HospitalInspections.org

Based on document review and staff interview it was determined that for 1 of 2 (Pt. #7)records reviewed, the Hospital failed to ensure physicians assessed their patients at least once per day as required by the Hospital Medical Staff Bylaws Rule and Regulation.
Findings include:
1. The Medical Staff Bylaws Rules and Regulation reviewed on 9/23/14 at approximately 11:30 AM, required, " Each Attending Physician and each Consultant who has assumed any portion of a patient's care or treatment... shall personally assess their patients at least once per day while admitted to the Hospital.... At the time of each such assessment, or as soon as possible thereafter, the Attending Physician or Consultant shall record a Progress Note in the patient's Medical Record. "
2. The clinical record for Pt. #7 was reviewed on 9/23/14 at approximately 10:15 AM. Pt. #7 was a 72 year old female admitted on 9/10/14 with a diagnosis of atypical chest pain. The clinical record included daily physician progress notes from 9/10/14 to 9/16/14. However, the record lacked documentation of physician progress notes from 9/17/14 to 9/22/14, 6 days without a physician assessment.
3. The findings were discussed with the Acting Supervisor/Manager for the Medical Surgical Unit (E #7), during an interview on 9/23/14 at approximately 10:45 AM, who stated that patients are routinely seen by the physician daily.

Based on document review and interview, it was determined for 2 of 4 patients (Pt #4 and Pt #6) reviewed for Psychotropic Medication consents, the hospital failed to ensure patients were informed of all psychotropic medications prescribed.
Findings Include:

1. The Hospital Policy entitled " Patient notification of Psychotropic Medication " (Revised 7/2014) indicated " Purpose: To provide patients with instructions concerning the therapeutic indications as well as the potential side effects of psychotropic medications. 4. The patient must sign the " Notification Medication " forms and witnessed by the registered nurse. "

2. On 9/23/14 at approximately 9:50 AM Pt #4's clinical record was reviewed. Pt. #4 was a 57 year old male admitted to the 4th floor (Addiction Unit) with a diagnosis of Drug Withdrawal. Pt. #4's medical record contained a physician order dated 9/22/14 for Trazadone (antidepressant medication) 100 milligram (mg) as needed for sleep. The " Notification of Psych meds. " form dated 9/22/14 signed by Pt. $#4 and a witness did not include Trazadone. Trazadone was not discussed with Pt. #4. " Pt #4 electronic medication administration record (MAR) indicated Trazadone was administered on 9/22/14 at 10:27 PM.

3. On 9/23/14 at approximately 10:00 AM Pt#6 clinical record was reviewed. Pt#6 was a 60 year old female admitted to the 4th floor (Addiction Unit) with a diagnosis of Drug Withdrawal. P#6's medical record contained a physician order dated 9/20/14 for Trazadone 100 mg as needed for sleep. The " Notification of Psych meds. " form dated 9/20/14 and signed by Pt. #6 and a witness did not include Standalone. Standalone was not discussed with Pt. #6. Pt#6 electronic medication administration record (MAR)indicated Pt#6 received a dose on 9/22/14 at 10:25 PM.

4. On 9/23/14 at approximately 10:40 AM the Charge Nurse (E#8) of the Addiction Unit stated the policy to obtain psychotropic medications consent required the nurses to fill out the form, print and review the medications with patient. The patient signature is obtained and the nurse signs as a witness.

Based on document review and staff interview, it was determined for 2 of 2 (Pt #26 and #27) clinical records reviewed for blood transfusions, the hospital failed to ensure the blood transfusion records were complete.
Findings include:

1. The hospital ' s policy entitled " Blood and Components Therapy " (reviewed 5/2014) was reviewed on 9/24/14 at approximately 12:00 pm and required, " ...Initiates blood transfusion within 30 minutes of being picked up from the Blood Bank ...A unit of blood is never to hang for more than four hours ...RN Starting Transfusion: 1. Verifies all information after obtaining blood from Blood Bank with another Registered Nurse or Physician at the bedside ...2. Writes their signature on the " Blood/Blood component Transfusion Record " ...Document date and time of completion and signature of RN completing transfusion ... "

2. The clinical record for Pt #26 was reviewed on 9/24/14 at approximately 10:30 am and included Pt #26 was a 51 year old female admitted to the hospital on 7/1/14 with diagnoses of pneumonia, hypoxia, and chronic obstructive pulmonary disease. Physician ' s orders included the following: 7/4/14 - two units of packed red blood cells (PRBCs); 7/8/14 - one unit of platelets. The transfusion record for the first unit of PRBCs dated 7/4/14 lacked initials in the boxes to identify the RN starting and discontinuing the transfusion. The transfusion record for the second unit of PRBCs lacked documentation of the date of the transfusion and the initials of the RN discontinuing the transfusion. The transfusion record for the unit of platelets on 7/8/14 lacked documentation of the date of the transfusion and the initials of the RN discontinuing the transfusion.

