HospitalInspections.org

Based on the Life Safety Code Validation survey completed on March 21, 2012, the Condition for Physical Environment is not met. See the Division of Safety Inspection 2567 for the specific findings.

Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined the facility failed to provide Medicare beneficiaries with the "Important Message from Medicare" form within two calendar days (48 hours) of discharge from the facility for four of five records reviewed (MR 40, MR41, MR42, and MR43).

Findings include:

Review on March 15, 2012, of the facility's "Important Message From Medicare Distribution," dated July 2011, revealed "I. Purpose: To make sure each Medicare of Medicare Advantage Patient receives 'The Important Message From Medicare'. This not only outlines the rights of the patient and the obligation of the hospital in regards to their admission to the hospital but also includes a second written notice that tells the patient that they will be discharged in 48 hours or less. The notice must be initialed by the patient that they know and understand that they are being discharged in 48 hours of [sic] less."

Review of MR40 revealed the patient was admitted on January 3, 2012, and was discharged January 12, 2012. Further review of MR40 revealed no documented evidence the patient was given or notified of the "An Important Message From Medicare About Your Rights" form prior to discharge from the facility.

Review of MR41 revealed the patient was admitted on January 7, 2012, and was discharged January 16, 2012. Further review of MR41 revealed no documented evidence the patient was given or notified of the "An Important Message From Medicare About Your Rights" form prior to discharge from the facility.

Review of MR42 revealed the patient was admitted on January 9, 2012, and was discharged January 18, 2012. Further review of MR42 revealed no documented evidence the patient was given or notified of the "An Important Message From Medicare About Your Rights" form prior to discharge from the facility.

Review of MR43 revealed the patient was admitted on January 13, 2012, and was discharged January 27, 2012. Further review of MR43 revealed no documented evidence the patient was given or notified of the "An Important Message From Medicare About Your Rights" form prior to discharge from the facility.

Interview with EMP1 on March 15, 2012, confirmed there was no documented evidence in MR40, MR41, MR42, and MR43, that these patients received a copy of the "An Important Message From Medicare About Your Rights" form prior to discharge from the facility.

Based on review of facility's Medical Staff Rules and Regulations, medical records (MR), and interviews with staff (EMP), it was determined the facility failed to ensure all medical record entries were dated, timed or authenticated by the person providing the service to the patient for 46 occurrences in 11 medical records reviewed (MR4, MR14, MR16, MR20, MR21, MR23, MR38, MR41, MR44, MR45, and MR46).

Findings include:

Review on March 12, 2012, of facility's "Medical Staff Rules and Regulations," last reviewed June 2011, revealed "1.2 Medical Records... 1.2.4.6 All entries in the record shall be dated and authenticated by the person making the entry ... 1.2.5 Under urgent circumstances when it is impractical for the order to be given in a written manner by the responsible practitioner, oral orders for medication and treatment may be given ... The responsible physician who gave the oral order shall countersign the order within twenty-four (24) hours."

There was no reference in the Medical Staff Rules and Regulations concerning dating and timing of the oral orders.

Review on March 14, 2012, of MR4 revealed a verbal order dated March 10, 2012. It was not dated or timed when countersigned by the practitioner. Further review of MR4 revealed a verbal order dated March 10, 2012. It was not dated when countersigned by the practitioner. Review of MR4 revealed one verbal order dated March 12, 2012. The verbal order was not countersigned, dated or timed by the practitioner.

Review on March 13, 2012, of MR14 revealed a verbal order dated January 14, 2012. It was not dated or time when countersigned by the practitioner. Further review of MR14 revealed a verbal order dated January 14, 2012. It was not countersigned by the practitioner until March 1, 2012. Review of MR14 revealed two verbal orders dated January 15, 2012. The verbal orders were not dated or timed when countersigned by the practitioner . Review of MR14 revealed a verbal order dated January 15, 2012. It was signed on February 6, 2012.

Review on March 13, 2012, of MR16 revealed a verbal order on January 3, 2012. It was not countersigned by the practitioner. Review of MR16 revealed a verbal order on January 14, 2012. It was not countersigned by the practitioner. Review of MR16 revealed a verbal order on January 17, 2012. It was not dated or timed when countersigned by the practitioner.

Review on March 13, 2012, of MR20 revealed two verbal orders dated January 19, 2012, that were not dated or timed when countersigned by the practitioner.

Review on March 13, 2012, of MR21 revealed a verbal order dated January 7, 2012, that was not timed when countersigned by the practitioner. Review of MR21 revealed a verbal order dated January 8, 2012. It was not dated or timed when countersigned by the practitioner. Review of MR21 revealed a verbal order dated January 9, 2012. It was not dated or timed when countersigned by the practitioner. Review of MR21 revealed three verbal orders dated January 10, 2012. They were not dated or timed when countersigned by the practitioner. Review of of MR21 revealed a verbal order dated January 12, 2012. It was not dated or timed when countersigned by the practitioner. Review of MR21 revealed two verbal orders dated January 14, 2011. They were not dated when countersigned by the practitioner. Continued review of MR21 revealed two verbal orders dated January 14, 2011. The time was documented as "cover" when countersigned by the practitioner.

