HospitalInspections.org

Based on record review and staff interview, it was determined the hospital failed to ensure an RN supervised and evaluated the nursing care for 1 of 3 obstetrical patients (#4) whose ED records were reviewed. This resulted in inadequate assessment and nursing care for an obstetrical patient who left the facility AMA. Findings include:

1. Patient #4 was a 28 year old pregnant female in her third trimester admitted to the ED on 7/14/13 at 3:02 AM. An ED triage note entered 7/14/13 at 3:17 AM, documented Patient #4's height, weight, and current medications she was taking. The triage note did not include vital signs or indicate an assessment had been completed. The entry did not include Patient #4's transfer to the OB unit for a MSE as per the facility policy.

A preprinted order sheet titled "ORDERS FOR OUTPATIENT VISIT, LABOR and DELIVERY," documented verbal orders had been received on 7/14/13 at 3:45 AM. The orders, although signed by a nurse, were not authenticated by a physician. The order sheet indicated the reason for Patient #4's visit as "convulsions." Also included on the sheet was an order to "Evaluate patient including: Fetal Heart monitoring, U/A Urine Culture if indicated." The order sheet had another section, also dated 7/14/13 at 3:45 AM, which stated "Transfer to ED." Patient #4's record contained a fetal heart monitor strip which documented her uterine contractions and fetal heart pattern from 3:40 AM to 3:53 AM. An "Ante/OBED Flowsheet," dated 7/14/13 at 3:45 AM and 3:53 AM, documented "Report to (obstetrician) that (Patient #4) brought from ER with c/o "convulsions." Pt states "had diarrhea all night." "... orders rcvd (received) to transfer pt back to ER for evaluation." The flowsheet did not indicate an RN assessment had been performed while in the OB unit.

An ED nursing entry at 6:03 AM, documented Patient #4 left the ED against medical advice, and stated she was leaving the ED due to the long waiting time. The record did not include evidence of assessment related to her presenting complaint of convulsions. A nursing assessment and vital signs were not found in Patient #4's record.

Patient #4's record included a sheet titled "CODING SUMMARY," which included diagnoses of "EPILEPSY COMP PREG/CHILDBIRTH, ANTEPARTUM." The sheet also included her discharge disposition of "Against Medical Advice."

In a report titled "ER DOCUMENTATION," dated 7/14/13 at 5:43 AM, the ED physician documented Patient #4 had left before he had been able to examine or speak with her.

During an interview on 8/08/13 at 11:00 AM, the ED physician who was working on 7/14/13 at the time Patient #4 had come to the ED reviewed her record. He stated Patient #4 had been taken to L&D for an MSE and when cleared was brought back to the ED. He stated he was busy with multiple traumas, but had looked at Patient #4's presenting complaint on the ED board and had entered orders on the computer before seeing her. He stated he later canceled the orders as she had left AMA.

During an interview on 8/08/13 beginning at 10:35 AM, the Director of the ED reviewed Patient #4's medical record. The ED Director stated there was an algorithm the ED staff followed. He stated a patient in her third trimester of pregnancy would be sent immediately to L&D for assessment of the pregnancy and fetal well being. After determining a patient was stable in that respect, the patient would be returned to ED for an assessment of further medical conditions. The ED Director was unable to determine Patient #4 had vital signs taken or had been assessed by an RN in the ED or the OB units.

The hospital failed to ensure an RN had supervised and evaluated the nursing care for Patient #4.

Based on staff interview, review of medical records, and review of policies, it was determined medical record entries were incomplete for 5 of 48 patients (#4, #19, #26, #40, #42) whose medical records were reviewed. This resulted in a lack of clarity related to patient care and the inability of the hospital to determine whether care had been provided. Findings include:

The "Physician Orders" policy, effective 6/21/12, stated "Verbal/telephone orders are to be authenticated by the ordering medical staff member." In addition, the policy stated that medication orders should include the date and time of the order and the signature of the person ordering the medication. The hospital failed to adhere to the policy as follows:

1. Patient #42 was a 41 year old female admitted to the hospital through the ED on 3/15/13 for treatment of injuries sustained in a motor vehicle accident. She was discharged from the hospital on 3/19/13. Her medical record contained the following incomplete documentation:

a. A verbal order from the physician for Lortab Elixir, a narcotic pain medication, was documented by an LPN on a "Physician's Orders" form on 3/17/13 at 10:11 AM. The LPN signed off the order at 10:25 AM. The order had not been authenticated by a physician.

