HospitalInspections.org

Based on record review and interview the hospital failed to ensure the Administrator exercised control over the administrative activities of the hospital by failing to have documented evidence the Administrator attended all meetings of the governing board as required by the hospital's governing body by-laws and failed to appoint a replacement for the Administrator who had been out on sick leave for an extended period of time.
Findings:

Review of the personnel files presented revealed that S4 was the current governing body appointed administrator for the hospital.

Review of the management meeting minutes revealed a following:
Meeting 06/07/10- Members present: S2, Administrative Consultant, S6, RN, S7, RN;
Meeting 06/21/10- Members present: S2, Administrative Consultant, S6, RN, S7, RN;
Meeting 07/19/10- Members present: S1, Director of Nursing (DON), S2, Administrative Consultant, S8, Occupational Therapy Director;
Meeting 07/26/10- Members present: S1, DON, S2, Administrative Consultant, S8, Occupational;
Meeting 08/02/10- Members present: S1, DON, S2, Administrative Consultant;
Meeting 08/09/10- Members present: S1, DON, S2, Administrative Consultant;
Meeting 08/16/10- Members present: S1, DON, S2, Administrative Consultant;
Meeting 08/23/10- Members present: S1, DON, S2, Administrative Consultant;
Meeting 10/04/10- Members present: S1, DON, S2, Administrative Consultant;

Review of the Governing Body by-laws revealed, in part, "Article VII. Administrator- Section 2- Specifically, the authority and duties of the Administrator shall be: To attend all meetings of the Board, To perform any other duties that may be necessary and in the best interest of the hospital".

In interview on 11/17/10 at 10:00 a.m. S1, DON, and S2, Administrative Consultant, indicated that the hospital's Administrator has been out sick since February 2010. S2 further indicated that even prior to the Administrator's absence, she (S2) was delegated the duties of the Administrator for the hospital. S2 indicated that this was done since she has more of a clinical background than the current appointed Administrator. S2 confirmed that she only works in the hospital as a consultant and further indicated that she is currently employed as a full time Administrator for another hospital provider.

On 11/17/10 at 10:30 a.m. S2, Administrative Consultant, indicated that the board had met as a result of the surveyors concerns and S5, CEO, would be appointed in his place until further arrangements could be made.

Based on observations, interviews, and record reviews the hospital failed to ensure 1) The Registered Nurse performed daily skin assessments and accurately documented the assessment for 2 of 6 patients reviewed for skin assessments out of a total sample of 21 patients (#2, #9); 2) 1 of 6 patients reviewed out of a total sample of 6 received a daily bath.
(#2). Findings:

1.Patient #2

An observation was made on 11/13/2010 at 11:00 am of Patient #2 sitting in the dining room in his wheel chair. An interview was held with Patient #2 at this time. He indicated that he had been in the hospital for over a week and had a reddened area on his buttock.

Review of the medical record for Patient #2 revealed he had been admitted to the hospital on 11/03/2010. His admitting diagnosis included in part"... Diabetes Mellitus, Diabetic Neuropathy, Obesity, Unsteady Gait and History of Falls..." Further review of the medical record revealed documentation on his admission assessment on 11/03/2010 that his buttock was "...very reddened..." Record review of the Nursing Documentation/Physical Assessment Form revealed under the Integument Sections:
11/04/2010 on the 7:00 am to 7:PM shift: Sacral area red
11/04/2010 on the 7:00 pm to 7:am shift: Buttock reddened
11/05/2010 on the 7:00 am to 7:pm shift: Bruise right flank,redness to lower buttocks
11/05/2010 on the 7:00 pm to 7:00 am shift: No documentation/Left Blank
11/06/2010 on the 7:00 am to 7:00 pm shift: Skin intact
11/06/2010 on the 7:00 pm to 7:00 am shift: Documented N/A
11/07/2010 on the 7:00 am to 7:00 pm shift: Skin intact
11/07/2010 on the 7:00 pm to 7:00 am shift: Documented N/A
11/08/2010 to 11/13/20 for the 7:00 am to 7:pm shift: Skin intact
shift: Skin intact
11/14/2010 on the 7:00 am to 7:00 pm shift: Redness- Stage 1 to buttock area
11/14/2010 on the 7:00 pm to 7:00 pm shift: Some redness to buttocks
11/15/2010 on the 7:00 am to 7:00 pm shift: Skin intact
11/15/20 on the 7:00 pm to 7:00 am shift: Skin intact

An additional interview was held with Patient #2 on 11/16/2010 at 1:35 pm. He indicated that his buttocks had been red since he was admitted to the hospital. He further indicated that he had a bump on his bottom and that it hurts when he sits.

An interview was held with S3 RN Charge Nurse on 1/16/2010 at 1:20 pm. He indicated that Patient #2's sacral area was better since his admission, the skin was intact and added that the redness on the buttocks is idiopathic.

An observation was made on 11/16/2010 at 1:40 pm when S3, RN Charge Nurse performed a skin assessment on Patient #3 that revealed a reddened sacral area. S3 RN indicated the reddened sacral area had not been measured. He indicated he visualized the area during his shift but never measured the redness on the sacrum.

