HospitalInspections.org

Based on observation, review of facility documents and interview with staff (EMP), it was determined that the facility failed to ensure that the dietary department management maintained a clean and orderly equipment and work areas in the kitchen.

Findings include:

Review on January 4, 2011, of the "Director of Food and Nutrition Services" job description and the "Assistant Director of Food Services" job description, both last reviewed February 2008, revealed "... Job duties: ... Complies with federal, state, and local health and department sanitation regulations. Maintains a clean, sanitary working environment. ..."

Review on January 4, 2011, of the "Food and Supply Storage Procedure" policy, last reviewed April 8, 2010, revealed "Policies: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to maintain the safety and wholesomeness of the food for human consumption. ... Frozen Storage: ... Wrap food tightly to prevent cross contamination. Food stored frozen should be kept no longer that 90 days for quality purposes. Date and rotate items; first in, first out (FIFO)."

Review on January 4, 2011, of the "Sanitation and Infection Control" policy, last reviewed April 8, 2010, revealed "Subject: Required Cleaning and Sanitation Policies: ... The food-contact surfaces of grills, griddles, and similar cooking devices, food storage equipment ... shall be cleaned and sanitized at least once a day; except that this shall not apply to hot oil cooking equipment and hot oil filtering systems. The food-contact surfaces of all cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil."

A tour conducted on January 4, 2011, of the facility kitchen beginning at 9:00 AM revealed the dietary delivery entrance had spider webs, spiders and dirt on the light fixture. The archway had concrete chips missing. The dietary hall wall was missing pieces of paint and dry wall. The floor under the 12 food storage racks in the walk in freezer was covered with frozen food debris and littered with paper scraps. The surface of the electric deep fryer and the gas deep fryer was covered with dried white food debris, and the wire baskets had areas of a dried brown encrusted substance attached to the baskets. The electric and gas deep fryers contained a yellow substance identified by EMP6 as oil for deep frying food. The floor mat at the cook's counter contained a heavy accumulation of dried food. Under the three bin sink, there was a six inch grease trap which contained a thick accumulation of corrosion, dirt and food debris. The floor under the counters in the dish wash room was dirty, dusty and littered with paper scraps.

The dietary department walk in freezer contained bulk food products that were open, undated, partially used and not properly sealed to protect from freezer elements. The bulk food products included a box of diced carrots, a box of baby carrots, a box of Italian blend vegetables, a box of California blend vegetables, two boxes of chicken wings, a plastic bag of hot dogs, a plastic bag with turkey dogs, a box of meatballs, a box of chicken patties, a box of perogies and a bag of peeled shrimp.

Interview conducted on January 4, 2011, at 9:30 AM with EMP5 and EMP6 confirmed the findings of dirt, food debris and unclean areas in the walk in freezer and throughout the kitchen. Further interview with EMP6 revealed that the open, undated, partially used and not properly sealed food identified in the walk in freezer was intended for patient consumption.

Interview conducted on January 4, 2011, at 9:45 AM with EMP5 revealed that the facility was not able to provide documentation regarding the cleaning of the gas deep fryer and that the facility was not able to provide documentation of when the oil was last changed in the deep fryers.

Based on review of facility documents and staff interview (EMP), it was determined that the facility failed to provide a written notice of its resolution of grievances for two of nine patient grievances reviewed (OTH4 and OTH6).

Findings include:

Review on January 6, 2011, of the facility's "Grievance Policy," last reviewed December 2010, revealed "Policy: It is the policy of Memorial Hospital, Inc. to maintain a policy and procedure on handling patient grievances and resolution thereof within a timely manner. ... Definition: a) A "patient grievance" is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with CMS Hospital Conditions of Participation (CoP) ... Resolution of Patient Grievances: ... 7. All grievances will result in a written response to the patient/family ... The written response will include: a) name of hospital contact person b) steps taken by hospital to investigate the complaint c) results of the investigation ... d) the grievance will be considered resolved when the patient or the patient's representative and administration are satisfied."

Review on January 6, 2011, of the facility's "Complaint/Grievance" log from January to December 2010 revealed that the facility conducted complaint investigations filed by OTH4 and OTH6. Further review of OTH4 and OTH6 revealed the facility did not provide a written notice of its decision that included: the decision, hospital contact person, steps taken on behalf of OTH4 and OTH6 or the completion date when OTH4 and OTH6's grievances were resolved.

An interview conducted on January 6, 2011, at 2:30 PM with EMP1 and EMP2 confirmed that a written notice of the facility's grievance decision, the hospital contact person, steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion was not provided to the OTH4 and OTH6.

