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Based on interview and record review, the hospital failed to ensure two of five employees (Surgical Technician (ST) and Registered Nurse (RN) 2) were qualified and competent in their roles when:

1. The ST's employee file did not contain evidence she met the minimum qualifications to be in her role; and

2. RN 2's employee file did not contain a unit specific orientation that validated training and education to work in the peri-operative (period of time extending from when the patient goes into the hospital for surgery until the time the patient is discharged home) department.

These failures had the potential for staff to perform work tasks and patient care without the necessary education, training, and competency.

Findings:

1. During a concurrent interview and record review with the Human Resources Coordinator (HRC), on 4/10/19, at 9:47 a.m., she validated that ST's employee file did not contain evidence she was a high school graduate or equivalent and did not have evidence she had successfully completed a certified nursing assistant (CNA) or emergency medical technician (EMT) certification per the minimum qualifications stated in her signed job description.

During an interview with the Chief Human Resources Officer (CHRO), on 4/10/19, at 1:42 p.m., she stated her expectations of the employee files were for the staff's certifications and qualifications to be readily available in the employee's file.

A review of the ST's job description signed, 1/3/17, indicated, "...Job Description ...Job Title: Surgical Technician ...II. Minimum Qualifications: A. Education ...1. High school graduate or equivalent. 2. Successful completion of a CNA or EMT Certification ..."

2. During an interview with the HRC, on 4/10/19, at 9:10 a.m., she validated RN 2's employee file did not contain evidence she was oriented, which provided education and training to be in her current position. The HRC stated RN 2 has been in her role since 11/3/16.

During an interview with the Director of Patient Care Services (DPCS) on 4/11/19 at 11:10 a.m., she stated RN 2 did not have evidence of orientation to her current role. The DPCS stated the importance of staff orientation to their current position is it assists in tracking competency and identifies where additional training is needed.

The hospital policy and procedure titled, "New Employee District Orientation" dated 12/12, indicated, "Department Orientation: Additionally, each department of the District has a department specific orientation for their new employees. Some departments' orientation contains items that require completion or review before the employee can perform patient care duties or begin regular work duties, i.e. skills competency tests, operation of equipment, etc ...The department manager is responsible for submitting to the Human Resources a completed Units Orientation Checklist within fourteen (14) days from of the employee's first day of beginning work in the department..."

The hospital policy and procedure titled, "Employee Personnel Files" dated 2/13, indicated, "Policy: It is the policy of (name of hospital) that all District employee records are maintained in the Human Resources and Payroll office to insure accurate, confidential, complete records of education, experience, attendance, and performance of each employee..."

Based on observation, interview, and document review the hospital failed to have emergency medications readily available as evidence by:

1. The hospital emergency medications were not found in the crash cart as required by the hospital content list. This failure increases the potential for medication errors (i.e. administration of wrong doses and/or administration of the wrong medication).

2. The hospital failed to complete the daily crash carts checks in accordance to hospital policy. This failure increases the potential for not having adequate emergency supplies/medications in case of an emergency.

Findings:

1. A review on 4/08/19 of the hospital emergency content listed policy indicated that the following medications and the quantity where found in the emergency crash cart:
*Amiodarone 150mg/3ml vial #3
*Atropine 1mg/10ml syringe #3
*Epinephrine 1:10,000 10ml syringe #8

During an observation on 04/08/19 at 1:54 p.m., in the medical-surgical nursing station the unopened crash cart was opened and the following inventory was observed:
*Amiodarone 150mg/3ml vial #2 (1 missing)
*Atropine 1mg/10ml syringe #1 (2 missing)
*Epinephrine 1:10,000 10ml syringe #7 (1 missing)
*Amiodarone 150mg/100ml Injection (not listed on content list)

The above indicated that there were missing emergency medications.

During an interview on 4/09/19 at 1:54 p.m., the Director of Patient Care Services (DPCS) stated there were missing medications when comparing the hospital emergency content list and what was stocked in the emergency crash cart. She acknowledged the importance of having a fully stocked crash cart in case of an emergency.

