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Based on document review and staff interview it was determined the facility failed to implement corrective action related to identified problems by Health Information Management (HIM) for tracking of verbal and phone orders. This practice does not ensure identified problems are corrected.

Findings include:


Review of the quality indicators for the HIM department revealed monitoring of telephone and verbal orders for authentication within 48 hours, dating and timing. The goal of 90% compliance was set for the indicator. Overall compliance was consistently less than 50 % with trending downward since July, 2011, when overall compliance was 44 %.

The Director of HIM was interviewed on 3/2/11 at approximately 9:00 a.m. She indicated that the data was reported into the Utilization Review Committee meeting. Review of those minutes revealed no discussion of the data and no development and implementation of an action plan to address the low compliance.

The Interim Chief Nursing Officer provided information of the data provided to the Medical Executive Committee and Governing Body that indicated telephone and verbal orders compliance was 84.49%. The Director of HIM was asked to explain the discrepancy in the reports. She indicated the information given to the Medical Executive Committee and Governing Body was data collected by nursing regarding documenting the required read back by nursing when taking a verbal or phone order. She could provide no documentation of the HIM data being reported to the governing body. The only documentation of communication with the Governing Body was noted in the October 26, 2011 meeting minutes, which noted "It was noted that a major issue with the Medical Staff is the timing, dating of their signature. It was noted that another issue was the authentication of verbal or telephone orders that has not been authenticated within 48 hours". There was no discussion of a plan of action to address the issue. The Chief Executive Officer (CEO) presented a copy of the news letter to hospital staff in November 2011 that included a message from the CEO that showed a report regarding the most recent survey by an accreditation organization. He listed the opportunities identified by the organization, which included the dating and timing of medical records entries and authentication of verbal and phone orders. Again, there was no documentation of a plan of action.

Based on interviews of the credentialing staff, Chief of Staff; and review of (5) physician credential files the hospital failed to provide for
quality medical care for the patients.

1. Physicians placed on suspension for incomplete medical records, continued to give orders, write progress notes and conduct rounds; in violation of the hospital bylaws. Refer to A0340.

2. The facility failed to provide for quality physician appraisals for reappointment. Refer to A0340.

3. The facility failed to enforce bylaws established for suspension of physicians. Refer to A0353.

4. The review of Reappointment Profiles for (3) physicians suspended for incomplete medical records did not contain the quality data collection for documentation completion or suspension activity. Refer to A0340.

5. Interview with the Chief of Staff, named on the memo of suspensions to the physicians, revealed he may not see all of the suspension notices that go out for suspended physicians. Refer to A0353.

Due to the systemic lack of maintaining reappointment profiles with quality data, suspended physicians continuing to provide services in violation of the Medical Staff Bylaws and the Chief of Staff not being aware of all suspension notices, the Condition of Participation for Medical Staff was found to be out of compliance.

Based on review of (5) physician credentialing files, interview of the Chief of Staff and interview of medical records staff and credentialing staff the hospital failed to provide for quality appraisals for reappointment. This practice does not ensure safe quality care is delivered to patients.

Findings Include:

1. Five of the (5) physician files reviewed, with the Medical Staff Coordinator and Credentialing staff, on 3/2/12 at 9:30 a.m. did not contain evidence of data or performance reviews for the reappointment.

Interview of the credentialing staff revealed the information was kept at the corporate office, if present. The surveyor asked that quality, performance reviews that was conducted for the reappointments be made available. Three of the five physician reappointment profiles were presented for review. None of the three profiles reviewed were evident of the number of records reviewed or percentage of cases and expected outcomes for performance.

2. Physician #1 was reappointed November 2010 for a two year period. A review of the credentialing and additional information for performance reviews was conducted. Information on the March 2012 reappointment profile contained the physician had "1" under behavior. The credential staff stated that was for a "1" time/incident were the physician wrote orders while suspended from writing orders.

Patients #34, #35, and #36's medical records contain 9 orders written by physician #1, while on administrative suspension.

Interview of the medical records staff on 3/2/12 revealed the physician was placed on suspension 8/30/11 and remains on suspension for incomplete medical records.

