HospitalInspections.org

Based on a Life Safety Code Validation survey, the Condition of Physical Environment is not met based on the results of the Division of Safety Inspection completed on January 13, 2010. Those deficient practices and the associated regulations can be found in the respective Life Safety Code survey (0OIU11).

Based on review of facility documents, review of medical records (MR), and staff interviews (EMP), it was determined that the facility failed to provide Medicare beneficiaries with an Important Message from Medicare within two calendar days (48 hours) of discharge from the facility for five of five medical records reviewed (MR9, MR10, MR11, MR12, and MR13).

Findings include:

Review of facility policy "Registration of Medicare Patients Date: June 2009 " revealed "Purpose : To ensure proper registration of inpatients with Medicare Insurance ... documentation of notification of Hospital Discharge Appeal Rights to Medicare beneficiaries. ...3. Registrar will provide Medicare patient with notification of Hospital Discharge Appeal Rights to Medicare beneficiaries form for review and signature. This form will be sent to the floor and placed in the patient's chart. The original will serve as primary notification- per Medicare guidelines."

Review of Care Management Policy and Procedure "Case Management Program revised December 2007" revealed " Procedure: ... 11. a. Ensuring compliance with contractual obligations for notification, authorization and documentation where applicable. ... 3) Within 48 hours of planned discharge, the case managers will obtain 2nd signature on the Notice of Hospital Discharge Appeal Rights. "

1) Review of MR9 revealed that the patient was admitted on September 15, 2009, and was discharged on October 30, 2009. Further review of MR9 revealed no documented evidence that within 48 hours of discharge that a 2nd signature was obtained on the "Notice of Hospital Discharge Appeal Rights" form as required by facility policy.

2) Review of MR10 revealed that the patient was admitted on June 9, 2009, and was discharged on June 17, 2009. Further review of MR10 revealed no documented evidence that within 48 hours of discharge that a 2nd signature was obtained on the "Notice of Hospital Discharge Appeal Rights" form as required by facility policy.

3) Review of MR11 revealed that the patient was admitted on, and was on October 29, 2009 and discharged on November 17, 2009. Further review of MR11 revealed no documented evidence that within 48 hours of discharge that a 2nd signature was obtained on the "Notice of Hospital Discharge Appeal Rights" form as required by facility policy.

4) Review of MR12 revealed that the patient was admitted on January 4, 2010, and was discharged on January 15, 2010. Further review of MR12 revealed no documented evidence that within 48 hours of discharge that a 2nd signature was obtained on the "Notice of Hospital Discharge Appeal Rights" form as required by facility policy.

5) Review of MR13 revealed that the patient was admitted on January 8, 2010, and was discharged on January 20, 2010. Further review of MR13 revealed no documented evidence that within 48 hours of discharge that a 2nd signature was obtained on the "Notice of Hospital Discharge Appeal Rights" form as required by facility policy.

6) Interview with EMP15 on January 29, 2010, at approximately 11:30 AM confirmed the above findings and revealed "We haven't got the second signature for more than six months; admissions and discharge is supposed to do that now."

Based on a review of facility policies, review of medical records (MR), and interviews with staff (EMP), it was determined that the facility failed to ensure each patient's plan of care was modified to include the use of physical restraints for five of five restraint medical records reviewed (MR3,MR4,MR6, MR8 and MR15).

Findings include:

Review of facility policy, "Standard of Nursing Practice," revised January 2010, revealed, "I. Documentation must be in accordance with a written modification of the patient's plan of care."

Review of facility policy "Nursing Problem List" revised August, 2008, revealed "3. The Problem List will be re-evaluated every 24 hours and whenever necessary according to the patient's condition. ... 4. Problems will be stated as nursing diagnoses (which reflect the Standards of Care) and include related factors. ... 13. Problems will be numbered and the nurse will develop the Problem list/plan of care based on collaboration with the patient, significant others, and other disciplines."

1) Review of MR3, MR4, MR6, MR8, and MR15 on January 27-28, 2010, revealed an order for restraints. Further review of MR3, MR4, MR6, MR8 and MR15 revealed no documented evidence that the patient's problem list addressed the patients' need for restraints.

Interview on January 28, 2010, at 2:10 PM with EMP4 confirmed the above findings and revealed " [There is] no written plan of care on medical records related to restraints because the order for restraints triggers the nursing practice standard for patient care."

Interview on January 28, 2010, at 3:25 PM with EMP4 confirmed the above findings and stated "Yes it is our education to form a plan of care. Yes the patient problem list is our care plan."

