and also reviews and identifies patients' home medications, using the Identi-Drug System.

In a face to face interview on 01/03/12 at 1:30 p.m. S6 Pharmacy Facilitator indicated she reviews patient home medications and uses the Identi-System, which is a medication identifier software, to identify the home medications.

In a face to face interview on 1/5/12 at 9:40 a.m. S2 Director of Outpatient and Inpatient Services indicated S6, Pharmacy Facilitator was under her supervision. S2 confirmed that S6 helped to identify patients' home medications. S2 also confirmed that S6's Performance Review was performed on 2/23/11 for the period from December 01, 2010 to February 27, 2011. S2 also confirmed the job title listed on the Performance Review was "Pharmacy Tech".

Record review of the hospital's policy titled "Patient's Own Medication - Usage" revised 08-15-11, pg 1 of 1 reads under Policy: "Home medications ordered by the physician during hospital stay will be obtained from the patient in the original prescription bottle/container." Under Procedure, the policy indicates that "a patient may utilize his/ her medications when ...medications have been examined by the physician, nurse, or pharmacist for positive identification, integrity, and correct labeling. The identification of the medication will be verified by Ident-a-Drug or a review of the Physicians Desk Reference."






26313

Based on record review and interview with the CNO (Chief Nursing Officer) the hospital failed to ensure nursing care plan approaches were individualized to meet the needs of 4 of 4 patients (#7, #9, #11, #16), who received blood transfusions as evidenced by using preprinted care plan approaches that did not address a potential for reactions to blood. Findings:

1. Review of the closed medical record revealed patient #7 was a 69 year-old who was admitted on 11/11/2011 with chief complaint of osteoarthritis in the right knee. Further review revealed a physician order on 11/12/2011 to transfuse 2 units of packed red blood cells (PRBCs). Review of the preprinted nursing care plan failed to reveal approaches for blood transfusion reactions.

2. Review of the closed medical record revealed patient #9 was a 38 year-old who was admitted on 12/16/2011 with diagnoses of uterine leiomyoma menometrorrhagia, dysmenorrhea and thrombocytopenia. Review of the physician orders dated 12/16/2011 revealed an order to transfuse one unit of PRBCs. Review the care plan for patient #9 failed to reveal interventions for potential reactions to blood.

3. Review of the closed medical record revealed patient #11 was a 72 year-old who was admitted on 12/02/2012 with diagnoses of degenerative joint disease of the left knee and partial arthrofibrosis of the right knee. Review of the 12/04/2011 at 1:30 PM physician order revealed an order to transfuse one unit of PRBCs. Review of the nursing plan of care failed to revealed the nurse documented a plan of care for the blood transfusion.

4. Review of the closed medical record revealed patient #16 was a 60 year-old who was admitted on 11/28/2011 with diagnoses of degenerative joint disease of the right knee. Review of the physician orders revealed an order dated 11/30/2011 to transfuse 2 units of PRBCs. Review of the nursing care plan failed to reveal documented evidence that approaches were developed for the transfusion of blood.

In a face to face interview on 1/05/12 at 3:00 PM RN S2 Director of Inpatient and Outpatient Services verified that the Nursing Care Plans were not individualized and did not contain a plan of care for blood transfusions.


20177

Review of the medical record for Patient #3 revealed a 71 year old female admitted to the hospital on 01/03/12 for a Colonoscopy. Review of the History & Physical dated/timed
01/03/12 at 7:00am revealed Patient #3 had an allergy to Aspirin, Codeine and Latex.

Review of the Intra and Post Procedure Nursing Care Plan revealed the following pre-printed nursing diagnosis used for all surgical patients admitted to the hospital for services: alteration in respiratory function, alteration in circulation, presence of bleeding, alteration in neuro status, alteration in GI (Gastro-Instestinal) function, potential for injury, alteration in emotional status and alteration in comfort. Further review revealed no documented evidence the Nursing Care Plan was individualized to address Patient #3's latex allergy, a band denoting a latex allergy had been placed on the wrist of Patient #3 at the time of admit or that any communication had taken place between the healthcare team concerning the latex allergy.

Review of the policy titled "Latex Sensitivity" last revised 08/12/11 and submitted as the one currently in use, revealed.... "Procedure: .... The patient will wear an allergy band noting latex allergy. Non-latex products will be substituted for those products containing latex. All latex products will be removed from the operating room. Communication between the operating room team, surgeons and anesthesia will occur".

In a face to face interview on 01/05/12 at 3:00pm RN S2 Director of Inpatient and Outpatient Services verified the Nursing Care Plans are not individualized. Further S2 indicated the hospital is latex free for the most part, so that is probably why the Latex allergy was not addressed on the care plan.

