HospitalInspections.org

Based on document review and interview it was determined that the facility failed to ensure that the governing body approved policies and procedures that were in use at the facility.

Findings were:

Review of facility policy and procedure manuals on 12/08/2010 revealed the following.

The policy and procedure manual entitled "Quality Assessment Performance Improvement Program" was revised on 08/01/2010 and the last time it was approved by the governing body was on 10/14/2008.

During an interview with the facility's quality assurance nurse on 12/08/2010 she confirmed that the policy was revised in 08/01/2010 and she stated that she has planned on getting it reviewed by the governing body.

Based on document review and interview it was determined that the facility failed to follow it's policies and procedures for drug administration in 1 of 20 medical records reviewed.

Findings were:
Review of the hospitals policy and procedure manuals on 12/08/2010 revealed a document entitled "Prohibited Abbreviations" which stated "YOU CANNOT USE... MS or MS04 (write Morphine Sulfate)".

Review of patient #5's medical record on 12/08/2010 revealed a document entitled "Medication Administration Record - PRN" which had "M.S." hand written on it. This document indicated that "M.S." was administered to patient #5 11 times between 07/18/2010 and 07/22/2010.

During an interview with the CNO on 12/08/2010 she stated that "M.S." on patient #5's medical record stood for "Morphine Sulfate" and she confirmed that this was the use of a prohibited abbreviation.

Based on observation and interview it was determined that the sanitary environment of the hospital was compromised by the presence of dust in 2 patient care areas and in 1 food preparation area.

Findings were:
During a tour of the hospital on 12/07/2010 the following was observed:

1. Dust was present on top of the movable light that is attached to the ceiling of Operating Room.

2. Dust was present on the top of a cabinet in the Emergency Room.

3. Dust was present on top of the refrigerators and freezers and around the air conditioner vents in the food preparation area (kitchen).

The above findings were confirmed by the CEO during the same tour.

Based on document review and interview it was determined that the facility failed for appropriately obtain informed consent for 2 of 7 surgical medical records reviewed.

Findings were:

1. Review of patient #1's medical record on 12/08/2010 revealed a consent for a procedure that was not signed by the patient or the patients guardian.

2. Review of patient #3's medical record on 12/08/2010 revealed a consent for a procedure that was signed by the patient, but the signature was not dated or timed. Therefore it could not be determined if the consent was signed before the procedure.

Facility policy, "Procedure for Surgical Consents", was reviewed on 12/08/2010 and it stated "Purpose: To establish guidelines to obtain a valid consent from all patients receiving treatments, certain defined diagnostic procedures and for all surgical procedures".

The above findings were confirmed by the CNO during an interview on 12/08/2010.