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Based on review of hospital policies and procedures, medical records and interview with staff, it was determined the facility failed to require medical staff follow the facility policy requiring a discharge order for three ( 3) of five (5) Out Patient Surgery Patients ( Patient #'s 27, 28, and 29), and one (1) of two (2) cardiac catheterization outpatient procedure Patients (Patient # 34).

Failure to discharge the patient without a documented order from the physician poses the high potential risk related to patient safety that the required needs of the patient will not be met if follow up care needs are not clearly identified through an order .

Findings include:

Hospital policy titled "Ambulatory Care and Patient Discharge OR surgical services" requires: "...The operating practitioner must examine, evaluate, and write the discharge order...."

Review of medical records of Patient #'s 27, 28, and 29 revealed no documentation of a physician order for discharge.

Hospital policy titled "Discharge and transfer Criteria Cardiac Cath Lab" requires: "...The patient must have a discharge order from a licensed rendering provider...."

Review of Patient # 24's medical record revealed no documentation of a physician order for discharge.

RN # 21 confirmed during an interview conducted on 03/07/2018 that the above medical records did not have a Provider/practitioner's order for patient discharge.

The facility failed to follow their policies related to discharging a patient with an order.

Based on review of facility records and interview, it was determined the facility failed to have the new and existing staff review the emergency preparedness policies and procedures. Failure to have staff review the emergency preparedness policies and procedures consistent with their expected roles may cause harm to the patients during an emergency.

Findings include:

On March 06, 2018, the surveyor, along with the Director of Security, Director of Plant Operations, and Internal Audit Manager Quality Management reviewed the facility's emergency policies and procedures. There was no documentation that new and existing staff reviewed the emergency preparedness policies and procedures.

The Director of Security, Director of Plant Operations, and Internal Audit Manager Quality Management confirmed during the record review on 3/6/18, the facility did not have documentation that new and existing staff reviewed the emergency preparedness policies and procedures.

During the exit conference on March 08, 2018, the above finding was again acknowledged by the Chief Operating Officer, Chief Medical Officer, Director of Nursing, Director of Quality, Director of Plant Operations, and Internal Audit Manager Quality Management.