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Based on interview and record review, the hospital failed to ensure state licensure requirements were followed for five of 33 sampled patients (Patient 7, Patient 27, Patient 28, Patient 32, and Patient 33) when these inpatients were allowed to remain overnight in the Day Patient Unit (outpatient). This violates the state licensure requirements.

Findings:

During an interview with Registered Nurse 4, on 3/21/19, at 4:41 PM, he stated on 3/20/19, several patients had orthopedic surgery performed and were admitted to the hospital. These same patients stayed overnight in the Day Patient Unit. The patients were then brought to telemetry floor on 3/21/19.

During an interview with Licensed Vocational Nurse 1, on 3/22/19, at 11:37 AM, the following inpatients remained overnight on 3/20/19 in the Day Patient Unit: Patient 7, Patient 27, Patient 28, Patient 32, and Patient 33.

Title 22 California Code of Regulation Division 5 indicates,
70533 (e)(1) Inpatients shall not be allowed to occupy an outpatient bed.
70533 (e)(2) Outpatients shall not be allowed to remain over 24 hours in outpatient beds.

Based on interview and record review, the hospital failed to:

1. Provide adequate staffing to appropriately meet the nursing needs and care of one of 33 sampled patients (Patient 1) in the Patient Care Unit/Telemetry Unit (PCU/TELE -a unit in the hospital for patients at risk for abnormal heart activity and require continuous electronic monitoring) when Patient 1 was not transferred to the Intensive Care Unit (ICU- a specialized unit for the management of life-threatening conditions that may require sophisticated life support and intensive monitoring) due to shortage of nursing staff and Patient 1's treatment and medication were delayed.

2. Ensure the tube feeding order for one of 33 sampled patients (Patient 22) was started as ordered.

3. Perform nursing assessments timely and accurately for six of 33 sampled patients (Patient 1, Patient 3, Patient 6, Patient 12, Patient 15, and Patient 20) to meet the needs of each patient.

These failures had the potential for patients to not receive the appropriate care and needs.

Findings:

1. During an interview with Registered Nurse 1 (RN 1), on 1/30/19, at 10:30 AM, she stated, "We had a patient [Patient 1] who needed transfer to ICU but did not get transferred timely because there was no nurse to take care of him in the unit. I think the order was written around 8 AM but the patient was not transferred out of the Patient Care Unit (PCU) until change of shift, around 7 PM at night."

During a review of the clinical record for Patient 1, the Physician Progress Notes, dated 1/24/19, indicated [Patient 1] is a 73 year old male who was admitted on 1/15/19, at 9:07 AM. Patient underwent cardiac surgery, Coronary Artery Bypass Graft (CABG -a surgical procedure to restore normal blood flow to the heart) and was transferred from ICU to the (PCU/TELE) Unit. Patient gradually declined in his renal (kidney is the organ that removes waste material from the body) function, which prompted a renal consultation (kidney doctor to evaluate patient).

During a concurrent interview with the Chief Nursing Executive (CNE) and review of the clinical record for Patient 1, on 3/15/19, at 1:20 PM, the CNE reviewed Physician B's Progress Notes, dated 1/28/19, indicated "The patient was seen and examined in room (room number)today. The patient's overall condition is worsening and the patient is showing signs of fluid retention, episodes of desaturation (blood's oxygen level drop). Vital signs stable, but blood pressure is staying systolically(systolic blood pressure SBP - amount of pressure that blood exerts on the vessels while the heart is contracting) less than 100 at all times. O2 (oxygen) saturation is barely in the 90s on high-flow oxygen. Plan: Transfer to ICU for Levophed (medication to treat life-threatening low blood pressure) drip, VAS Cath placement (specialized catheter used for dialysis treatment to remove wastes and fluid from the body) followed by dialysis initiation." The CNE verified the findings.

