HospitalInspections.org

Based on the review and interview, the facility failed to:

A. appoint an Interim Chief Executive Officer who was responsible for managing the hospital. Review of records and interview demonstrated that Staff #3 was managing the daily operation of the hospital. No Governing Body records were found that appointed Staff #3 or Staff #1 as the Interim Chief Executive Officer.

(Refer to Tag A0057)


B. have documentation of an elected and effective Governing Body (GB) and follow its own Governing Body bylaws of electing a Director and having a majority of the board members as a quorum. Governing Body bylaws requires that each Director be elected to serve by the Governing Body and a majority of the board of Directors constituted a quorum for the transaction of business. Governing Body meeting minutes revealed Directors were being appointed to the Governing Body and decisions were being made with only 2 of 6 members of the Governing Body present.



Review of the facility's Governing By-laws stated, "Article III Directors Section I. Number and Qualification. The number of Directors which shall constitute the whole board shall not be less than three nor more than ten. Directors need not be residents of Texas nor shareholders of the Corporation. The Directors shall be elected at the annual meeting of the shareholders, and each director elected shall serve until the next succeeding annual meeting and until its successor shall have been elected and qualified."

"Section II Quorum and Voting. A majority of the board of Directors shall constitute a quorum for the transaction of business unless a greater number is required by law or by the Articles of Incorporation."


Review of the facility's GB minutes revealed there was an AD HOC meeting on 3/31/17. Review of the Governing Board Committee Members revealed there was six people on the member list staff #14, and 28-32. Staff #28 was documented as the president of the board.


Review of the AD HOC Governing Board meeting minutes on 4/20/17 revealed the meeting was held to appoint a credentialing applicant. In attendance was staff #28 and 29. There was not enough for a quorum according to the by-laws. The applicant was a nurse practitioner. In the action status the notes read, "Credentialing file was discussed with the board in detail. Staff #28 motioned to approve. Staff #29 second the motion and the applicant approved."


Review of the AD HOC Governing Board meeting minutes on 5/4/17 revealed there was a new president. Staff #1 was written as new member of the committee. There was no documentation that staff # 28 was no longer a committee member or had stepped down. There was no documentation of an election held to vote staff #1 in as president.


Review of the AD HOC Governing Board meeting minutes on 5/19/17 revealed committee member staff #31 was no longer on the committee and she had been replaced with staff #2 (Interim DON- in training.) There was no documentation that staff #31 was no longer a committee member or had stepped down. There was no documentation of an election held to vote staff #2 on the committee.


Review of the AD HOC Governing Board meeting minutes on 6/23/17 revealed there was no change in committee members. There was no documentation by the board that staff #2 was approved as the current Director of Nurses.


Review of the AD HOC Governing Board meeting minutes on 8/4/2017 revealed a GB Meeting was held. Only two members of the GB members were present staff #1 and staff #14. There was not enough members for a quorum.


An interview was conducted with staff #32, #2, #3, and #21 concerning the GB Committee Members. Staff #32 and 21 confirmed these were all of the GB meeting minutes for the year 2017. Staff #32 confirmed her name was on the list of committee members but was not elected as a GB member. Staff #32 stated she took the notes in the meetings. Staff #32 stated she was not aware of the GB by-laws contents. Staff #32 was not aware that the positions for the GB board were elected positions. Staff #2 confirmed the above findings. Staff #3 stated that she was the interim CEO when staff #1 was not there. There was no documentation in the GB minutes that staff #3 was approved as an interim CEO nor did she have a job description for that position. Staff #2 was not aware of the GB by-laws and was not aware of the elected position on the GB committee.


Staff # 32 or #2 could not supply the surveyor with a list of approved Governing Board Members that were elected and approved by the stock holders.


An interview with staff #1 on 10/5/17 revealed the he was not aware that the meeting minutes did not reflect an election or change in the committee members. Staff #1 was unable to provide a list of Governing Board Committee Members.

Based on review of records and interview, the Governing Body failed to appoint an Interim Chief Executive Officer who was responsible for managing the hospital.

