HospitalInspections.org

Based on observation and interview, the facility failed to protect the patient's right to privacy of health information by not securing the medical records for 26 of 26 patients(#1-17, #21,
#25, #26 #32-36) . Findings include:

During observation of the facility on 09/21/2010 at 1030, the "wall-a-roos" (wall units) containing patient's medical records were noted to be unsecured.

Interview at the time of the observation with staff A, she confirmed that all of the units were unlocked and that there had been discussion between facility staff about the records being unsecured. She further replied that they had not come up with a way to secure the records and still make them available to all staff that will need access to them. At time of observation, the units are observed to have a locking system available on them.

Based on observation and interview, the facility failed to secure the medical records for 26 of 26 patients(#1-17, #21, #25, #26 #32-36) . Findings include:

During observation of the facility on 09/21/2010 at 1030, the "wall-a-roos" (wall units) containing patient's medical records were noted to be unsecured.

Interview at the time of the observation with staff A, she confirmed that all of the units were unlocked and that there had been discussion between facility staff about the records being unsecured. She further replied that they had not come up with a way to secure the records and still make them available to all staff that will need access to them. At time of observation, the units are observed to have a locking system available on them.

Based on record review, interview and policy review, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care provided to each patient on a daily basis for 7 of 10 ( #7, #8, #9, #10, #21, #26 and #32 ) records reviewed. Findings include:

Review of documentation provided as Charge Nurse Job Description it reads under position summary "The primary purpose of this position is to administer and supervise the clinical care provided on the assigned shift. All clinical service policies, procedures and objectives are to be maintained. This position is responsible for all safety, infection control and quality of care issues for the assigned shift..."

Review of the Clinical Services Policy and Procedure Number MO1-N revised 02/19/2010 subject Medication Administration reads under Policy: #24 Non-Respiratory Therapy medications are given at the time ordered or within 30 minutes before or 30 minutes after the time designated.

During review of the medical records on 09/22/2010 & 09/23/2010:
Patient #7's medication administration record dated 09/22/2010 revealed at 0800 the lack of documentation for 0600 medications being administered.

Patient #8's medication administration record dated 09/22/2010 at 1045 contained a duplicate order for Valporic Acid 500mg every 8 hours. Documentation reveals that the 7 pm -7 am RN gave only one dose at 0600 but did not discontinue the duplicate order on the medication administration record.

Patient #9's medication administration record dated 09/19/2010 lacked documentation for the administration of the 0600 and 1000 medications being administered. Further discussion with staff M revealed that the 7 am - 7 pm RN had "lost" the medication sheets and obtained a duplicate from the pharmacy. Staff M was unable to locate documentation in the medical record that the 0600 and 1000 medications were administered. Staff P was able to provide documentation that the medications were administered at both 0600 and 1115 per electronic documentation.

Patient # 10's medication administration revealed that on 09/21/2010 at 1145 there was a lack of documentation that the 1000 medications had been administered. During interview with staff E at the time above, it was confirmed that staff E was busy and unable to get the medications administered on time.

Patient #21's medication administration record dated 09/21/2010 revealed at 1100 that Novolin NPH insulin ordered for 0730 lacked documentation as being administered. When staff E queried at 1105 about the lack of documentation he replied, "I have a question about the dose and was waiting to give it until after I speak with the doctor when she comes in to do rounds." When asked if he had called the physician regarding his concern with the medication he state, "No, I was just going to wait until she came in."

Patient #26's medication administration record dated 09/22/2010 at 1010 revealed that there was a lack of documentation for a 0800 dose of Oxycontin being administered. This was confirmed by electronic documentation provided by staff P at 1015.

Patient #32's medication administration record dated 09/22/2010 revealed that on 09/23/2010 there was a lack of documentation of the 2200 Morphine being administered. This was confirmed by staff D and the electronic medication dispense record at 1155.

Based on record review, interview and policy review, the facility failed ensure that all entries in the medical record were complete and accurate for 4 of 10 records reviewed (#7, #8, #9, #32). Findings include:

Review of document provided Clinical Services Policy and Procedure Number MO1-N revised 02/19/2010 subject Medication Administration under section titled Documentation it reads B. "A given medication dose will be designated by placing a slash (/) through the time followed by the administrator's initials ." C. "When a medication dose is NOT administered due to the patient ' s condition or other unavoidable factor, the individual responsible for administering the medication will circle doses NOT given and not the reason on the MAR."

During review of the medical records it was determined that they lack proper documentation of medication administration.

For Patient # 7 on 09/23/2010 at 1110, the medication administration record (MAR) for 09/22/2010 lacked documentation for the 0600 medications being administered. Review with staff D at 1115 on 09/23/2010, the electronic medication dispense machine record revealed that the medications had been administered on 09/22/2010 at 0545 but had not been documented on the MAR.

