HospitalInspections.org

25065

Based on record reviews and interview, the hospital failed to ensure all medical records were complete, timed, dated, and authenticated as required by hospital policy for 5 of 12 sampled patients (#FF1, #FF3, #FF5, #FF6, #FF11). Findings:

Patient # FF1
Review of Patient #FF1's medical record revealed he was a 62 year old male who had a Bilateral Total Knee Replacement on 07/02/12. Review of his "Operative Progress Note" dated 07/02/12 revealed no documented evidence of the time the note was written by Physician SFF4.

Review of Patient #FF1's "Physician Consult" revealed no documented evidence of the date or time the consult was performed.

Review of Patient #FF1's "Total Knee Replacement Clinical Progression Management" orders revealed no documented evidence of the date and time the standing orders were initiated, the name of the nurse initiating the standing orders, and the name of the physician for whom the standing orders were given. Further review revealed an order for Ambien 5 milligrams was written on 07/03/12 with no documented evidence of the time the order was written.

Patient #FF3
Review of Patient #FF3's medical record revealed he was a 65 year old male admitted on 06/17/12 with a diagnosis of possible bowel obstruction, nausea, and vomiting. Review of his "Progress Notes" revealed a progress note was written by Physician SFF6 on 06/19/12 with no documented evidence of the time the entry was written.

Patient #FF5
Review of Patient #FF5's medical record revealed he was a 74 year old male who had a Right Total Arthroplasty on 06/20/12. Review of the "Physician Consult" revealed no documented evidence of the date and time the consult was performed. Review of the dictated "Operative Report" revealed no documented evidence of the date and time Physician SFF4 reviewed and signed the report.

Patient #FF6
Review of Patient #FF6's medical record revealed he was a 67 year old male who had an Incisional Hernia Repair with Mesh on 06/26/12. Review of his "Operative Progress Note" revealed no documented evidence of the time the note was written. Review of the "Progress Notes" revealed progress notes were written by the physician on 6/27 and 6/28 at 9:00am with no documented evidence of the year the note was written. Further review revealed a progress note was written by the physician on 6/29 with no documented evidence of the year or the time the note was written.

Patient #FF11
Review of Patient #FF11's medical record revealed she was a 52 year old female who had a Colonoscopy on 06/19/12. Review of the "Endoscopy" standing orders dated 06/19/12 at 6:30am revealed no documented evidence of the the name of the nurse initiating the standing orders and the name of the physician for whom the standing orders were given.

In a face-to-face interview on 07/05/12 at 12:20pm, Director of Nurses (DON) SFF2 indicated the date, year, and time were not documented as noted by the above chart reviews.

Review of the hospital policy titled "Accurate and Timely Record Completion/Deficiency Analysis", policy number, MR-02, revised 06/12, and submitted by DON SFF2 as the current policy, revealed, in part, "...Operative Progress Note To satisfy the requirement of providing an operative note immediately following a procedure; in the event the surgeon does not dictate after a procedure. A written operative progress note describing techniques, findings, and tissues removed or altered must be written or dictated immediately following surgery and signed by the surgeon. ... a) tag for signature, date and time... All orders including preprinted orders must be signed, dated and timed...".

Review of the Medical Staff "Rules and Regulations", presented by Administrator SFF1 as the current rules and regulations, revealed, in part, "...All medical records / order entries shall be properly authenticated by the physician's signature along with the date and time of the signature.


26351

25065

Based on record reviews and interview, the hospital failed to ensure physicians signed, dated, and timed their verbal orders within 10 days as required by hospital policy for 2 of 12 sampled patients (#FF5, #FF11). Findings:

Patient #FF5
Review of Patient #FF5's medical record revealed he was a 74 year old male who had a Right Total Arthroplasty on 06/20/12. Review of the "Physicians Orders" revealed telephone orders received on 06/21/12 at 8:45am, 06/21/12 at 10:10am, 06/21/12 at 11:30am, and 06/21/12 at 1:00pm had no documented evidence of the date and time the physician signed the telephone orders. There was no means of determining whether the telephone orders were authenticated within 10 days as required by hospital policy. Further review revealed telephone/verbal orders received 06/22/12 at 8:00am (2 separate orders), 06/22/12 at 11:30am, 06/22/12 at 12:30pm, 06/22/12 at 6:15pm, and 06/23/12 at 10:50am were not documented by the physician as of the date of the chart review on 07/05/12, more than 10 days since the date of the orders.

Patient #FF11
Review of Patient #FF11's medical record revealed she was a 52 year old female who had a Colonoscopy on 06/19/12. Review of the "Endoscopy" standing orders dated 06/19/12 at 6:30am revealed no documented evidence of the the name of the nurse initiating the standing orders and the name of the physician who gave the verbal standing orders. Further review revealed no documented evidence that Physician SFF7 had signed the verbal/standing orders within 10 days as required by hospital policy.