The CNO reviewed the record and was interviewed on 8/08/13 at 4:10 PM. She confirmed the verbal order had not been authenticated by the ordering physician per hospital policy.

b. A "PHYSICIAN'S PREPRINTED ORDERS" titled "POST ANESTHESIA" contained orders for pain medication, nausea medication, oxygen therapy, seizure medications, hypotension medications and IV fluids to be given if needed during post-anesthesia recovery. The orders contained an electronic signature of the anesthesiologist on 3/21/13 at 7:48 AM, two days after Patient #42 was discharged from the hospital.

The CNO reviewed the record and was interviewed on 8/08/13 at 4:10 PM. She stated the preprinted orders should have been signed, dated, and timed by the anesthesia provider during the time Patient #42 was in recovery. She confirmed the orders had not been authenticated during Patient #42's admission in accordance with hospital policy.

Patient #42's record contained incomplete orders.

2. Patient #19 was a 6 year old female admitted to the hospital on 7/01/13 for surgery after a dog bit her face. She was discharged 7/02/13. Her medical record contained the following:

a. "PHYSICIAN'S PREPRINTED ORDERS" titled "DISCHARGE ORDERS" contained orders for medication and when to make a follow-up appointment. The orders were signed by the physician on 7/01/13 but were not timed.

The ACNO reviewed the record and was interviewed on 8/07/13 at 2:20 PM. She confirmed the orders were not timed in accordance with hospital policy.

b. A "PHYSICIAN'S PREPRINTED ORDERS" titled "POST ANESTHESIA" contained orders for pain medication, nausea medication, oxygen therapy, seizure medications, hypotension medications and IV fluids to be given if needed during post-anesthesia recovery. The orders contained an electronic signature of the anesthesiologist on 7/05/13 at 4:01 PM, 3 days after Patient #19 was discharged from the hospital.

The ACNO reviewed the record and was interviewed on 8/07/13 at 2:20 PM. She stated the preprinted orders should have been signed, dated, and timed by the anesthesia provider during the time Patient #19 was in recovery. She confirmed the orders had not been authenticated during Patient #19's admission in accordance with hospital policy.

Patient #19's record contained incomplete orders.



28544

3. Patient #40 was a 67 year old male admitted to the hospital on 5/06/13 for chest pain. He expired on 5/07/13.

a. A form, titled "RECORD OF DEATH," indicating Patient #40 expired 5/07/13 at 2:18 PM, required a physician signature, and was not signed by the attending physician. The remaining areas on the form were complete and had been signed by the RN who provided care to Patient #40 upon his passing.

The Director of ICU was interviewed on 8/08/13 beginning at 9:45 AM. After reviewing Patient #40's record, he confirmed the form had not been signed by the attending physician.

b. A "PHYSICIAN'S PREPRINTED ORDERS" titled "RESTRAINTS FOR NON-VIOLENT BEHAVIOR-INITIAL ORDER" contained orders for restraint use on upper and lower extremities for a 24 hour period beginning 5/07/13 at 00:20 AM. The order contained an electronic signature of the attending physician on 5/09/13 at 11:07 AM, 2 days after Patient #40 had expired.

The Director of ICU was interviewed on 8/8/13 beginning at 9:45 AM. After reviewing Patient #40's record, he confirmed the form had not been signed by a physician at the time restraints had been initiated.

Patient #40's record contained incomplete orders.

4. Patient #4 was a 28 year old female admitted to the ED on 7/14/13 at 3:02 AM with an admission complaint of "convulsions".

A preprinted order sheet titled "ORDERS FOR OUTPATIENT VISIT, LABOR and DELIVERY," documented verbal orders had been received on 7/14/14 at 3:45 AM. The orders, although signed by a nurse, were not authenticated by a physician. The order sheet indicated the reason for Patient #4's visit as "convulsions." Also included on the sheet was an order of "Evaluate patient including: Fetal Heart monitoring, U/A Urine Culture if indicated." The order sheet had another section, also dated 7/14/13 at 3:45 AM, which stated "Transfer to ED."

