HospitalInspections.org

Based on medical record review and policy review, the facility failed to provide visitation rights for 20 of 20 medical records reviewed (Patients #1 through #19, and #24). Failure to inform patients of all visitation rights prevents patients from receiving or refusing to receive designated visitors.

Findings Include:

- Patient #1's closed medical review on 4/3/2017 revealed signed documentation that the patient received the "Patient Bill of Rights" pamphlet at admission. Review of the document received by the patient lacked evidence of any visitation rights.

- Patient #2's closed medical review on 4/3/2017 revealed signed documentation that the patient received the "Patient Bill of Rights" pamphlet at admission. Review of the document received by the patient lacked evidence of any visitation rights.

- Patient #3's closed medical review on 4/3/2017 revealed signed documentation that the patient received the "Patient Bill of Rights" pamphlet at admission. Review of the document received by the patient lacked evidence of any visitation rights.

- Patient #4's closed medical review on 4/3/2017 revealed signed documentation that the patient received the "Patient Bill of Rights" pamphlet at admission. Review of the document received by the patient lacked evidence of any visitation rights.

- Patient #5's closed medical review on 4/3/2017 revealed signed documentation that the patient received the "Patient Bill of Rights" pamphlet at admission. Review of the document received by the patient lacked evidence of any visitation rights.

- Patient #6's closed medical review on 4/3/2017 revealed signed documentation that the patient received the "Patient Bill of Rights" pamphlet at admission. Review of the document received by the patient lacked evidence of any visitation rights.

- Patient #7's closed medical review on 4/3/2017 revealed signed documentation that the patient received the "Patient Bill of Rights" pamphlet at admission. Review of the document received by the patient lacked evidence of any visitation rights.

- Patient #8's closed medical review on 4/3/2017 revealed signed documentation that the patient received the "Patient Bill of Rights" pamphlet at admission. Review of the document received by the patient lacked evidence of any visitation rights.

- Patient #9's closed medical review on 4/3/2017 revealed signed documentation that the patient received the "Patient Bill of Rights" pamphlet at admission. Review of the document received by the patient lacked evidence of any visitation rights.

- Patient #10's closed medical review on 4/3/2017 revealed signed documentation that the patient received the "Patient Bill of Rights" pamphlet at admission. Review of the document received by the patient lacked evidence of any visitation rights.

- Patient #11's closed medical review on 4/3/2017 revealed signed documentation that the patient received the "Patient Bill of Rights" pamphlet at admission. Review of the document received by the patient lacked evidence of any visitation rights.

- Patient #12's closed medical review on 4/3/2017 revealed signed documentation that the patient received the "Patient Bill of Rights" pamphlet at admission. Review of the document received by the patient lacked evidence of any visitation rights..

- Patient #13's closed medical review on 4/3/2017 revealed signed documentation that the patient received the "Patient Bill of Rights" pamphlet at admission. Review of the document received by the patient lacked evidence of any visitation rights.

- Patient #14's closed medical review on 4/3/2017 revealed signed documentation that the patient received the "Patient Bill of Rights" pamphlet at admission. Review of the document received by the patient lacked evidence of any visitation rights.

- Patient #15's closed medical review on 4/3/2017 revealed signed documentation that the patient received the "Patient Bill of Rights" pamphlet at admission. Review of the document received by the patient lacked evidence of any visitation rights.

- Patient #16's closed medical review on 4/3/2017 revealed signed documentation that the patient received the "Patient Bill of Rights" pamphlet at admission. Review of the document received by the patient lacked evidence of any visitation rights.

- Patient #17's closed medical review on 4/3/2017 revealed signed documentation that the patient received the "Patient Bill of Rights" pamphlet at admission. Review of the document received by the patient lacked evidence of any visitation rights.

- Patient #18's closed medical review on 4/3/2017 revealed signed documentation that the patient received the "Patient Bill of Rights" pamphlet at admission. Review of the document received by the patient lacked evidence of any visitation rights.

- Patient #19's closed medical review on 4/3/2017 revealed signed documentation that the patient received the "Patient Bill of Rights" pamphlet at admission. Review of the document received by the patient lacked evidence of any visitation rights.

- Patient #24's closed medical review on 4/3/2017 revealed signed documentation that the patient received the "Patient Bill of Rights" pamphlet at admission. Review of the document received by the patient lacked evidence of any visitation rights.

Brochure "Patients Rigts and Responsibilities" provided in the admission packet to all patients does not address visitation rights for patients.

Policy titled Patient Bill of Rights and Responsibilities; Informed Consent reviewed on 4/6/2017 does not address visitation rights for patients.

