HospitalInspections.org

Based on review of Medical Staff Bylaws, hospital policies/procedures, medical records, and interviews, it was determined that the hospital governing body failed to ensure that the medical staff be accountable for the quality of care provided to patients.

Findings include:

Review of the hospital Medical Staff Bylaws revealed: "...The Medical Staff is responsible to the Hospital Governing Board of Directors for the professional medical care performed in the hospital and the quality of medical care rendered...The Medical Staff appointees practicing at...Hospital must agree to practice in conformity with the Medical Staff Bylaws, Rules and Regulations and the Hospital Policies and Procedures...."

Cross reference Tag A0353 regarding failure of the hospital medical staff to enforce bylaws to carry out its responsibilities as evidenced by:

1. failing to require physicians #3, 6, and 7 to write complete orders for 4 of 4 patients receiving care in the ICU (Pts #16, 17, 18, and 19);

2. failing to require physician #3 to write complete insulin orders for 1 of 2 patients (Pt #30); and

3. failing to require physician #2 to screen Pt #14 for risk of suicide as required by hospital policy/procedure.

The Director of Pharmacy confirmed during interview conducted on 10/13/11, that the medication orders were incomplete.

The Clinical Director of the Emergency Department confirmed during interview conducted on 10/11/11, that the medical record did not contain documentation of an assessment of the patient's behavioral health status.

Based on review of hospital policy/procedure, medical records, and interview, it was determined that the hospital failed to assure that the use of restraint be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient for 2 of 3 patients (Pt's #17 and 18).

Findings include:

Review of the hospital policy/procedure titled Restraints revealed: "...Restraint orders: An order from a physician or other licensed independent practitioner must be written...."

Review of medical records:

Pt #17 was admitted on 12/01/10. His medical record contained documentation that he was placed in bilateral wrist restraints at 1200 on 12/5/10 without a physician's order being obtained until 1945.

Pt #18 was admitted on 2/18/11. His medical record contained documentation that the patient was in wrist restraints on 2/20/11 from 0700 through 2/21/11 at 0600. The medical record did not contain an order for restraints on 2/20/11.

Pt #18's medical record contained documentation that he was in wrist restraints on 2/22/11 from 0700 through 1400. The medical record did not contain an order for restraints on 2/22/11. On 2/22/11 at 0600, an RN completed documentation of alternative interventions employed before the application of restraints and the clinical justification for the use of restraints. Physician #3 wrote the order for restraints on 3/10/11, after the patient was discharged.

The CNO confirmed during interview conducted on 10/13/11, that the medical records did not contain the required physician orders for restraints.

Based on review of hospital policy/procedure, medical records, and interview, it was determined that the hospital failed to require that restraints be discontinued at the earliest possible time regardless of the length of time identified in the order for 3 of 3 patients (Pts #17, 18 and 19).

Findings include:

Review of the hospital policy/procedure titled Restraints revealed: "...Restraint orders:...The restraint order will end at the earliest possible time...."

Review of medical records:

Pt #17's medical record contained documentation that he was in wrist restraints from 1200 on 12/05/10 through 0600 on 12/06/10. Review of the Restraint section of the nursing flow sheet revealed a section for the RN to document need for restraints. An RN recorded "T R" from 1200 through 1900 (Intubated/ Removing Med. Dev. Medical Devices). The RN recorded only "T" (Intubated) in the spaces from 2000 on 12/5/10 through 0600 on 12/6/10. There was no further documentation of behaviors requiring restraints. An RN also documented on the 24 Hour Critical Care Assessment Flow Sheet every hour, from 2000 on 12/5/10 through 0400 on 12/6/10 a "Mod. Ramsey Scale" #4 (Asleep, sluggish response). An RN documented #3 (Asleep, brisk response) at 0500 on 12/6/10 and #2 (Tranquil, oriented) at 0600 on 12/6/10.

Pt #18's medical record contained documentation that he was in wrist restraints from 0700 on 2/21/11 through 0600 on 2/22/11. An RN documented need for restraints as "R" (Removing Med. Dev) on 2/21/11 from 0700 through 1900. The RN recorded only "T" (Intubated) on the Restraint flow sheet in the spaces from 2000 on 2/21/11 through 0600 on 2/22/11. There was no further documentation of behaviors requiring restraints. An RN documented on the 24 Hour Critical Care Assessment Flow Sheet every hour from 2000 on 2/21/11 through 0600 on 2/22/11 a "Mod. Ramsey Scale" #4 (Asleep, sluggish response).

