HospitalInspections.org

Based on interview, medical record review, and policy review, the facility failed to provide oversight of the mid-level provider by a supervising physician when orders were given for three patients (Patients 15, 16, and 18) of the 20 sampled patients. Specifically, the facility's supervising physician did not sign, or date orders made by the mid-level provider for these three patients. This practice had the potential to adversely affect all patients receiving medical orders by mid-level practitioners in the facility.

Findings Include:

1. Review of electronic medical record for Patient 15, dated 05/10/18, showed Staff F, Physician Assistant, had placed orders for morphine (three times), ondansetron (twice), transfer patient, lidocaine, and sodium chloride 0.9% (twice).

Review of Patient 15's "Chart Deficiency Slip," showed Staff H, Supervising Physician, had not co-signed the orders of the mid-level staff.

2. Review of electronic medical record for Patient 16, dated 06/27/18, showed Staff F had placed orders for the following medications, labs, and X-rays: complete blood count, comprehensive metabolic panel, lactic acid, blood culture (twice), X-ray chest two views, establish intravenous access, sodium chloride, sodium chloride 0.9% (three times), computed tomography with contrast, Iversol, glucose level, insulin aspart, and levofloxacin (four times).

Review of Patient 16's "Chart Deficiency Slip," showed Staff H had not co-signed the orders of the mid-level staff.

3. Review of electronic medical record for Patient 18, dated 10/26/18, showed Staff F had placed orders for the following medications, labs, X-rays, and therapies: admit to inpatient, resuscitation status, vital signs, pulse oximetry, blood glucose monitoring (twice), physical therapy, occupational therapy, speech language, memantine, lorazepam (three times), insulin aspart (five times), insulin glargine (twice), non-formulary medication (four times), oxybutynin (twice), levofloxicin, sodium chloride 0.9% (twice), sodium chloride, urinalysis, urinary catheter (twice), diet order, insulin aspart, complete blood count (three times), comprehensive metabolic panel (twice), X-ray chest, and tramadol.

Review of Patient 18's "Chart Deficiency Slip," showed Staff H had not co-signed the orders of the mid-level staff.

During an interview on 01/23/19 at 11:55 AM, Staff E, Owner/Operator of the contracting company who employees the medical staff, explained they had not been aware of the instances of Staff H not providing the oversight required for these medical orders. Staff E explained the supervising physician was required to co-sign the orders of the physician's assistant.

Review of the undated facility's "Bylaws, Rules and Regulations of the Professional Staff Stafford County Hospital," showed the attending physician shall be held responsible for the preparation of a complete medical record for each patient. This record shall include...medical and surgical treatment..."

Based on interview and medical record review, the facility's staff failed to authenticate orders for one patient (Patient 13) of the 20 sampled patients. Specifically, after receiving verbal orders for Patient 13, the facility failed to ensure the orders were signed and dated by the prescribing provider. This practice had the potential to adversely affect all patients, for whom verbal orders for care are received in the facility.

Findings Include:

Review of electronic medical record for Patient 13, dated 02/03/18, showed Staff G, Nurse Practitioner entered a verbal order for Patient 13 to receive Depo Medrol 80 milligrams (mg) (a steroid that prevents the release of substances in the body that cause inflammation). The order for Depo Medrol 80 mg was not authenticated by the Staff G who initiated the order but had been instead routed to the supervising practitioner to be signed, thus skipping the authenticating signature of the Staff G.

In an interview on 01/23/19 at 08:43 AM, Staff C, Director of Nursing explained the electronic health record software, in use by the facility, automatically routed verbal orders to the supervising physician and this was a glitch in the system. Staff C explained the facility authentication process would require the provider who gave the verbal order to sign the order for authentication.

Review of the facility's policy, "Authentication of Order Entries," dated 06/18/97, showed, "The system will automatically create a deficiency for the ordering practitioner to authenticate. When the practitioner signs the order, it will document time and date that it was completed."

Review of the undated facility's "Bylaws, Rules and Regulations of the Professional Staff Stafford County Hospital indicated, "The signing of telephone or verbal orders by the dictating professional shall be considered delinquent if not signed within 7 days."