In a face to face interview on 01/05/12 at 3:00pm RN1 Chief Nursing Officer verified the Latex policy does not specify the hospital is latex-free and that Nursing Care Plans need to be individualized.


26313

Based on record review and interview the hospital failed to ensure a nursing plan of care was developed and implemented to meet the individualized needs of the patients as evidenced by 1)failing to include interventions for an identified Latex allergy in the plan of care for 1 of 1 patients with a Latex allergy (#3); 2) failing to include the potential for blood transfusion reactions to the pre-printed nursing care plan for 4 of 5 patients with orders for blood transfusions (#7, #9, #11, #16); and 3) failing to implement according to the orders of the physician as evidenced by administering pain medication for fever and stiffness (#20) and administering pain medication more frequently than ordered (#29) for 2 of 39 sampled patients (# 20, #29). Findings:

1) failing to include interventions for an identified Latex allergy
Review of the medical record for Patient #3 revealed a 71 year old female admitted to the hospital on 01/03/12 for a Colonoscopy. Review of the History & Physical dated/timed
01/03/12 at 7:00am revealed Patient #3 had an allergy to Aspirin, Codeine and Latex.

Review of the Intra and Post Procedure Nursing Care Plan revealed the following pre-printed nursing diagnosis used for all surgical patients admitted to the hospital for services: alteration in respiratory function, alteration in circulation, presence of bleeding, alteration in neuro status, alteration in GI (Gastro-Instestinal) function, potential for injury, alteration in emotional status and alteration in comfort. Further review revealed no documented evidence the Nursing Care Plan was individualized to address Patient #3's latex allergy, a band denoting a latex allergy had been placed on the wrist of Patient #3 at the time of admit or that any communication had taken place between the healthcare team concerning the latex allergy.

Review of the policy titled "Latex Sensitivity" last revised 08/12/11 and submitted as the one currently in use, revealed.... "Procedure: .... The patient will wear an allergy band noting latex allergy. Non-latex products will be substituted for those products containing latex. All latex products will be removed from the operating room. Communication between the operating room team, surgeons and anesthesia will occur".

In a face to face interview on 01/05/12 at 3:00pm RN S2 Director of Inpatient and Outpatient Services verified the Nursing Care Plans are not individualized. Further S2 indicated the hospital is latex free for the most part, so that is probably why the Latex allergy was not addressed on the care plan.

In a face to face interview on 01/05/12 at 3:00pm RN1 Chief Nursing Officer verified the Latex policy does not specify the hospital is latex-free and that Nursing Care Plans need to be individualized.


2) failing to include the potential for blood transfusion reactions to the pre-printed nursing care plan
Patient #7
Review of the closed medical record revealed patient #7 was a 69 year- old who was admitted on 11/11/2011 with chief complaint of osteoarthritis in the right knee. Further review revealed a physician order on 11/12/2011 to transfuse 2 units of packed red blood cells (PRBCs). Review of the preprinted nursing care plan failed to reveal approaches for blood transfusion reactions.

Patient #9
Review of the closed medical record revealed patient #9 was a 38 year- old who was admitted on 12/16/2011 with diagnoses of uterine leiomyoma menometrorrhgia, dysmenorrhea and thrombocytopena. Review of the physician orders dated 12/16/2011 revealed an order to transfuse one unit of PRBCs. Review the care plan for patient #9 failed to reveal interventions for potential reactions to blood.

Patient #11
Review of the closed medical record for patient #11 was year-old who was admitted on 12/02/2012 with diagnoses of degenerative joint disease of the left knee and partial orthrofibrosis of the right knee. Review of the 12/04/2011 at 1:30 PM physician order revealed an order to transfuse one unit of PRBCs. Review of the nursing plan of care failed to revealed the nurse documented a plan of care for the blood transfusion.

Patient #16
Review of the closed medical record revealed patient #16 was a 60 year-old who was admitted on 11/28/2011 with diagnoses of degenerative joint disease of the right knee. Review of the physician orders revealed an order dated 11/30/2011 to transfuse 2 units of PRBCs. Review of the nursing care plan failed to reveal documented evidence that approaches were developed for the transfusion of blood.


3) failing to implement according to the orders of the physician as evidenced by administering pain medication for fever and stiffness (#20) and administering pain medication more frequently than ordered
Patient #20
Patient #20 was admitted to the hospital on 12/2/11 for breast reconstruction after a bilateral mastectomy. Allergies listed included Cipro, Sulfa, and tape. Record review of patient #20's clinical record revealed the physician's orders on the form titled "First Stage-Post Operative Orders--Free Flap-POD#1 at 0700" dated 12/1/11 and timed 1645, pg 3 of 4, under PO Pain Medication: Lortab 7.5 mg/500 mg 1 tab PO q (every) 4 hours prn moderate pain (not to exceed 4000 mg Acetaminophen/24 h) was checked. Lortab 7.5 mg/500 mg 2 tabs PO q (every) 4 hours severe prn pain (not to exceed 4000 mg Acetaminophen/24 hr) was also checked.