During an interview on 8/08/13 beginning at 10:35 AM, the Director of the ED reviewed Patient #4's medical record and confirmed the order had not been authenticated in accordance with the hospital policy.

Patient #4's record contained incomplete orders.



32844

5. Patient #26 was a 56 year old male admitted to the hospital on 3/16/13 for chest pain. He was discharged on 4/02/13. His medical record contained the following incomplete documentation:

a. A verbal telephone order from the physician for "NPO"(nothing by mouth), was documented by an RN on a "Physician's Orders" form on 3/16/13 at 11:00 AM. The RN signed off the order at 12:41 PM. The order had not been authenticated by a physician.

b. A verbal telephone order from the physician for "increase IV fluids to 250 ml/hr" and "1 inch Nitropaste to chest now", was documented by an RN on a "Physician's Orders" form on 3/16/13 at 12:12 PM. The RN signed off the order at 12:41 PM. The order had not been authenticated by a physician.

c. A verbal telephone order from the physician for "Type and Cross 2 units PRBC's"(packed red blood cells) and "STAT (immediately) abdominal CT (computed tomography scan) without contrast now, rule out bleed", was documented by an RN on a "Physician's Orders" form on 3/16/13 at 7:40 PM. The RN signed off the order at 7:46 PM. The order had not been authenticated by a physician.

d. A verbal telephone order from the physician for "abdominal/pelvis CT with contrast now", was documented by an RN on a "Physician's Orders" form on 3/16/13 at 8:17 PM. The RN signed off the order at 9:13 PM. The order had not been authenticated by a physician.

The Director of ICU was interviewed on 8/8/13 beginning at 2:30 PM. After reviewing Patient #26's physician's orders, he confirmed the forms had not been signed by the physician.

Patient #26's record contained incomplete orders.

Based on staff interview and review of medical records and credential files, it was determined the hospital failed to ensure physical therapy services were provided by therapists under the orders of the physician who was responsible for the care of the patients. This affected the care of 2 of 3 patients (#3 and #24), who were receiving wound care by the physical therapist and whose medical records were reviewed, and had the potential to affect the care of all wound care patients. This resulted in the potential for persons to order medical treatment without the consent of the of the governing body. Findings include:

1. Patient #24's medical record documented a 67 year old male who was admitted to the hospital on 8/5/13 and was currently a patient as of 8/06/13. His diagnoses included lymphoma and a bowel infection. The "HISTORY AND PHYSICAL," dated 8/05/13, stated Patient #24 had an abdominal wound from a previous surgery. An order, dated 8/05/13 stated "Wound care for Abd wound." No further orders for wound care were present in the record.

Patient #24's wound care was observed on 8/06/13 beginning at 2:05 PM. Patient #24 had an open abdominal wound that measured approximately 5 inches by 3.5 inches. The Wound Care Therapist, a physical therapist, cleansed the wound with saline and applied a calcium alginate dressing with silver impregnated in it.

The Wound Care Therapist was interviewed on 8/06/13 beginning at 2:50 PM. He stated he determined the wound care treatment for patients and did not require orders or co-signatures by a physician for these treatments.

The physical therapist provided treatment without physician orders.

2. Patient #3's medical record documented a 76 year old female who was admitted to the hospital on 8/01/13 for acute encephalopathy with delirium and decubitus ulcers on her buttocks. "ADMISSION ORDERS," dated 8/01/13 at 7:00 PM, called for a wound care consultation for Patient #3's sacral decubitus ulcers. No further wound care orders were present in the medical record.

