HospitalInspections.org

Based on medical record review, the hospital failed to ensure that evidence existed to show that Medicare patients received a copy of the standardized notice "An Important Message from Medicare" upon or within two (2) days of admission for 5 of 7 Medicare patients reviewed for patient rights (P1-P5).

Failure to ensure that patients receive their rights, as required, places these patients at risk of harm related to a discharge that may be accomplished prior to the patient being ready for discharge.

Findings:

1. Per review of Patient #3's medical record, the patient was admitted with medicare benefits on 3/6/2010. The record did not contain the notice titled "An Important Message from Medicare", as of 3/23/201.

2. Per review of Patient #4's medical record, the patient was admitted with medicare benefits on 2/13/2010. The record did not contain the notice titled "An Important Message from Medicare", as of 3/23/201.

3. Per review of Patient #5's medical record, the patient was admitted with medicare benefits on 3/16/2010. The record did not contain the notice titled "An Important Message from Medicare", as of 3/23/201.

4. Per review of Patient #1's medical record, the patient was admitted with medicare benefits on 2/6/2010. The record contained the notice titled "An Important Message from Medicare", but this was not signed until 3/4/2010 (26 days later).

5. Per review of Patient #2's medical record, the patient was admitted with medicare benefits on 3/11/2010. The record contained the notice titled "An Important Message from Medicare", but this was not signed until 3/22/2010 (11 days later).

Based on observations and review of provided documentation, the hospital failed to ensure that code carts, more specifically, cardiac defibrillators on the carts were checked on a daily basis per facility policy.

Failure to ensure that emergency equipment is properly checked to ensure it is functioning places patients at risk of harm should the equipment be needed and/or it is not working properly.

Reference: Policy and Procedure "Use and Care of Emergency Cart", #NS 0340, last revised 11/06, states in part V, "Emergency carts will be checked once daily... Functional defibrillator (while unplugged)". Per review of the defibrillator's user manual, it states on page 7-4, that the machine will print out the test results after each user test.

Findings include:

1. On 3/22/2010 while checking the emergency cart located near the south Nurse's Station, the surveyor reviewed the "Crash Cart Checklist" log sheets. Documentation showed that the log had not been completed on 3/17-18/2010. The log showed that checks had been completed daily from the 1st to the 22nd of the month, otherwise. Per review of the defibrillator, a paper print-out was noted showing that checks were done on 3/11/2010 at 9:30 AM; and not until 3/16/2010 at 2:53 PM; then not till 3/19-20/2010, which was the last print-out as of 3/22/2010. By inference, it is assumed that the emergency defibrillator was not checked, per policy, on the missing dates.

2. On 3/22/2010 while checking the emergency cart located near the north Nurse's Station, the surveyor reviewed the "Crash Cart Checklist" log sheets. Documentation showed that the log had not been completed on 3/17/2010 and 3/21/2010. The log showed that checks had been completed daily from the 1st to the 20th of the month, but not the 21st, otherwise. Per review of the defibrillator, a paper print-out was noted showing that checks were done on 3/11/2010 at 9:17 AM; and not until 3/16/2010 at 2:52 PM; then not till 3/19-20/2010, which was the last print-out as of 3/22/2010. By inference, it is assumed that the emergency defibrillator was not checked, per policy, on the missing dates.

Based on medical record review, the hospital failed to ensure that patients were restrained only when less restrictive interventions have been determined to be ineffective to protect the patient from harm for 1 of 3 records reviewed for restraints (P6).

Failure to ensure that less restrictive interventions are documented, as required, places patients at risk of being restrained when other interventions may have prevented the use of restraint.

Findings:

1. Per record review, Patient #6 was admitted on 1/6/2010. The record showed the patient to have been on a mechanical ventilator and physically restrained. A review of the "Nursing Daily Flowsheet/ Treatment/ Intervention" form dated 1/12-17/2010 showed documentation of "Lesser Restrictive Alternatives Tried"(LRA) to only be "R" (reality orientation) and "R/O" (physiologic comfort measures). The number of possible LRA's on the form was nine (9), but these two were the only ones ever documented on the form. There was no documentation that any LRA was shown to be ineffective. There was no documentation that any of the other listed LRA's were determined by staff to be ineffective to protect the patient, prior to the introduction of more restrictive measures.

