HospitalInspections.org

Based on observation, record review, and interview the hospital failed to ensure the address and phone number to the State agency was made available to patients and their representatives and to inform the patient/patient representative(s). Findings:
Review of the policy and procedure titled "Complaint and Grievance Process" , number C06-A, revised dated of 01/01/12 and provided as current policy by the Chief Nursing Officer (CNO) S2 revealed, in part, the following: Procedure: ... 2. The grievance procedure is posted in a public area of the hospital ... The patient is also notified of the state survey agency, phone number, and address.
An observation made during an initial tour of the hospital on 1/7/13 from 9:45 a.m. to 10:00 a.m. revealed a document entitled "Quality Call " posted on a board in the front hallway leading to the administrative offices. The document contained the name and title of the Director of Quality Management (DQM), S5 and his phone number. Further review revealed information stating that concerns could be submitted to DQM, S5 with the name and address of the hospital. The document then read, "Additionally, you may call or write the state survey agency at: State of Louisiana, Department of Health and Hospitals" with the mailing address noted. There was no phone number for the Department of Health and Hospitals (DHH).

In an interview conducted 1/7/13 at 9:55 a.m. with CNO, S2 she verified no phone number was provided on the posted document titled "Quality Call" for a patient (or their representative) to call with a concern or complaint to the state agency. She reported that each patient is provided documents that include Patient's Rights on admission. CNO S2 verified that other posting around the hospital addressed privacy rights only and did not include the name or contact information for the State agency.

Review of a group of documents to be given to newly admitted patients, provided by CNO S2, included a document titled "Patient's Rights" , which was a 4 page document. Further review of the Patient Rights document revealed, in part, (page 1, Section 3) "Grievances: ...You may voice grievances and recommend changes in policies and services to the Hospital staff, to an individual designated by the Hospital for such purpose, or to outside representatives of your choice. The Hospital's Patient Representative functions as the primary contact to receive complaints from patients regarding Hospital services. You or the individual designated to the Hospital will be made aware of the state Department of Health to which you may address grievances." No state agency name, address or phone number to which complaints/grievances could be made was noted. The document did not inform the patient (or representative) that a grievance could be lodged with the State agency regardless of whether he/she had first used the hospital's grievance process.

In an interview conducted 1/9/13 at 11:15 a.m. with DQM S5 he verified that the name, address, and phone number was not included in the information given to each patient/patient representative. He verified that the State Agency name and address (no phone number) for complaints/grievances was only displayed on a board on the wall in the front hallway leading to administrative offices, and that not all patients and/or patient representatives used that hallway. DQM S5 also confirmed that no notices provided to the patients (and/or representatives) informed them that the hospital grievance process did not have to be used before contacting the state agency regarding a complaint.

Based on record review and interview the hospital failed to follow their policy and procedure for determining and ordering a "do not resuscitate" (DNR) order for 2 of 6 (#7, #25) current patients with a DNR Order from a total of 30 sampled patients as evidenced by: 1) A DNR status implemented with no documented evidence of a signed physician's order (#7); 2) No documented evidence of a physician progress note of the discussion of the patient's code status (#25); and, 3) Failure to notify the physician of changes in the code status of the patient (#25).
Findings:

Review of the policy and procedure titled, "DNR, Cardiopulmonary Arrest, Directive for Care", number D02-A, revised date of 10/01/11, and provided as current policy by the Chief Nursing Officer (CNO) S2, revealed in part the following:
Purpose: To provide a clear, consistent, and concise method for documenting the options to be taken in the event of a cardiopulmonary arrest; to provide a consistent written format and to assure its availability to all caregivers.
Policy: If there is no directive for care or written order regarding actions in response to a cardiopulmonary arrest, all efforts will be utilized in the resuscitation.
When an order is written outlining the resuscitative efforts it must be documented in the Physician Progress Notes.
Any hospital staff member who receives information regarding the code status (cardiopulmonary resuscitation efforts) of or about a patient at Hospital must report that information to the physician caring for the patient.
A physician must document in the progress notes any discussions that establish or change the code status of patients.
If a physician telephones a code status or change in status in on a patient, the progress note must be written within 24 hours.
The order must be signed by the physician.... If the order is a telephone order for the DNR then the nurse must document the specific order pertaining to the patient's code status. The physician who gave the telephone order must countersign the order within 24 hours....


1) A DNR status implemented with no documented evidence of a signed physician's order:

Patient #7
Review of the medical record for Patient #7 revealed the patient was a 72 year old female who was admitted to the hospital on 09/18/12 and was a current patient in the hospital. The patient's diagnoses included Respiratory Failure, End Stage Renal Disease, Sepsis, Pancreatitis, Obesity, and Tracheostomy. Further review of the patient's medical record, revealed the outside of the medical record was flagged "DNR".

Observation of the dry erase board in the nurse's station where Patient #7 was located, revealed that part of the patient's name, the patient's room number, the nurse assigned to the patient, the patient's physician, and the code status of "DNR" was posted on the board. The dry erase board was in plain view from the hall in front of the nurse's station.

Review of the physician's orders for Patient #7 revealed a "Resuscitation Orders/Consent form with "Do Not Resuscitate (DNR)" check on the form. The form revealed the husband of Patient #7 had signed the form on 12/02/12 at 1435 . The form revealed RN(Registered Nurse) S6 signed the form as a witness on 12/02/12 at 1435. There was no documented evidence of a physician's signature on the order/consent form.

Review of the "24 Hour Patient Record & Plan of Care" dated 01/05/13 and 01/06/13 revealed the Code Status was documented as "DNR".

In a face-to-face interview on 01/07/13 at 3:00 p.m. RN Charge Nurse S3 reviewed the medical record for Patient #7 and verified the "DNR" Order/Consent form was not signed by the physician. RN Charge Nurse S3 stated the Order/Consent form was the correct form to use for a DNR and should have been signed by the physician. RN Charge Nurse S3 verified the patient's medical record was flagged as a "DNR" and the patient information (dry-erase) board in the nurse's station indicated the patient was a "DNR" RN Charge Nurse S3 verified the "24 Hour Patient Record & Plan of Care" forms revealed the patient's code status was "DNR".




