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Based on record review and staff interview, the hospital failed to ensure radiologists providing interpretation of radiologic tests from the contracted hospital were credentialed and granted privileges to provide the services by the hospital's medical staff and governing body for 6 (S6Rad, S7Rad, S8Rad, S9Rad, S10Rad, S11Rad) of 6 (S6Rad, S7Rad, S8Rad, S9Rad, S10Rad, S11Rad) contracted radiologists reviewed providing services to current hospital patients.

Findings:

Review of the hospital's current written agreement with the host hospital revealed radiology services were provided by the host hospital. There was no documented evidence in the written agreement of a provision related to the credentialing and privileging process of the radiologists.

Review of the list of credentialed/privileged physicians and practitioners, presented as current by S1Adm, revealed S6Rad, S7Rad, S8Rad, S9Rad, S10Rad and S11Rad were not listed as credentialed/privileged radiologists providing tele-radiology services for the hospital.

Patient #2
Review of the medical record for Patient #2 revealed radiology reports for the following X-rays taken during the patient's hospitalization:

8/11/18 6:30 a.m.: Chest X-ray. Further review of the radiology report revealed the X-ray was read, interpreted and electronically signed by S10Rad.

8/12/18 1:33 p.m.: Chest X-ray. Further review of the radiology report revealed the X-ray was read, interpreted and electronically signed by S7Rad.

Patient #3
Review of the medical record for Patient #3 revealed radiology reports for the following X-ray taken during the patient's hospitalization:

8/8/18 7:03 a.m.: Chest X-ray. Further review of the radiology report revealed the X-ray was read, interpreted and electronically signed by S6Rad.

Patient #30
Review of the medical record for Patient #30 revealed radiology reports for the following X-rays taken during the patient's hospitalization:

8/7/18 6:35 a.m.: Chest X-ray. Further review of the radiology report revealed the X-ray was read, interpreted, and electronically signed by S8Rad.

8/9/18 11:13 a.m.: Chest X-ray. Further review of the radiology report revealed the X-ray was read, interpreted, and electronically signed by S9Rad.

8/10/18 6:03 a.m.: Chest X-ray. Further review of the radiology report revealed the X-ray was read, interpreted, and electronically signed by S6Rad.

In an interview on 8/15/18 at 8:35 a.m., S1Adm confirmed the radiology agreement with the host facility failed to contain provisions for credentialing and granting privileges for tele medicine radiology. As a result, he further confirmed the radiologists were not credentialed or privileged by the facility.



30984

Based on observations and interviews, the hospital failed to ensure that the RN supervised and evaluated the nursing care of each patient as evidenced by failing to ensure staff assigned to monitor telemetry patients was continuously monitoring the current inpatients on cardiac monitoring. This deficient practice had the potential to affect 15 of 15 current patients, in rooms (a, b, c, d, e, f, g, h, i, j, k, l, m, n, o) on telemetry monitoring at the main campus.

Findings:

An observation on 8/13/18 at 10:29 a.m. of the cardiac monitors in the nursing station revealed no one was monitoring the cardiac monitors.

In an interview on 8/13/18 at 10:35 a.m. S5RN verified the unit clerk is the primary monitor technician and she also has other responsibilities including but not limited to: answering the call bells, order entry and answering the phone. S5RN also verified that the charge nurse assist with observing the cardiac monitors when the unit clerk is unavailable. She then stated she has other duties to include but not limited to include: completing transfer paper work, admitting and discharging patients and completing chart checks by reviewing orders. S5RN also stated Respiratory will assist by monitoring the patients with the cardiac monitors at the end of C Hall.

An observation was made on 8/13/18 at 10:45 a.m. of the unit clerk was away from the cardiac monitors with patient charts towards the copy machine and the charge nurse was not in the nurses' station.

An observation was made of the cardiac monitors at the end of C Hall on 8/13/18 at 10:29 a.m. and 10:45 a.m. without anyone monitoring the cardiac monitors.

Based on record reviews, policy review, and interview, the hospital failed to ensure drugs and biologicals were administered by or under the supervision of, nursing or other personnel, in accordance with Federal or State law and approved medical staff policies and procedures. This deficient practice is evidenced by 1 medication error that had not been identified by the hospital for 1 (#13) of 8 (#9, #10, #11, #13, #14, #15, #16, #17) patients' records reviewed for medication administration from a total sample of 30 patients.

Findings:

Review of the hospital policy #9-4.13.0 titled Medication Administration last revised 7/25/18 revealed in part:
Patient safety:
Verify the rights of drug administration: right patient, right drug, right route, right dose, right time, and right documentation.
Verify there is no listed patient allergy to the medication.

Review of the medical record for Patient #13 revealed she was a 64 year old female admitted on 7/13/18 with a diagnosis of acute respiratory failure and chronic obstructive pulmonary disease. Further review revealed a red sticker on the front of the chart labeled "Allergy PCN".

