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Based on observation, interview, and record review, the hospital failed to protect one of 20 sampled patients' (14) confidential health information. This had the potential to deprive the right to maintain privacy and data integrity.

Findings:

During an observation on 9/15/15 at 10:15 AM, by the hallway in front of Patient 14's room, a portable printer labeled "QL 220 Plus" was on top of a cart unattended. Laboratory Technician (LT) 1 was inside Patient 14's room when a label for Patient 14 was printed. The printer (remotely controlled to print labels) had a printed label exposed with the name, date of birth, location and type of laboratory test for Patient 14.

During an interview with Registered Nurse (RN) 1, on 9/17/15, at 10:20 AM, she stated the LT should have printed the label for Patient 14 when he was in front of the cart. RN 1 also stated the LT should have kept the printer inside the cart when he was inside the patient's room.

The hospital policy and procedure titled "Safeguarding PHI (personal health information) and Sensitive Information" dated 1/12/15, read in part "...Users of portable computers and portable media shall implement safeguards required by the Portable Media Usage policy #110.2.015...PROCEDURE FOR ALL FACILITIES: B. In non-Restricted areas where Sensitive Information is maintained and access is not controlled, or other wise restricted, business unit or department managers shall implement the following safeguard: 3. Locate printers and fax machines in secure or supervised areas..."

Based on interview and record review, the hospital failed to ensure care plans were initiated for two of 20 sampled patients (6 and 7). This failure had the potential to result in unmet discharge care needs.

Findings:

During a review of the clinical record for Patient 6, on 9/16/15, the "Multidisciplinary Care Plan (MCP)" indicated there was no care plan initiated for Discharge Planning. Patient 6 was admitted on 9/15/15.

During a review of the clinical record for Patient 7, on 9/16/15 at 4:40 PM, the MCP for Patient 7 indicated there was no care plan initiated for Discharge Planning. Patient 7 was admitted on 9/14/15.

During an interview with the Director of Case Management, on 9/17/15, at 10:30 AM, she reviewed the clinical record for Patient 6 and 7 and verified there was no care plan initiated for Patient 6 and 7. She also stated the Case Manager should have initiated a care plan on Discharge Planning for both patients.

The hospital policy and procedure titled "MULTIDISCIPLINARY PATIENT CARE PLAN - ACUTE CARE" dated 3/2015, read in part "...A multidisciplinary plan of care will be utilized for each patient from admission to discharge. The MCP shall be initiated upon admission and updated/reviewed at a minimum daily except in the NICU where the MCP updated/reviewed every shift. The MCP will address patient problems identified on the Patient Admission Database (PAD)..."

Based on record review and interview, the hospital failed to follow its policy and procedure to have verbal orders authenticated within 48 hours for four of 20 sampled patients (5, 7, 14, and 16). This failure had the potential to delay or cause inappropriate treatment.

Findings:

1. During a review of the clinical record for Patient 14 with Registered Nurse (RN) 1 , on 9/16/15 at 3:05 PM, the "Physician Orders" form had the following verbal orders taken:

9/9/15 at 1130 (11:30 AM) - Only treat SBP (systolic blood pressure) > 180, NS (normal saline) 250 cc (cubic centimeters) bolus, change IV (intravenous) to D5 1/2 NS @ 75 cc hour, Hold MRI (magnetic resonance imaging, radio waves to make pictures) for now, 9/9/15 at 1130 (11:30 AM) - Hold Isosorbide (medication to prevent chest pain) for now, 9/9/15 at 1347 (1:47 PM) - NS bolus 250 cc IV now. Follow with Lasix 40 mg (milligram) IVP (intravenous push) x 1, 9/9/15 at 1900 (7 PM) - Restart OG [orogastic tube (a tube inserted from mouth to stomach) in mouth] feeding as ordered, and 9/12/15 at 1030 (10:30 AM) - D/C NS IV @ 125/hr (hour).

RN 1 verified the verbal orders had not been authenticated by the ordering physician for seven days.

2. During a review of the clinical record for Patient 16 with RN 1, on 9/16/15 at 4 PM, the "Physician Orders" form had the following verbal orders taken:

9/10/15 at 0948 (9:48 AM) - Obtain consent for exploratory laparotomy (explore organs in abdomen) lysis of adhesions (separating adhesions) and possible bowel resection (surgical removal of intestine); and,

9/10/15 at 2125 (9:25 PM) - IV Drips Critical Care, Fentanyl (treat pain) 10 mcg (microgram) per ml (milliliter), Midazolam (used for sedation) 1 mg per ml.

RN 1 verified the verbal orders had not been authenticated by the ordering physician for six days.



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3. During a review of the clinical record for Patient 5, on 9/16/15 at 4:05 PM, the "Physician Orders" record had the following verbal orders written:

9/11/15 at 10 PM- DC (discontinue) Morphine (drug for moderate to severe pain),
Dilaudid (drug for moderate to severe pain) one mg (milligram) IV (intravenous) every four hours PRN (as necessary), Stop Colace (stool softener), Stool for C. Diff (Clostridium Difficile - hospital acquired infection causing diarrhea), Flagyl (anti-infective) 500 mg P.O. (by mouth) every eight hours.
9/13/15 at 7:45 PM - Morphine 2 mg IVP (intra venous push) every four hours for pain as needed.

