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Based on interview and record review, the hospital failed to follow its policy and procedure on Pain Management for one of 30 sampled patients (Patient 1). This failure had the potential for Patient 1's pain to not be addressed.

Findings:



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During a concurrent interview with Quality Improvement Coordinator 2 (QIC 2) and review of the clinical record for Patient 1, on 5/16/19, at 5:05 PM, the pain assessment dated 5/21/19 indicated Patient 1 complained of pain at 5/10 pain scale. The Medication Administration Record (MAR) indicated Patient 1 was given Acetaminophen (pain medication) 1000 mg (milligram, a unit of measurement) and Dilaudid (narcotic pain medication) 1 mg intravenously (IV-into the vein) on 5/21/18, at 5:47 PM. The medical record did not show evidence the patient's pain was reassessed for effectiveness after pain medications were administered. QIC 2 stated the patient should have been reassessed 30 minutes after pain medications were administered intravenously."

The hospital policy and procedure titled "Pain Management" dated 10/24/18, indicated ". . . Assess and document severity on the MAR for inpatient . . . prior to and after administration of scheduled PRN (as needed) pain relieving medications: a. 15 minutes after IV or 30 minutes after PO (oral) opioid (narcotic) medications. b. Within 1 hour or more frequently after each non-opioid."

Based on interview and record review, the hospital failed to develop and update individualized, person-centered care plans for four of 30 sampled patients (Patient 25, Patient 1, Patient 8, and Patient 14). This failure had the potential for unmet care needs.

1. During a concurrent interview with Risk Management Nurse (RMN) and review of the clinical record for Patient 25, on 5/14/19, at 9:35 AM, the RMN stated Patient 25 was having pain and was medicated so Patient 25 should have had a care plan for pain. The RMN reviewed the care plan and was not able to find evidence a care plan was developed to address the patient's pain.



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2. During a concurrent interview with Quality Improvement Coordinator 3 (QIC 3), and review of the clinical record for Patient 14, on 5/15/19, at 3:20 PM, Patient 14 was admitted for reopening of previous lumbar laminectomy (surgery that creates space by removing the lamina [back part of a vertebrae that covers the spinal canal]) on 3/4/19. QIC 3 reviewed the clinical record and was unable to find a care plan developed for pain. QIC 3 stated there should be a care plan developed for pain since the hospital needed to deal with Patient 14's pain after surgery.



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3. During a concurrent interview with Registered Nurse 2 (RN) 2 and review of the clinical record for Patient 8, on 5/14/19, at 10:10 AM, RN 2 reviewed the electronic care plan and was unable to find documentation of a care plan developed for Patient 8's admission problems. The History and Physical dated 5/13/19 indicated Patient 8 was admitted to the hospital on 5/13/19 for further evaluation and treatment of right flank pain (pain in one side of the body between the abdomen and the back and indicative of a kidney problem), nausea, and presence of right ureteral calculus (stone in the ureter [tube through which the urine passes from the kidney to the bladder]). RN 2 verified the findings.

4. During a concurrent interview with QIC 2 and review of the clinical record for Patient 1 on 5/16/19, at 5:05 PM, QIC 2 was not able to find documentation of a care plan written for pain. The Medication Administration Record (MAR) indicated Patient 1 was given Acetaminophen (pain medication)1000 mg (milligram, a unit of measurement) and Dilaudid (narcotic pain medication) 1 mg intravenously (IV-into the vein) on 5/21/18, at 5:47 PM. The medical record did not show evidence Patient 1 was reassessed after pain medications were administered. QIC 2 verified there was no pain care plan to guide the nurse to reassess Patient 1.

The hospital policy and procedure titled "Multidisciplinary Patient Care Plan [MCP]-Acute Care" dated 4/24/18, indicated " Guidelines/Policy Statement: 1. A multidisciplinary plan of care will be initiated in the electronic health record for each patient from admission to discharge. . . 5. The MCP will be utilized to identify active clinically relevant patient problems and needs, interventions and goals/outcomes to meet the needs of the patient. . . Procedure: 1. Each discipline of the Multidisciplinary Care team will document the problem assessment on the MCP. . ."

Based on interview and record review, the hospital failed to ensure medical records were accurate for one of 30 sampled patients (Patient 16). This had the potential for adverse consequences when determining the patient's ongoing care.

Findings:

During a concurrent interview with Quality Improvement Coordinator 3 (QIC 3) and review of the clinical record for Patient 16, on 5/14/19, at 2:35 PM, the "Operative Report" dated 5/1/18, indicated under OPERATION PERFORMED: "1. Anterior cervical discectomy [removal of a disc in the neck] C [cervical] 3-C4 and C4-C5 2. Spinal canal decompression, C3-C4 and C4-C5 [procedures intended to relieve symptoms caused by pressure, or compression, on the spinal cord and/or nerve roots]." The Anesthesia Record dated 5/1/18, Anesthesia Time Start (0742) indicated under Anesthetic Plan "General [a state of unconsciousness produced by anesthetic agents]." The Anesthesia Physician Note Final Report dated 5/1/18, Time (1308) indicated under Anesthesia utilized: "Regional: Spinal [injection of an anesthetic into the spinal canal that reduces sensitivity to pain without loss of consciousness]." QIC 3 was informed regarding the discrepancies in the medical record. QIC 3 reviewed the medical record and stated Patient 16 had general anesthesia according to the Anesthesia Record and did not know why the Anesthesia Physician Note Final Report indicated Regional: Spinal.