Review of Patient #13's physician's orders revealed a verbal order dated 8/12/18 at 5:50 p.m. for "Zosyn 3.375 IVP Q 8 hrs." The verbal order had been taken by S17RN.

Review of Patient #13's MAR dated 8/12/18 7:00 a.m. to 8/13/18 6:59 a.m. revealed a handwritten entry for Zosyn 3.375m IVPB which was documented as having been administered on 8/12/18 at 9:00 p.m. and on 8/13/18 at 5:00 a.m. by S14RN. Further review revealed a MAR dated 8/13/18 7:00 a.m. to 8/14/18 6:59 a.m. was a transcribed pharmacy order for Zosyn. Review of the MAR also revealed "Allergies: PCN (Penicillin) documented on every page of the MAR.

On 8/15/18 at 10:15 a.m. in an interview with S5RN, she verified Patient #13 was allergic to Penicillin and was administered 2 doses of Zosyn, which contains Penicillin. She further verified the medication error was not identified.

On 8/15/18 at 12:45 p.m. in an interview with S2DON, she verified Patient #13 was allergic to Penicillin and was administered 2 doses of Zosyn, which contains Penicillin. She further verified the medication error was not identified by the pharmacy or the nursing staff.

Based on record review and interview, the hospital failed to ensure patients' medical records were accurately written and complete. This deficient practice was evidenced by failure to ensure all continuous medication infusion entries documented in patient records included the medication name, concentration, and rate, as set forth in hospital procedure, for 2 (#12, #30) of 2 patient records reviewed for continuous medication infusions from a total patient sample of 30.

Findings:

Review of the Medication Titration Flowsheet, presented by S2DON as the hospital's current documentation expectation for continuous infusion medications, revealed the following required elements of documentation: medication name, concentration, and rate (mcg/kg/min, mg/hr., etcetera) to be documented for continuous infusion medication entries.

Review of the hospital policy titled, "Standard Abbreviations and Symbols", Policy Number: 5-2.1.0, revealed in part: Purpose: To establish standards for the use of abbreviations and symbols in the patient's medical record. Policy: In order to assure clear and accurate communication of patient information, the use of abbreviations and symbols is discouraged. The facility recognizes " Neil Davis Medical Abbreviations" as an approved list of abbreviations. Procedure: The prohibited list of abbreviaiotns applies to ll orders, preprinted forms, and medication-related documentation.

Patient #12
Review of Patient #12's medical record revealed an admission date of 8/8/18 with admission diagnoses including Acute on Chronic Respiratory Failure and history of Astrocytoma. Additional review revealed the patient was requiring mechanical ventilation and vasopressor support (Norepinepherine continuous infusion) for hypotension.

Review of Patient #12's medication administration record revealed the following order: Norepinepherine - 8 mg mixed in 250 ml D5W (0.32 mg/ml) to run at 3 ml/hr. (2 mcg/minute).

Review of Patient #12's medical record revealed the following entries on the Norepinepherine continuous infusion vital sign flowsheet:

8/8/18 9:45 p.m. Levophed at 6 mcg. Further review revealed no documentation of time interval (minute or hour) for rate, no documentation of medication concentration/diluent solution.

Additional review revealed subsequent hourly entries on 8/8/18 - 8/9/18 from 10:00 p.m. - 6:00 a.m. were marked with ditto (") marks and no other documentation such as medication name, concentration, and rate.

8/9/18 7:00 a.m.: entry blank.

8/9/18 8:00 a.m.: Levophed decreased (marked with a downward facing arrow) 5mcg (no documentation of time interval for rate, medication concentration or type of fluid the medication had been diluted in).

8/9/18 9:00 a.m.: no documentation of the Levophed infusion.

8/9/18 10:00 a.m.: no documentation of the Levophed infusion.

8/9/18 11:00 a.m. Levophed decreased (marked with a downward facing arrow) 4 mcg (no documentation of time interval for rate, medication concentration or type of fluid the medication had been diluted in).

8/9/18 6:00 p.m. Levophed 2 mcg. Further review revealed no documentation of time interval (minute or hour) for rate, no documentation of medication concentration/diluent solution.

Additional review revealed subsequent hourly entries on 8/9/18 from 7:00 p.m. - 1:00 a.m., 3:00 a.m., and 5:00 a.m. - 6:00 a.m. were marked with ditto marks and no other documentation such as medication name, concentration, and rate.

8/10/18 7:00 a.m. Levophed at 2mcg/min (no documentation of medication concentration or type of fluid the medication had been diluted in).

Further review revealed subsequent hourly entries on 8/10/18 from 8:00 a.m. - 2:00 p.m. had no documentation of the Levophed infusion.

Additional review revealed hourly entries on 8/10/18 - 8/11/18 from 3:00 p.m. - 5:00 p.m. and 8:00 p.m. - 5:00 a.m. were marked with ditto marks and no documentation of medication name, concentration, and rate.

Patient #30
Review of Patient #30's medical record revealed an admission date of 8/6/18 with an admission diagnosis of Acute Respiratory Failure secondary to medication overdose. Additional review revealed the patient was requiring mechanical ventilation.

