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Based on record reviews and interview, the governing body failed to ensure its process for assuring that the medical staff's accountability for the quality of care provided to patients addressed whether the physician peer review could be conducted by a physician who was a partner in practice with the physician being reviewed and had assisted during the surgery being reviewed as evidenced by having a medical record review being conducted by the physician's partner in practice who was an assistant during one of the surgeries being reviewed for 1 (#3) of 1 patient record reviewed that had a peer review conducted.
Findings:

Review of the "Amended And Restated Bylaws Of The Governing Board", presented as the current bylaws by S1ADM, revealed that the purpose of the Governing Board shall be to oversee and promote the welfare and quality of care provided to patients of the hospital. Further review revealed the primary functions and purposes of the Governing Board shall be to develop a program for evaluating the quality of care and to address appropriately any identified problems in care. The Governing Board shall develop a system of risk management appropriate to the hospital, which system shall include, but not be limited to a periodic review of all incidents reported by staff and patients and review of all deaths, trauma, or adverse reactions occurring at the hospital.

Review of the "Peer Review Process", presented as a current policy by S1ADM, revealed doctors will be peer reviewed by physicians in their same specialty. Bariatrics procedures are peer reviewed by another Bariatrics surgeon. There was no documented evidence that the process addressed whether a physician could conduct a peer review of a physician in practice with him/her.

Review of a peer review conducted by S7MD on 11/20/16 revealed the reason for admission was direct admit with a diagnosis of abdominal pain, Atelectasis, status post Gastric Sleeve done on 07/26/16. On 08/03/16 a lap drainage and irrigation of an abscess cavity was performed with placement of a drain and insertion of a triple lumen catheter. On 08/04/16 an EGD with placement of a gastric stent was performed. Complications documented were transferred to tertiary hospital, re-admitted to the hospital within 30 days, cardiac/respiratory distress/arrest, and post-op infection. Comments included the following: readmitted on 08/02/16 with abdominal pain and Atelectasis; transferred to ICU at Hospital A on 08/05/16 with respiratory failure; discharged from Hospital A 08/20/16; EGD with stent revision at Physicians Medical Center on 08/30/16 and discharged on 09/02/16; EGD, stent removal, and percutaneous jejunostomy feeding tube placement on 09/16/16. Physician peer review revealed medical necessity was documented and patient care was medically appropriate. Standard of care severity level revealed "this medical morbidity/mortality was determined not to be unusual in this clinical situation, and was not found to be the result of any identifiable medical mismanagement.

Review of Patient #3's (the patient whose medical record was peer-reviewed by S7MD as noted above) "Operative Report" for 08/04/16 revealed the surgeon who performed the EGD with placement of a covered stent was S6MD, and the assistant was S7MD.

In an interview on 12/19/16 at 4:15 p.m., S1ADM confirmed the hospital's peer review process didn't address whether peer review could be conducted by a physician who was in partnership with the physician being reviewed. She also confirmed that the peer review done on Patient #3's medical record was conducted by S7MD who had been the assistant during Patient #3's second surgical procedure.

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:
1) The RN initiating a Diprivan drip and monitoring the patient which was prohibited by the LSBN's practice act for 1 (#3) of 1 patient record reviewed with Diprivan being administered by intravenous (IV) drip from a total sample of 5 patients.
2) The RN failing to obtain a physician's order for the administration of O2 for 1 (#3) of 5 patient records reviewed that had O2 administered during the hospital stay from a sample of 5 patients.
Findings:

1) The RN initiating a Diprivan drip and monitoring the patient which was prohibited by the LSBN's practice act:
Review of the LSBN's "Declaratory Statement On The Role And Scope Of Practice Of The Registered Nurse In The Administration Of Medication And Monitoring Of patients During The Levels Of Intravenous Procedural/Conscious Sedation (Minimal, Moderate, Deep, And Anesthesia) As Defined Herein" revealed drugs typically classified as anesthetic agents include Propofol (Diprivan), Ketamine, and Methohexital. It is not within the scope of practice for the RN either to administer an anesthetic agent for any of the levels of sedation or to monitor general anesthesia. A RN may administer, in accordance with an order of an authorized prescriber, anesthetic agents to intubated patients in critical care settings.

