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A. Based on Hospital policy, clinical record review and staff interview, it was determined for 1 of 1 clinical record for a restrained patient on 3 West, (Pt. #4) that for 3 of 10 days the Hospital failed to ensure physician orders for restraints were initiated and complete.

Findings include:

1. Hospital policy entitled, "Restraint Policy," requires, "The written or verbal order shall be obtained..." The "Medical/Surgical Restraint Order," requires "Start time... End time..."

2. On 4/28/08, the computerized and hard-copy clinical record of Pt. #4 was reviewed. This is a 98-year-old male admitted 4/11/08 with diagnoses of "Generalized Weakness and Tele Patient". The clinical record included documentation of an initial physician's order for bilateral soft wrist restraints on 4/11/08. The record included documentation that the patient remained in restraints through 4/20/08. The record lacked documentation of a physician's order for restraints on 4/17/08. In addition, the physicians' order for restraints dated 4/16/08 and 4/20/08 lacked documentation of a start and end time for the orders.

3. The above findings were conveyed to the Assistant Nurse Manager of 3 West and the VP of Nursing on 4/28/08 at approximately 11:00 A.M.

A. Based on review of the Hospital's Medical Staff Rules and Regulations, clinical record review, and staff interview, it was determined for 1 of 3 clinicals records reviewed for 3 West patients, (Pt. #4) that the physician failed to ensure a current history and physical examination were completed.

Findings include:

1. The Hospital's Medical Staff Rules and Regulations (approved January 22, 2008) included, "A complete admission history and physical examination shall be recorded on the medical record within 24 hours of admission..."

2. The computerized and hard-copy clinical record of Pt. #4 was reviewed on 4/28/08. This is a 98-year-old male admitted 4/11/08 with diagnoses of "Generalized Weakness and Tele Patient". The clinical record included documentation of a physician's history and physical examination dated 10/17/2007. The record lacked documentation of a current history and physical.

3. The above finding was conveyed to the Assistant Nurse Manager of 3 West and the VP of Nursing on 4/28/08 at approximately 11:00 A.M.

A. Based on Hospital procedure review, observation, clinical record review, and staff interview, it was determined that on the 3 West Unit, for 1 of 14 patients with ordered telemetry monitoring, (Pt. #4) the nursing staff failed to monitor the patient in accordance with the physician's order.

Findings include:

1. Hospital "Telemetry Procedure," requires, "Telemetry patients will be monitored by RN staff".

2. On 4/28/08 at approximately 10:55 A.M. the centralized telemetry monitors for the patients at the nursing station, included cardiac tracings for 12 of 14 patients. The monitor indicated "leads off" for the patients in rooms 304 and 311.

3. In an interview with the charge nurse on 3 West, (E#7) on 4/28/08 at approximately 10:55 A.M., E#7 was questioned as to why the leads were off on two of the patients. E#7 stated, "I believe the patient is having a bath...both of them". E#7 proceeded to put the monitor in stand-by and bath mode by adjusting the central monitor at the nursing station for both patients without first checking the patients to verify that they were receiving baths.

4. At approximately 10:57 A.M., an observation of room 304 was conducted. Pt. #4 was alone and in bed. He was wearing bilateral soft wrist restraints. The patient's leads were off and laying on his chest. The clinical record for Pt. #4 included a physician's order dated 4/11/08 for Telemetry.

On approaching room 311 to verify the patient's status, a nurse inside the room stated that she was just completing the bath for this patient.

6. The above findings were conveyed to the Assistant Nurse Manager of 3 West and the VP of Nursing on 4/28/08 at approximately 11:00 A.M.


B. Based on clinical record review and staff interview, it was determined for 2 of 2 patients receiving wound care on the 3 West Unit, (Pt. #2 and #3) the nurse failed to ensure treatment was provided for the patients' wounds as ordered.

Findings include:

1. On 4/28/08 the computerized and hard-copy clinical record of Pt. #2 was reviewed. This is an 85-year-old male, admitted 4/21/08 with multiple diagnoses including Multiple Decubs, COPD, UTI, Tele, and VRE-Contact Isolation. The clinical record included a physician's order dated 4/22/08 for "wound care nurse to evaluate for per day dressing change... suggest...QD"(daily). The record also contained the wound care nurse's order dated 4/23/08 for wound care and dressings to multiple areas of the body including the left heel and bottom of the right foot.