In a face-to-face interview on 07/05/12 at 1:05pm, Director of Nursing (DON) SFF2 confirmed the above telephone/verbal orders were not signed, dated, and timed within 10 days as required by hospital policy.

Review of the Medical Staff "Rules and Regulations", presented by Administrator SFF1 as the current rules and regulations, revealed, in part, "...The attending physician must sign, date and time all verbal or telephone orders as soon as possible but not later than 10 days following the date an order is transmitted verbally...".



26351

25065

Based on record review and interviews, the hospital failed to ensure the pharmacy was administered according to accepted professional principles. 1) The hospital failed to ensure the pharmacist reviewed all medication orders prior to dispensing the first dose of medication and reviewed the physician's medication order and patient record for known allergies, therapy contraindications, dose and route of administration, directions for use, duplication of therapy, interactions, and optimum therapeutic outcomes as required by hospital policy for 1 of 7 inpatients' charts reviewed who received medications from a sample of 12 patients (#FF1). 2) The hospital failed to ensure patients' home medications ordered by the physician to be resumed and used while in the hospital were verified by the pharmacist prior to the nurse administering the home medications for 1 of 6 inpatients' charts reviewed who received home medications from a sample of 12 patients (#FF5). Findings:

1) The hospital failed to ensure the pharmacist reviewed all medication orders prior to dispensing the first dose of medication and reviewed the physician's medication order and patient record for known allergies, therapy contraindications, dose and route of administration, directions for use, duplication of therapy, interactions, and optimum therapeutic outcomes as required by hospital policy:
Review of Patient #FF1's medical record revealed he was a 62 year old male who had a Bilateral Total Knee Replacement on 07/02/12.

Review of Patient #FF1's "Post-Op Total Knee Replacement" orders dated 07/02/12 at 11:10am revealed the orders were pre-printed standing orders. Further review revealed a hand-written addition included an order for Celebrex 200 milligrams (mg) 1 tablet by mouth every day. Further review revealed the pre-printed standing orders were reviewed by the pharmacist on 06/29/12 at 3:20pm (prior to the Celebrex being added on 07/02/12 at 11:10am). Further review of Patient #FF1's medical record revealed the pharmacist reviewed the Celebrex order dated 07/03/12 at 9:25am to increase Celebrex 200 mg to 1 tablet by mouth twice a day on 07/03/12 at 9:15am.

Review of Patient #FF1's MAR (medication administration record) revealed he received Celebrex on 07/02/12 at 4:00pm and on 07/03/12 at 9:00am prior to a pharmacist performing a first dose review.

In a face-to-face interview on 07/05/12 at 12:20pm, Director of Nursing (DON) SFF2 indicated when a new medication order was received by the nurse, the nurse faxed the order for review to the pharmacist. She further indicated the pharmacist would then fax back his signed review to be kept in the patient's record. SFF2 confirmed there was no documented evidence that a pharmacist had reviewed the Celebrex order prior to the nurse administering the medication to Patient #FF1.

Review of the hospital policy titled "First Dose Review", policy number PHM - 050, approved 06/06/12, and presented by DON SFF2 as the current policy, revealed, in part, "...It is the policy of PMC (Physicians Medical Center) that the Consultant Pharmacist will review all medication orders prior to administering the first dose, except in cases of emergency. ... a. The PSU (post surgical unit) Nurse will fax new medication orders as well as the patient's Admit History form, Patient Home Medication list ...for the Consultant Pharmacist review. ... c. The Consultant Pharmacist will authenticate the review on the Patient Home Medication List, if not reviewed during rounding, and authenticate Physician Orders. d. The Consultant Pharmacist will fax authenticated order review and if applicable the Patient Home Medication list back to PMC PSU department...".

2) The hospital failed to ensure patients' home medications ordered by the physician to be resumed and used while in the hospital were verified by the pharmacist prior to the nurse administering the home medications:
Patient #FF5
Review of Patient #FF5's medical record revealed he was a 74 year old male who had a Right Total Arthroplasty on 06/20/12.

Review of Patient #FF5's "Physicians Orders" revealed a telephone order received on 06/21/12 at 10:10am to administer Metoprolol 50 mg, 1/2 tablet orally now, Donepezil 10 mg orally at bedtime, Namenda 10 mg orally twice a day, and Omeprazole 20 mg orally every day. Review of the "Patient Medication List", which included these same home medications, revealed the medication list was reviewed by a pharmacist on 06/19/12 at 3:40pm, the day prior to admit, and the home medications were visually verified on 06/21/12 at 10:00am by the pharmacist.

Review of Patient #FF5's MAR revealed he received Namenda 10 mg orally and Omeprazole 20 mg orally on 06/21/12 at 9:00am, 1 hour and 10 minutes prior to the medication being ordered and 1 hour prior to the home medications being visually verified by the pharmacist.

In a face-to-face interview on 07/05/12 at 1:05pm, DON SFF2 confirmed the Namenda and Omeprazole were administered prior to the medication being ordered and prior to the pharmacist visually verifying the home medications.