30420

2) No documented evidence of a physician progress note of the discussion of the patient's code status, and 3) Failure to notify the physician of changes in the code status of the patient:
Patient #25 Review of the medical record for Patient #25 revealed the patient was a 71 year old male admitted to the hospital on 01/05/12 and was a current patient in the hospital. The patient ' s diagnoses included Terminal Pancreatic Cancer, Malignant Ascites, and Bacteremia.
Observation of a dry erase board at the nurse's station where Patient #25 was located revealed a portion of his name, his room number, his assigned nurse, his physician, and a code status of "Full" (Full code).
Review of the physician's orders for Patient #25 revealed a documented code status of DNR (Do Not Resuscitate). Further review of Patient #25's physician's orders revealed a page titled Resuscitation Orders/Consent with Do Not Resuscitate check marked with an X. The orders were stamped with a "Read back and verified telephone order" stamp that had a line for the physician's signature, and under the line, the stamp contained the name of an APRN (Advanced Practice Registered Nurse) and the Physician's name. The signature line was signed by the physician. A date and time of 01/07/2012, 1900 (7:00 p.m.) had been written. The order sheet contained no signature of Patient #25 (or his surrogate) or a witness. The order had not been noted by a nurse.
Review of Progress Notes by APRNs on 1/07/13 (dictated 1/7/13 at 1934{7:34 p.m.}) and 1/8/13 (dictated 1/8/13 at 1600{4:07 p.m.}) revealed an entry under Assessment and Plan that read, in part, "...Continue supportive care. The patient is DO NOT RESUSCITATE." Further review of progress notes revealed a handwritten note by an APRN dated 1/8/13 at 1345 (1:35 p.m.) that did not address Patient #25's code status. The note was counter-signed by the physician, with no mention of Patient #25's code status.

Review of the "24 Hour Patient Record & Plan of Care" dated 01/07/13 and 01/08/13 revealed the Code Status was documented as "FULL". Further review of nurse's notes revealed an entry 1/07/13 at 2000 (8:00 p.m.) that read, in part: ... "APRN for MD is aware of pain and reports to me there are a lot of family dynamics involved. The pt (patient) has an order for a DNR, however the pt son states 'he wants to live' and says 'my father wants to be resuscitated if necessary' ..."
There were no notations that the APRN(s) or physician were notified of the family member's communication that was in conflict with the DNR orders.

Review of the Discharge Planning Documentation revealed that Patient #25's discharge plan at the time of admission was to go home with home health or Hospice. The case manager's plan was to monitor and coordinate discharge. The discharge plan documented that the patient did not have an Advanced Directive. The patient/family reaction to/acceptance of the discharge plan (required per form) was blank.

In a face to face interview conducted 1/9/13 at 3:30 p.m. Charge Nurse S3 verified that a Do Not Resuscitate order had been signed by the physician, but not the patient or a patient representative, was on the patient's medical record. He also verified that the 24 hour Patient Record and Plan of Care, as well as the dry erase board designated Patient #25 as a "Full Code". He reported that there were many family dynamics going on, and the family could not agree on the patient's code status. He confirmed there was no documentation on the patient's record that an APRN or physician had been notified of the family's inability to reach an agreement with the DNR status.

In a face to face interview conducted 1/9/12 at 2:50 p.m. the Chief Nursing Officer S2 reviewed the DNR, Cardiopulmonary Arrest, Directive for Care Policy, and verified that it required a physician to document in the progress notes any discussions that establish or change the code status of a patient. CNO S2 also verified that the policy required any staff member who received information regarding the code status of or about a patient at the hospital must report that information to the physician caring for the patient. After review of Patient #25's medical record CNO S2 confirmed the above findings.

Based on record review and staff interview, the Governing Body failed to ensure that the QAPI program involved all hospital departments and services as evidenced by failing to include the Radiology Department in the QAPI program. Findings:

Review of the hospital's Quality Assessment and Performance Improvement Plan (QAPI) revealed in part the following:
B. Patient Focused Functions
3. At a minimum the following services, either hospital-owned or contracted, shall participate: a) dialysis services; b) dietary services; c) environmental services, housekeeping and plant operations; d) laundry/linen services; e) nursing services; f) rehabilitation services; g) respiratory services; h) pharmaceutical service; and i) case management services.

Review of the QIC (Quality Improvement Committee) quarterly reports for the first through third quarters of 2012 revealed no documented evidence the Radiology Department was included in the QAPI program.

In a face-to-face interview on 01/09/13 at 1:40 p.m. the Director of Quality Management S5 verified the hospital's Radiology Department was not included in the QAPI program.

Based on record review and interviews, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care of each patient.
1) The RNs failed to follow the hospital policy and procedure for continuous infusion of an anesthetic agent (Propofol) by: failing to notify the pharmacist prior to initiation of the therapy, initiate infusion rate per protocol, monitor and document the patient's level of sedation, monitor and document the patient's vital signs per protocol and clarify the physician's orders for the specific dose of the medication and the parameters for titration for 2 of 2 current sampled patients reviewed for Propofol infusions out of a total sample of 30 (#5, #10);
2) The RN failed to ensure all telemetry strip interpretations performed by a monitor technician were validated, completed and signed as per the hospital policy for 4 of 7 (#3, # 22, #26, #27) telemetry patients reviewed for telemetry monitoring from a total of 30 sampled patients.
Findings:


1) The RNs failed to follow the hospital policy and procedure for continuous infusion of an anesthetic agent (Propofol):

Review of the hospital policy titled, "Critical Drip: Continuous Infusion of Propofol in the Mechanically Ventilated Patient", Policy number C39-N, Revised date of 01/12, and provided as current policy by the RN Charge Nurse, S10, revealed in part the following:
Purpose: Propofol is a sedative/hypnotic drug with characteristics including a rapid onset of effect and rapid termination of sedation. Propofol will be administered by a registered nurse (RN) skilled in the management of intubated patients who are mechanically ventilated. The infusion rate will be adjusted to maintain an adequate level of sedation per the Richmond Agitation-Sedation Scale (RASS).
Policy:....2. Pharmacy must review the physician order prior to initiation of therapy. ***Note: Propofol is a High Risk Medication in Group 1 and must be prepared by the pharmacist when available. During off hours the charge nurse must contact the pharmacist On-Call to review product instructions and dosage.....6. Initiate infusion at 5 mcg/kg/min. (Micrograms per Kilogram per Minute). Obtain a baseline BP (Blood Pressure) prior to initiation. 7. Titrate infusion at 5 mcg/kg/min increments every 5 minutes. Titrate to desired level of sedation, as ordered by the physician. (Usual level of sedation is -1 to -3). Usual dose range 5-80 mcg/kg/min. Monitor the BP every five minutes during active titration. 8. Once the maintenance dose is achieved, monitor the patient's VS (Vital Signs) using standard vital sign monitoring routine for critical drips. Check RASS with each VS check.
Patient Assessment: 1. Document vital signs before initiation of therapy, 5 minutes after initiation of therapy, every 15 minutes X 4 (every 15 minutes for 1 hour), every 30 minutes X 4 (2 hours), every hour X 4 (hours), and then every 2 hours thereafter while stable. Repeat vital sign procedure for any rate change. Check vital signs every 5 minutes if patient is unstable. 2. Assess at baseline and after each dose titration: oxygen saturation, blood pressure, level of sedation: RASS....5. Vital signs, O2 sats (Oxygen saturation), RASS scale, and infusion rates must be documented on the Frequent Monitoring/Critical Medication Flowsheet.

