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Tag No.: A0117
Based on review of admission materials provided to patients and interview with facility staff , the hospital failed to provide patients with information on their rights.
Findings include:
Per interview with Social Worker DD on 02/08/2011 at 10:30 AM patients are provided a booklet entitled "Guest Services" which is left in their rooms. This booklet does not list all rights to which patients are entitled, nor is there any indication that patients are made aware of these rights.
There is nothing in patient's records which indicates that patients have been informed of their rights.
Tag No.: A0353
Based on observation, review of Medical Staff Bylaws/Rules and Regulations, Medical Record reviews, and staff interviews (3 out of 4 staff interviews-Director (Dir.) C, Vice President (VP) CC, and Medical Doctor (MD) Y) the medical staff failed to enforce its bylaws in regard to completion of medical records.
Findings include:
The Medical Staff Bylaws/Rules and Regulations, which are reviewed annually and last reviewed in January of 2011, state:
On page 27, Section 3 states, "A temporary suspension in the form of withdrawal of a practitioner's admitting privileges, effective until medical records are completed, shall be imposed automatically after warning of delinquency for failure to complete medical records as required in the Medical Staff Rules an Regulations. The suspension shall continue until the records are completed."
On page 60, #11 states, "All patients admitted to the hospital, excluding one-day surgery and observation beds, shall have a dictated discharge summary....Records not completed within 15 days after discharge of the patient shall be considered delinquent. The attending practitioner shall be notified on the 15th day after discharge of the patient and asked to complete said record immediately. Failure to immediately complete the delinquent record(s) could result in suspension of all privileges until said records are complete."
During a tour of the Medical Records (MR) department on 2/7/2011 at 3:20 p.m. accompanied by Director (Dir.)C, it was observed that several physicians had stacks of delinquent records.
According to Dir. C, the expectation is that the record will be complete within 30 days. The facility allows 24 hours for History and Physicals and Operation reports, and 15 days for discharge summaries. Dir. C stated that all documents need to be dated, timed, and signed by the provider.
Surveyors #26711 and #29963 returned to the Medical Record department on 2/9/2011 at 7:45 a.m. accompanied by Dir. C for further investigation of the delinquent records.
Dir. C stated, "We understand they are busy and try to cut them some slack, but we have taken this to the January [2011] QA [Quality Assurance] meeting to be discussed."
Dir. C stated that delinquent records are an issue and letters have gone out to some of the providers (6 MDs-N, P, Q, R, S and T). These letters are dated January 28, 2011.
A sampling of MRs were reviewed. MD N had 34 delinquent MRs on the shelf dating back to 2009 that needed completion, the following are some examples: Pt. #27, discharged 10/17/10 did not have a discharge (DC) summary; Pt. #32, discharged 2/18/2009 did not have a DC summary; Pt. #33, discharged 10/12/2010 had orders and verbal orders that needed to be signed by MD N; Pt. #34, discharged on 10/6/2009 did not have a DC summary; for Pt. #35, MD N did not sign the birth identification form from 10/18/2010; and Pt. #36, discharged on 11/6/2009 did not have a DC summary.
Also observed in the MR department: MD R had delinquent MRs dating back to May of 2010; MD P had delinquent MRs dating back to July of 2010.
An interview was conducted on 2/9/2011 at 12:50 p.m. with VP CC. VP CC confirmed that suspensions will be forth coming if delinquent work is not completed. VP CC has e-mails starting 12/23/2010 with MD N regarding incomplete work, giving a required completion date of 1/3/2011. The work is still not completed.
A phone interview was conducted on 2/10/2010 at 12:00 p.m. with MD Y. MD Y confirmed there are some providers that have fallen behind and stated, "In the past we held everybody's hand, now we are going to actually start following through."
The above findings were confirmed with Dir. C, VP CC, and MD Y at the time of the interviews.
Tag No.: A0395
Based on MR (medical record) review, and interviews with facility staff, in 3 of 6 MR reviewed of patients with potential for pain (#17, 41, 45) out of a total of 46 MR reviewed, the hospital failed to ensure that nursing reassessments after the administration of pain medication are completed within 30 minutes to 1 hours per hospital practice.
Findings include:
Examples per surveyor #13469:
Per interview, with RN (registered nurse) (W) on 2/8/11 at 11:00 AM and Nursing Director (I) on 2/8/11 at 2:00 PM, nursing reassessment following the administration of pain medication should be within 1/2 hour for intravenous medications and within 1 hour following the administration of oral medications.
1. Per MR review, on 2/8/11 at 1:00 PM, patient #17 was admitted to the hospital on 2/4/11 for a total left knee replacement. Pain medications were being given for her post-operative knee pain. On 2/4/11 Vicodin was given orally at 9:58 PM for knee pain. Documentation indicates the next assessment of patient #17 pain was at 11:13 PM. This assessment exceeded the 1 hour timeline.
On 2/5/11 at 11:38 PM patient #17 was given Vicodin for knee pain. The next assessment of patient #17 pain level was not done until 1:57 AM. This assessment exceeded the 1 hour timeline.
On 2/7/11 at 8:00 PM patient #17 was given Oxycodone for knee pain. The next assessment was 9:45 PM. This assessment exceeded the 1 hour timeline.
On 2/8/11 at 2:31 AM patient #17 was given Oxycodone for knee pain. The next assessment was at 3:58 AM. This assessment exceeded the 1 hour timeline.
The above examples were confirmed in interview with Nursing Director (I) on 2/8/11 at 1:00 PM.
2. Per MR review, on 2/9/11 at 9:35 AM, patient #41 was admitted to the hospital on 2/5/11 for left thigh pain after a hip hemiarthroplasty with a loose stem with pin. Pain medications were given for this left thigh pain. On 2/6/11 at 2:11 AM patient #41 was given Vicodin for left hip pain. The next assessment was not done until 3:58 AM. This assessment exceeded the 1 hour timeline.
On 2/7/11 at 8:30 PM patient #41 was given Vicodin for left leg pain. The next assessment was not done until 10:00 PM. This assessment exceeded the 1 hour timeline.
The above examples were confirmed in interview with Nursing Director (I) on 2/9/11 at 10:20 AM.
