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Based on observation the rehabilitation (rehab) unit failed to ensure the confidentiality of seven out of seven (7) patient ' s (Patient 106, Patient 37, Patient 38, Patient 39, Patient 107, Patient 108, Patient 109) privacy of treatment.
The facility census is 180.
Findings include:
Observation of the rehabilitation unit on 04/26/10 at approximately 2:00 p.m. revealed a large open area where the main nurses desk is located, and the general public, and other patient ' s walk past, or stop to talk with nurses, a large (approximately 4 feet wide by 3 feet deep) erasure board was visualized that identified the rehab inpatient ' s by the first three initials of their last name and the first two initials of their first name. This information is used by the rehab staff to track patients during their inpatient rehab stay.

Based on observation, interview and record review facility staff failed to ensure physical restraint orders for one (Patient #69) of one patients reviewed for timely authentication of restraint orders was authenticated within twenty-four hours as required. The facility census was 180 patients.

Findings included:

1. Record review of an undated copy of the facility Medical Staff Rules and Regulations, Section C. General Conduct of Care, paragraph C3. (provided during the survey) directed in part, the following:
-All orders for diagnosis and treatment shall be in writing.
-Telephone or verbal orders shall be used infrequently.
-The responsible physician shall sign such orders within a timely fashion.
-For the following "high risk" situations, timely shall be defined as within twenty-four hours; Physical Restraint usage.

Record review of the facility Non-Behavioral (Medical/Surgical) Restraint Order form revised 12/05/06 directed a written order must be co-signed by a physician within twenty-four hours. Every restraint episode requires a new physician order.

2. Record review of current Patient #69's admission history and physical revealed staff admitted the patient on 04/21/10 with diagnoses including altered mentation, weakness, and anemia, history of dementia, high blood pressure and stroke.

Record review of the patient's physician's orders revealed the following:
-An unauthenticated telephone/verbal order recorded on a Non Behavioral (Medical/Surgical) Restraint Order form for soft write restraints applied to both wrists dated 04/23/10, timed 2:00 PM.
-An unauthenticated verbal order recorded on a Non Behavioral (Medical/Surgical) Restraint Order form for soft write restraints applied to both wrists dated 04/28/10, timed 8:00 AM.

During an interview on 04/29/10 at 11:50 a.m. the Director of Nursing Operations 4 North & 4 West, Staff CCC reviewed the patient's verbal orders for restraints recorded on the patient's Non Behavioral (Medical/Surgical) Restraint Order form and stated the physician failed to authenticate the verbal orders for restraints as required within twenty-four hours.

Observation on 04/29/10 at 11:35 a.m. revealed staff had released the patient's soft wrist restraints and a staff sitter was at the patient's bedside.

During an interview on 04/29/10 at 11:35 a.m. the staff sitter stated the patient had been release from restraints at approximately 8:00 a.m. this morning.

Based on observation, interviews and policy review, the facility failed to administer medications as ordered. The facility census was 180.
Findings include:
1. During an observation/interview on 04/27/2010 at approximately 2:40 p.m. in the Intensive Care Unit (ICU) Registered Nurse (RN), Staff AAA, mentioned the " 60 minute window " during medication administration. For clarification, it was discussed that medication administration was 30 minutes each side of the ordered time and Staff AAA, RN, stated it is 60 minutes either side of the eMAR (electronic Medication Administration Record) time.
2. During an interview on 04/28/10 at approximately 10:45 a.m. with the Associate Chief Nursing Officer, Staff MMM, MSN (Master of Science in Nursing), RN, it was clarified that the facility policy and procedure for medication administration was 60 minutes before and 60 minutes after the time ordered for the medication. This would be a two-hour window for medication administration rather that the accepted standard of one-hour with 30 minutes before or after the medication order indicated on the eMAR.
3. During an interview on 04/28/10 at approximately 1:45 p.m. with the Director of Pharmacy, Staff AA stated the timeframe for medication administration of 60 minutes before or after the eMAR time was an acceptable window for medication administration.
4. Review of the facility policy, #PC - 413, titled, Medication Administration, with effective date, May, 2005 and revised dates of Nov 2006 and July 2009 states in part:
C. Administration
(5) Administration times
Medications are administered according to physician orders in concert with defined timeframes established by Patient Services in collaboration with the medical staff.
While STAT [Medical term used to imply urgent or rush] drugs are intended to be given immediately (within 30 minutes of order), routine drug times are established and determined in such a way to promote optimum blood levels while supporting patient routines.
5. The facility must administer a medication in accordance with the orders of the responsible practitioner. According to current regulation, If medications are not administered within 30 minutes either side of the documented time for administration, it is determined that the hospital staff is not administering medications as ordered.

Based on interview and record review facility staff failed to ensure entries in patient medical records were timed, timely and complete for six (Patient #70, #16, #18, #20, #22, #26 ) of fourteen patient medical records reviewed for completed entries. The facility census was 180 patients.

Findings included:

1. Record review of an undated copy of the facility Medical Staff Rules and Regulations, Section B. Medical Records, directed in part, the following:
-The attending physician shall be responsible for the preparation of a complete and legible medical record for each patient.
-Pertinent progress notes shall be recorded at the time of observation, sufficient to permit continuity of care and transferability.

Record review of the facility policy #CM-112-2006, titled Content of the Medical Record revised 08/09 directed the following:
-Paragraph D. Progress Notes incorporate pertinent chronological notes of the patient's course reflecting changes in condition and results of treatment. All entries must be signed, dated and timed by the appropriate individuals.
-Paragraph L. Nursing Notes contain physical assessment of nutritional screening, pertinent meaningful observations and information, dates, times and signatures.