Review of the hospital policy titled, "Orders, Physician", Policy number O02-G, Revised date of 01/01/13, and provided as current policy by the Chief Nursing Officer S2, revealed in part the following: .... Order Transcription-Medications. Policy: 1. A complete medication order consist of: A. Name of medication B. Dose of medication C. Frequency of administration D. Route of Administration E. Comments/qualifying phrases are optional for scheduled medications but are required for PRN (As Needed) orders, (i.e., for severe pain)....


Patient #5
Review of the medical record for Patient #5 revealed the patient was an 88 year old male admitted to the hospital on 12/29/12 at 1:45 p.m., and was currently a patient in the hospital. The patient's admitting diagnoses included: Multi-Organ Failure, End Stage Renal Disease, and Atrial Fibrillation with Rapid Ventricular Response. Review of the Admission Orders dated/timed 12/29/12 at 12:30 p.m. as a verbal order, revealed the patient was on Mechanical Ventilation and, "Propofol IV (Intravenous) PRN (as needed) for sedation" was ordered. There was no documented evidence of any further orders for Propofol, and there was no documented evidence the RN had obtained any clarification orders from the physician for the specific dose, for the desired level of sedation, or for the titration parameters.

Review of the, "Frequent Monitoring/Critical Medication Flowsheet" dated/timed 12/29/12 1400 to 12/30/12 0800 revealed the patient was on 20 mcg/kg/min at 1400. There was no documented evidence of the patient's level of sedation (RASS) documented on the "Frequent Monitoring/Critical Medication Flowsheet" as the policy directed, nor was there documentation of the RASS sedation level in the nurse's notes dated 12/29/12.
Further review of this flowsheet revealed Vital Signs were documented every 2 hours until 0500, when the medication rate was decreased to 18.99 mcg/kg/min. Vital Signs were then monitored every hour. There was no documented evidence the Vital Signs were monitored 5 minutes after the medication rate change, every 15 minutes X 4, or every 30 minutes X 4. Review of the Flow Sheet revealed the rate was again decreased to 15.98 mcg/kg/min at 0800, but the Vital Sign monitoring was was not increased as hospital policy directed.

Review of the, "Frequent Monitoring/Critical Medication Flowsheet" dated/timed 12/30/12 0900 to 12/30/12 1800 revealed the patient's medication rate/dose was decreased at 1100 (12.98 mcg/kg/min) and 1230 (10 mcg/kg/min), then increased at 1530 to 12.99 mcg/kg/min. There was no documented evidence of the patient's level of sedation (RASS) documented on the flow sheet and there was no documented evidence the patient's Vital Signs were monitored according to hospital policy and procedure (5 minutes after rate change, then every 15 minutes X 4, then every 30 minutes X 4).

Review of the, "Frequent Monitoring/Critical Medication Flowsheet" dated/timed 12/30/12 1900 to 12/31/12 0600 revealed the patient remained on the same dose of 12.99 mcg/kg/min., Vital Signs were documented every 1 hour, but there was no documented evidence of the patient's level of sedation (RASS) as directed in the policy and procedure (RASS to be documented with Vital Signs on Flowsheet).

Review of the, "Frequent Monitoring/Critical Medication Flowsheet" dated/timed 12/31/12 0700 revealed the only entry on the log was at 0700. The log revealed the patient was on 12.99 mcg/kg/min and there was no documentation of the patient's level of sedation.

There was no documented evidence of any monitoring of the Propofol infusion from 0700 to 1900 on 12/31/12.

Review of the, "Frequent Monitoring/Critical Medication Flowsheet" dated/timed 12/31/12 1900 to 01/01/13 1200 revealed the patient's rate/dose for the Propofol was 10 mcg/kg/min. There was no documented evidence in the patient's record of when the rate/dose was decreased to 10 mcg/kg/min. and there was no documented evidence the patient's Vital Signs and level of sedation were monitored according to the policy and procedure.

Review of the, "Frequent Monitoring/Critical Medication Flowsheet" dated/timed 01/01/13 1300 to 01/01/13 2400 revealed the patient remained on the same dose of 10 mcg/kg/min., Vital Signs were documented every 1 hour, but there was no documented evidence of the patient's level of sedation (RASS) as directed in the policy and procedure. Review of this flow sheet revealed the Propofol infusion rate/dose was not documented after 1900.

Review of the "24 hour Patient Record & Plan of Care" (Nursing documentation) dated 12/31/12 and 01/01/13 revealed the patient's RASS (Level of Sedation) was documented only once a shift.

In a face-to-face interview on 01/09/13 at 9:50 a.m. RN S6 verified she was assigned to Patient #5 when he was admitted to the hospital. RN S6 stated the patient was transferred from another hospital with the Propofol infusion in progress at 20 mcg/kg/min. After reviewing the medical record for Patient #5, she verified there was no physician's order for the Propofol infusion dose of 20 mcg/kg/min, and the only order for the Propofol Infusion was, "Propofol IV PRN for Sedation". RN S6 verified none of the, "Frequent Monitoring/Critical Medication Flowsheets" had any level of sedation (RASS) documented on the flowsheets. RN S6 stated she was not aware that the RASS was to be documented on the flowsheets and stated she documented the RASS on the, "24 Hour Patient Record & Plan of Care". RN S6 verified the RASS was only documented once a shift on the 24 Hour Record. RN S6 verified the patient's Vital Signs were not monitored and documented according to the policy and procedure when the rate/dose was changed.

In a face-to-face interview on 01/09/13 at 10:05 a.m., RN Charge Nurse S3 verified he had documented the Admission Orders as verbal orders for Patient #5 on 12/29/12. RN Charge Nurse S3 stated he copied the order from the transferring hospital orders, and the physician (Medical Director S16) ok'd them. RN Charge Nurse S3 verified he should have clarified the order for the Propofol Infusion to include the rate/dose the patient was on, the desired sedation level, and the parameters for titrating.

Patient #10
Review of the medical record for Patient #10 revealed the patient was a 66 year old male admitted to the hospital on 12/13/12 at 1:45 p.m., and was currently a patient in the hospital. The patient's admitting diagnoses included Acute Respiratory Failure, B-Cell Lymphoma, and Total Brain Irradiation.