Based on medical record review and staff interview it was determined the hospital's nursing staff failed to follow physician's orders for a turning schedule for 2 of 20 patients (Patient #1 and #6) reviewed. This deficient practice had the potential to place all patients at risk for skin breakdown and pneumonia.

Findings include:

- Patient #1's closed medical record reviewed on 4/3/2017 revealed a first admission on 2/6/2017 for a Total Knee Replacement procedure and discharged on 2/11/2017. The medical record revealed an order was placed by Physician Staff T on 2/6/2017 at 2:13 PM to turn the patient every 2 hours and patient may reposition self as desired.

Turning Schedule Documentation for 2/6/2017 and 2/17/2017 revealed the following information:
2/6/2017 The hospital staff repositioned the patient at 2:00 PM
2/7/2017 The hospital staff repositioned the patient at at 8:00 AM.
The medical record lacked evidence that nursing staff documented any further turns on 2/6/2017 and 2/7/2017 or followed the order to turn the patient every 2 hours as ordered.

- Patent #1's medical record reviewed on 4/3/2017 revealed the patient readmitted on 2/14/2017 with a fever, diarrhea, and hypoxia (low oxygen levels in the blood) and discharged on 2/20/2017.

- Physician Staff F orders reviewed revealed on 2/16/2017 at 3:20 PM Staff F ordered the patient to be turned every 1-2 hours.

- Turning Schedule Documentation for 2/15/2017 to 2/20/2017 revealed the following information:
2/17/2017 the hospital staff repositioned the patient at 1:37 AM, 3:41 AM, 8:15 PM, and 11:18 PM. The medical record lacked evidence that nursing staff documented any further turns on 2/17/2017 or followed the order to turn the patient every 1-2 hours as ordered.

2/18/2017 The hospital staff repositioned the patient at 2:15 AM, 4:42 AM, 6:45 AM, 8:32 AM, 8:51 AM, 5:30 PM, 8:00 PM, 10:00 PM. The medical record lacked evidence that nursing staff documented any further turns on 2/18/2017 or followed the order to turn the patient every 1-2 hours as ordered.

2/19/2017 The hospital repositioned the patient at 1:00 AM, 3:00 AM, 6:00 AM, 7:30 AM, 8:55 AM, 9:05 AM, 11:11 AM, 4:00 PM, 8:55 PM, and 10:25 PM. The medical record lacked evidence that nursing staff documented any furhter turns on 2/19/2017 or followed the order to turn the patient every 1-2 hours as ordered.

Registered Nurse Staff J interviewed on 4/4/2017 at 9:00 AM agreed nursing staff failed to appropriately document patient #1 was turned every 1-2 hours as ordered. Staff J indicated there is a whiteboard in patient rooms that staff uses to document when a patient is to be turned, but it is not always documented in the medical record.



- Patient #6's open medical record review on 4/3/2017 revealed the patient was admitted on 3/31/2017 with a diagnosis of acute and chronic hypoxemia (low level of oxygen in the blood) respiratory failure.

Medical record review revealed physician's orders written 4/1/2017 at 7:20 am directed the patient was to be turned every 2 hours.

- Turning Schedule Documentation for 4/1/2017 to 4/3/2017 revealed the following information:

4/1/2017 The hospital staff repositioned the patient at 7:00 pm, 8:00 pm, 9:00 pm and 10:00 pm. The medical record lacked evidence nursing staff documented any other turns on 4/1/2017 or followed the order to turn the patient every two hours.

4/2/2017 The hospital staff repositioned the patient at midnight, 2:00 am, and 4:00 am. The medical record lacked evidence nursing staff documented any other turns on 4/2/2017 or followed the order to turn the patient every two hours.

4/3/2017 The hospital staff repostitioned the patient at 8:36 am and 1:23 pm. The medical record lacked evidence nursing staff documented any other turns on 4/3/2017 or followed the order to turn the patient every two hours.

Based on record review, policy review and staff interview, it was determined the facility failed to ensure nursing staff developed and kept current a nursing care plan for potential alteration of skin integrity for 1 of 20 medical records reviewed (patient #1), who was assessed at risk for alteration of skin integrity with potential for skin breakdown. This deficient practice had the potential to place patients at an increased risk for injury.

Findings include:

- Patent #1's medical record reviewed on 4/3/2017 revealed the patient was admitted on 2/14/2017 for a fever, diarrhea, and hypoxia (low oxygen levels in the blood) and discharged on 2/20/2017. A Skin assessment documented by Registered Nurse Staff D on 2/14/2017 at 4:00 PM revealed the nurse identified a pressure injury (Pressure Ulcer) to Patient #1's coccyx (tailbone). The medical record lacked evidence the facility's nursing staff developed a care plan to include skin care after identifying a pressure injury (Pressure Ulcer) was present.
Registered Nurse Staff J interviewed on 4/4/2017 at 2:00 PM agreed nursing staff failed to develop a nursing care plan to address the patient's skin integrity concerns.

