HospitalInspections.org

Based on interview, record review and policy review, the hospital failed to:
- Follow their internal policy for the investigation of neglect and perform a timely and thorough investigation to accurately determine where neglect had occurred for two discharged patients (#26 and #27) of two records reviewed. The hospital failed to immediately remove one staff member (Staff V, Registered Nurse, [RN]) after allegations of neglect were reported for two discharged patient (#26 and #27) of two allegations of neglect reviewed; (C-2523)
- Follow their internal policy for staff to achieve and maintain job specific certifications for 37 certifications of 71 certifications reviewed; (C-2523)
- Follow their internal policy for medication reconciliation completion upon admission for 12 discharged patients (#7, #9, #12, #15, #16, #17, #18, #19, #20, #21, #22 and # 23) of 14 records reviewed; (C-2523)
- Follow their internal policy for checking crash carts (mobile cart which contains emergency medical supplies and medication) in three of three units observed; (C-2523)
- Ensure biohazard waste containers were secure in three of three units observed; (C-2523)
- Follow their internal policy for staff annual performance evaluation for four (Staff V, Z, AA and BB) of five personnel files reviewed; (C-2523)
- Follow their internal policy to assist patients in the formulation of an advanced directive (AD, a legal document where the patient can direct their medical care wishes should the patient become unable to make their own decisions) for three current patients (#1, #2 and #3) and six discharged patients (#8, #9, #14, #16, #17 and #18) of 11 records reviewed; (C-2515)
- Follow their internal policy for grievance follow up and response letters for two discharged patients (#29 and #30) of two grievances reviewed; and (C-2507)
- Follow their internal policy for the electronic signing of verbal/telephone orders within 24 hours for nine discharged patients (#8, #9, #10, #12, #16, #17, #18, #25 and #26) of 13 records reviewed. (C-2523)

These failed practices resulted in non-compliance with 42 CFR 485.614 Condition of Participation: Patient's Rights.

Based on interview, document review and policy review the hospital failed to follow their internal policy for grievance follow up and response letters for two discharged patients (#29 and #30) of two grievances reviewed.

Findings included:

Review of the hospital's policy titled, "Service Recovery for Patient Complaints and Grievances," dated 04/21/23, showed:
- The investigation proceeds via a chart review and staff and/or witness interviews as appropriate.
- The Grievance Coordinator will consult with the Grievance Committee as needed with the goal to complete investigation and submit a report so that the Chief Executive Officer (CEO) will have time to make the resolution decision and send the resolve letter within seven working days.
- In those cases where the grievance investigation may require extending time beyond seven working days, the CEO response will be issued as soon as able, not to exceed 30 days.

Review of the undated and untitled hospital document showed:
- On 02/14/24, Patient #29 verbalized a grievance. He stated he was misdiagnosed.
- On 03/05/24, a medical record peer review showed the clinical practice was expected and acceptable.
- On 03/20/24, Patient #29 was called after he left a message. He was upset about the time that had passed. He was informed of the investigation findings and was dissatisfied.
- On 03/27/24, an email from Staff F, CEO, showed she mailed Patient #29 a grievance letter 43 days after Patient #29 voiced his grievance to Staff K, Grievance Coordinator.

Review of the undated and untitled hospital document showed:
- On 11/01/23, Quality and Risk was contacted by Patient #30 and an insurance company to discuss readmission of the patient. The patient stated, "She was scared to come back to the facility."
- At 3:00 PM, Staff K, Grievance Coordinator, called and interviewed Patient #30. The patient stated she was "being roughed, she left the hospital too early; however, she was scared." The patient did not provide names of the alleged staff members.
- Statements of staff members that cared for Patient #30 were collected.
- A medical record review was completed.
- The abuse allegation was determined to be unsubstantiated.
- On 11/03/23, the hospital notified the Department of Health and Senior Services (DHSS) of the unsubstantiated abuse allegation.
- On 11/07/23, staff education on abuse, neglect, written statements, policies and procedures on neglect and abuse, patient lifting and reporting of patient care complaints was provided. The hospital reported to DHSS the education was provided.
- The attendance record for the education showed 23 of 55 staff members completed the education.
- No grievance response letter was mailed to Patient #30.

