HospitalInspections.org

Based on findings from document review, record review, and interview, preoperative standing orders were implemented by nursing staff without a physician signature authorizing the order for the individual patient, in 2 of 7 surgical medical records (MRs) reviewed (Patients A and B).

Findings include:

-- Per MR reviews, on 4/17/13 an intravenous line (IV) was started on Patient A prior to the procedure without a corresponding signed order in the MR. On 08/09/13, an IV was started on Patient B and IV antibiotic was administered prior to the procedure without a corresponding signed order in the MR.

-- Per interview on 8/14/13 at 2:15 pm, the Clinical Coordinator of Perioperative Services, the Vice President of Quality and Compliance, and the Chief Nursing Officer indicated the hospital has "standing orders", i.e., orders that a physician expects to be automatically implemented for all of his/her patients, prior to providing written authorization to implement such orders for the individual patient. They confirmed that the nursing staff administer IV fluids and medications to patients in accordance with standing orders.

-- In New York State, in August 2006, the State Board for Nursing within the State Education Department issued a memorandum addressing "Standing Orders or Protocols." The memorandum states "The use of non-patient specific standing orders ... in hospitals...has no legal standing..."

Based on findings from interview and record review, nursing staff failed to document a comprehensive assessment of discharge needs and a discharge plan in 1 of 2 patients' medical record (MRs) reviewed (Patient C).

Findings include:

-- Review of Patient C's MR on 08/16/13 revealed the following information:

On 2/7/13 this 56 year old patient was admitted to the hospital with diagnosis of difficulty breathing. The patient had a history of metastatic lung cancer to the brain. Upon admission the physician noted the patient was confused, and less alert and conversant. The physician also noted the patient was dehydrated and had not eaten much in the previous 3-4 days. The patient was admitted from home. He had been receiving hospice services at home since December 2012. Attached to the medical record was the hospice plan of care from prior to the patient's admission.

A Case Management note dated 2/8/13 at 13:44 documents the patient was unable to answer any questions. The note also describes the patient as very confused and rambling. The Case Manager noted the patient was receiving home hospice. There are no other Case Management notes. None of the nursing notes describe a discharge plan. The medical record section labeled "Discharge Arrangements:" is blank. The patient was discharged on 2/9/13.

-- The Case Manager for this patient, who is a Registered Nurse, was interviewed on 8/16/13 at 12:00 noon. The Manager recalled discussing the patient's needs with the patient's wife, who was the primary caregiver in the home. The Manager also discussed the patient's discharge needs with the hospice provider, who would be resuming services in the patient's home upon discharge. The Manager confirmed that neither of those discussions, or a comprehensive discharge plan, are documented in the patient's medical record.

Based on findings from document review, record review, and interview, 7 of 7 consent forms used for surgery and anesthesia (in the medical records of Patients A, B, D, E, F, G and H) lacked documentation of the times the consents were signed by patient, physician, and witness.

Findings include:

--Per document review, the hospital form titled "Special Consent Form for Operation, Procedure, or Treatment with Anesthesia," last reviewed 10/2012, lacks space for the time consent is obtained or witnessed to be documented.

--Per medical record reviews for the patients noted above, the surgical consent forms lacked documentation of the time the form was signed by the patients, the physician and the witness.

--During interview on 8/14/13 at 2:15 pm with the Chief Nursing Officer, Clinical Coordinator of Perioperative Services, and Vice President of Quality and Compliance, the above findings were acknowledged.