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Based on observation on April 20, 2010, it was noted that the facility failed to conform with Section 608.3 of the 2006 edition of the Michigan Plumbing Code, which states that a cross connection shall not be made between the potable water system and piping which may contain chemical contaminant. The finding include:

1. The scopes washer machine "Steris", serving the Surgical department, is not provided with a backflow preventer.

2. The film processor in the Radiology Department which contains a film developer and chemical tank lacks a backflow preventer.

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See C-231

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on April 20, 2010, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated April 20, 2010 for Life Safety Code.

Based on observation, interview and record review, the facility failed to obtain restraint orders signed by the attending physician indicating a specified, limited application time as required in Public Act 368 of 1978, as amended [the Michigan Public Health Code], Section 333.20201 for 1 of 1 in-patients with restraint orders. Findings include:

On 4/21/10 at 0840 patient #22 was observed resting in bed with 1 wrist restraint lying on her bed. On 4/21/10 at 1000, review of patient #22's clinical record revealed a 4/15/10 restraint order that had not been signed by the attending physician or any other physician.

Facility policy #1542.09 states that each restraint order may be written for up to 24 hours. Restraint orders for patient #22 dated 4/16/10 and 4/17/10 did not specify a length of time for restraint application.

Facility policy #1542.09 also allows for restraint orders to be authorized in writing by a physician or other licensed independent practitioner, however the Director of In-patient Services confirmed that physician assistants [who are not a licensed independent practitioner] write restraint orders.

These findings were verified by the Director of In-patient Services during record review.

Based on record review and interview, the facility failed to develop policies with the participation of at least 1 non-Community Access Hospital staff member. Findings include:

On 4/20/10 at approximately 1300, review of the facility policy manual revealed that a non-staff member had not signed-off on numerous policies, including: #1540.04, Assignment of Care, # 1210.20, Verbal/Telephone Orders, #1200.03, Policy and Procedure Development and #1540.031, Admission of the Patient and #1542.09, Restraint Use. On 4/20/10 at 1330 the Director of Quality Assurance and Risk Management confirmed these findings.

Based on interview and record review the facility failed to ensure that medical records were complete and accurately documented in 12 of 13 patient medical records (#1, #2, #3, #4, #5, #6, #7, #9, #10, #11, #12 and #13). Findings include:

The facility produced a "Focused Record Review" which included monitoring item EP#19 [All entries in the medical record are timed] with monthly data from August of 2009 through March of 2010. It could not be determined from the form whether or not the records reviewed in any given month were from patient service dates of that month, however, there were 2337 observations of which 1976 were compliant [a 85% overall success rate].

On 4/19/10 at approximately 1520 during a tour of the Emergency Department 5 of 5 (#1, #2, #3, #4, #5) medical records were absent of a nurse's signature and time in the "Orders Noted by RN" section on the "Physician Order Sheet". This was confirmed by the Director of Perioperative and Emergency Services.

On 4/19/10 at approximately 1800 while reviewing closed records, 7 of 7 (#7, #8, #9, #10, #11, #12, #13) medical records were incomplete and/or inaccurate as follows:
#7 and #9 contained medical abbreviations as QID and BID [without clarification or translation] on the "Home Medication Reconciliation Orders and Discharge Medication Instructions" which is given to the patient upon discharge for medication instructions.

#8 was absent of a patient and RN signature on the "Advanced Directive Assessment for Swing Bed Patients" form, allergy listing on the "Standing Orders for Swing Bed Patients" form, and no date on the "Physician Treatment Orders" form for a telephone order.

#10 contained a telephone order dated "11/23" that was illegible due to an order that was crossed out yet had a star symbol next to it.

#11 was absent of a nurse's signature and time in the "Orders Noted by RN" section on the "Physician Order Sheet" from the Emergency Department Record.

#12 was absent of a time on the "Emergency Room Flowsheet" to indicate what time a follow-up assessment was completed by the Registered Nurse.

#13 was absent of a nurse's signature and time in the "Orders Noted by RN" section on the "Physician Order Sheet" from the Emergency Department Record.

A delinquent record report [as of April 20, 2010] revealed 43 records were still incomplete.

These findings were confirmed by the Director of Inpatient Services and and Director of Clinical Services.

On 4/19/10 at 1600, review of patient #20's medical record revealed a telephone order dated 4/16/10 that had not been signed by the physician. On 4/21/10 at 1000, review of patient #22's medical record revealed 2 orders (dated 4/15/10 and 4/16/10) that had not been signed by a physician. These findings were confirmed by the Director of In-patient Services.


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Based on interview and medical record review the facility failed to ensure that physician's orders in the medical records were consistently signed, authenticated, dated, and/or timed in 15 of 18 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #20, #21) patient medical records . Findings include:

The facility produced a "Focused Record Review" which included monitoring item EP#11 [All entries in the medical record are dated] with monthly data from August of 2009 through March of 2010. It could not be determined from the form whether or not the records reviewed in any given month were from patient service dates of that month, however, there were 2337 observations of which 2302 were compliant [a 99% overall success rate].