3. Physician #2 was originally appointed 12/10 for a period of one year. There was no reappointment checklist or performance review evident. Information presented by medical records revealed that the physician was suspended for incomplete medical records on August 30, 2011 until January 12, 2012.

Patients #37 and #38's physician orders reveal the physician gave orders during December 2011, while on suspension.

4. Physician #3 was reappointed on February 2011 for a two year period. No quality data or performance was present in file or available. The medical records staff presented that the physician had been on suspension for incomplete medical records since 12/19/2011. The physician file and reappointment profile did not contain any information regarding numbers of records for the physician reappointment.

A review of the medical staff by-laws, 2012, for suspension stated that the suspended physician would not be allowed to admit, round, order, write progress notes, or consult. The exception was for patients that were being attended or consulted for by the physician at the time the suspension was placed.

Based on review of the physician credential files and patient medical record reviews two (#1, #2) of three suspended physicians gave orders,wrote progress notes, and wrote discharge orders while on suspended status. The medical staff failed to enforce the bylaws for suspended physician activity. This practice does not ensure safe medical care is delivered.

Findings Include:

1. On 3/2/2012 at 12:30 p.m. an interview was conducted with the Chief of Staff, named on the memo of suspensions to the three physicians. He stated that he may not see all of the suspension notices that go out. When asked if there was a credentialing process that included quality reviews for reappointment, he stated yes. However, he was not sure who or where any information may be kept. When asked what would occur with physicians who violate their suspensions by rounding or giving orders, he stated that the physician would be asked to come for a meeting/consultation.

2. A review of patient medical records for #34, #35, #36, #37, and #38 revealed physician orders, physician progress notes, and physician discharge orders. The orders and notes were written by physicians #1 and #2 while they were on administrative suspension for incomplete medical records.

A review of the current bylaws; article 6 (rules and regulations) 111,16; restrict a suspended physician from admitting patients, conducting elective surgery, rounding, ordering, writing progress notes or consultations.

Based on clinical record review and staff interview it was determined registered nurse (RN) failed to supervise the nursing care to ensure the care was in accordance with physician's orders for 2 (#4, #13) of 38 sampled patients. This practice does not ensure patient goals are met and may lengthen a hospital stay.

Findings Include:

1. Patient #4's history and physical revealed the patient was admitted to the facility on 2/27/12 with a positive blood culture and bacteremia.

Review of physician's admission orders dated 2/27/12 at 10:00 a.m. revealed an order for a urine culture that day before antibiotics. The order included Vancomycin intravenously (IV), give dose STAT after blood cultures are drawn. The nurse noted the orders had been faxed 2/27/12 at 1:20 p.m., approximately three and half hours later.

Review of laboratory entry and results revealed the blood cultures were collected 2/27/12 at 1:55 p.m. The urine culture were collected 2/28/12 at 9:00 a.m.

Review of the medication administration record (MAR) revealed Vancomycin was profiled by the pharmacy on 2/27/12 at 1:22 p.m. Nursing documented Vancomycin was administered on 2/27/12 at 3:22 p.m., which was more than 5 hours after the physician's STAT order was written and 23 hours before the urine culture was collected.

Interviews were conducted on 3/2/12 at 3:01 p.m. with staff RN #1. The interview revealed when a STAT order was received, it should be carried out immediately. An interview at 3::15 p.m. with RN #2 revealed a STAT order means to do it now. An interview at 3:25 p.m. with RN #3 revealed a STAT order should be called to the pharmacy and the laboratory to let them know that the order was STAT.

The Director of the Progressive Care Unit and the Quality Management Coordinator confirmed there was a order for a urine culture to be completed on 2/27/12 and Vancomycin to be given STAT. They also confirmed nursing did not follow the physician's order and the antibiotic should not have been given prior to collecting the urine culture. The Assistant Chief Nursing Officer confirmed that STAT on a physician's order means it should be done right away.


2. Patient #13's physician signed and dated an order protocol for Intravenous (IV) Access/Maintenance/
Flushing Orders. It was not specific to the patient. The order contained multiple selections for the physician to mark for the order. None were selected for Type of Catheter, Reason for Insertion, Reason for Femoral Insertion, Medications, Flush selections ranged from 3 to 10 milliliters (ml).