2. A review on 4/9/19 of the hospital policy dated 4/3/18 entitled Crash Cart Medications indicated "At a minimum, each crash cart will be checked: at the beginning of the a.m. shift (0700) and the p.m. shift (1900) in acute..."

During an observation on 4/09/19 at 1:15 p.m., in the Acute Care Nursing Station the Crash Cart Daily Check List for April appeared to have missing entries. The Daily Check Lists were not found on the cart for previous months.

During an interview on 4/09/19 at 1:16 p.m., the DPCS stated that the Crash Cart Daily Check List was found in her office and she would obtain the Daily Check List for me. She acknowledged that sometimes the nurses forget to check and document the daily checks.

A review on 4/09/19 of the December 2018 thru April 2019 Crash Cart Daily Check List indicated the following missed checks for the Acute Crash Cart:
*December 2018 missed checks-12/1, 12/2, 12/6, 12/13, 12/15, 12/18, 12/23, 12/24, 12/27, 12/28, 12/29
*January 2019 missed checks-1/4, 1/5, 1/6, 1/7
*February 2019 missed checks-2/20, 2/28
*March 2019 missed checks-3/14
*April 2019 missed checks-4/1, 4/2

Based on observations, interviews, and document reviews the hospital failed to appropriately store and monitor medications as evidence by:

1. The hospital staff failed to store "protect from light" medications appropriately when Lidocaine with Epinephrine (medication used for anesthesia) and Nitroglycerin (medication used to treat heart conditions and lowers blood pressure) were stored under direct light. This failure exposed patients to compromised and/or expired medications.

2. The hospital failed to complete the daily medication refrigerator checks in accordance to hospital policy. This failure increases the potential for administering compromised or reduced potency medications.

Findings:

1. A review on 4/08/19 of the manufacturer insert indicated "protect from light" for Lidocaine with Epinephrine, and Nitroglycerin. According to the manufacturer Lidocaine with Epinephrine and Nitroglycerin were to be stored away from light.

During an observation on 4/08/19 at 12:52 p.m., there were ten vials of Lidocaine with Epinephrine were found in the pharmacy and stored under direct light. During an observation on 4/08/19 at 12:55 p.m., there were five bottles of Nitroglycerin found in the pharmacy and were stored under direct light.

The above mentioned medications were found under direct light, were uncovered, and inappropriately stored. Medication that require protect from light deteriorate under direct light. The labels of each of these medications indicated "protect from light".

During an interview on 4/09/19 at 12:55 a.m., the Pharmacy Manager stated she did not know the Lidocaine with Epinephrine, and Nitroglycerin were stored under direct light. She said she would cover these medications immediately.

2. A review on 4/9/19 of the hospital policy dated 2/21/18 entitled Drug Room Physician Plant Environment indicated "Staff will maintain the temperature in the medication refrigerator between 36-46 degrees Fahrenheit ...A temperature log will be maintained twice daily, once one each shift, by the RN on duty in Med/Surg. This log will be posted in the Acute med room ... "

During an observation on 4/09/19 at 1:05 p.m., in the Acute Care med room the medication refrigerator temperatures for April appeared to have missing entries. The daily medication refrigerator temperatures were not consistently documented.

During an interview on 4/09/19 at 1:06 p.m., the Pharmacy Manager stated that the documentation for the medication refrigerator temperatures were found in her office and she would obtain the document for me. She acknowledged that sometimes the nurses forget to document the daily temperatures.

A review on 4/09/19 of the December 2018 thru April 2019 medication refrigerator temperatures indicated the following missed temperatures for the acute care medication refrigerator:
*December 2018 missed temperatures-12/1, 12/16, 12/21, 12/27
*January 2019 missed temperatures -1/4, 1/9, 1/16
*February 2019 missed temperatures -2/27
*March 2019 missed temperatures -3/13, 3/27
*April 2019 missed temperatures-4/7

Based on interview and record review, the hospital failed to monitor the temperature and humidity (the amount of water vapor in the air) levels in the surgical suite according to the hospital's policy and procedure titled, "Humidity & Temperature Levels in Surgical Suite/Endoscopy (procedure in which an instrument is introduced into the body to give a view of its internal parts) Room" when:

1. Corrective actions were not performed when the temperature and/or humidity levels were not within acceptable parameters; and

2. The temperature and humidity levels were not documented weekly or prior to procedures.

These failures had the potential to adversely affect the integrity of the supplies in the surgical suite.

