HospitalInspections.org

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Based on observation, the Critical Access Hospital failed to post a notice in the emergency department (ED) informing patients that the hospital did not have a doctor of medicine or a doctor of osteopathy present in the hospital 24 hours per day, 7 days per week.
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Failure to disclose this notice in the emergency department puts patients at risk of being unable to make an informed decision about their care.
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Findings:
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On 4/30/2015 at 9:27 AM during a tour of the emergency department, Surveyor #1 noticed that there was no posting on the wall in the ED notifying patients that the hospital did not have a doctor of medicine or a doctor of osteopathy present in the hospital 24 hours per day, 7 days per week.


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Item #1: Radiology Telemedicine Agreement

Based on document review, the hospital failed to ensure that the telemedicine contractor agreement for teleradiology specified that the telemedicine entity provided services in a way that allows the hospital to comply with all applicable conditions of participation for Medicare.

Failure to have contract language specific to compliance with all applicable conditions of participation for Medicare puts patients at risk of receiving inadequate care from telemedicine contractors.

Findings:

On 4/15/2015 at 11:00 AM, Surveyor #2 reviewed the document titled "Memorandum of Agreement Between (Garfield County Hospital) and Inland Imaging" dated 7/14/2011. The document did not explicitly state that Inland Imaging will provide teleradiology services in a manner that enables Garfield County Hospital to comply with all applicable conditions of participation for Medicare.

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Item #2: Absence of Telemedicine Agreement

Based on interview, the hospital failed to ensure that a telemedicine contractor agreement was in place prior to using emergency department physicians from another hospital as consultants.

Failure to have a telemedicine contractor agreement places patients at risk of receiving inadequate care from telemedicine contractors.

Findings:

An interview with the Chief Executive Officer (Staff Member #10) on 4/30/2015 at 2:05 PM revealed that the facility was using Tri-State Hospital emergency department physicians to provide phone consultation for nursing staff when a provider of the hospital was not available to provide emergency services. The Chief Executive Officer stated that the hospital did not have a contractual agreement with Tri-State Hospital for these services.


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Based on review of hospital policies and procedures, staff interviews, and review of the hospital's emergency services, the Critical Access Hospital failed to meet the requirements for the Condition of Participation for Emergency Services.

Failure to provide emergency care necessary to meet the needs of patients in the emergency department places patients at risk of harm related to lack of treatment or delays in treatment.

Findings:

Due to the cumulative effect of deficiencies detailed under the Condition of Participation at 42 CFR 485.618 Emergency Services, the Condition was NOT MET.

Cross-reference: C-0201, C-0207


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Based on record review, interview and review of policies and procedures, the hospital failed to provide medical staff coverage as a direct service for outpatient emergency services.

Failure to provide emergency services in the emergency department places patients at risk for delays in treatment possibly resulting in deterioration in the patient's condition or death.

Findings:

1. The hospital policy entitled "Medical Screening Exam Protocol" (Policy #728-0018; Effective date 8/9/2012) read in part:

"...The GCHD [Garfield County Health District] Board of Commissioners recognizes the Registered Nurses working in the GCHD ER, as qualified medical personnel (QMP) able to perform the MSE [medical screening exam] ..."

"The MSE may be initiated according to this protocol by the QRN [qualified registered nurse] and completed by Providers as appropriate to the condition."

"A determination that an Emergency Condition Does Not Exist is excluded if there is: Chest or abdominal pain..."

"9. The qualified RN will call the Provider for all ER visits. The MSE may be initiated according to this protocol by the QRN, and completed by Providers as appropriate to the condition."

"10. All patients transferred from the ER must have a MSE done by a provider."

2. Review of 6 medical records of patients admitted to the emergency department revealed the following:

a. Patient #17 was a 40 year old patient admitted to the emergency department on 3/21/2015 for evaluation and treatment of right lower abdominal pain. The patient had a temperature of 99.9 degrees Fahrenheit, pulse of 111 beats per minute, and pain was rated 5 on a scale of 1 to 10. The registered nurse (Staff Member #12) performing the exam documented that the patient's condition was "urgent" and that the patient "appeared ill" and was in "extreme pain".

