HospitalInspections.org

Based on record review and interview, the hospital failed to ensure contracted services were provided in a safe and effective manner.

This failed practice had the potential to affect all current patients due to the lack of evaluation of practices.

Findings:

A document titled "Contracted and Other Services" showed no documentation of evaluation of services provided by contract staff.

On 07/25/17 at 12:24 pm, Staff E stated contracted services were not reviewed annually for safety and effectiveness.

Based on record review and interview, the hospital failed to ensure qualified staff were credentialed to provide for the supervision of the CRNA.

Findings:

A CRNA provides anesthesia services in surgical services. The Oklahoma Board of Nursing requires a CRNA to be "under the supervision of a medical doctor..under conditions in which timely, on-site consultation by such medical doctor...is available..."

A review of Staff P and Staff Q credentialing files showed no supervision privileges of Staff O, CRNA, during surgical procedures.

On 07/25/17 at 3:00 pm, Staff E stated Staff P and Staff Q were not credentialed for the privilege of supervising the CRNA during surgical/endoscopic procedures.

Based on record review and interview, the hospital failed to ensure medical records were promptly completed for 5 (Patients #6, 7, 8, 11, and 15) of 20 records reviewed.

This failed practice had the potential to affect all patients due to the unavailability of pertinent information to make care decisions.

Findings:

Patient #6

A review of the clinical record showed no documentation of signed admission orders on 07/17/17 (7 days out) or a completed history and physical assessment (6 days late).

Patient #7

A review of the clinical record showed no documentation of signed admission orders on 07/17/17 (7 days out).

Patient #8

A review of the clinical record showed no documentation of signed admission orders on 07/13/17 (11 days out) or a completed history and physical assessment (10 days late).

Patient #11

A review of the clinical record showed no documentation of signed admission orders on 07/14/17 (10 days out).

Patient #15

A review of the clinical record showed no documentation of signed admission orders on 07/10/17 (15 days out) or a completed history and physical assessment (14 days late).

On 07/24/17 at 12:43 pm, Staff D stated orders and history and physical assessments should be in the "Transcribed" section of the EMR; and records were not entered timely and might take 2 months to be scanned into the EMR.

Based on record review and interview, the hospital failed to ensure a completed history and physical assessment was documented in the record for 2 (Patients #6 and 8) of 20 records reviewed.

This failed practice had the potential to affect all patients due to the unavailability of pertinent information to make care decisions.

Findings:

Patients #6 and 8

A review of the clinical records showed no documentation of a history and physical assessment completed within 30 days prior or within 1 day after admission.

On 07/24/17 at 12:43 pm, Staff D stated the history and physical assessments should be in the "Transcribed" section of the EMR; and records were not entered timely and might take 2 months to be scanned into the EMR. The opportunity to provide additional documentation was given.

On 07/24/17 at 1:10 pm, Staff D stated she could not find the assessments for either patient.

Based on record review, observation and interview, the hospital failed to:

A. Ensure pharmacy staff were appropriately evaluated and supervised.

B. Ensure pharmacy staff kept accurate records of controlled drugs.

C. Ensure pharmacy staff controlled and distributed drugs per acceptable standards of practice.

Findings:

A. See Tag A-0492
B. See Tag A-0494
C. See Tag A-0500

Based on record review and interview, the hospital failed to:

A. Ensure the drug room was managed by competent personnel.

B. Ensure a licensed pharmacist developed, supervised, and coordinated the activities of pharmacy services.

This failed practice had the potential to affect all patients due to unsafe practices in drug distribution.

Findings:

A. On 07/17/17 at 11:45 am, Staff L, M, and N were identified as drug room personnel. A review of personnel records showed no assessment of competency in drug room tasks for Staff L, Staff M and Staff N since 2015.

On 07/24/17 at 11:00 am, Staff K stated competencies for drug room staff were to be conducted annually.

B. See tags A 0494 and A 0500.

Based on record review and interview, the hospital failed to keep current and accurate records of distribution of controlled drugs.

This failed practice had the potential to affect all patients due to unsafe practices in the distribution of narcotic medications to patients.

Findings:

A document titled "Incident Report" dated 06/23/17 showed Staff I used an override in the automated medication system to remove 10 mg oxycodone (40 mg was the ordered dose) for Patient #19; and subsequently obtained an additional 40 mg of oxycodone to administer to the patient. The document stated the original 10 mg was undocumented and unaccounted for. Staff L documented there was no accounting system for medications obtained through an override.

On 07/17/17 at 11:05 am, Staff A stated nursing staff can obtain narcotics through an override of the automated system.

On 07/17/17 at 11:45 am, Staff L stated narcotic counts were only checked against the patients' charts after discharge, and the count sheets in the drug room did not record before and after counts of doses available.

Based on observation and interview, the hospital failed to control and distribute drugs per acceptable standards of practice.

This failed practice had the potential to affect all patients due to unsafe practices in the distribution of narcotic medications for patients.

Findings:

On 07/17/17 at 9:35 am, the surveyors conducted a tour of the private side of the facility. There were no patients on the private side at that time. At 9:55 am, the surveyors observed 2 boxes of a narcotic medication (Demerol) in the medication room.

On 07/17/17 at 9:55 am, Staff H stated there was not a count sheet in the medication room with the names and amounts of narcotic medications and the medication should not be there.

On 07/17/17 at 11:45 am, Staff L stated there should not be narcotic medications in the private side medication room when no patients were present and the count sheets in the drug room did not record before and after counts of doses available and could not account for the discrepancy.

Based on observation and interview, the hospital did not develop a system for identifying, reporting, investigating and controlling infections of patients and personnel.

Findings:

Surveyors observed the following during a tour of the facility on 07/17/17:
A. Three staff members wearing shoe covers outside the operating room suite
B. Corregated boxes in the surgical storage area
C. Jugs on the floor in the surgical storage area
D. Freezer temperature logs in the Dietary department did not indicate an acceptable temperature range

Observed on 07/25/17, a staff member carried an unwrapped, used LMA (laryngeal mask airway) from the operating room to the decontamination room.

On 07/24/17, Staff H stated she agreed with findings.

Based on record review and interview, the hospital failed to ensure discharge planning evaluations were included in the medical record for 19 (Patients #2-20) of 20 records reviewed.

This failed practice had the potential to affect all patients requiring assistance after discharge due to the lack of information to establish an effective discharge plan.

Findings:

Patients #2-20

During a review of clinical records, documentation showed no discharge planning assessments were included in the clinical records.

On 07/24/17 at 1:05 pm, Staff H stated the discharge planning assessments were not kept in the clinical record and was unable to provide any completed assessments for review.