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A. Based on a review of Hospital policy, a review of Root Cause Analysis (RCA), medical record review, and staff interview, it was determined that in 1 of 10 (Pt #1) medical records reviewed, the Hospital failed to ensure that all nursing staff prepared and administered all drugs as ordered by the physician, in accordance with Hospital policies.

Findings include:

1. The policy titled, "Medication Management" was reviewed on 08/03/10. It indicated under, "F. Required elements for the following types of orders #9. Range orders, orders in which the dose for dosing interval varies over a prescribed range depending on the patient status, are initiated by the physician for an individual patient based on clinical judgement. The goal is to administer the smallest dose necessary to achieve the desired clinical effect... a. Pain Management range orders: ... for a pain scale rating of 1-3 (mile)- initial dose equal to the lowest dose of the range..." Also, under, "V. Administration B. #2. Verifies that the medication selected for administration is the correct one based on the medication order...#5. Verifies that the medication is being administered at the proper time, in the prescribed dose...#8. Scans the patient ID band and the medication to ensure the correct medication is administered." And under, "J. Charting #1. All medication administration is documented in the patient's permanent medical record." Also, the policy titled, "Override for Pyxis Medications" was reviewed on 08/03/10. It indicated under, "Override medications are medications that can be accessed by nursing staff before review of an order by the pharmacist. The purpose of the override function is to allow for quick administration of medications in emergency and STAT situations." Under, "#4. Prior to administration of a medication that has been removed by the override function, it is recommended that a second nurse verify the order and the medication. Medications removed without a pharmacist review (via override) should be reviewed prior to administration including: a) Drug, dose, frequency and route of administration..."

2. The medical record of Pt #1 was reviewed on 08/03/10. It indicated that Pt #1 was admitted to the Hospital on 06/28/10 with a diagnosis of C4-C5, C5-C6 Anterior Fusion. On 06/28/10, there was a physician's order "Post-op order set...Dilaudid 0.2 - 0.4 mg IV every 2 hours as needed for pain." Nursing documentation at 1:00 PM indicated "pain: Current intensity-3; Acceptable rating-4; Interventions- Relaxation, repositioning." At 1:15 PM, Pyxis override documentation indicated that the RN (Registered Nurse) had withdrawn a 4 mg dose of Dilaudid. Documentation indicated that a "Code Blue" was called for Pt #1 at 1:29 PM due to respiratory arrest. Pt #1 was placed on a ventilator and transferred to ICU. There was no nursing documentation from 1:00 PM to 1:29 PM from the RN caring for Pt #1. There was no documentation to indicate that any drugs were given during this time period. RCA documentation indicated that the RN caring for Pt #1 had given a 4 mg dose of Dilaudid IV push, instead of the physician ordered 0.2 mg- 0.4 mg dose and outside of the Hospital's policy for ranges. It was indicated that an LPN had witnessed the withdrawal, but had not verified the amount with the physician's order. Documentation indicated that the RN had not contacted pharmacy to verify the medication or dose, had not scanned Pt #1's ID band to verify correct patient and medication and had not documented the medication given in Pt #1's permanent record.

3. During an interview, conducted on 08/03/10 11:00 AM with the Director of Pharmacy, it was determined that the physician orders had not been put into the Pyxis system due to the unusual 0.2 - 0.4 mg Dilaudid order. The pharmacy director stated that the pharmacist was waiting on clarification from the physician at the time the medication was withdrawn. During an interview, conducted on 08/03/10 at 3:00 PM with the Director of Quality Management and the Director of Surgical Care/Respiratory Care, the above findings were confirmed.

A. Based on a review of Hospital policy, medical record review, and staff interview, it was determined in 2 of 10 ( Pts #1, #5) medical records reviewed, the Hospital failed to ensure telephone orders were signed by the physician within 48 hours, as per Hospital policy.

Findings include:

1. The Hospital policy titled "Physician's order" was reviewed on 8/3/10. It indicated "General Information: II. It is the physician's responsibility to sign telephone/verbal orders within 48 hours."

2. The medical record of Pt #1 was reviewed on 8/3/10. Pt #1 was admitted to the Hospital on 6/28/10 with the diagnosis of C4-5, C5-6 Anterior Fusion. As of 8/3/10, the following telephone orders had not been signed: six on 6/28/10, three on 6/29/10, and one on 6/30/10.

3. The medical record of Pt #5 was reviewed on 8/3/10. Pt #5 was admitted to the Hospital on 7/20/10 with the diagnosis of Severe Cervical Spinal Stenosis. As of 8/3/10, two telephone orders, dated 7/24/10, had not been signed.

