HospitalInspections.org

Based on interview and physician file review, the facility failed to credential 1of 2 (#A) Telemedicine Radiologists. Findings include:

Interview with the Radiology Director, on 10/26/10 at approximately 1000, revealed that the Radiology Department utilized contract out-of-state Radiologists to read x-rays during off hours. A review of two contract physicians files specified revealed that Physician #A did not have a credential file. The Quality Manager was only able to provide a license and resume that stated the physician was self employed. An application, National Professional Data Base search, recommendation and privileges had not been done. Review of the facility Medical Staff Bylaws, Credential Procedures dated 2/27/10 specified that for Telemedicine Privileges, "the hospital fully privileges and credentials the practitioner; or the hospital privileges practitioners using credentialing information from the distant site if the distant site is a Joint Commission-accredited organization. The Telemedicine Physician #A did not meet this requirement as the information was not evident in the file provided. Further interview with the Quality Manager, on 10/28/10 at approximately 1200, verified that credentialing for this physician had not been done as required.

Based on records reviewed and interview the facility failed to ensure the medical record contained information to describe the patient's progress for 2 of 3 outpatient therapy records. (MR #'s 71 &72) Findings include:

MR #71: The patient's start of care date was 9/24/10 with diagnoses that included; left total knee arthroplasty. The "Physical Therapy-Plan of Care Certification, Initial Evaluation: Assessment and Treatment Plan" dated 9/24/10 had content that included; "Impression/Functional Limitations", "Long Term Goals", and "Treatment Plan"for the physicians review. The subsequent communication to the physician on the "Physical Therapy-Progress Note" dated 10/8/10, declared; "Short term goals are partially met". The outpatient facility failed to identify the content of the Short Term Goals for the physicians review on the initial plan of care.
Also, the "Physical Therapy Progress Note" dated 10/22/10, declared; "Long term goals are partially met". The physical therapist failed to identify which of the 3 Long Term Goals were partially met and the degree to which they remained unmet.

MR #72: The patient's start of care date was 8/19/10 with diagnoses that included; Back and Neck pain. The "Physical Therapy-Plan of Care Certification, Initial Evaluation: Assessment and Treatment Plan" dated 8/19/10 had content that included; "Impression/Functional Limitations", "Long Term Goals", and "Treatment Plan"for the physicians review. The subsequent communication to the physician on the "Physical Therapy-Progress Note" dated 9/16/10, declared; "Short term goals are partially met". The outpatient facility failed to identify the content of the Short Term Goals for the physicians review on the initial plan of care.

Based on record review, medical staff bylaws review and interview the facility failed to ensure that all patient medical record entries were complete with authentication, date and time, by the person responsible for providing the service, in 13 out of 28 (#17, #18, #19, #20, #21, #22, #37, #42, #43, #45, #67, #69, #70)clinical records reviewed. Findings include: During medical record review of patient #17, it was found that the "Pre-Operative Orders for Colon and Rectal Surgery" had not been signed by the ordering physician. The "Post-Anesthesia Care Unit Order Set" had not been dated or timed by the physician. The "Physician ' s Orders" had not been timed by the physician. The "Consult OR Management " had not been timed by the physician.
During medical record review of patient #18, it was found that the "Physician's Orders" on 10/23/2010 had not been signed, dated or timed by the physician. The "Physician ' s Orders" on 10/24/2010 had not been dated or timed by the physician. The "Laparoscopic Appendectomy or Cholecystectomy Outpatient Discharge Instructions" had not been timed by the physician. The " Acute Pain Control PCA Order Set " had not been dated or timed by the physician. The "Physician's Orders" on 10/22/2010 had not been timed by the physician. The "Physician's Orders "on 10/22/2010 had not been signed, dated or timed by the physician. The " Physician ' s Orders" on 10/22/2010 had not been signed dated or timed by the physician. The "Physician's Orders" on 10/22/2010 had not been dated or timed by the physician. The "Adult Nausea/Vomiting Prevention and Treatment Guidelines" had not been dated or timed by the physician. The "Post-Anesthesia Care Unit Order Set" had not been dated or timed by the physician.
These findings were confirmed by the 2 South Nurse Manager and the Director of Medical/Surgical and Respiratory Services.
During medical record review of patient #19, it was found that the "Emergency Dept. List of Medications" had not been signed, dated or timed. The "Physician's Orders" had not been timed.
During medical record review of patient #20, it was found that the "Physician's Orders" had not been timed by the physician.
These findings were confirmed by the 2 North Nurse Manager and the Director of Medical/Surgical and Respiratory Services.
During medical record review of patient #22 it was found that the "Record of Death" had not been signed by the registered nurse.
During medical record review of patient #37 it was found that the "Record of Death" had not been signed by the registered nurse.
During medical record review of patient #45 it was found that the "Consent for Surgery or Other Invasive Procedure had not been dated or timed by the physician. The "Physician's Diagnostic Record History and Physical" had not been dated or timed by the physician.
During medical record review of patient #67 it was found that the "Post-Anesthesia Care Unit Order Set" had not been dated or timed by the physician.
These findings were confirmed by the 4 South Nurse Manager and the Director of Medical/Surgical and Respiratory Services.
During medical record review of patient #69 it was found that on three pages of "Physician's Orders" had not been signed, dated or timed by physician. The "Physician's Orders" had not been dated or timed by the physician.
During medical record review of patient #70 it was found the "Inpatient VTE Prophylaxis Risk Assessment and Protocol for Adults Older than 17 Years" had not been signed, dated or timed by the physician.
These findings were confirmed by the 4 North Nurse Manager and the Director of Medical/Surgical and Respiratory Services.
During review of the medical staff bylaws under the section "ORDERS" (f), (1), it states "Orders for treatment shall be in writing and shall be signed, dated and timed ....Orders shall be signed by the person to whom dictated with the name of the physician per his or her own name. All orders should be signed within 48 hours."


