HospitalInspections.org

The Hospital identified a census of 118 patients. Based on policy review, review of the hospital's Medical Staff Rules and Regulations, Medical Staff By-Laws meeting minutes, document review and staff interview on 12/2/13, the Medical Staff failed to ensure and facilitate the enforcement of the suspension of admitting privileges of 3 of 4 physicians who failed to follow Medical Staff Rules and Regulations. (Physician K, J and ,I)

Findings include:

- Medical Staff Rules and Regulations, last revised on 5/30/13, and reviewed on 12/4/13, Medical Records"#17 required: The medical record shall be available in a stated place in the Medical Records Department for 15 days after discharge. If the record remains incomplete after 15 days , the practitioner shall be notified by mail that his/her clinical privileges shall be suspended seven (7) days from the date of notice ...The appropriate hospital departments shall be notified of this action ... "
Review of Medical Records and Medical Staff Credentialing records, on 12/4/13 revealed the following:
The Hospital documented the admitting and treatment privileges for Physician K were suspended on 11/26/13 due to incomplent lack of medical records completion for 2 patients. Documentation provided by Medical Records Manager O and reviewed 12/4/13 revealed the Hospital allowed this Physician to admit 11 patients between 11/26/13 and 12/1/13. Ten of these patients were admitted from the Emergency Department and one was a direct admission. The admissions occurred because the Hospital allowed this Physician to continue to be on call for their Physician group which then allowed this Physician to admit the patients.
The Hospital documented the admitting and treatment privileges for Physician J were stopped on 11/26/13 due to lack of medical records completion for 3 patients. Documentation provided by Medical Records Manager O and reviewed on 12/4/13 revealed the Hospital allowed this Physician to admit 2 patients on 12/3/13 through the Emergency department because the Hospital allowed this Physician to be on call for their Physician group.
The Hospital documented the admitting and treatment privileges for Physician I were stopped on 11/6/13 due to a lack of medical records completion for 6 patients. Documentation provided by Medical Records Manager O and reviewed on 12/4/13 revealed the Hospital first suspended this Physician on 10/15/13 for lack of completion of medical records. Medical Records Manager O, interviewed on 12/4/13 verified this Physician had remained on suspension since that time but the Hospital allowed this Physician to take call for them, which caused 4 other patients to receive care from this suspended Physician, 3 of which were babies and 1 patient from the Emergency department. Information provided revealed this Physician had a delinquent record from 5/7/13 and further information requested documented this Physician I admitted 33 patients between 6/13/13 and present. The Physician group allowed this Physician to take after hours and weekend call for the group, and therefore this Physician had treated multiple patients while on admission and treatment suspension.
- Medical Staff Meeting minutes and Joint Meeting Minutes of Medical Staff reviewed on 12/4/13 lacked evidence of any administrative actions to resolve the hospital ' s on-going issue and actions to ensure physicians completed medical records and enforced their by-laws which included the voluntary relinquishment of clinical privileges process.

The hospital reported a census of 118 current patients with 36 patient records chosen for review. Based on observation, policy review, document review and staff interview the hospital failed to ensure the nursing staff developed an individualized plan of care to meet the individualized nursing needs for 2 of 22 patients (patient # 26 and 27).

Findings include:

-The hospital policy entitled " Patient Plan of Care " reviewed on 12/4/13 directed nursing staff to assess patient needs every 24 hours and develop a plan of care that reflects their needs and update the plan as patient condition and care needs change.

- The hospital policy entitled " Infection Control.. Protective Precautions Specific to immune compromised patient " reviewed on 12/4/13 directed nursing staff to initiate isolation precautions to ensure restrictive access and the use of masks and protective interventions to protect compromised patients from contracting infections.

- Patient #26 ' s medical record review on 12/3/13 revealed they were admitted to the hospital with a diagnosis of pancytopenia (reduces immune system responses) and required protective isolation.

Observation with registered nurse Q on 12/3/13 at 9:30am during medication administration revealed they put a mask on prior to entering patient #26 ' s room. Registered nurse Q reported patient 26 ' s lacked an immune system and pointed at an isolation sign on the door which indicated all that enter the room required a mask to protect the patient.

Patient #26 ' s plan of care reviewed on 12/3/13 revealed a computerized plan of care which lacked evidence of an individualized plan for protective isolation.

Administrative staff H on 12/3/13 reviewed patient #26 ' s plan of care and verified their plan of care lacked an individualized plan of care for protective isolation.