During an interview on 04/23/24 at 2:00 PM and 04/24/24 at 10:15 AM, Staff K, Grievance Coordinator, stated that:
- On 02/14/24, Patient #29 brought his grievance to her in person.
- There was no communication with Patient #29 between 02/14/24 and 03/20/24.
- On 03/27/24, Staff F, CEO, mailed the response letter to Patient #29.
- Prior to Patient #30's grievance, the hospital did not mail response letters. The hospital was not following their policy.
- Patient #30's abuse allegation was ruled unsubstantiated.
- No response letter was mailed to Patient #30.

Based on interview, record review and policy review the hospital failed to follow their internal policy to assist patients in the formulation of an advanced directive (AD, a legal document where the patient can direct their medical care wishes should the patient become unable to make their own decisions) for three current patients (#1, # 2 and #3) and six discharged patients (#8, #9, #14, #16, #17 and #18) of 11 records reviewed.

Findings included:

Review of the hospital's policy titled, "AD/Directive for Resuscitation (emergency life-saving procedure performed when a person's breathing or heartbeat has stopped)," dated 08/03/21, showed patients will be asked on admission if they have an AD. If the patient does not have an AD, Scotland County Hospital (SCH) will assist the patient in formulating an AD per the patient request.

Review of Patient #1's medical record showed she did not have an AD and was not offered assistance in formulating an AD.

Review of Patient #2's medical record showed he did not have an AD and was not offered assistance in formulating an AD.

Review of Patient #3's medical record showed he did not have an AD and was not offered assistance in formulating an AD.

Review of Patient #8's medical record showed he did not have an AD and was not offered assistance in formulating an AD.

Review of Patient #9's medical record showed she did not have an AD and was not offered assistance in formulating an AD.

Review of Patient #14's medical record showed he did not have an AD and was not offered assistance in formulating an AD.

Review of Patient #16's medical record showed he did not have an AD and was not offered assistance in formulating an AD.

Review of Patient #17's medical record showed she did not have an AD and was not offered assistance in formulating an AD.

Review of Patient #18's medical record showed she did not have an AD and was not offered assistance in formulating an AD.

During an interview on 04/22/24 at 2:15 PM, Staff H, Registered Nurse (RN), stated that she was unaware that staff were to ask patients if they wanted to write an AD.

During an interview on 04/22/24 at 2:10 PM, Patient #3, stated that he was not asked if he wanted to write an AD when he arrived at the hospital.

During an interview on 04/22/24 at 2:00 PM, Patient #2, stated that he was not asked if he wanted to write an AD when he arrived at the hospital.

During an interview on 04/25/24 at 9:50 AM, Staff S, Emergency Department (ED) Supervisor, stated that the ED staff did not request AD information. That was the responsibility of the admission department's staff.

During an interview on 04/25/24 at 4:35 PM, Staff F, Chief Executive Officer (CEO), stated that she expected nurses to ask patients if they wanted to write an AD. If the patient agreed, the nurse called health information management.

During an interview on 04/25/24 at 5:30 PM, Staff E, Chief Operating Officer (COO), stated that he was not aware the hospital was to help patients with writing an AD.

Based on interview, record review and policy review, the hospital failed to:
- Follow their internal policy for the investigation of neglect and perform a timely and thorough investigation to accurately determine where neglect had occurred for two discharged patients (#26 and #27) of two records reviewed. The hospital failed to immediately remove one staff member (Staff V, Registered Nurse, [RN]) after allegations of neglect were reported for two discharged patient (#26 and #27) of two allegations of neglect reviewed;
- Follow their internal policy for staff to achieve and maintain job specific certifications for 37 certifications of 71 certifications reviewed;
- Follow their internal policy for medication reconciliation completion upon admission for 12 discharged patients (#7, #9, #12, #15, #16, #17, #18, #19, #20, #21, #22 and # 23) of 14 records reviewed;
- Follow their internal policy for checking crash carts (mobile cart which contains emergency medical supplies and medication) in three of three units observed;
- Ensure biohazard waste containers were secure in three of three units observed;
- Follow their internal policy for staff annual performance evaluation for four (Staff V, Z, AA and BB) of five personnel files reviewed; and
- Follow their internal policy for the electronic signing of verbal/telephone orders within 24 hours for nine discharged patients (#8, #9, #10, #12, #16, #17, #18, #25 and #26) of 13 records reviewed.