According to Staff Member #12's documentation, the patient was informed of the hospital's diversion status and offered an ambulance transport to Tri-State Memorial Hospital but the patient refused ambulance transport opting instead to drive her/his own vehicle.

The medical record contained no documentation to indicate that a provider had been consulted about the patient's condition or that a provider had examined the patient prior to the patient leaving the hospital.

b. Patient #18 was a 39 year old patient admitted to the emergency department on 3/29/2015 for evaluation and treatment of left lower abdominal pain. The patient rated his/her pain as 8 on a scale of 1 to 10. According to the patient's medical record, the patient was informed of the hospital's diversion status, the patient was offered an ambulance transport to another hospital but the patient refused opting instead to be transported by his/her significant other in his/her own vehicle.

The medical record contained no documentation to indicate that the provider had been consulted about the patient's condition or that a provider had examined the patient prior to the patient leaving the hospital.

c. Patient #19 was a 65 year old patient admitted to the emergency department for complaints of right sided chest pain. A registered nurse (Staff Member #13) performed an assessment then consulted with another hospital's emergency department physician. Hospital staff obtained medical orders and according to the medical record, the orders were completed. The patient was transferred via ambulance to another hospital.
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The medical record contained no documentation to indicate that a provider had examined the patient prior to the patient leaving the hospital.

3. An interview with the Chief Nursing Officer (Staff Member #3) on 4/30/2015 at 9:00 AM revealed that the hospital had recently lost 2 mid-level providers and that the hospital did not have enough medical staff to provide coverage for the emergency department 24 hours per day, seven days per week. The current list of medical staff consisted of one medical doctor and one advanced registered nurse practitioner (ARNP).

Due to the shortage of medical staff the hospital was diverting ambulances to other area hospitals when the hospital's physician and ARNP were not available to provide emergency services for patients in the emergency department. Staff Member #3 stated that if patients "walk in" to the emergency department for care a registered nurse would perform the medical screening exam then consult with an emergency room physician at another hospital as needed.


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Based on interview and document review, the hospital failed to ensure a physician or mid-level provider was on call and immediately available by telephone or radio contact and available on site within 30 minutes on a 24-hour a day basis.

Failure to provide on call practioners places patients at risk of harm due to delays in medical evaluation and treatment.

Findings:

1. Review of hospital policies and procedures related to on call medical coverage revealed the following:

a. The hospital's policy and procedure entitled "Emergency Care Policies" (Policy #607-1081; Effective 10/11/12) read in part:

"A primary care provider will also be on call 24/7 to meet facility needs."


b. The hospital medical staff contract entitled "Professional Employment Agreement" under the section entitled "Emergency Room Coverage Duties" read in part:

"Provider shall, in conjunction with the other professional medical provider employees of District, assure emergency department coverage twenty-four hours per day, seven days per week, and three-hundred sixty-five days per year."


c. The hospital policy and procedure entitled "Provider Communication" (Policy #861-7000; Effective 1/1/2005) under the section entitled "Policy" read in part:

"There must be a practitioner with training or experience in emergency care on call and immediately available by telephone or radio contact, and available on-site within 30 minutes on a 24 hour-a-day basis."

2. The Chief Executive Officer (Staff Member #10) presented an e-mail to Surveyor #4 that was from the Medical Director (Staff Member #11) and distributed to administrative staff on 4/29/2015 at 12:20 PM. The e-mail stated that "Because of staff shortage, ER [Emergency Room patients] will be diverted from 5 PM today (4/29) through Monday at 8 AM."

3. On 4/30/2015 at 9:00 AM, Surveyor #4 interviewed the Chief Nursing Officer (Staff Member #3) about 24-hour, 7 days per week, on call provider coverage for the emergency department. Staff Member #3 confirmed there was no hospital-employed or contracted provider coverage (by phone or in-person) as needed for the dates referenced in Finding #2. The surveyor conducted a subsequent interview with the Chief Executive officer (Staff Member #10) at 2:05 PM on the same day. Staff Member #10 also confirmed the hospital had been unable to ensure the required coverage for the emergency department due to the resignation of two mid-level providers. A poster dated 3/27/2015 stated "Until further notice, emergency services will be available: Monday thru Thursday 6:00 am - 10:00 pm & Friday until 5:00 pm."