Based on medical record review, the hospital failed to ensure that patients were restrained only in accordance with the order of a physician or other licensed independent practitioner for 3 of 3 records reviewed for restraints (P6-P8).

Failure to ensure that patients are not restrained with a proper physician order places these patients at risk of harm related to the potential that the physician had not ordered this intervention.

Findings:

1. Per record review, Patient #6 was admitted on 1/6/2010. The record showed the patient to have been on a mechanical ventilator and physically restrained. A review of the "Nursing Daily Flowsheet/ Treatment/ Intervention" form dated 1/13-17/2010 showed documentation that the patient was in restraints continuously until noon on 3/16/2010. The documentation shows that restraints were "off" from noon until 5:00 PM. At that time, the restraints were re-applied.
There was no documentation of any problems with patient behavior requiring the use of restraints during this time period. A review of physician orders did not show evidence of a new order to restrain the patient at 5:00 PM.
The above noted process was seen again on 3/17/2010 when the form documented that the patient was without restraints from 7:00 AM until 5:00 PM. At this time, restraints were re-applied without documentation of any problem behavior requiring the use of restraints. A review of physician orders did not show evidence of a new order to restrain the patient at 5:00 PM.

2. Per record review, Patient #8 was admitted on 3/3/2010. The record showed the patient to have been on a mechanical ventilator and physically restrained. A review of the "Nursing Daily Flowsheet/ Treatment/ Intervention" form dated 3/17/2010 showed documentation that the patient was in restraints. The physician order, signed by the licensed nurse on 3/17/2010, was timed at 7:00 AM. The physician signed the order at 11:00 AM on 3/18/2010 (a day later). Thus, the patient was restrained, without an order, for more than 24 hours.

3. Per record review, Patient #7 was admitted on 3/3/2010. The record showed the patient to have been on a mechanical ventilator and physically restrained. A review of the "Nursing Daily Flowsheet/ Treatment/ Intervention" form dated 3/5/2010 showed documentation that the patient was in restraints. The physician order, signed by the licensed nurse on 3/5/2010, was timed at 11:30 AM. The physician signed the order at 12:00 PM on 3/15/2010 (10 days later).

Based on medical record review, the hospital failed to ensure that patients were restrained only as long as necessary for 1 of 3 records reviewed for restraints (P6).

Failure to ensure that restraints are only used when the patient the behaviors, that initially required the use of restraint, places patients at risk of being restrained when the behaviors have ceased.

Findings:

1. Per record review, Patient #6 was admitted on 1/6/2010. The record showed the patient to have been on a mechanical ventilator and physically restrained. A review of physician orders showed the patient was restrained because of an inability "to comply with specific requests", and an inability "to refrain from activity that may dislodge lines, drains, and/or tubes necessary for treatment". A review of the "Nursing Daily Flowsheet/ Treatment/ Intervention" form dated 1/13-17/2010 showed documentation that the justification for keeping the patient in restraints was "Avoid displacement of invasive lines, drains, tubes". The flowsheet did not contain evidence that the patient was actually displaying behaviors that would lead to the documented reason to keep the patient in restraints.

Based on medical record review, administrative staff interview, and review of policy and procedure, hospital pharmacy services failed to ensure that physician orders for drugs/medications were obtained prior to the patients receiving these drugs/medications for 2 of 2 records reviewed (P1, P4).

Failure to ensure that drugs/medications are administered only with a physician order places all patients at risk of harm related to the administration of drugs/medications that were not specifically ordered by a physician.

Findings:

1. Per record review, Patient #1 was admitted on 2/6/2010. The record contained a form titled "Physician Standing Orders For Serum Potassium Replacement", last revised 11/06. This form documents patient blood laboratory values and allows licensed staff to make decisions about how much and in what manner replacement potassium is given to the patient. Patient #1 had this form signed by a licensed nurse on 3/15/2010 at 12:55 PM and another form on 3/7/2010 at 1:00 PM. The patient was given the medication prior to the physician signing the form at 4:00 PM and 2:00 PM, respectively. There was also no indication that a verbal/telephone order had been received to administer the medication.
Per interview with the Charge Nurse on 3/23/2010 at 10:10 AM, this form was a "standing order" that did not require a physician to sign it, prior to implementing the interventions. However, the hospital could provide no documentation that medical staff had approved the administration of potassium without a physician order. Per review of the hospital policy and procedure titled "Potassium Replacement Protocol" # NS 0622, last revised 11/06, it states in paragraph 4, "Sign off standing order sheet, i.e. noted by, date and time. Place a red "sign here" flag for physician on order sheet".
Thus, the record contained no order to administer the medication, prior to the licensed nurse administering the medication.