Review of the policy titled "Management Of Intravenous Medications When Caring For The Unstable Patient", presented as a current policy by S2DON, revealed that the preferred route of administration for vasoactive medications such as Diprivan is through a central line. Discuss with the ordering physician placement of a central line as soon as possible to decrease the likelihood of peripheral venous catheter infiltration. When the patient is initiated on Diprivan, transfer of the patient is recommended. Any drug will be initiated for stabilizing the patient, however, if continued use of the drug is necessary, transfer of the patient is recommended. Review of the policy revealed no documented evidence that the policy addressed that initiation and monitoring of a Diprivan drip was not within the scope of practice of the RN.

Review of patient #3's physician orders revealed a telephone order from S8MD was documented as a read-back telephone order on 08/05/16 at 2:55 p.m. by S12RN for Diprivan 0.5 mg/kg/hour drip.

Review of Patient #3's "Nursing Notes" revealed an entry at 3:00 p.m. by S12RN that Diprivan drip was initiated at 0.5 mg/kg/hour. Further review revealed Patient #3 was transported to CT at 3:05 p.m. with the RN bagging Patient #3 with Diprivan infusing.

In an interview on 12/19/16 at 10:10 a.m., S2DON indicated she didn't recall being informed by the post-surgical unit (PSU) staff that Patient #3 had been placed on a Diprivan drip.

In a telephone interview on 12/19/16 at 10:20 a.m. with S2DON and S3ADON present during the telephone conversation (phone placed on speakerphone mode), S12RN indicated she and another RN transported Patient #3 to Radiology for the CT scan, and S9RT was not present during the transport to CT, during the procedure, and during transport back to the PSU. She further indicated she initiated the Diprivan drip and monitored the infusion. S12RN indicated S6MD and S8MD were in the hospital but not continuously at Patient #3's bedside while Diprivan was being infused.

In a telephone interview on 12/19/16 at 10:35 a.m. with S2DON and S3ADON present during the telephone conversation (phone placed on speakerphone mode), S12RN indicated she was not aware of the LSBN's declaratory statement related to it not being within the RN's scope of practice to monitor an intubated patient on a Diprivan drip outside a critical care setting.

In an interview on 12/19/16 at 11:10 a.m., S6MD indicated he was in the hospital the entire time Patient #3 was on a Diprivan drip, but he was not continuously at the patient's bedside.

In an interview on 12/19/16 at 1:35 p.m. with S2DON and S3ADON present, S3DON indicated the hospital does not meet the definition of an ICU. She further indicated if she had been aware that Patient #3 had a continuous Diprivan drip in progress, she would have arranged for a CRNA (certified registered nurse anesthetist) to be at the bedside.

2) The RN failing to obtain a physician's order for the administration of O2:
Review of Patient #3's "Nurses Notes" revealed the following documentation:
08/02/16 at 5:05 p.m. by S14RN - heart rate 123 at rest; respirations diminished to bilateral lower lobes, oxygen saturation 85% to 88%; patient placed on 2lNC (liters per nasal cannula); oxygen saturation increased to 91%;
08/02/16 at 7:00 p.m. by S13RN - respirations shallow, tachypnea noted, bilateral breath sounds clear, diminished to bilateral lower lobes, oxygen saturation 89% on 2LNC, oxygen increased to 4LNC, oxygen saturation 93%;
08/02/16 at 7:30 p.m. by S13RN - oxygen saturation down to 83% on 4LNC; respiratory rate 48; 50% venti-mask initiated; oxygen saturation up to 91%, respiratory rate down to 32;
08/02/16 at 8:00 p.m. by S13RN - S6MD called, updated on patient's status - heart rate, oxygen saturation, venti-mask initiated, urine output, blood pressure; no new orders received.

