HospitalInspections.org

Based on observation, staff interview and document review the governing body failed to ensure that all health care professionals had on file a full set of verified credentials that had been reviewed in accordance with the medical staff bylaws prior to that individual being permitted to exercise professional privileges in the hospital. In so doing, the governing body had permitted one health care professional (Chiropractor FF) to treat patients, with only one certification document, his state license, on file. This failure exposed patients to care of unknown value and possible harm.

Findings:

On 8/13/12, during the initial hospital tour, a large poster was noted to be on display adjacent to the main elevator announcing the services of Chiropractor FF that was available in one of the hospital's out-patient clinics. On 8/13/12 at 4:45 p.m. the Medical Staff Coordinator (Staff G) was asked to provide Chiropractor FF's credential file, and a small manila folder was presented for review. This folder contained two copies of the practitioner's license issued by the California Board of Chiropractic Examiners, one expiring in May 2012 and the current one expiring in May 2013. The only other document in the folder was the practitioner's professional liability insurance certificate. Staff G stated that Chiropractor FF was not a member of the medical staff, had not been granted any clinical privileges and had never applied for membership or privileges.



15746

Based on observation, staff interview and document review the governing body failed to ensure that all health care professionals had on file a full set of verified credentials that had been reviewed in accordance with the medical staff bylaws prior to that individual being permitted to exercise professional privileges in the hospital. In so doing, the governing body had permitted one health care professional (Chiropractor FF) to treat patients, with only one certification document, his state license, on file. This failure exposed patients to care of unknown value and possible harm.

Findings:

On 8/13/12, during the initial hospital tour, a large poster was noted to be on display adjacent to the main elevator announcing the services of Chiropractor FF that was available in one of the hospital's out-patient clinics. On 8/13/12 at 4:45 p.m. the Medical Staff Coordinator (Staff G) was asked to provide Chiropractor FF's credential file, and a small manila folder was presented for review. This folder contained two copies of the practitioner's license issued by the California Board of Chiropractic Examiners, one expiring in May 2012 and the current one expiring in May 2013. The only other document in the folder was the practitioner's professional liability insurance certificate. Staff G stated that Chiropractor FF was not a member of the medical staff, had not been granted any clinical privileges and had never applied for membership or privileges.

Based on document review and staff interview, the facility failed to ensure that all outside companies were providing services under a current contractual arrangement in 2 of 11 contracts.

Findings:

1. The written agreements for outside services used by the medical records department were reviewed on 8/14-15/12. The release of information agreement, signed 7/8/2002 was with a differently-named company, who was apparently purchased by the current company. The duties described in this 10-year old agreement were not reflective of those currently being performed. The initial term of the agreement was for one year, with an automatic renewal for "a one-year term unless expressly terminated in writing at least 60 days prior to expiration." This wording was not clear whether the term was to automatically renew in successive years.

2. The agreement, signed 2/6/2012, with the company providing "secure destruction services" was reviewed on the afternoon of 8/14/12. There was no clause requiring that the confidentiality of the copies of medical records was being maintained. On the afternoon of 8/15/12, a Business Associate Agreement (BAA), signed 8/15/12, was provided. The BAA addresses the requirement of the company to maintain confidentiality of the medical records.

The above findings were confirmed by Staff QQ on the afternoon of 8/15/12.

Based on document review and staff interview, the governing body failed to have a mechanism in place that was designed to ensure that all services furnished under contracts are provided safely, effectively and in a manner that would always permit the hospital to comply with all applicable standards and conditions of participation. This lack overview for the contracted services could potentially permit contractors to provide unsafe or poor quality services that may harm employees or patients.

Findings:

On 8/13/12 the hospital's quality improvement plan and the administration's list of contracted services were requested. The list of contracts provided was laid out in a table with four columns, titled "ID", "Entity", "Scope" and "Department." The table contained 76 lines, each with a unique ID number. A number of the lines had the same "Entity" name repeated as found on other lines. The column titled "Scope" contained a short phrase that expressed some aspect of the service provided or the type of contract. The list did not contain any quality indicators or other information related to the quality of service provided or how the quality indicator by which that service was to be evaluated.

On 8/14/12 at 4:00 p.m. the administration's Executive Assistant (Staff DD) was asked to explain how the listed services provided under contract were evaluated for to make sure that those services were provided in a safe and effective manner. Staff DD said that the hospital's Chief Financial Officer (CFO, Staff F) was responsible for maintaining the list of contracts and for doing the related quality review.

The quality improvement plan provided by the hospital is a three page document titled "(Hospital Name) Quality Assurance Plan 2012" (QA Plan). On page 2 under the section titled "Quality Indicators," this document states that the "indicators shall focus on the functions listed in the attached QA Grid and shall measure the effectiveness and safety of services and quality of care." On 8/15/12 at 9:00 a.m. a list of the QA Grid and a list of the quality indicators that had been selected for each of the contracted services were requested of Staff DD. The QA Grid provided was a 24 page spreadsheet titled "(Hospital Name) Quality Assessment & Patient Safety Improvement Indicators 2011-1012." This printed spreadsheet contained 130 named "Indicators" each on a separate line and two columns for data obtained relative to that indicator during the first and second quarters of 2012. Many of these lines had no data recorded for either quarter 1 or quarter 2 or both.

During review of QA Grid it was noted that none of the 130 listed indicators contained any apparent reference to any of the 76 contracted services enumerated in the list of contracts. As a result of this observation, sometime later during the morning of 8/15/12 a second request was made for the quality indicators that had been selected for those services provided under contract and an explanation of how the quality review was done by the CFO. In response, a meeting was set up and on 8/15/12 at 2:00 p.m. during that meeting with the Chief Executive Officer (CEO, Staff P), the Chief Medical Officer (CMO, Physician BB) and the Chief Operations Officer (COO, Staff C), the hospital's QAPI activities were explained. The QA Grid was again reviewed and the administrative officers acknowledged that the QA Grid did not include quality indicators for the contracted services. It was explained that for contracted services a quality review survey tool (Survey Tool) was used to document containing 9 key questions. At that meeting there was no further data provided about how the quality assessment of contracted services was conducted, and the Survey Tool with 9 questions was not provided.

During the morning of 8/16/12 beginning at 10:15 a.m., during an interview with Staff C, a copy of the Survey Tool and a 4 page table containing the Survey Tool results for 2011 was provided and reviewed. The Survey Tool is titled "Business Associate Satisfaction Survey" and consists of two page with nine questions and check boxes to indicate either Y (yes), N (no) or N.A (not applicable). The table of Survey Tool results for 2011 has the names of 76 contracted "Entities" with their "Scope", "Department", the corresponding answers for questions 1 through 9 and a "Comments" column. Staff C acknowledged that no quality indicators (QI's) had been developed for any of the contracted services that had been tailored to the type of services provided.

The nine questions on the Survey Tool are:
1.) Are you satisfied with the quality of services that this Business Associate provides under the specific agreement?
2.) Is the service that this Business Associate provides timely?
3.) When you have contact with the Business Associate, is the response appropriate
4.) If applicable, does your Agreement have satisfactory assurance documented that your Business Associate will implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of the electronic protected health information that the Business Associate creates, receives, maintains or transmits on behalf of the covered entity?
5.) Does your Agreement ensure that any agent, including a subcontractor, to which the Business Associate provides such information, agrees to implement reasonable and appropriate safeguards to protect it?
6.) Does your Agreement authorize termination of the agreement by the covered entity if the covered entity determines that the Business Associate has violated a material term of the contract?
7.) Is this Business Associate's Quality Assurance program relevant and appropriate to the services provided by (Hospital)?
8.) Has this Business Associate provided their Quality Assurance program results to you?
9.) Has the services provided by this Business Associate been provided in a safe and effective manner?

At the conclusion of that interview, Staff C acknowledged that many of these nine questions were subjective and the hospital had not established any written guidelines specifying how the questions should be judged. He stated that the individuals filling out these Survey Tools varied depending on the department and type of service. Often but not always it was the department head associated with the service that completed the Survey Tools. He acknowledged that only the last question specifically addressed safety and efficacy. He did not know how the Survey Tool had been developed. Nor could he provide evidence that use of the Survey Too had improved the quality, safety or efficacy provided by any of the listed contacted services. He stated that the hospital had no other specific mechanism in place to assure the quality, safety or efficacy of these services.




15746

Based on document review and staff interview, the governing body failed to have a mechanism in place that was designed to ensure that all services furnished under contracts are provided safely, effectively and in a manner that would always permit the hospital to comply with all applicable standards and conditions of participation. This lack overview for the contracted services could potentially permit contractors to provide unsafe or poor quality services that may harm employees or patients.

Findings:

On 8/13/12 the hospital's quality improvement plan and the administration's list of contracted services were requested. The list of contracts provided was laid out in a table with four columns, titled "ID", "Entity", "Scope" and "Department." The table contained 76 lines, each with a unique ID number. A number of the lines had the same "Entity" name repeated as found on other lines. The column titled "Scope" contained a short phrase that expressed some aspect of the service provided or the type of contract. The list did not contain any quality indicators or other information related to the quality of service provided or how the quality indicator by which that service was to be evaluated.

On 8/14/12 at 4:00 p.m. the administration's Executive Assistant (Staff DD) was asked to explain how the listed services provided under contract were evaluated for to make sure that those services were provided in a safe and effective manner. Staff DD said that the hospital's Chief Financial Officer (CFO, Staff F) was responsible for maintaining the list of contracts and for doing the related quality review.