4. During a staff interview, conducted with the Director of Quality Management and the Director of Surgical Care/ Respiratory Care on 8/3/10 at 3:00 PM, the above findings were confirmed.

A. Based on a review of Medical Staff Rules and Regulations, medical record review, and staff interview, it was determined in 5 of 10 (Pts #1, #4, #6, #9, #10) medical records reviewed, the Hospital failed to ensure that all entries were timed.

Findings include:

1. The Medical Staff Rules and Regulations were reviewed on 8/3/10. It indicated "Medical Records: 5. All clinical entries in the patient's medical record shall be accurately dated, timed, and authenticated."

2. The medical record of Pt #1 was reviewed on 8/3/10. Pt #1 was admitted to the Hospital on 6/28/10 with the diagnosis of C4-5, C5-6 Anterior Fusion. The following Physician Progress Notes were not timed: 6/28/10 - Anesthesia, Pulmonary, and Cardiology; 6/29/10 and 6/30/10 - Pulmonary, Cardiology, and Neurosurgery.

3. The medical record of Pt #4 was reviewed on 8/3/10. Pt #4 was admitted to the Hospital on 6/30/10 with the diagnosis of Cervical Disc Displacement. On 7/1/10, the Neurosurgical note was not timed.

4. The medical record of Pt #6 was reviewed on 8/3/10. Pt #6 was admitted to the Hospital on 6/16/10 with the diagnosis of Degenerative Disc Disease. On 6/17/10 and 6/18/10, the Neurosurgery notes were not timed.

5. The medical record of Pt #9 was reviewed on 8/3/10. Pt #9 was admitted to the Hospital on 6/2/10 with the diagnosis of Cervical Disc Displacement. On 6/3/10 and 6/4/10, the Neurosurgery notes were not timed.

6. The medical record of Pt #10 was reviewed on 8/3/10. Pt #10 was admitted to the Hospital on 7/12/10 with the diagnosis of Severe Spinal Stenosis. On 7/13/10 and 7/15/10, the Physician Progress notes were not timed.

7. During a staff interview, conducted with the Director of Quality Management and the Director of Surgical Care/ Respiratory Care on 8/3/10 at 3:00 PM, the above findings were confirmed.

A. Based on a review of Hospital policy, medical record review and staff interview, it was determined that in 8 of 10 (Pts #1, #2, #3, #5, #7, #8, #9, #10) medical records reviewed, the Hospital failed to ensure that all physician orders and/or progress notes were dated, timed and authenticated promptly.

Findings include:

1. The policy titled, "Medical Staff Rules and Regulations" was reviewed on 08/03/10. It indicated under, "Medical Records. #5. All clinical entries in the patient's medical record shall be accurately dated, timed and authenticated."

2. The medical record of Pt #1 was reviewed on 8/3/10. Pt #1 was admitted to the Hospital on 6/28/10 with the diagnosis of C4-5, C5-6 Anterior Fusion. On 6/28/10, two physician orders were not timed.

3. The medical record of Pt #2 was reviewed on 08/03/10. It indicated that Pt #2 was admitted to the Hospital on 07/04/10 with a diagnosis of Upper GI Bleed. Documentation indicated that multiple physician's orders, dated 07/06/10 to 07/16/10, were not timed.

4. The medical record of Pt #3 was reviewed on 08/03/10. It indicated that Pt #3 was admitted to the Hospital on 06/09/10 with a diagnosis of Supraglottic Carcinoma. Documentation indicated that multiple physician's orders, dated 06/09/10 to 06/13/10, were not timed.

5. The medical record of Pt #5 was reviewed on 8/3/10. Pt #5 was admitted to the Hospital on 7/20/10 with the diagnosis of Severe Cervical Spinal Stenosis. Documentation indicated multiple physician orders dated 7/21/10 thru 7/23/10 without times.

6. The medical record of Pt #7 was reviewed on 08/03/10. It indicated that Pt #7 was admitted to the Hospital on 06/28/10 with a diagnosis of Subarachnoid Hemorrhage. Documentation indicated that multiple physician's orders, dated 06/28/10 to 07/14/10, were not timed.

7. The medical record of Pt #8 was reviewed on 08/03/10. It indicated that Pt #8 was admitted to the Hospital on 06/29/10 with a diagnosis of Respiratory Failure and Pneumonia. Documentation indicated that multiple physician's orders, dated 06/29/10 to 07/19/10, were not timed.