During a review of the clinical record for Patient 1, the Physician's Order, dated 1/28/19, at 11:15 AM, indicated "Transfer to ICU. DX (Diagnoses): ARF(Acute Renal Failure- abrupt loss of kidney function), Fluid Overload. Levophed IV (intravenous [within the vein]) drip to keep SBP > (greater than) 100."

During a review of the clinical record for Patient 1, the vital signs 1/28/19 AT 2:15 PM indicated "Temperature 98, Heart Rate 87, Respiratory Rate 18, Oxygen saturation 98%, Blood Pressure 99/65 on Dopamine (medication that improves the pumping strength of the heart and improves blood flow to the kidneys) at 5 micrograms (mcg-unit of measurement)." The CNE verified the findings.

During an interview with the CNE, on 3/15/19, at 1:25 PM, the CNE stated, "I was aware of the situation. The patient could not be transferred to ICU because there was no ICU nurse to take the patient. The house supervisor was already taking care of a patient being recovered."

During an interview with the Director of Patient Care Unit/Coronary Care Unit (DPCU/CCU), on 3/15/19, at 1:55 PM, she stated ICU census at that time was six with three registered nurses. ICU capacity was 10 but we could not take [Patient 1] because there was no ICU nurse. The DPCU/CCU stated she was not aware of the situation.

During a concurrent interview with the Clinical Analyst (CA) and review of the clinical record for Patient 1, on 3/15/19, at 2:50 PM, the CA reviewed the Nursing Progress Notes and was not able to find documentation the physicians were notified about the delay in [Patient 1]'s transfer to ICU. The record indicated the physician ordered transfer to ICU at 11:15 AM and the patient was transferred to ICU at 7:05 PM. Patient was in the PCU/TELE unit for approximately eight hours.

During an interview with RN 2, on 3/19/19, at 8:30 AM, she stated,"We cannot start Levophed Drip in PCU/TELE Unit. This patient needs to go to ICU. Levophed requires titration and monitoring of the blood pressure every 15 minutes."

During a concurrent interview with the CA and review of the Medication Administration Record (MAR), on 3/19/19, at 9:45 AM, the MAR dated 1/28/19, indicated Levophed drip was not started in PCU/TELE. The CA verified the findings.

The hospital policy and procedure titled " Over Capacity/Throughput Management Plan" dated 8/27/09, indicated ". . .The House Supervisor will be notified in the event that there is inadequate staffing to meet required patients needs, nurse ratio has been exceeded, or when the acuity is excessive beyond the unit's hours per patient per day,. or when staffing has been reduced due to sick calls, vacations, or other absences. In this instance, the House supervisor will maintain: 1 Adjustment of staffing mix, maintaining minimum numbers of personnel according to the predetermined staffing directives and acuities. 2. Temporary reassignment (floating ) from other units based on the competency of the nurse and the unit's needs. . .6. Calling in nursing personnel who are on call or scheduled off for possible extra help. . .8. Director assumes clinical care assignments."

2. During a concurrent interview with RN 8 and review of the clinical record for Patient 22, on 3/21/19, at 8:30 AM, the record indicated Patient 22 had altered mental status and hypoglycemia (low blood sugar). RN 8 stated Patient 22 failed swallow evaluation. RN 8 reviewed the Physician Order, dated 3/20/19, at 8 PM, indicated "Nephro 1.8 calories (a nutritional supplement) at 10 ml (milliliter, a unit of measurement) per hour via Nasogastric tube (NGT- a tube inserted into the nose or mouth for patients who are not able to chew or swallow food)." RN 8 stated Patient 22 had an NGT since 3/18/19 at 8 PM but the NGT got dislodged on 3/21/19 at 12 AM and had not been reinserted.

During a concurrent interview with RN 8 and review of the clinical record for Patient 22, RN 8 reviewed the MAR, on 3/21/19, at 8:45 AM, RN 8 was not able to find documentation the tube feeding was started as ordered on 3/20/19 at 8 PM. RN 8 reviewed the Nursing Progress Notes and did not find documentation the physician was notified about the tube feeding not being started. RN 8 stated the tube feeding could have been started before the NGT got pulled out. RN 8 verified the findings.