On 10-3-2017, a request to see the CEO was made at the reception desk. The receptionist stated that would be Staff #3. When asked about being the CEO, Staff #3 stated she was the Administrative and Clinical Lead and Staff #1 was Interim CEO. She stated she was responsible for the daily management of the hospital while Staff #1 was not in the building. Staff #3 was asked if Staff #1 was aware of the survey in progress since Staff #1 was not onsite. Staff #3 stated she had advised Staff #1 of the survey in progress.


Staff #3 was asked if she had any training or experience in managing a hospital. Staff #3 stated she did not. Staff #3 was asked if she had been given a job description that explained exactly what was expected of her as Administrative and Clinical Lead responsible for the daily management of the hospital when the CEO was not present. Staff #3 stated she had not. Review of Staff #3's personnel file did not include a job description and responsibilities for an Administrative and Clinical Lead. When asked what her responsibilities as the Administrative and Clinical Lead were, Staff #3 stated she was the Admissions Director. She had been assigned as the Interim Clinical Director. She was responsible for making sure "files are signed", "fire and hire", "interact with senior leadership team", "conduct flash meetings", "keeping census up", and other daily responsibilities of the three positions.


Upon review of the Organizational Chart, Staff #3's name appeared in the block titled "Interim Administrator" (the CEO position). Staff #3 was interviewed about the discrepancy between the organizational chart and Staff #3's statement that she was not the Interim CEO. Staff #3 provided a copy of letter, on hospital letterhead, dated 8-3-2017. It was not addressed to anyone specific. The letter read as follows:


"Please be advised that (previous CEO) has resigned her position as CEO of Glen Oaks Hospital. She will be greatly missed and we wish her well in her future endeavors. (Staff #1), Regional VP-BH, will be interim CEO effective today. He may be reached at (phone number).

Please feel free to contact (Staff #1) or myself if you should have any questions or concerns."

This letter was signed by the hospital's Risk Manager.


Staff #3 provided a copy of an email addressed to members of the leadership team of the hospital written by Staff #1 and sent out on 8-11-2017. The email read as follows:


"I wanted to let everyone know that I have appointed (Staff #3) as the clinical and administrative lead for day to day operations when I am not onsite. I will continue to be available by phone day and night.

Currently I plan to be back at the hospital the week 8/21/17.

Thank you for all your hard work there at Glen Oaks. Please share this email with anyone that I left off that needs to know."


A request was made for Staff #1's personnel file. The file was sent from corporate office and did not contain any job description or appointment letter from the governing board as Interim CEO of Glen Oaks Hospital. A request was made for the meeting minutes of the Governing Board where Staff #1 had been appointed as Interim CEO. None was provided.


A request for a list of dates that Staff #1 was in the facility was made. The list provided read:

"(Staff #1) onsite dates:

8/16-8/17, 9/20-9/21 and will be returning on 10/16."


Staff #1 arrived onsite for interview on 10-5-2017. When asked about only being in the facility 4 days out of the 62 since he had assumed the role of Interim CEO, he stated he had been there more often than that. He showed a calendar screen on his laptop that had 6 weeks highlighted as "Glen Oaks". He stated on those 6 weeks he had been in the facility one or two days each visit. He confirmed that this was only a range of 6 to 11 days out of the previous 62.

Staff #1 was asked about the lack of minutes from the Governing Body meeting to appoint him as Interim CEO. Staff #1 stated he did not know why there were not any meeting minute notes since it had been discussed by Governing Body.

Based on review of records and interview, the hospital failed to:


A. develop and implement appropriate policies and procedures for the prompt resolution of grievances. Review of the policy titled: "Patient Advocate and Patient/Family Complaint and Grievance Procedure", policy number: "ADM.22", revised: "5/16" was completed. The policy did not correctly identify what a complaint versus a grievance was or the correct steps for processing a complaint versus a grievance.


B. adequately train staff on the policies and procedures for the prompt resolution of grievances. Staff #4 was interviewed on 10-4-2017. Staff #4 stated she had been given the responsibility of the Complaints and Grievances on approximately August 4, 2017. Staff #4 stated this log was the only log she was aware of. Staff #4 stated she was given a copy of the hospital policy on complaints and grievances when she received the log, however, no training had been provided. Staff #4 was not able to verbalize the difference between a complaint and grievance. Staff #4 stated she referred to the policy if she had questions. Staff #4 confirmed that all patient complaints were written out on a complaint form and given to her, but was not aware that a written complaint becomes a grievance. Staff #4 was not aware that all grievances required a written response.

