HospitalInspections.org

The Governing Body of the hospital failed to ensure compliance with the medical staff bylaws and completion of medical records and failed to monitor and ensure compliance with Infection Control policies.

Findings were:
1.
There were 620 incomplete medical records, with the oldest being from 1/05/08. The medical staff bylaws were not enforced.
2.
Multiple patient visits were completed on one Emergency room record. There was not a record for each person who was treated at the hospital.
3.
Infection control failed to monitor both the dietary department and the physical therapy department to include the pool.
Interviews on 10/12/10 in the classroom area, with the Interim CEO and Director of Nursing confirmed the above findings.

refer to A263, A431, A1124 for complete findings

The facility failed to ensure that quality assessment and performance improvement program required improved outcomes.

Findings were:

The number of delinquent medical records has been consistently reported for the years of 2009 an 2010. There has been no resolution to the identified problem of the delinquent records as of the date of the survey. At the current time there are 620 incomplete records. The QAPI process not attempted any resolution process, nor have the Medical Staff bylaws been enforced.
In an interview with the Interim CEO and Director of Nursing on 10/11/10 the above was confirmed.

The facility failed to ensure that there was administrative responsibility for the Medical Record services of the hospital there were 620 incomplete records, multiple visits to the ER on the same record for one patient and a physician order form dated 3/25/09 for a surgery completed on 1/22/10.

Findings were:
1.
Review of Quality Improvement meeting minutes and interview with staff revealed that there were 620 medical records that were incomplete and over 30 days past admission. The medical staff bylaws had not been enforced by the CEO.
2.
Review of medical record #5 revealed that there were three visits on three separate, consecutive days to the emergency room contained on the one record.
3.
The clinical record for patient #23 revealed that surgery was scheduled and completed on 1/22/10. The "preoperative standing orders for general anesthesia surgeries" was predated 3/25/09 by the surgeon. There was not a current date on the form.

Interviews on 10/12/10 in the classroom area, with the interim CEO and medical records staff confirmed the above findings.

Based on review of emergency room records, interview with medical records staff and review of the medical staff bylaws, the facility failed to ensure a record for each visit to the hospital and failed to ensure that all medical records were complete within 30 days of discharge.

Findings were:
1.
Review of Quality Improvement meeting minutes and interview with staff revealed that there were 620 medical records that were incomplete and over 30 days past admission. There are 7 physicians on staff. The average admission and discharges per month are 117 (per medical record staff). The record that was the most over due was from 1/5/08 and still had not been completed. Medical staff bylaws revealed that 1.2-14 "If the medical record is incomplete 30 days after discharge a written notice shall be sent to the physician by the CEO notifying him/her that his/her admitting privileges shall be suspended 7 days from the date of the notice and that he/she shall remain suspended until all incomplete medical records have been completed." This policy had not been enforced by the CEO.
2.
Review of medical record #5 revealed that there were three visits on three separate, consecutive days to the emergency room contained on the one record.
3.
The clinical record for patient #23 revealed that surgery was scheduled and completed on 1/22/10. The "preoperative standing orders for general anesthesia surgeries" was predated 3/25/09 by the surgeon. There was not a current date on the form.

Interviews on 10/12/10 in the classroom area, with the CEO and medical records staff confirmed the above findings.

Based on observation and interview it was determined that the facility failed to ensure that expired medications were removed from patient care areas.

Findings were:

Expired medications were found in patient care areas and available for patient use. During a tour of the facility on 10/11/2010 an inspection of the overflow IV cart located adjacent to the MDG medication system revealed 3 each unopened 250ml IV bags of 5% Dextrose injection USP. The expiration dates listed on each of the three bags was Aug 10.

An inspection of the emergency crash cart in the surgery area revealed multiple expired medications to include:

2 each 250ml IV bags of Normal Saline, the expiration date on these bags was listed as Aug 10.

2 each 1000ml IV bags of Lactated Ringers solution, the expiration date listed on these bags was Aug 10.

2 each 250 ml IV bags of 5% Dextrose Injection USP, the expiration date listed on these bags was Sep 10.

