HospitalInspections.org

Based on a review of facility policy, observation, and staff interview (EMP), it was determined that the hospital failed to ensure that patient records were not accessible to unauthorized individuals.

Findings include:

Review of the facility policy, "Film Storage" last reviewed March 2010, revealed, "...3. All storage areas both within the department and outside the department must be kept secured and locked at all times..."

1) Observation on June 22, 2010, at 9:10 AM, of the Radiology Department revealed two film storage rooms. Both rooms contained patient films and paper information, and were unlocked and unattended by staff. One room is directly across the hallway from a patient waiting area.

2) An interview conducted on June 22, 2010, at 9:10 AM with EMP7 confirmed the film storage rooms were unlocked and unattended.

Based on review of medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure that all entries in the medical record were authenticated, dated and timed for 10 of 52 of medical records reviewed (MR17, MR19, MR45, MR46, MR47, MR48, MR49, MR50, MR51, and MR52).

Findings include:

A review conducted on June 23, 2010, of the "Berwick Hospital Center Medical Staff rules and regulation, reviewed February 2010" revealed "...2.8 Clinical entries/authentication: All clinical entries in the patient's medical record, including written and verbal orders, shall be accurately dated, timed and authenticated. Authentication shall be defined as the establishment of authorship by written signature, identifiable initials or computer key..."

1) A review conducted on June 23, 2010, of MR17, MR19, MR45, MR46, MR47, MR48, MR49, MR50, MR51, and MR52 revealed that the records contained entries that were not timed by the person making the entries.

2) An interview conducted on June 23, 2010, at 12:15 PM with EMP1 confirmed that MR17, MR19, MR45, MR46, MR47, MR48, MR49, MR50, MR51, and MR52 contained entries that were not timed by the person making the entries.

Based on review of facility policy and procedure, medical record (MR), and interview with staff (EMP), it was determined the facility failed to document medications that were administered to the mother into the newborn medical record for two of four newborn medical records reviewed (MR33 and MR40)

Findings include:

A review of the department policy manual revealed that they did not have a specific policy that required medications administered to the mother be documented on the newborn medical record.

1) A review on June 23, 2010, of MR33 and MR40 revealed medication was administered to the mother of the newborn. There was no documentation on the newborn record of the medication that was administered to the mother.

2) An interview conducted on June 23, 2010, at 10:40 AM with EMP6 confirmed that the medication that was administered to the mother was not documented on the newborn record.

Based on review of facility policy, documents, and staff interview (EMP), it was determined that the hospital failed to ensure that medical records were completed within 30 days following discharge.

Findings include:

Review of the facility policy, "Medical Record Timeliness" last reviewed January 2010, revealed, "... It is the direction of the Medical Staff Rules and Regulations and Bylaws that if a medical record is still incomplete at 30 days after discharge, the record is then considered delinquent for the physician who has outstanding documentation on it..."

1) Review of facility documentation on June 22, 2010, revealed that there were 108 medical records that were not completed within 30 days.

2) An interview with EMP5 on June 22, 2010, at 1:30 PM confirmed that there were 108 medical records that have not been completed within 30 days.

Based on a review of facility documents, policy and interview with staff (EMP), it was determined the facility failed to implement their fire safety management plan at their offsite locations.

Findings include:

A review conducted on June 23, 2010, at 9:30 AM, of the Berwick Hospital Center "Fire Safety and Management Plan", reviewed January 19, 2010, revealed " ...The hospital conducts quarterly fire drills in each building defined as an ambulatory health care occupancy... ."

1) A review of facility documents revealed that fire drills had not been conducted at the King Center Physical Therapy and the Sixth Avenue Sleep Lab since March 25, 2009, and November 9, 2007, respectively.

1) An interview conducted on June 23, 2010, with EMP3 confirmed that quarterly fire drills had not been conducted on a quarterly basis at King Center Physical Therapy and the Sixth Avenue Sleep Lab.

Based on review of facility policy, observation and interview with staff (EMP), it was determined that the facility failed to ensure that the facilities, supplies and equipment were maintained to ensure an acceptable level of safety and quality throughout the hospital.

Findings include:

1) A tour conducted on June 21, 2010, of the newborn nursery revealed eight bottles of infant formula that expired December 2009, and four bottles of infant formula that expired July 2009.

An interview conducted on June 21, 2010, at 2:00 PM with EMP9 confirmed the infant formula had expired July 2009 and December 2009.

2) A tour conducted on June 22, 2010, of the Radiology Department revealed one bottle of contrast media in a warmer. The contrast media was dated as placed in the warmer on May 18, 2010.

An interview conducted on June 22, 2010, at 10:30 AM with EMP7 confirmed the contrast media is to be kept in the warmer for no more than 30 days per manufacturer recommendation. EMP7 confirmed the contrast media should have been removed by June 18, 2010. The facility does not have a policy to address length of time contrast media can be stored in a warmer.

3) A tour conducted on June 21, 2010, of the medical/surgical care unit revealed a clean supply room with at least 15 dead insects on the floor. The dead insects varied in sizes. The tour also revealed a patient freezer with brown/yellow melted and then refrozen debris on the floor of the freezer.

An interview conducted on June 21, 2010, at 11:30 AM with EMP8 confirmed the dead insects were in the clean supply room. EMP8 stated that the outside of the building had recently been sprayed for insects. EMP8 also confirmed that the freezer was dirty with brown/yellow debris.