HospitalInspections.org

[Information from our copies of record may be released only to authorized individuals,] and the hospital must ensure that unauthorized individuals cannot gain access to or alter patient records.

This STANDARD is not met as evidenced by:
Based on touring the hospital and interviews with the Chief Operating Officer July 12-14, 2011, it was determined that the hospital did not ensure that unauthorized individuals could not gain access to or alter patient records.

Findings include:

Patient lists were found in an unsecured closet in Room 1137.

Drug administration errors, adverse drug reactions, and incompatibilities must be immediately reported to the attending physician and, if appropriate, to the hospital-wide quality assurance program.

This STANDARD is not met as evidenced by:
Based on review of medical records and interviews with the Director Quality, Risk * Safety on July 14, 2011, it was determined the there was no documented evidence that drug errors were immediately reported to the attending physician in three (3) of five (5) records.
(RECORDS: FF, HH and II)

Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality.

This STANDARD is not met as evidenced by:
Based on touring the hospital and interviews with the Chief Operating Officer July 12-14, 2011, it was determined that there was evidence that the hospital failed to maintain the facilities and equipment to ensure an acceptable level of safety and quality.

Findings include:

1. Ceiling tiles were stained in hallway outside the Operating Room, in the Endoscopy cleaning room and storage area, in the Infusion Center and Anticoagulation Clinic and in the PARC reception area.

2. Ceiling tiles were missing in Central Sterile, in the Operating Room housekeeping closet and in the scope storage closet in the Endoscopy Unit.

3. Electrical cords/wires were plugged into outlets but not into electrical devices. These live wires ends were found in the Psychiatric Unit, and in the in the Penobscot Bay internal Medicine building.

4. There was an extension cord being used for a microwave oven in the Penobscot bat Internal Medicine building.

The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice.

This CONDITION is not met as evidenced by:
Based on review of medical records, review of meeting minutes and interviews with key staff on May 16-18, 2011 and additional interviews on July 13, 2011, it was determined that the hospital failed to meet the emergency needs of the patients in accordance with acceptable standards of practice. The evidence is as follows:

1. The Emergency Department Policy "Triage of the Obstetrical Patient" stated, "PROCEDURE...6. Vaginal bleeding - late in pregnancy (more than 20 weeks gestation). This may indicate placenta previa or placenta abruption. a. Notify Maternity. b. Transfer to maternity as quickly as possible on a stretcher. OR 7. Abdominal pain/cramping: no vaginal bleeding (more than 20 weeks gestation). Triage to Maternity. 1. Notify maternity. 2. Arrange transport."

2. Patient b was evaluated in the ED. The Director, Quality, Risk & Safety agreed during an interview on May 18, 2011, that this was a violation of the policy.

3. During an interview with the CNW on May 18, 2011, he/she stated, "The ED called me and said should Patient B come to OB and I said no, please keep the patient and evaluate for kidney stones. I did not do an evaluation on OB..I should have but I had seen the patient that a.,. and figured it was the same issue." Additionally he/she stated, "If the patient had come to OB another vaginal exam would have been prepared for the outcome."

4. The Director, Quality, Risk & Safety stated that the Nurse midwife gave an order for Patient B to be evaluated in the ED but no documentation of the order was found in Patient B's medical record.

5. During an interview with the Nurse Midwife on May 18, 2011, he/she stated, "I received a call from the ED nurse asking if [Patient B] should be sent to OB. I said no, please keep her in the ED and evaluate for renal stones.

6. During interviews with key staff on May 18 and July 13, 2011, it was verified that the same level of fetal monitoring was not available in the Emergency Room as was available on the OB/GYN Unit, for Patient B.

7. A Nursing Note which documented an assessment of Patient B performed in the ED by an OB nurse reported, "It was noted by the nurse a pad in the trash that appeared to have a bloody discharge. ED MD [Medical Doctor] states he was aware.

8. The Emergency Department Note for Patient B dated July 16, 2010 stated, "She states that the pain started a day or 2 before across her lower back and into the lower abdomen. She denied any uterine contractions or bleeding." There was no documentation of a speculum examination, nor any notation of vaginal bleeding or acknowledgement of a bloody pad."

9. A review of Patient b's history and Physical dictated by Physician A stated, "....She did report some vaginal discharge and in the Emergency room, began to experience some vaginal bleeding." There was no documentation in the ED Note of any vaginal bleeding.

10. Patient B was admitted to the OB unit and the nurses note dated 0100 7/17/2010 stated, "Pt admitted to ob [obstetrics] unit with report of 10/10 pain r/t [related to] renal stones. Upon arrival to unit, assisted patient to bathroom. pt [patient] noted to have frank bloody discharge on pad. [physician A] notified, and entered pt's room for assessment, vaginal exam, revealed 9cm cervix, clear ROM occurred. Non-viable male infant delivered at 0048. Infant wrapped in warm blanket and cuddled by mother."

11. A telephone interview was conducted with the Emergency Department Medical Director on July 13, 2011. He/she stated that there were no new protocols/practices identified related to the incident with Patient B.

-----

12. Patient A's medical record stated that she presented to the hospital on August 14, 2010, and was diagnosed with abruption placenta. A C-Section was performed on August 15, 2010. Patient A's initial hemoglobin was 12 fell to 6 after the surgery with a documented blood loss of 1000 cc.

13. During an interview with Physician A on may 18, 2011, he/she stated, "[Patient A's] medical record does not contain evidence of my medical decision making regarding the patient's anemia."

14. During an interview with Physician B on May 18, 2011, when asked what he/she would expect to see in a medical record regarding the medical decision making process, he/she stated that there should be clear documentation of that process.