HospitalInspections.org

Based upon review of medical records, Medical Staff Rules and Regulations, and staff interview, the hospital failed to ensure the Medical Staff followed the established Medical Staff Rules and Regulations as evidenced by: 1) Failure of the physician to document the date on the dictated History and Physical for 1 of 9 medical records (#2), and 2) Failure to complete a History and Physical for 1 of 9 medical records (#6). Findings:

Review of the Medical Staff Rules and Regulations revealed "#13. A complete history and physical examination shall be completed by a physician or other qualified individual no more than 30 days before or 24 hours after admission for each patient..."

Review of patient #2's medical record revealed a dictated History and Physical (H&P) was in the medical record; however, the dictated H&P failed to identify a date when the H&P was dictated or transcribed.

Review of patient #6's medical record revealed the patient was admitted to the hospital on 11/13/12 and discharged on 12/04/12. Further review of the medical record revealed a pre-printed H&P form that was dated 01/08/13 by physician S6; however, the H&P form was blank. Interview with S2 RN, on 01/15/13 at 1:30 PM, revealed after reviewing the H&P form, he confirmed the H&P was left blank. Further interview with S2 RN revealed he spoke with physician S6 who told him that on 01/08/13, he was directed by the medical record department that he needed to sign some medical record entries; however, he did not notice that he had signed a blank H&P on patient #6.

Based upon observations and staff interviews, the hospital failed to ensure the medication room where drugs were stored was locked. On 01/16/13 at 10:55 AM, observations revealed the medication room door, located at the back of the nursing station, was left open with no staff present. Findings:

Observations on 01/16/13 at 10:55 AM, revealed the medication room door was left open and no staff were present in the nursing station. Located on the window ledge on the inside of the nursing station was a manilla envelope containing a patient specific medication, Clozapine in a punch card. At 10:59 AM, S11 Licensed Practical Nurse, returned to the nursing station.

On 01/16/13 at 11:25 AM, S2 RN observed the medication room door open with no staff present in the nursing station or the medication room. Interview with S2 RN during this observation revealed the medication room door was to remain closed at all times if the nurse was not in the nursing station or in the medication room. Further observations on 01/16/13 from 1:00 PM to 4:00 PM and 01/17/13 from 8:30 AM to 2:00 PM revealed the medication room door was closed and locked.

Based upon review of the Therapeutic Dietary Manual and staff interview, the hospital failed to ensure the manual was current. The Manual had not been reviewed and approved by the Dietitian and Medical Staff since January 2009. Findings:

Review of the dietary manual titled "Manual of Medical Nutrition Therapy" revealed the manual was last reviewed and approved by the Dietitian, Medical Staff, and Governing Body in January 2009.

Interview with S2 RN on 01/17/13 at 9:30 AM, revealed he produced the Dietary Manual, which was located in the nurse charting area, and stated this was the only Therapeutic Dietary Manual the hospital had. S2 RN further confirmed the manual had not been reviewed or approved since 2009.

Based upon review of personnel files and staff interviews, the hospital failed to ensure the nursing staff was qualified to perform respiratory treatments to the patients. The personnel files for Registered Nurses (RN's) S14, S15, S17 and S18, and Licensed Practical Nurse (LPN) S16 failed to contain education, training, and competency evaluations to ensure the nursing personnel were competent to administer respiratory treatments to the hospital patients. Findings:

Review of the personnel files for RN S14, RN S15, LPN S16, RN S17 and RN S18 revealed the files failed to contain documented evidence the nurses were competent to perform respiratory care treatments to the patients.

Interview with S2 RN on 01/17/13 at 11:00 AM revealed the nursing staff administer respiratory therapy treatments and the hospital has a contract with a respiratory therapist who provides inservices and training to the nursing staff; however, the education and training failed to be documented in the nursing personnel files.

Interview with S13 RN and S11 LPN on 01/17/13 at 11:15 PM, revealed they had received training from the contract respiratory therapist "some time in 2012". Interview with S12 LPN revealed she had prior experience administering respiratory treatments but since her employment with the hospital, has not received any education or training or had her competencies evaluated by the contract respiratory therapist.

Based upon review of 3 of 4 closed records out of a sample size of 9, Medical Staff Rules and Regulations, and staff interview, the hospital failed to ensure a discharge summary was completed within 30 days after discharge, in accordance with the Medical Staff Rules and Regulations, for patients #5, #6, and #7. Findings:

Review of the Medical Staff Rules and Regulations revealed "#12. The attending physician shall be held responsible for the preparation of a complete medical record for each patient within thirty (30) days after discharge..."

Review of patient #5's medical record revealed the patient was admitted to the hospital on 09/24/12 and discharged on 10/11/12 to an acute care hospital. There failed to be a documented discharge summary related to the patient's psychiatric, physical and functional condition upon discharge.

Review of patient #6's medical record revealed the patient was admitted to the hospital on 11/13/12 and discharged on 12/04/12. There failed to be a documented discharge summary related to the patient's psychiatric, physical and functional condition upon discharge.

Review of patient #7's medical record revealed the patient was admitted to the hospital on 11/06/12 and was transferred to an acute care hospital for admission due to acute renal failure on 11/12/12. Further review of the medical record revealed there failed to be a documented discharge summary related to the patient's psychiatric, physical and functional condition upon discharge.

Interview with S7 on 01/15/13 at 3:25 PM, revealed she was responsible for all dictation transcriptions and there were no outstanding discharge summary dictations that needed to be transcribed. S7 further stated if the discharge summary was not in the patient's medical record, then the discharge summary was not completed by the physician.