HospitalInspections.org

Based on medical record review, policy and procedure review and interview, the facility failed to ensure that the medical record services held administrative responsibility to maintain complete and accurate medical records for every individual evaluated or treated in the hospital.

Findings include:

1. The facility failed to ensure medical records were accurately written, promptly completed, properly filed and retained and accessible. See tag A 438

2. The facility failed to ensure that the medical records contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient's progress and response to medications and services. See tag A 449

3. The facility failed to ensure that all patient medical record entries are legible, complete, dated, timed, and authenticated in written or electronic form. See tag A 450

4. The facility failed to ensure that all verbal orders are authenticated within 48 hours. See tag A 457

5. The facility failed to ensure that all medical records contain a discharge summary with the outcome of hospitalization, disposition of case, and provisions for follow-up care. See tag A 468

6. The facility failed to ensure that medical records contain the final diagnosis with the completion of all medical records within 30 days following discharge. See tag A 469

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-709.

Based on observation, record review, and interview it was revealed that the facility failed to ensure the authentication and accuracy of restraint orders for the use of restraints in the focused chart review of 1 out of 1 patients (#23), resulting in the potential of restraining a patient beyond need for restraint.

On 05/03/2011 at approximately 1530 it was revealed that one of one patient charts (#23) contained unsigned verbal orders for restraints 48 hours after the order was taken. On 05/03/2011 at approximately 1545 both the house supervisor (#J), the director of quality, and the director of nursing confirmed that the patient restraint order from 05/01/2011 had not been signed by the physician.

On 05/03/2011 at approximately 1540 it was observed that a patient (#23) was restrained by use of soft limb restraints, tied mittens, and 4 side rails. The restraint order for 05/01/2011 and 05/02/2011 did not have an order for soft limb restraints to be used on either day. On 05/03/2011 at approximately 1545 it was confirmed by the house supervisor (#J), the director of quality, and the director of nursing that the patient restraint order from 05/01/2011 and 05/02/2011 did not have an order for sort limb restraints.

Based on interview and record review the facility failed to ensure that the condition of 1 of 8 restrained patients (#3) was appropriately monitored while in restraints according to the facility policy. Findings include:

On 05/04/11 at 0900 review of the facility policy entitled "2010 Annual Restraint Use Plan" revised 03/15/11 revealed, "The condition and needs of the restrained patient should be assessed, monitored, and re-evaluated by the patient care nurse. This assessment/evaluation should be documented every 2 hours and PRN by an RN or LPN."

Record review on 05/03/11 at 1030 revealed that patient #3 was admitted into the facility on 04/21/11 and was ordered bilateral mitten restraints on 04/29/11 at 0320. Review of the Restraint flow sheet dated 04/29/11 revealed that there was no monitoring for skin/circulation, no range of motion or repositioning was noted and no documentation that the patients' hydration/nourishment or elimination needs were assessed from 0800 through 1600.

These findings were verified by Staff (B) on 05/03/11 at approximately 1045 a.m.

Based on medical record review, policy and procedure review and interview, the facility failed to ensure that documentation and the description of the patient's behavior and the intervention used was in the medical record in 1 out of 8 (#17) restrained patients. Findings include:

During patient #17's medical record review on 5-2-11 at approximately 1110 it was found on the document titled, "Non-Behavioral Restraint Order & Assessment", for the dates 4-29-11 and 4-30-11 that there was no documentation or description of the patient's behavior or interventions used for this patient.

During policy and procedure review on 5-3-11 at approximately 0930 it was found in the policy titled, "2011 Annual Restraint Plan", under Nursing Documentation, it states, "Documentation should include the following: Rationale for use and continued use (clinical justification) including less restrictive interventions attempted. Type of restraint applied...".

During an interview on 5-2-11 at approximately 0940 it was confirmed by staff A and K that no documentation had been completed as required per policy.

Based on medical record review, policy and procedure review and interview the facility failed to document any other alternatives or other less restrictive interventions attempted in 1 out of 8 (#17) restrained patients. Findings include:

During policy and procedure review on 5-3-11 at approximately 0930 it was found in the policy titled, "2011 Annual Restraint Plan", under Procedure, #1, states, "A restraint should only be used based on the patient's clinical assessment/condition, should be needed to improve the patient's well being, and documentation should show that less restrictive interventions have been determined to be ineffective".

