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Based on the findings of noncompliance referenced in the following Conditions of Participation, it was determined 42 CFR 482.12 Condition of Participation: Governing Body, was out of compliance.

The Governing Body failed to ensure the Hospital was in compliance with all Conditions of Participation (specifically those listed below) and failed to ensure sufficient actions were taken to correct the areas of non-compliance identified on the 9/4/09 complaint survey.

See the following for details:

I. Condition of Participation: PHYSICAL ENVIRONMENT (42 CFR 482.41) - The Hospital failed to meet the requirements of the federal register at 42 CFR 482.41(b) using the standards of the 2000 National Fire Protection Association (NFPA) 101 Life Safety Code and failed to maintain the facilities, supplies, and equipment at an acceptable safety level for the patients.

Additionally the Hospital had made corrections from the 9/4/09 complaint survey to ensure proper signage and a dedicated ED, but the Hospital had not fully implement their Plan of Correction regarding the ED services. The Governing Body failed to take sufficient actions to ensure compliance with the Condition of Participation: Emergency Services (42 CFR 482.55).

Through observation and staff interview during the health recertification survey completed 1/8/10 and the Life Safety survey completed 1/22/10, it was determined the Hospital failed to meet the Condition of Participation: PHYSICAL ENVIRONMENT ( 42 CFR 482.41 ) due to the nature of Standards not met.

The Hospital failed to meet the requirements of the federal register at 42 CFR 482.41(b) using the standards of the 2000 National Fire Protection Association (NFPA) 101 Life Safety Code and failed to maintain the facilities, supplies, and equipment of the Hospital to ensure an acceptable safety level for the patients.

Based on record review and staff interview, it was determined the Governing Body failed to ensure the Medical Staff was accountable for the quality of care provided to patients. The findings included:

1. The medical staff bylaws indicated a section regarding the Committees of the Medical Staff including peer review. The duties and responsibilities of the Medical Executive Committee included, "Monitor and evaluate patient care by the routine collection of information about significant aspects of patient care such as periodic and objective evaluation of medical staff."

2. Evaluation of ED peer review forms completed in December 2009 showed cases being reviewed were from April - June 2009. The peer review procedure did not provide adequate review of cases in a timely manner to ensure provision of appropriate care in all hospital departments.


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3. On 1/8/10 at 8:45 AM, in an interview with a nurse consultant, she verified peer review had not been done prior tO 12/09.

Based on record reviews and staff/patient interviews, the Hospital failed to ensure the patient was given the right to participate in the development and implementation of his/her plan of care (Patients #22 and #20). Findings included:

1. On 1/6/10 at 9:40 AM, in an interview with the Chief Pharmacist, she revealed patient pain agreements could be found in the patients' medical records. She indicated there were two forms which required the patient's signature. The patient's responsibilities were listed on the Chronic Conditions Agreement and the pain medications were included on the Current Care Plan.

2. On 1/7/10 at 2:45 PM, in an interview with patient #20, he/she complained about not receiving the pain medications the physician had ordered from the pharmacy. He/she indicated the pharmacy would not give him/her the ordered medications or would diminish the dose prescribed by the provider. The patient stated he/she was forced to sign a pain contract two or three years ago and the Hospital refused to give him/her a copy of the contract. He/she discussed the array of medications and doses he/she has received for back pain. The patient commented he/she was not made aware of or was not involved in the medication changes.

a. Although the patient had signed a Chronic Pain Agreement on 4/5/04, an amended notation dated 5/12/04 on the Medical Management plan indicated "need to sign new contract for increased dose". There was no evidence of a new "contract" in the medical record.

b. The patient's record evidenced a Current Care Plan (for pain) which was signed and dated by the patient on 8/24/07. This plan was not reflective of the medication the patient was currently receiving from the pharmacy. The hospital failed to ensure the pharmacy dispensed medications as ordered by the physicians/providers (See A0491 for patient specifics).

c. On 1/7/10 in an interview with the Chief Pharmacist, she verified the patient's Current Care Plan and Chronic Pain Agreement as well as the medications the patient was currently receiving.

d. In a later interview (on 1/8/10 at 9:50 AM), she indicated the patient was currently not supposed to receive any pain medications.

e. This plan for 'no pain medications' was not reflective of the current care plan signed by the patient or his/her current pain medication regime being dispensed by the pharmacy.

f. There was no evidence to show the patient was involved in the care plan/treatment plan for his/her pain.

g. Although the patient had signed a pain agreement, this agreement had not been kept current when medications were changed in order to show the patient was involved in the care plan/treatment plan.