Based on interview and record review, the facility's staff failed to develop and implement a care plan for two patients, (Patients 7 and 17) of the 20 sampled patients. Specifically, the facility did not develop a working care plan for the two inpatients before 24 hours had elapsed since their admission. This practice had the potential to adversely affect all inpatients receiving services in the facility.

Findings Include:

1. Review of electronic medical record for Patient 7 lacked evidence a care plan had been developed for the inpatient stay of 05/30/18 through 06/02/18.

In an interview on 01/23/19 at 10:15 AM, Staff C, Director of Nursing confirmed a care plan had not been developed for Patient 7's inpatient stay of four days.

2. Review of electronic medical record for Patient 17 lacked evidence a care plan had been developed for the inpatient stay of 02/15/18 through 02/18/18.

In an interview on 01/23/18 at 12:15 PM, Staff C confirmed a care plan was to be developed by the admitting nurse during the admission process but had not been developed for Patient 17's inpatient stay of four days.

Review of the undated facility's policy, "Nursing Care Plans," showed, "Chart care plan will be addressed within 24 hours of admission."

Based on interview, document review, and policy review, the facility's staff failed to include the medical director in the Quality Improvement (QI) meetings for the 2018 calendar year. The facility failed to monitor identified performance improvement needs, to ensure progress toward correction of the need or ensure improvement was sustained. This practice had the potential to affect all patients receiving services at the hospital.

Findings Include:

Review of the facility's document, "Quality Improvement Committee Meeting" minutes from the fourth quarter of 2017 through the third quarter of 2018, showed the medical director had not attended QI meetings and did not have evidence of any physician involvement with the QI program.

Review of the facility's policy titled, "Quality Improvement Committee," revised 02/2010, showed the QI committee should include: "Quality improvement Medical Director."

Review of an undated facility document titled, "Quality Improvement Plan," showed the following: "The Governing Board shall reaffirm its delegation of the responsibilities for the quality of medical care to the Medical Staff. It shall delegate responsibilities for all other patient care quality to the Chief Executive Officer, with the stipulation that the Medical Staff and Administration work together to create a unified program by the joint formation of a committee with representation from the Medical Staff, Administration, Nursing Service, Clinical Ancillary Services, and additional persons. The Quality Improvement Committee will be composed of: The Medical Director of Quality Improvement, who shall be a physician from the Active Medical Staff. The Medical Director of Quality Improvement shall be responsible for the medical direction of the Quality Improvement Committee."

Review of the facility's document for a QI improvement project that had been identified through the infection control department and written on a "Quality Pace Worksheet," which was not dated, showed there was a need to develop policies for Legionella (a type of bacterium found naturally in freshwater environments that can become a health concern when it grows and spreads in human-made building water systems). The policies would be written to reach the standard requirements of the Centers for Disease Control, and the next steps were "Proceed with the plan."

During an interview on 01/23/19 at 2:00 PM, Staff B, the assistant Administrator, explained the medical director had not attended the QI meetings for the past year, and that no one from the medical staff attended the QI meetings. Staff B explained the medical staff held their own meetings and the information from the medical staff meetings was not discussed in the facility QI meetings. Staff B explained each department in the facility made a quarterly report to the QI committee. When a problem was identified the department would fill out a "Quality Pace Work Sheet." Staff B explained the identified problems were not monitored for specific plans of correction and resolution, after a problem had been identified. Staff B explained they would be unable to provide an outline of how the QI improvement plan [for the Legionella policy] would proceed or show a timeline associated with the plan. Staff B explained the project had not been monitored and the status of the plan was unknown.

Based on interview and review of the facility's Emergency Preparedness Plan (EPP), the facility failed to annually update the EPP. This failure had the potential to affect all four current patients and the safety of potential patients receiving care in the facility as well as staff and visitors.

Findings Include:

Review of the facility's EPP lacked evidence that the EPP had been reviewed annually. The community table talk had occurred, but there was no documentation that the facility had reviewed the plan as a whole.

In an interview on 01/23/19 at 9:10 AM, Staff A, Administrator stated there was no documentation of an annual program review.