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Based on observation, review of facility contract for Physical Therapy (PT) services, employee interview, and personnel record review revealed that the facility failed to ensure that the PT services performed for Resident #14 were provided in a safe and effective manner.


Findings include:


On 9/18/13 at 4:20 p.m. Employee #18 was observed providing wound-care for Patient #14. The wound was cleaned in an up and down motion, going over the wound numerous times with the same gauze. Interview with Employee #18 revealed that she had not received wound care training, other than formal education.

Review of the contract between (the facility) and "the contracting company" revealed, "Section #8 (b) (Contracting Company) contracted services shall be coordinated with nursing and other therapeutic services by such personnel as shall be designated by the hospital. Coordination includes authoritative and procedural guidance by qualified hospital staff and includes initial direction and periodic inspection of actual acts of accomplishing the function or activity being assessed."

Review of Employee #18's personnel record revealed no ongoing training for wound care and assessment by hospital or hospital personnel.

Based on observation, documentation review, policy and procedure review and staff interview, the facility failed to ensure that a properly functioning suction machine was on two (2) of two (2) crash carts for use in emergency situations in the Surgery Department and Emergency Department.

Findings include:

Observations made in the Surgery Department on 9/19/13 from 10:00 a.m. to 10:25 a.m. revealed suction machines were located on top of the two (2) crash carts in the unit. There was no evidence that the suction machine on either crash cart was routinely checked to ensure it worked properly.

Observations made in the Emergency Department (ED) on 9/19/13 from 11:15 a.m. to 11:25 a.m. revealed two (2) crash carts in the Fast Tract section of the ED. There was a suction machine was sitting on the top of one (1) of the two (2) machines. There was no evidence that the portable suction machine on this crash cart was routinely checked to ensure that it worked properly. There was no portable suction machine on the other crash cart, which was for pediatrics.

These findings were discussed with the Chief Nursing Officer (CNO) on 9/19/13 from 11:35 a.m. to 11:45 a.m. She stated that she was aware that some of the crash carts did not contain a suction machine. She also stated that the facility did not have a policy requiring the suction machines to be checked routinely.

Review of the facility's Policy Number PC-010 revealed no evidence that a suction machine was to be maintained on each of the crash carts.

Based on record review, policy and procedure review and employee interview, the facility failed to ensure that staff followed hospital policy during the discharge procedure for Patient #12 by failing to repeat a verbal order back to the physician for clarification prior to writing the order.


Findings include:


Review of record for Patient #12 revealed an order to discharge the patient dated of 9/18/13 at 12:00 p.m. and noted by the Registered Nurse on 9/18/13 at 12:45 p.m.


Interview with Employee #15 on 9/18/13 at approximately 3:40 p.m. revealed that Patient #12 was seen at 12:00 p.m. by the Physician, but the order was not written on the patient's medical record until approximately 3:35 p.m. Employee #15 stated, "The Doctor gave me the patient's prescriptions and told me to discharge the patient." She said that she would put it in CPSI (Physicians order entry program).

Review of the facility's "Physician Orders" policy (reviewed 9/08) revealed, "Policy" (8) ...staff...receiving telephone or verbal orders will repeat the orders back to the physician for clarification prior to writing the order(s) in the chart. Telephone and verbal orders will be carried out in the same manner as written order."

Based on medical record review, policy and procedure review and staff interview, the facility
1. failed to ensure all entries/orders in all medical records contained a documented date, time and signature;
2. failed to ensure a History and Physical (H&P) is completed and documented within 24 hours after admission; and
3. failed to ensure all consents are properly executed
This affected 11 of 36 patient's records reviewed, #1, #2, #3, #4, #5, #6, #7, #8, #12, #17 and #18.


Findings include:


Cross Refer to A450 for the facility's failure to ensure all entries in Patients #1, #2, #3, #4, #5, #6, #7, #8, #12, #17 and #18 medical records contained a documented date, time and signature.

Cross Refer to A454 for the facility's failure to ensure all orders, including verbal orders, are dated, timed and authenticated by the ordering physician for Patients #3 and #8.

Cross Refer to A458 for the facility's failure to ensure a H&P was completed and documented within 24 hours after admission for Patient #7.

Cross Refer to A466 for the facility's failure to ensure a properly executed consent was documented for Patient #5 and #12.

Based on record review, policy and procedure review and staff interview, the facility failed to ensure all entries in the medical record contained a documented date, time and signature for 11 of 36 patients reviewed (Patients #1, #2, #3, #4, #5, #6, #7, #8, #12, #17 and #18).


Findings include:


Record review for Patient #3 revealed that the nursing orders and medication orders had no documented date of when the orders were noted.


Record review for Patient #5 and #12 revealed that the consent for medical or surgical procedures and the anesthesia consent had not been signed or dated by the physician.


Record review for Patients #1, #2, #3, #4, #5, #6, #7, #8, #17 and #18 revealed that physician's orders had not been dated or timed when written into the medical record. This included orders written by the physician, verbal and/or telephone orders taken by the nurse and routine order sheets placed on the patient's medical record.


On 9/17/13 at 2:45 p.m. Registered Nurse (RN) #1 was asked what the facility's policy was on the noting of physician orders. She stated, "I do not note in out-patient."


