HospitalInspections.org

Based on observation, interview and record review, the hospital's Governing Body failed to hold the facility Medical Staff accountable for adhering to approved and accepted hospital policies and procedures and for the care provided to 3 of 6 sampled patients as evidenced by the following:

1. Failure to supply complete treatment orders for 1 of 6 sampled patients (Patient 6) for an intravenous (within the vein) medication intended to increase blood pressure (Levophed).

2. Failure to complete and document a comprehensive and updated patient physical examination for 2 of 6 sampled patients (Patient's 1 and 4) prior to an invasive procedure (any surgical or exploratory activity in which the body is pierced by a device, instrument or by manual digitation) being performed.

These deficient practices had the potential to contribute to negative health outcomes and increase the risk of harm for those patients affected as well as for a universe of 71 patients.

Findings:

1. A record review of Patient 6 was conducted on March 27, 2013 at 10:15 AM. Patient 6 was transported to the Emergency Department (ED) via ambulance on March 27, 2013 at 1:40 AM with a diagnosis of exacerbation (worsening) of Chronic Obstructive Pulmonary Disease (a lung disease that causes difficulty breathing). At 2:45 AM, Patient 6's nursing documentation at 3 AM indicated that Patient 6 coded (required resuscitation/restoration of life), the patient was placed on mechanical ventilation (a machine used to provide an artifical means of breathing) and physician orders read to admit to the Intensive Care Unit (ICU).

A telephone order obtained by Registered Nurse (RN) 2, dated March 27, 2013 at 4 AM for Patient 6 read, "Levophed drip (a continuous infusion of medication into the vein), titrate to keep systolic blood pressure (the pressure exerted within the blood vessels when the heart contracts) greater than or equal to 120." The physician order did not contain complete orders or instructions specifying the start rate or titration instructions (a process used to increase or decrease a medication that is specific to a patient's response to the medication) for the Levophed. The order also did not include instructions for the nurses as to when to turn off or hold the Levophed.

An observation was made on March 27, 2013 at 10:30 AM of Patient 6. The patient was in the ICU, both eyes were closed, was on mechanical ventilation, was on a Levophed drip and had a Foley catheter in place (a tube inserted to relieve the bladder of urine).

An interview was conducted on March 27, 2013 at 10:30 AM with RN 3 (Patient 6's ICU RN). She stated that she did not know when she was supposed to turn off the Levophed drip because there were no orders for that but that if the blood pressure dropped too much, she would increase the rate that the medication was given and that if the blood pressure increased too much, she would decrease the rate that the medication was given. RN 3 also stated that she did not have specific titration orders and "I just titrate according to my judgment. It's a nursing judgment." RN 3 was asked by the surveyor how she felt about titrating the medication and she stated, "I don't feel good about it but that's how the doctors write the orders."

An interview was conducted on April 2, 2013 at 9 AM with RN 2 (the RN who obtained the initial order dated March 27, 2013 at 4 AM for the Levophed). RN 2 stated that she obtained the telephone order for the Levophed and started the medication at 10 micrograms per minute then increased it to 15 micrograms. RN 2 stated that she had recently been in-serviced by the hospital staff and understood that the initial order she received from the physician on March 27, 2013 at 4 AM was not a complete order. RN 2 stated that the physicians did not provide a start rate or titration orders, they only provided the blood pressure parameter. RN 2 also stated that the nurses titrated differently and it depended on a patient's response to the medication.

A record review on April 2, 2013 at 2:40 PM was conducted of the hospital policy titled, Medication Administration, revised on 10/11", it read in part, "...Titrating orders are initiated (started) by the physician and monitored by the nurse..."




28066

2a. A record review was conducted on March 26, 2013 at 10:54 AM, of Patient 1's clinical record. The review revealed that the patient was admitted on March 26, 2013 at 1:35 AM with the diagnosis of repeat cesarean section (c-section; the surgical removal of a live baby from the mother's body). According to the "Operating Room Progress Note," Patient 1 had undergone a scheduled repeat c-section on March 26, 2013 at 6:30 AM.

A further record review of Patient 1's clinical record and a concurrent interview was conducted on March 26, 2013 at 3:15 PM, with RN 7. The RN stated that there was no updated examination of Patient 1 completed by the MD prior to the surgery and that there was no physician's documentation on a "History & Physical Short Form" in the medical record.

