HospitalInspections.org
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RED BAY HOSPITAL
No Description Available
Tag No.: C0204
Based on interview with staff and review of emergency equipment, it was determined the facility's emergency equipment did not include a ventilator. This had the potential to affect all patients served.
Findings include:
On a tour of the facility on 5/4/10, the surveyor reviewed the emergency equipment. There was no ventilator available for use.
An interview with Employee Identifier # 1 (Director of Nurses) on 5/4/10 at 2:00 P.M. verified the facility did not have a ventilator.
No Description Available
Tag No.: C0205
Based on interview with staff and review of policy manual, it was determined the facility failed to have a policy in place to address infectious blood or blood products. This had the potential to affect all patients served.
Findings include:
The laboratory policies and procedures were reviewed on 5/5/10. There was no policy available for review to address potentially infectious blood and blood products.
An interview with Employee Identifier #2 (Director of Laboratory Services) on 5/5/10 at 11:30 AM confirmed there was no established policy.
No Description Available
Tag No.: C0220
Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.
Findings were:
Refer to Life Safety Code violations.
No Description Available
Tag No.: C0303
Based on observations of the medical records department, review of medical staff bylaws and interview with staff, it was determined the facility failed to follow the medical staff bylaws for completion of medical records.
Findings include:
The medical staff bylaws, approved and reviewed 1/18/10, included, "21. If the medical record is incomplete fifteen days after being placed in the physician's box in the Medical Records Department, a written notice shall be sent to the physician by the CEO (Chief Executive Officer) notifying him that his admitting privileges shall be suspended seven days from the date of notice and that he shall remain suspended until all incomplete records of the physician have been completed."
A tour of the medical records department was conducted on 5/5/10 at 10:30 AM. The storage area for uncompleted records revealed numerous discharged patient records requiring completion by the physicians.
An interview conducted on 5/5/10 at 10:30 AM with Employee Identifier # 3 (Director of Medical Records) revealed 50% of discharged records were incomplete and the bylaws had not been followed for completion of records.