3 A. During a concurrent interview with RN 2 and review of the clinical record for Patient 1, on 3/19/19, at 8:30 AM, RN 2 reviewed the "Daily Focus Assessment Report" dated 1/28/19, and was not able to find documentation of RN 1's initial nursing assessment completed at the beginning of the shift. The record indicated RN 1 performed her nursing assessment on Patient 1 at 1:51 PM and RN 1 documented "No change in previous assessment." RN 2 verified there were no previous nursing assessments completed by RN 1 prior to 1:51 PM. RN 2 stated, "Nursing assessment on the PCU/TELE Unit is done every four hours; in the Intensive Care Unit, nursing assessment is done every two hours."

During a concurrent interview with the CA and review of the clinical record for Patient 1, the Physician's Order, dated 1/28/19, at 11:15 AM, indicated "Transfer to ICU." The CA reviewed the Daily Focus Assessment Report" and was not able to find a nursing assessment done by RN 1 when Patient 1's condition changed. The CA stated [Patient 1] should have an assessment completed at 8 AM and then followed by every two hours nursing assessment when his level of care changed from telemetry care to ICU care.

3 B. During a concurrent interview with RN 9 and review of the clinical record for Patient 20, on 3/21/19, at 10:30 AM, the record indicated Patient 20 was admitted in the ICU, on 3/16/19 for Coronary Artery Bypass Graft (CABG -a surgical procedure to restore normal blood flow to the heart). RN 9 stated. "We assess within the first 15 minutes of admission and every two hours, or when there is a change in condition." RN 9 reviewed the The Daily Focus Nursing Assessment for Patient 20 and was not able to find a complete body system assessment of the patient on 3/21/19, at 8 AM and 10 AM. RN 9 acknowledged she had not done the assessments yet.

The hospital policy and procedure titled "Assessment/Reassessment" dated 6/12/18, indicated "A. Nursing Reassessments" 1. Patients will receive nursing reassessments on a regular basis to determine patient's condition and ongoing care requirements. Patients are assessed by the RN within the first 2 hours of a shift. . .Patients are assessed by the RN within the first 2 hours of a shift. . . Critical Care Unit, initial assessment done upon arrival and reassessed at least every two hours. . . Patient Care Unit, initial assessment is done upon arrival and reassessment is done every 4 hours; initial shift assessment within two hours of the start of the shift."

The hospital policy and procedure titled "Standards of Care/Patient Care Unit (PCU), dated 12/11/13, indicated ". . .Patients will be assessed on admission and at the beginning of each shift and then every 4 hours if MD order does not state a specific frequency."



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3 C. During an interview with Licensed Vocational Nurse 1 (LVN 1) and a review of the clinical record for Patient 3, on 3/20/19, at 3:50 PM, the clinical record indicated on 3/18/19, at 2:37 PM, the patient arrived to the Emergency Department (ED). There was no documented evidence the licensed nurse performed a complete body assessment of the patient until 3/18/19, at 10:02 PM (more than seven hours after his arrival time). LVN 1 verified the patient's full body assessment was performed on 3/18/19, at 10:02 PM.

3 D. During an interview with LVN 1 and a review of the clinical record for Patient 6, on 3/20/19, at 3:50 PM, the clinical record indicated on 3/18/19, at 10:37 PM, the patient arrived to the ED. There was no documented evidence the licensed nurse performed a complete body assessment of the patient until 3/19/19, at 10 AM (almost 12 hours after his arrival time). LVN 1 verified the patient's full body assessment was performed on 3/19/19, at 10 AM.

