HospitalInspections.org

REMAINS CITED

Based on observation, medical record review, staff interview and facility policy and procedure, the facility failed to prepare comprehensive plans of care to address patient care needs for wounds, skin concerns and restraints for three patients (#3, 13, and 5) of 46 medical records reviewed for comprehensive care plans. The facility census was 216.

Findings include:

1) Patient #3 was admitted to the facility on 04/28/14 following a cardiac catheterization (insertion of a flexible catheter into the veins usually through the groin) with an abnormal finding and arrhythmia as well as a secondary cardiac catheterization for interventional placement of a stent. Review of the medical record revealed the plan of care for skin integrity was left blank despite Patient #3 having two wounds from recent cardiac catheterization procedures. Review of nursing flow sheets indicated the nursing staff documented Patient #3's plan of care was reviewed on 04/28/14 at 7:00 PM, 9:00 PM, 11:00 PM, and every two hours thereafter on 04/29/14.

Interview with Staff D on 04/29/14 at 10:29 AM confirmed the plan of care did not address the cardiac catheterization wound sites in the patient's groin.


2) Review of the medical record for Patient #13 revealed the patient was admitted on 04/25/14 with diagnoses including cellulitis of right lower extremity and diabetes mellitus. The nursing admission assessment, dated 04/25/14, revealed Patient #13 had a pressure ulcer of the coccyx with measurements of 1.9 inches, by 1.1 inches by .02. Review of the care plan for skin for Patient #13 revealed a care plan for cellulitis was initiated on 04/25/14. There was no care plan for the pressure ulcer of the coccyx.

On 04/29/14 at 4:30 PM, Staff E confirmed there was no care plan for Patient #13's pressure ulcer.

Review of the facility's policy and procedure on Nursing Plan of Care Policy, effective March 2014, indicated the purpose of this policy was to ensure nursing interventions address the patient's unique needs and promote desired patient outcomes.


3) Patient #5 was admitted to the facility on 04/26/14 with diagnoses which included acute respiratory failure with mechanical ventilation and pulmonary edema. Review of the medical record revealed the patient had a daily physician's order since admission to current (04/29/14) for bilateral soft wrist restraints related to the patient's inability to understand and follow directions in the maintenance of the ventilator. Review of Patient #5's plan of care failed to document the presence of the bilateral wrist restraints nor the associated nursing care and education necessary for the provision of care for physical restraints. Review of the nursing flow sheets from 04/26/14 through current date of 04/29/14 revealed nursing staff had documented the plan of care was reviewed and updated to reflect Patient #5's care needs.

Staff D confirmed on 04/29/14 at 9:45 AM Patient 5's plan of care does not address the patient's physical restraint.

Review of the facility's policies and procedure entitled Management of non-violent or non-self destructive behaviors with a most recent revision date of March 2014 at Item M and numeral 2 of the policy directed staff the use of restraints needs to be addressed in the patient's Plan of Care as a problem and also the education provided to the patient and the family. Review of the facility's policy entitled Nursing Plan of Care with a most recent revision date of March 2014 directed nursing staff was to review the plan of care at least every 24 hours for achievement of goals and outcomes and appropriate interventions as well as diagnoses, goals and interventions should be reviewed and evaluated based on the patient assessment and re-assessment.









22432

Based on interview and record review, the facility failed to ensure two patients (Patient #34 and #36) of 46 medical records reviewed were given medications as ordered.

Findings include:

1) The clinical record review for Patient #34 revealed the 63 year old patient was admitted to the hospital on 04/25/14 with a diagnosis of leg and finger pain. The record revealed a verbal order dated 04/26/14 for Carvedilol (a medication to treat high blood pressure) to be given on 04/24/14 at 5:00 P.M. The record revealed the medication was not given until 04/25/14 at 7:59 A.M.

On 04/29/14 at 4:30 P.M. in an interview Staff B confirmed the documentation.

2) The clinical record review for Patient #36 revealed the 53 year old patient was admitted to the hospital on 04/25/14 with a diagnosis of left hip fracture. The record revealed a physician's order for normal saline to be infused at 50 milliliters an hour dated 4/25/14 at 5:30 PM. Review of the medication administration record (MAR) revealed the IV was discontinued on 4/26/14 at 5:08 PM. The MAR lacked evidence of how much of the solution had been infused.

On 04/26/14 at 5:08 PM in an interview Staff C confirmed this finding.

Based on observation, staff interview and review of policy, the facility facility failed to ensure timely completion of medical records (A438), medical records are legible (A450) and protect medical records from potential water damage (A438). The cumulative effect of these systemic practices resulted in the facility's inability to ensure the integrity and retention of all facility patient medical records would be met. The current patient census was 216.