Record review of Nurse's Notes dated 12/5/11 and timed at 2300 revealed documentation by the RN (Registered Nurse) that she administered "Lortab 7.5 mg p.o. for sl (slight) low temp 99.0 and to prevent stiffness."

Patient #29
Patient #29 was admitted to the hospital on 12/13/11 for a left total knee arthroplasty. Allergies listed included Hydrocodone, Phenergan, and Adhesives. Record review of patient's clinical record revealed the physician's orders on the form titled "Physician Orders Inpatient Orders Total Knee"dated 12/13/11 and timed 1400, pg 1 of 2, #8 read: "Encourage PO pain medication. Discourage IM use." Under #9 Medications, the following medications were checked by the physician indicating these drugs can be used for pain management: "Oxycontin 10 mg (milligram) PO q 12 hrs x 3 days"; "Percocet 5 mg PO q 4 hr prn mild pain (score 1-5) OR Percocet 10 mg PO q 4th prn mod/severe pain (score 6-10)"; Lortab 5 mg PO q 4 hr PRN mild pain (score 1-5) OR Lortab 10 mg PO q 4 h PRN mod/severe pain (score 6-10)"; Dilaudid 2 mg PO 1 tablet q 4 h prn mild pain (score 1-5) OR Dilaudid 2 mg PO 2 tabs q 4 h prn mod/severe pain (score 6-10); Morphine 5 mg IM q 4 h prn mild breakthrough pain (score 1-5) OR Morphine 10 mg IM q 4 h prn moderate/severe breakthrough pain (score 6-10).

Record review of Nurse's Notes dated 12/13/11 and timed at 1340 revealed documentation by the RN that "Percocet 5 mg was given po for c/o (complain of) pain 4/10 (rated 4 on a 10 point scale). " At 1425 (45 minutes after 1st dose of pain medication given at 1340), the RN documented "Pt (patient) given 2 mg po of Dilaudid after pt c/o pain level increasing to 10/10." At 1510 (90 minutes after 1st dose of pain medication administered at 1340 and 45 minutes after the 2nd dose of pain medication was given) the RN documented "Pt given IM injection of Morphine 5 mg after pt c/o pain unchanged, continues with 10/10 rating."

Based on record review and interview the hospital failed to ensure a nursing plan of care was developed and implemented to meet the individualized needs of the patients as evidenced by 1)failing to include interventions for an identified Latex allergy in the plan of care for 1 of 1 patients with a Latex allergy (#3); 2) failing to include the potential for blood transfusion reactions to the pre-printed nursing care plan for 4 of 5 patients with orders for blood transfusions (#7, #9, #11, #16); and 3) failing to implement according to the orders of the physician as evidenced by administering pain medication for fever and stiffness (#20) and administering pain medication more frequently than ordered (#29) for 2 of 39 sampled patients (# 20, #29). Findings:

1) failing to include interventions for an identified Latex allergy
Review of the medical record for Patient #3 revealed a 71 year old female admitted to the hospital on 01/03/12 for a Colonoscopy. Review of the History & Physical dated/timed
01/03/12 at 7:00am revealed Patient #3 had an allergy to Aspirin, Codeine and Latex.

Review of the Intra and Post Procedure Nursing Care Plan revealed the following pre-printed nursing diagnosis used for all surgical patients admitted to the hospital for services: alteration in respiratory function, alteration in circulation, presence of bleeding, alteration in neuro status, alteration in GI (Gastro-Instestinal) function, potential for injury, alteration in emotional status and alteration in comfort. Further review revealed no documented evidence the Nursing Care Plan was individualized to address Patient #3's latex allergy, a band denoting a latex allergy had been placed on the wrist of Patient #3 at the time of admit or that any communication had taken place between the healthcare team concerning the latex allergy.

Review of the policy titled "Latex Sensitivity" last revised 08/12/11 and submitted as the one currently in use, revealed.... "Procedure: .... The patient will wear an allergy band noting latex allergy. Non-latex products will be substituted for those products containing latex. All latex products will be removed from the operating room. Communication between the operating room team, surgeons and anesthesia will occur".

In a face to face interview on 01/05/12 at 3:00pm RN S2 Director of Inpatient and Outpatient Services verified the Nursing Care Plans are not individualized. Further S2 indicated the hospital is latex free for the most part, so that is probably why the Latex allergy was not addressed on the care plan.

In a face to face interview on 01/05/12 at 3:00pm RN1 Chief Nursing Officer verified the Latex policy does not specify the hospital is latex-free and that Nursing Care Plans need to be individualized.