Based on review of facility policy, medical records (MR) and interview of staff (EMP), it was determined that the facility failed to ensure accurate documentation of advance directives and code status on two of three open medical records reviewed for patients in swing bed status (MR67 and MR69).

Findings include:

Review on January 11, 2011, of the facility's policy "Do Not Resuscitate (DNR) Policy," last reviewed October 2010, revealed "... While there may be various situations where the withholding or withdrawal of medical treatment may be justified, this policy covers only the specific issues of whether or not to initiate cardiopulmonary resuscitation (CPR) when the patient experiences an acute cardiac or respiratory arrest. This is not intended to address termination of care. Definition: DNR ... means that in the event of a cardiac or respiratory arrest in a terminally ill patient, cardiopulmonary resuscitative measures will not be initiated or carried out. Considerations: 1. An appropriate knowledge of the patient's medical condition is necessary before consideration of a DNR order. ... 2. The attending physician should determine the appropriateness of DNR orders for any given patient. ... 4. When a patient is capable of making this judgment, the DNR decision should be reached consensually by the patient and the physician. When the patient is not capable of making this decision, the decision should be reached consensually after consultation between the appropriate family member(s) and the physician. ... Procedure/Protocol 1. Once the DNR decision has been made, this directive shall be written as a formal order by the attending physician to ensure that this order and its meaning are discussed with appropriate members of the hospital staff. A verbal or telephone order for DNR cannot be justified as sound medical practice. This decision is communicated to all involved health care personnel by a DNR sticker placed on the patient's Kardex, on the front of the medical record, and on the care plan. Key Points/Rationale Exceptional case; If the patient/family has made known their wishes for a DNR order to a physician but the physician may not be able to come in and write the order before the patient arrests, the order may be given by phone with two RN [registered nurses] or 1 RN and 1 physician witnesses. The physician must immediately dictate a note with information regarding the assessment and patient/family decision for a DNR order. 2. The facts and considerations relevant to this decision shall be recorded by the attending physician in the progress notes. The DNR order shall be subject to review at any time by all concerned parties, and shall be reviewed on a regular basis. This order may be rescinded at any time. ... Evaluation/Documentation: DNR order is written as physician order and noted in physician progress note. Patient outcomes: DNR policy is followed."

Review on January 7, 2011, of the facility's policy "Advance Directives," last reviewed October 2009, revealed "Purpose: The purpose of this policy is to establish procedures to support the effective administration of a patient's advance directive at Memorial Hospital and to ensure compliance with Act 169 of 2006. Furthermore, as a facility, we wish to assure that medically indicated treatment decisions correspond with the wishes of individual patients, whether expressed by patients or made by surrogates acting in the patient's behalf. We also wish to assure that decision-making regarding treatment options is done with keeping with current ethical, legal, and clinical standards. The Advanced Directive is designed to [sic] prolong the prolongation of dying and to allow the individual to exercise his/her autonomy in the event of terminal illness or permanent unconsciousness. ... Procedure/Protocol 1. On admission, all adults will receive an information packet containing Advance Directive materials at the time they receive their identification bracelet. ... 2. The admitting nurse will complete the Advance Directive information on the admission sheet. 3. If the patient has a Living Will and/or Health Care Power of Attorney, a copy of the original document is made and placed on the medical record. It remains in place throughout the patient's hospital stay and becomes a part of the permanent record. ... 5. Healthcare personnel will communicate Advance Directive information when transferred to another unit or another facility. If there is a change in the level of care, the Advance Directive should be reviewed with the patient/surrogate. Key Points/Rationale To provide continuity of care. ... 9. Physician will be made aware of Advanced Directives obtained from the patient. 10. An Advance Directive becomes operative when: 1. A copy is present in the medical record. 2. The patient is determined by the physician to be in a terminal condition or in a state of permanent unconsciousness, and/or incompetency. 3. The physician certifies in writing on the medical record that the patient is in a terminal condition or in a state of permanent unconsciousness, and/or incompetence. ... "

Review of MR67 on January 7, 2011, revealed the facility admitted the patient to acute care. At the time of admission, the physician documented the code status on the patient's history and physical form as "Presently Full Code Status. Will reupdate [sic] with any new changes as patient wishes." Patient was admitted into swing bed status four days later with no change in code status. Nursing documentation dated three days post admission to swing bed status revealed "DNR Status." MR67 did not contain a physician's order for DNR status and did not contain documentation of discussion with the patient or the patient's family regarding the change in code status.

Interview with EMP7 on January 7, 2011, at 11:45 AM confirmed that MR67 contained a "Do Not Resuscitate" sticker on the front of the chart. Further interview with EMP7 confirmed that MR67 did not contain a physician's DNR order and did not contain documentation of discussion with the patient or the patient's family regarding the change in code status.

