HospitalInspections.org

Based on document review and interview, the facility failed to perform performance improvement activities which monitor and report adverse patient events.

Findings include:

1. Review of Quality Assurance Committee meeting minutes on 7-28-10 indicated lack of evidence that adverse patient events were included in the facility Quality Assurance and Performance Improvement (QAPI) activities.
2. Interview with #S4 on 7-29-10 at 1150 hours confirmed that adverse patient events are not included in the facility's QAPI activities. Additional documents were requested; none were provided prior to exit.

Based on policy and procedure review, medical record review, and staff interview, the facility failed to ensure an updated examination of the patient, including any changes in the patient's condition, was completed and documented within 24 hours after admission for 1 of 1 (N8) closed patient medical record reviewed of a patient who was discharged and re-admitted on the same day.

Findings:
1. Policy titled, "History & Physical", was reviewed on 7/29/10 at 11:00 AM, and indicated on pg. 1, under Policy section, "If the patient is readmitted to the hospital within 7 days from the date of the last H&P (History & Physical), a copy of the previous H&P may be used as an Interval H&P. This copy must be updated by an interval note which includes what has transpired since the last discharge, as well as any physical changes. This interval note must be dated and signed at the time of re-admission. If the Interval H&P is dictated, the dictator must instruct the Medical Records File Clerk to attach a copy of the previous H&P to the new H&P."

2. Review of closed patient medical records on 7/28/10 at 11:25 AM indicated:
A. patient N8 was discharged on 6/7/10 at 2:15 PM and re-admitted on 6/7/10 at 9:00 PM and lacked an interval note updating the H&P, which includes what has transpired since the last discharge, as well as any physical changes.

3. Personnel P5 was interviewed on 7/29/10 at 11:15 AM and confirmed that patient N8 was discharged and re-admitted and lacked an interval note updating the H&P as required per facility policy and procedure.

Based on policy and procedure review, medical record review, and staff interview, the facility failed to ensure an updated psychiatric evaluation was in the medical record for 1 of 1 (N8) closed patient medical records reviewed of a patient who was discharged and re-admitted on the same day.

Findings:
1. Policy titled, "Comprehensive Psychiatric Evaluation", was reviewed on 7/29/10 at 11:00 AM, and indicated on pg. 1, under Policy section, "If the patient is readmitted to the hospital within 24 hours from the date of the last discharge, a copy of the previous Comprehensive Psychiatric Evaluation may be used for the current admission. This copy must be updated by an interval note which includes current precipitating events and any pertinent changes which have transpired since the last discharge, as well as new estimated length of stay. The interval note must be dated and signed at the time of re-admission."

2. Review of closed patient medical records on 7/28/10 at 11:25 AM indicated:
A. patient N8 was discharged on 6/7/10 at 2:15 PM and re-admitted on 6/7/10 at 9:00 PM and lacked an interval note updating the Comprehensive Psychiatric Evaluation, which includes current precipitating events and any pertinent changes which have transpired since the last discharge, as well as new estimated length of stay.

3. Personnel P5 was interviewed on 7/29/10 at 11:15 AM and confirmed that patient N8 was discharged and re-admitted and lacked an interval note updating the Comprehensive Psychiatric Evaluation as required per facility policy and procedure.

Based on policy and procedure review, medical record review, and staff interview, the facility failed to implement its policy and procedure related to completion of medical record entries specific to transfer forms for 2 of 2 (N1 and N2) closed patient medical records reviewed.

Findings:
1. Policy titled, "Transfer of Patients with Emergency Medical Conditions", was reviewed on 7/29/10 at 11:00 AM, and indicated on pg. 2, under Procedure for Transfer of an Inpatient to Another Facility section, point 11., "The qualified medical personnel shall complete the Transfer Documentation Form and ensure that it is filed in the patient's record along with a copy of the Certification and Authorization for Transfer Form."

2. Review of closed patient medical records on 7/28/10 at 11:25 AM indicated:
A. patient N1 was transferred to another facility on 3/4/10 and the Transfer Documentation Form lacked documentation of the transferring physician, receiving hospital, receiving physician, and time of signature of transferring personnel.
B. patient N2 was transferred to another facility on 4/17/10 and:
a. the Transfer Documentation Form lacked documentation of the receiving hospital, receiving physician, time transfer accepted, and date and time of signature of transferring personnel.
b. the Certification and Authorization for Transfer Form lacked documentation of physician contacted, signature of physician and date, and signature of transferring personnel and date.

3. Personnel P5 was interviewed on 7/29/10 at 11:15 AM and confirmed that the above-mentioned transfer forms lacked complete documentation as required per facility policy and procedure.

Based on policy and procedure review, medical record review, and staff interview, the facility failed to ensure verbal orders were authenticated within 48 hours for 8 of 10 (N1-N6, N9 and N10) closed medical records reviewed; and facility policy and procedure does not address the process related to read back and verified orders or authentication of those orders within 48 hours.

Findings:
1. Policy titled, "Verbal/Telephone Orders Authentication", was reviewed on 7/29/10 at 11:30 AM, and lacked the process related to read back and verification of verbal orders and authentication of those orders within 48 hours.