Review of Patient #30's physician's orders revealed an order for Dexmedetomidine (Precedex) 0.4 mg/100 ml normal saline IV infusion 1mcg/kg/hr.

Review of Patient #30's medical record revealed the following entries on the Precedex continuous infusion vital sign flowsheet:

8/10/18 7:00 a.m.: Precedex at 1.0 mcg/kg/hr. Further review revealed subsequent hourly entries from 8:00 a.m. - 6:00 p.m. were all marked with ditto marks and no documentation of medication name, concentration, and rate.

8/10/18 7:00 p.m.: 10.1 cc/hr - Precedex at 1.0 mcg/kg/hr. Further review revealed subsequent hourly entries from 8:00 p.m. -5:00 a.m. were all marked with ditto marks and no documentation of medication name, concentration, and rate.

8/11/18 7:00 a.m.: Precedex at 1.0 mcg/kg/hr. Further review revealed subsequent hourly entries from 8:00 a.m. - 5:00 p.m. were all marked with ditto marks and no documentation of medication name, concentration, and rate.

8/11/18 7:00 p.m.: 10.1 cc/hr. - Precedex at 1.0 mcg/kg/hr. Further review revealed subsequent hourly entries from 8:00 p.m. -5:00 a.m. were all marked with ditto marks and no documentation of medication name, concentration, and rate.
.
8/12/18 7:00 a.m.: Precedex at 1.0 mcg/kg/hr. Further review revealed subsequent hourly entries from 8:00 a.m. - 6:00 p.m. were all marked with ditto marks and no documentation of medication name, concentration, and rate.

8/12/18 7:00 p.m.: 10.1 cc/hr - Precedex at 1.0 mcg/kg/hr. Further review revealed subsequent hourly entries from 8:00 p.m. -5:00 a.m. were all marked with ditto marks and no documentation of medication name, concentration, and rate.

8/13/18 7:00 a.m. Precedex 400 mcg/100 ml (no IV fluid diluent listed) 1.0 mcg/kg/hr. at 10.1 ml/hr.

8/13/18 8:00 a.m.: 1mcg/kg/hr. 10.1 ml/hr. Further review revealed no documentation of medication name or diluent used for dilution.

Additional review revealed of subsequent hourly entries documented on 8/13/18 from 9:00 a.m. - 1:00 p.m. were marked with ditto marks and no documentation of medication name, concentration, and rate.

8/13/18 3:00 p.m.: Precedex 10.1. ml/hr. with no documentation of medication name, concentration, and rate.

8/13/18 4:00 p.m. and 5:00 p.m. entries were documented with ditto marks and no documentation of medication name, concentration, and rate.

In an interview on 8/14/18 at 1:40 p.m. with S2DON, she confirmed, after review of the above referenced documentation, ditto marks should not have been used to document information in the patients' medical records. S2DON verified each continuous medication infusion documentation entry should have included the medication name, medication/fluid used for dilution of medication, and the rate for each entry in the medical record.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice, consistent with state law. This deficient practice was evidenced by failing to ensure all medication orders were reviewed by a pharmacist, before the first dose was dispensed, for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications.
Findings:

Review of hospital policy 10-14.110 titled Order Processing: Pharmacy received as current policy revealed in part, a pharmacist shall review the prescriber's original order, before the initial dose is dispensed (emergency exception). This review shall include the patient's demographic information (allergies ...) and drug therapy.

Review of hospital policy 9-4.15.0 titled Medication Variance received as current policy revealed in part, a medication variance is defined as any preventable event that may cause or lead to inappropriate medication use and/or patient harm. Employees accountable for medication variances include pharmacists. Further review revealed Prescribing/Ordering Variance is a variance that originated from the written medication order including, but not limited to: Patient with allergy to the drug ordered.

Review of the medical record for Patient #13 revealed she was a 64 year old female admitted on 7/13/18 with a diagnosis of acute respiratory failure and chronic obstructive pulmonary disease.

Review of Patient #13's physician's orders revealed a verbal order dated 8/12/18 at 5:50 p.m. for "Zosyn 3.375 IVP Q 8 hrs." The verbal order had been taken by S17RN.

Review of Patient #13's MAR dated 8/12/18 7:00 a.m. to 8/13/18 6:59 a.m. revealed a handwritten entry for Zosyn 3.375m IVPB which was documented as having been administered on 8/12/18 at 9:00 p.m. and on 8/13/18 at 5:00 a.m. by S14RN. Further review revealed a MAR dated 8/13/18 7:00 a.m. to 8/14/18 6:59 a.m. was a transcribed pharmacy order for Zosyn. Further review of the MAR revealed documented "Allergies: PCN (Penicillin) on every page of the MAR.

On 8/15/18 at 9:45 a.m. in an interview with S16Phar, he verified Zosyn is a Penicillin and he verified Patient #13 is allergic to Penicillin. He also verified pharmacy did not identify the medication allergy and the order was not clarified with the physician.