HospitalInspections.org

Based on the findings detailed in Tag A - 0263, it was determined that this CONDITION IS NOT MET.

Reference Tag A - 0263

Based on review of the hospital's policies and procedures, document review, and interview, it
was determined that the hospital governing body failed to ensure that the hospitals Quality
Assurance, Process Improvement program reflected the complexity of the hospital's organization and services; involved all hospital departments and services (including those services furnished under contract or arrangement); and focused on indicators related to improved health outcomes and the prevention and reduction of medical errors.

As demonstrated by examples identified throughout the body of this report, the cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality patient health care in a safe environment and was evidence that this Condition of Participation was NOT MET.

The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program.

The hospital's governing body must ensure that the program reflects the complexity of the hospital's organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors.

The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS.

Based on interview and document review, it was determined that this CONDITION WAS NOT MET.

Based on interview and review of documents, it was determined that the hospital failed to measure, analyze and track quality indicators...that assessed processes of care, hospital services and operation, relative to the hospital's transport team. The hospital's failure to do so resulted in 12 of 12 patient records being incomplete and accurate; not containing authenticated physicians' orders for care and services and placed all patients who received transport services at risk for inaccurate, incomplete or inappropriate care and services. The hospital's failure to develop and implement a Quality Assurance/Process Improvement plan for transport services also resulted in a lack of identification of areas for improvement and did not provide consistent and objective evaluation of events and any actions taken.

Findings include:

On 10/13/2010, a joint interview was held with the Senior Vice President for Patient Care Services/Chief Nursing Officer (SVP/CNO); the Medical Director of Emergency Department Services and Chief of Emergency Medicine; the acting NICU Nurse Educator; the Respiratory Therapist who was the Program Manager for transport services and the Medical Director for Transport Services. The group discussed multiple issues, including how care and services provided by the Seattle Childrens' Hospital (SCH)transport team were evaluated for quality.

The Medical Director of Emergency Department Services and Chief of Emergency Services stated that all transport medical records were evaluated by physicians after each transport. S/he also stated that the focus of the review was on the condition of the patient upon arrival at SCH and if it appeared that the appropriate interventions had occurred.

The SVP/CNO stated that there was a review of cases after each transport, and that monthly case review included Airlift Northwest as well as SCH ground transport.

When asked if the hospital contacted customers regarding their experiences with the SCH transport team, the SVP/CNO stated that sending hospitals were contacted as part of the hospital's outreach program. Personnel involved in the outreach program included the Medical Director of Emergency Department Services and Chief of Emergency Services, the Medical Director for Transport Services and a nurse specialist. S/he stated that personnel contacted sending hospitals when a case was particularly difficult, and would offer to review the case with the sending hospital and/or provide consultation and education to the sending hospital.

The SVP/CNO stated that the nurse specialist partnered with another physician regarding the hospital's outreach program, and that the two reported to the Neonatology Division. S/he stated that the work and findings of the nurse specialist and the physician were not integrated into the hospital-wide or the transport services quality assessment/process improvement plans.

Physicians
The Medical Director for Transport Services was asked if SCH had contacted the sending/referring hospital regarding her/his experience with Patient #1, the patient identified in the complaint. The Medical Director stated that the sending/referring hospital had been contacted by SCH to determine if they would be interested in doing a "bilateral case review". When the sending/referring hospital declined the offer, no further communications were held regarding the event.

On November 2, 2010, board-certified Neonatologist #2, not directly affiliated with SCH, or Patient #1, was interviewed. The physician stated that s/he had concerns about communication issues between the SCH physicians, the SCH transport team members and the referring/sending hospital staff. The physician stated that there needed to be a clearer understanding of how care was to be managed when a Neonatologist was onsite [at the referring/sending hospital], and a clearer understanding of how and when the transport team assumed responsibility for care of the patient.

Neonatologist #2 also stated that all care provided to the patient at the referring/sending hospital needed to be collaborative and everyone involved must know their role and scope. The Neonatologist stated that s/he thought there was a need for better communication between the Medical Consultation (Med Con) physicians and the on-site physicians and a clear process for how the transport team got orders/permission for medications and treatments while in the field.

