HospitalInspections.org

Based on a review of Medical Staff Rules and Regulations, medical records (MR), and staff interview (EMP), it was determined that the medical staff failed to ensure Medical Staff compliance with Medical Staff Rules and Regulations relative to the authentication of verbal orders within 24 hours for four of 12 medical records reviewed (MR51, MR52, MR54 and MR62).

Findings include:

Review of the "Rules and Regulations of the Excela Health Medical Staff, Reviewed, September 2010. ... 3. ... b. Verbal Orders, ... The verbal and/or telephone orders shall be taken by qualified personnel who shall transcribe the orders in the proper place in the medical record of the patient. ... It shall be countersigned by within (24) twenty-four hours, dated and timed by the ordering practitioner or another practitioner who is responsible for the care of the patient."

1) Review of MR51, MR52, MR54 and MR62 on August 3 and August 8, 2011, revealed verbal orders written between June 25 and July 28, 2011, that had no countersignature and/or date or time the verbal orders were written.

Interview with EMP1 and EMP7 on August 3 and August 8, 2011, respectively confirmed the above findings.

2) Review of a previous state licensure (E94S11) completed June 2009 and a federal validation survey (QGZC11) completed December 2008 revealed deficiencies for verbal orders with no counter signature and/or date or time the orders were written.

Cross reference with: 482.24(c)(1)(iii)

Based on review of facility documentation, medical records (MR), and staff interviews (EMP), it was determined that the facility failed to assess and/or reassess patient's neurovascular status for three of four medical records reviewed (MR11, MR12, and MR13).

Findings include:

Review of facility documentation "Job Description ... Title ... RN" revealed "I. Core Essential Functions: ... c. ... follows physician orders"

1) Review of MR11 on August 4, 2011, revealed a physician order dated July 28, 2011 "4. Nursing: Neurovascular checks every 2 hours for 8 hours then every 8 hours." Further review revealed Neurologic nursing documentation was performed every four hours.

2) Review of MR12 on August 4, 2011, revealed a physician order dated July 29, 2011 "4. Nursing: Neurovascular checks every 2 hours for 8 hours then every 8 hours." Further review revealed Neurologic nursing documentation was performed every four hours.

3) Review of MR13 on August 4, 2011, revealed a physician order dated July 28, 2011 "4. Nursing: Neurovascular checks every 2 hours for 8 hours then every 8 hours." Further review revealed Neurologic nursing documentation was performed every four hours.

Interview with EMP5 on August 4, 2011, at approximately 10:45 AM confirmed the above findings and revealed "We [nursing] chart every four hours."

Interview with EMP7 on August 4, 2011, at approximately 1:30 PM confirmed the above findings and revealed "They [nursing] are charting it [neurovascular checks] every four hours."

Based on a review of facility documents and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure Medical Staff compliance with Medical Staff Rules and Regulations relative to the authentication of verbal orders within 24 hours for six of 12 medical records reviewed (MR7, MR8, MR51, MR52, MR54 and MR62)

Findings include:

Review of the "Rules and Regulations of the Excela Health Medical Staff, Reviewed, September 2010. ... 3. ... b. Verbal Orders, ... The verbal and/or telephone orders shall be taken by qualified personnel who shall transcribe the orders in the proper place in the medical record of the patient. ... It shall be countersigned by within (24) twenty-four hours, dated and timed by the ordering practitioner or another practitioner who is responsible for the care of the patient."

1) Review of MR7 on August 3, 2011, at approximately 1:00 PM revealed verbal order's written July 21, and 25, 2011. The order's had no countersignature, date or time the order was written. Further review of MR7 revealed verbal order's written July 22, 27, and 31, 2011. The order did not have a date or time the order was written. Continued review of MR7 revealed a verbal order written on July 29, 2011. The order had no time it was countersigned.

2) Review of MR8 on August 3, 2011, at approximately 1:30 PM revealed three verbal order's written July 28, 2011. The order's had no countersignature, date or time the order was written. Further review of MR8 revealed two verbal order's written August 1, 2011. The order's had no countersignature, date or time the order's were written.

Interview with EMP1 August 2, 2011 at approximately 2:30 PM confirmed the above findings and revealed "No they don't."

3) Review of MR51 on August 3, 2011, at approximately 10:00 AM revealed two verbal orders written on July 15, 2011, the order had no countersignature date or time. Continued review revealed a verbal order written July 16, 2011. The order had no countersignature date or time the order was written.

Interview with EMP1 August 2, 2011 at approximately 2:00 PM confirmed the above findings.

4) Review of MR52 on August 3, 2011, at approximately 10:15 AM revealed a verbal order written June 28, 2011. The order did not have a countersignature date, or time the verbal order was written. Further review of MR52 revealed two verbal orders written June 29, 2011. The orders did not have a countersignature, date or time the order was written.

Interview with EMP1 August 3, 2011, at approximately 2:00 PM, confirmed the above findings.