3 E. During an interview with LVN 1 and a review of the clinical record for Patient 12, on 3/22/19, at 7:56 AM, the clinical record indicated on 3/20/19, the patient was admitted to the Day Patient Unit for an invasive heart procedure. After the procedure the patient was transferred to the post procedure area. At 10:04 AM, the documentation indicated the groin's puncture site was "WNL (within normal limits)". At 10:30 AM, the documentation indicated the puncture site was "WNL oozing". LVN 1 acknowledged there was inconsistent documentation for the assessment of the puncture site when the nurse documented the site was WNL and oozing.

3 F. During an interview with LVN 1 and a review of the clinical record for Patient 15, on 3/22/19, at 7:56 AM, the clinical record indicated on 3/21/19 at 5:02 PM, the patient arrived to the ED for right lower quadrant pain radiating to the right flank area. On 3/21/19, at 8 PM, the first nursing assessment documented by the licensed nurse indicated, under the gastrointestinal (GI - relating to stomach and intestines) system, the gastrointestinal assessment was WNL and that the patient has "abdominal pain". LVN 1 acknowledged there was inconsistent documentation for the GI assessment when the nurse documented the GI assessment was WNL and the patient has abdominal pain.

During a review of the hospital's policy and procedure titled, "ASSESSMENT/REASSESSMENT" last revised on 6/12/18, " . . . Nursing Reassessments . . . Patients will receive nursing reassessments on a regular basis to determine patient's condition and ongoing care requirements. Patients are assessed by the RN (registered nurse) within the first 2 hours of a shift . . . " The time frames for patient assessments in the ED, according to this policy and procedure, indicates the initial assessment should be completed "Upon arrival".

The hospital policy and procedure titled "Assessment/Reassessment" dated 6/12/18, indicated "A. Nursing Reassessments" 1. Patients will receive nursing reassessments on a regular basis to determine patient's condition and ongoing care requirements. Patients are assessed by the RN within the first 2 hours of a shift. . .Patients are assessed by the RN within the first 2 hours of a shift. . . Critical Care Unit, initial assessment done upon arrival and reassessed at least every two hours. . . Patient Care Unit, initial assessment is done upon arrival and reassessment is done every 4 hours; initial shift assessment within two hours of the start of the shift."

Based on interview and record review, the hospital failed to monitor five of 33 sampled patients (Patient 10, Patient 11, Patient 8, Patient 9, and Patient 12) after invasive procedures in the Day Patient Unit according to the hospital's policy and procedure. This has the potential to result in a decline in the patients' physical conditions without the nursing staff being aware.

Findings:

1. During an interview with Licensed Vocational Nurse 1 (LVN 1) and review of the clinical record for Patient 10, on 3/21/19, at 9:32 AM, the clinical record indicated the patient was admitted to the Day Patient Unit on 3/20/19, at 8:20 AM for a left heart catheterization (LHC is an invasive heart procedure where a thin hollow tube [catheter] is inserted through a plastic introducer [sheath] into a large blood vessel that leads to your heart to examine how well your heart is working). The procedure was completed at 10:23 AM and Patient 10 was transferred to the post procedure area to be monitored. The following vital signs (temperature [T], blood pressure [BP], pulse [P] and respiratory rate [RR]) and pain assessments were not documented:

At 10:30 AM - No RR, T, or pain assessment
At 10:46 AM - No P, RR, T, or pain assessment
At 11:01 AM - No RR, T, or pain assessment
At 11:16 AM - No RR, T, or pain assessment
At 11:31 AM - No RR, T, or pain assessment
At 12:01 PM - No T, or pain assessment.

After further review of the clinical record it was noted from 12:01 PM to 1:31 PM, the RR, the T, and the pain assessment were not documented. LVN 1 acknowledged the findings.

