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Tag No.: A0143
Based on observation and policy and procedure revealed the facility failed to ensure patient information was kept private in the lobby of the hospital.
Findings include:
Review of facility policy and procedure "Patient Rights and Responsibilities Policy" last revised July 19, 2018, revealed "D. A patient has the right to every consideration of his or her privacy, safety and security concerning his or her own medical care program .....Case discussion, consultation, examination, and treatment are confidential and should be conducted discreetly, making every attempt to maintain the patient's verbal and visual privacy."
During an observation on July 12, 2018, at approximately 8:15 AM, in the front lobby of the hospital a patient was seen and overheard discussing financial concerns at the volunteer's desk. Further observation revealed that patients enter the front door and proceed to the volunteer's desk and state their name and the reason why they were at the facility (for procedure, blood work, etc.). Approximately seven other individuals were in the lobby at the time the patient was overheard discussing personal financial concerns.
Interview with EMP2 on July 16, 2018, at approximately 1:30 PM confirmed that patients go to a window located in the front lobby and discuss personal information. EMP2 also confirmed that the discussions can be overheard by others in the lobby.
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Tag No.: A0395
Based on review of facility documentation, medical record (MR), and staff interview (EMP), it was determined that the facility failed to follow adopted nursing care guidelines consistent with professionally recognized standards of nursing practice for one of one medical record reviewed (MR1).
Findings include:
Review of facility documentation "Lippincott Procedures - Cardiac monitoring" revealed "Cardiac monitory revised: August 18, 2017 ... Documentation ... Document a rhythm strip at least every shift and with any changes in the patient's condition ... make sure the strip is labeled with the patient's name and identification number ... appropriate measurements"
1. Review of MR1 revealed rhythm strips dated from April 6, 2018 thru May 2, 2018. a total of 32 strips. Further review revealed no documentation of appropriate measurements as per above documentation.
Interview with EMP1 on July 16, 2018, at approximately 10:00 AM confirmed the above findings and revealed "there is none"
Tag No.: A0508
Based on review of facility documents, review of medical records (MR), and interview with staff, it was determined the facility failed to document drug administration errors in the medical record for three of three medical records reviewed (MR2, MR3, and MR4).
Findings include:
Review of facility policy, Medication Management, last revised July 12, 2018, revealed, " ...X V. Medication Errors: ... 3. Evaluation and Reporting. ...1. The prescribing/attending physician is to be notified of the medication error and the Physician's orders are followed as appropriate. 2. An entry of the medication administered is properly recorded in the medical record by the person administering the drug. The name of the medication, dose, time, route. 3. Nurses note should also reflect the medication administered, physician notification, and any follow-up patient assessment."
1. Review of facility medication error log revealed a medication error occurred on June 11, 2018 for MR2. Review of MR2 revealed no documentation in nurses note of the medication administered, physician notification, or follow-up patient assessment.
2. Review of facility medication error log revealed a medication error occurred on June 21, 2018 for MR3. Review of MR3 revealed no documentation in nurses note of the medication administered, physician notification, or follow-up patient assessment.
3. Review of facility medication error log revealed a medication error occurred on June 26, 2018 for MR4. Review of MR4 revealed no documentation in nurses note of the medication administered, physician notification, or follow-up patient assessment.
4. Interview with EMP1 confirmed the above findings.