HospitalInspections.org

Based on medical record review, staff interview and review of the hospital policy, the hospital failed to ensure telephone orders were timely signed by the ordering physician for one of ten medical records reviewed (Patient #9). The census was 45.

Findings include:

Review of the hospital policy titled, Delinquent Record Process, issued in 02/2019 and revised in 2022, revealed it is the policy of the facility to maintain an information management process that supports timely, accurate and complete documentation of medical records. The medical record is to be completed within 30 days.

Review of Patient #9's medical record revealed the patient was admitted via pink slip on 11/26/21 for psychosis. On 12/05/21 telephone orders were obtained for Immodium (treatment for diarrhea) 2 milligrams (mg). On 12/11/21, 12/19/21, 01/01/22 and 01/02/22 telephone orders for Ativan (sedative), Thorazine (antipsychotic) and Benadryl (antihistamine) intramuscularly (IM) now were obtained. On 12/21/22 Haldol was ordered. On 12/27/21 telephone orders for four hours of seclusion and intramuscular injections of Thorazine and Benadryl were obtained. On 01/03/22 telephone orders for Haldol, Ativan, Benadryl and four hours of seclusion were obtained. None of the orders were signed by the physician.

Interview on 02/10/22 at 2:15 PM with Staff B confirmed the orders were not signed by the physician.

Based on staff interview and policy review, the facility failed to ensure the hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing the transmission of COVID-19 within the hospital (A749).

Based on staff interview and policy review, the facility failed to ensure the hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing the transmission of COVID-19 within the hospital. This had the potential to affect all patients receiving services from this facility. The census was 45.

Findings include:

Review of the policy titled, for Emergency Management Plan Annex For Pandemic Pathogen- COVID-19, revised 02/21, revealed there are four principles for emergency management which include mitigation, preparedness, response, and recovery. Preparedness includes actions taken to increase the facility's ability to respond when there is an infectious pathogen outbreak or pandemic. These actions include planning, organizing, training, equipping, exercising, and corrective action to ensure a continued readiness.

Staff A stated in an interview on 02/07/22 at 9:50 AM that the facility designated a COVID-19 unit on 01/20/22 due to the Omicron variant surge. This unit was designed for prompt identification and isolation of potentially and/or infectious individuals with COVID-19. The facility partnered with a network hospital for the planning stages and training was conducted onsite for staff on infection prevention control to prevent the spread of infectious disease. Per Staff D, staff initially received Coronavirus (COVID-19) training through an online portal at the start of the pandemic and continued to receive ongoing Centers For Disease Control and Prevention (CDC) updates/guidance. In preparation of opening the designated COVID-19 unit, staff received verbal/spot training over a two day period on workplace protocols related to the designated COVID-19 unit. Staff D confirmed on 02/07/22 at 9:50 AM the facility lacked documented evidence that all staff were trained on the established protocols.

An interview was conducted with Staff L on 02/07/22 at 11:10 AM who reported not receiving any additional training and/or being aware of the protocols for the COVID-19 unit.

An interview was conducted with Staff K on 02/07/22 at 11:42 AM who reported the COVID-19 unit opened several weeks ago and he/she had not received training on the protocols. There was confusion among nursing staff on how the COVID-19 patients were processed at intake, who obtained the physician orders, transporting of the patient's personal belongings, report for positive patients being called to the units and intake staff unaware the patient was COVID-19 positive. She stated she showed up for work one day and found there was a table outside the COVID-19 unit with personal protective equipment.

An interview was conducted with Staff I on 02/07/22 at 4:07 PM who reported not receiving any additional training on how COVID-19 positive patient intake/admissions were handled.

An interview was conducted with Staff N on 02/08/22 at 12:59 PM who reported staff training to the designated COVID- 19 unit had been verbal and there was no current policy and/or protocol in place. She flet there was just a table set up with personal protective equipment and staff were left to figure it out.

An interview was conducted with Staff Q on 02/09/22 at 2:12 PM who reported not having to go to the COVID-19 unit as of yet. She was unaware of the personal protective equipment available on the table. The admission nurse was required to go to the COVID-19 unit to gather patient information, and they had never been trained on the protocol and/or expectations of the COVID-19 unit.

This substantiates Substantial Allegation OH00129743.