The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

NYE REGIONAL MEDICAL CENTER 825 ERIE MAIN ST (AKA SOUTH MAIN) TONOPAH, NV April 12, 2013
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on interview, the facility failed to ensure the priorities were set for performance improvement activities.

Findings include:

On 4/10/13, the Director of Nursing reported they were still working on developing the performance improvement activities, and had not set any priorities for the activities.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on record review and staff interview, the facility failed to provide a written disclosure to patients indicating the hospital was physician owned and failed to notify patients in writing that a Medical Doctor (MD) or Doctor of Osteopathy (DO) was not present in the hospital 24 hours a day for 20 of 20 patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20).

Findings include:

Record review revealed no evidence patients were informed in writing of physician ownership of the hospital and patients were not informed a MD or DO were not onsite 24 hours a day.

An interview with the Director of Nursing on 4/11/13, confirmed patients were not provided written information regarding hospital ownership or the lack of onsite 24 hour MD or DO coverage.
VIOLATION: DELIVERY OF DRUGS Tag No: A0500
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, the facility failed to ensure the pharmacist regularly reviewed therapeutic appropriateness of medication therapies and adverse drug reactions.

Findings include:

On 4/9/13, the consultant pharmacist was interviewed and reported the last time he was in the facility was 6/27/12. The pharmacist reported when he was coming monthly he would participate in quality assurance and pharmacy and therapeutics meetings, review adverse medication reactions, review short stay admissions, review all antibiotic use for appropriateness, and provide general oversight of the pharmacy and dispensing of medications by the physicians.

There were no monthly pharmacy reports to be reviewed for the past year. Review of February and March medical staff meeting minutes revealed pharmacy and therapeutics had been tabled. Review of new business for the medical staff meetings revealed the committee was looking at updated [DIAGNOSES REDACTED] protocol and a protocol for prescribing of Testosterone. There was no pharmacy input into these discussions.
VIOLATION: PHARMACEUTICAL SERVICES Tag No: A0490
Based on interview and document review, the facility failed to ensure pharmaceutical services met the needs of the patients. The following processes were not in place: Pharmacy Management and Administration (A-0491, A-492) and Delivery of Services (A-0500).

The cumulative effect of the systemic practices resulted in the failure of the facility to deliver statutory mandated care to patients.
VIOLATION: CONTRACTED SERVICES Tag No: A0083
Based on interview, the facility failed to ensure that contracted services were provided to ensure the facility complied with regulatory requirements.

Findings include:

An interview with the Director of Nursing on 4/9/13, revealed the consulting pharmacist had not been in the facility to perform pharmacy inspections, medication reviews or any consulting activities for about nine months.

A telephone interview with the pharmacist revealed he had not made a consulting visit to the facility since June 27, 2012. The pharmacist indicated he had not been paid by the facility per his contract and therefore he was no longer providing services.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on record review, interview, and policy review, the facility failed to ensure the medical record was legible, complete, dated, timed, and authenticated in written or electronic form by the person who provided services or evaluated the patient for 2 of 20 sampled patients (Patient #16 and #8).

Findings include:

Patient #16

Patient #16 entered the facility's Emergency Department (ED) on 3/01/13 at 1:03 AM, with a chief complaint of chest pain (CP).

Patient #16's medical record revealed:

* Nursing Progress Notes initialed by Employee #4 indicated patient given 1 Nitroglycerin (NTG) sublingual (SL) spray after medical doctor (MD) finished exam at 3:08 AM.

* The ED Emergency form revealed a medication order time of 3:08 AM for one nitroglycerin spray may repeat x 2. The initials box next to the medication order was blank.

* An Emergency Department Transfer Note by Employee #3, electronically signed 03/01/13 10:45 AM.

The medical record revealed no other documentation indicating the date and time of an MD examination.

On 4/11/13 at 3:05 PM, Employee #4 revealed a recall of the MD's presence and examination of the patient within thirty minutes of notifying him of Patient #16's 1:03 AM arrival time at the ED. Employee #4 stated, "he was here immediately, within minutes, I remember because I had thought to myself his hair is flipped up on the back of his head meaning he didn't even take time to comb his hair."

Patient #8

Review of Patient #8's medical record revealed:

* Nursing Progress Notes initialed by Employee #7 at 3:30 PM revealed, MD/PA (physician assistant) bedside discussing patients condition with patient and family. Patient agreed to central line insertion. MD/PA bedside setting up for femoral line insertion.

* emergency room form dated 2/18/13 had no entry indicating completion of an MD examination or time of an examination.

* Physician's Orders form with five entries for orders with a time entered for each order. No date was indicated for any of the five entries.

Review of the facility's medical record instructions revealed, "Before Discharging the emergency room (ER) patient from computer did you: Fill out your Emergency form completely? *Dr time notified and responded." The medical records instructions did not contain an effective or revised date.
VIOLATION: PHARMACIST RESPONSIBILITIES Tag No: A0492
Based on interview and document review, the facility failed to ensure a pharmacist was responsible for supervising all the activities of the pharmacy services.

