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Based on medical record review, interview and document review, the facility failed to ensure current physician orders were in place prior to the performing a laboratory test for 1 of 20 patients (Patient #11); and failed to ensure an occupational therapy evaluation was performed in a timely manner for 1 of 20 patients (Patient #19).

Findings include:

Patient #11

Patient #11 was being seen on an outpatient basis for laboratory blood draws and blood transfusions on a weekly basis at the facility due to a diagnoses including thrombocytopenia and myelodysplastic syndrome.

On 11/4/14 at 1:00 PM, the patient was observed receiving a blood transfusion.

The physician's orders dated 2/3/14, included:
-Tests
- Type & Cross - Reason: Standing order for 2 units PRBC (Packed Red Blood Cells) if HGB (hemoglobin) is less than 9
- CBC (complete blood count) (Auto Diff) (Differential)

The physician's orders dated 8/26/14, included:
- Transfuse 1 unit of platelets if Platelet Count is less than 15
- Transfuse 1 unit of of PRBC (Packed Red Blood Cells) if HCT (Hematacrit) is less than 28
- Transfuse 2 units of PRBC if HCT is less than 24

On 11/4/14 at 1:00 PM, the Registered Nurse (RN) verbalized the patient has been coming to the hospital on a weekly basis. The patient has his blood drawn in the lab, and then based on the results, would come to the floor for the blood transfusions.

On 11/4/14, at 2:00 PM, the Director of Quality verbalized the physician orders for outpatient tests and procedures were good for 6 months. The Director of Quality confirmed the order for the blood tests, CBC and Type and cross match, were dated 2/3/14. The Director was unable to locate any orders for blood tests after that date.

The facility policy titled, "Laboratory orders (dated 8/20/13), documented:
- "All Outpatient orders or standing orders are good for a period of 6 months. If a patient has an order older than 6 months, the Physician must be contacted for a new order. Testing and results cannot be completed until order is received with new acceptable dates."


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Patient 19

Patient #19 was admitted to the facility on 11/2/14, with diagnoses that included a hip fracture.

On 11/3/14, Patient #19's Physician ordered an evaluation by the Occupational Therapist. On 11/5/14, Patient #19's clinical record was reviewed. No Occupational Therapist evaluation could be located.

On 11/6/14, the Director of Quality was interviewed. The Director stated the evaluation by the Occupational Therapist had not been conducted because the contracted therapy agency did not have an Occupational Therapist licensed in Nevada, and the agency did not convey the information to the facility. The Director further stated the evaluation should have been perform within 24 hours of the order.

On 11/6/14, the Policy titled, "Assessment and Reassessment" (dated July 2014), was reviewed. The Policy stated in part, "Area/Discipline Therapy Services (PT, OT, Speech)... Initial Assessment Initiated... 24 hours of referral."

Based on record review and confirmation with radiology personnel, services furnished by the CAH were provided by personnel not qualified under State law.

Findings include:

One of two mammographers did not have a current license as a mammographer in the State of Nevada. The mammographer's license expired on July 31, 2014.

Based on medical record review, document review, and interview, the facility failed to ensure consent forms were completed accurately prior to a surgical procedure for 1 of 20 sampled patients (Patient #4); and failed to ensure a transfer form was completed accurately for 1 of 2 sampled patient (Patient #13).

Findings include:

Patient #4

Patient #4 was admitted on 11/2/14, in active labor and was expected to have a normal vaginal delivery.

Review of the medical record revealed the consent form dated 11/2/14 at 9:30 AM, included the physician's name, but did not include the name of the procedure the patient was to have. The consent form was signed by the patient.

Review of the patient's Anesthesia Consent form revealed the form was signed by the patient but did not include the date and time. The form included an area for the patient to initial which indicated the patient was informed and was aware of possible complications of anesthesia. The patient did not initial the anesthesia form. The form also included an area which indicated the anesthesia provider explained the risks, side effects, and potential problems with the patient. This was not signed by the anesthesia provider.

On 11/4/14 in the morning, the Director of Quality Improvement confirmed the consent forms did not include the name of the procedure, had not been signed by the anesthesia provider, and did not include the date and time of the patient's signature.

The Registered Nurse on the Obstetrics Unit verbalized the consent should have indicated Vaginal Delivery with Possible Cesarean Section.

The facility policy titled, "Informed Consent (dated May 2014), documented"
- "VI. Consent Procedure
A. The physician who obtains the informed consent or licensed healthcare provider who witnesses the consent will complete the form with:
- 1. The patient's name
- 2. Date and time the informed consent is obtained
- 3. A listing of the specific procedure(s) to be performed
- 4. Name of specific physician performing the procedure
- 5. All other pertinent information required on the form. LEAVE NO BLANKS."

Patient #13

Patient #13 was admitted on 10/15/14, with diagnoses including osteomyelitis, gangrene of the toe and diabetes.

Review of the medical record revealed, the patient required a higher level of care for a surgical procedure and was to be transferred to another acute care facility on 10/23/14.

The patient's transfer form included a section to be completed by the physician which indicated the patient received a screening exam performed by (Physician Name) on (Date). This section was left blank.

Additional section of the form included:
1. Condition of the Patient:
2. Reason for Transfer
3. The risks that can reasonably be anticipated by the transfer
4. The benefits that may reasonably be anticipated

This section of the form was not completed.

On 11/11/6/14 in the morning, the Chief Nursing Officer confirmed the transfer form was not completed and verbalized all sections of the form must be complete.

The facility policy titled, "Transfer of Patients to Other Institutions" (dated June 2014), documented:
- "5. The Interfacility Transfer of Patient form must be completed. It includes documentation of explanation of risks and benefits of transfer, as well as the patient's or responsible person's consent to transfer...."