HospitalInspections.org

20638

Based on record review and interview the hospital failed to have an effective system in place to ensure the governing body appoint members of the medical staff after considering recommendations of the existing members of the medical staff by failing to follow the Governing Body Bylaws and Medical Staff Bylaws for credentialing of physicians for 2 of 2 physicians on staff providing care and treatment to patients admitted to the hospital (S3, S4) which resulted in the hospital having no physicians providing care and treatment to patients in the hospital that had approved delineation of privileges or that had written approval for appointment to the medical staff. Findings:

Review of Physician #S3's credentialing file revealed his last medical staff appointment by the Governing Body to be dated 5/01/2006 with no documented evidence as to whether the appointment was Temporary, Emergency, or Permanent and no documented evidence of whether the physician's appointment was as Active Staff, Courtesy Staff, or Consulting Staff.

Review of Physician #S4's credentialing file revealed his last medical staff appointment by the Governing Body to be dated 10/01/2005 when the physician was appointed as Temporary Staff (not to exceed 180 days).

During a face to face interview on 10/28/2010 at 9:30 a.m., Hospital Administrator S1 confirmed the hospital's governing body had failed to ensure appointment to the medical staff was properly executed by failing to hold medical staff accountable for reviewing medical staff applications, medical staff's request for privileges, and data bank searches. S1 confirmed the governing body had not reviewed any recommendations for medical staff appointments since 2005 for Physician S4 and 2006 for Physician S3.

During a face to face interview on 10/28/2010 at 11:00 a.m., Medical Director S3 indicated he had not been aware that credentialing of physicians had not been properly executed by the Medical Staff and Governing Body. S3 indicated that he had thought having a contracted service for credentialing meant that the entire credentialing process would be done by the Contracted Agency.

Review of the hospital's "Constitution and Bylaws of the Medical Staff" presented by the hospital as current revealed in part, "Hospital privileges for all members of the medical Staff will automatically expire on June 30th every two years. Every two years each staff member shall submit a written application for reappointment to the Medical Staff. At least thirty days prior to the final scheduled Governing Body meeting in the Medical Staff year, the medical Staff shall review all pertinent information available on each practitioner scheduled for periodic appraisal for the purpose of determining its recommendations for reappointment to the Medical Staff, and for the granting of clinical privileges for the ensuring period. These recommendations shall be transmitted in writing to the Executive Committee which will forward it's recommendations to the Governing Body. . . . Every initial application for staff appointment or new privileges must contain a request for the specific clinical privileges desired by the applicant. The application is reviewed by the Medical Staff which will then make it's recommendations to the medical Executive Committee concerning the requested privileges. . . The evaluation of requests for specific clinical privileges shall be based upon the applicant's education, training, experience, and documented current competence testified to in writing by at least three of his/her references, known reputable practitioners, and other relevant information. . . Temporary Privileges: Upon receipt of any application for Medical Staff membership from an appropriately licensed practitioner, the Administrator my, upon the basis of information then available which may reasonable be relied upon as the current competence and ethical standing of the applicant, and with written concurrence of the chief of Staff, grant temporary admitting and clinical privileges to the applicant. Temporary privileges for applicants with automatically lapse after one-hundred eighty (180) days from approval date for temporary privileges. . . Emergency Privileges: In the case of emergency, any physician or dental member of the Medical Staff, to the degree permitted by his license and regardless of service or staff status or lack of it, shall be permitted and assisted to do everything possible to save the life of a patient, using every facility of the Hospital necessary, including the calling for any consultation necessary or desirable. When an emergency situation no longer exists, such physician or dentis must request the privileges necessary to continue to treat the patient."

20638

Based on record review and interview the hospital failed to focus on high risk problem prone areas by failing to identify and implement a plan of correction regarding the hospital having no credentialed physicians providing care and treatment to patients in the hospital. Findings:

Review of Physician #S3's credentialing file revealed his last medical staff appointment by the Governing Body to be dated 5/01/2006 with no documented evidence as to whether the appointment was Temporary, Emergency, or Permanent and no documented evidence of whether the physician's appointment was as Active Staff, Courtesy Staff, or Consulting Staff.

