HospitalInspections.org

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to determine specific qualifications, as evidenced by education, training and experience, required for the staff restraint trainer position.

Findings include:

1. Review of the July 2008, "Restraints" policy failed to reveal the qualifications for the person assigned to train staff in the use of restraints.

2. Review of the job description for the person assigned to provide staff education regarding restraints failed to address the qualifications required for the trainer.

3. Interview on August 11, 2010, at 2:15 PM with EMP2 confirmed, "No. It [qualifications of the trainer] is not spelled out in the policy or job description." When asked what qualifications the trainer had for educating staff about restraints, EMP2 replied, "The trainer has a certification in non-violent crisis management or whatever you call it when you do not use restraints, and has done it [training for restraints] for several years. But it is not spelled out anywhere that is why they are the trainer. What type of qualifications should they have?"

Based on review of facility documents and medical records, and staff interviews, it was determined that the facility failed to ensure nursing staff implemented nursing policies and procedures related to pressure ulcer/wound prevention in five of six medical records. (MR2, MR3, MR6, MR7, MR9 and MR10).

Findings include:

Review of facility document, "Position Description, Job Title: Registered Nurse, ... Typical Examples of Work: 1. The Registered Nurse is Responsible to utilize the nursing process in order to assure quality patient care, ... B. Initiate implement and/or update the written plan of care reflecting the current standards of professional nursing practice in the clinical setting.
F. Evaluates patient response and documents all significant, patient data in an accurate and complete manner."

Review of facility policy "4.4 Pressure Ulcer/Wound Prevention, I. Purpose: A. To identify patients at risk for developing pressure ulcers and to initiate preventative treatment. ... II. Objectives: A. To maintain skin integrity. ... C. To prevent further damage to the tissue. ... III. Information: ... B. all patients who are admitted with impairment in skin integrity or a risk assessment score less than or equal to 18 are placed on the Wound Prevention Program, ... IV. Procedure, ... 2. Moderate Risk Braden Score, All intervention for low risk plus the following: b. If bed bound, turn and reposition every two hours, document on the patient record. ... . High to very high risk Braden Score of 12 or less. All interventions for low and moderate risk risk plus the following: a. Consider the use of speciality mattress. ... D. Documentation, ... 3. The nurse will document all preventative measures utilized with the patient's care."

1) Review of MR2, MR3, and MR6, medical records of patients with moderate risk Braden Scores, failed to reveal documentation of repositioning the patient every two hours. There also was no documentation of the patient's ability to reposition themselves.

2) Interview with EMP2 August 9, 2010, at approximately 1:00 PM, when asked about the lack of documentation related to Braden Scores revealed, "A screen (computer) is supposed to drop down when it is triggered by low, moderate or high risk Braden Score. For some reason it's not. If the nurses don't document it there, they can put it in their notes."

3) Review of MR9 and MR10, medical records of patients with high risk Braden Scores, failed to reveal documentation of repositioning the patient every two hours. There was also no daily documentation of other preventative measures.

4) Interview with EMP19 at 11:00 AM on August 11, 2010, verified that there was no documentation on MR9 and MR10 of repositioning the patients every two hours.

Based on review of facility documents and medical records (MR), and staff interviews,(EMP), it was determined that the facility failed to ensure that all entries in the medical record were authenticated, dated and timed in written form by the person responsible for providing or evaluating the service provided for 15 of 28 medical records (MR1, MR2, MR3, MR4, MR6, MR7, MR8, MR9, MR10, MR11, MR13, MR14, MR20, MR22, and MR26).

Findings include:

Review of the "Titusville Area Hospital Medical Staff Rules and Regulations" revised June 29, 2010, revealed, "Medical Records ... B. ... The H&P must be authenticated by the practitioner who recorded it. Authentication must include the date and time... H. All clinical entries in the patient's medical record shall be accurately dated and authenticated. Comment: Authentication means to establish authorship by written signature, identifiable initials or computer key... "

Review of the "Medical Record Department Policies...100.06" revised October 2004, revealed, "Physician orders shall be dated, timed and signed...."

1) Further review of the Medical Staff Rules and Regulations failed to reveal the need for all entries in the medical record to be timed by the person responsible for providing or evaluating the service provided.

2) Review of MR1, MR2, MR3, MR4, MR6, MR7, MR8, MR9, MR10, MR11, MR13, MR14, MR20, MR22, and MR26 revealed physician orders, verbal orders and/or physician progress notes that were not authenticated, dated and/or timed.

