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Tag No.: A0115
Based on a review of 59 medical records, policies, procedures and other documentation, it was determined that the Condition of Participation for Patient Rights remains out of compliance. While the deficiencies noted on the February 14, 2013 survey have been remediated, serious deficient practices having to do with the application of seclusion and restraints were identified during this survey as noted at:
A154 for failure to use appropriate criteria for the use of seclusion for 3 patients;
A179 for the failure to document the one hour face to face evaluation for 3 patients;
A186 for the failure to attempt less restrictive means to control a patient's behavior;
A194 for the failure to provide training in the use of pepper foam for security staff; and
A205 for the failure to monitor patients who are restrained for their care needs.
Tag No.: A0147
During a unit review of the Observation Unit (2C), report sheets containing the protected health information of 20 patients were found under the sink in the clean utility room. According to the dates on the papers, the patients were in the hospital during December 2009 and January 2010. The protected health information included names, ages, sex, diagnoses, medications, and lab results.
Tag No.: A0154
Review of the hospital restraint policy and three closed medical records of patients who were restrained in the ED for violent and self destructive behavior reveals that inappropriate criteria were used to justify the continued restraint of three out of three patients. The hospital policy for restraints also contains inappropriate criteria for release of restraints.
Review of hospital's policy for "Removal of Restraints" states that the criteria for release are: "Patient is aware of surroundings, coherent and demonstrates ability to process information" and "Patient is quiet/calm." While patient awareness and the above behaviors are desirable, the lack of awareness/orientation and the ability to process information are not justification for continued restraint. Additionally,determining a patient is quiet and calm is subjective determination. Patients need only stop any harmful/dangerous behaviors in order to have restraints terminated.
1. Patient #56 is an 18-year-old male who presented to the emergency department (ED) with aggression and suspected substance abuse. Patient #56 was placed in 4-point restraint at 1230 following aggression towards staff. The pre-printed physician order for restraints states the criteria for release are: "Patient no longer exhibits aggressive/violent harm to others."
An RN restraint flow sheet entry for the first hour reveals the following statements: "Pt. unable to commit to safety, tried to get off of restraints (sic)." The RN entry entry during the second hour of restraints states, "Pt asleep, arousable, unable to commit to safety." "During the third hour, the RN entry states, "Pt. arousable, pt states he will behave, 2 restraints removed. Pt is now in 2 points restraint one on R wrist and L ankle." Restraints were not discontinued until 1613. Thought patient #56 had not demonstrated violent behaviors after the first hour, and had been sleeping for three of the nearly four hours of restraint time. Additionally, superimposing a requirement of providing a "safety commitment"does not meet regulatory requirements.
Further, only one entry regarding patient behavior is entered per hour on a flow sheet that has 15-minute increments. Behavioral documentation is to be documented every fifteen minutes in order to determine the earliest possible release time. The lack of accurate and timely descriptions of patient behavior does not meet this directive. Patient #56 was restrained for three hours and 45 minutes.
2. Patient #57 is an 18-year old male who was brought to the ED after making threats to others and exhibiting bizarre behavior. Patient #57 was placed in 4-point restraint at 0220 when he became disruptive and severely agitated. Following the second hour in restraint, the RN documented "Pt remains unpredictable but calmer. Reduced to 2-points." "Documentation of the third hour states "Pt calm, resting; restraints removed at 0545."
The term "unpredictable" is subjective and does not satisfy the requirement that restraints be used only for the immediate physical safety of the patient or others. A nursing note of 0421 reveals in part, "Pt is sleeping at present but prior to falling asleep was very restless and attempting to get off stretcher." "Restlessness and attempts to rise from the stretcher are, again, not appropriate justification for continuing restraints. The nurse documents no other less restrictive alternatives for patient #57, who was restrained for approximately 3 1/2 hours.