The Chief Executive Officer also stated that more recently the coverage has changed from day to day so it was difficult to predict with certainty what the provider availability would be.

During this same interview, Staff Member #10 told Surveyor #4 that the hospital had made arrangements to divert ambulance patients to another hospital and that an arrangement had been made for emergency physicians from another hospital to provide registered nurses with phone consultations for "walk in" emergency department patients during periods of time when the hospital did not have provider coverage. However, during periods of provider unavailability, the hospital did not have a physician or mid-level provider on call to be on site at the hospital to provide services in the emergency department if needed.


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Based on interview, and document review, the hospital failed to maintain a complete inventory of all facility and medical equipment and ensure that it was subject to the facility's preventive maintenance program.

Failure to have all equipment included in the hospital's preventive maintenance program puts patients at risk from malfunctioning equipment.

Findings:

On 4/14/2015 at 3:37 PM, Surveyors #1 and #2 interviewed the facility's director (Staff Member #7) about the hospital's preventive maintenance program. The surveyors asked to see the preventive maintenance history for the autoclave (Model Name: Ritter M11 Ultraclave) located in the central supply department. The facility's director was unable to locate any maintenance history for this item and concluded that it was not part of the current facility inventory. S/he reported that the current inventory did not include all facility and medical equipment.


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Based on observation and interview, the critical access hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Findings:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY CODE inspection report.


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Based on record review and staff interviews, it was determined that the Critical Access Hospital's Governing Body failed to meet the requirements for the Condition of Participation for Organizational Structure.

Failure to meet established organizational structure requirements resulted in an unsafe healthcare environment.

Reference: 42 CFR 485.627(a) Standard: Governing Body or Responsible Individual

The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH's total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment.

Findings:

Due to the cumulative effect of deficiencies detailed under the Conditions of Participation at 42 CFR 485.618 Emergency Services; and 42 CFR 485.635 Provision of Services, the Condition of Participation for Organizational Structure was NOT MET.

Cross-reference: C-200, C-201, C-207, C-0241, C-270, C-271, C-284


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Based on interview and document review, the hospital failed to follow its credentialing process for emergency department physicians from another hospital that were providing telephone consultation for nursing staff when the hospital's providers were not available.

Failure to adhere to criteria for medical staff appointments put patients at risk for inadequate or unsafe care.

Findings:

1. The hospital's medical staff bylaws (adopted & approved 7/2/2014; next revision: 7/2016) read as follows:

"1.9 Effect of other Affiliations: No practitioner shall automatically be entitled to appointment or to exercise clinical privileges merely because the practitioner is licensed to practice in this or any other state or is certified by any clinical board; or had or presently has staff appointment or similar privileges at another hospital. Each practitioner must complete and maintain their GCHD [Garfield County Hospital District] Appointment process."

2. On 4/30/2015 at 9:00 AM, during an interview with Surveyor #4, the hospital's Chief Nursing Officer (Staff Member #3) stated that since 3/17/2015 the hospital has not had 24 hours per day, 7 days per week provider availability for phone consultation and availability on site as needed for the emergency department. During periods of time when hospital providers were unavailable, the hospital had arranged for another hospital's emergency department providers to provide phone consultation and physician's orders for nursing staff who were conducting medical screening exams.

3. A phone interview conducted by Surveyor #4 on 5/11/2015 at 3:58 PM with Staff Member #3 revealed that providers from Tri-State Memorial Hospital's emergency department, who provided emergency phone support when hospital providers were not available, did not have privileges at the hospital and did not complete the medical staff appointment process.


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Based on review of hospital policies and procedures, staff interviews, and review of the hospital's emergency services, the Critical Access Hospital failed to meet the requirements for the Condition of Participation for Provision of Services.

Failure to implement hospital policies and procedures for provision of medical services in the emergency department, 24 hours per day, 7 days per week, risks patient harm due to lack of initial intervention, treatment and medical stabilization.

