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Based on record review and interview the facility failed to protect and promote the rights of the patients. See tags: (A 117) failed to inform each patient, or the patients representative of the patient's rights before initiating or discontinuing patient care; (A 131) failed to ensure the general consent for treatment was obtained;( A 147) failed to ensure the patients right to confidentiality of his or her clinical records;(A 168) facility failed to obtain a completed physicians order for restraints; and (A 169) the facility's staff failed to follow the facility's policy in regards to standing orders for restraints on a patient.

Based on record review, interview and policy review the facility failed to obtain a signed, completed " Important Message from Medicare " (IMM) from each Medicare patient, or the patients representative, before initiating or discontinuing patient care in 9 out of 10 Medicare charts reviewed (patients #5, #6, #10, #11, #58, #60, #62, #65, and #67). Findings include:

On 09/19/11 at approximately 1140 during record review of patient #5's chart, it was determined that the patient was admitted on 09/09/11. The document titled "Important Message from Medicare" was in the chart but was signed by one of the Customer Service Representatives on 09/12/11. The signature of the patient or the patient's representative was never obtained during the rest of the hospitalization for the patient.
On 09/19/11 at approximately 1245 during record review of patient #6's chart, it was determined that the patient was admitted on 09/08/11. The document titled "Important Message from Medicare"(IMM) was in the chart but was signed by one the patient's sons on 09/12/11.
On 09/20/11 at 1400 during review of the policy titled "Important Message from Medicare Distribution/Implementation" , dated 11/09, it revealed "The Customer Service Coordinator will meet with the patients and/or their family and provide the IM notice at admission and obtain a signature."
On 09/19/11 at 1200, during an interview, Staff B confirmed these findings.


28273


The closed medical record for patient #60 revealed that they were admitted on 03/26/2011. The first IMM was not signed until 03/30/2011. Staff LL was unable to locate an IMM signed by the patient at the time of their discharge on 04/16/2011.

During review of the closed medical records for patients #62 and #65 staff LL was unable to locate an IMM signed by either patient.

Review of the closed medical record for patient #67 revealed that the patient was admitted on 02/18/2011. The IMM was signed and dated by the patient on 02/21/2011. The patient was discharged on 03/10/2011. Staff LL was unable to locate a second IMM signed by the patient at the time of discharge.

The above findings were confirmed by staff LL at the time of the record reviews on 09/20/2011.


29955

During medical record review of patient #10 and #11 on 09/19/2011 at approximately 1430, it was revealed that the IM had not been given to, or signed by the patient. Patient #10 was admitted on 9/15/2011 and had signed his consent for treatment, however, had not been provided his IM. Patient #11 was admitted on 9/15/2011 and had signed her consent for treatment, however, had not been provided her IM.

During an interview with staff II on 9/21/2011 at approximately 1030 it was confirmed the important message had not been provided to either patient. Staff II stated it had not been provided within the 48 hours as the 48 hour period ended on the weekend and there had not been coverage to ensure the delivery of the IM.

During a review of policy on 9/21/2011 at approximately 1300 it was revealed the policy titled "Important Message from Medicare Distribution/Implementation" #2. states "The customer service coordinator will meet with patient and/or their family and provide the IM notice at admission and obtain a signature. It was confirmed by Staff II the IM message had not been provided according to policy.

Based on medical record review and interview the facility failed to ensure the general consent for treatment was obtained for 1 of 25 patients (#10) resulting in the potential of providing medical or surgical care against the patient or guardian's approval.

On 9/19/2011 at approximately 1420 during medical record review it was revealed in patient #10 chart the general consent had not been signed by the patient or the guardian of the patient. A document for authorization for disclosure of patient medical information dated 9/15/2011 had been signed by the patient's daughter. The general consent for treatment was dated for 9/15/2011 and lacked signature for treatment. This finding was confirmed on 9/19/2011 by staff #J.