2. Record review of current Patient #70's admission history and physical revealed staff admitted the patient on 04/24/10 with recurrent pneumonia, diabetes, history of stroke, difficulty swallowing and gastroesophageal disease (stomach acids backflow into the swallowing tube). Further review of the patient's admission history and physical revealed the patient had a gastrostomy feeding tube (tube through the stomach wall for infusion of liquid nutrition).

Record review of the patient's admission forms dated 04/24/10 revealed nursing staff failed to perform a timely nutritional screening and subsequent consult to the dietitian for nutrition problems.

Record review of the patient's nutrition assessment dated 04/27/10 revealed the dietitian performed initial assessment (three days after admission) due to the patient being on tube feeding.

During an interview on 04/29/10 at 9:42 a.m. the Unit Manager of Ortho/Neuro, Staff K reviewed the patient's admission forms and stated nursing staff should have completed the nutrition screening on admission and consulted the dietitian on 04/24/10.

3. Record review of closed Patient #16's admission history and physical revealed staff admitted the patient on 02/10/10 with diagnoses including out of hospital cardiac arrest, ventricular fibrillation (life threatening abnormal heart rhythm), anoxic brain damage (brain damage due to lack of oxygen), kidney failure, epilepsy and high blood pressure.

Record review of the patient's physician's progress notes revealed the following:
-Two untimed progress notes dated 02/12/10.
-One untimed progress note dated 02/13/10.
-One untimed progress note dated 02/14/10.
-Three untimed progress notes dated 02/15/10 from cardiology and neurology.
-Three untimed progress notes dated 02/16/10 from neurology, one regarding an MRI (magnetic resonance imaging, radiology test) and one regarding the patient being unresponsive.

During an interview on 04/29/10 at 1:16 p.m. the Director of HIM reviewed the entries and stated staff failed to time the entries.

4. Record review of closed Patient #18's admission history and physical revealed staff admitted the patient on 02/15/10 with diagnoses including brain tumor, mental status changes, confusion, fatigue, fatigue and lack of appetite.

Record review of the patient's physician's progress notes revealed the following:
-An untimed, unauthenticated note dated 02/15/10.
-An untimed Hematology Oncology note dated 02/20/10.
-An undated, untimed note.
-An untimed discharge note.

During an interview on 04/29/10 at 1:20 p.m. the Director of HIM reviewed the entries and stated staff failed to date and time the entries.

5. Record review of closed Patient #20's admission history and physical revealed staff admitted the patient on 02/21/10 with diagnoses including mild pancreatitis (inflammation of the insulin producing organ the pancreas), possible underlying gallstones, high blood pressure, high blood lipids and diabetes.

Record review of the patient's physician's progress notes revealed the following:
-Two untimed progress notes dated 02/22/10.
-Two untimed progress notes dated 02/24/10.

During an interview on 04/29/10 at 1:25 p.m. the Director of HIM reviewed the patient's progress notes and stated staff failed to time the entries.

6. Record review of closed Patient #22's admission history and physical revealed staff admitted the patient on 03/16/10 with diagnoses including out of hospital cardiac arrest, possible anoxic brain injury (brain damage due to lack of oxygen) and pneumonia.

Record review of the patient's physician's progress notes revealed the following:
-An unauthenticated note dated 03/17/10.
-An untimed note dated 03/16/10.

Record review of the patient's Consultants' reports revealed an unauthenticated Pulmonary Service Consultant's report dated 03/16/10.

During an interview on 04/29/10 at approximately 1:30 p.m. the Director of HIM reviewed the patient's physician's progress notes and Consultant's reports and stated staff failed to authenticate and time the entries as required.

7. Record review of closed Patient #26's admission history and physical revealed staff admitted the patient on 03/24/10 with diagnoses including cancer of the head and neck, kidney insufficiency and dehydration and poor social situation.

Record review of the patient's physician's progress notes revealed an untimed note dated 03/28/10.

During an interview on 04/29/10 at 1:30 p.m. the Director of HIM reviewed the patient's progress notes and stated staff failed to time the note as required.

Based on interview and record review facility staff failed to ensure physician orders in eight (Patient #4, #6, #7, #74, #16, #18, #20, #22) of seventeen patient medical records reviewed for dated, timed and authenticated physician orders. The facility census was 180 patients.

Findings included:

1. Record review of an undated copy of the facility Medical Staff Rules and Regulations, Section B. Medical Records, directed in part, the following:
-The attending physician shall be responsible for the preparation of a complete and legible medical record for each patient.
-A physician's routine orders, when applicable to a given patient, shall be reproduced in detail on the order sheet of the patient's medical record, dated and signed by the physician.

Record review of an undated copy of the facility Medical Staff Rules and Regulation, Section C. General Conduct of Care directed in part, the following:
-All orders for diagnosis and treatment shall be in writing.

2. Record review of current Patient #74's admission history and physical revealed staff admitted the patient on 04/19/10 with lower leg swelling and pain.

Record review of the patient's physician's orders revealed the following:
-An unauthenticated, untimed order recorded on a form titled Device Reprogramming Orders for Medtronic.
-An untimed, undated order for pain medication recorded on a form titled Post Anesthesia Care Unit-Department of Anesthesiology.

3. Record review of closed Patient #16's admission history and physical revealed staff admitted the patient on 02/10/10 with diagnoses including out of hospital cardiac arrest, ventricular fibrillation (life threatening abnormal heart rhythm), anoxic brain damage (brain damage due to lack of oxygen), kidney failure, epilepsy and high blood pressure.

Record review of the patient's physicians orders revealed an undated, untimed, unauthenticated multi-paged order set titled Status Epilepticus Orders (page 1 of 2), with a blank line at the bottom of the page with prompts for authentication, date and time.

During an interview on 04/29/10 at 1:16 p.m. the Director of HIM reviewed the patient's multi-paged order set titled Status Epilepticus Orders (page 1 of 2) and stated the physician failed to authenticate, date and time each page of the order set as required.

