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Based on review of records and interview with staff, the facility failed to ensure that the physician on-call to the emergency department (ED) was available on-site within the time-frame required by the hospital Medical Staff Rules and Regulations for 1 of 14 applicable patients whose records were reviewed.

Findings were:

The facility MEDICAL STAFF BY-LAWS AND RULES AND REGULATIONS, last revised and approved in October 2003, state under the section entitled EMERGENCY SERVICES that the physician on-call shall respond to the ED within 20 minutes after call from the hospital.

Review of the medical record of patient #6 revealed that the patient presented to the facility ED on 6/6/12 at 5:05 am. The patient complained of chills and a sore throat. Patient #6 had chronic illnesses listed as coronary artery disease, diabetes mellitus, and hypertension. The physician on-call, staff # 7, failed to respond to the ED within the facility's requirement of 20 minutes and left telephone orders for the disposition of the patient.

These findings were acknowledged by the facility Director of Nursing during an in-person interview the afternoon of 7/10/12.

Based on observation during a tour of the facility with staff #11, the facility failed to ensure that all electrical and patient care equipment was maintained in safe operating condition.

Findings were:
A tour of the facility was conducted the morning of 7/10/12 in the company of staff #11.
In the bedroom area of room 113 there was no call light available for patient use. In the bathrooms of rooms 110, 112, 113, 114 and 115 it was observed that the call light cord was only six inches long. If a patient had fallen and was on the floor, this cord could not be reached and patient safety would be compromised.

In the kitchen area, the screen door leading outside had a torn screen; therefore, it does not prevent vermin from entering the building. This was the only door to the outside and was utilized by vendors and meals on wheels volunteers Inside the walk-in freezer, the plastic strips were observed to be iced over and there was ice on the floor and frame of the door.
This posed a safety hazard and may lead to alterations in the temperature in the freezer
An interview with staff #11 during the tour confirmed the above findings.

Based on a tour of the facility with staff #11 conducted the morning of 7/10/12, the facility was found to have patient care supplies and equipment and areas of the facility that were not intact and could not be cleaned, causing potential infection control problems.

Findings were:

In the ultrasound room, the patient table had a 1 1/2 inch tear in the upholstery and the physical therapy area had a positioning device that was cracked, with peeling areas. These items are not cleanable and are a potential infection control issue.

In the kitchen there was a 4 inch hole in the ceiling from a water leak. In the X-ray department there were holes in the walls by the electronic units in room #1 and in room #2. Also in the emergency department (ED) trauma room, the wall behind the code timer was not intact, as there was a 5 inch hole. These items are not cleanable and are a potential infection control issue.

In the x-ray department, boxes and positioning devices were observed to be stored on the floor making it difficult to clean the floor under the items and exposing them to liquids. Also in the x-ray department was an IV pole which had multiple areas of chipped paint. Another IV pole in the medical inpatient unit was observed with chipped paint. The ceiling tiles in multiple areas of the facility were observed to be stained from leaks and water damage; at least 20 tiles were affected. These items are not cleanable and are a potential infection control issue.

In the ED, the patient exam table in treatment room #1 had a 2 inch ripped area on the bottom corner. The walls in the two treatment room were observed to have multiple areas of chipped and missing paint, and the cabinets in both rooms also had chipped paint. In trauma rooms #1 and #2, the wallpaper was loose by the windows and peeling from the walls, and there were also areas of chipped paint. These open areas are not smooth and cleanable and are a potential infection control issue.
In an in-person interview conducted during the tour, staff #11 confirmed the above findings.

Based on review of documentation and interview with staff, the facility governing body failed to ensure that policies were revised and administered in order to provide quality health care in a safe environment for 5 of 5 applicable CAH patients whose records were reviewed. The governing body failed to update medical staff rules and regulations to ensure compliance with state requirements pertaining to verbal physician order authentication and reports placed in patient charts in a timely manner.

Findings were:

The facility MEDICAL STAFF BY-LAWS AND RULES AND REGULATIONS, last approved by the governing body in October 2003, state under the section MEDICAL RECORDS that a complete history and physical examination shall be done on all patients ....."within forty-eight (48) hours after admission." Additionally, the RULES AND REGULATIONS state under the section PHYSICIAN ORDERS, that physician orders shall be signed "as soon as possible" by the attending physician and that orders dictated over the phone shall be signed by the person giving the order.

Review of the medical record of Patient #15 revealed that between the dates of 6/12/12 - 6/21/12, physician Staff #10 gave 9 telephonic and/or verbal orders; none of the orders were signed by the physician. Review of the medical record for Patient #17 revealed that on 6/18/12, a verbal order was received from a physician that was not signed. It could not be determined if the order was issued by physician Staff #7 or physician staff #10, as the nursing staff who received the order did not indicate the first name of the physician. Patients #16, #18 and #19 had verbal and telephonic orders in their medical records that had been signed by the physicians; however, it could not be determined if they were authenticated within 48 hours, as the physicians did not date or time their signatures.