During patient #17's medical record review on 5-2-11 at approximately 1110 it was found on the document titled, "Non-Behavioral Restraint Order & Assessment", for the dates 4-29-11 and 4-30-11 that there was no documentation of any other alternative or less restrictive interventions attempted for this patient.

During an interview on 5-2-11 at approximately 0940 it was confirmed by staff A and K that no documentation had been completed as required per policy.

Based on medical record review, policy and procedure review and interview, the facility failed to document the patient's condition and/or symptoms that warranted the use of restraints in 1 out of 8 (#17) restrained patients. Findings include:

During patient #17's medical record review on 5-2-11 at approximately 1110 it was found on the document titled, "Non-Behavioral Restraint Order & Assessment", for the dates 4-29-11 and 4-30-11 that there was no documentation of of the patient's condition and/or symptoms that warranted the use of restraints.

During policy and procedure review on 5-3-11 at approximately 0930 the policy titled, "2011 Annual Restraint Use Plan", in Procedure, #1 states, "a restraint should only be used based on the patient's clinical assessment/condition, should be needed to improve the patient's well being, ...1.1 In accordance with an appropriate, documented assessment of the patient's needs...".

During an interview on 5-2-11 at approximately 0940 it was confirmed by staff A and K that no documentation had been completed as required per policy.

Based on observation, medical record review and interview the facility failed to document care given, provide medication as needed to patients in a timely manner, provide care to patients when needed and meet the staffing guidelines put in place by the facility for 3 out of 4 patients (#6, #16, #32). Findings include:
On 5/4/2011 during medical record review of patient #16's chart it was revealed that the staff were unable to document care given. The patient had several wounds that required care several times a day, on 5/3 no wound care was documented. When interviewing staff O regarding wound care the staff member stated "I just don't have time to document it, I hardly have time to get it done."



29774

On 5/3/2011 at approximately 1130 interview with patient #6 reveals that the call light is answered in a timely manner "most of the time". Patient states that they (healthcare staff) will answer his call light at the desk right away, but sometimes it takes from 15 to 30 minutes for the nurse to come to the room with the requested pain medication. Observation of response to call light signals confirms that healthcare personnel sitting at the desk will reply to the call light on the overhead intercom inside the patient room and respond with "I will let the nurse know".

On 5/4/11 at approximately 0930 interview with patient #32 reveals that ..."sometimes they (healthcare workers) get real busy rushing around here". "I put my call light on and someone at the desk tells me she will let the nurse know...but I have to use the bedpan and sometimes can't wait the 10 to 20 minutes it takes for them to get here (into her room)". Observation of call light response confirms that when a call light is activated, the overhead intercom is used to reply to the patient, however response time for reporting to the room ranges from 15-30 minutes. Interview with staff O and P reveals that the unit census is 9 and each nurse has 4 or 5 patients, however none of the patients are capable of walking independently and most are confused or disoriented. A single certified nursing assistant is assigned to the unit.


29955

On 05/04/2011 at approximately 0940 during an interview with the Chief Executive Officer, Chief Nursing Officer, and Director of Quality Management it was asked how nurse staffing was determined. The Chief Nursing Officer responded that "staffing was determined based on numbers, if patients were stable or unstable, and acuity." On 05/04/2011at approximately 1115 a review of the staffing grid and the nurse staffing matrix revealed that on 20 of the past 21 days the staffing did not meet the staffing guidelines as set by the facility.

On 05/04/2011 at approximately 1115 a review of the staffing grid for 05/04/2011 and a review of the past 21 day nurse staffing was conducted in which the acuity of the patient census was not identified. The Chief Nursing Officer was asked to produce the acuity grid used when making nurse staffing determinations at 1000. The Chief Nursing Officer was unable to provide an acuity grid tool stating "We do not have an actual acuity grid tool."

Based on interview and record review the facility failed to ensure the integrity and accuracy of the medical record in 2 of 12 records (#23, #31) reviewed, resulting in the potential of inaccurate records for all facility patients.