The quality improvement plan provided by the hospital is a three page document titled "(Hospital Name) Quality Assurance Plan 2012" (QA Plan). On page 2 under the section titled "Quality Indicators," this document states that the "indicators shall focus on the functions listed in the attached QA Grid and shall measure the effectiveness and safety of services and quality of care." On 8/15/12 at 9:00 a.m. a list of the QA Grid and a list of the quality indicators that had been selected for each of the contracted services were requested of Staff DD. The QA Grid provided was a 24 page spreadsheet titled "(Hospital Name) Quality Assessment & Patient Safety Improvement Indicators 2011-1012." This printed spreadsheet contained 130 named "Indicators" each on a separate line and two columns for data obtained relative to that indicator during the first and second quarters of 2012. Many of these lines had no data recorded for either quarter 1 or quarter 2 or both.

During review of QA Grid it was noted that none of the 130 listed indicators contained any apparent reference to any of the 76 contracted services enumerated in the list of contracts. As a result of this observation, sometime later during the morning of 8/15/12 a second request was made for the quality indicators that had been selected for those services provided under contract and an explanation of how the quality review was done by the CFO. In response, a meeting was set up and on 8/15/12 at 2:00 p.m. during that meeting with the Chief Executive Officer (CEO, Staff P), the Chief Medical Officer (CMO, Physician BB) and the Chief Operations Officer (COO, Staff C), the hospital's QAPI activities were explained. The QA Grid was again reviewed and the administrative officers acknowledged that the QA Grid did not include quality indicators for the contracted services. It was explained that for contracted services a quality review survey tool (Survey Tool) was used to document containing 9 key questions. At that meeting there was no further data provided about how the quality assessment of contracted services was conducted, and the Survey Tool with 9 questions was not provided.

During the morning of 8/16/12 beginning at 10:15 a.m., during an interview with Staff C, a copy of the Survey Tool and a 4 page table containing the Survey Tool results for 2011 was provided and reviewed. The Survey Tool is titled "Business Associate Satisfaction Survey" and consists of two page with nine questions and check boxes to indicate either Y (yes), N (no) or N.A (not applicable). The table of Survey Tool results for 2011 has the names of 76 contracted "Entities" with their "Scope", "Department", the corresponding answers for questions 1 through 9 and a "Comments" column. Staff C acknowledged that no quality indicators (QI's) had been developed for any of the contracted services that had been tailored to the type of services provided.

The nine questions on the Survey Tool are:
1.) Are you satisfied with the quality of services that this Business Associate provides under the specific agreement?
2.) Is the service that this Business Associate provides timely?
3.) When you have contact with the Business Associate, is the response appropriate
4.) If applicable, does your Agreement have satisfactory assurance documented that your Business Associate will implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of the electronic protected health information that the Business Associate creates, receives, maintains or transmits on behalf of the covered entity?
5.) Does your Agreement ensure that any agent, including a subcontractor, to which the Business Associate provides such information, agrees to implement reasonable and appropriate safeguards to protect it?
6.) Does your Agreement authorize termination of the agreement by the covered entity if the covered entity determines that the Business Associate has violated a material term of the contract?
7.) Is this Business Associate's Quality Assurance program relevant and appropriate to the services provided by (Hospital)?
8.) Has this Business Associate provided their Quality Assurance program results to you?
9.) Has the services provided by this Business Associate been provided in a safe and effective manner?

At the conclusion of that interview, Staff C acknowledged that many of these nine questions were subjective and the hospital had not established any written guidelines specifying how the questions should be judged. He stated that the individuals filling out these Survey Tools varied depending on the department and type of service. Often but not always it was the department head associated with the service that completed the Survey Tools. He acknowledged that only the last question specifically addressed safety and efficacy. He did not know how the Survey Tool had been developed. Nor could he provide evidence that use of the Survey Too had improved the quality, safety or efficacy provided by any of the listed contacted services. He stated that the hospital had no other specific mechanism in place to assure the quality, safety or efficacy of these services.

2. The Medical Staff Rules and Regulations, approved 7/26/11, were reviewed on 8/15/12. Section XVII, F. (a) (vii) states that the Quality Assessment and Improvement/Utilization Review Committee shall perform the duty to " review, act upon, and disseminate information, on a regular basis, reports and factors affecting the quality, appropriateness, and efficiency of patient care provided in the hospital, including review of ...medical records .... "

The minutes of the Committee, which meets quarterly, were reviewed with Staff M on 8/16/12, beginning at 3:05 pm. In the two meetings held so far in 2012, there was no Health Information Management (medical records department) representative at the meeting, nor was a report submitted. Upon review of the 2011 meeting minutes, there was minimal reporting of medical records issues presented; and nothing was presented regarding information about documentation, clinical pertinence, or timely completion issues. Staff M concurrently verified the lack of substantive data being shared and discussed by this committee.





28773

Based on staff interviews and review of hospital documents the hospital failed to measure, analyze and track quality indicators for the social services department.

Findings:

1. On 8/15/12 at 12:15 p.m. an interview was conducted with the Social Worker UU regarding quality assessment for his department. Social Worker UU stated he does not monitor or track any quality or performance indicators for his department or report to the quality committee. He stated he came back from a medical leave in April and since that time, he has had a day nurse tell him there should be a message for him to come and see a patient but when he checks his messages there is nothing regarding that patient. Social Worker UU stated this has happened about five times since he has been back (approximately four months). During medical records review on 8/15/12, one of three records reviewed for nutrition care revealed there was a social worker consult ordered however Social Worker UU was not ever notified by nursing staff.

On 8/16/12 at 1:30 p.m. an interview was conducted with Administrative Staff M regarding the quality assessment indicators for the social services department. Staff M stated they track utilization management reports, immunization and smoking cessation. At 2:00 p.m. Administrative Staff C joined the interview and confirmed the three things they track for case management and social service departments. They acknowledged they did not track or monitor any activity relating to the social worker consults for the patients admitted into the hospital or identify this as an issue.

Based on document review, and staff interview the bylaws do not contain specifications that a qualified health care provider must complete and document a medical history and physical examination for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. This omission permitted patients to be admitted and/or undergo surgeries or procedures without the benefit of documented information intended to help keep patients less likely to have additional medical problems.

Findings:

On 8/13/12 and 8/14/12 the Medical Staff Bylaws and Rules were reviewed and it was noted that sections II-B and II-F of the Rules are the sections dealing with the admission and/or pre-surgical Medical History and Physical Examination (H&P) as well as the update to the H&P. These sections do not specify that the H&P must be (both) completed and recorded no more than 30 days prior of 24 hours after admission, but also prior to any surgeries or procedures requiring anesthesia services. Nor do they specify that the H&P must be dated, signed and specifically placed in the patient's hospital record before any surgery/procedure and at least within the first 24 hours after admission.

During review of patients records 7 of 26 records (Patients 23, 24, 25, 26, 27, 28 & 29) of patients undergoing either surgery or a procedure done with anesthesia services did not contain an H&P which had been completed and documented no more than 30 days prior to procedure and prior to admission, dated, signed and in the hospital record prior to the procedure. (Refer to A-952).

On 8/16/12 at 10:00 a.m. the Chief Executive Officer (CEO, Staff P), the Chief Medical Officer (CMO, Physician BB), the Medical Staff President (MS Pres., Physician AA) and the Medical Staff Coordinator (Staff G) all agreed that sections II-B and II-F were well intended, but did specify everything in this section of the regulations.




15746

Based on document review, and staff interview the bylaws do not contain specifications that a qualified health care provider must complete and document a medical history and physical examination for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. This omission permitted patients to be admitted and/or undergo surgeries or procedures without the benefit of documented information intended to help keep patients less likely to have additional medical problems.

Findings:

On 8/13/12 and 8/14/12 the Medical Staff Bylaws and Rules were reviewed and it was noted that sections II-B and II-F of the Rules are the sections dealing with the admission and/or pre-surgical Medical History and Physical Examination (H&P) as well as the update to the H&P. These sections do not specify that the H&P must be (both) completed and recorded no more than 30 days prior of 24 hours after admission, but also prior to any surgeries or procedures requiring anesthesia services. Nor do they specify that the H&P must be dated, signed and specifically placed in the patient's hospital record before any surgery/procedure and at least within the first 24 hours after admission.

During review of patients records 7 of 26 records (Patients 23, 24, 25, 26, 27, 28 & 29) of patients undergoing either surgery or a procedure done with anesthesia services did not contain an H&P which had been completed and documented no more than 30 days prior to procedure and prior to admission, dated, signed and in the hospital record prior to the procedure. (Refer to A-952).

On 8/16/12 at 10:00 a.m. the Chief Executive Officer (CEO, Staff P), the Chief Medical Officer (CMO, Physician BB), the Medical Staff President (MS Pres., Physician AA) and the Medical Staff Coordinator (Staff G) all agreed that sections II-B and II-F were well intended, but did specify everything in this section of the regulations.

Based on document review, and staff interview the bylaws do not contain specifications that a qualified health care provider must complete and document an updated examination of the patient, including any changes in the patient's condition within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination are completed within 30 days before admission or registration. This omission permitted patients to be admitted and/or undergo surgeries or procedures without the benefit of documented information intended to help keep patients less likely to have additional medical problems.

Findings:

On 8/13/12 and 8/14/12 the Medical Staff Bylaws and Rules were reviewed and it was noted that section II-F of the Rules is the section dealing with the update to the H&P (H&P Update). This section does not specify that the H&P Update must be (both) completed and recorded within 24 hours of admission and no more than 24 hours prior to any surgeries or procedures requiring anesthesia services. Nor does it specify that the H&P Update must be dated, signed and specifically placed in the patient's hospital record before any surgery/procedure and at least within 24 hours prior to or after admission.

During review of patients records 7 of 26 records (Patients 23, 24, 25, 26, 27, 28 & 29) of patients undergoing either surgery or a procedure done with anesthesia services, did not contain pre-surgical H&Ps Updates that documented an examination of the patient done within 24 hours before the procedure, documented if any changes that may have occurred since the prior exam, which had been signed and placed in the hospital record before the procedure. (Refer to A-952).