Further review of the medical record of Patient #2 revealed no documentation that the reddened area on the patients sacrum had ever been measured since his admission to the hospital on 11/03/2010. There was no documentation of the color, width, length, depth, or if there was odor or drainage at this site.

An interview was held with S1 Director of Nurse (DON) and S2 Administrative Consultant on 11/16/2010 at 2:00 pm. After review of the medical record of Patient #2, S1 and S2 indicated the reddened area to the patient's sacrum should have been measured. They further indicated that an accurate skin assessment should have been documented daily on Patient #2 who is also a diabetic.

Review of the hospital procedure titled Wound Care revealed "...There is ongoing assessment of the wound and the prescribed treatment to reduce complication and promote the best possible environment for healing. There are pictures taken of the wound initially and weekly, unless otherwise indicated to show progress. The wound description will include size, depth, color, drainage, odor (if applicable), treatment performed, tolerance to treatment, changes and any other characteristics noted..."

Patient #9

Review of Patient #9's History and Physical dated 04/23/10 at 5:00 p.m. revealed, in part, "Skin: Sacral Decubitus- Stage I".

Review of Patient #9's Occupational Therapy Initial Evaluation dated 04/24/10 revealed, in part, "Special precautions/equipment/needs: abrasion to bilateral great toes, stage I- sacrum, Left knee, and Right posterior thigh".

Review of Patient #9's Admission Assessment Form dated 04/23/10 revealed, in part, "Skin: Dry and warm. There was no documented evidence the registered nurse assessed the patients decubitus ulcer on admit. Review of Patient #9's nurses notes dated 04/23/10 through 05/05/10 revealed the patient's skin condition was documented as "intact".

In interview on 11/17/10 at 1:20 p.m. S1, DON, and S2, Administrator, indicated that the registered nurse should have documented an accurate wound assessment. S1 and S2 further indicated that the hospital would have to improve on wound assessments.

2. An observation was made on 11/13/2010 at 11:00 am of Patient #2 sitting in the dining room in his wheel chair. Further observation reveled the patient to not be shaven. An interview was held with Patient #2 at this time. He indicated that he had been in the hospital for over a week and added that he had received 2 baths since his admission. He further indicated that he would like to have a daily bath.

Review of the medical record revealed documentation that Patient #2 received a bed bath on 11/06/2010, a bath on 11/07/2010 and 11/11/2010.

An interview was held with S1 DON on 1/16/2010 at 1:05. She indicated that most baths are performed on the 7:00 pm to 7:00 am shift. She added the charge nurse for that shift is responsible to ensure patients receive daily baths. She indicated there was no additional documentation in the medical record for Patient #2 that he had received a daily bath since he was admitted to the hospital on 11/3/2010. She added that she expects patients to receive a daily bath.







25892

Based on record reviews and interviews the hospital failed to ensure that the nursing staff developed a nursing care plan for each patient. This was evident by 5 of 5 medical records reviewed for care plans on patients that were diabetics or who have impaired skin integrity out of a total sample of 21 patients. ( #2, #5,#7, #8, #9) Findings:

Review of the medical record for Patient #2 revealed an admitting diagnosis on 11/03/2010 that included Diabetes Mellitus. Further review of the medical record revealed no documentation that the nursing staff developed a nursing care plan for diabetes or for impaired skin integrity.

Review of the medical record for Patient #5 revealed an admitting diagnosis on 11/03/2010 that included Diabetes Mellitus. Further review of the medical record revealed no documentation that the nursing staff developed a nursing care plan for diabetes.

Review of the medical record for Patient #7 revealed an admitting diagnosis on 11/15/2010 that included Diabetes Mellitus. Further review of the medical record revealed no documentation that the nursing staff developed a nursing care plan for diabetes.

Review of the medical record for Patient #8 revealed an admitting diagnosis on 11/03/2010 that included Diabetes Mellitus. Further review of the medical record revealed no documentation that the nursing staff developed a nursing care plan for diabetes.

Review of the medical record for Patient #9 revealed the patient was admitted on 04/23/10 with a Stage I decubitus to the sacral area. Review of the nursing care plan revealed no documented evidence that a nursing care plan was developed for wound assessment and wound care.

Review of the medical record for Patient #11 revealed an admitting diagnosis on 11/15/2010 that included Diabetes Mellitus. Further review of the medical record revealed no documentation that the nursing staff developed a nursing care plan for diabetes.

An interview was held with S1 Director of Nurse (DON) and S2 Administrative Consultant on 11/16/2010 at 2:00 pm. After review of the medical record of Patient's #2, #5,#7, #8, #9, the DON indicated there was no care plan in the medical records for the for these patients that were diabetics and/or who have impaired skin integrity. She further indicated these care plans should be in the medical record.

Review of the hospital policy and procedure titled Nursing Care Plan revealed "... A nursing care pan will be initiated within 24 hours of admission to the unit. The primary nurse is responsible for carrying out the care after reviewing the care plan and revising as needed. the care plan services as a guide for patient care and educational needs during their hospital stay. Each plan is patient specific..."