Review of MR69 on January 7, 2011, revealed that the patient was admitted to the hospital for acute care on December 29, 2010, and was changed to swing bed status on January 5, 2011, seven days later. Review of the nursing assessment form for swing bed patients revealed that MR69 did not have an advance directive or a living will.

Review of MR69's physician orders revealed that MR69 is a "DNR status per pt [patient] and family request." Review of the physician progress notes revealed no documented discussion with MR69 or MR69's family regarding a code status.

Interview with EMP7 on January 7, 2011, at 12:00 PM confirmed that MR69 did not contain documentation of any discussion with MR69 or MR69's family regarding a code status. Further interview with EMP7 confirmed that MR69 held a completed Advance Directive and nursing staff should have updated the medical record regarding the presence of the advance directive.

Based on review of facility policy, medical record review (MR) and interview with staff (EMP), it was determined that the facility failed ensure that verbal orders were signed, dated and timed by a physician within 24 hours for one of six swing-bed records reviewed (MR38) and five of 28 acute care medical records reviewed (MR19, MR22, MR36, MR40, and MR60).

Findings include:

Review on January 7, 2011, of "Medical Staff Bylaws & Rules and Regulations," last revised December 2007, revealed "Medical Staff Rules & Regulations ... 6. Oral Orders and Administration of Drugs- ... The order shall include the date, time, and full signature of the person taking the order and shall be countersigned by a practitioner within 24 hours in the Hospital ..."

Review on January 7, 2011, of the "Signing of Verbal Orders" policy, last reviewed December 24, 2007, revealed "Purpose: The purpose of physicians other than initiator of verbal orders being able to sign. To facilitate timely signing, dating and timing. To comply with state regulations. Policy: Verbal orders will be signed, dated and timed within 24 hours as mandated by the Department of Health. ..."

Review on January 4, 2011, of MR36 revealed a verbal order that was not authenticated within 24 hours with a physician signature, date and/or time.

Interview on January 4, 2011, at 11:30 AM with EMP9 confirmed a verbal order on MR36 was not authenticated within 24 hours with a physician signature, date and/or time.

Review on January 7, 2011 of MR19, MR22, MR38, MR40, and MR60 revealed that all contained verbal orders which were not authenticated within 24 hours with a physician signature, date and/or time.

Interview on January 7, 2011, at 11:30 AM with EMP1 and EMP2 confirmed that verbal orders on MR19, MR22, MR38, MR40, and MR60 were not authenticated within 24 hours with a physician signature, date and/or time.

Based on review of facility documents, medical record review (MR) and interview with staff (EMP), it was determined that the facility failed to ensure that a history and physical was placed in the patient's medical record within 24 hours after admission for one of six medical records reviewed of patients in swing-bed status (MR39).

Findings include:

Review on January 7, 2011, of the facility "Medical Staff Bylaws & Rules and Regulations," last revised December 2007, revealed "Medical Staff Rules & Regulations ... 13. A complete history and physical examination shall in all cases be dictated within 24 hours after admission of the patient ..."

Review on January 7, 2011, revealed MR39 was admitted to swing-bed status on October 28, 2010. Further review of MR39 revealed that MR39's history and physical was completed on December 29, 2010, 62 days after MR39's admission.

Interview on January 7, 2011, at 10:30 AM with EMP1 confirmed that MR39's history and physical was completed 62 days after MR39 was admitted to swing-bed status.

Based on review of facility documents, medical record review (MR) and interview with staff (EMP), it was determined that the facility failed to ensure that a discharge summary was completed within 30 days following discharge for one of three discharged patients from swing-bed status (MR37) and one of 12 patients discharged from acute care status (MR42).

Findings include:

Review on January 7, 2011, of facility policy "Chart Tracking for Physicians," last reviewed November 2010, revealed "Policy: The medical record will be completed 30 days following discharge. ..."

Review on January 7, 2011, of facility document "Medical Staff Bylaws & Rules and Regulations,", last revised December 2007, revealed "Medical Staff Rules & Regulations ...11. ... A complete discharge summary will be dictated within 15 days of discharge. The medical record will be completed within fifteen days following discharge and in no event will it exceed 30 days following discharge. ..."

Review on January 7, 2011, of MR37 revealed that MR37 was discharged from swing-bed status on October 5, 2010. The discharge summary for MR37 was completed on December 29, 2010, 85 days following discharge.

Review on January 7, 2011, of MR42 revealed that MR42 was discharged from acute care status on October 8, 2010. The discharge summary for MR42 was completed on November 18, 2010, 41 days following discharge.