4. Record review of closed Patient #18's admission history and physical revealed staff admitted the patient on 02/15/10 with diagnoses including brain tumor, mental status changes, confusion, fatigue, fatigue and lack of appetite.

Record review of the patient's physician's orders revealed the following:
-An untimed order dated 02/16/10.
-An untimed order dated 02/22/10 to stop an anticoagulant medication.

During an interview on 04/29/10 at 1:20 p.m. the Director of HIM reviewed the patient's physician's orders and stated staff failed to time the orders.

5. Record review of closed Patient #20's admission history and physical revealed staff admitted the patient on 02/21/10 with diagnoses including mild pancreatitis (inflammation of the insulin producing organ the pancreas), possible underlying gallstones, high blood pressure, high blood lipids and diabetes.

Record review of the patient's physician's orders revealed the following:
-An untimed order from Gastroenterology service dated 02/22/10.
-An untimed order for cancer testing dated 02/22/10.

During an interview on 04/29/10 at 1:25 p.m. the Director of HIM reviewed the patient's physician's orders and stated staff failed to time the orders.

6. Record review of closed Patient #22's admission history and physical revealed staff admitted the patient on 03/16/10 with diagnoses including out of hospital cardiac arrest, possible anoxic brain injury (brain damage due to lack of oxygen) and pneumonia.

Record review of the patient's physician's progress notes revealed a four page order set titled Therapeutic Hypothermia for Treatment of Cardiac Arrest Survivors and pages one, two and three without authentication, date or time.

During an interview on 04/29/10 at approximately 1:30 p.m. the Director of HIM reviewed the patient's orders and stated staff failed to authenticate, date and time each page of the multi-page order set titled Therapeutic Hypothermia for Treatment of Cardiac Arrest Survivors as required.


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Findings included:

7. Record Review of Patient # 4's medical chart revealed the patient was in the Emergency Department on 4/26/10 for a laceration (cut) to the lip.
-Record review of the Clinical Impression revealed no date or time of authentication.

8. Record review of Patient # 6's medical chart revealed the patient was admitted to the facility on 4/25/10 for complaints of right knee pain.
-Record review on 4/27/10 at 11:00 a.m. revealed the following information:
The Admission Medication Orders had not been dated or timed by the physician.

9. Record review of Patient # 7's medical chart revealed the patient was admitted to the facility on 4/23/10 for left wrist fracture after a fall.
-Record review on 4/27/10 of the History and Physical dated 4/23/10 revealed no time of authentication.
-Record review on 4/27/10 of the History and Physical dated 4/26/10 revealed no time of authentication.
-Record review of the Post-Op Orders dated 4/26/10 revealed no time of authentication.
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Based on interview and record review facility staff failed to ensure physician verbal and telephone orders were authenticated within forty-eight hours as required in seven (Patient #6, #7, #69, #71, #73, #74, #20, #22, #26) of sixteen patient medical records reviewed for authenticated verbal orders. The facility census was 180 patients.

Findings included:

1. Record review of an undated copy of the facility Medical Staff Rules and Regulation, Section C. General Conduct of Care directed in part, the following:
-All orders for diagnosis and treatment shall be in writing. Verbal/telephone orders will address the "read back process". The responsible physician shall sign such orders within a timely fashion.

During an interview on 04/26/10 at 3:14 p.m. the Director of Health Information Management (HIM) stated the facility required physicians to authenticate verbal orders within forty-eight hours.

2. Record review of current Patient #69's admission history and physical revealed staff admitted the patient on 04/21/10 with diagnoses including altered mentation, weakness, and anemia, history of dementia, high blood pressure and stroke.

Record review of the patient's physician's orders revealed the following:
-An unauthenticated telephone order for a special mattress dated 04/22/10.
-An unauthenticated verbal order to discontinue Pepcid and start Protonix dated 04/23/10.
-An unauthenticated verbal order to insert a nasogastric tube dated 04/23/10.
-An unauthenticated telephone order to start breathing treatments, decrease the intravenous fluids and obtain a chest x-ray dated 04/23/10.
-An unauthenticated telephone order to change medications, obtain a radiology test in the morning and obtain a Pulmonary Services consultation dated 04/23/10.
-An unauthenticated telephone order for chest x-ray in the morning and for blood gas tests dated 04/23/10.
-An unauthenticated telephone order for blood gas studies in the morning dated 04/23/10.

3. Record review of current Patient #71's admission Nutrition Assessment revealed staff admitted the patient on 04/13/10 with right colon mass, history of colon cancer, surgical removal of the cancer, esophagogastrectomy (surgical removal of the lower part of the swallowing tube and upper stomach), hypertension, peripheral vascular disease (decreased blood circulation in the arteries to the arms and legs).

Record review of the patient's physician's orders revealed the following:
-An unauthenticated telephone order to consult the Infectious Disease Service dated 04/23/10.
-An unauthenticated telephone order to resume Physical and Occupational Therapies dated 04/24/10.
-An unauthenticated telephone order for changes in respiratory therapy dated 04/25/10.
-An unauthenticated verbal order for a bedside swallowing study dated 04/25/10.
-An unauthenticated verbal order for a change in intravenous solutions dated 04/25/10
-A five page unauthenticated, undated, untimed Medication Reconciliation Order form with verbal orders for continuation or discontinuation of medications.
-An unauthenticated Potassium Drug Therapy Protocol form with verbal orders to infuse potassium and obtain a blood level of potassium in the morning dated 04/26/10.

During an interview on 04/29/10 at 11:50 a.m. the Director of Nursing Operations 4 North & 4 West, Staff CCC reviewed the patient's verbal orders and stated the physicians failed to authenticate the verbal orders as required.

4. Record review of current Patient #73's admission history and physical revealed staff admitted the patient on 04/19/10 with chief complaints including mental status changes and dehydration.