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3. Review of the medical record for patient #22 revealed a "Chronic Pain Agreement (6 pages)" which outlined the conditions, risks, obligations, requirements for refills, and consequences of behavior involved with receiving medications used in the treatment of chronic pain.

a. This agreement had not been signed by the patient or the provider.

b. The medical record contained a "Current Care Plan" dated 10/23/06 which indicated "replaced 3/24/08". This plan had not been signed by the patient or the provider. The 3/24/08 plan was not included in the record.

c. In an interview with the patient on 1/6/10 at 9:15 AM the patient confirmed he/she had not signed any pain agreement.

Based on observation and interview it was determined the Hospital failed to ensure the patient's right to the confidentiality of his or her clinical records. Findings included:

1. On 1/7/10 at approximately 2:30 PM, during a tour of the Kyle Heath Center, observations revealed a maintenance staff (H) who provided assistance during the tour had keys which opened various clinic offices, including an office housing medical records. These records were observed not to be secured and were accessible to view.

2. On 1/7/10 at 4:00 PM, an interview with maintenance staff (H) revealed three additional maintenance staff had key access to the medical records office in this clinic.

3. On 1/5/10 during a tour of the outpatient area, there were two rooms identified as waiting rooms for patients who had been screened and were waiting to be seen by a provider. The rooms used to examine patients were noted to have chart holders on the wall in the hallway by each room. Patients and family members were noted standing in the hallway, creating the potential for unauthorized access to medical records.

4. On 1/8/10 at 9:30 AM a large copy machine in the hallway of the outpatient area was observed. The clinic staff confirmed this machine was used to receive patient medical information faxed to/from the clinic. The machine was not always monitored by staff when they were busy screening and caring for patients. This created a potential for unauthorized access of medical records when information was faxed to the machine.

5. The above concerns regarding privacy and confidentiality of patient medical records was voiced by several clinic providers and nurses. Staff indicated the unlimited traffic flow of patients and families in the clinic areas as well as the volume of patients seen in the clinic increased the changes of others viewing confidential information in records or on the fax machine.

6. Staff indicated these concerns had been reported to Hospital administration in 12/09 but no actions had been taken to limit access of patients who were not accompanied by clinic staff to areas of the clinic where records were available.

Based on record review and staff/patient interviews, the Hospital failed to ensure the pharmacy was administered in accordance with accepted professional principles (Patient #20). Findings included:


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1. On 1/7/10 at 2:45 PM, in an interview with patient #20, he/she complained about not receiving the pain medications the physician had ordered from the pharmacy. He/she indicated the pharmacy would not give him/her the ordered medications or would diminish the dose prescribed by the provider.

a. The most current plan of care for pain (signed by patient/provider on 8/24/07) indicated the following:

1) An initial order for Morphine which had been changed to 30 mg three times a day on 9/10/07.

2) The plan also indicated orders for Vicodin (pain medication), Celexa (antidepressant) and Bupropion (antidepressant).

b. The patient's Chronic Pain Agreement was signed by the physician and the patient on 4/5/04 but did not show the current medications listed above. An amended notation dated 5/12/04 indicated "need to sign new contract for increased dose" which was not evident in the medical record.

2. On 1/7/10 in an interview with the Chief Pharmacist, she verified the above Current Care Plan and Chronic Pain Agreements were the current ones in use.

