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Based on observations, record reviews, and staff interviews, it was determined the facility failed to ensure that each patient's intravenous (IV) tubing and/or tubing administration sets (Intravenous piggy backs/IVPB) were maintained in accordance with the facility's policy and procedures for three patients (#9, #28, and #30) in the selected sample of 30. Findings include:

Review of the policy and procedure "Guidelines for Infection Control in Intravenous Therapy" revealed all IV tubing and tubing administration sets are to be changed every 72 hours.

1. Review of Patient #9's medical record and review of the "IV Flow Sheet" revealed the patient was admitted on 01/03/11 and had an IV started on 01/03/11. As of 01/11/11, there was no documented evidence Patient #9's IV tubing and/or the patient's IVPB tubing was changed since the patient's admission on 01/03/11.

Observations conducted during a medication pass on 01/11/11 at 10:00 AM, revealed Patient #9 had an IV line with an IVPB line infusing into the main IV line.

An interview with the Registered Nurse, on 01/11/11 at 10:00 AM, revealed IV line tubing and IVPB line tubing was changed every 72 hours. She stated the patient's "IV Flow Sheet" indicated when his/her IV was started and this was also the tool used to enable the nurses to know when the IV tubing needed to be replaced.

2. Closed record review revealed Patient #28 was admitted to the facility on 11/08/10 and had an IV started on 11/08/10. Review of the medical record and the "IV Flow Sheet" revealed there was no documented evidence Patient #28's IV tubing was changed and/or the patient's IVPB tubing was changed since the patient's admission on 11/08/10. Patient #28 was discharged on 11/15/10.

3. Closed record review revealed Patient #30 was admitted to the facility on 11/12/10 and had an IV started on 11/12/10. Review of the medical record and "IV Flow Sheet" revealed the patient's IV infiltrated on 11/12/10 and was re-started on 11/13/10. There was no documented evidence Patient #30's IV tubing was changed since 11/13/10. The patient was discharged home on 11/22/10.

Interviews conducted with the Registered Nurse, Performance Improvement Nurse, Director of Nursing, and the Infection Control Nurse on 01/11/11, revealed all IV tubing and/or IVPB tubing should be changed within 72 hours as per the facility's policy and procedure. The Registered nurse revealed the failure to change Patient #9's IV tubing within 72 hours was an "oversight."

Based on record review and staff interviews, it was determined the facility failed to ensure that each patient's record contained either a history and physical examination completed within 24 hours of admission or an updated history and physical that had previously been completed within 30 days of admission for seven patients (Patients #6, #8, #9, #13, #19, #20, and #22) in the selected sample of 30. Findings include:

1. Review of the medical record for Patient #6 revealed he/she was admitted on 01/05/11. This record contained a history and physical examination that documented it was dictated and typed on 01/07/11, two days following admission.

2. Review of the medical record for Patient #8 revealed he/she was admitted on 01/08/11. This record contained a history and physical examination that documented it was dictated and typed on 01/10/11, two days following admission.

3. Review of the medical record for Patient #13 revealed he/she was admitted on 01/08/11. This record contained an updated history and physical examination that had been completed on a previous admission. However, review of this document revealed it was completed on 12/06/10, 33 days prior to the current admission date of 01/08/11.


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4. Review of the medical record of Patient #19 revealed he/she was admitted on 12/01/10. This record contained a history and physical examination that documented it was dictated and typed on 12/03/10, two days following admission.

5. Review of the medical record of Patient #22 revealed he/she was admitted from the emergency department on 11/21/10 at 1:30 PM. This record contained a history and physical examination that documented it was dictated on 11/22/10 at 11:52 PM and typed on 11/23/10 at 1:31 AM. Therefore, the history and physical was not in the medical record within 24 hours.

6. Review of the medical record of Patient #9 revealed he/she was admitted on 01/03/11. This record contained a history and physical examination that documented it was dictated on 01/05/11 at 8:33 AM and typed on 01/05/11 at 9:33 AM. Therefore, the history and physical was not in the medical record within 24 hours.