3. Per MR review, on 2/9/11 at 10:10 AM, patient #45 was admitted on 2/4/11 with dyspnea, lightheadedness, second degree heart block and metastatic breast cancer to the lung. A chest tube was surgically placed on 2/5/11. Patient #45 was taking pain medication for pain at the chest tube site. On 2/4/11 at 12:22 PM patient #45 was given Tylenol for a headache. There was no evidence found of a reassessment for the effectiveness of the pain medication. On 2/4/11 at 7:40 PM patient #45 again reports an unrelieved headache and was given Tylenol. The next assessment at 11:12 PM indicates that patient #45 is resting quietly. This assessment exceeded the 1 hour timeline. The above examples were confirmed in interview with Nursing Director (I) on 2/8/11 at 1:00 PM.
On 2/5/11 at 4:05 PM patient #45 complains of pain (6 out of 10) at the chest tube insertion site. Vicodin was given. The next assessment was at 7:20 PM when patient #45 is again complaining of unrelieved pain at the chest tube site (6 out of 10). Again Vicodin is given for pain. This assessment exceeded the 1 hour timeline and failed to identify patient #45 on-going pain timely.
The above examples were confirmed in interview with Nursing Director (I) on 2/9/11 at 10:30 AM.
Tag No.: A0396
Based on MR (medical record) review, policy and procedure review, and interviews with facility staff, in 16 of 16 medical records reviewed requiring a nursing care plan (#15, 16, 17, 18, 6, 19, 20, 21, 10, 26, 11, 2, 8, 9, 14, 25 ) out of a total of 46 MR reviewed, the hospital does not ensure that nursing care plans include nursing interventions, and that care plans are relevant to patient needs. Failure to develop a complete and relevant nursing care plan for each patient can result in a lack of coordination among nursing staff which could lead to poor quality of care.
Findings include:
Examples by surveyor #13469:
Per policy and procedure review on 2/8/11 in the AM, the "Problem List (care plan) policy effective date 5/29/09 directs the following: Policy: It is the policy that each patient shall have a problem list (care plan) that defines the patient's primary acute care healthcare issues. To provide a structured framework for all disciplines involved in patient care to organize, interpret and communicate data pertinent to the care of each patient. 1. Upon admission, the nurse will assess what issues or needs the patient has based on information obtained from the admission assessment. 2. The RN or other licensed healthcare provider will select a problem or problems (nursing diagnosis) from the problem list that address the patient's needs and individualize it as necessary. 5. Problems and/or goals will be added as new problems are identified by any member of the multidisciplinary team. 7. Documentation of problems, goals, interventions and evaluation can be found on the progress notes."
1. Per MR review between 2/7/11 and 2/9/11 16 of 16 nursing care plans found in the MR of patients #15, 16, 17, 18, 6, 19, 20, 21, 10, 26, 11, 2, 8, 9, 14, and 25 do not include interventions to direct nursing staff what cares are to be provided to meet patient needs.
Per interview, with RN (registered nurse) (FF) on 2/8/11 at 8:30 AM and Nursing Director (I) on 2/8/11 at 8:35 AM, nursing interventions are not a part of the computerized nursing care plan. The computer system lets nursing staff select a nursing problem which includes nursing goals. Nurses on each shift must individually determine the interventions and then document the assessments and outcomes. Per (FF) and (I), nursing staff make up the interventions as they go along. Per (I), there is no nursing care plan developed that identifies interventions specific to each patient, to be followed by all nursing staff. Per (I), there is potential of inconsistency of nursing care.
2. Per MR review, on 2/8/11 at 8:15 AM, patient #15 was admitted to the facility on 2/7/11 for shortness of breath and exacerbation of chronic obstructive pulmonary disease. One nursing problem was selected: Activity Intolerance causing shortness of breath. On 2/7/11 nursing staff assessment identifies that patient #15 has a loss of appetite. A nursing problem related to this assessment was not identified. This example was confirmed with Nursing Director (I) on 2/8/11 at 9:50 AM.
3. Per MR review, on 2/8/11 at 8:40 AM, patient #16 was admitted to the facility on 2/7/11 with asthma with acute exacerbation. One nursing problem was selected: activity intolerance. Per nursing assessment on admission patient #16 was short of breath. A nursing problem related to patient #16 potential for ineffective breathing was not identified. This example was confirmed with Nursing Director (I) on 2/8/11 at 11:40 AM.
4. Per MR review, on 2/8/11 at 1:00 PM, patient #17 was admitted to the hospital for a total left knee replacement. Nursing problems identified did not include the potential for alteration in comfort which was a frequent complaint. This example was confirmed with Nursing Director (I) on 2/8/11 at 1:50 PM.
5. Per MR review, on 2/9/11 at 9:35 AM, patient #41 was admitted to the hospital on 2/5/11 for left thigh pain. Nursing problems identified were alteration in comfort and fall risk for this 96 year old female. Patient #41 was started on two new antihypertensive medications for increased blood pressure. Nursing problems do not include the potential for alterations in hemodynamic stability related to blood pressure. This example was confirmed with Nursing Director (I) on 2/9/11 at 10:20 AM.
6. Per MR review, on 2/9/11 at 8:10 AM, patient #43 was admitted to the hospital on 2/7/11 for nausea and vomiting, diarrhea and possible aspiration pneumonia. The nursing care plan was limited to "ineffective breathing pattern related to pneumonia." Patient #43 has a gastrostomy tube for feedings, is at high risk for skin breakdown per nursing assessment, has a Foley catheter and a tracheostomy. There was no nursing care plans related to these problems. This example was confirmed with Nursing Director (I) on 2/9/11 at 9:00 AM.
26711
Findings by Surveyor #26711:
A Medical Record (MR) review was completed on 2/8/2011 at 11:05 a.m. on Pt. #11's closed newborn record. Pt. #11 was born by cesarean section on 2/5/2011 and discharged on 2/8/2011. Pt. #11's care plan listed the following problem/goal on 2/6/2011, 2/7/2011 and was resolved on 2/8/2011: "Knowledge deficit related to infant care focused on the mother and no problems or goals related to the baby."
There were no goals/problems pertaining to the infant listed.
These findings were discussed on 2/8/2011 at 11:15 a.m. with Director E.
Tag No.: A0442
Based on observation, interview with facility staff and facility policy, the hospital failed to ensure the security of medical records.