Interview with the charge nurse on 3/1/12 at 2:00 p.m. revealed that the order sets usually are checked specific to the type of IV line, medications and flushes for each patient.











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Based on record review and staff interview it was determined the facility failed to ensure that orders for medications are only accepted from physicians authorized to provide them for 2 (#34, #38) of 38 sampled patients. This practice does not ensure safe administration of medications.

Findings Include:

1. Review of patient #34's medical record revealed on 12/31/11 at 7:43 p.m. a physician's telephone order was received from physician #1 for 20 milli equivalents (meq) of potassium by mouth now and 20 meq by mouth in the morning. Physician's order dated 12/31/11 at 3:20 p.m. instructed for Ambien 5 milligram (mg) at bedtime as needed, discontinue intravenous fluids, and Lisinopril 10 mg orally for systolic blood pressure greater than 170 daily. Review of the pharmacy order entry of the medications revealed the medication orders had been entered under another physician and not the ordering physician.

2. Review of patient# 38 medical record revealed on 12/30/11 at 6:00 p.m. a physician's order from physician #2 for Librium 50 mg by mouth every 6 hours, hold for sedation and Procardia XL 60 mg by mouth daily, change Lisinopril to 40 mg by mouth two times a day, change Lopressor to 25 mg twice a day, and clonidine 0.1 mg three times a day. Review of the pharmacy order entry of the medications revealed the medication orders had been entered under another physician and not the ordering physician.

An interview conducted on 3/2/12 at approximately 6:00 p.m. with the pharmacist revealed physician's orders for medications are scanned to pharmacy from all units of the hospital. The pharmacist checks the order and enters the medications into the patient's medication profile. He indicated the pharmacist would have a list of suspended physician's in the pharmacy that would be used to verify the physician was not suspended and the orders could be entered into the computer. He indicated a memo was sent from medical records every day to all units to notify staff of physician's who have suspended privileges and are not allowed to write orders for patients. He indicated the memo was usually on the bulletin board, but it could not be found at the time of the interview. The pharmacist indicated there was no stop in the pharmacy order entry software that would prevent a medication ordered by a suspended physician from being entered into a patient's medication profile.

The Director of Pharmacy and the Chief Operating Officer confirmed the orders were not entered under the ordering physician. They also confirmed it was the pharmacist entering the medication orders responsibility to confirm the ordering physician was not on the medical records suspension list that was distributed daily to all departments. There was no explanation of how or why the orders were entered under another physician's name.

3. Interview with the Director of Health Information Management on 3/2/12 at approximately 9:00 a.m. revealed that physicians #1 and #2 were under suspension when the orders were written and were not authorized to write or give verbal or phone orders.

Based on review of physician orders and policy and staff interview it was determined physician verbal orders were not signed for one (#16) of 38 sampled patients. This practice does not ensue orders are authenticated by the physician.

Findings include:

1. Physician orders dated 2/25/12 for patient #16 revealed orders for cardiac monitoring with no admitting diagnosis, but all boxes had been checked as indicating it applied to this patient. The patient's addressogram indicated the patient's name and identifying criteria had been attached to the bottom of the form. There was evidence in the patient's medical record that the patient was being monitored by telemetry. The physician had not dated, timed, or signed the document. Telephone orders taken on 02/25/12 at 11:10 a.m. and admission orders dated 02/25/12 at 11:15 indicated by "T/O/C" and the doctors and nurses name. It did not include the physician's signature.
Two orders, dated 02/26/12 for an increase in Tylenol daily, a CBC (complete blood count) and stool occult blood test were noted as written by the physician that did not include the time of the order.

Based on record review and staff interview it was determined the facility failed to ensure the physician completed a discharge summary for 1 (#37) of 38 sampled patients. This practice does not ensure all information is available to the medical team.

Findings include:

Patient #37 was admitted to the facility on 12/23/11 and discharged on 12/27/11. Review of the medical record revealed no evidence that a discharge summary had been entered into the medical record.