On 8/16/12 at 10:00 a.m. the CEO (Staff P), the CMO (Physician BB), the MS Pres. (Physician AA) and Staff G all agreed that section II-F was well intended, but did specify all aspects required of the H&P Update by this section of the regulations.




15746

Based on document review, and staff interview the bylaws do not contain specifications that a qualified health care provider must complete and document an updated examination of the patient, including any changes in the patient's condition within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination are completed within 30 days before admission or registration. This omission permitted patients to be admitted and/or undergo surgeries or procedures without the benefit of documented information intended to help keep patients less likely to have additional medical problems.

Findings:

On 8/13/12 and 8/14/12 the Medical Staff Bylaws and Rules were reviewed and it was noted that section II-F of the Rules is the section dealing with the update to the H&P (H&P Update). This section does not specify that the H&P Update must be (both) completed and recorded within 24 hours of admission and no more than 24 hours prior to any surgeries or procedures requiring anesthesia services. Nor does it specify that the H&P Update must be dated, signed and specifically placed in the patient's hospital record before any surgery/procedure and at least within 24 hours prior to or after admission.

During review of patients records 7 of 26 records (Patients 23, 24, 25, 26, 27, 28 & 29) of patients undergoing either surgery or a procedure done with anesthesia services, did not contain pre-surgical H&Ps Updates that documented an examination of the patient done within 24 hours before the procedure, documented if any changes that may have occurred since the prior exam, which had been signed and placed in the hospital record before the procedure. (Refer to A-952).

On 8/16/12 at 10:00 a.m. the CEO (Staff P), the CMO (Physician BB), the MS Pres. (Physician AA) and Staff G all agreed that section II-F was well intended, but did specify all aspects required of the H&P Update by this section of the regulations.

Based on staff interview and review of the hospital personnel records, the hospital failed to ensure that all nursing personnel have current performance evaluations.

Findings:

On 8/16/12 at 11:00 a.m., review the personnel records indicated that 2 of 6 Licensed nursing staff had performance evaluations that were not current.
One licensed nurse had a performance evaluation completed on 4/2011 and one licensed nurse evaluation was last completed 11/14/10.

During an interview on 8/16/12 at 1:00 p.m., Staff I acknowledged that the evaluations were not current and indicated that the hospital policy was that performance evaluations were to be completed annually.

Based on staff interviews and review of medical records and hospital documents the hospital failed to ensure: 1) the nursing screen was accurate for one patient (Patient 5), 2) there was a new admission weight for one patient (Patient 5), 3) there was a timely follow up on a social services referral for one patient (Patient 6). Not effectively evaluating or implementing the required nursing care for each patient can result in compromising their medical status.

Findings:

1. Review of the medical record for Patient 5 was conducted on 8/15/12. Patient 5 was admitted to the hospital on 8/10/12 with diagnoses that include right subdural hematoma (a form of traumatic brain injury). Review of the "Med/Surg Nursing Admission Assessment" dated 8/10/12, indicated under the section titled skin there was a pressure ulcer (bedsore, a lesion caused by unrelieved pressure on soft tissues overlying a bony prominence which reduces or completely obstructs the blood flow to the superficial tissues) on the coccyx (tailbone) with a date of 8/8/12. It indicated the wound status was current. It also indicated there was redness, swelling, odor and drainage. Further review of the Nursing Admission Assessment indicated the weight on admission was 120.78 pounds (54.9 kilograms) with a date of 7/27/12. Review of the Nursing Admission Assessment indicated the gastrointestinal (GI) section was within normal limits. There was no anorexia or no recent weight loss. No documentation that the Registered Dietitian (RD) was notified despite nutrition risk factors.

Review of the ICU Nursing Flowsheet dated 8/13/12 indicated Patient 5 weighed 49.4 kg (108.68 pounds). This weight indicated Patient 5 has a BMI of 16. Review of the ICU Nursing Flowsheet dated 8/14/12 indicated Patient 5 weighed 47.9 kg (105.38 pounds). This weight indicated Patient 5 had a BMI of 15.5. This weight indicates that Patient 5 had lost 12.1 pounds from 7/27/12 to 8/13/12 (17 days) which is 10% weight loss and considered severe weight loss.

An interview was conducted on 8/15/12 at 9:20 a.m. with the Registered Dietitian (RD) OO. RD OO stated they will get a consult from the Nursing Admission Assessment if there is any kind of pressure ulcer and if any two criteria from the gastrointestinal section are checked. The criteria includes anorexia (decreased appetite) and recent weight loss.

An interview was conducted on 8/15/12 at 3:26 p.m. with Nurse Manager O. Nurse Manger O stated the dietitian should have been consulted with a wound. She stated the electronic form should populate a section to consult the dietitian. Upon further review of the electronic nursing admission assessment it was identified that when the old wound was carried over, the part about consulting the dietitian did not populate. The Nurse Manager O stated someone should update the electronic medical record with the recent weight however it should have been taken upon admission.

An interview was conducted on 8/15/12 at 3:50 p.m. with Nurse Manager O. Nurse Manager O stated if a nurse sees a pressure ulcer they need to contact the manager or the house supervisor who would stage the wound and write the wound care order for the stage of wound. The Nurse Manager O stated the nurse could initiate the wound care protocol but the orders would only come from the manager or designee.

An interview was conducted on 8/16/12 at 10:50 a.m. with RD SS. RD SS stated when she spoke with Patient 5 he easily stated he had been losing weight and had not been eating well. RD SS stated she was unsure why the Nursing Admission Assessment stated he was within normal limits with no recent weight loss or no anorexia. RD SS stated either the wound or GI section should have brought them in earlier.

An interview was conducted on 8/16/12 at 12:10 p.m. with Nurse Manager O. The Nurse Manager O stated and showed the surveyor there was a picture of the wound taken on 8/11/12 however they did not follow their policy by calling a manager or house supervisor then initiating the protocol and wound care order sets. The Nurse Manager O stated she did not see any wound order sets in the medical record.

An interview was conducted on 8/16/12 at 1:30 p.m. with Nursing Administrative Staff M. Staff M stated a fresh assessment should be done on each patient when they are admitted to the hospital. Staff M also stated they should not be able to bring over past skin issues from previous admissions in the electronic medical record onto the new admission assessment. Staff M stated they should have entered in a current weight into the electronic medical record with each new admission.

Review of the hospital's policy and procedure titled Admission Nursing Form Procedure dated 8/91 revised 5/08 reviewed 6/09 indicated the Registered Nurse will perform a problem focused assessment on admission based on data gathered by the Licensed Vocational Nurse. On admission the date, time, and mode of arrival and the first set of vital signs will be recorded. Height and weight will be taken and at completion of the assessment the form will be given to the unit clerk to enter into the computer. It also indicated the skin condition is to be described by checking the appropriate box indicating the location of the rash, wound, etc. on the body picture, and by describing the skin problem in narrative notes. All wounds must be photographed. A skin risk score will be made using the Braden scale and the pressure ulcer prevention protocol will be initiated if indicated. It indicated if two or more of the following abnormalities exist for the gastro-intestinal assessment then the nurse will request a clinical dietitian consult. The abnormalities are weight loss, anorexia, nausea, vomiting, diarrhea, constipation or dysphagia (swallowing difficulty).

Review of the hospital's policy and procedure titled Pressure Ulcers dated 9/88 revised 8/11, indicated for all wound care upon assessment of patient and discovery of a pressure ulcer the bedside nurse will notify their charge nurse, house supervisor, and physician within their shift. It indicated the house supervisor will notify the units nurse manager or their designee within 24 hours; either by phone call or email. The Nurse Manager or their designee will stage the wound and initiate wound care orders per protocol.

2. Review of the medical record for Patient 6 was initiated on 8/15/12. Patient 6 was admitted to the hospital on 8/4/12. Review of the physician's orders dated 8/9/12 at 1:59 p.m. indicated a social services consult. Review of the medical record and the electronic medical record showed no documentation of a social services note. Review of a consult notification worksheet dated 8/9/12 at 3:21 p.m. indicated the Social Worker was paged. The worksheet indicated if the consult is not completed after two days then to notify the supervisor. There was no documentation on the worksheet of any further communication regarding the consult.

An interview was conducted on 8/15/12 at 11:11 a.m. with Case Manager TT. The Case Manager TT stated the social worker who works in her department saw the patient today (6 days after the consult was ordered). The Case Manager stated the patient's mother called and left a message with the social worker and the social worker contacted the social worker who works in Case Management. The Case Manager TT provided the surveyor with an Utilization Management Acuity Assessment. The Case Manager TT stated they document in an electronic file which is not a part of the electronic record or put in the paper chart. Review of the Utilization Management Acuity Assessment with an admission date of 8/4/12 indicated in the Case Manager notes dated 8/15/12 that a social services note was completed.

An interview was conducted on 8/15/12 at 12:15 p.m. with Social Worker UU. Social Worker UU stated he never received the page on 8/9/12. Social Worker UU stated he received a voicemail from Patient 6's mother on 8/14/12 and then he referred to the Case Management Social Worker to see. Review of Social Worker UU's calendar indicated he left work at 3:00 p.m. on 8/9/12. Social Worker UU stated when he leaves he turns off his pager. He stated the staff know that if he does not call back in 60 seconds then to page again and if still no call back they should leave him a voicemail.

An interview was conducted on 8/16/12 at 1:30 p.m. with Administrative Nursing Staff M. Staff M stated the social worker should have documented in the progress notes not on the other form. Staff M stated it is her expectation that the referral would be completed quicker than six days. Staff M stated the morning checks should be done by the unit clerk and if a consult has not been completed then they should notify their supervisor or charge nurse. Staff M stated the staff know the system and she was not sure what happened and why this referral was missed.

Based on staff interviews, review of medical records, and review of hospital documents the hospital failed to ensure the social worker was notified of a consult therefore there was lack of a timely assessment completed by social services for one patient (Patient 6).