The hospital policy and procedure titled "Accurate and Proper Documentation of Medical Records" dated 1/22/19, indicated under Policy: "It is the policy of the hospital to provide a medical record of the patient that is timely, meaningful, authentic, accurate and legible description of the patient's clinical condition and treatment course."

Based on interview and record review, the hospital failed to ensure all verbal/telephone orders were authenticated by the providers within 48 hours for three of 30 sampled patients (Patient 22, Patient 23, and Patient 12). This failure placed patients at risk for medical errors and transcription errors which had the potential to adversely affect patient safety.

Findings:

During a concurrent interview with the Risk Management Nurse (RMN) and review of the clinical record for Patient 22, on 5/14/19, at 1:47 PM, a verbal/telephone order to discontinue a regular diet was entered and electronically signed on 5/1/19, at 10:53 AM by Registered Nurse 3 (RN 3). On 5/2/19, at 5:05 PM a verbal order for bethanechol (used to treat bladder problems) 30 milligrams one tablet once was entered and electronically signed by RN 4, and on 5/2/19, at 6:32 PM, RN 4 entered and electronically signed a verbal order for straight cath ([catheterization] placement of a tube into the bladder). These orders were not authenticated by Physician 1 within 48 hours. The RMN verified the findings.

During a concurrent interview with the RMN and review of the clinical record for Patient 23, on 5/14/19, at 3:17 PM, a verbal/telephone order for insulin Lispro (used to lower blood glucose) 5 units subcut ([subcutaneous] under the skin) TID (three times a day), insulin Glargine (helps move sugar from the blood into other body tissues) 20 units subcut qhs (every evening) and Lopressor (used to treat high blood pressure) were entered and electronically signed on 5/9/19, at 7:20 AM, by RN 5. These orders were authenticated by Physician 4 on 5/14/19, at 12:15 PM, which was five days later. The RMN verified the orders were not authenticated within 48 hours.



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3. During a concurrent interview with Quality Improvement Coordinator 3 (QIC 3) and review of the clinical record for Patient 12, on 5/15/19, at 2:55 PM, Patient 12 was admitted on 1/14/19, and was discharged on 1/16/19. There was a verbal order electronically entered by a registered nurse on 1/14/19, for Colace (stool softener) 100 milligrams 1 capsule two times daily, hold for loose stools. QIC 3 was unable to find evidence the physician authenticated this verbal order within the required period of authentication. QIC 3 stated the physician should authenticate the verbal order within 48 hours.

The hospital policy and procedure titled "Accepting Written, Verbal, and Telephone Physician Orders" dated 1/23/19, indicated ". . .g. Telephone and verbal order will be dated and authenticated within 48 hours by the ordering practitioner or another practitioner who is responsible for the care of the patient."

Based on interview and record review, the hospital failed to ensure pre-operative x-rays were done according to the physician's order for one of 30 sampled patients (Patient 2). This failure had the potential to delay surgery.

Findings:

During a concurrent interview with Registered Nurse 3 (RN) 3 and the Medical Surgical Nurse Manager (MSNM) and review of the clinical record for Patient 2, on 5/14/19, at 9:15 AM, RN 3 reviewed the Orthopedic Consultation Note dated 5/14/19, which indicated "Patient 2 was knocked over at work yesterday with immediate onset (sic) left hip and inability to bear weight . . . Patient 2 was . . . diagnosed with left displaced femoral neck fracture [broken hip]." RN 3 reviewed the Physician's Orders and noted the following x-rays ordered on 5/14/19 between 2:42 AM to 2:46 AM:

Two Pelvis XRs (x-rays) ordered as soon as possible (ASAP), two or more Femur (bone in the upper leg) XRs ASAP, Chest XR ordered immediately (STAT), and two forearm XRs ordered ASAP. These XRs were not done until 5/14/19 at 9:41 AM, seven hours after the order.

During an interview with RN 3 and the MSNM on 5/14/19, at 9:25 AM, RN 3 and the MSNM were not able to provide explanation for the delay in getting the x-rays done as ordered. RN 3 stated "STAT means the order should be done within 15 minutes and ASAP means the orders should be done within 45 minutes."

The hospital policy and procedure titled "Results Reporting" Imaging Department, dated 1/24/18, indicated " . . .All procedures ordered as STAT will automatically be moved to the next highest level on the current PACS (Picture Archiving Communication System) work list and manually populated as a STAT in PACS and processed as a Critical Result finding."