Review of Physician #S4's credentialing file revealed his last medical staff appointment by the Governing Body to be dated 10/01/2005 when the physician was appointed as Temporary Staff (not to exceed 180 days).

During a face to face interview on 10/28/2010 at 9:30 a.m., Hospital Administrator S1 indicated there were only two physicians that were currently providing care and treatment to patients admitted to the hospital at the time of the survey (S3, S4). S1 confirmed the governing body had not reviewed any recommendations for medical staff appointments since 2005 for Physician S4 and 2006 for Physician S3. S1 confirmed there was no physician practicing in the hospital that was appointed to the medical staff (credentialed by the medical staff) at the time of the survey.

During a face to face interview on 10/28/2010 at 11:00 a.m., Medical Director S3 indicated he had not been aware that credentialing of physicians had not been properly executed by the Medical Staff and Governing Body. S3 indicated that he had thought having a contracted service for credentialing meant that the entire credentialing process would be done by the Contracted Agency. The Director of Nursing who also served in the role of Quality Assurance Performance Improvement (QAPI) Director was present during this interview and confirmed the QAPI department had never identified credentialing of physicians as a problem.

Review of the hospital's "Constitution and Bylaws of the Medical Staff" presented by the hospital as current revealed in part, "Hospital privileges for all members of the medical Staff will automatically expire on June 30th every two years. Every two years each staff member shall submit a written application for reappointment to the Medical Staff. At least thirty days prior to the final scheduled Governing Body meeting in the Medical Staff year, the medical Staff shall review all pertinent information available on each practitioner scheduled for periodic appraisal for the purpose of determining its recommendations for reappointment to the Medical Staff, and for the granting of clinical privileges for the ensuring period. These recommendations shall be transmitted in writing to the Executive Committee which will forward it's recommendations to the Governing Body. . . . Every initial application for staff appointment or new privileges must contain a request for the specific clinical privileges desired by the applicant. The application is reviewed by the Medical Staff which will then make it's recommendations to the medical Executive Committee concerning the requested privileges. . . The evaluation of requests for specific clinical privileges shall be based upon the applicant's education, training, experience, and documented current competence testified to in writing by at least three of his/her references, known reputable practitioners, and other relevant information. . . Temporary Privileges: Upon receipt of any application for Medical Staff membership from an appropriately licensed practitioner, the Administrator my, upon the basis of information then available which may reasonable be relied upon as the current competence and ethical standing of the applicant, and with written concurrence of the chief of Staff, grant temporary admitting and clinical privileges to the applicant. Temporary privileges for applicants with automatically lapse after one-hundred eighty (180) days from approval date for temporary privileges. . . Emergency Privileges: In the case of emergency, any physician or dental member of the Medical Staff, to the degree permitted by his license and regardless of service or staff status or lack of it, shall be permitted and assisted to do everything possible to save the life of a patient, using every facility of the Hospital necessary, including the calling for any consultation necessary or desirable. When an emergency situation no longer exists, such physician or dentis must request the privileges necessary to continue to treat the patient."

Based on record review (credentialing files, medical staff bylaws) and interviews, the hospital failed to meet the Condition of Participation for Medical Staff as evidenced by failing
to have an effective system in place to ensure medical staff examined credentials of candidates for membership and made recommendations to the governing body regarding the appointment of candidates which resulted in the hospital having no physicians providing care and treatment to patients in the hospital that had approved delineation of privileges or that had written approval for appointment to the medical staff.