Refer to Tag A0118


C. ensure the patients and patient care areas were monitored for potential harm, elopements, and paraphernalia in 5 of 5 patient care areas. Patient room 126 was found to have an open widow and screen to the outside. The gym door was found to be unlocked to the outside and gaps in the wooden fence that would allow for weapons or paraphernalia to be exchanged. Patient #4 was allowed to go outside in the court yard unsupervised. Patient #4 was able to elope the facility by stacking chairs and jumping the fence due to no supervision.


D. follow physician orders to discharge a patient upon request in 1(4) of 3 (1, 3, and 4) charts reviewed. The facility failed to follow the physician order written 7/7/17, for patient #4 to sign out AMA, and discharge to his own accord.


E. protect the patient's rights by having a warrant or physician order to hold the patient from leaving the facility in 1(4) of 3(1, 3, and 4) charts reviewed. The facility did not allow patient #4 to leave the facility due to "no safe transportation" when there was no legal means to hold him. The patient eloped from the facility and was picked up by police with no warrant or physician orders. The facility wanted him brought back in order to have the patient sign AMA paperwork.


F. develop and/or implement policies and procedures for the safe transport of all patients. No list of trained and qualified drivers was available. Subsequent checks of driver's records for staff that appeared on the transport logs revealed that Staff #26 had transported patients while his driver's license was suspended. Staff were required to transport patients to court for involuntary commitment hearings without any additional staff present. Involuntary commitment was sought when the physician had determined the patient was a risk to harm of self and/or others, but would not or could not voluntarily agree to stay for treatment. Male staff were required to transport female patients without chaperones for the safety of staff and patients.

Refer to Tag A0144

Based on review of records and interview, the hospital failed to:

A. develop and implement appropriate policies and procedures for the prompt resolution of grievances.

B. adequately train staff on the policies and procedures for the prompt resolution of grievances.


Findings were as follows:


The Grievance Log was requested. A log was provided that was titled, "Complaint Log". It contained the following blocks for each entry:

Date/Time:
Complaintants (sic) Name:
Received By:
Nature of Complaint (reason dissatisfied)
Summary of Investigation: Steps and Findings
Action Taken (Signature)


The log did not indicate if the complaint was processed as a complaint or grievance. The log did not indicate that any written responses had been provided to the complainant. The log did not indicate a time frame from when the complaint was actually written to the actual date of resolution.


Staff #4 was interviewed on 10-4-2017. Staff #4 stated she had been given the responsibility of the Complaints and Grievances on approximately August 4, 2017. Staff #4 stated this log was the only log she was aware of. Staff #4 stated she was given a copy of the hospital policy on complaints and grievances when she received the log, however, no training had been provided. Staff #4 was not able to verbalize the difference between a complaint and grievance. Staff #4 stated she referred to the policy if she had questions. Staff #4 confirmed that all patient complaints were written out on a complaint form and given to her, but was not aware that a written complaint becomes a grievance. Staff #4 was not aware that all grievances required a written response.


Review of the policy titled: "Patient Advocate and Patient/Family Complaint and Grievance Procedure", policy number: "ADM.22", revised: "5/16" was completed. The policy did not correctly identify what a complaint versus a grievance was or the correct steps for processing a complaint versus a grievance. The review was as follows:

"Policy: It is the policy of Glen Oaks for our designated Patient Advocate, as well as our employees in direct patient care roles, to listen and respond to concerns from patients and/or family members in a prompt and courteous manner. The Patient Advocate has been designated to coordinate the efforts of Glen Oaks Hospital to investigate complaints. Any complaint, written or verbal, regarding the quality or appropriateness of patient care, that cannot be resolved by the complaint process will be considered a grievance and will be formally reviewed.

...

Complaint Investigation and Resolution Process:

A. Any staff member receiving a complaint from a patient or patient representative should immediately attempt to resolve the complaint. The employee can confer with Clinical Director, Director of Nursing, CEO or the patient's physician as appropriate to resolve the issue.


