HospitalInspections.org

Based on observation and staff interviews, the hospital failed to discard expired supplies in 2 of 5 areas. Findings include:

1. On 1/2/13 at 3:45 p.m., during review of the intensive care unit, the surveyor observed one bottle of Betadine Solution with a manufacturer's expiration date of 8/2012.

At 3:45 p.m., staff member D stated the staff checks for expired supplies once a month.

2. On 1/3/13 at 2:15 p.m., during review of the emergency department medication room, the surveyor observed 11 blue top Vacutainers with a manufacturer's expiration date of 11/2012.

At 2:15 p.m., staff member E stated the unit staff check for expired supplies once a month.

Based on record reviews and staff interview, the hospital failed to maintain records that were complete for 5 (#s 28, 29, 30, 31, and 32) of 29 organ procurement records reviewed. Findings include:

1. Patient #28's Record of Death document was reviewed. The document did not contain the name of procurement coordinator and the case number.

2. Patient #29's Record of Death document was reviewed. The document did not contain if the patient was a candidate for organ/tissue donation.

3. Patient #30's Record of Death document was reviewed. The document did not contain if the patient was a candidate for organ/tissue donation.

4. Patient #31's Record of Death document was reviewed. The document did not contain if the patient was a candidate for organ/tissue donation.

5. Patient #32's Record of Death document was reviewed. The document did not contain if the patient was a candidate for organ/tissue donation.

6. On 1/3/12 at 5:00 p.m., staff member A stated the Record of Death form should be filled out completely.

Based on review of medical staff by-laws and staff interview, the facility failed to implement the policies relating to physicians completing medical records in a timely manner. Findings include:

Review of the Medical Staff Rule and Regulations, Part Seven - Medical Records, section 7:11 showed:

"All portions of the medical record for both inpatients and outpatients should be completed at the time of discharge or at least with seven (7) days and must be completed and signed by the responsible Practioner within fifteen (15) days after the patients discharge...

2. If a physician has not signed all of his/her records within the time required, a letter will be sent...stating such with a copy of the sentence out of the bylaws...

4. If records are not signed for an additional 14 days, a second letter is sent by medical records, and the physician's office is called...

5. If the records are not signed within one week (no records signed for 5 weeks total, two letter and one phone call made), then physician admitting privileges are temporarily suspended until all records are signed."

On 1/3/13 at 10:45 a.m.,during review of the deficiencies list for 5/1/11 to 1/13/13, there were 12 records that had not been completed for 5 or more weeks.

On 1/3/13 at 10:45 a.m.,during an interview with staff member F, the Health Information Management Director stated, "One of the physicians is a locum and has been having trouble logging on the computer system to finish his records. We finally had to send hard copies to get his signature."