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Based on review of facility documentation, medical records (MR) and staff interview (EMP), it was determined that the facility failed to follow hospital policy to ensure that the physician document the reason for, and patient response to a restraint when reordered at 24 hours for one of two medical records (MR17).

Findings include:

Review of the Titusville Area Hospital "Restraint Procedure," revised April 2007 revealed, "III. Information: ... J. ... The physician and/or his/her designee must document the reason for, the type of restraint, the duration, and the response of the patient to restraints. ... VII. Physician's Orders: ... 2. After 24 hours, before writing a new order, a physician who is responsible for the care of the patient must see and reassess the patient to determine the need for restraints."

1. Review of the "Physician's Order and Assessment Note for Restraint Utilization" for MR17 revealed bilateral soft wrist restraints were ordered on June 29, 2014, and reordered daily from June 30 to July 3, 2014. Further review of the form revealed the section titled "Reason/Response of Patient" for each corresponding reorder to be blank. Additional review of MR17 revealed no documentation by the physician of the reason for the restraint to have been reordered, or the patient's response.

On July 22, 2014, at 1:44 PM EMP5 confirmed there was no documentation by the physician of the reason for the restraint to have been reordered, or the patient's response to the restraint for MR17. EMP5 added, "Some doctors feel if they write it once, they shouldn't have to write it again."

Based on review of facility documents and staff interview (EMP), it was determined that the facility failed to specify in hospital policy, the training requirements for physicians authorized to order restraints.

Findings include:

Review of the Titusville Area Hospital "Restraint Procedure," revised April 2007 revealed no training requirements for physicians authorized to order restraints.

1. On July 22, 2014, at 11:00 AM, EMP1 confirmed there was no training requirement for physicians specified in hospital policy stating, "Our policy is silent on that."

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined that the facility failed to ensure that anesthesia drugs were administered in accordance with the orders of a practitioner for five of five surgical records (MR19, MR20, MR21, MR22 and MR23).

Findings include:

Review of the Titusville Area Hospital Medical Staff Bylaws, Policies, and Rules and Regulations, approved September 28, 2012, revealed, "Article III General Conduct of Care ... B. Orders General Requirements: (a) All orders for treatment shall be in writing. The practitioner's orders should be written clearly, legibly and completely. ... (d) Orders for all medications and treatments for all patients shall be under the supervision of the attending physician and shall be reviewed by that physician in a timely manner to assure discontinuance when no longer needed. ... Who May Issue Written or Verbal Orders: (a) Medical Staff members and allied health professionals (specifically including LIPs, PAs, and CRNPs) shall have the authority to issue written and verbal orders only as permitted by their licenses and by the clinical privileges granted them by the Hospital."

1. Review of MR19 revealed fentanyl, versed, propofol, Lidocaine,Toradol, Zofran and Decadron was administered by a CRNA during a July 18, 2014, procedure. Further review of the record revealed no corresponding physician signature for the aforementioned medications.

2. Review of MR20 revealed fentanyl, versed, propofol and Zofran was administered by a CRNA during a July 11, 2014, procedure. Further review of the record revealed no corresponding physician signature for the aforementioned medications.

3. Review of MR21 revealed propofol and Lidocaine was administered by a CRNA during a July 16, 2014, procedure. Further review of the record revealed no corresponding physician signature for the aforementioned medications.

4. Review of MR22 revealed propofol and Zofran was administered by a CRNA during a July 15, 2014, procedure. Further review of the record revealed no corresponding physician signature for the aforementioned medications.

5. Review of MR23 revealed propofol and Zofran was administered by a CRNA during a July 15, 2014, procedure. Further review of the record revealed no corresponding physician signature for the aforementioned medications.

6. On July 24, 2014, at 1:50 PM EMP15 confirmed that medications administered by a CRNA had no corresponding physician signature or co-signature. When asked if medications administered by a CRNA had ever been co-signed, EMP15 stated, "Yes but not since we took things over. Our anesthesiologist left earlier this year." EMP15 further confirmed that CRNAs did not have prescriptive authority or possess a DEA license.

Based on review of facility documents, medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure that medical record entries be authenticated, and timed for four of four outpatient therapy records (MR13, MR14, MR15 and MR16).

Findings include:

Review of the Titusville Area Hospital "Medical Record Department Policies," reviewed February 2014, revealed, "100.02 ... All patient medical record entries must be legible, complete, times authenticated in written or electronic form by clinical and ancillary personnel providing or evaluating the service provided."

1. Review of MR13 revealed outpatient Physical Therapy progress notes dated June 30, 2014, July 2, 2014, July 3, 2014, and July 7, 2014, with no corresponding time documented for the entries.

2. Review of MR 14 revealed outpatient Physical Therapy progress notes dated July 11, 2014, July 14, 2014, July 18, 2014, and July 22, 2014, with no corresponding time documented for the entries.

On July 23, 2014, at 1:20 PM, EMP20 confirmed the absence of a documented time for the aforementioned entries on MR 13 and MR14.

3. Review of MR 15 revealed outpatient Speech Therapy progress notes dated June 19, 2014, June 24, 2014, July 1, 2014, and July 15, 2014, with no corresponding time and/or signature documented for the entries.

3. Review of MR 16 revealed outpatient Speech Therapy progress notes dated June 20, 2014, June 30, 2014, and July 3, 2014, with no corresponding time and/or signature documented for the entries.

On July 23, 2014, at 2:00 PM, EMP17 confirmed the absence of a documented time and/or signature for the aforementioned entries on MR 15 and MR16.