HospitalInspections.org

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure nursing staff followed the established facility policy for the completion of the Daily Code Cart check for three of four patient care units (the Fourth floor, the Third floor and the Intensive Care Unit) and the facility failed to ensure nursing staff completed a manual defibrillator test every seven days for three of four patient care units (the Fourth floor, the Third floor and the Intensive Care Unit).

Findings include:

Review on April 5, 2022, of facility's "Code Carts-Checking" policy, last reviewed March 2, 2021, revealed "Policy: It is the policy of Wayne Memorial Hospital to maintain the integrity of the code carts. Purpose: To detect possible electrical and mechanical problems, as well as to keep personnel acquainted with the normal operating procedure in order to provide for patient safety...Procedure: A. Code Carts are inspected daily by department personnel for lock integrity in departments that are open 24 hours. All other department code carts are inspected daily by department personnel when the department is open. B. Inspection of the crash cart is documented on the Crash Cart Check form/department checklist. C. Routine testing of the Defibrillator / Monitor is performed weekly by department staff, with no more than a 7-day lapse between checks. D. Testing of the Defibrillator / Monitor is documented on the Crash Cart Check form/department checklist..."

Review on April 5, 2022, of the facility's "Daily Code Cart Check" sheet, last revised July 18, 2018, revealed a place for staff to list the month and year. There were columns identified as Date Time, Locked Lock number, AC and Battery Self test and Manual Test, Equipment Outdates and Nurse's signature. This sheet also had a column listing the dates of the month from 1 through 31.

1. Review on April 5, 2022, of the Daily Code Cart Check sheets for the fourth-floor patient care unit revealed no documentation nursing staff completed the required daily check of code cart 1 on the following dates:
December 6, 7, 9, 12 13, 14, 16, 20, 24, and 28, 2021.
January 2, 3, 4, 5, 14, 18, 21, 22, 24, 26, and 31, 2022.
February 5, 8, 12, and 25, 2022.
March 1, 2, 9, 11, 20, 24, 25, 30 and 31, 2022.
April 2 and 3, 2022.

Review on April 5, 2022, of the Daily Code Care Check sheets for the fourth-floor patient care unit revealed no documentation nursing staff completed the required daily check of code cart 2 on the following dates:
December 6, 7, 9, 12 13, 14, 16, 20, and 28, 2021.
January 2, 3, 4, 5, 14, 18, 21, 22, 24, 25, 26, and 31, 2022.
February 5, 8, 12, and 25, 2022.
March 1, 2, 9, 11, 24, 25, 30 and 31, 2022.
April 2 and 3, 2022.

Interview with EMP13 on April 5, 2022, at approximately 1000 confirmed there was no documentation indicating the fourth-floor nursing staff completed the required Daily Code Cart checks on the above dates.

Review on April 5, 2022, of the Daily Code Cart Check sheets for the third-floor patient care unit revealed no documentation nursing staff completed the required daily check of code cart 1 on the following dates:
December 5, 7, 10, 14, 14, 16, 17, 21, 25, 30 and 31, 2021.
January 1, 16, 17 and 20, 2022.
February 16, 21 and 27, 2022.
March 11, 17, 24, 25 and 31, 2022.
April 1, 2022.

Review on April 5, 2022, of the Daily Code Cart Check sheets for the third-floor patient care unit revealed no documentation nursing staff completed the required daily check of code cart 2 on the following dates:
December 21, 22, 23, 25, 30 and 31, 2021.
January 1, 7, 16, 17, 20 and 23, 2022.
February 20, 21 and 26, 2022.
March 11, 17, 24, 25 and 31, 2022.
April 1 and 2, 2022.

Interview with EMP13 on April 5, 2022, at approximately 1050 confirmed there was no documentation indicating the third-floor nursing staff completed the required Daily Code Cart Check checks on the above dates.

Review on April 5, 2022, of the Daily Code Cart Check sheets for the Intensive Care Unit (ICU) unit revealed no documentation nursing staff completed the required daily check of code cart 1 on the following dates:
January 30, 2022.
February 26, 2022.
March 3 and 4, 2022.

Interview with EMP13 on April 5, 2022, at approximately 1130 confirmed there was no documentation indicating the ICU nursing staff completed the required Daily Code Cart checks on the above dates.

2. Review on April 5, 2022, of the Daily Code Cart Check sheet for the fourth-floor patient care unit revealed no documentation nursing staff completed the required weekly manual test of the defibrillator battery on code carts 1 and cart 2 on the following dates:
December 7 and 14, 2021.
January 1, 14, 21 and 28, 2022.
February 1 and 7, 2022.
March 1, 2022.

Interview with EMP13 on April 5, 2022, at approximately 1000 confirmed there was no documentation on the Daily Code Care Check sheets indicating the fourth-floor nursing staff completed the required weekly manual test of the defibrillator battery on code carts 1 and 2 on the above dates.