A "Wound Care Initial Evaluation," dated 8/01/13 at 6:00 PM by the Wound Care Therapist, stated Patient #3 had an "Unstageable" pressure ulcer on her "SACRAL/BUTTOCKS" area with serous drainage. The evaluation stated the therapist used a "Melgisorb AG" dressing, a special absorbent dressing impregnated with silver ions, to treat the wound. The evaluation stated the therapist would visit Patient #3 at 1-3 day intervals to treat the wound. A "Wound Care Follow-up Treatment" note, dated 8/02/13 at 6:00 PM by the Wound Care Therapist, stated he again saw Patient #3 and again applied a "Melgisorb AG" dressing. A "PATIENT ASSESSMENT" by the Wound Care Therapist, dated 8/03/13, stated the Melgisorb dressings were not lasting due to Patient #3 being incontinent of stool. The note stated the therapist recommended nursing remove the dressings, perform routine skin cares and apply Criticaid moisture barrier to the affected area 2-3 times a shift and as needed. A visit by the Wound Care Therapist was documented on 8/04/13 at 7:22 PM. A description of the wound and care provided by the therapist was not documented. A final note by the Wound Care Therapist, dated 8/05/13 at 6:00 PM, stated Patient #3's RN called him and informed him the RN had removed a gauze dressing and replaced it with Mepilex Border (a self-adherent soft silicone dressing). The note stated the therapist planned to leave the dressing in place for now. It also stated he supplied Patient #3's nurse with EXU-DRY Dressings, a specific type of wound dressing.

The Wound Care Therapist was interviewed on 8/06/13 beginning at 2:50 PM. He confirmed there were no physician orders for Patient #3's wound care treatment.

The physical therapist provided treatment without physician orders.

3. The ACNO was interviewed regarding wound care on 8/06/13 beginning at 3:45 PM. She stated the hospital did not have policies that defined the roles of wound care therapists in relation to writing orders, determining the treatment of wounds, and physician responsibilities for the oversight of wound care. She stated the Wound Care Therapist did not have privileges which authorized them to determine and order wound care treatment.

The hospital allowed the physical therapist to treat patients without physician orders.

Based on staff interview, review of medical records, and review of policies, it was determined medical record entries were incomplete for 5 of 48 patients (#4, #19, #26, #40, #42) whose medical records were reviewed. This resulted in a lack of clarity related to patient care and the inability of the hospital to determine whether care had been provided. Findings include:

The "Physician Orders" policy, effective 6/21/12, stated "Verbal/telephone orders are to be authenticated by the ordering medical staff member." In addition, the policy stated that medication orders should include the date and time of the order and the signature of the person ordering the medication. The hospital failed to adhere to the policy as follows:

1. Patient #42 was a 41 year old female admitted to the hospital through the ED on 3/15/13 for treatment of injuries sustained in a motor vehicle accident. She was discharged from the hospital on 3/19/13. Her medical record contained the following incomplete documentation:

a. A verbal order from the physician for Lortab Elixir, a narcotic pain medication, was documented by an LPN on a "Physician's Orders" form on 3/17/13 at 10:11 AM. The LPN signed off the order at 10:25 AM. The order had not been authenticated by a physician.

The CNO reviewed the record and was interviewed on 8/08/13 at 4:10 PM. She confirmed the verbal order had not been authenticated by the ordering physician per hospital policy.

b. A "PHYSICIAN'S PREPRINTED ORDERS" titled "POST ANESTHESIA" contained orders for pain medication, nausea medication, oxygen therapy, seizure medications, hypotension medications and IV fluids to be given if needed during post-anesthesia recovery. The orders contained an electronic signature of the anesthesiologist on 3/21/13 at 7:48 AM, two days after Patient #42 was discharged from the hospital.

The CNO reviewed the record and was interviewed on 8/08/13 at 4:10 PM. She stated the preprinted orders should have been signed, dated, and timed by the anesthesia provider during the time Patient #42 was in recovery. She confirmed the orders had not been authenticated during Patient #42's admission in accordance with hospital policy.

Patient #42's record contained incomplete orders.

2. Patient #19 was a 6 year old female admitted to the hospital on 7/01/13 for surgery after a dog bit her face. She was discharged 7/02/13. Her medical record contained the following:

a. "PHYSICIAN'S PREPRINTED ORDERS" titled "DISCHARGE ORDERS" contained orders for medication and when to make a follow-up appointment. The orders were signed by the physician on 7/01/13 but were not timed.

The ACNO reviewed the record and was interviewed on 8/07/13 at 2:20 PM. She confirmed the orders were not timed in accordance with hospital policy.

b. A "PHYSICIAN'S PREPRINTED ORDERS" titled "POST ANESTHESIA" contained orders for pain medication, nausea medication, oxygen therapy, seizure medications, hypotension medications and IV fluids to be given if needed during post-anesthesia recovery. The orders contained an electronic signature of the anesthesiologist on 7/05/13 at 4:01 PM, 3 days after Patient #19 was discharged from the hospital.

