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Based on interview and record review, the hospital failed to ensure its P&P was implemented as evidenced by:

1. The hospital did not ensure two physicians (Physicians 3 and 4) submitted the required annual TB screening.

2. Physician 1 did not complete two informed consent forms prior to performing the medical procedures as per the hospital's P&P for one of four sampled patient (Patient 1).

These failures posed the potential risk to patient safety and unsafe hospital environment.

Findings:

Review of the hospital's General Medical Staff Rules and Regulations showed medical staff members are responsible for abiding by the Medical Staff Bylaws, Rules and Regulations of their assigned department, as well as other relevant standards and hospital policies.

1. Review of the hospital's P&P titled Tuberculosis Screening for Physicians and/or Allied Health Professional Staff reviewed February 2024 showed the following:

* TB screening is essential to detect latent or active tuberculosis and ensure treatment and follow-up as per CDC's guidelines.

* The screening program applies to all members of the AHP staff.

* All medical staff and AHP members must provide documentation of TB screening upon appointment and must complete an annual TB symptom screening (Attestation).

* Practitioners who fail to provide TB screening evidence may face referral to the Medical Staff committee and suspension of clinical privileges until compliance is demonstrated.

a. On 6/5/25 at 0931 hours, an interview and concurrent review of credential files for Physicians 3 and 4 were conducted with the Director of Medical Staff Services and the Medical Staff Coordinator.

Review of Physician 3's credential file showed the physician signed an Information Release/Acknowledgment form on 2/13/25, agreeing to abide by Medical Staff Bylaws and Regulations.

The credential file included documented evidence of a TB skin test from December 17, 2023. However, the 2024 annual TB attestation was missing.

The Medical Staff Coordinator provided the email records showing multiple requests Physician 3 to submit the required attestation on 2/3/25 at 1502 hours, 2/10/25 at 1222 hours, 3/10/25 at 1005 hours, and 4/24/25 at 1230 hours. As of 6/5/25 at 0931 hours, the hospital had not received Physician 3's TB attestation.

The Director of Medical Staff Services confirmed the above findings and stated it would be presented for review at the next MEC meeting.

b. Review of Physician 4's credential file showed the completion of an Annual TB Screening Questionnaire on 2/21/24. However, the required TB attestation was not found.

The Medical Staff Coordinator provided email correspondence showing the follow-up attempts on 2/3/25 at 1502 hours, 2/10/25 at 1228 hours, 3/10/25 at 1010 hours, 4/24/25 at 1210 hours, and 5/26/25 at 1206 hours. As of June 5, 2025, the attestation remained outstanding. The Director of Medical Staff confirmed the issue and planned to bring it to the next MEC meeting for review.

2. Review of the hospital's P&P titled Informed Consent last reviewed June 2024 showed the following:

* Informed consent must be documented in the patient's chart before a medical procedure.

* There must be evidence of appropriate informed consent for any procedure or treatment, including documentation of the date, the practitioner who informed the patient, and the signature of the individual obtaining consent.

On 6/4/25 at 0910 hours, review of Patient 1's closed medical record was conducted with the CNO.

Patient 1's closed medical record showed Patient 1 underwent the paracentesis procedures on 3/12 and 3/26/25, performed by Physician 1.

Review of Patient 1's informed consent showed two informed consent forms titled Consent to Surgical or Special Procedures did not meet the documentation requirements with the hospital's P&P as follows:

* The Consent to Surgical or Special Procedures dated 3/12/25, showed the consent form lacked Physician 1's signature, date, and time.

* The Consent to Surgical or Special Procedures dated 3/26/25, showed the consent form lacked Physician 1's printed name, date, and time.

The CNO confirmed both forms lacked the necessary elements and did not meet policy standards.

Based on interview and record review, the hospital failed to ensure RN 2 followed the hospital's P&P for administering the oral medication for one of four sampled patient (Patient 1) despite the patient's NPO status. This failure created the risk of patient safety.

Findings:

Review of the hospital's P&P titled Medication Administration, General Guidelines reviewed in July 2024 showed all medication orders must specify the exact route of administration. Nurses are responsible for contacting the physician if an order appears unclear or inappropriate.

On 6/4/25 at 0910 hours, an interview and concurrent review of Patient 1's closed medical record was conducted with CNO.

Patient 1's closed medical record showed Patient 1 was admitted to the hospital on 3/10/25, due to abdominal pain, gastrointestinal bleeding, and hematemesis. Patient 1's closed medical record showed on 3/15/25 at 0953 hours, RN 2 entered the physician's order for NPO status for Patient 1.

Review of the MAR dated 3/17/25 at 1600 hours, showed RN 2 administered duloxetine (an antidepressant) 20 mg by mouth to Patient 1.

On 6/5/25 at 1226 hours, an interview was conducted with the Director of Quality and Risk. The Director of Quality and Risk confirmed for the patient who had an NPO order and received oral medication, the physician's order must explicitly state, "NPO except meds." In the absence of such instructions, nurses were required to contact and verify the order with the physician before administering any oral medications. There was no documented evidence RN 2 consulted the ordering physician to determine whether the oral medication administration was appropriate for Patient 1 who was in NPO status.