Interview on January 7, 2011, at 10:30 AM with EMP1 confirmed that the discharge summary for MR 37 was completed 85 days following discharge and the discharge summary for MR42 was completed 41 days following discharge.

Based on review of facility documents, observation, and interview with staff (EMP), it was determined that the facility failed to keep current and accurate records regarding the receipt and distribution of scheduled drugs in the facility pharmacy's narcotic room.

Findings include:

Review on January 4, 2011, of the facility's policy "Controlled Substances Distribution System," last reviewed December 2, 2009, revealed "Policy - It is the policy of Memorial Hospital's Department of Pharmacy that the ordering, dispensing, and record keeping functions for controlled substances shall follow strict adherence to the state and federal law, as well as work in collaboration with the medical staff and nursing staff. Procedure/Protocol: Pharmacy Storage Area - the Department of Pharmacy maintains a properly secure area for the storage of all Scheduled II controlled substances of known as "Narcotic". ... Maintenance of Perpetual Balance - As supplies of all Scheduled II controlled substances are dispensed to patient care areas, the pharmacist must maintain strict record keeping. The quantities dispensed are subtracted from the perpetual inventory sheet for Scheduled II item available on the formulary. ... A quarterly audit is conducted determined the accuracy of the documented balance for each item against the actual physical inventory on the shelf. Any discrepancies are corrected immediately. ... Returned Drugs to Pharmacy - If a controlled medication needs to be returned to the pharmacy - due to overstock or discontinuation of an order - it must be signed out on the nursing unit's perpetual narcotic sheet. The pharmacist or pharmacy technician may write return "return to pharmacy" on the name line of the sheet, subtract the quantity being removed and have a nurse cosign. The medication is brought back to the pharmacy, given to the pharmacist to be placed in the narcotic room. The pharmacist shall write in the perpetual log book the date, amount and nursing unit it came from and then finally calculate and verify count of that med. Returning xpired [sic]/Outdated Drugs to Pharmacy - When a controlled drug is found to be expired/outdated or otherwise unusable it also is signed out on the nursing unit's perpetual narcotic sheet. ... When it is returned to pharmacy, the pharmacist places it back into narcotic room. The pharmacist adds the expired control back into stock ... and then on the next line of log book, remove/subtracts it from log book. All expired/outdated/unusable CII Drugs are stored in narcotic room until approved drug return company comes and takes it away."

Review on January 4, 2011, of the facility's "Preparation of Out-Patient Preparations for Hospice" policy, last reviewed October 2009, revealed "... Purpose: To provide guidelines for dispensing medications for Hospice patients. ... Medications Returned to Pharmacy - Upon notification of patient death, the hospice nurse may request of the family if they would like hospice to dispose of the medications. In these instances, hospice nurse will bring the medications to pharmacy for disposal. Any controlled medications are returned to pharmacy must be accounted for on the "Disposal of Controlled Drugs Form" ... this must be signed and witnessed by hospice and pharmacist. The form is to be returned to hospice."

Review on January 6, 2011, of EMP3's signed job description "Director of Pharmacy," last reviewed March 2010, revealed "Job Summary: Responsible for the overall pharmaceutical care provided to patients, medical and other health care personnel. ... The Director of Pharmacy shall ensure that the department meets all legal and accreditation/certification requirements. In addition, the Director shall ensure that the department complies with all applicable hospital policies and procedures, codes and standards. ... Job Duties: ... Responsible for purchase, inventory, and record keeping of controlled substances."

Observation on January 4, 2011, at 10:30 AM of the narcotic room located in the pharmacy department revealed two storage containers. Review of the contents in the first storage container revealed: 16 open and partially used 50 milliliter (ml) vials of Morphine Sulfate 50 mg (milligrams)/ml (a narcotic medication), 31 open and partially used vials of Roxanol 20 mg/ml (a narcotic medication) , three Fentanyl 25 micrograms (mcg)/hour (hr) patches (a narcotic medication in patch form) and two Fentanyl 50 mcg/hr patches.

Review of the contents in the second storage container revealed: nine Fentanyl 25 micrograms (mcg)/hour (hr) patches, two Fentanyl 50 mcg/hr patches, a clear plastic bag containing five unit dose of Percocet 5/325 mg (narcotic medication) and three bottles of TEC (a narcotic pharmacy mixture of Tetraine, Epinephrine and Cocaine), two bags of Dilaudid 4 mg/50 ml (a narcotic medication) and five bags of Dilaudid 2 mg/50 ml.

