HospitalInspections.org

Based on observation and staff interview, the facility failed to be in compliance with all Federal, State and local laws and regulations.

Findings Include:

Observations made in the Emergency Department (ED) on 07/19/16 at 1:00 p.m. revealed no evidence of emergency call light systems in the patient rooms. An interview with the ED Director on 07/19/16 at 1:30 p.m. confirmed these findings. The Director stated, "There are only two (2) rooms, one (1) which is semi-private. There is a nurse outside each door so the patient is either in view or can easily be heard. Hand bells were found to temporarily use until a call system can be arranged."

Observations made in the Sleep Study Unit on 07/20/16 at 8:45 a.m. revealed no evidence of emergency call light systems in the patient bathrooms. Interview with the Director of Sleep Study on 07/20/16 at 9:00 a.m. confirmed these findings. The Director stated, "The patients have to be unhooked from the machine before getting up. I will get a battery operated doorbell system."

Observations made with the Rehabilitation (Rehab) Director in the Therapy Department on 07/20/16 at 10:55 a.m. revealed there was no emergency call light system in the patient bathroom. The Rehab Director confirmed the finding.

Based on observation and staff interview, the facility failed to provide equipment necessary to meet the needs of its patients. Emergency call light systems were missing in patient rooms and/or bathrooms in the Emergency Department (ED), Sleep Study Unit and Therapy Department.

Findings Include:

Observations made in the ED on 07/19/16 at 1:00 p.m. revealed there were no emergency call light systems in the patient rooms. An interview with the ED Director on 07/19/16 at 1:30 p.m. confirmed these findings. The Director stated, "There are only two (2) rooms, one (1) which is semi-private. There is a nurse outside each door so the patient is either in view or can easily be heard. Hand bells were found to temporarily use until a call system can be arranged."

Observations made in the Sleep Study Unit on 07/20/16 at 8:45 a.m. revealed there were no emergency call light systems in the patient bathrooms. Interview with the Director of Sleep Study on 07/20/16 at 9:00 a.m. confirmed these findings. The Director stated, "The patients have to be unhooked from the machine before getting up. I will get a battery operated doorbell system."

Observations made with the Rehabilitation (Rehab) Director in the Therapy Department on 07/20/16 at 10:55 a.m. revealed there was no emergency call light system in the patient bathroom. The Rehab Director confirmed this finding.

Based on observation, and policy and procedure review, the facility failed to ensure biohazard medical waste was properly stored in accordance to State Licensure law and failed to ensure the patient care environment is clean,orderly and safe.

Findings Include:

On 07/20/16 at 11:30 a.m. observations of the outside locked storage room marked "Biohazard" revealed six (6) red biohazard containers, one (1) blue soiled linen cart, janitor supplies, kitchen tray racks, and an oxygen tank stored inside the room.

Observations were made in the Swing Bed and Emergency Room Units on 07/20/16 beginning at 2:00 p.m. Both units had Bio Hazard storage rooms which contained one (1) bio hazard container, one (1) blue cart for soiled linen, and one (1) trash can. Housekeeping was notified of these findings.

Review of the facility's undated "Environmental Services" policy revealed: "Segregation of Hazardous Wastes: 1) Hazardous wastes must be separated from non-hazardous wastes at the site of origin, during storage and transport."

Based on observation, policy review, and staff interview, the facility failed to provide a safe environment for patients and staff.

Findings Include:

Observations made in the facility on 07/20/16 from 11:15 a.m. to 12:45 p.m. revealed:
1. The second hallway on the right from the facility entrance, headed to the Swing Bed unit, had a double door with a red sign posted which stated "Employees Only. Do Not Enter." This hallway led to nurse's station, the Emergency Room (ER) Department and the observation rooms. There was no evidence of any type of security mechanism to prevent wandering patients or visitors from gaining access to the facility from outside unmonitored entrances.
2. Down the first hallway on the left side of the facility a door labeled "Employees Only" led to an entrance to the kitchen and an employee area. There was also a door leading outside to the loading dock. The door leading outside to the loading dock was left unlocked and unattended leaving the facility fully accessible to staff, visitors and patients. When a telephone call was placed to a maintenance employee about the unlocked door he stated, "That's the way it's always been. Security does lock it at night from 6:00 p.m. to 6:00 a.m. But we will keep it locked from now on."
3. Outside in the loading dock area an unlocked door was noted to have a sign on it which stated "Shipping and Receiving". When the door was opened a medical crash cart, sterile supplies and two (2) staff members were visible. When the Materials Manager Director was asked if the door was ever locked when employees left the room he stated, "No we don't lock it. There is always someone back here, unless I have to take supplies to the floor and the other staff member might have to use the restroom or be on break. There can be times it is unattended with the door unlocked."

