HospitalInspections.org

Based on observation, review of documentation and an interview with staff # 29 on the morning of 7/9/2013 the facility failed to maintain the facility generator in safe operating condition; the facility failed to perform weekly and monthly generator checks according to the facility policy.
Findings were.
Review of documentation Electrical Safety Policy stated, " The generator set will be inspected weekly and will be exercised under load and operating temperature conditions for at least 30 minutes at intervals not more than 30 days.
Review of the Emergency Generator Operation Log form 9/5/12 through 10/25/12 revealed the last generator checks was performed in October 25, 2012. There was no documentation for the months of Nov, Dec 2012 and no generator checks for 2013.
In an interview with staff # 26 on the morning of 7/9/13 the findings were confirmed. The facility failed to perform weekly monthly checks according to facility policy.

Based on review of documentation and interviews with staff, the facility failed to ensure that clinical records were maintained according to medical staff policies, as 8 of 26 applicable patient records did not comply with the requirements for completing History and Physical (H&P) exams or Discharge Summaries.

Findings were:
Review of Medical Staff polices for delivery of patient care shall be; 4. A physical examination and medical history will be completed for each patient by an M.D. or D. O. or there appropriate by an or-maxillofacial surgeon no more than seven days prior to or 48 hours after admission.5. At the time of discharge the discharging physician will assure all patient discharge planning is complete, proper disposition of the patient is executed and that follow-up care planned is documented. Also at the time of discharge the attending physician shall see that the record is complete, state his/her final diagnosis and sign the record.
Review of the medical records of 5 patients revealed that the H&P reports were not placed on the medical record within 48 hours of admission. Patient # 6, 8, 4, 5, and 10 medical records did not contain H/P ' s. Patient # 9 was admitted 2/6/13, H/P was electronically authenticated 3/26/13.

Review of the medical records of 3 patients revealed that the Discharge Summaries were not completed by the physician at the time of discharge according to facility policy. Patient # 7, 6, 9, and patient # 10 ' s record did not contain a discharge summary.

In an interview with staff # 1 on the morning of 7/9/13 at the facility the findings were confirmed.

Based on review of documentation and interviews with the facility staff, the facility failed to provide medical related social services for 5 of 8 swing bed patients; as incomplete interdisciplinary team forms were blank with no social work communication documented

Findings were;

Review of Social Services facility policy stated, Function of Social Service to take responsibility for recognizing medically related social problems and to take the action necessary to solve them.

Review of patient # 4, 7, 8, 10, and 11, revealed social work documentation was not available for review at the time of the survey.

In an interview with staff # 1 she stated the interdisciplinary team does not have a meeting to discuss the patient ' s progress. The members randomly communicate the findings to her.