HospitalInspections.org

Based on medical record reviews, facility policy review and staff interviews, the facility failed to provide a written history and physical within twenty four hours of admission for 3 of 10 patients whose charts were reviewed (#9, #15, and #20) and failed to provide a comprehensive history and physical prior to surgery for 1 of 3 surgery records reviewed (#13).

The findings are:

Patient #9 was admitted to the facility on 12/21/14; however, review of the patient's history and physical showed that it was not dictated and transcribed by the physician until 5/28/15.

Patient #15 was admitted to the hospital on 1/30/15. Review of the history and physical for patient #15 showed that it was not signed by the physician until 5/28/15.

Patient #20 was admitted to the hospital on 4/20/15. Review of the history and physical for the patient showed that it had not been completed until 4/23/15

A review of the medical staff bylaws last reviewed on 3/29/14 revealed that an admission history and physical examination shall be performed and recorded within twenty four hours of the patient's admission

Review of the facility's policy and procedure related to medical records content that was last revised in April 2014 showed that it is the policy of the facility that all medical records shall contain sufficient information to identify the patient, support the diagnosis, to justify the treatment and document the results accurately.

An interview with the Health Information Management Director (HIMD) on 5/28/15 at approximately 2:30pm revealed that a history and physical is to be completed within twenty four hours of a patient's admission in accordance with the medical staff bylaws. The HIMD stated that physician #1 has a large patient population and has fallen behind. She further stated it has been a problem since conversion from a dictation system to an electronic entry system.



29722

2. A closed record review was conducted for Patient #13, who underwent a surgical procedure on 05/26/2015. A review of the history and physical, dated May 21, 2015, 5 days prior to surgery, failed to include a comprehensive physical exam. The physical exam failed to include a heart and lung assessment. There was not an updated entry immediately prior to surgery to indicate any changes or review to the patient's current condition.

On 05/27/2015 at approximately 10:00am, the Operating Room Supervisor indicated that a comprehensive history and physical was not indicated because the patient was not sedated and received a local anesthetic.

A review of the facility's policy and procedure No. 19, entitled "History and Physical Requirement", reviewed date: 1/2000 indicates "History and physicals must be within 30 days prior to scheduled surgery date. All patients, regardless of type of anesthesia to be given, shall have a history and physical on the chart at the time of surgery or a dictated History and Physical that is easily attainable."

An additional policy and procedure presented, No. 6211:207, entitled "History and Physical Requirement," created 1/2000, last reviewed 5/14 indicates "A. A written (dictated and transcribed or handwritten) patient history and physical examination must be readily available in the medical record prior to surgery. The history and physical shall include: 1. A review of the symptoms 2. Major complaints 3. Reason for operative procedure 4. Initial diagnosis. ...B. In the event an operative procedure is to be performed due to a life-threatening emergency, a minimum of the following elements are required: 1. Examination of heart and lungs 2. Examination of vital signs, 3. Examination of operative/ invasive procedure site; 4. Hemoglobin level; 5. If patient condition and time elements permit, venous access.

A review of the facility Medical Staff Bylaws:
Article II - Admission of Patients, "3. .....If a previous history and physical was performed within thirty (30) days of admission, the provider credentialed and privileged to perform a history and physical must update any changes to the previous history and physical at the time of admission. The update note must be on or attached to the original history and physical with documentation of the date and time the update was made. Any required update of the history and physical must be completed prior to the start of any surgical or invasive procedure. 4. Patients who are admitted to the hospital more than seven (7) days prior to a surgery or invasive procedure shall have a new physical examination performed by a provider of the Medical Staff who is credentialed and privileged to perform a physical examination which will minimally include at least examination of the heart, lungs and vital signs. A legible notation of the findings shall be entered into the medical record, and it shall be the responsibility of the Medical staff member performing the procedure or surgery to see that such physical examinations have been completed and recorded in the medical record prior to starting any procedure or surgery."

Based on medical record review, review of the facility's policies and procedures, and staff interview, the facility failed to provide a completed discharge summary within thirty days of patient discharge for 2 of 10 patients whose charts were reviewed (#8 and #17).

The findings are:

Patient #8 was discharged on 11/26/14. Review of the patient's discharge summary revealed that it had not been dictated by the physician until 1/7/15 and was not signed by the physician until 2/7/15.

Patient #17 was discharged on 2/9/15. Review of the patient's discharge summary showed that it was not dictated by the physician until 5/28/15.