2) failing to include the potential for blood transfusion reactions to the pre-printed nursing care plan
Patient #7
Review of the closed medical record revealed patient #7 was a 69 year- old who was admitted on 11/11/2011 with chief complaint of osteoarthritis in the right knee. Further review revealed a physician order on 11/12/2011 to transfuse 2 units of packed red blood cells (PRBCs). Review of the preprinted nursing care plan failed to reveal approaches for blood transfusion reactions.

Patient #9
Review of the closed medical record revealed patient #9 was a 38 year- old who was admitted on 12/16/2011 with diagnoses of uterine leiomyoma menometrorrhgia, dysmenorrhea and thrombocytopena. Review of the physician orders dated 12/16/2011 revealed an order to transfuse one unit of PRBCs. Review the care plan for patient #9 failed to reveal interventions for potential reactions to blood.

Patient #11
Review of the closed medical record for patient #11 was year-old who was admitted on 12/02/2012 with diagnoses of degenerative joint disease of the left knee and partial orthrofibrosis of the right knee. Review of the 12/04/2011 at 1:30 PM physician order revealed an order to transfuse one unit of PRBCs. Review of the nursing plan of care failed to revealed the nurse documented a plan of care for the blood transfusion.

Patient #16
Review of the closed medical record revealed patient #16 was a 60 year-old who was admitted on 11/28/2011 with diagnoses of degenerative joint disease of the right knee. Review of the physician orders revealed an order dated 11/30/2011 to transfuse 2 units of PRBCs. Review of the nursing care plan failed to reveal documented evidence that approaches were developed for the transfusion of blood.


3) failing to implement according to the orders of the physician as evidenced by administering pain medication for fever and stiffness (#20) and administering pain medication more frequently than ordered
Patient #20
Patient #20 was admitted to the hospital on 12/2/11 for breast reconstruction after a bilateral mastectomy. Allergies listed included Cipro, Sulfa, and tape. Record review of patient #20's clinical record revealed the physician's orders on the form titled "First Stage-Post Operative Orders--Free Flap-POD#1 at 0700" dated 12/1/11 and timed 1645, pg 3 of 4, under PO Pain Medication: Lortab 7.5 mg/500 mg 1 tab PO q (every) 4 hours prn moderate pain (not to exceed 4000 mg Acetaminophen/24 h) was checked. Lortab 7.5 mg/500 mg 2 tabs PO q (every) 4 hours severe prn pain (not to exceed 4000 mg Acetaminophen/24 hr) was also checked.

Record review of Nurse's Notes dated 12/5/11 and timed at 2300 revealed documentation by the RN (Registered Nurse) that she administered "Lortab 7.5 mg p.o. for sl (slight) low temp 99.0 and to prevent stiffness."

Patient #29
Patient #29 was admitted to the hospital on 12/13/11 for a left total knee arthroplasty. Allergies listed included Hydrocodone, Phenergan, and Adhesives. Record review of patient's clinical record revealed the physician's orders on the form titled "Physician Orders Inpatient Orders Total Knee"dated 12/13/11 and timed 1400, pg 1 of 2, #8 read: "Encourage PO pain medication. Discourage IM use." Under #9 Medications, the following medications were checked by the physician indicating these drugs can be used for pain management: "Oxycontin 10 mg (milligram) PO q 12 hrs x 3 days"; "Percocet 5 mg PO q 4 hr prn mild pain (score 1-5) OR Percocet 10 mg PO q 4th prn mod/severe pain (score 6-10)"; Lortab 5 mg PO q 4 hr PRN mild pain (score 1-5) OR Lortab 10 mg PO q 4 h PRN mod/severe pain (score 6-10)"; Dilaudid 2 mg PO 1 tablet q 4 h prn mild pain (score 1-5) OR Dilaudid 2 mg PO 2 tabs q 4 h prn mod/severe pain (score 6-10); Morphine 5 mg IM q 4 h prn mild breakthrough pain (score 1-5) OR Morphine 10 mg IM q 4 h prn moderate/severe breakthrough pain (score 6-10).

Record review of Nurse's Notes dated 12/13/11 and timed at 1340 revealed documentation by the RN that "Percocet 5 mg was given po for c/o (complain of) pain 4/10 (rated 4 on a 10 point scale). " At 1425 (45 minutes after 1st dose of pain medication given at 1340), the RN documented "Pt (patient) given 2 mg po of Dilaudid after pt c/o pain level increasing to 10/10." At 1510 (90 minutes after 1st dose of pain medication administered at 1340 and 45 minutes after the 2nd dose of pain medication was given) the RN documented "Pt given IM injection of Morphine 5 mg after pt c/o pain unchanged, continues with 10/10 rating."

On 1/5/11 at 3:00 p.m. in a face-to-face interview with S1 CNO and S2 Director of Inpatient and Outpatient Services, both nurses verified that they were unaware of the 2 incidents when the staff nurses failed to follow the physician's orders.

