HospitalInspections.org

Based on review of records and interviews, the medical records of 12 of 12 patients (Patients #1 through #4 and Patients #7 through #14) hospitalized after June 2010 were not complete in that the medical record entries were not dated, timed, and/or signed by the person responsible for providing the hospital services.

Findings included:

The "Physicians Progress Record" signatures were not timed by the physician for the following Patients:

Patient #1 - Dated 01/05/11, 01/06/11, 01/07/11, and 01/08/11.
Patient #4 - Dated 02/11/11.
Patient #8 - Dated 12/18/10

The "Hourly Blood Pressure" information that included blood pressure, heart rate, respiration, heart rhythm, and oxygen saturation were not signed for the following Patient:

Patient #1 - Dated 01/08/11 from 12:00 Noon through 06:00 PM.

The "Interdisciplinary Team Care Plan" signatures were not timed and dated for the following Patients:

Patient #1 - Signatures were not timed and dated for "Fall Risk," "Diarrhea," and "Impaired Skin Integrity" problems dated 01/05/11 with 01/26/11 target dates.
Patient #2 - Signatures were not timed and dated for "Impaired Swallowing" problem dated 12/31/10 with 01/26/11 target date.
Patient #3 - Signature was not timed and dated for "Pain" problem dated 07/22/10 with 08/14/10 target date.
Patient #8 - Signature was not timed and dated for "Pneumonia" problem dated 12/09/10 with 12/27/10 target date.

The "Admission Physician Orders" signatures were not timed and/or dated for the following Patients:

Patient #2 - Dated by physician 12/31/10 (not timed).
Patient #3 - Telephone order dated by nurse 07/22/10 (not timed), Physician's signature (not timed and dated).
Patient #3 - Telephone order 09/30/10 12:00 Noon, Physician's signature (not timed and dated).
Patient #8 - Telephone order 12/09/10 10:15 AM, Physician's signature (not timed and dated).

The "Hypoglycemic Protocol Standard Order" was not timed by the physician for the following Patient:

Patient #2 - Dated 01/01/11.

The "Adult Sliding Scale Standard Insulin Orders" were not timed by the physician for the following Patient:

Patient #2 - Dated 01/01/11.

The "Graphic Record" was not signed for the following Patients:

Patient #2 - Dated 01/01/11 08:00 AM.
Patient #3 - Dated 07/22/10 04:00 PM through 07/25/10 08:00 AM.
Patient #4 - Dated 10/08/10 04:00 PM through 10/11/10 04:00 AM, 10/11/10 04:00 PM through 10/14/10 04:00 PM.

The "Potassium Replacement Orders for General Nursing Units" signatures were not dated and/or timed for the following Patient:

Patient #3 - Telephone order to nurse 07/23/10 06:00 PM - Physician's signature (not timed and dated).

The "Respiratory Care Service Patient Assessment and Evaluation" signature was not timed and dated for the following Patient:

Patient #3 - Patient admitted 07/22/10, No date of evaluation, Respiratory signature (not timed and dated).

The "Speech and Language Pathology Bedside Swallow Evaluation" signature was not timed for the following Patients:

Patient #3 - Speech/Language Pathologist signature dated 07/23/10 (not timed). There was no physician's signature.
Patient #8 - Speech/Language Pathologist signature dated 12/09/10 (not timed). There was no physician's signature.

The "Interdisciplinary Daily Progress Note" Physical Therapy, Occupational Therapy, and Speech Therapy signatures were not timed and/or dated for the following Patient:

Patient #3 - 07/23/10 report, Physical Therapist and Speech Therapist signatures not timed and dated.

The "Therapy Narrative" signature was not timed for the following Patient:

Patient #3 - Speech Therapist signature dated 07/23/10.

The "Daily Treatment Documentation" signature was not timed for the following Patient:

Patient #3 - Nurse signature dated 07/23/10.

The "Consent for Medical Treatment" witness signature was not timed for the following Patients:

Patient #4 - Dated 10/04/10.
Patient #8 - Dated 12/09/10.
Patient #13 - Dated 01/01/11

The "Consent Form" nurse signature was not timed for the following Patients:

Patient #8 - Dated 12/09/10.
Patient #13 - Dated 12/23/10.

The "Pre-Admission History & Assessment" signature was not timed and/or dated for the following Patients:

Patient #7 - Assessment Date 08/27/10, Liaison signature (not timed and dated).
Patient #8 - Assessment Date 12/07/10, Liaison signature (not timed and dated).
Patient #9 - Assessment Date 09/27/10, Liaison signature (not timed and dated).
Patient #10 - Assessment Date 08/16/10, Liaison signature (not timed and dated).
Patient #11 - Assessment Date 08/06/10, Liaison signature (not timed and dated).
Patient #12 - Assessment Date 11/03/10, Liaison signature (not timed and dated).
Patient #13 - Liaison signature 12/22/10 (not timed).
Patient #14 - Assessment Date 10/11/10, Liaison signature (not timed and dated).

The "Informed Consent Special Procedure - PICC/Midline" healthcare professional signature was not timed for the following Patient:

Patient #7 - Dated 08/29/10.