2. On 4/28/08 during a tour of 3 West, Pt #2 was in bed in room 313 with gauze dressings on both feet. The dressings were dated 4/25/08 (3 days ago). The dressings were partially unraveled and hanging loosely.

3. On 4/28/08 at approximately 11:25 A.M. an interview was conducted with the Wound Care Nurse, (E#6). E#6 stated that the dressing changes should have been done daily.

4. The computerized and hard-copy clinical record of Pt. #3 was reviewed on 4/28/08. This is a 79-year-old male admitted 4/23/08 with diagnoses of Intractable Back Pain and Renal Dialysis. The clinical record included documentation of a wound care order dated 4/25/08 for Xenaderm to the coccyx area and inner buttocks and bilateral heels twice daily. The record lacked documentation that any wound care was done on 4/26/08 and lacked documentation that the wound care was completed for the second time on 4/25/08 and 4/27/08.

5. The above findings were conveyed to the Assistant Nurse Manager of 3 West and the VP of Nursing on 4/28/08 at approximately 11:30 A.M.


C. Based on clinical record review and staff interview, it was determined for 1 of 3 clinical records reviewed on the 3 West Unit, (Pt. #3) that the nurse failed to document the dosage of narcotic analgesic administered.

Findings include:

1. The computerized and hard-copy clinical records of Pt. #3 were reviewed on 4/28/08. This is a 79-year-old male admitted 4/23/08 with diagnoses of Intractable Back Pain and Renal Dialysis. The clinical record included documentation of a physician's order dated 4/23/08 for Morphine 2-4 mg intravenously every 3 hours as needed and included documentation in the medication administration record, (MAR) that the patient received a dose of Morphine on 4/26/08 at 9:40 A.M. The record lacked documentation of the amount of Morphine (between 2-4 mg) that was administered.

5. The above finding was conveyed to the Assistant Nurse Manager of 3 West and the VP of Nursing on 4/28/08 at approximately 11:30 A.M.

A. Based on clinical record review and staff interview, it was determined that in 1 of 2 (Pt. #1) clinical records reviewed in the 5 South unit, the Hospital failed to ensure all medications were administered according to physician's orders.

Findings include:

1. The clinical record of Pt. #1 was reviewed on 4/28/08. Pt. #1 was a 72 year old female, admitted on 4/21/08, with diagnoses of Cardiovascular Accident and Diabetes. The Physician's order dated 4/25/08 at 5:20 PM, indicated: "...D/C high dose Novolog sliding scale. ...New sliding scale: 200-250 = 6 units, 251-300 = 9 units, ...400 call MD...." The accucheck documentation on 4/26/08 at 6:00 AM indicated the accucheck was 171. The MAR (medication administration record) indicated that at 8:00 AM on 4/26/08, Pt. #1 received 3 units of Novolog insulin. However, the clinical record lacked an order for the administration of the Novolog for an accucheck less than 200.

2. The above findings were conveyed to the Assistant Unit Manager of 5 South, during interview on 4/28/08, at approximately 11:30 AM.

A. Based on a review of the Hospital's Medical Staff Rules and Regulations, review of a document titled "delinquent record counts ", and staff interview, it was determined that the Hospital failed to ensure that medical records were completed within 30 days of discharge.

Findings include:

1. The Hospital's Medical Staff Rules and Regulations page 9 required, " ...the medical record will be available in the medical records department and must be completed within 30 days of discharge or the medical record will be considered delinquent..."

2. On 4/30/08 at approximately 10AM, the Director of Medical records presented a document titled "delinquent records count". As of 4/30/08, the Hospital has 1,389 incomplete records.

3. The above finding was conveyed to the Director of Medical Records during an interview on 4/30/08 at 10:00AM.

A. Based on observation and staff interview, it was determined, for 2 of 3 Operating Room (OR) suites (suites 9 & 10) that the Hospital failed to ensure that biological supplies were not outdated.