On this medical record as well, only one behavioral descriptor is entered per hour which does not meet regulations for releasing patients at the earliest possible time. Behavioral documentation is to be documented every fifteen minutes in order to determine earliest possible time of release. The lack of accurate and timely descriptions of patient behavior does not meet the regulatory requirements and the continuation of restraints while the patient is sleeping violates the requirement to release at the earliest possible time.
3. Patient #58 is a 20-year old female who was brought in the ED with psychosis secondary to substance abuse. Patient #58 was placed in 4-point restraint following a police report that she was fighting them and spitting. A nursing note of 1234 states in part, "Pt arrived combative and spitting..."However, the restrain order of 1130 states the patient was restrained for "Fighting police, spitting. "Additionally, the emergency medical services report states that patient #58 received intramuscular (M) medication at 1045, and after fifteen minutes "Pt calmed down" and was transferred to the ED in an "improved" condition. The physician assessment of 1217 reveals in part, "combative towards police officer," and "Non-cooperative, & refuses to speak. No new assessment indicating continued dangerous behavior was found in the medical record. Therefore, it appears that patient #58 was restrained due to the behavior that occurred prior to the entry into the hospital,not because the patient evidenced violent or harmful behaviors while in the ED. Restraining a patient due to history fails to meet the patient right to be free of restraint.
A nursing note written during the first hour of Restraint states, "Pt shouting 'Alah' (sic) I don't have any kids anymore." Another RN entry during the secondhour states, "Pt refusing to talk or answer any questions." An RN progress note of 1359 reveals "Patient awoke and begun screaming and chanting."
There is no documentation indicating that the patient presented an on-going threat to herself or others. No justification for continuing restraint is found in the ED RN documentation. Patient may not be restrained for yelling, nor may they be restrained for refusing totalk and answer questions. Only the imminent danger of harm to sell or others may be used as justification for restraint.
As on the medical records for patients #56 and #57, the 15 minute flow sheet for patient #58 is devoid of information sufficient to determine that this patient required continued restraint. Only one entry of behavior wasentered per hour. Incremental documentation is performed in part to determine whether the patient continues to need restraint as well as to determine the earliest possible time of release. The lack of behavioral descriptors on these records fails to meet the standard.
Tag No.: A0179
(the patient must be seen fact to face within 1 hour after the initiation of the intervention)
482,13(E)(12)(II) To evaluate -
1. The patient's immediate situation;
2. The patient's reaction to the intervention;
3. The patients medical and behavioral condition; and
4. The need to continue or terminate the restraint or seclusion.
Based on a review of the hospital restraint policy, restraint forms and review of three closed patient records for patients #56, 57, and 58, the hospital failed to consistently perform the face to face commensurate with policy and regulatory directives for one of three patients.
Excepting thelanguage of "in-person evaluation," the hospital restraint policy mirrors CMS regulation directives for performing the elements of a face-to-face. However, the restraint order form itself reveals an attestation which states, "In accordance with Centers for Medicare and Medicaid (CMS) Conditions of Participation. I have evaluated this patient (within one hour of application if this is an initial order) and have determined the need to use/continue the use of restraint as specified by this order." This attestation does not meet the requirements and is incomplete as to the elements of the face-to-face evaluation.
Review of patient #57's record reveals a face-to-face form on which the physician could document the required elements of the face-to-face evaluation. While this complies with the regulations, it demonstrates that this form is not always used as it was not found on the other two medical records for patients #56 and #58.
Review of patient #58's medical record reveals a Physician assessment within one hour of the initiation of restraints which does not reference the restraint process, and does not document justifying behaviors for restraint. This assessment does not provide the required elements of a face-to-face evaluation.
Based on these findings, the assestation does not contain the required elements of the face-to-face and no consistent process for conducting the face-to-face is found. Additionally, the hospital failed to document a face-to-face for patient #58.