3. Review of the pain medications provided to the patient from the Pharmacy revealed the following doses of Morphine had been dispensed to the patient from 10/6/09 to 1/7/10 and were not in accordance with provider's order for 30 mg three times a day:

1/7/10 - Morphine 15 mg SR tab #14 (7 days) Take one by mouth every 12 hours

12/29/09 - Morphine 15 mg SR tab #7 (7 days) Take one by mouth every 24 hours.

12/15/09 - Morphine 15 mg SR tab #7 (7 days) Take one by mouth every 24 hours.

11/30/09 - Morphine 15 mg SR tab #7 (14 days) Take one by mouth every other 24 day.

11/16/09 - Morphine 15 mg SR tab #14 (14 days) Take one by mouth every day.

10/30/09 - Morphine 15 mg SR tab #28 (14 days) Take one by mouth every 12 hours.

10/16/09 - Morphine 15 mg SR tab #28 (14 days) Take one by mouth every 12 hours.

10/6/09 - Morphine 15 mg SR tab #20 (10 days) Take one by mouth twice a day.

4. On 1/8/10 at 9:50 AM, in an interview with the Chief Pharmacist, she indicated patient #20 was currently not supposed to receive any pain medications (current plan indicated Morphine). She expressed surprise the patient had received the above multiple doses of Morphine with variations in the amount and frequency of administration.

5. There was no evidence to show the pharmacists or providers had questioned the patient's variable doses of Morphine or reviewed the pain contract. There was a lack of consistency amongst the providers regarding the dosage and the plan not to administer any Morphine (per Chief Pharmacist interview).

Based on record reviews, staff interviews and patient interviews the Hospital failed to ensure the pharmacist was responsible for developing, supervising, and coordinating all the activities of the pharmacy services. Findings included:

1. Review of inpatient records revealed a form titled, "____ Hospital Assessment Record" which was to be completed on all admissions to the hospital. The form included a section titled, "Pharmacy Admission Assessment" which was to be completed by the pharmacist.

2. On 1/7/10 at 1:15 PM, in an interview with the Chief Pharmacist, she verified the pharmacy assessment section on the Assessment Record (fourth page of the form) needed to be completed by the Pharmacist within 24 hours of the patient's admission.

3. Interview with Pharmacist (B) on 1/7/10 at 10:30 AM confirmed the "Pharmacy Admission Assessment" was to be completed by the pharmacist within 24 hours of admission. However completion of the assessment was based on the workload and availability of a pharmacist.

4. Review of inpatient records (patients #48, #13, and #9, and #20) showed incomplete "Pharmacy Admission Assessments".

a. Record review for patient #48 revealed the patient was admitted (11/12/09) to the ACN unit with a diagnosis of alcohol withdrawal. Review of the patient's Assessment Record evidenced the Pharmacy review section was blank and crossed through.

b. Record review for patient #13 revealed the patient was admitted following a hysterectomy on 12/17/09. The assessment record showed the patient was taking multiple medications including: Catapres, Atenolol, Lisinopril, Lexapro, Synthroid and Nitroglycerin as needed. Review of the section for "Pharmacy Admission Assessment" showed no evidence a pharmacy review had been completed for this patient.

c. Record review for patient #9 revealed the patient was admitted to the hospital on 1/4/10 with diagnoses including: cellulitis of the left leg, ulcer left leg, PVD (peripheral vascular disease), right leg amputee, CHF (congestive heart failure) and pulmonary hypertension. The medication administration sheet showed the patient was taking multiple medications and had multiple allergies to medications. Review of the of the section for "Pharmacy Admission Assessment" on 1/8/10 showed the Pharmacy Assessment had not been completed.

5. On 1/7/10 at 2:45 PM, in an interview with patient #20, he/she complained about not receiving the pain medications from the pharmacy which the physician ordered. He/she indicated the ordered medications are not given or the dose was diminished by the pharmacy. (see A0491 for patient specifics).

a. Review of the pain medications provided to the patient from the Pharmacy revealed multiple doses of Morphine were dispensed to the patient from 10/6/09 to 1/7/10. Pharmacy records showed varying doses and frequencies (varied from 12-24 hours) had been dispensed to the patient.

b. On 1/8/10 at 9:50 AM, in an interview with the Chief Pharmacist, she expressed surprise the patient had received these multiple doses of Morphine. Although the current plan of care listed the Morphine, she indicated the patient was currently not to receive any pain medications.

c. There was no evidence to show the Pharmacist(s) had questioned the patient's variable doses of Morphine when according to the Chief Pharmacist, the patient was not to receive any Morphine.