Findings include:
During an interview with staff G on 02/07/2011 at 2:00 PM it was revealed that the medical records department is cleaned in the early morning before staff arrive. Housekeeping staff have free access to medical records without the supervision of medical records staff supervision.
During an interview and subsequent tour of the rehabilitation department on 02/07/2011 at 2:30 PM with staff H it was revealed that housekeeping has access to medical records after hours. The records are kept in unlocked file cabinets in the reception area.
During a tour of the large storage room in the basement of the hospital on 02/10/2011 at 10:58 AM with staff J and K medical records were observed to be unsecured.
Hospital policy on security and safety of medical records states; "Access to those areas housing medical records shall be limited to medical information department personnel and/or those designated by the Director of Medical Information Department. Open medical records will be under the responsibility of the supervisor or director of the department."
Tag No.: A0450
Based on 12 of 46 medical records reviewed (#4, 8, 9, 10, 16, 19, 20, 21, 24, 41, 42 and 45 ), staff interview and facility policy the hospital failed to ensure all medical record entries were complete.
Findings include:
26711
The facility's Medical Staff Rules and Regulations, which are renewed annually and last reviewed in January 2011, state on page 59, #5, "Operative reports shall be written or dictated immediately following surgery, for outpatient as well as inpatients, and shall be promptly signed by the surgeon and made a part of the patient's current record."
On page 60, #6 states, "All clinical entries in the patient's medical record shall be legible, complete, dated, timed, and authenticated promptly by the person who is responsible for ordering, providing or evaluating the service furnished."
On page 60, #10 states, "All patients admitted to the hospital, excluding one-day surgery and observation beds, shall have a dictated discharge summary...Records not completed within 15 days after discharge of the patient shall be considered delinquent..."
On page 60, #11 states, "Emergency room records not completed within 24 hours shall also be considered delinquent and the same rules enforced as for the medical record. (Medical Records, rule No. 10)."
In an interview with Director (Dir.) C on 2/7/2011 at 3:20 p.m., C stated that record completeness is based on type of record and policy. Overall there is a 30 day completion expectation, 24 hours for history and physicals, and 15 days for discharge summaries.
A Medical Record (MR) review was completed on Patient (Pt.) #4's closed Emergency room (ER) record on 2/7/2011 at 4:17 p.m. Pt. #4 was a 3 month old brought to the hospital by ambulance on 1/11/2010. The ER report from 1/11/2010, which has a corrected date (meaning some type of correction to the report took place) of 3/3/2010 is not dated, timed, or signed by the physician as of the time of the record review on 2/7/2011.
This finding is confirmed by Dir. B on 2/7/2011 at 4:35 p.m.
A MR review was completed on Pt. #10's closed Maternity record on 2/8/2011 at 10:50 a.m. The pre-operative orders to prepare for a cesarean section do not include a time the physician wrote them.
This finding was confirmed by Dir. B on 2/8/2010 at 11:15 a.m.
A MR review was completed on Pt. #19's closed surgical record on 2/8/2011 at 1:10 p.m. Pt. #19's MR contains ER orders that do not include times medications and tests were ordered, the dictated ER report from 4/11/2010 is not signed, dated or timed by the physician, the history and physical from 4/11/2010 does not include a date or time when the physician signed it, and the Operation Report (Op report) of 4/11/2010 is not dated or timed for the physician's signature.
A MR review was completed on Pt. #20's closed surgical record on 2/8/2011 at 1:50 p.m. Pt. #20's MR contains physician orders that are not dated or timed when the physician wrote them and the Op report of 6/4/2010 is not dated or timed for the physician signature.
A MR review was completed on Pt. #21's closed surgical record on 2/8/2011 at 2:30 p.m. Pt. #21's MR contains a dictated ER note that is not signed, dated, or timed by the physician from 5/10/2010, medications ordered in the ER do not include a time that they were ordered, the history and physical from 5/10/2010 does not include a time or date when the physician signed it, and there are 8 out of 10 physician progress notes that do not indicate the time they were written by the physician.
These findings were discussed on 2/8/2011 at 4:00 p.m. where Dir. B was present.
Examples by surveyor #20878:
Patient #9's record contained physician progress notes dated 12/27/10 which were not timed.
Patient #8's record contained physician progress notes dated 06/23, 06/24, 06/26, 06/27 and 06/28/2011 which were not timed.
Patient #19's record contained an emergency department note which was dictated by the physician on 04/10/2010 and was not signed.
Patient #24's record contained a transfer form dated 01/25/11 which was signed but not timed by the physician.
The above findings were confirmed per interview with staff B on 02/09/11 at 11:00 AM.
Examples by surveyor #13469:
1. Per MR (medical record) review, on 2/9/11 at 10:10 AM, physician progress notes dated 2/4/11, 2/5/11, 2/6/11, 2/7/11, 2/8/11 , and 2/9/11 found in the MR of patient #45 do not include the time the progress notes were entered into the MR.
The above examples were confirmed in interview with Nursing Director (I) on 2/9/11 at 10:30 AM.
2. Per MR review, on 2/9/11 at 9:35 AM, the general consent for treatment found in the MR of patient #41 dated 2/5/11 contains a witness signature without a title.
Per interview with Nursing Director (I) on 2/9/11 at 10:20 AM any staff who make an entry into the MR must sign with their name and title.
3. Per MR review, on 2/8/11 at 8:40 AM, the general consent for treatment found in the MR of patient #16 dated 2/7 contains a witness signature without a title. In addition, the date on the consent did not include the year.
This example was confirmed by Nursing Director (I) on 2/8/11 at 11:40 AM.
4. Per MR review, on 2/9/11 at 7:50 AM, the general consent for treatment found in the MR of patient #42 dated 2/8/11 contains a witness signature without a title.
This example was confirmed by Nursing Director (I) on 2/9/11 at 9:00 AM.
5. Per MR review, on 2/9/11 at 10:10 AM, the general consent for treatment found in the MR of patient
#45 dated 2/7/11 contains a witness signature without a title.
This example was confirmed by Nursing Director (I) on 2/9/11 at 10:30 AM.