2. Per record review, Patient #4 was admitted on 2/13/2010. The record contained a form titled "Physician Standing Orders For Serum Potassium Replacement", last revised 11/06. Patient #4 had this form signed by a licensed nurse on 3/13/2010 at 11:00 AM. The patient was given the medication on a four hour, two dose schedule. There was also no indication that a verbal/telephone order had been received to administer the medication, and the physician signed the form the following day at an unknown time.
The above process was repeated on 3/22/2010 at 3:45 PM. A copy of the order form was made on 3/23/2010 at 9:30 AM that showed the physician had yet to sign the order form even though the medication had already been given to the patient.

Based on medical record review and review of policy and procedure, the hospital failed to ensure that blood administration documentation was complete for 6 of 6 records reviewed for blood administration (P1, P7, P8, P12-P14).

Failure to ensure that policy and procedure is followed places patients at risk of harm related to the administration of blood and blood components.

Reference: Per policy and procedure titled "Administering Blood and Blood Components" # IV 0020, last revised 4/09, it states under paragraph B. (2), "At the patient's bedside, check the following with the Transfusion Compatibility report and sign the compatibility report...".; under paragraph C.(5)(b) it states, " Document tolerance to transfusion... and vital signs (BP[blood pressure], TPR[temperature, pulse, respiration]) at initiation of transfusion, in 15 minutes, then every 30-60 minutes, and at the end of transfusion. document on Blood and blood components sheet...".

Findings:

1. Per record review, Patient #12 was given thawed fresh frozen plasma on 3/22/2010 at 2:35 AM. The vital sign documentation started at 2:35 AM. The "fifteen minute" set did not include a temperature. The vital sign documentation at 3:15 AM did not include a temperature. The blood components were stopped at 3:40 AM without a set of vital signs at the end of the transfusion.
An additional unit of red blood cells was administered on 3/4/2010 at 2:00 PM. The time the transfusion was completed was not on the form.

2. Per record review, Patient #1 was given red blood cells on 2/7/2010 at 12:05 AM. The vital sign documentation started at 12:05 AM. The "fifteen minute" set was not recorded until 12:40 AM (20 minutes late).

3. Per record review, Patient #7 was given red blood cells on 3/15/2010 at 4:00 PM. The vital sign documentation started at 4:00 PM. The "fifteen minute" set was not recorded until 4:30 PM (15 minutes late). Additional vital signs were taken at 5:00 PM and then not until 7:00 PM (60 minutes late).
The patient was given red blood cells on 3/15/2010 at 8:10 PM. The vital sign documentation started at 8:10 PM. The "fifteen minute" set was not recorded until 8:30 PM (5 minutes late). Additional vital signs were taken at 9:30 PM and then not until 11:00 PM (30 minutes late).
The patient was also given red blood cells on 3/17/2010 at 10:20 PM. The vital sign documentation started at 10:22 PM. The "fifteen minute" set was not recorded until 10:45 PM (8 minutes late). Additional red blood cells were given on 3/18/2010 at 12:55 AM. The vital sign documentation started at 12:56 AM. The "fifteen minute" set was not recorded until 1:15 AM (4 minutes late).

4. Per record review, Patient #8 was given red blood cells on 3/19/2010 at 7:00 PM. The vital sign documentation started at 7:00 PM. The "fifteen minute" set was not recorded until 7:45 PM (30 minutes late).

5. Per record review, Patient #13 was given red blood cells on 3/21/2010 at 2:15 PM. The "Transfusion Report" form did not contain a signature, date or time for the verifying licensed nurse who started the transfusion.

6. Per record review, Patient #14 was given red blood cells on 3/1/2010 at 10:45 PM. The "Transfusion Report" form did not contain a signature, date or time for the verifying licensed nurse who started the transfusion. The time of the second verifying licensed nurse was also not present on the form.
The patient's blood was started at 10:45 PM. The "fifteen minute" set was not recorded until 11:15 PM (15 minutes late). An additional unit was given on 2/18/2010 and the vital sign documentation started at 9:55 PM. The "fifteen minute" set was not recorded until 10:20 PM (10 minutes late).

