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145 NORTH 6TH STREET

READING, PA 19601

MEDICAL STAFF - ACCOUNTABILITY

Tag No.: A0049

Based on a review of facility policy, medical records (MR) and interviews with staff (EMP), it was determined that the facility failed to ensure that quality patient care was provided, maintained and that policies were developed to establish standards of patient care.

Findings include:

Review of facility policy "Medical Staff Rules ad Regulations" last approved 1/2021 revealed, "8.2 Practitioners will review the current list of medications, including over-the counter and herbals when prescribing medications during the hospital stay and upon discharge to ensure accurate reconciliation of medications."

Medical Staff Bylaws-Reading, last approved 1/2021 revealed "Purposes of the Medical Staff: ... 3. To serve as the primary means for accountability to the Governing Board for the quality and appropriateness of the professional performance and ethical conduct of Medical Staff Members and AHP Staff Members, and to provide a focus for Medical Staff endeavors to provide quality patient care, efficiently delivered and maintained, consistent with locally available facilities and resources and, to the degree reasonably possible ... Qualifications and Obligations of Membership or Clinical Privileges 2. General Obligations: In addition to the other prerequisites for the granting of Medical Staff or AHP Staff membership or Clinical Privileges set forth in these Bylaws, each Applicant by applying :for any category of membership or Clinical obligates himself to continuously: ... k. Seek consultation whenever warranted by a patient's condition ... Committees and Functions: 3. Staff Functions (2)(c)Bylaws and the Rules and Regulations(iii) Developing and implementing policies and procedures to establish standards of patient care and ascertaining that these policies and procedures are consistent with these Bylaws, and Rules and Regulations, and with Hospital and Governing Board policies ... ."

Review of MR1 "History and Physical" dated June 10, 2021 and signed June 11, 2021. "Patient states that they gave patient a steroid shot and a steroid dose pack.... Mouth and oral cavity did reveal multiple areas of skin sloughing involving the palate area and buccal mucosa especially on the right. There also was inflammation with ulceration involving the soft palate and uvula. ... Review of Nursing Assessment note for June 14, 2021, " states they have something wrong with their throat and can't swallow meds."
Nursing Assessment note for June 15, 2021 revealed, "Pt stated I'm am not going to be able to eat breakfast this morning because I'm all dried out and I can't swallow anything."
Physician Medication Orders (PMO) or Ancillary Orders (AO) did not include an Order for Methylprednisolone throughout hospitalization. Additional review of MR1 Discharge Instructions noted patient to follow up with primary care physician (PCP) for mouth sores.

On July 15, 2021 at approximately 1:54 pm interview was conducted with EMP4. "On June 10, 2021, during patient's admission exam EMP4 was made aware by the patient that they had gone to Urgent Care where they received Decadron, but was told by the patient they had completed the pack. EMP4 stated that they ordered Magic Mouthwash for treatment of oral issues. EMP4 confirmed they had reviewed the Medication Reconciliation Report.

Review of MR1 Medication Reconciliation Report revealed, patient Home Medications- Methylprednisolone 4mg tablets in a dose pack last filled June 7, 2021, given a six (6) day supply; Qty 21.
At time of admission patient would have been on day two (2) of regimen.

MR1 Medication Administration Record revealed patient received Magic Mouthwash only on June 13 and June 14.


MR1 revealed patient lost eight (8) pounds during 15 day hospitalization. MR1 Graphic Sheet noted patient was 168 pounds on June 9, 2021 and 160 pounds on June 19, 2021, no other weights noted in chart. Patient was discharged on June 24, 2021.
Nursing Assessment notes for June 14, 2021, Pt states they have something wrong with their throat and can't swallow meds. ... June 15, 2021, Pt stated I'm am not going to be able to eat breakfast this morning because I'm all dried out and I can't swallow anything.
Further review of MR1 revealed that a Dietician Consult was never ordered.

During interview on July 15, 2021 at approximately 1:54 pm, EMP4 could not recall if they had reviewed the patient's weight changes in. EMP4 confirmed they did not order a Dietician Consult.

On July 15, 2021 request was made for policy on how much weight lost constitutes a Dietician consult, EMP 1 confirmed there is not a policy in place.

VERBAL ORDERS FOR DRUGS

Tag No.: A0407

Based on a review of policy and procedures, medical records (MR) and interviews with staff (EMP), it was determined that the facility failed to ensure that verbal orders were not used infrequently or in an emergency for ten of ten medical records reviewed.

Findings include:

A review on July 15, 2021, of "Medication Administration" last revised February 2019, revealed "C. Verbal Orders/Telephone Orders"...Verbal orders are not allowed except in an emergency. Medication orders should be entered by prescriber, when possible.

Review of MR1,2,3,4,5,6,7,8,9,10 reviewed revealed verbal orders were entered during admissions for medications, treatments and ancillary orders. Additional review of MR1, MR3, MR4 and MR8 showed that verbal orders were used for additional occurrences other than on admission in each of these medical records for non-emergent medication and treatment orders.

Interview with EMP2 confirmed verbal orders were used for admission orders and non-emergent orders in ten out of ten medical records reviewed.

CONTENT OF RECORD: ORDERS DATED & SIGNED

Tag No.: A0454

Based on a review of facility documents, medical records (MR) and interview with staff (EMP), it was determined that the facility failed to ensure that oral orders were countersigned by a practitioner within 24 hours in four of 10 medical records reviewed (MR1, MR3, MR5, and MR8).

Findings include:

A review on July 15, 2021, of "Medication Administration" last revised February 2019, revealed "C. Verbal Orders/Telephone Orders"...Verbal orders and telephone orders for medications shall be given only to a Registered Nurse, or a licensed pharmacist by a person lawfully authorized to prescribe and shall be recorded promptly in the patient medically record, noting the name of the person giving the telephone order and signature of the individual receiving the order. The prescriber shall counter sign the medicaiton order within (24) hours.


A review on July 15, 2021, of MR1, MR3, MR5, and MR8, revealed they contained verbal orders that were not signed by the physician within 24 hours.

An interview conducted on July 15, 2021, with EMP2 confirmed that MR1, MR3, MR5, and MR8, contained verbal orders that were not signed by the physician within 24 hours.