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PIONEER HEALTH SERVICES OF NEWTON
FORM AND RETENTION OF RECORDS
Tag No.: A0438
Based on review of medical records, review of Medical Staff Committee meetings, and review of Medical Staff Bylaws Rules and Regulations the facility failed to ensure that records of discharged patients are promptly completed and properly filed.
Findings include:
The facility ' s Medical Staff Bylaws Rules and Regulations require that a medical record be complete at the time of discharge. If this is not possible, the physician has fifteen days to complete the medical record before it is considered delinquent.
The last count of delinquent medical records made by the facility on 06-02-10, was 230 delinquent records. A count of medical records in the physicians ' incomplete chart files on 06-15-10, revealed a total of 230 records that were delinquent over 15 days. The majority of the records belonged to one physician. These records lacked dictation and/or signatures, and included both hospital and swingbed medical records.
DISPOSAL OF TRASH
Tag No.: A0713
The facility failed to store biohazardous waste in accordance with the Minimum Standards of Operation for Mississippi Hospitals.
Enclosures or containers used for containment of infectious medical waste shall be so secured so as to discourage access by unauthorized persons. During a tour of the X-Ray Department of 06/15/2010, the surveyor observed that the two Biohazard Rooms were unlocked. One was equipped with a locking device, but the other door was note equipped with a locking device.
FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE
Tag No.: A0724
Based on policy review, observation and staff interview the facility failed to ensure that all patient care equipment was maintained in safe operating condition.
Findings Include:
Review of the facility ' s policy " Anesthetic Gases (Safety) " revealed that " All tanks must be supported at all times. "
A tour of the surgical department was made with the Director of Nursing (DON) and a Surgical Tech on 6/15/10 at approximately 2:30 p.m. Observation in the surgical suite revealed an unsecured nitrogen tank.
These findings were confirmed with the DON and the Surgical Tech during the tour.