Findings:

Review of the medical record for Patient 6 was initiated on 8/15/12. Patient 6 was admitted to the hospital on 8/4/12 with diagnoses that include chest pain, chronic obstructive pulmonary disease (disease of the lungs in which the airways become narrowed). Review of the physician's orders dated 8/9/12 at 1:59 p.m. indicated a social services consult. Review of the medical record and the electronic medical record showed no documentation of a social services note. Review of a consult notification worksheet dated 8/9/12 at 3:21 p.m. indicated the Social Worker was paged. The worksheet indicated if the consult is not completed after two days then to notify the supervisor. There was no documentation on the worksheet of any further communication regarding the consult.

An interview was conducted on 8/15/12 at 11:11 a.m. with Case Manager TT. The Case Manager TT stated the social worker who works in her department saw the patient today. The Case Manager stated the patient's mother called and left a message with the social worker and the social worker contacted the social worker who works in Case Management. The Case Manager TT provided the surveyor with an Utilization Management Acuity Assessment. The Case Manager TT stated they document in an electronic file which is not a part of the electronic record or put in the paper chart. Review of the Utilization Management Acuity Assessment with an admission date of 8/4/12 indicated in the Case Manager notes dated 8/15/12 that a social services note was completed (6 days after the consult was ordered).

An interview was conducted on 8/15/12 at 12:15 p.m. with Social Worker UU. Social Worker UU stated he never received the page on 8/9/12. Social Worker UU stated he received a voicemail from Patient 6's mother on 8/14/12 and then he referred to the Case Management Social Worker to see. Review of Social Worker UU's calendar indicated he left work at 3:00 p.m. on 8/9/12. Social Worker UU stated when he leaves he turns off his pager. He stated the staff know that if he does not call back in 60 seconds then to page again and if still no call back they should leave him a voicemail. Social Worker UU stated he usually sees his referral the day he receives them or the next day.

An interview was conducted on 8/16/12 at 1:30 p.m. with Administrative Nursing Staff M. Staff M stated the social worker should have documented in the progress notes that is in the electronic medical record not on the other form. Staff M stated it is her expectation that the referral would be completed quicker than six days. Staff M stated the morning checks should be done by the unit clerk and if a consult has not been completed then they should notify their supervisor or charge nurse. Staff M stated the staff know the system and she was not sure what happened and why this referral was missed and not done timely.

Review of the hospital's policy titled Social Services Case Identification revision dated 3/10, indicated cases are referred by Registered Nurses/Case Managers, physicians, nursing staff, and other hospital staff, patients and their families. It indicates in order to provide comprehensive health care for the hospital-based patient, it is essential that the psychosocial needs of the patient be professionally assessed and treated.

Based on review of the hospital personnel records, the hospital failed to ensure that: 1) One non-employee licensed nurse received orientation that included training for emergency procedures and 2) One non-employee licensed nurse received basic orientation, training of nursing and safety policies and procedures and training in emergency procedures.

Findings:

Review of two non-employee nursing care staff personnel files on 8/16/12 at 11:00 a.m., revealed no documentation of training for emergency procedures.

There was no documentation that one non-employee licensed nurse received basic orientation or who the regular staff nurse was that provided supervision. There was no documentation of training of nursing and safety policies and procedures.

Based on document and medical record review, and staff interview, the facility failed to ensure that all entries were complete, dated, timed, and authenticated in 5 of 6 records.

Findings:

The Medical Staff Rules and Regulations, approved 7/26/11, were reviewed on 8/14/12. Section II. L. states: "All clinical entries in the patient's medical record shall be accurately dated, timed, and authenticated by the responsible practitioner...."

The following records were reviewed 8/15-16/12. The findings were confirmed with Staff M on 8/16/12, beginning at 2:25 p.m.:

1. Records 13 and 14 each contained entries that were not timed when written (pre and post procedure/operative orders and anesthesia orders)

2. Record 14 contained an "Ambulatory Services Physician's Record" form that included sections for a brief history and physical examination, orders, the operative procedure note, and the discharge summary. The only section that included a date was on the pre and post procedure orders sections.

3. Records 15 and 16 each contained an Oxygen Record; however the entries were only initialed and there was no space on the form for staff to document their full signature and credentials.

4. Record 11 contained a Pre Anesthesia Evaluation form that was incomplete. Three of the five sections for documenting assessment of the body systems were not completed by the anesthesiologist.

Based on medical record review and staff interview, the facility failed to ensure that the Conditions of Admission (COA) consents were signed in 1of 6 records. This failure had the potential to result in the facility treating patients without documentation of the patient/responsible party's consent and to result in the lack of documentation of financial responsibility for payment of services rendered.

Findings:

Record 12, an infant born in the hospital, was reviewed on 8/15/12 beginning at 1:20 p.m. On the COA consent in the space where the parent/guardian was to sign, the word "surgery" was written. Upon interview with Staff SS on 8/16/12 at 2:40 p.m., she stated that it meant the mother was in surgery and unable to sign the consent. She further explained that the usual procedure was to leave the COA with the nursing unit for the staff to obtain the mother's signature later; however, this was not done and there was no method for follow-up. Staff SS stated that there was no written policy and procedure addressing this process.

Based on document review and interview, the facility failed to ensure that records were completed within the required time period (14 days following the patient's discharge).

Findings:

During an interview with Staff QQ on 8/15/12 beginning at 2 p.m., she stated that there were 401 delinquent medical records (those that are still incomplete 14 days following the patient's discharge, as defined by the facility). She provided the report showing that, for the past 12 months, the average number of discharges was 760 inpatients per month. On the afternoon of 8/20/12, the facility provided a report with a breakdown of these delinquent records, showing that there were 35 reports that needed to be dictated (for example: discharge summaries, operative reports, and consultations) and 391 entries that needed to be signed by a total of 66 providers (physicians and allied health professionals).

Based on staff interviews, record review and review of hospital documents the hospital failed to ensure the nutrition needs of patients were met as evidenced by: 1) the renal diet and meal plans were not analyzed to ensure they met the current Recommended Dietary Allowances (RDA) or the Dietary Reference Intakes (DRIs) of the Food and Nutrition Board or the National Research Council, and 2)lack of a timely nutrition assessment was completed for one patient (Patient 5). This put patients at risk of renal menus not providing required nutrients and compromising medical care.

Findings:

1. An interview was conducted on 8/16/12 at 11:00 a.m. with the Food Service Director K regarding the nutrient analysis of the menus. Food Service Director K stated she did the analysis for the cardiac and 2 gram Sodium, Regular, and consistent carbohydrate controlled diets. She stated the Chief Clinical RD did the nutrient analysis for the renal diets.

Registered Dietitian OO was asked for the nutrient analysis of the renal menus on 8/16/12 at 11:00 a.m. She stated that nutritional analysis of the renal menus was based on the regular diet with some changes for the high potassium foods which they give the kitchen a list of foods then they would make a selection. RD OO stated they did not have a formal renal menu. RD OO stated they analyzed the renal menu for protein, carbohydrate, sodium, potassium, and phosphorus however it is just a template that does not include the actual food items. RD OO stated they did not do an analysis of all the different RDAs or DRIs.

Review of the renal calories and protein calculation figure sheet, indicated it was a generic template that did not have any of the actual food items. Review of the meal plans indicated there is a 60 gram (g) protein, 2 g sodium, 2 g potassium, 1 g phosphorus diet renal diet; a standard renal diet that is 70 g protein, 2 g sodium, 2 g potassium, 1 g phosphorus; a standard renal diet that is 80 g protein, 2 g sodium, 2 g potassium, 1 g phosphorus, and a standard renal diet that is 100 g protein, 2 g sodium, 2 potassium, 1 g phosphorus. These diets show an actual calorie, protein, sodium, potassium and phosphorus amount however it is not clear what food items were used to come up with this calculation. The menus did not analyze for the extensive nutrition listing in the Recommended Dietary allowances for fiber, Vitamin K, Zinc, Vitamin C, Vitamin A, Calcium, Folate, B12, B6, Niacin, Vitamin D, Magnesium, and Iron.

There was no complete analysis to ensure the quantifiable amounts of all nutrients were provided for the renal diet.


2. Review of the medical record for Patient 5 was conducted on 8/15/12. Patient 5 was admitted to the hospital on 8/10/12 with diagnoses that include right subdural hematoma (a form of traumatic brain injury). Review of the Med/Surg Nursing Admission Assessment dated 8/10/12 indicated under the section titled skin there was a pressure ulcer (bedsore, a lesion caused by unrelieved pressure on soft tissues overlying a bony prominence which reduces or completely obstructs the blood flow to the superficial tissues) on the coccyx (tailbone) with a date of 8/8/12. It indicated the wound status was current. It also indicated there was redness, swelling, odor and drainage. Further review of the Nursing Admission Assessment indicated the weight on admission was 120.78 pounds (54.9 kilograms (kg)) with a date of 7/27/12 and a Body Mass Index (BMI) of 18. A BMI of 18.5 or less indicates underweight. Further review of the Nursing Admission Assessment indicated the gastrointestinal (GI)section was within normal limits. There was no anorexia or no recent weight loss. No documentation that the Registered Dietitian (RD) was notified despite nutrition risk factors.

Review of the ICU Nursing Flowsheet dated 8/13/12 indicated Patient 5 weighed 49.4 kg (108.68 pounds). This weight indicated Patient 5 has a BMI of 16. Review of the ICU Nursing Flowsheet dated 8/14/12 indicated Patient 5 weighed 47.9 kg (105.38 pounds). This weight indicated Patient 5 had a BMI of 15.5. This weight indicates that Patient 5 had lost 12.1 pounds from 7/27/12 to 8/13/12 (17 days) which is 10% weight loss and considered severe weight loss.