During an additional record review of Patient 1's clinical record and a concurrent interview, on March 27, 2013 at 9:15 AM, with the Director of Maternal Child, she verified that there was no physician's documentation on a "History & Physical Form" in the clinical record. The Director of Maternal Child located a handwritten "Physician's Progress Note" in Patient 1's medical record. The handwritten note was illegible, had no date and time recorded and the Director of Maternal Child was unable to read the information.

b. A record review was conducted on March 26, 2013 at 3:00 PM, of Patient 4's clinical record. The record noted that the patient was admitted on March 26, 2013 at 6:39 AM with the diagnosis of pregnancy/induction of labor (the artificial initiation of childbirth). Patient 4 underwent a scheduled epidural anesthesia (the injection of a numbing medicine into the space around the spinal nerves in the lower back, the medicine numbs the area below the point of injection and allows the patient to remain awake during the delivery of the baby) and delivered the baby at 2:30 PM.

During an interview conducted on March 26, 2013 at 3:30 PM, with RN 8, she stated that there was no updated examination of Patient 4 completed by the physician prior to the epidural anesthesia procedure and there was no physician's documentation on a "History & Physical Short Form" in the medical record. RN 8 stated that she was informed to use the prenatal examination record when the History and Physical was not completed. A concurrent review of Patient 4's clinical record noted that the last prenatal exam was on March 22, 2013.

During an interview, on March 27, 2013 at 9:15 AM with the Director of Maternal Child, she stated that the prenatal examination record may be used if the prenatal exam was completed within 30 days of the procedure and when the History & Physical Short Form had not been completed.

A record review, on March 27, 2013, of the hospital's "Medical Staff Bylaws and General Rules & Regulations of Medical Staff, revised on 12/6/11", noted the following: "...All medical record entries shall be dated, timed and authenticated...When performing surgery or any potentially hazardous diagnostic procedure and the History & Physical is not recorded in the chart, the procedure will be cancelled unless the attending physician states in writing "such delay would be detrimental to the patient." If so, the case shall be deemed an emergency case and the physician must provide a brief admission note in the chart that includes the heart rate, respiratory rate, and blood pressure. If the History & Physical has been dictated but is not recorded in the chart, the attending physician must document that he/she has dictated the History & Physical and the dictation must be verified with the Health Information Management Department. Once the dictation has been verified and prior to surgery or any potentially hazardous diagnostic procedure, the attending physician must document in the chart, the patient's history, all positive physical findings and the admitting diagnosis."

Based on observation, interview and record review, the hospital failed to ensure the quality of patient medical care through enforcement of the hospital policies and medical staff bylaws.

1. The hospital failed to ensure that physicians supplied complete orders for intravenous (within the vein) blood pressure medications. (Refer to A-0353 and A-0405)

2. The hospital failed to ensure that physicians documented a complete history and physical before all invasive procedures. (Refer to A-0359)

The cumulative result of these deficient practices meant that the hospital did not organize the medical staff to operate under the medical staff bylaws in order to provide quality patient medical care to a universe of 71 patients in the hospital.

Based on observation, interview and record review, the hospital's Medical Staff failed to ensure that all physicians supplied complete orders for an intravenous medication intended to increase patients' blood pressure (Levophed) and the hospital failed to ensure that the Medical Staff enforced and adhered to the hospital policies, creating the risk of substandard medication administration and poor health outcomes for 1 of 6 sampled patients (Patient 6) for whom incomplete medication orders were written for.

Findings:

A record review of Patient 6 was conducted on March 27, 2013 at 10:15 AM. Patient 6 was transported to the Emergency Department (ED) via ambulance on March 27, 2013 at 1:40 AM with a diagnosis of exacerbation (worsening) of Chronic Obstructive Pulmonary Disease (a lung disease that causes difficulty breathing). At 2:45 AM, Patient 6's nursing documentation at 3 AM indicated that Patient 6 coded (required resuscitation/restoration of life), the patient was placed on mechanical ventilation (a machine used to provide an artifical means of breathing) and physician orders read to admit to the Intensive Care Unit (ICU).

A telephone order obtained by Registered Nurse (RN) 2, dated March 27, 2013 at 4 AM for Patient 6 read, "Levophed drip (a continuous infusion of medication into the vein), titrate to keep systolic blood pressure (the pressure exerted within the blood vessels when the heart contracts) greater than or equal to 120." The telephone order did not contain complete orders or instructions specifying the start rate or titration instructions (a process used to increase or decrease a medication that is specific to a patient's response to the medication) for the Levophed. The order also did not include instructions for the nurses as to when to turn off or hold the Levophed.

An observation was made on March 27, 2013 at 10:30 AM of Patient 6. The patient was in the ICU, both eyes were closed, was on mechanical ventilation, was on a Levophed drip and had a Foley catheter in place (a tube inserted to relieve the bladder of urine).