Based on observation, review policy and staff interview, the facility failed to ensure prompt completion of medical records and failed to protect medical records from potential water damage. This has the potential to affect all patients of the hospital. The facility's active census was 216.

Findings include:

1. Review of the facility's delinquent medical records report for delinquencies on 04/28/14 revealed the facility had 1071 patient charts missing physician's signatures greater than 30 days. On 04/29/14, the facility had five physicians suspended since 04/07/14 for delinquent records.

2. During a tour of medical records department on 04/29/14 at 1:30 PM, medical records were observed filed on open rolling shelves. Sprinkler heads were observed on the ceiling over the medical records. During the tour, Staff F indicated the facility's medical records were electronic and also paper files. Staff F also indicated the medical records filed on the open shelves were for the years of 2008, 2009, 2010, 2011 and 2012. Staff F confirmed the medical records were not scanned and could have water damage if the sprinklers were activated.

3. Medical records were observed at the facility's off-site location on 05/01/14 at 3:30 PM with Staff H. The off-site location was two large rooms with multiple large open shelves. Staff H indicated the medical records were from the years of 1970's to 2005. Staff H revealed some of the files were medical records of pediatric patients and were not scanned.

Review of the Health Information Management Policy, effective March 2002 and reviewed on August 2013, revealed Attachment III, which was titled Records Storage. The policy indicated the off-site storage facilities are to be secure locations that safeguard the records from ordinary hazards, such as water.

Based on observation, clinical record review, policy review and interview, the facility failed to ensure each clinical record had legible clinical entries for one patient (Patient #37) of 46 medical records reviewed. The facility census was 216.

Findings include:

The clinical record review for Patient #37 was completed on 04/30/14. The clinical record review revealed handwritten medical progress notes for 04/26/14, 04/27/14, 04/28/14, and 04/29/14.

On 04/30/14 at 2:00 P.M. in an interview, Staff B and Staff C stated they were unable to read the notes in their entirety.

On 04/30/14 a review of medical staff policy entitled Medical Records and last revised 03/28/14, was completed. The review revealed the contents shall address patient data and information legibly.

Based on review of facility schematics and documentation, facility observation and staff interview the facility failed to ensure the building was constructed, arranged, and maintained to ensure the safety of all patients staff and visitors.

The facility failed to ensure that that corridors were separated from use areas by walls constructed with at least ½ hour fire resistance rating. In non-sprinklered buildings, walls were to properly extend above the ceiling (K17), failed to ensure that stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour (K20), failed to ensure that access to exits was marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants, failed to ensure that any door in an exit passageway, stairway enclosure, horizontal exit or smoke barrier that was held open only by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of the required manual fire alarm system, local smoke detectors designed to detect smoke passing through the opening and or the automatic sprinkler system, if installed (K21), failed to ensure that access to exits was marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants, (K22), failed to ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3.(K25), failed to ensure that door openings in smoke barriers had at least a 20-minute fire protection rating. Doors were to be self-closing or automatic closing.(K27)

The facility also failed to ensure that one hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas. When the approved automatic fire extinguishing system option was used, the areas were to be separated from other spaces by smoke resisting partitions and doors (K29), failed to maintain protection of exit stairwells from fire,(K33) failed to have the releasing mechanism of an exit door less than 48 inches from the floor.(K38), failed to ensure that horizontal exits, if used, were in accordance with 7.2.4 with regards to doors required to be self-latching were either self-latching or become self-latching upon operation of approved smoke detectors (K44), failed to have two light sources at an exit discharge (K45), failed to ensure that medical gas storage and administration areas were protected in accordance with NFPA 99, Standards for Health Care Facilities with regards to oxygen storage locations of greater than 3,000 cu.ft.( K76), failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors.(K130), Also addressed under K130 was the facility failure to ensure exit access doors in the facility were arranged so that the exits were readily accessible at all times in accordance with the code at 39.2.1.1 and 7.2.1.5.1, also failure to ensure one exit discharge contained a hard surface to the public way in accordance with the code at 39.2.1.1 and 7.7.1, and failure to ensure ten exits discharges were arranged so that failure of any single lighting fixture (bulb) would not leave the area in darkness in accordance with the code at 39.2.1.1 and 7.8.1.4. (K130) and failed to perform an annual 90 minute emergency light lest on battery powered emergency lighting. (K146). The cumulative effect of these systemic practices resulted in the facility's inability to ensure the physical environment was safe for all 216 patients, staff and visitors.