Tag No.: A0454
Based on MR (medical record) review, review of medical staff rules and regulations, and interviews with facility staff, in 9 of 46 MR reviewed, (#6, 8, 9, 16, 18, 19, 44, 41 and 45), the hospital failed to ensure that orders are dated and timed and that all telephone and verbal orders are authenticated within 48 hours of receipt. The lack of dating and timing of orders does not provide a chronological picture to delineate the course of treatment. The lack of physician validation of telephone and verbal orders within 48 hours could result in inaccurate and inappropriate medication administration and treatment of patients.
Findings include:
Per review, of the medical staff rules and regulations on 2/7/11 in the afternoon, the rules and regulations direct the following: "Orders must be complete, written legibly in ink and include the date and time written." additionally: "All verbal orders (including telephone orders) must be signed or countersigned within 48 hours by the prescriber who gave the orders or by the physician designated by the prescriber."
Per interview, with Nursing Director (I) on 2/8/11 in the AM, telephone/verbal orders are to be countersigned by the MD within 48 hours of receipt.
The following examples were found by surveyor #13469:
1. Per MR review, on 2/8/11 at 9:35 AM, MD (medical doctor) telephone orders dated 1/31/11 and 2/3/11 found in the MR of patient #18 do not identify the time the orders were taken and entered into the MR. In addition, the telephone orders do not have a physician counter-signature that was due by 2/5/11.
MD verbal orders dated 1/31/11 at 7:20 PM and 5:30 PM do not have a physician counter-signatures that was due by 2/2/11.
MD telephone orders dated 1/31/11 at 12:00 noon are countersigned by the MD, but lack the date and time the orders were counter-signed to ensure they were validated within 48 hours.
MD telephone orders dated 2/1/11 do not have a MD counter-signature that was due by 2/3/11.
The above examples were confirmed by Nursing Director (I) on 2/8/11 at 1:20 PM.
2. Per MR review, on 2/8/11 at 8:40 AM, the MD orders dated 2/7/11 found in the MR of patient #16 do not indicate the time the orders were entered into the MR.
This example was confirmed by Nursing Director (I) on 2/8/11 at 11:40 AM.
3. Per MR review, on 2/9/11 at 9:10 AM, MD orders dated 2/9/11 found in the MR of patient #44 do not indicate the time the orders were entered into the MR.
MD telephone orders dated 2/8/11 at 3:50 PM are countersigned by the MD, but lack the date and time the orders were counter-signed.
The above examples were confirmed by Nursing Director (I) on 2/9/11 at 9:40 AM.
4. Per MR review, on 2/9/11 at 9:35 AM, MD orders dated 2/7/11 and 2/9/11 found in the MR of patient #41 do not indicate the time the orders were entered into the MR.
The above examples were confirmed by Nursing Director (I) on 2/9/11 at 10:20 AM.
5. Per MR review, on 2/9/11 at 10:10 AM, MD telephone orders dated 2/7/11 and 2/8/11 found in the MR of patient #45 are countersigned by the MD, but lack the date and time the orders were counter-signed.
The above examples were confirmed by Nursing Director (I) on 2/9/11 at 10:30 AM.
20878
The following examples were found by surveyor #20878:
Patient #6's medical record contained 2 telephone orders written on 03/16/10 which were not countersigned by the physician until 04/19/10.
Patient # 8's medical record contained orders written on 6/24, 6/25, 6/26 and 6/27/10 which were lacking times.
Patient #9's medical record contained orders written on 12/21/10 which were not timed by the physician.
Patient #19's medical record contained a telephone order written on 4/10/10 which the physician countersigned without a time or date.
These findings were confirmed by staff B on 2/9/11 at 11:00 AM.
Tag No.: A0469
Based on medical record (MR) review in 2 out of 5 infant deaths (Patients [Pt.] #4 and #5) out of a total of 33 MRs, and staff interview, this facility failed to complete discharge summaries (one of which is the Emergency room note) according to Medical Staff by-laws and within 30 days of discharge.
Findings include:
The Medical Staff Bylaws/Rules and Regulations, which are reviewed annually and were last reviewed in January of 2011, state:
On page 60, #11 states, "All patients admitted to the hospital, excluding one-day surgery and observation beds, shall have a dictated discharge summary....Records not completed within 15 days after discharge of the patient shall be considered delinquent..."
A medical record review was completed on 2/7/2011 at 4:17 p.m. for Pt. #4. Pt. #4, a 3 month old, was brought to the hospital on 1/11/2010 after being found not breathing during a nap. An Emergency Department note was dictated on 3/1/2010 (more than 30 days from the date of record closure on 1/11/2010) and remains unsigned on the date of record review (2/7/2011).
These findings were discussed with and confirmed by Dir B on 2/7/2011 at 4:35 p.m.
A medical record review was completed on 2/7/11 at 8:45 a.m. for Pt #5. Pt # 5 was a stillborn death on 3/31/2010. The death summary was dictated on 5/2/2010. This is more than 30 days after the Pt death. The death summary was electronically signed by the MD on 10/26/2010, again more than 30 days after Pt death.
These finding were discussed and confirmed by Dir B on 2/7/2011 at 4:35 p.m.
Tag No.: A0491
Based on observation, interview and record review, the hospital did not monitor refrigerated medication storage in two of two large refrigerators located in the pharmacy area near the sterile products preparation area. The pharmacy is open Monday thru Friday 7 a.m. until 5 p.m. and on Saturday and Sundays from 7.a.m. until noon. The refrigerators are checked daily for temperature and do have an alarm on them. However the alarm is not centrally monitored and cannot be heard when no one is in the pharmacy.
Findings Include:
During the tour of the hospital pharmacy with Pharmacist F on February 8th 2011 between 7:20 a.m. and 8:42 a.m. two refrigerators in the pharmacy near the sterile products area were observed. The refrigerators did have an outside digital thermometer on them with a reading within 36-46 degrees Fahrenheit. The refrigerator closest to the sterile products area (refrigerator #1) indicated that the refrigerator had an alarm system. The refrigerator closer to the center of the pharmacy (refrigerator #2) was observed to have an alarm that no longer operated. The refrigerators were observed to contain medications including Remicade (for Crohn ' s disease), Darbopoetin (for anemia of cancer), Retuximab (for non Hodgkin ' s Lymphoma), and Herceptin (for breast cancer).