Neonatologist #2 also stated that s/he had not been solicited for input regarding any quality assurance/process improvement issues regarding transports and that s/he believed that SCH needed "a mechanism for feedback with the actual team involved..."

Registered Nurses
On December 2 & 3, 2010, 7 Registered Nurses (RNs) were interviewed. The RNs were identified as having provided transport services during the month of September, 2010.

RNs' #2, #3, #4, #5, #7 and #8 were unable to identify any quality assurance/process improvement plan specific to the transport team service, or to describe any participation in such a process.

RN #6 stated that s/he believed the quality assurance/process improvement process consisted of medical records being reviewed by one of the Med Con physicians and possibly some other people. The RN stated that s/he thought the records were reviewed to "keep track of intubations and attempts".

Respiratory Therapists
One December 2 &3, 7 respiratory therapists (RTs) were interviewed. The RTs were identified as having provided transport services during the month of September, 2010.

RT#1 was unable to identify a quality assurance/process improvement plan and stated that s/he had "not been asked" to participate in such a process.

RT# 3 stated that the quality assurance/process improvement plan consisted of a monthly meeting of the transport team, during which cases were reviewed. The cases were reportedly selected for review based on patient acuity.

RT# 4 stated that the team was "always working on policies and procedures", but that s/he had not been aware of any quality assurance/process improvement work prior to the Department of Health investigation.

RT# 5 stated that it "seems like we're doing QA stuff all the time". S/he also stated that the quality assurance/process improvement process consisted of the monthly case review and the hospital's electronic feedback program.

RT#6 also described monthly case chart audits, done by "the entire transport team" and including the RN and RT on the transport, as the quality assurance/process improvement plan for the transport team.

Emergency Medical Technicians
On December 7 & 8, 4 of 4 Emergency Medical Technicians (EMTs) who were assigned to the transport team were interviewed. The EMTS, who were not employees of the hospital, were dedicated staff of the ambulance company which was contracted by SCH.

The 4 EMTs did not provide direct patient care, but did act assist with retrieving medications and equipment from the ambulance for the RN and RT on the team, helping to lift isolettes and documenting vital signs obtained by the RN and RT All 4 EMTs stated that they had not been contacted by hospital leadership regarding their observations in the field, nor had they been asked for feedback regarding any operational issues with the transport team.

Leadership Interviews
The SVP/CNO and the Medical Director for Transport Services both acknowledged that there was not a formalized and consistent process in place to solicit feedback from customers, i.e., sending/referring hospitals. They acknowledged that the lack of customer feedback resulted in SCH not receiving information about the sending hospitals' satisfaction, or concerns or other issues, such as the performance of the SCH transport team in the field

Discussion with the leadership group included discussion of the the findings of the Department of Health investigator relative to the 12 transport records. The leadership group acknowledged that the current process of review of medical records had not identified the lack of authenticated physician orders, the incomplete and inaccurate orders recorded by the RNs, the inaccurate documentation by the RNs or the inaccurate documentation by the respiratory therapists for 12 of 12 medical records.

As demonstrated by examples identified throughout the body of this report, the cumulative effect of these systemic problems resulted in the hospital's inability to ensure effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program and was evidence that this Condition of Participation was NOT MET.

Based on interview and review of hospital documents, it was determined that the hospital failed to ensure that a registered nurse (RN) provided supervision to all RNs who provided transport services. The hospital's failure to do so resulted in the RNs who provided transport services, not having direct observation or supervision while providing those services, away from the hospital proper.The lack of supervision resulted in the inconsistent nursing practice during the delivery of transport services and resulted in transport RNs providing services that were not consistent with hospital policy, procedure and expectations, with potentially negative outcomes for all transport patients.

Findings include:

Patient #1
Neonatologist #1, a physician at a sending/referring hospital, stated on 10/4/2010 that s/he had provided medical care to Patient #1. The physician stated that s/he was called to the "code" [cardiopulmonary arrest] by the the Neonatal Nurse at the sending/referring hospital. At that time, the patient had been under the care of the transport team for approximately 70 minutes.