Record review of the patient's physician's orders revealed the following:
-An unauthenticated verbal order for a spinal tap dated 04/21/10.
-An unauthenticated verbal order for intravenous medication, Valium dated 04/22/10.

During an interview on 04/29/10 at 11:20 a.m. Unit Clerk, Staff CCCC reviewed the patient's physician's orders and stated staff failed to authenticate the verbal orders as required.

5. Record review of current Patient #74's admission history and physical revealed staff admitted the patient on 04/19/10 with lower leg swelling and pain.

Record review of the patient's physician's orders revealed the following:
-An unauthenticated telephone order for clear liquid diet and two bottles of laxative dated 04/20/10.
-A page of unauthenticated, undated, untimed telephone admission orders for blood transfusion, blood testing, intravenous medications and compression stockings and titled continued from previous page.
-An unauthenticated, untimed, undated telephone order for blood thinning medication and blood testing recorded on a two page form titled Anticoagulation Orders.
-An unauthenticated, untimed order recorded on a form titled Device Reprogramming Orders for Medtronic.
-An unauthenticated verbal order directing staff to not place compression stocking on the patient dated 04/21/10.
-An unauthenticated verbal order for (an illegible entry) before and after surgery dated 04/21/10.
-An unauthenticated telephone order for intravenous infusion of normal saline solution dated 04/21/10.
-A second unauthenticated verbal order for intravenous infusion of normal saline solution dated 04/22/10.
-A third unauthenticated telephone order for intravenous infusion of normal saline solution dated 04/21/10.
-An unauthenticated telephone order to increase the intravenous fluids, give normal saline and if the urine output does not increase then, give another normal saline infusion dated 04/22/10.
-An unauthenticated verbal order to provide normal saline solution over two hours for decreased urine output dated 04/22/10.
-An unauthenticated telephone order to provide intravenous albumin dated 04/22/10.
-An unauthenticated telephone order for albumin {protein} infusion dated 04/22/10.
-An unauthenticated verbal order for intravenous Lasix dated 04/22/10.
-An unauthenticated telephone order to administer a blood thinning medication dated 04/26/10.

During an interview on 04/29/10 at 11:20 a.m. the Director of 3 North and 4 East, Staff V reviewed the patient's physician's orders and stated the physician's failed to authenticate the verbal orders.

6. Record review of closed Patient #20's admission history and physical revealed staff admitted the patient on 02/21/10 with diagnoses including mild pancreatitis (inflammation of the insulin producing organ the pancreas), possible underlying gallstones, high blood pressure, high blood lipids and diabetes.

Record review of the patient's physician's orders revealed an unauthenticated verbal order to keep the patient NPO (medical abbreviation for nothing by mouth) dated 02/22/10.

During an interview on 04/29/10 at 1:25 p.m. the Director of HIM reviewed the patient's physician's orders and stated staff failed to authenticate the verbal order within forty-eight hours as required.

7. Record review of closed Patient #22's admission history and physical revealed staff admitted the patient on 03/16/10 with diagnoses including out of hospital cardiac arrest, possible anoxic brain injury (brain damage due to lack of oxygen) and pneumonia.

Record review of the patient's physician's orders revealed the following:
-An unauthenticated verbal order for Levophed drip (medication used to treat low blood pressure) dated 03/16/10.
-An unauthenticated Sliding Scale Insulin Orders form with verbal orders dated 03/16/10.
-An unauthenticated verbal order to discontinue the Sliding Scale Insulin orders dated 03/16/10.
-An unauthenticated verbal order to administer bicarbonate and obtain arterial blood gases (blood test) dated 03/16/10
-An unauthenticated verbal order to call the physician if the lab tests of the blood showed a high content of a mineral potassium dated 03/16/10.
-A verbal order recorded on page one of a multi page set titled Insulin-Glucose Infusion order set dated 03/16/10.
-An unauthenticated verbal order to administer a medication to decrease the blood level of potassium dated 03/16/10.
-An unauthenticated verbal order to discontinue the intravenous solution containing potassium dated 03/16/10.
-An unauthenticated verbal order to discontinue the hypothermia protocol dated 03/16/10.
-An unauthenticated order to consult the Cardiology Service dated 03/16/10.

During an interview on 04/29/10 at approximately 1:30 p.m. the Director of HIM reviewed the patient's verbal orders and stated staff failed to authenticate the verbal orders within forty-eight hours as required.

8. Record review of closed Patient #26's admission history and physical revealed staff admitted the patient on 03/24/10 with diagnoses including cancer of the head and neck, kidney insufficiency and dehydration and poor social situation.

Record review of the patient's physician's orders revealed the following:
-An unauthenticated verbal order for intravenous pain medications (morphine and Demerol) dated 03/27/10.
-An unauthenticated verbal order to allow the staff to pronounce the patient dead dated 03/28/10.

During an interview on 04/29/10 at 1:30 p.m. the Director of HIM reviewed the patient's orders and stated staff failed to authenticate the verbal orders as required within forty-eight hours.





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Findings included
9. Record review of Patient # 6's medical chart revealed the patient was admitted to the facility on 4/25/10 for complaints of right knee pain.

-Record review on 4/27/10 at 11:00 a.m. revealed the following information:
· The verbal order dated 4/25/10 at 8:25 a.m. had not been timed by the physician.
· The verbal order dated 4/25/10 at 6:50 p.m. had not been signed, dated or timed by the physician.

10. Record review of Patient # 7's medical chart revealed the patient was admitted to the facility on 4/23/10 for left wrist fracture after a fall.
-Record review of a verbal order dated 4/26/10 at 9:12 a.m. revealed no date or time of authentication.

11. Record review of the facility policy on Ordering and Transcribing Medications PC - 421 in part revealed the following information:

5.4 Verbal and telephone orders will be reviewed and authenticated (signed, dated, and timed) by the prescriber at the earliest time available but not to exceed 48 hours.