Findings:

1. During a concurrent interview and record review with the Infection Prevention Registered Nurse (IPRN), on 4/10/19 at 2:10 p.m., she stated the surgical suite temperature and humidity levels should be monitored and documented prior to procedures. The IPRN stated the acceptable temperature range was 68 to 75 degrees Fahrenheit (F) (the scale of temperature) and the acceptable humidity range was 35-60%. The IPRN stated she was not aware the temperature or humidity levels were not within range. The IPRN stated the manager and the maintenance department should have been notified if the temperatures and humidity levels were not within the acceptable ranges. The IPRN stated the hospital should have canceled procedures if the temperatures and/or humidity levels continued to be out of range.

During a concurrent interview and record review with the Director of Patient Care Services (DPCS), on 4/10/19, at 2:27 p.m., she validated from October 2018 to April 2019, there were 11 of 13 occurrences where the temperature or humidity levels were not within the acceptable parameters. The DPCS stated she expected the IPRN and maintenance staff to be called.

During an interview with the Plant Operations Manager (POM), on 4/10/19 at 2:43 p.m., he stated he was informed verbally on a few occasions when the temperature or humidity levels were out of range, but cannot recall the dates. The POM stated there was no work order to show evidence of when the temperature or humidly levels were out of range or when it was reported to him. The POM stated his expectation was for a work order to be placed to track the work orders.

A review of the "Temperature/Humidity log Surgical Suite (Endoscopy room)" dated 2018 and 2019 indicated:

10/25/18- Humidity 29%
11/08/18- Humidity 31%
11/15/18- Humidity 31%
12/13/18- Humidity 29%
12/27/18- Humidity 28.4%
01/03/19- Humidity 17%
01/17/19-Temperature 67.1-degree F
02/07/19-Temperature 67.9-degree F, Humidity 25.5%
02/14/19-Temperature 66.9-degree F
02/28/19- Temperature 67-degree F
03/28/19-Temperature 67-degree F

The hospital policy and procedure titled, "Humidity & Temperature Levels in Surgical Suite/Endoscopy Room" dated 3/18, indicated, "Purpose: To provide appropriate methods of monitoring and adjusting the surgical suite temperature and relative humidity levels...Policy: This is to ensure that the surgical suite relative air humidity is maintained accordance with recommended standards in the interest of patient safety with respect to both fire and safety and infection control and prevention...1. The temperature of the Surgical Suite should be maintained between 68 and 75 degrees F. 2. The relative humidity level of the Surgical Suite will be maintained at 35%-60% in regard to infection prevention standards to inhibit bacterial growth...4. Reporting and Maintenance: a. Any deviations of relative humidity outside the range of 35-60% will be recorded and reported to in the Infection Prevention Nurse along with the Maintenance Department ..."

2. During an interview with the DPCS, on 4/9/19, at 9:23 a.m., she stated the temperature and humidity log located in surgical suite was required to be completed prior to procedures.

During a concurrent interview and record review on 4/10/19 at 2:27 p.m., the DPCS provided a schedule of when the surgical room was used between the dates of October 2018 to April 2019. The DPCS validated the following days, the surgical room was used, but there was no documentation of temperature or humidity levels on the log for: 10/4/18, 10/18/18, 11/21/18, 11/29/18, 12/19/18, and 3/21/19.

The hospital policy and procedure titled, "Humidity & Temperature Levels in Surgical Suite/Endoscopy Room" dated 3/18, indicated, "Purpose: To provide appropriate methods of monitoring and adjusting the surgical suite temperature and relative humidity levels...Policy: This is to ensure that the surgical suite relative air humidity is maintained accordance with recommended standards in the interest of patient safety with respect to both fire and safety and infection control and prevention...3...this will be monitored on a weekly basis or prior to procedures on a temperature and humidity log. This is to ensure proper functioning of the equipment..."