5) Review of MR54 on August 3, 2011, at approximately 10:30 AM revealed a verbal order written June 25, 2011. The order had a countersignature but no date or time the order was written. Further review of MR54 revealed a verbal order written June 27, 2011. The order did not have a countersignature date or time the order was written. Continued review of MR54 revealed two verbal orders written on June 28, 2011. One order did not have a countersignature date or time, the other had a countersignature but no date or time the order was written. Additional review of MR54 revealed a verbal order written June 30, 2011. The order did not have a countersignature, date or time the order was written.

Interview with EMP1 August 3, 2011, at approximately 2:00 PM, confirmed the above findings.

6) Review of MR62 August 3, 2011 at approximately 9:30 AM revealed a verbal order written July 28, 2011. The order did not have a countersignature, date or time the order was written. Further review of MR62 revealed a verbal order written July 30, 2011. The order did not have a countersignature date or time.

Interview with EMP7 August 8, 2011 at approximately 9:45 AM confirmed the above findings.

Cross reference with: 482.22(c)

These are repeat deficiencies from state licensure survey (E94S11) completed June 2009 and a federal validation survey (QGZC11) completed December 2008.

Based on a review of facility policies and staff inteview (EMP), it was determined that the facility failed to ensure that drugs and biologicals not specifically prescribed to time or number of doses were not automatically stopped after a reasonable time that is predetermined by the medical staff.

Findings include:

Review of facility policy "Automatic Stop Orders, Revised, July 2011" revealed automatic stop orders for Colchicine, Demerol, Toradol, DHE, Xigris, Integrilin, Post-Op Antibiotics, Nartecor, Entereg, IV Acetaminophen, Antibiotics, Anticoagulants, Controlled substances, Corticosteriods, Sedatives and Oxytoxics.

Interview with EMP1, August 4th 2011, at approximately 10:00 AM, "The only automatic stop orders we have are the one listed on the automatic stop order policy."

Based on review of facility documentation, and staff interview (EMP), it was determined that the facility failed to ensure in-house preparation of radio pharmaceuticals was by, or under, the direct supervision of an appropriately trained registered pharmacist or doctor of medicine or osteopathy.

Findings include:

Review of facility "Radiation Safety Manual" dated "September, 2010" revealed "The patient must receive the correct radiopharmaceutical at the correct dose with a high radiochemical purity. This requires that accurate and sterile doses are prepared for patient administration by well trained and qualified personnel."

Interview with EMP12 on August 3, 2011, at approximately 11:00 AM when asked if in house preparation of radio pharmaceuticals is under the direct supervision of the doctor or pharmacist revealed "No, the tech's mix it themselves, there are protocol's in place."

Based on a review of Medical Staff Rules and Regulations, medical records (MR), and staff interview (EMP), it was determined that the medical staff failed to ensure Medical Staff compliance with Medical Staff Rules and Regulations relative to the authentication of verbal orders within 24 hours for four of 12 medical records reviewed (MR51, MR52, MR54 and MR62).

Findings include:

Review of the "Rules and Regulations of the Excela Health Medical Staff, Reviewed, September 2010. ... 3. ... b. Verbal Orders, ... The verbal and/or telephone orders shall be taken by qualified personnel who shall transcribe the orders in the proper place in the medical record of the patient. ... It shall be countersigned by within (24) twenty-four hours, dated and timed by the ordering practitioner or another practitioner who is responsible for the care of the patient."

1) Review of MR51, MR52, MR54 and MR62 on August 3 and August 8, 2011, revealed verbal orders written between June 25 and July 28, 2011, that had no countersignature and/or date or time the verbal orders were written.

Interview with EMP1 and EMP7 on August 3 and August 8, 2011, respectively confirmed the above findings.

2) Review of a previous state licensure (E94S11) completed June 2009 and a federal validation survey (QGZC11) completed December 2008 revealed deficiencies for verbal orders with no counter signature and/or date or time the orders were written.

Cross reference with: 482.24(c)(1)(iii)

Based on review of facility documentation, medical records (MR), and staff interviews (EMP), it was determined that the facility failed to assess and/or reassess patient's neurovascular status for three of four medical records reviewed (MR11, MR12, and MR13).

Findings include:

Review of facility documentation "Job Description ... Title ... RN" revealed "I. Core Essential Functions: ... c. ... follows physician orders"

1) Review of MR11 on August 4, 2011, revealed a physician order dated July 28, 2011 "4. Nursing: Neurovascular checks every 2 hours for 8 hours then every 8 hours." Further review revealed Neurologic nursing documentation was performed every four hours.

2) Review of MR12 on August 4, 2011, revealed a physician order dated July 29, 2011 "4. Nursing: Neurovascular checks every 2 hours for 8 hours then every 8 hours." Further review revealed Neurologic nursing documentation was performed every four hours.

3) Review of MR13 on August 4, 2011, revealed a physician order dated July 28, 2011 "4. Nursing: Neurovascular checks every 2 hours for 8 hours then every 8 hours." Further review revealed Neurologic nursing documentation was performed every four hours.

Interview with EMP5 on August 4, 2011, at approximately 10:45 AM confirmed the above findings and revealed "We [nursing] chart every four hours."