Findings include:

On 4/9/13, at approximately 3:00 PM, the Director of Nursing (DON) was interviewed regarding pharmacy services. The DON reported the pharmacist had last been on site last May or June of 2012.

On 4/9/13 at 4:00 PM, the facility contracted pharmacist was interviewed and reported the last time he was in the facility was 6/27/12. The pharmacist reported he would return if he were paid. The pharmacist reported when he was coming monthly he would participate in quality assurance and pharmacy and therapeutics meetings, review adverse medication reactions, review short stay admissions, review all antibiotic use for appropriateness, and provide general oversight of the pharmacy and dispensing of medications by the physicians.

The pharmacist's contract with the facility was reviewed and revealed the pharmacy consultant's responsibilities included:

a. Review drug regimen of each resident in facility (no residents in facility).

b. Serve on the facility's Patient Care Policy committee and Pharmaceutical Services Committee

c. Submit monthly, written report to Facility Quality Assurance or Pharmaceutical Services on status of facility's pharmaceutical services and nursing staff performance related to medication administration and handling of drug orders.

d. Prepare and maintain facility's pharmaceutical services policy and procedure manual.

e. Assist facility in accounting, destruction, and reconciliation of unused controlled substances.

f. Assist facility staff in establishing and implementing policies and procedures for the safe and effective distribution, control, and use of drugs.

g. Participate (at least quarterly) in facility's in-service training program for nursing staff.

h. Assist staff in establishing and implementing a formulary of drug products, upon request.
VIOLATION: CONTENT OF RECORD - INFORMED CONSENT Tag No: A0466
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to ensure patients being admitted to the emergency department or inpatient hospital signed consents for treatment for 13 of 20 patient records reviewed (Patient # 2, #3, #4, #5, #6, #7, #9, #10, #11, #12, #14, #18, and #19).

Findings include:

Patient #2

Patient #2 was admitted to the emergency department (ED) on 2/5/13 at 5:30 PM. The patient was admitted as an observation patient to the inpatient unit at 8:45 PM on 2/5/13.

Review of Patient #2's record failed to reveal a consent for treatment in the ED or a consent for admission to the hospital.

Patient #3

Patient #3 was admitted on [DATE] at 9:30 AM. The patient was admitted to the inpatient unit at 3:00 PM on 2/6/13.

Review of Patient #3's record failed to reveal a consent for treatment in the ED or a consent for admission to the hospital.

Patient #4

Patient #4 was admitted on [DATE] at 8:40 PM. Review of the patient's record failed to reveal a consent for emergency treatment.

Patient #5

Patient #5 was admitted on [DATE] at 11:35 PM. The patient was admitted to the inpatient unit at 9:30 AM on 2/11/13.


Review of Patient #5's record revealed a consent for emergency treatment and financial agreement was signed, but undated. There was no consent for admission to the hospital.

Patient #6

Patient #6 was admitted on [DATE] at 4:38 PM. The patient was admitted to the inpatient unit 2/14/13 at 6:00 PM.

Review of Patient 36's record revealed a consent for emergency treatment and financial agreement was signed, dated, and timed. There was no consent for admission to the hospital.

Patient #7

Patient #7 was admitted on [DATE] at 1:00 PM. The patient was admitted to the inpatient unit at 6:30 PM.

Review of Patient #7's record failed to reveal a consent for treatment in the ED or a consent for admission to the hospital.

Patient #9

Patient #9 was admitted on [DATE] at 3:00 PM, and admitted as an observation patient to the inpatient unit at 4:00 PM.

Review of Patient #9's record revealed an unsigned consent. Handwritten on the signature line was, "Patient in ER (emergency room )".

Patient #10

Patient #10 was admitted on [DATE]. The time was not documented. The patient was admitted as an observation patient to the inpatient unit at 11:00 AM.

Review of Patient #10's record failed to reveal a consent for treatment in the ED or a consent for admission to the hospital.

Patient #11

Patient #11 was admitted on [DATE] at 5:25 AM. The patient was admitted as an observation patient to the inpatient unit at 8:30 AM.

Review of Patient #11's record revealed a consent for emergency treatment and financial agreement was signed. There was no consent for admission to the hospital.

Patient #12

Patient #12 was admitted on [DATE] at 6:55 PM and admitted to the inpatient unit at 9:00 PM.

Review of Patient #12's record failed to reveal a consent for treatment in the ED or a consent for admission to the hospital.

Patient #14

Patient #14 was admitted on [DATE] at 11:10 PM. The patient was admitted on [DATE] at 10:45 AM.

Review of Patient #14's record failed to reveal a consent for treatment in the ED or a consent for admission to the hospital.

Patient #18

Patient #18 was admitted on [DATE] at 6:15 PM. The patient was admitted to the inpatient unit at 11:00 PM on 4/8/13.

Review of Patient #18's record failed to reveal a consent for treatment in the ED or a consent for admission to the hospital.

Patient #19

Patient #19 was admitted on [DATE] at 10:10 AM. The patient was admitted as an observation patient to the inpatient unit at 12:43 PM.

Review of Patient #19's record revealed a consent for emergency treatment and financial agreement was signed. There was no consent for admission to the hospital.