Review of the Physician's Orders, dated/time 12/15/12 at 00:40 revealed the following order: "Diprivan (Propofol) 5-50 mcg/kg/min for mild sedation". There was no documented evidence of any other physician's orders for Propofol until 12/18/12 at 6:50 p.m. when an order was written to discontinue the Propofol.

Review of the "24 Hour Patient Record & Plan of Care" dated/timed 12/14/12 at 12:30 a.m. revealed Patient #10 was having increased periods of apnea and was intubated and placed on a ventilator. The nursing documentation revealed the patient was started on a continuous Propofol Infusion at 10 mcg/kg/min. RN S4 documented, "will titrate for light sedation". The only RASS documented on this document was at 7:55 a.m. and was 0 (Alert & Calm).

Review of the "Frequent Monitoring/Critical Medication Flowsheets" from 12/15/12 at 0030 to 12/18/12 at 0600 revealed no documented evidence of any assessment of the patient's level of sedation (RASS). Review of the Flowsheets revealed the medication rate/dose was changed on 12/16/12 at 10:00 a.m., 12/17/12 at 3:00 a.m., and on 12/17/12 at 12:00 a.m. The flowsheets revealed the patient's Vital Signs were monitored every hour. There was no documented evidence the patient's Vital Signs were monitored in accordance with the hospital's policy and procedure (5 minutes after rate change, every 15 minutes X 4, then every 30 minutes X 4.)

Review of the "24 hour Patient Record & Plan of Care" (Nursing documentation) dated 12/15/12 and 12/18/12 revealed the patient's RASS (Level of Sedation) was documented once a shift only.

There was no documented evidence that the pharmacist was notified of the physician's orders prior to the initiation of the Propofol Infusion.

On 01/09/13 at 9:10 a.m., a telephone interview was conducted with RN S4. RN S4 verified he was the nurse assigned to Patient #10 on 12/15/12 when the patient was started on the Propofol Infusion. RN S4 verified he was familiar with the hospital policy for Propofol Infusions and stated, "We don't usually do the RASS score." When asked if the On-Call Pharmacist was notified of the physician's order for the medication, he stated, "Probably not." RN S4 stated he would have called the pharmacist On-Call if a high dose was reached or if there was a problem. RN S4 verified he had not documented any level of sedation. RN S4 verified he started the Propofol Infusion at 10 mcg/kg/min., and not at 5 mcg/kg/min. as the policy and procedure directed. RN S4 stated he had a "Verbal exchange at the bedside with the physician to start the infusion at 10 mcg/kg/min." RN S4 verified he did not document the "verbal exchange" as a verbal order, and he verified he did not obtain an order for the desired level of sedation, and did not clarify with the physician the titrating parameters.

In a face-to-face interview on 01/09/13 at 10:25 a.m. the Chief Nursing Officer (CNO) S2 verified the hospital policy for Propofol Infusion was not followed for Patient #5 and Patient #10. CNO S2 verified the RNs did not obtain clarification of the physician's orders for the desired level of sedation and parameters for titrating the medication. CNO S2 verified the RNs failed to assess and document the patient's level of sedation on the flowsheets as directed in the policy. CNO S2 stated the RNs are required to take a class and a post test on Propofol Infusion prior to being assigned to patients with Propofol Infusions.





30364


2) The RN failed to ensure all telemetry strip interpretations performed by a monitor technician were validated, completed and signed as per the hospital policy:

A review was made of the hospital policy titled Telemetry, Alarms, Prioritization, Number: T05-N, Last Revised 9/2012. The policy read in part:
3. Telemetry Techs are expected to perform an initial rhythm analysis at the start of each shift. This analysis must be validated and cosigned by the assigned RN or Charge Nurse that is telemetry competent. Interpretations are to include heart rate, PR interval, QRS duration, QT interval, QTc, rhythm interpretation, date, time, signature, and title. [PR interval, QRS duration, QT interval, and QTc are measurements of the electrical tracing of heart activity.]
7. ...All rhythm interpretations will be validated by a monitor competent RN and so noted by signing the telemetry strip. The rate, PR interval, QRS duration, QT interval, QTc, and interpretation will be noted.

Patient #3
Review of the medical record for Patient #3 revealed 6 telemetry rhythm strips dated 1/5/13 and 1/6/13. The strips for each day were timed 0800, 1200 and 1600. The PR interval, QT, and QRS interpretations had not been written on any of the strips. Further review revealed 3 telemetry rhythm strips dated 1/3/12 (wrong year) and 1/4/12 (wrong year). The times listed on the strips were 20:00, 00:00, and 04:00. None of the rhythm strips had interpretations for the PR interval, QT or QRS written and the 20:00 and 00:00 readings did not have a signature from a registered nurse on the strips.

In an interview on 1/7/13 at 11:00 a.m. with Registered Nurse (RN) S14, she said when reviewing the telemetry rhythm strips for Patient #3 , the technicians were supposed to fill in the PR interval, QT, QRS. She said the telemetry technician should have filled out that information, but it should have also been verified by the nurses. She said if the technicians did not fill out the interpretation on the rhythm strips, the nurses should have completed it and signed it.

In an interview on 1/9/13 at 3:45 p.m. with Chief Nursing Officer (CNO) S2, she stated when a patient was on telemetry monitoring, the rhythm strips were printed and placed on the medical records every 4 hours. She said the technicians were supposed to interpret the rhythm strips and fill in the PR interval, QT and QRS. Then, she said the nurses were supposed to verify once per shift that the interpretations were complete and co-sign the interpretations. After review of the rhythm strips for Patient #3, she stated the nurse should have filled out the missing PR intervals, QT, and QRS readings on the strips. She also said the nurses should have co-signed the strips.


Patient #22
A review of the medical record for Patient #22 revealed 8 telemetry rhythm strips dated 1/1/13 at 8:00 p.m., 1/2/13 at 12:00 a.m., 1/3/13 at 9:17 p.m., 1/4/13 at 12:00 a.m. and 4:00 a.m. and 1/5/13 at 8:00 a.m.,12:00 p.m. and 4:00 p.m. did not have a documented signature from the RN who reviewed the strips.