Neonatologist #1 stated that the patient had a good airway, but it had been a difficult intubation; s/he stated s/he gave explicit instructions to the transport team to not lose the airway [let the endotracheal tube become dislodged] and to not attempt to re-tape the airway tube.

After the second dose of epinephrine [a drug to regulate heart rate] had been given, Neonatologist #1 stated that s/he asked the SCH transport nurse if the baby had received any medications other than the epinephrine. The physician stated that the RN reported that s/he had administered 3 medications, including ativan [an anti-anxiety medication], morphine [a pain reliever] and vecuronium [ a paralytic].

The physician stated that s/he was "shocked", and clarified with the transport RN that the patient had been given vecuronium. When asked why the patient had been given the vecuronium, the transport RN reportedly stated "it's within my power to give these meds". The RN reportedly stated that the patient had been agitated and s/he was going to retape the airway to prevent the airway from being dislodged.

The Neonatal Nurse at the sending/referring hospital also was interviewed on 10/4/2010 and stated that s/he had observed Patient #1. The Nurse stated that s/he had not observed any thrashing of the patient, and believed that the airway tube was secure. The Nurse stated that s/he questioned the transport nurse about what medications s/he was giving and why, and the transport RN reportedly stated "because it's in my power to do so..."

On 11/4, a phone interview was conducted with respiratory therapist (RT) #1, who was on the transport team that cared for Patient #1. The RT stated that Neonatologist #2 "made it clear" that it was a difficult intubation and clearly said "do not lose the airway". The RT stated that s/he was not comfortable with how secure the airway was taped, and that while the tube may have been secure in the eyes of the sending/referring hospital team, s/he was not sure the tube would be secure with transport "in a bumpy ambulance". The RT stated that s/he did not re-tape the airway tube, but held the tube in place by hand.

RT# 1 stated that s/he knew RN# 1 was going to administer medications but did not observe the administration of the medications. The RT stated that RN #1 said the patient needed to be sedated because the patient was agitated, and the RT stated s/he also observed the patient to be agitated.

Emergency Medical Technician (EMT) #1 had been present during the transport effort for Patient #1 and was also interviewed about her/his observations during the transport team's efforts at the sending/referring hospital. The EMT stated that s/he retrieved the requested medications and needles from the "box' for the RN to administer. The EMT stated that the RN appeared to feel that administering the medications was within her/his scope of practice and s/he believed that the RN had "standing orders". The EMT stated that the RN told Neonatologist #2 that giving the medications was within her/his scope of practice.

Review of the patient's medical record and interview with physicians and staff at the sending/referring and receiving hospitals revealed that the resuscitation efforts were eventually discontinued and the patient died while still at the sending/referring hospital.

Neonatologist #1 stated that her/his main concerns with the actions of the transport team RN were:
-the advice of the physician at the sending/referring hospital "was not respected" [by the team]
-the transport RN was on the phone with the Med Con physician during the code and would not relinquish the phone to the Neonatologist at the sending/referring hospital
-disregarded the orders of Neonatologist #1

Neonatologist #1 stated that whenever possible, s/he chose to use a transport team other than that of SCH because the other transport team had medical personnel on the team and that team worked quickly and collaboratively with the sending/referring hospital and s/he believed that the SCH team to be "just is not as professional".

The Neonatologist also stated that the events that occurred with Patient #1 "wouldn't have happened with a more experienced and better trained staff"...and that, while the team was adequate in some circumstances, it was not comparable to those transport teams which had a fellow or attending physician on the team.

Training and Supervision of Transport Team RNs
On 10/13/2010, the Senior Vice President/Chief Nursing Officer (SVP/CNO) was interviewed about the supervision process for the RNs who worked on the hospital's Neonatal Intensive Care Unit (NICU) transport team. The SVP/CNO stated that the RNs who provided transport services worked in the hospital's NICU and each shift had specific, specially-trained RNs assigned to transport services.