Tag No.: A0186
A review of 3 closed ED records revealed that for one of three patients reviewed where restraints were applied, there was no evidence that less restrictive alternatives were attempted as evidenced by:
Patient #58 is a 20 year old female who was brought to the ED by law enforcement with psychosis secondary to substance abuse. Patient #58 was placed in 4-point restraint following police report that she was fighting and spitting prior to admission. According to the EMS records, patient #58 had been given a dose of haloperidol, an antipsychotic, prior to being brought to the hospital and had calmed down and was transferred to the ED in an "improved" condition. She arrived at the hospital at 1109.
A restraint order, written at 1130 and signed by the physician at 1210, states a justification of "Fighting police, spitting" even though the hospital had had physical custody of the patient for 20 minutes and law enforcement was no longer involved. At 1145, the RN documented on the restraint flow sheet that patient was shouting "Alah", I don't have any kids." The physician evaluation at 1217 notes "brought by police with abnormal behavior, refusing to speak" and "combative towards police officer." This note was written at least an hour after the police had left the ED. No new assessment of dangerous behavior was found. The patient was medicated
with haloperidol and diphenhydramine (a sedating anthistamine) IM at 1339. A nurse's note from 1339 states "patient awoke and chanting in Arabic (sic) attempted to bite this RN when medicating pt. Security called toassist with blood draw and urine cath." Since the patient was sedated and in four-point hard restraints at this point, it is difficult to see what threat she posed to the staff.
Since no documentation of concurrent dangerous behavior can be found on the medical record, and no documentation exists regarding any less restrictive methods considered or attempted, it appears that patient #58 was restrained for 3.5 hours based on behavior she exhibited prior to arriving at the hospital.
Tag No.: A0194
Based on staff interviews on April 30 and May 2, 2013, along with a review of security measures in use in the emergency department and the hospital's freestanding emergency care facility, it was revealed that security staff carry pepper foam spray, but are not trained in minimizing the risks of the use of pepper foam and have no policy for environmental clean-up.
The hospital employs security staff who monitors activity in the emergency department and the off-campus freestanding emergency facility. Interview with security staff reveals that they carry pepper foam spray, but state that they have not used the pepper foam for several years. On inquiry, security staff revealed a written process for the use of the foam, and a process for the cleanup of the individual who is sprayed. However, staff were unable to produce a policy related to mitigating the risks to other people including vulnerable patients, the environmental risks, and cleanup of the pepper foam when used in clinical areas. Since pepper foam is a know noxious substance, the hospital must make provision for using it with minimal risks to patients, and for cleaning it up after use.
Tag No.: A0205
Based on a review of three closed medical records for patients restrained in the ED along with the content of staff training regarding
restraint, it was determined that three of three patients reviewed did not receive monitoring for care needs during the restraint episodes, including toileting, food/fluids, and range of motion.
Patient #56 was an 18-year old male who was brought to the emergency department (ED) with aggression and suspected substance abuse. Patient #56 was placed in 4-point restraint at 1230 following aggression towards staff.
fifteen-minutes flows over the restraint course of nearly four hours for patient #56 reveals that, even thought the restraint tracking form has space for documenting, only circulation checks are noted on the nursing flow sheet for behavior and care. The form contains spaces for toileting, food and fluids, and range of motion, but these are blank.
Patient #57 was an 18-year old male who was brought to the ED following threats to others, and bizarre behavior. Patient #57 was placed in 4-point restraint at 0220 when he became disruptive and severely agitated.
Fifteen-minute flows over the restraint course of 3 hours and 15 minutes reveals no range of motion, no fluids or food offered, and no toileting, thought patient #57 was turned and repositioned once, and had a rotation of restraintsonce. Only circulation is noted on the nursing flow sheet for behavior and care.
Patient #58 was a 20-year old female who was brought to the ED due to psychosis secondary to substance abuse. Patient #58 was placed in 4-point restraint following a police report that she was fighting and spitting.
Fifteen-minute flows over therestraint course of three and a half hours reveals no range of motion, no fluids or food offered, and no toileting, thought patient #58 received a catherization for urine testing at 1342. Only circulatory is noted on the nursing flow sheet for behavior and care.