Pt #19's medical record contained documentation that she was in bilateral wrist restraints from 0700 on 7/14/11 through 0600 on 7/15/11. On 7/14/2011, at 0700, an RN recorded on the Physician's Restraint Order form: "...Consider potential cause of behavior...other...intubated, using chemical restraint of Propofol...Clinical Justification...Unable to control activities or self movement, prevent interference from medical safety/care..." The medical record did not contain documentation of patient behaviors which required restraints at 0700 or at any time from 0700 on 7/14/11 until 7/15/11 at 0200, when an RN documented that the patient exhibited: "...agitated movements...moving all extremities...." An RN documented need for restraints as "T" (Intubated) on the Restraint flow sheet in the spaces from 0700 on 7/14/11 through 0600 on 7/15/11. An RN documented on the 24 Hour Critical Care Assessment Flow Sheet every hour from 0700 through 1400 on 7/14/11 a "Mod. Ramsey Scale #3 (Asleep, brisk response). An RN documented #4 (Asleep, sluggish response) from 1500 through 2300 on 7/14/11 and from 2400 through 0600 on 7/15/11.

The CNO confirmed during interview conducted on 10/13/11, that the documentation indicated that the RN did not remove restraints at the earliest possible time for Pt's #17, 18 and 19 as required by policy.

Based on review of hospital policy and procedure, hospital documents and interview, it was determined that the hospital failed to require that physicians have a working knowledge of hospital policy regarding the use of restraints for 1 of 2 physician (physician #3).

Findings include:

Review of the hospital Medical Staff Bylaws revealed: "...The Medical Staff is responsible to the Hospital Governing Board of Directors for the professional medical care performed in the hospital and the quality of medical care rendered...The Medical Staff appointees practicing at...Hospital must agree to practice in conformity with the Medical Staff Bylaws, Rules and Regulations and the Hospital Policies and Procedures...."

Review of Physician #3's credential file revealed that he is an Active member of the Medical Staff.

Review of hospital policy/procedure titled Restraints revealed: "...Staff education:...All staff with direct patient contact will have ongoing education and training in the proper and safe use of restraints...."

Review of medical records:

Physician #3 provided medical care to Pt's #17, 18, and 19. He ordered the use of restraints for Pt's #18 and 19.

Review of Pt #18's medical record revealed that an RN completed documentation on 2/22/11 at 0600, of alternative interventions employed before the application of restraints and the clinical justification for the use of restraints. Physician #3 wrote the order for restraints on 3/10/11, after the patient was discharged.

Review of Physician #3's credential file revealed that it did not contain documentation of any training related to restraints or hospital policy regarding the use of restraints.

The Coordinator of Medical Staff Services confirmed on 10/13/11, that the hospital was unable to provide documentation that Physician #3 had received training or written information regarding the use of restraints in the hospital.

Based on review of Medical Staff Bylaws, hospital policies/procedures, medical records, and interviews, it was determined that the medical staff of the hospital failed to enforce bylaws to carry out its responsibilities as evidenced by:

1. failing to require physicians #3, 6 and 7 to write complete orders for 4 of 4 patients receiving care in the ICU (Pts #16, 17, 18 and 19);

2. failing to require physician #3 to write complete insulin orders for 1 of 2 patients (Pt #30); and

3. failing to require physician #2 to screen Pt #14 for risk of suicide as required by hospital policy/procedure.

Findings include:

Review of the hospital Medical Staff Bylaws revealed: "...The Medical Staff is responsible to the Hospital Governing Board of Directors for the professional medical care performed in the hospital and the quality of medical care rendered...The Medical Staff appointees practicing at...Hospital must agree to practice in conformity with the Medical Staff Bylaws, Rules and Regulations and the Hospital Policies and Procedures...."

Review of the hospital document titled La Paz Regional Hospital-Medical Staff-By Status revealed that physicians #2, 3, 6 and 7 are all Active members of the Medical Staff.

1. Review of the hospital policy/procedure titled Orders: Medications revealed: "...CONTENTS OF MEDICATION ORDERS...Medication name, strength (and dosage form, if necessary)...Directions for use (including route of administration, frequency, and symptom or indication for use as required by hospital policy)...Orders that are not complete...will be clarified with the prescriber...QUALIFICATION OF TIMES OF DOSE ADMINISTRATION...Each practitioner who prescribes medications must clearly state the administration times or the time interval between doses...."

