HospitalInspections.org

Based on interviews and record reviews the hospital's Governing Body failed to ensure that the the Medical Staff By-Laws approved by the Governing Body were enforced and followed by all members of the medical staff. This failed practice was evidenced by the continued documented non-compliance of 2 (S23MD, S31MD) out of 3 (S23MD, S29MD, S31MD) active members of the medical staff to adhere to the Medical Staff Rules and Regulations regarding the authenticating of physicians orders.

Findings:
A review of the Governing Body By-Laws, as provided by Administration as the most current, revealed that the Medical Staff By-Laws are approved by the Governing Body. The Governing Body By-Laws revealed that all members of the medical staff are to adhere to the Medical Staff Rules and Regulations. The review further revealed that the authority and duties of the hospital's Administrator shall include in part: to carry out and execute all policies established by the Governing Body and to enforce the rules and regulations of the Governing Body and the Medical Staff.

A review of the Medical Staff By-Laws, as provided by Administration as the most current, revealed that "the medical staff was responsible for the quality of medical care in the hospital and must accept and assume this responsibility, subject to the ultimate authority of the hospital's Governing Body".

A review of the Medical Staff Rules and Regulations and the Medical Record's Policy Manual revealed that verbal orders shall be authenticated (signed, dated, timed) within 10 days and failure to do so shall be brought to the attention of the Medical Staff Committee.

A review of the Medical Staff Committee meeting minutes dated 01/22/14 revealed the following committee reports: the Medical Records Committee reported that physicians authenticating verbal orders was still an issue and signing, dating and timing orders within 10 days were "still non-compliant". The report further reported that there was only a 55% compliance and that the medicals records department again asked for medical staff support on this non-compliance. The Quality Assurance Committee reported that authenticating orders within 10 days by physicians were still non-compliant and only 1 (S29MD) active physician out of the 3 (S23MD, S29MD, S31MD) active physicians were 100% complaint.

In an interview on 02/26/14 at 10:30 a.m. with S4MR/QA Director, she was asked about her Medical Records report and her Quality Assurance report at the monthly Medical Staff Committee meetings regarding non-compliance of authenticating verbal orders by the physicians. S4MR/QA indicated that the hospital only had 3 active physicians at present: S23MD Chief of Staff, S31MD Vice Chief of Staff and S29MD Secretary of Medical Staff. S4MR/QA further indicated that S29MD was usually 100% compliant and that S23MD and S31MD were mostly non-compliant. S4MR/QA indicated that this non-compliance had been an ongoing concern for almost a year and that the direction given to her at the Medical Staff Committee meetings were to continue to monitor the non-compliance.

In an interview on 02/26/14 at 1:30 p.m. with S23MD Chief of Staff, he was asked about the Medical Records report and the Quality Assurance report at the monthly Medical Staff Committee meetings regarding continued non-compliance of authenticating verbal orders by the physicians. S23MD indicated they would continue to encourage the physicians to authenticate verbal orders within 10 days. S23MD further indicated that there was no penalty imposed upon physicians for not complying with this Medical Staff Rule and Regulation. S23MD indicated that the Medical Staff Committee would not be enforcing this Rule and Regulation since this non-compliance did not affect the quality of patient care

In an interview on 02/26/14 at 2:00 p.m. with S1Adm. he was asked about the Medical Records report and the Quality Assurance report at the monthly Medical Staff Committee meetings regarding continued non-compliance of authenticating verbal orders by the physicians. S1Adm indicated that the direction given to the Medical Records department at the Medical Staff Committee meetings were to continue to monitor this non-compliance.

Based on interviews and record reviews the Nursing Service department failed to ensure that nursing personnel had appropriate competency skills to meet the individual needs of each patient during IV (intravenous) conscious sedation. This failed practice was evidenced by no documented competency skills checklist for IV conscious sedation by nurses when caring for patients during procedures involving IV conscious sedation.

Findings:
A review of the Nursing Policy, "Conscious Sedation by the RN (Registered Nurse)", provided by S2DON as the most current, revealed that IV conscious sedation shall be administered by an RN that was specifically trained with demonstrated knowledge, skills and abilities to provide IV conscious sedation to patients to ensure safe administration of non-anesthetic medication and appropriate monitoring of patients in minimal, moderate and deep sedation levels.

In an interview on 02/26/14 at 10:45 a.m. with S16RN, she indicated that she was one of the endoscopy procedure nurses. S16RN indicated that endoscopy procedures were performed in the procedure room under IV conscious sedation. S16RN further indicated that she was the IV conscious sedation nurse that monitored the patients during these procedures.

In a review of S16RN employee in-service file, there was no evidence of a documented competency skills checklist for IV conscious sedation.

In an interview on 02/26/14 at 11:00 a.m with S16RN, she indicated that all nurses were ACLS(Advanced Cardiac Life Support) certified and further indicated that she had not been checked off for IV conscious sedation competency skills in the last few years.

In an interview on 02/27/14 at 11:30 a.m with S2DON she indicated that RNs had not been checked off for IV conscious sedation competency skills. S2DON further indicated that the nursing service department had not been adhering to their IV conscious sedation policy regarding documented competency skills for IV conscious sedation.

Based on interview, observation and record review the hospital failed to ensure that the Medical Records department stored and maintained patient medical records to ensure the integrity, security and protection of the medical records from damage, water and fire with limited access to only authorized individuals. This failed practice was evidenced by patient medical records being stored in open cabinets in the medical records department under the ceiling sprinkler system and by medical records being stored in outside buildings with access by unauthorized individuals.

Findings:
A review of the Medical Records Policy manual revealed it was the responsibility of the hospital to safeguard the information on the patient medical records against loss, damage and unauthorized individuals.
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An observation of the medical records department revealed patient medical records filed in open metal file cabinets with a ceiling sprinkler system in place. There was no evidence of the file cabinets being able to be closed or covered in the event of a fire and the sprinkler system being activated. An observation of the 2 outside buildings which stored patient medical records revealed over 250 boxes (approximately 12 inches by 24 inches) containing multiple patient medical records being stored on top of one another on wooden shelves or on the floor. There was no evidence of a sprinkler system in either of the buildings to protect against fire damage and the medical records stored in the boxes on the floor were not protected from water damage due to flooding. In both of the 2 outside buildings were noted rooms with maintenance equipment and supplies.

In an interview on 02/26/14 at 1:30 p.m. with S4MR Director, she indicated that the records stored in the Medical Records department were patient medical records for the past 5 years and were the original records. S4MR indicated that if the sprinkler system was activated, the file cabinets were not able to be closed and the medical records would not be protected from water damage. S4MR was asked about the 2 outside buildings that stored patient medical records. S4MR indicated that the 2 outside buildings that stored medical records were medical records from 5 years or earlier and those buildings did not have a sprinkler system in place. S4MR further indicated that the medical records in those 2 buildings were not protected from fire or from water damage due to flooding. S4MR Director was asked about the security of the patient medical records in the 2 outside buildings from unauthorized personnel. S4MR indicated that the 2 outside buildings were also used by maintenance for storage and work projects and that maintenance would have key access to those buildings. S4MR Director indicated that patient medical records should be protected from damage (fire and water) and unauthorized access according to their Medical Record Policy manual.