HospitalInspections.org

Based on clinical record review, hospital documentation review, staff interview, and patient caregiver interview the hospital failed to inform the mother (caregiver) of a child (patient) on the Pediatric Unit who to contact to file a grievance. This was one (1) of three (3) patients reviewed (Patient #1).

Findings include:

Review of clinical record #1's History and Physical revealed the following: Patient is a 4-year old male child admitted from the Emergence Room (ER) to the Pediatric Unit on 3/14/11 and discharged 3/17/11. This patient is well known to Attending Medical Doctor. Patient's chief complaint was increased wheezing, increased work of breathing and respiratory distress. (History of Asthma noted).

Review of Policy LD011 revealed the following: (Definitions)

"Complaints- is a concern represented by a patient or patient's representative that can be addressed or resolved promply by staff members who are present at the time of the complaint. "Staff present" includes those individuals close to the complaint situation or who can quickly be at the patient's location (i.e. nursing, administration, nursing supervisors, patient advocate, etc.) to resolve the patient's complaint. Generally, complaints can be resolved timely while the patient is still receiving care at the facility."

"Patient Grievance- is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the representative, regarding the patient's care, abuse or neglect, issues related to compliance with Centers Medicare/Medicaid Services (CMS) Conditions of Participation (CoP), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 Code of Federal Regulatiosn (CFR) 489."

"Verbal Complaint- is a grievance if it cannot be resolved at the time of the complaint by staff present, if it is postponed for later resolution, if it is referred to other staff for later resolution, if it requires investigation, and/or if it requires further actions for resolution."

On 3/15/11 at 1:30 p.m. an interview with Patient #1's mother (caregiver) revealed that she was very pleased with the care her son had received by the second floor nurses, however, she could not say that about the ER doctor. She revealed that the ER doctor treated her very disrespectful and accused her of being her son's cause of present illness. She stated, "The ER doctor told me that my child was sick because I did not bring him to the hospital sooner. He also said I used dirty inhalers to treat my son's asthma." When asked "Did you tell anyone else about this complaint?", she said "No, what good would that do?" She also revealed she has never been told anything about patient rights and denied receiving any type of information written or verbal.

On 3/15/11 at 2:00 p.m. the Unit Director of Pediatrics was informed about concerns and complaint voiced by Patient #1's mother during interview. (ER visit on 3/15/11 prior to admission) The Unit Director stated, "I will follow up on that today."

On 3/16/11 at 4:00 p.m. the Unit Director was asked had she taken care of Patient #1's mother's complaint. The Unit Director stated, "I forgot but, I will do that today."

On 3/17/11 at approximately 8:30 a.m. Patient #1 was discharged home.

On 3/17/11 at 9:30 a.m. the Pediatric Unit Director was asked had she talked with Patient #1's mother concerning the complaint she voiced on 3/14/11. "She stated, I went by the room yesterday, but the child was asleep." No documentation offered concerning a follow up about Patient #1's mother's complaint offered.

On 3/17/11 the Patient Access Director provided a statement indicating that on admission the patient should receive a written packet which includes the Patients Rights.

On 3/17/11 a statement from the Chief Nursing Officer provided a statement that the hospital provides each patient a facility patient handbook. Patient complaints are discussed as follows: 'If you believe your privacy rights have been violated, you may file a complaint with the facility by following the process outlined in the facility's Patient Rights documentation....

Review of Hospital Policy Number LD011 reveals that each patient and/or patient's representative will be informed of the grievance process, including whom to contact to file a grievance or complaint. The patient will be informed that a grievance may be directly lodged with the State department of health, regardless of whether he/she has first used the organization's grievance process. Patient grievances are to be addressed in a timely, reasonable, and consistent manner. Dedication to providing quality care and service to patients requires an effective mechanism for resolving patient grievances ...

Based on medical record review, staff interview and policy and procedure review, the facility failed to ensure that the nurse assessed the condition of Patient #1's pressure ulcers and the need for pain medication prior to provision of pressure ulcer treatment and were assessed. One (1) of one (1) patient was affected (Patient #1).