6. On 1/5/10 at 10:10 AM, during an initial tour of the Outpatient Pharmacy, the Chief Pharmacist indicated the pharmacy department was currently short two pharmacy technicians. The staff in the pharmacy included the Chief Pharmacist, seven staff pharmacists and two pharmacy technicians.

7. She indicated the pharmacy filled 850 to 1200 prescriptions/day.

Based on record review, interview and observations, it was determined the Hospital failed to ensure the Pharmacy was secured from access by unauthorized personnel. Findings included:

1. A secure area means drugs and biologicals are stored in a manner to prevent unmonitored access by unauthorized individuals. Drugs and biologicals must not be stored in areas readily accessible to unauthorized persons.

2. During initial observations on 1/5/10 of the different departments in the hospital, staff indicated the hospital had two pharmacies. One was used for outpatients and the other was located on the inpatient unit. The hallways going into both pharmacies were noted to have removable ceiling tiles.

3. In an interview with the Maintenance Supervisor on 1/8/10 at 9:00 AM, she reported the walls around the inpatient pharmacy were solid and extended up to the roof. However the outpatient pharmacy had been identified as a concern due to the removable ceiling tiles.

4. The surveyor accompanied the Maintenance Supervisor to a room identified as an electrical closet 601. The door was unlocked and a ladder in the room was positioned under a open trap door. Upon inspection from the ladder, an access to a large area above the ceiling tiles was noted. The area was identified by the Maintenance Supervisor as the area above the pharmacy.

5. The Maintenance Supervisor indicated eighteen (18) maintenance staff and housekeeping staff currently had keys with access to this electrical room (closet 601) and potentially the pharmacy. Further interview revealed the concern had been identified approximately two months ago.

6. Interview with the pharmacist on 1/8/10 at 9:30 AM revealed she had not been made aware of the issue with potential access to the pharmacy. She reported there had not been any recent issues with missing narcotics however stock medication would be difficult to monitor.


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7. On 1/7/10 at approximately 2:00 PM, during a tour of the Kyle Clinic, observations of the crash cart revealed an amber colored medicine vial with a note indicating the number "91504". The staff confirmed this number was the code to the pharmacy door key pad.

8. On 1/7/10 at 3:00 PM, at Kyle, an interview with pharmacy staff (I) revealed the key pad lock access code on the doors to the pharmacy are changed by maintenance and maintenance then stores the code in the maintenance office.

9. On 1/7/10 at 4:00 PM, at Kyle, an interview with maintenance staff (H) revealed maintenance staff changes the key pad lock access code to the pharmacy and keeps the current access code under lock and key in the maintenance department office. The interview further revealed all three maintenance staff have keys which access the cabinet where the pharmacy code is kept.

10. A review of the Pharmacy Security policy (revised 5/1/09) revealed the following:

a. "Security of the Pharmacy shall be maintained in accordance with federal laws. All personnel on duty shall protect Pharmacy assets and records and guard against the theft or diversion of drugs.

b. All areas occupied by the Pharmacy shall be capable of being locked by key (electronic swipe cards or manually), to prevent access by unauthorized personnel by force.

c. Keys may only be in possession of Pharmacists

d. Locks in the Pharmacy must be re-keyed

? When keys are lost

? In case of Theft

? With changes in personnel, if necessary

e. Restricted access to the Pharmacy (Traffic Control):

Only Pharmacy or authorized personnel shall be permitted to have free access to the Pharmacy.

Medical staff, Nursing Services, Administrative, Environmental Services and other facility personnel are authorized admission in conjunction with their duties and while under the supervision of Pharmacy staff.

The pharmacy shall limit nonessential traffic (by medical service representatives, visitors and other)."