During interview and tour with Pharmacist F on February 8th between 7:20 a.m. and 8:42 a.m. Pharmacist F indicated the refrigerators are not centrally alarmed or monitored therefore when no one is in pharmacy they are unable to know if the refrigerator alarm goes off indicating the refrigerator is outside of recommended temperature. If the refrigerator happens to go back into recommended range the alarms stop. Therefore it is possible for the refrigerators to go outside of temperature and then back into temperature yet pharmacy would not know this occurred. During interview with Pharmacist F he indicated he did not think the alarm on refrigerator #2 worked. Pharmacist F pointed out in refrigerator #2 that they do have refrigerator sticker that changes color when temperature gets out of range. This sticker is changed monthly. However if staff go in and out of the refrigerator a lot that sticker may change color and will not be accurate.
Surveyor #14941 consulted drug manufacturer records. Records for Remicade, darbopoetin, Retuximab and Herceptin indicate these medications must remain between 36 and 46 degrees Fahrenheit at all times to insure stability. Remicade, darbopoetin and Retuximab do not contain preservative. During an interview on Feb 10th 2011 at 9:30 a.m. with Medical Information from the manufacturer of darbopoetin, if the medication did reach room temperature the pharmacy would need to contact the manufacturer to determine if the medication would need to be destroyed.
The two pharmacy refrigerators are not monitored 24 hours a day as the alarm is not centrally monitored and there are 12 hours or more each week day and on weekends where the refrigerators are not monitored. In addition the alarms will go on and off when temperature goes in and out of range. Therefore, it is not possible for the pharmacy to determine if medication is at risk.
Tag No.: A0502
Based on observation and interview with staff, in 3 of 8 units toured, the facility failed to ensure the emergency crash carts containing medications are secure from unauthorized access.
Findings include:
During a tour of the Post Anesthesia Care Unit (PACU) on 2/7/2011 at approximately 2:15 p.m. Surveyor #26711 was accompanied by Director (Dir.) B and Dir D.
It was observed that the crash cart was situated at the end of the unit to the left of the nurses station where it would not be in continuous sight of staff. The crash cart was equipped with a break away lock that would not prevent unauthorized persons from tampering with the contents.
This finding was confirmed by Dir. B and Dir D at the time of discovery.
During a tour of the Maternity unit on 2/8/2011 at 10:40 a.m.. Surveyor #26711, was accompanied by Dir. B and Dir E.
It was observed that the crash cart was situated at the end of the hall on the unit where it would not be in continuous sight of staff despite the security mirror on the wall. The crash cart was equipped with a break away lock that would not prevent unauthorized persons from tampering with the contents.
This finding was confirmed by Dir. B and Dir. E at the time of discovery.
13469
Example by surveyor #13469:
Per observation and interview, in one of two crash carts observed while touring the medical-surgical nursing unit on 2/8/11 at 2:10 PM with Nursing Director (I), it was noted that the unit has three nursing stations. At the time of the tour only two of the three nursing stations were operational. The third station (South) contained a crash cart with medications and equipment for medical emergencies which was located in a hallway alcove. The crash cart had a breakaway locking device and was not secure from unauthorized access. The crash cart was not in-view by staff at all times to ensure integrity of it's contents. Per (I), the crash cart could be accessed by unauthorized hospital staff, patients and visitors. As a result, medications and equipment could be removed or tampered with.
Tag No.: A0508
Based on interview and record review, the hospital did not report medication errors to the attending physician in 14 of 16 medication reports reviewed between July 2010 and September 2010. This affected 14 of 16 patients including patients # 47 thru #60.
This is evidenced by the following:
On February 8, 2011 medication error reports were reviewed for actual medication errors that occurred between July 2010 and September 2010. The form the facility uses did not have a section to specifically document when the attending physician was notified of the medication error. Of the 16 reports reviewed only two of them had documentation on the form that the attending physician was contacted.
The 14 reports where there was no documentation that the attending physician was notified included the following:
July 2010
July 8, 2010: Wrong dose of Clonazepam. Dose ordered was 0.25 mg but 0.5 mg was given. Patient 47
July 8, 2010: Wrong dose of diazepam. Dose ordered was 2.5 mg but 5 mg was given. Patient 48
July 6, 2010: Hydralazine was to be given for systolic pressure above 170. Was given when pressure was less than 170. Patient 49
July 26, 2010: Antibiotic (Piperacillin/Tazobactam) did not infuse. Patient 50
August 2010
August 31, 2010: Missed Coumadin 7 mg dose. Patient 51
August 25th 2010: Ativan 2 mg ordered but 1 mg given. Patient 52
August 20th, 2010: Antibiotic Zosyn did not infuse. Patient 53
August 20th, 2010: Novolin R ordered but Novolog given Patient 54
August 17th, 2010 Duoneb was given late. Patient 55
August 14th 2010: Regular insulin ordered Humalog given. Patient 56
August 14th, 2010: Albuterol nebulizer missed for three doses. Patient 57
August 4th, 2010: Lorazepam 1 mg ordered but 2 mg given. Patient 58
September 2010
September 30th, 2010: Glipizide 2.5 ordered but 5 mg given. Patient 59
September 16th, 2010 Lorazepam 1 mg ordered but 2 mg given. Patient 60
Review of Medication Use Occurrence Reporting Policy dated 05/01 on page 3 of 4 the policy indicates the following:
III A. The Nurse responsible for the patient notifies the physician of actual occurrences and receives orders for treatment if applicable.
IIIB. Nurse to document the dose given, dose ordered, patient response, physician notification for orders or treatment, family notification per physician direction.
The policy indicates that the physician will be notified and that documentation will occur. However, documentation is not found on the Medication Occurrence reports.
On 2/8/11 at 1:50 p.m. interview with Performance Improvement Director B on February 8th at 1:50 p.m. about medication errors and evidence of physician notification. Performance Improvement Director B indicated the documentation of physician notification may be in the nursing notes. She would look for those notes
As of exit on 2/9/11 no evidence of physician notification was provided.
Tag No.: A0700
Based on observation, staff interviews, and review of maintenance records, the hospital failed to ensure the physical environment of the building met the minimum requirements of the 2000 Edition of the Life Safety Code for "New Healthcare Occupancy" and also "Existing Healthcare Occupancy" chapters of this code.
The findings include:
Main Hospital Building
K15: The facility did not provide room finishes with rated wall finishes.
