HospitalInspections.org

Based on review of the credentialing files, review of the facility Bylaws, and interview, the facility failed to ensure privileges requested by the physicians were granted in four of four credential files reviewed.

The findings included:

Review of the credential file for physician #1 (Emergency Medicine Practitioner) revealed an appointment to the medical staff date of July 1, 2009-June 30, 2011. Review of the "Delineation of Hospital Privileges" revealed the Emergency Procedures were indicated as "requested." Review revealed the line for approval was not marked or indicated as a granted privilege; and the Board Chairman did not sign on the designated line.

Review of the credential file for physician #2 (Chief of Staff) revealed a re-appointment period of November 17, 2010-November 16, 2012.

Review revealed the "Privileges" for the re-appointment were to remain the same without changes.

Review of the "Delineation of Hospital Privileges" requested by Physician #2 for the previous period on October 26, 2010, revealed, "Medical staff instructions: Please check to indicate 1) no restrictions, 2) OK with assistance, 3)not approved."
Review revealed there was no check mark or indication of granting the requested privileges.

Review of the credential file for physician #3 (Family Practice) revealed an appointment period of June 25, 2009-June 24, 2011.

Review of the "Delineation of Hospital Privileges" revealed the Medical Procedures were indicated as "requested." Review revealed the line for approval was not marked or indicated as a granted privilege; and the Board Chairman Secretary did not sign on the designated line.

Review of the credential file for physician #4 (Radiologist) revealed a re- appointment period of April 27, 2011-April 26, 2013.

Review of the "Delineation of Privileges" signed by physician #4, on March 30,2011, revealed the requested privileges "remain the same as previous appointment. " Review of the document revealed no other approving signature.

Review of the previous privileges dated February 18, 2009, revealed the lines below "GRNT" (grant) were all blank and not marked to indicate the requested privileges were granted. Review revealed the line for approval was not marked or indicated as a granted privilege; and the Board Chairman Secretary did not sign on the designated line.

Review of the facility Bylaws of the Medical Staff approved 2001, revealed, 7.1 Exercise of Privileges:
"Every practitioner or other professional providing direct clinical services at the hospital by virtue of Medical Staff membership or otherwise shall, in connection with such practice...be entitled to exercise only those clinical privileges or specified services specifically granted to him by the Board."

Interview in the conference room with the Credential Staff Coordinator on July 26, 2011, at 11:20 a.m., revealed the "Credential Committee looks at the entire application and signs off on it...The Medical staff take the recommendations of the Credential Committee."

Interview in the conference room with the Risk Manager on July 26, 2011, at 2:20 p.m., confirmed the credentialing files were incomplete as to specify which requested privileges were granted to the physicians.

Based on observation and interview, the facility failed to ensure contracted services were provided in a safe and effective manner.

The findings included:

Review of the facility's contracted services revealed the following patient centered contracted services: new employee background checks, billing transmittal, physical therapy, dietary services, Certified Registered Nurse Anesthetist, outside lab testing, Occupational Therapy, Speech Therapy, data storage, security, pest control, linen services, and Emergency Department (ED) Physician coverage. Review of the facility's Quality Assurance program meeting minutes for the past twelve months revealed no monitoring for the provision of safe and effective contracted services.

Interview with Quality Assurance Manager on July 26, 2011, at 3:00 p.m., in the office of the ED Manager, confirmed there was no documentation within the Quality Assurance meeting minutes to indicate the facility was monitoring the safe and effective delivery of care provided by contracted services.

Based on observation, and interview, the facility failed to ensure the patient bathroom was safe for the sleep study patients.

The findings included:

Observation on July 26, 2011, at 7:40 a.m., of the shared bathroom utilized by two sleep study rooms revealed the bathroom was located on the hall near the sleep study bedrooms. Continued observation revealed the bathroom had a locking door from the inside. Continued observation revealed there was no operational emergency call system available in the bathroom.

Interview with the Sleep Study Manager on July 26, 2011, at 7:50 a.m., in the hall outside the bathroom utilized by the sleep study patients, confirmed the bathroom had no emergency call system for use by the sleep study patient utilizing the bathroom.

Based on medical record review, facility policy review, and interview, the facility failed to ensure an order for the use of restraints was time limited for one patient (#10) of two restraint records reviewed.

The findings included:

Patient #10, a 26 year old, was admitted to the Emergency Department (ED) on June 23, 2011, at 1:00 a.m. Medical record review revealed the patient was treated for Acute Alcoholism and Severe Inappropriate Behavior. Continued medical record review of the Nurse's Note, dated June 23, 2011, at 1:05 a.m., revealed "...Patient became combative...security called..." Continued medical record review of the ED Physician Record, dated June 23, 2011, at 1:15 a.m., revealed "V.O. (Verbal Order) Physician order - 4 point ext (extremity) restraint for patient/staff safety due to pt (patient) violent behavior."

