HospitalInspections.org

A. Based on clinical record review and staff interview, it was determined in 1 (Pt. #27) of 6 clinical records reviewed with restrained patients, the Hospital failed to ensure there were physician's orders for all restrained patients.

Findings include:

1. The clinical record of Pt. #27 was reviewed on survey date 06/23/10. The patient was restrained on 03/07/10 at 4:30 am and there was no physician's order for the restraint.

2. The above finding was verified with the Quality Coordinator on 06/23/10 at 10:00 am.

A. Based on Hospital policy, review of clinical records and staff interview, it has been determined in 1 (Pt. #12) of 5 clinical records reviewed with blood administration that the Facility failed to ensure policies were always followed.

Findings include:

1. The Hospital policy indicated that all nurses are responsible for following the guidelines for safe, proper administration of blood components and products.

2. Pt. #12 was admitted to the hospital on 05/12/10. Pt. #12 received one unit of PRBCs on 05/14/10. The blood component transfusion form did not have the required dual signatures. The witness' signature was present and the form lacked the transfusionist's signature.

3. During an interview conducted on 06/23/10 at 11:30 AM with the Quality Improvement Coordinator, the above finding was confirmed.

A. Based on a written statement of delinquent medical records and staff interview, it was determined that the Hospital failed to ensure all medical records were processed in a timely manner.

Findings include:

1. A delinquency rate for dates ranging from 05/22/10 - 06/21/10 indicated that there were 251 delinquent records as of 06/21/10.

2. During an interview conducted on 06/21/10 at 10:00 AM with the Quality Improvement Coordinator, the above finding was confirmed.

A. Based on a review of the medical staff rules and regulations, medical record review and staff interview, it was determined that in 5 of 30 (Pt #'s 10, 21, 25, 27, & 29) medical records reviewed, the Hospital failed to ensure that telephone orders were signed, dated and timed by the physician within 48 hours of the order.

Findings include:

1. The Hospital Medical Staff Rules and Regulations were reviewed on 06/21/10. It indicated under section, "11. Physician Orders a) Timeframe: ...Telephone orders shall be used sparingly and authenticated by the ordering practitioner within 48 hours of the order.".

2. The medical record of Pt. #10 was reviewed on 6/21/10. Documentation indicated that Pt. #10 was admitted on 6/19/10 with diagnoses of Respiratory Acidosis, Congestive Obstructive Pulmonary Disease, Diabetes Mellitus and Obesity. Documentation indicated that one telephone order written on 6/19/10 and three telephone orders written on 6/20/10 were not signed by the physician as of 6/23/10.

3. The medical record of Pt #21 was reviewed on 06/23/10. Documentation indicated that Pt #21 was admitted on 01/23/10 with a diagnosis of Subcutaneous Abscess. Documentation indicated that from 01/24/10 to 01/27/10, there were four telephone orders written. The physician's signature, date and time were not completed until 02/15/10, 02/16/10 and 02/17/10.

4. The medical record of Pt. # 25 was reviewed on 6/23/10. Pt. #25 was admitted to the Hospital on 2/12/10 with the diagnosis of Left Hip Fracture. Documentation indicated that one telephone order written on 2/14/10 and two telephone orders written on 2/16/10 were not signed by the physician until 3/4/10.

5. The medical record of Pt. #27 was reviewed on 6/23/10. Pt. #27 was admitted to the Hospital on 3/7/10 with the diagnosis of Chest Pain. Documentation indicated that four telephone orders written on 3/7/10 were not signed by the physician until 3/12/10.

6. The medical record of Pt #29 was reviewed on 06/23/10. Documentation indicated that Pt #29 was admitted on 01/28/10 with a diagnosis of Left Knee Infection. Documentation indicated from 01/29/10 to 02/02/10, there were nine telephone orders written. The physician's signature, date and time were not completed until 02/18/10 to 02/25/10.

7. During an interview conducted on 06/23/10 at 2:00 PM with the Quality Improvement Coordinator, the above findings were confirmed.

A. Based on observation and a tour of the pre-operative holding area, it was determined that all medication carts were not secure and locked.

Findings include:

1. A tour of the pre-operative holding area was conducted on 06/22/10. The medication cart was locked but the top two levels were broken and patient medications were accessible.

2. During an interview conducted on 06/22/10 at 10:00 AM with the Education Interim Manager, the above finding was confirmed.

A. Based on policy and procedure, observation, and staff interview it was determined that the Hospital failed to ensure that all foods were labeled with dates per policy.

Findings include:

1. The Hospital policy titled, "Infection Control" under "Policy Regarding Cold Food Storage" under 11. "Foods taken out of the original container or case will be labeled with a date and time. Frozen foods will be used within 6 months of that date and refrigerated items will be used with in 7 days or discarded." was reviewed.

2. During a tour of the dietary department on 6/22/10 at 1:00 PM, a ziplock bag containing sliced meat was observed in the refrigerator without a date. It was observed that several plastic containers of different fruits had no dates.

3. During a tour of the North nursing unit on 6/21/10 at 11:00 AM, 5 individual ice cream containers and 2 individual sherbets were observed in the patient's freezer without dates.

4. During an interview with the Quality Improvement Coordinator on 6/22/10 at 2:00 PM, the above findings were confirmed.

A. Based on Hospital policy, observation and a tour of the Operating Room/Suites, it was determined that the Hospital failed to ensure all policies associated with the control and prevention of Infection were followed as required.

Findings include:

1. Hospital policy #MCOR002 indicates "Head and facial hair, including sideburns and neckline, will be covered while in the semi-restricted and restricted areas of the surgical suite."

2. During a tour of the OR and suite #7, conducted on 06/22/10, it was observed that the Circulating Nurse had a significant amount of scalp hair exposed from the surgical cap.

3. During an interview conducted on 06/22/10 at 10:00 AM with the Surgical Director and Interim Educator, the above finding was confirmed.

A. Based on a tour of the (Obstetrics) OB/GYN department and interview with the Housekeeping staff, it was determined that Hospital failed to ensure all staff were aware of and implemented infection control procedures to prevent potential cross contamination of contagions.

Findings include:

1. A tour of the Obstetrics department was conducted on 06/21/10. The Housekeeper was interviewed and asked what his environmental mop bucket contained. The Housekeeper revealed that the disinfectant utilized had a contact time on non-porous, hard surfaces of "1 minute." Documentation on the manufacturer's instructions/data indicated that the contact time, (amount of time the product is to remain wet on a surface for full effectiveness), for this product is 10 minutes.

2. During an interview conducted on 06/21/10 at 10:00 AM with the Interim Educator, the above finding was confirmed.