HospitalInspections.org

Based on review of governing body meeting minutes, review of off-campus department documents and interviews with hospital staff, the governing body failed to ensure the medical staff develop and enforced written policies and procedure for appraisal, stabilizing care and referral for emergency situations and individuals at the off-campus department (formerly known as Muskogee Community Hospital).

Findings:

1. Governing body meeting minutes for 2012 stipulated that Muskogee Regional Medical Center (MRMC) policies would be adopted, available and used by the staff at the facility site formerly known as Muskogee Community Hospital (MCH), which if now a department of MRMC.

2. On the morning of 10/10/2012 that MCH, Staff A and B told the surveyor that MCH, as a department of MRMC offered the following services: radiology, surgery, laboratory, occupational patient medicine and kitchen/dining to staff and visitors. They stated MCH no longer had an emergency room and individuals would have to be stabilized and sent to the main campus of MRMC.

3. The surveyors interviewed care staff at all the different areas of MCH. Staff could not produce, either by paper documents or via computer, policies and procedures for MRMC. Staff H, I and L stated they did not have access to MRMC policies. When asked what policies they followed, they stated they would follow MCH unless it was different that MRMC.

4. Staff A, E, H, I and J stated MCH no longer had an emergency room. When asked what they would do in case of an emergency situation involving patient/individual care, the surveyors were told they would call "911." No policy was provided that stipulated this was the procedure to be followed.

5. The policies and procedures for MCH and MRMC, when reviewed, documented emergency room staff would respond.

6. When interviewed on the afternoon of 10/10/2012, administrative Staff C, D and M stated each area was supposed to have a folder that told them to call the operator/switchboard.

Based on observation, staff interview and document review, it was determined the hospital failed to ensure there was adequate nursing staff and supervision to provide care to all patients as needed. Findings:

The surveyors entered the Muskogee Community hospital campus on 10/10/12 at 8:45 a.m. The receptionist was asked by the surveyors to speak with the person in charge of the facility. She suggested we speak with her boss, the billing manager. She asked if this person was in charge of the campus. She stated she wasn't sure.

Eventually the manager of the OR introduced herself and stated she was sorry for the delay in meeting the surveyors, but she was involved with patient care. She stated she was a "working manager" and had direct patient care duties.

She further stated she was the "interim clinical leader" and was a resource person for all areas on the campus including imaging, respiratory, pharmacy, laboratory, pre-op, surgery, recovery and endoscopy.

She stated there was no emergency room or emergency physician on campus. She stated she was required to respond to any cardiac/respiratory arrest or medical emergency on the campus.

She stated it was a usual and customary practice for her take a patient load and assume direct patient care responsibilities and also to oversee the various patient care areas. She stated there was no other nursing administrator on the campus.

She was asked if she had been given a job description for the position of clinical leader. She stated she had not been.

She was asked about the services provided at the MCH campus on a typical weekday. She stated the campus usually admitted between 10 and 20 patients for outpatient surgery and twenty or more daily for endoscopy. She was not sure of the patient load for other outpatient services. She stated the campus served a patient population from pediatrics to geriatrics.

Several times during the tour of the facility, the clinical leader had to leave the surveyors to attend to her direct patient care assignment.

At 2:30 p.m., the CNO was asked if the interim clinical leader could perform patient care and adequately supervise all the care areas of the hospital. She stated she wasn't aware the clinical leader was taking a patient assignment.

The CNO was asked if MCH had a "house supervisor". She stated there was no house supervisor, only the interim clinical leader. She was asked if the clinical leader was present at all times when patients were present in house. She stated, "Yes."

She was asked if the clinical leader was present when patients were in house after normal hours. She stated the leader would not be, but two nurses were present at all times when any patient was still in house.

She was asked if there was a nursing administrative policy that addressed this. She stated there was. No policy was provided to the surveyors.