Class of Construction did not meet non-combustible standards of a Type II (2,2,2)
K18: Positive latching was not provided on all doors to the corridor or doors were held open.
K20: Vertical shafts were not constructed to the proper hourly rating.
K21: Smoke detectors were not provided for doors being held open
K25: the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations, and rated wall construction.
K29: Reliable enclosure of hazardous areas was lacking at locations throughout the building.
K33: the facility failed to remove an abandoned electrical conduit which passed into the exit enclosure
K38: The facility did not provide egress paths at all times with a properly swinging door, obstructions, non level walking surface at doorways, doors that were unlockable in the egress path, and door hardware that did not operated with a single release motion.
K39: The facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code.
K40: The facility did not ensure corridor doors were side-hinged and were the required clear width with the proper width of doors.
K43: The facility did not provide all spaces that can be exited without the use of a key or locked as permitted by the code, such as delayed egress with locks that release in less than 15 seconds.
K47: The facility did not provide and maintain emergency illumination of exit and directional signs with compliant sized lettering on "no-exit" signs, and exit signs when the egress path is not readily apparent.
K48: The facility did not maintain a written evacuation plan that contained all the elements with staff trained on life safety procedures
K56: Sprinkler system did not meet all minimum regulations per NFPA 13.
K67: The facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A.
K69: The facility did not provide a properly constructed kitchen extinguishing system as required by NFPA 96.
K75: The facility did not provide and maintain linen/trash collection receptacles in compliance with the codes with and properly sized storage containers for soiled/trash.
K76: The facility did not provide the safe storage and use of medical gases, as required by NFPA 99 with separation of oxygen from.
K77: The facility did not provide medical gas piping as required by NFPA 99 with compliant medical gas piping.
K106: The facility failed to provide a critical branch receptacle in patient care areas who require life support.
K130: The facility failed to provide proper sprinkler coverage.
K143: The facility did not provide oxygen transfer space with rated doors.
K144: The facility did not test the emergency electrical generator in accordance with the codes with derangement signals at a continuously monitored location..
K147: The facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with working clearances at electrical panels, and fixed wiring rather than extension cords.
Medical Office Clinic
K130: The facility did not provide enclosures around multi-floor vertical openings with sealed wall penetrations, the facility did not provide the safe storage and use of medical gases, as required by NFPA 99 with separation of oxygen from combustibles, and the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code and the proper use of flexible cords.
The cumulative effect of these deficiencies indicates that the facility failed to provide a safe environment and reliable systems to ensure safety to all occupants, patients and staff of this facility.
Tag No.: A0709
Based on observation, staff interviews, and review of maintenance records, the hospital failed to ensure the physical environment of the building met the minimum requirements of the 2000 Edition of the Life Safety Code for "New Healthcare Occupancy" and also "Existing Healthcare Occupancy" chapters of this code.
The findings include:
Main Hospital Building
K15: The facility did not provide room finishes with rated wall finishes.
Class of Construction did not meet non-combustible standards of a Type II (2,2,2)
K18: Positive latching was not provided on all doors to the corridor or doors were held open.
K20: Vertical shafts were not constructed to the proper hourly rating.
K21: Smoke detectors were not provided for doors being held open
K25: the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations, and rated wall construction.
K29: Reliable enclosure of hazardous areas was lacking at locations throughout the building.
K33: the facility failed to remove an abandoned electrical conduit which passed into the exit enclosure
K38: The facility did not provide egress paths at all times with a properly swinging door, obstructions, non level walking surface at doorways, doors that were unlockable in the egress path, and door hardware that did not operated with a single release motion.
K39: The facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code.
K40: The facility did not ensure corridor doors were side-hinged and were the required clear width with the proper width of doors.
K43: The facility did not provide all spaces that can be exited without the use of a key or locked as permitted by the code, such as delayed egress with locks that release in less than 15 seconds.
K47: The facility did not provide and maintain emergency illumination of exit and directional signs with compliant sized lettering on "no-exit" signs, and exit signs when the egress path is not readily apparent.
K48: The facility did not maintain a written evacuation plan that contained all the elements with staff trained on life safety procedures
K56: Sprinkler system did not meet all minimum regulations per NFPA 13.
K67: The facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A.
K69: The facility did not provide a properly constructed kitchen extinguishing system as required by NFPA 96.
K75: The facility did not provide and maintain linen/trash collection receptacles in compliance with the codes with and properly sized storage containers for soiled/trash.
K76: The facility did not provide the safe storage and use of medical gases, as required by NFPA 99 with separation of oxygen from.
K77: The facility did not provide medical gas piping as required by NFPA 99 with compliant medical gas piping.
K106: The facility failed to provide a critical branch receptacle in patient care areas who require life support.
K130: The facility failed to provide proper sprinkler coverage.
K143: The facility did not provide oxygen transfer space with rated doors.
K144: The facility did not test the emergency electrical generator in accordance with the codes with derangement signals at a continuously monitored location..
K147: The facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with working clearances at electrical panels, and fixed wiring rather than extension cords.
Medical Office Clinic
K130: The facility did not provide enclosures around multi-floor vertical openings with sealed wall penetrations, the facility did not provide the safe storage and use of medical gases, as required by NFPA 99 with separation of oxygen from combustibles, and the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code and the proper use of flexible cords.
The cumulative effect of these deficiencies indicates that the facility failed to provide a safe environment and reliable systems to ensure safety to all occupants, patients and staff of this facility.
City of Wausau, inspections@mail.ci.wausau.wi.us
Rene Gorski, Aspirus Hospital, ReneGorski@aspirus.org
Michael Schaefer, Plunkett Raysich Architects, mschaefeer@prarch.com
Rodger Musolf, Engineering Concepts Inc., rodgerm@eciengineering.com
Timothy Larson, Geiger & Larson Engineering Inc., tim@geigereng.com
Tag No.: A0724
Based on observation, staff interviews and review of maintenance records, the facility did not maintain supplies and equipment to ensure an acceptable level of safety and quality. This deficiency occurred in 4 of the 14 smoke compartments, and had the potential to affect all of the 73 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.
