HospitalInspections.org

Based on document review and staff interview, the facility failed to ensure that patients were free from all forms of abuse or harassment. Findings include:

During the review of facility policies and procedures beginning on 9/26/11 at approximately 2:00 p.m., the surveyor noted that the facility policy for abuse and harassment was incomplete. The facility policy addressed the issues of child and elder abuse, but did not include the potential for patient abuse by the staff. The policy did not address the potential for abuse or harassment by members of the facility staff to the patients. The facility policy did not include the recommended components for protection of patients from abuse:
-Prevention through adequate staffing on all shifts.
-Proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect.
-Training of hospital staff during orientation and through an on-going training program providing information regarding abuse and neglect, reporting requirements, and including prevention, intervention, and detection.
-Investigation of, in a timely and thorough manner, all allegations of abuse, neglect, or mistreatment.
-Report /Respond to any incident of abuse, neglect, or harassment, report and analyze each event, and ensure that appropriate corrective, remedial, or disciplinary actions occur, in accordance with applicable local, state, or federal law.

Review of the facility employee handbook released in 2005 contained, under the heading Performance Issues, subheading; Major Infractions reads "Improper conduct including, but not limited to, obscene or abusive language, spreading malicious or untrue gossip or rumors, verbal or physical fighting, threatening, intimidating, or coercing patients or staff members, making inappropriate, disrespectful, and/or derogatory remarks/gestures to or about a fellow staff member, etc. Misappropriation of HCNW (Health Center Northwest) funds or property of others including patients."

In interviews with staff member A on 9/27/11 at approximately 10:30 a.m., and staff member J on 9/28/11 at 11:00 a.m., both staff members stated that the facility did not have a specific policy regarding staff abuse of patients. When asked about staff training in abuse prevention, staff member J stated that she personally reviewed the employee handbook with every new employee and covered all of the items in the sections containing the major and minor infractions of performance. Staff member J stated that there was no formal policy or annual training for abuse prevention at the facility.

Based on record review and staff interview, the facility failed to ensure that patient medical record entries were legible, complete, dated, timed, and authenticated in written or electronic form for 6 (#s 9, 10, 11, 13, 15, and 16) of 25 reviewed records. Findings include:

1. Patient #9, a 66 year old female was admitted on 4/4/11. Hospice service nursing and social services notes dated 4/5/11, 4/7/11, 4/9/11, and 4/11/11 did not include the time when the progress notes were entered into the clinical record.

2. Patient #10, a 51 year old female, was admitted on 10/1/10. Hospice service, social services, and Home Options progress notes dated 10/1/10, 10/2/10, 10/3/10, 10/4/10, 10/10/10, 10/11/10, and 10/14/10 did not include the time when the progress notes were entered into the clinical record.

3. Patient #11, a 70 year old male, was admitted on 3/15/11. Physician progress notes dated 3/15/11, 3/16/11, 3/17/11, 3/18/11, 3/19/11, 3/20/11, 3/21/11, 3/22/11, and 3/23/11, labeled "GU" (genito-urinary), did not include the times when the progress notes were entered into the clinical record.

4. Patient #13, a 52 year old male, was admitted on 5/9/11. A physician progress note dated 5/13/11 labeled "GU" (genito-urinary), did not include the time when the progress note was entered into the clinical record.

5. Patient #15, a 79 year old male, was admitted on 2/14/11. Hospice nursing and social service entries dated 2/14/11 and 2/17/11 did not include the times when the progress notes were entered into the clinical record.

6. Patient #16, a 43 year old female, was admitted on 5/18/11. Physician progress notes dated 5/20/11 and 5/25/11 did not include the times when the progress notes were entered into the clinical record.

During an interview with staff members A and B on 9/28/11 at 4:30 p.m. both staff acknowledged that there were still some physicians and nurses that did not complete the authentication process for progress notes.

Based on record review and staff interview, the facility failed to ensure that all orders, including verbal orders, were properly and promptly authenticated for 6 (#s 10, 11, 13, 14, 15, and 16) of 25 reviewed patients. Findings include:

During the review of closed records beginning on 9/28/11 at 8:30 a.m., the surveyor noted the following physician orders that were not properly authenticated:

1. Patient #10, a 51 year old female was admitted on 10/1/10. Physician orders for medications and treatments written on 10/3/10, 10/7/10, 10/12/10, 10/16/10, 10/17/10, 10/18/10, and 10/21/10 did not include the times that the verbal orders were received and documented in the clinical record.

2. Patient #11, a 70 year old male was admitted on 3/15/11. Two separate physician orders for medications, intravenous fluids, lab tests, and one medication dose changed did not include the times when the orders were written into the clinical record.

3. Patient #13, a 52 year old male was admitted on 5/9/11. The physician discharge order did not contain the time when the order was written into the clinical record.

4. Patient #14, an 87 year old male, was admitted on 10/22/10. A physician telephone order for a medication did not include the time when the verbal order was received and entered into the clinical record.

5. Patient #15, a 79 year old male was admitted on 2/14/11. A physician telephone order for titration of a narcotic medication did not include the time when the verbal order was received and entered into the clinical record.

6. Patient # 16, a 43 year old female, was admitted on 5/18/11. A physician telephone order dated 5/19/11 for lab tests and medication dosing did not include the time when the verbal order was received and entered into the clinical record. A second physician telephone order for medication changes and lab tests dated 5/24/11 did not include the time when the verbal order was received and entered into the clinical record.

During an interview with staff members A and B on 9/28/11 at 4:30 p.m., both staff acknowledged that there were still some physicians and nurses that did not complete the authentication process for orders.