Based on interview and document review the hospital failed to accurately and promptly document in the patient's medical record a physician verbal order for Hydromorphone (pain relieving medication), Ondansetron (a medication that relieves nausea), and Promethazine (a medication that releives nausea) for Patient 17 in accordance to hospital policy.

This failure increases the risk for diversion and medication errors.

Findings:

A review on 4/10/19 the hospital policy dated 1/16/19 entitled Verbal and Telephone Orders indicated "When a provider gives a verbal or telephone order to a licensed nurse, that order will be entered in the electronic medical record as soon as possible after receiving the order...The licensed nurse will enter the order as a verbal or telephone order in the EMR...The physician will be responsible for electronically signing the order..."

A review on 4/10/19 of Patient 17's clinical record indicated that on 12/28/19 at 12:53 a.m., there were telephone orders for Hydromorphone, Ondansetron, and Promethazine. The orders were never electronically signed by the physician. There was no listed ordering physician. The Hydromorphone and Ondansetron were administered by the nurse's multiple times without a listed ordering physician.


During an interview on 4/10/19 10:50 a.m., the Director of Patient Care Services (DPCS) stated she did not know who wrote the physician's orders. She also said she was unsure of the physician that called in the order. She agreed that it was important to have accurate documentation of telephone orders in order to prevent diversion and medication errors.

Based on interview and record review, the hospital failed to ensure medications were administered as ordered by the physician when:

1. Patient (Pt) 3 received Acetaminophen (a medication used for pain relief and/or fever reducer) 650 mg (milligram-a form of measurement) that was not in accordance with the physician's orders; and

2. Four of 24 Pts (Pts 1, 5, 6, 7,) had PRN (when necessary) medications ordered without an indication for administration.

These failures had the potential to adversely affect Pt's 1, 3, 5, 6, and 7's health.

Findings:

1. During a concurrent interview and record review with the Director of Patient Care Services (DPCS), on 4/9/19, at 1:50 p.m., she stated Pt 3 had Acetaminophen 650 mg ordered PRN every six hours for pain or temperature greater than 100.5 degrees Fahrenheit (F) (the scale of temperature). Pt 3's clinical record titled, "Medication Administration" dated 4/7/19 indicated Pt 3 received Acetaminophen 650 mg orally on 4/7/19 at 7:57 p.m. for "temperature." The DPCS stated Pt 4's vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) were taken on 4/7/19 at 7:40 p.m., and Pt 3's temperature was 99.9 degrees F. The DPCS stated the nurse that administered the Acetaminophen 650 mg did not follow the physician's order. The DPCS stated she would have expected the nurse to follow the physician's orders because the nurse needed to function within their scope of practice and follow the physician's order.

During an interview with the DPCS on 4/10/19, at 2:50 p.m., a request was made for the hospital's policy and procedure on medication administration. The DPCS stated the hospital did not have a policy or procedure on medication administration. The DPCS stated the hospital uses a (name of professional reference that offers clinical reference and training for nurses) book and a medication drug book for medication administration practices. The DPCS provided a print out from the (name of professional reference) book.

During a review of the clinical record for Pt 3, the physician's orders dated 4/7/19 indicated, "Acetaminophen 650 mg...Route: PO (by mouth)...Instructions: for pain or Temp >(greater than) 100.5..."

A review of the "(name of professional reference) Nursing Procedures" dated 2013, indicated, " ...Safe Medication Administration Practices, General ...Implementation ...Verifying the medication order: Follow a written or typed order ..."

2. During a review of the clinical record for Pt 1, the physician's order dated 4/5/19, at 12:58 p.m. indicated, " ...Acetaminophen 650 mg ...oral ...PRNQ(every)6H(hours) ...Indication: N/A (not applicable) ..."

During a review of the clinical record for Pt 5, the physician's order dated 4/7/19, at 9:19 p.m., indicated, " ...Oxycodone-Acetaminophen 5mg/325mg ...1 tab (tablet) ...oral ...PRNQ4H ...Indication: (N/A) ..."