Further review of the contents in the second container revealed: 18 bags containing a solution of Meperidine 1000 mg/100 ml (a narcotic medication) for PCA (Patient Control Analgesia) administration and 23 bags of Morphine Sulfate 100 ml/100 ml for PCA administration. There was a medication bottle labeled Percocet 5/325 mg that did not have a lid and did not contain any medication. On the bottom of the second container were nine white tablets identified by EMP3 as Percocet tablets from the opened medication bottle.

Interview with EMP3 on January 4, 2011, at 10:30 AM confirmed the contents of the two storage containers. EMP3 revealed the contents in the first storage container were controlled drugs from hospice patients who have passed away and the contents of the second storage container were controlled drugs from hospice patients who have passed away, expired controlled drugs which were removed from the shelf, and discontinued patient orders for controlled drugs. Further interview with EMP3 confirmed that there were no current and accurate records regarding the receipt and distribution of scheduled drugs in the facility pharmacy's narcotic room.

Interview with EMP4 on January 5, 2011, at 9:30 AM revealed the review of the pharmacy perpetual narcotic inventory sheet for Demerol 1000 mg/100 ml PCA from October 29, 2010, to January 4, 2011, indicated that eight bags were returned to the pharmacy. EMP4 also revealed that the perpetual narcotic inventory sheet for Morphine Sulfate 100 ml/100 ml PCA from October 29, 2010, to January 4, 2011, indicated that five bags were returned to the pharmacy. Further interview with EMP4 confirmed that there were 18 bags of Demerol 1000 mg/100 ml PCA in the second storage container in the narcotic room and that only eight of the bags were accounted for on the perpetual narcotic inventory sheet. EMP4 also confirmed that there were 23 bags of Morphine Sulfate 100 ml/100 ml PCA in the second storage container in the narcotic room and that only five of the bags were accounted for on the perpetual narcotic inventory sheet.

Review on January 6, 2011, of the "EXP Pharmaceutical Services Corporation" (a company utilized by the facility to return pharmaceuticals for reimbursement) reverse distributor form dated October 29, 2010, revealed the facility returned 10 - 100 ml packages of Meperidine (Demerol) 10 mg/100 ml and nine Morphine Sulfate 1 mg/100 ml were picked up.

Interview with EMP4 on January 6, 2011, at 9:45 AM revealed that there was no definite count of the Meperidine and Morphine PCA's to determine how many were present in the pharmacy narcotic room before the EXP Pharmaceutical Services pick up on October 29, 2010, and the amount of Meperidine and Morphine PCA's not picked up. Further interview with EMP4 revealed there was no current and accurate count of the Meperidine and Morphine PCA's in the pharmacy narcotic room.

Based on review of facility documents and interview with staff (EMP), it was determined that the facility failed to ensure that the established policy of requiring two nursing signatures for wasting narcotics and controlled substances was followed on five narcotic records from the operating room and four narcotic records from the post anesthesia recovery area.

Findings include:

Review on January 5, 2011, of the "Administration of Medication" policy, last revised January 2010, revealed "Administration of Medication, Purpose: To provide guidelines for proper administration of medications. ... Key Points/Rationale ... 7. When a narcotic is wasted, the amount wasted is recorded and witnessed by a 2nd nurse. Narcotic waste requires 2 nursing signatures. ..."

Review on January 7, 2011, of the "Controlled Substances Distribution System" policy, last revised December 2, 2009, revealed "Policy: It is the policy of Memorial Hospital's Department of Pharmacy that the ordering, dispensing and record keeping functions for controlled substances shall follow strict adherence to the state and federal law, as well as work in collaboration with the medical staff and nursing staff. ... Procedure/Protocol ... Nursing - Administration of Controlled Substances As each dose or doses is/are needed for a specific patient, the nursing personnel responsible for the patient goes to the narcotic cabinet, selects the appropriate supply and documents the disposition of the dose on the perpetual narcotic control sheet. On this narcotic control sheet the nurse must document time, patient's full name, room #, quantity (ml or mg), selected drug, nurse's initials and 2nd initials if waste needs to be documented. ... Key Points/Rationale ... If nursing needs to waste or discard a dose, this must be written on the line in which the drug is signed out. The amount of waste must be documented and must be signed by another nurse other than the person administering the dose. ..."

Interview with EMP1 on January 6, 2011, at 9:00 AM identified that the form for indicating the count, usage and wastage of narcotic and controlled substances was referred to as a narcotic record.

Review on January 6, 2011, of the narcotic record for the post anesthesia recovery area (PAR) revealed the narcotic record did not contain the signature of a witness as required by the facility policy when narcotics were wasted for the following dates and narcotic: October 5, 2010, one ml (milliliter) of Morphine So4 (narcotic medication) 2 mg/ml required wasting. November 21, 2010, 12.5 ml of Demerol (narcotic medication) 25 g/ml injectable was wasted. December 9, 2010, one mg (milligram) of Hydromorphone (narcotic medication) 2 mg was wasted. December 24, 2010, 50 ml of Demerol 50 g/ml injectable was wasted.

