HospitalInspections.org

Based on review of hospital policies and interviews with hospital staff, the hospital failed to develop a policy concerning patient abuse, harassment and neglect that included the procedures to follow when a patient alleges abuse by a hospital employee or contract worker. This findings was reviewed and verified by Staff A on the morning of 05/15/13.

Based on record review and staff interview, it was determined the hospital failed to include seclusion in it's patient's rights policies and procedures and failed to monitor and evaluate seclusion when it was utilized.

On 05/14/13, the Director of Performance Improvement was asked to provide the hospital's seclusion and restraint logs. No seclusion log was provided. She stated the hospital did not utilize seclusion.

She was asked if the hospital ever received patients in the ER or ICU who had an emergency order of detention. She stated they did. She was asked if these patients were ever prevented from leaving the hospital. She stated they would be prevented from leaving the room they were admitted to and also could not leave the hospital.

She stated the hospital did not consider these situations as seclusion events and had not been documenting them as such. She stated this had not been considered for inclusion in the patients' rights policies and procedures.

Based on review records and interviews with hospital staff, the hospital failed to assure certified registered nurse anesthetists with prescriptive authority have the required narcotic permits for practitioners who order, select, obtain and administer scheduled drugs in the perioperative or periobstetrical setting in accordance with the registration requirement of the Uniform controlled Dangerous Substances Act. Two (V and X) of three (V, W, X) CRNAs' credential files who have prescriptive authority did not have evidence of registration with state and Federal Drug Enforcement Administration (DEA) and Oklahoma Bureau of Narcotics and Dangerous Drug (OBNDD) as required.

Findings:

1. The Oklahoma State Board of Nursing Requirements for CRNA Authority to Select, Order, Obtain and Administer Drugs (09/05/2012), requirement number 6 titled DEA and OBNDD Registration: The CRNA with authority to select, order, obtain, and administer drugs who selects, orders, obtains, and administers Schedule II-V drugs will comply with state and Federal Drug Enforcement Administration (DEA) and Oklahoma Bureau of Narcotics and Dangerous Drug (OBNDD) requirements prior to selecting, obtaining, ordering, and administering controlled substances. Requirement number 6 also states if either the OBNDD or the DEA registration lapses or is otherwise in an inactive status, the CRNA must immediately notify the Oklahoma Board of Nursing and cease selecting, ordering, obtaining and administering Schedule II-V drugs.

2. Oklahoma Administrative Rules Title 475, Chapter 10, Section 10-1-10 (c), application notices for registration and re-registration states that any place or person licensed by their appropriate State of Oklahoma licensing board who desires to professional handle controlled dangerous substances in their practice of medicine, retail pharmacy, hospital, teaching institution, or institutional drug department shall apply for registration.

3. Oklahoma Statute Title 63. Public Health and Safety, Chapter 2, Uniform Controlled Dangerous Substances Act, Article 3, Section 2-312 - Prescription and Administration of Controlled Dangerous Substances, (D) states the an advanced practice nurse who is recognized to order, select, obtain and administer drugs by the Oklahoma Board of Nursing as certified registered nurse anesthetist pursuant to Section 1 of this act and who has complied with the registration requirements of the Uniform controlled Dangerous Substances Act, in good faith and in the course of such practitioner's practice only, may order, select, obtain and administer Schedules II through V controlled dangerous substances in a preanesthetic preparation or evaluation; anesthesia induction, maintenance or emergence; or postanesthesia care setting only. A certified register nurse anesthetist may order, select, obtain and administer such drugs only during the perioperative or periobstetrical period.

4. Hospital staff stated on 05/14/13 in the morning that CRNAs that ordered and administered drugs in the perioperative or periobstetrical period who had prescriptive authority from the Oklahoma Board of Nursing did not have DEA and OBNDD registrations as required.

Based on record review and interviews with hospital staff, the hospital does not ensure all orders for drugs are ordered by a practitioner who is authorized to write orders in accordance with State law. Orders for drugs administered by a certified registered nurse anesthetist (CRNA) who does not have prescriptive authority to order, select, obtain and administer drugs in the perioperative and periobstetrical setting without an order from a physician were not signed by the physician only by the CRNA. Hospital staff verified in an interview on 05/13/13 that they did not require the physician to sign for the drugs administered and ordered by the CRNA.

Based on policy and procedure review and staff interview, it was determined the hospital failed to ensure an off-site, outpatient surgery department developed and implemented policies and procedures that reflected integration with the main hospital.

Findings:

1. On 05/14/13, the OSDH surveyors toured the west outpatient surgery department. The staff stated the surgery center was purchased by the hospital in 2010.

The staff were asked to provide their policies and procedures. A manual was provided that was in the process of revision. Items were scratched out, notations were made in margins, and notes were taped to pages.

The surgery manager stated none of the policies were finished and none of them had been through a review and approval process with the main hospital.

The surgery manager stated the policies and procedures in the manual were the ones used by the staff. The administrator stated the staff could also access the main hospital's policies and procedures online. They were asked how the staff knew which policy to follow. No reply was made.

2. The clinical record was reviewed for patient #1 who had surgery at the outpatient surgery center. She had a complication from the procedure and required a transfer by ambulance to the main hospital campus emergency room.

The clinical record had a nurse's note that documented the patient was transferred to Stillwater Medical Center. There was no transfer forms or documentation of the process surrounding the transfer.

The staff were asked to provide the transfer policy and procedure. The manager stated it was being revised.

She described the transfer procedure. She stated if the transfer was non-emergent, the surgery center would call the main hospital house supervisor and request an ambulance for transportation to emergency department. She stated for true emergency cases, the surgery center staff called for an ambulance directly using the 911 system.

She was asked if a transfer form was used. She stated it should have been. The manager later located a transfer form for the patient. She stated it had not been attached to the clinical record.

The form was an EMTALA transfer form and was not appropriate for an inter-departmental transfer.

There was no documentation of information handed off from the surgery center to the emergency department physician or nurses. There was no documentation of clinical records that were sent with the patient.

The surgery manager stated the staff copied the entire clinical record and sent it with the patient to the ER.

On the afternoon of 05/14/13, the Director of Performance Improvement stated more review was needed of the processes surrounding integrating the surgery center into the main hospital system. She stated more work needed to be done on the surgery department's policies and procedures.

Based on document review and staff interview, it was determined the hospital failed to maintain an operating room register that contained all the elements required.

On 05/13/13 and 05/14/13, the operating room registers were reviewed. The main OR department did not keep an operating room register.

At 10:00 a.m., the staff stated they believed they could retrieve all the required information from computer records. After several hours, the staff stated they had obtained the required elements in an electronic format, but the record could not be printed to show all the elements.

One outpatient surgery department kept a paper OR register. It did not contain all the required elements, including the total time of the surgical procedure, the age of the patient, and the name of the scrub tech or other personnel that may be present during the case.

The surgery department manager confirmed these findings.