Review of the hospital policy titled "Medications Brought From Home:, policy number PHM-014, approved 06/06/12, and presented by DON SFF2 as the current policy, revealed, in part, "...Prior to administration of patient's home medications, the Consulting Pharmacist will conduct a first dose review and verify the patient's medication. In the event the Consulting Pharmacist is not available or the patient does not have the medication with them at the hospital, the hospital stock of medications will be administered as prescribed by the physician. Once consulting pharmacist has reviewed, verified, and authenticated home medications, the nurse can then administer the patient's home medications...".


26351

Based on record review and interviews, the hospital failed to ensure the consulting pharmacist was responsible for developing, supervising, and coordinating all the activities of the pharmacy services. The consulting pharmacy failed to follow hospital policy related to the review of medication orders prior to the first dose being administered ( #FF1) and to visually verify patients' home medications prior to the medications being administered (#FF5) for 2 of 6 inpatients' charts reviewed who received home medications from a sample of 12 patients. Findings:

Patient #FF1
Review of Patient #FF1's medical record revealed he was a 62 year old male who had a Bilateral Total Knee Replacement on 07/02/12.

Review of Patient #FF1's "Post-Op Total Knee Replacement" orders dated 07/02/12 at 11:10am revealed the orders were pre-printed standing orders. Further review revealed a hand-written addition included an order for Celebrex 200 milligrams (mg) 1 tablet by mouth every day. Further review revealed the pre-printed standing orders were reviewed by the pharmacist on 06/29/12 at 3:20pm (prior to the Celebrex being added on 07/02/12 at 11:10am). Further review of Patient #FF1's medical record revealed the pharmacist reviewed the Celebrex order dated 07/03/12 at 9:25am to increase Celebrex 200 mg to 1 tablet by mouth twice a day on 07/03/12 at 9:15am.

Review of Patient #FF1's MAR (medication administration record) revealed he received Celebrex on 07/02/12 at 4:00pm and on 07/03/12 at 9:00am prior to a pharmacist performing a first dose review.

In a face-to-face interview on 07/05/12 at 12:20pm, Director of Nursing (DON) SFF2 indicated when a new medication order was received by the nurse, the nurse faxed the order for review to the pharmacist. She further indicated the pharmacist would then fax back his signed review to be kept in the patient's record. SFF2 confirmed there was no documented evidence that a pharmacist had reviewed the Celebrex order prior to the nurse administering the medication to Patient #FF1.

Patient #FF5
Review of Patient #FF5's medical record revealed he was a 74 year old male who had a Right Total Arthroplasty on 06/20/12.

Review of Patient #FF5's "Physicians Orders" revealed a telephone order received on 06/21/12 at 10:10am to administer Metoprolol 50 mg, 1/2 tablet orally now, Donepezil 10 mg orally at bedtime, Namenda 10 mg orally twice a day, and Omeprazole 20 mg orally every day. Review of the "Patient Medication List", which included these same home medications, revealed the medication list was reviewed by a pharmacist on 06/19/12 at 3:40pm, the day prior to admit, and the home medications were visually verified on 06/21/12 at 10:00am by the pharmacist.

Review of Patient #FF5's MAR revealed he received Namenda 10 mg orally and Omeprazole 20 mg orally on 06/21/12 at 9:00am, 1 hour and 10 minutes prior to the medication being ordered and 1 hour prior to the home medications being visually verified by the pharmacist.

In a face-to-face interview on 07/05/12 at 1:05pm, DON SFF2 confirmed the Namenda and Omeprazole were administered prior to the medication being ordered and prior to the pharmacist visually verifying the home medications.

Review of the hospital policy titled "First Dose Review", policy number PHM - 050, approved 06/06/12, and presented by DON SFF2 as the current policy, revealed, in part, "...It is the policy of PMC (Physicians Medical Center) that the Consultant Pharmacist will review all medication orders prior to administering the first dose, except in cases of emergency. ... a. The PSU (post surgical unit) Nurse will fax new medication orders as well as the patient's Admit History form, Patient Home Medication list ...for the Consultant Pharmacist review. ... c. The Consultant Pharmacist will authenticate the review on the Patient Home Medication List, if not reviewed during rounding, and authenticate Physician Orders. d. The Consultant Pharmacist will fax authenticated order review and if applicable the Patient Home Medication list back to PMC PSU department...".

Review of the hospital policy titled "Medications Brought From Home:, policy number PHM-014, approved 06/06/12, and presented by DON SFF2 as the current policy, revealed, in part, "...Prior to administration of patient's home medications, the Consulting Pharmacist will conduct a first dose review and verify the patient's medication. In the event the Consulting Pharmacist is not available or the patient does not have the medication with them at the hospital, the hospital stock of medications will be administered as prescribed by the physician. Once consulting pharmacist has reviewed, verified, and authenticated home medications, the nurse can then administer the patient's home medications...".