HospitalInspections.org

Based on interview, the governing body failed to ensure contracts of services were in place to permit the hospital to comply with all applicable conditions of participation and standards.

Findings included:

In an interview with the Chief Executive Officer on the afternoon of 05/02/16, she stated, "We have 3 different contracts with wound vac [vacuum] suppliers. If one is not able to get us one [a wound vac], we can go to our next one." When asked if they have had to wait for a wound vac, she stated, "Not that I can think of. Yes, we will have to wait a few hours, but not longer than that. 24 hours is probably the longest, it's never very long. If we can't get it from KCI [wound vac and wound care supplier], we can always get it from Medella [another supplier]. We just have to go back to the physician and make sure it is OK for them to have a Medella. KCI is preferred by our physicians."

In an interview with the CEO on 5/3/16 at 2:15 pm, she stated, "I just got off the phone with corporate. They said there are not contracts for the four you asked for [Medline, who supplies most medical supplies and the three wound vac suppliers: KCI, Medella and Recovery Care]. They said they called [the companies] and said they wanted supplies, so they sent pricing lists. Contracts are something they haven't executed with others. I know that's very bad."


Based on facility policy review, record review and interview, the governing body failed to ensure the facility followed established policies and procedures for medical records.

Findings included:

Facility based policy entitled, "Closed Medical Records" stated in part,
"Procedure:
5. Completion of Standard: Medical Record
5.1 All medical records shall be complete within thirty (30) days of the discharge date. This shall include all dictated reports, written forms, and required signatures."

Clinical record of patient number 1 revealed a discharge summary dated 1/12/16 not signed at time of review on 05/03/16.

Clinical record for patient number 2 revealed a verbal order on 1/18/16 not authenticated at time of review on 05/03/16.

Clinical record of patient number 3 revealed the following not signed at time of review on 05/03/16:
· Progress note dated 12/30/15
· Progress note dated 1/1/16
· Progress note dated 2/1/16
· Consultation dated 1/6/16
· Verbal order dated 1/4/16 at 4:00 pm
· Verbal order dated 1/1/16 at 4:30 pm
· Verbal order dated 12/30/15 at 8:00 pm
· Verbal order dated 12/27/15 at 8:15 am
· Verbal order dated 12/24/15 at 2:00 am

Clinical record for patient number 5 revealed a verbal order on 1/26/16 not authenticated at the time of review on 05/03/16.

Clinical record of patient number 7 revealed a progress note dated 1/25/16 not signed at time of review on 05/03/16.

Since the records of patients #1, 2, 3, 5 and 7 lacked necessary physician signatures, these records are lacking closure within the established facility policies.

The above was confirmed with the Chief Nursing Officer on 05/03/16. She stated they have been having some problems and have suspended a few doctors because of delinquent charts.

Based on interview, the governing body failed to ensure contracts of services were in place to permit the hospital to comply with all applicable conditions of participation and standards.

Findings included:

In an interview with the Chief Executive Officer on the afternoon of 05/02/16, she stated, "We have 3 different contracts with wound vac [vacuum] suppliers. If one is not able to get us one [a wound vac], we can go to our next one." When asked if they have had to wait for a wound vac, she stated, "Not that I can think of. Yes, we will have to wait a few hours, but not longer than that. 24 hours is probably the longest, it's never very long. If we can't get it from KCI [wound vac and wound care supplier], we can always get it from Medella [another supplier]. We just have to go back to the physician and make sure it is OK for them to have a Medella. KCI is preferred by our physicians."

In an interview with the CEO on 5/3/16 at 2:15 pm, she stated, "I just got off the phone with corporate. They said there are not contracts for the four you asked for [Medline, who supplies most medical supplies and the three wound vac suppliers: KCI, Medella and Recovery Care]. They said they called [the companies] and said they wanted supplies, so they sent pricing lists. Contracts are something they haven't executed with others. I know that's very bad."

Based on review of facility documents, clinical records and interview, the facility failed to ensure verbal orders were dated, timed, and authenticated within 48 hours.

Findings included:

Facility based policy entitled, "Closed Medical Records" stated in part,
"Procedure:
1. Completion Standard: Verbal or telephone orders
1.1 All verbal orders shall be co-signed and dated by the ordering physician or another member of the medical staff within seventy-two (72) hours or as outlined in the State Administrative Code."

Clinical record for patient number 2 revealed a verbal order on 1/18/16 not authenticated at time of review on 05/03/16.

Clinical record for patient number 3 revealed the following verbal orders not authenticated at the time of review on 05/03/16:
· 1/4/16 at 4:00 pm
· 1/1/16 at 4:30 pm
· 12/30/15 at 8:00 pm
· 12/27/15 at 8:15 am
· 12/24/15 at 2:00 am

Clinical record for patient number 5 revealed a verbal order on 1/26/16 not authenticated at the time of review on 05/03/16.

Clinical record for patient number 10 revealed a verbal order on 4/20/16 at 11:00 am not authenticated at the time of review on 05/03/16.

Clinical record for patient number 11 revealed the following verbal orders not authenticated at the time of review on 05/03/16:
· 4/21/16 at 4:00 pm
· 4/14/16 at 3:00 pm
· 4/1/16 at 6:00 pm

Since the records of patients #2, 3, 5, 10 and 11 lacked necessary physician signatures, these records are lacking closure within the established facility policies.