Based on observation and staff interviews, the Hospital failed to ensure outdated, mislabeled, or otherwise unusable drugs and biologicals were not available for patient use. Findings include:

1. On 1/5/10 at 9:12 AM, during an initial tour of the Obstetrics (OB) unit, there were multiple 50 cc and 100 cc IV solution bags which had been removed from the outside plastic covering. These bags were not dated.

2. On 1/5/10 at 10:10 AM, during an initial tour of the Pharmacy, the Chief Pharmacist was told about the IV bags which had been observed. She was asked about the length of time the IV bags could be kept once they were out of the original plastic covering. She was not aware of any time limit once the bags were opened. She indicated she would follow up to determine if the manufacturers' instructions included any time limitations.

3. On 1/6/10 at 9:40 AM, the Chief Pharmacist indicated she had received documentation verifying the IV bags needed to be disposed of 30 days after they were removed from the outside covering. She indicated there was no current policy regarding this issue.

4. During the tour of the outpatient and inpatient pharmacy areas, a water fill set-up was observed in each area which was hanging down from the water source. This set-up was used to mix oral medications needing water added. Neither of the tubing ends were covered to ensure the system was protected from contamination.

Based on staff interviews and record reviews, the Hospital failed to ensure radiology equipment was routinely monitored to ensure proper safety precautions are maintained against radiation hazards. This failure included the failure to ensure routine monitoring on all radiologic equipment was completed timely. Findings included:

1. During the review of radiologic services on 1/6/10 at 11:00 AM a concern with routine and timely monitoring on all radiologic equipment was identified.

2. Interviews with radiology staff revealed all equipment scanners and protective equipment such as aprons and gloves had been checked to ensure safety.

3. Staff provided documentation on "Protective Devices Inspection Record" and reports of scanners being checked for the hospital.

4. However staff was unable to provide documentation for equipment checks and services being provided in an outlying clinic in Kyle.

5. On 1/7/10 at 2:00 PM an onsite review of the Kyle Clinic was completed. Interview with the radiology staff at the clinic confirmed a check of protective devices had not been done prior to the time of the survey. Staff stated, "The checks are supposed to be done annually but somehow it was missed". A check list showed the last inspection had been done on 10/7/08.

6. Additionally, the staff reported the routine check on the radiologic equipment had not been done. Staff stated, "The GE contract stopped so the service on equipment was dropped. When the preventative maintenance dropped off contract and the equipment didn't get checked until I had an issue. Since then it was check three times."

7. Staff provided documentation of those service calls for 3/27/09, 5/12/09 and 9/25/09. There was no documentation provided regarding any routine checks after 9/25/09.

Based on staff interviews and record reviews the Hospital failed to ensure a utilization review program was established and maintained to review the medical necessity of admissions and continued stays. Findings included:

1. On 1/7/10 at 11:45 AM, in an interview with the Utilization Review (UR) nurse, she revealed the staff (physician(s) and discharge planner) do daily rounds to check on the status of patients. She indicated there are no UR meetings, but she uses a worksheet to document the information discussed on the rounds.

2. Review of the Utilization Review for Admission Certification forms for 7/1/09 to 9/30/09 and 10/6/09 to 11/28/09 revealed no physician had signed these forms to indicate his/her agreement or involvement in these UR reviews for admission justification.

Based on the survey completed on 1/22/10 and observation during the tour of the Hospital, it was determined the Standards of the 2000 National Fire Protection Association (NFPA) 101 Life Safety Code were not met.

See the attached CMS form 2567 for specific Life Safety Code deficiencies and details.

Based on observation and staff interview, it was determined the Hospital failed to maintain the facilities, supplies, and equipment to ensure an acceptable safety level for the patients. The findings included:

DIETARY DEPARTMENT:

1. On 1/7/10 at 4:20 PM an observation of the kitchen was conducted with the Compliance Officer and the Registered Dietitian (RD) responsible for the Food Service. The following observations were made:

Freezer #1:
a. There was a large bag of strawberries which had been opened. This bag was not labelled or dated and the top was twisted closed.

b. There was five bags of chicken which were unlabelled and undated.

c. Rolls of cookie dough (identified by the RD) were unlabelled and undated. The RD was not aware of why the cookie dough rolls were in the freezer and indicated these appeared to be homemade.