During a review of the clinical record for Pt 5, the physician's order dated 4/7/19, at 9:52 p.m., indicated, " ...Morphine (a medication used to help relieve moderate to severe pain) ...IV (intravenous-given into the vein) Push ...PRNQ4H ...Indication: (N/A) ..."

During a review of the clinical record for Pt 6, the physician's order dated 4/7/19, at 6:13 a.m., indicated, " ...Morphine ...0.1 mL (milliliters-form of measurement) solution ...IV Push...PRNQ4H ...Indication: (N/A) ..."

During a review of the clinical record for Pt 7, the physician's order dated 6/19/18, at 9:02 p.m., indicated, "Oxycodone-Acetaminophen 5mg/325mg ...1 tab ...oral ...PRNQ6H ...Indication: (N/A) ..."

During an interview with the DPCS on 4/10/19, at 2:50 p.m., she validated the findings of the physician's orders did not have an indication for the medications to be administered "when necessary." The DPCS stated the physician's orders should have specified what the medication was ordered for. The DPCS stated the hospital did not have a policy or procedure on contents of a physician's medication order. The DPCS stated the hospital uses a (name of professional reference) book and a medication drug book for medication administration practices. The DPCS provided a print out from the (name of professional reference) book.

A review of the "(name of professional reference) Nursing Procedures" dated 2013, indicated, " ...Safe Medication Administration Practices, General ...Implementation ...Verifying the medication order ...Make sure the prescriber's order contains a diagnosis, a condition, or an indication for the medication ..."

Based on interview and record review, the hospital failed to ensure nursing care plans were kept current for five of 24 Patients (Pts 1, 2, 4, 7, and 21) when nursing care needs were identified but there were no nursing interventions implemented.

These failures had the potential for Pts 1, 2, 4, 7, and 21's health and safety needs to not be met.

Findings:

During a review of the clinical record for Pt 1, the "History and Physical" dated 4/5/19, at 11:04 a.m., indicated, " ...99 year old female ...for admission because of change in level of consciousness (a measurement of a person's responsiveness to stimuli from the environment) ..."

During a concurrent interview and record review with the Director of Patient Care Services (DPCS), on 4/9/19, at 1:43 p.m., she validated Pt 1's nursing care plan indicated, "Altered thought process," but did not have interventions identified that were to be implemented that would address the nursing care need. The DPCS stated there should have been interventions listed and carried out to address and assess Pt 1's needs.

During a review of the clinical record for Pt 1, the "Problems/Goals" dated 4/8/19, indicated there were no interventions or evaluations for the problem "Altered thought process."

During a review of the clinical record for Pt 2, the "History and Physical" dated 4/8/19, at 9:46 a.m., indicated, " ...93 year old female ...some memory issues brought in by ambulance because daughter noted abnormal movements of the left leg and arm ...Assessment/Plan ...Possible stroke ..."

During a concurrent interview and record review with the DPCS, on 4/9/19, at 1:24 p.m., she validated Pt 2's nursing care plan indicated, "Sensory Perception (gaining an understanding or awareness of what is happening or present in the surrounding environment) Disturbed Rt (related to) CVA (cerebral vascular disease- when blood flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel)," but did not have interventions identified that were to be implemented that would address the nursing care need.. The DPCS stated she would have expected interventions to be carried out and documented to address Pt 2's need.

During a review of the clinical record for Pt 2, the "Problems/Goals" dated 4/7/19, indicated there were no interventions or evaluations for the problem "Sensory Perception Disturbed Rt CVA."

During a review of the clinical record for Pt 4, the "History and Physical" dated 4/8/19, at 9:43 a.m., indicated, " ...86 year old female ...while in ER (emergency department) she dropped her BP (blood pressure- the pressure exerted by circulating blood upon the walls of blood vessels) ...Assessment/Plan ...admitted with hypotension (abnormally low blood pressure) ..."