Findings:

Due to the cumulative effect of deficiencies detailed under the Condition of Participation a 42 CFR 485.635 Provision of Services, the Condition was NOT MET.

Cross-reference: C-271, C-284


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Item #1: Discharge Instructions

Based on record review and review of policy and procedure, the hospital failed to provide discharge instructions for emergency department patients in 6 of 6 patient records reviewed (Patient #17, #18, #19, #20, #21, #22) .

Failure to provide patients with discharge instructions risks patients not following healthcare advice, potentially resulting in patient harm.

Findings:

1. The hospital's policy and procedure entitled "Medical Screening Exam Protocol" (Policy #728-0018; Effective 8/9/12) read in part:

"12. The QRN [qualified registered nurse] performing the MSE [medical screening exam] should also provide discharge instructions in the appropriate form."

2. Review of the records of 6 patients cared for in the emergency department while the hospital was on diversion status and registered nurses were performing the MSE for "walk in" patients revealed the following:

a. Patient #17 was a 40 year old patient admitted to the emergency department on 3/21/2015 for evaluation and treatment of right lower abdominal pain. The patient had a temperature of 99.9 degrees Fahrenheit, pulse of 111 beats per minute, and pain was rated 5 on a scale of 1 to 10. The registered nurse (Staff Member #12) performing the exam documented that the patient's condition was "urgent" and that the patient "appeared ill" and was in "extreme pain" .

According to Staff Member #12's documentation, the patient was informed of the hospital's diversion status and offered an ambulance transport to Tri-State Memorial Hospital but the patient refused ambulance transport opting instead to drive her/his own vehicle.

There was no evidence in the medical record that hospital staff provided Patient #17 discharge instructions that pertained to his/her medical condition.

b. Patient #18 was a 39 year old patient admitted to the emergency department on 3/29/2015 for evaluation and treatment of left lower abdominal pain. A registered nurse (Staff Member #12) performed the medical screening exam. According to the patient's medical record, the patient was informed of the hospital's diversion status, the patient was offered an ambulance transport to another hospital but the patient refused opting instead to be transported by his/her significant other in his/her own vehicle.

There was no evidence in the medical record that hospital staff provided Patient #18 discharge instructions that pertained to his/her medical condition.

c. Similar findings were found in the medical records of Patient #19, #20, #21, #22.


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Item #2: Medical Screening Exam(MSE)

Based on record review and review of policy and procedure, the hospital failed to ensure the medical screening exams (MSE) performed by registered nurses complied with hospital policy and procedure in 5 of 6 patient records reviewed.

Failure to complete the MSE according to hospital policy and procedure places patients at risk for deterioration in physical condition due to unidentified health issues.

Findings:

1. The hospital's policy and procedure entitled "Medical Screening Exam Protocol" (Policy #728-0018; Effective 8/9/2012) read in part:

"Every patient presenting to the hospital ER, must receive an appropriate MSE within the capability of the hospital's emergency department ...to determine if an Emergency Medical Condition (EMC) exists, they must be provided either further evaluation and treatment or attempted stabilization and transfer to another facility."

"The exam will include information about the chief complaint, the patient's vital signs, mental status assessment, general appearance, and a focused physical exam related to the patient's complaint."

2. Review of 6 emergency department patient records where registered nurses performed the MSE revealed the following:

a. Patient #20 was an 8 year old patient admitted to the emergency department on 3/22/2015 for evaluation and treatment of a "stomach ache". There were no vital signs documented in the medical record as part of the MSE.

b. Patient #18 was a 30 year old patient admitted to the emergency department on 3/29/2015 for evaluation and treatment of right flank pain that radiated to the patient's groin area. The patient's pain was rated 8 on a scale of 1 to 10 with 10 being the worst pain. There were no vital signs documented in the medical record as part of the MSE.

c. Patient #19 was a 65 year old patient admitted to the emergency department on 4/16/2015 for evaluation and treatment of right sided chest pain. Review of the patient's MSE completed by a registered nurse revealed that there were no vital signs documented in the patient's medical record as part of the MSE.

d. Patient #21 was a 13 year old patient admitted to the emergency department on 3/30/2015 for evaluation and treatment of injuries sustained when he/she fell off a bicycle. According to nursing documentation the patient reported pain in the left knee and left hand. The patient's parents voiced concern about a possible concussion.