Review of the facility's policy and procedure manual regarding Environmental Services, revealed: "Introduction: It is our responsibility to maintain for the patient, resident, and the employee, an environment that is safe, pleasant and functional."

Based on observation, medical record review, document review, staff interview, and policy and procedure review, the facility failed to ensure medical records are complete, readily accessible and systematically organized; and failed to ensure all entries in six (6) of 14 patients reviewed contained a documented date, time and/or signature. (Patient #3, #4, #5, #6, #7 and #8)

Findings Include:

Record review for Patient #3 revealed the "Physician's Order Sheet" contained no documented evidence of the physician's signature, or of a date or time authenticating the verbal order taken on 06/01/16 at 10:35 a.m.

Record review for Patient #4 revealed the "Medical Nutrition Therapy" note dated 07/19/16 contained no documented evidence of a medical record entry time.

Record review for Patient #5 revealed the "Physician's Order Sheet" contained no documented evidence of the time the nursing staff noted the verbal order dated 07/15/16 at 2058 or of a physician's signature authenticating the verbal order. The "Medical Nutrition Therapy" note dated 07/19/16 contained no documented evidence of a medical record entry time.

Record review for Patient #6 revealed the "Admission Orders" dated 07/07/16 at 1106 contained no documented evidence of the date or time the nursing staff noted the order.

Record review for Patient #7 revealed the "Physician's Admission Orders" contained no documented evidence of the date or time the orders were entered into the medical record, no date or time the nursing staff noted the orders or the physician signature, date or time of the orders. The "Physician's Order Sheet" dated 07/09/16 at 9:35 p.m. contained no documented evidence of the date or time the nursing staff noted the order. The "Physician History and Physical Update" dated 07/06/16 contained no documented evidence of the time of the physician's signature. The "Medical Nutrition Therapy" note dated 07/19/16 contained no documented evidence of the medical record entry time.

Record review for Patient #8 revealed the "Physician's Order Sheet" contained no documented evidence of the date and/or time the nursing staff noted the orders written on 06/29/16 at 2325, 06/30/16 at 0845, 06/30/16 at 2138, 06/30/16 at 0100, 07/01/16 at 0920, 07/02/16 at 0857 or 07/18/16 at 2138.

Observations made in the medical record department filing room with the Medical Records Director on 07/19/16 at 12:40 p.m. revealed that an excess of more than 120 outpatient rehabilitation (rehab) therapy records, dating back to 2014, had not been scanned into the hospital's electronic medical record system. The Medical Records Director stated, "A patient's medical record is not considered complete until the record is scanned into the electronic medical record system for permanent filing. I have been working with the Rehab Department because they are not sending the outpatient medical record to us (Medical Record Department) until the physician signs the record. The Rehab Department holds the record and I am not aware of how many records they are holding or how long they have been holding a medical record until it is forwarded to the medical record department for filing. I have been working with the Rehab Director on this issue to get it resolved." When asked if the Rehab Department was holding patient medical records on this day and how she would locate a Rehab Department record that had not been scanned into the electronic medical record system if it was needed, she stated, "I do not know what they have. If it has not been scanned, I would look through the medical records that still need to be scanned or check with the Rehab Department." When asked if she had reported the delinquent medical records to the Medical Staff she stated, "No." She also confirmed that all medical record entries require a date, time and/or signature of the discipline.

Review of a statement signed and dated by the Medical Records Director on 07/19/16 at 2:55 p.m. revealed:
"From 9/1/14 -- 2/2/16
118 - PT's
9 - OT's (Occupational Therapy) - all o/p (out patient)
1 - ST (Speech Therapy)
Medical Record Department
Rehab Department Records
Records received for scanning delinquent passed 30 days
pass (post) discharge."

Observations made in the Rehab Department with Physical Therapist (PT) #1 on 07/19/16 at 3:05 p.m. revealed a file drawer filled with patient medical records. PT #1 stated, "I do not know how many medical records are in the drawer, but all we are waiting on is for the physician to sign the discharge summary for each record. I was instructed to hold the records until the physician signed the discharge summary." He confirmed that some of the records dated back to 2015.

