HospitalInspections.org

Based on interview and record review, the facility failed to ensure that a patient had the right to have his or her physician notified promptly of their admission to the hospital for 1 of 38 sampled patients (#28).

Findings:

A review of the medical record of patient #28 was performed. The patient was admitted to the facility on 10/18/12. There was no evidence in the record that the patient or caregiver was asked upon admission whether the hospital should notify his/her own physician.

A review of patient right's revealed no evidence that notification of a physician upon admission was an established patient right.

During an interview of the director of nursing on 4/17/13 at 3:50 PM, she confirmed the finding.

Based on observation, interview and record review, the facility failed to ensure confidentiality of patient records for all 19 currently admitted patients at the North campus.

Findings:

Observation at the North campus of the hospital on 4/17/13 throughout the day showed all patient records were stored in the unlocked nurse servers outside of patient rooms on the public corridor. The nurse servers store patient charts with confidential information such as social security numbers, diagnosis, and personal information.

During an observation on 4/17/13 at 2:50 p.m., a physician reviewed a patient record outside of room 8621. He left the chart open and went into the patient's room. The chart was left unattended in the public corridor for approximately 5 minutes until a staff nurse passed by and closed the record.

During an interview on 4/17/13 at 3 p.m., the chief nursing officer was shown the unattended record and confirmed the facility is in process of purchasing some chart racks, but has not corrected the problem yet.

Review of the policy "Confidentiality of Records", dated as revised on 01/01/10 read, the policy "is to maintain the tight to privacy for the patient/staff by keeping all records confidential....only authorized personnel shall have access to records."

Based on interview and a review of facility documentation, the facility failed to ensure that the Quality Assessment Performance Improvement (QAPI) program reflected all hospital housekeeping services under contract for the prevention and treatment of pest infestation.

Findings:

A review of facility documentation revealed that the facility had a contract with the company "The Steritech Group" for the provision of pest control services. Further review of documentation for the facility's QAPI program did not reveal any evidence that the services of this company had been incorporated into QAPI.

During an interview with the director of nursing on 7/18/13 at approximately 11:30 AM, she confirmed the finding.

Based on interview and record review, the facility failed to ensure that the care plan in the form of physician orders for a calorie count and the discharge of a patient without discharge orders was kept current for 2 of 38 sampled patients (#7 & 15).

Findings:

1. Physician orders for patient #7 dated 4/01/13 read, "Initiate calorie count on 4/02/13 X (times) 72 hours." Further review of the medical record revealed documentation of a calorie count for only one day (twenty four hours), on 4/04/13. This did not fulfill the requirement for seventy-two hours, as stated in the physician orders.

During an interview of the director of nursing (DON) on 4/16/13 at approximately 2 PM, she confirmed the finding.

2. Nurses' notes for patient #15, dated 1/04/13, indicated that the patient was discharged to home with hospice care. A Discharge Summary, dictated by the physician on 1/16/13 read, "He had a hospice consult and was discharged to hospice services at home." However, there was no evidence in the medical record of actual physician orders for discharge.

During an interview of the DON on 4/16/13 at approximately 3:30 PM, she confirmed the finding.

Based on observation, interview and a review of facility documentation, the facility failed to ensure that policies concerning general sanitation and the storage of sterile items which would inhibit the spread of infections were implemented.

Findings:

During an inspection of the supply room of the north campus at approximately 9:05 AM on 4/17/13, the following items were observed in the supply bins: one opened package of "Sterile Kelly Hemostat Curved" and one opened "Sterile Staple Removal Kit."

During an interview of the director of nursing (DON) at the above stated time, she confirmed that if items were on the bins were intended to be available for use.

A review of facility policy "General Sanitation" revealed that "Clean/sterile items shall be handled as follows: free of holes in packaging (Intact)." The facility was not in compliance with this policy.

During an interview of the DON at approximately 11:30 AM, she confirmed the finding.

Based on observation, interview and record review, the facility failed to ensure staff provided a sterile environment for 1 of 2 sampled patients receiving a wound dressing change (#6), and failed to provide a sanitary environment for 1 sampled patient with padded side rails (#6).

Findings:

1. During an observation on 4/15/13 at 2:20 p.m. staff #D did a sterile dressing change for patient #6's central line IV. She wore sterile gloves, a gown and mask. She was assisted by staff #C, who did not wear her mask to cover her nose, only her mouth.

During an interview on 4/15/13 at 2:30 p.m., she said she usually covers her nose does, but because she was not actually close to the field, would not require her nose to be covered.

During an interview on 4/15/13 at 3:40 p.m., the administrator, who was present during the dressing change observation, verified the nurse assisting with the dressing change did not have her mask on securely and exposing her nose.

Review of the policy "Central Venous Catheter, PICC, Midline, Care of: Dressing Change tubing and cap change, Flushing Post-Insertion Care Bundle", dated as revised 04/01/11, read "Put on mask ...."

