HospitalInspections.org

Based on review of facility policies, medical records (MR) and interview with staff (EMP), it was determined the facility failed to document that each patient (or support person) was informed of their visitation rights for 56 of 56 medical records reviewed.

Findings include:

Review on December 6, 2016, of the facility policy "Patient Rights," last reviewed January 2016, revealed "Policy: The patient handbook is given to all patients or their representative upon admission. (If the patient is admitted after 10:00 PM, the handbook will be given to the patient or their representative the following day). ..."

Review on December 6, 2016, of facility brochure titled "Patient Guide," no review date, revealed "... Rights and Responsibilities You Have the Right to the Best Care ... Patient Rights: ... 41. You have the right to be informed of your visitation rights, including any clinical restrictions or limitations on such rights, when informed of rights. ... 43. You have the right to subject your consent, to receive visitors whom you designate, including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member or a friend, and have the right to withdraw or deny such consent at any time. 44. You have the right to have nonrestrictive, limited, or otherwise denied visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation or disability. 45. You have the right to be ensured that all visitors enjoy full and equal visitation privileges consistent with patient preferences. ..."

Review on December 5, 2016, of MR1, MR2, MR3, MR4, MR5, MR6 and MR7 revealed no documentation that each patient (or support person) was informed of their visitation rights.

Interview on December 5, 2016, at 10:49 AM with EMP4 confirmed MR1, MR2, MR3, MR4, MR5, MR6 and MR7 did not contain documentation the patient visitation rights were provided to the patient (or support person). EMP4 also confirmed this was a pattern. There was no documentation patient visitation rights were provided to the patient (or support person) present in the medical records reviewed during this survey, i.e. 56 medical records in total.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure the informed discharge instructions were dated on three out of nine Surgical Department (SD) medical records reviewed (MR38, MR39 and MR42).

Findings include:

Review on December 6, 2016, of the facility policy "GI [gastrointestinal] Endoscopy Discharge," last reviewed April 29, 2016, revealed "Policy: It is the policy of Memorial Hospital to ensure all outpatients undergoing a GI endoscopy are discharged without misunderstanding or mishap; and to ensure that the patient's association with the Surgical Department will be an educational one. Purpose: To ensure that the patient has been well taught and understands all discharge instructions. Guidelines: 1. The physician will complete discharge instructions after the procedure. 2. The physician will sign the GI Endoscopy Discharge Instruction Form. ..."

Review on December 6, 2016, at 1:30 PM, of the facility "GI Endoscopy Discharge Instructions" form, revealed an area for the patient's name, the date, the doctor, and the medical doctor's phone.

Review on December 6, 2016 at 1:40 PM, of MR38 revealed the patient had a GI Endoscopy procedure completed on December 6, 2016. Further review revealed a "GI Endoscopy Discharge Instructions" form with no documentation of the date of discharge.

Review on December 6, 2016 at 2:10 PM, of MR39 revealed the patient had a GI Endoscopy procedure completed on December 6, 2016. Further review revealed a "GI Endoscopy Discharge Instructions" form with no documentation of the date of discharge.

Review on December 6, 2016 at 1:40 PM, of MR42, revealed the patient had a GI Endoscopy procedure completed on December 6, 2016. Further review revealed a "GI Endoscopy Discharge Instructions" form with no documentation of the date of discharge.

Interview with EMP11 on December 6, 2016, at 1:45 PM, confirmed the facility "GI Endoscopy Discharge Instructions" form contained an area for the patient's name, the date, the doctor, and the medical doctor's phone. EMP11 confirmed MR38, MR39 and 42 did not have the date of discharge documented on the GI Endoscopy discharge instruction form.

Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure proper storage of non-infectious trash at the trash compactor site on campus.

Findings include:

Review on December 6, 2016, of the facility policy "Trash and Linen Disposal (Non Infectious), last reviewed October 26, 2016, revealed "Policy: Trash and linen disposal - non infectious Purpose: To establish a proper procedure for the disposal of non-infectious trash and linen ... 2. Trash disposal areas: A. All trash is put into trash bin an [sic] delivered to trash compactor located in lower level o [sic] parking lot. ..."

Observation on December 5, 2016, at 11:40 AM, revealed five bags of non-infectious trash sitting on the ground beside the trash compactor.

Interview with EMP2 on December 5, 2016, at 11:40 AM, confirmed there were five bags of non- infectious trash sitting on the ground beside the trash compactor.