Findings include:

The facility ' s Pain Management, Pain Assessment/Reassessment Policy Number PC 010 contained the following requirements:

"II. A. Assessment/Reassessment of Pain:
1. Patient will be assessed for pain upon admission to the hospital. Thereafter, the patient is monitored for pain: a. At least every shift. b. Within one hour of an intervention or treatment to relieve pain. c. Outpatient ' s assessments are done as appropriate to setting, condition, and procedure. 2. Ask the patient how he/she feels. Include the family or significant others in the assessment if appropriate. 3. Have the patient describe their pain in terms of location, intensity, duration and how their pain has affected activities of daily living.

The facility ' s Wound Assessment Policy/Procedure page one (1) contained the following requirements:
"Procedure:
1. Within the 1st 4 hours of admission all patients should be assessed for wounds.
2. All wounds should be identified by location and description.
3. Wound(s) should be measured by size, width, depth, and length.
4.A description of the wound bed, drainage (if applicable), odor of drainage, and temperature of the surrounding tissue (ex. Red and warm to touch) should also be documented.
5. Wound(s) should be reassessed with each dressing change as ordered by physician."

Observation of pressure ulcer treatment for Patient #1 on 3/16/11 from 10:55 a.m. to 1:20 p.m. revealed during the treatment the patient cried out "oh, oh". When asked if it hurt when the dressings were changed, the patient stated, "Indeed it does." Interview with the treatment nurse on 3/16/11 revealed the patient had not been given pain medication since 12:00 p.m. on 3/15/11.

Review of the medical record revealed the following: Medication ordered included Tylenol 325 milligrams (mg) two (2) tablets orally every four (4) hours PRN (as needed), Percocet 10/325 mg tablets orally every six (6) hours PRN. The patient was admitted to the facility on 03/07/11 with five (5) pressure ulcers. There was no documented evidence that the stage and size of the pressure ulcers were assessed until 3/17/11. Review of the photographic wound documentation on 3/07/11 revealed the following information: the wound size, width, depth, and length were not assessed for pressure ulcers on the patient ' s right ankle, left ankle, right buttock, inner buttock, and left lower buttock. There was no documented evidence that that stage of the pressure ulcer was assessed on the: right ankle, left ankle, right buttock and left lower buttock.
Wound assessments on 3/17/11 revealed the following information. The pressure ulcer on the right ankle was a stage III. It was 3.5 centimeters (cm) long, 3 cm wide, and 0 cm deep. The one on the right buttock was a stage IV. It was 3 cm long, 2 cm wide, and 0 cm deep. The one on the sacrum was a stage III. It was 2 cm long, 1.5 cm wide, and 0.5 cm deep. The one on the left buttock was 1 cm long, 1 cm wide, and 1 cm deep. The one on the left heel was 4.6 cm, 8 cm wide and 0 cm deep.

These findings were discussed and confirmed during the exit interview on 03/17/11 from 3:00 p.m. to 3:30 p.m.

Based on interview, review of Medical Staff Rules and Regulations, and review of medical records, the hospital failed to ensure that the medical record service is administratively responsible for medical records.

Findings include:

1. The hospital failed to ensure that the Health Information Management (HIM) Department functions with a current policy and procedure manual. Refer to A0432

2. The hospital failed to ensure that all medical records in storage are easily retrieved and readily accessible. Refer to A0438

3. The hospital failed to ensure that records of discharged patients are completed within 30 days of discharge. Refer to A0469

Based on review of the HIM Department's policies and procedures, review of the Medical Executive Minutes, and interview, the hospital failed to ensure that the HIM Department functions with a current policy and procedure manual.

Findings include:

1. Review of the HIM Department's policy and procedure manual, and interview with the Director of the Department revealed November, 2003, as the last time the department's manual had been updated.

2. Job descriptions, the method for record storage and the procedures for record retrieval, for example, were two items not contained in the manual.

3. Several 2010 revisions made to HIM policies PRI 010 and PRI 004 were found attached to the Medical Executive Minutes. These policies were not found in the department's manual.

Based on interview, review of policies and procedures, and observation, the hospital failed to ensure that medical records in storage are readily accessible.

