Survey faults CCGH record-keeping Drugs also found in unlocked area

July 01, 1993|By Donna E. Boller | Donna E. Boller,Staff Writer

The state survey team that sampled patients' medical records at Carroll County General Hospital faulted the hospital's record-keeping in four main areas: the psychiatric unit, surgery, nursing care and anesthesia.

The team also found drugs on a counter in the medication room of a minor surgery suite. Hospitals are required to keep drugs locked in storage.

Hospital officials said the drugs were not narcotics or other medicines that might be attractive to thieves.

The drugs included a sedative, and antibiotic, ulcer and anti-inflammatory drugs. The medicines had been delivered by the hospital pharmacy, but the nurse had not yet had time to put them away, the report indicated.

Other deficiencies included:

* Psychiatric unit. Surveyors checked 10 records and found that all 10 reported that patients had received art therapy, a therapy the hospital does not offer. [See article, 1B.]

Three records had discharge summaries that said the patients had been under treatment plans but didn't include the plans. A treatment plan details what is to be done for the patient while he or she is hospitalized.

Tricia Supik, the hospital's director of medical, surgical and psychiatric nursing, said all psychiatric patients receive discharge summaries that show plans for post-hospital care, social services or housing, depending on needs.

She said the survey team looked at the discharge summary but didn't see what the hospital staff called an "after-care treatment plan."

* Surgery. The team found seven closed surgical case records that had incomplete health histories or physical examination reports.

Joan M. Spear, director of perioperative services and maternal-child health, said one of these was a patient who had a colonoscopy as an outpatient and later was admitted to the hospital.

The record failed to note that he didn't need a rectal exam because of the recent colonoscopy.

* Nursing care. The survey team reported seven records that contained incomplete nursing care plans, three that weren't updated to reflect changes in treatment and four without nursing care plans.

Linda Harder, CCGH's vice president for marketing, said that records the survey team listed as incomplete may not have had the information on the page or in the format that the HCFA required.

* Anesthesia. The team found that seven of 10 records examined didn't show that patients had been checked for drug and allergy histories before they received anesthetics.

None of the 10 reports showed all of the observations required during surgery, and six didn't indicate when the patient regained consciousness.

Ms. Spear said that the hospital reported the total amount of fluid given during surgery, but HCFA wanted a breakdown of how much and how often.

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