S/he stated that the RNs were required to pass the NICU competencies as well as additional competencies for transport services. The SVP/CNO also stated that direct supervision of the RNs was accomplished by the supervision of practice that occurred in the NICU, as well as by observing the nurses during the verification of the nurse's skills, for example, performing intubations. The SVP/CNO confirmed that after the initial orientation period, direct supervision did not occur during actual transport services.

On 10/13/2010, a joint interview was held with the SVP/CNO; the Medical Director of Emergency Department Services and Chief of Emergency Medicine; the acting NICU Nurse Educator; the Respiratory Therapist who was the Program Manager for transport services and the Medical Director for Transport Services. Discussion involved multiple issues, and included how RNs who provide transport services are supervised in the field.

When asked to describe how supervision of transport RNs was accomplished, the Program Manager, a Respiratory Therapist, stated that s/he provided first-line supervision to the RNs. Upon further discussion, the Program Manager acknowledged that supervising RN nursing practice was not within the scope of practice of a respiratory therapist and discussion was held regarding the Washington State Nurse Practice Act.

During the conversation, the acting Nurse Educator stated that during the orientation process for the RNs, a "ride along" was done. When the RN felt able, and competencies had been verified, the RN then practiced independently without direct observation, including no further supervision on an intermittent basis while the RN was on the transport team.
The Medical Director for Transport Services stated that the hospital also provided continuing education and verification of competencies to assure nurse competency in the field. S/he also stated that the RNs had direct observation during orientation, as well as during their regularly-assigned work in the NICU.

During the conversation, the investigator noted that RN practice in an unfamiliar environment, such as that of the sending/referring hospital, could be a different experience for the NICU RNs than practicing in the NICU in which the RN usually worked. Also noted was that practice under what could be stressful and urgent conditions, such as an emergency during a transfer, might not necessarily reflect practice that was observed during observation of the RN in the NICU or in a skills laboratory setting.

On 12/7/2010, an Emergency Medical Technician, who was one of the dedicated EMTs assigned to the transport team, stated that the nurses seemed to be out in the field without support and they "...don't have anyone to bounce things off of except the RTs [respiratory therapists]".

Transport Nurse Interviews
On December 2 and 3, 2010, transport team RNs #2 through #8 were interviewed and asked who their supervisor was while they were on the transport team and out in the field.

The responses were:

RN #2 stated that the Transport Program Services Manager (a respiratory therapist) was her/his supervisor, and that the NICU [Neonatal Intensive Care Unit] manager was her/his full-time supervisor.

RN #3 stated that [the Director of the Intensive Care Units] was her/his supervisor while s/he was in the field on transports.

RN #4 stated that Med Con was the supervisor for transport, but that there was no nursing supervisor.

RN #5 stated that Med Con was the supervisor, but the nursing supervisor was [the Director of the Intensive Care Units].

RN #6 stated that Med Con was the supervisor. When asked who the nursing supervisor/contact was, the RN stated that there was no nursing supervisor for the RNs on transport, and that s/he followed the Med Con directions.

RN #7 state that while on transports, s/he was accountable to Med Con, but there was no nursing supervisor.

RN #8 stated that Med Con "directs care", and also named two other physicians who were on the "supervisor team". When asked who the nursing supervisor was, the RN stated that s/he did not know.

Hospital Failure to Supervise Practice of Transport Team RNs Field Practice, Including Medication Administration

All of the above RNs were also asked if it was their practice to administer medications and/or deliver treatments while in the field on transport, without a physician's order for same.

The responses were:
RN #2 stated that s/he did not administer medications without an order.

RN #3 also stated that s/he did not administer medications without an order.

RN #4 stated that s/he did not administer medications without an order, but had heard of other transport RNs who did so.

RN #5 stated that s/he did not administer medications without an order.

RN #6 stated that on 3 occasions s/he had given medications without an order, but believed that under the conditions that were present, her/his actions had been appropriate. RN #6 stated that s/he had been told in orientation, that if a life-threatening situation was present, it was acceptable to give medications and get an order later.

RN #7 stated that s/he had not given medications without an order. The RN, who was also identified as a transport team preceptor, and had been identified as the preceptor for RN #1, stated that s/he did not know how any RN could have gotten the impression that it was acceptable for RNs to give medications without an order.