Review of the medical record of Patient #16 revealed that the patient was admitted on 5/10/12; however, the H&P report was not placed in the chart until 5/25/12. Review of the medical record of Patient #19 revealed that the patient was admitted 4/30/12; however, the H&P report was not placed in the medical record until 5/3/12. Patient #15 was admitted to the facility on 6/12/12; however, the H&P was not placed in the medical record until 7/3/12.

These findings were acknowledged by the facility Director of Nursing during an in-person interview the afternoon of 7/10/12.

Based on observation and interviews with staff on 7/10/12, the facility failed to ensure that that drugs were stored according to accepted professional principles; that current and accurate records were kept of the receipt and disposition of all scheduled drugs; and that outdated, mislabeled, or otherwise unusable drugs were not available for patient use.

Findings were:

On the morning of 7/10/12 a medication cabinet in the endoscope cleaning room contained Narcan, Versed and Morphine. Versed and Morphine are controlled medications. The pharmacy tech in interview indicated that the pharmacy staff, including the director of Pharmacy, did not have a key to the medication cabinet. There were no control medication reconciliation records available for review for these medications to trace the movement of the scheduled drugs throughout the hospital.

Facility policy #15-01 revealed that the facility has overall responsibility for controlled drugs and that the director of Pharmacy acts as the hospital agent to ensure security of the control drugs.

In an interview conducted the morning of 7/10/12, staff #11 revealed that the nursing director for surgery has the keys to the medication cabinet. At the time of the survey the nursing director for surgery was on vacation. The keys to the controlled medication cabinet were brought to staff #11 by the respiratory therapist. At the time of the survey, these were the only keys available to the controlled medication cabinet. It appeared that while the surgery nurse was on vacation, the respiratory therapist was in control of the keys to the controlled medication cabinet in surgery.

Also found during the tour of the facility on 7/10/12 were the following expired drugs and supplies:
The following patient care supplies were also observed to be beyond the manufacturers expiration dates, but available for patient use -
4 each pediatric urine collector exp 6/10
1 gastrocult developer exp 5/12
6 endotraechael tubes expired 12/08
6 angiocaths expired from 05/08
1 dee lee suction exp 11/09
15 each connecting tubing exp 11/10
3 each Vaseline gauze exp 12/10
1 IV catheter exp 1/04
8 butterfly IV expired 9/09
39 each winged tip IV sets exp 4/12
14 each coiled extension sets exp 12/10
6 Flexam exp 9/10
12 Allevyn exp 12/10
4 duo derm exp 10/11
8 Iontophoresis pads exp 7/09
9 electrodes exp 8/04

These findings were confirmed in an interview with staff #11 conducted on 7/10/12 during the tour of the facility.

Based on review of documentation and interviews with staff, the facility failed to have an effective quality assurance (QA) program that evaluates all patient care services and other services affecting patient health and safety. The facility QA program evaluates services on an inconsistent basis and does not address all issues reported by the various departments.

Findings were:

The facility TOTAL QUALITY MANAGEMENT PLAN was reviewed. According to the plan ' s Purpose and Objectives, the QA program should include an " on-going monitoring and reporting system for problem and/or improvement identification. " The form entitled SURGERY QI SCREEN FOR ONGOING MONITORING for August 2011 was completed by the surgery director. All critical indicators were scored 100%. The director noted that the QI indicators were no longer relevant to the department ' s needs and requested that the indicators be updated. In the meeting the following month, August 2011, those issues raised by the surgery director were not addressed and the minutes stated that there were no problems identified by the Surgery Department.

The facility TOTAL QUALITY MANAGEMENT PLAN also designates which departments are to report monthly and which report quarterly. According to the plan, the Emergency Department (nursing) is supposed to report monthly. In the minutes of the meeting 4/18/12, the ED report indicated that several clinical indicators were falling below the established threshold. The following month, 5/16/12, meeting minutes did not reference the ED at all.

The facility TOTAL QUALITY MANAGEMENT PLAN outlines the responsibilities of the Total Quality Manager. The Manager has the responsibility and authority to request follow-up information from any hospital department. The minutes of meetings 9/21/11, 4/18/12, and 5/16/12 indicate that Medical Nursing Service did not supply the required reports to the committee for review. Additionally, the Manager stated in minutes of 5/16/12 that an ER Audit Filter (not defined in the TOTAL QUALITY MANAGEMENT PLAN) had not been officially completed since July of 2011. The Total Quality Manager did not indicate in any documentation that follow-up to these missing reports was requested or pursued.

These findings were acknowledged by staff #11 in an in-person interview conducted the afternoon of 7/10/12.