Interview with EMP9 on December 5, 2016, at 11:40 AM, confirmed there were five bags of non-infectious trash sitting on the ground beside the trash compactor. The trash compactor was locked. A key was required to open the trash compactor to put in the trash into the trash compactor. The key is maintained by Housekeeping. EMP9 noted the off-site services bring their trash to the trash compactor and place beside the trash compactor for Housekeeping staff.

Interview with EMP10 on December 5, 2016, at approximately 11:50 AM, confirmed the trash compactor was locked, and Housekeeping had the key. EMP10 confirmed the non-infectious trash bags sit beside the trash compactor until Housekeeping staff place in the trash compactor.

Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure appropriate use of personal protective equipment, including gowns, masks, eye protection and hair coverage devices in the Operating Room.

Findings include:

Review on December 6, 2016, of facility policy "Surgical Attire," last reviewed August 23, 2016, revealed "Policy: This document is the policy for The Guthrie Clinic in regards to surgical attire including scrub attire, head and hair coverings, masks, jewelry and shoes worn in the semi-restricted and restricted areas of the perioperative department. This policy also includes instructions for stethoscopes, backpacks and other personal items brought into the semi-restricted and restricted areas. Purpose: These recommended practices provide guidelines for attire worn within the semi-restricted and restricted areas of the surgical environment. Procedure: ...7. All personnel entering the restricted areas of the perioperative department should cover the head, hair and facial hair. All personnel entering the semi-restricted areas of the perioperative department should cover the head and hair. A. A clean surgical head cover or hood that confines all hair and completely covers the scalp skin, side burns and nape of the neck should be worn. B. No cloth caps may be worn. C. No skull caps will be worn. D. Bouffant caps or hoods must be worn, depending on the amount of coverage that is needed. E. When mask or hood is not worn or does not cover facial hair, a beard covering must be used. ..."

Observation on December 6, 2016, at 9:50 AM, in the Operating Room, revealed EMP12 and EMP13 wearing masks provided by the facility. The mask provided covered of the nose and mouth areas. The mask did not provide coverage of the hair stubble from the cheek areas by the mouth to the ears.

Interview with EMP11 on December 6, 2016, at 11:30 AM, confirmed EMP12 and EMP13 wearing masks provided by the facility. The mask provided covered of the nose and mouth areas. The mask did not provide coverage of the hair stubble from the cheek areas by the mouth to the ears. EMP11 confirmed the facility has hair covering devices available for staff with beards.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure the swing bed patient participated in determining a code status for three of four applicable swing bed program medical records reviewed (MR47, MR50 and MR51).

Findings include:

Review on December 7, 2016, of the facility's "Do Not Resuscitate (DNR) Policy," last reviewed December 2013, revealed "Policy: It is widely recognized that in some clinical situations the initiation of potentially life prolonging treatment is inappropriate. 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 (Do Not Resuscitate) means that in the event of a cardiac or respiratory arrest in a terminally ill patient, cardiopulmonary resuscitation 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..."

Review of MR47 on December 7, 2016, revealed the patient was admitted to the facility's swing bed program on November 22, 2016, and was alert and oriented. Continued review of MR47 revealed a physician order for a Do Not Resuscitate (DNR). There was no documentation in MR47 indicating the physician discussed the DNR status with MR47 or the patient participated in the decision of the DNR status.

Review of MR50 on December 7, 2016, revealed the patient was admitted to the facility's swing bed program on October 11, 2016, and was alert and oriented. Continued review of MR50 revealed a physician order for a Do Not Resuscitate. There was no documentation in MR50 indicating the physician discussed the DNR status with MR50 or the patient participated in the decision of the DNR status.

Review of MR51 on December 7, 2016, revealed the patient was admitted to the facility's swing bed program on October 25, 2016, and was alert and oriented. Continued review of MR51 revealed a physician order for a Do Not Resuscitate. There was no documentation in MR51 indicating the physician discussed the DNR status with MR51 or the patient participated in the decision of the DNR status.

Interview with EMP1 and EMP4 on December 7, 2016, at approximately 1:00 PM confirmed MR47, MR50 and MR51 were admitted to the facility's swing bed program and were alert and oriented. MR47, MR50 and MR51's physicians wrote DNR status for these patients, and there was no documentation in the patients' medical records indicating a physician discussion regarding the DNR status or that the patients participated in the decision for a DNR status.