According to policy #304 titled "Informed Consent" a general consent for treatment is signed for routine care or non-invasive treatments that involve an insubstantial risk of harm to the patient.

Based on medical record review, policy review, and interview the facility failed to ensure in 2 of 25 patients (#5 and #3) the safety of the patient in failure to identify a latex allergy and failure to document the skin assessment resulting in the potential of causing: 1) an anaphylactic latex allergy reaction, and 2) potential in causing a skin wound which would require additional care and extended stay of the patient.

On 9/19/2011 at approximately 1130 during medical chart review it was revealed patient #10 had a latex allergy which had not been marked on the patient, the patient's doorway, or above the patient's bed. An interview with staff #K confirmed patient #10 did indeed have a latex allergy and the appropriate signage and armband had not been placed in the patient's room or on the patient. Staff #I also confirmed the appropriate signage and armband had not been placed on the patient, the patient's door, or above the patient's bed.

On 9/20/2011 at approximately 1430 during a revisit of patient #10 after a transfer of the patient to another floor the appropriate signage was on the patient's door and above the patient's bed. However the patient lacked an armband identifying the patient's latex allergy.

During an interview on 9/20/2011 at approximately 1630 staff #Z confirmed the patient had not been identified with an armband as required per policy.

On 9/21/2011 at approximately 1230 a review of policy #580 titled "latex allergy" page 3 #6.) b.) 2.) states "Place green latex alert wristband on patient and place green sign "latex allergy" on door".



27408

On 09/19/11 at approximately 1140 during record review it was determined that patient #5 was admitted to the hospital on 09/09/11. Patient #5 was then transferred to the Intensive Care Unit on 09/15/11. The first care plan that was found to be initiated by nursing staff was dated 09/15/11. According to physicians orders dated 09/15/11 a rotation bed and Tegaderm (dressing) were ordered as a treatment because patient #5's "sacral area has a stage I ulcer (blister)...or stage II ulcer to the right side of the wound". There was no other documentation to prove that the patient was admitted to the hospital with this wound.
On 09/19/11 at approximately 1155 staff B confirmed that there was no other documentation, care plan, or skin assessment that was completed upon admission on 09/09/11 until the patient was moved to ICU on 09/15/11.

Based on observation and interview the facility failed to ensure the patients right to confidentiality of his or her clinical records. Findings include:

During initial tour of the Emergency Department on 9-19-11 at approximately 1210 it was observed an electronic census board in the main hallway with patient information, including, last name, first initial, age and room number for 9 patients.

These findings were confirmed by staff R at the same time as surveyors observation.

On 09/19/11 at approximately 1130 during record review for patient #5, it was revealed that the patient was placed into restraints with the last order written on 09/18/11 at 0800. The order does not identify the specified type of restraint or which limb to be restrained on the patient.
On 09/19/11 at approximately 1150 during record review for patient #6 , it revealed that the patient was placed into restraints on September 13, 14, 15,16,17,18, and 19, 2011. The orders do not identify the specified type of restraint to be used on the patient.
On 09/19/11 at approximately 1155 staff B confirmed that there was no specified limb that was to be restrained.


28273

During review of the medical record for patient #9 on 09/19/2011, it revealed that the patient was placed into restraints on 09/15/2011 at 0124. The order does not identify the specified type of restraint to be used on the patient. Another order was written on the patient for restraints on 09/15/2011 at 0918 again the order lacked the specified type of restraint to be used on the patient.

Based on record review, interview, and policy review it was determined that the facility's physician wrote standing orders for restraints (patient #6) in 1 out of 3 restrained patient charts reviewed. Findings include:

On 09/19/11 at approximately 1130 during record review it was revealed patient #6 was intubated on 09/14/11 at 1945. Nursing applied the restraints at 2000 and obtained an order for the restraints from the physician at 2248. The physician did not specify which limbs to be restrained. According to nursing documentation the restraints were not being used on the patient since 09/16/11 at 1054. The physician continued to write orders for restraint on 09/17/11, 09/18/11, and 09/19/11.