Cross reference Tag A0404 #1 for information regarding Pt #16's incomplete orders for Propofol and Dopamine.

The Chief Nursing Officer (CNO) confirmed during interview conducted on 10/11/11, that the physician orders for the Propofol and Dopamine were incomplete.

Cross reference Tag A0404 #1 for information regarding Pts #17, 18 and 19, and incomplete orders contained in their medical records.

The Director of Pharmacy confirmed during interview conducted on 10/13/11, that the medication orders in Pts #17, 18 and 19's medical records were incomplete.

2. No Specific Policy or Procedure on Insulin was available for review by surveyor. CNO confirmed on 10/13/11 at 1220, that there is no facility policy for Sliding Scale Insulin Administration, and that the facility follows the protocol titled "DR. ( # 8) Routine Sliding Scale" for Regular Insulin sliding scale.

See #1 above for information included in hospital policy/procedure titled Orders: Medication.

Cross reference Tag A0404 #2 for information regarding Pt #30, and incomplete orders contained in Pt #30's medical record.

The Director of Pharmacy confirmed during interview conducted on 10/13/11, that the Insulin orders in Pt #30's medical record were incomplete.

3. Review of policy/procedure titled Suicide Prevention revealed: "...All patients receiving hospital treatment with a primary diagnosis or primary complaint of an emotional or behavioral disorder will be screened for risk of suicide in the hospital, regardless of assessment by outside mental health agency. 'Emotional or behavioral disorders' refers to any primary DSM (Diagnostic and Statistical Manual of Mental Disorders) diagnosis or condition, including those related to substance abuse. If a patient is identified to be at risk for suicide, then suicide precaution interventions will be implemented...PROCEDURE:...A licensed healthcare professional will screen for suicide risk by identifying those who are being treated for the following emotional or behavioral disorders: Mood Disorders...Mental Disorders...History of suicide attempts or current suicide ideation...History of aggressive or disruptive behavior...After identification of a patient who is receiving treatment for the emotional or behavioral disorders listed above, the licensed healthcare professional whill (sig) then screen patients for suicide risk by questioning and observing the patient utilizing the sample 'Yes or No' question (sig) listed...."

Review of medical record:

On 10/11/11, at 1930, an Emergency Room (ER) RN triaged Pt #14. The RN documented: "...Chief Complaint: Bipolar Episode-'Destroyed House'...Brought by ACTS (Arizona Counseling Treatment Services)/or Nursewise...Treatment Prior to arrival?...Nursewise/ACTS...Past Medical History: Bipolar...Addicted to Vicodin...Nurses Notes: pt said she 'Destroyed her house' during a Bipolar Episode...."

The medical record contained a document titled ACTS CRISIS EVALUATION, completed by a Clinician/Assessor employed by an outside agency. Review of the document revealed: "...On Site Time 1645...Presenting Problem or Request for Assistance...'I thought about taking all of my Vicodin'...Triage...Are you able to keep yourself safe until this assessment is completed?...No...Are you in possession of a gun or weapon or do you have easy access to a gun or weapon?...Yes...Have you felt like hurting yourself?...Yes...Ideations...'Anything can trigger me...I would beat them to death or stab them the neighbor girl...I will kill her if I see her'...Plan:...'I would find my Vicodin and take them all'...'3 weeks ago I cut my wrist and today I thought about taking my pills'...Substance Abuse/Use...'Vicodin, Speed, Cocaine, and I drink alcohol'...Mental Status Exam...Mood...anxious, angry, depressed, hopeless, irritable...Thought Content...suicidal or homicidal ideation...Psychotic Processes:...'I see demons and spirits, there are children that run down the halls a man and a woman and my grandmother'...Does not feel she can be safe in her house at this time and feels she may hurt her children or husband unintentionally this staff transported C (Client) to hospital for medical clearance and faxed...to the SAF (Subacute Facility) for medication stabilization and Detox from Vicodin...."

On 10/10/11, at 2230, the ER physician documented: "...Chief Complaint...Anxiety...context: wants to kill neighbor...associated symptoms:...suicidal thoughts...Past Hx (History) psychiatric problems...bipolar disorder...Medically Clear for SAF Yuma Az...Clinical Impression...Bipolar...."

