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Based on record review and interview during an onsite Allegation Survey, the facility failed to ensure a complete history and physical was performed as per hospital By-Laws for five (5) medical records reviewed (Patients #3, #7, #30, #31 and #50).

Findings:

Review of medical records for Patients #30 and #31 revealed there were no history and physical.

Review of medical records for Patients #3, #7 and #50 revealed the history and physical's were incomplete.

Review of the medical staff current By-Laws documented, "a complete history and physical examination shall be recorded within twenty-four (24) hours of admission."

This finding was confirmed with the Director of Accreditation and Patient Safety during the onsite visit.
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Based on record review and interview during an onsite Allegation Survey, the facility failed to ensure the medical staff secured autopsies in four (4) of five (5) medical records reviewed as per hospital policy (Patients #8, #9, #26 and #50).

Findings:

Review of the "Expiration Progress Note," for Patients #8, #9, #26 and #50 revealed that the physician section was blank and there was no documented evidence that the medical staff attempted to obtain an autopsy.

Review of the policy entitled "Autopsy Services" dated 2007, documented "when a patient expires, the attending physician will attempt to secure permission for a post-mortem examination from a legally responsible survivor."

This finding was confirmed with the Director of Accreditation and Patient Safety during the onsite visit.

Based on record review and interview during an onsite Allegation Survey, the facility failed to ensure that the Director of Nursing (DON), reviewed the policies and procedures on an ongoing basis.

Findings:

Review of the following policies and procedures revealed no documented evidence of Director of Nursing annual review from 2007 through 2011.

" Auditory and Visual Privacy - ED" dated 2007.

" Medication Reconciliation Policy" dated 2007.

" Confidential Information - Non-Employees" dated 2007.

" Chain of Communication" dated 2007.

" Autopsy Criteria" dated 2007.

" Medical Examiner Cases" dated 2007.

" Autopsy Service" dated 2008.

" Emergency Department Triage - Initial Patient Assessment" dated 2008.

" Confidential Information - Medical Staff " dated 2008.

" Patients' Bill of Rights" dated 2008.

" Pain Assessment and Management" dated 2008.

This finding was confirmed with the Director of Accreditation and Patient Safety during the onsite visit.

Based on observations, staff interviews and policy review during a onsite Allegation Survey, the facility failed to ensure that the pediatric playroom toys were cleaned as required by the hospital policy.

Findings:

Observations on 03/07/11 at 2:00PM in the pediatric playroom revealed a stationary infant walker with food crumbs and particles on the tray, seat and footrest.

An interview on 03/07/11 at 2:15PM with the housekeeper (Staff Member #1) assigned to the unit revealed that a housekeeper was responsible for cleaning all patient care items in the patient's room, which would include any toys the child was using. She stated that the nursing staff was responsible for cleaning toys and other items located in the playroom.

An interview on 03/07/11 at 2:30PM with the Registered Nurse (Staff Member #2) revealed that the housekeepers were responsible for cleaning the playroom toys and equipment which included the play-pen, high chairs and walkers. The housekeeper would also clean anything in a patient's room before returning them to the playroom.

Review of the policy entitled "Decontamination of Toys (Pediatrics)" dated 03/22/10, states all toys are scrubbed by the nurse aide staff once a week and as needed.

This finding was confirmed with the Director of Accreditation and Patient Safety during the onsite visit.

1. Based on record review and interview during the onsite Allegation Survey, the facility failed to ensure that medication reconciliations were performed on admission for five (5) of six (6) medical records reviewed (Patients #2, #8, #9, #10 and #51) and a medication reconciliation was performed at discharge for one (1) of six (6) medical records reviewed (Patient #2) as per hospital policy.

Findings:

Review of Medical Records #9 and #51 revealed no admission medication reconciliation.

Review of Medical Records #2, #8 and #10 revealed an incomplete admission medication reconciliation.

Review of Medical Record #2 revealed no discharge medication reconciliation. The discharge orders were incomplete.