Findings included:

1.Review of the hospital's policy titled, "Abuse-Child, Domestic, Elder, Vulnerable Patient," dated 10/16/23, showed:
- All allegations of neglect will be investigated thoroughly and immediately once the allegation has been made.
- The investigation will include interviews of all persons involved.
- The caregiver will be removed from caring for the patient and an alternate caregiver will be assigned.
- Contact the house supervisor immediately. The house supervisor must contact the Chief Nursing Officer (CNO) immediately.
- Incidents of neglect will be reported and analyzed with appropriate corrective, remedial, or disciplinary actions taken in accordance with applicable local, state or federal law.
- Reports of suspected neglect shall be made to senior leadership over the specific department or the risk manager immediately.
- The caregiver affected by the allegation will be placed on administrative leave during the investigation.
- If the allegations are substantiated the employee will be terminated and the appropriate agencies will be notified.

Review of the hospital's untitled document dated 04/16/24, showed:
- Staff Q, Certified Nurse Assistant (CNA), notified Staff V, RN, two to three times that "something was not right'" with Patient #26.
- Staff Q later entered Patient #26's room and her oxygen saturations (measure of how much oxygen is in the blood. Normal is between 95% and 100%. Lung disease normal oxygen saturation level may be lower) were "60 percent" and the patient was "almost purple."
- Staff Q called Staff V to the room and Staff V "frantically" applied oxygen at 15 liters per minute (lpm) per non-rebreather mask (a face mask to deliver oxygen).
- Another nurse called the provider and requested an assessment.
- Patient #26 "continued to go downhill."
- "Staff V went outside, another nurse called the provider and Patient #26 was placed on bi-level positive airway pressure (Bi-PAP, type of ventilator that is used to treat conditions in which a person is able to breathe on their own but needs assistance).

Review of the hospital's email document dated 04/18/24, showed:
- Staff Z, RN, received a report from Staff Q, CNA; Staff FF, Licensed Practical Nurse (LPN) and Staff EE, RN, regarding Staff V, RN.
- Staff Q reported to Staff V, Patient #26 had an oxygen saturation level in the "high 60s to 70s range and the patient was unresponsive."
- Staff Q stated that Staff V was "not concerned and did not assess the patient."
- Staff Q asked Staff EE to assess Patient #26.
- Staff EE stated that she was asked by Staff Q to assess a patient with an oxygen saturation of 78 percent.
- When Staff EE arrived in the unit, Staff V was "sitting at the desk on her phone."
- The patient was unresponsive, tachypneic (rapid, shallow breathing) and purple.
- Staff EE instructed Staff V to call the doctor.
- Staff FF stated that she asked Staff V to call the doctor more than once before Staff EE came to the floor and Staff V "refused."

Review of the hospital's document titled, "Email Complaint" dated 4/10/24, showed:
- Staff C, Interim CNO, questioned Staff V's, RN, care of Patient #26.
- Staff V was on a personal phone call for an extended period of time while call lights and intravenous (IV, in the vein) pumps (a medical device used to deliver fluids into a patient's body) alarmed.
- Staff V sat at the desk when a bed alarm sounded.
- Staff C requested Staff V e-mail her response to the concerns.
- On 04/12/2024, Staff V responded and stated she did not know of the events and did not "usually" ignore bed alarms.
- Staff V stated she received calls from her daughter but did not stay on the phone, she was at work.
- She stated she was "usually the first one to look at the beeping" if she heard alarms.

Review of the hospital's document titled "Timecard Report," dated 04/07/24 through 04/20/24, showed on 4/17/24 and 4/18/24 Staff V, RN, worked from 6:45 PM through 7:00 AM.