The medical record did not contain a suicide risk assessment conducted by a licensed healthcare professional as required by hospital policy/procedure. The medical record contained documentation that the patient remained in the ER from 1930 on 10/10/11 until 1030 on 10/11/11, when she was transported by ambulance to SAF in Yuma.

The Clinical Director of the Emergency Department confirmed during interview conducted on 10/10/11, that the medical record did not contain documentation of an assessment of the patient's behavioral health status by hospital staff. She explained that ACTS and Nursewise are contracted by Cenpatico, the Regional Behavioral Health Authority (RBHA), to provide crisis services.

The Director of Quality Assessment/Performance Improvement confirmed during interview conducted on 10/12/11, that the hospital does not have a contract with Cenpatico or ACTS or Nursewise.

On 10/14/11, the Clinical Director of the Emergency Department provided a document titled La Paz County Crisis Protocols. Review of the document revealed: "...The protocols should never override the obligation to provide the most clinically appropriate intervention based on each individual situation...."

Based on review of hospital policies/procedures, medical records, and interviews, it was determined that the facility failed to assure that the Registered Nurse assessed/evaluated a patient's suicide risk for 1 of 1 patient (Pt #14).

Findings include:

Cross reference Tag A0353 #3 for information regarding the policy/procedure titled Suicide Prevention and failure to require a licensed healthcare professional (RN) to screen Pt #14 for suicide risk.

The Clinical Director of the Emergency Department confirmed during interview conducted on 10/10/11, that the medical record did not contain documentation of an assessment of the patient's behavioral health status.

Based on review of hospital policies/procedures, medical records, and interviews, it was determined that the hospital failed to assure that drugs be controlled and distributed in accordance with applicable standards of practice and hospital policy/procedure as evidenced by failure to clarify incomplete medication orders prior to dispensing medication for 4 of 4 patients receiving care in the ICU (Pt's #16, 17, 18 and 19) and 1 of 2 patients receiving Insulin (Pt #30).

Findings include:

Review of the hospital policy/procedure titled Medication Administration revealed: "...Medication Administration...Nursing...Nursing and the hospital Pharmacist will work in a collaborative manner in pursuing the policies and procedures for medication administration...REQUIREMENT FOR A VALID ORDER: Individuals who prepare, dispense, and administer medications shall do so only upon the order of a practitioner who has been granted clinical privileges and...legally authorized to prescribe/order medication...COMPLIANCE WITH MEDICATION ORDERS: Medications shall be prepared and administered in accordance with the orders of the prescriber or practitioner responsible for the patient's care and accepted standards of practice...."

Review of the hospital policy/procedure titled Orders: Medications revealed: "...CONTENTS OF MEDICATION ORDERS...Medication name, strength (and dosage form, if necessary)...Directions for use (including route of administration, frequency, and symptom or indication for use as required by hospital policy)...Orders that are not complete...will be clarified with the prescriber...QUALIFICATION OF TIMES OF DOSE ADMINISTRATION...Each practitioner who prescribes medications must clearly state the administration times or the time interval between doses...."

Review of the hospital policy/procedure titled Dispensing: Verification/Clarification of Orders revealed: "...POLICY...Orders that are incomplete, illegible, or otherwise unclear shall not be filled and shall be verified or clarified prior to dispensing. All orders must be complete, accurate and timely...VERIFICATION/CLARIFICATION OF MEDICATION ORDERS...If there is any question regarding a medication prescribed, dose, strength, administration frequency, or dosage interval, a nurse or pharmacist shall contact the prescriber. All questionable orders shall be verified/clarified prior to dispensing the medications...."

Cross reference Tag A0404 #1 for information regarding Pt #16 and the incomplete medication orders contained in Pt #16's medical record.

The Chief Nursing Officer (CNO) confirmed during interview conducted on 10/11/11, that the physician orders for the Propofol and Dopamine were incomplete and required clarification before administration of the medications.

Cross reference Tag A0404 #1 and #2 for information regarding Pts #17, 18, 19 and 30 and the incomplete medication orders contained in their medical records.

The Director of Pharmacy confirmed during interview conducted on 10/13/11, that the medication orders in Pts #17, 18, 19 and 30's medical records were incomplete and required clarification by Pharmacy before dispensing and administration of the medications.

Based on review of hospital policy/procedure, hospital documents, and interviews, it was determined that the hospital failed to assure that when a pharmacist is not available, drugs and biologicals are removed from the pharmacy only by personnel designated in the policies of the medical staff and pharmaceutical service.

