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Based on medical record review, review of facility policies and procedures and staff interviews, the facility failed to ensure adequate supervision by nursing to protect patients by transcribing provider orders including STAT (immediate need for lab) and transfer orders. The facility failed to transcribe 2 of 20 sampled patients (Patient 2 and Patient 6) physician orders timely. This failed practice had the potential to affect all patients of the hospital. On 5/21/2024 the inpatient census was 25.

Findings are:

A. Review of the medical record for Patient (Pt) 6 identified the patient was admitted 5/14/24 at 3:04 PM to the Long Term Care Hospital (LTCH are certified acute-care hospitals, but focus on patients who, on average, stay more than 25 days, many are transferred there from an intensive or critical care unit.) for care following a hospitalization for the treatment of respiratory failure requiring being intubated (placement of a tube down throat to lungs to provide breathing assistance by a machine/ventilator).

Review of the medical record identified the following:
-On 5/23/24 at 12:27 AM, the (Respiratory Flowsheet) identified that the patient was experiencing an increase in respiratory effort, requiring the Respiratory Therapist to change the settings on the ventilator to assist the patient with breathing effort.
-On 5/23/24 at 9:24 AM, the patient was experiencing a deterioration of the patients condition per the Provider Progress notes. Due to the patients deteriorating condition, the RN House Supervisor, Respiratory Therapist, and the Pulmonology (lung specialist) Physician Assist (PA-B) had to provide the patient immediate bedside care and orders.
-On 5/23/24 at 9:50 AM, PA-B ordered STAT (to be done immediately) lab including: Lactic Acid; Complete Metabolic Profile; Magnesium; Phosphorus and a Chest X-ray (the orders for STAT lab and x-ray are used to help manage the care of the patient at the time of the order).

B. Interview with the Quality Manager (5/23/24 at 10:20 AM) confirmed in a phone call to the Registered Nurse J (RN J), the house supervisor on 5/23/24 at 9:50 AM, that the lab and X-ray order for Pt 6, had not yet been drawn or completed. When inquired what the policy indicated a STAT order was to be completed, the Quality Manager stated, "I believe it is 30 minutes." "We have to notify contracting hospital of the STAT orders, we contract their services."

C. Review of the completed laboratory results ordered STAT on 5/23/24 at 9:50 AM, revealed the following:
-The results of the lab identified the Complete Metabolic Profile; Magnesium; Phosphorus were drawn on 5/23/24 at 11:07 AM. The STAT lab was drawn 1 hr and 27 minutes after the lab was ordered.
-The result of the Chest X-ray identified the STAT Chest X-ray was completed on 5/23/24 at 10:44 AM, 54 minutes after the Chest X-ray was ordered.

D. Interview with the Medical Director (MD-C a physician of Pulmonology) on 5/23/24 at 11:40 AM when asked how quickly STAT orders should be processed? MD-C stated, "I think ideally with in 30 minutes, especially if you are caring for a patient that is actively decompensating."

E. Review of the policy titled Orders (Revised 4/1/23) stated "STAT Orders should be administered within 30 minutes of the order being entered/written."

F. Interview with the Unit Clerk (UC-F) (5/23/24 at 11:30 AM) stated "STAT Orders if notified occur immediately. The issue this morning when those orders were placed (5/23/24 9:50 AM), I was busy scanning in the previous lab results from the early morning draw. No one came and verbally made me aware that a new STAT order was received, and I hadn't been back to my computer and refreshed it, so didn't know. Normally I refresh my computer to check my work list frequently, but I was away from the desk scanning, and there is not any type of notification that alarms of STAT orders. As soon as I know, I notify contracting hospital lab to tell them we have a STAT order."

G. Review of the form identified as Unit Secretary (Clerk) Workflow/Support Bulletin stated the following:
-Miscellaneous Lab Workflow: Physician enters lab order in Epic (Computer System) for Miscellaneous Lab and writes in the comments what the lab should be (i.e. STAT-NOW-Routine);
-Unit Clerk receives worklist task to transcribe into (contracted hospital EPIC);
-Phlebotomist collects specimen, labels with (contracted lab) label, and packages specimen with Epic order request for transport to lab;
-Specimens are processed; results print to the unit;
-Unit Secretary (Clerk) scans results, attaches to order and marks as final;
-Results available in Chart Review Critical results called to the unit."

H. Review of the medical record for Patient (Pt) 2, identified the patient was admitted 2/13/24 at 4:23 PM for care per the Physician Discharge Summary (Dated 3/15/24) following a hospitalization for the treatment of adenocarcinoma (cancer) of the stomach with gastrointestinal (GI) bleed and has been undergoing debilitation; severe protein caloric malnutrition and has been extremely weak. The patient had been periods of GI bleed with intermittent blood transfusions. The patient returned to this hospital on 3/22/24.

Review of the medical record identified the following:
-On 3/31/24 at 12:29 AM, the Physician Progress note stated the Patient examined and chart reviewed. The Nurse reported 400+ ml (milliliters) of bloody emesis and bleed from fistual (a tract under the skin). The patient has a history of GIB (gastrointestinal Bleed). Labs ordered. ER (Emergency Room) called for transfer.
-The patient was transported to the ED on 3/31/24 at 12:52 AM.

I. The CEO (Chief Executive Officer) verified (5/23/24 at 12:00 Noon) that the medical record for Pt 2 lacked a telephone order to transfer the patient to an acute care hospital on 3/31/24.

J. Review of the policy titled Order (Revised 4/1/23) stated under Procedures:
-Verbal Orders (VO) and Telephone Orders (TO); Verbal and telephone orders should be used only to meet the care needs of the patient when it is impossible or impractical for the ordering Licensed Provider to write/enter the order without delaying treatment.
-Entering VO/TO; Staff member taking the VO or TO will either enter it directly into computer system (CPOE) or transcribe it to the order sheet (written); CPOE:Staff member taking the order will select the "Verbal with read back" or Telephone with read back" order mode.