The hospital policy and procedure titled "Lab Turn Around Time" dated 7/25/18, was provided by hospital staff who indicated the laboratory turn around time was used as a reference for the radiology department as well. The following turn-around times guidelines are used:

STAT - 15-60 minutes
ASAP - 45-120 minutes

Based on interview and record review, the hospital failed to follow its policy and procedure on Informed Consent (the process in which the patient or his/her representative is informed by the treating physician of the nature of the procedure, the expected benefits, any discomfort or risks that may occur, and a description of any alternative methods of treatment) for one of 30 sampled patients (Patient 4) when the informed consent was obtained by Registered Nurse 2 (RN 2) prior to the surgeon informing the patient of the nature, the risks, benefits, and alternatives of the surgery. This failure had the potential to misinform the patient or his/her representative of the treatment or procedure.

Findings:

During a concurrent interview with RN 2 and review of the clinical record for Patient 4, on 5/14/19, at 10 AM, RN 2 reviewed the Informed Consent form and found the document was signed by the patient on 5/13/19, at 4:40 PM. Patient 4's medical record did not show evidence of a Physician Progress Note indicating the surgeon discussed the risk, benefits, and alternatives of the proposed surgery. RN 2 stated, "The doctor has not come to talk to the patient. There was an order for it [the consent] so I did it [obtained the patient's signature]."

The hospital policy and procedure titled "Informed Consent" dated 3/18, indicated ". . .4. The Role of the Physician in the Informed Consent Process: It is the responsibility of the treating physician to obtain the patient's informed consent. The Hospital shall not be involved in providing the information necessary to secure the patient's informed consent or responding to the patient's questions concerning the procedure. The duty to provide this information and obtain the patient's informed consent is the exclusive duty of the treating physician. . . b. The physician shall document in the patient's Hospital medical record that a discussion and the general substance thereof was held with the patient and that the patient's informed consent was obtained. . ."

Based on observation, interview, and record review, the hospital failed to ensure one anesthesiologist (Physician 3 - a physician certified and legally qualified to administer numbing medications for surgery) monitored one of 30 sampled patients (Patient 3) while Patient 3 was under general anesthesia. This failure had placed Patient 3 at risk for harm during surgery.

Findings:

1. During an observation of a surgical procedure on 5/15/19, at 2:20 PM, in Operating Room 8 (OR 8), while Patient 3 was under general anesthesia, Physician 3 was observed with his back away from the patient, removed six vials of medications from the automated pharmacy dispensing cabinet located by the anesthesia machine. Then, he proceeded to draw up each medication into individual syringes and placed all syringes back into the automated dispensing cabinet.

During a concurrent interview with Physician 3 and review of the medications that had been pre-drawn, on 5/15/19, at 3:07 PM, he stated, "Yes, I was preparing medications for the next case." Physician 3 reviewed the surgery schedule that was in his possession, and stated he was preparing it for Patient 8. Physician 3 stated, "The surgeon told me he had to get out of here so I did it to save time." Physician 3 opened the automated pharmacy dispensing cabinet and took the pre-prepared medications out of the drawer. The following medications were pre-drawn for the next surgical patient:

a. Propofol (a strong anesthetic used to help one relax before and during general measurement) 200 mg (milligram, a unit of measurement).
b. Zemuron (medication used to relax the muscles) 50 mg.
c. Fentanyl (an opioid [narcotic] used as a pain medication) 15 mcg (microgram, a unit of measurement).
d. Neostigmine (agent of choice to reverse Neuromuscular Blockade (NMB) after muscle paralysis during general anesthesia) 5 mg.
e. Robinul (given before surgery to reduce secretions in the mouth, throat, airways, and stomach) 0.4 mg.
f. Acetaminophen (used to treat mild to moderate pain and to reduce fever) 1000 mg IV (intravenous-into the vein) bottle.

2. During a concurrent observation and interview with the Quality Improvement Coordinator 1 (QIC 1), on 5/15/19, at 2:25 PM, in OR 8, Patient 3 was on the surgical table, under general anesthesia for a surgical procedure. Physician 3 was observed sitting behind the patient's head and facing the anesthesia machine. Physician 3's eyes were noted to be closed for approximately three minutes. At 2:28 PM, when the surgeon spoke and asked to do a second sponge/sharp count, Physician 3 got startled and stood up and peaked his head by the surgical barrier (a sheet that separates the sterile field from the non-sterile field). QIC 1 verified the findings.

During an interview with Physician 3, on 5/15/19, at 3:05 PM, he stated, "I have been up since 6:30 AM and was on-call for the obstetrics cases last night (5/14/19). I was called to come in at 6:30 PM (5/14/19). I have not slept but I am okay. I returned again today (5/15/19) for the cases."

The hospital policy and procedure titled "Facility Rules and Regulations Department of Surgery Anesthesia Section," undated, indicated ". . .Standard 1 Qualified anesthesia personnel shall be present in the room throughout the conduct of all general anesthetics, regional anesthetics and monitored anesthesia care. Because of the rapid changes in patient status during anesthesia, qualified anesthesia personnel shall be continuously present to monitor the patient and provide anesthesia care. Standard 11 During all anesthetics, the patient's oxygenation, ventilation, and circulation shall be continually evaluated. . ."