Based on clinical record review and staff interview, it was determined the hospital failed to maintain complete and accurate medical records. Findings:

The hospital was asked to provide complete medical records for patients #1 and #2. Hard copies of the electronic medical record were provided.

1. The following findings were noted in patient record #1:

~ A preoperative testing order sheet documented the patient had an appointment with the POEM clinic, had laboratory studies, an ECG and a chest x-ray performed prior to surgery. None of this data was included in the clinical record provided to the surveyors.

~ There were no preoperative physician's orders found in the clinical record.

~ A preoperative evaluation and management assessment was incomplete. There was no documentation on the nursing admission history section.

~ A pre-anesthesia evaluation and management assessment was not completed. There was no documentation of a pre-anesthesia assessment found in the clinical record.

~ A preoperative nursing assessment had no vital signs documented. The form referred to a printout that was not attached to the clinical record. There was no documentation an IV was inserted in the preoperative area. The form referred to the E-MAR for antibiotic administration information. The E-MAR was not provided in the clinical record given to the surveyors.

~ The preoperative nursing assessment form documented the patient provided the history information, but no history information was found in the clinical record.

~ A short-stay summary form documented the reader should refer to the history and physical done on 09/17/12. No history and physical report was found in the clinical record.

~ No consent for anesthesia or for the surgical procedure was found in the clinical record.

~ There was no anesthesia record found in the clinical record.

~ There were no PACU physician's orders found in the clinical record.

~ A post anesthesia care unit (PACU) flowsheet documented, "...Vital Signs [see Nihon Kohden printout]..." No printout was attached to the record. There was no documentation of PACU vital signs found in the clinical record that was provided to the surveyors.

~ The PACU flowsheet documented, "... Pain/Nausea Assessment... See E-MAR for Medication Administration..." There was no pain or nausea assessment documented in the clinical record. There was no E-MAR (electronic medication administration record) attached to the clinical record provided to the surveyors. It could not be determined what medications were administered to the patient.

~ The PACU flowsheet had no documentation of amounts of fluids administered in the OR. There was also no documentation of output during surgery, although the patient left the OR with a JP drain.

~ The PACU flowsheet documented the patient was received in PACU with 200 ml of Normosol on admission. The flowsheet documented 200 ml of Normosol was administered in PACU. There was no documentation another type of IV fluid was administered after the Normosol, or that the IV was discontinued.

~ The PACU flowsheet documented the patient was "transferred to Med/Surg". There was no documentation vital signs were taken, assessment of the IV and surgical dressing, removal of monitoring equipment, skin condition and notification of the family at the time of transfer. There was no documentation of the transferring /discharge nurse's name. There was no documentation a report was provided to a receiving nurse and how and when the patient was transferred.

~ Although the PACU flowsheet documented the patient was transferred to a medical / surgical bed within the same hospital (on a different campus), the flowsheet also documented the patient was discharged at 3:30 p.m. with written and verbal discharge instructions. (There was no documentation of instructions for wound care, although the patient had a chest incision with a drain) The flowsheet documented the patient's belongings were returned and the patient left PACU via wheelchair to go home with her family via personal vehicle.

~ A hospital transfer form documented the patient was "a direct admit to MRMC." The form documented the patient was given copies of a discharge summary, home medication list, MAR, medication reconciliation and lab.

No MAR, medication reconciliation form or lab reports were provided in the clinical record given to the surveyors.

~ Physician's orders, dated 09/28/12 at 2:50 p.m., documented, "OK to send patient to MRMC with IV saline locked..." The orders did not specify the patient was to be transferred from the Muskogee Community campus (which is a department of MRMC) and sent to the main MRMC campus via personal vehicle for further care on the surgical unit.

~ A PACU nurse's note documented, "... D/C instructions, personal belongings given to family, verbalized understanding. Family instructed to take patient to ER and check in via personal vehicle as directed by [physician's name deleted]... Papers faxed to surgical floor, copy of chart sent with patient and family..."