Review of the hospital's undated document titled, "Just Culture Employee Event Reporting Documentation Tool-Cumulative," showed:
- On 04/10/24, Staff V, RN, was counseled for at risk/repetitive behavior.
- On 04/17/24, Staff V was counseled for a breach of duty to avoid causing risk or harm.
- On 04/19/24, Staff V was terminated for unsafe conduct regarding multiple complaints of not placing a patient on oxygen when low oxygen saturations were reported, not calling a physician when asked and unethical conduct by performing chest compressions (involves giving strong, rapid pushes to the chest to keep blood moving through the body) on a patient with a pulse who had do not resuscitate (DNR, written instructions from a physician telling health care providers not to perform Cardiopulmonary Resuscitation (CPR, emergency life-saving procedure performed when a person's breathing or heartbeat has stopped) order.

Review of the hospital's document titled, "Performance Evaluation and Planning (PEP)", dated 08/09/22, showed Staff V, RN was asleep at work.

Review of Patient #26 skilled nursing facility (SNF, facility providing skilled nursing care and services to patients who require medical, nursing, or rehabilitative services but not the level of care or treatment available in a hospital) medical record showed:
- On 04/03/24, she was a 64-year-old female admitted for physical deconditioning (a process that affects all areas of the body after a long period of inactivity).
- Her past medical history was congestive heart failure (CHF, a weakness of the heart that causes it to not pump blood like it should leading to a buildup of fluid in the lungs and surrounding body tissues.), chronic obstructive pulmonary disease (COPD, a lung disease that prevents normal airflow and breathing) and diabetes (a disease that affects how the body produces or uses blood sugar, and can cause poor healing).
- On 04/17/24, she was transferred to inpatient status for a fever and difficulty breathing. She was diagnosed with influenza (highly contagious condition affecting the respiratory system).
- On 04/17/24 at 12:28 AM, Staff V, RN, was called to Patient #26's room by Staff Q, CNA. Patient #26's oxygen saturation was 70 percent on four liters of oxygen via a nasal cannula (NC, a lightweight tube with two prongs for insertion into the nostrils and delivery of oxygen) and her "right ear was bluish purple."
- Patient #26 was "not very responsive", she did respond to a sternal rub (painful pressure applied with the knuckles to the center of the chest of a patient who is not alert to elicit a response).
- A non-rebreather mask was applied at 15 lpm and her oxygen saturations increased to 94 percent to 97 percent.
- The Emergency Department (ED) physician was called to assess the patient.
- On 4/17/24 at 1:23 AM, Patient #26's oxygen saturations declined to 86 percent, and she required BiPAP.

Review of Patient #27's inpatient medical record showed:
- On 04/16/24, she was a 68-year-old female admitted to the medical-surgical unit for shortness of breath, respiratory failure (condition in which not enough oxygen passes from the lungs into the blood) and CHF.
- Her past medical history was atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow), angina (chest pain caused by low blood flow to the heart), high blood pressure, anxiety and depression.
- At 9:16 PM, her oxygen saturation was 86 percent.
- On 04/17/24 at 12:43 AM, she "complained of not feeling like she was getting enough air." Her continuous positive airway pressure (CPAP; a machine that uses mild air pressure to keep breathing airways open while a person sleeps) was applied. Her oxygen saturations increased to 91 percent.
- At 5:34 AM, Patient # 27's oxygen flow rate was increased from three lpm to eight lpm via a NC. No oxygen saturations were charted.

During an interview on 04/25/24 at 4:05 PM, Staff C, Interim CNO, stated that Staff V, RN, was given a verbal warning for reports of not answering patients' call lights on 04/10/24. Staff Z, RN, informed her of the events with Staff V and Patient #26. Staff C did not interview witnesses or speak to the patient. She did not speak with Staff V's supervisor. On 04/16/24, she received and email from Staff Q, CNA, that described the events with Staff V and Patient #26. On 04/17/24, Staff C reviewed Patient #26's medical record and requested an email statement from Staff V. Staff V documented oxygen was applied and the physician was notified. She did not review the physician progress notes. Staff V manually documented the patient's oxygen saturation as 97 percent. She agreed the documentation did not "reflect the true status of the patient." Staff V's actions were neglectful. Staff V, continued to work on 04/16/24, 04/17/24 and 04/18/24. Staff C was not aware of the events with Patient #27.

During an interview on 04/25/24 at 4:35 PM, Staff F, Chief Executive Officer (CEO), stated that Staff V, RN, had several 'write ups' and should have been "terminated a long time ago." Her care of Patient #26 was neglectful.