Review of the policy titles "Nursing Care Plans" last reviewed 08/12/11and submitted as the one currently in use revealed..... "Care, treatment, and services are planned to ensure that they are appropriate to the patient's needs. Therefore it is the policy of this hospital to provide an individualized, interdisciplinary plan of care for all patients that is appropriate to the patients' needs, strengths and limitations and goals".

Based on record review and interview the hospital failed to ensure blood was administered according to policy and procedure as evidenced by failure of the nursing staff to obtain a rate of infusion for 4 of 4 patients receiving blood (#7, #8, #9, #11) out of a total of 39 sampled medical records. Findings:

Review of the medical closed records for patient #7, #9 and #11 revealed physician orders to administer blood. Further review failed to reveal a physician order instructing the nurse on the rate in which to infuse the blood. The CNO confirmed in an interview on 1/04/2012 at 10:00 AM that patients #7, #9 and #11 did not have physician orders for infusion rates.

Patient #8
Review of the medical record for Patient #8 revealed a 55 year old female admitted to the hospital for an arthroscopy of the hip.

Review of the Physician's Orders for Patient #8 dated 07/20/11 at 0400 (4:00am) revealed a verbal order to transfuse 2 units PRBC (packed red blood cells). Further review revealed no documented evidence clarification of the order to obtain a rate of infusion was obtained.

Review of the Blood Administration Record for Patient #8 dated 07/20/11 revealed the following: first unit of PRBC was started at 5:45am with no documented evidence of a rate. Further review revealed at 6:45am the rate was 175ml/hr, 07:45am 175ml/hr and the infusion completed at 0830 (8:30am); second unit of blood was started at 11:25am at 125ml/hr until 1210 when the rate of infusion was changed to 150ml/hr and at 1310 the rate of infusion was increased to 175ml/hr.

In a face to face interview on 01/05/12 at 3:00pm RN S2 Director of Inpatient and Outpatient Services indicated the nurses should have clarified the order with the physician to obtain a rate of transfusion. Further S2 confirmed the nursing staff had not followed the policy and procedure for blood administration.

Review of the policy titled "Blood/Blood Component Transfusion/Whole Blood/Packed Cells last revised 08/10/11 and submitted as the one currently in use, revealed..... "Essential Steps: Open all the clamps between the blood bag and the patient to deliver 25-30 drops per minute. The patient then receives about 50ml of blood over 30 minutes to minimize any transaction reaction, which usually occurs within this period. Remain with the patient during the first 15 minutes, or first 50ml of blood and watch for signs of transfusion reaction....... If no signs of a reaction appear within 30 minutes, adjust the flow clamp infusion pump to the ordered infusion rate".

Based on interview and policy review, the hospital failed to follow the policy of ensuring the medical records contained signed, dated, and authenticated verbal orders within 10 days as evidenced by 2 of 39 clinical records reviewed had orders being signed by physicians after a 10 day period. (#28, #29). Findings:

Patient #28
Record review revealed Patient #28 was admitted for surgery related to chronic low back pain on 12/13/11. Record review of the Physician's Orders revealed no signature by the physician and no times authenticating the Read Back Telephone Order (RBTO) on 12/13/11 at 2400, 12/13/11 at 0005, 12/14/11 at 1035, and 12/14/11 at 1145.

Patient #29
Patient # 29 was a 62 year old female who underwent surgery 12/13/11 for a left knee arthroplasty. Record review of the Intra-Operative Physician Orders dated 12/13/11 and timed 0815 a.m. revealed the Read Back Verbal Order (RBVO) was signed by the physician and stamped with the date "12-27-2011 PO4:49". Record review of Physician's Orders dated 12/14/11 and timed at 1330 (1:30 p.m.) and 1725 ( 5:25 p.m.) revealed the physician's RBVO was signed by the physician and stamped 12-27-2011 PO4:59 at each entry. Record review of Physician's Orders dated 12/16/11 at 0530 revealed RBVO was signed by physician and then stamped with 12-27-2011 PO4: 59.

On 1/5/12 at 1:30 p.m., S2 Director of Inpatient and Outpatient Services confirmed that the stamp indicated the physician had signed the verbal orders.

Review of the Medical Staff Rules and Regulations last reviewed 01/22/10 and submitted as the one currently in use revealed...... "11. Verbal Phone orders: The prescribing/ordering physician shall authenticate each verbal/phone order within 10 days of issuing the order".