2. During an interview with LVN 1 and review of the clinical record for Patient 11, on 3/21/19, at 10:15 AM, the clinical record indicated the patient was admitted to the Day Patient Unit on 3/20/19 at 9:34 AM for an invasive heart procedure with a possible stent (a tube shaped device placed in the heart vessels to keep open, the stent is introduced through a sheath that is inserted in a large vessel [usually in the groin area]) placement. At 12:06 PM, the procedure was completed and the patient was then transferred to the post procedure area. On 3/20/19, at 12:05 PM, the physician ordered to document vital signs/groin check/distal pulse every 15 minutes x 4, every 30 minutes x 4, every 1 hours x 4 and then every 4 hours. The following vital signs (temperature [T], blood pressure [BP], pulse [P] and respiratory rate [RR]) were not documented:

At 1:31 PM - No RR, T
At 1:46 PM - No RR, T
At 2:01 PM - No RR, T, P
At 2:16 PM - No RR, T
At 2:47 PM - No RR, T, P
At 3:02 PM - No RR, T
At 3:17 PM - No RR, T
At 3:31 PM - No RR, T
At 3:46 PM - No RR, T
At 4:01 PM - No RR, T
At 4:16 PM - No RR, T
At 4:31 PM - No RR, T

LVN 1 acknowledged there was no evidence the vital signs were monitored for the first 1 hour and 25 minutes after the procedure and he acknowledged the vital signs that were monitored between 1:31 PM and 4:31 PM, were incomplete.

During an interview with LVN 1 and review of the clinical record for Patient 11, on 3/21/19, at 2:40 PM, the clinical record indicated there was no documented evidence the pulses distal to the catheter insertion site (in the groin area) were monitored and there was insufficient documented evidence the catheter insertion site was monitored as ordered by the physician. LVN 1 verified the findings.

3. During an interview with LVN 1 and review of the clinical record for Patient 8, on 3/21/19, at 10:15 AM, the clinical record indicated the patient was admitted to the Day Patient Unit on 3/20/19 for an invasive heart procedure including a possible stent placement. At 9 AM, the patient was transferred to post procedure area. There was insufficient documented evidence the vital signs, the pulses distal to the catheter insertion site, and the insertion site (in the groin area) were monitored every 15 minutes for one hours, every thirty minutes for one hour, and every one hour for four hours. LVN 1 acknowledged there was insufficient documented evidence the patient was monitored according to the hospital policy and procedure.

4. During an interview with LVN 1 and review of the clinical record for Patient 9, on 3/21/19, at 1:42 PM, the clinical record indicated the patient was admitted to the Day Patient Unit on 3/20/19 for an invasive heart procedure. At 10:46 AM, the procedure was completed and at 10:47 AM, and the patient was transferred to the post procedure area. There was no documented evidence the pulses distal to the catheter insertion site were monitored after the procedure. LVN 1 verified there was no documented evidence the pulses distal to the catheter insertion site were monitored.

5. During an interview with LVN 1 and review of the clinical record for Patient 12, on 3/22/19, at 7:56 AM, the clinical record indicated the patient was admitted to the Day Patient Unit on 3/20/19 for an invasive heart procedure. At 9:31 AM, the procedure was completed and at 9:32 AM, the patient was transferred to the post procedure area. There was insufficient documented evidence the vital signs were complete and were monitored every 15 minutes for one hours, every thirty minutes for one hour, and every one hour for four hours. There was no documented evidence the pulses distal to the catheter insertion site were monitored post the procedure. LVN 1 verified there was insufficient documented evidence the patient was monitored according to the hospital policy and procedure.

During a review of the hospital policy and procedure titled, "STANDARDS OF CARE ADMITTING GUIDELINES FOR PRE- AND POST-INVASIVE PROCEDURES FOR THE DAY PATIENT UNIT", last revised on 4/29/16, the policy indicated, " . . . Post-Invasive Procedures: 1. Assessment . . . A. Vital signs - every 15 min (minutes) x 4, every 30 min x 2, and every 1 hour x 4[hours] . . . Pulses in affected extremity (ies) - every 15 min x 4, every 30 min x 2, and every 1[hour]x 4 . . . C. Presence and/or severity of pain . . . E. Condition of percutaneous (through the skin) puncture site - every 15 min x 4, every 30 min x 2 and every 1[hour] x 4 . . . "

Based on interview and record review, the hospital failed to develop and update individualized, person-centered care plans for three of 33 sampled patients (Patient 20, Patient 19, and Patient 14). This failure had the potential for unmet care needs.