There was no documented evidence the verbal orders for Patient 5 were authenticated by the physician since the dates they were ordered.

4. During a review of the clinical record for Patient 7, on 9/16/15 at 4:20 PM, the "Physician Orders" record had the following verbal orders written:

9/13/15 at 12:43 PM - UA (urine analysis- urine test), CXR (chest roentgen ray-radiographic images for diagnostic purposes), EKG (electrocardiogram-records the electric activity generated by the heart muscle).

There was no documented evidence these verbal orders for Patient 7 had been authenticated by the physician.

During an interview with RN 1, on 9/16/15 at 4:35 PM, she reviewed the clinical records and verified the physician had not authenticated the verbal orders for both Patients 5 and 7. RN 1 gave no further information.

The Medical Staff Rules and Regulations, dated 7/24/13, indicated: "Telephone orders must be authenticated (countersigned) by the practitioner giving the order. This authentication must occur within 48 hours."

The hospital policy and procedure titled "Accepting Written, Verbal, and Telephone Physician Orders", dated 2/26/14, read, under Procedures 5.h. "Telephone and verbal orders will be dated and authenticated within 48 hours by the ordering practitioner or another practitioner who is responsible for the care of the patient."

Based on record review and interview, the hospital failed to follow its policy and procedure to have verbal orders authenticated within 48 hours for four of 20 sampled patients (5, 7, 14, and 16). This failure had the potential to delay or cause inappropriate treatment.

Findings:

1. During a review of the clinical record for Patient 14 with Registered Nurse (RN) 1 , on 9/16/15 at 3:05 PM, the "Physician Orders" form had the following verbal orders taken:

9/9/15 at 1130 (11:30 AM) - Only treat SBP (systolic blood pressure) > 180, NS (normal saline) 250 cc (cubic centimeters) bolus, change IV (intravenous) to D5 1/2 NS @ 75 cc hour, Hold MRI (magnetic resonance imaging, radio waves to make pictures) for now, 9/9/15 at 1130 (11:30 AM) - Hold Isosorbide (medication to prevent chest pain) for now, 9/9/15 at 1347 (1:47 PM) - NS bolus 250 cc IV now. Follow with Lasix 40 mg (milligram) IVP (intravenous push) x 1, 9/9/15 at 1900 (7 PM) - Restart OG [orogastic tube (a tube inserted from mouth to stomach) in mouth] feeding as ordered, and 9/12/15 at 1030 (10:30 AM) - D/C NS IV @ 125/hr (hour).

RN 1 verified the verbal orders had not been authenticated by the ordering physician for seven days.

2. During a review of the clinical record for Patient 16 with RN 1, on 9/16/15 at 4 PM, the "Physician Orders" form had the following verbal orders taken:

9/10/15 at 0948 (9:48 AM) - Obtain consent for exploratory laparotomy (explore organs in abdomen) lysis of adhesions (separating adhesions) and possible bowel resection (surgical removal of intestine); and,

9/10/15 at 2125 (9:25 PM) - IV Drips Critical Care, Fentanyl (treat pain) 10 mcg (microgram) per ml (milliliter), Midazolam (used for sedation) 1 mg per ml.

RN 1 verified the verbal orders had not been authenticated by the ordering physician for six days.



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3. During a review of the clinical record for Patient 5, on 9/16/15 at 4:05 PM, the "Physician Orders" record had the following verbal orders written:

9/11/15 at 10 PM- DC (discontinue) Morphine (drug for moderate to severe pain),
Dilaudid (drug for moderate to severe pain) one mg (milligram) IV (intravenous) every four hours PRN (as necessary), Stop Colace (stool softener), Stool for C. Diff (Clostridium Difficile - hospital acquired infection causing diarrhea), Flagyl (anti-infective) 500 mg P.O. (by mouth) every eight hours.
9/13/15 at 7:45 PM - Morphine 2 mg IVP (intra venous push) every four hours for pain as needed.

There was no documented evidence the verbal orders for Patient 5 were authenticated by the physician since the dates they were ordered.

4. During a review of the clinical record for Patient 7, on 9/16/15 at 4:20 PM, the "Physician Orders" record had the following verbal orders written:

9/13/15 at 12:43 PM - UA (urine analysis- urine test), CXR (chest roentgen ray-radiographic images for diagnostic purposes), EKG (electrocardiogram-records the electric activity generated by the heart muscle).

There was no documented evidence these verbal orders for Patient 7 had been authenticated by the physician.

During an interview with RN 1, on 9/16/15 at 4:35 PM, she reviewed the clinical records and verified the physician had not authenticated the verbal orders for both Patients 5 and 7. RN 1 gave no further information.

The Medical Staff Rules and Regulations, dated 7/24/13, indicated: "Telephone orders must be authenticated (countersigned) by the practitioner giving the order. This authentication must occur within 48 hours."

The hospital policy and procedure titled "Accepting Written, Verbal, and Telephone Physician Orders", dated 2/26/14, read, under Procedures 5.h. "Telephone and verbal orders will be dated and authenticated within 48 hours by the ordering practitioner or another practitioner who is responsible for the care of the patient."