HospitalInspections.org

Based on review of credential files, staff interview, and medical staff bylaws review, the facility failed to ensure the governing body appointed members of the medical staff for 1 of 1 new appointments and 4 of 4 reappointments reviewed. The findings were:

1. Review of credential files on 4/10/18 revealed the following:
a. APRN #1 had an initial appointment date of 1/16/18. The privileges were signed by the Medical Executive Committee, but there was no evidence the governing body had approved the appointment or granted privileges. The signature line for the governing body on the privileges form was blank.
b. APRN #2 was due for reappointment in February 2018 (previous appointment was February 2016 for 2 years). Review of the privileges form showed the Medical Executive Committee signed on 3/6/18, but there was no evidence the governing body had approved the reappointment or granted privileges. The signature line for the governing body on the privileges form was blank.
c. MD #1 was due for reappointment in February 2018 (previous appointment was February 2016 for 2 years). The privileges were signed by the Medical Executive Committee on 3/6/18, but there was no evidence the governing body had approved the reappointment or granted privileges. The signature line for the governing body on the privileges form was blank.
d. APRN #3 was due for reappointment in February 2018 (previous appointment was February 2016 for 2 years). Review of the privileges form showed the Medical Executive Committee signed on 3/6/18, but there lacked evidence the governing body approved the reappointment or granted privileges. The signature line for the governing body on the privileges form was blank.
e. APRN #4 was due to reappointment in February 2018 (previous appointment was February 2016 for 2 years). The privileges form was signed by the Medical Executive Committee on 3/13/18, but there lacked evidence the governing body approved the reappointment or granted privileges. The signature line for the governing body on the privileges form was blank.

2. During an interview on 4/10/18 at 4:05 PM, Senior Support Specialist #1 (person in charge of credential files) confirmed the credential files for APRN #1, #2, #3, and #4 and MD #1 lacked a signature from the governing body to show the governing body approved the appointment and granted privileges. She stated normally the governing body representative signs the privileges form and then she typed a letter.

3. Review of the "Medical Staff Bylaws"(revised September 2017) showed "Procedures for Appointment and Reappointment...A favorable recommendation by the Medical Executive Committee will cause the application to first be forwarded to the Hospital Administrator for review and approval, and then to the Governing Body for review and final approval.." and "Reappointments to any category of the Medical Staff will be for not more than a two (2) year period."

Based on review of policies and procedures and staff interviews, the facility failed to develop policies and procedures for administration of all drugs and biologicals that address time-sensitive medications. The findings were:

On 4/11/18 and 4/12/18, the following policies and procedures regarding medication administration were reviewed: "Medication Control," revised 8/25/17; "Medication Training, Education and Counseling," revised 8/25/17; "Medication Variance," revised 10/16/17; "Medication Administration," revised 8/25/17; and "High Risk Medications," revised 10/26/17. This review revealed the following acceptable standards of nursing practice for medication administration had not been addressed in the medication administration policies and procedures:
a. Medications eligible for scheduled dosing times that also addressed first dose medications, including parameters within which nursing staff are allowed to use their own judgement regarding the timing of the first and subsequent doses, which may fall between scheduled dosing times; retiming of missed or omitted doses; medications that will not follow scheduled dosing times and patient units that are not subject to following the scheduled dosing times if applicable.
b. Actions to be taken when medications eligible for scheduled dosing times are not administered within their permitted window of time.
c. Identified parameters within which nursing staff are allowed to use their own judgement regarding the rescheduling of missed or late doses and when notification of the practitioner responsible for the care of the patient is required prior to doing so.
d. A process for determining whether specified scheduled medications are always time-critical, or only under certain circumstances and how staff involved in medication administration will know when a scheduled medication is time-critical.
e. Established windows of time for medication administration that address time-critical scheduled medications, medications prescribed more frequently than daily, but no more frequently than every 4 hours, and medications prescribed for daily or longer administration intervals.

Interview on 4/12/18 at 11:20 AM with the DON revealed he had not had an opportunity to review the regulatory requirements regarding policies and procedures for medication administration and he was not aware that revisions were needed to include the required missing elements.