HospitalInspections.org

Based on a review of facility documents and medical records (MR), and interview with staff (EMP), it was determined that the facility failed to obtain an informed consent for five of five medical records where PICC (peripherally inserted central catheter) lines were inserted at the facility (MR13, MR14, MR15, MR16, and MR17).

Findings include:

A review on November 8, 2010, of policy entitled "Informed Consent" last reviewed December 29, 2009, revealed ... "Policy: It is the policy of the hospital and Medical Staff that all patients and families shall have information that will allow full understanding of the risks, benefits, and alternatives of invasive procedures, as well as allowing for questions and answers prior to the performance of the procedure. The patient shall not be subjected to any procedure without his voluntary, competent, and informed consent, or that of his appropriate legal representative ... A physician is responsible for providing information for informed consent ... "

A review on November 8, 2010, of MR13, MR14, MR15, MR16, and MR17 revealed there was no documentation that the physician informed the patient of the nature of the proposed procedure or treatment and of those risks and alternatives to treatment or diagnosis.

An interview conducted on November 8, 2010, at 2:30PM, with EMP1 confirmed that MR13, MR14, MR15, MR16, and MR17 did not have documentation that the physician informed the patient of the nature of the proposed procedure or treatment and of those risks and alternatives to treatment or diagnosis.

A review on November 9, 2010 of the "Medical Staff Executive Committee" meeting minutes dated "May 18, 2009", revealed "PICC (MEC recommends removing)"

An interview conducted on November 9, 2010, at 11:00AM, with EMP2 revealed the Medical Staff Executive Committee met on May 18, 2008, and reviewed universal protocols. The protocol revealed the facility determined an informed consent was not required for insertion of PICC lines. .

482.13(e) (5) In accordance with the order of a physician or other licensed independent practitioner permitted by the state and hospital to order a restraint.

This is not met as evidenced by:

Based on a review of facility policy, medical records (MR) and interview with staff (EMP), it was determined that the facility failed to conform to all applicable State and Federal laws and regulations.

HealthSouth Regional Specialty Hospital was not in compliance with the following Federal regulations related to the use of restraints.

482.13(e) (5) In accordance with the order of a physician or other licensed independent practitioner permitted by the state and hospital to order a restraint.

This is not met as evidenced by:

Based on a review of facility policy, medical records (MR) and interview with staff (EMP), it was determined the facility failed to obtain orders for the use of restraints for two of four restraint medical records reviewed (MR11 and MR12).

Findings include:

A review on November 10, 2010, of facility policy "Use of Restraints: In Non-Psychiatric Hospital or Unit", last revised August 2009 revealed: "... Procedure: Restraints may only be initiated after care assessment of the patient and a determination that alternatives to the use of restraints are not effective. A Physician must provide an order per the requirements listed below...Content of Order Renewal: Type of restraint, reason for restraint, time limitation for restraint, and No PRN orders allowed"

A review on November 9, 2010, of MR11 and MR12 revealed that restraints were used for these patients. The medical record did not contain a physician order for each episode of restraint usage.

An interview conducted on November 9, 2010, at 10:00 AM with EMP1 confirmed that there was no physician order for each episode of restraint usage in MR11 and MR12.

A review on November 9, 2010, of MR11 and MR12 revealed that restraints were removed and reapplied without obtaining a new order.

An interview conducted on November 9, 2010, at 2:00 PM with EMP1 confirmed that the restraints were removed and reapplied without obtaining a new order for MR11 and MR12

Based on a review of facility policy, medical records and interview with staff (EMP), it was determined the facility failed to comply with its adopted policy for medication administration and documentation for two of five medical records reviewed (MR 28 and MR30).

Findings include:

A review on November 10, 2010, of facility policy, "Medication Administration and Documentation" last revised 6/10 revealed, " ... All entries noting administration of medication must be entered properly in the medical record. All entries must include the: Name of medication, Dosage administered, Route of administration and site of injections, Time of administration, Individual who administered medication ... "

A review on November 10, 2010, of MR28 revealed the patient was ordered Hectorol 2 micrograms (dialysis medication) to be given on each day of dialysis. The patient had dialysis on August 2, 2010, August 8, 2010, and August 9, 2010. There was no documentation that Hectorol was given on those dialysis days.

An interview conducted on November 10, 2010, at 10:00AM with EMP4 confirmed there was no documentation that the physician order for Hectorol 2 micrograms was administered on August 2, 2010, August 8, 2010, and August 9, 2010.