An immediate jeopardy situation was identified on 10/28/2010 at 11:45 a.m. and reported to the Hospital Administrator S1 and the Director of Nursing S2. The immediate jeopardy was a result of the hospital's failure to:
1) have physicians providing care and treatment to patients located in the hospital that had privileges approved by the medical staff or that had a current written approval by the Governing Body for being on the Medical Staff at the Hospital (Physician S3 and S4).
2) have Medical Staff review all credentialing information that had been collected by an outside agency contracted to do credentialing of the physicians, review and approve all applications for privileges requested, and make recommendations to the Governing Body on all members for appointment to the hospital since 2006 for 2 of 2 physicians that were currently providing care and treatment to patients in the hospital (Physicians S3 and S4).
3) have the Governing Body grant current written approval since 2008 for all members of the medical staff to provide care and treatment to patients for 5 of 5 physicians on staff at the hospital (S3, S4, S5, S6, S13) with 2 of 2 physicians that were currently providing care and treatment to patients in the hospital (S3 and S4). Physician S3's last review date was 06/01/2006 and Physician S4's last review date was 10/01/2005.

A corrective action plan was submitted by the hospital on 10/28/2010 at 3:20 p.m. which revealed the hospital had Physicians S3 and S4 complete their application for re-credentialing and request for clinical privileges, accessed the Integrated Query and Reporting Service for the National Practitioner Databank and queried Physician S3 and S4, had the Medical Director review physician's credentialing files to include physician peer reviews, called a special meeting of the Governing Board which reviewed credentialing data for Physicians S3 and S4 and approved appointment to the Medical Staff for Active Membership with approval of requested privileges, and implemented quality indicators for monthly monitoring of physician credentialing to ensure all physicians were current in the credentialing process. Further the hospital's governing body indicated no physician other than the two credentialed staff (S3 and S4) were to provide any medical services at the hospital until they had completed the credentialing process.

As a result of the hospital's action plan, the Immediate Jeopardy situation was removed on 10/28/2010 at 3:20 p.m. due to the hospital's governing body reviewing credentialing forms, delineating privileges, and approving medical staff appointment for the only two physicians that were to be treating patients in the hospital (S3 and S4). Deficient practice remains at the Standard Level due to the hospital's need to credential remaining physicians.

Based on record review and interview the hospital failed to have an effective system in place to ensure medical staff examined credentials of candidates for membership and made recommendations to the governing body regarding the appointment of candidates which resulted in the hospital having no physicians providing care and treatment to patients in the hospital that had approved delineation of privileges or that had written approval for appointment to the medical staff for 2 of 2 physicians (S3, S4) currently providing care and treatment to patients in the hospital and 3 of 3 (S5, S6, S13) additional physicians that had a history of working in the hospital. Findings:

Review of Physician #S3's credentialing file revealed a current copy of the Physician's Medical License, Drug Enforcement License, Controlled Dangerous Substance License, and Medical Malpractice Insurance as collected by a contracted outside Credentialing Agency (Agency A). Further review revealed no documented evidence of approval of the physician's clinical privileges and no documented evidence of a National Data Bank Search. Credentialing file review revealed the physician's last medical staff appointment by the Governing Body to be dated 5/01/2006 with no documented evidence as to whether the appointment was Temporary, Emergency, or Permanent and no documented evidence of whether the physician's appointment was as Active Staff, Courtesy Staff, or Consulting Staff.

Review of Physician #S4's credentialing file revealed a current copy of the Physician's Medical License, Drug Enforcement License, Controlled Dangerous Substance License, and Medical Malpractice Insurance as collected by a contracted outside Credentialing Agency. Further review revealed no documented evidence of approval of the physician's clinical privileges and no documented evidence of a National Data Bank Search. Credentialing file review revealed the physician's last medical staff appointment by the Governing Body to be dated 10/01/2005 when the physician was appointed as Temporary Staff (not to exceed 180 days).