On 05/04/2011 at 0815 review of the original restraint order (#23) dated 05/01/2011 it was revealed an alteration in the documentation of restraint orders had occurred between 05/03/2011 at approximately 1530 and 05/04/2011 at 0815. The original document dated 05/01/2011 timed at 2000 defined the restraint to be used as tied mittens and side rails. The alteration discovered on 05/04/2011 at 0815 showed that soft limb restraints had been added without any initials or signature of the person making the change. The Director of Quality Management, Chief Nursing Officer, and house supervisor #J confirmed these findings.

On 05/03/2011 at approximately 1400 it was revealed during record review that the attending physician failed to sign the patient's plan of care. The house supervisor #J confirmed these findings.


29774

On 5/3/11 at approximately 1330 during record review for patient #21 found that on 4/28/11 the RN recorded blood sugar testing results at 1100 of 144 and at 1700 of 203. These results were documented on the form titled "Diabetic Flow Chart". Additionally after the 1700 blood sugar entry, the RN recorded 3 units of Novolin R were given. Pt #21 is not diabetic and doesn't have medical orders for blood sugar checks nor insulin range orders. Additionally on the diabetic flow chart line three stipulates " no accucheck is ordered (patient states is not diabetic)". Interview with Staff #A to inquire whether a medication error was reported or if the physician was informed, she states that there was no medication error reported however she was going to fill out an incident report and call the nurse to determine what happened. On 5/4/11 Staff #A states that she asked the nurse to come in and figure out what happened. The nurse states that the blood sugar tests and insulin administration occurred but to a different patient #7. Documentation for patient #7 confirms the blood sugar result and insulin administration were documented for that day and those times. The nurse relays that she doesn't know or can't remember how it (documented blood sugar testing results and insulin administration on the wrong patient) happened.

Policy review of facility policy titled "Sure Step Flex Whole Blood Glucose Testing" Policy #550.526, specifies 5. Identify the patient using two (2) identifiers (patient name and medical record number)..." and 7. "documentation of the test results...testing should be documented in the patient medical record on the Diabetic Flow Sheet...the record should include the results, date and time the test was performed and the name of the testing operator". Staff # A confirms that the nurse documented the blood sugar testing results on the wrong medical record.


29313

Based on medical record review and interview the facility failed to ensure an appropriately written record was produced for each patient for 5 out of 7 (#26, #27, #29, #30, #31) closed medical records.

Findings include:

During medical record review on 5-3-11, it was observed that medical records #26, #27, #29, #30 failed to have patient identifiers on the form titled, "Preadmission Screening Summary" for pages 2 thru 9. The only identifier of the patient was on page one, where the name was written in at the top of the page. Separation of the top page from the remaining pages would prevent the association of those records with the patient.

In medical record #27 on the form titled, "Initial Health History & Physical Assessment Form", there was no patient identifier on pages 2 thru 4. The only identifier was a hand written name in the lower left corner on page one.

During medical record review of # 30 on the from titled, "Interdisciplinary Progress Notes", there was no patient identifier found on the page.

During an interview with staff B on 5-4-11 at approximately 0940, when asked who is responsible for placing patient identifiers on each page the reply was "The Health Unit Secretaries throughout the day as medical record pages are placed in the chart". When asked how you would know who's medical records these papers belong to if they became separated and received no response. Staff B confirmed the above findings.

Based on medical record review, policy review and interview the facility failed to provide a complete medical record providing content regarding interventions taken and follow up care for the interventions in 2 out of 7 medical records reviewed for patients #15 and #20. Findings include:
On 5/2/2011 during medical record review of patient #15 it was revealed that the patient spiked a temperature six times in a one month period. None of the elevated temperatures were followed up with the ordered tylenol or followed up within four hours of the last vital sign check.
During policy review on 5/2/2011, the policy titled Assessment: Daily Flow Sheet, it is stated "Temperatures greater than 100.4 should be rechecked and documented."
On 5/2/2011 during an interview with staff J the above findings were confirmed. Staff J stated "I don't know why they did not give tylenol and document any intervention they may have taken."