Patient # 26
A review of the medical record for Patient #26 revealed 2 telemetry rhythm strips dated 1/9/13 at 12:00 a.m. and 4:00 a.m. were not dated and timed by the RN who reviewed and signed the telemetry strips.
Patient # 27
A review of the medical record for Patient #27 revealed 6 telemetry rhythm strips dated 1/7/13 at 8:00 p.m., 1/8/13 at 12:00 a.m., 4:00 a.m. and 8:00 p.m., 1/9/13 at 12:00 a.m. and 4:00 a.m. were not dated and timed by the RN who reviewed and signed the telemetry rhythm strips.
An interview on 1/9/13 at 1:50 p.m. was conducted with RN S8. RN S8 was asked about the patient's telemetry rhythm strips. RN S8 indicated the patient's telemetry rhythm strips should be reviewed by the RN assigned to the patient. The RN should sign, date and time the telemetry rhythm strips by the end of every shift.
An interview on 1/9/13 at 2:20 p.m. was conducted with RN S9. RN S9 indicated he was the charge RN for 1/9/13. The telemetry rhythm strips of Patient #26 and Patient #27 were reviewed with RN S9. RN S9 indicated the RN assigned to the patient should sign, date and time the telemetry strips by the end of every shift according to hospital policy. RN S9 indicated this was not done.
In an interview on 1/9/13 at 3:45 p.m. with Chief Nursing Officer (CNO) S2, she stated when a patient was on telemetry monitoring, the rhythm strips were printed and placed on the medical records every 4 hours. She said the technicians were supposed to interpret the rhythm strips and fill in the PR interval, QT and QRS. Then, she said the nurses were supposed to verify once per shift that the interpretations were complete and co-sign the interpretations. After review of the rhythm strips for Patient #3, she stated the nurse should have filled out the missing PR intervals, QT, and QRS readings on the strips. She also said the nurses should have co-signed the strips.

Based on record review and interview, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan as evidenced by failing to have an individualized patient care plan that provided interventions to meet the needs of the patient, had measurable goals, and included all identified patient problems and needs for 5 of 19 current sampled patients (#3, #5, #7, #25, #27). Findings:

Review of the hospital policy titled, "Nursing Care Plan", Number N02-N, revised date of 11/08, and provided as current policy by Administrator S1, revealed in part the following:
Purpose: 1. To provide guidelines for a pragmatic approach to the planning of patient care. 2. To recognize the key care issues faced by the Chronic Critically Ill (CCIS) patient population and standardize the approach....7. To simplify the care planning process for Nursing, the care plan along with relevant internal and external bundles and standard assessment formats have been incorporated into the 24 Hour Patient Record and Plan of Care. This allows for Nursing Priorities to be maintained "top of mind" an to prompt critical thinking and standard approaches....
Procedure: ....2. On the 24 Hour Patient Record and Plan of Care, the nurse will implement and document approaches related to key nursing care issues....

Review of the "24 Hour Patient Record and Plan of Care" form revealed a folded document with 8 pages on which nurses documented assessments by the following problems and goals: Page 1 of 8 - Problem: Nutrition, FSBG (Finger Stick Blood Glucose), I &O (Intake and Output), Personal Care. Goal: Successful implementation of protein and caloric intake. Adequate hydration. Page 2 of 8 - Problem: Neuro (Neurological)-Delirium-GCS (Glasgow Coma Scale) Goal: Recognition and return to baseline mental status. Page 3 of 8 - Problem: No problem to this goal listed. Goal: Early recognition and interventions for abnormal assessment parameters. Page 4 of 8 - Problem: Integumentary-IV (Intravenous) Therapy Goal: Maintain skin integrity. Promote wound healing. Page 5 of 8 - Problem: Infection Control: Sepsis Screen, Ventilator/VAP (Ventilator Acquired Pneumonia), Central Line and Foley (Urinary Catheter). Goals: Promote early recognition of signs and symptoms of infection. Employ early interventions. Prevent HAI (Hospital Acquired Infections) Page 6 of 8 - Problem: Safety: Alarms, Falls, Restraints Goals: Reduce injury and risk of harm.
Page 7 of 8 - Problem: Psychosocial-Pain-Comfort-Rest-Education. Goals: Pain rating less than 4 (on a 1-10 scale). Environment conductive to rest. Patient/family communication, educational, spiritual and cultural needs are met. Patient/Family involved in plan of care. Page 8 of 8- Nurses progress/narrative notes.
Review of the medical records for 5 of 19 current sampled patients revealed all 5 patients had the same Problems/Goals as above. Review of the "24 Hour Patient Record and Plan of Care" for Patients #3, #5, #7, #25, #27 revealed no documented evidence of any resolution dates for the above goals and no individualized interventions to address the above Problems/Goals.

Patient #3
Review of the medical record for Patient #3 revealed he was an 81 year old male admitted on 11/28/12. Patient #3 was listed as having diagnosis which included Aspiration Pneumonia, Gastrointestinal Bleed, Dysphagia and Respiratory Failure.
Review of the Physician's Orders for Patient #3 dated 1/3/13 at 1340 revealed an order to consult Hospice.
Review of the Resuscitation Orders/Consent for Patient #3 dated 11/30/12 at 1255 revealed an order not to resuscitate (DNR).
Review of the medical record for Patient #3 revealed no care plans for Hospice or DNR status. This was verified by Registered Nurse (RN) S14. RN S14 said the nurses notes/care plans were the only care plans the patients had in their medical records.

Patient #5
Review of the medical record for Patient #5 revealed he was an 88 year old male admitted on 12/28/12 with diagnoses of Multi-Organ Failure, End Stage Renal Disease with Hemodialysis, and Atrial Fibrillation with Rapid Ventricular Response. The record revealed the patient was admitted on a ventilator and on a Propofol Infusion (Anesthetic agent for sedation).

Review of the "24 Hour Patient Record and Plan of Care" from 12/28/12 to 01/07/13 revealed no documented evidence of any interventions, goals, or resolution dates for the patient's Hemodialysis or the Propofol Infusion. There was no documented evidence of individualized interventions to address the above stated standardized problems/goals, and there was no documented evidence of any resolution dates.

Patient #7
Review of the medical record for Patient #7 revealed she was an 72 year old female admitted on 09/18/12 with diagnoses of Respiratory Failure, Chronic Lung Failure, Obstructive Sleep Apnea, Insulin Dependent Diabetes, and Rapid Atrial Fibrillation. The record revealed the patient was admitted on a ventilator and was currently receiving Hemodialysis three times a week.

On 01/07/13 at 3:20 p.m. an observation was made of Patient #7. The patient was observed to be sitting on the edge of the bed with Physical Therapist (PT) S17 and Respiratory Therapist (RT) S18 attempting to transfer the patient from the bed to a wheelchair. RT S18 was observed to plug the patient's tracheostomy tube and the patient was then able to speak. A sign was noted to be posted on the wall near the head of the bed that indicated the staff that were allowed to plug the tracheostomy and the time frames for the use of the tracheostomy plug.