Review of Physician #S5's credentialing file revealed a current copy of the Physician's Medical License, Drug Enforcement License, Controlled Dangerous Substance License, and Medical Malpractice Insurance as collected by a contracted outside Credentialing Agency. Further review revealed no documented evidence of approval of the physician's clinical privileges and no documented evidence of a National Data Bank Search. Credentialing file review revealed the physician's last medical staff appointment by the Governing Body to be dated 10/01/2005 when the physician was appointed as Temporary Staff (not to exceed 180 days).

Review of Physician #S6's credentialing file revealed a current copy of the Physician's Medical License, Drug Enforcement License, Controlled Dangerous Substance License, and Medical Malpractice Insurance as collected by a contracted outside Credentialing Agency. Further review revealed no documented evidence of approval of the physician's clinical privileges and no documented evidence of a National Data Bank Search. Credentialing file review revealed the physician's last medical staff appointment by the Governing Body to be dated 1/22/2008 when the physician was appointed as Temporary Staff (not to exceed 180 days).

Review of Physician #S13's credentialing file revealed a current copy of the Physician's Medical License, Drug Enforcement License, Controlled Dangerous Substance License, and Medical Malpractice Insurance as collected by a contracted outside Credentialing Agency. Further review revealed no documented evidence of approval of the physician's clinical privileges and no documented evidence of a National Data Bank Search. Credentialing file review revealed the physician's medical staff appointments as follows:
Temporary Privileges on 4/24/2008, Temporary Privileges on 10/27/2008, Emergency Privileges on 8/17/2009, Temporary Privileges on 1/21/2010, Emergency Privileges on 2/23/2010, Emergency Privileges on 4/19/2010, Emergency Privileges on 5/27/2010, Emergency Privileges on 6/30/2010, and Emergency Privileges on 8/31/2010.

During a face to face interview on 10/28/2010 at 9:30 a.m., Hospital Administrator S1 confirmed the hospital had failed to ensure Credentialing of Physicians included review by the Medical Staff, delineation of privileges, data bank search, and governing body appointment. S1 also confirmed there were no physicians that provided care and treatment to patients in the hospital, at the time of the survey, that had been credentialed to include approval of clinical privileges and written approval for appointment to the Medical Staff. S1 indicated there had been a communication misunderstanding between the hospital and the outside Credentialing Agency contracted by the facility. S1 indicated the hospital had assumed the Credentialing Agency would provide Credentialing in completion and he did not realize they would only gather information and the remainder of the process would remain the responsibility of the Medical Staff and Governing Body. Further S1 indicated Physician S13 had been repeatedly approved for either temporary or emergency privileges for short periods of time because she was the psychiatrist that covered for Physician S3 when he was out on leave. S1 confirmed that the hospital's definition of Emergency Appointment did not fit with the situation of coverage for a physician to be on leave.

During a telephone interview on 10/28/2010 at 9:30 a.m., Agency "A" Representative S14 indicated the Agency's role in credentialing for the hospital was data collection which consisted of Medical License, Drug Enforcement Agency Licensing, Controlled Dangerous Substance License, and Malpractice Insurance. S14 indicated the Agency would do a physician search in the National Data Base for the hospital as a courtesy but could only perform that task if the hospital added them (Agency A) as a third party to their Data Base for performing searches. S14 indicated Magnolia Behavioral Healthcare had not added them to their data base for searches. S14 indicated the Agency is not involved in privileging or Board approval.

During a face to face interview on 10/28/2010 at 11:00 a.m., Medical Director S3 indicated he had not been aware that credentialing of physicians had not been properly executed by the Medical Staff and Governing Body. S3 indicated that he had thought having a contracted service for credentialing meant that the entire credentialing process would be done by the Contracted Agency.

