HospitalInspections.org

A. Based on observation and staff interview it was determined that the Hospital failed to ensure that confidentiality of patient records is maintained.

Findings include:

1. During a tour of the pain management clinic on 7/14/09 at 2:00 PM, it was observed that five patient medical records were laying on top of an open file cabinet which contained other patient records. The medical records were visible and accessible to the patient waiting room.

2. During an interview with the Nurse Manager on 7/14/09 at 2:00 PM, the above findings were confirmed.

A. Based on policy and procedure, record review and staff interview it was determined that in 1 of 3 (Patient (Pt.) #17) records reviewed with restraints the Hospital failed to ensure that a timely physician order was received according to Hospital policy.

Findings include:

1. The Hospital policy titled, " Restraints, Use of" under "Protective Restraints-2 Point Only" "1. The order must originate from the physician...nurse. The physician must be notified within 12 hours...order."

2. The medical record of Pt. #17 was reviewed on 7/15/09. Pt. #17 was admitted to the Hospital on 2/18/09 with the diagnosis of Altered Mental Status. Documentation indicated that Pt. #17 was "restless"and was in a Geriatric chair on 2/19/09 at 0900. Documentation indicated a physician order dated 2/20/09 at 1430 was signed by the physician in the wrong area on the restraint form with no time or date.

3. During an interview with the Nurse Manager on 7/15/09 at 3:00 PM, the above findings were confirmed.

A. Based on medical record review and staff interview, it was determined that in 1 of 20 (Pt # 29) in which the patient had surgical procedures, the Hospital failed to ensure that all informed consents for procedures and treatments were signed, dated and timed by the physician prior to the procedure being performed.

Findings include:

1. The medical record of Pt #29 was reviewed on 07/16/09. It indicated that Pt #29 was admitted to the Hospital on 03/17/09 for a Cesarean Section. Documentation indicated that a form titled, "Consent for Surgical and/or Special Procedures" and the form titled, "Consent and Release for Shared Cesarean Birth Experience" was not signed, dated or timed by the physician.

2. During an interview conducted on 07/16/09 at 10:00 AM with the Quality Resources Coordinator, the above finding was confirmed.

A. Based on Hospital policy, observation and staff interview, it was determined that the Hospital failed to provide patient safety by failing to ensure that drugs and biologicals are maintained in accordance with applicable standards of practice, consistent with Federal and State law.

Findings include:

1. The Hospital policy titled, "Crash Cart Check List, sentence #2, Crash carts in all department except ICU (see specific policies) are checked every 24 hours for the following: 1) Drawers locked..."

2. During a tour of the Obstetrical (OB) unit on 07/14/09 at 1:30 PM with an OB nurse, it was observed that the crash cart located in the Caesarean Section (C-section) suite was unlocked.

3. During an interview with the OB nurse, it was reported that the pharmacy staff had recently checked the cart and replaced medications but had not placed a lock on the cart. On 07/15/09 at 3:30 PM during an interview with the Director of Medical Surgical Services, the above finding was confirmed.

A. Based on observation, policy and procedure, and staff interview it was determined that the Hospital failed to ensure that staff followed surgical attire policies.

Findings include:

1. During a tour of the surgical suites on 7/14/09 at 9:30 am, it was observed that six staff were observed to be wearing jewelry while in restricted areas.

2. The Hospital policy titled, "Operating Room Attire" Policy: " No jewelry allowed" revised 12/08.

3. During an interview with the Nurse Manager on 7/14/09 at 10:00 am, the above findings were confirmed.