Findings include:

Review of the hospital policy/procedure titled Obtaining Medication from After-Hours Stock revealed: "...The pharmacy shall maintain a limited supply of commonly used medications in specially designated location(s) for use when: The pharmacy is closed...A pharmacist is unavailable...Medications are not in the patient's supply and cannot be obtained from the pharmacy in a timely manner...Only designated individuals (by name and title or qualification) shall remove medications from the after-hours stock. These individuals shall be oriented to the removal of medications from the after-hours stock...."

The Director of Pharmacy confirmed during interview conducted on 10/12/11, that the pharmacy is open and a pharmacist available 7 days a week from 0700 until 1530. After those hours, it is necessary for RN's to access the pharmacy to obtain medication that is not available in the Pyxis.

Review of the hospital document titled After Hours Pharmacy Log revealed:

RN #26 removed medications from the pharmacy on 6/15/11, 6/16/11, 6/19/11, 6/21/11, 6/25/11, 6/26/11, 7/3/11, 7/11/11, 7/18/11, 7/19/11, 7/20/11, 7/29/11, 7/30/11, and 7/31/11. Review of her personnel file revealed that it did not contain documentation that she had been designated to remove medications from the pharmacy after hours or oriented to do so.

RN #27 removed medications from the pharmacy on 6/19/11, 6/27/11, 7/14/11, 7/25/11, and 9/6/11. Review of her personnel file revealed that it did not contain documentation that she had been designated to remove medications from the pharmacy after hours or oriented to do so.

RN #28 removed medications from the pharmacy on 7/15/11, 1/21/11, 7/22/11, 7/23/11, 7/24/11,7/31/11, 8/4/11, 8/7/11, 8/18/11, 8/31/11, 9/5/11, 9/7/11, and 9/8/11. Review of her personnel file revealed that it did not contain documentation that she had been designated to remove medications from the pharmacy after hours or oriented to do so.

The Director of Pharmacy confirmed during interview conducted on 10/12/11, that RN's are accessing the pharmacy after hours several times a week. He confirmed that he had no documentation of specific individuals designated to remove medications from pharmacy after hours or their orientation to do so.

The Director of Human Resources confirmed during interview conducted on 10/13/11 at 1200, that the facility did not have a list of individuals designated to remove medications from pharmacy after hours or documentation of their orientation to do so.

Based on observation during tour, review of hospital policies/procedures, and interview with staff, it was determined that the hospital failed to ensure availability of emergency equipment on two hospital units as evidenced by the absence of a Pediatric Code cart in the Surgery area and in the Medical-surgical unit for use in an emergency.

Findings include:

Facility Policy and Procedure titled "Admission- Pediatric" dated 09/02 revealed: "...Refer to emergency medications/actions for children if needed...."

Facility Policy and Procedure titled "Admission to Medical Surgical Unit" dated 03/05 revealed: "...all patients admitted...will ensure a safe transition to inpatient status for proper medical treatment...prior to transport...the Medical/Surgical Unit Charge Nurse with a full status report as to the patient's condition, equipment needs...If service is not available within the hospital at that time, then the patient may be transferred to an outside facility...."

The code cart on the Medical Surgical unit was observed on the afternoon of October 11, 2011 to
only be for adults. It was observed that there was no pediatric code cart available on the Medical Surgical Unit.

RN # 6 confirmed on October 11, 2011 at 1400, that there is no Pediatric Code Cart located on the Medical Surgical Unit. RN # 6 also confirmed that patient # 26 was a Pediatric patient and currently admitted to the Medical Surgical unit.

The code cart on the Surgery unit was observed on the afternoon of October 11, 2011 to
only be for adults. It was observed that there was no pediatric code cart available in the Surgical Unit.

RN # 10 confirmed on October 12, 2011 at 0830, that there is only one Pediatric Code Cart in the facility, and it is located in the Emergency Department. RN # 10 confirmed on October 12, 2011, that Patient # 26 was a pediatric patient and was seen in the Surgical Unit for a procedure on October 11, 2011.

The CNO confirmed on October 13, 2011 at 1220, that there is no Pediatric Code cart located in Surgery or on the Medical/Surgical Unit of the facility.

Based on review of hospital documents, medical records, and interview, it was determined that the hospital failed to:

1. measure, analyze, and track high risk, problem-prone areas related to incomplete physician medication orders; and

2. measure and analyze data related to quality indicator relevant to restraint data.

