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Based on record review and interviews, the facility failed to ensure that all patients received information regarding whom to contact within the facility to file a grievance. Citing 2 (#14 and # 20) out of 2 (#14 and # 20) patients' medical records reviewed on the medical unit. This deficient practice has the potential for patient complaints and grievance to not have appropriate follow up.

Findings include:

The facility document titled, "Patient Rights and Responsibilities," contained information regarding the following topics:
-patient rights and responsibilities;
-complaint/grievance process;
-advance directives.

Review of patient medical records #14 and # 20 revealed no evidence that these patients received a copy of "Patient Rights and Responsibilities" that informed them who to contact within the facility to file a grievance.

During an interview on 04/23/2013 at 2:15 p.m. in the conference room, staff #15 confirmed the facility had listed only the external agency to contact for complaints, but failed to include a telephone number persons could call internally to file a complaint or grievance.

Based on record review and interview, the facility failed to ensure that all patients consented to medical treatment prior to receiving treatment. There was no documented general consent to medical treatment, citing 3 (#15, #19, and # 21) out of 12 ( # 11, #12, #13,# 14, #15, #16, #17, #18, #20, #21, #23, and #25) patient medical records.

Findings include:

Review of the facility document titled, "Inpatient /Outpatient Conditions of Admission and Consent to Medical Treatment," revealed that it is a document to be signed by the patient, indicating the patient was aware of and agreed to the following:
-assignment of insurance benefits;
-cost of a private room;
-responsibility for personal valuables;
-general consent for tests and treatment;
-advance directive acknowledgement.

Review of patient medical records (#15, #19, and # 21) revealed no "Inpatient /Outpatient Conditions of Admission and Consent to Medical Treatment," signed or unsigned. All three of these patients were newborns.

During an interview on 04/22/1013 at 2:15 p.m. in the conference room, staff #15 confirmed the consent for patients #15, #19 and #21 were not signed by the newborns' parent/guardian. Staff #15 stated when the facility developed the plan of correction and educated the staff, they failed to implement the process to include newborns.

Based on record review and interview, the facility failed to ensure all verbal orders were dated and timed with in 48 hours. Citing 9 (#11, #13, #14, # 16, #17, #18, #20, #23, and # 25) out of 12 medical records reviewed (#11, # 12, #13, #14,#15, #16, #17, #18, #20, #21, #22, #23, and # 25), for a total of 30 out of 30 telephone orders that were not dated and signed.

Findings:

Review of #11 medical record on 04/23/2013 revealed there were 4 out of 4 telephone orders that were not dated and timed when signed.

Review of # 13 medical record on 04/23/2013 revealed there were 3 out of 3 telephone orders that were not dated and timed when signed.

Review of # 14 medical record on 04/23/2013 revealed there was 1 out of 1 telephone order that was not dated and timed when signed.

Review of # 16 medical record on 04/23/2013 revealed there was 1 out of 1 telephone order that was not dated and timed when signed.

Review of # 17 medical record on 04/23/2013 revealed there were 9 out of 9 telephone orders that were not dated and timed when signed.

Review of # 18 medical record on 04/23/2013 revealed there were 5 out of 5 telephone orders that were not dated and timed when signed.

Review of # 20 medical record on 04/23/2013 revealed there was 1 out of 1 telephone order that was not dated and timed when signed.

Review of # 23 medical record on 04/23/2013 revealed there were 4 out of 4 telephone orders that were not dated and timed when signed.

Review of # 25 medical record on 04/23/2013 revealed there were 2 out of 2 telephone orders that were not dated and timed when signed.

An interview with staff # 15 on 04/15/2013 at 3:00 p.m. confirmed the physicians were not dating and timing telephone orders when signed.

Based on record review and interview, the facility failed to ensure the emergency room physical examination sheet was dated and/or timed by the physician performing the examination, citing 7 of 10 emergency room records reviewed. (Patients #2, 3, 6, 7, 9, 10, and 13).

While reviewing medical records on 4/23/2013 at 10:00 am in the conference room, the following observations were noted:
1. Physical examination sheets for patients #2, 6, 7, and 13 had no documentation of the date and/or time the physician performed the physical examination.
2. Physical examination sheets for patients #9 and 10 had no documentation of the time the physical examination was performed by the physician.
3. Physical examination sheet for patient #3 had no documentation of the date that the physical examination was performed by the physician.

An interview with staff #27 on 4/22/2013 confirmed the findings.

Based on record review and interview, the facility failed to ensure all verbal orders were dated and timed within 48 hours. Citing 9 (#11, #13, #14, # 16, #17, #18, #20, #23, and # 25) out of 12 medical record reviewed (#11, # 12, #13, #14,#15, #16, #17, #18, #20, #21, #22, #23, and # 25), for a total of 30 out of 30 telephone orders that were not dated and signed.

Findings:

Refer to tag 408 for details

Based on observation, interview, and record review, the facility failed to ensure preventive maintenance was performed in a timely manner for 1 of 1 pharmacy glove box (enclosure where medications are prepared in a safe manner).


Findings include:

During a facility tour on 4/22/13 at 2:45pm, the pharmacy glove box was found with a preventive maintenance sticker with a 12/2012 expiration date.

During the tour, staff #3 confirmed this finding.

Review of a document titled, "Glove Box Certification Report," provided by staff #37 revealed the glove box certification expired on 12/2012. Staff #37 reported the glove box had not been inspected for safety since 12/2012.

Based on observation and interview, the facility failed to ensure expired items were removed from the emergency room patient treatment areas. These findings have the potential to cause cross contamination and increase the chance of infection to all patients treated in the emergency department.

While touring the emergency department on 4/22/2013 at 2:30 pm, the following observations were made:
Trauma Room #1 contained the following expired items:
1. 3 Pressure Monitoring kits Lot# 58974871 Expired: 1/2013
2. 1 Bolus Gastrostomy Feeding Tube Lot# AA9341D09 Expired: 12/2012
3. 1 Adult Gastric Lavage System Lot# 329400 Expired: 11/2005
4. 3 Red top vacutainer tubes Lot# 0182621 Expired 7/2012
5. 1 PSI Kit with hemostasis valve/side port. Found open in cabinet. Lot# RF1010421 Expiration date: 7/2013
Pediatric Crash Cart in Trauma Room #1 contained the following expired items:
1. Purple intubation system Lot# 113P Expired: 3/2013
2. Orange intubation system Lot# 096P Expired: 3/2013
3. Pink/Red intubation system Lot# 116P Expired 3/2013
4. Green intubation system Lot# 116P Expired 3/2013
5. Blue intubation system Lot# 095P Expired: 3/2013
6. White intubation system Lot# 116P Expired: 3/2013

An interview with staff #27 on 4/22/2013 at 2:30 pm confirmed these findings.