HospitalInspections.org

Based on document review and interview the facility failed to adopt Medical Staff Bylaws which gave only the Governing Body the authority to grant medical staff privileges. This deficient practice affects all patients in the facility. The facility census was 11.

Findings included:

1. Review of the facility's Medical Staff Bylaws, conducted on the morning of 03/12/13 showed the following:
Article II, Section 9.B. Emergency and Temporary Privileges
The Administrator of the hospital shall have the authority to grant temporary privileges to a physician who is not a member of the staff. Such temporary privileges shall be granted after a conference with the President of the Staff who will direct supervision for the temporary work. Temporary privileges shall be for a limited period of time and may be extended no more than twice.

2. During an interview on 03/12/13 at 10:15 AM, Staff F, Administrator, stated he had granted physicians temporary privileges many times in the past.

Based on policy review, and interview the facility failed to ensure that a pharmacist reviewed patient medication profile and physicians medication orders prior to administration of the medication. These failures had the potential to cause medication errors or drug interactions and could affect all patients that required medications while being cared for at the facility. The facility census was 11.

Findings included:

1. Review of the facility policy 2025, titled, "Uniform Drug Administration Policy", dated 03/31/99, reviewed 01/31/13 showed direction that the "nurse verifies the physicians order at the time of transcription and the pharmacist independently verifies the physician's order at the time of computer encoding."

Review of facility policy 2013, titled, "Pharmacist Order Verification", dated 03/31/99 showed direction that:
-The pharmacist will review each prescription for medication;
-A copy of the prescription or order is provided to the Pharmacy Department immediately after it is written;
-The pharmacist reviews and confirms the prescription;
-Orders requiring clarification will be discussed with the prescriber before verification.

2. During a telephone interview on 03/19/13 Staff O, Director of Pharmacy, stated that when he arrives, around 7:00 AM (Monday through Friday), he reviews all orders placed since the last time he reviewed orders (typically the day before or, on Mondays, the Friday before). He reviews orders for proper dose, diagnosis related to medication use, duration (is order time limited), drug/drug interactions, drug/patient interactions, drug/fluid interactions, to be sure medication is on hospital formulary, and patient allergies. Staff O stated that he doubted if nurses were checking these elements when verifying the order. Staff O stated that nurses mainly check that the right patient is getting the right medication. Staff O stated that he is not aware of any formal nurse education or policy related to the elements that the pharmacist verifies. Staff O stated that patients admitted during the day or on weekends do receive medication prior to the order being verified by the pharmacist and that sometimes patients are discharged from the facility prior to medication orders being reviewed and verified by the pharmacist. Staff O stated that there are quite a few 23 hour admissions. Staff O stated that he would estimate there are 25 new medication orders per day and about half of them are administered prior to being verified by the pharmacist.

3. During an interview on 03/13/13 at 12:40 PM Staff J, Pharmacy Technician, stated that the Pharmacist verified all physician orders that were entered since the previous morning. Staff J stated that the Pharmacist worked Monday through Friday From 7:00 AM to 8:30 AM. Staff J stated that patients that are admitted during the day or on weekends do receive medication prior to the order being verified by the pharmacist and that sometimes patients are discharged from the facility prior to the orders
being reviewed by the pharmacist. Staff J stated that she is not aware of any facility policy on how nurses should verify medication orders from the pharmacy perspective.

4. During an interview on 03/13/13 at 2:00 PM Staff B, Registered Nurse, stated that nurses check to ensure the medication they are giving is what was ordered by the physician, they verify patients identity, and check for allergies. Staff B stated that she has not received any education on how to verify orders from the pharmacy perspective.

Based on interview and record review, the facility failed to ensure medical record entries were signed and dated for one current (#3) and three discharged (#10, #12 and #15) patient records, of 13 patient records reviewed. The facility census was 11.

Findings included:

1. During an interview on 03/13/13 at 2:10 PM, Staff L, Medical Records Director stated that she doesn't have a policy for authentication (signing and dating) of entries in the medical record, but should have.

2. Review of current Patient #3's medical record showed a History and Physical which was signed by a physician, but not dated.

3. Review of discharged Patient #10's medical record showed a History and Physician which was signed by a physician, but not dated.

4. Review of discharged Patient #12's medical record showed a History and Physical which was signed by a physician, but not dated.

5. Review of discharged Patient #15's medical record showed a History and Physical which was signed by a physician, but not dated.

6. During an interview on 03/12/13 at approximately 3:00 PM, Staff L stated that the medical record History and Physical should be signed and dated, and added that the department monitors this as part of their Quality Assurance program, and have on-going issues with physician compliance.

Based on observation, interview and policy review, the facility failed to ensure that patient medical records were protected against loss, destruction, unauthorized use, and unauthorized access and/or tampering. The facility census was 11.

Findings included:

1. Record review of the facility's policy titled "Availability of Medical Records (facility)" dated 01/01/03, showed direction for the following:
-Access to medical records is restricted to authorized personnel and medical staff;
-The facility shall safeguard the information in the medical record against loss, defacement, tampering or use by unauthorized persons;
-Controlled locked access to the inactive medical record storage files is maintained;
- The Medical Record Department shall remain locked at all times when Medical Records personnel are not present. During such times the Director of Nursing and/or Charge Nurse shall control access.

2. Observation on 03/12/13 at 2:50 PM, of a medical records storage area located in the basement of the hospital, showed patient X-ray films, Surgery Department records, Laboratory records and financial records were stored along with patient Medical Records.

3. During an interview on 03/12/13 at 2:00 PM, Staff L, Medical Records Director, stated the following:
-The Medical Records Department is staffed Tuesday through Thursday, from 7:00 AM until 4:30 PM;
-The Medical Records Department is staffed on Monday and Friday from 7:00 AM until 7:00 PM;
-The Charge Nurse has access to Medical Records storage areas after hours;
-Occasionally, housekeeping staff will vacuum in the Medical Records Department after hours.

4. Review of an untitled document, presented by housekeeping staff as the daily Housekeeping Department cleaning schedule, showed that the Medical Records Department is to be cleaned in the evening.

5. During an interview on 03/13/13 at 9:20 AM, Staff L stated that a key used to access the active medical records room is kept in a drawer next to the unit secretary on the patient care floor, and the unit secretary will access the medical records department after hours when the charge nurse is busy and cannot access it herself. Staff L added the she didn't know who had access to the inactive medical records storage area in the basement, but could find out.

6. Observation on 03/13/13 at 9:40 AM showed medical records department keys in an unlocked drawer in the nurses' station, next to the Unit Secretary.

7. During an interview on 03/13/13 at 9:40 AM, Staff M, Unit Secretary, stated that keys used to access the active and inactive medical records rooms are kept in the nurses' station drawer. Staff M added that the Unit Secretary is responsible for obtaining medical records when the medical records department is closed, but nurses or Patient Care Technicians may access the medical records department to obtain records, if the Unit Secretary is busy.

8. During an interview on 03/13/13 at 9:50 AM, Staff N, Registered Nurse (RN), stated that Emergency Department (ED) staff have a key, which is kept in a nurses' station drawer, to access the active and inactive medical records areas, and that all of the RN's who work in the ED know how to access and retrieve medical records from those areas.

9. During an interview on 03/13/13 at approximately 2:00 PM, Staff L stated that the following departments have a key and access to the inactive medical records department:
-Laboratory;
-Radiology;
-Accounting;
-Health Information Management; and
-Nursing.