HospitalInspections.org

Based on a review of facility documentation and staff interviews (EMP), it was determined that the facility failed to follow their adopted policy related to the establishment of a Grievance Committee.

Findings include:

Review of "Patient/Family Complaint/Grievance Process," revised December 2012, revealed, "... IRMC (Indiana Regional Medical Center) Board of Directors delegated the management of patient/family/designee complaint/grievance to the Patient Advocate and the Grievance Committee ... ."

1) Interview with EMP1 on June 16, 2014, confirmed that there is no formal Grievance Committee and revealed, "We have no committee. It's been like this for years. We have no formal meeting minutes where we discuss Grievances."

2) Telephone interview with EMP7 on June 24, 2014, revealed that the last set of minutes recorded for a Grievance Committee was December 2012.

Based on a review of facility documentation, medical records (MR) and interview with staff (EMP), it was determined that the facility failed to ensure that the orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN) for two of two medical records (MR26 and MR27)

Findings include:

Review of facility policy Use of Restraints in the Non-Violent Non-Self-Destructive Patient, revised May 2014, revealed, "Purpose: To provide guidelines for the use of a restraining device to promote medical/surgical care while protecting and preserving the patient's safety, dignity, rights and well-being ... Restraints Specific for ICU Intubated Patients: ... For all intubated patients the standing ICU Ventilator Orders will be initiated ... Orders: 1 Standing orders, PRN orders and restraint protocols are prohibited ... ."

Review of Order Sheet Indiana Regional Medical Center ... ICU Ventilator Orders, revised February 2014, revealed, "Implement Ventilator Orders, Nursing Orders ... [checked] Restraint Protocol for Intubated Patients ... ."

1) Review of MR26 dated June 17, 2014, revealed, "Implement Ventilator Orders Nursing Orders ... [checked] Restraint Protocol for Intubated Patients ... ."

2) Review of MR27 dated May 5, 2014, revealed phone orders at 10:20 P.M., "Intubate pt -Ventilator protocol."

3) An interview with EMP5 on June 18, 2014, confirmed the above findings. "When the ICU Ventilator Order sheet prints out, the Restraint Protocol for Intubated Patients is automatically checked."

Based on a review of the facility documentation, medical records (MR), and interviews with staff (EMP), it was determined that the facility failed to ensure that orders for drugs and biologicals were documented, and failed to ensure that each drug, including dosage, administered to the patient, was documented in the medical record for two of three applicable medical records reviewed. (MR26, MR27)

Findings include:

"Indiana Regional Medical Center Medical Staff Bylaws, January 2, 2013. ... Article II ... Medical Orders. Section 1. General Requirements: ... (f) Orders for all medications, treatments and procedures for all patients shall be under the supervision of the attending physician and shall be reviewed by the attending physician in a timely manner to assure discontinuance when no longer needed ... (b) All orders must be entered in the patient's record, dated, timed, and signed or countersigned by the responsible Medical Staff member. A practioner's orders shall be written in detail (except when reproduced by departmental agreement) on the order sheet of the patient's record ... ."

1) MR26, dated June 16, 2014, revealed a Physician Progress and Procedure Note indicating that the patient was administered Etomidate and Succinyl Choline for patient intubation. MR26 revealed no documented evidence of a Physician Order for the medications that were administered.

2) MR27, dated June 5, 2014, revealed nursing documentation that the patient was to be intubated, and to see orders. MR27 revealed no documentation Of Physician Orders or administration documentation of the medications related to intubation.

3) Interview with EMP8 on June 18, 2014, revealed (regarding intubation medications), that there are two paralytics and one sedation medication in the bag (Rapid Intubation Kit).

4) Telephone interview with EMP7 on June 24, 2014, confirmed the above findings related to MR26 and MR27. "It was discovered that there was some confusion between the nurses and the Intensivist. The nurses were assuming the physicians were writing the orders and the physicians were assuming the nurses were writing verbal orders."

5) Review of Automated Dispensing Cabinet Information for the patient associated with MR27, on June 25 and 26, 2014, revealed that a Rapid Intubation Kit, was pulled from the Automated Dispensing Cabinet on June 5, 2014.

6) Continued review of MR27 confirmed no documentation of Physician Orders for medications utilized in the Rapid Intubation Kit, and no documentation of which medications from the Rapid Intubation Kit were administered to the patient.

7) Telephone interview with EMP9, on June 26, 2014, revealed that the Rapid Intubation Kit contains four items; sterile water, Vecuronium, Succinyl Choline, and Etomidate. EMP9 revealed that the Automated Dispensing Cabinet was not communicating with the hospital's computer system, and therefore these medications were not posted on the patient's electronic medication administration record.

Based on a review of facility documents and medical records (MR), it was determined the facility failed to ensure that entries in the medical record were timed, as required by adopted Medical Staff Rules and Regulations, in seven of 18 applicable medical records reviewed. (MR10, MR12, MR21, MR22, MR27, MR31, MR32)

Findings include:

"Medical Staff Bylaws Rules & Regulations", dated January 2, 2013. "... Article III, ... Section 3. Authentication: ... (b) All entries in the medical record shall be dated, timed, and authenticated by the person making the entry ... ."

1) Review of MR10, MR12, MR21, MR22, MR27, MR31, and MR32, revealed all contained Progress Notes which were not timed.

2) Interview with EMP6, on June 16 and 18, 2014, confirmed the findings related to MR10, MR12, MR31, and MR32.

3) Interview with EMP2 on June 18, 2014, confirmed the findings related to MR21 and MR22.

Based on a review of facility documents and medical records (MR), it was determined the facility failed to ensure that Verbal Orders were authenticated according to adopted Medical Staff Rules and Regulation in five of 18 applicable medical records reviewed. (MR19, MR23, MR27, MR28, MR29)

"Medical Staff Bylaws Rules & Regulations," dated January 2, 2013. "... Article II, ... Section 3. Verbal Orders: ... (c) A Verbal Order shall include the date, time, and full signature of the person to whom the Verbal Order has been given and shall be countersigned by the prescribing member within 24 hours ... ."

1) Review of MR19 and MR23 revealed signed Verbal Orders, which did not indicate the date and time the Orders were authenticated.

2) Review of MR 27, MR28, and MR29, revealed that Verbal Orders were not authenticated within 24 hours, as described in the facility's adopted Rules and Regulations.

3) Interview with EMP2 on June 17, 2014, confirmed the findings related to MR19.

4) Interview with EMP3 on June 17, 2014, confirmed the findings related to MR28 and MR29.

5) Interview with EMP3 on June 18, 2014, confirmed the findings related to MR23.