Review of Policy and Procedure entitled, "Medication Reconciliation" dated 12/07 documented within twenty-four (24) hours of the admission the nurse will document all the medications that the patient takes at home on the home list form. "The registered nurse must than compare the home medication list with the admitting list of medications for discrepancies. The registered nurse will contact the ordering physician for any discrepancies or omitted medications on the home list and obtain orders where required." At discharge use the current Medication Recompilation Physician Order form and home list as a guide to write the discharge prescription orders.

This finding was confirmed with the Director of Accreditation and Patient Safety during the onsite visit.




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2. Based on record review and observation during an onsite Allegation Survey, the facility failed to ensure that the nurse accurately identified the patients' pressure ulcers and documented a complete pressure ulcer assessment for two (2) out of three (3) records reviewed (Patients #38 and #43).

Findings:

Observation of a dressing change to Patient #43 on the morning of 03/11/11 revealed that there was a pressure ulcer on the sacrum and on the right buttock.

Review of Patient #43's current "Pressure Ulcer/Wound Details" documented three (3) sacral pressure ulcers: Site I - Sacral Media, Site 2 - Sacral Left and Site 3 - Sacral Right and no pressure ulcer on the right buttock which was observed during the dressing change. The pressure ulcer documentation was inconsistent with the pressure ulcer observation.

Review of Patient #43's "Pressure Ulcer Wound Detail" section documenting pressure ulcer drainage, characteristics and surrounding tissue were blank for sixteen (16) days of seventeen (17) days between 02/22/11 and 03/11/11.

Review of the hospital policy entitled "Skin Integrity, Maintenance" dated 06/10 revealed that the nurse must document the condition of the patient's skin on the Pressure Ulcer Record Flow sheet every shift.

Medical record with similar occurrence - Patient #38.

1. Based on record review and staff interview during an onsite Allegation Survey, the facility failed to ensure that the exit length of the Nasogastric (NG) tube was documented every shift as per hospital policy for three (3) out of three (3) records reviewed (Patients #30, #32 and #36).

Findings:

Review of medical records for Patients #30, #32 and #36 revealed that the NG tube boxes were checked, but the "GI Tube Comments" sections were blank. There was no documented evidence that the patients' NG tube exit length was measured each shift.

Interviews on 03/08/11 in the AM with Staff Member #5 (2 Central) and Staff Member #6 on (4 South) revealed the nurses were not aware that the exit length of the NG tube had to be measured every shift and documented on the "GI Tube Comment" section.

Review of the hospital policy entitled "Enteral Feeding with a Pump" dated 01/10/11 revealed the exit length of the Naso/Orogastric tube must be measured each shift and documented on the "GI Tube Comment" section.

These findings were confirmed with the 2 Central Nurse Manager and the 4 South Nurse Manager during the onsite visit.


2. Based on record review, observation and staff interview during an onsite Allegation Survey, the hospital failed ensure that the medication route was reordered via NG tube prior to administering medication to a NPO patient as per hospital policy in two (2) out of three (3) records reviewed (Patients #32 and #36).

Findings:

Observations on the morning of 03/08/11 in 4 South revealed Staff Member #6 administering medications to Patient #32 via a NG tube.

Review of Patient #32's Medication Administration Records dated 03/08/11 incorrectly documented that the medications were administered by mouth (PO) although the patient was observed receiving medication via a NG tube.

Review of Patient #32's physician's orders dated 02/25/11 at 7:00AM documented Digoxin, Aspirin, Potassium Chloride, Lopressor, Synthroid and a Multivitamin to be given by mouth. A physician's order dated 03/04/11 at 12:40AM, documented the NG tube was in place and could be used. There was no documented evidence that the PO medication orders were suspended as hospital policy.

Interview on 03/08/11 in the morning with Staff Member #6 revealed that the nurse was not aware that the medication needed to be reordered via the NG tube prior to administration.

Review of the hospital policy entitled "Medication Administration" dated 06/10 documented when a patient is made NPO, oral medications will be suspended unless the prescriber writes the order as "NPO except meds." A "Patient Specific Suspended Medication" form is printed and the practitioner will resume or discontinue the medications on this form. "Nursing will perform MED CHECKS at the start of every shift. Obtain the original physician order and check that all parts of the order are correct."

Medical record with a similar occurrence - Patient #36.