The clinical record provided to the surveyors was not presented in a logical order. There were pages missing from documents, there were entire documents missing and there were random, unrelated pages inserted in documents where they did not belong. There was no way to see chronologically what happened with the patient.

The clinical record provided initially did not include any documentation from the patient's care at the MRMC campus. When this part of the clinical record was specifically requested, an incomplete record from MRMC was provided.

When management staff were asked about various issues with the clinical record, no information was provided. They stated there were problems with the electronic medical records.

They were asked if the patient was discharged and then immediately re-admitted. They stated she was. They stated the physician did this to be able to send the patient to the other campus by personal car.

They were asked why transfer information was found in the clinical record if the patient was discharged. They stated they could not explain that.

2. A Muskogee Community electronic medical record was provided for patient #2. The record was not in chronological order. Random items were printed and presented in no particular order. The following were findings in the clinical record for patient #2 and are documented here as found in the clinical record:

~ A PACU flowsheet documented the patient was transferred to MRMC from the Muskogee Community campus by EMS with an IV that was patent, a foley that was patent and that family was notified. However, the flowsheet also documented the patient was discharged and went home by private vehicle.

~ Discharge instructions documented the patient was discharged home and the patient's IV was discontinued. The discharge instructions form documented the instructions were reviewed with the patient and family. However, no instructions were documented.

~ A preoperative evaluation and management assessment was incomplete. A pre-anesthesia evaluation form was included in the clinical record and had no documentation on it.

~ A preoperative nursing assessment referred to an E-MAR. No E-MAR was included in the clinical record.

~ A physician's post-procedure note documented, "... Will transfer to MRMC..."

~ A Transfer Consent / Physician's Statement form documented, "... Pt being transferred for post surgical care..." The physician also ordered an ambulance transfer to the MRMC campus.

Hospital administration was asked if why the physician wrote a transfer statement when the patient was moved from one MRMC department (Muskogee Community campus) to another MRMC department (main campus). They stated they did not know.

~ The following items were not found in the Muskogee Community medical record:

Physician's orders for preoperative care
Physician's order for postoperative care
An anesthesia record
Records of vital signs taken
Medication administration records

The hospital management staff were asked to provide a complete medical record for the patient's entire stay at MRMC. An incomplete medical record was provided at the end of the survey, as the surveyors prepared to leave the hospital.

The record provided was not in order. There were forms included that had no documentation on them. There were duplicate documents. There were documents with pages missing. Many of the pages provided were computer screen shots. The Muskogee Community records were duplicated and inter-mingled with the MRMC record.

It was not possible to discern (in a logical, cohesive fashion) what care was provided. There was no narrative nursing care documentation provided.

Some physician's orders were handwritten and some were computer documented elsewhere. Some documentation on the physician's orders had been "blacked out" and could not be read.

Vital sign and intake/output records were presented in two different formats. One format listed intake including IV fluids. Another format listed intake with IV fluids and IV piggyback fluids. No piggy back fluid amounts were documented but the patient received medications via IV piggyback method.

At one point the patient had a temperature over 101 degrees F. There was no documentation of nursing intervention found in the clinical record.

Pain medications were administered but there was no documentation of assessment of pain before and after pain medication was given. Nausea medications were administered but there was no documentation of effectiveness.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure the medical record contained information to describe the patient's progress and response to medications and services. Findings:

The hospital was asked to provide complete medical records for patients #1 and #2. Hard copies of the electronic medical record were provided.

1. The following findings were noted in patient record #1:

~ A preoperative testing order sheet documented the patient had an appointment with the POEM clinic, had laboratory studies, an ECG and a chest x-ray performed prior to surgery. None of this data was included in the clinical record provided to the surveyors.

~ There were no preoperative physician's orders found in the clinical record.

~ A preoperative evaluation and management assessment was incomplete. There was no documentation on the nursing admission history section.

~ A pre-anesthesia evaluation and management assessment was not completed. There was no documentation of a pre-anesthesia assessment found in the clinical record.