B. If a resolution cannot be reached, or if the patient wants to proceed directly with the patient advocate they may contact the Patient Advocate for assistance by calling Glen Oaks Hospital and asking for the Patient Advocate. If the Patient Advocate is not immediately available, the complainant may leave a message on the Patient Advocate's voice mail. The Patient Advocate will contact the complainant within 24 hours.


C. The Patient Advocate will set a specific time to visit with the complainant to obtain pertinent facts and complete the Complaint Form. (Attachment A)


D. The Patient Advocate will log the complaint on the Patient Tracking Log in the patient complaint logbook, noting name and date received (Attachment B)


E. After reviewing the facts, including the complainant's proposed resolution, the Patient Advocate will contact the appropriate departments/individuals to resolve the issue.


F. If resolution is not found, the complaint will be forwarded to the CEO/Managing Director. The CEO/Managing Director will conduct such investigation of the complaint as may be appropriate. CEO to notify the Risk Manager.


G. The CEO/Managing Director will issue a written decision within 24 hours of receipt of the complaint.


H. Results of resolutions and corrective actions are to be documented and reported to the CEO/Managing Director and Medical Director. The information gathered through these actions is reviewed, and this process leads to the development and coordination of in-services, policy changes, QI teams, etc. based on trends or patterns or safety issues. A quarterly report of aggregated data will be reviewed with MEC and the Board of Governors.


I. The Patient Advocate will assure timely response to each complaint through periodic tracking of the complaint reduction process.


J. Any complaint regarding the appropriateness of patient care that is not resolved through the complaint process will be forwarded to the Hospital Quality Council by the CEO/Managing Director.


K. The Hospital Quality Council will review the grievance within 72 hours of notification by the CEO/Managing Director. The chair of this Ad Hoc Hospital Quality Council meeting will be the Patient Advocate. The committee will develop an action plan to investigate the grievance. A decision will be made within 72 hours regarding the grievance. The Chairperson will review written findings and results with the grievant."

Based on review and interviews the facility failed to:

A.) monitor the patients and patient care areas for potential harm, elopements, and paraphernalia.

B.) follow physician orders to discharge a patient upon request in 1(4) of 3 (1, 3, and 4) charts reviewed.

C.) protect the patient's rights by having a warrant or physician order to hold the patient from leaving the facility in 1(4) of 3(1, 3, and 4) charts reviewed.

D.) develop and/or implement policies and procedures for the safe transport of all patients.


Findings related to items A.), B.), and C.) were as follows:

Review of patient #4's chart revealed he was admitted to the facility on 7/1/2017 for suicidal ideation and was diagnosed with Major Depression, Recurrent, Severe with Psychotic Features and with Polysubstance Abuse. Patient #4 was brought in on a police officer's warrant on 7/1/17. Patient #4 was not able to sign the consents for treatment. The admission personnel wrote on the consent, "Patient too psychotic to sign consents at this time."

Review of the physician orders dated 7/3/17 at 13:38 stated, "Have pt sign in as voluntary." Review of the chart revealed patient #4 signed in as a voluntary patient and signed all consents on 7/3/17.

Review of patient #4's nurses notes dated 7/6/17 at 2040 stated, "Pt appears upset by a new admit on the floor. Asked for discharge stating, 'My mom is having back surgery and I feel like I am doing better." Request filled out house supervisor notified, _____ staff #13(MD) notified. Chart changed to invol."

Review of the chart revealed patient #4 signed a "Request for Discharge" notice on 7/6/17 at 2130. The nurse notified the physician at 2035.A telephone physician order was dated 7/6/17 at 2040 stated, "twenty four hour hold." The 24 hour hold allows the physician to have 24 hours to assess the patient to see if he is eligible for discharge or if a warrant is needed to keep the patient in the facility.

Review of patient #4's chart revealed the physician saw patient #4 on 7/7/17. The physician reported the patient could leave the facility only as Against Medical Advice (AMA). The physician wrote the AMA order on 7/7/17 at 1130AM.