2. Review of closed patient medical records on 7/28/10 at 11:25 AM indicated Patient:
A. N1 had documentation of a read back and verified verbal order on 3/3/10 at 08:20 AM, but lacked a date and time by the signature of the physician authenticating it.
B. N2 had documentation of a read back and verified verbal order on 4/16/10 at 21:00 PM, but lacked physician authentication with date and time.
C. N3 had documentation of a telephone verbal order on 12/8/09 at 8:00 PM, but lacked a date and time by the signature of the physician authenticating it.
D. N4 had documentation of a read back and verified verbal order on 1/26/10 at 12:10 PM, but lacked a date and time by the signature of the physician authenticating it.
E. N5 had documentation of a telephone verbal order on 3/29/10 at 18:00 PM, but lacked a date and time by the signature of the physician authenticating it.
F. N6 had documentation of a read back and verified verbal order on 4/26/10 at 14:15 PM, but lacked a date and time by the signature of the physician authenticating it.
G. N9 had documentation of a read back and verified verbal order on 1/28/10 at 18:00 PM, but lacked a date and time by the signature of the physician authenticating it.
H. N10 had documentation of a telephone verbal order on 2/16/10 at 18:45 PM, but lacked a date and time by the signature of the physician authenticating it.

3. Personnel P5 was interviewed on 7/29/10 at 11:45 AM and confirmed the above-mentioned telephone and/or verbal orders were either lacking physician authentication and/or date and time. Also, the policy on telephone and verbal orders does not address the process related to read back and verified orders or authentication of those orders within 48 hours.

Based on document review and interview, the facility failed to ensure two or more practitioners (doctors of medicine or osteopathy) carry out the utilization review function

Findings include:

1. Review of facility documents on 7-29-10 indicated the Utilization Review Committee composition is limited to one physician, #S20.
2. Review of Utilization Review Committee minutes on 7-29-10 indicated #S20 was absent from 3 of the 5 meetings held over the past 12 months.
3. Interview with #S4 on 7-29-10 at 1145 hours confirmed #S20 is the only physician on the Utilization Review Committee and #S20 was absent from 3 of the 5 meetings held over the past 12 months. Additional documents were requested; none were provided prior to exit.

Based on policy and procedure review and staff interview, the facility failed to ensure recording of daily defibrillator checks for 1 of 1 Automated External Defibrillator (AED).

Findings:

1. Policy titled, "Use and Care of Portable Life Pak AED Defibrillator", was reviewed on 7/29/10 at 10:00 AM, and indicated on pg. 2, under Care of the Defibrillator section, point 1., "The defibrillator must be inspected daily."

2. Personnel P5 was interviewed on 7/29/10 at 10:03 AM and confirmed that although daily inspections of the AED are being done they are not being documented. Therefore, it could not be determined that the equipment was maintained at an acceptable level of safety.

Findings:
1. Review of employee health records at 1:55 PM on 7/27/10, indicated:
a. Personnel P1 (Mental Health Tech), P3 (MHT), and P5, Registered Nurse (R.N.) provide direct patient care and lacked documentation of Rubella, Rubeola, and Varicella immunity or vaccination.
b. Personnel P2 (MHT), P4 (MHT), P6 (R.N.), P7 (Licensed Practical Nurse) and P8 (L.P.N.) provide direct patient care and lacked documentation of Varicella immunity or vaccination.




27548

Based on document review and interview, the infection control officer failed to develop a system to identify, report, investigate, and control infections and communicable diseases for 5 of 5 (#S14 - #S18) personnel files reviewed.

Findings include:

1. Review of personnel files on 7-28-10 indicated the following:
a.) #S14 did not have documented immunity to varicella
b.) #S15 did not have documented immunity to varicella
c.) #S16 did not have documented immunity to varicella
d.) #S17 did not have documented immunity to rubella, rubeola, or varicella
e.) #S18 did not have documented immunity to varicella
2. Interview with #S21on 7-29-10 at 1220 hours confirmed the above findings and confirmed that the facility did not have a system in place to identify, report, investigate or control infections and communicable diseases related to facility personnel. Additional documents were requested; none were provided prior to exit.

Based on document review and interview, the facility failed to provide Quality Assurance and Performance Improvement (QAPI) data to the Governing Board for 3 of 3 meetings ( 8-10-09, 11-9-09, 2-8-10) over the past 12 months.

Findings include:

1. Review of the facility Quality Improvement Plan on 7-29-10 indicated the Board of Directors will ensure that Madison Center fulfills and demonstrates fidelity to its mission, and provides guidance and support to executive leadership in the maintenance of quality of care and patient safety (document presented identifies Madison Center, not Riverside Hospital).
2. Review of Governing Board meeting minutes on 7-28-10 indicated lack of evidence that QAPI data was provided or discussed at the governing board meetings for 3 of 3 meetings over the past 12 months.
3. Interview with #S4 on 7-29-10 at 1150 hours confirmed that QAPI data was not provided for review to the Governing Board at the past 3 of 3 meetings. #S4 confirms that the Governing Board conducted 3 meetings over the past 12 months, and QAPI plan is draft and under current revision. Additional documents were requested; none were provided prior to exit.

Based on document review and interview, the facility failed to ensure 4 direct services and 1 contract service were included in the Quality Assurance and Performance Improvement (QAPI) program.

Findings include:

1. Review of facility documents on 7-28-10 indicated lack of evidence that the direct services of alcohol/drug services, psychiatry, housekeeping, and infection control were included in the facility QAPI program.
2. Review of facility documents on 7-28-10 indicated lack of evidence that the contract service of radiology was included in the facility QAPI program.
3. Interview with #S4 on 7-29-10 at 1150 hours confirmed the above services are not included in the facility QAPI program. Additional documents were requested; none were provided prior to exit.