~ A preoperative nursing assessment had no vital signs documented. The form referred to a printout that was not attached to the clinical record. There was no documentation an IV was inserted in the preoperative area. The form referred to the E-MAR for antibiotic administration information. The E-MAR was not provided in the clinical record given to the surveyors.

~ The preoperative nursing assessment form documented the patient provided the history information, but no history information was found in the clinical record.

~ A short-stay summary form documented the reader should refer to the history and physical done on 09/17/12. No history and physical report was found in the clinical record.

~ No consent for anesthesia or for the surgical procedure was found in the clinical record.

~ There was no anesthesia record found in the clinical record.

~ There were no PACU physician's orders found in the clinical record.

~ A post anesthesia care unit (PACU) flowsheet documented, "...Vital Signs [see Nihon Kohden printout]..." No printout was attached to the record. There was no documentation of PACU vital signs found in the clinical record that was provided to the surveyors.

~ The PACU flowsheet documented, "... Pain/Nausea Assessment... See E-MAR for Medication Administration..." There was no pain or nausea assessment documented in the clinical record. There was no E-MAR (electronic medication administration record) attached to the clinical record provided to the surveyors. It could not be determined what medications were administered to the patient.

~ The PACU flowsheet had no documentation of amounts of fluids administered in the OR. There was also no documentation of output during surgery, although the patient left the OR with a JP drain.

~ The PACU flowsheet documented the patient was received in PACU with 200 ml of Normosol on admission. The flowsheet documented 200 ml of Normosol was administered in PACU. There was no documentation another type of IV fluid was administered after the Normosol, or that the IV was discontinued.

~ The PACU flowsheet documented the patient was "transferred to Med/Surg". There was no documentation vital signs were taken, assessment of the IV and surgical dressing, removal of monitoring equipment, skin condition and notification of the family at the time of transfer. There was no documentation of the transferring /discharge nurse's name. There was no documentation a report was provided to a receiving nurse and how and when the patient was transferred.

~ Although the PACU flowsheet documented the patient was transferred to a medical / surgical bed within the same hospital (on a different campus), the flowsheet also documented the patient was discharged at 3:30 p.m. with written and verbal discharge instructions. (There was no documentation of instructions for wound care, although the patient had a chest incision with a drain) The flowsheet documented the patient's belongings were returned and the patient left PACU via wheelchair to go home with her family via personal vehicle.

~ A hospital transfer form documented the patient was "a direct admit to MRMC." The form documented the patient was given copies of a discharge summary, home medication list, MAR, medication reconciliation and lab.

No MAR, medication reconciliation form or lab reports were provided in the clinical record given to the surveyors.

~ Physician's orders, dated 09/28/12 at 2:50 p.m., documented, "OK to send patient to MRMC with IV saline locked..." The orders did not specify the patient was to be transferred from the Muskogee Community campus (which is a department of MRMC) and sent to the main MRMC campus via personal vehicle for further care on the surgical unit.

~ A PACU nurse's note documented, "... D/C instructions, personal belongings given to family, verbalized understanding. Family instructed to take patient to ER and check in via personal vehicle as directed by [physician's name deleted]... Papers faxed to surgical floor, copy of chart sent with patient and family..."

The clinical record provided to the surveyors was not presented in a logical order. There were pages missing from documents, there were entire documents missing and there were random, unrelated pages inserted in documents where they did not belong. There was no way to see chronologically what happened with the patient.

The clinical record provided initially did not include any documentation from the patient's care at the MRMC campus. When this part of the clinical record was specifically requested, an incomplete record from MRMC was provided.

When management staff were asked about various issues with the clinical record, no information was provided. They stated there were problems with the electronic medical records.

They were asked if the patient was discharged and then immediately re-admitted. They stated she was. They stated the physician did this to be able to send the patient to the other campus by personal car.

They were asked why transfer information was found in the clinical record if the patient was discharged. They stated they could not explain that.