Review of the hospital's "Constitution and Bylaws of the Medical Staff" presented by the hospital as current revealed in part, "Hospital privileges for all members of the medical Staff will automatically expire on June 30th every two years. Every two years each staff member shall submit a written application for reappointment to the Medical Staff. At least thirty days prior to the final scheduled Governing Body meeting in the Medical Staff year, the medical Staff shall review all pertinent information available on each practitioner scheduled for periodic appraisal for the purpose of determining its recommendations for reappointment to the Medical Staff, and for the granting of clinical privileges for the ensuring period. These recommendations shall be transmitted in writing to the Executive Committee which will forward it's recommendations to the Governing Body. . . . Every initial application for staff appointment or new privileges must contain a request for the specific clinical privileges desired by the applicant. The application is reviewed by the Medical Staff which will then make it's recommendations to the medical Executive Committee concerning the requested privileges. . . The evaluation of requests for specific clinical privileges shall be based upon the applicant's education, training, experience, and documented current competence testified to in writing by at least three of his/her references, known reputable practitioners, and other relevant information. . . Temporary Privileges: Upon receipt of any application for Medical Staff membership from an appropriately licensed practitioner, the Administrator my, upon the basis of information then available which may reasonable be relied upon as the current competence and ethical standing of the applicant, and with written concurrence of the chief of Staff, grant temporary admitting and clinical privileges to the applicant. Temporary privileges for applicants with automatically lapse after one-hundred eighty (180) days from approval date for temporary privileges. . . Emergency Privileges: In the case of emergency, any physician or dental member of the Medical Staff, to the degree permitted by his license and regardless of service or staff status or lack of it, shall be permitted and assisted to do everything possible to save the life of a patient, using every facility of the Hospital necessary, including the calling for any consultation necessary or desirable. When an emergency situation no longer exists, such physician or dentis must request the privileges necessary to continue to treat the patient."

Based on observations, record review, and interview the hospital failed to ensure staffing was appropriate to meet the needs of the patients as evidenced by failing to have the number of staff on duty to monitor patients at the level of observation ordered by the patient's physician for 1 of 2 shifts reviewed (7:00 p.m. - 7:00 a.m.). Findings:

Observations on 10/27/2010 at 11:45 a.m. revealed all patient units in the hospital to be L-shaped with each room to contain three beds and one bathroom. Further observation revealed an inability for one employee to maintain constant visual contact for three patients located in one room when one of the patients went to the bathroom due to the shape of the room and location of the bathroom.

Review of the staffing form completed by Director of Nursing S2 for the dates of 10/10/2010 through 10/26/2010 revealed all patients admitted to the hospital were ordered the observation level of (Full) Visual Contact by the admitting psychiatrist. This finding was confirmed by S2 who further indicated the practice of placing all patients on Visual Contact (per physician's order) had been instituted at the hospital as a safety measure due to having an elderly population that was at risk for falls.

During a face to face interview on 10/27/2010 at 12:00 p.m., Director of Nursing S2 indicated the way that she ensures she has enough staff to monitor all patients according to physician's orders for full visual contact on the night shift (7:00 p.m. - 7:00 a.m.) was to staff the unit with enough employees to assign one employee to each of the three-bed patient rooms. S2 confirmed that it would not be possible to maintain full visual contact on three patients in one L shaped room when one of the patients was in the bathroom. S2 further indicated that many of the patients would be safe with an order for Modified Visual Contact however it had been the practice of the hospital for all patients to have physician's orders for (Full) Visual Contact.

Review of the hospital policy titled, "Levels of Observation-Therapeutic Safety Measures and Special Observations, NU.432" presented by the hospital as their current policy revealed in part, "Visual Contact: The patient must be in sight of a staff member at all times and 15 minute checks documented. . . The following precautions must have a V.C. (Visual Contact) status ordered: Suicide Precautions, Fall Precautions, Homicidal Precautions, Elopement Precautions, Impulse Precautions."