On 4/10/13, the Director of Nursing (DON) reported a consent was to be obtained for every patient seeking emergency care and a separate consent for admission was signed upon admission to the inpatient unit. The DON reviewed the records and was unable to locate consents for Patients #2, #3, #4, #5, #6, #7, #9, #10, #11, #12, #14, #18, and #19.
VIOLATION: PHARMACY ADMINISTRATION Tag No: A0491
Based on document review, observation, and interview, the facility failed to ensure all pharmaceuticals listed on the formulary were available for use.

Findings include:

On 4/9/13, a tour of the emergency department was conducted. Six ten cc (cubic centimeters) syringes were observed on the counter.

On 4/9/13 at approximately 1:00 PM, the registered nurse (RN) working in the emergency department was interviewed and reported they were out of intravenous (IV) saline flushes, so they were drawing up saline from a 500 cc IV bag of normal saline at the beginning of the shift. Each syringe was observed to be timed, dated, and initialed by the RN who drew up the saline. The RN reported they were out of certain medications, including Etomidate, Bactrim, Tramadol, bacteriostatic water for injection, and saline flushes.

On 4/9/13, the facility pharmacy was inspected with the Director of Nursing (DON). The DON reported the facility had a pharmaceutical order in, but it was currently on hold due to payment concerns. The DON confirmed the facility was out of Etomidate, Bactrim, Tramadol, Medrol dose packs, Bacteriostatic water, and normal saline flushes. The DON also reported they were low on Solu-Medrol, but thought the supply would last until they received a shipment of medications. The DON reported the Cro-Fab, an anti-venom medication had expired 3/13, but they were keeping it in the event it was needed.

Review of the facility's formulary revealed there were par levels for each medication.

On 4/9/13, at approximately 3:45 PM, the pharmaceutical supply company representative was interviewed with the facility assistant administrator. The pharmaceutical supply company representative reported the last delivery to the facility was in January 2013, and they were currently on hold for lack of payment. The pharmaceutical supply company representative reported as soon as they received payment from the facility, the current drug order would be filled and shipped.

On 4/11/13, the facility provided confirmation the pharmaceutical supply company had received payment and was preparing the current drug order, with an estimated delivery time of three days.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on document review and interview the facility failed to collect data to monitor the effectiveness and safety of services and quality of care.

Findings include:

Review of the Risk Management and Quality Assurance (QA) minutes failed to reveal each hospital department was participating in the QA program or was collecting data to monitor the effectiveness of hospital services and quality of care.

The Director of Nursing was interviewed and reported they were still working on the QA indicators and data collection for each hospital department.
VIOLATION: USE OF VERBAL ORDERS Tag No: A0407
Based on record review and staff interview, the facility failed to ensure verbal orders were used infrequently for 20 of 20 patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20).

Findings include:

Review of emergency room patient records revealed verbal orders were used exclusively in the emergency department.

On 4/10/13 in the afternoon, Registered Nurse #7 reported only verbal orders were taken from the physicians and physician assistants in the emergency room . The nurse reported she would take verbal orders from the physician and later enter the orders into the electronic charting system.

On 4/11/13, the Director of Nursing reported only verbal orders were used in the emergency room . The DON reported verbal orders were given by the physician or physician assistant and were entered into the electronic charting system by the nurse. The DON reported there could be a delay in the entry of verbal orders onto the patient record. The DON reported there was "a near miss" medication error in the emergency department which caused the facility to make the decision to allow only verbal orders in the emergency room . The DON reported the near miss medication error was related to their electronic charting system when physicians were entering their own orders.

Nursing staff interviews confirmed there could be delays in order entry at times.

Record review revealed physician hand written orders were done once the patient left the emergency department and was admitted to the inpatient unit.

Review of the facility policy entitled "Physician Orders" effective 3/1/2002 and last revised 10/28/08, revealed the policy did not address the reduction of verbal orders. The policy did not address the situations in which verbal orders were to be used as well as limitations or prohibitions on their use. The policy did not reflect the use of an electronic record system.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on document review and staff interview, the governing body failed to ensure the hospital had a comprehensive quality improvement program.

Findings include:

The policy entitled Quality Assurance Committee Meetings, effective 3/1/2002 with a revision date of 5/26/2009, was reviewed and revealed:

"-The Quality Assurance Committee shall meet monthly to adopt, implement and monitor the comprehensive facility wide Safety Program...

- The Quality Assurance Committee will prioritize environment of care issues and will delvelop a plan of correction that is communicated to the appropriate Administrative and Performance Improvement Staff.

- The Quality Assurance Program will address requirements related to the staffing, equipping, operation and maintenance of the facility, and is designed to produce safe characteristics and practices and to eliminate, or reduce to the extent possible, hazards to patients, facility staff and visitors."

Review of available documents and risk management and quality assurance committee minutes did not identify current performance improvement measures for each hospital department with the exception of the infection control. Review of the risk management and quality assurance committee minutes did not reveal performance improvement priorities for the year, did not identify each departments improvement programs or measurable improvement towards their goals.

On 4/11/13 at approximately 3:30 PM, the Director of Nursing confirmed all hospital departments were not currently participating in the quality assurance/performance improvement process.