A review on November 10, 2010, of MR30 revealed the patient was administered Ferriecit 100 milligrams dialysis medication). MR30 did not have a route or time administered included in the documentation.

An interview conducted on November 10, 2010, at 10:45AM with EMP2 confirmed MR30 nursing documentation did not contain the route or time the Ferriecit was administered.

Based on a review of Medical Staff Rules & Regulations, medical records (MR), and interview with staff (EMP), it was determined that staff failed to follow facility policies for ensuring all entries into the MR were timed, dated and/or authenticated by the person making the entry in 11 of 31 medical records reviewed (MR9, MR10, MR11, MR20, MR21, MR22, MR23, MR24, MR25, MR27 and MR28).

Findings include:

A review on November 9, 2010, of "Medical Staff Rules & Regulations June, 2010 ... A. Management of Information 1. All Clinical entries in the patient's medical record shall be accurately dated and authenticated by persons authorized to assess, write orders, and treat patients. The medical record must be clear, concise, complete, and accurate."

A review on November 9, 2010, of MR9, MR10, MR11, MR20, MR21, MR22, MR23, MR24, MR25, MR27 and MR28 revealed discharge summaries and/or verbal orders that were not dated when signed by the physician.

An interview conducted on November 9, 2010 at approximately 3:10 PM with EMP1 confirmed the above discharge summaries and/or verbal orders were not dated, timed and/or signed by the physician.

Based on a review of Medical Staff Rules and Regulations and facility documentation of delinquent medical records, it was determined the facility failed to ensure that the Medical Staff conformed to established delinquent policy for completion of medical records within 30 days.

Findings include:

A review on November 9, 2010, of facility policy "Medical Record Completion; Physicians: Notification to Physician Regarding Incomplete and/or Delinquent Records", last reviewed September 2009, revealed, "...An ongoing audit of incomplete medical records will be conducted to identify medical records not completed on day 27 of 30. The results will be reported to the CEO the same day. The CEO, representing the Governing Body, will notify the physicians responsible for the medical records identified in the audit and will continue to notify the physicians on day 28 of 30; day 29 of 30, and day 30 of 30 until the records are completed. Physicians with outstanding medical records after day 30 of 30 will be suspended.

A review on November 9, 2010, of facility documentation "Deficiency Rate" revealed the following: "As of October 31, 2010, there were 10 physicians that had records that were not completed for at least 55 days."

An interview conducted on November 9, 2010, at 10:00 AM, with EMP3 confirmed there were at least 10 physicians that had incomplete medical records greater than 55 days. EMP1 and EMP3 confirmed that none of those physicians had been suspended.

Based on a review of facility policy and procedures, facility documents and interview with facility staff (EMP), it was determined that the facility failed to ensure that periodic checks were done by the pharmacist for all areas of the hospital where drugs are stored.

Findings include:

A review on November 8, 2010, of facility policy, "Unit Inspections", last reviewed September 2009 revealed: " ... Policy: The Pharmacy will conduct a monthly inspection of each nursing station and drug storage area ... 6. Pharmacist or designee will sign the form when inspection is completed ... "

A review on November 8, 2010, of the pharmacy monthly inspection reports revealed the inspections were completed by a pharmacy technician. There was no documentation that a pharmacist signed the monthly inspections.

An interview conducted on November 8, 2010, at 10:30 AM, with EMP5 confirmed that the pharmacy technicians completed the monthly inspections and the pharmacist was to review the inspection log. EMP5 also confirmed that there was no documentation to indicate that the monthly inspections were reviewed or signed by a pharmacist.

Based on a review of facility policy, observation and interview with staff (EMP), it was determined the facility failed to follow their established policy for the disposal of expired medications.

Findings include:

A review on November 9, 2010, of facility policy "Unit Inspections" last reviewed September 2009 revealed " ... Purpose: To promote better patient care through improved safety, by the removal and replacement of out-dated, deteriorated, improperly stored, contaminated or otherwise unsuitable drugs ... "

Observation on November 9, 2010, of two respiratory carts in the respiratory supply room revealed two Xopenax inhalers (respiratory treatments) that expired in September 2010; two Flovent inhalers that expired in March 2010 and July 2010; and three Xopenax inhalers that had an expiration date that was illegible. The expiration date could not be determined.

An interview conducted on November 9, 2010, at 9:45 AM with EMP6 confirmed the two Xopenas inhalers expired in September 2010, two Flovent inhalers expired in March 2010 and July 2010, and three Xopenax inhalers that had expiration dates that were illegible and could not be determined.