Findings:

1. During a concurrent interview with Registered Nurse 9 (RN 9) and review of the clinical record for Patient 20 in the Intensive Care Unit (ICU- a specialized unit for the management of life-threatening conditions that may require sophisticated life support and intensive monitoring) on 3/20/19, at 10:30 AM, RN 9 reviewed the care plan and was not able to find a care plan written specific for the care of a patient status-post Coronary Artery Bypass Graft (CABG -a surgical procedure to restore normal blood flow to the heart). RN 9 stated care plans are written based on patient's diagnosis and specific to the clinical assessment of the patient.

During an interview with the Director of Patient Care Unit/Coronary Care Unit, on 3/20/19 at 12 PM, she stated, "I expect the care plan to be specific to the problem/condition."

2. During a concurrent interview with RN 11 and review of the clinical record for Patient 19 in ICU, on 3/20/19, at 11 AM, RN 11 was not able to find a care plan specific for the care of the patient status-post mitral valve replacement (a cardiac procedure performed when the valve becomes too tight for blood to flow into the left heart, or too loose in which case blood can leak back into the left heart and back into the lung) with chest tube insertion (a procedure to place a flexible, hollow drainage tube into the chest wall in order to remove an abnormal collection of air or fluid from the pleural space [located between the inner and outer lining of the lung]). RN 11 stated,"Yes, I would write a care plan specific to the care of patients with chest tube and also add a care plan on skin integrity." RN 11 verified the findings.



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3. During an interview with Licensed Vocational Nurse 1 (LVN 1) and a review of the clinical record for Patient 14, on 3/21/19, at 4:10 PM, the patient was admitted for an irregular heart rate. There was no care plan developed to address the patient's irregular heart rate. LVN 1 acknowledged there was no care plan to address the patient's irregular heart rate and there should have been one developed for the irregular heart rate.

The hospital policy and procedure titled "Patient Care Plan" dated 8/25/15, indicated ". . .A nursing care plan outlines the nursing care to be provided to a patient and complements the Physician's orders. . .INSTRUCTIONS: 1. . .The Nurse will select a system identified care plan or patient specific problems. . .Problems within Paragon have pre-identified Goals and interventions built in. The Nurse may edit the Goals and interventions as necessary taking into consideration the patient's needs."

Based on observation, interview, and record review, the hospital failed to:

1. Ensure antibiotic medications (used to treat infections) were administered timely for two of 33 sampled patients (Patient 3 and Patient 2). This has the potential for the infection to worsen.

2. Ensure Pain Medications were administered for five of 33 sampled patients (Patient 19, Patient 20, Patient 24, Patient 27, and Patient 31). This failure had the potential for patients to continuously suffer pain due to inadequate pain management.

Findings:

1 A. During an observation of the Emergency Department (ED) on 3/20/19, at 10:25 AM, with the Interim Chief Nursing Executive and the Emergency Department Director, an electronic "tracking board" was noted at the nursing station. The electronic board contained information about each patient including the number of hours the patient had been waiting in the ED, whether the patient had orders from the physician, and if the patient was waiting for an inpatient bed.