Based on record review and interview the hospital failed to ensure a Registered Nurse supervise and evaluate nursing care by:
1) failing to ensure patients' physicians were notified for abnormal vital signs for 2 of 2 patients with hypotension out of a total sample of 20 (#4, #7),
2) failing to ensure Quality Control measures were performed as per manufacturer's recommendations for 1 of 1 accucheck machine used at the hospital for assessing capillary blood glucose levels. Findings:

1) failing to ensure patients' physicians were notified for abnormal vital signs:

Patient #4:
Review of Patient #4's medical record revealed the patient was admitted to the hospital on 9/27/2010 with diagnoses that included Psychosis Rule Out Delirium Superimposed as Dementia. Further review revealed the patient's blood pressure to be documented as 82/44 on 10/06/2010 at 1920 p.m. (7:20 p.m.). Review of Patient #4's Medication Administration Record revealed the patient's Catapress 0.1 milligrams was held on 10/06/2010 at 8:00 p.m. for having a blood pressure of less than 90/60 as per physician's order. Further review revealed staff made an attempt to recheck Patient #4's blood pressure at 2000 (8:00 p.m.). Review of the entire medical record revealed no documented evidence of informing Patient #4's physician that the patient's blood pressure had dropped to 82/44. Review of Patient #4's Graphic Record revealed Patient #4's blood pressure typically ranged from 110 to 150 systolic over 60 to 80 diastolic.

During a face to face interview on 10/26/2010 at 2:15 p.m., Assistant Director of Nursing S15 indicated the nursing staff should have notified the patient's physician of the hypotensive blood pressure.

Patient #7:
Review of Patient #7's medical record revealed the patient was admitted to the hospital on 10/14/2010 with diagnoses that included Major Depressive Disorder. Review of Patient #7's Physician's orders dated 10/14/2010 at 1330 (1:30 p.m.) revealed an order for Metoprolol 50 milligrams by mouth two times per day. Review of #7's Medication Administration Record revealed the Patient's Blood Pressure was 90/50 on 10/21/2010 at 9:00 p.m. when Metoprolol was administered to the patient.

During a telephone interview on 10/27/2010 at 9:40 a.m., Licensed Practical Nurse S16 indicated she would have circled Metoprolol if she had not given it. S16 indicated when a physician has not indicated parameters for holding the medication, her practice would be to hold the medication and call the physician if the systolic was less than 90 and the diastolic was less than 60. S16 indicated both numbers would have to be below 90/60 for her to hold the medication and inform the patient's physician.

During a face to face interview on 10/27/2010 at 9:50 a.m., Assistant Director of Nursing S15 indicated any patient on Metoprolol with no physician ordered parameters for holding the medication should have their medication held for any reading below 100/60 and their physician should be notified for further instruction.

Review of the Metoprolol education sheet provided by the facility revealed in part, "Metoprolol: Monitor blood pressure frequently; drug masks common signs and symptoms of shock."

Review of the hospital policy titled, "Vital Signs NU.449 (no documented date)" presented by the hospital as their current policy revealed in part, "If the vital signs are needed to administer medications, the nurse dispensing the medication will take the vital signs immediately preceding the administrator (administration) of that particular medication. Any of the following vital signs readings will be reported to the staff or unit nurse immediately. . . Blood Pressure- Greater than 140/90 or less than 100/60, or a reading of 20 mm (millimeters) HG (mercury) above the patient's normal systolic pressure or a reading of 20 mm Hg below the patient's normal distolic (diastolic) pressure."



2) failing to ensure Quality Control measures were performed as per manufacturer's recommendations:

Review of the hospital Glucometer Nightly Checks: Glucometer Control Checks revealed in part, "Glucometer Strip Lot # 44788" to be the current strip used for testing quality controls from the dates of 9/24/2010 through 10/26/2010. Further review revealed documentation on the form from the date of 9/24/2010 through 10/03/2010 indicating the acceptable range for "Hi" to be listed as 243 - 393 and from the date of 10/04/2010 through 10/26/2010 indicating the acceptable range to be listed as 243 - 353 (package insert indicated the acceptable range to be 220 - 369). Further review revealed documentation on the form indicating the acceptable range for "Lo" to be listed as 25 - 56 (package insert indicated acceptable to be 27 - 58). Further review revealed the Lo reading for the date of 9/29/2010 and 10/26/2010 to be 62 (above the acceptable range listed on the package insert of 27 - 58). Review of the entire log revealed no documented evidence of repeating the out-of-acceptable-range Low reading or of reporting the out-of-range reading to the Director of Nursing.

