HospitalInspections.org

Based on review of facility documents, credential files (CF), and staff interviews (EMP), it was determined that the facility failed to provide training for physicians regarding the hospital policy for the use of restraint and seclusion.
Findings include:
Review of facility policy number 1960, "Restraints," dated November 1997, revealed, "All direct patient care providers will receive education and training regarding restraint/seclusion during orientation, followed by annual review/updates and competency."
1) Review of CF1 through CF20 revealed no documentation of annual training and competency for restraints and seclusion.
2) Interview on October 31, 2012, with EMP1, at approximately 1:45 PM, revealed, "We don't have any training for the physicians for restraints."

Based on review of facility documentation, medical records(MR), and staff interview(EMP), it was determined the facility failed to ensure all patient medical entries were complete, dated, timed, and authenticated for ten of 15 medical records reviewed.
(MR1, MR2, MR4, MR5, MR8, MR9, MR11, MR12, MR13, and MR16,)

Findings include:

Review of facility "Medical Staff Rules & Regulations" revised February 2009, revealed "Article II Medical Records And Physician Orders ... Each entry made into the medial[sic] record must be properly authenticated according to the following guidelines: ... J. All orders shall be recorded in writing. An order shall be considered to be in writing if dictated to a registered nurse, pharmacist, physical therapist, or credentialed members of the respiratory therapy staff within the scope of their practice and signed by the attending physician. Verbal orders must be signed, dated and timed within 24 hours of the order by the ordering practitioner or another practitioner who is responsible for the care of the patient. K. All orders must be written clearly, legibly and completely, dated, timed, and authenticated in written or electronic form by the responsible practitioner."

Review of facility policy "Physician Orders" dated July 2012, revealed "Purpose: To insure quality patient care by proper order entry of all physicians orders. ... 2. Accepting telephone orders: ... c. The nurse will note: 1) date 2) time 3) physician from whom receiving the order ... e. The order shall be countersigned by the prescribing physician within 24 hours."

Review of facility policy "Clarification of Physician Orders" dated July 2012, revealed "All registered nurses will clarify physician's orders as necessary according to established procedure. All physician related concern will be referred to the nurse director. ... Procedure ... 4. Any physician order or physician related concern that cannot be resolved after intervention by the Vice President of Patient Care Services and Nurse Director will be presented to the Chief Executive Officer and Chairman/Medicine or Surgery."

Review of facility policy "PRN Orders" dated June 2011, revealed a physician order "To provide a guideline on how PRN orders are to be written and maintained. ... c. If a PRN order is written for a medication, the prescriber must include the indication for use on the order."

1) Review of MR1 on October 31, 2012, revealed a physician order "10/12 OK to give Ativan prn for anxiety" The order failed to include the dosage. "10/16 Resume meds via NG" The order failed to include the list of medications. "10/18 Morphine 5mg IV[intravenous] q[every] 1 hour PRN[as needed]" The orders failed to include the indication as per policy.

2) Review of MR2 on October 31, 2012, revealed a physician order "10/23/12 Resume tube feeds a 0900" The order did not include the dosage as per policy. Further review of MR2 revealed verbal orders dated October 9, at 9:20 AM, October 14, at 6:00 PM and 20, at 09:30 AM that did not include the date and time by the ordering practitioner.

3) Review of MR4 on October 31, 2012, revealed a physician order "10/16 Morphine 2mg IV q 3 hours PRN ... 10/18 Ativan 2mg(milligram) IV q 2 hours PRN" The orders did not include the indication as per policy. Further review of MR4 revealed verbal orders dated October 14, at 12:45, October 15, at 0930, that did not include the date and time by the ordering practitioner. Continued review revealed a verbal order dated October 16, at 5:30 PM that did not include the practitioner's name, date, or time as per policy.

4) Review of MR5 on October 31, 2012, revealed a physician order "10/10 Morphine 2mg IV q 2 hours prn." The order failed to include the indication as per policy.

5) Review of MR8 October 31, 2012, revealed a verbal order dated July 23, 2012 at 3:20 PM, the order had no countersignature of the physician. Continued review of MR8 revealed a verbal order dated July 25, 2012 at 10:35 AM, the verbal order had the physician's countersignature but did not have a date or time of the counter signature.

6) Review of MR9, October 31, 2012, revealed a verbal order dated August 2, 2012 at 11:15 PM. The order had the physician's countersignature but did not have a date or time of the counter signature. Continued review of MR9 revealed a verbal order dated August 3, 2012. The order had the countersignature of the physician but did not have the date or time of the counter signature.

7) Review of MR11, October 31, 2012, revealed a verbal order dated September 7, 2012 at 8:10 PM, The order did not have a countersignature of the physician. Continued review of MR11 revealed a verbal order dated September 8, 2012 at 3:30 AM. The order did not have the countersignature of the physician.

8) Review of MR12 October 31, 2012 revealed, a Physician Progress Note without a date of time of the entry.

9)Review of MR13, October 31, 2012 revealed a verbal order dated September 18, 2012. The verbal order had a physician countersignature but did not have a date or time.

10) Review of MR16 on October 31, 2012, revealed a physician order "10/29 Lactulose 20 gm as needed." The order failed to include the the indication as per policy.

Interview with EMP1 on October 31, 2012, at approximately 3:00 PM confirmed the above findings and revealed "When it is a PRN order they[physicians] have to write the reason. It's part of our policy." Further interview with EMP1 on November 1, 2012, at approximately 10:00 AM revealed "We have been trying, we are always after them[physicians] to sign, date, and time, verbal orders, we even have signs up to remind them."

Based on a review of facility documents and staff interview it was determined that the facility failed to have automatic stop orders for all drugs and biologicals not specifically prescribed as to time or number of doses.

Findings include:

1) Interview with EMP7, November 1, 2012 at approximately 10:00 AM, "We have stop orders for our dangerous drug list but not for all the medication."

2) Interview with EMP1, November 1, 2012 at approximately 11:00 AM, "We don't have a stop order policy for all the medications."

Based on a Life Safety Code Validation survey, the Condition for Physical Environment is not met based on the results of the Department of Safety Inspection surveyor completed on October 31, 2012. See the Life Safety Code survey 2567 for the deficiencies.

Review of facility documentation, tour of the facility and staff interview(EMP) revealed the facility failed to keep the condition of the physical plant and the overall hospital environment maintained in such a manner that the safety and well-being of patients are assured.

Findings include:

Review facility policy "Emergency Department Cleaning" dated August 2, 2011, revealed "The Emergency Department will be cleaned seven days per week on the first shift (7am - 3:30 pm) using the 7-step cleaning procedure.'

Review facility policy "Room Cleaning Steps" dated August 2, 2011, revealed "Seven steps for room cleaning - Health Care Patient Rooms. 1. High Dust"

1) During a tour of the Emergency Department on November 2, 2012, at approximately 8:20 AM revealed a large amount of dust on the top of the monitors, and procedure lights above the beds in room 13, 14, 15, and 16.

Interview with EMP4 on November 2, 2012, at approximately 8:45 AM confirmed the above findings and revealed "Oh yeah that's high dusting"