4 each 250ml IV bags of 5% Dextrose injection USP, the expiration date listed on these bags was Aug 10.

2 each 10ml 10% Calcium Chloride injection, the expiration date on the packaging listed the date as 1 Mar 2010.

1 each Pediatric Atropine Sulfate Injection 0.25(0.05mg/ml), the expiration date on the packaging listed the date as 1 Sep 2010.

3 each Metoprolol Tartate 5mg/5ml ampules, the expiration date listed on each of these ampules was 1 Sep 2010.

In an interview with the Interim CEO and Director of Nursing on 10/11/2010 it was confirmed that there were expired medications found on the premises by the surveyors.

Based on observation, and interview it was determined that the facility failed to ensure that expired supplies were removed.

Findings were:

During a tour of the facility on 10/11/2010 it was discovered that there were expired medical supplies found in patient care areas and available for use.

1.) Expired supplies were found in the pediatric crash cart to include:

2 each unopened Bard Add a Foley tray kits, the expiration dates on these kits were 2009-04 and 2009-04.

4 each Jamshidi disposable Illinois bone marrow aspiration/intraosseous infusion needle. The expiration date on these needles was listed as 2009/06.

2 each unopened Nellcor Pedi-Cap CO2 Detector, the expiration date on each of these packages was listed as 2009-10.

2 each unopened Kendall MediTrace 1310P Multifunction Electrode packages, the expiration dates listed on both of these packages was 2010-05.

One each unopened Medtronic Physio-Control Quik-Pace, the expiration date listed on the package was 2010-08-28.

Four each unopened Bard all purpose urethral catheter, 12 French, the expiration date listed on these two packages was 2008-05.

Four each unopened PDI Povidone-Iodine swabsticks, each of these four packages had expiration dates of 09/2010. Additionally two each of these were found with expiration dates of 1/05 and 11/05.

Eight each unopened PDI Compound Benzoin Tincture, USP 10% Swabsticks were found with expiration dates of 2009/11 were listed on the packages.

2 each unopened Liftloc safety infusion sets, both of these sets had expiration dates of 2008-05.

Two each unopened Insyte Autoguard shielded IV catheters, one of these was a 22 gauge and the other was a 20 gauge, the expiration dates for both of these packages was 2010-05.

Three each unopened Pulset arterial blood gas collection syringe kits, each of these three kits had expiration dates listed as 2009-12.

One each Rusch nasopharyngeal airway, size 22 Fr, 7.3mm, the expiration date on the packaging was listed as 2004-07.

2.) Expired supplies were found on the physical therapy wound care cart; four opened bottles of Kendall Curity Plain Packing Strip, the expiration dates on each of these bottles were 2006-05.

In a cabinet in the wound care area additional expired supplies were found to include: three unopened packages of Ferris PolyMem membrane island film dressing, the expiration dates on these three packages were listed as 2006-03.

One each unopened Smith and Nephew Allevyn Adhesive package, the expiration date was listed as 2006-04.

Four each unopened Smith and Nephew No-Sting Skin Prep swabs, each of these four packages had an expiration date of 09-10.

Eight each unopened PDI Compound Benzoin Tincture USP, 10% Swabstick, each of these packages listed the expiration date as 2006/08.

One opened 473 ml bottle of McKesson Medi-Pak Hydrogen Peroxide Topical Solution USP, the expiration date on the side of the bottle was listed as 05/2008.

3. There was blood observed on one bed in the emergency room and the bed was ready for patient use

There were 8 blue sleeper chairs that were observed to be ready for use and were observed to be dirty as there was dust and food particles in them, one of the eight chairs was torn and an infection control problem.

There were holes in the wall behind the linen cart, as well as dust behind and under this cart.

The area behind the medication storage system was observed to be covered with dust and debris.

In room 25 there was a rip in the floor that was six inches long, and four inches wide at one end and one inch wide at the other end.

In an interview with the Director of Nursing on 10/12/2010 it was confirmed that there were expired patient care supplies found in the physical therapy area and the Pediatric crash cart.

Based on a review of documentation and interview it was determined that the facility failed to ensure that departmental Infection Control requirements were met.