Review of the "24 Hour Patient Record and Plan of Care" dated 01/05/13 and 01/06/13 revealed no documented evidence of any interventions, goals, or resolution dates for the patient's Hemodialysis or the use of the Tracheostomy plug. Further review of the "24 Hour Patient Record and Plan of Care" forms revealed the patient's code status was "DNR" (Do Not Resuscitate). There was no documented evidence of a care plan to address the DNR status. There was no documented evidence of individualized interventions to address the above stated standardized problems/goals, and there was no documented evidence of any resolution dates.

Review of the "Interdisciplinary Plan of Care" dated 01/02/13 revealed no documented evidence the use of the Tracheostomy plug was addressed.

In a face-to-face interview on 01/07/13 at 3:00 p.m. RN Charge Nurse S3 stated the only care planning documents were the "24 Hour Patient Record and Plan of Care" and the "Interdisciplinary Plan of Care". After reviewing the medical record for Patient #7, RN Charge Nurse S3 verified the problems/goals on the "24 Hour Patient Record and Plan of Care" were the same for all the patients in the hospital. He verified there were no interventions or goal dates for the standardized problems/goals. RN Charge Nurse S3 verified the "24 Hour Patient Record and Plan of Care" was the documentation of the nurses' assessments. RN Charge Nurse S3 verified the "24 Hour Patient Record and Plan of Care" did not include all the patient's problems or needs.


Patient #27
A review of the medical record for Patient #27 revealed the patient was admitted on 12/21/12 with diagnoses to include in part: pneumonia, encephalopathy and sacral ulcers. Patient had a Percutaneous Endoscopic Gastrostomy (PEG) feeding tube in place upon admit. A review of Patient #27's "24 Hour Patient Record and Plan of Care" record revealed no documented evidence of any interventions, goals or resolution dates for Patient #27's PEG tube.
An interview on 1/9/13 at 2:20 p.m. was conducted with RN S9. RN S9 indicated he was the charge nurse. RN S9 was asked about the PEG tube care plan for Patient #27. RN S9 indicated the patient's care plan needs are incorporated into the "24 Hour Patient Record and Plan of Care" record. RN S9 indicated the "24 Hour Patient Record and Plan of Care" record was more of a nursing assessment flow sheet rather than a care plan. RN S9 indicated there was no specific area on the "24 Hour Patient Record and Plan of Care" record that addressed individualized patient care needs with specific goals, interventions and resolution dates. RN S9 was unable to show a PEG tube care plan for Patient #27 that addressed the identified patient problem with specific goals, interventions and resolution dates.



30364




30420


Patient #25
Review of the medical record of Patient #25 revealed that he was a 71 year old male admitted to the hospital 01/05/13 with diagnoses that included Terminal Pancreatic Cancer, Malignant Ascites, and Bacteremia.
Review of Physician's orders for Patient #25 revealed a DNR order on admission (1/5/13) and a separate DNR order signed and dated 1/7/13. The patient's admission orders also included accurate intake and output, and Central line care, flush each lumen every 8 hours with 10 milliliters of Normal Saline. An order dated 1/8/13 at 2240 (10:40 p.m.) read (1) Place Foley catheter to gravity.
Review of Patient #25's record revealed that he was documented as a full code in the 24 Hour Patient Record and Plan of Care, in the Discharge Planning Record, and on the dry erase board by the nurses' station. A nurse's narrative note dated 01/08/13 at 2000 (8:00 p.m.) reported that a son of the patient told the nurse that his father wanted to resuscitated if necessary. Further review of the 24 hour records revealed no plan of care that addressed the patient's terminal condition, or resuscitation status. There were no interventions that addressed the need for accurate Intake and output, and after the insertion of a Foley catheter, only a justification for the Foley was documented. There were no intervention plans documented for the care of Patient #25's Central Line (Intravenous), only assessments of the site, and care that was given on that shift, documented in preprinted boxes. A nurse's narrative note dated 1/8/13 at 2000 (8:00 p.m.) noted that Patient #25 had nothing ordered for pain and complained of pain at 8 on a 1-10 scale, and that his abdomen was distended and firm. The note continued that the APRN for the physician was aware of the pain and reported to the nurse that there were a lot of family dynamics involved. There was no documentation of a care plan for Patient #25's pain.
Further review of Patient #25's medical record revealed no documentation from an interdisciplinary team.

In a face-to-face interview on 01/09/13 at 1:45 p.m., Chief Nursing Officer S2 stated the "24 Hour Patient Record & Plan of Care was a corporate form and verified the nursing assessment and the plan of care were the same document. After reviewing the plan of care, Chief Nursing Officer S2 verified the care plans were not individualized and did not have measurable goals or interventions to meet the patient's identified needs.

Based on interview and record review, the hospital failed to ensure all verbal and written orders were dated and timed by the ordering practitioner responsible for the care of the patients for 5 of 19 current sampled patients from a total sample of 30 (#3, #4, #5, #7, #10). Findings:

Review of the Medical Staff Rules and Regulations provided by Chief Nursing Officer S2 as current and approved, revealed in part the following: ....D. General Conduct of Care: 1. All orders for treatment shall be in writing. A verbal order shall be considered to be in writing if given to a licensed nurse or licensed personnel as approved by the Medical Staff, functioning within their sphere of competence and signed by the responsible practitioner.... The responsible practitioner or another licensed independent practitioner within the same group practice or specialty or the responsible practitioner who is responsible for the patient's care shall authenticate such order within the time frame specified by state law or if no state law applies, no later than thirty (30) days after discharge.... 3. All orders, including verbal orders, must be dated, timed and authenticated by the prescribing practitioner, a licensed independent practitioner within the prescribing practitioner's group practice or speciality who is responsible for the patient's care or another practitioner responsible for the care of the patient, even if the order did not originate with him/her.

Review of the hospital policy titled, "Orders, Physician" Number O02-G, revised 01/01/13 and provided as current by the Administrator S1, revealed in part the following: C. Written Orders - All written orders are to be dated and timed....

Patient #3
Review of a telephone order dated 12/3/12 at 0930 for Patient #3 revealed an order to D/C (discontinue) Carafate (anti-ulcer medication). Further review revealed the Physician had signed the order, but did not time or date his signature.
Review of a telephone order dated 11/29/12 at 1100 for Patient #3 revealed an order to give 40meq (milliequivalent) KCl (Potassium Chloride) Rider today. Further review revealed the Physician had signed the order, but did not time or date his signature.