2. A Muskogee Community electronic medical record was provided for patient #2. The record was not in chronological order. Random items were printed and presented in no particular order. The following were findings in the clinical record for patient #2 and are documented here as found in the clinical record:

~ A PACU flowsheet documented the patient was transferred to MRMC from the Muskogee Community campus by EMS with an IV that was patent, a foley that was patent and that family was notified. However, the flowsheet also documented the patient was discharged and went home by private vehicle.

~ Discharge instructions documented the patient was discharged home and the patient's IV was discontinued. The discharge instructions form documented the instructions were reviewed with the patient and family. However, no instructions were documented.

~ A preoperative evaluation and management assessment was incomplete. A pre-anesthesia evaluation form was included in the clinical record and had no documentation on it.

~ A preoperative nursing assessment referred to an E-MAR. No E-MAR was included in the clinical record.

~ A physician's post-procedure note documented, "... Will transfer to MRMC..."

~ A Transfer Consent / Physician's Statement form documented, "... Pt being transferred for post surgical care..." The physician also ordered an ambulance transfer to the MRMC campus.

Hospital administration was asked if why the physician wrote a transfer statement when the patient was moved from one MRMC department (Muskogee Community campus) to another MRMC department (main campus). They stated they did not know.

~ The following items were not found in the Muskogee Community medical record:

Physician's orders for preoperative care
Physician's order for postoperative care
An anesthesia record
Records of vital signs taken
Medication administration records

The hospital management staff were asked to provide a complete medical record for the patient's entire stay at MRMC. An incomplete medical record was provided at the end of the survey, as the surveyors prepared to leave the hospital.

The record provided was not in order. There were forms included that had no documentation on them. There were duplicate documents. There were documents with pages missing. Many of the pages provided were computer screen shots. The Muskogee Community records were duplicated and inter-mingled with the MRMC record.

It was not possible to discern (in a logical, cohesive fashion) what care was provided. There was no narrative nursing care documentation provided.

Some physician's orders were handwritten and some were computer documented elsewhere. Some documentation on the physician's orders had been "blacked out" and could not be read.

Vital sign and intake/output records were presented in two different formats. One format listed intake including IV fluids. Another format listed intake with IV fluids and IV piggyback fluids. No piggy back fluid amounts were documented but the patient received medications via IV piggyback method.

At one point the patient had a temperature over 101 degrees F. There was no documentation of nursing intervention found in the clinical record.

Pain medications were administered but there was no documentation of assessment of pain before and after pain medication was given. Nausea medications were administered but there was no documentation of effectiveness.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure a complete history and physical examination was included in the medical record prior to surgery. Findings:

The hospital was asked to provide complete medical records for patients #1 and #2. Hard copies of the electronic medical record were provided.

1. A short-stay summary form for patient #1 documented the reader should refer to the history and physical examination done on 09/17/12. No history and physical report from 09/17/12 was found in the clinical record.

2. A short-stay summary form for patient #2 documented the reader should refer to the history and physical examination done on 08/10/12. No history and physical report from 08/10/12 was found in the clinical record.

When management staff were asked about various missing components with the clinical record, no information was provided. They stated there were problems with the electronic medical records.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure the medical record included an informed consent for surgery and anesthesia. Findings:

No consent for anesthesia or for the surgical procedure was found in the clinical record for patient #1.

When management staff were asked for missing documents in the clinical record, no information was provided.

Based on clinical record review and staff interview, it was determined the hospital failed to maintain complete and accurate medical records. Findings:

The hospital was asked to provide complete medical records for patients #1 and #2. Hard copies of the electronic medical record were provided.

1. The following findings were noted in patient record #1:

~ A preoperative testing order sheet documented the patient had an appointment with the POEM clinic, had laboratory studies, an ECG and a chest x-ray performed prior to surgery. None of this data was included in the clinical record provided to the surveyors.

~ There were no preoperative physician's orders found in the clinical record.