Review on March 12, 2012, of MR23 revealed a verbal order dated March 6, 2012. It was not dated or timed when countersigned by the practitioner.

Review on March 14, 2012, of MR38 revealed a verbal order dated December 30, 2011. It was not dated or timed when countersigned by the practitioner. Further review of MR38 revealed a verbal order dated January 9, 2012. It was not dated or timed when countersigned by the practitioner. Review of MR38 revealed one verbal order dated January 10, 2012. It was not dated or timed when countersigned by the practitioner. Review of MR38 revealed one verbal order dated January 11, 2012. It was not dated or timed when countersigned by the practitioner.

Review on March 15, 2012, of MR41 revealed a verbal order dated January 8, 2012. It was not dated or timed when countersigned by the practitioner. Review of MR41 revealed two verbal orders dated January 9, 2012. They were not dated or timed when countersigned by the practitioner. Review of MR41 revealed two verbal orders dated January 11, 2012. They were not dated or timed when countersigned by the practitioner. Further review of MR41 revealed one verbal order dated January 13, 2012. It was not dated or timed when countersigned by the practitioner.

Review on March 15, 2012, of MR44 revealed two verbal orders dated January 14, 2012, that were not dated or timed when countersigned by the physician. Review of MR44 revealed one verbal order on January 15, 2012, that was not dated or timed when countersigned by the practitioner. Review of MR44 revealed one verbal order on January 17, 2012, that was not dated or timed when countersigned by the practitioner. Review of MR44 revealed one verbal order on January 20, 2012, that was not dated or timed when countersigned by the practitioner.

Review on March 14, 2012, of MR45 revealed one verbal order on January 12, 2012, that was not dated or timed when countersigned by the practitioner. Review of MR45 revealed one verbal order on January 18, 2012, that was not dated or timed when countersigned by the practitioner. Review of MR45 revealed one verbal order dated January 25, 2012, that was not dated or timed when countersigned by the practitioner.

Review on March 14, 2012, of MR46 revealed one verbal order on January 19, 2012. It was not dated or timed when countersigned by the practitioner. Review of MR46 revealed one verbal order on January 20, 2012. It was not dated or timed when countersigned by the practitioner. Review of MR46 revealed one verbal order on January 21, 2012. It was not was not dated or timed when countersigned by the practitioner. Review of MR46 revealed one verbal order on January 23, 2012. It was not dated or timed when countersigned by the practitioner. Review of MR46 revealed two verbal orders on January 28, 2012. They were not countersigned by the practitioner.

Interview with EMP1 on March 12, 2012, confirmed the oral orders for MR14, MR16, MR20, MR21, MR23, MR41, MR44, MR45, and MR46 were not complete. EMP1 confirmed the facility was unable to provide documentation the verbal orders were countersigned within 24 hours.

Interview with EMP5 on March 14, 2012, confirmed the oral orders for MR4 and MR38, were not complete. EMP5 confirmed the facility was unable to provide documentation the verbal orders were countersigned within 24 hours.

Based on review of facility policy and procedures, facility documents, and interview with staff (EMP), it was determined the facility failed to ensure accurate dispensing inventory logs were maintained for sample medications in the outpatient clinic area.

Findings include:

Review on March 14, 2012, of the facility's "Pharmacy Drug Samples" policy, last reviewed June 2010, revealed "III. Responsibility: It is the responsibility of each physician receiving drug samples or his/her designee to comply with proper storage and documentation of drug samples ... Clinics and Physician's Offices ... The responsibility for the handling and use of drug samples in the clinic and physician's offices rest with the physician in charge. The pharmacy will inspect samples areas to check for expired meds and to ensure the logs are completed ... The physician or his designee must: ... c) insure that when samples are dispensed, the name of the drug, dosage, route of administration, amount, lot number, etc. is noted on the patient's record and on a separate dispensing inventory ... The Pharmacy must: ... b) Check both inventory and sign-out books for compliance to policy. c) Report any problems or discrepancies to the physician in charge and the director of pharmacy."

Review on March 14, 2012, of facility's "Sample Medication Inventory" log revealed each sample drug medication had a separate inventory tracking sheet. Further review of the sample mediation log revealed the inventory log for "Aciphex 20 mg" revealed entries for "Aleve, Advair, Celebrex." Review of the inventory log for "Aleve 220 mg" revealed an entry for "Lexapro." Review of the inventory log for "Benicar 20 mg" revealed entries for "Boniva and Crestor." Review of inventory log for "Celebrex 200 mg" revealed entries for "Crestor and Cymbalta." Review of inventory log for "Levitra 10 mg" revealed entries for "Lexapro, Lantus and Spivera [sic]."

Review on March 14, 2012, of facility's "Nursing Unit Inspection Report Area: Allentown Family Practice," dated September 2011 through February 2012 revealed no documentation regarding problems or discrepancies for the sample medications.

Interview on March 14, 2012, with EMP2 at approximately 11:00 AM confirmed the pharmacy conducted monthly inspections of the outpatient clinic sample medication area to check for expired meds and to ensure the logs were completed. EMP2 confirmed the pharmacy did not check the accuracy of the log.