During a concurrent interview and record review with the DPCS, on 4/11/19, at 9:25 a.m., she validated Pt 4's nursing care plan indicated, "At risk decreased cardiac output secondary to hypotension," but did not have interventions identified that were to be implemented that would address the nursing care need. The DPCS stated her expectation was for interventions to be listed and carried out to address Pt 4's needs.

During a review of the clinical record for Pt 4, the "Problems/Goals" dated 4/8/19, indicated there were no interventions or evaluations for the problem "At risk decreased cardiac output secondary to hypotension."

During a review of the clinical record for Pt 7, the "History and Physical" dated 6/19/18, at 9:41 p.m., indicated, " ...95-year-old-female ...Plan ...will be admitted to inpatient services ...We will follow her cardiovascular status closely she will be on telemetry ..."

During a concurrent interview and record review with the DPCS, on 4/11/19, at 10:06 a.m., she validated Pt 7's nursing care plan indicated, "At risk decreased cardiac output secondary to CHF (congestive heart failure- chronic condition that affects the pumping power of your heart muscles)" but did not have interventions identified that were to be implemented that would address the nursing care need. The DPCS stated her expectation was for interventions to be listed and carried out to address Pt 7's needs.

During a review of the clinical record for Pt 7, the "Problems/Goals" dated 6/25/18, indicated there were no interventions or evaluations for the problem "At risk decreased cardiac output secondary to CHF."

During a review of the clinical record for Pt 21, the "SOAP (Nursing note that indicated the patient's concerns, what the nurse observed, assessment, and plan)" dated 2/19/19, indicated, " ...received call from family members reporting that patient is a very anxious and agitated and caregivers are sick ...arrange respite (temporary care of a sick, elderly, or disabled person, providing relief for their usual caregiver) stay in the hospital ..."

During a concurrent interview and record review with the DPCS, on 4/11/19, at 10:45 a.m., she validated Pt 21's nursing care plan indicated, "Caregiver Role Strain" but did not have interventions identified that were to be implemented that would address the nursing care need.. The DPCS stated her expectation was for interventions to be listed and carried out to address Pt 21's needs.

During a review of the clinical record for Pt 21, the "Problems/Goals" indicated there were no interventions or evaluations for the problem "Caregiver Role Strain."

The hospital policy and procedure titled, "Care Plans" dated 11/12, indicated, "Policy: Patient care is to be delivered in accordance with a patient-specific care plan that addresses the patient's physical and psychosocial needs. Purpose: To ensure appropriate nursing evaluation of and response to each hospitalized patient's physical and psychosocial needs. Procedure ...2. The initial care plan includes identification and prioritization of patient problems, planned nursing interventions, and patient specific, measurable goals. 3. Care plans for both Inpatient ...will be re-evaluated every shift and updated as patient condition and/or needs require ...5. Documentation will reflect communication on plans to meet ongoing needs ..."

Based on observation and interview, the facility failed to have a disaster plan to provide clinical patient information in an emergency evacuation situation.

This failure has the potential to impede the ability to retrieve patient care history, and clinical records pertinent for individualized care.

Findings:

During an observation on 4/8/19 at 10:20 a.m., the Health Information Management Director (HIM1) was observed retrieving back up clinical information on one dedicated back up "view only" terminal, which was located in the Acute Care Ward. The information that was accessed showed back-up Electronic Health Record (EHR) information only available through 3/15/19. The HIM1 contacted Information Technology (IT) support, and requested for the computer to be backed-up through the previous day.

During an interview on 4/8/19 at 10:30 a.m., the HIM1 stated the backing up of EHR data should occur daily. The facility had just installed a newer extension of the inpatient EHR system on 4/1/19, replacing an older system in the Emergency Department (ED)which did not network with the inpatient clinical records. HIM1 stated that prior to the adoption of the EHR system, when ED patients were admitted as an inpatient to the hospital, those records could not be viewed immediately in the inpatient EHR.