The Director of Nursing for Critical Care confirmed there was no discharge summary during interview on 3/2/12 at approximately 1:00 p.m.

Based on observations of the 5 operating rooms and one endoscopy procedure room; on 3/1/2012 at 1:15 p.m. surgical equipment, oxygen tanks, and wheel casters were not maintained to prevent corrosive build up. Surgical table arms were visible for tape that prevent adequate cleaning and disinfecting. This practice does not provide for a clean surgical environment.

Findings Include:


1. Observation of operating room (OR) #2 revealed the operating table arm board contained 3 pieces of tape and uneven surface. On a cart in the OR, the wheel cover casters were observed to have a corrosive, rust colored substance.

2. Observation of OR #5 revealed the operating room arm board contained tape and uneven repair. A blue stand holding the laser equipment had wheel cover casters that were observed to have a corrosive, rust colored substance.

3. Observation of OR room #8 revealed an anesthesia cart that had portable oxygen tanks that were observed to have corrosive, rust colored substance. Two stands and one table wheel cover casters were observed to also have flaking build up of corrosive, rust colored substance present.

4. All of the operating room observations were conducted with the surgery manager. A review of the operating room audit tool used by the facility was conducted. Corrosive or rust build up was not present on the monitored items listed.

Based on observation, interview with dietary staff, and review of cleaning schedules, the facility failed to ensure that the main kitchen was maintained in sanitary order to prevent transmission of food borne illness, and physical contamination.

Findings include:

During a tour of the main kitchen, on 02/29/12 beginning at 10:00 a.m. , with the Director of Food Service, the following was noted:
· Along the bottom edge of the right side of the ventilation hood, drips were noted at an interval of an inch or two. When the edge was wiped with a paper towel, the drips appeared to be grease. The grease collection container, located in the back right side of the hood, was noted to be full of liquid grease. The Director of Food Service reported, at that time, that the hood and grease trap were to be cleaned weekly on Sundays, but someone must had missed cleaning it.
· The tray return/conveyor track leaving the clean side of the dish machine was noted, on 02/29/12 at 1:40 p.m. . to have food (penne pasta) and an unknown substance on the rack. The unknown substance was slippery feeling and looked like small clumps of oatmeal .
· Several ceiling tiles throughout the kitchen, including ceiling vents and lattice coverings over vents, were noted to be coated with a dust like debris, indicating air flow.
· The wall behind the slicer was noted to be splattered with bits of an orange substance, that was hard and dried onto the wall.
· A tall open metal cart located in the cold reach in, holding meals for same day surgery, was noted to be soiled with a beige crusty substance on the horizontal and vertical supports. A tall open metal cart located in the heated reach in, was noted to be soiled with a beige crusty substance on the horizontal and vertical supports.
· Clean wet steam table pans were noted to be stacked together on a drying storage rack, located across from the 3-compartment sink. The drying storage rack was noted to be encrusted with beige debris and a dust like substance. The steam table pans were noted to have standing water in the lips of the pans and were wet inside and out.
· The Robot-Coupe was pushed against the back wall of the cook's prep table and the lid was on and secured. Upon request the robot coupe was opened and noted to be wet inside. The staff member reported that the equipment had been used for lunch service and cleaned for later use. He confirmed that the inside was wet and the lid should not have been secured as the inside would not have air dried.
· The Dairy walk in shelving was noted to have dried white and black debris in the corners on the shelving.
· The lattice fan cover in the produce walk in was noted to be wet with a black substance caught in the lattice work.
· In the walk in freezer two bags of a battered food were noted to be open to the air. A bag of frozen vegetables was noted to be ripped, exposing the vegetables to the air.
· The inside of the door to the ice machine was noted to have a thin black coating of a substance.
· Extension cords hanging down from the ceiling, coiled and secured to be hanging 3-4 feet from the ceiling, were noted to be dusty.
Interview with the Food Service Director on 03/02/12 at 10:30 a.m. revealed that cleaning assignments were in place specific for job assignments and for bigger cleaning (ceilings, equipment) the department had a cleaner three times a week. She reported that the assignment for this cleaner was based on a walk through sanitation checklist and was not a formal assignment that would be written and signed off.