During an interview on 07/19/16 at 3:58 p.m. the Rehab Director confirmed that it was the practice of the Rehab Department to hold a patient medical record until the discharge summary was signed by the physician.

Review of the facility's "Physician Order Entry" policy (Reviewed November 2015) revealed: "Purpose: ...If the order is verbal or telephone ...The physician should sign, date and time the order within twenty-four hours if the nurse writes the order ...".

Review of the facility's "Orders, Physician" policy (reviewed November 2015) revealed: "...General Instructions: A. ...All telephone or verbal orders may be dictated to the RN, LPN and signed by the physician within twenty-four hours ...B. Transcription of orders: ...Each order should be initialed as it is taken off. When finished, a line is drawn after the set of completed orders and the date, time and signature of the nurse noting the orders is documented ...".

Review of the facility's "Bylaws of the Medical Staff/Rules and Regulations of the Medical Staff " (reviewed 08/06/15) revealed: "...II. Medical Records ...A. Complete And Legible Medical Record: The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient ...K. Orders For Treatment: All orders for treatment shall be in writing. A verbal (i.e. telephone) order shall considered to be in writing if dictated to a duly authorized person ...and signed, dated and time by the responsible practitioner ...The responsible practitioners shall authenticate such orders by their signature with date and time ...O. Dating, Timing, And Signing Of All Clinical Entries: All entries in the patient's medical record shall be dated, timed, and authenticated ...W. Permanent Filing: A medical record shall not be permanently filed until it is completed by the responsible practitioner ...Y. Timeliness Of Completion Of Records: ...Records should be complete at the time of discharge, including ...discharge summary ...the patient's chart should be completed within fifteen (15) days ...If the record still remains incomplete after fifteen (15) days, the Director of the Medical Records Department shall notify the practitioner of the incomplete records and request that they be competed promptly. Records are considered delinquent after 30 days past discharge. A list of any practitioners with delinquent records (i.e. records more than 30 days past discharge) shall be presented to the Medical Administrative Committee (MAC) ...A list of physicians with delinquent medical records shall be prepared and furnished monthly to the MAC ...Z. Signature Requirements: All clinical entries in the patient's medical records must be accurately dated, timed, and individually authenticated ...The following areas of the medical record require the responsible practitioner's signature: ...b. Progress notes and orders ...AA. Master (Unit) Record: In case of readmission of a patient, all previous medical records shall be available for the use of the attending practitioner. This shall apply whether the patient will be attended by the same practitioner or by another ...All record components are assembled in a timely manner, as needed, for patients seen for unscheduled ambulatory and emergency services visits. The medical record (and master index) indicates when a portion of the records has been filed elsewhere, in order to alert authorized personnel of its existence ...Section III: General Conduct Of Care: ...E ...Orders For Treatment: All orders for treatment shall be in writing ...Verbal Orders are accepted only by personnel designated by the medical staff ...All orders dictated over the telephone shall be signed/dated/times by the appropriately authorized person to receive the order ...The responsible practitioners shall authenticate such orders by their signature with date and time ...".

Based on observation, medical record review, document review, staff interview, and policy and procedure review, the facility failed to ensure medical records were complete, readily accessible and systematically organized.

Findings Include:

Cross Refer to C300 for the facility's failure to ensure medical records were compete, readily accessible and systematically organized.

Based on observation, medical record review, document review, staff interview, and policy and procedure review, the facility failed to ensure all entries in the medical record contained a documented date, time and/or signature for six (6) of 14 patient records reviewed, Patient #3, #4, #5, #6, #7 and #8.

Findings Include:

Cross Refer to C300 for the facility's failure to ensure all entries in the medical record for Patient #3, #4, #5, #6, #7 and #8 contained a documented date, time and/or signature.

Based on Activity Calendar review, policy review, and staff interview, the facility failed to ensure that it provided an ongoing program of activities.

Findings Include:

Review of the Activity Calendar for June and July 2016 revealed no activities were scheduled for Fridays, Saturdays and/or Sundays.

During an interview on 07/20/16 at 9:15 a.m. the Activity Director stated that activities were not routinely provided on Sundays and Saturdays and she did not work on Fridays in the month of June 2016.

Review of Swing Bed policies and procedures revealed that the requirement for activities to be provided on a daily basis was not addressed.