During an interview on 4/8/19 at 1:00 p.m., with the facility Compliance Director (CMPL DIR) who had been the Health Information Management Director until 2/1/19, CMPL DIR stated an average of 526 patients were seen in the first three months of 2019. Of those ED patients seen, an average of 23 were admitted as inpatients (admitted to the hospital) each month. The major diagnoses treated in the hospital were chronic conditions such as chronic obstructive pulmonary disease (COPD) (lung disease characterized by chronic obstruction of lung airflow), congestive heart failure (CHF) (heart is unable to pump blood adequately), diabetes mellitus (DM) (disorder with prolonged high blood sugars in the body) cellulitis (skin infection), and pancreatitis (inflamed diseased pancreas). A listing of the most frequent diagnoses and procedures was requested on 4/8/19 and provided on 4/9/19, and confirmed the frequent reasons for admission to the acute hospital with an older demographic population in the district.

During an interview on 4/9/19 at 9:15 a.m., with HIM1 and Information Technology Manager (IT MGR), they were asked if there had been any long-term downtime or power outages at the facility. A facility EHR downtime policy had been requested on 4/8/19, and IT MGR stated that the policy was being developed on and was not available. When asked about the longest duration of an HER outage, they stated that a power outage incident occurred on 10/15/18 for 6 hours due to a planned emergency shut-down by the electric company. A copy of the 10/15/18 incident report was requested on 4/9/19 and provided 4/9/19.

The 10/15/18 incident report for the power outage was reviewed on 4/9/19 and showed that the backup electric generator system provided access to the EHR acute care area of the hospital and the E.D. The report included a notation that the computer located in the acute care ward was not plugged into a backup outlet which prevented printing of records.

During an interview on 4/10/19 at 10:00 a.m., with HIM1, the provision of backup disaster support with a third party disaster recovery vendor was discussed. HIM1 stated a vendor is contracted to provide computer and communication support, and a second out of state vendor located remotely would provide the backup generator equipment on a container truck. A copy of the business associate agreement was requested on 4/10/19.

A review of the vendor agreement, provided on 4/10/19, indicated it was not a valid contract nor in the format of a Health Information Portability and Accountability Act (HIPAA) business associated agreement to assure privacy and security for protected health information of patients. The agreement did not assure continuity of care for timely health information exchange in a disaster.

Based on interview and record review, the facility failed to assure accurate clinical documentation for an inpatient who expired.

This failure to accurately document (Patient 21's) death in the clinical record, had the potential for data inaccuracy, inaccurate death certification, and potential probate, billing or claims fraud.

FINDINGS:

During a review of the facility's Death Register report on 4/8/19 that had been requested for the time period 6/1/18 - 3/31/19, duplication of 2 patients on the register was noted.

During an interview with Health Information Management Dicrector (HIM1) on 4/9/19, it was explained that the Admission-Discharge-Transfer system had erroneously duplicated 2 patient expirations and that the Death Register report was corrected for total expirations of 16 patients treated from 6/1/18 to 3/31/19.

During a record review of Patient 21, an 84 year old female who expired as an inpatient on 2/20/19, the time of pronouncement of death varied from the death certificate indicating 01:00 a.m., on 2/20/19, on the nursing Discharge Death report from the electronic health record (EHR) of 2:12 a.m., and the Health Information Management discharge reporting 5:15 a.m. The medical record was noted as incomplete and there was no death summary documentation or progress notes by the physician during the two day stay.

Based on observation, interview and record review, the facility failed to have physician verbal and telephone orders authenticated (signed) within 48 hours of issuance in accordance with state law.

This failure of having unsigned physician orders carried a higher risk of miscommunication, drug diversion and error, when 1,594 verbal and telephone orders for inpatients in a three-month period from 12/1/18 to 3/1/19, were unauthenticated in the hospital electronic health record (EHR) system.

Findings:

During a concurrent observation and interview on 4/8/19 at 10:15 a.m, at the acute nursing station, the acute ward clerk (AWC) was asked which document in the EHR was the most critical for patient care, especially if the EHR system was not functioning. The AWC stated that the Medication Administration Record (MAR) ( a legal record of the drugs administered to a patient)


During a record review on 4/8/19 at 10:30 a.m., the printed 5 day Medication Administration Record (MAR) for Patient 1 indicated "Unsig VO" meaning unsigned verbal order on all 11 orders of the patient's medical record dating back to 4/5/19.