Based on medical record review and staff interview during an onsite Allegation Survey, the facility failed to ensure that the telephone/verbal orders were documented as read back (VORB) and were authenticated by the prescribing physician within forty-eight (48) hours as per hospital policy for five (5) out of six (6) records reviewed (Patients #4, #6, #7, #8 and #10).

Findings:

Review of the physician's orders for Patient #6 dated 11/29/10 at 6:45AM documented a telephone order for "Naso Gastric tube to low suction and Zofran 4 mg IV every 6 hours as needed for nausea" and on 12/03/10 at 4:31AM a telephone order to place patient on "continuous suction and to administer D5Normal Saline at 50 milliliters an hour" were not authenticated by the prescribing physician.

Medical records with similar occurrences - Patients #7, #8 and #10.

Review of the physician's orders for Patient #4 dated 08/26/10 at 2:45PM documented a telephone order for Potassium Chloride 40 milli-equivalents by mouth administering one (1) dose now and then another dose prior to discharge. There is no documented evidence of a Verbal Order Read Back (VORB).

Medical record with similar occurrence - Patient #8.

Review of the hospital policy entitled "Telephone/Verbal Orders" dated January 2011 revealed that all verbal and telephone orders are to be "read back to the prescriber." The receiver of the order will write "VORB for telephone order" and it is the responsibility of the prescribing physician to authenticate the order within forty-eight (48) hours.

An interview with the Director of Accreditation and Patient Safety on 03/11/11 at 8:45AM confirmed this information.

Based on observation, staff interviews and record review during an onsite Allegation Survey, the facility failed to ensure that A) that a licensed practitioner obtained the chief complaint from the patient on arrival to the Emergency Room resulting in a delay in triage for six (6) out of six (6) records reviewed (Patients #7, #20, #21, #24, #25 and #27) and B) visual privacy for Emergency Department patients receiving care and treatment as per hospital policy.

Findings:

A) Observations on 03/08/11 at 10:15AM, revealed patients presenting to the Emergency Room triage desk were greeted by the registrars (Staff Members #3 and #4) who asked the patient's name, address and chief complaint, then directed the patients to the waiting room or the treatment area according to the chief complaint. The registrar also was observed directing a patient to the waiting area and instructed him to "sit in the waiting area until called."

Interviews conducted on 03/08/11 at 10:20AM with the two (2) registrars (Staff Members #3 and #4) revealed that they preform a "quick registra" which includes the chief complaint. They then determine where to send the patient based on the chief complaint. Patients with chest pain, shortness of breath or visible injuries would go straight back to the nurse if a space was available. Other patients would be sent to the waiting area. They stated that they had no formal training and "just know how to do it."

Review of the personnel files for registrars (Staff Members #3 and #4) revealed they were unlicensed staff members and had no formalized training in triage as required by hospital policy.

Review of medical records for Patients #7, #20, #21, #24, #25 and #27, revealed a twenty-seven (27) to fifty-seven (57) minute delay between "quick registra" and triage.

Review of the policy entitled "Emergency Department Triage - Initial Patient Assessment" dated 04/2008 documented a triage provider (Registered Nurse, Physician Assistant, Nurse Practitioner or Emergency Room Physician) will assess each incoming patient by eliciting a chief complaint, obtaining a brief history and performing a focused physical examination then assign a triage acuity level 1-5 using the ESI Triage Algorithm.


B) Observations in the morning on 03/08/11 revealed while in the Emergency Department entrance, three (3) patients on separate occasions arrived at the ambulance triage area. The patients could be easily observed receiving physical examinations, medical care and nursing care through an uncovered unprotected glass window.

This finding was confirmed with the Director of the Emergency Department during the onsite visit.

Observations on 03/08/11 in the afternoon revealed a physican performing an abdominal examination on a patient in the Emergency Department hallway, Location #32, without the curtains drawn and a nurse administering medications to another patient in the hallway without the curtains drawn.

Review of the policy entitled "Auditory and Visual Privacy - Emergency Department" dated 12/2007, documented the examination should be elicited in an area that affords visual privacy and when a patient is not in a solitary room, curtains should be drawn around the patient's bedside.

This finding was confirmed with the Emergency Department Administrator and the Assistant Vice President of Performance Improvement during the onsite visit.