Based on record review and interview with the CNO the hospital failed to ensure 1 of 1 patients (patient #33) in a total sample of 39 patients had a discharge summary dictated or written in the medical record. Finding:

A tour of the medical record department on 1/05/2012 at 1:30 PM revealed a shelf where incomplete medical records were stored. Further review revealed patient #33's medical record was included in those records. Review of the closed record revealed patient #33 was a 45 year-old who was admitted on 12/22/2011 with a history of breast cancer. Further review revealed surgery was performed on 12/22/2011 for bilateral breast flap revision, primary repair of reducible incisional hernia and revision of abdominal donor deformity with excision of excess skin with a complex wound closure. There failed to be a discharge summary or documentation that a summary was included in this medical record. The CNO reviewed this chart on 1/05/2012 3:00 PM and confirmed that patient #33's medical record did not contain a discharge summary.

Based on policy review, interview, and observation, the hospital failed to; 1) follow their policy of ensuring the Consulting Pharmacist supervised and coordinated activities with the outsourced Pharmacy as evidenced by failing to reconcile the contents of the emergency kits to ensure outdated medications were removed from the inpatient floor stock contained in those emergency boxes resulting in expired medications in 2 of the 3 emergency kits (Box "a", Box "c") and 2) follow their policy for control and securing of drugs and biologicals as evidenced by allowing Nursing Service to delegate the duty of a pharmacy tech to an unlicensed staff member. Findings:

On 1/3/12, at 1:30 p.m., three boxes labeled "Emergency Medication Box were observed in the inpatient unit's medication room. Review of the PARR level list for Emergency Box "c" revealed the box should contain 10 vials of Heparin Sodium 5,000 units in the top shelf.
Upon inspection of Emergency Box "c", 4 of 10 Heparin Sodium 5,000 units/ml (milliliters) injection vials had an expiration date of 09/01/11. Further observation revealed Emergency Box "a", 1 vial of Phynytoin (Phenytoin) Sodium (Dilantin) 250 mg/ 5 ml injection had an expiration date of 12/2011.

In a face to face interview on 01/3/12 at 1:40 p.m. Consulting Pharmacist (S14) confirmed the 4 vials in Emergency Box "c" had expired in September 2011 and the vial of Dilantin in Box "a" had an expiration date of December 2011. S14 confirmed that the medications in the locked emergency boxes were reviewed by the outsourced pharmacy weekly and outdated drugs were removed and replaced with current drugs. S14 was not sure why the vial of Dilantin with an expiration date of 12/2011 was not removed earlier.

In a telephone interview on 01/04/12 at 10:00 a.m. S14 confirmed that the outsourced Pharmacy was responsible for checking for expired drugs in the emergency boxes located on the inpatient unit. S14 also stated that one of her duties included ensuring the drugs in the emergency boxes were accounted for and the correct drug and count in the emergency kit reconciled.

Record review of Consultant Pharmacist's Duties and Responsibilities dated 02/25/11, which were found in S14's personnel folder, revealed one of the duties, (#9) read "Reconciling emergency kits at least weekly."

Record review of the hospital's policy titled "Floor Stock" revised 08/15/11, pg 1 of 1, reads under Policy: "Responsibility for control of floor stock medications within this hospital rests with the Consulting Pharmacist or their designee." Under Procedure, "As with all other medications, all floor stock are accurately labeled with contents, expiration dates and appropriate warnings."

Record review of the hospital's policy titled "Pharmacy General Policy" revised 08/15/11, pg 2 of 2, under Policy, reads "Outdated, mislabeled or otherwise unusable drugs and biologicals shall be separated from useable stock and are not available for patient use and will be returned to an authorized agency for credit or destroyed according to current state or federal laws as applicable."

2) follow their policy for control and securing of drugs and biologicals as evidenced by allowing Nursing Service to delegate the duty of a pharmacy tech to an unlicensed staff member

In a telephone interview on 1/4/12 at 10:00am S14 Consulting Pharmacist indicated because S6 Pharmacy Facilitator is not a licensed Pharmacy Tech, S6 cannot work under her (S14)'s supervision. Further S14 indicated S6 performs the duties of checking the stock cabinets for expired drugs and also reviews and identifies patients' home medications, using the Identi-Drug System.

In a face to face interview on 1/5/12 at 9:40 a.m. S2 Director of Outpatient and Inpatient Services indicated S6, Pharmacy Facilitator was under her supervision. S2 confirmed that S6 helped to identify patients' home medications. S2 also confirmed that S6's Performance Review was performed on 2/23/11 for the period from December 01, 2010 to February 27, 2011. S2 also confirmed the job title listed on the Performance Review was "Pharmacy Tech".

Review of the policy titled "Scope of Service" last reviewed 08/10/11 and submitted as the one currently in use revealed.... "Controlled Substances: All drugs and biologicals must be controlled, secured and ditributed in accordance with applicable standards of practice and consistant with Federal and State laws at all times....... Only personnel authorized by the pharmacy service shall have access to locked areas".