The "Nutrition Therapy Interdisciplinary Team Conference Record" signatures were not timed by the Dietitian for the following Patient:

Patient #8 - Dated 12/15/10, Dated 12/29/10.

The "Pharmacy Review Interdisciplinary Team Conference Record" signature was not timed by the Pharmacist for the following Patient:

Patient #8 - Dated 12/29/10.

The "Notice of Physician Availability" witness signature was not timed for the following Patients:

Patient #13 -Dated 01/01/11.
Patient #14 - Dated 10/20/10.

The "Conditions of Admissions" witness signature was not timed for the following Patient:

Patient #14 - Dated 10/20/10.

The "Disclosure of Health Care Information and Request for Restriction of Information" witness signature was not timed for the following Patient:

Patient #14 - 10/20/10.

On 02/24/11 at approximately 10:30 AM, the Chief Nursing Officer (Personnel #1) reviewed the above medical records of Patients #1 through #4 and #8 through #14 with the surveyor and agreed that the signatures were missing dates and/or times.

The "Authentication" policy 9000-05 effective 03/27/08 noted, "...employees shall make sure that all entries in the medical record shall be dated and authenticated by the person making the entry..."

The "Medical Staff Rules and Regulations" adopted by the Medical Staff 03/28/08 noted, "An appointee's routine orders...shall be dated, timed and signed by the attending appointee...all entries in the record shall be dated and authenticated by the person making the entry..."

Based on review of records and interviews, the medical records of 4 of 4 patients (Patients #1, #2, #3, and #8) were not complete in that the hospital did not implement their own policy that included recording of pupillary information on expiration for patients who expired at the hospital between 07/22/10 and 01/09/11. This information was necessary to monitor the condition of Patients #1, #2, #3, and #8.

Findings included:

1) The "History and Physical" of Patient #1, age 70, noted that Patient #1 was admitted to the LTAC (Long Term Acute Care) hospital on 01/05/11 for treatment that included wound care and antibiotic therapy. Her admitting diagnoses included "candidiasis... sacral decubitus ulcer, stage IV...with some necrotic tissue...aspiration...tube in place...general debility...Parkinson's disease..."

The "Nursing Progress Notes" dated 01/08/11 noted that Patient #1 stopped breathing at 10:50 PM, "...asystole on monitor..." and was "pronounced by two RN's (Registered Nurses)" at 11:15 AM. The "Release of Body-Organ/Tissue Donation" dated 01/08/11 included that Patient #1 was pronounced by RN #4. Patient #1's medical record did not include documentation of the assessment of Patient #1's pupils on expiration.

On 02/23/11 at 09:45 AM, RN #4 (who pronounced that Patient #1 had expired) reviewed the medical record with the surveyor. RN #4 was asked if Patient #1's pupils were checked and the information recorded in the medical record. RN #4 said that she had checked Patient #1's pupils, but had "apparently not" recorded the information in the medical record.

2) The "Death Summary" of Patient #2, age 86, noted that Patient #2 was admitted to the LTAC hospital on 12/31/10. On admission, Patient #2 appeared to be "...very terminal, poorly responsive..." History included "...advanced Alzheimer's, recent left hip surgery and incision cyst infection with Staph and status post acute renal failure and hypertension..."

The "Physicians Progress Record" dated 01/01/11 noted that at 01:08 PM Patient #2 was "...asystole...0 respirations, 0 pulses...okay for 2 RNs to pronounce death..." The "Release of Body-Organ/Tissue Donation" dated 01/01/11 included that Patient #2 was pronounced by RN #5. Patient #2's medical record did not include documentation of the assessment of Patient #2's pupils on expiration.

On 02/22/11 at 04:55 PM, RN #5 (who pronounced that Patient #2 had expired) reviewed the medical record with the surveyor. RN #5 was asked if Patient #2's pupils were checked and the information recorded in the medical record. RN #5 said that the pupils were checked, but not recorded in the medical record.

3) The "History and Physical" of Patient #3, age 86, noted that Patient #3 was admitted to the LTAC hospital on 07/22/10 with "cellulitis...cardiovascular complaint...abdominal pain." Patient #3 had a "surgical resection with a ruptured appendix with appendiceal abscess..." at another hospital and was transferred to the LTAC for continued care. Patient #3's history included "...Alzheimer's...sacral decubitus...coronary artery disease...seizures..."

The "Nursing Flow Sheet" dated 07/25/10 noted that at 11:57 AM Patient #3 was "declared...asystole..." The "Release of Body-Organ/Tissue Donation" dated 07/25/10 included that Patient #3 was pronounced by RN #6. Patient #3's medical record did not include documentation of the assessment of Patient #3's pupils on expiration.

On 02/22/11 at 04:15 PM, RN #6 (who pronounced that Patient #3 had expired) reviewed the medical record with the surveyor. RN #6 was asked if Patient #3's pupils were checked and the information recorded in the medical record. RN #6 said that the pupils were checked, but that the pupil information was not charted.