A comprehensive nutrition assessment dated 8/15/12 (5 days after admission) revealed Patient 5 had a nutritional diagnosis of severe protein-energy malnutrition related to acute disease resulting from acute/severe inflammation, sepsis, acute kidney injury, pneumonia, chronic disease resulting from milk to moderate inflammation, chronic obstructive pulmonary disease, recent acute respiratory failure, previous admission with mechanical ventilation as evidenced by depleted albumin, 80% usual body weight in a 6-8 month period, 75% of his ideal body weight, BMI of 18. It also indicated Patient 5 had inadequate oral food/beverage intake related to chewing difficulty and an extended period of poor intake as evidenced by the patient's assessed nutrition needs are not consistently being met when/if the patient does not drink all of the supplements. The estimated nutrition needs were based on the weight dated 7/27/12 not on the most recent weight dated 8/14/12. There was no documentation or mention of the 10% weight loss.

An interview was conducted on 8/15/12 at 9:20 a.m. with the Registered Dietitian (RD) OO. RD OO stated they will get a consult from the Nursing Admission Assessment if there is any kind of pressure ulcer and if any two criteria from the gastrointestinal section are checked. The criteria includes anorexia (decreased appetite) and recent weight loss. RD OO stated if something is identified in the high nutrition risk category then that alone will place the patient in that time frame. RD OO stated they will assess high nutrition risk in 1-3 days of admission.

An interview was conducted on 8/15/12 at 3:20 p.m. with RD OO. RD OO stated they should have gotten a consult if there was a wound identified upon admission. RD OO stated the RD should have assessed his weight using the recent weights.

An interview was conducted on 8/15/12 at 3:26 p.m. with Registered Nurse (RN) O. RN O stated the dietitian should have been consulted with a wound. She stated the electronic form should populate a section to consult the dietitian. Upon further review of the electronic nursing admission assessment it was identified that when the old wound was carried over, the part about consulting the dietitian did not populate. The RN OO stated someone should update the electronic medical record with the recent weight however it should have been taken upon admission.

An interview was conducted on 8/16/12 at 10:50 a.m. with RD SS. RD SS stated when she spoke with Patient 5 he easily stated he had been losing weight and had not been eating well. RD SS stated she was unsure why the Nursing Admission Assessment stated he was within normal limits with no recent weight loss or no anorexia. RD SS stated either the wound or GI section should have brought them in earlier.

Review of the hospital's policy titled Nutritional Assessment and Prioritization Guidelines dated 1/31/11, indicated priority one is high nutrition risk and that is for a 75% ideal body weight, unintentional weight loss of greater than 10% in six month or 5% in one month. It indicated a high nutrition risk would being the RD in to assess the patient in 1-3 days.

Based on observation, dietary staff interview of emergency preparedness and review of the hospital documents, the hospital failed to ensure: 1) the required food and water supplies planned for use in a disaster were adequate to meet the hospital developed plan, 2) the hospital developed plan was detailed to indicate the recipes that would be used during a disaster, and 3) the hospital's disaster plan for meals was in-serviced to the dietary staff, and 4) the extreme disaster food plan is inadequate to meet the nutritional needs of the patients. Failure to ensure a planned, comprehensive disaster menu with adequate food and water supplies would put medically frail patients at risk in the event of a disaster that required the hospital to shelter in place.
Findings:
1. During an observation and review of the hospital's disaster food plan and supplies on 8/14/12 at approximately 9:20 a.m., the disaster food on hand was reviewed. A concurrent interview was conducted with the Kitchen Manager NN. Kitchen Manager NN stated the disaster plan was for 400 patients, staff and visitors for three days. The hospital's "Three Day Disaster Menu" was reviewed and compared to supplies on hand. There was no inventory or inventory list of how much food supplies were needed for the 400 people that the hospital planned to supply food and water for three days in the event of a disaster. The surveyor had to count the food items listed on the Disaster Menu to determine how much food was available and if it was adequate for the three day disaster menu. The Kitchen Manager NN stated she had not been able to complete an inventory of the disaster supplies at this time but was something on her list to be done.
A further review of food supplies on hand was conducted with a concurrent interview on 8/14/12 at approximately 2:35 p.m. with the Kitchen Manager NN. The Kitchen Manager NN stated there was not any recipes for the sandwiches (turkey, ham and tuna salad) on the disaster menu. She stated it would be prepared differently than they would under normal circumstances. The Kitchen Manager NN stated she did not think they had enough food on hand but was going to get it in. Review of the supplies on hand revealed there were inadequate amounts of some items on the disaster menu. There was only 216 servings of beef stew when 400 servings were needed, and 402 servings of peanut butter when 800 servings were needed (two meals).
Review of the hospital's policy and procedure titled, Dietary Emergency & Disaster Procedures dated 2/02, revised 4/11, indicated that depending on the degree of disruption there are three feeding options available. If there are no disruption in services then they will use the standard cycle menu, if there is no electricity they will use the three day disaster menu and if the kitchen is damaged or not accessible they will use the extreme disaster situation. The policy indicated the extreme disaster situation would consist of two 8-ounce nutritional supplements and 16 ounces of bottled water which would provide 480 calories, 29 grams of protein per day, and a total of 888 milliliters (29.6 ounces) of free fluid daily. There was no recipes for the disaster menu in the disaster binder.
Review of disaster in-services for the kitchen staff indicated there was no formal in-service about the dietary disaster procedures. There was no documentation that the kitchen staff were in-serviced on all of the disaster procedures and plan for the kitchen and menu.
A telephone interview was conducted with the Food Service Director K on 8/16/12 at approximately 10:30 a.m. The Food Service Director K stated the extreme disaster situation was developed after previous surveyors concerns. The Food Service Director K acknowledged it used to contain both nutrition supplements and food items. She stated they do not have any formal in-service or documentation on what they have told the kitchen staff for the Dietary Disaster plan. The Food Service Director K stated they would need to revisit the disaster plan and make some updates.
2. During an observation and review of the hospital's disaster food plan and supplies on 8/14/12 at approximately 9:15 a.m., the disaster water on hand was reviewed. A concurrent interview was conducted with the Kitchen Manager NN. Kitchen Manager NN stated the disaster plan was for 400 patients, staff and visitors for three days. There was approximately 311 gallons of water on hand located in the kitchen and in the storage area downstairs (under the extended care unit).
Review of a hospital document located in the Dietary Disaster binder (given to the surveyor by the Kitchen Manager NN) on water indicated two quarts of water per person times three times 400 equals 600 gallons. It also indicated there is 1000 gallons of water in the boiler.
Review of a hospital document in the form of an e-mail from the Food Service Director K to the Kitchen Manager NN with the subject "Emergency Supply Calcs" dated 9/21/10 was given to the surveyor, indicated there is 50 cases of water (1200 bottles of 16.9 ounces) and this is enough for 400 people per day for three days. It indicated the boilers hold approximately 5000 gallons.
Review of the hospital's policy titled Dietary Emergency & Disaster Procedures dated 2/02 revised 4/11 indicated there will be one pint of drinking water per patient per day for three days which is maintained in the kitchen storeroom and in the storage area under the extended care unit and walk-in refrigerator. It indicated 12-one gallon bottles are also maintained in the kitchen storeroom for dishwashing, cooking, or drinking as deemed necessary. There was no one gallon bottles that were shown to the surveyor during the survey.
An interview was conducted with the Director of Plant Operations E on 8/16/12 at 1:10 p.m. regarding water. The Director of Plant Operations E stated the hospital had a 500 gallon water tank and an 80 gallon water tank.
An interview was conducted on 8/16/12 at 5:00 p.m. with Hospital Staff RR regarding the hospital disaster plan. Hospital Staff RR stated she leaves it up to each department to determine what is needed. Hospital Staff RR stated she knows there are agreements to get non-potable water in if needed. Hospital Staff RR agreed there could be an issue if there was a disaster which would prevent trucks from getting to their hospital. Hospital Staff RR stated they did not have any other water on hand in the hospital other than the amount the plant operations person informed the surveyor about.
The water tanks and the bottled water were approximately 891 gallons of water on-site and available for use in the event of a disaster. This would only provide water for approximately 2 days not 3 days as their plan states.

Based on interview and observation the facility failed to ensure that there was proper ventilation, light and temperature controls in the perioperative area.

Findings:

An interview was conducted with WW on 8/14/12 at 11:55 a.m.in the perioperative area. When asked about monitoring the sterile processing and decontamination areas for temperature and humidity, the WW indicated there was no system to monitor and log daily temperatures and humidity levels in the perioperative areas. WW indicated there was no documentation kept of notification when temperatures and or humidity was out of range and needed to be adjusted. WW confirmed the Association of Registered Perioperative Nurses (AORN) was the standard of care the hospital followed in the perioperative area.

The 2012 edition of Perioperative Standards and Recommended Practices, published by the AORN , made the following recommendations related to Safe Environment of Care: "
Temperature should be monitored and recorded daily using a log format or documentation provided by the HVAC system. Temperature should be maintained between 68? F to 73? F (20? C to 23? C) within the operating room suite and general work areas in sterile processing. The decontamination area temperature should be maintained between 60? F to 65? F (16? C to 18? C).

Relative humidity should be maintained between 30% and 60% within the perioperative suite, including operating rooms, recovery area, cardiac catheterization rooms, endoscopy rooms, instrument processing areas, and sterilizing areas and should be maintained below 70% in sterile storage areas.

Low humidity increases the risk of electrostatic charges, which pose a fire hazard in an enriched environment or when flammable agents are in use and increases the potential for dust. High humidity increases the risk of microbial growth in areas where sterile supplies are stored or procedures are performed. Free-standing humidifiers should not be used because they can harbor microorganisms in fluid reservoirs and aerosolize these microorganisms into the clean environment. Humidity should be monitored and recorded daily using a log format or documentation provided by the HVAC system.