Review on January 6, 2011, of the narcotic record for anesthesia cart five dated May 10, 2010, revealed that 1.5 ml of Fentanyl (narcotic medication) two ml was wasted. The narcotic record did not contain the signature of a witness as required by the facility policy when narcotics were wasted.

Review on January 6, 2011, of the narcotic record for anesthesia cart four dated May 19, 2010, revealed that 25 mcg (microgram) of a Fentanyl two ml was wasted. The narcotic record did not contain the signature of a witness as required by the facility policy when narcotics were wasted.

Review on January 6, 2011, of the narcotic record for anesthesia cart five dated July 5, 2010, revealed that 40 mcg of a Fentanyl two ml was wasted. The narcotic record did not contain the signature of the person wasting the medication as required by the facility policy when narcotics were wasted.

Review on January 6, 2011, of the narcotic record for anesthesia cart three dated July 14, 2010, revealed that 50 mcg of a Fentanyl two ml was wasted. The narcotic record did not contain the signature of a witness as required by the facility policy when narcotics were wasted.

Review on January 6, 2011, of the narcotic record for the black/orange anesthesia cart dated December 2, 2010, revealed that 0.5 ml of a Fentanyl two ml was wasted. The narcotic record did not contain the signature of a witness as required by the facility policy when narcotics were wasted.

Interview with EMP1 on January 6, 2011, at 9:00 AM confirmed that narcotic records dated October 5, 2010, November 21, 2010, December 9, 2010, December 24, 2010, May 10, 2010, May 19, 2010, July 5, 2010, July 14, 2010, and December 2, 2010, did not contain two nursing signatures as required by facility policy when controlled substances were wasted.

Based upon review of facility documents, observation and interview with staff (EMP), it was determined that the facility failed to provide a sanitary hospital environment.

Findings include:

Review on January 4, 2010, of facility document "Governing Body Bylaws of the Memorial Hospital, Inc. of Towanda, Pennsylvania", last reviewed and accepted October 28, 2010, revealed "... Article VI ... Section 5. Buildings and Grounds Committee Building and Grounds Committee shall have responsibility for the development and oversight of a hospital Safety Program and general oversight of the physical plant of the Hospital as to additions, alterations, repairs and maintenance. ... "

Review on January 7, 2010, of the facility's policy "Infection Control/Housekeeping Cleaning Procedures - Specific to all areas," last reviewed October 2009, revealed "... Cleaning procedures for Miscellaneous Equipment: ... 4. Equipment rooms are dust mopped and wet mopped each day by housekeeping personnel. Cleaning refrigerators: Refrigerators on all floors in all departments are defrosted monthly. All refrigerators are checked each day by housekeeping aides and cleaned as needed. ... Cleaning Room LDRP Rooms: (Labor, Delivery, Recovery and Postpartum Rooms) 1. Cleaning of the LDRP1 through 6, scrub room, and utility rooms are done once in every 24-hour period, and after each use. ... Cleaning the Surgical Department: 1. Cleaning of the operating rooms, recovery room, utility rooms, office, lounges, and scrub area is done in every 24-hour period, and after each use. ...3. Every 24-hour period and after each use, ... Aide washes all equipment, such as tables and overhead lights down with germicidal solution..."

1) A tour of the obstetrical department on January 5, 2011, revealed three of the four Labor, Delivery, Recovery, Postpartum rooms (LDRP) contained a mobile wooden cabinet with closed compartments for the storage of supplies needed for labor and delivery, including a fetal heart monitor. The computer for the fetal heart monitor was mounted within the bottom compartment. An accumulation of white dust, approximately 3/8 inch, was noted on the surfaces of the computers and within their compartments in the cabinets in LDRP rooms 4, 5 and 6. Observation of the clean utility room used for labor and delivery patients contained accumulation of dust under the storage shelves and behind the door.

An interview with EMP1 on January 5, 2011, at 2:15 PM confirmed the accumulation of white dust on the fetal heart monitor computers located in LDRP rooms 4, 5, and 6. Further interview with EMP1 confirmed the accumulation of white dust on the floor in the clean utility room.

2) A tour of the newborn nursery on January 5, 2011, revealed the door to the housekeeping closet located in the center of the nursery was held open by a bassinet. The closet contained a utility sink, empty shelves and a dust brush. An electrical warming unit, used for warming patient clothing, was located beside the utility sink on a metal table. The warmer contained clean baby clothes for use on the newborns.