While staff receives training regarding the care of patients while in restrain, there is no documented evidence that the hospital provided that care for three patients restrained in the ED, and failed to provide oversight to ensure staff are following policies and procedures related to care during restraint episodes.
Tag No.: A0273
Based on review of QAPI data, it was determined that the hospital's QAPI program has failed to monitor, with sufficient rigor, three areas affecting patient care.
A review of the ED restraint log shows 62 instances of restraints used for violent/harmful behavior from 1/1/13 through 4/30/13. No QA data could be found evidencing a review of the indications for, and the care of, patients in restraints for violent/harmful behaviors. Three out of three records randomly chosen from the log evidenced problems and regulatory violations in care and in documentation. See A-0186 and A-0205.
A review of outpatient off-campus maternity clinic on 4/30/12 revealed on QAPI monitoring or reporting. See A1077.
A review of pharmacy personnel records revealed no unit-based episodic or on-going training or skills updates for the pharmacy technicians. This lack of consistent training had not previously been identified by the pharmacy, Human Resources, or QAPI. See A-0493.
Tag No.: A0396
Based on observation, review of a patient medical record, and interview with the 4D licensed nursing staff on 04/20/13 at 3Pm, it was determined that the nursing staff failed to reassess one patient's tuberculosis skin test within the time frame specified in hospital policy. In addition, review of the medical record of another patient (#36) who was seen in the ED in early Aprin revealed that the patient left without
being seen by the physician after staff failed to plan for his care and failed to address his needs in accordance with the standard of care. A complaint had been received by patient #36 and his medical record was included in the 10 closed records chosen for review by the survey team.
1. Patient #30 was admitted tot he hospital on 04/26/13 with a cough that lasted a week without relief. The patient also complained of chest pain of 8/10 (10 being the most painful). The patient was placed in a negative pressure isolation room on airborne precautions for possible tuberculosis infection.
The patient's physician ordered on 4/26/13 that the patient be given PPD (protein purified derivative-skin test) used in the diagnosis of tuberculosis. The physician specified in the order that the skin test was to be read in 48 hours.
Observation and review of the patient's Medication Administration Record (MAR) indicated that the PPD was administered by a RN on 4/27/13 at 16:56. Observation and review of a multidisciplinary progress note revealed a black stamped skin test grid in the middle of the page. Staff noted the PDP administration on 4/27/13 at
16:56 on the patient's left forearm. There were no other entries by staff in the grid for a 24 hour, 48 hour, and 72 hour assessment reading (grid spaces were blank).
Interview of the 4D charge nurse and the interim clinical coordinator on 4/30/13 day at 3PM confirmed after additional review the paper and electronic medical records that the nursing staff failed to reassess and document the patient's PPD results at the 24 and 48 hour time lines. In
addition, the staff reported that the facility's policy and procedure (Skin Test Procedure, NO: 101-01-094a, dated 10/12), stated to read the site 24, 48, and 72 hours after
the injection. A nursing Progress Note electronically entered on 04/29/13 at 08:36 noted that patient's PPD measured: 1 centimeter (CM). This assessment/reading of the skin site was 39 to 40 hours after the initial administration of the PPD. While the patient's skin test was negative, the failure to read it in a manner consistent with the plan of care and hospital policy might have caused a delay in appropriate treatment.
2. Patient #36 was a 47 year old male who arrived at the hospital's ED at 3:07PM accompanied by a friend. Patient #36's chief complaint was chest pain. A triage assessment was completed by the nurse at 3:29 PM and at that time Patient #36 informed the nurse that his pain level was 5 on scale of 1-10. Patient #1 also informed the nurse that he had chest pain earlier that morning which lasted 15-20 minutes with shortness of breath, diaphoresis (sweating), numbness, and radiation of the pain to his right arm. Patient #36 further informed the RN that 30 minutes prior to his arrival to the ED, the pain had returned, he fell short of breath, "couldn't catch his breath," and had fallen but reported no loss of consciousness.