2. During an observation on 4/15/13 at 2:45 p.m. in room 132, patient #6's bed had four side rails with manufactured built type padding on the side rails. The padding was patched with a duct tape like substance coving holes in the pads. Many of the pads had the foam core exposed and sticking out of the tape. The administrator was present at this time and confirmed the tape was not appropriate repair for the holes in the padding.

Mattresses and padded positioning devices surfaces should be moisture-resistant and intact. If the surfaces are not intact, it inhibits the ability to appropriately clean the surface. Damaged or worn coverings should be replaced.

Based on interview and record review, the facility failed to ensure the inclusion in the discharge plan of patients discharged to Home Health a list of agencies that are available to the patient in two of 38 sampled patients. (#27, #28)

Findings:

A review of the medical record of patient #27 revealed final discharge orders to home health on 7/25/12 which read, "Home health referral for skilled nursing." Physician orders of 7/26/12 read, "OK to DC (discharge) home with Home Health." In preparation for the anticipated discharge orders as indicated in the preceding, case management staff had made arrangements on an earlier date for home health care. A case management note of 7/24/12 at 5:30 PM read, "Son in agreement ... home health ... Contact made ... Mederi Caretenders." A Case Management note of 7/26/12 read, "Pt (patient) to be followed by Mederi Caretenders for home health." The record included a checked attestation from the patient which read, "I have been given or have reviewed a list of providers to choose from. Yes." However, the record did not include a listing of the agencies from which the patient would have made a choice.

A review of the medical record of patient #28 was performed. Physician orders of 11/19/12 read, "D/C (discharge) to home today once all HHC (home health care) arrangements are made." A Case Management note of 11/19/12 at 4 PM read, "HHC arrangements for wound care through Conficare ... per pt (patient) choice. The record included a checked attestation from the patient which read, "I have been given or have reviewed a list of providers to choose from. Yes." However, the record did not include a listing of the agencies from which the patient would have made a choice.

During an interview of the director of nursing on 4/17/13 at 1:50 PM, she confirmed the preceding.

Based on record review and interview, the facility failed to ensure staff documented organ procurement instructions following notification for 2 of 4 patients (#13 & 14) expiring in January 2013, and failed to have a policy defining "imminent death" and "timely notification" of the organ procurement organization.

Findings:

Review of the facility form titled "Record of Death" showed areas of required documentation in the section called-Organ/Tissue Procurement (OPO) - Was request made? And Was donation made?

Review of 2 of 4 deaths for the month of 1/2013 showed the following:

1. Patient #13, age 63, admitted on 11/13/12 and expired on 1/15/13 at 5:52 p.m. Medical record review of the "Record of Death" showed-OPO notified at 1/15/13 at 18:30 p.m. There was no documentation of OPO declination of the patient.


2. Patient #14, age 70, admitted on 11/26/12 and expired on 1/04/13 at 8:48 a.m. Medical record review of the "Record of Death" showed - OPO notified at 1/04/13 at 10 a.m. There was no documentation of OPO declination of the patient.

Review of both of the "Record of Death" for patient #13 & #14 showed in the Organ/Tissue Procurement-Was request made? And Was donation made? was blank for both patients.

During an interview on 4/16/13 at 3:15 p.m., the director of quality management reviewed the medical records and confirmed there was no documentation as to the disposition of the organ request. Review of the facility policies related to Organ Procurement showed the policy does not specifically define imminent death and timely notification.

Based on interview and record review, the facility failed to ensure that policies for written procedures were followed for 1 of 38 sampled patients (#19).

Findings:

A review of the medical record of patient #19 was performed. She underwent a debridement of a decubitus ulcer on the right heel on 4/08/13. The document "Bedside / Procedure Room/OR (Operating Room)" read, "Initial, date & time each entry."

Corresponding to these instructions were three separate columns with the respective headings of "RN" (Registered Nurse); "Physician" and "Other". There were also a listed series of steps which required corresponding signatures in the above mentioned columns. The steps were, "(1) Verification that the patient's informed consent describes the operative/procedure site as appropriate; (2) Verbal confirmation of the surgical/procedure site with the patient and/or family/significant other when possible; (3) Surgical/procedure site marked prior to the procedure with indelible marker when appropriate; (4) All relevant documents and related information or equipment are: (A) Available prior to the start of the procedure; (B) Correctly identified, labeled and matched to the patient's identifiers; (C) Reviewed and are consistent with the patient's expectations and with the team's understanding of the intended patient, procedure, and site; (5) Time-out conducted by team immediately prior to procedure for final confirmation of patient identity, site and surgery / procedure to be done."

Except for the RN column, steps (1) through (3), none of the available spaces had the required initials. Furthermore, none of the available spaces had any of the required dates or times.

During an interview of the director of nursing on 4/17/13 at approximately 11:30 AM, she confirmed the finding.