HospitalInspections.org

Based on document review and staff interview, the facility failed to enforce their Bylaws.

Findings Include:

Review of the facility's "Medical Staff Bylaws" revealed: "Section 2. Description of Functions B. Pharmacy and Therapeutics..."

The Pharmacy Department policy dated 10-01-10 (Reference # 6101) lists the Pharmacy and Therapeutics Committee Purpose, Policy, Organization, Functions and Scope in detail.

Review of the Medical Executive Committee Agenda for the previous six (6) months revealed no listing for the Pharmacy and Therapeutic function.

During an interview on 8/19/14 between 3:40 p.m. and 4:30 p.m. the Pharmacist stated that the Pharmacy and Therapeutic Committee was an Agenda item for the Medical Executive Committee. He stated, "They decide the Formulary contents and protocols." The Pharmacist also stated that he was not on the Pharmacy and Therapeutic part of the Medical Rxecutive Committee and that things had not been stable with the physicians, but there would be a steady set of doctors in September.

Based on record review, policy and procedure review and staff interview, the facility failed to ensure all entries in the medical record are complete and contain a documented date, time and signature. Seven (7) of 23 patoents reviewed were affected: Patient #13, #14, #15, #17, #21, #22 and #23.


Findings Include:


Record review for Patient #13, #14, #15, #17, #21, #22 and #23 revealed the "Patient Authorization and Consent/Consent for Authorization and Treatment" form contained no documented evidence of the date and time the consent was obtained or a date, time and witness signature. The "Signature of Witness" line contained an electronic stamp which stated "On File".


Record review for Patient #23 revealed no documented evidence of the time the History and Physical (H&P) was signed by the physician.


Record review for Patient #17 and #20 revealed no documented evidence of the time the physician orders were written into the medical record.


Review of facility policy "Entries in the Medical Record" revealed: "Policy: It is the policy ...that entries in the medical record are made only by authorized individuals, dated and timed and signed ...".


Review of facility policy "Consent to Treat" revealed: "...Policy: ...proper consent for treatment will be signed before treatment...".


Review of "Medical Staff Bylaws" revealed: "....Article XVI: Medical Records: 1. The attending staff member credentialed by the Medical staff shall be responsible for the preparation of a complete ...Medical Record for each patient ...8. All clinical entries in the patient's Medical Record shall be accurately dated, timed and authenticated...".


During an interview on 8/20/14 at 4:40 p.m. the Medical Record Director was asked, "Do you expect the signature, date and time to be documented by the staff member obtaining consent for admission and treatment?" She stated, "Yes."

During an interview on 8/20/14 at 4:50 p.m. with Collections Representative #1 concerning the "Patient Authorization and Consent" form, when asked are the staff are suppose to witness the admission for treatment consent form, she stated, "Yes, but the electronic MR does not have a place for the clerk to document the date and time". She further stated, "The electronic MR does not provide a place for the patient or responsible person to document a date and time of signature." Observation of the online consent process revealed there is no automatic electronic date and time stamp for the patient, responsible person or witness signature line.

During an interview on 8/20/14 at 5:00 p.m. with the Director of Nursing (DON) concerning electronic MR signature, date and time; revealed all consents are not complete with the date and time the consent is obtained or a date, time and witness signature. The DON stated, "We will contact our electronic MR vendor for revisions to our documents/MR."

Based on record review and policy and procedure review, the facility failed to ensure a properly executed consent documented for seven (7) of 23 patients reviewed, Patient #13, #14, #15, #17, #21, #22 and #23.


Findings Include:


Cross Refer to A450 for the facility's failure to ensure consents contain documented evidence of the date and time the consent was obtained or a date, time and witness signature.

Based on observation, policy and procedure review and staff interview, the facility failed to appropriately implement their procedure for Contact Isolation.

Findings Include:

During Surveillance Rounds on the Medical/Surgical Unit on 8/19/14 at 2:00 p.m. observation revealed that the patient in Room #218 was in Contact Isolation. The door to the room was wide open. There were no gowns in the over-the-door Isolation Cart. His soiled linen was outside his room in the hallway. His contaminated (Red Liner) garbage was also in the hallway beside the linen hamper.

Review of the facility's "Isolation" policy (effective date 12/95 and last revision 1/16-/3) revealed that for Contact Isolation a private room is required and the door is to be kept closed. Gowns are indicated if contact is anticipated.

During an interview on 8/19/14 at approximately 2:10 p.m. with the Infection Control Nurse revealed that they are supposed to keep the door to the patient's room closed, and that they do need to replenish the over-the-door Isolation Cart.