Based on observation, interview, and medical record reviews the facility failed to provide an environment to avoid sources and transmission of infections and communicable disease in accordance with nationally accepted infection control guidelines and hospital policy as evidenced by the hospital's failure to have effective systems in place to ensure:

1. Staff were trained and competent to effectively disinfect shared patient equipment potentially exposed to bloodborne pathogens (Hepatitis B, C, and HIV, the virus that causes immunodeficiency), between patient use when:
i. Shared patient glucometers were not cleaned after each patient use with an EPA registered disinfectant that kills blood borne pathogens.
ii. Shared patient EKG was not cleaned after each patient use.
iii Shared x-ray equipment was found in unsanitary condition.
iv. Shared electroencephalogram (EEG) equipment was not disinfected according to the manufacturer instructions.
v. A disinfectant was used in the nursery in manner inconsistent with the manufacturer ' s recommendations.

2. Single use patient items were not available for reuse.

3. Participating medical staff persons were screened for vaccine preventable diseases

4. Clean and contaminated patient items were stored in a manner to prevent cross contamination.

5. Daily documentation of the medical necessity of central lines.

Findings:

1. i. During an interview with Staff NNN on 8/13/12 at 4:15 p.m. in the emergency room, she indicated the shared patient glucometer (a machine that measures patient blood sugar levels) was cleaned after each patient use by wiping it down with an alcohol swab or sometimes the super sani-wipes located in the purple top bottle.

During an interview with Staff OOO on 8/15/12 at 11:50 a.m. on the medical unit, he indicated he had never cleaned the shared patient glucometer after patient use. Staff NNN indicated he was unsure if he had received training related to cleaning the glucometer.

An interview was conducted with S on 8/16/12 at 2:35 p.m. S stated it was the hospital ' s policy to clean shared patient glucometers both before and after each patient use with a 10% bleach product.

Review of the hospital ' s competency checklist for the glucometer stipulated ' Clean meter using 10% bleach each day. '

The hospital ' s policy titled ' Fingerstick Blood Glucose Monitoring " , dated revised 6/09, and presented as current was reviewed. The policy stipulated " Clean meter using manufacturer ' s guidelines between each use. "

On the ONLINE LifeScan web site, the website designated for the Sureflexx Glucometer, under Professional Resources, was accessed 8/21/12, and it stipulated " If a single meter is used to treat multiple patients, the meter must be cleaned and disinfected after each use whether or not blood contamination is suspected. "

An ONLINE Centers for Disease Control and Prevention communication titled Infection Prevention during Blood Glucose Monitoring and Insulin Administration was accessed on 8/21/12. The article stated " The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting hepatitis B virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration. CDC is alerting all persons who assist others with blood glucose monitoring and/or insulin administration of the following infection control requirements: Finger-stick devices should never be used for more than one person. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer ' s instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. "
An article published in volume 38, number 3 (April 2010), of the American Journal of Infection Control, by the Association for Professionals in Infection Control and Epidemiology (APIC), provided the following guidance: "Assign a glucometer to each patient if possible. Clean and disinfect glucometers if they must be shared between multiple patients. Thoroughly clean all visible soil or organic material (e.g., blood) from the glucometer before disinfection.
Disinfect the exterior surfaces of the glucometer after each use following the manufacturer's
directions. Use an E.P.A. (Environmental Protection Agency) registered disinfectant
effective against HBV, HCV, and HIV (bloodborne pathogens) or a 1:10 bleach solution (1 part bleach to 9 parts water)."

The hospital failed to ensure were staff were trained and competent to clean shared patient glucometers. This failure placed patients at potential risk for infection from microorganisms, including bloodborne pathogens (HBV, HCV, and HIV).

1. ii. On 8/13/12 at 4:15 p.m. in the hospital emergency room Staff LLL was observed wheeling an electroencephalogram (EKG) machine into patient room E. After completing the procedure, which involved placing patches on the patient that were connected to cable lines, the EKG tech was observed exiting the room with the EKG machine. The tech then plugged the machine into wall socket located in the hall and exited the area.

During an interview with Staff LLL on 8/13/12 at 4:40 p.m. he indicated the EKG machine he had recently used had not been cleaned after patient use and was available for patient use. Staff LLL explained the EKG machine was only cleaned after patient use if the machine results showed artifact or if the patient was on isolation. Staff LLL indicated if the patient was on isolation for methicillin-resistant Staphylococcus aureus (MRSA-A germ that does not get better with the first-line antibiotics that usually cure staphylococcus infections) he cleaned the EKG machine after use with the super-sani wipe cloths located in the purple top bottles or a green solution, name unknown, supplied by environmental services. Staff LLL indicated when he cleaned the machine he cleaned the leads and the area of the machine that was in close contact with the patient. When asked if he knew how long the cleaning solutions needed to stay on the surfaces being cleaned in order to kill the germs, he responded " It supposedly kills on contact " . Staff LLL indicated the hospital did not have a policy procedure for cleaning the EKG machine.

Review of the super sani-wipe label (purple top) stipulated treated surfaces must remain visibly wet for two minutes. Label directions indicated, " Treated surfaces must remain wet for the stated contact time on the product label. Use additional wipe(s) if needed to assure continuous contact time stated on label. "

1. iii On 8/13/12 at 4:40 p.m., an x-ray machine was observed in a hallway located in the emergency room. The machine surfaces had portions of its exterior surfaces peeled back and the metal surfaces underneath were exposed. Pink dots and brown and grey spots were visible on several surfaces of the machine.

On 8/13/12 at 4:30 p.m., during an interview with Staff R, she acknowledged the x-ray machine was available for patient use and was not clean. She stated " It could use a wipe down. "

The 2003 Centers for Disease Control and Prevention (CDC) environmental guidelines were reviewed. The guidelines stipulated, " Manufacturers of medical equipment should provide care and maintenance instructions specific to their equipment. These instructions should include information about a) the equipment ' s compatibility with chemical germicides, b) whether the equipment is water-resistant or can be safely immersed for cleaning, and c) how the equipment should be decontaminated if servicing is required. In the absence of manufacturers ' instructions, non-critical medical equipment (e.g., stethoscopes, blood pressure cuffs, dialysis machines, and equipment knobs and controls) usually only require cleansing followed by low- to intermediate-level disinfection, depending on the nature and degree of contamination.

1. iv. An interview was conducted with Staff LLL on 8/16/12 at 12:20 p.m. Staff KKK indicated she disinfected the EEG equipment with a disinfectant called Neutral Quaternary Disinfectant and she mixed the solution with water. When asked the ratio of disinfectant to water recommended by the manufacturer, she indicated she prepared the solution to clean the patient EEG equipment by mixing equal amounts of disinfectant and water.

The manufacturer ' s recommendation for dilution of the disinfectant was reviewed on the product label. The manufacturer stipulated, " Mix one half ounce of disinfectant per one gallon of water. ' Information on the product label also indicated, ' It is a violation of federal law to use a product in a manner inconsistent with its label. '

1. v. An unlabeled spray bottle half full with fluid was observed on a counter in the newborn nursery immediately adjacent to an infant scale and within a few feet of the infant cribs. When questioned about the product, Staff JJJ picked the container up without wearing gloves. During a concurrent interview with Staff JJJ, she indicated the spray bottle contained a quaternary ammonia (later identified as the disinfectant product Virex II 256) and she and other obstetric nursing staff used the product clean and disinfect surfaces in the nursery such as counters as well as thermometers, and instrument used on infants to check the newborns ' bilirubin (which is a substance produced from the breakdown of old red blood cells). Staff JJJ emphasized the disinfected patient items were then thoroughly rinsed with water. Staff JJJ acknowledged the spray was used when infants were present in the nursery. Staff JJJ acknowledged gloves should be worn when using the product.

The Material Safety Data sheet for Virex II 256 under the section titled Handling and Storage stipulated, " Avoid breathing vapors or mists. Use only with adequate ventilation ...Wash thoroughly after use. Avoid contact with skin, eyes, and clothing. Product residue may remain on/in empty containers. All precautions for handling the product must be used in handling the empty container and residue. " Under Exposure Controls /Personal Protection, it stipulated use of " Chemical-Splash goggles and chemical-resistant gloves. "

A telephone consult was conducted with AAA, a technical support representative for the Virex II 256 product, on 8/15/12 at 1:25 p.m. AAA confirmed individuals should avoid breathing this product ' s vapors or mists. AAA stated the manufacturer would not recommend the product be used as a spray in a nursery if individuals, including the newborns could potentially inhale the product vapors or mists.

The hospital ' s policy titled " Solutions used in secondary containers " , reviewed 5/12 and presented as current stipulated, " It is the policy of the hospital to label all solutions used in secondary containers. For continuity of this process the labels must include solution name, pertinent exposure concerns, required personal protective equipment needed during use, expiration date of product, and discard date based on individual product requirements. '

2. On 8/14/12 at 9:20 a.m., during an initial tour of the Intensive Care Unit (ICU) the sterile storage room was inspected. Four white plastic pressure infusor cuffs (devises that are inflated to rapidly infuse liquids or hold pressure) were observed hanging on a supply cart. They were stamped with the words " Recommended for single use. " Closer inspection found one cuff had yellow discoloration and another cuff had reddish brown marks on its surface.

On 8/14/12 at 9:25 a.m., during an interview with Staff D, she indicated that the stamped wording on the cuff, " recommended for single use " , indicated the infusor cuffs were supposed to be new (never used) and for single patient use only. Staff D stated the cuffs should be removed and discarded.

The hospital ' s policy titled " Reprocessing of Disposable Items " , dated reviewed 5/12 and presented as current, stipulated " Disposable devises that are not intended for re-use by the manufacturer shall not be reprocessed unless the manufacturer provides written guidelines for reprocessing in the event of contamination. If the devise has been contaminated by blood or body fluids, under no circumstances will it be reprocessed. "

The used cuffs in the sterile supply room placed the clean /sterile supplies located near the cuffs at potential risk cross for cross contamination and also placed patients at potential risk for contact with infectious microorganisms from the reused cuffs.