Based on medical record review, the hospital failed to ensure that medical records were complete within 30 days of discharge for 3 of 3 records reviewed for discharge summaries (P9-P11).

Failure to ensure that medical records are completed places patients at risk of harm related to the potential need for discharge information from another provider that would not be in the medical record in a timely manner.

Findings:

1. Per record review, Patient #9 was discharged on 2/2/2009. The Discharge Summary was dictated on 3/23/2010 (more than 12 months late).

2. Per record review, Patient #10 was discharged on 7/14/2009. The Discharge Summary was dictated on 3/23/2010 (more than 7 months late).

3. Per record review, Patient #11 was discharged on 5/27/2009. The Discharge Summary was dictated on 1/8/2010 (more than 6 months late).

Based on medical record review and review of provided documents, the hospital failed to ensure that the medical record was completed for 4 of 6 records reviewed for blood administration (P7, P12, P14, P15).

Failure to have reports, orders, notes, etc. properly completed and placed in the record places patients at risk of receiving or not receiving care and services because of potential errors in dictation.

Findings:

1. Per record review, Patient #12 had "Transfusion Report" forms, for blood components, on 3/11/2010 at 4:20 PM and 10:10 PM. The signature blocks for both these forms had the same handwriting for the time of the signatures in both blocks even though different people signed their names. This process was also noted on the 7:30 PM form. The 11:40 PM form showed that the "date" portion had the same handwriting in both blocks.
The record had a "Transfusion Report" form on 3/18/2010 showed the signature blocks for the 1:45 AM unit had the same handwriting for the time of the signatures in both blocks even though different people signed their names. This process was also noted on the 5:15 AM form. The 11:40 PM form showed that the "date" portion had the same handwriting in both blocks.
The record had "Transfusion Report" forms on 3/21/2010 at 6:55 PM, 7:30 PM, and 11:40 PM. The signature blocks for the 6:55 PM unit had the same handwriting for the time of the signatures in both blocks even though different people signed their names. This process was also noted on the 7:30 PM form. The 11:40 PM form showed that the "date" portion had the same handwriting in both blocks.
The "Transfusion Report" form on 3/22/2010 at 2:35 AM showed both the "date and time" handwriting to be the same even though different people signed their names.

2. Per record review, Patient #7 was given red blood cells on 3/18/2010 at 12:55 AM. The "Transfusion Report" form on 3/18/2010 at 12:55 AM showed both the "date and time" handwriting to be the same even though different people signed their names.

3. Per record review, Patient #14 was given red blood cells on 3/1/2010 at 10:45 PM. The "Transfusion Report" form showed the "time" portion to be the same handwriting even though different people signed their names.

4. Per record review, Patient #15 was given red blood cells on 2/4/2010 at 9:45 AM. The "Transfusion Report" form showed the "time" portion to be the same handwriting even though different people signed their names. An additional unit was given on 2/16/2010 at 12:05 AM. The "Transfusion Report" form showed the "time" portion to be the same handwriting even though different people signed their names.

Based on medical record review, the hospital failed to ensure that the records contained the actual date and time when staff authenticated their telephone/verbal patient care orders for 4 of 4 records reviewed for signature authentication (P1, P4, P7, P8).

Failure to ensure that medical record documentation shows an authentication of verbal/telephone orders places all patients at risk of receiving or not receiving care as specified by the physician due to an inaccurately transcribed order.

Findings:

1. Per review of Patient #7's medical record, the patient was admitted on 3/3/2010. Per review of the Physician Orders form dated 3/3/2010, a telephone order was noted at 7:50 PM. This order had been authenticated by the physician on 3/3/2010 at 7:00 PM. Administrative staff could not provide rationale why the order was authenticated fifty (50) minutes before it was called in to staff.
Additional telephone orders were noted on 3/9/2010 at 5:00; 3/12/2010 at 3:20 PM; 3/15/2010 at 11:50 AM; and 3/18/2010 at 10:20 PM. None of these four (4) orders had been authenticated, in any manner, as of 3/23/2010.