Based on document review and staff interview, the facility failed to enforce their Bylaws.

Findings Include:

Review of the facility's "Medical Staff Bylaws" revealed: "Section 2. Description of Functions B. Pharmacy and Therapeutics..."

The Pharmacy Department policy dated 10-01-10 (Reference # 6101) lists the Pharmacy and Therapeutics Committee Purpose, Policy, Organization, Functions and Scope in detail.

Review of the Medical Executive Committee Agenda for the previous six (6) months revealed no listing for the Pharmacy and Therapeutic function.

During an interview on 8/19/14 between 3:40 p.m. and 4:30 p.m. the Pharmacist stated that the Pharmacy and Therapeutic Committee was an Agenda item for the Medical Executive Committee. He stated, "They decide the Formulary contents and protocols." The Pharmacist also stated that he was not on the Pharmacy and Therapeutic part of the Medical Rxecutive Committee and that things had not been stable with the physicians, but there would be a steady set of doctors in September.

Based on record review, policy and procedure review and staff interview, the facility failed to ensure all entries in the medical record are complete and contain a documented date, time and signature. Seven (7) of 23 patoents reviewed were affected: Patient #13, #14, #15, #17, #21, #22 and #23.


Findings Include:


Record review for Patient #13, #14, #15, #17, #21, #22 and #23 revealed the "Patient Authorization and Consent/Consent for Authorization and Treatment" form contained no documented evidence of the date and time the consent was obtained or a date, time and witness signature. The "Signature of Witness" line contained an electronic stamp which stated "On File".


Record review for Patient #23 revealed no documented evidence of the time the History and Physical (H&P) was signed by the physician.


Record review for Patient #17 and #20 revealed no documented evidence of the time the physician orders were written into the medical record.


Review of facility policy "Entries in the Medical Record" revealed: "Policy: It is the policy ...that entries in the medical record are made only by authorized individuals, dated and timed and signed ...".


Review of facility policy "Consent to Treat" revealed: "...Policy: ...proper consent for treatment will be signed before treatment...".


Review of "Medical Staff Bylaws" revealed: "....Article XVI: Medical Records: 1. The attending staff member credentialed by the Medical staff shall be responsible for the preparation of a complete ...Medical Record for each patient ...8. All clinical entries in the patient's Medical Record shall be accurately dated, timed and authenticated...".


During an interview on 8/20/14 at 4:40 p.m. the Medical Record Director was asked, "Do you expect the signature, date and time to be documented by the staff member obtaining consent for admission and treatment?" She stated, "Yes."

During an interview on 8/20/14 at 4:50 p.m. with Collections Representative #1 concerning the "Patient Authorization and Consent" form, when asked are the staff are suppose to witness the admission for treatment consent form, she stated, "Yes, but the electronic MR does not have a place for the clerk to document the date and time". She further stated, "The electronic MR does not provide a place for the patient or responsible person to document a date and time of signature." Observation of the online consent process revealed there is no automatic electronic date and time stamp for the patient, responsible person or witness signature line.

During an interview on 8/20/14 at 5:00 p.m. with the Director of Nursing (DON) concerning electronic MR signature, date and time; revealed all consents are not complete with the date and time the consent is obtained or a date, time and witness signature. The DON stated, "We will contact our electronic MR vendor for revisions to our documents/MR."

Based on record review and policy and procedure review, the facility failed to ensure a properly executed consent documented for seven (7) of 23 patients reviewed, Patient #13, #14, #15, #17, #21, #22 and #23.


Findings Include:


Cross Refer to A450 for the facility's failure to ensure consents contain documented evidence of the date and time the consent was obtained or a date, time and witness signature.

Based on observation, policy and procedure review and staff interview, the facility failed to appropriately implement their procedure for Contact Isolation.

Findings Include:

During Surveillance Rounds on the Medical/Surgical Unit on 8/19/14 at 2:00 p.m. observation revealed that the patient in Room #218 was in Contact Isolation. The door to the room was wide open. There were no gowns in the over-the-door Isolation Cart. His soiled linen was outside his room in the hallway. His contaminated (Red Liner) garbage was also in the hallway beside the linen hamper.

Review of the facility's "Isolation" policy (effective date 12/95 and last revision 1/16-/3) revealed that for Contact Isolation a private room is required and the door is to be kept closed. Gowns are indicated if contact is anticipated.

During an interview on 8/19/14 at approximately 2:10 p.m. with the Infection Control Nurse revealed that they are supposed to keep the door to the patient's room closed, and that they do need to replenish the over-the-door Isolation Cart.