29955

On 05/02/2011 at approximately 1100 during medical record review, it was revealed that the facility failed to follow up on the patient's response to medication. Medical records indicated that patient #20 had a temperature of 102.8 degrees Farenheit at 2000 on 04/29/2011. According to the vital sign record and nursing flow chart the temperature was not repeated until 0100 on 4/30/2011 at which time the temperature was 102.5 degrees farenheit. According to the vital sign record and nursing flow sheet the temperatue was not checked again until 1600. According to the document titled "flow sheet instructions med surg/ tele" #11. Vital signs states "Temperatures greater then 100.4 degrees F should be rechecked with 4 hours and documented on the flow sheet." This was confirmed by staff #J on 05/04/2011 at approximately 1130.

Based on medical record review, policy and procedure review and interview, the facility failed to ensure that all patient medical record entries are legible, complete, dated, timed and authenticated in 9 out of 23 (#2, #3, #4, #9, #10, #23, #27, #29, #31) medical records.

During medical record review of patient # 27 it was found that the Discharge Summary had not been authenticated by the physician as of the date of our survey. The patient was discharged on 2-27-11.

During medical record review of patient # 29 it was found that the Operative Report had not been authenticated by the physician as of the date of our survey. The patient had the procedure on 2-27-11.

During medical record review of patient # 31 it was found that the Operative Report and the Death Summary had not been authenticated by the physician as of the date of our survey. The patient's procedure was on 1-11-11, the patient died on 2-7-11.

During policy and procedure review on 5-3-11 at approximately 1500, the policy titled, "Physician Orders and Nursing Responsibility" states, "All diagnostic and therapeutic procedures require a written, signed doctor's order. This includes: Admission, discharge, therapeutic home evaluations, and transfer. Diagnostic testing. Activity level. Diet. Therapeutic evaluations, procedures, and treatments..."

During an interview with staff A and R these findings were confirmed as not being completed according to policy.


27781

On 05/30/11 at 1130 a.m., review of clinical records for three patients (all of whom were ordered restraints) (#2, #3, and #4) revealed the following:
Patient #2 was admitted into the facility on 04/13/12 with diagnoses that included acute Cerebral Vascular Accident, Hypertension, and Diabetes. The patient was ordered a right upper extremity soft limb restraint and the orders were noted to be incomplete or not properly authenticated by a physician.
On 04/13/22 an RN took a telephone order from a physician at 2350 for the soft limb restraint, but the order was not signed by the physician until 04/16/11 at 5pm, over 24 from the time that it was written.
On 4/16/11 another telephone order for the restraint was again written by an RN at 0700, but was signed by a physician at the same time that the telephone order was written.
On 4/18/11 at 0000, an order was written by an RN for a soft restraint for patient #2. The order did not indicate that it was a telephone or verbal order. The order was signed by a physician at 0000 on 04/19/11, the following day.
Patient #3 was admitted into the facility on 04/21/11 with Insulin dependent Diabetes Mellitus, Gout, Hypertension, Arthritis and Atrial Fibrillation. On 04/29/11 at 0320, and order was written by an RN for Bilateral Mittens. However, the order was not properly authenticated because the physician failed to indicate the time that he signed and dated the order.
Patient #4 was admitted into the facility on 04/04/11, a victim of a hit and run accident. On 04/14/11 at 1600 a telephone order by an R.N. for bilateral mitten and soft limb restraints was written. The order was signed by the physician at what appeared to be 04/18/11 at 0800, over 48 hours from the time that it was written.
On 4/24/11 at 1700 another telephone order for mitten restraints was written but never signed by a physician, thus there was no documented evidence that the patient was assessed by the physician to address the patients' medical condition within 24 hours of the restrains being applied.
On 4/27/11 at 0600 another telephone order for restraints was written by a Registered Nurse from an unknown physician, as there was not a physicians name listed on the order indicating from whom the order was taken. A physician signed the order using the same date and time that the order was written.


29955

On 05/02/2011 at approximately 1115 during medical record review of patient #9, it was revealed that the facility failed to ensure the physician sign the plan of care for the patient. It was confirmed by staff #J that the plan of care had not been signed by the physician.

On 05/02/2011 at approximately 1125 during medical record review of patient #10, it was revealed that the facility failed to ensure the authentication of two consultation reports by signature from the physician. Further review of the medical record also revealed failure of the physician to sign the plan of care for patient #10. It was confirmed by staff #j that the consultation reports had not been signed by the physician. It was confirmed by staff #j that the plan of care had not been signed by the physician.