8. The medical record of Pt #9 was reviewed on 8/3/10. Pt #9 was admitted to the Hospital on 6/2/10 with the diagnosis of Cervical Disc Displacement. On 6/2/10, there was a physician's order that was not timed.

9. The medical record of Pt #10 was reviewed on 8/3/10. Pt #10 was admitted to the Hospital on 7/12/10 with the diagnosis of Severe Spinal Stenosis. On 7/14/10, there was a physician's order that was not timed.

10. During an interview, conducted on 08/03/10 at 3:00 PM with the Director of Quality Management and the Director of the Surgical Care/Respiratory Care, the above findings were confirmed.

A. Based on medical record review and staff interview, it was determined in 3 of 10 (Pts #4, #6, #10) medical records reviewed, in which the patient underwent surgical intervention requiring anesthesia, the Hospital failed to ensure that the History and Physical (H&P) was updated prior to the surgical procedure.

Findings include:

1. The medical record of Pt #4 was reviewed on 8/3/10. Pt #4 was admitted to the Hospital on 6/30/10 with the diagnosis of Cervical Disc Displacement and underwent surgical intervention on that day. There was no documentation to indicate that the H&P was updated prior to the surgical procedure.

2. The medical record of Pt #6 was reviewed on 8/3/10. Pt #6 was admitted to the Hospital on 6/16/10 with the diagnosis of Degenerative Disc Disease and underwent surgical intervention on that day. There was no documentation to indicate that the H&P was updated prior to the surgical procedure.

3. The medical record of Pt #10 was reviewed on 8/3/10. Pt #10 was admitted to the Hospital on 7/12/10 with the diagnosis of Severe Spinal Stenosis and underwent surgical intervention on that day. There was no documentation to indicate that the H&P was updated prior to the surgical procedure.

4. During a staff interview, conducted with the Director of Quality Management and the Director of Surgical Care/ Respiratory Care on 8/3/10 at 3:00 PM, the above findings were confirmed.

A. Based on a review of Medical Staff Rules and Regulations, medical record review, and staff interview, it was determined in 4 of 10 (Pts #4, #6, #9, #10) medical records reviewed, that the Hospital failed to ensure Discharge Summaries were performed upon discharge and contained all the required elements, as per the Medical Staff Rules and Regulations.

Findings include:

1. The Medical Staff Rules and Regulations were reviewed on 8/3/10. It indicated "Medical Records: 10. Discharge Summaries are to be dictated within fourteen (14) days of discharge... A discharge summary must include the reason for hospitalization, significant findings, procedures, treatment, condition on discharge and pertinent patient instructions..."

2. The medical record of Pt #4 was reviewed on 8/3/10. Pt #4 was admitted to the Hospital on 6/30/10 with the diagnosis of Cervical Disc Displacement and was discharged on 7/1/10. The Discharge Summary indicated that it was dictated on 6/30/10 at 11:20 AM (the same time as the Operative Report was dictated.) It contained "Final Diagnosis" and "Name of Operation." It contained none of the other required elements.

3. The medical record of Pt #6 was reviewed on 8/3/10. Pt #6 was admitted to the Hospital on 6/16/10 with the diagnosis of Degenerative Disc Disease and was discharged on 6/18/10. The Discharge Summary indicated that it was dictated on 6/16/10 at 1:17 PM (the same time as the Operative Report was dictated.) It contained "Final Diagnosis" and "Name of Operation." It contained none of the other required elements.

4. The medical record of Pt #9 was reviewed on 8/3/10. Pt #9 was admitted to the Hospital on 6/2/10 with the diagnosis of Cervical Disc Displacement. The Discharge Summary indicated that it was dictated on 6/2/10 at 5:36 PM (the same time as the Operative Report was dictated.) It contained "Final Diagnosis" and "Name of Operation." It contained none of the other required elements.

5. The medical record of Pt #10 was reviewed on 8/3/10. Pt #10 was admitted to the Hospital on 7/12/10 with the diagnosis of Severe Spinal Stenosis and was discharged on 7/15/10. The Discharge Summary indicated that it was dictated on 7/12/10 at 2:20 PM (the same time as the Operative Report was dictated.) It contained "Final Diagnosis" and "Name of Operation." It contained none of the other required elements.

6. During a staff interview, conducted with the Director of Quality Management and the Director of Surgical Care/ Respiratory Care on 8/3/10 at 3:00 PM, the above findings were confirmed.