The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on observations and staff interview, the facility failed to ensure that the patients' right to privacy, which included the patients' presence and location in the facility, was maintained. This was evident on two (2) of five (5) Nursing Units toured, the (Cardio-Thoracic Intensive Care Unit {CT-ICU} and the Surgical / Medical ICU).


During a tour of the Surgical / Medical ICU on 03/24/15 at 1:00PM, Telemetry Monitors were observed positioned on the wall in the hallway outside the Isolation Rooms displaying the first and last names of the patients housed in the Unit. These Monitors were in full view of anyone walking into that area of the Unit.

During a tour of the adjacent Cardio-Thoracic ICU at 1:30PM, observations revealed additional Telemetry Monitors were positioned on the wall of the Unit hallway outside Rooms #23 and #26. These Monitors also displayed patients' first and last names, which were visible to other patients, visitors and staff walking in the corridor.

During an interviews on 03/24/15 at 1:45PM, both Staff Members #1 and #2 confirmed that the Monitors displayed the patients' first and last names. Staff #3 stated "We had considered using only last names with first initials, but that was felt to be a patient safety concern".

This finding was confirmed with Staff #4 at that time.
Based on observations, document review and staff interview, it was determined that the facility did not ensure confidentiality of the patient's Medical Record, in one (1) out of one (1) observations made (Patient #13).


During a tour of the Post Anesthesia Care Unit (PACU) on 03/20/15 at 1:00PM, pages of the Medical Record (the Surgical Safety Checklist, the Operative Assessment Plan and the Perioperative Services Operating Room Count Sheet) for Patient #13 were found placed on top of the Critical Care Cart in the hallway near PACU (Post Ambulatory Care Unit) Beds #15 and #16, visible to other patients, visitors and staff walking into the area. This patient had surgery on 05/30/14 and was discharged the same day, over nine (9) months ago.

On interview at the time of the observation, Staff #5 stated that "The pages of the Medical Record should not have been left on the cart".

The current Medical Staff Rules and Regulation document under the Section titled HIPAA (Health Insurance Portability and Accountability Act of 1996) that "All members shall maintain the confidentially, privacy, security and availability of all protected health information in records maintained by the hospital" and "protected health information shall not be requested, accessed, used, shared, removed, released or disclosed".

This observation was confirmed with Staff #6.
Based on document review and interview, the facility failed to ensure that corrective actions for Medication Occurrences were completed and monitored by the facility's Quality Improvement Organization. This was evident in forty-five (45) out of fifty-three (53) Occurrences reviewed.


Medication Occurrences document review on 03/25/15 at 10:30AM revealed that forty-five (45) out of fifty-three (53) Medication Occurrence Reports for 2014 without Plans of Action or Final Resolutions documented.

On interview with Staff #4 on 03/25/15 at 11:40AM, Staff #4 stated that she compiles a Medication Occurrence Summary Report, which is presented and discussed at the Hospital-Wide PICG (Performance Improvement Committee Group) Meetings. Staff #4 stated this Report lists all Medication Occurrences and their respective Plans of Action.

Document review of the Report titled "2014 Medication Report for Safety" dated 03/13/15, revealed the date and time of the Medication Occurrence, the reported concern / error, the issue / reason the Incident occurred, the duration and the Nursing Unit the Incident occurred on. During interview, Staff #4 identified an untitled column as the area for the documentation of the Resolution. Further review revealed that this column documented "Process" as the Resolution in thirty-three (33) out of the fifty-three (53) total Occurrences. There were only eight (8) out of the fifty-three (53) total Occurrences that had Final Resolutions documented.

On interview Staff #4 identified an additional two (2) Final Resolutions that were not documented on the original Medication Occurrence Report or the 2014 Medication Report for Safety.

Upon further interview on 03/25/15 at 12:41PM, Staff #4 stated "Many times the Occurrence may be referred to the respective Nurse Manager who may counsel a staff member, or refer that staff member to education for remediation. Often times, I do not always get the results back to my Department". When asked how the Incident is finally closed on the Occurrence Report, if this information does not come back to your Department. Staff #4 stated "The Nurse Manager may document the outcome in a staff member's file. I may have some emails from the Nurse Managers documenting this". Staff #4 added "I could probably add a column to the existing Report to document the Final Resolution".

Based on record review and interview, the facility failed to ensure timely documentation of initial Wound Care Assessment and Wound Care Services provided for one (1) out of five (5) Colostomy / Ileostomy Patients (Patient #17).


Review of Medical Record on 03/23/15 at 9:30AM revealed that Patient #17 is a [AGE]-year-old female with a history of Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), Diverticulitis and an Ileostomy (as a result of the Diverticulitis). Patient #17 (MDS) dated [DATE] at 6:10PM with complaints of not being able to urinate for two (2) days prior to admission. Patient #17 was admitted for Acute on Chronic Renal Failure and for Rehydration.

An ED Nurse's Note dated 01/08/15 at 2:20AM documented "Patient has a large abdominal dressing leaking green drainage from the ileostomy ... patient has a Stage 2 bilateral buttocks ... ".

A Patient Profile Note dated 01/08/15 at 3:04AM documented the patient had "Colostomy and G-Tube, triple stomas with watery green color drainage and Stage 2 Pressure Ulcer to buttocks" on admission.

A Physician History and Physical Note dated 01/08/15 at 12:31PM documented that the "Patient has a colostomy bag over two (2) open lesions in abdomen with G-Tube present" as well as "Pressure Ulcer of buttock, unspecified laterality, Stage 2. Plan: continue Wound Care, Wound Care Nurse consulted".