Based on interview and record review facility staff failed to ensure completed patient admission history and physicals were on the medical records within twenty four hours of admission in six (Patient #74, #15, #18, #20, #22, #26) of fourteen medical records reviewed for completed patient admission history and physicals. The facility census was 180 patients.

Findings included:

1. Record review of an undated copy of the facility Medical Staff Rules and Regulation, Section B. Medical Records directed in part, the following:
-Paragraph B2. The medical history and physical assessment shall be completed, documented and included in the medical record within the first twenty-four hours of admission to inpatient services.
-Paragraph B2. D. The history and physical, including all updates, must be in the patient's medical record within twenty-four hours after admission.

During an interview on 04/26/10 at 3:14 p.m. the Director of Health Information Management (HIM) stated the facility required physicians to have an admission history and physical on the medical record within twenty-four hours of admission.

2. Record review of current Patient #74's admission history and physical (titled as clinic note) revealed staff admitted the patient on 04/19/10 with lower leg swelling and pain.

Further review of the admission history and physical (titled clinic note) revealed the patient was admitted on 04/19/10 and the documentation was electronically authenticated on 04/21/10.

During an interview on 04/29/10 at 11:20 a.m. the Director of 3 North and 4 East, Staff V reviewed the patient's admission history and physical (titled clinic note) and stated the document had all the required elements of a history and physical and the physician's failed to authenticate within twenty-four hours of admission.

3. Record review of closed Patient #15's admission history and physical revealed staff admitted the patient on 04/12/10 with diagnoses including hypotension (low blood pressure), bradycardia (slow heart rate), end stage kidney disease, diabetes, high blood fats, anemia and ischemic cardiomyopathy (heart muscle disease due to insufficient blood and oxygen).

Further record review of the patient's admission history and physical revealed the patient was admitted on 04/12/10 and the physician failed to authenticate the documentation.

During an interview on 04/29/10 at 1:15 PM the Director of Health Information Management (HIM) reviewed the patient's admission history and physical and stated the physician failed to authenticate the document.

4. Record review of closed Patient #18's admission history and physical revealed staff admitted the patient on 02/15/10 with diagnoses including brain tumor, mental status changes, confusion, fatigue, fatigue and lack of appetite.

Further record review of the patient's admission history and physical revealed the patient was admitted on 02/15/10 and the physician electronically authenticated the documentation on 02/17/10.

During an interview on 04/29/10 at 1:20 p.m. the Director of HIM reviewed the patient's admission history and physical and stated the physician failed to authenticate the documentation within twenty-four hours.

5. Record review of closed Patient #20's admission history and physical revealed staff admitted the patient on 02/21/10 with diagnoses including mild pancreatitis (inflammation of the insulin producing organ the pancreas), possible underlying gallstones, high blood pressure, high blood lipids and diabetes.

Further record review of the patient's admission history and physical revealed the patient was admitted on 02/21/10 and the physician electronically authenticated the documentation on 02/25/10.

6. Record review of closed Patient #22's admission history and physical revealed staff admitted the patient on 03/16/10 with diagnoses including out of hospital cardiac arrest, possible anoxic brain injury (brain damage due to lack of oxygen) and pneumonia.

Further record review of the patient's admission history and physical revealed the patient was admitted on 03/16/10 and the physician electronically authenticated the documentation on 03/18/10.

7. Record review of closed Patient #26's admission history and physical revealed staff admitted the patient on 03/24/10 with diagnoses including cancer of the head and neck, kidney insufficiency and dehydration and poor social situation.

Further record review of the patient's admission physician's orders revealed the physician admitted the patient on 03/24/10 and electronically authenticated the documentation on 03/29/10.

Based on interview and record review facility staff failed to ensure patient discharge summaries were on the medical record within thirty days of discharge in three (Patient #18, #22, #26) of seven closed medical records reviewed for completed discharge summaries. The facility census wads 180 patients.

Findings included:

1. Record review of an undated copy of the facility Medical Staff Rules and Regulation, Section B. Medical Records, paragraph B12 directed in part, the following:
-A discharge clinical summary shall be written or dictated on all medical records of patients hospitalized over forty-eight hours.
-All summaries shall be authenticated by the responsible practitioner.

During an interview on 04/26/10 at 3:14 p.m. the Director of Health Information Management (HIM) stated the facility policy directed physicians to complete a patient medical records within thirty days of discharge.

2. Record review of closed Patient #18's admission history and physical revealed staff admitted the patient on 02/15/10 with diagnoses including brain tumor, mental status changes, confusion, fatigue, fatigue and lack of appetite.

Record review of the patient's discharge summary revealed the physician completed the documentation on 04/21/10 (over two months after the patient's discharge).

3. Record review of closed Patient #22's admission history and physical revealed staff admitted the patient on 03/16/10 with diagnoses including out of hospital cardiac arrest, possible anoxic brain injury (brain damage due to lack of oxygen) and pneumonia.

Record review of the patient's discharge summary revealed the physician completed the documentation on 04/27/10 (over thirty days after the patient's discharge).

4. Record review of closed Patient #26's admission history and physical revealed staff admitted the patient on 03/24/10 with diagnoses including cancer of the head and neck, kidney insufficiency and dehydration and poor social situation.

Record review of the patient's physician's orders revealed an unauthenticated verbal order "okay to pronounce" dated 03/28/10.

Further record review revealed the physician failed to provide a discharge summary of the patient's admission and death as of 04/29/10.

Based on observation, interview and record review facility staff at the main campus and in the Radiology Department of the Brookside campus failed to ensure drugs, supplies and equipment intended for use during patient emergencies was maintain in a tamper-resistant, locked and secured manner. The facility census was 180 patients.