An interview was conducted on March 27, 2013 at 10:30 AM with RN 3 (Patient 6's ICU RN). She stated that she did not know when she was supposed to turn off the Levophed drip because there were no orders for that but that if the blood pressure dropped too much, she would increase the rate that the medication was given and that if the blood pressure increased too much, she would decrease the rate that the medication was given. RN 3 also stated that she did not have specific titration orders and "I just titrate according to my judgment. It's a nursing judgment." RN 3 was asked by the surveyor how she felt about titrating the medication and she stated, "I don't feel good about it but that's how the doctors write the orders."

An interview was conducted on April 2, 2013 at 9 AM with RN 2 (the RN who obtained the initial order dated March 27, 2013 at 4 AM for the Levophed). RN 2 stated that she obtained the telephone order for the Levophed and initiated the medication at 10 micrograms per minute then increased it to 15 micrograms. RN 2 stated that she had recently been in-serviced by the hospital staff and understood that the initial order she received from the physician on March 27, 2013 at 4 AM was not a complete order. RN 2 stated that the physicians did not provide a start rate or titration orders, they only provided the blood pressure parameter. RN 2 also stated that the nurses titrated differently and it depended on a patient's response to the medication.

A record review on April 2, 2013 at 2:40 PM was conducted of the hospital policy titled, Medication Administration, revised on 10/11", it read in part, "...Titrating orders are initiated by the physician and monitored by the nurse..."

Based on observation, interview and record review, the hospital failed to ensure that all patient medical records were kept confidential and secured to prevent unauthorized individuals from accessing the records. This failure had the potential for unauthorized individuals to access patient personal health information for a universe of 71 patients.

Findings:

During a tour of the hospital's pediatric unit and accompanied by Registered Nurse (RN) 1, on March 26, 2013 at 11:40 AM, an observation was made of an unlocked soiled utility room located near the nurses' station. The soiled utility room contained a bin with dimensions approximately 2.5 feet by 2 feet. The bin was overfilled with various copies of patients' personal health information such as patient names, medical record numbers, patient diagnoses and physician orders among other information.

During an interview with RN 1, on March 26, 2013 at 11:40 AM, she stated that their unit's "shred it box" was taken from them about 2 months ago and placed in another department. She also stated that their current practice was to wait until the bin was full and then a certified nurse assistant would carry the bin out of the pediatric unit and into another unit to dispose of the patient records. RN 1 stated that the housekeeping staff had access to the unlocked soiled utility room.

A record review was conducted on April 2, 2013 at 1:30 PM of the hospital policy titled, "Destruction of Paper Personal Health Information." The policy documented the following, "Protected Health Information (PHI) - PHI refers to individually identifiable health information that is transmitted or maintained in any form (including written, verbal or electronic) which is protected under federal regulations. Examples include the patient's name and other demographic information, medical records, ..." The policy also instructed staff to maintain and secure records which contain PHI in a secure and locked area.

Based on observation, interview and record review, the hospital's Governing Body failed to hold the facility Medical Staff accountable for adhering to approved and accepted hospital policies and procedures and for the care provided to 3 of 6 sampled patients as evidenced by the following:

1. Failure to supply complete treatment orders for 1 of 6 sampled patients (Patient 6) for an intravenous (within the vein) medication intended to increase blood pressure (Levophed).

2. Failure to complete and document a comprehensive and updated patient physical examination for 2 of 6 sampled patients (Patient's 1 and 4) prior to an invasive procedure (any surgical or exploratory activity in which the body is pierced by a device, instrument or by manual digitation) being performed.

These deficient practices had the potential to contribute to negative health outcomes and increase the risk of harm for those patients affected as well as for a universe of 71 patients.

Findings:

1. A record review of Patient 6 was conducted on March 27, 2013 at 10:15 AM. Patient 6 was transported to the Emergency Department (ED) via ambulance on March 27, 2013 at 1:40 AM with a diagnosis of exacerbation (worsening) of Chronic Obstructive Pulmonary Disease (a lung disease that causes difficulty breathing). At 2:45 AM, Patient 6's nursing documentation at 3 AM indicated that Patient 6 coded (required resuscitation/restoration of life), the patient was placed on mechanical ventilation (a machine used to provide an artifical means of breathing) and physician orders read to admit to the Intensive Care Unit (ICU).

A telephone order obtained by Registered Nurse (RN) 2, dated March 27, 2013 at 4 AM for Patient 6 read, "Levophed drip (a continuous infusion of medication into the vein), titrate to keep systolic blood pressure (the pressure exerted within the blood vessels when the heart contracts) greater than or equal to 120." The physician order did not contain complete orders or instructions specifying the start rate or titration instructions (a process used to increase or decrease a medication that is specific to a patient's response to the medication) for the Levophed. The order also did not include instructions for the nurses as to when to turn off or hold the Levophed.

An observation was made on March 27, 2013 at 10:30 AM of Patient 6. The patient was in the ICU, both eyes were closed, was on mechanical ventilation, was on a Levophed drip and had a Foley catheter in place (a tube inserted to relieve the bladder of urine).

