HospitalInspections.org

Based on record review and interview, the hospital failed to ensure all patients admitted to the emergency department (ED) were advised of their patient's rights in advance of furnishing or discontinuing patient care. This deficient practice likely resulted in or could result in patients and families not being able to make informed decisions about care. The findings are:

A. Record review of medical records for patients admitted to the ED showed no evidence of patients informed of their rights.

B. Record review of the facility's face sheet revealed patients sign for authorization for treatment, release of information and direct payment only.

C. On 08/29/17 at 1:30 pm during interview, the Health Information Manager (HIM) director stated, "There are no patient rights signed except for the face sheet."

D. On 08/29/17 at 3:03 pm during interview, the Administrator confirmed ED patients sign the face sheet only.

E. On 08/29/17 at 3:40 pm during interview, the Director of Nursing (DON) stated when patients come to the ED they sign the face sheet which gets scanned into their charts. When asked how patients are informed of their rights, DON stated, "We are not doing this... I think the techs [sic] or nurse will talk with them but they don't sign anything ... We have seen the paperwork in the admission paperwork that includes the patient's rights but not in the ED paperwork".

Based on record review and interview the hospital's pharmacy policies and procedures were missing several elements of accepted standards of practice to minimize medication errors. This deficient practice could result in medication related errors which could harm or be fatal to a patient. The findings are:

A. Record review of the hospital pharmacy policy: PH9 MEDICATION ERRORS, Formulated 1-8-04 and Revised 5-21-12 indicated the following regulatory requirements were not addressed:
1. Instruction regarding high alert medications (medications with a narrow therapeutic range which should be monitored via lab tests while receiving).
2. An alert system for look-alike/sound-alike medications.
3. Guidelines for dangerous and/or accepted abbreviations for use in the hospital.
4. Guidelines to address identification for weight based dosing (the amount of medication to be given would be based on how much the patient weighs) when required for pediatric patients.
5. Non-punitive (without punishment) reporting of medication errors or near misses.

B. On 08/29/17 at 5:15 pm during interview, the pharmacist confirmed the above noted findings.

Based on interview and record review the hospital's infection control plan failed to include a process for maintaining a sanitary physical environment during internal or external construction or renovation. This deficient practice could likely result in the hospital's inability to provide care in a sanitary environment. The findings are:

A. On 08/28/17 at 3:15 pm during interview, the surveyor requested the infection control officer talk through the process in place for construction, renovation or repair of the facility. The infection control officer replied, "We do not have a policy or specific procedure for that scenario."

B. On 08/30/17 at 9:00 am during interview, the Hospital Administrator confirmed the above information. "We do not have a policy for construction or renovation. We also looked at our disaster plan to see if it was covered there but it is not."

C. Record review of the hospital's infection control plan indicated no policy and procedure for construction/renovation.