~ A preoperative nursing assessment had no vital signs documented. The form referred to a printout that was not attached to the clinical record. There was no documentation an IV was inserted in the preoperative area. The form referred to the E-MAR for antibiotic administration information. The E-MAR was not provided in the clinical record given to the surveyors.

~ There was no anesthesia record found in the clinical record.

~ There were no PACU physician's orders found in the clinical record.

~ A post anesthesia care unit (PACU) flowsheet documented, "...Vital Signs [see Nihon Kohden printout]..." No printout was attached to the record. There was no documentation of PACU vital signs found in the clinical record that was provided to the surveyors.

~ The PACU flowsheet documented, "... Pain/Nausea Assessment... See E-MAR for Medication Administration..." There was no pain or nausea assessment documented in the clinical record. There was no E-MAR (electronic medication administration record) attached to the clinical record provided to the surveyors. It could not be determined what medications were administered to the patient.

~ The PACU flowsheet had no documentation of amounts of fluids administered in the OR. There was also no documentation of output during surgery, although the patient left the OR with a JP drain.

~ The PACU flowsheet documented the patient was received in PACU with 200 ml of Normosol on admission. The flowsheet documented 200 ml of Normosol was administered in PACU. There was no documentation another type of IV fluid was administered after the Normosol, or that the IV was discontinued.

~ The PACU flowsheet documented the patient was "transferred to Med/Surg". There was no documentation vital signs were taken, assessment of the IV and surgical dressing, removal of monitoring equipment, skin condition and notification of the family at the time of transfer. There was no documentation of the transferring /discharge nurse's name. There was no documentation a report was provided to a receiving nurse and how and when the patient was transferred.

~ A hospital transfer form documented the patient was "a direct admit to MRMC." The form documented the patient was given copies of a discharge summary, home medication list, MAR, medication reconciliation and lab.

No MAR, medication reconciliation form or lab reports were provided in the clinical record given to the surveyors.

The clinical record provided initially did not include any documentation from the patient's care at the MRMC campus. When this part of the clinical record was specifically requested, an incomplete record from MRMC was provided.

2. A Muskogee Community electronic medical record was provided for patient #2. The record was not in chronological order. Random items were printed and presented in no particular order. The following were findings in the clinical record for patient #2 and are documented here as found in the clinical record:

~ A preoperative nursing assessment referred to an E-MAR [electronic medication administration record]. No E-MAR was included in the clinical record.

~ The following items were not found in the Muskogee Community medical record:

Physician's orders for preoperative care
Physician's order for postoperative care
An anesthesia record
Records of vital signs taken
Medication administration records

The hospital management staff were asked to provide a complete medical record for the patient's entire stay at MRMC. An incomplete medical record was provided at the end of the survey, as the surveyors prepared to leave the hospital.

The record provided was not in order. There were forms included that had no documentation on them. There were duplicate documents. There were documents with pages missing. Many of the pages provided were computer screen shots. The Muskogee Community records were duplicated and inter-mingled with the MRMC record.

It was not possible to discern (in a logical, cohesive fashion) what care was provided. There was no narrative nursing care documentation provided.

Some physician's orders were handwritten and some were computer documented elsewhere. Some documentation on the physician's orders had been "blacked out" and could not be read.

Vital sign and intake/output records were presented in two different formats. One format listed intake including IV fluids. Another format listed intake with IV fluids and IV piggyback fluids. No piggy back fluid amounts were documented but the patient received medications via IV piggyback method.

At one point the patient had a temperature over 101 degrees F. There was no documentation of nursing intervention found in the clinical record.

Pain medications were administered but there was no documentation of assessment of pain before and after pain medication was given. Nausea medications were administered but there was no documentation of effectiveness.

When management staff were asked about various issues with the clinical record, no information was provided. They stated there were problems with the electronic medical records.

Based on interviews with staff, and review of available policies and procedures at the time of facility tour, the facility failed to approve, implement and have available for staff, radiology policies and procedures to protect patients and personnel.