2. Review of the hospital's policy titled, "Certification for Specific Competence," dated 11/15/22, showed Scotland County Hospital (SCH) employees were required to complete the training necessary to maintain certification for specific competencies for job specific elements. The copy of all certifications will be placed in the permanent record in the employee's personnel file.

Review of the hospital's policy titled, "RN Medical/Surgical Job Description," dated 04/04/24, showed Basic Life Support (BLS, level of medical care for victims with life-threatening illnesses or injuries, until full medical care by more qualified individuals can be given, or at a facility that offers advanced life support) certification is required.

Review of the hospital's policy titled, "LPN Job Description," dated 04/04/24, showed BLS certification is required.

Review of the hospital's policy titled, "CNA Job Description," dated 06/22/21, showed BLS certification is required.

Review of the hospital's undated document titled, "BLS," showed four RNs, two LPNs, and five CNAs with expired BLS certification. Three RNs and five CNAs did not have BLS certification.

Review of the hospital's policy titled, "RN ED Job Description," dated 04/04/24, showed Trauma Nurse Core Coarse (TNCC, certification that recognizes a nurse's advance expertise in the assessment and management of patients with traumatic injuries), Advanced Cardiac Life Support (ACLS, specific life saving measures taken by certified health professionals when a patient's heartbeat or breathing stops) and Pediatric Advanced Life Support (PALS, specific life saving measures taken by certified health professionals for pediatric [pertaining to children] patients who are experiencing life-threatening emergencies) certifications are required.

Review of the hospital's undated document titled, "TNCC," showed three RNs with expired TNCC certification and six RNs without TNCC certification.

Review of the hospital's undated document titled, "ACLS," showed one RN without ACLS certification.

Review of the hospital's undated document titled, "PALS," showed four RNs without PALS certification.

Review of the hospital's policy titled, "Nursing Staffing," date 04/04/23, showed Obstetric (OB, the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) nurses will be Neonatal Resuscitation Program (NRP, interventions at the time of birth to support the establishment of breathing and circulation) certified within six months of hire.

Review of the hospital's undated document titled, "NRP," showed one RN with expired NRP certification and three RNs without NRP certification.

During an interview on 04/24/24 at 3:55 PM, Staff R, ED Medical Director, stated that he was unaware that staff members were working with expired certifications. Staff members certifications needed to be current.

During an interview on 04/25/24 at 4:35 PM, Staff F, CEO, stated that the hospital allowed staff members to work with expired certifications. She expected to reorganize the process and all staff members were to be certified.

During an interview on 04/25/24 at 5:30 PM, Staff E, Chief Operating Officer (COO), stated that he was unaware of the expired certifications. He expected staff members to have current certifications.

During an interview on 04/25/24 at 11:30 AM, Staff Y, CNO, stated that the hospital had a poor process for tracking certifications. She wanted to see staff members maintain competencies. Staff members were to be removed from the schedule without current certification. Certifications were a professional responsibility.

During an interview on 04/25/24 at 9:50 AM, Staff S, ED Supervisor, stated that she was "unsure" of the staff members certification status. Staff with expired certifications were allowed to work.

During an interview on 04/24/24 at 2:25 PM, Staff I, OB Supervisor, stated that staff were allowed to work with expired certifications. She did not know how many OB staff members had expired certifications.

During an interview on 04/25/24 at 11:25 AM, Staff X, Medical-Surgical Supervisor, stated that it "stressed her out" that staff were allowed to work with expired certifications.

3. Review of the hospital's policy titled, "Medication Reconciliation," dated 08/03/21, showed:
- It is the policy of SCH to ensure timely and accurate capture of medication and documented information is to be a complete and comprehensive list of a patient's medication.
- Staff members are to obtain and document the most complete and accurate list possible of all current medications for each patient.
- A complete medication entry will include the medication or product name, dose, route or site, frequency, last dose and reason/indication for use.
- After completion of the medication reconciliation process, the prescriber will enter new orders.

Review of Patient #9's medical record showed:
- On 02/16/24, she was admitted to the Medical-Surgical unit;
- On 02/16/24 12 home medications were reconciled; and
- Three home medications were not reconciled.

Review of Patient #12's medical record showed on 01/30/24, he was seen in the ED and 18 home medications were not reconciled.