Findings include:

1. Emergency Department (ED) records are sent to the record storage facility located in Mobile, AL. According to HIM staff, the Department files ED records alphabetically by month, and when all the shelves allotted for these records are filled, the ED records are sent to the Mobile facility for storage. When records are requested from the storage facility, they are faxed to the hospital. On 03-15-11, the only ED records the hospital had were those for February and March 2011. Inpatient medical records from 2007 through to the present are in the file room in the department. Records prior to 2007 are in storage.

2. At 10:30 a.m. on 03-15-11, a Registered Nurse (RN) surveyor requested the 10 Emergency Department records that she had selected for review. All of the records she had selected were at the storage facility in Mobile.

3. At 2:30 p.m. on 03-15-11, the HIM Director called the storage facility to check on the status of the ED records. At this time only 3 records had been received. The employee of the storage facility told the Director it was taking so long because they only had one (1) fax machine.

4. On interview with the HIM Director at 4 p.m. on 03-15-11, they were still waiting on one (1) record. This record was received at 5 p.m. on 03-15-11, in the department.

Based on review of Medical Staff Rules and Regulations, and review of medical records, the hospital failed to ensure that all entries in the medical record are timed, and that all dictated reports are complete.

Findings include:

1. Fifteen (15) discharged records were selected at random from a list of recent discharges from November and December 2010 and January and February, 2011, along with 19 inpatient medical records and reviewed for a total of 34 medical records.

2. On 23 of 34 medical records reviewed, all progress notes had not been timed when entered in the medical record.

3.On 23 of 34 medical records reviewed, all physician orders had not been timed when entered into the medical record. This included orders written by the physician as well as when routine order sheets were placed into the record.

4. On seven (7) of 17 surgery records reviewed, the pre-anesthesia evaluation had not been timed. Refer to A1003

5. The HIM Department outsources transcription. On review of both discharged and inpatient medical records, dictated reports, such as the history and physical exam, were found to have blanks in the reports for the physician to complete. Physicians had signed some of these incomplete reports, but no information had been recorded in the blanks on any of the dictation. Dictated reports with blanks were observed on six (6) of 19 medical records reviewed.

Based on review of Medical Staff Rules and Regulations, and review of medical records, the hospital failed to ensure that all history and physical exams are documented within 24 hours of admission to the hospital.

Findings include:

1. Fifteen (15) discharged records were selected at random from a list of recent discharges from November and December 2010, and January and February, 2011, along with 19 inpatient medical records and reviewed for a total of 34 medical records.

2. On one (1) of 19 inpatient medical records reviewed, the history and physical exam was absent.

Based on review of Medical Staff Rules and Regulations, and review of medical records, the hospital failed to ensure that all history and physical exams performed prior to admission are updated within 24 hours of admission.

Findings include:

1. On five (5) of 10 inpatient medical records reviewed, the history and physical exam had been performed prior to admission, and had not been updated within 24 hours of admission to the hospital.

Based on review of Medical Staff Rules and Regulations, review of medical records, and review of the hospital's delinquency rates from the past year, the hospital failed to ensure that records of discharged patients are completed within 30 days of discharge.

Findings include:

1. The Medical Staff Rules and Regulations consider a medical record delinquent when it has not been completed for any reason within 30 calendar days following a patient's discharge.

2. According to the information provided the surveyor by the Director of the department, the average delinquency rate for the year 2010 was 32.52%. The delinquency rate for January 2011 was 51% and for February 2011 was 53%.

3. The physician's incomplete medical record list was run at 8:25 a.m. on 03-16-11. According to this list, the hospital has total of 1642 records that are delinquent over 30 days. It was noted from looking through the records in the physician's files that these records dated back to 2008, 2009 and 2010.

Based on observation, and testing, the hospital failed to be constructed, arranged, and maintained to ensure the safety of patients.

Findings include:

Refer to A709 for the hospital's failure to comply with the Life Safety Code, and A710 for the hospital's failure to comply with the applicable provisions of the Life Safety Code of the National Fire Protection Association.

Based on observation and testing, the hospital failed to be constructed, arranged, and maintain to ensure the safety of the patients.

Findings include:

The standard of Life Safety Code is considered not met due to the hospital's failure to comply with the applicable provisions of the Life Safety Code of the National Fire Protection Association. Refer to A710.

Based on observation and testing, the hospital failed to be constructed, arranged, and maintained to ensure the safety of the patients.