Findings:

1. Governing body meeting minutes for 2012 stipulated that Muskogee Regional Medical Center (MRMC) policies would be adopted, available and used by the staff at the facility site formerly known as Muskogee Community Hospital (MCH), which if now a department of MRMC.

2. During the tour of the radiology department at the MCH location on the morning of 10/2012, radiology staff told the surveyor that unless the policy differed, they would follow the radiology policies for MCH.

3. The surveyor asked to be shown the different policies. The radiology manager was unable to access the policies for MRMC. The Director of Radiology could not produce these policies from the computers available to radiology staff.

4. The surveyor asked if the staff had a printed policy and procedure manual and was told no by Staff E and F at 1020.

5. At 1200, Staff F brought the surveyors a printed copy of the MRMC radiology policy manual. The manual did not describe what scope of services were available at the MCH facility and did not describe the procedure MCH staff were to follow in case of a patient emergency/crisis. Staff E and F told the surveyors that staff were to "Call 911". Both policy manuals, MRMC and MCH, documented notifying the emergency room for help. The MCH facility does not have an emergency room.

Based on observation, policy and procedure review and staff interview, it was determined the facility failed to ensure emergency preparedness plans were in place for the Muskogee Community Hospital campus of the Muskogee Regional Medical Center. Findings:

On 10/10/12 at 9:30 a.m., tour of the pre-operative care area, the surgery and endoscopy areas, and the PACU was conducted. The staff were asked to show the surveyors the emergency preparedness plans. A flip chart for various emergencies was found in the main surgery department. The emergency flip chart was not visible in other areas when the surveyors toured.

The flip chart "Code Blue Emergency Guide" instructed the staff to call "5555" and announce the Code Blue. They were asked if this was a current policy for the campus. They stated it was.

Staff were asked if they had access to emergency policies and procedures specific to the MCH campus. They stated they were told the policies were "online" but they did not know if they could access them. They stated they were told they were to follow some MCH policies and some MRMC policies, but were not clear how these were written.

At 2:00 p.m., the interim quality manager brought another emergency flip chart to the surveyors. (It was not the same flip chart found in the OR.) She stated this flip chart was found in every department of the MCH campus. This flip chart instructed staff to call "1111" for a code blue. The guidance went on to reference the emergency department. The MCH campus no longer has an emergency department. The flip chart also referenced various departments at the MRMC campus and was not applicable to the MCH campus.

The quality director was asked why the two flip charts were different, i.e. directing staff to call "5555" or "1111" in an emergency. She stated the phone number did not matter, the call would still end up at the operator.

She stated a call made at the MCH campus would ring the MCH operator and a call made at the MRMC campus would reach that campus operator. She stated in the event of a Code Blue event at MCH, the operator was responsible for calling 911.

No policy was provided that detailed the instructions and responsibilities for the PBX operator in the event of an emergency.

She was asked if the staff had access to written policies and procedures for the MCH campus and how they interfaced with the main MRMC campus. She stated the policies were online and could be access on the receptionist's computer in the administration office. She was asked if the staff working the various patient care areas had access to the policies online. She stated the policies and procedures were only available on the administrative office computer.

She was asked to provide a hard copy of the emergency procedures for MCH. A MRMC code blue policy (PC 1006) was provided that had no information specific to MCH. No other emergency policies were provided.

At 2:30 p.m., the CNO provided another version of PC 1006, "Code Blue, Nursing Services."

The policy documented, "... MCH Campus: The house supervisor will respond to any Code Blue or R.A.T. call within the walls of the hospital... House Supervisor will call 911... Procedure:... summon assistance by calling for help and/or utilizing the emergency signal..."

The policy did not elaborate on the "emergency signal." None of the staff interviewed mentioned an emergency signal when talking about a Code Blue.

The policy went on to document, "... Activate the Code Blue call system by pushing the designated button and utilizing the telephone, dial "5555, Voicera and state "Code Blue..."