Initial vital signs were taken and were within normal parameters with the exception of Patient #36's blood pressure which was elevated at 137/85. Normal range is <120 systolic and <80 diastolic. A triage assessment was completed and Patient #36 was assigned an acuity level of 3. According to hospital triage policy, a level 3 patient requires at minimum two or more studies such as x-rays, EKG and lab work. Patient #36 subsequently received an EKG, labwork, and chest x-ray and had a cappedoff IV inserted. However, the medical record shows no documentation of any further musing assessments, pain assessments of vital signs assessments after triage. The only other note
found in the medical record is the Physician Assistant (PA) note from 3:28PM that states "Pt seen briefly in triage.: However there is no documentation of what findings of the exam or initial testing were, or what the pain for further testing and care was. There is also no documentation of the laboratory tests or EKG results having been discussed with Patient #36.
According to the medical record, Patient #36 left the ED at some time prior to 9:52 PM when a note from the RN indicates that he left prior to a physician evaluation. However there is no indication or documentation that staff discussed any risk or benefits related to leaving or remaining in the ED prior to Patient #36 leaving. According to the patient's complaint, he was treated at another hospital after the ED.
Tag No.: A0405
The patient's vital signs were stable. The patches were removed and the patient placed on continuous pulse-ox monitoring and admitted to IMCU for observation.
The hospital staff failed to dispense and administer medications in accordance with accepted standards of practice for patient #75 when despite the physician order clearly written for Fentanyl 12.5 mcg the pharmacy (during investigation stated they seldom see order written for such small doses) sent patches to the unit totaling 125 mcg (100 mcg and 25mcg patches; the pharmacist did not take into consideration the patient's age and weight; the pharmacist did not request clarification from the physician regarding the dose; and nurse administered the medication, again without clarifying or apparently reading the order. In this case the pharmacy and nursing staff mistook the 12.5 mcg for 125 mcg. The staff failed to correlate the patient's age or weight or question theaccuracy of the dosage allowing the medication error to get to the patient. The hospital's failure to clarify the dosage could have led to serious harm and possible death.
Based on staff interviews and review of the medical record for one patient, it was determined that the hospital failed to administer medication in accordance with physician orders for one of 59 patients reviewed and failed to follow good practice for this same elderly patient with
backpain and cancer.
Patient #75 was an 89 year old patient who presented to the hospital with weakness, inability to ambulate and severe back pain on 12/3/12. The patient was admitted to the hospital and an order for Fentanyl Patch 12.5 mcg ordered for the patient who weighted 51kg (112.2 lb) and had received pain medication on prior admission for treatment of T12 compression fracture status post surgery in the setting of multiple myeloma. The pharmacist sent Fentanyl Patches 100mcg and 25mcg. Per the medication administration record the nurse placed one patch of 100 mcg and one patch of 25 mcg Fentanyl on patient #75 and 1850 on 12/3/12. During rounds by the physician on 12/4/12 at 0800 the patient was found to be lethargic and confused with respirations 15-[16 and oxygen saturation at 94%
The patient's vital signs were stable. The patches were removed and the patient placed on continuous pulse-ox monitoring and admitted to IMCU for observation.
The hospital staff failed to dispense and administer medications in accordance with accepted standards of practice for patient #75 when despite the physician order clearly written for Fentanyl 12.5 mcg the pharmacy (during investigation stated they seldom see orders written for such small doses) sent patches to the unit totaling 125 mcg (100 mcg and 25 mcg patches; the pharmacist did not take into consideration the patient's age and weight; the pharmacist did not request clarification from the physician regarding the dose; and nurse administered the medication, again without clarifying or apparently reading the order. In this case the pharmacy and nursing staff mistook the case the pharmacy and nursing staff mistook the 12.5 mcg for 125 mcg. The staff failed to correlate the patient's age or weight or question the accuracy of the dosage allowing the medication error to get to the patient. The hospital's failure to clarify the dosage could have led to serious harm and possible death.