Patient #8's MAR revealed a duplicate order for Valporic Acid 500mg every 8 hours, the MN nurse who gave one dose and documented it in the correct area then documented in the duplicate area with a circle around the specified time of 0600. She failed to discontinue the duplicate order on the MAR. Patient # 9's MAR dated 09/19/2010 was reviewed on 09/23/2010 at 0800; it lacked documentation for administration of 0600 and 1000 medications being administered. Interview with staff M at 0830, she stated that "the 7 AM-7PM RN had lost the medication sheets for this patient and had to obtain another copy form the pharmacy." Staff M was unable to locate documentation in the patient's record regarding the lost MAR. Staff P able to produce documentation form the electronic medication dispense record that the 1000 medications were administered late at 1115 but not documented on the MAR.

During review on 09/23/2010 at 1145 of patient #32's MAR dated 09/22/2010 revealed a lack of documentation for Morphine 2 mg ordered for 1600 and 2200. Interview with staff D on 09/23/2010 at 1155, she confirmed that the staff are to document the medications when they are given.

Based on medical record review, interview with the Director of HIM, and policy/procedure review it was determined that verbal orders were not signed in 4 of 7 (#11, #27, #31, #32) medical records, within 48 hours. Findings include:

During review of the facilities policies/procedures, it was stated in the " Rules and Regulations of the Medical Staff of Select Specialty Hospital - Pontiac, INC " that " The responsible practitioner or another licensed independent practitioner within the same group practice or specialty of the responsible practitioner who is responsible for the patient ' s care shall authenticate such orders (verbal/telephone) within the time frame specified by state law or if no state law applies the responsible practitioner shall authenticate such order within forty-eight (48) hours..."

Review of the medical records (#11, #27, #31) demonstrated lack of authentication of verbal orders within 48 hours.

For #11, the record contained, "RB&VTO 9-17-10, 0.63mg Xoponex Neb (nebulizer) tx (treatment) Q6 (every 6 hours) WA (while awake)." No signature on order, physician rounded on 9-18-10 and 9-20-10 and did not sign the order.

For #27, the record contained, "TO 8-1-10, TC (tracheotomy care) around the clock as pt (patient) tolerates place back on ventilator if AM distress" No signature on order.

"Add 1800 cal (calorie) diabetic to current diet RX (order). TO 8-2-10." No signature on order.

"D/C (discontinue) reglan. TO 7-31-10" No signature on order.

"7-23-10 TO May use Nebulizer Duoneb Q6 (every 6 hours) in place of combivent MDI when pt (patient) is on back collar." No signature on order.

"7-11-10 TO Change Trach tube to #8 DFEN" No signature on order.

"7-9-10 TO Restart GINN Wean = Rate = 12." No signature on order

"7-7-10 TO Cancel flat plate of abd (abdomen). Get consent for EGD and J-Tube placement for AM." No signature on order.

"7-8-10 TO Ativan 0.5mg IVP (IV Push) X1 now for increased agitation." No signature on order.

"6-30-10 TO SMAC, CBC on Friday 7/2/10." No signature on order.

"6-17-10 TO 6-18 decrease to 1MV of 7 if tolerated, 6-19 decrease to 1MV of 6 if tolerated, rest on A/C." No signature on order.

"6-10-10 TO Please hold vent wean for now." No signature on order.

For #31, the record contained, "7-22-10 TO Discontinue standby ventilator. Continue ATC Trach Collar." No signature on order.

"7-10-10 TO Pt (patient) may wear DMV when alert, cuff deflated, supervised by RT or SLP." No signature on order.

"7-7-10 TO K clorcon 40meq liquid per peg X once. Add on magnesium to today ' s labs. Consult Dr Holabi - PAD eval (evaluation) and recommendation. D/C (discontinue) autoflush and increase free water to 250 Q8 (every 8 hours)." No signature on order.

Interview with the Director of HIM on 9-21-10 at approximately 1125, revealed that verbal orders need to be signed within a 48 hour period from the time taken, and confirmed that Chart #11 contained an order that was not signed.


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During review of the medical record for patient #32 on 09/22/2010 at 1730, it was noted that a telephone order dated 09/19/10 had not been authenticated within the 48 hour timeframe. This was confirmed at the time of the record review by staff J.

Based upon observation during the building tour on September 21, 2010 between 9:00 AM and 1:30 PM, it was determined that the facility failed to maintain a clean and sanitary environment which may adversely affect the safety and well-being of patients The findings include:

1, There was a significant accumulation of dust on top of the light over the sink in the airborne infectious isolation ante room.
2. The floor of the soiled utility room was very dirty/sticky on the day of the survey.
3. The equipment storage (Res Therapy) had debris under the oxygen storage cabinet.
4. The floor was very dirty under the sink in the Rehab room (approximately 11 AM).
5. The floor of the emergency supplies closet was very dirty on the day of the survey.
6. The housekeeping closet had debris on the floor and boxes of paper towels on the floor.