Based on review of Medical Staff Bylaws, facility policy, facility documents, and staff interviews (EMP), it was determined the facility failed to investigate incidents, ensure the investigation of all reports of serious events and incidents, and to report serious events to the Department within 24 hours of the medical facility's confirmation of the occurrence.

Findings include:

Review of the "Medical Staff Bylaws" dated April 2009, revealed "h) ... Patient Safety shall be responsible for: ... (iii) Evaluating investigations, root cause analyses, and actions."

Review of "Patient Safety Improvement & Management Program" dated January 2009, revealed "Key Definitions: ... Serious Event - An event, occurrence, or situation involving the clinical care of a patient in a medical facility ... that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health services to the patient. ... Incident - An event, occurrence, or situation involving the clinical care of a patient in a medical facility ... which could have injured the patient but did not either cause an unanticipated injury or require the delivery of additional health care services to the patient. Infrastructure Failure An undesirable or unintended event, occurrence, or situation involving the infrastructure of a medical facility (hospital, ambulatory surgery facility, or birthing) or the discontinuation of significant disruption of a service, which could seriously compromise patient safety ... Authority and Responsibility: ... Patient Safety Officer ... Ensure compliance with sentinel event, serious event, incident, and infrastructure failure reporting requirement as mandated by law/regulations or to meet accreditation standards; Oversee the investigation of serious events and as appropriate identified incidents ... Patient Safety Committee The patient Safety Committee (PSC) is an interdisciplinary committee comprised of individuals with organizational responsibility for the development of a safety plan and ongoing monitoring and evaluation of the implementation and effectiveness of the same ... The PSC will meet monthly to evaluate investigations, root cause analyses, and actions; review and evaluate the quality of patient safety measure utilized. It will report, at least quarterly, the number of serious events and incidents and their recommendations to eliminate future occurrences ... External Reporting - A serious event report or incident as defined in PA Act 13 must be submitted to the Patient Safety Authority and/or the Department of Health no later than 24-hours after the occurrence or discovery of the serious event or incident."

Review of policy "Incident Reporting" dated August 2009, revealed "D. The Risk Manager will: 1) Review all reports 2) Investigate incidents to determine the cause 3) Report incidents to the appropriate parties or committee 4) Recommend corrective action 5) Determine trends in occurrence 6) Follow-up to assess improvement 7) Conduct a Root Cause Analysis when appropriate ... Reporting And Follow-UP 1. Events/Situations that are reported to the Risk Manager will be reviewed, evaluated and outcomes reported to the appropriate committees and senior administrators. 2. After review of an event(s) and consultation with the Patient Safety Officer and the Vice President of Hospital Administration, the Risk Manager will be responsible for reporting events to the PA Department of Health and the Patient Safety Authority"

1) A request was made on January 26, 2010, to review the investigations for incidents/events and none was provided.

Interview with EMP14 on January 27, 2010, at approximately 9:00 AM confirmed the above findings and revealed "We look at them but I don't have any documentation [of investigations] to show you."

Interview with EMP14 on January 27, 2010, at approximately 9:30 AM revealed "Only serious events get reported to the Patient Safety Committee." During further interview with EMP14; EMP14 stated "We do not report anything to the Department of Health except serious events."

3) Review of serious event reports from March 2009 thru November 2009 revealed that six serious events were reported to the Department.

Further review of the six events revealed that three of six were reported past the required 24 hours.

Review of Event 1 revealed the event occurred on January 10, 2009, was confirmed on January 14, 2009, and was reported to the Department on March 3, 2009.

Review of Event 2 revealed the event occurred on January 28, 2009, and was not confirmed until March 2, 2009.

Review of Event 3 revealed the event occurred on September 11, 2009. Further review revealed that testing on September 11, 2009, confirmed the serious event. The report to the Department was on September 15, 2009.

Interview with EMP14 on January 27, 2010, at approximately 9:30 AM confirmed the above findings and revealed "My interpretation of the 24 hours was after I confirmed it[serious event]. Further interview with EMP14 revealed "Some of them [serious events] have an investigation and some don't, we decided they didn't warrant an investigation."

Based on review of facility policy, medical records (MR), and staff interviews (EMP), it was determined that the facility staff failed to ensure that medications were administered only upon accurately written and signed orders of a practitioner for three of three medical records reviewed (MR3, MR15, and MR17).

Findings include:

Review of Medical Staff "Rules and Regulations", approved April 2009, revealed ": ... A. Orders ... All orders for medications must specify the drug, dosage, route, and frequency of administration and include the date, time the order was written, and the signature of the authorized prescriber writing the order."

Review of "Policy: Prescribing Guidelines: Regulations For Writing Orders, Prescribing, Dispensing, and Administering Medications At Fox Chase Cancer Center ... Authorized Prescribers: ... All orders must be legible, specific, and complete. All orders for medications must specify the drug, dosage, route, and frequency of administration."