Tag No.: A0468
Based on a review of 10 closed medical records, it was determined that one patients discharge/transfer summary did not meet the requirements of this standard.
Patient #75 was admitted to the hospital on 12/3/12 and discharged to long-term care for rehabilitation on 12/7/12. the patient's discharge/transfer summary did not address the patient sacral pressure ulcer, lacked a description of the ulcer including measurements, and lacked orders for treatment at time of discharge.
Tag No.: A0493
Based on interview and review of pharmacy Employee personnel records, it was determined that while the pharmacy employs sufficient staff, pharmacy technicians receive inconsistent, sparse and ultimately unit-based training. In addition, one of the pharmacy technicians reviewed had had no documented annual evaluations following the employee's initial evaluation in 2004.
Review of pharmacy tech #1's (PT1) personnel file reveals the initial general hospital orientation of 2003-2005, one single hospital learning task for 2006 and 2007 and then only general annual hospital competencies of 210, 2011 and 2012. In addition, the competency test taken shortly after hire in 2004 were incomplete and did not meet the hospital's own standards as below:
1.. Aseptic Technique-Never completed
2. Pharmacy Math - Test taken revealing a score of 70%. No recommendation or validation of competency was entered the personnel record.
3. Basic Drug Knowledge - Test taken, but never scored and competency was ever validated.
Other electronic documentation reveals in part, Center Basics-Pharmacy, registered 2012, and never started. Additionally, PT1 was registered for, but had not had taken, Care Excellence Pharmacy Tech Onboarding, thought this is documented as "in progress.: Additionally, no annual quality evaluations of PT1 are found for this entire time of employment.
Review of other documentation included a list entitled "Pharmacy Technicians I and II Competencies," dated 2009. This list included such unit-based competency training as "Pain Management for the non-Licensed Staff."
"Adverse Drug Reactions," and IV Training Program," No documentation of completion of these or other competencies listed could be found in PT1's file.
Executive staff of the pharmacy, in an interview on April 30, 2013, acknowledged that staff competencies and evaluations are completed "inconsistently." In fact, only sporadic unit-based training and skills updates have been done with the pharmacy technician staff for at least the nine or 10 years covered in the personnel files. Even though the Pharmacy Service employees approximately 40 pharmacy technicians, there is no formal oversight of the quality of their work, while skills and education are updated only sporadically.
Tag No.: A0701
Based on observation it was determined that facility staff failed to maintain the facility to ensure the safety of the patient as evidenced by:
On April 30, 2013, the surveyor accompanied by the food service director and the infection control nurse observed the following concerns in the main kitchen:
1. The spray hose above the garbage grinder in the Salad Preparation Area is too long and sits down in the well of the garbage grinder creating a potential cross connection. It should sit at least six inches above the food rim of the garbage grinder.
2. The lens of the final rinse pressure gauge of the dish machine was missing.
On April 30, and M1, 2013, the surveyor accompanied by the infection control nurse and a maintenance representative noted the following concerns in ancillary and patient areas of the facility:
1. Operating Room Suite - Electrical Closet #1A005, two ladders and one step stool were stored in front of the electrical panels. A 36-inch clearance in front of all electrical panels must be maintained.
2. Conversation with an environmental services supervisor yielded the fact that he was not aware that environmental services staff did the terminal
cleaning of the operating rooms and surgical services staff did the "between procedures" cleaning and disinfection. Hospital staff explained that he was new and the environmental service Contractor was also new to the hospital.
3. The hosebib (faucet) on the loading dock where a hose was connected was not equipped with a backflow preventer. Another wall-mounted hosebib nearby was equipped with a backflow preventer and should be used to connect this hose to protect against back-siphonage should a negativity pressure occur in the water line.
Tag No.: A0726
Based on observation it was determined that facility staff failed to maintain proper ventilation, and temperature controls as evidenced by:
On April 30, 2013 the surveyor accompanied by the food service director and the infection control nurse observed the following concerns in the main kitchen:
1. The exhaust vents in the Cart Wash Room and Soda Box Room were not removing air from these rooms. This was corrected the afternoon of April 30th.