During an interview with Emergency Department Charge Nurse 1 (EDCN 1), and review of the clinical record for Patient 3, on 3/20/19, at 10:40 AM, the clinical record indicated the patient arrived to the ED on 3/18/19, at 2:37 PM, with a chief complaint of a dental abscess. EDCN 1 stated Patient 3 arrived to the ED and required intravenous antibiotic medication. On 3/18/19, at 3:54 PM, the physician ordered Unasyn (antibiotic medication) 3.375 grams to be administered. The record indicated the Unasyn was administered on 3/18/19, at 10:05 PM (more than six hours after the medication was ordered). On 3/18/19, at 5 PM, the physician ordered Vancomycin (antibiotic medication) 1 gram. The record indicated the Vancomycin 1 gram was administered at 10:56 PM (more than six hours after the medication was ordered.). EDCN 1 stated the antibiotics should be administered "within one hour" of the physician's order. She stated the nursing staff wait for the pharmacy to review the orders and when the pharmacy indicates the order is okay then they administer the medication. After reviewing the clinical record, she was unable to find the reason the antibiotics were not started timely.

1 B. During an interview with Licensed Vocational Nurse 1 (LVN 1), and review of the clinical record for Patient 2, on 3/21/19, at 8:25 AM, it was noted the patient arrived to the ED on 3/19/19, with altered mental status and was nonresponsive. On 3/19/19, at 11 AM, the physician ordered Unasyn 3.33 grams every 8 hours. The first dose of the Unasyn was administered at 5:41 PM (more than six hours after the medication was ordered). No further information was provided.

During an interview with the Director of Pharmacy, on 3/22/19, at 7:43 AM, he stated the pharmacy department receive the physician's orders as soon as the physician puts the order into the computer. He stated it takes a couple of minutes for the pharmacy to process the physician's medication orders. When the pharmacist processes the order, the pharmacist notifies the ED via the "tracking board". He stated antibiotics should be started within one hour of the physician's order unless they are waiting for laboratory results. If they are waiting for laboratory results, the pharmacist contacts the licensed nurse and the licensed nurse should document the reason for delay in medication administration in the patient's clinical record.

During a review of the hospital policy titled, "MEDICATION - STANDARD ADMINISTRATION TIMES" last revised on 2/28/18, indicated, " . . . Antibiotics Administered at the exact time indicated . . . "



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2. During a concurrent interview with the Clinical Analyst (CA) and review of the clinical record for Patient 24, on 3/21/19, at 10:25 AM, the record indicated Patient 24 was a status-post Left Hip Replacement (surgery to replace a diseased or injured hip joint). On 3/20/19, at 8 PM, Patient 24 complained of pain on her left hip, with a pain scale of 3/10. The Medication Administration Record (MAR) indicated no pain medication was administered. The Physician Order, dated 3/20/19, indicated "Oxycodone (narcotic pain medication) 5 mg (milligram, unit of measurement) one tablet every 4 hours PRN (as needed) for pain scale ranging from 1-6 (mild to moderate pain)." The CA verified the findings.

During a concurrent interview with the CA and review of the clinical record for Patient 19, on 3/21/19, at 3:12 PM, the record indicated Patient 19 had a mitral valve replacement (a cardiac procedure performed when the valve becomes too tight for blood to flow into the left heart, or too loose in which case blood can leak back into the left heart and back into the lung). The Pain Assessment Record indicated Patient 19 complained of pain, on 3/20/19 at 12:20 PM, with a pain scale of 3/10. The MAR indicated no pain medication was administered. The Physician Order, dated 3/18/19, indicated "Acetaminophen (Tylenol) 650 mg every 4 hours for pain scale ranging from 1-3 (mild pain)" The CA verified the findings.

During a concurrent interview with the CA and review of the clinical record for Patient 20, on 3/21/19, at 3:15 PM, the record indicated Patient 20 was status post Coronary Artery Bypass Graft (CABG -a surgical procedure to restore normal blood flow to the heart). The pain assessment record indicated Patient 20 complained of pain on 3/21/19, at 2 AM, with a pain scale of 9/10 (severe pain). The MAR indicated no pain medication was administered. The Physician Order indicated "Acetaminophen 1000 mg (milligram, a unit of measurement) IV (intravenous) every 6 hours PRN pain." The CA verified the findings.