An interview with EMP1 on January 5, 2011, at 2:30 PM confirmed the door to the housekeeping closet was held open by a bassinet and clean baby clothes were stored in the electrical warming unit.

3) A tour of the coronary critical care unit (CCU) on January 6, 2011, revealed the soiled utility room contained packages of respiratory supplies used for care of patients on ventilators, an electric patient bathing system, a fax machine and numerous resource manuals. The room also contained covered hampers for soiled linen and trash.

An interview with EMP1 on January 6, 2011, at 1:00 PM confirmed the presence of the packages of respiratory supplies, resource manuals and the electric patient bathing system in the soiled utility room.

4) A tour of the magnetic resonance imaging (MRI) area January 4, 2011, revealed an accumulation of dust the size of a half dollar when gathered together on an equipment table beside the magnet, cracks in a three foot area of the surface of the floor and an accumulation of thick dust on the closet floor. Two boxes of supplies were stored directly on the closet floor.

An interview with EMP8 January 4, 2011, at 12:00 PM confirmed there were cracks in the surface of the floor beside the magnet. EMP8 confirmed that supplies were not to be stored on the floor of the MRI closet. Further interview with EMP3 confirmed that the MRI staff were responsible for cleaning of equipment, and the presence of dust on the equipment table and dust on the floor of the closet in the MRI room.

5) A tour of the occupational therapy area on January 4, 2011, revealed the freezer unit in the refrigerator was soiled with food debris, dust and spillage. Patients utilized the refrigerator and freezer during occupational therapy sessions in preparation for discharge.

An interview with EMP8 on January 4, 2011, at 3:00 PM confirmed the freezer in the occupational therapy suite was soiled.

6) A tour of the operating suite was completed on January 4, 2011. In operating room one, there were multiple one inch cracks in the vinyl of one of the operating table arm boards. In operating room two, there were multiple one inch cracks noted in the vinyl of both operating table arm boards. White fabric was visible through the cracks in the vinyl.

Interview with EMP9 on January 4, 2011, at 10:00 AM confirmed the cracks in the vinyl of one of the operating table arm boards in operating room one and on two operating table arm boards in operating room two.

Based on review of facility documents and interview with staff (EMP), it was determined that the facility failed to inform patients on swing bed status of their Patient Rights regarding medical assistance and medicare reimbursement.


Findings include:

Review on January 7, 2010, of facility document "Patient Handbook" dated November 2010, revealed "A Statement of the Patient's Rights and Responsibilities As a health care facility, we are committed to delivering quality medical care to you, our patient, and to making your stay as pleasant as possible. The following "Statement of Patient's Rights" was developed by the Department of Health, Commonwealth of Pennsylvania, and is endorsed by the administration and staff of this hospital. As it is our goal to provide medical care that is effective and considerate, we submit these to you as our statement of policy. ..."

Review on January 11, 2011, of "A Statement of the Patient's Rights and Responsibilities" located within the Patient Handbook revealed no notification of patients on swing bed status of their Patient Right regarding medical assistance and medicare reimbursement.

Interview on January 7, 2010, at 3:15 PM with EMP1 and EMP7 confirmed that the A Statement of the Patient's Rights and Responsibilities located within the Patient Handbook dated October 2010 contained Patient Rights for patients in acute care and swing bed status.

A telephone interview with EMP1 and EMP7 on January 11, 2010, at 1:30 PM confirmed that the A Statement of the Patient's Rights and Responsibilities located within the Patient Handbook did not include the swing bed patient's right to receive notification regarding medical assistance and medicare reimbursement.

Based on review of facility documents and interview with staff (EMP), it was determined that the facility failed to inform patients on swing bed status of their patient right to choose their own personal attending physician.

Findings include:

Review on January 7, 2010, of the facility document "Patient Handbook," dated November 2010, revealed "A Statement of the Patient's Rights and Responsibilities As a health care facility, we are committed to delivering quality medical care to you, our patient, and to making your stay as pleasant as possible. The following "Statement of Patient's Rights" was developed by the Department of Health, Commonwealth of Pennsylvania, and is endorsed by the administration and staff of this hospital. As it is our goal to provide medical care that is effective and considerate, we submit these to you as our statement of policy. ..."

Review on January 7, 2010, of "A Statement of the Patient's Rights and Responsibilities" located within the Patient Handbook revealed no notification of patients on swing bed status of their patient right to choose their own personal attending physician.

Interview on January 7, 2010, at 3:15 PM with EMP1 and EMP7 confirmed that the "A Statement of the Patient's Rights and Responsibilities" located within the Patient Handbook dated October 2010 contained Patient Rights for patients in acute care and swing bed status.