2. The make-up air system for the cooking hood was not functioning. This was corrected the afternoon on April 30.
3. The walk-in-freezer was not holding 0 degrees Fahrenheit or below. The dial read 15, the interior thermometer read 14 and the Sanitarian's thermometer read 14. This was corrected and upon re-inspection the following day was holding 1 degree.
4. The dial thermometer on the roll-in, Victory brand refrigerator in the Salad Preparation Area was inaccurate. The dial read 38, the interior read 24 and the Sanitarian's read 24.
5. The condensers of two Victory brand refrigerators and one True brand refrigerators located near the Tray Preparation Line were dusty. These were clean upon re-inspection on May 1, 2013.
Tag No.: A1002
During a unit review on 4/30/13, it was determined that the anesthesia service failed to comply with standards of practice for maintaining and checking emergency equipment sufficient to provide for safe practice of anesthesia in nine areas of the hospital.
During a review of the Labor and Delivery (L&D) surgical suite on 4/30/13 at 10:55, accompanied by the clinical nurse manage, an emergency intubation cart used by anesthesia was found to be unlocked. There were emergency medications in the cart including non-depolarizing muscle relaxants (paralytics) used during intubation. The cart contained no inventory or checklist and interview with an anesthesiologist and anesthesia technician present in the area revealed that neither could identify when the cart was opened or by whom. The inventory lists are kept in the anesthesia office.
On 5/21/13, an anesthesiologist provided a checklist for March and April, 2013, which identified nine emergency specially anesthesia carts, including difficult airway carts, bronchoscopy carts, and pediatric carts located in the MRI, L&D, cardiac Cath Lab and other areas. The checklist stated that the carts were to be checked every weekend.
Failure of staff to check anesthesia carts on at least a daily basis places both the anesthesiologist and the patient at risk for suffering a delay in treatment during an emergent situation of medications and equipment are not available. In addition, the lack of timely oversight and control of anesthetic medications and equipment may lead to a delay in recognizing tamperingt or theft.
Tag No.: A1077
Based on interviews, and review of the outpatient Maternity service, it was revealed that outpatient records are not integrated into the hospital record until the 32nd week of pregnancy, and the outpatient service is not involved in any quality improvement initatives.
The off-site outpatient maternity clinic serves pregnant women who have no insurance or are covered by Medicaid and provides pre-natal care in the clinic and delivery at the hospital. Interview with clinic administrative staff conducted on 4/30/13 reveals that the clinic is run by a hospital privileged physician who employs physician laborists and a nurse practitioner who and also members of the hospital's medical staff.
Patient appointment data and assessment are documented in a database belonging to the clinic. Administrative staff states that all women in the program are slated to give birth at the hospital, and that when patients are at 32 weeks of gestation, their records are printed and taken to the hospital obstetric nursing station where they are stored until needed following admission. Administrative staff state that a physician is on duty at the hospital at all times to cover the
clinic's patients. The on duty physician can access the electronic clinic record, for instance for emergency purposes, though no other emergency physicians or obstetrics have access to the electronic clinic health record if the patient presents prior to 32 weeks.
In an interview conducted on 4/30/13, Administrative staff stated that if the on duty physician is engaged in assisting a labor, another pregnant clinic patient present to the emergency department. The lack of an integral medical record puts the clinic's patients at a disadvantage during an emergency when critical data may not be available to the ED. The lack of record integration does not meet the standard of care or regulatory directives.
Based on interview with Administrative staff, it is also revealed that the clinic conducts no quality initiatives. Administrative staff states that, for instance, they keepa record of TDAP(adult Tetanus-Diphtheria-Pertussis) vaccinations administered, but gather no data related to the vaccinations, nor do they perform any other QA activities.
The hospital has failed to integrate both the clinic's electronic health record and failed to provide QA oversight of the outpatient maternity clinic. See A-0273