On 09/19/11 at approximately 1200 while reviewing the physicians orders with staff B, it was determined that the physician did continue to write orders for 3 days for the patient's restraints that had been discontinued on 09/16/11.

Based on policy review, medical record review and interview the facility failed to evaluate the care for each patient in accordance with the hospital's policy for 1 out of 1 patients reviewed (#13) resulting in the potential for adverse outcomes to the patient's health status. Findings include:

On 9/19/2011 at approximately 1500 during review of policy #491 titled Epidural and Intrathecal (intraspinal) Analgesia, External Delivery System it is stated "For adult patients monitor and document the following Q 15 min x 2, Q 30 min X 2, Q 1 hour X 12 (respirations and sedation only from 11pm - 6am), the Q 4 hours for the duration of the infusion unless otherwise ordered:
a. Vital signs
b. PCA doses attempted and given
c. Sedation level
d. Motor function
e. Sensation level
f. Pain Scale
g. Interventions
h. Side effects."

On 9/19/2011 at approximately 1530 during review of the medical record for patient #13 it was revealed that monitoring from 1300 until 1530 had not been documented in the electronic medical record. The form in the paper medical record titled Single Dose Epideral/Intrathecal Morphine Analgesic Recording Documentation for 9/19/2011 was completely blank for the entire day. Staff A was asked if the form was currently expected to be used on applicable patients, she responded "Yes." These findings were confirmed by staff W at 1545 who stated "I just put it in the computer, I hadn't had a chance to document it."

Based on record review and interview the facility failed to ensure that the nursing staff developed and kept current a nursing care plan in 1 of 13 charts reviewed.(Patient#5) Findings include:

On 09/19/11 at approximately 1140 during record review it was determined that patient #5 was admitted to the hospital on 09/09/11. Patient #5 was then transferred to the Intensive Care Unit on 09/15/11. The first care plan that was found to be initiated by nursing staff was dated 09/15/11 which was 6 days after admission.

On 09/19/11 at approximately 1155 staff B confirmed that there was no other care plan that was completed upon admission on 09/09/11 until the patient was moved to ICU on 09/15/11.

Based on observation and interview the facility failed to ensure that unauthorized individuals cannot gain access to confidential patient records in 5 out of 8 patient units resulting in the potential for a breach in confidentiality of patient records. Findings include:


29313

During the initial tour of the observation unit on 9/19/2011 at approximately 1515 it was revealed that patient charts were unsecured in corridor wall units outside of the patient rooms. These findings have the potential to allow access to individuals not authorized to review patient information.

These findings were confirmed on 9/19/11 by staff C during the same initial tour and observation.



29774

On 9/19/11 at approximately 1110 found medical records for the medical-surgical unit 2 South (census of 34), stored in chart boxes (two per box) with a lock that was not implemented. Interview with staff M confirms that the medical records are kept in the chart boxes but are not locked. She further stated that they "have never had a problem with unauthorized access to medical records on their unit".


29955

On 9/19/2011 at approximately 1130 during a tour of the surgical patient care area, it was observed that access to patient charts [stored in corridor wall units outside of the patient rooms] was possible for individuals not authorized to provide patient care. The same storage of records was observed in the orthopedic patient care area at 1430.

On 9/21/2011 at approximately 1100 it was revealed the medical record for patient #70 chart was available to the access of visitors and all non-medical staff at the nurse's station where there was no staff within sight to secure the chart. At approximately 1330 staff #Z was alerted to patient #70 chart being unsecured at which time the chart was immediately moved to a secured area. Staff #Z confirmed that the chart was unsecured and should have been in a secure area.


28273

During observations on the step down unit on 09/19/2011 at 1100 with staff D and staff H, it was noted and confirmed that the patient records were stored unsecured in chart boxes on the walls outside of the patient ' s rooms.
During a return visit to the unit on 09/19/2011 at 1700 with staff Z revealed an open chart box with a patient's record lying unattended on the opened shelf.