Cooler (produce) #2:
There were two boxes of cherry tomatoes (dated 12/17/09 and 12/24/09) and a box of grapes (dated 12/10/09). These items were shriveled and soft. The RD indicated these items needed to be discarded.

Other Dietary Areas:
a. The garbage disposal located at the produce preparation sink had a damaged cover gasket. This damage allowed for garbage to splash out of the disposal when it was operating.

b. There was a plastic scoop lying in the sugar bin.

c. The fan above the #3 cooler was noisy and dusty.

d. There were several large jars of spices stored with the lids open.

e. The lid on the large plastic bin which held rice was open half way.

f. A pipe located next to the tilt skillet had a thick layer of grease and dust on it.

g. The garbage disposal gaskets on the disposals located at the three compartment sink and at the dishwasher were damaged and in need of replacement.

h. There was an open, undated can of Beneprotein sitting on top of the steam table. The manufacturer's label on the can noted the can was to be only used for six months and then discarded.


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2. On 1/5/10 during an initial observation of the different departments in the hospital safety the following concerns were identified:

a. There was a unlocked cupboard in the dietary area being used for chemical storage.

b. A room in the dietary area (identified as G402) was noted to have a large opening around a ceiling fluorescent light. The wall directly below the opening was stained and identified by the dietitian as water damage. The Maintenance Supervisor reported the water leak was from the floor above due to a change of equipment in the operating room.

3. Ice machines were noted in various departments of the hospital, including the dietary department, OB (obstetrics) and a small counter type machine on the inpatient unit. The machine on the inpatient unit had a sign indicating it was not working.

a. Interview with the Maintenance Supervisor on 1/8/10 at 9:00 AM revealed maintenance did not have evidence to show cleaning and sanitation of the internal components of the ice machine as per manufacturers's instruction. She reported the issue of cleaning the ice machines had been identified on a mock survey in October 2009 but no follow-up actions had been taken.

b. The RD indicated in an interview on 1/8/10 at 9:15 AM the dietary department only cleaned the ice bin. She was not aware the internal components of the ice machine had to be cleaned and sanitized and indicated she did not know if this had been done.

c. On 1/8/10 at 9:30 AM, the Maintenance Supervisor provided a copy of the manufacturer's instructions for cleaning the ice machines. The manufacturer's instruction stated, "Maintenance and cleaning/sanitizing should be scheduled at a minimum of twice per year". The Maintenance Supervisor confirmed the cleaning/sanitizing of the ice machines was not being completed as per the manufacturer's instructions.

4. On 1/5/10 a tour of the outpatient area identified the following:

a. After going through an unlocked door into a hallway, there were two rooms identified as waiting rooms for patients who had been screened and were waiting to be seen by a provider. Both rooms were noted to have patients waiting to be seen.

b. Directly across from one waiting room was room A136 which was identified as a medication/supply room and was labelled "Restricted Area Do Not Enter". This room was found to be unlocked. Supplies which included syringes and lancets were not in a secured area/unit.

c. When staff was asked about the room, they reported it was to be locked. The keys were kept in a drawer in a room used as the nurse station.

d. After several attempts the key was found. However the door could not be locked. The staff reported they would report the broken lock to maintenance for repair.

e. Three days later on 1/8/10 at 9:30 AM a check of the outpatient area identified the following:

Room A136 as well as A151 (medication/supply rooms) remained unlocked with patients noted in both waiting areas.

5. Observations in the Surgical Department revealed the temperature and humidity of the operating suites were not maintained at an acceptable level per the hospital policy (humidity 35-60% and temperature 68-75 degrees Fahrenheit). Although maintenance was aware of the problem and low humidity had been an ongoing problem since October 2009, the problem continued. Humidity at the time of the survey showed a low humidity reading of 25% in OR room #1.