Patient #4
Review of a verbal/telephone order dated 12/17/12 at 0950 for Patient #4 revealed an order to Use 4% Lidocaine to remove NPWT (negative pressure wound therapy) with each dressing change. Further review revealed the physician had signed the order, but did not date or time his signature.
Review of a verbal/telephone order dated 12/15/12 at 2200 for Patient #4 revealed an order for Ritalin 20mg po (by mouth) Qam (every morning), Sucralfate 1 gram po QID (four times daily) , D/C Oxycodone, Hydrocodone 7.5/500mg po Q6 prn pain and increase Seroquel to 100mg po hs (hour of sleep). Further review revealed the physician had signed the order, but did not date or time his signature.

In an interview on 1/8/13 at 2:25 p.m. with Chief Nursing Officer (CNO) S2, she stated the hospital has always had a problem with certain physicians not timing or dating their orders. CNO S2 stated the hospital has tried to enforce physicians to date and time their signatures, but some just remained out of compliance.

Patient #5
Review of the patient's medical record revealed the patient was an 88 year old male admitted to the hospital on 12/28/12 and was currently a patient in the hospital.

Review of the physician's orders revealed the following:
Admission orders were documented as a verbal orders on 12/29/12 at 12:30 p.m. The admission orders were signed by the physician (Medical Director S16), but there was no documented evidence of the date or time the physician authenticated the verbal orders.
A verbal order dated 12/31/12 was received at 12:10 p.m. to wean the ventilator per protocol. The order was signed by the physician, but there was no documented evidence of the date or time the physician authenticated the verbal order.
A verbal order dated 12/31/12 was received at 4:47 p.m. to lock ports(Multi-lumen catheter) with Heparin. The order was signed by the physician, but there was no documented evidence of the date or time the physician authenticated the verbal order.

Patient #7
Review of the patient's medical record revealed the patient was an 72 year old female admitted to the hospital on 09/18/12 and was currently a patient in the hospital.

Review of the physician's orders revealed the following:
A verbal order dated 12/23/12 was received at 9:15 a.m. for 2 sets of blood cultures, Sputum Culture & Sensitivity, CBC, Urine C&S (Laboratory tests), and change Tylenol to rectal. Also ordered were Zosyn 2.25 mg. IV (Intravenous), one dose now, Diflucan 200 mg. IV now, Vancomycin 500 mg. IV now (Antiobiotics), and CBC, CMP, and Vancomycin level in a.m.(Laboratory tests). The order was signed by the physician, but there was no documented evidence of the date or time the physician authenticated the verbal order.
A verbal order dated 12/23/12 was received at 7:45 p.m. for 2 sets of blood cultures, chest x-ray in the a.m., and a urine culture. The order was signed by the physician, but there was no documented evidence of the date or time the physician authenticated the verbal order.
A verbal order dated 12/25/12 was received at 12:05 p.m. for Tobramycin 120 mg. (Antibiotic) IV for one dose now and a random Tobramycin level in the a.m. The order was signed by the physician, but there was no documented evidence of the date or time the physician authenticated the verbal order.
A written order dated 12/26/12 for Type and Match 2 units of PRBC's (Packed Red Blood Cells), CBC, PT/INR in a.m. (Laboratory tests) was signed by the physician, but there was no documented evidence of the time of the order.
A written order dated 12/26/12 for RFP, Magnesium, CBC with differential (Laboratory tests) and Type and Match 2 units of PRBC's if not already done. The order also indicated if the Hemoglobin was less than 8.0 in a.m. to notify the physician for transfusion orders. The written order was signed by the physician, but there was no documented evidence of the time of the order.
A written order dated 12/27/12 was documented for Maalox 30 cc per PEG (Percutaneous Endoscopic Gastrostomy) now. CMP, Magnesium, CBC (Laboratory tests) now, and KUB (Abdominal X-ray) in a.m. The order was signed by the physician, but there was no documented evidence of the time the physician wrote the order.
A verbal order dated 12/28/12 was received at 6:05 p.m. for Tobramycin 120 mg. IV, one dose now and a random Tobramycin level in the a.m. The order was signed by the physician, but there was no documented evidence of the date or time the physician authenticated the verbal order.
A written order dated 12/29/12 to continue Tobramycin 120 mg. IV after each dialysis, discontinue Vancomycin and Diflucan was signed by the physician but there was no documented evidence of the time the physician wrote the order.
A verbal order dated 01/03/13 (with no time received documented) for Physical Therapy 3-5 times a week for 4 weeks or until discharge was signed by the physician, but there was no documented evidence of the date or time the physician authenticated the verbal order.
A written order dated 01/07/13 to discontinue Zosyn after the next dose and discontinue Tobramycin after the next post-dialysis dose was signed by the physician, but there was no documented evidence of the time the physician wrote the order.

In a face-to-face interview on 01/07/13 at 3:00 p.m. RN Charge Nurse S3 reviewed the medical record for Patient #5 and Patient #7. RN Charge Nurse S3 verified the above orders were not timed when the physician wrote the order, and they were not date/timed when the physician authenticated the verbal orders. RN Charge Nurse S3 stated some physicians were worse than others about dating and timing their orders.

Patient #10
Review of the patient's medical record revealed the patient was an 66 year old male admitted to the hospital on 12/13/12 and was currently a patient in the hospital.

Review of the physician's orders revealed the following:
A written order dated 12/15/12 was documented for the "Insulin (subcutaneous) Physician Order Set" that included orders for blood glucose monitoring and sliding scale insulin coverage every 6 hours. The order was signed by the physician, but there was no documented evidence of the time the physician wrote the order.
A written order dated 12/25/12 was documented to add Keppra level/Dilantin level to a.m. labs, discontinue Zyvox-Primaxin after 10 days of therapy, out of bed twice a day, and nebulizer four times a day as needed. The order was signed by the physician, but there was no documented evidence of the time the physician wrote the order.
A written order dated 12/30/12 was documented to discontinue Lovenox, PT/INR (Laboratory test) in am and if less than 3, resume Warfarin at 3 mg. by mouth at bedtime, if less than 2 or greater than 5 call physician. The order was signed by the physician, but there was no documented evidence of the time the physician wrote the order.

In a face-to-face interview on 01/08/13 at 10:30 a.m. RN S10 verified the above physician orders were not timed by the physician when the order was written.





