Review on April 5, 2022, of the Daily Code Cart Check sheet for the third-floor patient care unit revealed no documentation nursing staff completed the required weekly manual test of the defibrillator battery on code carts 1 and 2 on the following dates:
December 1, 7, 14 and 21, 2021.
January 1, 7, 14, 21 and 28, 2022.
February 21, 2022,

Interview with EMP13 on April 5, 2022, at approximately 1050 confirmed there was no documentation on the Daily Code Care Check sheets indicating the third-floor nursing staff completed the required weekly manual test of the defibrillator battery on code carts 1 and 2 on the above dates.

Review on April 5, 2022, of the Daily Code Cart Check sheet for the ICU unit revealed no documentation nursing staff completed the required weekly manual test of the defibrillator battery on the following dates:
December 7, 2021.
January 7, 2022.

Interview with EMP13 on April 5, 2022, at approximately 1130 confirmed there was no documentation on the Daily Code Care Check sheets indicating the ICU nursing staff completed the required weekly manual test of the defibrillator battery on the above dates.

Repeat deficiency
September 27, 2019

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure medical records were completed 30 days following discharge for four of four applicable providers reviewed (OTH1, OTH2, OTH3 and OTH4).

Findings include:

Review on April 6, 2022, of the facility's "Medical Staff Rules and Regulations" last reviewed July 2021, revealed "...Medical Records ... 11) Completion of Medical Records a) The Centers for Medicare and Medicaid Services (CMS) require chart completion within thirty days of discharge. However, providers should electronically complete all available medical records on a weekly basis. b) Providers will receive notification of all charts assigned to them on a weekly basis. A chart will be considered delinquent in the following situations: i) Unsigned entries greater than 30 days from date deficiency identified ii) Incomplete entries greater than 30 days from date deficiency identified iii) History and Physical greater than 24 hours post admission order iv) Operative Reports greater than 24 hours post procedure v) Discharge Summaries greater than 15 days from date deficiency identified ..."

Review on April 6, 2022, of the facility provided "Provider's incomplete Records list by Days Outstanding" identified by EMP9 as the medical record delinquent report dated April 6, 2022. This medical record delinquent revealed tracking of delinquent medical records from November 1, 2021, through March 3, 2022. The log contained the part of the medical record not completed, the name of the provider and allied health professional, medical record number, the patient's name, the day the patient was discharge, the days outstanding and the reason the medical record is delinquent. EMP9 revealed a delinquent medical record was one that was not closed within 30 days after the patient was discharged. Per the Unresolved Deficiencies by Responsibility report, providers (OTH) who had delinquent medical records as of April 6, 2022, were as follows:

OTH1 had 13 medical records not completed ranging from March 3, 2022, to March 4, 2022.

OTH2 had 27 medical records not completed ranging from November 1, 2021, to February 28, 2022.

OTH3 had 2 medical records not completed from February 16, 2022.

OTH4 had one medical record not completed from January 6, 2022.

Interview with EMP9 on April 6, 2022, at approximately 1045 confirmed OTH1, OTH2, OTH3 and OTH4 had medical records that were not completed within 30 days of the patients' discharge date.

Repeat deficiency
September 27, 2019

Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to ensure laboratory supplies ready for patient use on the patient care units were not expired on the third floor, 3 South and at the laboratory blood draw site located in Waymart.

Findings include:

Review on April 5, 2022, of the facility's "Supply Inventory Control" policy, last approved October 14, 2019, revealed "Principle: ...A good inventory par level plan would keep ample amounts of product on the shelf while minimizing overstocks and waste. Policy: ...All supplies routinely come from the manufacturer with an expiration date printed on them..."

Observation on April 5, 2022, of the laboratory supplies stored on the 3rd floor patient care unit revealed the following: one Aerobic (a group of microorganisms that grow in the presence of oxygen) blood culture bottle with an expiration date of March 3, 2022; one Anaerobic (a group of microorganisms that grow in the absence of oxygen) blood culture bottle with an expiration date of March 17, 2022; four red top laboratory tubes with an expiration date of October 21, 2021 and three white top laboratory tubes with an expiration date of August 31, 2021.

Interview with EMP13 on April 5, 2022, at approximately 1015 confirmed the one Aerobic blood culture bottle with an expiration date of March 3, 2022; the one Anaerobic blood culture bottle with an expiration date of March 17, 2022; the four red top laboratory tubes with an expiration date of October 21, 2021, and the three white top laboratory tubes with an expiration date of August 31, 2021, stored on the 3rd floor patient care unit.

Observation on April 5, 2022, of the laboratory supplies stored on 3 south COVID patient care unit revealed 35 gray top laboratory tubes with an expiration date of April 3, 2022.

Interview with EMP13 on April 5, 2022, at approximately 1055 confirmed the 35 gray top laboratory tubes with an expiration date of April 3, 2022, stored on the 3 south COVID unit.

Observation on April 7, 2022, of the laboratory blood draw site located in Waymart, revealed seven gray top laboratory tubes with an expiration date of April 3, 2022.

Interview with EMP10 on April 7, 2022, at approximately 0845 confirmed the seven gray top laboratory tubes with an expiration date of April 3, 2022, stored at the laboratory blood draw site in Waymart.