During review of the medical record for in patient #9 on 09/19/2011, it revealed that a physician's telephone (voice order) taken on 09/14/2011 was not signed by a physician within 48 hours.




29314


Based on medical record review and interview the facility failed to ensure all orders are signed by physicians for 3 of 25 charts reviewed (#9, #13,
#25), consents are completed for 1 of 25 patients (#25) and that the medical record is legible in 1 of 25 patients (#14), resulting in the potential for medical errors. Findings include:

On 9/19/2011 at approximately 1525 during review of the paper medical record for patient #13 it was revealed that the "pre-operative" orders were not signed, dated or timed by a physician. When reviewing the electronic medical record it was revealed that there was another set of pre-operative orders entered electronically. It was unclear which set of orders were carried out.

On 9/19/2011 at approximately 1545 it was confirmed with staff W that the paper orders are "used sometimes" and that they were filled out for patient #13, however, not dated, signed or timed. "I always follow the orders in the electronic medical record if there are 2 sets of orders, especially if they are not signed" stated staff W.

On 9/20/2011 at approximately 1615 during review of patient #14's paper medical record it was revealed that the History and Physical portion of the chart was illegible. This finding was confirmed with staff W who stated "I don't know what that says, I can't read that, and it is not dictated."


29955

On 9/19/2011 at approximately 1400 during medical record review it was revealed the verbal order for patient #25 had not been authenticated by the physician. It was confirmed by staff #Z all verbal orders are to be authenticated by the ordering physician.

On 9/19/2011 at approximately 1420 during medical record review it was revealed the informed consent for surgery lacked the complete name of the physician performing the surgery and the surgeon was identified as "Dr. H", which was an abbreviation of the physician's name to last initial only.

The consent further lacks identification of the individual signing the informed consent which is other than the patient. According to policy #304 titled "Informed Consent" page 3 "documenting receipt of information and consent to treatment" it states 3. "if the signature is other than the patient's, the relationship of the signer to the patient should be noted below the signature".

Based on record review and interview, the facility failed to complete a discharge summary for 4 of 10 (#52, #57, #65, #66) patients within 30 days of discharge. Findings include:

During review of closed medical records with staff LL on 09/20/2011 the following records lacked a completed discharge summary:

Review of the medical record for patient #52 discharged on 02/25/2011 the document titled Obstetric Discharge Summary lacked documentation of an admitting diagnosis and discharge diagnosis.

During review of the records for patient #57 discharged on 03/17/2011, patient #63 discharged on 06/19/2011 and patient #66 discharged on 07/20/2011 staff LL was unable to locate the discharge summaries for the three patients.

Based on record review and interview, the facility failed to complete medical records within thirty (30) days of the patient's discharge. Findings include:

During interview and document review with staff MM on 09/20/2011 at 1015 they revealed that the hospital had 140 delinquent medical records not completed within thirty (30) days of the patients being discharged from the hospital, 15 records not completed within 60 days of discharge and 11 records not completed for patients that had been discharged for more than 90 days.

Based on observation, interview and document review the facility failed to ensure that outdated pharmaceuticals were not available for patient use for employees and discharged hospitalized patients who filled their prescriptions in the Outpatient Pharmacy resulting in the potential for less than optimal pharmaceutical effects. Findings include:

On 9/19/11 at approximately 1440 during tour of the outpatient retail pharmacy found Varivax two individual-dose vials in the freezer with an expiration dates of June 2010. Additionally found a box of acetylcysteine tablets with an expiration date of February 2011. Interview with staff P confirms these medications are beyond the manufacturers expiration date. He states that they usually check their stock regularly for close-date or expired medications and return them. A review of the policy titled Pharmacy Services- Expired Medications: Policy number 3520 dated 5/2011 states "Pharmacy inventory shall be checked regularly for outdated items...any outdated items shall be placed in the designated holding area...Pharmacy inventory is inspected monthly by pharmacy technicians assigned to each section of stock....".