Findings include:

1. On survey date 4/29/08 between 6:45 AM and 8:30 AM, operating suites 2, 9, and 10 were toured. Suites 9 and 10 contained expired sutures:

- suite 9 - one box 2.0 Vicryl suture expired 1/08
- suite 10 - six 0 Silk sutures expired 1/07

2. These findings were conveyed to the Director of Surgical Services during an interview on 4/29/08 at 8:50 AM.

A. Based on observation and staff interview, it was determined, for 1 of 3 Operating Room, (OR) suites (suite 9), the Hospital failed to ensure that equipment was properly cleaned to reduce potential infections.

Findings include:

1. On survey date 4/29/08 between 6:45 AM and 8:30 AM, operating suites 2, 9, and 10 were toured. Suite 9 OR table contained tape on the head and lower pads. One arm pad contained several pieces of tape and approximately 2 by 6 inches of tape residue. Disinfection of tape and tape residue can not be certain. An orthopedic case began at 8:05 AM.

2. These findings were conveyed to the Director of Surgical Services during an interview on 4/29/08 at 8:50 AM.

A. Based on Hospital policy, observation, and staff interview, it was determined that in Operating Room (OR) #2, the Hospital failed to ensure adherence to Hospital policy governing operating room apparel.

Findings include:

1. Hospital policy entitled "Operating Room Apparel," required, "No jewelry is to be worn in the surgical restricted area."

2. On 4/29/08 observations were conducted in OR#2 from 7:00 A.M. - 8:25 A.M. The nurse circulator, (E#8) was wearing a ring on the right hand, middle finger. The anesthesiologist (E#9) was wearing a ring on the left hand, ring finger.

3. The above findings were conveyed to the OR Director on 4/29/08 at approximately 8:45 A.M.




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B. Based on review of Hospital policy, observation, and interview, it was determined that the Hospital failed to ensure that all staff adhered to policy governing attire in the surgical suites.

Findings include:

1. Hospital policy titled, "Operating Room Apparel" required, "...Surgical cap or hood must be worn in the surgical restricted and semi-restricted areas ....Completely covers all head and facial hair ...surgical masks are to be worn at all times: ...completely covers mouth and nose, ...completely secured to prevent venting at the sides...."

2. During observation of surgical packs being opened in room 10 on 4/29/08, between 7:00 and 8:50 AM., the following were observed: A Physician's assistant (E #1) entered the room with approximately 2 inches of hair exposed on the back of the head, a Certified Registered Nurse Anesthetist (E #2) entered the suite with the mask hanging over the mouth and nose, not completely secured, and an Anesthesiologist (E #3) entered the suite with an unsecured mask, held over by hand.

3. During the observation of surgical packs being opened in room 9 on 4/29/08, between 7:00 and 8:30 AM., a Physician's assistant and an Orthopedic Surgeon entered the suite with unsecured masks.
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4. The above findings were conveyed to the Director of Surgical services during interview on 4/29/08, at approximately 9:50 AM

A. Based on a review of the Hospital's Medical Staff Rules and Regulations, clinical record review, and staff interview, it was determined for 1 of 1 surgical patient in the Intensive Care Unit (ICU), (Pt. #6) the anesthesiologist failed to ensure a pre-anesthesia evaluation was completed prior to surgery being performed.

Findings include:

1. Hospital's Medical Staff Rules and Regulations (approved January 22, 2008) included, "Pre-Sedation or Pre-Anesthesia Assessment/Evaluation must be documented and must include... A pre-anesthesia record will be placed in the patient's medical record indicating the patient's past and present medical and drug history, any previous anesthesia experiences..."

2. On 4/29/08, the clinical record of Pt. #6 was reviewed. This is a 68-year-old male admitted 4/23/08 with a diagnosis of Gastrointestinal Bleed. The record included documentation that the patient underwent an Exploratory Laparoscopy, Subtotal Colectomy surgery on 4/27/08. The record lacked documentation of a pre-anesthesia evaluation prior to the surgery.

3. The above finding was conveyed to the ICU Nurse Manager and the VP of Nursing on 4/29/08 at approximately 10:00 A.M.