RN #8 stated that s/he always called Med Con for orders, and did not know what other RNs did. S/he also stated that it "could be okay in emergency situations" to give medications without an order, and that it was "a given" that nurses could give medications in an emergency without orders. The RN stated that s/he thought it was written "in the guidelines", but was not sure where to find those guidelines.

Washington State Nurse Practice Act

The Washington State Nurse Practice states in part:

WAC 246-840-700 Agency filings affecting this section
Standards of nursing conduct or practice.
(1) The purpose of defining standards of nursing conduct or practice through WAC 246-840-700 and 246-840-710 is to identify responsibilities of the professional registered nurse and the licensed practical nurse in health care settings and as provided in the Nursing Practice Act, chapter 18.79 RCW. Violation of these standards may be grounds for disciplinary action under chapter 18.130 RCW. Each individual, upon entering the practice of nursing, assumes a measure of responsibility and public trust and the corresponding obligation to adhere to the professional and ethical standards of nursing practice. The nurse shall be responsible and accountable for the quality of nursing care given to clients. This responsibility cannot be avoided by accepting the orders or directions of another person. The standards of nursing conduct or practice include, but are not limited to the following;

(2) The nursing process is defined as a systematic problem solving approach to nursing care which has the goal of facilitating an optimal level of functioning and health for the client, recognizing diversity. It consists of a series of phases: Assessment and planning, intervention and evaluation with each phase building upon the preceding phases.

(a) Registered Nurse:
Minimum standards for registered nurses include the following: Minimum standards for licensed practical nurses include the following:
(D) Implementation: The registered nurse implements the plan of care by initiating nursing interventions through giving direct care and supervising other members of the care team; and
(ii) Standard II Delegation and Supervision: The registered nurse is accountable for the safety of clients receiving nursing service by:
(A) Delegating selected nursing functions to others in accordance with their education, credentials, and demonstrated competence as defined in WAC 246-840-010 (10);
(B) Supervising others to whom he/she has delegated nursing functions as defined in WAC 246-840-010 (10); (B) The licensed practical nurse in delegating functions shall supervise the persons to whom the functions have been delegated;
(C) Evaluating the outcomes of care provided by licensed and other paraprofessional staff;
(4) Other responsibilities:

(a) The registered nurse... shall have knowledge and understanding of the laws and rules regulating nursing and shall function within the legal scope of nursing practice;

(b) The registered nurse and the licensed practical nurse shall be responsible and accountable for his or her practice based upon and limited to the scope of his/her education, demonstrated competence, and nursing experience consistent with the scope of practice set forth in this document; and

(c) The registered nurse...shall obtain instruction, supervision, and consultation as necessary before implementing new or unfamiliar techniques or procedures which are in his/her scope of practice.

(d) The registered nurse ...shall be responsible for maintaining current knowledge in his/her field of practice...

Nursing leadership failed to adequately educate transport RNs to their scope of practice and responsibility when acting as transport nurses, and subsequently failed to supervise the RNs while the RNs performed their duties as transport nurses.

Reference citation written under Tag 0263 - QAPI, Condition Level
Reference citation written under Tag 0406 - Written Medical Orders for Drugs

Based on review of medical records and interviews with hospital personnel, it was determined that the hospital failed to ensure that drugs and biologicals were administered upon the documented and signed order of a practitioner who was authorized to write orders by hospital policy and in accordance with State law, and who was responsible for the care of the patient as specified under ?482.12(c), for 12 of 12 medical records reviewed.

The hospital's failure to ensure authentication of physician orders placed all patients at risk for receiving care and services which were not what the ordering physician had intended, or not receiving care and services which were what the ordering physician had intended, with the potential for harm to patients as a consequence.

Findings include:

Twelve (12) out of 28 records were reviewed for patients who had received services from the Seattle Children's Hospital (SCH) transport service. The records were selected for review from a list of 28 patients who the hospital reported as having received transport services in September, 2010. Included in the review was the medical record of Patient #1, who was identified in the complaint.