Review of the package insert for the test strips Lot # 44788 revealed the expected results for use with mediSense or Optium Control Solutions to be Low: 27 - 58 milligrams per deciliter, Mid: 65- 121 milligrams per deciliter, and High 220 - 369 milligrams per deciliter.

During a face to face interview on 10/26/2010 at 3:00 p.m., Assistant Director of Nursing S15 indicated there should be accurate data recorded for expected ranges on the Quality Control Log for the Accucheck machine. S15 confirmed the numbers documented on the log did not reflect the numbers on the insert for the strips with the matching log number. S15 further confirmed that the Lo readings on 9/29/2010 and 10/26/2010 were outside the acceptable range and should have been re-tested.

Based on observation, record review, (medical record and policy) and interview the facility failed to ensure medications were administered as per physician's orders for 2 of 20 sampled patients. (#16, # 19) Findings:

Patient #16
The medical record for Patient #16 was reviewed. Patient #16 was admitted on 08/27/10 with a diagnosis of Bipolar Disorder, ETOH (Alcohol) Dependence, HTN (Hypertension) and DM (Diabetes).

Review of the physician's admit orders dated 08/27/10 at 7pm revealed an order for Gemfibrozil 600 mg by mouth twice a day. Review of the Medication Administration Record dated 08/28/10 revealed the Gemfibrozil was not administered until 08/28/10 at 3:05pm (20 hours and 5 minutes after the physician's order was written).

S2, Director of Nurses was interviewed face to face on 10/26/10 at 3:30pm. S2 indicated there were issues with delivery of medications timely and this had been addressed with the pharmacist but there were still problems. Further she was tracking and trending the delayed doses and was bringing this to the attention at the Medical Executive Meeting scheduled this month. This was evident by review of the 3rd quarter July through September 2010 Performance Improvement Action plan.

Patient #19:
The medical record for Patient #19 was reviewed. Patient #19 was admitted on 02/19/10 with a diagnosis of Major Depression, Dementia, Hypertension. Review of the physician's admit orders dated 02/19/10 at 11:05am revealed an order for Augmentin 500mg by mouth twice daily for 5 days. Review of the Medication Administration Record dated 02/19/10 revealed the Augmentin was not administered until 02/19/10 at 9pm. (9 hours and 55 minutes after the physician's order was written) Further review of Physician's Orders dated 03/01/10 2:15pm revealed an order for Cipro 500 mg by mouth twice daily for 7 days. Review of the Medication Administration Record dated 03/01/10 revealed the Cipro was not administered until 03//01/10 at 9pm. (6 hours and 45 minutes after the order was written)

This finding was confirmed by S DON on 10/27/10 at 11:15am. Further she indicated the hospital policy was twice a day dosages are administered at 9am and 9pm and the policy would have to be changed to avoid delay of the antibiotics being administered.

Review of the hospital policy # NU.521 entitled "First Dose Procedure," presented as the hospital's current policy, revealed in part, I. "It is the policy of Magnolia Behavioral Healthcare that the contract pharmacy provides after hour medications within two hours of receipt or notification of physician order. II. Purpose. To ensure medication orders are called to contract pharmacy and delivered within two hours of notification of order. To ensure patients receive medications as prescribed by the physician without delay."

Based on observation, record review, and interview the hospital failed to ensure medical records were stored in a manner to protect them from water damage were the sprinkler system to be triggered for 15 of 23 shelves of Medical Records stored in the hospital. Findings:

Observations on 10/27/2010 at 1:35 p.m. revealed 15 shelves of the 23 shelves of medical records stored in the hospital to be located on open wooden book shelves with no doors. Further observations revealed a sprinkler system to be located in the ceiling of the Medical Records Room where the files were stored.

