HospitalInspections.org

Based on a review of the facility's policies and procedures, Medical Staff Rules and Regulations, Medical Staff Bylaws, meetings minutes, medical records and interviews, it was determined the CAH's admission services where not provided in accordance with written policies when the facility did not have written policies available for surveyor review regarding new admissions. Eleven of thirteen records ( Patients # 1, 2, 3, 4. 5, 6, 8, 10, 11, 12, and 36) reviewed had no admission orders upon admission, which resulted in a delay in administration of IV antibiotics for one of one Patient. (Pt # 36)

Findings include:

The Director of Compliance and Quality Assurance confirmed in an interview on 4/17/15, that the facility was unable to provide a policy and procedure for the Admission orders ordered by an Emergency Room Physician, and that the orders need to be confirmed with the Hospitalist, and by the Admitting RN before orders can be entered into the computer and then administered to the patient.

The facility procedure titled "Admissions" updated 3/26/15, revealed the following: "...The nurse puts in meds (sic)...Temporary: If physician is not on site, enter orders...Verify orders...."

The facility policy and procedure titled "Medication Administration Record (MAR)" dated 9/03 revealed: "...Each medication to be given to the patient must have an accompanying physician/provider order that must clearly indicate the name of the medication, the medication dosage, the route of administration, frequency of administration and any special considerations regarding the administration...."

Review of the Medical Staff Rules and Regulations dated July 27,2011 reveal: "...Admissions...Each patient admitted to the Hospital will have an attending Physician who is a Member of the Medical Staff... with admitting Privileges in good standing...Order Guidelines...All orders for treatment shall be in writing. An order shall be considered to be in writing if dictated to a Registered Nurse and signed by the Practitioner...Verbal orders for medications may be accepted by appropriately licensed personnel in accordance with approved Medical Staff Rules and Regulations...Verbal orders must be reduced to writing immediately including the time and date, and authenticated by the responsible Practitioner at that Practitioner's next visit or within twenty-four (24) hours after issuance of the order...Verbal communication of orders should be limited to urgent situations where immediate written or electronic communication is not feasible...."

Review of the Medical Staff bylaws dated December 18, 2014 reveal: "...Active Medical Staff shall have the following Prerogatives...Admit and discharge patients...Active AHP Medical Staff shall have the following Qualifications...Regularly participate in the admission of patients to the Medical Center...."

Review of the Pharmacy and Therapeutic Meeting Minutes dated December 24, 2014 reveal: "...Computerized physician order entry (CPOE) will be instituted with CPSI (Computer Program and systems Incorporate) Orders entered by the provider are signed orders and can be verified by nursing and pharmacy without a paper copy. Verbal and Telephone orders given from the provider to the nurse will require the nurse to write the order on paper for the pharmacist to verify. The nurse will then read back the order and enter it into the CPSI system. The paper copy will go directly to pharmacy and not become a part of the paper chart. Written orders by the provider will be discouraged as they fall outside the meaningful use guidelines...."

Review of the Board of Directors' Meeting Minutes dated February 26, 2015 revealed there was no mention of the issues with the Admitting Orders or the process with orders for admission. There was no mention in the Board of Directors' Meeting minutes of the issue the facility has with the Emergency Room Physicians refusal to use the new inpatient electronic medical record system.

Medical record review of patient # 1 revealed that the patient was admitted on 4/12/15. Patient # 1 had admission orders that were verbal orders written by the nurse after a call to the Hospitalist.

Medical record review of patient # 2 revealed that the patient was admitted on 4/14/15. Patient # 2 had admission orders that were verbal orders written by the nurse after a call to the Hospitalist.

Medical record review of patient # 3 revealed that the patient was admitted on 4/14/15. Patient # 3 had admission orders that were verbal orders written by the nurse after a call to the Hospitalist.

Medical record review of patient # 4 revealed that the patient was admitted on 3/19/15. Patient # 4 had admission orders that were verbal orders written by the nurse after a call to the Hospitalist.

Medical record review of patient # 5 revealed that the patient was admitted on 3/18/15. Patient # 5 had admission orders that were verbal orders written by the nurse after a call to the Hospitalist.

Medical record review of patient #6 revealed that the patient was admitted on 4/9/15. Patient # 6 had admission orders that were verbal orders written by the nurse after a call to the Hospitalist.

Medical record review of patient # 8 revealed that the patient was admitted on 3/4/15. Patient #8 had admission orders that were verbal orders written by the nurse after a call to the Hospitalist.

Medical record review of patient #10 revealed that the patient was admitted on 2/4/15. Patient # 10 had admission orders that were verbal orders written by the nurse after a call to the Hospitalist.

Medical record review of patient #11 revealed that the patient was admitted on 3/8/15. Patient # 11 had admission orders that were verbal orders written by the nurse after a call to the Hospitalist.

Medical record review of patient # 12 revealed that the patient was admitted on 3/24/15. Patient #12 had admission orders that were verbal orders written by the nurse after a call to the Hospitalist.