Findings were:

1.
A). The physical therapy department failed to ensure that a required monthly infection control checklist had been completed as policy dictated. A review of the physical therapy department policy and procedure manual revealed a document entitled: " Infection Control Checklist " stated: " The Rehabilitation Services supervisor or responsible designee will use the following checklist once a month at the end of the day. Findings will be documented, Yes or No, and the reports compiled as part of the PI quarterly report. " Upon request by the surveyor to see the most recent of these checklist none were found. In an interview with the CEO on 10/12/2010 the surveyors were informed that no such check list was available for review.

B). The hospital physical therapy department has two pools that are used by patients. For pool #1 The staff record the chlorine in parts per million(ppm) in the water with a recommended (by the pool supplier) range of 0.5 to 1.5 ppm. On 7 of 27 days of testing the chlorine was low (below 0.5 ppm) on 12 days and high (above 1.5 ppm) on 9 days. When chlorine was added on 20 days, the water was not retested to ensure that it was in the range for the chlorine.
The pool staff record the pH of the water (with a range of 7.4 to 7.8 on the pH scale of acid base balance). There were 6 days when the pH was out of range. On 3 days "pH down was added, " however the water was not retested for proper pH.
The pool staff also record the total alkalinity of the water, with the range of 80 to 120 ppm. On 22 of 27 days the alkalinity was too high over 120 ppm. There were no days when the alkalinity was too low. There was no documentation of any product added to lower the total alkalinity.

For pool #2 The staff record the chlorine in parts per million(ppm) in the water with a recommended (by the pool supplier) range of 0.5 to 1.5 ppm. On 7 of 28 days of testing the chlorine was low (below 0.5 ppm) on 14 days and high (above 1.5 ppm) on 9 days. When chlorine was added on 14 days, the water was not retested to ensure that it was in the range for the chlorine.
The pool staff record the pH of the water (with a range of 7.4 to 7.8 on the pH scale of acid base balance). There were 5 days when the pH was out of range. On four days "pH down was added, " however the water was not retested for proper pH.
The pool staff also record the total alkalinity of the water, with the range of 80 to 120 ppm. On 14 of 28 days the alkalinity was too high over 120 ppm and was not recorded on one day. There were no days when the alkalinity was too low. On one day a product "alkalinity increase was added", however, the water was not retested.

2.
A review of the hospital infection control committee meeting, dated May 25, 2010 revealed that the physical therapy department and the dietary department had not attended as evidenced by no signature from the director of the physical therapy or dietary department found on the sign in sheet for this meeting. Additionally a review of the infection control committee meeting minutes signature sheets for the last four meetings of the infection control committee revealed no signature or signature block for the physical therapy or the dietary department. In interview with the facility infection nurse on 10/13/2010 the surveyors were told that the physical therapy and dietary departments are not usually in attendance at these meetings. In the same interview the surveyors were told that by the infection control nurse that she was unaware of the physical therapy department ' s monthly infection control checklist. In addition she has not reviewed the dietary department for possible sources of infection.
In an interview with the Interim CEO and Director of Nursing on 10/11/2010 the above statements were confirmed.

Based on review of documentation and interview it was determined that the facility failed to ensure that the physical therapy department policy and procedure manual had been reviewed and complied with since a new Therapist was in charge .

Findings were:

The physical therapy department policy and procedure manual had not been reviewed since July, 2006. A review of the policy and procedure signature review sheet found in the front of the policy manual revealed that it had last been signed on 7-28-06. There is currently a new physical therapist in charge of this department.

An interview with the Director of Nursing and the Director of Physical Therapy on 10/12/2010 it was confirmed that the policy and procedure manual had not been reviewed or followed recently.

The hospital CEO failed to ensure that the QAPI process addressed identified problems and that the problematic areas were scheduled for improvement.

Findings were:

The number of delinquent medical records has been consistently reported for the years of 2009 an 2010. There has been no resolution to the identified problem of the delinquent records as of the date of the survey. At the current time there are 620 incomplete records. The QAPI process not attempted any resolution process, nor have the Medical Staff bylaws been enforced.
In an interview with the Interim CEO and Director of Nursing on 10/11/10 the above was confirmed.