Based on facility observation and staff confirmation, the facility failed to ensure the hospital met the applicable provisions of the Life Safety Code of the National Fire Protection Association. The facility had a capacity of 441 beds with a census of 216 patients at the time of the survey. Potentially all patients, visitors and staff could be affected.

Findings include:

On 04/28/14 through 05/01/14 between the hours of 8:15 A.M. and 5:00 P.M. tour of the facility was conducted with Staff PP, QQ, SS and TT. The following observations of life safety measures revealed the following findings:

The facility failed to ensure that corridors were separated from use areas by walls constructed with at least ½ hour fire resistance rating. In non-sprinklered buildings, walls were to properly extend above the ceiling. Please refer to K17 for further detail.

The facility failed to ensure that stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour. Please refer to K20 for further detail.

The facility failed to ensure that any door in an exit passageway, stairway enclosure, horizontal exit or smoke barrier was held open only by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of the required manual fire alarm system, local smoke detectors designed to detect smoke passing through the opening and or the automatic sprinkler system. Please refer to K21 for further detail.

The facility failed to ensure that access to exits was marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. Please refer to K22 for further detail.

The facility failed to ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. Please refer to K25 for further detail.

The facility failed to ensure that door openings in smoke barriers had at least a 20-minute fire protection rating. Doors were to be self-closing or automatic closing. Please refer to K27 for further detail.

The facility's failure to ensure that one hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas. When the approved automatic fire extinguishing system option was used, the areas were to be separated from other spaces by smoke resisting partitions and doors. Doors were to be self-closing. Please refer to K29 for further detail.

The facility failed to maintain protection of exit stairwells from fire. Please refer to K33 for further detail.

The facility failed to have the releasing mechanism of an exit door less than 48 inches from the floor. Please refer to K38 for further detail.

The facility failed to have two light sources at an exit discharge. Please refer to K45 for further detail.

The facility failed to ensure that medical gas storage and administration areas were protected in accordance with NFPA 99, Standards for Health Care Facilities with regards to oxygen storage locations of greater than 3,000 cu.ft. Please refer to K76 for further detail.

The facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. Also addressed under K130 was the facility failure to ensure exit access doors in the facility were arranged so that the exits were readily accessible at all times in accordance with the code at 39.2.1.1 and 7.2.1.5.1, also failure to ensure one exit discharge contained a hard surface to the public way in accordance with the code at 39.2.1.1 and 7.7.1, and failure to ensure ten exits discharges were arranged so that failure of any single lighting fixture (bulb) would not leave the area in darkness in accordance with the code at 39.2.1.1 and 7.8.1.4. Please refer to K130 for further detail.

The facility failed to perform an annual 90 minute emergency light lest on battery powered emergency lighting. Please refer to K146 for further detail.

Based on clinical record review and interview, the facility failed to include discussion for treatment for alcohol abuse in the patient's discharge planning for one (Patient #35) of 46 medical records reviewed. The facility census was 216.

Findings include:

1) The clinical record review for Patient #35 revealed the 71 year old patient was admitted to the facility on 03/29/14 with a chief complaint of right upper quadrant and back pain. Review of the patient's history and physical as dictated on 03/30/14 revealed the patient had a social history of heavy alcohol consumption.

A review of the patient's discharge summary dictated on 04/16/14 revealed the patient was diagnosed with esophageal ulcer and alcohol abuse.

The record review revealed Patient #35 was re-admitted to the facility on 04/22/14 for a chief complaint of leg weakness. Review of the patient's history and physical dictated on 04/22/14 revealed the patient fell at home four times. The history and physical described an impression of possible stroke versus radiculopathy and neuropathy.

Review of case worker notes dated 04/23/14 at 2:58 P.M. and 04/15/14 at 12:03 P.M. failed to reveal if the patient was offered treatment information for alcohol abuse.

On 04/30/14 at 10:00 A.M. in an interview, Staff B and Staff C stated they could not find where the patient had been offered information for alcohol abuse.

Based on interview and record review, the facility failed to properly execute an informed consent form for one patient (Patient #44) of 46 medical records reviewed.

Findings include:

The clinical record review revealed on 04/29/14 Patient #44 had laparoscopic gall bladder surgery. Review of the consent for surgery revealed the response to the questions "I understand that my condition could be treated in other ways" and "The Doctor and I have discussed alternatives that include the option to forego treatment" were marked as No. The consent was signed by the patient on 04/21/14, and by the surgeon on 04/29/14.

On 05/01/14 at 3:58 P.M. in an interview, Staff B confirmed the documentation.