Interview on March 15, 2012, with EMP3, approximately 9:30 AM confirmed the drug sample inventory log in the Allentown Family Practice clinic was not accurately maintained.

Based on review of facility policy and procedures and interview with staff (EMP), it was determined the facility filed to ensure the pharmacist was responsible for the procurement, distribution, and control of sample drugs the outpatient Allentown Family Practice Clinic.

Findings include:

Review on March 14, 2012, of the facility's "Pharmacy Drug Samples" policy, last reviewed June 2010, revealed "V. Procedures/Methods ... Clinics and Physician Offices ... The responsibility for the handling and use of drug samples in the clinic and physician's office rest with the physician in charge. The pharmacy will inspect the sample areas to check for expired meds and to ensure the logs are completed."

Review on March 14, 2012, of facility's "Allentown Family Practice Manual Medication Samples" policy, last revised July 2010, revealed "V. Policy/Procedure ... Samples received 1. Pharmaceutical representatives will leave samples of medication with nurses after speaking with the nurse or practice manager, and physician who has signed the appropriate documentation. Samples may also be received by mail."

Interview on March 14, 2012, with EMP2 at approximately 1:30 PM confirmed the facility did not require sample medications to be delivered through the Pharmacy Department and they were delivered directly to the outpatient clinics areas. EMP2 confirmed the pharmacy inspected the areas for sample medication expiration dates and to ensure the logs were completed.

Interview on March 14, 2012, with EMP3 at approximately 11:00 AM confirmed the sample drugs were delivered directly or received in the mail at the outpatient Allentown Family Practice Clinic.

Based on review of the "Guidelines for Design and Construction of Health Care Facilities," facility documents and staff interviews (EMP), it was determined the facility failed to monitor temperature and humidity levels in the Post Anesthesia Care Unit (PACU), Neonatal Intensive Care Nursery (NICU) and Newborn Nursery.

Findings include:

Review of current "Guidelines for Design and Construction of Health Care Facilities Table 7-1 Design Parameters," dated 2010, revealed the PACU is required to maintain temperature in the range of 70-75 degrees Farenheit and relative humidity in the range of 30% to 60%. The Neonatal Intensive Care Nursery is required to maintain temperature in the range of 70-75 degrees Farenheit and relative humidity in the range of 30% to 60%. The Newborn Nursery is required to maintain temperature in the range of 72-78 degrees Farenheit and relative humidity in the range of 30% to 60%.

Review on March 13, 2012, of the facility policy "Temperature and Humidity Monitoring," last revised March 2011, revealed no provision that addressed monitoring of temperature and humidity in the PACU, NICU and Newborn Nursery.

Review on March 13, 2012, of the facility temperature and humidity logs revealed no documentation of monitoring of temperature and humidity for PACU, NICU and Newborn Nursery.

Interview with EMP4 on March 13, 2012, at approximately 11:30 AM confirmed there was no documentation for the temperature and humidity levels in the PACU, NICU and Newborn Nursery.

Based on review of facility documents, medical records (MR), and interviews with staff (EMP), it was determined the facility failed to provide Medicare beneficiaries with a list of Skilled Nursing Facilities (SNF) and document this in the medical record in five of five medical records reviewed (MR18, MR19, MR40, MR45, and MR46).

Findings include:

Review on March 14, 2012, of policy "In-patient referral to an Alternative Level of Care," dated June 2011, revealed there was no provision in it to provide Medicare beneficiaries with a list of Skilled Nursing Facilities and to document this in the patients' medical records.

Review of MR18, MR19, MR40, MR45, and MR46 on March 14, 2012, revealed these patients were Medicare patients who were discharged to a Skilled Nursing Facility. There was no documented evidence in these medical records of a SNF list or that the patients received the list.

Interview with EMP1, on March 14, 2012, at approximately 1:30 PM confirmed there was no documented evidence in MR18, MR19, MR40, MR45, and MR46 that these Medicare patients received a SNF list.

Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined the facility failed to disclose its financial interest to Medicare beneficiaries who were transferred to a Skilled Nursing Facility in which the hospital had a financial interest in five of five medical records reviewed (MR18, MR19, MR40, MR45, and MR46).

Findings include:

Review on March 14, 2012, of the facility's policy "In-patient referral to an alternative Level of Care," dated June 2011, revealed no requirement to disclose its financial interest to Medicare beneficiaries who were transferred to a Skilled Nursing Facility (SNF) in which it had a financial interest.

Review of MR18, MR19, MR40, MR45, and MR46 on March 14, 2012, revealed these patients were Medicare patients who were discharged to a Skilled Nursing Facility. The hospital had a financial interest in the SNF. There was no documented evidence in these medical records the patients were informed of the hospital's financial interest in the SNF.

Interview with EMP1, on March 14, 2012, at approximately 1:30 PM confirmed there was no documented evidence in MR18, MR19, MR40, MR45, and MR46 that these Medicare patients were informed of the hospital's financial interest in the Skilled Nursing Facility to which they were transferred.