Review of Patient #15's medical record showed on 03/16/24, she was admitted to the Labor and Delivery unit and three home medications were not reconciled.

Review of Patient #16's medical record showed on 03/23/24, he was admitted to the Medical-Surgical unit and three home medications were not reconciled.

Review of Patient #17's medical record showed:
- On 03/30/24, she was admitted to the Medical-Surgical unit;
- On 03/30/24, eight home medications were reconciled; and
- One home medication was not reconciled.

Review of Patient #18's medical record showed:
- On 03/24/24, she admitted to the Medical-Surgical unit;
- On 03/24/24, five home medications were reconciled;
- On 03/25/24, 15 home medications were reconciled;
- On 03/27/24, one home medication was reconciled; and
- Three home medications were not reconciled.

Review of Patient #19's medical record showed on 03/09/24, he was seen in the ED and three home medications were not reconciled.

Review of Patient #20's medical record showed on 03/09/24, he was seen in the ED and two home medications were not reconciled.

Review of Patient #21's medical record showed on 03/11/24, he was seen in the ED and six home medications were not reconciled.

Review of Patient #22's medical record showed on 02/07/24, she was seen in the ED and 11 home medications were not reconciled.

Review of Patient #23's medical record showed on 03/16/24, she was admitted to the Labor and Delivery unit and six home medications were not reconciled.

4. Review of the hospital's policy titled, "Emergency Crash Carts Checks," dated 11/30/21, showed:
- All emergency carts/boxes will be checked monthly for all medication and non-medication outdates and replaced as indicated.
- Nursing personnel shall visually inspect the numbered break-away lock located on the crash cart at each change of shift, documenting that the cart is properly locked with all appropriate contents present and intact.
- Crash carts and boxes are to be checked on the first day of the month. If unable to be completed on this date, they should be checked as close to the first day of the month as possible.

Review of the hospital's undated document titled, "Med Surg Checklist," showed the medical-surgical crash cart numbered break away lock was not visually inspected and documented 96 days out of 178 days.

Review of the hospital's undated documented titled, "Med/Surg Crash Cart Checklist," showed the monthly crash cart, boxes, medications and non-medications dates were not checked January and February of 2024.

Review of the hospital's undated document titled, "Emergency Room (ER) Crash Cart Checklist," showed the monthly crash cart, boxes, medications and non-medications dates were not checked August of 2023, January, February and April of 2024.

There was no ED Checklist for the daily inspection of the numbered break-away lock.

During an interview on 04/25/24 at 4:35 PM, Staff F, CEO, stated that crash cart seals were checked daily and the carts' supplies were checked monthly.

During an interview on 04/25/24 at 5:30 PM, Staff E, COO, stated that he expected crash carts to be checked per policy.

During an interview on 04/25/24 at 9:50 AM, Staff S, ED Supervisor, stated that crash carts were checked monthly on the first day of the month. Any staff member was responsible to check the carts.

5. Review of the hospital's policy titled, "Handling of Biohazard Waste," dated 04/25/22, showed it is the policy of SCH to handle biohazard waste in a safe way.

Observation on 04/24/24 at 10:15 AM, showed six ED rooms with sharps (a term used for devices with sharp points or edges that can puncture or cut the skin) containers sitting unsecured on the counter.

Observation on 04/24/24 at 10:30 AM, showed four labor and delivery rooms with sharps containers sitting unsecured on the counter.

Observation on 04/24/24 at 10:40 AM, showed six medical-surgical rooms with sharps containers sitting unsecured on the counter.

During an interview on 04/25/24 at 11:25 AM, Staff X, Medical-Surgical Supervisor, stated that she was unaware the sharps containers were sitting on the counters. Sharps containers were to be hung on the wall.

During an interview on 04/25/24 at 4:35 PM, Staff F, CEO, stated that she expected sharps containers were attached to the wall.

During an interview on 04/25/24 at 5:30 PM, Staff E, COO, stated that he expected sharps containers were attached to the wall.

6. Review of the hospital's policy titled, "PEP Competency Review," dated 05/24/21, showed the purpose of the PEP is to clearly define competency-based performance expectations, provide summary feedback to staff members regarding their performance on a regular basis during the current year and to provide clear goals and development plans for the coming year. Mid-year and annual PEP review meetings are required.