On 05/03/2011 at approximately 1550 during medical record review of patient #23, it was revealed that the facility failed to ensure the physician authenticate of restraint orders. It was confirmed by the Director of Quality management that the restraint orders had been unsigned by the physician.

Based on medical record review, policy and procedure review, the facility failed to ensure that all verbal orders were authenticated based on the facilities policy in 2 out of 5 (#17, #26) medical records. Findings include:

During policy and procedure review on 5-3-11 at approximately 1430, the policy titled, "Physician Orders and Nursing Responsibility" states, "2. If the situation warrants, a telephone order may be taken by a Registered Nurse or LPN and should be countersigned by the physician within 24 hours".

During medical record review of patient #17, on 5-3-11, it was observed that on several forms titled, "Physician Orders", verbal orders were taken by the Registered Nurse, but not authenticated by the physician within 24 hours or never completed. On 3-28-11 a verbal order was taken at 1700, as of 5-3-11 there is no authentication by the physician. On 4-26-11 a verbal order was taken at 0650 and 1315 as of 5-3-11 there is no authentication by the physician. On 4-27-11 a verbal order was taken at 0830, as of 5-3-11 there is no authentication by the physician.

During medical record review of patient #26 on 5-3-11, it was observed on the, "Admit to Triumph Hospital Detroit" sheet, that verbal orders had been received on 1-28-11 at 1845 and were not authenticated by the physician until 4-31-11 at 1115.

Based on interview, the facility failed to complete medical records within 30 days following discharge for 12 medical records.
During an interview with staff R, it was reported that twelve records were beyond the 30 day requirement.

Based on interview and record review, the facility failed to provide adequate monitoring of serum Digoxin concentrations for 1 of 1 (#2) patients requiring drug level monitoring. Findings include:

Review of patient #2's medical record on 05/04/11 at 11:00 a.m., revealed that the resident was admitted into the facility on 04/13/11 with diagnoses that included Atrial Fibrillation (Irregular Heart Rate), Hypertension, Acute Cerebral Vascular Accident (Stroke), Diabetes and Vent supported respiratory failure.

Review of an ER Consultation report dated 4/5/11 (prior to the patients admission) revealed, "The patient has an irregular heart rate consistent with atrial fibrillation . . . and sub-therapeutic Digitalis (Digoxin) level."

Medication records revealed that throughout the patient's hospital stay, he continued receiving the same dose of Digoxin 0.125 mg (milligrams) daily, that he was taking prior to his admission.

Interview with Nurse Manager ( K) on 05/04/11 at approximately 1115 revealed that monitoring of serum levels of Digoxin had not been done since the patient's admission even though it had been noted at the previous ER that his levels were sub-therapeutic.

Review of the Facility Policy entitled "Drug Level Monitoring" revised on 06/20/09 revealed, "The pharmacist, under the direction of the attending physician, should provide monitoring of serum levels of appropriate drugs."

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors, the facility does not comply with the applicable provisions of the Life Safety Code.

See the K-tags on the CMS-2567 dated May 3, 2011 for Life Safety Code.

Based on observation, policy and procedure review, the infection control officer and the facility failed to investigate and control infections and communicable diseases in patients and personnel. Findings include:

During observation on 5-2-11 at approximately 1025 on the Medical Observation Unit (MOU), it was observed a patient in contact precautions had hemodialysis in progress, with staff L in the room. It was observed that staff L with gloves on, touching papers on the bedside table, going to dialysis machine and connecting patient to the dialysis machine, without face shield/eye protection. She then removed gloves and returned to the dialysis machine and touched the machine without gloves on.

During observation on 5-4-11 at approximately 1040 on the MOU, it was observed staff U in a patient's room whom was on contact precautions, without any gloves on and didn't clean stethoscope prior to leaving patient's room.

During policy and procedure review on 5-3-11 at approximately 1530, the policy titled, "Standards and Transmission Based Precautions" states for contact precautions, "Intended for patients with highly transmissible or epidemiologically important infections that do not require strict isolation... Gloves and gown should be worn when entering the room. Masks should be used for those performing direct patient care; add eye/facial protection if splashing is anticipated. Hand hygiene should be performed after touching the patient potentially contaminated articles, after removing gear, and before leaving the patient".