Interview with EMP7 on August 4, 2011, at approximately 1:30 PM confirmed the above findings and revealed "They [nursing] are charting it [neurovascular checks] every four hours."

Based on a review of facility documents and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure Medical Staff compliance with Medical Staff Rules and Regulations relative to the authentication of verbal orders within 24 hours for six of 12 medical records reviewed (MR7, MR8, MR51, MR52, MR54 and MR62)

Findings include:

Review of the "Rules and Regulations of the Excela Health Medical Staff, Reviewed, September 2010. ... 3. ... b. Verbal Orders, ... The verbal and/or telephone orders shall be taken by qualified personnel who shall transcribe the orders in the proper place in the medical record of the patient. ... It shall be countersigned by within (24) twenty-four hours, dated and timed by the ordering practitioner or another practitioner who is responsible for the care of the patient."

1) Review of MR7 on August 3, 2011, at approximately 1:00 PM revealed verbal order's written July 21, and 25, 2011. The order's had no countersignature, date or time the order was written. Further review of MR7 revealed verbal order's written July 22, 27, and 31, 2011. The order did not have a date or time the order was written. Continued review of MR7 revealed a verbal order written on July 29, 2011. The order had no time it was countersigned.

2) Review of MR8 on August 3, 2011, at approximately 1:30 PM revealed three verbal order's written July 28, 2011. The order's had no countersignature, date or time the order was written. Further review of MR8 revealed two verbal order's written August 1, 2011. The order's had no countersignature, date or time the order's were written.

Interview with EMP1 August 2, 2011 at approximately 2:30 PM confirmed the above findings and revealed "No they don't."

3) Review of MR51 on August 3, 2011, at approximately 10:00 AM revealed two verbal orders written on July 15, 2011, the order had no countersignature date or time. Continued review revealed a verbal order written July 16, 2011. The order had no countersignature date or time the order was written.

Interview with EMP1 August 2, 2011 at approximately 2:00 PM confirmed the above findings.

4) Review of MR52 on August 3, 2011, at approximately 10:15 AM revealed a verbal order written June 28, 2011. The order did not have a countersignature date, or time the verbal order was written. Further review of MR52 revealed two verbal orders written June 29, 2011. The orders did not have a countersignature, date or time the order was written.

Interview with EMP1 August 3, 2011, at approximately 2:00 PM, confirmed the above findings.

5) Review of MR54 on August 3, 2011, at approximately 10:30 AM revealed a verbal order written June 25, 2011. The order had a countersignature but no date or time the order was written. Further review of MR54 revealed a verbal order written June 27, 2011. The order did not have a countersignature date or time the order was written. Continued review of MR54 revealed two verbal orders written on June 28, 2011. One order did not have a countersignature date or time, the other had a countersignature but no date or time the order was written. Additional review of MR54 revealed a verbal order written June 30, 2011. The order did not have a countersignature, date or time the order was written.

Interview with EMP1 August 3, 2011, at approximately 2:00 PM, confirmed the above findings.

6) Review of MR62 August 3, 2011 at approximately 9:30 AM revealed a verbal order written July 28, 2011. The order did not have a countersignature, date or time the order was written. Further review of MR62 revealed a verbal order written July 30, 2011. The order did not have a countersignature date or time.

Interview with EMP7 August 8, 2011 at approximately 9:45 AM confirmed the above findings.

Cross reference with: 482.22(c)

These are repeat deficiencies from state licensure survey (E94S11) completed June 2009 and a federal validation survey (QGZC11) completed December 2008.

Based on a review of facility policies and staff inteview (EMP), it was determined that the facility failed to ensure that drugs and biologicals not specifically prescribed to time or number of doses were not automatically stopped after a reasonable time that is predetermined by the medical staff.

Findings include:

Review of facility policy "Automatic Stop Orders, Revised, July 2011" revealed automatic stop orders for Colchicine, Demerol, Toradol, DHE, Xigris, Integrilin, Post-Op Antibiotics, Nartecor, Entereg, IV Acetaminophen, Antibiotics, Anticoagulants, Controlled substances, Corticosteriods, Sedatives and Oxytoxics.

Interview with EMP1, August 4th 2011, at approximately 10:00 AM, "The only automatic stop orders we have are the one listed on the automatic stop order policy."

Based on review of facility documentation, and staff interview (EMP), it was determined that the facility failed to ensure in-house preparation of radio pharmaceuticals was by, or under, the direct supervision of an appropriately trained registered pharmacist or doctor of medicine or osteopathy.

Findings include:

Review of facility "Radiation Safety Manual" dated "September, 2010" revealed "The patient must receive the correct radiopharmaceutical at the correct dose with a high radiochemical purity. This requires that accurate and sterile doses are prepared for patient administration by well trained and qualified personnel."

Interview with EMP12 on August 3, 2011, at approximately 11:00 AM when asked if in house preparation of radio pharmaceuticals is under the direct supervision of the doctor or pharmacist revealed "No, the tech's mix it themselves, there are protocol's in place."