Based on observation record review and interview the hospital failed to follow their policy and procedure for ensuring expired and outdated drugs were not available for patient use as evidenced by have expired heparin in the emergency box on the inpatient unit, expired insulin in the refrigerator of the PACU (Post Anesthesia Care Unit) and Bacteriostatic water without a date of puncture on the shelf in the PACU unit. Findings:

On 1/3/12, at 1:30 p.m., three boxes labeled "Emergency Medication Box were observed in the inpatient unit's medication room. Review of the PARR level list for Emergency Box "c" revealed the box should contain 10 vials of Heparin Sodium 5,000 units in the top shelf.
Upon inspection of Emergency Box "c", 4 of 10 Heparin Sodium 5,000 units/ml (milliliters) injection vials had an expiration date of 09/01/11. Further observation revealed Emergency Box "a", 1 vial of Phynytoin (Phenytoin) Sodium (Dilantin) 250 mg/ 5 ml injection had an expiration date of 12/2011.

In a face to face interview on 01/3/12 at 1:40 p.m. Consulting Pharmacist (S14) confirmed the 4 vials in Emergency Box "c" had expired in September 2011 and the vial of Dilantin in Box "a" had an expiration date of December 2011. S14 confirmed that the medications in the locked emergency boxes were reviewed by the outsourced pharmacy weekly and outdated drugs were removed and replaced with current drugs. S14 was not sure why the vial of Dilantin with an expiration date of 12/2011 was not removed earlier.

In a telephone interview on 01/04/12 at 10:00 a.m. S14 confirmed that the outsourced Pharmacy was responsible for checking for expired drugs in the emergency boxes located on the inpatient unit. S14 also stated that one of her duties included ensuring the drugs in the emergency boxes were accounted for and the correct drug and count in the emergency kit reconciled.

Observation on 01/03/12 at 1:15pm of the shelf located within the nurses' station of the PACU revealed one multidose vial of Bacteriostatic NACL (sodium chloride) 0.9% 30mL with no documented of the date the vial was punctured.

In a face to face interview on 01/03/12 at 2:00pm RN S1 Chief Nursing Officer indicated all multi-dose vials should be tabled with the date when first punctured and the initials of the nurse.

Review of the policy titled "Use of Multi Dose Vials" last reviewed 01/04/12 and submitted as the one currently in use, revealed...."Once a vial has been opened, it must be labeled with the date and the nurse's signature or initials. The vial will expire 28 days after the vial has been opened. All unlabeled vials will be discarded".

Based on observation, policy review, and interview, the hospital failed to follow their policy on proper food storage as evidenced by having undated and unlabeled food supplies. Findings:

On 1/3/12 at 2:00 p.m., an observation was made of the frozen foods stored in the walk-in freezer. There were 3 large family size plastic packages of frozen vegetables and 2 large plastic wrapped packages of frozen meat. Also, a partially opened box of frozen single serving size prepared packages (i.e. lasagna) were also in the walk-in refrigerator. These food items were not labeled and dated as to when the hospital received these food items.

In another observation of the walk-in storage room, which held large containers of food items, such as tomato sauce, were unlabeled as to when these food items were purchased. The smaller cans of tomato sauce had a date on the top of the lid.

On 1/3/12 at 2:15 p.m., in a face-to-face interview with S13 Dietary Manager, he stated that he purchases the food supply and rotates the stock himself. He added that if his food supplies are not in when meal time arrives, the staff can heat up a prepackaged lasagna dinner or any of the prepackaged food in the freezer.

On 1/3/12 at 2:30 p.m., these observations were verified by S3 QA Director.

A record review of the hospital's policy titled "Food Storage" revised 8/11/11, under II. Procedure, G., it reads "Fresh, prepared and portioned foods shall be covered, labeled and dated for storage in the following manner: 1. All frozen foods are stored in the walk-in freezer at 0 degree F."

Based on observation, record review and interview the hospital failed to: 1) ensure a process was in place for prevention of communicable disease by the staff as evidenced by no documented evidence the physicians credentialed at the hospital were screened for TB for 2 of 2 credentialing files reviewed out of 121 credentialed physicians and 2) monitor the physical environment to ensure a sanitary environment was maintained as evidenced by accumulated dust in patient care areas, holes in the walls in the surgery suite, and a PACU room ready for patient occupancy with a pulse oximeter on the floor and blood pressure cuff hanging in a full can of garbage. Findings:

1) Annual TB screening
Review of the Credentialing files for MD S7 and S8 revealed no documented evidence annual TB screening had been performed.

In a face to face interview on 01/05/12 at 4:00pm RN S1 Chief Nursing Officer verified physicians are currently not required to have annual screening for TB; however all employees are required to be screened annually. Further S1 indicated the hospital is physician owned.

