HospitalInspections.org

Based on staff interview it was determined the facility failed to ensure written policies were available to facilitate the safe delivery of patient care in the Outpatient Infusion Center (OIC). This failure creates the potential for inconsistent care, treatment and delivery of services to all patients receiving outpatient infusion therapy, with possible negative outcomes.

Findings include:

1. An interview was conducted with the Director of Nursing/Emergency Department (ED) on 9/14/15 at 10:00 a.m. She indicated some of the OIC rooms are currently being used for ED "overflow" patients. At this time a request was made to provide policies regarding how the OIC department generally operates, including acceptance of patients into the OIC, staff assigned to provide their care, maintenance of rooms dedicated to OIC patients and overall OIC unit policies. She stated there are no policies currently specific to the OIC unit and the Registered Nurses (RN) working in the OIC use "med.-surg. (Medical-Surgical inpatient) policies".

2. An interview was conducted with RN #1 on 9/14/15 at 10:30 a.m. When asked to provide policies relative to outpatient infusion therapy patient monitoring, procedures to employ if no room is available and criteria for discharge, she was unable to provide the requested policies.

3. An interview was conducted with RN #2 on 9/14/15 at 10:35 a.m. When asked to provide policies related to scheduling of infusion therapy patients to provide a room for each patient upon arrival and the process for registering and assessing the patients, she was unable to provide the policies.

4. The Chief Medical Officer was interviewed on 9/16/15 at 9:00 a.m. When asked if he was aware of the OIC operating without the guidance of policies specific to that unit, he reported he was aware and reported plans to re-locate the infusion center in the next fiscal year, stating, "at that time, we plan to use the chemo infusion center policies" to develop the unit-specific guidelines for the OIC.