Initial Comments:
This report is the result of an annual Registration survey conducted on March 2, 2012, at the Allentown Medical Services. It was determined that the facility was in compliance with the requirements of the Pennsylvania Department of Health Regulations 28 Pa Code, Chapter 29, Subchapter D, Ambulatory Gynecological Surgery in Hospitals and Clinics.
Safe and sanitary recommendations were provided to the facility in Tag 9999 - Recommendations. The facility is encouraged to provide a plan of correction.
Plan of Correction:
No POC Required STANDARD
Recommendation
Name - Component - 00
Observations:
Based on a tour of the facility on March 2, 2012, and interview with staff (EMP), it was determined that the Allentown Medical Services should address the following finding in order to ensure a safe and sanitary environment for its patients.
Findings include:
1) Review on March 2, 2012, of the facility's Patient Safety meeting minutes revealed the facility's last Patient Safety meeting was conducted in August 2011. The facility was unable to provide documentation that a Patient Safety meeting was conducted after August 2011.
Interview with EMP1 and phone interview with EMP2 on March 2, 2012, at approximately 9:00 AM confirmed the facility has not conducted a Patient Safety meeting since August 2011.
2) Review of the facility's Preventative Maintenance records revealed the facility's two suction machines last preventative maintenance check was completed on February 28, 2011.
Interview with EMP1 on March 2, 2012, at approximately 9:30 AM confirmed the facility's two suction machines did not have a current preventative maintenance check completed and the check should be completed yearly.
3) Review of the facility's Recovery room revealed an opened and partially used bottle of Ibuprofen (a non-narcotic pain medication) 800 milligrams (mg) on the top of the patient beverage refrigerator. Further review of the recovery room revealed an unlocked and unsecured cabinet containing the following opened and partially used bottles of: Tylenol (a non-narcotic pain medication) 325 mg; Ibuprofen 800 mg; Doxycycline (an antibiotic) 200 mg; Amoxicillin 500 mg; and Erythromycin 250 mg.
Interview with EMP1 on March 2, 2012, at approximately 9:45 AM confirmed the opened and partially used bottle of Ibuprofen 800 mg on the top of the patient beverage refrigerator; the unlocked and unsecured cabinet containing opened and partially used bottles of: Tylenol 325 mg; Ibuprofen 800 mg; Doxycycline 200 mg; Amoxicillin 500 mg; and Erythromycin 250 mg.
4) Review on March 2, 2012, of the facility's "Consent For Conscious Sedation" form, no review date revealed "... I acknowledged that I have been warned not to drive a motor vehicle for six hours after the abortion procedure. ..."
Review on March 2, 2012, of MR4, MR5, MR10, MR12, MR14, MR15, MR16, MR17, MR18 and MR19 revealed these patients received conscious sedation. Further review of these medical records revealed no documentation these patients did not drive a motor vehicle when leaving the facility following the abortion procedure.
Interview with EMP1 on March 2, 2012, at approximately 11:30 AM confirmed these medical records revealed no documentation these patients did not drive a motor vehicle when leaving the facility following the abortion procedure. Further interview with EMP1 confirmed these patients may have left following the abortion procedure and drove home on their own.
5) Review on March 2, 2012, revealed MR4, MR5 and MR16 had splatters of dried brown red stains on the patient procedure notes.
Interview with EMP1 on March 2, 2012, at approximately 10:15 AM confirmed the splatter of dried brown red stains on these patient's procedure notes. Further interview with EMP1 revealed the splatter stains were dried blood stains.
6) Observation of the hallway space located outside the procedure rooms and the recovery room revealed a sink and countertop. There was a physician prescription pad containing blank prescription sheets. The prescription pad was in full view on the counter top.
Interview with EMP1 on March 2, 2012, at approximately 10:00 AM confirmed the prescription pad was not in a secure location.
This is a repeated Recommendation finding from September 21, 2011.
Plan of Correction:POC is optional and not required.
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