30364

Based on record review and interviews, the hospital failed to ensure verbal orders were authenticated within 10 days by the practitioner responsible for the patient's care for 2 of 19 (#3, #10) active sampled patient from a total sample of 30..
Findings:
Review of the Medical Staff Rules and Regulations provided by Chief Nursing Officer S2 as current and approved, revealed in part the following: ....D. General Conduct of Care: 1. All orders for treatment shall be in writing. A verbal order shall be considered to be in writing if given to a licensed nurse or licensed personnel as approved by the Medical Staff, functioning within their sphere of competence and signed by the responsible practitioner.... The responsible practitioner or another licensed independent practitioner within the same group practice or specialty or the responsible practitioner who is responsible for the patient's care shall authenticate such order within the time frame specified by state law or if no state law applies, no later than thirty (30) days after discharge.... 3. All orders, including verbal orders, must be dated, timed and authenticated by the prescribing practitioner, a licensed independent practitioner within the prescribing practitioner's group practice or speciality who is responsible for the patient's care or another practitioner responsible for the care of the patient, even if the order did not originate with him/her.

Patient #3
A review made on 1/7/13 at 10:45 a.m. of a slip of paper titled "Telephone or Verbal Orders" attached to the Physician's Order sheet for Patient #3 revealed the following orders: Tylenol 650 mg (milligrams) per rectal q4hr (every 4 hours) prn temp (as needed for temperature), blood culture x 2 sets, and UA (urinalysis) and C&S (culture and sensitivity). The order had been written by Registered Nurse (RN) S14 on 12/17/12 at 0926. Further review revealed no physician had countersigned the order.

In an interview on 1/9/13 at 4:00 p.m., Chief Nursing Offier (CNO) S2 stated physicians should have been signing their verbal or telephone orders within 10 days as required by the state law.


Patient #10
Review of the patient's medical record revealed the patient was an 66 year old male admitted to the hospital on 12/13/12 and was currently a patient in the hospital.

Review of the physician's orders revealed the following:
Admission orders dated 12/13/12 and received at 2:00 p.m. were documented as verbal orders. The admission orders included Labs(laboratory studies), diet, isolation, neuro (neurological) checks, physical, speech, occupational therapy consults, dietary consults and the patient's current medications. The orders were written by the RN, but there was no documented evidence the physician had signed the orders, 24 days after the verbal orders were received.

Review of the physician orders revealed a slip of paper titled "Telephone or Verbal Orders" attached to the Physician's Order sheet for Patient #10 that included the following orders: O2 (Oxygen) at 2 liters per minute nasal cannula to keep O2 saturation greater than 92% per Respiratory Protocol. The order had been written by the Respiratory Therapist on 12/14/12 at 3:30 a.m. Further review revealed no physician had countersigned the order, 23 days after the verbal order was received.

Review of the physician orders revealed a slip of paper titled "Telephone or Verbal Orders" attached to the Physician's Order sheet for Patient #10 that included the following orders: Chest X-ray now, Telemetry, Decadron 8 mg. IVP (Intravenous Push) now, ABG (Arterial Blood Gases) now and PRN (As Needed), and Bipap (Bilevel Positive Airway Pressure) 10 or 12/6 The order had been written by the RN on 12/14/12 at 5:15 p.m. Further review revealed no physician had countersigned the order, 23 days after the verbal order was received.

Review of the physician orders revealed a slip of paper titled "Telephone or Verbal Orders" attached to the Physician's Order sheet for Patient #10 that revealed the following orders: Hold Phenytoin (Medication for seizures) next 2 doses, then start Phenytoin 100 mg. every 12 hours IVPB (Intravenous piggy back), Phenytoin level in 3 days (12/18/12). The order had been written by the RN S6 on 12/15/12 at 2:05 p.m. Further review revealed no physician had countersigned the order, 22 days after the verbal order was received.

Review of the physician orders revealed a slip of paper titled "Telephone or Verbal Orders" attached to the Physician's Order sheet for Patient #10 that revealed the following orders: Discontinue Decadron IVP 2 mg. every 8 hours. The order had been written by the Pharmacist on 12/18/12 at 8:39 a.m. Further review revealed no physician had countersigned the order, 20 days after the verbal order was received.

Review of the physician orders revealed a slip of paper titled "Telephone or Verbal Orders" attached to the Physician's Order sheet for Patient #10 that revealed the following orders: Change Zyvox to 600 mg. every 12 hours per PEG (Percutaneous Endoscopic Gastrostomy). The order had been written by the Pharmacist on 12/19/12 at 4:53 p.m. Further review revealed no physician had countersigned the order, 19 days after the verbal order was received.

In a face-to-face interview on 01/08/13 at 10:30 a.m. RN S10 verified the above verbal physician orders were not signed by the physician.

In a face-to-face interview on 01/09/13 at 4:00 p.m. Health Information Manager (HIM) S19 stated verbal orders were to be signed by the physician within 10 days as that was the state law for authenticating orders.

Based on interview, the hospital failed to ensure patient safety by controlling the distribution of drugs and biologicals as evidenced by failing to have a pharmacist review all non-emergent medication orders before the first dose was dispensed for therapeutic appropriateness, duplication, interactions, appropriateness of the physician's order, allergies, variations from criteria for use, or other contraindications.
Findings:
In an interview on 1/7/13 at 4:00 p.m. with Pharmacy Director S7, she stated the pharmacy hours were 8:00 a.m. to 6:00 p.m. Monday through Friday and 8:00 a.m. to 2:00 p.m. on the weekends. Pharmacy Director S7 stated when medications were ordered at night after the pharmacy had closed, the nurses would override the computer medication system and administer the medication without having a pharmacist review the medication prior to the administration. She also said the pharmacist did not review the medication for appropriateness until the next morning when the pharmacy opened. Pharmacy Director S7 verified that if the medication was given by the nurses at night, the pharmacist would be performing a second dose review of the medications the next morning.

In a telephone interview on 1/7/13 at 4:15 p.m. with Chief Pharmacy Officer S15, he verified the pharmacy staff did not review medications ordered after the pharmacy was closed until the next day during operating hours at the pharmacy. Chief Pharmacy Officer S15 said two nurses reviewed the medications ordered at night before administration, not a pharmacist.

Based on interview and record review, the hospital failed to have a qualified full-time, part-time or consulting radiologist supervise the ionizing radiology services.
Findings:
Review of the Organizational chart for the Hospital revealed no Director of Radiology Listed.

In an interview on 1/8/13 at 9:15 a.m. with Radiology Manager S12, he stated he was not sure who the Medical Director of Radiology was, but he thought it would probably be Radiologist S13.

In an interview on 1/8/13 at 3:32 p.m. with Director of Nursing (DON) S2, she stated she did not believe there was a physician designated to be the Director of Radiology. DON S2 said there were radiologists who were contracted to read x rays, but no one who came to the facility to oversee the radiology department.

In an interview on 1/9/13 at 11:30 a.m. with Administrator S1 , he stated the facility did not have a Physician designated as the Director of Radiology.

The hospital could not present contracts or credentialing files for a radiologist who was appointed as Director of the Radiology Department.