Findings included:

1. Observation on 04/28/10 at 9:48 a.m. in the Radiology Department, Brookside campus revealed an emergency cart with one of the drawers unsecured and easily opened by the surveyor.

During an interview on 04/28/10 at 9:48 a.m. the Radiology department Supervisory Nurse, Staff FFF stated the following:
-The locked emergency cart contained medication and equipment to be used in case of patient emergencies in the department.
-One drawer had remained unlocked when the lock on the cart was engaged.
-The defect had been reported.
-No repair or replacement of the cart or drawer had been done.
-Staff felt the one unlocked drawer remained secure because the entire cart was located in a secured area of the department.

Record review of the inventory check list titled Sterile Processing Code Blue Cart revealed the unsecured drawer of the cart should contain intravenous solutions, intravenous start kits and supplies.


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Findings included:

2. Observation on 4/26/10 at 3:02 p.m. revealed an unlocked cart sitting across from the nursing station in the Emergency Department. The cart contained supplies such as syringes, needles, Sodium Chloride in 10 cc syringes and 50 cc bags of Sodium Chloride.

During an interview on 4/26/10 at 3:03 p.m. with the Director of the Emergency Department (ED) Q stated the cart should be locked at all times and that someone had forgotten to lock it.

Based on observation, interview and record review facility staff failed to ensure the correct diet manual was accessible to physicians and unit nursing staff on two of five units reviewed for presence of the facility diet manual. The facility census was 180 patients.

Findings included:

1. During an interview on 04/26/10 at 1:50 p.m. the Director of Food Services, Staff C stated the approved facility diet manual, the Morrison Diet Manual, approved 07/28/09 was on line and accessible to nursing staff and unit personnel.

2. During an interview on 04/27/10 at 12:03 p.m. the Nurse Manager of Ortho/Neuro unit, Staff K stated the unit maintained a copy of the diet manual in a cabinet at the back of the unit.

Observation on 04/27/10 at 12:03 PM revealed the Nurse Manager of Ortho/Neuro unit; Staff K retrieved a loose leaf binder from a cabinet far from the nurse's station.

Record review of the loose leaf binder retrieved from the cabinet revealed the contents was the Manual of Clinical Dietetics, 6th edition (not the approved Morrison Diet Manual).

3. During an interview on 04/29/10 at 9:50 a.m. the Unit Clerk of Nephrology stated he/she had been in position for about five years and was not aware of a diet manual for the unit.

Based on observation, interview and record review facility staff failed to clean and maintain dietary department equipment and surfaces to prevent cross contamination of foods and supplies and prevent subsequent food borne illness; and failed to assure a sanitary environment and a high quality of infection control, and promote acceptable levels of safety and quality in patient care services in one patient only refrigerator on the sixth floor med-surg unit, one patient nourishment kitchen on the fourth floor, one ice machine on the third floor and two ice machines on the second floor. This deficient practice potentially affects all staff, visitors and census of 180 patients

Findings included:

1. Record review of the United States Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code directed in part the following:
-Chapter 3-302.12 Storage containers, identified with common name of food. Working containers holding foods removed from original packages shall be identified with the common name of the food.
-Chapter 3-305.11 Food shall be protected from contamination by storing the food in a clean dry location not exposed to dust or other contaminants.
-Chapter 3-305.12 Food may not be stored under other sources of contamination.
-Chapter 4-903.12 Cleaned, sanitized utensils and single-service and single-use articles {plastic forks, spoons, and knives} may not be stored under other sources of contamination.

2. Observation on 04/26/10 from 2:18 p.m. through 2:40 p.m. in the facility kitchen revealed staff failed to clean and maintain equipment and surfaces including:
-A heavily soiled floor in a walk-in refrigerator with littered with food spills and unknown debris.
-A reach-in refrigerator with heavily soiled tray racks ladened with food debris and blackened food remnants.
-A second walk-in refrigerator (where staff stored meats) with soiled shelving splashed with unknown food debris.
-A third walk-in refrigerator (where staff stored vegetables) with soiled food splashed shelving.
-A soiled unlabeled, undated bulk bin with white powdered food later identified as flour.
-Four metal can racks with heavily soiled can slides ladened with gray powdered debris easily dislodged by the surveyors finger tip.
-An opened to air case of plastic forks stored on a lower shelf.

Observation on 04/27/10 at 9:46 a.m. in the facility kitchen revealed staff failed to clean and maintain the following:
-Grease and food encrusted control knobs of the stove.
-Stove control panel between the soiled control knob fuzzy with tendrils of lint and grease.
-The soiled, black mold rimmed acrylic cutting board on the sandwich and cold food service unit on the patient tray assembly line.
-The black mold and dried food spattered table mounted can opener with metal can shaving encrusting the gears behind the blade.

3. During an interview on 04/27/10 at 9:50 a.m. the Director of Dietary, Staff C stated the department had a detail crew that deep cleaned equipment during the end of each month.


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4. Observation of a 6th floor med-surg lounge on 4/27/10 at 8:20 a.m. showed an unlabeled medication, Forteo, (an injection medication for the treatment of osteoporosis that stimulates new bone formation) in an unsecured staff use only refrigerator. There was no name or personal identification on the package.

During an interview on 4/27/10 at 8:30 a.m., the unit director took the package and said she did not know who it belonged to and would have to investigate. She returned a short time later and reported the injection belonged to a member of her staff who had picked up the prescription medication from pharmacy earlier that morning and did not have time to take the medication back home before beginning her shift at the hospital.

5. Observation of a 4-east nourishment kitchen on 4/27/10 at 2:10 p.m. showed two patient-use-only refrigerators in need of maintenance and cleaning. One had broken shelves inside the door, and red colored splatters from a liquid spill had dried and stained the lower interior surfaces, shelves and bottom of a second refrigerator, also labeled for patient use. A four inch wide by 24 inches deep area of brown stains and semi-dried liquid residue that looked like spilled coca-cola product was on the floor between the second refrigerator and kitchen cabinets.

