HospitalInspections.org

Based on observation, staff interview and documentation review during the survey conducted 03/07/11 to 03/10/11, it was determined due to the volume of deficiencies issued to the hospital for non-compliance with the 2000 Edition of the Life Safety Code, that the hospital failed to maintain the environment and all equipment to ensure the safety of the patients, staff and public. Therefore this Condition is not met. Refer to Life Safety Code deficiencies identified as tag numbers K018, K069, K077, K133 and K147.

Based on document review and staff interview, it was determined the hospital failed to develop patient care policies with the advice of a physician assistant. This has the potential to adversely affect the care provided to patients of the hospital. Findings include:

1. A review of the hospital's "Policy Review Committee Meeting Minutes" for the past six (6) months revealed no participation by a midlevel practitioner, specifically a physician assistant, who is on staff at the hospital.

2. During interview with the Chief Executive Officer in the afternoon of 3/8/11, she agreed a physician assistant is not a member of the hospital's "Policy Review Committee."

Based on medical record review and staff interview, the hospital failed to ensure the nursing staff develops adequate nursing care plans in ten (10) of twelve (12) inpatient medical records (Patient #1, 2, 4, 6, 7, 8, 9, 10, 11 and 12) reviewed. This has the potential to negatively impact all hospitalized patients by nursing staff not adequately assessing the patients' nursing care needs and appropriately developing nursing interventions. Findings include:

1. Review of the medical record for Patient #1 revealed no documented evidence of a nursing care plan.

2. Review of the medical record for Patient #2 revealed no documented evidence of a nursing care plan.

3. Review of the medical record for Patient #4 revealed no documented evidence of a nursing care plan.

4. Review of the medical record for Patient #6 revealed no documented evidence of a nursing care plan.

5. Review of the medical record for Patient #7 revealed no documented evidence of a nursing care plan.

6. Review of the medical record for Patient #8 revealed no documented evidence of a nursing care plan.

7. Review of the medical record for Patient #9 revealed no documented evidence of a nursing care plan.

8. Review of the medical record for Patient #10 revealed no documented evidence of a nursing care plan.

9. Review of the medical record for Patient #11 revealed the patient was admitted with a diagnosis of Left Leg Deep Vein Thrombosis (DVT), however the only nursing diagnosis on the nursing care plan was Knowledge Deficit; therefore, the nursing care plan was inadequate.

10. Review of the medical record for Patient #12 revealed no documented evidence of a nursing care plan.

11. The above records were reviewed in separate interviews with Nursing Supervisor #1 (NS #1) in the afternoon of 3/9/11 and NS #2 in the morning of 3/10/11. Both agreed with the above findings.

Based on document review, medical record review and staff interview, the hospital failed to ensure the medical staff follows its own Bylaws, Rules and Regulations by appropriately dating and timing the authentication signatures in eleven (11) of fourteen (14) medical records (Patients #2, 3, 4, 5, 6, 8, 10, 11, 12, 13 and 14) reviewed. This has the potential to negatively impact all patient care by not allowing the QA/PI process to function properly. Findings include:

1. Preston Memorial Hospital Medical Staff Bylaws, Rules and Regulations, approved January 26, 2010 state in part "...pg. 6 #9. All clinical entries in the patient's medical record shall be accurately dated, timed and authenticated..."

2. Review of the medical record for Patient #2 revealed the Operative note was dated and timed 2/10/11 at 1045 and again 3/3/11 at 0830 with the physicians signature only with the 3/3/11 date; telephone orders (T.O.) on 2/11/11 at 0835, 1915 and 2000 authenticated without a date or time.

3. Review of the medical record for Patient #3 revealed the Operative note authenticated without a date and/or time.

4. Review of the medical record for Patient #4 revealed the History and Physical (H&P) authenticated without a date and/or time; verbal orders (V.O.) on 4/26/10 at 2220, 4/27/10 at 0252, 4/27/10 at 2330, 4/28/10 at 1415, 4/28/10 at 1450, 4/29/10 at 1900, 4/29/10 at 2100 all authenticated without a date and/or time; order written 4/30/10 by Nurse Midwife (CNM) without date and/or time; and Post-Operative delivery note authenticated without date and/or time.

5. Review of the medical record for Patient #5 revealed the H&P was updated on 6/18/10 and authenticated without a time; the Post-Operative noted was written without a time.

6. Review of the medical record for Patient #6 revealed the H&P was authenticated without a date and/or time; V.O. on 9/2/10 at 0920 was authenticated by CNM without date and/or time.

7. Review of the medical record for Patient #8 revealed the H&P was authenticated without a date and/or time.

8. Review of the medical record for Patient #10 revealed the H&P was authenticated without a date and/or time; the Discharge (D/C) Summary was authenticated without a date/or time; two (2) physician orders written on 9/29/10 with no time; T.O. on 9/29/10 at 0313, 9/30/10 at 0450; 9/29/10 Pharmacy Consult order written at 0745 - all with documented evidence of physician authentication without a date and/or time; Emergency Room medication reconciliation form with no documented evidence of physician authentication.

9. Review of the medical record for Patient #11 revealed the H&P was authenticated without a date and/or time; the D/C Summary was authenticated without a date and/or time; 11/30/10 Physician Progress Note documented without a time.

10. Review of the medical record for Patient #12 revealed the H&P was authenticated without a date and/or time; the D/C Summary was authenticated without a date and/or time; Progress Notes written on 11/9/10, 11/10/10, 11/11/10 all written without a time.

11. Review of the medical record for Patient #13 revealed Physician Progress Notes written on 3/2/11, 3/3/11, 3/4/11, 3/5/11, 3/6/11, 3/7/11, 3/8/11, 3/9/11 all written without a time.

12. Review of the medical record for Patient #14 revealed the H&P authenticated without a date and/or time; Physician Progress Notes written on 2/28/11, 3/4/11, 3/5/11 all without a time.

13. The above records were reviewed in separate interviews with Nursing Supervisor #1 (NS #1) in the afternoon of 3/9/11 and NS #2 in the morning of 3/10/11. Both agreed with the above findings.