Upon review of the facility's list on 4/9/19 of unsigned orders from 12/1/18 to 3/1/19, there were a total of 1,594 verbal and telephone orders that had not been authenticated (signed electronically) in the EHR. system:
· Physician 1 (MD1), a hospitalist (a physician who specializes in the care of patients in the acute care hospital), with 578 unsigned orders
· Physician 2 (MD2), a hospitalist, with 549 unsigned orders
· Physician 3 (MD3), a hospitalist, with 337 unsigned orders
· Physician 4 (MD4), a hospitalist with 34 unsigned orders
· Physician 5 (MD5), an attending physician, with 15 unsigned orders


Of the 1,594 unsigned orders, 83 were medication orders for Schedule II controlled substances (drugs regulated by the government, that have a high potenial for abuse) that required the prescribing physician's signature by state law.

During an interview on 4/9/19 at 10:00 a.m., HIM1 stated that the signing of verbal and telephone orders had not been tracked for the previous year of 2018. HIM1 stated that the group of hospitalists assigned for monitoring acute care at the facility had changed on 9/1/18.

Upon review on 4/10/19 of the facility's list of unsigned orders for twelve months in 2018, there was a total of 153 pages of the listing (Outstanding Cosignature/Verbal Orders 1/1/18 to 12/31/18), for more than 3800 unsigned orders.

During an interview on 4/10/19 at 9:30 a.m., with HIM1, the Director of Patient Care Services(DOCS) and MD3 entered the room to talk to HIM1 regarding the signature of MD3's verbal and telephone orders. HIM1 stated that MD3 had never been trained on how to sign the E.H.R. orders since joining the hospitalist staff on 9/1/18.

The facility policy and procedure titled "Physician Verbal and Telephone Orders" (P&P VO/TO) dated 4/15/15 was reviewed and indicated authentication (verification) of unsigned orders by phsicians was to occur within 48 hours of receipt.

The facility policy and procedure titled "Verbal Orders - General" (P&P VO) dated 3/21/14 was reviewed and indicated that "all orders of medication and treatment shall be electronically entered into the District's electronic medical record (EMR)" and "the prescriber shall cosign the order within 24 hours". Also the policy and procedure indicated that the HIM department "shall audit for the timeliness of these orders and report any delay in signing off on the verbal orders by the physician to the District's Medical Staff".

Based on interview and record review, the facility failed to retain medical records for ten years as required by state law.

This failure failed to assure availability of medical records for the benefit of the patient, staff, and district, as a source of information for continuity of care.

Findings:

During an interview on 4/8/19 at 9:45 a.m., medical records clerk (MRC) of the Health Information Management (HIM) department stated that medical records in hardcopy were stored in two HIM storage areas around the hospital facility. Medical records were being purged (set aside for destruction) from 7 years prior to the date of last discharge.

During an interview on 4/8/19 at 10:00 a.m., the HIM Director (HIM1) stated that records were being destroyed by a contracted business records vendor for patient records older than 7 years from the most recent discharge, and for 1 year past the age of 18 years for minor patients. When asked, the HIM1 was not aware of the change of California law that took effect on 1/1/18 requiring hospitals rendering care for patients covered by the Department of Health Care Services to keep records for at least 10 years. A copy of the facility's policy and procedure for record retention was requested on 4/8/19 and provided on 4/10/19.

During the interview on 4/18/19, HIM1 was asked whether certificates of destruction were kept from the contracted vendor for medical records that had been destroyed and stated that they were not obtained.

A copy of the Business Associate Agreement with the contracted business record destruction vendor was requested on 4/8/19 and provided 4/10/19, which did not include mention of destruction certificates to be provided that would be needed for tracking of record retention.

The facility policy and procedure titled "Medical Record Retention" dated 4/8/14 indicated medical record retention for a minimum of 7 years following the most recent discharge date for all adult inpatients and at least to age 19 for minor patients.