6. Observation of the 3-north ice machine on 4/28/10 at 1:40 p.m. showed no siphon break or air gap between a hose that was plumbed from the drain directly into a floor drain below the surface level of the floor.

7. Observation of the 2-west and 2-east ice machines on 4/28/10 at 4:00 p.m. showed no siphon breaks or air gaps between the hose that was plumbed from the drain directly into a floor drain below the surface level of the floor.

During an interview on 4/28/10 at 1:50 p.m., the Director of Plant Operations said he would have them fixed immediately, as he called and ordered the repair. He said they opted to keep the hose in the drain so it did not get displaced or interfere with housekeeping efforts. He said they would simply T-off the drain and attach the drain tube to the lower end of the T to provide an air gap that would not sustain vacuum pressure.

8. Observation on 4/30/10 at 10:30 a.m. showed a large amount of paper and plastic trash lay on the concrete drive off of the rear shipping/receiving dock, where the trash compactor is located. A white plastic bag of trash, including paper and plasticware was split open on the ground exposing more paper trash and plastic cups. A light rainfall caused enough standing water in spots to float some of the plastic cups and plates around the base of the loading dock, potentially becoming a food source for uninvited pests and vermin.

During an interview on 4/30/10 at 10:30 a.m., the Environmental services Supervisor. (EVS) said she usually rotates the duty of staff climbing down to police up the area between a couple of her male housekeeping staff. She said one has been home sick recently and could not work, which has caused her to be a little behind. She said she does not have an official schedule or procedure by which to clean the area. She said she decides if the area needs cleaning based on what she sees and has them go down and pick up trash. She said the trash bags are supposed to be dumped into the compactor so that nothing ends up on the ground.

Based on observation, interview and record review facility infection control staff failed
-to develop a system to identify and control poor food handling practices in the dietary department and prevent possible food borne illness;
-to ensure the staff follow the facility hand hygiene policy when entering and leaving a patient's room;
-to ensure the staff followed the facility hand hygiene policy after removing gloves;
-to remove surgical attire as directed by facility policy;
-to follow the facility hand hygiene policy and wash hands with soap and water after exiting from one of one isolated patients' room (Patient #57). The facility census was 180 patients.

Findings included:

1. Record review of the facility Food Services policy #170-AC-1002, titled Personal Hygiene, effective 06/04 directed the following:
-All associates {dietary staff} will practice good personal hygiene habits at all times while on duty.
-The purpose of the policy was to prevent the spread of food borne illness.
-The guidelines included wear a clean uniform, wear hair restraints, no nail polish or artificial nails and wash hands after scratching head, touch hair, or other acts of a personal nature.

Record review of the United States Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code directed the following:
-Chapter 2-301.14 Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, after touching bare human body parts
or disposable tissue, using tobacco, eating, or drinking; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; after engaging in other activities that contaminate the hands.
-Chapter 2-302.11 A food employee may not wear fingernail polish or artificial fingernails when working with exposed food.
-Chapter 2-304.11 Food employees shall wear clean outer clothing to prevent contamination of food and equipment.
-Chapter 2-402.11 Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils.
-Chapter 3-304.15 Gloves, Use Limitation. Single-use gloves shall be used for only one task, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.

Record review of the facility Food Service policy, #170-EC-829, titled Hand washing HACCP) {hazard analysis critical control point}, effective date 03/06 directed all employees associated with handling foods shall wash hands before putting on gloves.

Record review of the facility policy, #CM-189, titled Hand Hygiene Policy, effective 07/06 directed staff to wash hands prior to donning gloves and after removing soiled gloves.

2. Observation on 04/27/10 in the facility kitchen revealed dietary staff failed to use good food handling practices including:
-At 11:00 a.m., Diet Aide, Staff D applied gloves without hand washing then, assembled foods and serving utensils for the patient noon meal service.
-At 11:10 a.m., Diet Aide, Staff E applied gloves without hand washing then, assembled foods and serving utensils for the patient noon meal service.
-At 11:12 a.m., Diet Aide, Staff F touched his/her face with gloved hands then, failed to remove soiled gloves, wash hands and apply clean gloves while assembling patient meal trays.
-At 11:13 a.m., Diet Aide, Staff KK wore artificial fingernails and hair extending outside of a hair net and worked on the patient tray assembly line.
-At 11:16 a.m., Diet Aide, Staff H with facial hair, walked though the food production without a beard cover.

During an interview on 04/27/10 at 11:14 a.m. the Director of Food Service, Staff C stated the following:
-The facility policy directed food employees not to wear fingernail polish or artificial nails.
-It was the responsibility of the lead staff or the shift supervisor to check the food employees for hair nets and nail polish at the beginning of the shift.

During an interview on 04/27/10 at 11:16 a.m. Diet Aide, Staff H stated he had been told to wear a beard cover over facial hair however had forgotten to wear one today.
During an interview on 04/27/10 at 11:16 a.m. the Director of Food Service, Staff C stated the Infection Control (IC) Nurse used to perform a quarterly review of procedures in the kitchen however, he/she had not seen the IC nurse recently.

Observation on 04/27/10 at 11:20 a.m. in the facility kitchen revealed the Lead Diet Aide, Staff G reached across the chest high food cart to retrieve a diet menu and touched the arm pit side of his/her short sleeve shirt to the tines of silverware wrapped and placed on a tray on top of the cart.

Observation on 04/27/10 at 11:22 a.m. in the facility kitchen revealed Chef, Staff I failed to use a tray or cart and held two bundles of produce against his/her shirt while carrying them to the refrigerator.

Observation on 04/27/10 at 11:29 a.m. in the facility kitchen revealed Lead Diet Aide, Staff G again reached across the chest high food cart to retrieve an article and touched the arm pit side of his/her short sleeve shirt to the rims of coffee mugs intended for use in patient tray service.