4) The "Death Summary" of Patient #8, age 93, noted that Patient #8 was transferred to the LTAC hospital on 12/09/10 for "continued antibiotic therapy, Speech Therapy, Physical Therapy." On 12/27/10 Patient #8 had "decreased oxygen saturations...placed on nonrebreather...complains of chest pain...x-ray demonstrates some congestive heart failure...care is discussed with her family...only interested in comfort measures..."

The "Nurse's Notes" dated 12/31/10 noted that at 02:35 PM Patient #8 was "deceased..." A late entry noted, "...0 respirations, 0 heart sounds, 0 pulses..." The "Release of Body-Organ/Tissue Donation" dated 12/31/10 included that Patient #8 was pronounced by RN #21. Patient #8's medical record did not include documentation of the assessment of Patient #8's pupils on expiration.

On 02/24/11 at approximately 08:30 AM, RN #21 (who pronounced that Patient #8 had expired) reviewed the medical record with the surveyor. RN #21 was asked if Patient #8's pupils were checked and the information recorded in the medical record. RN #21 said that the pupils were checked, but that it appeared the information was not documented.

The hospital's "Pronouncement" policy 2.05 reviewed May 2011 included that "... The RN may pronounce the death of a patient after the following steps are taken...record the position of the pupils and the absence of pupillary light reflex..."

Based on review of records and interview, the Infection Control Officer did not maintain a log of incidents related to infections in that 4 of 4 patients (Patient #1, #2, #3, and #8) hospitalized with community acquired infections were not included as part of the monthly Infection Control Log information from July 2010 through January 2011. This deficient practice presents a risk for the spread of infections and potential harm to patients and staff.

Findings included:

1) The "History and Physical" of Patient #1, age 70, noted Patient #1 was admitted to the LTAC (Long Term Acute Care) hospital on 01/05/11 for treatment that included wound care and antibiotic therapy. Her admitting diagnoses included "candidiasis... sacral decubitus ulcer, stage IV...with some necrotic tissue...C.diff colitis still with persistence of diarrhea on oral vancomycin...aspiration...tube in place...general debility...Parkinson's disease...fever that has been recurrent at times. Etiology to be determined. "

The "Infection Control Screening Tool" dated 01/05/11 noted that Patient #1 did not have a "hospital acquired" infection.

2) The "Death Summary" of Patient #2, age 86, noted that Patient #2 was admitted to the LTAC hospital on 12/31/10. On admission, Patient #2 appeared to be "...very terminal, poorly responsive..." History included "...advanced Alzheimer's, recent left hip surgery and incision cyst infection with Staph and status post acute renal failure and hypertension..."

The "Infection Control Screening Tool" dated 12/31/10 noted that Patient #2 did not have a "hospital acquired" infection.

3) The "History and Physical" of Patient #3, age 86, noted that Patient #3 was admitted to the LTAC hospital on 07/22/10 with "cellulitis...cardiovascular complaint...abdominal pain." Patient #3 had a "surgical resection with a ruptured appendix with appendiceal abscess..." at another hospital and was transferred to the LTAC for continued care. Patient #3's history included "...Alzheimer's...sacral decubitus...coronary artery disease...seizures..."

The 07/21/10 "Microbiology" report abdominal wound culture exam noted Patient #3 had "light growth of Group F strep."

The "Infection Control Screening Tool" dated 07/22/10 noted that Patient #3 did not have a "hospital acquired" infection.

4) The "Death Summary" of Patient #8, age 93, noted that Patient #8 was received at the LTAC hospital on 12/09/10 for "continued antibiotic therapy" after she had been identified to have "aspiration pneumonia with dysphagia with MRSA and Pseudomonas as well as a urinary tract infection" in the transferring hospital.

An "Aerobic Bacterial Culture" report dated 12/30/10 noted Patient #8's results included "Methicillin-resistant Staphylococcus aureus 3+ (MRSA)."

The "Infection Control Screening Tool" dated 12/09/10 noted that Patient #8 did not have a "hospital acquired" infection since Patient #8 had been hospitalized with "...MRSA..."

The hospital's "Infection Prevention & Control/Employee Health/Education" reports dated July 2010 through January 2011 did not contain community acquired infection information for any of the hospital's patients identified with community acquired infections during the period from July 2010 through January 2011.

During an interview at approximately 03:00 PM on 02/23/11, the Infection Control Coordinator (Personnel #3) was asked if community acquired infections were part of the tracked infection control information. Personnel #3 said that the hospital tracked the "Healthcare Associated Infections," but not the community acquired infections in it's monthly reports. After review of the infection control information of Patients #1, #2, #3, and #8 with the surveyor, Personnel #3 said that the infections of Patients #1, #2, #3, and #8 were community acquired and that this information was not tracked in the hospital's monthly reports.

The infection control "Surveillance: Collecting, Analyzing, and Reporting Data" policy 1.09 reviewed May 2011 noted: "Although the hospital's infection control program is focused on nosocomial and communicable infections, it is recognized that patients admitted with "community acquired" infections are relevant to the infection control program insofar as the ability of these patient's infections to spread to susceptible patients and personnel in the hospital."