The above was verified with the Chief Nursing Officer on the afternoon of 05/03/16.

Based on facility policy review, clinical record review and interview, the facility failed to ensure nursing notes, reports of treatment and other information necessary to monitor the patient's condition were documented.

Findings included:

Facility based policy entitled, "Wound Care" stated in part, "Purpose: To delineate responsibilities for the management of patients with actual or potential for impaired skin integrity.
Procedure: ...
8. The Wound Care Professional will make rounds weekly assessing skin, wound healing and providing wound care interventions. Documentation of these rounds will occur on the wound management documents.

On 01/26/16, patient #9 was ordered, "3) Xeroform gauze to incision site ... 5) wound vac [vacuum] L foot ulcer." No charting was found regarding the dressing or wound vac.

The above was confirmed with the Chief Nursing Officer on 05/03/16. She stated, "I know he was transferred downstairs and may have received his wound vac then, but I'm not sure."

Based on review of facility policy, review of clinical records, and interview, the facility failed to ensure medical records were completed within 30 calendar days following discharge.

Findings included:

Facility based policy entitled, "Closed Medical Records" stated in part,
"Procedure:
5. Completion of Standard: Medical Record
5.1 All medical records shall be complete within thirty (30) days of the discharge date. This shall include all dictated reports, written forms, and required signatures."

Clinical record of patient number 1 revealed a discharge summary dated 1/12/16 not signed at time of review on 05/03/16.

Clinical record for patient number 2 revealed a verbal order on 1/18/16 not authenticated at time of review on 05/03/16.

Clinical record of patient number 3 revealed the following not signed at time of review on 05/03/16:
· Progress note dated 12/30/15
· Progress note dated 1/1/16
· Progress note dated 2/1/16
· Consultation dated 1/6/16
· Verbal order dated 1/4/16 at 4:00 pm
· Verbal order dated 1/1/16 at 4:30 pm
· Verbal order dated 12/30/15 at 8:00 pm
· Verbal order dated 12/27/15 at 8:15 am
· Verbal order dated 12/24/15 at 2:00 am

Clinical record for patient number 5 revealed a verbal order on 1/26/16 not authenticated at the time of review on 05/03/16.

Clinical record of patient number 7 revealed a progress note dated 1/25/16 not signed at time of review on 05/03/16.

Since the records of patients #1, 2, 3, 5 and 7 lacked necessary physician signatures, these records are lacking closure within the established facility policies.

The above was confirmed with the Chief Nursing Officer on 05/03/16. She stated they have been having some problems and have suspended a few doctors because of delinquent charts.

Based on observation, the facility failed to ensure alcohol-based hand rub dispensers were installed in a manner that minimizes leaks and spills that could lead to falls.

Findings included:

On a tour of the facility on the afternoon of 05/02/16, there were three alcohol-based hand dispensers on the main hall that would drip to the ground if a leak or spill occurred.

This was confirmed with the Maintenance Director and the Chief Nursing Officer.

Based on observation and interview, the facility failed to ensure equipment were maintained to ensure an acceptable level of safety and quality.

Findings included:

On a tour of the facility on the afternoon of 05/02/16, the preventative maintenance was overdue on the following items:
· Covidien kangaroo pump without a sticker
· Kangaroo pump with maintenance due 10/2015
· Kangaroo pump with maintenance due 05/2014
· Kangaroo pump with maintenance due 2014 without a month
· HillRom IV [intravenous] pump due 10/2015
· One vital sign machine without a preventative maintenance sticker in place

There was no indication these items were not to be used. The above was confirmed with the Maintenance Director on 05/02/16. He stated some of these items were in storage and may have been pulled out but was available for staff use.

Based on record review and interview, the facility failed to ensure the infection control officer had specialized training.

Findings included:

Centers for Disease Control and Prevention [CDC] has defined "infection control professional" as "a person whose primary training is in either nursing, medical technology, microbiology, or epidemiology and who has acquired specialized training in infection control."

Facility Job Description for the Infection Control coordinator job description states "Advanced infection prevention and control training and CIC [Certified in Infection Control] certification preferred."

In an interview with the Infection Control Officer on the afternoon of 05/03/16, she stated, "I do not have certification."

The above was confirmed with the Chief Nursing officer on the afternoon of 05/03/16. She stated, "I have already recognized that and have submitted to corporate an on-line class she can take. We are waiting for approval." Documentation was provided showing the Association for Professionals in Infection Control and Epidemiology [APIC] on-line class and pricing.

Based on document review, observations and interview, the facility failed to provide a safe and sanitary environment for its staff and patients.

Findings included:

"OSHA/Blood Borne Pathogen Regulations Policy #138-030-060" stated in part "The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner."

Facility based policy entitled, "Standard Precautions" stated in part, "Linen - used or soiled linen is considered contaminated, handled as little as possible and bagged at the place of its use."

Tour of the facility on 05/02/16 revealed the following:
· 513 restroom call-light touching the floor
· Shower room call-light touching the floor
· Dirty utility room with soiled linens laying on the floor
· Dirty utility room with items being stored under the sink
· Most patient doors with multiple gouges and scratches making thorough cleaning impossible
The above was confirmed with the Maintenance Director on the afternoon of 05/02/16.