3. The clinical record for Pt #27 was reviewed on 9/24/14 at approximately 10:45 am and included Pt #27 was an 84 year old male admitted to the hospital on 8/31/14 with diagnoses of acute sepsis, end stage renal disease, and anemia. Physician ' s order dated 8/31/14 included transfusion of two units of PRBCs. The transfusion record for the first unit of PRBCs lacked documentation of the date of the transfusion, start time, finished time, initials of the RN starting and discontinuing the transfusion, amount given, and the signature of the second RN or physician verification prior to initiation of the transfusion. The transfusion record for the second unit of PRBCs lacked initials for the RN who discontinued the transfusion and the time the transfusion was finished.

4. On 9/24/14 at approximately 1:30 pm, the Chief Nursing Officer (E #1) stated that the transfusion records were incomplete.

Based on document review and staff interview, it was determined for one of one medical record department, the hospital failed to ensure medical records were complete within 30 days after discharge.

Findings include:

1. The Medical Staff Rules and Regulations (approved 6/20/11) was reviewed on 9/24/14 at approximately 10:00 AM and required, " ...Medical records of discharged patients are to be completed no later than thirty days following the date of discharge ...the charts are considered delinquent ... "

2. On 9/24/14 at approximately 9:30 am, the Director of Medical Records (E #2) presented the surveyor with a list of delinquent medical records signed and dated by E #2 which documented 4033 records.

3. On 9/24/14 at approximately 9:45 am, the Chief Nursing Officer (E #1) stated that the number of delinquent medical records documented on the list was correct.

A. Based on document review and interview, it was determined that for 4 of 54 days the Hospital failed to ensure the temperatures of the food for the tray-line were taken and recorded.

Findings include:

1. The tray-line Food temperature log was reviewed on 9/24/14 at approximately 11:50 AM. Four of 54 days between 8/1/14-9/23/14 lacked documentation of temperature for the various foods served during dinner service on the following dates: 8/16/14, 8/22/14, 8/25/14 and 9/13/14.

2. The Nutritional Services Manager, interviewed on 9/24/14 at approximately 12:00 PM, stated that it is the practice and policy that all hot food temperatures should be taken and recorded for every meal service.

3. The Hospital policy titled " Prevention of Food Contamination " (revised 5/14), reviewed on 9/24/14 at approximately 12:15 AM, required, " 8. Food will be heated to the correct temperature, per recipe, before being served. Hot potentially hazardous food will be held at 140 degrees F or above. All food will be reheated to 165 degrees F. "

B. Based on observation, interview and document review, it was determined that for 1 of 1 staff (E #6) the Hospital failed to ensure staff used the appropriate measuring scoop ensuring the correct meal proportion size was given to each patient.

Findings include:

1. During an observational tour on 9/24/14 at approximately 11:00 AM, E #6 was observed scooping (unmeasured) potatoes and green beans using a slotted spoon.
2. An interview with the Clinical Dietician (E #4) was conducted during the tour on 9/24/14 at approximately 11:30 AM. When asked how much potatoes and green beans should go on each plate, and how do staff ensure accurate portions are scooped on the individual plates, E #4 stated the correct portion for each of these two items is ½ cup. E #4 also stated that there are serving (measuring) spoons designed to measure correct portion size for use during tray-line service.

3. The Hospital policy titled " Portion Control " (revised 5/14), was reviewed on 9/24/14 at 2:00 PM. The policy required, "Nutritional Service staff will serve each meal with the correct portion size as identified in the menu. The required scoops and measures will be available on the tray-line and used."

4. The above findings were discussed with the Manager of Nutritional Services during an interview on 9/24/14 at approximately 2:30 PM who acknowledged the policy indicated use of the required scoops and measures for the tray-line service.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Survey Due to a Complaint conducted on September 22 - 24, 2014, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Survey Due to a Complaint conducted on September 22 - 24, 2014, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated September 24, 2014.

Based on document review, observational tour, and interview, it was determined, for 1 of 1 newborn transport cart in the Emergency Department (ED), the hospital failed to ensure the newborn transport cart was clean.

Findings include:

1. On 9/24/14 at 12:00 PM, policy #: ES-7616, titled, "Environmental Services Emergency Department", revised on 12/13, was reviewed. The policy required, "Damp dust counters, furniture..."

2. On 9/24/14 at 9:20 AM, an observational tour was conducted in the Emergency Department (ED). One of one newborn transport cart contained dust on the papoose board, sheets, hood, and other parts of the cart.

3. On 9/24/14 at 9:40 AM, an interview was conducted with the ED Manager (E #7), who stated the newborn transport cart was dusty.