The ACNO reviewed the record and was interviewed on 8/07/13 at 2:20 PM. She stated the preprinted orders should have been signed, dated, and timed by the anesthesia provider during the time Patient #19 was in recovery. She confirmed the orders had not been authenticated during Patient #19's admission in accordance with hospital policy.

Patient #19's record contained incomplete orders.



28544

3. Patient #40 was a 67 year old male admitted to the hospital on 5/06/13 for chest pain. He expired on 5/07/13.

a. A form, titled "RECORD OF DEATH," indicating Patient #40 expired 5/07/13 at 2:18 PM, required a physician signature, and was not signed by the attending physician. The remaining areas on the form were complete and had been signed by the RN who provided care to Patient #40 upon his passing.

The Director of ICU was interviewed on 8/08/13 beginning at 9:45 AM. After reviewing Patient #40's record, he confirmed the form had not been signed by the attending physician.

b. A "PHYSICIAN'S PREPRINTED ORDERS" titled "RESTRAINTS FOR NON-VIOLENT BEHAVIOR-INITIAL ORDER" contained orders for restraint use on upper and lower extremities for a 24 hour period beginning 5/07/13 at 00:20 AM. The order contained an electronic signature of the attending physician on 5/09/13 at 11:07 AM, 2 days after Patient #40 had expired.

The Director of ICU was interviewed on 8/8/13 beginning at 9:45 AM. After reviewing Patient #40's record, he confirmed the form had not been signed by a physician at the time restraints had been initiated.

Patient #40's record contained incomplete orders.

4. Patient #4 was a 28 year old female admitted to the ED on 7/14/13 at 3:02 AM with an admission complaint of "convulsions".

A preprinted order sheet titled "ORDERS FOR OUTPATIENT VISIT, LABOR and DELIVERY," documented verbal orders had been received on 7/14/14 at 3:45 AM. The orders, although signed by a nurse, were not authenticated by a physician. The order sheet indicated the reason for Patient #4's visit as "convulsions." Also included on the sheet was an order of "Evaluate patient including: Fetal Heart monitoring, U/A Urine Culture if indicated." The order sheet had another section, also dated 7/14/13 at 3:45 AM, which stated "Transfer to ED."

During an interview on 8/08/13 beginning at 10:35 AM, the Director of the ED reviewed Patient #4's medical record and confirmed the order had not been authenticated in accordance with the hospital policy.

Patient #4's record contained incomplete orders.



32844

5. Patient #26 was a 56 year old male admitted to the hospital on 3/16/13 for chest pain. He was discharged on 4/02/13. His medical record contained the following incomplete documentation:

a. A verbal telephone order from the physician for "NPO"(nothing by mouth), was documented by an RN on a "Physician's Orders" form on 3/16/13 at 11:00 AM. The RN signed off the order at 12:41 PM. The order had not been authenticated by a physician.

b. A verbal telephone order from the physician for "increase IV fluids to 250 ml/hr" and "1 inch Nitropaste to chest now", was documented by an RN on a "Physician's Orders" form on 3/16/13 at 12:12 PM. The RN signed off the order at 12:41 PM. The order had not been authenticated by a physician.

c. A verbal telephone order from the physician for "Type and Cross 2 units PRBC's"(packed red blood cells) and "STAT (immediately) abdominal CT (computed tomography scan) without contrast now, rule out bleed", was documented by an RN on a "Physician's Orders" form on 3/16/13 at 7:40 PM. The RN signed off the order at 7:46 PM. The order had not been authenticated by a physician.

d. A verbal telephone order from the physician for "abdominal/pelvis CT with contrast now", was documented by an RN on a "Physician's Orders" form on 3/16/13 at 8:17 PM. The RN signed off the order at 9:13 PM. The order had not been authenticated by a physician.

The Director of ICU was interviewed on 8/8/13 beginning at 2:30 PM. After reviewing Patient #26's physician's orders, he confirmed the forms had not been signed by the physician.

Patient #26's record contained incomplete orders.