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Based on record review and family interview, the hospital failed to ensure implementation of a discharge plan including arrangement of necessary post-hospital services/care and education of the patient and family about post hospital plans (patient #21). Findings included:

Review of the medical record for patient #21 revealed the patient was admitted from the ED on 1/3/10 with diagnoses which included: hypertension, possible SVT (supraventricular tachycardia), R/O WPW Syndrome and possible diabetes mellitus.

a. WPW syndrome (Wolff-Parkinson-White syndrome) is the presence of an extra abnormal electrical pathway in the heart which leads to periods of a very fast heartbeat (tachycardia). The extra electrical pathway of Wolff-Parkinson-White syndrome is present at birth. While people of all ages, including infants, can experience the effects of Wolff-Parkinson-White syndrome, episodes of a fast heartbeat often first appear when people are in their teens or early 20s.

b. The patient was admitted to the ACN unit and placed on telemetry to monitor his/her heart rate. The telemetry showed the patient's heart rate was in NSR (normal sinus rhythm).

c. Review of the provider's progress note on 1/04/10 at 12:20 PM indicated the provider's plan for discharge with follow-up at his/her clinic and a referral to a cardiologist.

d. Review of provider's discharge orders identified the name of the physician (cardiologist) and listed a phone number for the cardiologist.
.
e. Review of the "Patient Discharge Instructions" sheet dated 1/4/10 showed no evidence the physician's orders were followed for the referral to the cardiologist. The sheet only listed the patient's diagnoses, medication, lab work to be drawn on 1/5/10 and follow-up in the provider's clinic on 1/7/10.

f. Review of the "Patient Care Flow Sheet"only stated, "Instructed on follow-up."

g. There was no documentation to show the Hospital had provided the family/patient with the referral information or assisted in setting up a referral appointment for this patient.

h. In an interview on 1/20/10 with a family member of patient #21, he/she indicated when the patient was discharged from the hospital no one had assisted the patient or the family with making arrangements or appointments to see the heart specialist.

i, This family member also indicated the ED physician knew there was a family history of heart disorders when the patient was treated in the ED, but no referral to a cardiologist was made at the time the patient was initially examined in the ED.

Based on observation, record review, and staff interview the Hospital failed to ensure surgical services were provided in a manner to ensure the health and safety of patients. This failure related to surgical counts for items including sponges, swabs, instruments and sharps. The findings include:
Maintenance.

1. During tour on 1/6/10 at 9:45 AM of the OR with nurse supervisor (H), the procedure for counts of sponges, sharps and instruments was reviewed. The nurse identified there was an area for a final count on the "Perioperative Record". This count was shown as a check mark on the form.

a. She indicated the OR staff had changed how they were documenting the surgical counts about a month ago. A second form was now being used which is started when the instrument tray is set up and sterilized to record all instrument counts, sponges and needles for each procedure.

b. Review of the form titled, "Instrument Count Sheet" showed columns labeled as "QTY, CPD count, Initial count and Final count". These forms were completed during the surgical procedure for each patient.

c. Nurse (H) reported, "The Instrument Count Sheets do not become a part of the patient's record. They are kept in my office. We just started keeping these forms about a month ago."

2. Review of three surgical patient records (patients #1, #13, and #17) identified the "Final Count" area on the "Perioperative Record" was checked as correct.

a. In two of the three records (#13 and #17) reviewed, the "Instrument Count Sheets" were incomplete and the sheets were not signed by the staff who completed/verified the counts.

b. Nurse (H) confirmed the Instrument Count Sheets were incomplete. She reported the P&P(Policy and procedure) was being revised.

3. Review of the policy titled, "Sponge, needles, small items and instrument count" (dated 1/2010) indicated the following:

a. Initial counts will be accomplished before the start of the surgical procedure and running talley made during the case will be maintained on an instrument count sheet.

b. The final count will be conducted as soon as the surgeon announces that they are closing.

c. The results of final count are recorded on OR page 2 Perioperative Nursing Record.

d. This Perioperative Nursing Record is not the same form as the instrument count sheet. Therefore the OR report does not show how many counts were actually done during the procedure.