Review of Staff Z's, RN, personnel file showed no annual PEP.

Review of Staff AA's, RN, personnel file showed no annual PEP.

Review of Staff BB's, RN, personnel file showed no annual PEP.

Review of Staff V's, RN, personnel file showed no annual PEP.

During an interview on 04/25/24 at 4:35 PM, Staff F, CEO, stated that performance appraisals were completed within six months of hire and then yearly. She was not surprised that performance appraisals were not consistently completed.

During an interview on 04/25/24 at 5:30 PM, Staff E, COO, stated that he expected annual performance appraisals. He did not know why this expectation was not met.

7. Review of the hospital's policy titled, "Verbal and Telephone Orders," dated 09/05/23, showed prescribers should verify and electronically sign orders within 24 hours. The ordering practitioner must electronically sign verbal orders within 24 hours. (We recognize that in some instances, weekends or time off, the ordering physician may not be able to authenticate the verbal order so in such cases, they sign off to the covering practitioner). It is acceptable for the covering practitioner to co-sign the verbal order.

Review of Patient #17's medical record showed:
- On 03/30/24 at 4:11 AM, a verbal order was written for a medication.
- On 04/13/24 at 12:45 AM, the provider signed the order.
- The order was signed 332 hours and 34 minutes after it was placed.

Review of Patient #26's medical record showed:
- On 04/03/24 at 12:52 PM, a verbal order was written for a medication.
- On 04/16/24 at 8:49 AM, the provider signed the order.
- The order was signed 307 hours and 57 minutes after it was placed.

Review of Patient #25's medical record showed:
- On 02/28/24 at 8:57 AM, a verbal order was written for a medication.
- On 03/05/24 at 7:09 AM, the provider signed the order.
- The order was signed 142 hours and 12 minutes after it was placed.

Review of Patient #12's medical record showed:
- On 01/30/24 at 5:28 AM, a verbal order was written for a medication.
- On 02/02/24 at 10:32 AM, the provider signed the order.
- The order was signed 77 hours and 4 minutes after it was placed.

Review of Patient #9's medical record showed:
- On 02/16/24 at 12:16 PM, a verbal order was written for a medication.
- On 02/19/24 at 3:57 PM, the provider signed the order.
- The order was signed 75 hours and 41 minutes after it was placed.

Review of Patient #16's medical record showed:
- On 03/25/24 at 11:45 AM, a verbal order was written for a medication.
- On 03/28/24 at 8:53 AM, the provider signed the order.
- The order was signed 69 hours and 8 minutes after it was placed.

Review of Patient #18's medical record showed:
- On 03/24/24 at 9:16 PM, a verbal order was written for a medication.
- On 03/26/24 at 12:48 PM, the provider signed the order.
- The order was signed 51 hours and 32 minutes after it was placed.

Review of Patient #8's medical record showed:
- On 02/12/24 at 10:29 AM, a verbal order was written for a medication.
- On 02/14/24 at 8:35 AM, the provider signed the order.
- The order was signed 46 hours and six minutes after it was placed.

During an interview on 04/25/24 at 4:35 PM, Staff F, CEO, stated that she expected providers to meet the policy requirements for the signing of telephone/verbal orders.

During an interview on 04/25/24 at 5:30 PM, Staff E, COO, stated that he expected telephone/verbal orders were signed as soon as possible. He was not aware the orders were not signed per policy.

During an interview on 04/25/24 at 11:30 AM, Staff Y, CNO, stated that she expected providers to follow the telephone/verbal order policy and sign the orders within 24 hours.

During an interview on 04/24/24 at 2:25 PM, Staff I, OB Supervisor, stated that nurses enter verbal/telephone orders. The order entered the providers "que," and the expectation was for the order to be signed by the provider within 24 hours.

During an interview on 04/25/24 at 9:50 AM, Staff S, ED Supervisor, stated that ED providers were expected to sign their telephone/verbal orders by the end of the shift.

During an interview on 04/25/24 at 11:45 AM, Staff X, Medical-Surgical Supervisor, stated that she expected telephone/verbal orders to be signed within 24 hours.