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Based on record review and interviews, the Hospital failed to have a well-organized Nursing Service with a plan of administrative authority and delineation of responsibilities for patient care. The Hospital failed to ensure that the Chief Nursing Officer (CNO) was responsible to oversee the nursing care to all areas of the Hospital.

Review of the Organizational Chart, dated 7/2018, indicated the nurses under inpatient and outpatient (ambulatory)surgery did not report to the CNO; it was divided into 3 areas:

Vice President of Acute Care
Vice President of Surgical Services
Vice President of Ambulatory Services

The Organizational Chart indicated that each of the above had their own separate Vice President in Surgical Services which did not report to the Nursing Service and, as such, the CNO did not have administrative authority over the nurses under inpatient and outpatient (ambulatory) surgery.

The Surveyor interviewed the CNO at 12:30 P.M. on 7/24/18. The CNO said that the Vice Presidents of Surgical Services and of Ambulatory Services did not report to the CNO.

Based on record reviewed and interviews, for five of thirteen patients (Patient #3, #5, #11, #12 and 13), the Hospital failed to use physician verbal orders infrequently and failed to follow their policy for verbal orders.

Findings include:

The Hospital Policy, Medical Orders dated 9/1/2016, indicated all medical orders must be in writing. Verbal orders will only be accepted in an extreme emergency situation.

Review of Patient #3's Anesthesiology Record indicated a verbal order, dated 7/24/18 at 11:45 A.M., for Lispro Insulin 8 units subcutaneously.

The Surveyor interviewed Nurse #3 at 11:35 A.M. on 7/24/18. Nurse #3 said in the Post Anesthesia Care Unit (PACU), Patient #3 had a blood sugar of 327 milligrams (mg)/deciliter (dl). Nurse #3 contacted the covering Anesthesiologist for a verbal order for insulin coverage. Nurse #3 said Patient #3's elevated blood sugar was a non-emergent situation.

The following were Patient Records in PACU with non-emergent verbal orders:

Review of Patient #5's Doctor's order sheets indicated on 4/13/18 at 1:00 P.M., a verbal order for beneprotein (a protein supplement) with meals, skin prep (a treatment to prevent skin breakdown) to the heels and instructions for a colostomy change.

Review of Patient #11's Anesthesiology Record indicated on 6/25/18 at 11:45 A.M., there was a verbal order to administer Benadryl (an antihistamine) 25 mg/dl intravenously and Dilaudid (a pain medication) 0.5 mg every 10 minutes up to 2 mg.

Review of Patient #12's Anesthesiology Record indicated on 6/27/18 at 4:40 P.M., there was a verbal order to administer Phenergan (an anti-nausea medication) 6.25 mg as an intravenous push once.

Review of Patient #13's Anesthesiology Record indicated on 6/26/18 at 4:25 P.M., there was a verbal order to administer Tylenol 975 mg once (with no designated route of administration).

The Surveyor interviewed Anesthesiologist #1 at 9:25 A.M. on 7/25/18. Anesthesiologist #1 said that verbal orders were given for patients in PACU for non-emergency situations because the Anesthesiologists are frequently involved with other patients intraoperatively.

The Surveyor interviewed Nurse #2 at 10:15 A.M. on 7/25/18. Nurse #2 said that, although Patients enter the PACU with written Physician Orders, these orders may not meet the changing needs of the patients. Nurse #2 said when the Anesthesiologists are called, they are busy with other patients intraoperatively, therefore the verbal orders are given for additional pain medications, intravenous fluids, unrelieved nausea, or a non-emergent change in a heart rate or blood pressure.