A telephone interview with EMP1 and EMP7 on January 11, 2010, at 1:30 PM confirmed that the "A Statement of the Patient's Rights and Responsibilities" located within the Patient Handbook did not include the swing bed patient's right to choose their own personal attending physician.

Based on review of facility documents and interview of staff (EMP), it was determined that the facility failed to inform patients on swing bed status of their patient right to send and receive unopened mail and have access to associated supplies at their own expense.

Findings include:

Review on January 7, 2010, of the facility document "Patient Handbook," dated November 2010, revealed "A Statement of the Patient's Rights and Responsibilities As a health care facility, we are committed to delivering quality medical care to you, our patient, and to making your stay as pleasant as possible. The following "Statement of Patient's Rights" was developed by the Department of Health, Commonwealth of Pennsylvania, and is endorsed by the administration and staff of this hospital. As it is our goal to provide medical care that is effective and considerate, we submit these to you as our statement of policy. ..."

Review on January 7, 2010, of "A Statement of the Patient's Rights and Responsibilities" located within the Patient Handbook revealed no notification of patients on swing bed status of their patient right to send and receive unopened mail and have access to associated supplies at their own expense.

Interview with EMP7 on January 7, 2010, at 3:15 PM with EMP1 and EMP7 confirmed that the "A Statement of the Patient's Rights and Responsibilities" located within the Patient Handbook dated October 2010 contained patient rights for patients in acute and swing bed status.

A telephone interview with EMP1 and EMP7 on January 11, 2010, at 1:40 PM confirmed that the "A Statement of the Patient's Rights and Responsibilities" located within the Patient Handbook did not include the patient right of swing bed patients to send and receive unopened mail and have access to associated supplies at their own expense.

Based on review of facility documents and interview of staff (EMP), it was determined that the facility failed to inform patients on swing bed status of their patient right to use personal possessions, including some furnishings, and appropriate clothing, as space permitted.

Findings include:

Review on January 7, 2010, of the facility document "Patient Handbook," dated November 2010, revealed "A Statement of the Patient's Rights and Responsibilities As a health care facility, we are committed to delivering quality medical care to you, our patient, and to making your stay as pleasant as possible. The following "Statement of Patient's Rights" was developed by the Department of Health, Commonwealth of Pennsylvania, and is endorsed by the administration and staff of this hospital. As it is our goal to provide medical care that is effective and considerate, we submit these to you as our statement of policy. ..."

Review of "A Statement of the Patient's Rights and Responsibilities" located within the Patient Handbook revealed no notification of patients on swing bed status of their patient right to use personal possessions, including some furnishings and clothing, as space permitted.

Interview on January 7, 2010, at 3:15 PM with EMP1 and EMP7 confirmed that the "A Statement of the Patient's Rights and Responsibilities" located within the Patient Handbook dated October 2010 contained the patient rights for patients in acute care and swing bed status.

A telephone interview with EMP1 and EMP7 on January 11, 2010, at 1:50 PM confirmed that the "A Statement of the Patient's Rights and Responsibilities" located within the Patient Handbook dated October 2010 did not include the swing bed patient's right to retain and use personal possessions, including some furnishings, and appropriate clothing, as space permitted.

Based on review of facility documents and interview of staff (EMP), it was determined that the facility failed to inform patients on swing bed status of their patient right to share a room with their spouse when married patients live in the same facility and both spouses consent to the arrangement.

Findings include:

Review on January 7, 2010, of the facility document "Patient Handbook," dated November 2010, revealed "A Statement of the Patient's Rights and Responsibilities As a health care facility, we are committed to delivering quality medical care to you, our patient, and to making your stay as pleasant as possible. The following "Statement of Patient's Rights" was developed by the Department of Health, Commonwealth of Pennsylvania, and is endorsed by the administration and staff of this hospital. As it is our goal to provide medical care that is effective and considerate, we submit these to you as our statement of policy. ..."

Review of "A Statement of the Patient's Rights and Responsibilities" located within the Patient Handbook revealed no notification of patients on swing bed status of their patient right to share a room with their spouse when married residents live in the same facility and both spouses consent to the arrangement.

Interview on January 7, 2010, at 3:15 PM with EMP1 and EMP7 confirmed that the "A Statement of the Patient's Rights and Responsibilities" located within the Patient Handbook dated October 2010 contained the patient rights for patients in acute care and swing bed status.

A telephone interview with EMP1 and EMP7 on January 11, 2010, at 1:30 PM confirmed that the "A Statement of the Patient's Rights and Responsibilities" located within the Patient Handbook did not include the swing bed patient's right to share a room with their spouse when married patients live in the same facility and both spouses consent to the arrangement.