Review of the facility policy Restraints, policy #2199, dated December 4, 2008, revealed "...In accordance with the order of the physician...each written order for violent/self-destructive patient restrain...is limited to four (4) hours for ages 18 and over..."

Interview in the ED Manager office with the ED Manager on July 26, 2011, at 9:40 a.m., confirmed the order for the restraint was not time limited per the facility policy.

Based on medical record review, facility policy review, and interview, the facility failed to ensure pain was assessed on one patient (#6) of sixteen patients reviewed.

The findings included:

Patient #6 presented to the Emergency Department (ED) on July 25, 2011, at 3:04 p.m., with Chief Complaint of MVA (motor vehicle accident) - head, neck shoulder pain. Medical record review of the Nurse's Triage Note, dated July 25, 2011, at 3:09 p.m., revealed the area on the note indicating "pain level" was blank.

Review of the facility policy Pain Assessment, policy #2015, dated December 4, 2008, revealed "...Pain is assessed on all patients in our organization...at the time of admission to the facility...during the initial assessment..."

Interview with the ED Manager in the office of the ED Manager on July 26, 2011, at 9:45 a.m., confirmed the patient's pain had not been documented as being assessed on initial assessment per the facility's policy.

Based on observation, facility policy review, and interview, the facility failed to ensure the cardiac monitoring (telemetry) was performed by a trained staff for one of one telemetry units observed.

The findings included:

Observation on July 25, 2011, at 10:40 a.m., revealed the Medical/Surgical (Med/Surg) unit nursing station contained one nursing station and revealed one Unit Clerk (UC #1) sitting facing the telemetry monitor while performing other tasks. Observation revealed three patients were being monitored for heart rhythm and rate. Continued observation until 11:11 a.m., (31 minutes) revealed no other staff member was monitoring the telemetry screen.

Review of the July, 2011, schedule for the Med/Surg unit revealed UC #1 worked July 17th 7A-7P, July 20th 7A-11P, July 24th 7A-7P, and July 25th 7A-11:30A and duties included telemetry monitoring. Review reviewed no other UC was assigned to work at those times and no one was assigned the responsibility of telemetry monitoring.

Review of the facility policy #2197 stated, "It is required that ether a Unit Clerk, Charge Nurse, or other nurse is always at the nurses' station observing telemetry, and reporting any changes..."

Review of the personnel file for UC #1 revealed a hire date of June 21, 2011. Review of the file revealed UC #1 has not attended the training for recognizing arrhythmias (change in heart pattern or rate).

Interview with the Chief Nursing Officer at the Med/Surg nurses' station on July 25, 2011, at 11:15 a.m., confirmed UC #1 has not attended the telemetry training and confirmed the facility failed to ensure staff was trained prior to being assigned to monitor patients on telemetry.

Based on medical record review, facility policy review, and interview, the facility failed to ensure allergies were listed in all areas of the medical record for one patient (#8) of sixteen records reviewed.

The findings included:

Patient #8, a six year old, was admitted to the facility on July 15, 2011, for out patient dental surgery. Medical record review of the pre-operative nursing assessment, dated July 15, 2011, at 7:10 a.m., revealed "ALLERGIES: Bananas and Latex." Continued medical record review revealed the allergy to Latex was not listed in any other area requiring allergies to be listed.

Review of the facility policy Allergy Identification, (un-numbered), dated June 1, 2011, revealed "...ensure all patients are assessed for food and drug allergies...Allergy documentation fields in the EMR...all allergies should be listed in the front of the chart..."

Interview on July 26, 2011, at 10:00 a.m., with the Registered Nurse (RN) who documented the pre-operative allergy, confirmed the RN had called the patient's Pediatritian and confirmed the patient's allergies during the pre-operative assessment.

Interview in the Emergency Department Manager's office with the Medical Surgical Manager, on July 26, 2011, at 9:50 a.m., confirmed the Latex allergy was only identified in the pre-operative Nurse's assessment and all other areas in the operative record did not include Latex as an allergy.

Based on observation, review of manufacturer's recommendations, and interview, the facility failed to properly store an intravenous solution (Mannitol) in the Surgical Suite.

The findings included:

Observation in the Surgical semi-sterile core on July 25, 2011, at 2:45 p.m., revealed a warmer with a temperature of 111 degrees Fahrenheit. Observation of the contents of the warmer revealed 2 bottles of 25% Mannitol (osmotic diuretic) 50 ml (milliter).

Interview with the Manager of the Surgical Services on July 25, 2011, at 2:45 p.m., revealed the bottles were placed in the warmer "about a month ago" and confirmed the bottles were undated.

