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Based on observation, record review and interview, the hospital failed to meet the requirement of the Condition of Participation for Governing Body as evidenced by failing to have a governing body which is effective in carrying out its responsibilities for the conduct of the hospital. This is evidenced by failing to implement corrective action for the following deficiencies that were cited on the previous survey dated 05/25/16:

1. Failing to provide care in a safe setting as evidenced by failing to provide a functioning emergency call system or a reliable alternate method for a patient to promptly request staff assistance. (See Findings at A-144)

2. Failing to ensure a registered nurse supervised and evaluated the nursing care for each patient as evidenced by failing to document an assessment or interventions between when a patient was discovered to have an acute injury and when they were transferred to the hospital for 1 of 1 patient (Patient #F1) who was transferred to the hospital with a fracture in a total sample of 5. (See Findings at A-395)

3. Failing to ensure the skill and competence of all individuals providing direct patient care had been evaluated as evidenced by failing to maintain documented evidence of skills competency evaluations for 3 of 3 nurses whose competency skills were reviewed (S5RN, S6RN, S7LPN). (See Findings at A-397)

4. Failing to ensure drugs and biologicals were administered as ordered by the practitioner responsible for the patients care as evidenced by failing to ensure a physician's order was complete before transcribing the order onto the MAR and administering the medication for 3 (Patient #F1, F2, F3) of 5 patients reviewed for medication administration. (See Findings at A-405)

5. Failing to ensure all medication orders (except in emergency situations) 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. (See Findings at A-500)

6. Failing to ensure outdated, mislabeled, or otherwise unusable drugs were not available for patient use as evidenced by (a) having open vials of multi-dose medication available for use that was not dated, (b) having discharged patients' medications available for use and (c) marking through the label of discharged patients medications and placing them in the medication cart as stock use for all patients. (See Findings at A-505)

Based on observation and interview, the hospital failed to ensure that all orders must be dated, timed and authenticated by the ordering physician or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope of practice laws. This deficient practice is evidenced by S1DON writing narcotic prescriptions on a blank prescription pad that had allegedly been signed by the physician.
Findings:

On 06/20/16 at 9:30 a.m., observation revealed S1DON was at the nurses station writing on a sheet from a prescription pad. Further observations revealed the prescription sheet had a physician's signature on it, but was otherwise blank. S1DON was observed to write a prescription for a Fentanyl patch (Schedule II Narcotic)50mcg every 72 hours for Patient #F4. When S1DON was questioned about the prescription, she stated that S10Physician had signed multiple blank sheets on a prescription pad, but the pad was locked up in her office. She stated that she was the only one with the key.

When asked why she was writing the prescription for Patient #F4, S1DON stated that she frequently writes the narcotic prescriptions for S10Physician's patients because she did not want them to run out of their narcotics. S1DON further stated that S10Physician makes rounds at the hospital every day. When asked why S10Physician did not write his own narcotic prescriptions for the patients, S1DON shrugged her shoulders.

Review of the record for Patient #F4 revealed that he was discharged on 06/20/16 with discharge orders for a Fentanyl 50mcg patch every 72 hours.

On 06/23/16 at 10:35 a.m., an interview was held with S2Administrator, S3Coorporate Compliance Officer and S4Chief Nursing Officer. They revealed that they were unaware that S1DON had S10Physician's blank prescription pad. At that time, S4Chief Nursing Officer left the room and returned a short time later with S10Physician's prescription pad. She stated that S1DON had unlocked her desk and given them to her. Observation revealed they were all blank, except for a physician's signature on each one. At that time, S2Administrator and S3Coorporate Compliance Officer confirmed that the signature was S10Physician. S3Coorporate Compliance Officer then tore up the prescription pad and stated that S1DON should not have been writing narcotic prescriptions for the patients of S10Physician because that was not in her scope of practice.

On 06/23/16 at 12:30 p.m., interview with S2Administrator and S2Coorporate Compliance Officer revealed that they had met with S10Physician over his lunch break that day. They stated that S10Physician confirmed that he had given S1DON a prescription pad that already had his signature on it. When asked what S10Physician stated his reasoning was for giving S1DON the pad, they stated that he did not have much to say about it. They further confirmed that S10Physician's office is right across the street from the hospital.