Review of Patient #3's physician orders revealed no documented evidence of a physician's order for the initiation of oxygen at 2LNC, increase to 4LNC, and venti-mask at 50%.

In an interview on 12/19/16 at 11:00 a.m. with S2DON and S3ADON present, S2DON indicated there should have been a report of the need for oxygen by the RNs to S6MD and an order for the oxygen that was administered.

Based on record reviews and interviews, the hospital failed to ensure the RNs employed in the post-surgical unit (PSU) received education and were evaluated for competency to administer and monitor medications contained in the Code Blue cart and medications administered by continuous infusion for sedation/analgesia as evidenced by having no documented evidence of such training and competency evaluations for 3 (S12RN, S13RN, S14RN) of 3 PSU RN personnel files reviewed for education and competency from a total of 17 PSU RNs employed.
Findings:

Review of the policy titled "Management Of Intravenous Medications When Caring For The Unstable Patient", presented as a current policy by S2DON, revealed that the nurse administering intravenous drugs used to treat a patient who is unstable is to be knowledgeable about the drug, dosage, monitoring, possible side effects, and adverse reactions. The nurse will collaborate with the consulting pharmacist and/or refer to the approved drug book references as deemed necessary. Annually, nurses will be in-serviced for competency.

Review of the "Attendance Record" for the program "Skills/Medication", presented as documentation of attendees at the skills fair related to medications by S3ADON, revealed no documented evidence of the date the education was presented. Further review revealed no documented evidence that S12RN, S13RN, and S14RN had signed the attendance record.

Review of the "Attendance Record" for the program "Skills Med List", presented as documentation of attendees at the skills fair related to medications by S3ADON, revealed no documented evidence of the date the education was presented. Further review revealed no documented evidence that S13RN and S14RN had signed the attendance record.

Review of the "Attendance Record" for the program "Annual Code Blue Equip (equipment) Day/Medicine Inservice" dated 06/21/16, presented as documentation of attendees at the skills fair related to medications by S3ADON, revealed no documented evidence that S12RN, S13RN, and S14RN had signed the attendance record. Further review revealed the information contained in the training related to Diprivan stated that Diprivan can only be administered by the anesthesiologist.

No documented evidence of education related to administering and monitoring medications contained in the Code Blue cart and medications administered by continuous infusion for sedation/analgesia was presented by S3ADON for S13RN and S14RN. No documented evidence of an evaluation of competency in administering and monitoring medications contained in the Code Blue cart and medications administered by continuous infusion for sedation/analgesia was presented by S3ADON for S12RN, S13RN, and S14RN.

In an interview on 12/19/16 at 4:05 p.m. with S2DON and S3ADON present, S2DON indicated the skills fair included education on the medications contained in the crash cart. She confirmed the hospital did not have any means of evaluating the competency of RNs related administering and monitoring medications contained in the Code Blue cart and medications administered by continuous infusion for sedation/analgesia, such as a test geared to the calculation of dosages of drips.

Based on record reviews and interviews, the hospital failed to ensure policies and procedures were developed in accordance with medical staff directives for respiratory care services provided at the hospital by the respiratory care staff as evidenced by having policies and procedures contained in a nursing skills manual that were related to care provided by nurses and not the respiratory services staff. This resulted in failure of IS to be performed by the respiratory care staff as ordered for 4 (#1, #2, #4, #5) of 4 patients with physician orders for IS from a sample of 5 patients.
Findings:

Review of respiratory care services policies, provided by S2DON when a request was made at the entrance conference for the hospital's respiratory care services policies and procedures, revealed a policy titled "Respiratory Care" and a policy titled "Staffing Respiratory" were presented. Procedures for incentive spirometry and care of the patient on a mechanical ventilator were attached to the policies presented to the surveyor. Review of the procedures revealed they were related to care provided by the nursing staff and not the respiratory services staff.