Review of the Medical Staff By-Laws and the Medical Staff Rules and Regulations last reviewed 01/22/10 revealed no documented evidence requiring annual screening was included as an annual practice or a requirement for appointment or reappointment to the staff.


2) Physical Environment
Observation on 01/03/12 at 1:30pm of the Post Anesthesia Care Unit (PACU) revealed the following: accumulated dust on all surfaces including the equipment for patient use in the unoccupied over-flow room; Room 5, verified by the CNO (Chief Nursing Officer who accompanied the surveyor on observations of the environment) as ready for patient occupancy revealed accumulation of dust of the wardrobe, overbed light, and suction cover. Further observations revealed the pulse oximeter (which is placed on the patient's finger) was lying on the floor and the blood pressure cuff and other tubing hooked on the side of the closet by the bed were hanging in the garbage can which was full of waste from the previous patient.

Observation of the clean linen room, located on the PACU unit revealed an accumulation of dust on all open counter surfaces and debris on the floor.

In a face to face interview on 01/03/12 at 2:00pm RN S1 Chief Nursing Officer indicated the pulse oximeter should not be on the floor and the blood pressure cuff and other tubing should not be hanging in the garbage can.

Observation on 01/05/12 at 1:45pm of Operating Suite revealed large holes (two measured approximately 1 foot by 1/2 foot) on the lower walls in the halls located outside of the surgery rooms. Further observation revealed the sheet rock was crumbling and the studs of the wall could be visualized.

In a face to face interview on 01/04/12 at 3:45pm S12 Director of Plant Management indicated he has a staff of four housekeepers, two of whom are assigned exclusively to the Operating Suite responsible for cleaning 42,000 square feet. Further S12 indicated the Housekeeping Department is understaffed and was recently downsized from 5 to 4 housekeepers.

In a face to face interview on 01/05/12 at 1:30pm RN S19 Director of Surgical Services indicated the holes were made by the stretchers and continued to happen even after repairs were performed.

Based on record review and interview the hospital failed to ensure the Post- Procedure Note used by the hospital to document the information required post-operatively as evidenced by having blank preprinted forms titled Post-Procedure Note used by the hospital to document describe techniques, findings, tissues removed and 2) not having documented evidence or a dictated note for 5 of 39 sampled medical records (#4, #28, #31, #34, #36). Findings:

Patient #4
Review of the medical record for Patient #4 revealed a 16 year old male admitted to the hospital on 01/03/12 for a Bilateral Otoplasty. Further review of the medical record revealed no documented evidence a Post-procedure note was written as evidenced by a blank form titled "Post-Procedure Note" with the name of Patient #34 at the top.

Patient #28
Patient #28 was admitted for a surgical repair of a lumbar degenerative disc and spondylolisthesis on 12/13/11. Record review of the Post Procedure Note revealed missing documentation related to who the Surgeon and Assistants were during surgical procedure; Pre-Op Diagnosis; Post-Op Diagnosis; Procedure/Findings; Speciments; Complications and Comments; Estimated Blood Loss (EBL); Blood Administered; Type of Anesthesia; Grafts or Implants; and Physician Signature, Date, and Time.

Patient #31
Review of the medical record department on 1/05/2012 revealed a shelf with delinquent records. Patient #31's medical record was included in that section. Review of the record revealed patient #31 was a 64 year old who had left shoulder pain, decrease range of motion exercise and a torn left shoulder rotator cuff. According to the medical record on 12/07/2011 the surgeon performed a left shoulder arthrogram on patient #31. There was documentation on a red sticky note shaped like an arrow addressing that this medical record did not have an operative note.

Patient #34
Review of the medical record for Patient #34 revealed an 11 year old female admitted to the hospital on 12/22/11for a T&A (Tonsillectomy and Adenoidectomy). Further review of the medical record revealed no documented evidence a Post-procedure note was written as evidenced by a blank form titled "Post-Procedure Note" with the name of Patient #4 at the top.

Patient #36
Review of the medical record department on 1/05/2012 revealed a shelf with delinquent records and patient #36's medical record was included in these records. Review of the closed record revealed patient #36 was a 75 year-old who had diagnoses of weakness and fever and to rule out pelvic abscess. Further review revealed a yellow stick note shaped in the form of an arrow with black documentation instructing the surgeon to complete the operative note. Close review of the medical record revealed no documented evidence that the operative note was dictated. In a face to face interview on 01/05/12 at 3:00 PM S1 CNO stated that the post-operative procedure note should be written immediately after surgery.

In a face to face interview on 01/05/12 at 3:00pm RN S1 Chief Nursing Officer indicated the post-operative procedure note should be written immediately after surgery.

Review of the Medical Staff Rules and Regulations last reviewed 01/22/10 and submitted as the one currently in use, revealed.... "5. Surgical reports: A brief operative note must also be written in the chart immediately following the operation".




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