The Director of Compliance and Quality Assurance confirmed in an interview conducted on 4/15/15, that the Emergency Room Physicians do not use the new Electronic Medical System for inpatients. She confirmed the procedure for admission is for the Emergency Room Physician to write admitting orders on paper for the Patient, the Admitting Nurse will take those orders, call the Hospitalist who will be taking over the care of the patient, go over the orders written by the Emergency Room Physician, write down the orders from the Hospitalist on paper and then enter the orders into the computer. The orders from the Emergency Room Physician are never entered into the computer system.

RN # 21 confirmed in an interview conducted on 4/15/15, that the system for admission is time consuming and can delay patient care.

RN # 24 confirmed in an interview conducted on 4/15/15, that the current system for admission is time consuming, and can delay patient care. She also verified that errors could happen with this current system.

Pharmacist # 9 confirmed in an interview conducted on 4/15/15, that the current system for admission is time consuming and can delay patient care. He also verified that errors could happen with this current system.

Employee #22 confirmed in an interview conducted on 4/15/15, that this current system for admission is in place since the Emergency Room Physicians have it in their contract to only use the Electronic Medical System in the Emergency Room. He confirmed that the system in the Emergency Room is not compatible with the inpatient system. Orders that are written in the Emergency Room system dos not transfer over the the Inpatient system.

CEO confirmed in an interview conducted on 4/15/15, that the current system for admission is the process identified above; since the Emergency Room Physicians have it in their contract that they do not have to use the inpatient Electronic Medical System. He also confirmed that the Emergency Room Physicians do have admitting privileges.

Patient # 36's medical record review revealed that the patient was ordered Vancomycin 1 gram IV every 12 hours. Patient #36 was admitted to the Inpatient Unit on 3/13/15, at 1500. The RN taking care of the patient received telephone orders from the Hospitalist at 1815, confirming the order for Vancomycin written by the Emergency Room Physician. The Medical administration record revealed that Patient # 36 received the Vancomycin at 2100.

The Director of Compliance and Quality Assurance confirmed in an interview conducted on 4/15/15, that the process for obtaining orders led to a delay of over five hours before the patient received the Vancomycin.

Pharmacist # 9 confirmed in an interview conducted on 4/15/15 that there was a delay in the administration of the Vancomycin of over five hours. This delay was timed from when the admission order for the antibiotic was written by the Emergency Room Physician to administration of the medication on the inpatient unit.

Based on review of the Association of Perioperative Registered Nurses' (AORN) standards, manufacturer's recommendations, hospital documents and interviews, it was determined the Administrator failed to provide a sanitary environment for surgical services in the hospital as evidenced by:

1. failure to provide the quantity of surgical instruments necessary for the scheduled daily surgical procedure volume; and

2. failure to follow nationally accepted standards of practice; failure to follow manufacturer's recommendations for high level disinfection, which has resulted in the potential risk of the spread of contaminants on the instrumentation and equipment used during patient surgeries and endoscopic procedures.

Findings include:

1. AORN Perioperative Standards and Recommended Practices For Inpatient and Ambulatory Settings 2014 Edition; Recommendation VII.a. pg. 582 requires: "...Immediate use steam sterilization should not be used as a substitute for sufficient instrument inventory...."

The hospital's policy/procedure titled "Flash Sterilization" requires: "...Flash sterilization should be avoided whenever possible, Flash sterilization may be utilized...Emergency situations when no replacement instruments are available...."

Steam Sterilization Record Keeping Envelope revealed the following information: for sterilizer ID #1, dated 02/11/15, revealed a total of 9 loads/cycles of Physician #5's cataract instrument trays completed by the 4 minute, immediate use cycle.

Steam Sterilization Record Keeping Envelope revealed the following information: for sterilizer ID #1, dated 03/11/15, revealed a total of 9 loads/cycles of Physician # 5's cataract instrument trays completed by the 4 minute, immediate use cycle.

Steam Sterilization Record Keeping Envelope revealed the following information: for sterilizer ID #1, dated 04/08/15, revealed a total of 4 loads/cycles of Physician # 5's cataract instrument trays completed by the 4 minute, immediate use cycle.

Employee #31 confirmed during an interview conducted 04/15/15, that Physician #5 has a total of three (3) cataract eye trays at the facility, however, the facility uses only two (2) of the sets according to the physician's direction.

2. AORN Perioperative Standards and Recommended Practices For Inpatient and Ambulatory Settings 2014 Edition; Recommendation IV.a.4, IV.c and IV.c.2 pg. 519 requires: "...High-level disinfection should occur at appropriate temperature, contact time ...Manufacturer's written instructions should be followed...test strip...specific for the disinfectant...should be used for the monitoring solution potency prior to each use...."

Cidex OPA directions for use revealed: "...High level disinfectant at a minimum of 20 degrees centigrade (68 Fahrenheit), immerse device completely, for a minimum of 12 minutes. It is recommended that the solution is tested with the test strips prior to each use.

Review of the solution testing log sheet revealed no documentation of the solution concentration prior to each patient use and no documentation of the temperature of the solution.

Hospital policy titled "High level Disinfection of Endoscopes" revealed: "... An EPA registered sterilant/disinfectant to be used on all endoscopes per manufacturer's guidelines.

Employee's #31 and 36 confirmed during an interview conducted 04/15/15, that the facility's staff was not aware the disinfectant solution was required to be tested prior to each patient use.