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-709.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors, the facility does not comply with the applicable provisions of the Life Safety Code.

See the K-tags on the CMS-2567 dated September 23, 2011 for Life Safety Code.

Based on observation and interview the facility failed to ensure that supplies and equipment were maintained to an acceptable level of safety and quality. Findings include:


During observation in the Emergency Department on 9-19-11 at approximately 1115 it was observed that two packages of Temporary Pacing Electrode Catheters in the Resuscitation room had expired 01-2011.

During observation in the Emergency Department on 9-19-11 at approximately 1150 it was observed that 48 Needle-Free valve ports in the medication room expired 08-2011.

During observation in the Emergency Department on 9-19-11 at approximately 1220 it was observed that that stacks of orthopedic supplies used for patients were setting beside the sink, within splashing distance and the potential for contamination.

During observation in the Emergency Department on 9-19-11 at approximately 1230 it was observed in the dirty utility room that clean supplies of urine test tubes were being stored on the dirty utility sink.

During observation in the Emergency Department on 9-19-11 at approximately 1245 it was observed that in the isolation room corridor under the sink there were approximately fifteen 10 packs of yellow cover gowns being stored.

The above findings were all confirmed at the time and date of observation by Staff R.



29314


On 9/19/2011 at approximately 1200 during the tour of the fourth floor Women's Services Unit, it was observed in the Refreshment Center that stacks of Styrofoam cups used for patients and staff were setting beside the sink, within splashing distance. The surveyor performed hand hygiene in the sink and confirmed that the water splashed onto the cups contaminating them.

Based on observation, interview and policy review the facility failed to:
1.) maintain a sanitary environment
2). ensure staff are using personal protective equipment according to facility policy for "Enhanced Contact Precautions
3). ensure access to hopper sinks and soiled linen hampers
resulting in the potential for transmission of infectious agents among both patients and staff.

Findings include:

On 9/19/11 at approximately 1125 during facility tour of 2-South's soiled utility room found three full soiled linen bags stored on the floor blocking access to the handwashing sink. Additionally in the soiled utility room, found a used food tray stored on top of the hopper sink, blocking it's availability for use. Interview with staff M confirmed the floor storage of the linen bags and storage of the food tray over the hopper sink. She states that "it is Monday and sometimes these linen bags may accumulate before they are picked up.." Additionally staff M states that "they rarely use the hopper sink" and that they are going to be renovating the unit that will provide a larger soiled utility room to accommodate the census for the newly combined two medical-surgical units".

On 9/19/11 at approximately 1135 found staff N in room 219, a room marked with a sign designating "Enhanced Contact Precautions". Staff N did not have a gown nor gloves on. Upon interview with staff N she states that "as long as I don't touch anything in the room or the patient, I don't have to wear them". Interview with staff M confirms that Staff N should have on the gown and gloves when entering the room.

On 9/19/11 at approximately 1140 found staff O in room 201, a room marked with a sign designating "Enhanced Contact Precautions". Staff O did have gloves on however did not have on a gown. Interview with staff O confirms that she "forgot to put on her gown".

A review of policy titled "Precautions to Prevent Transmission of Disease" policy number 2.20 dated 4/09 states that "E. Enhanced Contact Transmission Precautions ... gloves must be worn when entering the room and gowns should be worn when entering the room ...".


28273

During observation on the step down unit on 09/19/2011 with staff D & staff H the soiled utility room was noted to have food trays sitting on the top of dirty linen hampers and the hopper (sink) was very soiled with splashes of brown spots and a very dirty bowl. Staff H made the comment that "we don't even use these anymore" and "I don't know why they just don't take them out." The room also had patient care items being stored in the corner such as a back board and several commode chairs.