7. Review of the medical record of Patient #20 revealed he/she was admitted on 11/16/10 at 3:28 PM. This record contained a history and physical examination that documented it was dictated on 11/17/10 at 11:53 PM and typed on 11/18/10 at 7:10 AM. Therefore, the history and physical was not in the medical record within 24 hours.

An interview with the medical records director, on 01/12/11 at approximately 10:30 AM, revealed inpatient records were reviewed Monday through Friday by a member of the medical records office for timeliness of history and physical completions. Weekly listings of deficiencies were sent to the responsible physicians, quality assessment coordinator and chief executive officer. This information was also reported monthly in the medical staff meetings and to the chief of staff. Medical staff by-laws listed the possible suspension of privileges for any physician member who was delinquent in medical record completion. However, the medical records director was not aware if this disciplinary action had ever been used.




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Based upon record review and staff interviews, it was determined the facility failed to ensure a discharge summary was completed for each patient within thirty days of discharge. This was found for 8 of 12 discharge records reviewed (#19, #22, #23, #24, #25, #27, #29, and #30). Findings include:

Review of the Medical Staff Bylaws and Rules and Regulations revealed a discharge summary was to be completed and signed within 30 days following discharge. Additionally, if the hospital stay was less than 48 hours with only minor problems, a final progress note would substitute for a discharge summary. The progress note was to include the outcome of the stay, instructions given to the patient or family, final diagnoses, and provisions for follow-up care.

1. Review of the medical record for Patient #23 revealed he/she was admitted on 11/11/10 and had a hospital stay of 50 hours and 15 minutes before his/her discharge on 11/13/10. The record did not contain a discharge summary; even though, approximately two months had passed since the patient's discharge.

2. Review of the medical record for Patient #24 revealed he/she was admitted on 11/05/10 and discharged on 11/08/10. The record contained a discharge summary but review of this document revealed it was not dictated and typed until 01/03/11, approximately two months following the patient's discharge.

3. Review of the medical record for Patient #25 revealed he/she was admitted on 11/19/10 and discharged on 11/23/10. Review of this record on 01/12/11 revealed it did not contain a discharge summary.

4. Review of the medical record for Patient #27 revealed he/she was admitted on 12/02/10 and discharged on 12/05/10. Review of this record on 01/12/11 revealed it did not contain a discharge summary.

5. Review of the medical record for Patient #29 revealed he/she was admitted on 11/23/10 and discharged on 11/28/10. This record did not contain a discharge summary as of 01/12/11.


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6. Review of the medical record for Patient #19 revealed he/she was admitted on 12/01/10 and discharged on 12/03/10. Review of this record on 01/12/11 revealed it did not contain a discharge summary. There was a discharge progress note dictated and typed on 12/03/10. The progress note failed to contain information regarding instructions given to the patient or family and provisions for follow-up care (as in accordance with the Medical Staff Bylaws and Rules and Regulations). This record did not contain a discharge summary as of 01/12/11.

7. Review of the medical record for Patient #22 revealed he/she was admitted on 11/21/10 and discharged on 11/24/10. This record did not contain a discharge summary as of 01/12/11.

8. Review of the medical record for Patient #30 revealed he/she was admitted on 11/12/10 and discharged on 11/22/10. The record contained a discharge summary but review of this document revealed it was not dictated until 01/11/11 at 3:13 PM and typed until 01/11/11 at 8:53 PM, approximately one and a half months following the patient's discharge.

An interview with the medical records director, on 01/12/11 at approximately 10:30 AM, revealed medical records were reviewed by a member of the medical records office for timeliness of discharge summaries. Weekly listings of deficiencies were sent to the responsible physicians, quality assessment coordinator and chief executive officer. This information was also reported monthly in the medical staff meetings and to the chief of staff. Medical staff by-laws listed the possible suspension of privileges for any physician member who was delinquent in medical record completion. However, the medical records director was not aware if this disciplinary action had ever been used.
















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