Observation on 04/27/10 at 11:29 a.m. revealed Maintenance Supervisor, Staff J with facial hair, walked through the food production area and failed to wear a beard cover.

3. During an interview on 04/28/10 at 1:50 p.m. the interim Infection Control Nurse, Staff FF stated the following:
-He/she had been in position since approximately 02/10.
-The previous Infection Control Nurse had input into the policies and procedures of different departments.
-The Infection Control Nurse should be involved with infection control policies and procedures in all facility departments.
-Hand hygiene was taught in new employee orientation and was not re-done annually.


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4. Observation on 04/26/10 at 2:50 p.m. revealed Registered Nurse O entered the patient's room in the Emergency Department without washing his/her hands with soap and water or hand sanitizer.
-Observation on 04/26/10 at 3:02 p.m. revealed Physician P entered and exited the patient's room in the Emergency Department without washing his/her hands with soap and water or hand sanitizer.
- Observation on 04/27/10, 04/28/10, 04/29/10 and 04/30/10 revealed numerous staff wearing scrubs, surgical booties, hats and face masks outside of the surgical area such as the hospital cafeteria.

5. During an interview on 04/26/10 at 3:15 p.m. the Director of the Emergency Department Q stated he/she would expect anyone entering or leaving a patient's room to perform hand hygiene.

6. During an interview on 04/27/10 at 2:05 p.m. Infection Control/Employee Health DD stated she would expect staff to wash or foam entering, leaving and between glove changes.

7. Record review of the Hand Hygiene Policy last revised on February 2010 stated in part the following:
IV. Purpose:
Hands are the principal route by which cross-infection occurs. Decontaminating hands by washing with soap and water or by using an alcohol-based hand sanitizer are simple and effective ways in which Health Care Worker (HCW) can prevent the transmission of infection between patients and protect themselves.
VI. Procedure
B. If hands are not visibly soiled, use an alcohol-based hand foam for routinely decontaminating hands:
* before having direct contact with patients
*after contact with a patient's intact skin (e.g. when taking a pulse or blood pressure, and lifting a patient).


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8. Observation of medication pass for Patient #57 on 4/28/10, at 8:45 a.m. revealed: The patient's clinical record confirmed the patient is in isolation for C-Diff (Clostridium difficile, often called C. difficile or "C. diff," is a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon). ICU (Intensive Care Unit) RN (Registered Nurse), ZZ, did a medication pass for eight medications. After administering the medications the RN took off her gloves and gown then proceeded to take medication packages with the patient's name on them out of the patient's room to discard them into a shredding bin at the nurse's station, and then washed her hands. The nurse failed to wash his/her hands with soap and water before leaving the patient's ICU room. Review of infection control/hand washing policy requires staff to wash their hands with soap and water prior to leaving the patient's room when caring for a patient with C-Diff.


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9. Review of Policy # CM-189 titled "Hand Hygiene Policy", with a review-revise date of 1/29/10, revealed the following: All employees are expected to perform appropriate hand hygiene before every episode of direct patient contact/care and after any activity or contact that potentially results in hands becoming contaminated.
10. Interview on 4/26/10 at 3:07 pm with Patient # 47, revealed there is no handwashing completed by ED staff or doctor when they were providing care to the patient.
11. Observation on 4/26/10 at 2:15 pm revealed Staff W, Registered Nurse (RN), Emergency Department (ED) Staff Nurse, entered Patient # 44's room without washing hands. The nurse typed on the in-room computer, scanned the patient's wrist band for medication administration, then opened medication packaging and administered it to the patient.
Observation on 4/26/10 at 3:02 pm revealed Staff XX, CT Technician, transported Patient # 46 into room 10 on a cart. Staff XX left the patient room without washing his/her hands.
Observation on 4/26/10 at 3:10 pm revealed Staff YY, RN, ED Staff Nurse, entered Patient # 47 ' s room without washing hands. Staff YY placed gloves on, took patient's blood pressure, answered portable phone, then gave IV pain medication of Fentanyl 100 mcg. Staff YY removed gloves, went to the bedside computer and documented on the computer. Staff YY then exited the room without washing hands.




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12.Observation on 04-29-10 at 10:20 AM showed RN (registered nurse) RRR wore gloves to prepare a specimen from the hernia sac, documentation on pathology requisition, and to put supplies in order. RN Staff RRR removed gloves and did not wash his/her hands. RN Staff RRR wore gloves to dispose of trash. RN Staff RRR removed gloves and did not wash hands. RN Staff RRR wore gloves to dispose of medication bottles and Normal Saline (salt water solution) IV (intravenous line used to administer medication and fluids into a vein) bag. RN Staff RRR removed gloves and did not wash hands. RN Staff RRR wore gloves for patient care and moving patient to a cart. RN Staff Nurse removed gloves and did not wash hands. During an interview immediately following the observation RN Staff RRR stated hand hygiene should be performed when hands were soiled and to try to perform hand hygiene between glove changes.
13.Interview on 04-29-10 at 10:50 AM RN Staff NNN Director of OR (operating room) stated that the expectation was for staff to use foam (a hand disinfectant) between glove changes.
14.Observation on 04-29-10 at 10:53 AM showed RN Staff XXX wore gloves while cleaning equipment. Gloves removed and did not wash hands. During an interview immediately following observation, RN Staff XXX stated hand hygiene should be performed between patients and after removing gloves.
15.Observation on 04-29-10 at 1:20 PM showed RN Staff YYY wore gloves to insert and IV. Gloves removed and hand hygiene not performed. RN Staff YYY wore gloves to prepare blood specimen. Gloves were removed and did not wash hands. During interview immediately following observation, RN Staff YYY stated hand hygiene should be performed before patient care and to try to wash as often as one can.