Review of "Standard Of Nursing Practice Practice Area: Continuos I.V. Propofol (Generic Diprivan) in the Intensive Care Unit Standard: The critical care nurse will institute measures to assure safe and accurate administration of propofol. ... A. Indications for use: 1. The nurse will ensure that propofol is ordered for an appropriate indication ... C. Administration: ... 7. Reduce rate of administration for daily evaluation of level of consciousness. To determine minimal dose required for desired level of sedation (Ramsay Sedation Scale 3-4)

1) Review of MR3 physician order dated September 24, 2009, revealed "Propofol gtts. titrate to deep sedation."

2) Review of MR15 revealed a physician order "10/12/09 3 pm ... propofol titrate to appropriate sedation" further review revealed "10/14/09 1830 pm propofol gtt(drip) titrate to effect"

3) Review of MR17 telephone verbal order dated July 20, 2009, at 7:00 PM revealed "Maintain propofol drips for sedation ... "

4) Interview with EMP23 on January 27, 2009, at approximately 10:00 AM confirmed the above findings and revealed "That's not written correctly, they(physicians) should put a Ramsay score."

5) Interview with EMP12 on January 28, 2009, at approximately 2:00 PM confirmed the above findings and revealed "I know we are writing propofol to sedation and I know it should be to at least a Ramsay scale."

Based on review of Medical Staff Rules and Regulations, facility policy, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure verbal orders were dated and timed by the ordering practitioner within 24 hours for seven of eight medical records reviewed (MR1,MR3, MR4, MR6, MR15,MR16 and MR17).

Finding include:

Review of the Medical Staff "Rules and Regulations" approved April, 2009, revealed "2. Verbal Orders ... Transcriptions of verbal orders must be countersigned by the authorized prescriber within twenty-four (24) hours. The countersignature should be dated to show evidence that the order was signed within 24 hours. "

Review of facility policy "Prescribing Guidelines: Regulations for Writing Orders, Prescribing, Dispensing, and Administering Medications At Fox Chase Cancer Center" dated April 2009, revealed "Authorized Prescribers: All orders for medications must be written, dated, and signed by a physician, dentist, or other practitioner authorized to prescribe medications in the state of Pennsylvania. ... Verbal Orders: ... Transcriptions of verbal orders must be countersigned by the prescriber within 24 hours."

1) Review of MR1, MR3, MR4, MR5, MR6, MR15, MR16, and MR17 revealed 106 verbal/telephone orders dated March 11, 2009, thru January 25, 2010, that were not dated and timed by the ordering practitioner.

Interview with EMP4 on January 27, 2010, at approximately 11:30 AM confirmed the above findings and revealed "We missed the mark on the verbal order sticker for time and date. No they are not timed or dated by the physician."

Based on review of facility policies, facility documents, and staff interviews (EMP), it was determined that the storage of drugs was not provided at a location with proper temperature controls.

Findings include:

Review of facility policy "Medication Storage Area Inspections" revised April 2009, revealed "Procedures Pharmacy personnel will inspect all medication storage areas on a monthly basis using the drug storage area inspection form. ... 1. Refrigerators 1.1 Thermometer must be present and temperature reading between 2-8 C."

Review of "Infection Control Manual Nursing Service" revised December 2009, revealed "4. Monitoring, Cleaning and Maintaining Unit Area Refrigerators a) Medication Refrigerators All medication refrigerators must be monitored on a daily basis to assure that medication is stored in a safe environment. - Temperature log must be maintained on a daily basis. ... c) If the temperature of either medication or patient food refrigerators is noted to be less than 36 F or greater than 46 F: - Check the thermostat setting and correct as necessary - Recheck the temperature in one hour and document - If the temperature is still outside of the correct range, contact the Maintenance Department to evaluate and repair the refrigerator and document this action on log sheet."

1) Review of Intensive Care Unit (ICU) "Medication Refrigerator Temperature Log dated December 2009" on January 27, 2010, revealed no documented evidence of temperature readings for 19 days. Further review of the ICU "Medication Refrigerator Temperature Log" for January 2010 revealed no documented evidence of temperature readings for 13 days.

Interview on January 27, 2010 at 12:15 PM with EMP11 confirmed the above findings and revealed "The charge nurse should assign someone to do it. It has been inconsistent for the last six months."

2) Interview on January 28, 2010 at approximately 10:15 AM with EMP13 revealed "Temperature monitoring of the refrigerator is done by the staff in that area. Pharmacy is responsible for medications. I was stunned to see it; that the logs were inconsistent."