FINDINGS INCLUDE:
On 02/07/2011 at 12:05 pm surveyor #12187 observed in the North Patient smoke compartment on the 2nd floor in the patient room 2005, that the water temperature out of the hot water tap in the sink of the patient rooms was 130 F. The hot water discharge temperature is adjustable and over time, the maximum temperature of the hot water increases due to wearing of the parts inside the facet according to interview with staff L. The initial temperature of the mixing valve was set at 115 F when the building was built in 2003. The condition of the equipment indicated it had not received a periodic maintenance inspection by a qualified maintenance person, in accordance with the manufacturer's recommendations. This observed situation was not compliant with CFR 482.41(c)(2). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff L (Maintenance Coordinator) and staff M (Vice President of Finance).
Tag No.: A0749
Based on observations, policy and procedure review and interviews with facility staff, the hospital failed to ensure that the facility is kept clean, maintained, and arranged so as to provide a sanitary environment.
In 2 of 6 observations, hand hygiene is not followed per hospital policy. In 5 of 6 isolations rooms the ceiling tiles are not washable. In 4 of 12 observations, clean patient supplies are not stored to protect their integrity.
The lack of using appropriate infection control practices allowed for the possible transfer of dust, debris and microorganisms, and communicable diseases to staff, patients and environmental surfaces. This affected all 20 patients and staff in the facility during the survey between 2/7/11 and 2/10/11.
Findings include:
Examples by surveyor #13469:
1. Per observation and interview, while touring the ED (emergency department) on 2/7/11 at 1:50 PM with ED Nursing Director (A), it was noted that the decontamination room, which is considered dirty, held clean patient supplies. Examples included a colonoscope machine, intravenous pumps, spit masks and EMS (emergency medical services) equipment. Per interview with (A), clean patient supplies should not be stored in the decontamination room.
2. Per observation and interview, while touring the nursing units on 2/8/11 at 2:10 PM with Nursing Director (I), it was noted that in 5 of 6 negative pressure rooms used for isolation patients the ceiling tiles are non-washable. Examples include rooms 2001, 2002, 2007, 2008 and 1812. Per interview, with (I), there is the potential for splash and spray of blood and bodily fluids to the current ceiling tiles that could not be washed.
3. Per observation, on 2/9/11 at 8:15 AM it was noted that MD (medical doctor) (EE) was making rounds on patient #41 in room 2019. MD (EE) sat in a chair next to patient #41 and touched the patient during the visit as well as the overbed table. MD (EE) did not wash his hands when he left patient #41 room and proceeded to the nursing station and picked up patient #41 medical record and began to write orders and progress notes.
Per review, of policy "Hand Hygiene" reviewed date 2010, the policy directs the following: "1. Hand should be washed/decontaminated: a. Before and after direct contact with patients, and j. after contact with "inanimate objects in the immediate vicinity of the patient."
26711
Findings by Surveyor #26711:
Surgery:
A tour of the Surgical Suite area, including Post Anesthesia Care Unit (PACU) and Central Sterilization (CS) was conducted on 2/8/2011 from 7:50 a.m.-8:00 a.m. and again from 9:15 a.m.-9:25 a.m. accompanied by Director (Dir.) B and Dir. D. The following discoveries were made in the above areas:
Along the walls in the surgery's sterile hallway, in 3 out of 4 Operating Rooms (rooms 1, 2, and 3; room 4 was not observed due to an ongoing surgery), and in walls and along corners of the walls in CS, numerous areas were observed to be gouged away, missing paint, and visibly damaged.
The lack of a smooth, cleanable surface is a potential source of contamination as these areas cannot effectively be cleaned.
In the CS receiving room (where dirty equipment is brought to go through an initial cleaning phase) on top of a shelf over the sink there were 3 bottles of sterile water with the words "Distilled Water" written in heavy black marker on the label. There were no dates of when these bottles were opened (or when they should be discarded) except for one bottle that had the date of 2/27/09 which was scratched out with the same type of black marker.
Failure to indicate when these bottles were opened, or when they should be discarded, does not allow for staff to be certain the water is safe to use for cleaning the equipment.
These findings were confirmed by Dir. B and Dir. D at the time of discovery.
In the CS room that houses the back of the sterilizer, it was observed that the insulating cover that incases the back of the sterilizer unit was breaking down and exposing the metal underneath. The break down of this insulating cover results in a fine dust residue and according to Surveyor #12187 (who was accompanied by Staff L, M, and N on 2/8/2011 at 3:07 PM) the air flows in to the sterile side of CS. This is the wrong way for the air flow and is a potential contaminate for sterile equipment and packs.
Also in the CS room, Surveyor #12187 observed on 2/8/2011 at 3:10 PM while accompanied by Staff L, M, and N, that the air flow was from the corridor into the CS (clean) room. This is the wrong way for the air flow and is a potential contaminate for sterile equipment and packs.
Also, according to Surveyor #12187, on 2/8/2011 at while accompanied by Staff L, M, and N, it was observed that a housekeeping closet which has a door that opens in to the sub sterile hallway on the surgical suite (an area that needs to be kept as sterile as possible) and also a door that opens in to the PACU (an area that is not considered sterile) had both of these doors open at the same time. This allowed for air flow to potentially carry contaminates from a non-sterile area to a sterile area.
These findings were confirmed by Staff L, M, and N at the time of discovery.
Newborn Nursery:
An observation of Laboratory Technician (Lab Tech) V was done in the new born nursery on 2/9/2011 at 8:55 a.m. for Pt. #36. After obtaining blood for an ordered test, Lab Tech V cleansed the excess blood with a gauze pad and an alcohol pad and placed these on the edge of the crib, then removed and discarded gloves and washed hands.
Upon leaving the treatment room Lab Tech V noticed V did not discard the contaminated gauze and alcohol pad and did so with cleaned hands. V then exited the nursery without washing hands again, thereby contaminating the door and the basket of supplies V carried.
These finding were discussed with Dir. E on 2/9/2011 at 9:10 a.m.
Findings by surveyor #20878:
During a tour of the facility on 02/08/11 at 12:30 PM it was discovered that in room #1708, "Stress Lab" there was a crash cart (emergency medication/equipment) kept in the adjoining bathroom. Having this cart stored in such an area has the potential to expose it and its contents to contamination.
During a tour of the facility on 02/08/11 at 12:35 PM it was discovered that in soiled utility room #1978 were kept various supplies. These supplies included; holiday decorations, stationary and bottles of alcohol used for cleaning. The storage of these items in this location has the potential for contamination.
