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Based on interview and document review, it was determined the facility failed to abide by, and enforce, the Bylaws' Rules and Regulations in responding to ordered consultations within a twenty-four-hour period for one (1) out of nine (9) patients reviewed.

The findings include:

01/04/23 at 9:37 am: The surveyors initiated medical record review of Patient # (1-9) with the assistance of both Staff Member #11 (Assistant Director of Advanced Clinicals) and Staff Member #12 (Director of Advanced Clinicals).

Upon review of Patient #7's medical record, the surveyor found an order for a psychiatry consult which was ordered by the attending physician on 11/09/22 at 9:32 pm for the evaluation of hallucinations and altered mental status (AMS). The surveyor confirmed with the EMR (electronic medical record) Navigator, Staff Member #11, that Patient #7 was not seen by a psychiatrist for the consult until 11/12/22 at 2:44 pm.

The surveyor received the facility's Medical Staff Bylaws and Rules and Regulations (with last revision date of 01/2022) as requested from Staff Member #1 (Director of Quality and Patient Safety) in the afternoon of 01/04/23. On page twenty-one (21) of document, under "XIV. Consultations" section, reads, "The Medical Staff shall assist the hospital [sic] in fulfilling its obligation to provide full consulting services at all times in the hospital".

The document also stated that, "The Medical Staff shall respond to consultations, as defined by the attending physician, within no greater than twenty-four hours of the time the consultant is notified". The "Rules and Regulations of the Medical Staff" document continues to say that the "goal for urgent consultations is for patient assessment or consult to occur within four (4) hours".

The surveyor addressed the finding of Patient #7 receiving a delayed psychiatric consultation following the consult order to both Staff Member #1 and Staff Member #6. Both staff members confirmed finding was accurate and inconsistent with the Medical Staff Bylaws.

Based on staff interview, observation, and document review, it was determined the facility failed to ensure all nursing staff who provide services in the hospital followed the policies and procedures of the hospital. Specifically, hospital nursing staff failed to properly dispose of sharps in one (1) of one (1) one observation of sharps disposal after finger stick blood glucose.

Findings:

The surveyor conducted observations on the 5th floor step down unit on 01/04/23 beginning at 11:00 AM. The surveyor observed staff member #14, a nursing technician obtain a fingerstick blood glucose on an unsampled patient. After completing the fingerstick, staff member #14 disposed of the used lancet into the trash can. The surveyor confirmed with the staff member before leaving the room that staff member #14 disposed of the items in the trash can and not in the biohazard sharps container.

The facility's policy and procedure, Whole Blood Glucose by Novastrip was reviewed and did not contain any information regarding how to dispose of the used test strip or lancet after obtaining the sample and conducting the blood glucose test.

The facility's procedure related to disposal of sharps and hazardous waste was reviewed with the Vice President of Quality on 01/04/22 at 2:25 PM. During the policy review, the Vice President of Quality confirmed that used lancets were considered sharps and should be disposed of in the sharps container.