During a face to face interview on 10/27/2010 at 1:50 p.m., Medical Records Coordinator S11 confirmed that there was no protection from water damage for the Medical Records stored on open shelves in the Department were the sprinkler to be triggered. S11 further indicated there were approximately 300 medical records stored on the 15 open shelves in the department.

Based on record review (patient medical records, pharmacy contract) and interviews, the hospital failed to ensure the pharmacy services met the needs of the patient 24 hours a day 7 days a week by having medications not available for timely administration for 2 of 2 patients out of a total sample of 20 patients. (Patient #16 and Patient #19) Findings:

Patient #16
The medical record for Patient #16 was reviewed. Patient #16 was admitted on 08/27/10 with a diagnosis of Bipolar Disorder, ETOH Dependence, HTN and DM.

Review of the physician's admit orders dated 08/27/10 at 7pm revealed an order for Gemfibrozil 600 mg by mouth twice a day. Review of the Medication Administration Record dated 08/28/10 revealed the Gemfibrozil was not administered until 08/28/10 at 3:05pm (20 hours and 5 minutes after the physician's order was written).

S2, Director of Nurses was interviewed face to face on 10/26/10 at 3:30pm. S2 indicated there were issues with delivery of medications timely and this had been addressed with the pharmacist but there were still problems. Further she was tracking and trending the delayed doses and was bringing this to the attention at the Medical Executive Meeting scheduled this month. This was evident by review of the 3rd quarter July through September 2010 Performance Improvement Action plan.

Patient #19:
The medical record for Patient #19 was reviewed. Patient #19 was admitted on 02/19/10 with a diagnosis of Major Depression, Dementia, Hypertension. Review of the physician's admit orders dated 02/19/10 at 11:05am revealed an order for Augmentin 500mg by mouth twice daily for 5 days. Review of the Medication Administration Record dated 02/19/10 revealed the Augmentin was not administered until 02/19/10 at 9pm. (9 hours and 55 minutes after the physician's order was written) Further review of Physician's Orders dated 03/01/10 2:15pm revealed an order for Cipro 500 mg by mouth twice daily for 7 days. Review of the Medication Administration Record dated 03/01/10 revealed the Cipro was not administered until 03//01/10 at 9pm. (6 hours and 45 minutes after the order was written)

This finding was confirmed by S2, DON on 10/27/10 at 11:15am.

S17, Registered Pharmacist was interviewed face to face on 10/27/10 at 11am. S17 reviewed the records for Patient #16 and Patient #19. He confirmed there was a delay for the administration of Gemfibrozil, Augmentin and Cipro. Further he indicated he would have to alert his pharmacy technicians to alert the pharmacist when orders are received from the hospital for antibiotics so the medications could be delivered more timely.

Review of the hospital policy # NU.521 entitled "First Dose Procedure," presented as the hospital's current policy, revealed in part, I. "It is the policy of Magnolia Behavioral Healthcare that the contract pharmacy provides after hour medications within two hours of receipt or notification of physician order. II. Purpose. To ensure medication orders are called to contract pharmacy and delivered within two hours of notification of order. To ensure patients receive medications as prescribed by the physician without delay."

Based on record review (Medical Staff Bylaws, Medical Staff Roster) and interview, the hospital failed to ensure a qualified radiologist was appointed to the medical staff . Findings:

Based on record review (governing body bylaws, medical staff bylaws, physician files, list of the medical staff) and interview, the hospital failed to ensure a radiologist was credentialed and privileged as a member of the medical staff. Findings:

Review of the list of the medical staff presented by the hospital as the most current list of the medical staff revealed no documented evidence of a radiologist on the medical staff.

Review of the physician credentialing files revealed no file for a radiologist.

This was confirmed by the DON (Director of Nursing) and the Administrator on 10/28/10 at 1:00 p.m.