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Based on observation and staff interview, the Condition of Physical Environment is NOT met relating to the 13 life safety code violations cited during tours of the hospital from 08/15/11-08/18/11. These violations limit the hospital's ability to ensure the safety of each patient in the event of a fire. The hospital census was 85 with staffed beds numbering 188.

Findings include:

Please see A710 for the 13 K tags cited.

During medical record review of Patients 34, 35, 36, 37, 38 and 39 on 08/17/11 and 08/18/11, it was noted that there were several undated and untimed physician orders and progress notes, as well as unsigned verbal/telephone orders. Illegibility of medical record entries on Patients 34 and 35 were also noted.

Patient 35 had an order written on 08/14/11 at 08:30 PM for a medication. There was no signature on this order. On 08/15/11 a "stat" order was written but no time was written for the order. Progress notes that were written on several days were illegible and on 08/14/11 the progress note was not timed.

Patient 36 was noted to have an order written on 08/14/11 that was not timed or signed and one that was signed but not timed. There were three orders written on 08/15/11 that were not timed and one on 08/16/11 that was not timed. One of the progress notes had areas written over and not marked as an "error".

Patient 37 was noted to have an order written 08/16/11 and 08/17/11 that were signed but not timed.

Patient 38 was noted to have illegible pulmonary physician progress notes.

Patient 39 was noted to have three orders written on 08/15/11 for medications, that were not signed and one on 08/16/11 that was not signed.

This information was acknowledged by Staff A, AA and BB on 08/17/11 and 08/18/11.


03193

Based on medical record review and staff interview, seven of 26 patient records reviewed did not have progress notes, physician orders or post-anesthesia evaluation timed. The census was 85. This includes Patients 28, 34, 35, 36, 37, 38 and 39.

Findings include:


20866

The medical record review for Patient 28 was completed on 08/17/11. This patient received outpatient surgery on 08/16/11 for an umbilical hernia repair. The surgical procedure began at 2:37 PM and was completed at 4:21 PM. The anesthesia documentation revealed the patient was seen by anesthesia staff after the procedure, however the visit did not reveal a time this occurred. This finding was confirmed with Staff Y and Z on 08/17/11 at 3:20 PM.

Review of Patient 43's medical record on 08/18/11 revealed that the patient had been in the hospital from 05/30/11 thru 06/03/11. The record review revealed that there was no discharge summary available for this hospital stay. This was verified on 08/18/11 at 03:55 PM by Staff B.


21893

Based on staff interview, medical record review, and review of the medical staff bylaws; the facility failed to ensure all medical records were completed, including discharge summaries, within 30 days of discharge from the facility. This affected 225 medical records. The facility census was 85 at the time of the survey.

Findings include:

Staff X was interviewed on 08/18/11 at 11:15 AM. Staff X stated that 225 medical records were delinquent or incomplete after 30 days post discharge. The medical staff bylaws were reviewed on 08/18/11. The medical staff bylaws stated a medical record would be considered delinquent when not completed within 30 days post discharge.

The medical record for Patient 32 was reviewed on 08/17/11. The patient expired on 05/01/11. The discharge summary was dictated on 07/25/11 and was signed by the physician on 08/03/11. This was verified by Staff B on 08/17/11 at 4:30 PM.

Per medical record review on 08/17/11, Patient 27 received speech therapy as an outpatient from 01/17/11-02/14/11 for dysphagia. On 02/14/11 a modified barium swallow was completed and the patient was determined to continue to need speech therapy. A note in the medical record revealed the patient would restart therapy in April 2011 after returning from vacation. The patient has not returned as of 08/17/11. Interview with Staff CC on 08/17/11 at 02:53 PM confirmed that a discharge summary should have been written in April 2011 when Patient 27 did not return for further therapy.

Based on observation and staff interview during the four days of survey, 08/15/11-08/18/11, the following life safety code violations were identified. The census was 85.

Findings include:

K11 Penetrations in the 2 hour fire rated separations

K17 Penetrations in corridor walls

K20 Vertical openings not protected with at least a one hour fire rated
construction

K25 Penetrations in smoke/fire barriers

K29 Penetrations in hazardous areas and doors not rated

K43 Thumb turn deadbolt lock on patient room door

K47 Exits lacking directional signs

K51 Pull station device not located near exit access

K62 Dirty sprinkler heads

K71 Laundry chute door unable to close due to bags of laundry backed up into
chute

K75 Large mobile trash container located unattended in stairwell

K76 Med gas room lacked a vent and light switch/receptacle not located at
least 5 feet above the floor

K130 Smoke detectors located near air flow devices