During a concurrent interview with the CA and review of the clinical record for Patient 27, on 3/21/19 at 3:15 PM, the record indicated Patient 27 was a status-post Total Left Knee Arthroplasty (surgical procedure to replace the weight-bearing surfaces of the knee joint to relieve pain and disability). The Pain Assessment Record indicated Patient 27 complained of left knee pain at 8 AM, with a pain scale of 7/10 (severe pain). The MAR indicated no pain medication was administered. The Physician Order, dated 3/20/19, indicated "Oxycodone 10 mg one tablet every 4 hours for pain scale ranging from 7-10." The CA verified the findings.

During a concurrent interview with the CA and review of the clinical record for Patient 31, on 3/21/19, at 4:35 PM, the record indicated Patient 31 was a status-post Total Left Knee Arthroplasty. The Pain Assessment Record indicated Patient 31 complained of pain on the left knee with a pain scale of 3/10 at 4 AM and 8 AM. The MAR indicated no pain medications were administered on both times. The Physician Order, dated 3/20/19, indicated Oxycodone 5 mg one tablet every 4 hours PRN for pain scale ranging from 1-6 (mild to moderate pain)" The CA verified the findings.

The hospital policy and procedure titled "Interdisciplinary Pain Screening, Assessment, and Management" dated 12/11/18, indicated". . .3. A multimodal approach is the recommended strategy to manage pain using scheduled non-opioids analgesics first and adding opioids for moderate to severe pain. . .C. Post-operative patients may require around-the-clock dosing during the first 24 hours. . .16. PRN medication may be administered to facilitate effective pain management for patients with constant pain or in anticipation of painful activities procedures."

Based on interview and record review, the hospital failed to ensure physician's verbal orders were authenticated within 48 hours for three of 33 sampled patients (Patient 22, Patient 20, and Patient 23). This failure had the potential for miscommunication that could result in medication errors or adverse consequences.

Findings:

During a concurrent interview with the Clinical Analyst (CA) and review of the clinical record for Patient 22, on 3/21/19, at 9:32 AM, the CA reviewed the Physician's Verbal Order, dated 3/18/19, at 3:31 PM. The record indicated "Ultram (Tramadol-pain medication) 50 mg (milligram-a unit of measurement) one tablet orally every 6 hours PRN (as needed)" was not signed and dated by the prescribing physician within 48 hours. The Physician's Verbal Order, dated 3/18/19 at 3:31 PM, indicated "Morphine (narcotic pain medication) 10 mg every 6 hours PRN. The record indicated the physician signed and dated the order on 3/21/19, at 1:30 PM, which was more than the 48 hours of the required authentication period. The CA verified the findings.

During a concurrent interview with the CA and review of the clinical record for Patient 23, on 3/21/19, at 10:22 AM, the CA reviewed the Physician's Verbal Order, dated 3/20/19, at 12:37 AM. The record indicated "Zolpidem (a medication used to treat a certain sleep problem [insomnia] in adults) 10 mg every day at bedtime PRN" was not authenticated within 48 hours. The CA verified the findings

During a concurrent interview with the CA and review of the clinical record for Patient 20, on 3/21/19, at 3:15 PM, the CA reviewed the Physician's Verbal Order, dated 3/19/19, at 8:56 PM. The record indicated "Dexemedetomidine (an anxiety reducing, sedative, and pain medication) 400 mcg (microgram, a unit of measurement) in 0.9% Normal Saline was not signed and dated within 48 hours of the required authentication period. The CA verified the findings.

The hospital policy and procedure titled "Patient Specific Data and Information" dated 1/28/16, indicated ". . .Authentication: All entries are dated, timed, and authenticated by the appropriate physician and are legible. Proper authentication of entries means written signature, or electronic signature. . .Orders: . .All verbal and telephone orders must be authenticated by the responsible physician or dentist as soon as possible (within 48 hours for medication orders)."