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A. Based on clinical record review, stated unit practice, and staff interview, it was determined that for 1 of 1 (Pt. #1) record reviewed the Hospital failed to ensure implementation of orders in a timely manner.

Findings include:

1. The clinical record of Pt. #1 was reviewed on 2/1/10 at 1:30 PM. Pt. #1 was an 87 year old male who was transferred from another hospital on 5/16/09 at 12:30 AM. The ambulance transfer note indicated that Pt. #1' s left leg was in a 5 lbs traction. The nursing admission note dated 5/16/09 at 1:30 AM did not contain documentation of the left leg traction. A physician order dated 5/16/09 at 10:00 AM included: " Bucks Tx (traction) 5 lbs (pounds) L." However the patient care flow sheet dated 5/16/09, indicated that Pt. #1 was placed on traction at 5:00 PM, a delay of 7 hours from the time of order.

2. An interview with the Nurse Manager of the 3 South Unit, was conducted on 2/2/09 between 2:00 and 2:45 PM. The Manager stated that it is the Unit's standard of practice and expectation that orders such as the placement of Pt. #1's leg on traction should be carried out within an hour.

3. The above finding was confirmed with the Nurse Manager during an interview 2/2/09 at 2:20 PM.



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B. Based on a review of Hospital policy, clinical record review, and staff interview, it was determined for 1 of 10 (Pt. #7) clinical records reviewed, that the Hospital failed to ensure the record included accurate times for interventions performed.

Findings include:

1. Hospital policy #65.118.003 entitled, "Nursing Documentation," was reviewed on 2/3/10 at approximately 11:00 A.M. The policy requires, "A 'late entry' may be charted, if necessary. The correct date and time is recorded..."

2. The clinical record for Pt. #7 was reviewed on 2/1/10 at approximately 1:55 P.M. This was a 59-year-old male admitted 12/7/09 with a diagnosis of Acute Respiratory Failure. The record included a "Cardiopulmonary Resuscitation Record" dated 12/7/09, that included "CPR start time" 7:59 P.M. for cardiac arrest. The "Cardiopulmonary Resuscitation Record" lacked documentation of any actions/interventions until 9:00 P.M.

3. In the clinical record for Pt. #7, the "Emergency Flow Sheet Record," dated 12/7/09 included documentation of vital signs for Pt. #7 through 11:08 P.M., even though it was documented that the patient expired at 9:21 P.M.

4. In an interview on 2/3/10 at approximately 9:45 A.M., the Director of Clinical Operations stated that the "Cardiopulmonary Resuscitation Record", initiated in the Cath lab included an incorrect "CPR start time", and should have been documented as 8:59 P.M. instead of 7:59 P.M.

5. In an interview with the Emergency Department Manager on 2/3/10 at approximately 10:00 A.M., the Manager stated that the times on the "Emergency Flow Sheet Record" were after the patient expired because they were computer data entry times, and not intervention times. She further explained that these were late entries, and confirmed that the late entry documentation was not a part of the permanent medical record.

6. The above findings were discussed with the Vice President of Nursing Services on 2/2/10 at approximately 4:00 P.M.

A. Based on a review of Hospital's Transfusion Administration Record, clinical record review, and staff interview, it was determined that for 2 of 2 (Pt. #s 8 and 9) clinical records reviewed for patients that received blood transfusions, the Hospital failed to ensure blood transfusion administration records were completed.

Findings include:

1. The Hospital's "Transfusion Administration Record," requires, "Date Completed... Time Completed... Amount Transfused... Adverse Reaction... Temperature, Pulse, Blood Pressure, Respirations (pre, 15 min., 30 min. post)".

2. The clinical record for Pt. #8 was reviewed on 2/1/10 at approximately 3:05 P.M. This was a 55-year-old female admitted 11/28/09 with a diagnosis of Acute Respiratory Failure. The record included documentation that the patient received 2 units of packed red blood cells on 11/28/09. The "Transfusion Administration Records" were incomplete for the following:

* start time 8:40 P.M.- end time 9:40 P.M. (incomplete for amount transfused; adverse reactions)
* start time 10: 05 P.M.- (incomplete for date and time completed and vital signs 15 minutes after unit initiated).

3. The clinical record for Pt. #9 was reviewed on 2/2/10 at approximately 9:42 A.M. This was a 20-year-old male admitted 11/28/09 with a diagnosis of Sickle Cell Pain Crisis. The record included documentation that the patient received 2 units of leukocyte-reduced red cells on 11/28/09 from 8:00 -10:00 A.M. and from 10:05 A.M.-12:00 P.M. The "Transfusion Administration Records" were incomplete for the amount transfused and adverse reactions.

4. The above findings were confirmed during an interview with the 3 South Nurse Manager on 2/2/10 at approximately 2:45 P.M.