No written policies and procedures approved by the medical staff were presented during the survey that addressed at least the following: equipment assembly, operation, and preventive maintenance; safety practices, including infection control measures for equipment, sterile supplies, biohazardous waste, and posting of signs; handling, storage, and dispensing of therapeutic gases to both inpatients and outpatients; procedures to follow in the advent of adverse reactions to treatments or interventions; pulmonary functioning testing; mechanical ventilatory and oxygenation support; aerosol, humidification, and therapeutic gas administration; storage, access, control, administration of medications and medication errors; procedures for obtaining and analyzing arterial blood gases.

Patient #1
Review of Patient #1's physician orders revealed an order on 12/15/16 at 9:00 a.m. for IS 15 times per hour while awake. Review of Patient #1's medical record revealed S5RRT documented a respiratory assessment on 12/16/16 at 8:35 a.m. (day after patient had a surgical procedure) that had no documented evidence of the IS goal and the patient's oxygen saturation, respiratory rate, and heart rate after the IS was performed.

Patient #2
Review of Patient #2's physician orders revealed an order on 12/15/16 at 1:50 p.m. for IS 15 times per hour while awake. Review of Patient #2's medical record revealed S5RRT documented a respiratory assessment on 12/16/16 at 8:25 a.m. (day after patient had a surgical procedure) that had no documented evidence of the IS goal and the patient's oxygen saturation, respiratory rate, and heart rate after the IS was performed.

Patient #4
Review of Patient #4's physician orders revealed an order on 12/09/16 at 2:30 p.m. for IS 15 times per hour while awake. There was no documented evidence that a respiratory therapist assessed Patient #4 and instructed on and provided IS. IS was first documented by the RN on 12/11/16 at 3:00 a.m.

Patient #5
Review of Patient #5's physician orders revealed an order on 11/28/16 at 11:44 a.m. for IS 15 times per hour while awake. Review of Patient #5's medical record revealed no documented evidence of a respiratory therapy assessment. IS was first documented by the RN on 11/28/16 at 4:45 p.m.

In an interview on 12/19/16 at 1:35 p.m. with S2DON and S3ADON present, S2DON confirmed she didn't have respiratory services policies that addressed the above topics related to respiratory care services.

In an interview on 12/19/16 at 3:25 p.m., S5RRT confirmed the hospital does not have policies and procedures for specific respiratory procedures that includes the amount of supervision required to perform the procedure. She confirmed that the current policies and procedures are based on a nursing skills book and not related to respiratory services staff. S5RRT indicated the nursing staff was not used to having a respiratory therapist available, so the nurses had been doing IS and breathing treatments prior to her being hired. She further indicated she has instructed the post-surgical unit (PSU) RNs to notify her of any patient admitted with physician orders for IS and breathing treatments. She further indicated IS should be the responsibility of the respiratory therapist. S5RRT indicated there isn't enough communication between the nursing and respiratory department.

Based on record reviews and interviews, the hospital failed to have designated in writing the personnel qualified to perform specific procedures and the amount of supervision required for personnel to carry out specific procedures as evidenced by failure to have documented evidence of such designation. The hospital failed to have documented evidence of orientation and evaluation of competency for 1 (S5RRT) of 3 respiratory therapists' personnel files reviewed for orientation and competency from a total of 8 respiratory therapists employed.
Findings:

Review of the respiratory care services policies presented by S2DON revealed no documented evidence that a policy had been developed that addressed the personnel qualified to perform specific procedures and the amount of supervision required for personnel to carry out specific procedures.

Review of S5RRT's personnel file revealed no documented evidence of orientation and training in respiratory services and an evaluation of competency.

In an interview on 12/19/16 at 1:35 p.m. with S2DON and S3ADON present, S2DON confirmed she didn't have respiratory services policies that designated the personnel who can perform specific procedures and the supervision required.

In an interview on 12/19/16 at 4:05 p.m., S2DON confirmed she had no documentation to present of orientation and evaluation of competency for S5RRT.