3. Review of 8 hospital physician medical files (Physicians BBB, CCC, DDD, GG, FFF, GGG, HHH, and III) was conducted on 8/14/12 at 3 p.m. and on 8/16/12 at 12:50 p.m. Eight of the eight files reviewed (Physicians BBB through III) did not contain evidence of screening for measles, mumps, rubella, or varicella (MMRV), or hepatitis B. Three of the eight physician files did not contain evidence of screening for tuberculosis upon hire (Physicians DDD, GGG, and HHH). Of the remaining five physicians, two (physicians CCC and GG) received a one-step tuberculin skin test upon hire.

During an interview with Staff G on 8/14/12 at 3:10 p.m., she indicated the hospital ' s policy required employees to provide a current tuberculosis test (two-step) upon hire and then annually. Staff G confirmed participating physicians were currently not screened for MMRV or hepatitis B. Staff G indicated the hospital had systems in place to screen employees for vaccine preventable diseases but this was just beginning to be developed for screening physicians for tuberculosis. Staff G indicated the hospital followed the Centers for Disease Control and Prevention (CDC) guidelines for screening its employee ' s vaccine preventable diseases

Review of the hospital ' s " Medical Staff Rules and Regulations " was conducted. The rules stipulated, " All staff practitioners or appropriately approved associated hospital physicians shall be tested annually for tuberculosis. "

The Centers for Disease Control Guidelines for Preventing the Transmission of Tuberculosis in a Health-Care Setting, 2005, page 10, indicated "The classification of medium risk should be applied to settings in which the risk assessment has determined that health care workers (HCW) will or will possibly be exposed to persons with TB disease or to clinical specimens that might contain M. tuberculosis. The recommendations for medium risk included, "All HCWs should receive baseline TB screening (checked to identify presence of the disease) upon hire, using two-step TST (skin test) or a single BAMT (alternate test) to test for infection, and after baseline testing for infection, HCWs should receive TB screening annually."
The Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Report (MMWR Volume 46, Number RR-18, December 26, 1997) documented on page 24: "Persons who work within medical facilities should be immune to measles and rubella. Immunity to mumps is highly desirable for all Healthcare Workers. Because any HCW (i.e., medical or nonmedical, paid or volunteer, full time or part time, student or nonstudent, with or without patient-care responsibilities) who is susceptible can, if exposed, contract and transmit measles or rubella, all medical institutions (e.g., inpatient and outpatient, public and private) should ensure that those who work within their facilities are immune to measles and rubella. Likewise, HCWs have a responsibility to avoid causing harm to patients by preventing transmission of these diseases on page 25, the MMWR documented: "All HCWs should ensure that they are immune to varicella."
The Occupational Safety and Health Administration (OSHA) requires hepatitis B vaccine be offered to healthcare workers (HCWs) who have a reasonable expectation of being exposed to blood on the job.

Review of the 7/30/09 Association for Professionals in Infection Control and Epidemiology (APIC) Position Paper: Safe Injection, Infusion, and Medication Vial Practices in Healthcare indicated that healthcare workers whose activities involved contact with blood or body fluids be offered hepatitis B vaccination.

4. On 8/13/12 at 4:10 p.m., during a tour of the hospital emergency room a dirty utility room, with an unlocked door was observed: The small room contained a hopper, a large toilet without a lid, located adjacent to a cart that stored clean and sterile patient supplies. The bowl of the hopper contained brown stains and particles. The supply cart was located 12 to 24 inches away from the hopper and housed the following items: 50 to 60 bottles of blood culture mediums, blood culture collection tubes, three way stop cocks for intravenous tubing, wrapped baby nipples, and a cervical collar. Additionally there was a machine for printing out urine lab results located on a nearby counter. Waste bins marked as containing biohazardous waste were observed located near the supply cart.

During an interview with Staff R on 8/13/12 at 4:10 a.m. in the dirty utility room, she acknowledged storing clean equipment in close location to a hopper, which she indicated was used to clean/decontaminate soiled patient equipment and to dispose of the bodily wastes of patients, and bio-hazardous waste bins could result in contamination of the patient items.

A hospital policy on separation of clean and dirty areas, supplies, equipment was requested and not provided.
The 6/03 Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) for Environmental Infection Control in Health-Care Facilities were reviewed and provided the following information, "The most common point-of-use fixtures for water in patient-care areas are sinks, faucets, aerators, showers, and toilets. The potential for these fixtures to serve as a reservoir for pathogenic microorganisms has long been recognized. Wet surfaces and the production of aerosols facilitate the multiplication and dispersion of microbes."
This practice placed patients at potential risk for serious infections.
5. The medical record for intensive care unit patients 7 and 20 were reviewed on 8/14/12 at 10 a.m. Review of the records showed both patients had central lines and there was no evidence found of daily documentation by the physician of the medical necessity for of the central lines.

During an interview with Staff D, she indicated the hospital had implemented including discussion of central line necessity during the daily team visit made to all intensive care unit patients but had not implemented documentation of the necessity in the patient ' s medical records.

The California Department of Public Health (CDPH) all facilities letter (AFL) dated April 22,
2008 was reviewed. The regulatory requirements for compliance with Senate Bill 749
stipulated, "All hospitals are required to develop and implement a process to ensure daily
assessment of central line necessity for all patients with central lines on units under surveillance
and to be able to present results of that process to CDPH surveyors. "

Based on medical record review, staff interview and document review, the hospital failed to ensure that before all non-emergent surgeries and/or procedures requiring anesthesia services there was in the medical record before the case began:
1.) a medical history and physical examination (H&P) that had been completed and documented no more than 30 days prior to the surgery/procedure and,
2.) for those H&Ps more than done more than 24 hours prior, an updated examination (H&P Update) of the patient, including any changes in the patient's condition since the earlier H&P, that had been completed and documented within 24 hours before the surgery/procedure. This failure allowed patients to have surgeries and/or procedures without the full set of medical data used to minimize risk to the patient.

Findings:

From 8/13/12 to 8/16/12 twenty-six (26) hospital patients' records were reviewed. In seven of the twenty-six records (Patients 23, 24, 25, 26, 27, 28 & 29) the contained documentation indicated that each patient had their surgery or procedure without the required pre-procedure H&P and Update to the H&P as follows:

1.) The record of Patient #23 documents that on 8/15/12 he had ambulatory care endoscopic procedures done with minimal sedation (a form of anesthesia services) by Physician II. The patient's hospital record contained an undated "Consultation" report that had been electronically signed by Physician II on 8/7/12. This Consultation report contained an incomplete H&P and since it was undated, there was no way to ascertain if it had been completed and documented within 30 days before the procedure. The record had an "Ambulatory Services Physician's Record" that did not have an H&P Update, but did have written in two places the words "See Dictated H&P." This record has neither the required H&P nor the required H&P Update.

2.) The record of Patient #24 documents that on 8/13/12 he had an ambulatory care endoscopic procedure done with minimal sedation by Physician JJ. The patient's hospital record contained only an "Ambulatory Services Physician's Record." This form had no medical history recorded and the "Physical Exam" portion contained an undated, unsigned set of marks with some illegible writing beside it. Section II-B of the Medical Staff Rules requires that "A complete medical history and physical examination shall be dictated ..." The only documentation in this record relative to an H&P was on the Ambulatory Services Physician's Record, which was unsigned, undated, lacked any history, had only an incomplete, illegible and was not dictated. This record has neither the required H&P nor the required H&P Update.

3.) The record of Patient #25 documents that on 8/13/12 he had an ambulatory care endoscopic procedure done with minimal sedation by Physician KK. The patient's hospital record contained an undated but complete H&P that was electronically signed by Physician KK on 8/10/12. The record had an Ambulatory Services Physician's Record that did not have an H&P Update, but did have written in two places the words "See H&P." This record has neither the required (dated) H&P nor the required H&P Update.

4.) The record of Patient #26 documents that on 5/16/11 he had a surgery (fusion of the right ankle) performed by Podiatrist GG. The surgical plan was for the patient to be discharged to his home that same day. On 5/5/11 Podiatrist GG had done an incomplete H&P that did not contain an examination of portions of the patient's body above his knees. On 5/16/11, just prior to surgery, Podiatrist GG signed a typed generic "Pre-procedure Interval Note" that did not document an examination and contained no information about the patient. The patient's hospital record did contain a short form H&P record titled "SP/SDDS Physician's Record" which contained some H&P information and the signature of Anesthesiologist PP, however it was undated, and did not contain Patient #26's name or any other identifying information. After the surgery the patient was seen by Physician Z and admitted to the hospital for "control of pain." In a detailed admission H&P Physician Z recorded a full exam and some very pertinent medical history and diagnoses that would indicate Patient #26 had significantly higher risk associated with the general anesthesia and surgical procedure. This record has neither the required H&P nor the required H&P Update.

5.) The record of Patient #27 documents that on 4/15/11 she had surgery (total left ankle replacement) performed by Podiatrist GG. The surgical plan was for the patient to be discharged to his home that same day. On 3/23/11 Podiatrist GG had done an incomplete H&P with an examination of only the lower extremities. Just prior to surgery on 4/15/11, Podiatrist GG signed a non-specific interval note that did not document an examination of the patient. The record does not contain an examination of the patient by the anesthesiologist (Physician HH) that was done prior to the surgery. After the surgery, Patient #27 held over because of "post-op L ankle pain" and not discharged until the following day, 4/16/11. The medical record also contains two other recorded "H&P" reports that were documented well after the surgery. One which is undated was dictated by Podiatrist GG on 6/7/11, and the other, also undated, was dictated by Physician HH on 7/7/11. This record has neither the required pre-surgical H&P nor the required pre-surgical H&P Update.