27781

On 05/03/11 at 11:30a.m., during an observation of blood glucose monitoring by Staff T and in the presence of the Chief Nursing Officer (A), Staff T failed to clean the blood glucose monitor prior to use and after using the moitor.

Cheif Nursing Officer (A) verified that the blood glucose monitor should have been disinfected before being placed back into the case.


29314

On 5/2/2011 during observations of the unit, it was revealed that the accucheck machine was visibly soiled. When interviewing staff I it was stated "I clean the machine after every patient with an alcohol wipe." When asked about the soiled machine, staff I stated, "that stuff doesn't come off." The surveyor then used a saniwipe to wipe the accucheck machine, which easily removed the soiled contents on the machine. This finding was confirmed by staff J.



29955

On 05/02/2011 at approximately 1520 staff #I was observed walking from the interior of a patient's room donning gloves into the common area unit hallway. Staff #I continued to walk to the doorway of an isolation room to speak to another staff member, returned to the patient room from which she donned the gloves, touched patient A's bed and then proceeded to walk to patient B's bedside table moving objects on the table. Staff # I removed the gloves and returned to the floor. When queried about wearing gloves into the common hallway and touching patient A's bed and then patient B's bedside table the staff member responded "Oh no. You must be mistaken. I didn't do that. You are wrong." Staff # J confirmed that she had witnessed staff #I walk in the common hallway with gloves donned.

Based on medical record review, policy and procedure review and interview, the facility failed to ensure implementation of there written protocols in 2 out of 4 (#28, #31) death medical records. Findings include:

During policy and procedure review on 5-3-11 at approximately 1600, the policy titled, "Organ Donation, Mandatory Notification", states, "Call 1-800-482-4881 and inform Gift of Life of a patient death within one (1) hour of pronouncement".

During medical record review of patient #28 on 5-3-11 at approximately 1530, it was found that the patient was pronounced dead at 1524 on 1-6-11 and Gift of Life (GOL) was never contacted as required.

During medical record review of patient #31 on 5-3-11 at approximately 1530, it was found the the patient was pronounced dead at 0750 on 2-7-11 and GOL was not notified until 1018 on 2-7-11.

During an interview on 5-4-11 at approximately 0930 these findings were confirmed by staff A and B.

Based on medical record review, policy and procedure review and interview, the facility failed to provide services in accordance with the orders of a doctor in 2 out of 3 (#17, #18) respiratory medical records.

During medical record review of patient #17 on 5-2-11 at approximately 1110, it was noted on the most recent doctor's order dated 4-26-11 at 1315, for this patient to receive breathing treatments four times per day and as needed. During the period of 4-28-11 thru 5-1-11, it was noted that treatment times were not consistent with the orders.
4-28-11: Treatments given at 0415, 0830, 1415, 2015.
4-29-11: Treatments given at 0410, 0745, 1320, 1948.
4-30-11: Treatments given at 0115, 0610, 1146, 2130.
5-1-11: Treatments given at 0415, 1010, 1605, 2130.
During this 4 day period the treatment times varied form 3.5 hours to 8 hours in between each treatment, when the orders required a treatment at least every 6 hours.

During medical record review of patient #18 on 5-2-11 at approximately 1140, it was noted on the most recent doctor's order dated 4-21-11 at 1000 for this patient to receive breathing treatments four times per day. During the period of 4-21-11 thru 4-24-11, it was noted that treatment times were not consistent with the orders.
4-21-11: Treatments given at 0915, 1530, 2050.
4-22-11: Treatments given at 0555, 0945, 1440, 2323, .
4-23-11: Treatments given at 0115, 0610, 1146, 2130.
4-24-11: Treatments given at 0520, 1900.
During this 4 day period the treatment times varied form 4 hours to 13.5 hours in between each treatment, when the orders required a treatment at least every 6 hours.

During policy and procedure review on 5-3-11 at approximately 1530, the policy titled, "Medication Administration", states, " 16. Medications should be administered on a standardized administration schedule, unless otherwise ordered by the physician. A thirty-minute window is allowed before and after each tome for the actual administration of the medications".

During an interview on 5-2-11 at approximately 1400, staff M confirmed these findings.