Registered Nurse Staff H interviewed on 4/4/2017 at 4:00 PM indicated nursing staff would be expected to develop a nursing care plan to address any skin integrity concerns immediately after identifying them.

Policy titled "Plan of Care" reviewed on 4/6/2017 at 8:00 PM directed " ...Each patient will have his/her needs assessed by a Registered Nurse. These needs will be reflected in the plan of care. The plan of care will be updated throughout the hospitalization as needed to address changing patient needs ..."

Based on document review and staff interview the facility failed to ensure that medical records were complete within 30 days after discharge for 1 of 20 patients (Patient #2). This deficient practice has the potential to increase the risk for inadequate post-hospitalization follow-up care.


Findings include:

Patient #2's medical record reviewed on 4/4/2017 revealed an admission date of 2/3/2017 and a discharge date of 2/6/2017. The discharge summary was dictated on 3/8/2017. As of survey date of 4/3/2017 (56 days) the discharge summary was not authenticated by a physician.

Chief Nursing Officer Staff A interviewed on 4/5/2017 at 2:45 PM agreed the medical record for Patient #2 lacked a physician authentication signature within 30 days after the patient was discharged.

Medical Staff Bylaws reviewed on 4/5/2017 at 4:00 PM directed " ...All portions of the medical record of a pending hospitalized patient shall be complete at the time of discharge except when there are pending reports when there are pending reports, transcriptions and associated authentication, or at the maximum with in thirty (30) days after the patient's discharge. Medical records are considered delinquent if they are incomplete at day thirty one (31) following discharge."

Based on observation, staff interview and policy review, the Hospital failed to maintain a sanitary healthcare environment: by ensuring the staff perform acceptable hand hygiene practices (Staff J, K, and L), by wearing appropriate surgical attire in different settings (two unidentified operating room personnel), and by restricting contaminated patient care items and equipment from clean common care areas (Staff L). These deficient practices have the potential to expose all patients and healthcare workers to cross contamination of bacteria and viruses.

Findings include:

- Nursing assistant (NA) Staff L, observed on 4/4/2017 at 2:00 pm in patient #19 room, revealed NA Staff L removing the water pitcher and disposable ice bag from the patients room. Staff L left the room with both items without performing hand hygiene. Staff L reentered the room carrying both items and did not perform hand hygiene.

NA Staff L confirmed that she took the patients water pitcher and ice bag to the ice machine in the patient kitchen area and refilled both with ice and water and returned them to the patient. When asked about filling used patient items in the clean common area and the possibility of cross contamination, NA Staff L confirmed that the staff had always refilled water pitchers and ice bags that way and she also acknowledged she had questioned if that was the right thing to do. Staff L confirmed she did not perform hand hygiene as she had been instructed.

- Case Manager (CM) RN Staff K, observed on 4/4/2017 at 2:15 pm in patient #19 room, revealed CM RN Staff K leaving the room without performing hand hygiene.

- RN Staff J, observed on 4/5/2017 at 3:00 pm in patient #23 room, revealed RN Staff J leaving the room without performing hand hygiene. RN Staff J then returned to the same patient room and performed hand hygiene when entering the room.

- Two unknown staff dressed in surgical attire, observed on 4/3/2017 during hospital tour at 12:00 pm were observed in the hallway with surgical masks hanging loosely around their necks.

DON Staff A acknowledged masks are not to be worn around the neck when not in use, but are to be removed and disposed.

Policy titled Hand Hygiene reviewed on 4/5/2017 directed " ...In the following situations that require hand hygiene either alcohol-based hand sanitizer or soap and water are appropriate: Before having direct contact with patients ... after contact with a patients intact skin, after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings, when moving from a contaminated body site to a clean body site during patient care, after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient, for routine decontamination of hands, after removing gloves ... ...the use of gloves does not eliminate the need for hand hygiene ..."

Policy titled Standard Precautions reviewed on 4/5/2017 directed " ...Patient-care equipment ...Handle used patient-care equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothes, and transfer of microorganisms to other patients and environments ..."

Policy titled Dress Code in the Surgical Setting reviewed on 4/5/2017 directed " ... Shoe covers should be changed as soon as possible after torn, soiled, or wet ... ...Masks should not hang around neck to be saved or placed into pocket for later use ..."