Findings include:

1. Cross reference Tag A0353 #1 and #2 regarding the failure of the hospital medical staff to enforce bylaws to carry out its responsibilities as evidenced by failure to require physicians #3, 6, and 7 to write complete orders for 4 of 4 patients receiving care in the ICU (Pts #16, 17, 18 and 19); and failure to require physician #3 to write complete insulin orders for 1 of 2 patients (Pt #30).

Cross reference Tag A0404 #1 and #2 related to nursing responsibility for clarifying the physicians' medication orders for Pts #16, 17, 18, 19 and 30.

Cross reference Tag A0500 related to pharmacy responsibility for clarifying the physician's medication orders for Pts #16, 17, 18, 19 and 30.

The Director of Quality Assessment/Performance Improvement confirmed during interview conducted on 10/12/11 at 1515, that the Quality Assessment Performance Improvement Program had not identified the problem of incomplete physician medication orders. She stated that physician entries in the medical records were monitored for completeness, but the completeness of medication orders was not included in this monitor.

2. Cross reference Tag A0168 regarding failure to assure that the use of restraint be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient for 2 of 3 patients (Pt's #17 and 18).

Cross reference Tag A0174 regarding failure to require that restraints be discontinued at the earliest possible time regardless of the length of time identified in the order for 3 of 3 patients (Pts #17, 18 and 19).

Review of the hospital documents titled Monthly Restraint Data revealed data for February 2011 and July 2011. The data did not include measurement or analysis of data regarding removal of restraints at the earliest possible time. The data regarding physician orders indicated 100% compliance.

The Director of Quality Assessment/Performance Improvement confirmed during interview conducted on 10/12/11 at 1515, that the Quality Assessment Performance Improvement Program had not identified any problems related to restraints.

Based on review of hospital policies/procedures, medical records, and interviews, it was determined that the hospital failed to assure that a registered nurse administer medication in accordance with the orders of the practitioner/s responsible for the patient's care, as evidenced by:

1. failing to clarify incomplete medication orders prior to administering medication, per hospital policy for 4 of 4 patients receiving care in the Intensive Care Unit (ICU) (Pt's #16, 17, 18 and 19); and

2. failing to clarify incomplete insulin orders for 1 of 2 patients (Pt #30).

Findings include:

Review of the hospital policy/procedure titled Medication Administration revealed: "...Medication Administration...Nursing...Nursing and the hospital Pharmacist will work in a collaborative manner in pursuing the policies and procedures for medication administration...REQUIREMENT FOR A VALID ORDER: Individuals who prepare, dispense, and administer medications shall do so only upon the order of a practitioner who has been granted clinical privileges and...legally authorized to prescribe/order medication...COMPLIANCE WITH MEDICATION ORDERS: Medications shall be prepared and administered in accordance with the orders of the prescriber or practitioner responsible for the patient's care and accepted standards of practice...."

Review of the hospital policy/procedure titled Transcribing medication to the "MAR" (medication profile) revealed: "...The Charge Nurse will then view the original orders in the chart...Before noting the doctor's orders, she is responsible that (sic) all medications are verified for the correct patient, dosage, route, time, and drug on the medication profile...."

Review of the hospital policy/procedure titled Orders: Medications revealed: "...CONTENTS OF MEDICATION ORDERS...Medication name, strength (and dosage form, if necessary)...Directions for use (including route of administration, frequency, and symptom or indication for use as required by hospital policy)...Orders that are not complete...will be clarified with the prescriber...QUALIFICATION OF TIMES OF DOSE ADMINISTRATION...Each practitioner who prescribes medications must clearly state the administration times or the time interval between doses...."

Review of the hospital policy/procedure titled Dispensing: Verification/Clarification of Orders revealed: "...POLICY...Orders that are incomplete, illegible, or otherwise unclear shall not be filled and shall be verified or clarified prior to dispensing. All orders must be complete, accurate and timely...VERIFICATION/CLARIFICATION OF MEDICATION ORDERS...If there is any question regarding a medication prescribed, dose, strength, administration frequency, or dosage interval, a nurse or pharmacist shall contact the prescriber. All questionable orders shall be verified/clarified prior to dispensing the medications...."