On 9/17/13 at 4:00 p.m. RN #2 was asked what the facility's policy was on noting of physician orders. She stated, "We note with date, time and signature."


On 9/18/13 at 11:30 a.m. RN #9 was asked what the facility's policy was on noting orders. He stated, "Date, time and signature are required when you note an order."


Review of the facility's "Medical Record Creation/Content and Distribution-Documentation" policy revealed:
" ...Policy: All medical record entries must be ...complete, dated, timed and authenticated in written or electronic form by the person responsible for providing or evaluating the services ...
Procedure: D. Content of Medical Record n. Evidence of appropriate informed consent for procedures and treatments for which informed consent is required"


Review of the facility's "Physician Orders" policy revealed:
"Purpose: To provide guidelines for coordinating, implementing ...executing physician orders. To provide guidelines for the receiving of/verification of verbal/telephone orders.
Policy:..12..RN or LPN will sign off/note order(s) indicating nurse's name, title, date and time...".


Review of the facility's "Department of Surgery and Obstetrics/Gynecology: OR Rules" policy revealed:
"..Procedure: A. General:
10. Elective patients must have the following on their charts prior to admission to the OR: a. Signed Consents.
11. Anesthesia and or nursing staff will not transfer the patient to the OR suite if...c. If there is not a correctly signed consent on the chart.."


Review of the facility's "Duties and Responsibilities of the Anesthesia Provider" policy revealed: "Policy: J. Obtain anesthesia consent: Anesthesia provider is responsible for obtaining informed consent..."


Review of the facility's "Medical Staff Bylaws Rules and Regulations" policy revealed: "Section 2. Medical Records.. 10. Clinical Entries: All clinical entries in the patient's medical record shall be accurately dated, timed and authenticated.. 16: Orders: 2. All orders for treatment shall be in writing, dated, timed and authenticated..."

Based on record review, policy and procedure review and staff interview, the facility failed to ensure all orders, including verbal orders, are dated, timed and authenticated by the ordering physician for two (2) of 36 records reviewed (Patients #3 and #8).


Findings include:


Cross Refer to A450 for the facility's failure to ensure all orders, including verbal orders, for Patients #3 and #8 are dated, timed and authenticated by the ordering physician.

Based on record review, policy and procedure review and staff interview, the facility failed to ensure a history and physical (H&P) was completed and documented within 24 hours after admission for Patient #7, one (1) of 36 patient's reviewed.


Findings include:


Record review for Patient #7 revealed an admission date of 9/16/13 at 9:45 p.m. There was no documented evidence of a completed and documented H&P.


On 9/18/13 at 1:45 p.m. in an interview the lack of a documented H&P was discussed with Registered Nurse (RN) #8. The RN stated. "It (H&P) has not been dictated."


Review of facility policy "Medical Record Creation/Content and Distribution-Documentation" revealed: " ...Procedure: D. Content of Medical Record ...d. Medical history, (including chief complaint, details of present illness; relevant past, social and family histories ...; and an inventory by body system."


Review of "Medical Staff Bylaws, Rules and Regulations" revealed: "Section 2. Medical Records ...4. History & Physical: A complete history and physical examination on each case shall be recorded within twenty-four (24) hours of admission and this report shall include all pertinent findings resulting from an assessment of all pertinent systems of the body ...".

Based on record review and policy and procedure review, the facility failed to ensure a consent form was completed and was documented for Patients #5 and #12, two (2) of 36 patient's reviewed.


Findings include:


Cross Refer to A450 for the facility's failure to ensure all forms in Patient #5 and #12 medical records were completed, and dated and signed by a physician.


Record review for Patient #5 revealed that the consent for medical or surgical procedures and the anesthesia consent were not signed by a physician.


Record review for Patient #12 revealed a consent for anesthesia which was signed by the patient and dated 9/16/13 at 0602 AM. There was no selection of what type of anesthesia the patient would be receiving or whom would administer the medication. There was no documentation on the consent by the anesthesia provider.


Interview with Employee #11 revealed, "The RN (Registered Nurse) gets the consent signed by the patient. She also stated that the anesthesia provider usually comes back and signs the consent.




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Based on observation and staff interview, the facility failed to ensure that equipment is maintained to provide an acceptable level of safety and quality.


Findings include:


During a tour of the nursery on 9/17/13 at 11:40 a.m., made with Employee #11, observation revealed a Datascope Passport XG with a date for service check of 12/12. There was no documented evidence this check was done. Employee #11 stated, "I don't know how they missed that."

Based on observation, employee interview, and review of policy and procedures, the facility failed to ensure that a system was in place for controlling infections and communicable diseases of patients and personnel.


Findings include:


During tour of the facility's Labor and Delivery Room #3 on 9/17/13 at 10:30 a.m., made with the Director of Nursing (DON), observation revealed a brownish/red substance on the fetal monitor pad area. The DON used a sani-wipe and removed the substance. She stated, "It looks like betadine."


On 9/17/13 at 10:40 a.m. observation revealed a linen cart, containing what appeared to be clean linen, in the hallway of the labor and delivery department. There was a curtain covering the clean line with a tear at the top right, exposing the linen.