On 4/19/10 at approximately 1520 during a tour of the Emergency Department 5 of 5 (#1, #2, #3, #4, #5) medical records selected at random were absent of a physician's signature authenticating the orders written by the physician on the "Physician Order Sheet". These findings were confirmed by the Director of Perioperative and Emergency Services.

On 4/19/10 at approximately 1800 while reviewing closed records, 7 of 8 (#6, #7, #8, #9, #10, #11, #12) medical records selected at random were absent of multiple physician signatures and/or dates and times authenticating telephone orders throughout each record as follows:
#6-Physician order dated 4/3/10 had a physician signature but did not have a date and time and telephone order dated 4/3/10 did not have a physician signature.
#7-Physician order dated 1/19/10 had a physician signature but did not have a date and time and a verbal order dated 1/18/10 had a physician signature but did not have a date and time.
#8-Did not have a date on a physician telephone order yet it was authenticated by the physician.
#9-Admission orders for swing bed patients had a physician signature but was not dated or timed and a telephone order dated 4/8/10 did not have a physician's signature.
#10-A telephone order dated 11/24/09 had a physician signature but not date and time and a telephone order dated 11/23/07 did not have a date or time when the order was signed by the physician.
#11-The emergency physician order sheet did not have a physician signature.
#12-The emergency physician record did not have a time of disposition.

In the facility policy titled "Maintenance of Medical Records" under section 4 states "Records are to be completed within guidelines set forth in the Medical Staff Bylaws."The facility's Medical Staff Bylaw Rules and Regulations indicate under section 8.6 "Authentication" that "All orders, including verbal orders, in the patient's record must be accurately dated, timed, and individually authenticated within 48 hours or at the time of the next visit, whichever occurs first." These findings were confirmed by the These findings were confirmed by the Director of Inpatient Services and and Director of Clinical Services.

Based on record review and interview, the facility failed to conduct an annual review of policies. Findings include:

On 4/20/10 at approximately 1300, review of the facility policy manual revealed that numerous policies had not been signed-off as reviewed on an annual basis, including: #1540.031, Admission of the Patient, signed by a former Chief Nurse Executive on 10/16/06, #1540.04, Assignment of Care, signed by a former Chief Nurse Executive on 11/8/06 and #1210.20, Verbal/Telephone Orders, signed by a former Nurse Executive on 8/17/06.

On 4/20/10 at 1330 the Director of Quality Assurance and Risk Management confirmed these findings. Facility policy #1200.03 states that policies and procedures are to be reviewed and revised at least annually.

Based on interview and record review, the facility failed to ensure medically related social services were provided to ensure that patients received appropriate care following discharge. The findings include:

On 4/20/10 at 2:05 PM in the second floor conference room, the Social Worker (SW) and Casemanager (CSM) was interviewed. The CSM stated the hospital maintains a log of available Skilled Nursing Facility beds upon notification from two area Nursing Homes and receives this information approximately each day or every other day. The log presented to confirm the notification did not contain any entries for 2010.

The CSM confirmed that area nursing homes are not contacted by the hospital to inquire about the availability of beds and services for patient consideration upon discharge from the hospital. The CMS stated that if a patient requires skilled care and meets eligibility requirements, they are admitted to the Swing Bed Program. This practice also represents failure to follow Hospital Policy - Discharge Planning which states: "7. Case management will inform patients of available and appropriate community resources to meet their needs as well as the financial eligibility requirements and expenses of same."

During review of records on 4/21/10 at 1210 PM in the second floor conference room, the medical records of 3 of 3 patients admitted to the Swing Bed Program (pt. #22, pt. #23 and pt. #24) lacked documentation of interaction with the patient and/or family which identified potential community medical resources available or appropriate to meet the patients needs upon discharge from the hospital. This was confirmed in the presence of the CSM and the Chief Nursing Officer.

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for each resident.

This is evidenced by:

On 4/21/10 at 1210 PM in the second floor conference room, the medical records of 3 patients admitted to the Swing Bed Program were reviewed. In 1 of 1 patients admitted for the purpose of Rehabilitation Services (pt. #22), the medical record did not contain a physicians order for services to be provided and there was not a Comprehensive Plan of Care identifying Goals, Objectives and/or interventions for Physical therapy or Occupational Therapy Services. This was confirmed in presence of the Administrative Assistant and the Chief Nursing Officer.

In 2 of 2 patients admitted for the purpose of skilled nursing care including the administration of IV antibiotics (pt. #23 and pt. #24), the medical record did not contain a physicians order for the establishment of an Intravenous access or administration an Iv fluid other than the prescribed antibiotics. This was confirmed in presence of the CSM and the Chief Nursing Officer.