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Based on record review and interview, the medical staff bylaws did not include a requirement for a history and physical examination to be completed and documented for each patient no more than 30 days before or 24 hours after admission.

Findings included:

1) Review of the medical staff bylaws/rules and regulations did not include a requirement for a history and physical for patients.
2) In an interview with the surveyor the afternoon of 05/30/12 the CEO, employee #1, was asked if there were other medical staff bylaws and/or rules and regulations. He stated there were no other documents. He was asked about the requirement for a history and physical. He stated the legal department would need to update the bylaws.

Based on observation and interview, the facility had 2 of 2 bottles of unusable drugs (Lidocaine), available for patient use.

Findings included:

During a tour of the hospital at 3:25 PM on 05/30/12 with Personnel #8, the surveyor observed the following unusable drugs available for patient use.

Rolling Wound Care Cart:

1 - Bottle of Lidocaine 2%, 20 milligrams (mg.), expired 03/12.
1 - Bottle of Lidocaine 2%, 20 mg., unopened, in a bag labeled with a patient name, with a notation "for debridement procedure," and dated 02/23/12.

In an interview at 4:00 PM on 05/30/12 with Personnel #8, she confirmed these 2 bottles of Lidocaine had been available for use on wound care patients. When asked if she routinely kept individually labeled medications for discharged patients, on the wound cart for use on current inpatients, she said "no," that these are usually returned to the pharmacy if they have not been opened.

Based on observation and interview, the facility did not comply with the Clinical Laboratory Improvement Amendments of 1988 (CLIA 1988), in accordance with federal regulatory requirements, in that, 188 expired laboratory tubes were available for patient use in 2 of 2 patient care areas.

Findings Included:

During a tour of the hospital's Emergency Treatment Room at 9:50 AM, and High Observation Unit (HOU) Medication Room at 1:00 PM, on 05/29/12 with the Chief Nursing Officer (CNO), Personnel # 3, the surveyor observed the following expired laboratory tubes:

Emergency Treatment Room:
100 - Green top laboratory tubes, expired 04/12.
88 - Red top laboratory tubes, expired 04/12.

High Observation Unit (HOU) Medication Room:
14 - Blue top laboratory tubes, expired 01/12.
5 - Green top laboratory tubes, expired 04/12.


In interviews at 09:50 AM and 1:00 PM, on 05/29/12 with the CNO, she verified the above laboratory tubes were expired, and were available for patient use.

Based on observation and interview, the facility did not ensure that supplies and equipment had been maintained at an acceptable level of safety and quality, in that: A) expired medical supplies were available for patient use, and B) equipment had not had biomedical/electrical maintenance safety checks.

Findings included:

A) On tours of the facility at 9:50 AM and 1:00 PM on 05/29/12 with Personnel #3, and at 2:25 PM on 05/30/12 with Personnel #8, the surveyor observed the following expired supplies available for patient use:

Emergency Treatment Room:
3 - Compression bandages, expired 07/11.
1 - 3 inch undercast padding, expired 07/09.

Emergency Treatment Room Crash Cart:
1 - Nasopharyngeal airway, size 6.0, expired 12/11.
1 - Nasopharyngeal airway, size 8.0 expired 04/12.
3 - 18 gauge Angiocath needles, expired 12/11.

HOU (High Observation Unit), Medication Room:
3 - 18 gauge Angiocath needles, expired 12/11.

HOU Crash Cart:
3 - 24 gauge Angiocath needles, expired 12/09.
3 - 18 gauge Angiocath needles, expired 12/11.

Rolling Wound Care Cart:
6 - Dermal curettes, size 4 millimeters (mm.), expired 01/12.
1 - Dermal curettes, size 5 mm., expired 03/11.
1 - Bioclusive dressing, expired 10/11.
1 - Acticoat anti-microbial dressing, expired 11/11.
1 - Acticoat anti-microbial dressing, expired 12/11.
5 - Acticoat anti-microbial dressing, expired 03/12.

In interviews at 9:50 AM and 1:00 PM on 05/29/12 with Personnel #3, and at 2:25 PM on 05/30/12 with Personnel #8, they confirmed that the above medical supplies were expired and had been available for patient use.

B) On a tour of the facility at 9:50 AM on 05/29/12 with Personnel #3, the surveyor observed the following equipment had not had biomedical/electrical maintenance safety checks:

Emergency Treatment Room:
1 - Atmos Air with oxygen saturation machine had not had a biomedical/electrical maintenance safety check.
1 - Heat therapy pump had not had a biomedical/electrical maintenance safety check.
1 - Vital sign machine. last biomedical/electrical maintenance safety check expired 03/12.

In an interview at approximately 4:00 PM on 05/29/12 with Personnel #4, he verified the above medical equipment did not have current biomedical/electrical maintenance safety checks, and the equipment was available for patient use.

Based on record review, and interview, the facility did not ensure that each patient's discharge planning evaluation was included in their medical record, or that the results of this evaluation had been discussed with the patient, for 20 of 20 patients (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11,#12,#13, #14, #15, #16, #17, #18, #19 & #20).

Findings Included:

Review of 20 patient medical records, revealed there was no documentation that a discharge planning evaluation had been performed, or discussed with each of these patients or an individual acting on their behalf. The only documentation in the official medical record regarding discharge planning were occasional telephone orders written by the facility's case manager when he received physician orders for him to set up a receiving facility to discharge the patient to.

In an interview at 9:15 AM on 05/31/12 with the case manager (Personnel #7), he was asked if he was responsible for the discharge planning evaluations in this facility, and he said "yes." He stated that he participates in a daily telephone conference with the Regional Case Management Director, and that this facility also holds an inter-disciplinary conference every Thursday, where the care planning and discharge planning for each patient is discussed. When asked why there was no documentation in the patient's medical records that discharge planning evaluations had been performed, he said the facility had been going through some changes in their Medical Records department, and so he had been filing these forms in his office. He confirmed that documentation of the discharge planning evaluations had not been included in the official medical records of these patients, as required.

Based on observation, and interview, the facility did not ensure they had available all required emergency equipment, in that, their Emergency Treatment Room did not include a telephone or any type of emergency call system, so that services were integrated with other departments of the hospital.

Findings included:

On a tour of the facility's Emergency Treatment Room at 9:50 AM on 05/29/12 with Personnel #3, the surveyor observed their was no telephone located in this room, and no other type of emergency call system. This room was located at the end of a back hallway, by an outside door, and was not contiguous with other clinical units in the hospital for immediate help if needed for an emergency.

In an interview at 9:50 AM on 05/29/12 with Personnel #3, she verified there was no telephone, or other emergency call system available in the Emergency Treatment Room. She confirmed that the emergency services were not integrated with other departments of the hospital, as it was not located near other clinical units, and had no way of calling for help from them during an emergency.