Review of the medical staff bylaws last reviewed on 3/29/14 revealed that all medical records must be completed within thirty days or they will be deemed as delinquent.

Review of the facility's policy and procedure related to medical records content that was last revised in April 2014 showed that it is the policy of the facility that all medical records shall contain sufficient information to identify the patient, support the diagnosis, to justify the treatment and document the results accurately.

An interview with the Health Information Management Director on 5/28/15 at approximately 2:30pm revealed that a Discharge Summary is to be completed within 30 days of discharge date in accordance with the Medical Staff By-Laws. The Director stated that Physician #1 has a large patient population and has fallen behind. She further stated it has been a problem since conversion from a dictation system to an electronic entry system.

Based on observation and interviews, the facility failed to ensure the inhibition of microbial growth and reduce the risk of infection by failing to monitor temperatures and humidity levels in 4 of 4 Operating Rooms (OR).

The findings include:

On 05/27/2015 at approximately 10:50 am, a tour of the facility's four operating rooms was conducted, accompanied by the facility's Operating Room Supervisor (ORS). Observed in Operating Room #4 was an atomic clock with a temperature indicating 64 degrees. The ORS was asked how temperature and humidity levels were monitored in the Operating Rooms. She stated, they just adjust the temperature if they need it, and that Maintenance would be responsible for monitoring humidity levels. She stated, as far as she knew this was not documented anywhere.

On 05/27/2015 at approximately 11:30 am, an interview was conducted with the Maintenance Director. He stated that currently the OR temperatures and humidity levels are not documented. Temperatures are monitored per room, but humidity level are not. He said the facility is in the process of inquiring the cost for a process to monitor humidity levels in each OR.

Per AORN (Association periOperating Room Nurses), the recommended temperature levels in the Operating Suite should range from 68 degrees to 75 degrees. Operating Room (OR) #4 was 64 degrees but was not currently in use.

Based on staff interview, facility record review and review of the facility's Infection Control Program, the facility failed to implement measures to reduce the risk of infection in the Operating Room, establish a documented system to ensure staff identified and reported infections and failed to utilize active surveillance data to improve the facility's Infection Control Program

The findings include:

1. On 05/27/2015 beginning at approximately 10:00am, an interview was conducted with the Operating Room Supervisor, who was also designated as the Infection Control Nurse. She was asked what the facility's process was for identifying surgical site infections for the post-op patient. She stated the only way she would be informed was if she received a culture report on a patient, or if they were re-admitted into the facility within 7 days. She was not aware of any post-surgical infections.

She stated, other patients that present to the hospital or are admitted, an infection would be identified by the monthly culture report received from Quest Diagnostic Laboratory. As far as staff involvement - she stated that if a staff member thought someone might have an infection they would call her. That would be the only way she would know. There was not a documented process that staff members followed to ensure the identification and reporting of infections to the Infection Control Nurse or Program. The Infection Control Nurse stated that she has been employed with the facility since December 2014 and her current focus has been on staff education. She stated she is monitoring hand hygiene, and developed a hand hygiene sheet which encourages staff to correct any observed hand hygiene breeches that may be observed. There was no documented data available. The facility did install additional hand sanitizer dispensers in the halls, outside of the patients room.

A review of the facility's Infection Control Meeting minutes from February 18, 2015 identifies reported to the NHSN (National Health Safety Network) - No ICU (Intensive Care Unit) infections from October - December (2014). Quest Lab report from October to December (2014), addressed the number of Blood, Urine, Respiratory and Miscellaneous infections - but no other information included for the committee to evaluate. Preceding quarter meeting minutes were not located. April 2014 meeting minutes discussed a TB exposure incident; an infection report given (no #'s presented); and next meeting June 2014.

On 05/28/2015 at approximately 08:40am a review of the facility's surveillance and infection identification process was reviewed with the Infection Control Nurse. She stated every month she receives a report from Quest Laboratory that identifies any patients ordered a 'culture' through the hospital. The report identifies the source of the culture: Urine, Blood, Respiratory or miscellaneous. The ICN then stated she reviews for Central Line associated infections, Ventilator associated infections and Urinary Catheter associated infections for the ICU patient and reports these numbers to the National Health Safety Network (NHSN). Blood stream, MRSA(Methicillin Resistant Staphylococcus Areas) infections and Clostridium difficile (C Diff) for inpatients are also reported to the NHSN. The ICN stated she had received no feedback from the NHSN.