Review of the nurse's notes dated 7/7/17 at 12:30PM stated," Patient had discharge order written prior to expiration of 24 hour hold by Dr._____ (staff#16). Pt was told by therapist that his paperwork would be ready by 1400. Pt called parent for ride from GOH to bus station. She refused and an argument ensued. Pt was loud, threatening, cursing and slamming phone against wall and his hand injuring his right hand. Nurse cleaned wound applied TAO and gauze bandage to it. Pt asked if anyone else could give him a ride and he said a cousin but he did not have phone number. Pt was told he could not just walk out front door. When unit went to cafeteria to lunch door to smoke deck left unlocked. Another pt was escalating at the time and opened the door and walked out to the deck. ____ (pt#4) followed behind him and apparently stacked three chairs and eloped over fence. Nurse called Code Amber and 911 and was informed that the pt had been apprehended and was on way back to hospital. Pt is voluntary was returned to admissions where therapy will complete remaining paperwork and pt will be discharged AMA, new orienting tech informed that the door to the smoke deck should be locked when patients are in group or at meals. As the door was not locked pt was able to walk outside, stack three chairs and elope over the fence. He simply could not wait for a ride. Pt apprehended and returned to the admissions where his discharge paperwork was completed and pt. was discharged AMA. 1250 Pt discharged AMA. Copies of all documents given. Pt transported to bus station by GOH staff.(SIC)"


Review of the chart revealed there was no AMA paperwork found. Patient #4 was discharged by the physician on 7/7/17 at 1130AM. The facility did not allow the patient to leave due to "no safe transportation" when there was no legal means to hold him. The patient eloped from the facility and was picked up by police with no warrant or physician orders. The facility wanted him brought back in order to have the patient sign AMA paperwork.


An interview with staff #2 and #21 concerning patient #4's discharge. Staff #2 and #21 confirmed the findings above. Staff #21 stated that there was no incident report done and that she guessed, "The staff obviously is not clear on this." Staff #2 and Staff #21 confirmed that additional training is needed on holding a patient against their will when there is no warrant or physician order to hold the patient.


A tour of the facility was taken on 10/3/17 with staff #9. In the patient gym, a door to the outside was found unlocked. The door lead to an open area that was not fenced in. Staff #9 confirmed the door was unlocked. Staff #9 viewed video up to 12 days prior and was unable to see when the door was unlocked. The wooden fence that runs along the sidewalk going into the gym had a 12 inch gap from the concrete all the way up to the top of the fence. The gap opened up to the parking lot and grounds of the facility. This gap could be used to receive paraphernalia, drugs, or other contraband through the opened area. Inside the Gymnasium was a basketball backboard. The wall supports for the backboard had pulled away from the anchors in the wall and was only supported from the ceiling.


A tour of the Stabilization Care Unit (SCU) on 10/3/17 was found to have a window that would open in room 126. The window would open approximately 10 inches. The screen was not secured and the surveyor was able to push on the screen to allow a gap to receive paraphernalia, drugs, or other contraband through the window.


The medication room on the SCU had a computerized medication dispense machine. The medication dispense machine computer screen and keyboard were mounted in such a way that they hung over a functioning sink. This created a potential hazard for injury to staff, electrical shortage, or fire.


In the Progressive Care Unit (PCU) nurses station there were two openings to two different units, SCU and PCU. It was built so the nurses shared one nurse's station and could view both sides. The facility built another nurses station on the SCU. The nurses did not share a station anymore. The facility decided to put a solid screen over the opening to the SCU side so patients from the two separate units could not talk back and forth and create issues. Behind the screen was a counter and on the counter was a metal coffee cup, a copier with cords, a cordless telephone with batteries, and blinds with cords all within reach of the SCU patients. The screen would not allow the nurses from the PCU to see the patients grab the items that could be used to cause harm to themselves or others.


The seclusion room for the PCU had a hard metal screen. The hard metal screen had a hole in it with sharp pieces of metal sticking out, creating the potential for a patient in seclusion to self-harm.


A tour of the New Freedom Unit (NFU) revealed that there was a blood pressure machine in the nursing station next to the counter. Inside the basket on the blood pressure machine was a container of disinfectant wipes. The machine had multiple lengthy cords. These were all within the reach of patients standing on the opposite side of the counter. This presented a potential for patients to harm themselves or others.



36827

Findings related to D. ) were as follows:

On 10-3-2017, an interview was conducted with Staff #9. Staff #9 stated he did not have a complete list of drivers who were authorized to drive the hospital vehicles while transporting hospital patients. He hand wrote the names of the 3 primary drivers. Review of vehicle transportations logs revealed an additional 12 staff members had transported patients.