Findings include:

1. Refer to K-025- The hospital failed to provide the one-half hour fire resistance rating for smoke barrier walls in a an existing sprinklered facility.
2. Refer to K-033- The hospital failed to provide the required 1 hour fire resistance rating for stairways in a fully sprinklered facility.
3. Refer to K-052- The hospital failed to provide a properly tested and maintained fire alarm system.
4. Refer to K-147- The hospital failed to maintain electrical wiring and equipment in accordance with NFPA 70, National Electrical Code 9.1.2

Based on facility tours, interviews, in-service reviews and policy reviews the facility failed to implement policies governing the control of infections and communicable diseases.

Findings include:

1. Initial facility tour beginning on the Fourth (4th) floor at 11:00 a.m. on 03/15/2011, revealed patient rooms #446, #312, #311, #306, and #247 had posted on the doors "STOP" signs.

2. The Director of Orthopedics/Surgical and Education was asked what was the purpose of the "STOP" signs and the Director stated that they were used to indicate patient isolation is being used. Surveyor then asked what type of isolation per room was in use and Director stated that she was uncertain by looking at the "STOP" signage being used on Third (3rd) and Fourth (4th) floors. The Director did report that the second (2nd) floor. Room #247 was for wound precaution, but she was unaware of organism type. The Director noted that this was her assigned floor.

3. At 11:50 a.m. on 03/15/2011, Infection Prevention Practitioner (IPP) was interviewed about the "STOP" signs and the IPP noted the "STOP" signs should have been replaced with the new color coded isolation signs. The IPP noted that: Blue noted airborne precautions. Red was for contact precautions and that yellow was used for droplet precautions.

4. Review of the Infection Prevention Coordinator September 2010 Action Plan revealed:
New Isolations Signs - Have had one trial with out issue. A folder of the signs will be supplied to each nursing unit hospital wide. The sign will be posted using a 3M type/Command hanger on the Personal Protective Equipment (PPE) Cabinet when placed on the patient's room door.

5. Surveyor asked to see the attendance sheets of employees that had New Isolations Signs training. Infection Prevention Practitioner reported that the education was initiated on the nursing units by using a story board presentation and rosters of attendance were not signed when the story board was initially used.

6. At 2:00 p.m. on 03/15/2011, the patient areas were toured again with the Infection Prevention Practitioner and revealed: Room #446 (which is an isolation room with anti-room with negative air flow) had a blue sign noting airborne precautions. Rooms #312, #311, #306, and #247 had posted red sign for contact precautions.

7. Infection Prevention Practitioner was asked what type organism each patient had and she produced a list of the patients and organisms that IPP reported that she prints out daily. She reported that room 446 was on airborne precautions due to suspect for tuberculosis but the laboratory reports were still pending. Rooms #312, #311, #306, and #247 were on contact precautions due to multi drug resistant organisms (MDRO). Medical record review for these five (5) patients reflected the same information as given by the Infection Prevention Practitioner.

8. At 2:45 p.m. on 03/15/2011, review of the infection control policies and procedures dated 05/2007, did not reflect the new color coded isolation signs. Infection Prevention Practitioner noted that the policies and procedures are currently in draft form. Standard & Transmission Based Isolation Precautions Draft was provided which did reflect the new color coded isolations signs.

9. At 1:10 p.m. on 03/16/2011, Education Coordinator was asked to provide employee in-service training for infection control. Annual Skills Fair documentation for March and April 2010 with attendance records were provided and new hires attendance for hospital wide orientation were reviewed. Education Coordinator reported that each year in March & April the Annual Skills Fair is held for all employees.

10. At 11:50 a.m. on 03/17/2011, an Infection Prevention Action Plan dated March 16, 2011 was given to the surveyor with a completion date of April 3, 2011. The plan was signed by the Chief Nursing Officer, Quality Director, Infection Prevention Practitioner and the Education Coordinator.

Based on review of Medical Staff Rules and Regulations, and review of medical records, the facility failed to ensure that all pre-anesthesia evaluations were timed when they were performed.

Findings include:

1. On seven (7) of 17 surgery records reviewed, the pre-anesthesia evaluation had not been timed when it was performed.