All 12 records were reviewed for evidence that a Medical Consultation(Med Con) physician from SCH had authenticated the verbal orders, as evidenced by her/his signature on the medical record. Medical records were also reviewed for evidence that medications and biologicals were administered per physicians' orders. The review revealed that 12 of 12 records reviewed did not have authenticated physician orders, as evidenced by the signature of the ordering physician.

Medical Consultation Physician Interviews

On December 6, 2010, Med Con physician #1 was interviewed regarding her/his practices regarding giving orders for care and services. The physician stated that there was a "progressive assumption of care...collaboration..." and that the responsibility for care "may go back and forth".

Med Con physician #1 stated that if s/he was the SCH attending physician for the transport, s/he now signed the orders when the transport team brought the patient to the hospital; otherwise, s/he signed orders "in a day or two".

On December 6, 2010, Med Con physician #2 was interviewed regarding her/his practice for signing orders for care and services.

When asked when s/he authenticates the orders s/he has given to the transport team, Med Con physician #2 stated that "until recently", s/he had not signed orders "ever", but now was signing the orders. The physician stated "...if we'd thought it was important for good patient care we would have done it".

On December 6, 2010, Med Con physician #3 was interviewed regarding her/his practice for signing orders for care and services. The physician stated that things have changed because s/he did not "ever" sign orders before. Now s/he authenticates her/his orders "usually within a day".

On December 6, 2010, Med Con physician #4 was interviewed regarding her/his practice for signing orders for care and services. The physician stated that before the Department of Health investigation had begun, s/he had not signed for orders given to the transport team. S/he stated now "a process is being put in place..."

Medical Record Review
Patient #1: Nursing notes documented that the patient received epinephrine [a drug used to regulate heart rate], morphine [a pain reliever], ativan [an anti-anxiety medication] and vecuronium [a paralytic] while still at the sending hospital. An internal investigation by SCH had determined, prior to the Department of Health investigation, that the RN #1 had administered the morphine, ativan and vecuronium without a physician's order.

The RN documented that epinephrine was administered. No physician orders were evident in the medical record for the administration of the epinephrine, and it is not clear from the medical record if a physician at the sending hospital or a physician from SCH ordered the epinephrine. Intravenous (IV) fluids were also documented as given to the patient.

In addition, the medical record documented that Patient #1 was on a ventilator and had received manual "bagging" during the resuscitation throughout the transfer process and subsequent resuscitation effort.
No verbal orders were authenticated for the medications or the IV fluids.

Patient #2:
The patient's medical record revealed that IV fluids were established at the sending hospital and reportedly continued while under the care of the SCH teammate medical record also documented that the patient received phenobarbital while under the care of the SCH team.

No physician verbal orders were authenticated.

Patient #3:
The patient's medical record documented that IV fluids, with added trophamine [an amino acid] had been established by the sending hospital. The established IV fluids and medication additive were reportedly continued while the patient was under the care of the SCH transport team.

No authenticated physician verbal orders were evident.

Patient #4:
Review of the patient's medical record indicated that the patient had IV fluids established at the sending hospital. The SCH plan of care indicated that the patient was to receive the same IV fluids, with an additive of trophamine [an amino acid].

No authenticated physician verbal orders were evident in the medical record.

Patient #5:
The patient's medical record revealed that the patient had had IV fluids established at the sending hospital. The SCH plan of care indicated that the patient was to receive the same IV fluids, at the rate of "80 cc/kg/D".

The plan of care also stated that the SCH team was to "cont. amp & gent" [ampicillin and gentamicin, both antibiotics], the dosage was not specified.

The medical record documented that both antibiotics had been given at the sending hospital on the previous day; however, there was no documentation that the antibiotics had been administered at the sending hospital since the previous day.

No authenticated physician verbal orders were in the medical record.

Patient #6
Review of the patient's medical record revealed that IV fluids, with trophamine, had been established at the sending hospital. The dose was continued, and increased, while the patient was under the care of the SCH transport team.
The medical record also documented that the patient received "PGE 0.03 mcg/kg/min (mcg/ml)" [unknown drug/nutrient] while under the care of the SCH transport team.