Staff #9 stated that Human Resources (HR) had previously been responsible for keeping up with an authorized driver's list since HR had to verify the staff member had a valid driver's license. Staff #9 stated there was not an orientation to drivers, orientation checklist, or any special training/competencies for the safe transport of patient's. Staff #9 stated the only requirement was a valid driver's license. Staff #9 stated that if there was a list of authorized drivers, it would be with HR.

On 10-3-2017, an interview was conducted with Staff #8. Staff #8 did not have a list of authorized drivers. Staff #8 reviewed the list of 15 drivers and stated recent driver's license checks had not been accomplished.

On 10-4-2017, Staff #8 reported that all of the staff on the list had been checked for valid driver's licenses. Staff #26 had been transporting patients with a suspended license.

Interviews with Staff #10 and Staff #11 were conducted. Staff #10 stated he is often required to transport patients to court for involuntary commitment hearings without any additional staff present. (Involuntary commitment was sought when the physician had determined the patient was a risk to harm of self and/or others, but would not or could not voluntarily agree to stay for treatment) Review of patient transport logs indicated that 11 out of 14 court transports occurred with the driver and 1 passenger in the van, confirming the driver was alone with the patient.

Both Staff #10 and Staff #11 reported they were asked to pick up and drop off female patients without chaperones. Staff #11 stated he requires the female patients to sit at least two rows behind him when he transports without a chaperone. Staff #9 confirmed that there were not cameras on the vans to record events of transport. Review of the van log and admission log for 7-22-2017 showed that a male driver was sent on a 173 mile round trip to pick a female up and bring her to the hospital for evaluation for admission.


Review of policy titled: "Transportation of Patients", policy number: "ADM.15", revised: "08/16" was as follows:

"Purpose:

Define the criteria under which patients will be transported in a safe manner.

Policy:

It is the policy of Glen Oaks Hospital to provide guidelines to ensure the safety of patients and staff being transported to other facilities, from home or to home for partial patients and to activities, and to provide guidelines in the operation and maintenance of the hospital vehicles.

All drivers of the hospital vehicles will be oriented as to the policies by the Director of Plant Operations during new hire orientation. All personnel driving a van shall submit a copy of a valid current Texas license to operate a motor vehicle. (See Fleet Safety Policy)

It shall also be the policy of Glen Oaks Hospital that all transporting of patients shall be conducted in a safe manner and hospital-owned vehicles utilized be free of defective safety components.

Procedure:

A. Scheduling of vehicle:

1. The log book/keys will be kept in the front desk with the receptionist.
2. The driver will be responsible for supervision of the patients.

...

B. The hospital-owned vehicles are to be operated and maintained according to the following guidelines:
...
6. The driver of the vehicle is responsible for the following:
a. Employee driving hospital vehicles shall have a valid driver's license.

...

C. Adequate authorization and supervision of patients must be maintained for off-grounds activities, including medical appointments and court.
...
3. Adequate supervision is to be maintained. In addition, patient's status levels and acuity should be considered and additional staffing provided if indicated.

...

H. The hospital provides transportation and must take into consideration the gender of the driver and the gender of the patient when providing transportation. When possible, have the patient and driver of the same gender.

1. It is acceptable for patients and staff to be a different gender.

2. Each case is to be evaluated by the driver and the charge nurse. When there is a concern, stop and carefully evaluate the situation. Be sure to consult the Risk Manager and AOC if necessary.

3. If the situation reflects a high risk, consider not providing the transportation or having two staff members."



The policy did not clearly explain what may be considered a situation that "reflects a high risk" when a psychiatric patient of an opposite gender of the driver is sent for transport.

Based upon record review and interview, the facility failed to prevent unauthorized individuals from gaining access to patient records and ensure the confidentiality of patient records in 6 (1, 2, 5, 6, 7 and 9) of 6 patient charts reviewed.

Review of the medical records revealed the Physician Discharge Summary was being dictated by Registered Nurses (RN) who were employed by the physicians of the facility.


Review of staff #20's employee file reveled she was currently employed as a RN in the facility to perform patient care. Staff #20 stated that she comes in Medical Records after her regular work hours and dictates the physicians discharge summary. Staff #20 stated that she is paid by the physician to do this job and performs it as a "side job." Staff #20 stated that she goes into medical records and gets the charts off the shelves that have been flagged for discharge.