Review of the patient's MSE completed by a registered nurse revealed that there were no vital signs documented in the patient's medical record as part of the MSE.

e. Patient #22 was a 13 year old patient admitted to the emergency department on 4/10/2015 for evaluation and treatment of injuries sustained after a motorcycle accident. Review of the patient's medical record revealed that the required elements of the medical screening exam were not documented. The nurse performing the exam only documented a focused exam of the patient's injured right arm. The medical record did not include the patient's general appearance, vital signs, perfusion, mental status, and ability to walk.


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Item #3: Use of restraints

Based on interview and record review, the hospital failed to develop and implement a policy and procedure for patient's placed in restraints during their hosptial stay for 1 of 1 patient records reviewed (Patient #5).

Failure to implement policies and procedures related to restraint use puts patients at risk of harm due to inappropriate or prolonged restraint.

Findings:

1. A hopsital policy titled "Chemical & Physical Restraints" dated 1/10/2011 read in part: "c. Restraints applied for emergency situations will be checked every thirty minutes, released at least every two hours, for resident exercise, hydration, and toileting for a minimum of ten minutes. d. Documentation in the resident's chart will contain the date; time of the restraint application, reason for the application, type of restraint used, and alternative methods used to assist the resident without success, and the resident's behavior after the restraint was applied."

This policy was for the use of restraints for swing bed patients not acute care patients. The Hospital did not have a restraint policy for acute care patients.

2. On 4/16/2015 at 11:00 AM, Surveyor #3 reviewed evidence of restraint documentation in the medical record of an acute care patient (Patient #5). The record indicated that medical staff had placed the patient in restraints, but there was no evidence to indicate time of application, type of restraint, use of alternative methods or the resident's response. Additionally, there was no evidence in the record to indicate that the medical staff checked the patient every 30 minutes or that staff released the patient from restraints for exercise, hydration or toileting as described in the hospital policy.

This was confirmed at the time of record review by the Chief Nursing Officer (Staff Member #3).


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ITEM #1: Hand Hygiene

Based on observation and policy review staff members failed to follow the hospital's policy for Hand Hygiene.

Failure to follow hospital policy for performing hand hygiene puts patients, staff and visitors at risk of infection.

Findings:

1. The hospital's policy titled "Hand Hygiene" (undated) read in part: "Careful hand hygiene must be performed: ...Before and after any direct patient contact... Before and after gloves are used..."

2. On 4/15/2015 at 12:00 PM Surveyor #3 observed a Registered Nurse (RN) (Staff Member #1) administering medication to a patient. The RN did not perform hand hygiene (HH) prior to donning gloves and removing a medicated patch from the patient. The RN changed gloves but did not perform HH prior to donning the new ones. After applying the new medicated patches, the RN removed the gloves but did not perform HH, nor did s/he do so after returning the patient to the dining room.



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ITEM #2: Infection Control Plan and Activities
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Based on interview and review of the infection control plan, the hospital failed to adequately develop and implement the hospital's infection control program.

Failure to develop and implement an adequate infection control program puts hospital patients, staff and visitors at risk of infection.
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Findings:
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1. On 4/15/2015 at 4:00 PM, Surveyor #1 reviewed the hospital's infection control plan and interviewed the hospital infection preventionist (Staff Member#4). The infection control plans were missing the following key elements:
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a. In the prevention and control of Multi-Drug Resistant Organisms, the infection control preventionist could not provide evidence that s/he analyzed infection control incidents, problems or trends or that s/he initiated corrective actions as a result of his/her assessment.
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b. In the hospital's infection control plan it is stated in part, "compliance with infection control practices is monitored and documented through staff evaluations and observation of practices." Surveyor #1 asked to see documentation of hand hygiene observations, the infection control preventionist (Staff Member #4) could not provide evidence to indicate achievement in staff compliance with the hospital's infection control plan requirements.