No authenticated physician verbal orders were in the medical record.

Patient #7:
The patient's medical record documented that the patient had IV fluids established at the sending hospital. While under the care of the SCH transport team, the IV fluids were continued, along with dopamine [a medication used to regulate heart rate and blood pressure]. The patient also received "NS" [normal saline] and "alt" [unknown].

The SCH plan of care revealed that the physician had ordered "TF = 80cal/Kg/D [tube feeding] as well as "continue amp & gent". The medical record documented that the patient had received ampicillin and gentamycin [antibiotics] at the sending hospital. Documentation indicated that the antibiotics had been administered as one-time doses, and were not being administered as a continuing dose.

No authenticated physician orders were evident for the IV fluids, the dopamine, the tube feeding or the 2 antibiotics.

Patient #8:
The medical record documented that the sending hospital established IV fluids, and indicated that the fluids had been continued while under the care of the SCH transport team.

The medical record also documented the administration of ampicillin and gentamicin, both antibiotics, both administered while the patient was under the care of the SCH transport team. The medical record also documented that the patient received sodium acetate [a salt solution] and Survanta [a surfactant administered intra-tracheally] at the time the SCH transport team arrived. It is not clear who administered the sodium acetate or Survanta, or whether those were one-time doses.

The physician's verbal order was for "ampicillin, gentamicin...0.1mg/kg morphine, PRN, agitation".

No clarification of the incomplete orders was found on the record, and no authenticated physician verbal orders were on the medical record.

Patient #9:
The patient had IV fluids and parenteral nutrition established at the sending hospital and reportedly continued while under the care of the SCH transport team. The patient also received insulin intravenously. The physician's orders on the plan of care noted that the patient had received ampicillin, gentamicin, and flagyl [an antibiotic] while at the sending hospital, but the medication record did not document that those medications had been administered by the sending hospital.

No authenticated physician's verbal orders were on the medical record relative to the fluids and parenteral nutrition which were administered while the patient was under the care of the SCH transport team.

Patient #10:
Review of the medical record revealed that the patient had IV fluids established at the sending hospital. The fluids were reportedly continued while the patient was under the care of the SCH transport team.

No authenticated physician verbal orders were on the medical record.

Patient #11:
Review of the patient's medical record revealed that the patient had IV fluids and lipids [fat for nutrition] established at the sending hospital, both reportedly continued while under the care of the SCH transport team. The patient also received heparin [used to prevent blood clots] and fentanyl [pain medication] while under the care of the SCH transport team.

No authenticated physician verbal orders were found for any of the fluids, the lipids or for the heparin and fentanyl.

Patient #12:
The patient's medical record revealed that the patient had IV fluids established at the sending hospital. The medical record also documented that the patient had received clindamycin [antibiotic] IV while under the care of the SCH transport team. The physician's orders, as documented on the plan of care, stated that clindamycin was given at the sending hospital, and the patient was to receive ampicillin and gentamicin. No documentation was found in the record that the patient received ampicillin or gentamicin.

No authenticated physician verbal orders were found in the record.

The Senior Vice President/ Chief Nursing Officer (SVP/CNO) and the Registered Nurse (RN#9) liaison for transport services were interviewed and the issue of authentication was discussed. The SVP/CNO and the RN reviewed each of the 12 transport patient medical records and confirmed that none of the records contained evidence that the physician's verbal orders had been authenticated.

During the first week of December, 2010, the 4 Emergency Medical Technicians (EMT) dedicated to the transport team were interviewed. One EMT stated, "The nurses [transport RNs] are really freaked out since all of this, especially the night nurses. They make sure to ask the Med Con doc what drugs they can give before they go out now". The EMT was asked for clarification, and s/he confirmed that the transport nurses asked permission from the Med Con physicians to give medications before the nurses left to pick up the transport patient and before they had evaluated and assessed the patient.

Reference citation written under Tag 0395 - RN Supervision of Nursing Care
Reference citation written under Tag 027 - QAPI Indicators