These findings were confirmed per interview with staff B on 2/8/11 at 3:00 PM.
Tag No.: A0940
Based on policy review, surgical observation and staff interview the hospital failed to incorporate their adopted standards of practice for alcohol based skin preparations into their policy and failed to follow the hospital's standards of practice in surgery.
This Condition is NOT MET as evidenced by:
Based on policy and procedure review, observation of 1 of 1 surgical procedures, and staff interview, this facility failed to ensure that surgical patients are protected from fire by ensuring that the alcohol based skin preparation (prep) is dry prior to starting surgery. See tag 951.
The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the safety of surgical patients.
Tag No.: A0951
Based on policy and procedure review, observation of 1 of 1 surgical procedures (Patient [Pt.] #46, and staff interview, this facility failed to ensure that surgical patients are protected from fire by ensuring that the alcohol based skin preparation (prep) is dry prior to starting surgery. Failure to ensure that flammable alcohol based skin preps are dry during the time out process in surgery could lead to patient surgical fires.
Findings include:
Facility policy titled, "Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery," with a revision date of 11/5/2010 states, on page 3 of 3, #4:
"During the time-out, the team members agree on the following:
*Correct patient identity; *Correct side and site; *Confirmation that the correct side and site marking are visible; *Agreement of the procedure to be done; *Correct patient position; *Availability of correct implants and any special equipment or special requirements including antibiotics or fluids for irrigation purposes; *Any safety precautions based on patient history or medication use."
The policy does not incorporate that if an alcohol based skin preparation is used, the preparation is dry prior to draping the patient and starting the surgery.
Facility policy titled, "Skin Preparation of the Patient," with an effective date of 8/4/2006 states, "See current edition of AORN [Association of periOperative Registered Nurses]; Standards, Recommended Practices and Guidelines."
Attached to this page is a photocopied page from AORN 2008 Standards, Recommended Practices and Guidelines which highlights in VIII.c., "The prep agent should not contact fabric...Solution in contact with fabric may not dry adequately."
VIII.f., "The use of a flammable prep agent should be discussed during the 'time out' period used to verify the surgical procedure and site."
VIII.f.1., "Active communication between the surgical team members should include that a flammable prep agent was used; the application site was dry before draping; pooling of the prep solution did not occur or has been corrected; and any materials soaked with the prepping agent have been removed from the procedure room."
Attached to this policy the facility made available a photocopy of a DuraPrep (alcohol based skin prep) package which indicates that it is flammable and states, "To reduce the risk of fire, wait until solution is completely dry (minimum of 3 minutes on hairless skin...)."
In an interview with Director (Dir. D) on 2/7/2011 at 1:45 p.m., D stated the department adhered to the standards of practice of the AORN.
An observation of Pt. #46's hernia repair surgery was conducted on 2/8/2011 from 8:04 a.m.-9:08 a.m. accompanied by Dir. B and Dir. D. DuraPrep was used as the skin prep. A cautery device (a device that uses high heat to seal off blood vessels for minimal bleeding) was used during the surgery.
At 8:13 a.m. Registered Nurse (RN) DD cleansed the surgical area (abdomen) with DuraPrep. At 8:14 a.m. Surgical Technician (ST) AA applied a sterile blue cloth towel to the lower left side of Pt. #46, and at 8:15 a.m. ST AA applied a similar sterile blue cloth towel to the right lower right side of Pt. #46.
The time frame between when the towels were applied and the prep was done did not allow for proper drying time of the alcohol based prep according to manufacturer guidelines.
At 8:16 a.m. RN DD called for a time out. At this time the following was verified: correct patient, procedure to be done, verified no implants to be used, no allergies, the pre-surgical antibiotic that the patient received, and the irrigation solution to be used during the surgery.
The time out process did not include the alcohol based skin prep, or that the prep was dry prior to starting surgery.
Dir. B and Dir. D were present at the time of the observation.
Tag No.: A1005
Based on Medical Record (MR) review, policy and procedure review and staff interview, this facility failed to ensure the post-anesthesia evaluation by a person qualified to administer anesthesia included respiratory function (including respiratory rate, airway patency and oxygen saturation); cardiovascular function (including pulse rate and blood pressure); mental status; temperature; pain; nausea and vomiting; and postoperative hydration in 2 out of 5 (Patients [Pt.] #20, and 21) out of a total of 33 MR reviewed.
Findings include:
Facility policy titled, "Discharge from PACU," dated 7/1/2001, was reviewed on 2/9/2011 at 1:00 p.m. The policy provides guidelines for patient's care following surgery and anesthesia. Discharge from the Post Anesthesia Care Unit (PACU) is determined by an Aldrete Score (Patient's Post Anesthesia Recovery Score) which gives a number value to: activity, respirations, circulation, consciousness, and color.
In a phone interview with Certified Registered Nurse Anesthetist (CRNA) BB on 2/9/2011 at 1:04 p.m., BB stated the post-anesthesia note can be found on the Anesthesia note, on the back side, the bottom right hand corner. CRNA BB stated, "The post-anesthesia note can be found there whether its 10 minutes, a half hour, or the next day. That's where it should be."
A MR review was completed on 2/8/2011 at 1:50 p.m. on Pt. #20's closed surgical record. Pt. #20 was admitted for observation after a surgical procedure on 6/4/2010 and was discharged on 6/5/2010. Pt. #20's anesthesia ended at 9:03 a.m. on 6/4/2010. There is an assessment documented in the section titled, "Recovery Notes," on the back side of the anesthesia record at 9:03 a.m., however the section called, "Post Anesthesia Note," is blank.
A MR review was completed on 2/8/2011 at p.m. on Pt. #21's closed surgical record. Pt. #21 was admitted for after a surgical procedure on 5/10/2010 and was discharged on 5/17/2010. Pt. #21's anesthesia ended at 2:10 p.m. on 5/10/2010. There is an assessment documented in the section titled, "Recovery Notes," on the back side of the anesthesia record at 2:10 p.m., however the section called, "Post Anesthesia Note," is blank.
In a phone conversation on 2/14/2011 at 4:30 p.m., Dir. B confirmed that the post-anesthesia notes were not completed.