2. Per review of Patient #1's medical record, the patient was admitted on 2/6/2010. Per review of the Physician Orders form dated 3/9/2010, telephone orders were noted at 7:20 AM, 9:00 AM and on 3/11/2010 at 9:35 AM. None of these three orders had been authenticated, in any manner, as of 3/23/2010.
Additional telephone orders were noted on 3/9/2010 at 2:55 PM and 3/12/2010 at 6:30 PM. The physician authenticated these orders by signature only, there was no date or time the authentication had been done, so determination of compliance could not be accomplished.

3. Per review of Patient #4's medical record, the patient was admitted on 2/13/2010. Per review of the Physician Orders form dated 3/11/2010, a telephone order had been added to the chart at 3:05 PM. The physician authenticated this order by signature only, there was no date or time the authentication had been done, so determination of compliance could not be accomplished. Additional telephone orders were noted on 3/16/2010 at 9:40 AM and 3/17/2010 at 12:30 AM. Neither of these two orders had been authenticated, in any manner, as of 3/23/2010.

4. Per review of Patient #8's medical record, the patient was admitted on 3/3/2010. Per review of the Physician Orders form dated 3/17/2010, telephone orders were noted at 3:00 PM and 5:00 PM. Neither of these orders had been authenticated, in any manner, as of 3/23/2010.

Based on medical record review, the hospital failed to ensure that properly executed informed consent forms for treatment were completed for 1 of 7 records reviewed for informed consent (P1).

Failure to ensure that informed consent is documented in the record places patients at risk of harm related to receiving care and services that may not be what the patient desires.

Reference: Per policy and procedure # 8560.C.13 titled "Consent to Medical Care" last revised May 2009, it states: in paragraph 8 "... If patient is unable to sign, admitting representative will check off box with yes or no minor and why patient is incapable to signing".

Findings:

Per record review, Patient #1 was admitted on 2/6/2010. The record contained a "Consent For Care" form that was signed on 3/4/2010 (26 days after admission). There was no documentation in the record that informed consent had been attempted and/or why the hospital was unable to secure proper consent until the form was signed on 3/4/2010.

Based on observations, the director of food and dietary services failed to ensure that food items and nutritional supplements were not maintained for immediate patient access after their manufacturer's listed expiration dates.

Failure to ensure that dietary supplements are maintained in a manner to not allow expired products to be immediately available for patient use places all patients at risk of harm related to the possibility of ingesting an unsafe or ineffective dietary supplement.

Findings:

During observational rounds in the clean utility room (North) the following items were noted in cupboards: a) eight (8) packages of "Resource Breeze" dietary supplement with an expiration date of 26 Aug 2009; b) "Instant Breakfast" in a can that was expired on 1 Feb 2009 and another expired on 9 Apr 2009; c) "Ensure Plus" in a can that was expired on 1 Nov 2009 and another expired on 1 Mar 2010; and d) five (5) plastic containers of "Jevity 1.2 Cal" liquid nutritional supplement with an expiration date of February 2010.

Based on observation and interview of hospital staff the hospital failed to install and maintain Alcohol Based Hand Rub dispensers in the health care facility in accordance with the provisions of the 2000 edition of the Life Safety Code chapter 19.3.2.7 as amended by the NFPA Temporary Interim Amendment 00-1 (101).

Findings included:

Refer to deficiency written in the FIRE AND LIFE SAFETY MEDICARE VALIDATION SURVEY report dated 3/24/2010

Tag, K211, 2000 Existing, Where Alcohol Based Hand Rubs (ABHR) are installed:
The dispensers shall have a minimum spacing of 4 ft from each other.

On 3/23/2010 the surveyor found that the ABHR(s) on the second floor west wing were from 3 to 3.5 feet from each other in the hallway outside the patient rooms.

Based on observation and interview with hospital staff the hospital failed to maintain oxygen equipment to ensure an acceptable level of safety.

Failure to properly secure oxygen cylinders places the patient at risk for injury from falling and damaged oxygen cylinders that can become a missile.

Findings include:

On 3/24/2010 the surveyor observed in the radiology department a single oxygen cylinder standing upright on a shelf next to the x-ray exam table and the oxygen cylinder was not in a holder or secured.

This was confirmed during an interview by the surveyor with S2. The single oxygen cylinder was immediately removed from the room by S2 and was properly secured during the survey on 3/24/2010.