A Wound Care Consult Order was entered on 01/07/15 at 11:25PM. The Order was acknowledged by a staff RN on 01/08/15 at 3:21AM. The Order was documented as completed by Staff #9 on 01/21/15 at 3:15PM.

The Initial Wound Care Advanced Practice Nurse Consult Note, written by Staff #9 was dated 01/13/15 at 6:50PM. A second follow-up Consult Note was initially entered on 01/15/15 at 7:36PM, then revised on 01/21/15 at 2:07PM. A final Discharge Note was dated 01/21/15 at 2:28PM.

On interview with Staff #9 on 03/24/15 at 10:40AM, it was revealed that Patient #17 was evaluated and treated by this Wound Care Nurse prior to documenting the Initial Wound Care Assessment on 01/13/15. Staff #9 states that she attended to Patient #17 on 01/08/15, 01/09/15 and 01/11/15, but did not document these encounters on Patient #17's Medical Record. This was verified with Staff #10 on 03/24/15 at 11:30AM and Staff #11 on 03/24/15 at 11:52AM.

Nursing documentation on 01/11/15 at 4:00PM by Staff #13 stated "Wound Care Nurse [Staff #17] attended to patient. New wound pouch applied and attached to Dignicare drainage system ... ".

Nursing documentation on 01/08/15 at 4:26PM by Staff #14 stated "Ileostomy appliance changed by Wound Care Nurse ... ".

Nursing documentation on 01/9/15 at 4:39PM by Staff #14 stated "Ileostomy with appliance in place with leakage from side noted. Wound Care Nurse attended and changed. Skin excoriation present. Mepilex to bilateral buttock Stage 2 in place ... ".

Interview with Staff #12 on 03/24/15 at 12:00PM verified that although the facility's current Wound Care Clinical Guidelines do not specify a timeframe in which Wound Consults are to be completed, the staff member confirmed the six (6) day lapse between the Wound Consult Order and the documentation of the Wound Care Initial Assessment was excessive. Staff #12 also verified that the undocumented Wound Care Services provided should have been documented in the patient's Record.
Based on record review and interview, there was no documented evidence that the facility ensured that the Initial Discharge Plan was arranged for Post-Operative Same Day Surgery Orthopedic Patients in five (5) out of eight (8) records reviewed (Patents #12, #24, #25, #27 and #28).


Review of Patient # 12's Medical Record on 03/20/15 at 1:15PM revealed that the patient was admitted to Same Day Surgery on 03/20/15 with a diagnosis of Left Knee Arthrofibrosis and underwent a Left Knee Manipulation under sedation at 11:46AM. The "ASU (Ambulatory Surgery Unit) Discharge Plan" documented that the patient would be going home, and under "Special Instructions", documents "Continued use of CPM (Continuous Positive Motion) Machine"; "Patient to continue Physical Therapy. Prescription issued for Physical Therapy five (5) x (times) a week for six (6) weeks" and "Aggressive left knee ROM 0-120 degrees of flexion recommended".

The Record also contained a prescription for both the Physical Therapy and the Instructions for the CPM Machine. However, there was no documentation found in the Medical Record indicating if the patient had the CPM Machine or was instructed on its use.

On interview at the time of the record review, Staff Members #7 and #5 stated they did not know if the Physical Therapy was arranged or if the patient had the CPM Machine.

An interview with Patient #12 at 1:30PM revealed that the CPM Machine was arranged and delivered to his home on 03/19/15, the day prior to surgery by the Orthopedic Surgeon's Office. The patient stated he has "an appointment at home with a Physical Therapist later today for instructions on using the machine". This information was then confirmed by a copy of the "Customer Information Form" obtained from the Physician's Office.

An interview at 2:00PM on 03/20/15 with Staff #8 revealed that there is a person in the Orthopedics' Office responsible for getting the DME (Durable Medical Equipment) delivered to the patient's home and instructing the patient prior to surgery, but this information is not documented in the Medical Records.

Review of the "Discharge Planning Policy" dated 03/2015, revealed that there is no formal mechanism for the Same Day Surgery Staff to obtain the information from the Orthopedic Surgeon's Office to ensure that the Initial Discharge Plan is arranged.

Review of the Medical Record for Patient #24 revealed that the patient was admitted to Same Day Surgery on 02/09/15 with a diagnosis of Degenerative Joint Disease with a Medial Meniscal Tear and underwent a Right Knee Arthroscopy with a lateral Meniscectomy and Debridement. The "ASU Discharge Plan" documented under "Special Instructions" to "Start Physical Therapy as soon as possible" but there is no documentation contained in the Medical Record that the patient received a prescription for Physical Therapy or that a referral for follow-up was provided.

Review of the Medical Record for Patient #28 revealed that the patient was admitted to Same Day Surgery on 03/16/15 with a diagnosis of Bilateral Knee Arthrofibrosis and underwent Bilateral Knee Manipulation under sedation. The "ASU Discharge Plan" documented under "Special Instructions" to "Ice and elevate Bilateral Knees. Physical Therapy weight bear as tolerated" but there is no documentation contained in the Medical Record that the patient received a prescription for Physical Therapy or that a referral for follow-up was provided.

During interview on 03/24/15 Staff #4 stated that the Physical Therapy was arranged pre-operatively and provided the referral information made by the Physician's Office.

Similar findings were identified during Medical Record review for Patients #25 and #27.