Review of the staff #27's file revealed she was a former employee of the facility with 12/3/2015 as her last day of work. However, staff #27's employment was not terminated until 7/12/16. Staff #27 was currently coming to the facility several times a week to perform physician discharge summary dictation. There was no written documentation that allowed staff #27 to have access to patient information. Staff #27 had not been an employee of the facility for 15 months.


Review of the Medical Staff By-laws stated, "The attending physician shall be responsible for the preparation of a complete and legible medical record for each patient. The records shall include, #14 Discharge Summary." There was no documentation in the medical by-laws that allow an RN to dictate the physicians discharge summary.


An interview with staff #18 was conducted on 10/5/17. Staff #18 confirmed staff # 20 and 27 came to medical records several times a week and performed dictation on patient charts. Staff #18 stated she was not aware that staff #27 did not have any credentials or contract to allow her to come into the facility and dictate from medical records. Staff #18 was unable to provide any documentation on how medical records were protected from non-employees/credentialed individuals.


An interview with staff #1 on 10/5/17 revealed he was not aware that staff #27 was coming into the facility to perform dictation from medical records and was not aware she had no credentials or contract to perform that service.

Based on observation, review of records, and interview, the facility failed to ensure that the removal of medications from the emergency medication box was appropriately documented with information allowing the tracking of medication to patient administration in 2 unit medication rooms (Progressive Care Unit and New Freedom Unit) of 3 unit medication rooms observed.


On 10-3-2017, a tour of the facility was made with Staff #2. During the tour of the medication room with Staff #6 also present on the Progressive Care Unit (PCU), a metal box in a locked cabinet was observed. In the box was a log with the heading "RX Medication Emergency Box Log". Twenty-three medications were listed on the log along with the inventory totals for each medication. A count of the medications was completed and it was found that Ketorolac injectable was supposed to have 4 in the box, but only 3 were present. Staff #6 stated that the box had been used the night before. The box was supposed to have a seal on it and it was missing that morning. Staff #6 stated she did not know who the medication was used for. Staff #6 stated that when the seal is broken the night before, nurses do not count the box at shift change to ensure all medications are accounted for.


During a tour of the New Freedom Unit (NFU), the emergency medication box was also found to be open and the inventory incorrect. This box was missing one dose of Olanzapine oral disintegrating tablet and one dose of Ketorolac injectable. The form did not list which patient or patients had received the medication.


An interview was conducted with Staff #23. Staff #23 stated that incorrect counts of the emergency medication box had not been previously identified as a problem. Staff #23 researched the patient Medication Administration Records and was able to identify the three patients who received the missing medications. They had been given by three different nurses who all failed to document the logs.


A policy for managing the emergency medication boxes was requested but never provided by the facility.

Based on observation, review of documents, and interview, single-use vials that had been opened and accessed were stored in drawers designated for usable drugs in 1 unit medication room (Stabilization Care Unit) of 3 units observed.


A tour of the nursing units was completed with Staff #2 on 10-3-2017. Two vials of single-use Sterile Water were observed in a grey drawer marked Normal Saline in the medication room on the Stabilization Care Unit (SCU). The vials had been accessed and contained some remaining solution. A drawer in the medication cart was opened and revealed a third vial of sterile water that had been opened and accessed. Staff #2 confirmed that these vials should have been discarded and not stored.


Interview was conducted with Staff #23 on 10-4-2017. Staff #23 stated there was no reason, nor was it permissible, to store or re-use the sterile water vials after they had been opened and accessed. Staff #23 denied a shortage of sterile water in the facility and was able to show that there was adequate stock of sterile water.


Review of policy titled, "Multi-dose Vials and Single-dose Containers"; Policy Number: 49; Effective Date: 10/21/2016; Page 3 of 5, was as follows:


"Single Dose Containers

Single dose containers (vials and ampoules [sic]) are only entered and used one time.

Ampules are single dose containers and must be used immediately after opening. The dose removed from an ampule is filtered (use of a filter needle) prior to administration. Any remaining solution is discarded.

Open single dose vials are not stored for future use."