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ITEM #3 Cleaning and Disinfecting of Medical Equipment

Based on observation and interview the hospital failed to implement policies and procedures designed to prevent exposure to infectious agents during the processing of medical equipment.

Failure to adhere to manufacturer's guidance for processing medical equipment puts patients at risk from infection caused by improper cleaning and disinfection.

Reference: Chattanooga Hydrocollator User Manual page 19-20 part 6, indicated "Regularly clean and drain the tank (every two weeks)."

Findings:

On 4/14/2015 at 1:50 PM, Surveyor #1 interviewed a physical therapist (Staff Member #5) about their process for cleaning and disinfecting the hydrocollator. Staff Member #5 explained that s/he cleaned the hydrocollator monthly but had not documented the monthly cleanings and had not created a policy for cleaning and disinfecting the hydrocollator. Upon review of the manufacturer's instructions for use, it indicated that the hydrocollator should be cleaned every two weeks.


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Based on observation and interview, the hospital failed to implement policies and procedures to ensure compliance with the Washington State Retail Food Code (246-215 WAC).

Failure to comply with food service codes puts patients, staff, and visitors of the facility at risk from food borne illnesses.

Findings:

1. On 4/14/2015 at 11:43 AM, Surveyors #1 and #2 observed one bulk container of oats and one bulk container of flour without labels. When food is removed from its original container it must be labeled to identify the name of the food.

Reference: Washington State Retail Food Code, WAC 246-215-03309

2. On 4/14/2015 at 11:47 AM, Surveyors #1 and #2 observed mold growth and debris on the fan cover and storage racks in the walk-in refrigerator. This was confirmed by the dietary manager (Staff Member #6) at the time of the observation.

Reference: Washington State Retail Food Code, WAC 246-215-04615

3. On 4/14/2015 at 11:55 AM, Surveyors #1 and #2 observed serving equipment stored on a wood shelf under the dining room serving table. The shelf was deteriorated and its surface could not be easily cleaned.

Reference: Washington State Retail Food Code, WAC 246-215-04214

4. On 4/14/2015 at 2:42 PM, Surveyors #1 and #2 observed mold growth on the backsplash of the ice machine in the clean utility pantry. This was confirmed by the chief nursing officer (Staff Member #3) at the time of the observation.

Reference: Washington State Retail Food Code, WAC 246-215-04615


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Based on observation and interview, the hospital failed to implement policies and procedures designed to prevent exposure to radiological hazards during radiological services.

Failure to implement radiation protection standards and practices puts patients at risk from radiological hazards.


Findings:

1. On 4/14/2015 at 10:14 AM, Surveyors #1 and #2 interviewed a radiology technician (Staff Member #8) about preventive maintenance of radiological equipment. The surveyors asked to see the inspection history for the shielding aprons used during x-rays. The radiology technician reported that s/he did not document the periodic apron inspections.

2. On 4/14/2015 at 10:25 AM, Surveyors #1 and #2 observed that there was no signage identifying radiation areas. This was confirmed by a radiology technician (Staff Member #8) at the time of the observation.


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Based on interview and document review, the hospital failed to maintain the ability to provide medical services to patients arriving in the emergency department via ambulance or for pateints who "walk in" needing emergency services.

Failure to maintain the ability to provide medical services in the emergency department places patients at risk due to delays in treatment possibly resulting in deterioration in the patient's condition or death.

Findings:

1. A poster dated 3/27/2015 stated "Until further notice, emergency services will be available: Monday thru Thursday 6:00 am - 10:00 pm & Friday until 5:00 pm."

In addition, the Chief Executive Officer (Staff Member #10) presented an e-mail to Surveyor #4 that was from the Medical Director (Staff Member #11)and distributed to administrative staff on 4/29/2015 at 12:20 PM. The e-mail stated that "Because of staff shortage, ER [Emergency Room patients] will be diverted from 5 PM today (4/29) through Monday at 8 AM."