An interview was conducted on March 27, 2013 at 10:30 AM with RN 3 (Patient 6's ICU RN). She stated that she did not know when she was supposed to turn off the Levophed drip because there were no orders for that but that if the blood pressure dropped too much, she would increase the rate that the medication was given and that if the blood pressure increased too much, she would decrease the rate that the medication was given. RN 3 also stated that she did not have specific titration orders and "I just titrate according to my judgment. It's a nursing judgment." RN 3 was asked by the surveyor how she felt about titrating the medication and she stated, "I don't feel good about it but that's how the doctors write the orders."

An interview was conducted on April 2, 2013 at 9 AM with RN 2 (the RN who obtained the initial order dated March 27, 2013 at 4 AM for the Levophed). RN 2 stated that she obtained the telephone order for the Levophed and started the medication at 10 micrograms per minute then increased it to 15 micrograms. RN 2 stated that she had recently been in-serviced by the hospital staff and understood that the initial order she received from the physician on March 27, 2013 at 4 AM was not a complete order. RN 2 stated that the physicians did not provide a start rate or titration orders, they only provided the blood pressure parameter. RN 2 also stated that the nurses titrated differently and it depended on a patient's response to the medication.

A record review on April 2, 2013 at 2:40 PM was conducted of the hospital policy titled, Medication Administration, revised on 10/11", it read in part, "...Titrating orders are initiated (started) by the physician and monitored by the nurse..."




28066

2a. A record review was conducted on March 26, 2013 at 10:54 AM, of Patient 1's clinical record. The review revealed that the patient was admitted on March 26, 2013 at 1:35 AM with the diagnosis of repeat cesarean section (c-section; the surgical removal of a live baby from the mother's body). According to the "Operating Room Progress Note," Patient 1 had undergone a scheduled repeat c-section on March 26, 2013 at 6:30 AM.

A further record review of Patient 1's clinical record and a concurrent interview was conducted on March 26, 2013 at 3:15 PM, with RN 7. The RN stated that there was no updated examination of Patient 1 completed by the MD prior to the surgery and that there was no physician's documentation on a "History & Physical Short Form" in the medical record.

During an additional record review of Patient 1's clinical record and a concurrent interview, on March 27, 2013 at 9:15 AM, with the Director of Maternal Child, she verified that there was no physician's documentation on a "History & Physical Form" in the clinical record. The Director of Maternal Child located a handwritten "Physician's Progress Note" in Patient 1's medical record. The handwritten note was illegible, had no date and time recorded and the Director of Maternal Child was unable to read the information.

b. A record review was conducted on March 26, 2013 at 3:00 PM, of Patient 4's clinical record. The record noted that the patient was admitted on March 26, 2013 at 6:39 AM with the diagnosis of pregnancy/induction of labor (the artificial initiation of childbirth). Patient 4 underwent a scheduled epidural anesthesia (the injection of a numbing medicine into the space around the spinal nerves in the lower back, the medicine numbs the area below the point of injection and allows the patient to remain awake during the delivery of the baby) and delivered the baby at 2:30 PM.

During an interview conducted on March 26, 2013 at 3:30 PM, with RN 8, she stated that there was no updated examination of Patient 4 completed by the physician prior to the epidural anesthesia procedure and there was no physician's documentation on a "History & Physical Short Form" in the medical record. RN 8 stated that she was informed to use the prenatal examination record when the History and Physical was not completed. A concurrent review of Patient 4's clinical record noted that the last prenatal exam was on March 22, 2013.

During an interview, on March 27, 2013 at 9:15 AM with the Director of Maternal Child, she stated that the prenatal examination record may be used if the prenatal exam was completed within 30 days of the procedure and when the History & Physical Short Form had not been completed.

A record review, on March 27, 2013, of the hospital's "Medical Staff Bylaws and General Rules & Regulations of Medical Staff, revised on 12/6/11", noted the following: "...All medical record entries shall be dated, timed and authenticated...When performing surgery or any potentially hazardous diagnostic procedure and the History & Physical is not recorded in the chart, the procedure will be cancelled unless the attending physician states in writing "such delay would be detrimental to the patient." If so, the case shall be deemed an emergency case and the physician must provide a brief admission note in the chart that includes the heart rate, respiratory rate, and blood pressure. If the History & Physical has been dictated but is not recorded in the chart, the attending physician must document that he/she has dictated the History & Physical and the dictation must be verified with the Health Information Management Department. Once the dictation has been verified and prior to surgery or any potentially hazardous diagnostic procedure, the attending physician must document in the chart, the patient's history, all positive physical findings and the admitting diagnosis."