The total number of these infections were presented to the Infection Control Committee in February. There was no other information presented to indicate whether an investigation, or analysis from previous data or numbers was conducted to indicate any trends that might suggest the need for corrective action or additional staff education or additional attention through Risk Management or the Quality Assurance Performance Improvement Program.

The Infection Control Nurse stated that the infection numbers are presented to the Quality Assurance Performance Improvement (QAPI) Program, but she was not aware or currently involved into what performance improvement measures had been identified in association with Infection Control Activities and that she had not been with the facility long enough to really get a full overview of the needs of the Infection Control Program. She did indicate in January began collecting information on CAUTI (Catheter Associated Urinary Tract Infections) on the Medical /Surgical Units, but there was no data available.

Confirmed through QAPI notes, that CMS Core Quality Measures are tracked and addressed and that no new quality measures had been identified.

2. On 05/27/2015 at approximately 10:50 am, a tour of one of four of the facility's Operating Room was conducted, accompanied by the facility's Operating Room Supervisor (ORS). Observed in Operating Room #4 was an atomic clock with a temperature indicating 64 degrees. The ORS was asked how temperature and humidity levels were monitored in the Operating Rooms. She stated, they just adjust the temperature if they need it, and that Maintenance would be responsible for monitoring humidity levels. She stated, as far as she knew this was not documented anywhere.

On 05/27/2015 at approximately 11:30am, an interview was conducted with the Maintenance Director. He stated that currently the Operating Room (OR) temperatures and humidity levels are not documented. Temperatures are monitored per room, but humidity levels are not monitored. He said the facility is in the process of inquiring cost for a process to monitor humidity levels in each OR.

Per AORN (Association periOperating Room Nurses), the recommended temperature levels in the Operating Suite should range from 68 degrees to 75 degrees. Operating Room (OR) #4 was 64 degrees but was not currently in use.

3. On 05/27/2015 at approximately 10:50am, a tour of OR#4 was conducted with the presence of the Operating Room Supervisor (ORS). The anesthesia cart in the Operating room was inspected and revealed:

(1) opened single dose vial of Diphenhydramine 50mg/ml with medication remaining in the vial. The vial was not labeled with any additional information. Medication expiration date 07/2016. Medication was located in the Anesthesia cart in the operating room.

(1) opened single dose vial of Phenylephrine 10mg/ml. There was medication remaining in the vial. The vial was not labeled with any additional information. Medication expiration date 05/2016.

(1) opened multi-dose vial of Rocuronium 10mg/ml with a handwritten discard date of "06/11/2015." It was stored in the anesthesia cart in the Operating room.

(1) opened multi-dose vial of Flumazenil 0.5mg/5ml. The vial had been opened and past the best used by date of "05/08/2015."

(1) opened Multi-dose vial of Ondansetron 40mg/20ml - labeled best use by date of 06/07/15. It was stored in the anesthesia cart in the operating room.

(1) opened Multi-dose vial of Labetalol Hydrochloride 100mg/ 20ml, best use by date of 05/29/2015.

The medications located in the anesthesia cart were confirmed with the ORS. She stated that multi-dose medications that were opened were to be dated, 28 days from date of open. She was not aware that multi-dose medications, used for more than one patient, should not be kept or accessed in the immediate patient treatment area and should be dedicated to that patient only and discarded after use.

On 05/27/2015 at approximately 11:15am an interview was conducted with the CRNA. She stated that opened single dose medications should not be in the anesthesia cart and should have been discarded after use. She was asked about the storage and use of multi-dose medication in an immediate patient treatment area, she was not aware that multi-dose medication opened and used within an immediate patient care area (the operating room) were to be considered single use.
Facility policies and procedures follow the United States Pharmacopeia (USP) General Chapter 797, Pharmaceutical Compounding - Sterile Preparations ("USP <797>"), regarding the use of Single Dose vials and labeling. Policy and Procedure entitled "Beyond Use Dating of Injectable Medications" indicates "All multi-dose vials properly stored are to be labeled for discard 28 days from the date the vial is first opened. The person opening the vial for the first time should place their initials on the vial." "Single dose vials, without preservative, must be discarded after one hour (60 minutes). The facility did not have a policy and procedure related to multi-use medications in immediate patient treatment area.