2. On 4/30/2015 at 9:00 AM, Surveyor #4 interviewed the Chief Nursing Officer (Staff Member #3) about 24-hour, 7 days per week, on call provider coverage for the emergency department. Staff Member #3 confirmed there was no hospital-employed or contracted provider coverage (by phone or in-person) as needed for the dates and times referenced in Finding #1. The surveyor conducted a subsequent interview with the Chief Executive officer (Staff Member #10) at 2:05 PM on the same day. Staff Member #10 also confirmed the hospital had been unable to ensure the required coverage for the emergency department due to the resignation of two mid-level providers.

The Chief Executive Officer (Staff Member #10) stated that more recently the coverage has changed from day to day so it was difficult to predict with certainty what the provider availability would be.

During this same interview, Staff Member #10 told Surveyor #4 that the hospital had made arrangements to divert ambulance patients to another hospital and that an arrangement had been made for emergency physicians from another hospital to provide registered nurses with phone consultations and physician's orders for "walk in" emergency department patients during periods of time when the hospital did not have provider coverage. However, during periods of provider unavailability, the hospital did not have a physician or mid-level provider on call to be on site at the hospital to provide services in the emergency department if needed.

Cross reference: C200, C-201, C-207


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Based on observation, interview, and policy review, the hospital staff failed to follow the hospital policy for identifying patients prior to administering medications.

Failure to follow hospital policy for medication administration puts patients at risk for medication errors.

Findings:

1. The hospital policy titled "Medication Pass" dated 12/17/2012 read in part: "3. Medications will be safely administered after proper identification of the the resident. a. ID per client photo. c. Licensed nurses will verify clients by name as a second check."

2. On 4/14/2015 at 11:00 AM Surveyor #3 interviewed a registered Nurse (RN) (Staff Member #2) about the process of identifying patients prior to giving medications. The RN stated that they used a photograph of the patient to do so.

3. On 4/15/2015 at 12:00 PM Surveyor #3 observed an RN (Staff Member #1) administer medication to a patient. The RN did not refer to the patient's photograph, nor did s/he inquire as to his/her name, referring to him/her as "Grandma".


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Based on interview and record review, the hospital failed to document discharge planning information in the care plan in 2 of 3 records reviewed (Patients #10, #11).

Failure to develop current care plans puts patients at risk of having an inadequate needs assessment prior to discharge.

Findings:

1. On 4/15/2015 at 1:00 PM the chief nursing officer (Staff Member #3) told Surveyor #3 that the facility had let the Social Worker go as a cost saving measure, and now staff nurses were responsible for completion of discharge planning.

2. During review of the medical records for Patients #10 and #11 no information was found in the patient's records that would indicate discharge planning was being discussed or documented.

3. Staff Member #3 confirmed this finding at the time of the record review.

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Based on record review, interview and review of hospital policies and procedures, the hospital failed to ensure that physician orders were signed, dated and timed in accordance with current state hospital regulations in 1 of 6 patient records reviewed (Patient #19).

Failure to ensure that physician entries are authenticated by signature, date and time puts patients at risk for medical and/or medication errors.

Findings:

1. The hospital policy and procedure entitled "Provider Orders" (Policy #607-1108; Effective 11/27/2013) read as follows:

(14) All telephone/verbal orders will be authenticated by the ordering provider "within 48 hours" of receipt...

2. Review of 6 medical records on 4/30/2015 of patients seen in the emergency department (ED) while the ED was on diversion status revealed the following:

a. Patient #19 was a 65 year old patient admitted to the emergency department on 4/16/2015 for treatment of right sided chest pain. Because there was no hospital provider available to examine the patient, a registered nurse (Staff Member #13) performed an assessment and contacted an emergency department physician at another hospital (Staff Member #14). The physician ordered an EKG, placement of a saline lock intravenous catheter, and transfer to Tri-State Memorial Hospital. The ordering physician had not signed, dated or timed any of the physician orders.

3. An interview with a registered nurse (Staff Member #14) on 4/30/2015 at 3:15 PM revealed that there was currently no process in place for authentication of physician orders when the ordering physician was not a member of the hospital's medical staff.


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