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Based on observation, review of laboratory policies and procedures, and interview with the laboratory manager, the laboratory failed to ensure that blood collection tubes were not outdated and failed to establish procedures for the collection, preservation, transportation, receipt, and reporting of tissue specimen results.

Findings include:

1. An inspection of the draw stations revealed expired blood collection tubes available for use. Gray top Vacutainer tubes, lot #6064592, expired in July 2017. Blue top Vacutainer tubes, lot #B1608398, expired 8/08/17. The laboratory manager confirmed the finding during the on-site survey on 4/10/18 at approximately 1:30 PM and discarded the expired tubes found in the draw stations and in storage.

2. The laboratory did not have written policies and procedures for the collection, preservation, transportation, receipt, and reporting of tissue specimen results. The manager stated during the interview on 4/10/18 at approximately 12:45 PM that tissue specimens were not generally collected and sent for testing from the hospital and therefore no such written procedure was available.

Based on review of records, review of policies and procedure, and interview with the radiology services manager, the service failed to verify that services provided do not expose CAH patients or personnel to radiation hazards.

Findings include:

1. The Radiological Physics Evaluation from survey by the physicist on 1/18/18 had a requirement for service personnel to be contacted for the General Electric Radiographic equipment for an error message. There was no documentation of corrective action or follow up to the physicist's request to ensure optimal operation of the equipment.

2. The radiology services manager failed to provide requested policies and procedures during the survey on 4/10/18:
a. A written document, approved by the governing body (or responsible individual), delineating the scope and complexity of radiological services offered. The manager searched printed policies and procedures as well as the on-line procedures and stated during the on-site survey on 4/10/18 at approximately 1:45 PM that the document could not be found.
b. Policies and procedures for the types of personal protective shielding to be used, under what circumstances, for patients, including high risk patients as identified in radiological services policies and procedures, and CAH personnel.
c. Policies and procedures used to verify the integrity of patient shielding.
d. Policies and procedures for periodic inspections of radiology equipment.

3. The radiology services manager was unable to provide records of the inspections performed on shielding equipment.

4. The manager stated during the survey on 4/10/18 at approximately 1:45 PM that the CT scanner was serviced every three months by a contracted provider. A review of the service record for the GE Brightspeed CT scanner revealed two records for 2017, dated 6/13/17 and 10/23/17. Two records for 2017 were missing and no records were submitted for the first quarter of 2018. There was no documentation that the equipment was serviced every three months as stated by the manager.

5. No documentation of the preventative maintenance performed on the fixed and portable radiographic equipments was available for evaluation during the on-site survey on 4/10/18.

Based on observation, interview, and document review, the facility failed to ensure verbal orders were signed timely for 10 of 20 patients (Patient # 1, #2, #3, #4, #6, #7, #8, #10. #11, #20 ) and other physician orders were not signed timely for 2 of 20 patients.
(Patient #3 and #12)

Findings include:

Patient #1, #2, #3, #4, #6, #7, #8, #10, #11, and #20 all had identified verbal medication orders that were not signed timely by the physician as per policy.

During interview with the Risk Manager and Medical Records manager on 4/11/18 at 11AM, it was confirmed all verbal orders for medications should be signed within 48 hours and identified verbal orders were not signed within 48 hours. The current medical records system does not allow the physician to access the medical record from a remote location presently, and the physician must sign orders when on site at the facility.

The policy and procedure, entitled, "Physician Orders" dated 8/1/06, stated, "All medications administered to patients shall be ordered in writing and signed by the physician within 48 hours."

A second policy and procedure entitled, "Verbal Orders, dated 9/24/14, stated," b. The prescribing practitioner signs or initials the verbal order within the timeframes consistent with the Federal and State law or regulation and CAH policy (within 48 hours).

Patient #12 had a progress note dated 9/12/17, but wasn't signed by the physician until 2/12/18.

Patient #3 had a History and Physical ( H&P) dictated on June 7, 2017. The H&P was not signed until six days later.

During interview with the Risk Manager and Medical Records manager on 4/11/18 at 11AM, it was confirmed all dictation or other notes should be signed within 48 hours. The current medical records system does not allow the physician to access the medical record from a remote location presently, and the physician must sign orders when on site at the facility. There was not a specific policy and procedure that addressed that the physician must sign all documentation within 48 hours, but this was an expectation by the facility.