HospitalInspections.org

Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined that Somerset Hospital failed to provide documented evidence that authenticated protocols were placed in the medical records at the time of initiation, or promptly thereafter, for three of three medical records (MR1, MR3 and MR22).


Findings include:


A review of Somerset Hospital Medical Staff Bylaws Rules & Regulations 2011, revealed "... Rule 4. General Conduct of Care: ... F. Standing Orders - Standing Orders are defined as a pre-printed set of Orders for a specifically defined category of patients which are signed by the physician ... ."


1. MR1 dated September 8, 2014, revealed a physician Order for "Versed 1 mg/hour ... Note to RPh: titrate per protocol ... ."
There was no documented evidence of an authenticated protocol included in the medical record.


2. MR3 dated October 13, 2014, revealed a physician Order for "RT/O2 Protocol."
There was no documented evidence of an authenticated protocol included in the medical record.


3. MR22 dated October 12, 2014, revealed a physician Order for "Ventilator Protocol ... RT/O2 Protocol."
There was no documented evidence of an authenticated protocol included in the medical record.


4. An interview was conducted with EMP1 on October 24, 2010, at approximately 10:00 AM. EMP1 confirmed the above findings and stated, "We do not put protocols on the medical record. ... The ICU keeps a protocol book to refer to or depending on the protocol, it could be posted on the Unit."

Based on a review of facility documents and interview with staff (EMP), it was determined that Somerset Hospital failed to conduct quarterly fire drills at their provider based satellites, and failed to adopt a policy that requires quarterly fire drills at their provider based satellites.
Findings:
Review of Viewing: Fire Emergency policy and procedure dated March 2002, revealed, " ... Standards: ... 2. Practice of the Fire/Evacuation Plan is accomplished through fire drills held at each medical center at least annually. ... . "

1. Quarterly fire drills data for the facility's outpatient provider based satellites was requested and reviewed. It was noted that only one fire drill had been conducted in 2014 in two of the outpatient provider based satellites.

2. An interview was conducted with EMP7 on October 24, 2014. EMP7 confirmed that only one fire drill had been conducted in 2014 in two of the outpatient provider based satellites. EMP7 also confirmed that fire drills are conducted twice a year at the one provider based satellite and annually at the other provider based satellite.

Based on a review of facility documents and staff interview (EMP) it was determined that Somerset Hospital failed to follow their adopted policies and procedures for the transfer of Behavioral Health patients, in four of four medical records reviewed (MR25, MR26, MR27 and MR28), by failing to have a physician Order to transfer, a physician accepting the patient, and a consent signed by the patient or a patient representative.

Findings:

A review of Somerset Hospital Policy, ... Transferring a Patient to a Tertiary Care Facility. ... Policy Statement: To ensure that the patient's plan of care, medical regimen and status at the time of transfer is documented and communicated to the receiving department/facility to maximize coordination of care. ... Procedure: Transfer to another acute care facility must have a written Order for transfer. ... Decide mode of transportation and make necessary arrangements: If the physician is recommending transfer, complete the "Physician Recommendation Ambulance Transfer" form. ... ."



1. Medical records of patients that were treated at Somerset Hospital Emergency Department and transferred to another facility's Behavioral Health Unit were requested and reviewed. (MR25, MR26, MR27 and MR28)


Four of four MR failed to have a CPOE (computerized physican order entry) Order for their transfer.

Four of four MR failed to designate an accepting physican at the receiving facility.

Two of four MR failed to have the patient or guardian signature acknowledging the risks and benefits of the transfer. (MR25, MR28)



2. A telephone interview was conducted with EMP1, on October 28, 2014, at approximately 2:30 PM. EMP1 confirmed that the above mentioned policy is the only transfer policy the facility has, and the policy does not currently address the Behavioral Health patient.