25892

Based on record reviews and interviews the hospital failed to ensure the medical record of each patient was completed no later than 30 days after discharge as evidenced by 3 of 3 closed medical records reviewed out of a total sample of 21 records not being completed by the attending physician. (#9, #12, #21).
Findings:

Review of the medical record for Patient #9 revealed that the patient was admitted to the hospital on 04/23/10. Further review revealed the Resuscitation orders were not signed by the physician and the Discharge Summary Sheet was not completed by the attending physician.

Review of the medical record for Patient #12 revealed that the patient was admitted to the hospital on 04/19/2010. Further review revealed the Discharge Summary Sheet was not completed by the attending physician. Review of the admission physician orders on 4/19/2010 revealed the orders were not authenticated, dated,or timed by the admitting physician.

Review of the medical record for Patient #21 revealed that the patient was admitted to the hospital on 06/08/10. Review of the medical record revealed the Physician's progress notes dated from 06/09/10 through 06/17/10 were not signed by the physician. Further review revealed the Discharge Summary Sheet was not completed by the attending physician.

An interview was held with S1 DON and S2 Administrative Consultant on 11/17/2010 at 1:15 pm. After review of the medical records they indicated the discharge summaries had not been completed by the attending physicians. She further indicated the delinquency rate for discharge summaries for 2010 was 98%. S2 added she was aware the charts had not been completed. S2 indicated that if the hospital suspended the physicians for delinquent discharge summaries that there would be no physicians to admit patients to the hospital.

Based on record reviews and interviews the hospital failed to ensure that all entries in the medical records were authenticated with a signature, dated, and timed for 6 of 6 medical records reviewed out of a total sample of 21 charts. (#1,#2, #5,#7, #8, #9, #21) Findings:

Patient #1
Review of the medical record for patient #1 revealed a Physician Order on 11/04/2010 was not timed. Further review of the Resuscitation Orders did not have a date or time that the order was signed. Review of the Physician Progress Notes on 11/02/2010, 11/03/2010, 11/04/2010, 11/07/2010, 11/08/2010,11/09/2010, 11/10/2010,11/11/2010,11/12/2010, 11/13/2010, and 11/14/2010 revealed that the entries were not timed.

Patient #2
Review of the medical record for Patient #2 revealed the Consent for Treatment and Acknowledgement was not dated. The Authorization for Release of Information was not dated, timed or witnessed. The Resuscitation Orders containing full Resuscitaton, Resuscitation with Modifications, or Do Not Rescuctitate was not signed by the attenedng physician, dated or timed. Review of the Physician Progress Notes on 11/07/2010, 11/08/2010,11/10/2010,11/11/2010,11/12/2010,11/13/2010, and 11/14/2010 revealed that the entries were not timed.

Patient #5
Review of the medical record for Patient #5 revealed the Resuscitation Orders containing full Resuscitaton, Resuscitation with Modifications, or Do Not Rescuctitate was not signed by the attenedng physician, dated or timed.

Patient #7
Review of the medical record for Patient #7 revealed the Review of the Admission Orders were not signed, dated, or timedby the attending physician.

Patient #8
Review of the medical record for Patient #8 revealed the physician order on 11/15/2010 was not timed.

Patient #9
Review of the medical record for Patient #9 revealed "Resuscitation Orders- Full Resuscitation". Further review revealed the orders were not signed or dated by the physician.

Patient #21
Review of the medical record for Patient #21 revealed physician's progress notes dated from 06/09/10 through 06/17/10 not signed or timed by the physician.

An interview was held with S1 Director of Nurse (DON) and S2 Administrative Consultant on 11/16/2010 at 2:00 pm. After review of the medical record of Patient's #1,#2, #5,#7, #8, #9, #21, S1 DON confirmed the entries in the medical records were not all authenticated with a signature, dated, and/or timed. She further indicated the physicians are reminded at meeting to sign, date, and time all entries.

Review of the hospital policy and procedure titled Authorized Entries In A Medical Record revealed "...All entries will be authenticated by signature, date and time..."







25892

Based on records reviews and interview the hospital failed to ensure that 3 of 3 medical records reviewed for discharge summaries were completed out of a total sample of 18 closed records. (#9, #12, #21). Findings:

Review of the medical record for Patient #9 revealed that the patient was admitted to the hospital on 04/23/10. Further review revealed the Discharge Summary Sheet was not completed by the attending physician.

Review of the medical record for Patient #12 revealed that the patient was admitted to the hospital on 04/19/2010. Further review revealed the Discharge Summary Sheet was not completed by the attending physician.

Review of the medical record for Patient #21 revealed that the patient was admitted to the hospital on 06/08/10. Further review revealed the Discharge Summary Sheet was not completed by the attending physician.

An interview was held with S1 DON and S2 Administrative Consultant on 11/17/2010 at 1:15 pm. After review of the medical records they indicated the discharge summaries had not been completed by the attending physicians. She further indicated the delinquency rate for discharge summaries for 2010 was 98 %. S2 added she was aware the charts had not been completed. S2 indicated that if the hospital suspended the physicians for delinquent discharge summaries that there would be no physicians to admit patients to the hospital.