6.) The record of Patient #28 documents that on 5/16/11 he had surgery (fusion of the left first toe) performed by Podiatrist GG. On 5/5/11 Podiatrist GG had done an incomplete H&P with an examination of only the lower extremities. On 5/16/11, just prior to the surgery, Podiatrist GG signed a non-specific interval note that did not document an examination of the patient. The patient's hospital record does contain a short form H&P record titled "SP/SDDS Physician's Record" which contained some H&P information and the signature of Anesthesiologist PP, however it is undated, and does not contain Patient #28's name or any other identifying information. This record has neither the required pre-surgical H&P nor the required pre-surgical H&P Update.

7.) The record of Patient #29 documents that on 6/20/11 she had surgery (total left ankle replacement) performed by Podiatrist GG. On 5/17/11, 34 days prior to the scheduled surgery, Podiatrist GG had done an incomplete H&P with an examination of only the lower extremities. The record did not contain any pre-surgical notes and did not have an H&P Update written by Podiatrist GG. The record does contain a short form H&P record titled "SP/SDDS Physician's Record" signed by Anesthesiologist PP which contains some check marks in the section titled Physical Exam; however this form is undated and does not document if there were or were not changes since the prior H&P. This record has neither the required pre-surgical H&P (incomplete and more than 30 days prior to surgery) nor the required pre-surgical H&P Update.

In a meeting, on 8/16/12 at 3:00 p.m. the CEO (Staff P) and the CMO (Physician BB) were asked questions while we concurrently reviewed selected pages from the above hospital records for Patients 26, 27, 28 and 29. After this review, the CEO and CMO concurred that these records were missing the noted required pre-surgical documentation.




15746

Based on medical record review, staff interview and document review, the hospital failed to ensure that before all non-emergent surgeries and/or procedures requiring anesthesia services there was in the medical record before the case began:
1.) a medical history and physical examination (H&P) that had been completed and documented no more than 30 days prior to the surgery/procedure and,
2.) for those H&Ps more than done more than 24 hours prior, an updated examination (H&P Update) of the patient, including any changes in the patient's condition since the earlier H&P, that had been completed and documented within 24 hours before the surgery/procedure. This failure allowed patients to have surgeries and/or procedures without the full set of medical data used to minimize risk to the patient.

Findings:

From 8/13/12 to 8/16/12 twenty-six (26) hospital patients' records were reviewed. In seven of the twenty-six records (Patients 23, 24, 25, 26, 27, 28 & 29) the contained documentation indicated that each patient had their surgery or procedure without the required pre-procedure H&P and Update to the H&P as follows:

1.) The record of Patient #23 documents that on 8/15/12 he had ambulatory care endoscopic procedures done with minimal sedation (a form of anesthesia services) by Physician II. The patient's hospital record contained an undated "Consultation" report that had been electronically signed by Physician II on 8/7/12. This Consultation report contained an incomplete H&P and since it was undated, there was no way to ascertain if it had been completed and documented within 30 days before the procedure. The record had an "Ambulatory Services Physician's Record" that did not have an H&P Update, but did have written in two places the words "See Dictated H&P." This record has neither the required H&P nor the required H&P Update.

2.) The record of Patient #24 documents that on 8/13/12 he had an ambulatory care endoscopic procedure done with minimal sedation by Physician JJ. The patient's hospital record contained only an "Ambulatory Services Physician's Record." This form had no medical history recorded and the "Physical Exam" portion contained an undated, unsigned set of marks with some illegible writing beside it. Section II-B of the Medical Staff Rules requires that "A complete medical history and physical examination shall be dictated ..." The only documentation in this record relative to an H&P was on the Ambulatory Services Physician's Record, which was unsigned, undated, lacked any history, had only an incomplete, illegible and was not dictated. This record has neither the required H&P nor the required H&P Update.

3.) The record of Patient #25 documents that on 8/13/12 he had an ambulatory care endoscopic procedure done with minimal sedation by Physician KK. The patient's hospital record contained an undated but complete H&P that was electronically signed by Physician KK on 8/10/12. The record had an Ambulatory Services Physician's Record that did not have an H&P Update, but did have written in two places the words "See H&P." This record has neither the required (dated) H&P nor the required H&P Update.

4.) The record of Patient #26 documents that on 5/16/11 he had a surgery (fusion of the right ankle) performed by Podiatrist GG. The surgical plan was for the patient to be discharged to his home that same day. On 5/5/11 Podiatrist GG had done an incomplete H&P that did not contain an examination of portions of the patient's body above his knees. On 5/16/11, just prior to surgery, Podiatrist GG signed a typed generic "Pre-procedure Interval Note" that did not document an examination and contained no information about the patient. The patient's hospital record did contain a short form H&P record titled "SP/SDDS Physician's Record" which contained some H&P information and the signature of Anesthesiologist PP, however it was undated, and did not contain Patient #26's name or any other identifying information. After the surgery the patient was seen by Physician Z and admitted to the hospital for "control of pain." In a detailed admission H&P Physician Z recorded a full exam and some very pertinent medical history and diagnoses that would indicate Patient #26 had significantly higher risk associated with the general anesthesia and surgical procedure. This record has neither the required H&P nor the required H&P Update.

5.) The record of Patient #27 documents that on 4/15/11 she had surgery (total left ankle replacement) performed by Podiatrist GG. The surgical plan was for the patient to be discharged to his home that same day. On 3/23/11 Podiatrist GG had done an incomplete H&P with an examination of only the lower extremities. Just prior to surgery on 4/15/11, Podiatrist GG signed a non-specific interval note that did not document an examination of the patient. The record does not contain an examination of the patient by the anesthesiologist (Physician HH) that was done prior to the surgery. After the surgery, Patient #27 held over because of "post-op L ankle pain" and not discharged until the following day, 4/16/11. The medical record also contains two other recorded "H&P" reports that were documented well after the surgery. One which is undated was dictated by Podiatrist GG on 6/7/11, and the other, also undated, was dictated by Physician HH on 7/7/11. This record has neither the required pre-surgical H&P nor the required pre-surgical H&P Update.

6.) The record of Patient #28 documents that on 5/16/11 he had surgery (fusion of the left first toe) performed by Podiatrist GG. On 5/5/11 Podiatrist GG had done an incomplete H&P with an examination of only the lower extremities. On 5/16/11, just prior to the surgery, Podiatrist GG signed a non-specific interval note that did not document an examination of the patient. The patient's hospital record does contain a short form H&P record titled "SP/SDDS Physician's Record" which contained some H&P information and the signature of Anesthesiologist PP, however it is undated, and does not contain Patient #28's name or any other identifying information. This record has neither the required pre-surgical H&P nor the required pre-surgical H&P Update.

7.) The record of Patient #29 documents that on 6/20/11 she had surgery (total left ankle replacement) performed by Podiatrist GG. On 5/17/11, 34 days prior to the scheduled surgery, Podiatrist GG had done an incomplete H&P with an examination of only the lower extremities. The record did not contain any pre-surgical notes and did not have an H&P Update written by Podiatrist GG. The record does contain a short form H&P record titled "SP/SDDS Physician's Record" signed by Anesthesiologist PP which contains some check marks in the section titled Physical Exam; however this form is undated and does not document if there were or were not changes since the prior H&P. This record has neither the required pre-surgical H&P (incomplete and more than 30 days prior to surgery) nor the required pre-surgical H&P Update.

In a meeting, on 8/16/12 at 3:00 p.m. the CEO (Staff P) and the CMO (Physician BB) were asked questions while we concurrently reviewed selected pages from the above hospital records for Patients 26, 27, 28 and 29. After this review, the CEO and CMO concurred that these records were missing the noted required pre-surgical documentation.

Based on interview and clinical document review, the hospital failed to provide physical therapy as ordered by the physician.

Findings:

Patient 9 was admitted 8/9/12 with a diagnosis of sepsis.

Review of the clinical record was conducted on 8/14/12 at 10:00 a.m.
Physician's Orders dated 8/12/12 indicated that Patient 9 was to receive Physical therapy every day.

Review of the Physical Therapy Evaluation and Treatment progress notes dated 8/10/12 at 14:12, indicated that Patient 9 was assessed for risk of fall precautions.

The Physical Therapy Evaluation and Treatment progress note further identified Patient 9 with functional limitations due to decreased strength, decreased safety with mobility and decreased activity tolerance.
The problem list indicated a decrease in balance, strength, and impaired gait. Patient 9 ambulated with a single point cane prior to hospital admission.

The short term goal indicated that the patient will tolerate 30 minutes of physical therapy with O2 saturations > 92%.
The treatment plan indicated therapeutic strength exercises, balance training, transfer training, gait and endurance training and the frequency: Every day, >+3 per week.

Further review of the physical therapy progress notes revealed no documentation that Patient 9 received physical therapy on 8/12, 8/13 and 8/14. There was no documentation to indicate the reason Patient 9 did not receive Physical therapy daily.

During an interview on 8/14/12 at 11:00 a.m., Patient 9 stated that she had received Physical therapy once during her hospitalization and was concerned because she was very weak and would be going home tomorrow, 8/15/12.

Review of the clinical record on 8/14/12 at 3 p.m., revealed no documentation that Patient 9 had received physical therapy for the day. Review of the progress notes further indicated that Patient 9 had received a total of 20 minutes of physical therapy since the physician had written the order on 8/12/12.

Staff SS stated during an interview on 8/14/12 at 3:10 p.m., that "we made Patient 9 a lower priority as the physical therapy department is short staffed on week-ends." "Only the priority patients such as patients who have had a CVA etc., receive physical therapy on the week-ends." Staff SS further stated that Patient 9 did not receive physical therapy on 8/13/12 as she was scheduled for an ultrasound and that the other physical therapist will see her today.