- The hospital policy entitled " Use of sitters " reviewed on 12/4/13 directed nursing staff to perform an assessment to determine if their patient required a 1:1 sitter to ensure the safety such as fall prevention. The sitter service is directed by the nursing department and required nurses to supervise patients during sitter breaks and assess the patient every hour.

-Patient #27 ' s medical record reviewed on 12/3/13 revealed they were admitted to the hospital on 11/18/13 with a diagnosis of pneumonia. Registered nurse P interviewed on 12/3/13at 8:00am stated patient #27 required a 1 on 1 sitter to ensure their safety due to their increased confusion and increased risk for potential falls.

Observation on 12/3/13 at 8:00am revealed patient sitter R sitting in a chair at patient bedside. Patient sitter R reported they were assigned to sit with patient #27 until 3:00pm.

Observation on 12/3/13 at 8:50am revealed patient #27alone in their room and attempting to stand with the intravenous (IV) tubing stretched tight and calling out for help. Registered nurse P responded to patient #27 ' s call for help. Registered nurse P interviewed on 12/3/13at 8:50am reported another unit needed the 1 on 1 sitter and stated patient #27 lacked a sitter and remained confused.

Patient #27 ' s plan of care reviewed on 12/3/13 revealed a computerized plan of care which lacked an individualized plan of care for patient safety and the need to have 1 on 1 sitter to ensure their safety.

Administrative staff H on 12/3/13 reviewed patient #27 ' s plan of care and verified their plan of care lacked an individualized plan of care for the use of a 1 on 1 sitter.

The Hospital reported a census of 118 patients. Based on observation, policy review and staff interview the hospital failed to ensure pre-operative nursing staff prepared and administered injectable medications in accordance with accepted standards of practice from the Kansas State Board of Nursing and according to hospital policy for one of one patient who received pre-drawn medication (patient #36). The failure to follow acceptable standards of practice with medication preparation and administration and standard of practice established to safeguard patients placed patients at risk to receive unknown medications.
Findings include:
- Hospital policy titled " Prescribing and Administering Medication " revised August 2012 directed staff " ...under safe practice guidelines ...prepare medications for only one patient at a time ...to the extent possible, medications should be administered by the individual preparing the dose ...Medications should be given as soon as possible after the dose has been prepared ... ' '
- Prior to the survey the Kansas State Board of Nursing verified the standard of practice for medication administration included the requirement for the person who prepared medications should also administer those medications.
Pre-operative registered nurse B observed on 12/3/13 at 7:50am prepared to insert an IV (intravenous) line on patient #36. Registered nurse B had a pre-drawn syringe of clear solution labeled as Lidocaine which they used to numb patient #36 ' s hand. The pre-drawn syringe lacked the name or initials of who prepared the syringe. The staff member who prepared the syringe also failed to date, time and indicate the date or time the medication expired. Registered nurse B on 12/3/13 at 8:20am opened up the medication cart in the pre-operative area which revealed the medication cart contained six other pre-drawn syringes labeled as Lidocaine. These six pre-drawn syringes lacked the initials or name of which staff member prepared them and the label lacked the date, time and the date or time the medication expired. Registered nurse B verified registered nurse C prepared the syringes.
Pre-operative registered nurse C interviewed on 12/3/13 at 8:25am verified they pre-drew the syringes labeled as Lidocaine earlier that morning. Registered nurse C acknowledged they routinely prepared the Lidocaine for the day and placed it in the medication cart for all of the surgeries being performed that day and did not understand " what the problem was " with pre-drawn medications.

The Hospital identified a census of 118 patients. Based on policy review , document review and staff interview, the Hospital failed to enforce the admission and treatment suspensions for 3 of 4 physicians sampled who were under current suspension at the time of entrance on 12/2/13. (K,J,I)

Findings include:

- Medical Staff Rules and Regulations, last revised on 5/30/13, and reviewed on 12/4/13, Medical Records. "#17. The medical record shall be available in a stated place in the Medical Records Department for 15 days after discharge. If the record remains incomplete after 15 days, the practitioner shall be notified by mail that his/her clinical privileges shall be suspended seven (7) days from the date of notice ...The appropriate hospital departments shall be notified of this action ... "
Review of Medical Records and Medical Staff Credentialing records, on 12/4/13 revealed the following:
The Hospital documented the admitting and treatment privileges for Physician K were stopped on 11/26/13 due to lack of medical record completion for 2 medical records. Documentation provided by Medical Records Manager O and reviewed 12/4/13 revealed the Hospital allowed this Physician to admit 11 patients between 11/26/13 and 12/1/13. Ten of these patients were admitted from the Emergency Department and one was a direct admission. The admissions occurred because the Hospital allowed this Physician to continue to be on call for their Physician group which then allowed this Physician to admit the patients.
The Hospital documented the admitting and treatment privileges for Physician J were stopped on 11/26/13 due to lack of medical record completion of 3 patient records. Documentation provided by Medical Records Manager O and reviewed on 12/4/13 revealed the Hospital allowed this Physician to admit 2 patients on 12/3/13 through the Emergency department because the Hospital allowed this Physician to be on call for their Physician group.
The Hospital documented the admitting and treatment privileges for Physician I were stopped on 11/6/13 due to a lack of medical record completion for 6 patient records. Documentation provided by Medical Records Manager O and reviewed on 12/4/13 revealed the Hospital first suspended this Physician on 10/15/13 for lack of completion of medical records. Medical Records Manager O, interviewed on 12/4/13 verified this Physician had remained on suspension since that time but the Hospital allowed this Physician to take call for them, which caused 4 other patients to receive care from this suspended Physician.
Information provided revealed this Physician had a delinquent record from 5/7/13 and further information requested documented Physician I admitted 33 patients between 6/13/13 and present. The Physician group allowed this Physician to take after hours and weekend call for the group, and therefore this Physician had treated multiple patients while on admission and treatment suspension.

The hospital reported a census of 118 patients. Based on observation and staff interview the hospital failed to ensure an acceptable level of safety and quality in 2 of 9 operating suites (one in obstetrical surgical suite and one in the operating suites).
Findings include:
- The hospital ' s policy titled " Terminal Cleaning of Restricted OR " reviewed on 12/04/2013 at 4:30pm directed, " ... scrub OR ceilings, walls and lights quarterly ... "
- Tour of obstetrical unit surgical suite on 12/03/2013 at 2:45pm revealed the following non-cleanable surfaces:
1. One-wheeled adjustable sitting stool with rust on the wheel covers and base.
2. One-wheeled suction container apparatus with rust on the wheel covers and base.
3. One-step stool with rust on the base.
4. Two-laundry bag holders with rust at the bases.
Obstetrics supervisor Staff E interviewed on 12/03/2013 at 2:50pm acknowledged rust on the equipment created non-cleanable surfaces.
- Tour of surgical suite one on 12/03/2013 at 2:01pm revealed large black scuff marks several feet long located 4 feet above the floor on the walls.
OR (operating room) supervisor Staff A interviewed on 12/03/2013 at 2:01pm voiced belief the black scuff marks were caused from radiology machines as they were moved in and out of the OR. OR supervisor staff A thought it was etching in the tile and the tile needed replaced. OR supervisor Staff A acknowledged that the black scuff marks do rub off and that the other operating rooms have them. OR supervisor Staff A acknowledged the scuff marks become tacky with cleaning attempts and create a non-cleanable surface.
- AORN guidelines state " ...areas and equipment that should be cleaned on a weekly or monthly basis should include, but are not limited to ...walls and ceilings ... "

The Hospital reported a census of 118 patients. Based on observation, medical record review, policy review and staff interview the Hospital failed to ensure the operating room staff wore acceptable operating room attire for one of two surgeons observed in the operating room (physician D).

Findings include:

- The Hospital ' s policy titled " Operating Room Attire " reviewed on 12/4/13 at 4:00pm directed, " ...Surgical hats should cover head and facial hair, including sideburns and necklines ... "

- Association of Perioperative Registered Nurses (AORN) 2012 Recommendation IV reads: All personnel should cover their head and facial hair when in semi-restricted and restricted areas. Hair coverings should cover facial hair, sideburns and the nape of the neck ...Skull caps are not recommended because they do not completely cover the wearer ' s hair and skin: they fail to cover the side hair above and in front of the ears and hair at the nape of the neck ... "

- Staff D, Surgeon, observed on 12/3/13 at 9:32pm entered the operating room wearing a " skull cap " with ends rolled up. The " skull cap " hair cover failed to cover one inch of Staff D ' s sideburns and three inches of hair at the back of their head.

Staff A, Surgical Registered Nurse Supervisor, interviewed on 12/3/13 at 9:32am acknowledged surgeon D wears " skull caps " that do not cover all of their hair. Staff A explained all " skull caps " were removed from the operating room area and staff D had their own " skull caps " in their locker or brought them into the Hospital from another source.