HospitalInspections.org

Based on review of hospital policy/procedure, document, medical records, and interview, it was determined that the hospital failed to require that verbal/telephone orders given by a medical provider were authenticated, to include the medical provider's signature, date, and time, within the required seventy-two (72) hours after the verbal/telephone order was given. This deficient practice poses a risk to the health and safety of patients, when verbal/telephone orders are not authenticated by the medical provider ensuring that the verbal/telephone orders are accurate, and that patients receive accurate, and timely care/treatment.

Findings include:

Policy titled "Verbal, Telephone & Text Orders" (#4.016; 02/2020), revealed: " ...To provide staff with direction to ensure safe patient care when telephone or verbal orders are given by a privileged medical staff member ... the use of verbal orders is discouraged, including telephone or other oral orders ...verbal orders shall be processed in accordance with medical staff rules and regulations ... telephone orders can only be accepted if the prescriber is not on the patient care unit ...staff member accepting a telephone order must verify to whom they are speaking and write the order in the physician order sheet ...person accepting the telephone order must verify the order by reading back the transcription verbatim to the prescriber ...prescriber will then verify the order is correct ...process of verification must be documented on the order ... Authentication of Orders ...telephone orders must be authenticated and countersigned by the prescriber or other responsible practitioner per medical staff rules and regulations within 72 hours, but authentication should take place as close to 24 hours after the order has been accepted as possible ... authentication must include signature, date, and time of authentication ...."

Document titled "Sana Behavioral Hospital, Rules & Regulations of the Medical Staff" (02/2020), revealed: "...III. General Conduct of Care...2...verbal/telephone orders are governed by hospital policy...."

Review of eighteen (18) medical records, conducted 05/28/2020, revealed no documented evidence that verbal/telephone orders for Patient's #1, #2, #3, #8, 12, #13, and #17, were authenticated by the medical provider to include signature, date, and time, within the required seventy-two (72) hours, per hospital policy/procedure, and Medical Staff Rules & Regulations.

Provider #1 confirmed during an interview conducted 05/28/2020 (1100), that verbal/telephone orders are required to be authenticated (signed, dated, timed) by a medical provider, as soon as possible after giving the verbal/telephone order, but no later than seventy-two (72) hours after the order was given.

Based on review of hospital policy/procedure, documents and interview, it was determined that the Governing Body failed to require that infection control education/training was completed for the medical providers. This deficient practice poses a risk to the health and safety of the patients, when the Governing Body has no oversight to ensure that medical staff adheres to the requirements for infection control to keep patients free from infection.

Findings include:

Policy titled "Infection Control Plan" (#18.000; 02/2020), revealed: "...The purpose of the Infection, Prevention, and Control Program...to ensure that the organization has a functioning coordinated process in place to reduce the risks of endemic and epidemic healthcare-acquired infections...infection control policies and procedures are designed to reduce the risk of acquiring and transmitting infections among patients, employees, medical staff, and visitors...Governing Board roles and responsibilities...review and approve the Infection Control Plan...approve or directing corrective action when the actions taken are not appropriate or sufficient...."

Document titled "ByLaws of the Organized Medical Staff" (02/2020), revealed: "...general responsibilities of staff membership...abide by the Medical Staff ByLaws, Rules & Responsibilities, and by all other...policies, procedures, and rules of the facility, and the Board...abide by all applicable federal and state laws, rules, and regulations...."

Document titled "ByLaws of the Board of Trustees" (12/09/2019), revealed: "...3.10(b)(10)...overseeing of programs for continuous medical education for medical staff members...for the purpose of improving clinical...performance...."

Review of medical staff credential files, conducted 05/28/2020, revealed no documented evidence that infection control training was provided for Provider's #1, #2, #3, and #4, as required by the Conditions of Participation.

Personnel #1 confirmed during an interview conducted 05/28/2020 (0905), that s/he was not aware that infection control training was required for the medical providers.

Personnel #4 confirmed during an interview conducted 05/28/2020 (0930), that s/he has not seen documented evidence of infection control training in the medical provider files.

Based on review of hospital policy/procedure, medical records, and interview, it was determined that the hospital failed to require that the psychosocial assessment was completed within forty-eight (48) hours of the patient's admission. This deficient practice poses a risk to the health and safety of the patients, when the hospital has no oversight to ensure that the required psychosocial assessment is completed in a timely manner, and used to develop the patient's treatment plan.

Findings include:

Policy titled " Elements of the Psychosocial Assessment" (#4.005; 02/2020), revealed: "...All patients of Sana Behavioral Hospital-Prescott will receive a psychosocial assessment within forty-eight (48) hours of admission...psychosocial assessments will include at least the required elements defined in this policy...date, time, and signature of Social Worker/Social Services Counselor with credentials upon completion...."

Review of eighteen (18) medical records, conducted 05/28/2020, revealed no documented evidence that psychosocial assessments for Patient's #2, #3, #10, 12, #14, #17, and #18, were completed within the required forty-eight (48) hours, per hospital policy.

Personnel #3 confirmed during an interview conducted 05/28/2020 (1230), that psychosocial assessments are required to be completed by social services within forty-eight (48) hours after the patient is admitted. Personnel #3 revealed, that the above identified patient medical records, either did not have the required psychosocial assessments in the medical record, or that the psychosocial assessments were not completed within the required forty-eight (48) hours.

Based on review of hospital policy/procedure, medical records, and interview, it was determined that the hospital failed to require that the psychosocial assessment was completed within forty-eight (48) hours of the patient's admission. This deficient practice poses a risk to the health and safety of the patients, when the hospital has no oversight to ensure that the required psychosocial assessment is completed in a timely manner, and used to develop the patient's treatment plan.

Findings include:

Policy titled "The Therapeutic Milieu & Program" (#1.005; 02/2020), revealed: "...To describe the therapeutic environment and the treatment interventions that serve to create a setting encouraging growth, and empowerment along with healing for the patients we serve...our treatment objective is to focus on optimal wellness by aiding in the promotion and facilitation of "Whole Health" concepts and practices... ultimate goal of treatment and stabilization for our patients is the acknowledgement of each person from a holistic perspective...each patient receives care and focused treatment...from an interdisciplinary team of behavioral health professionals...recreational...therapists who assess the patient's needs, develops an individual treatment plan, and engages the patient in a therapeutic program...in order that the therapeutic activities program developed for each patient is appropriate to their needs and interests...a therapeutic activities assessment shall be completed within 72 hours of admission. ...."

Review of eighteen (18) medical records, conducted 05/28/2020, revealed no documented evidence that therapeutic activity assessments for Patient's #1, #2, #3, #4, #5, #6, #7, #9, #10, #11, #12, #14, and #17, were completed within the required seventy-two (72) hours, per hospital policy.

Personnel #3 confirmed during an interview conducted 05/28/2020 (1245), that a therapeutic activities assessment is required to be completed by the recreational specialist within seventy-two (72) hours after the patient is admitted. Personnel #3 revealed that the above identified patient medical records, did not have therapeutic activities assessments in the medical records, or that the therapeutic activities assessments were not completed within the required seventy-two (72) hours. Personnel #3 confirmed that s/he spoke with Personnel #1, and that it was identified on or about 04/28/2020, that the therapeutic activities assessments were not being completed per hospital policy, and that this was addressed with the appropriate personnel. Additionally, Personnel #3 revealed that since the date of 04/28/2020, five (5) out of the thirteen (13) above identified medical records, did not meet the required seventy-two (72) hours, for the completion of the therapeutic activities assessments.