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Based on review of facility policies and procedures, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure that nursing care plans were implemented and/or revised as necessary for four of 49 medical records reviewed (MR1, MR10, MR36 and MR39).

Findings include:

A review on March 22, 2011, of "Wellspan Health-York Hospital Nursing Policy and Procedure" entitled "General Nursing Practice Standards" revealed, " ... 1. Health data includes, but is not limited to information about physiological, spiritual, psychological, social, cultural, developmental and educational health needs of the patient ... Documentation time ... Within 24 hours of admission and updated as changes occur ... "

1) A review on March 22, 2011, of MR1 revealed that on March 21, 2011, the patient was ordered Nystatin powder for treatment of excoriated skin. Further review revealed there was no care plan developed to address the skin excoriation.

An interview conducted on March 23, 2011, at 9:20 AM with EMP1 confirmed no care plan had been developed to address the patient's skin condition.

2) A review on March 23, 2011, of MR10 revealed the patient had a diagnosis of Congestive Heart Failure (CHF) and Fluid Overload. Further review revealed there was no care plan developed that addressed CHF or Fluid Overload.

An interview conducted on March 23, 2011, at 2:45 PM with EMP1 confirmed that no care plan had been developed to address the patient's CHF.

3) A review on March 23, 2011, of MR36 revealed that the care plan addressed infection as a problem.whic resolved on March 18, 2011. Further review revealed the care plan continued to list infection as an active problem.

An interview conducted on March 23, 2011, at 2:00 PM with EMP5 confirmed that the care plan was not updated to include resolution of the infection.

4) A review on March 22, 2011, of MR39 revealed that on March 20, 2011, the patient developed a rash on their lower abdomen. Further review revealed the skin rash was not addressed on the care plan.

An interview conducted on March 22, 2011, at 1:45 PM with EMP5 confirmed that the care plan did not address the skin rash.

Based on review of facility policies, medical records (MR), observation and interview with staff (EMP) it was determined the facility failed to ensure that medications were administered timely for one of 49 medical records (MR1) reviewed.

Findings include:

A review on March 25, 2011, of the "Wellspan Health-York Hospital Nursing Policy and Procedure" last revised September 2010 revealed, " ... 7. Verify the medication is being administered at the proper time, in the prescribed dose, by the correct route ... "

Observation on March 22, 2011, of medication administration at 10:30 AM revealed that MR1 received Lovenox 40 milligrams (mg) subcutaneously.

A review on March 22, 2011, of MR1 revealed that the Lovenox injection was ordered to be administered at 9:00 AM. Further review of MR1 revealed that medications administered on March 21, 2011, were as follows: Pantroprazole 40 mg daily 9:00 AM was given at 9:54 AM; Meropenem scheduled for 2:00 PM was given at 2:41 PM; Lorazepam doses at 9:00 AM, 1:00 PM and 5:00 PM were given at 10:36 AM, 2:41 PM and 4:04 PM respectively.

An interview conducted on March 22, 2011, at 10:30 AM with EMP15, confirmed that medications were given more than 30 minutes before or after the specified administration time. Further interview revealed that medications were permitted to be administered up to an hour preceding or an hour after the scheduled administration time.

Based on review of facility policy, documentation, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure informed consent indicated the name of the hospital where the procedure or other type of medical treatment is to take place for eight of eight medical records (MR17 to MR24).

Findings include:

A review on March 23, 2011, of York Hospital policy PAA-C-1 "Informed Consent" last reviewed 10/2010 revealed, " ... To have a signed informed and witnessed consent for permission to perform a specific procedure ... " Further review revealed that the policy did not contain a listing of the specific elements required for a properly executed informed consent.

A review on March 23, 2011, of MR17 to MR24 revealed an informed consent form that did not indicate where the procedure was to be performed. Review of MR18 revealed it contained an informed consent that also did not indicate where the procedure was to be performed and was executed on third party letterhead that was not an approved facility form.

An interview conducted on March 22, 2011, at approximately 1:15 PM with EMP7 confirmed that the informed consent forms on MR17 to MR24 did not indicate where the procedure was to be performed. Further interview with EMP7 confirmed that MR18 contained an informed consent that was not on an approved facility form.

Based on review of facility documents, policy and interview with staff (EMP), it was determined the facility failed to implement their fire safety management plan at their offsite locations.

Findings include:

A review on March 23, 2011, of the York Hospital "Fire Management Plan" last reviewed November 2010 revealed, " ... Ambulatory sites conduct quarterly drills (one per shift) ... "

A review on March 23, 2011, of facility documents revealed that fire drills had not been conducted in the third quarter of 2010 at York Hospital Community Health Center, Rehabilitation Services Queensgate Towne and Rehab Services Adams Center Bannister Street.

An interview conducted on March 23, 2011, at 1:30 PM with EMP5 confirmed that fire drills were not conducted during the third quarter of 2010 at York Hospital Community Health Center, Rehabilitation Services Queensgate Towne and Rehab Services Adams Center Bannister Street.

Based on review of facility policy, observation and interview with staff (EMP), it was determined the facility failed to ensure that facilities, supplies and equipment were maintained to ensure an acceptable level of safety and quality throughout the hospital.

Findings include:

Observation on March 24, 2011, of the George W. T. Bentzel DDS Dental Center, 1001 South George Street, York, a service of York Hospital, revealed the following outdated dental materials: 17 boxes of Gutta Percha Points (objects used during root canal therapies) with expiration dates ranging from 4/2008 through 1/2011; 15 applicators of Flourocore (a dental filling buildup material) with expiration dates of 12/2009.

An interview conducted on March 24, 2011, at 2:00 PM with EMP7 confirmed the labels on the dental materials indicated they were expired. Further interview with EMP7 revealed the facility did not have a policy regarding the monitoring of expiration dates and discarding of expired materials in the Dental Center.

Based on review of facility documentation, medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure that operative reports were written or dictated immediately following surgery for eight of eight surgical records. (MR17 to MR24).

Findings include:

A review on March 22, 2011, of York Hospital Medical Staff Rules and Regulations last reviewed 12/2010 revealed, "... The dictated operative report should contain the name of the procedure(s), a comprehensive description of the findings, the technical procedures used, the specimens removed, the post-operative diagnosis, and the name of the primary surgeon and any assistants, and estimated blood loss ..."

A review on March 22, 2011, of MR17 to MR24 revealed operative reports that did not indicate date(s) and time(s) of the procedure. It could not be determined that the operative report was written or dictated immediately following surgery.

An interview conducted on March 22, 2011, at approximately 1:40 PM with EMP7, confirmed that the medical records contained operative reports that did not indicate the date and time(s) of the procedure and it could not be determined that the operative report was written or dictated immediately following surgery. Further interview confirmed the policy did not address that the operative report was to be written or dictated immediately following surgery.