3) Interview with EMP2 on August 11, 2010, at 2:15 PM, when asked about the lack of authentication, dates and times in the medical records, "We've known that has been a problem"

Cross reference with:
482.24(c)(1) Orders Dated and Signed

Based on review of facility documents and medical records it was determined that the facility failed to ensure that all orders, including verbal orders were dated, timed and authenticated promptly by the ordering physician for 16 of 28 medical records (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR13, MR14, MR20, MR22, and MR26).

Findings include:

Review of the "Titusville Area Hospital Medical Staff Rules and Regulations" revised June 29, 2010, revealed, "Medical Records ... H. All clinical entries in the patient's medical record shall be accurately dated and authenticated. Comment: Authentication means to establish authorship by written signature, identifiable initials or computer key... "

Review of the "Medical Record Department Policies...100.06" revised October 2004, revealed, "Physician orders shall be dated, timed and signed...."

1) Further review of the Medical Staff Rules and Regulations failed to reveal the requirement for all orders including verbal orders to be timed.

2) Review of MR1, MR2, MR3, MR4, MR6, MR7, MR8, MR9, MR10, MR11, MR13, MR14, R20, MR22, and MR26 revealed physician orders, including verbal orders, failed to be authenticated, dated and/or timed.

3) Interview with EMP6 on August 11, 2010, at approximately 1:00 PM, indicated that the entries and orders were not considered delinquent for missing the time.

Cross reference with:
482.24(c)(1) Medical Records Services

Based on review of facility documents, observations, and staff interviews (EMP), it was determined the facility failed to keep all drugs and biologicals in a secure area, and locked when appropriate.

Findings include:

Review of the "High Alert Medications" policy 5.9 revised March 2010, revealed, "III. A. The following medication categories are considered High Alert Medications at the Titusville Area Hospital ... 11. Anesthetics (ie: Propofol) ... V. Procedure: ... B. Preparation and Dispensing of the Medication 1. All storage locations of High Risk Medications are clearly labeled. Pharmacy will provide for the safe storage and labeling of all High Alert Medications. 2. All High Alert Medications requiring storage in patient care areas as stock will be clearly labeled High Alert Medication on the storage bins and separated from general stock. Pharmacy will provide for safe storage and labeling. 3. All medication areas will remain locked when unattended.

1. Observation of the unlocked Caesarian Section (C-section) room in the Obstetrical Department on August 10, 2010, at 10:15 AM revealed two vials of Diprivan and one vial of Isoflurane (both anesthetic agents) on top of the anesthesia cart. There was no staff in attendance. The observation was confirmed by EMP8 at that time.

2. Interview with EMP8 on August 10, 2010, at 10:15 AM revealed, "Those [anesthetic agents] are never left out. Maybe someone from pharmacy was checking for outdates and left them out."

3. Interview with EMP27 on August 11, 2010, at 10:15 AM revealed, "Monday morning someone from anesthesia was checking the cart and was called away to start an IV. After the interruption [he/she] forgot to come back and lock up the medication."

Based on review of facility documents and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to provide an ongoing program of activities to meet the needs of patients in swing bed status in three of four medical records reviewed (MR13, MR22, MR26).

Findings include:

The facility policy, review date of March 2010, "Rehabilitation Services G. Activities: A program of planned activities is provided to patients occupying Swing Beds by way of the Activities Program of the Titusville Area Hospital Swing Bed Program. The intent is to provide for an Activities Program appropriate to the needs, interest and maximum achievable potential of each patient in a Swing Bed setting ... Appropriate documentation shall be maintained th the patient's medical record by the Activities Coordinator of the activity assessment/plan of care ... and on the integrated progress notes..."

1. Review of MR13, MR22, and MR26 failed to reveal documentation that residents were offered an ongoing program of activities based on a comprehensive assessment according to their interests.

2. Interview with EMP8 on August 10, 2010, at approximately 11:50 AM confirmed the lack of documentation regarding an assessment for activities for MR22 and revealed, "The patients are offered activities. There used to be information about their interests on their assessment forms. I don't see it now. The occupational therapist offers activities if the patients want to do them." After review of the computerized documentation EMP8 stated, "I don't see any documentation of that [patients being assessed or offered activities by the occupational therapist]."

3. Interview with EMP19 at 9:00 AM on August 11, 2010, verified that there was no participation of activities or documentation of an activity assessment for MR13.