Review of the manufacturer's information provided by the facility regarding storage and stability of Mannitol read, "Mannitol solutions are stable but are recommended to be stored at room temperature..."

Interview in the Surgical Suite with the Manager of Surgical Services on July 26, 2011, at 8:10 a.m., confirmed the facility failed to properly store the Mannitol.

Based on observation and interview, the controlled substance medications in the ED (Emergency Department) were not secured by two locks in one of one ED medication room.

The findings included:

Observation of the medication room in the ED on July 25, 2011, at 10:40 a.m., revealed the door was open and no staff present to monitor the entry to the medication room. Continued observation revealed the controlled substances located in the medication room electronic dispensing machine and in the refrigerator were secured by one locking mechanism unless the medication room door was closed and locked.

Interview with the ED Manager in the medication room in the ED on July 25, 2011, at 10:45 a.m., confirmed controlled substances were to be secured by two locks. Continued interview confirmed controlled substances were located in the electronic medication dispensing machine and the refrigerator. Continued interview confirmed the ED medication room was usually left open. Continued interview confirmed the controlled substances were not secured by two locking mechanisms when the door was left open and unattended.

Based on observation, review of manufacturer's directions, and interview, the facility failed to ensure the equipment utilized in the Physical Therapy (PT) department was maintained to allow for sanitizing between patient care; failed to ensure the equipment utilized in the CT (Computerized Tomography) uptake room was maintained to allow for sanitizing between patient care; failed to ensure the manufacturer's directions were followed for mixing floor cleanser; failed to ensure clean patient supplies were not stored in the janitorial closet or the staff locker and bathroom area in the ED (Emergency Department); and failed to ensure the paper products storage area in the dietary department was maintained in a sanitary manner.

The findings included:

Observation, on July 25, 2011, at 10:20 a.m., in the Dietary Department's storage area for paper products intended for patient utilization revealed, in addition to paper products, staff purses, staff scrub tops, staff aprons, a 16 ounce bottle of commercial drinking water, 3/4 full, with condensation on the outside of the bottle, and a 32 ounce bottle of glass cleaner, 1/8 full, were located on the shelves with the paper products.

Interview with the Dietary Manager, on July 25, 2011, at 10:20 a.m., confirmed the item which were not paper products were not clean items, staff personal items and chemicals were not to be in the paper product storage area, and only the paper products were to be stored in the paper product storage area.


Observation on July 25, 2011, at 11:10 a.m., in the hall outside the Emergency Department revealed a mop bucket, half full of fluid with a small amount of foam on top of the fluid.

Interview on July 25, 2011, at 11:10 a.m., with housekeeper #1 in the hall outside the Emergency Department revealed the fluid in the mop bucket was a mixture of water and floor cleanser utilized on the floor in the Emergency Department, patient rooms, and halls. Continued interview with housekeeper #1 revealed "...pour some floor cleanser into the water...don't measure how much floor cleanser or water...haven't read the direction on mixing...couldn't say how much water or cleanser is in the bucket..."

Review of the (named) cleanser manufacturer's directions revealed "...for daily cleaning of floors...concentrated...Instructions: fill mop bucket with a hot solution of (named) floor cleanser by using the appropriate dilution equipment...Cleansing Solution Concentration: Mix 3 oz (ounces) per gallon of water..."

Observation with the ED Manager on July 25, 2011, at 11:10 a.m., of the janitor closet in the ED revealed the closet contained mops, chemicals, brooms, thermometers probe covers, paper towels, and crutches. Continued observation with the ED Manager on July 25, 2011, at 11:20 a.m., of the staff locker and bathroom area in the ED revealed clean and ready to use patient items such as crutches and wheel-chairs were stored in the staff locker bathroom area.

Interview with the ED Manager on July 25, 2011, at 11:10 a.m. and 11:20 a.m., at the janitor closet and the staff locker and bathroom area in the ED, confirmed patient supplies were not to be stored in the janitor closet or the staff locker or bathroom area.

Observation on July 25, 2011, at 2:00 p.m., of a chair utilized by patients in the CT uptake room (recliner used for infusion) revealed the vinyl covering of right and left armrest of the chair was cracked exposing the under foam.

Interview with the Radiology Manager on July 25, 2011, at 2:00 p.m., in the uptake room of the CT department confirmed the cracked vinyl and exposed foam made it impossible to sanitize the chair between patient use.


Observation on July 25, 2011, at 2:20 p.m., of the mat table utilized by patients in the Physical Therapy department revealed the vinyl on the corners and down one side of the mat were cracked and the under foam was exposed.

Interview the the PT Department on July 25, 2011, at 2:20 p.m., with the Physical Therapy Director confirmed the cracked vinyl with the exposed foam on the mat table made it impossible to sanitize the exposed areas of foam on the mat table between patient use.