1. Review of medical records:

Pt #16 was admitted on 9/30/11, and was in the Intensive Care Unit (ICU) during the on-site survey. A physician wrote an order on 10/8/11 at 0947: "...Propofol drip per protocol to achieve sedation...." On 10/8/11 at 1445, an RN wrote a physician's verbal order: "...Titrate propofol down to maintain MAP (Mean Arterial Pressure) (greater than or equal to) 65; if unable to do so/if pt is fighting et (and) MAP <65, Start dopamine drip 5 mcg/Kg/ml (5 micrograms per kilogram per milliliter)...(per protocol) IV...."

Pt #16's medical record did not contain a Propofol protocol or a Dopamine protocol. It did contain documentation that the RN initiated and titrated Propofol and Dopamine (intravenous) IV infusions without orders for dosage for the Propofol or directions for titration for either medication.

RN #19 confirmed during interview conducted on 10/11/11, that nursing initiated the Propofol and Dopamine IV infusions and titrated both medications according to the nurses' experience and judgment.

The Chief Nursing Officer (CNO) confirmed during interview conducted on 10/11/11, that the physician orders for the Propofol and Dopamine were incomplete and required clarification before administration of the medications.

Pt #17 was admitted on 12/1/10. He required care in the ICU and was placed on a ventilator. On 12/3/10 at 1200, an RN wrote a physician's telephone order: "...Dopamine 5 mcg titrate to keep SBP (Systolic Blood Pressure) >100...." On 12/3/10 at 1705, a physician wrote an order: "...Versed; titrate to ventilator tolerance...." On 12/4/10 at 2230, an RN wrote a physician's verbal order: "...May (increase) Versed to keep pt. sedated...."

Pt #17's medical record contained documentation that nursing initiated and titrated Dopamine and Versed IV infusions without orders for dosage or directions for titration.

On 12/5/10 at 1220, an RN recorded a physician's telephone order: "...Morphine 2-4 mg q2h (every 2 hours) prn (as needed) agit (agitation)...Ativan 2 mg q 2h prn (agitation)...Versaid (sic) 2.5 mg-5mg q 4 h prn (agitation)...." The medical record did not contain clarification regarding which medication to utilize first or for degree of agitation. The medical record contained documentation that an RN administered Versed, Morphine and Ativan at 1230, Morphine at 1430, Morphine at 1730, and Versed at 1730 without clarifying the physician's order.

The CNO confirmed during interview conducted on 10/13/11, that the orders in Pt #17's medical record were incomplete and required clarification before administration of the medications.

Pt #18 was admitted on 2/18/11. He required care in the ICU and was placed on a ventilator. On 2/20/11 at 0515, an RN wrote a physician's telephone order: "...Versed gtt (drip) titrate to tolerate ventilator...." On 2/20/11 at 0645, an RN wrote a physician's telephone order: "...Ativan 2 mg IVP (IV Push) q 1 hr prn...." The medical record contained documentation that an RN initiated and titrated the Versed infusion without orders for dosage or directions for titration and administered IV Ativan without clarifying the indication for the Ativan.

The CNO confirmed during interview conducted on 10/13/11, that the orders in pt #18's medical record were incomplete and required clarification before administration of the medication.

Pt #19 was admitted on 7/13/11. She required care in the ICU and was on a ventilator. On 7/13/11, a physician wrote an order: "...propofol per ICU protocol...." The medical record did not contain a Propofol protocol. The medical record contained documentation that an RN initiated and titrated the Propofol infusion without orders for dosage or directions for titration.

The CNO confirmed during interview conducted on 10/13/11, that the Propofol order was incomplete and required clarification before administration of the medication.

2. No Specific Policy or Procedure on Insulin was available for review by surveyor. CNO confirmed on 10/13/11 at 1220, that there is no facility policy for Sliding Scale Insulin Administration, and that the facility follows the protocol titled "DR. (# 8) Routine Sliding Scale" for Regular Insulin sliding scale.

Patient # 30 was admitted on 10/10/11. Chart review revealed MD # 3 wrote orders "...Sliding scale of regular insulin..." for Patient #30. Upon review, there was no documentation in the chart of an order signed by the MD for the specific Sliding Scale for insulin.

CNO confirmed 10/13/11 at 1220 that the chart did not contain specific orders for the sliding scale insulin.

Review of medical record revealed documentation that regular insulin was administered 10/10/2011 through 10/12/2011 by nursing staff.

The CNO confirmed during interview conducted on 10/13/11 at 1220, that the Insulin orders in pt #30's medical record were incomplete and required clarification before administration.