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Patient #21:
During review of the document titled "Post-Anesthesia Follow up Visit" , it was noted that there was no time or date for the order set. The document only contained a physician signature.

Patient #42:
During review of the document titled "Adult Nausea/Vomiting Prevention and Treatment Guidelines" there was no documented date, or time. The document only contained a physician signature.
During review of the document titled "Post-Anesthesia Care Unit Order Set" , it was noted that there was no time or date for the order set. The document only contained a physician signature.
During review of the document titled "Post-Anesthesia Follow up Visit" , it was noted that there was no time or date for the order set. The document only contained a physician signature.

Patient #43:
During review of the document titled "Post-Anesthesia Care Unit Order Set" , it was noted that there was no time or date for the order set, which included no time or date for when the physician signed the orders.
During review of the document titled "Implant / Explant Device Record" there was no record for the "Signature of Nurse/Physician " .
During review of the document titled "Pre-Procedure Protocol" there was no documented date by the physician who initiated the protocol.
During review of the document titled "Peri-Operative Anesthesia" (Adult, IV & Medication Order Set) there was no documented patient name, date, or time. The document only contained a physician signature.

Based on staff interview, record review, and Medical Staff By-Laws review it was determined the facility failed to ensure that all discharged inpatient's clinical records were complete, including an authenticated signature from the attending physician. Findings include:
During an interview, and record review with the Manager of Medical Records and Quality Information Specialist on 10-27-10 at 1000, it was identified there were 965 incomplete inpatient clinical records that were awaiting signatures from the physician 30 days following the patient's discharge from the hospital.
During review of the Medical Staff By-Laws under the section INCOMPLETE RECORDS it states (c) All records shall be completed within 30 days of discharge.

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-710.

The facility failed to maintain a sanitary and safe environment as evidenced by high dusting on pyxis machines and insufficient lighting levels at scrub & hand wash sinks.

Findings Include:

During the facility tour on 10/26/2010 with the Facilities Director high dusting was observed on top of the pyxis machines located in the clean supply rooms #3097, 3114, 3136, 3142, 3152, $ 3202.

During the facility tour on 10/28/2010 with the Facilities Director the lighting level at the scrub sink serving Cath Lab #2 measured 40 foot candles. This is below the minimum 75 foot-candles of illumination required per the Illuminating Engineering Society of North America, IESNA Publication CP29, Lighting for Health Facilities.

During the facility tour on 10/28/2010 with the Facilities Director the lighting level at the scrub sink serving Cath Lab #3 measured 50 foot candles. This is below the minimum 75 foot-candles of illumination required per the Illuminating Engineering Society of North America, IESNA Publication CP29, Lighting for Health Facilities.

During the facility tour on 10/28/2010 with the Facilities Director the lighting level at the hand wash sinks serving the Emergency Department measured between 14-21 foot candles. This is below the minimum 30 foot-candles of illumination required per the Illuminating Engineering Society of North America, IESNA Publication CP29, Lighting for Health Facilities.

During the facility tour on 10/28/2010 with the Facilities Director insufficient lighting levels were observed at the hand wash sinks serving the Pre & Post Op Recovery Area. The under cabinet lighting above the hand wash sinks lacked lens covers and light bulbs.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on October 29, 2010, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated October 29, 2010, for Life Safety Code.

Based on observation and interview the facility failed to ensure that all supplies and equipment were maintained to ensure an acceptable level of safety and quality. Findings include:
During the initial tour of the facility on unit 2 North on 10/25/2010 at approximately 1015 it was found that the following supplies were expired:
Supply Room #1:
Forty-five blue top blood collection tubes with expiration of 09/10
Thirty-eight yellow top blood collection tubes with expiration of 07/10
Twenty-two yellow top blood collection tubes with expiration of 09/09
One yellow top blood collection tube with expiration of 08/10
Supply Room #2:
Fifty-three blue top blood collection tubes with expiration of 09/10
Thirty-eight yellow top blood collection tubes with expiration of 07/10
Fifty-eight pink top blood collection tubes with expiration of 09/10
Eight pink top blood collection tubes with expiration of 04/09
These findings were confirmed by the 2 North Nurse Manager and the Director of Medical/Surgical and Respiratory Care.


27408

During tour of the Surgical Department on 10/26/10 at 1405, the following outdated supplies were found:
1. 45mm Endo-path staple reload outdated 04/10
2. 1 Stone Retrieval Basket Set outdated 08/10
3. 1 Stone Retrieval Basket Set outdated 03/10
4. Opened Endo tube, size 8.0 placed back in clean stock
5. Opened Endo tube, size 8.5 placed back in clean stock
6. Cordis H-Stick, 6 fr. Outdated 04/10