When direct care staff were interviewed, they stated the Voicera system was no longer used in the facility.

The policy did not include what should be done for a code blue outside the MCH hospital walls. The policy did not address who would respond to a code blue, i.e., the Emergency Response Team or Code Blue Team.

The policy did not address the roles of each code blue team member. The policy did not address what equipment should be brought to the code blue and what should happen when the code blue was concluded.

The CNO was asked if MCH had a "house supervisor". She stated there was no house supervisor, but there was an interim clinical leader. She was asked if the clinical leader was present at all times when patients were present in house. She stated, "Yes."

She was asked if the clinical leader was present when patients were in house after normal hours. She stated the clinical leader would not be, but two nurses were present at all times when any patient was still in house.

She was asked if there was a nursing administrative policy that addressed this. She stated there was. No policy was provided to the surveyors.

At the conclusion of the survey, no other emergency preparedness policies and procedures specific to the MCH campus had been provided to the surveyors.

Based on document review, clinical record review and staff interview, it was determined the hospital failed to integrate all Muskogee Community Hospital (MCH) outpatient services with Muskogee Regional Medical Center (MRMC) inpatient services. Findings:

On 10/10/12, hospital administrative staff stated MCH provided only outpatient services and that MCH was considered a "department" of MRMC. They were asked to provide documentation of how MCH services were organized and integrated with MRMC services. No documentation was provided.

Staff in various MCH departments were asked how their departments interfaced with the MRMC campus. They stated MRMC and MCH shared staff. They were asked if they had policies and procedures that designated what services were shared. They stated they did not have access to MRMC policies and procedures.

They stated the MCH staff continued to use old MCH policies. They stated they believed integrated policies were not yet available. They were asked if they had policies and procedures that guided them on transferring an MCH patient from the MCH campus to the MRMC campus and vice-versa. They stated they did not.

The clinical record for patient #1 was reviewed. The patient had outpatient surgery at MCH. The PACU flowsheet documented the patient was "transferred to Med/Surg". There was no documentation of a condition report given to a receiving nurse at MRMC.

Although the PACU flowsheet documented the patient was transferred to a medical / surgical bed, it did not document the bed was at the MRMC campus. The same flowsheet documented the patient was discharged at 3:30 p.m. from MCH with written and verbal discharge instructions. The flowsheet documented the patient's belongings were returned to the patient and the patient left by wheelchair to go home with her family in a personal vehicle.

Another hospital transfer form documented the patient was "a direct admit to MRMC." The form documented the patient was given copies of a discharge summary, home medication list, MAR, medication reconciliation and lab to take with her to MRMC.

A PACU nurse's note documented, "... D/C instructions, personal belongings given to family, verbalized understanding. Family instructed to take patient to ER and check in via personal vehicle as directed by [physician's name deleted]... Papers faxed to surgical floor, copy of chart sent with patient and family..."

No MAR, medication reconciliation form or lab reports were provided in the MCH clinical record given to the surveyors. There was no copy of the information provided to MRMC. There was no evidence medical information for continuing care was faxed to anyone at MRMC.

The clinical record provided to the surveyors initially did not include any documentation from the patient's care at the MRMC campus. When this part of the clinical record was specifically requested, an incomplete record from MRMC was provided.

When management staff were asked about various issues with the clinical record, (including failure to have a unified and complete medical record that had information from both campuses) no information was provided. They stated there were problems with the electronic medical records.

They were asked why the patient needed to be discharged from MCH (if it was a department of MRMC) and then immediately re-admitted. They stated the physician did this to be able to send the patient to the other campus by personal car, which was the patient's request.

They were asked why "transfer" information was also found in the clinical record if the patient was officially "discharged" from MCH. They stated they could not explain that.

The CNO was asked to provide a policy and procedure to guide MCH staff on patient transfers to MRMC. She provided a policy PC 1008 "Hand Off Communication."

The policy had no information specific to procedures necessary for transfers from MCH to the MRMC campus.