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SAMARITAN MEDICAL CENTER 830 WASHINGTON STREET WATERTOWN, NY 13601 April 5, 2017
VIOLATION: OUTPATIENT SERVICES: STANDARD LEVEL Tag No: A1080
Based on findings from interview, the hospital lacked evidence that its medical staff adopted a policy that allowed practitioners without hospital privileges to order outpatient services. This could lead to outpatient services being ordered by a practitioner who is not authorized by the hospital.

Findings include:

-- Per interview of Staff A on 4/4/17 at 12:00 pm, he/she accepts orders for laboratory and radiology services from practitioners who are not on the medical staff at Samaritan Medical Center (SMC). If a requisition is received for laboratory or radiology services from a practitioner, the diagnostic test is performed or obtained. He/she was not aware whether the hospital had a system to verify practitioner qualifications when the practitioner is not on the medical staff at SMC.

-- During interview with Staff B on 4/4/17 at 2:00 pm, he/she acknowledged lack of a hospital policy approved by the medical staff authorizing practitioners not on the hospital's medical staff to order outpatient services.
VIOLATION: STANDARD TAG FOR OUTPATIENT SERVICES Tag No: A1081
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on findings from medical record (MR) review, interview, document review and observation, the facility did not ensure that medication administration in an outpatient clinic met acceptable standards of medication practices. Specifically, 1) in 1 of 7 MRs reviewed, a patient (Patient #1) received an incorrect medication, 2) in 4 of 5 MRs reviewed (Patient #"s 2, 3, 4 and 5) of patients receiving BCG bladder instillations, practitioner medication orders contained incorrect dosages, 3) in 1 of 1 MR reviewed (Patient #6) a provider order for a intramuscular (IM) medication lacked a route of administration, 4) physician orders were not placed in a consistent area in the MR and 5) pharmacy oversight of medication administration in the outpatient clinics was lacking. This could place patients at risk for errors in administration of medications.

Findings regarding (1) include:

-- Per MR review, Patient #1 (MDS) dated [DATE] for Dimethyl Sulfoxide (DMSO) bladder instillation for interstitial cystitis. The practitioner order for DMSO instillation was dated 10/18/16.
Nursing documentation (documented at 12:02 pm), indicated that RIMSO (DMSO) was instilled in the bladder using a temporary bladder catheter as ordered. Additional nursing documentation (documented at 12:03 pm,) indicated administration of Live BCG (live attenuated [DIAGNOSES REDACTED] used in the treatment of [DIAGNOSES REDACTED]) reconstituted with 50 milliliters (ml) normal saline via a temporary bladder catheter using sterile technique.

-- Per interview with Staff C on 4/4/17 at 2:30 pm, the involved nursing staff member instilled BCG instead of DMSO as ordered and did not verify the medication (with another staff member) as required per clinic policy and procedure (P&P).

Findings regarding (2) include:

-- Review of the facility's P&P titled "BCG Live (Intravesical) Preparation and Instillation," last revised 1/2017, indicated that staff should prepare BCG live instillation using one vial of BCG. No dosage is indicated in the facility P&P.

-- Per review of Patient #2's MR, on 3/24/17 at 10:34 am, Staff D documented "Continue BCG Live suspension reconstituted, 80 milligrams (mg)/0.8 ml, intravesical, with 50 ml sodium chloride (NaCl) and 5 ml 2% lidocaine jelly, once a week x 3 weeks ... via straight cath." Nursing documented intravesical administration of BCG (no dose specified).

-- Per review of Patient #3's MR, on 1/25/17 at 3:30 pm, Staff E documented "Continue BCG Live suspension reconstituted, 81 mg/vial, as directed in 50 ml normal saline intravesical through 16 french temporary catheter, once weekly x 3 weeks, 1 vial, 2 refills." Nursing documented intravesical administration of BCG (no dose specified).

-- The same BCG dose orders were in Patients #4's and #5's MRs.

-- Per observation of BCG ordering by Staff E on 4/5/17 at 10:30 am, 2 dosage choices were available from the drop down menu on the screen in the MR used for BCG Live orders: 81 mg/vial or 50 mg/vial.

The providers were ordering 81 mgs/vial. However, the BCG dosage available at the clinic was 50 mg/vial.

-- Per interview of Staff F on 4/14/17 at 2:15 pm, BCG dosage information previously entered in the MR by information technology staff did not reflect the BCG preparation on hand at the clinic. He/she acknowledged the incorrect dosage in practitioner medication orders for BCG.

Findings regarding (3) include:

-- Review of the facility's P&P titled "Medication Orders in SFHN (Samaritan Family Health Network) Clinics- Documentation," last revised 9/2014, indicated that the provider should document date, time, name of medication, dose and route in the medication order prior to its administration.

-- Per review of Patient #6's MR, on 4/3/17 at 8:00 am, Staff G ordered Depomedrol 80 mg to be given "by injection." The order lacked a route of administration (e.g., IM, subcutaneous or intravenous).

-- Per interview of Staff H on 4/4/17 at 4:00 pm, the ordering practitioner was unable to indicate route in the ordering section of the MR and had verbally instructed Staff H regarding the route for administration.

Findings regarding (4) include:

--Per review of Patient #2's MR, on 3/24/17 at 10:34 am, BCG orders were documented in a telephone encounter under the "refill" section and again in a "virtual visit" under treatment.

-- Per review of Patient #5's MR, on 1/17/17 at 11:30 am, BCG orders were documented in the appointment section of the 1/17/17 cystoscopy appointment under the tab labeled "orders."

--Per observation on 4/5/17 at 11:00 am, Staff F was unable to find practitioner orders for Patient #5. He/she acknowledged this finding at the time of observation and revealed practitioner orders are not in a central location and are difficult to locate.

--During interview of Staff I on 4/5/17 at 10:00 am, he/she acknowledged that clinic nursing staff review several different areas of the MR in order to locate a current BCG order when the order is written several weeks earlier by the practitioner. If staff are unable to locate a current BCG order in the treatment section of the MR, they call or email the practitioner to obtain an order. The practitioner then documents the order in a virtual telephone encounter. He/she acknowledged that the lack of a specific location in the MR for medication orders can make finding the medication order confusing for nursing staff.

Findings regarding (5) include:

--During interview with Staff J (Director of Pharmacy) on 4/5/17 at 8:15 am, he/she acknowledged that pharmacy staff do not review medication orders that are written by practitioners in the SFHN clinics. This includes practitioner orders for BCG.