HospitalInspections.org

Based on review of documents, medical records and staff interview it was determined the medical staff failed to enforce the Bylaws, Rules and Regulations in ten (10) of ten (10) medical records reviewed (1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) for Written/Verbal/Telephone Treatment Orders. This has the potential to negatively affect all patient's in the event of an error in transcription and the error not being found in a timely manner.

Findings Include:

1. Medical Staff Bylaws, Rules and Regulations, last reviewed 10/12 state in part: "The physician who gave the verbal order or another practitioner (who is credentialed and granted privileges to write orders) who is also responsible for the care of the patient shall authenticate and date any order, including but not limited to medication orders, as soon as possible, such as during next patient visit, and in no case longer than forty-eight (48) hours from dictating the verbal order."

2. Patient #1 presented to the hospital on 11/23/12. Verbal orders given by the physician at 1640 and 1825 on 11/23/12 were not authenticated until 2/18/13.

3. Patient #2 presented to the hospital on 11/23/12. Verbal orders given by the physician at 1900, 1923 and 2000 on 11/23/12 were not authenticated until 2/18/13.

4. Patient #3 presented to the hospital on 11/30/12. Verbal orders given by the physician at 1817 on 11/30/12 were not authenticated by the physician until 2/18/13.

5. Patient #4 presented to the hospital on 11/18/12. Verbal orders given by the physician at 1530, 1655 and 1945 on 11/18/12 were not authenticated by the physician until 2/18/13.

6. Patient #5 presented to the hospital on 11/22/12. Verbal orders given by the physician at 0323 and 0415 were not authenticated by the physician until 2/18/13.

7. Patient #6 presented to the hospital on 11/12/12. Verbal orders given by the physician at 0945 and 1025 on 11/12/12 were not authenticated until 12/3/12.

8. Patient #7 presented to the hospital on 11/26/12. Verbal orders given by the physician at 0610 and 0650 on 11/26/12 were not authenticated by the physician until 2/18/13.

9. Patient #8 presented to the hospital on 12/3/12. Verbal orders given by the physician at 0805 and 0850 on 12/3/12 were not authenticated until 1/3/13.

10. Patient #9 presented to the hospital on 12/7/12. Verbal orders given by the physician at 1910 and 2010 on 12/7/12 were not authenticated until 2/18/13.

11. Patient #10 presented to the hospital on 9/30/12. Verbal orders given by the physician at 1900 and 1945 were not authenticated until 10/21/12.

12. These medical records were reviewed with the Clinical Nurse Manager of the Obstetrical Unit on 3/5/13 at 1545 and she agreed with these findings.

B. Based on review of documents, medical records and staff interview, it was determined the hospital failed to ensure the medical staff followed the Bylaws, Rules and Regulations in nine (9) of ten (10) medical records reviewed (1,2,3,4,6,7,8,9 and 10) for a qualified Registered Nurse (RN), to perform the medical screening examination in patients presenting to the Obstetrical Department (OB) from the Emergency Department (ED). This has the potential to negatively affect all obstetrical patients by the possibility of an unqualified nurse making the wrong assessment and the patient being discharged home via telephone order of the physician.

Findings include:

1. Medical staff Bylaws, Rules and Regulations last reviewed 10/12 state in part: "For patients presenting in labor without complications, the medical screening examination required under Article VI may be performed by a qualified RN under the orders of and in telephone contact with the obstetrical physician, where permitted under State law."

2. Patient #1 presented to the ED with complaints of contractions on 11/23/12. She was transferred to the OB unit and assessed by an RN who had no documentation to indicate the RN was qualified to perform the medical screening examination (MSE).

3. Patient #2 presented to the ED with complaints of contractions on 11/23/12. She was transferred to the OB unit and assessed by an RN who had no documentation to indicate the RN was qualified to perform the MSE.

4. Patient #3 presented to the ED with complaints of pregnancy elevated blood pressure on 11/30/12. She was transferred to the OB unit and assessed by an RN who had no documentation to indicate the RN was qualified to perform the MSE.

5. Patient #4 presented to the ED with complaints of contractions on 11/18/12. She was transferred to the OB unit and assessed by an RN who had no documentation to indicate the RN was qualified to perform the MSE.

6. Patient #6 presented to the ED with complaints of lower abdominal pressure on 11/12/12. She was transferred to the OB unit and assessed by an RN who had no documentation to indicate the RN was qualified to perform the MSE.

7. Patient #7 presented to the ED with complaints of decreased fetal movement on 11/26/12. She was transferred to the OB unit and assessed by an RN who had no documentation to indicate the RN was qualified to perform the MSE.

8. Patient #8 presented to the ED with complaints of contractions on 12/3/12. She was transferred to the OB unit and assessed by an RN who had no documentation to indicate the RN was qualified to perform the MSE.

9. Patient #9 presented to the ED with complaints of contractions on 12/7/12. She was transferred to the OB unit and assessed by an RN who had no documentation to indicate the RN was qualified to perform the MSE.

10. Patient #10 presented to the ED with complaints of contractions on 9/30/12. She was transferred to the OB unit and assessed by an RN who had no documentation to indicate the RN was qualified to perform the MSE.

11. These medical records were reviewed with the Clinical Nurse Manager at 1545 on 3/5/13 and she agreed with these findings.

Based on review of documents, medical record review and staff interview, it was determined the hospital failed to ensure the nursing staff followed hospital policy related to notification of the physician in seven (7) of ten (10) medical records reviewed (#1, 3, 4, 5, 7, 9 and 10). This has the potential to negatively affect all patient's who may be in an emergency situation and need the attention of a physician quickly.

Findings include:

1. Hospital policy titled Labor and Delivery Observation and Evaluation, last reviewed 07/11, states in part: "Notify physician of initial assessment".

2. Patient #1 presented to the Obstetrical (OB) unit for triage at 1645 on 11/23/12 where she was assessed. The physician was not notified of the initial assessment until 1825.

3. Patient #3 presented to the OB unit for triage at 1900 on 11/30/12 where she was assessed. The physician was not notified of the initial assessment until 2110.

4. Patient #4 presented to the OB unit for triage at 1549 on 10/22/12 where she was assessed. The physician was not notified of the initial assessment until 1655.

5. Patient #5 presented to the OB unit for triage at 0323 on 11/7/12 where she was assessed. The physician was not notified of the initial assessment until 0414.

6. Patient #7 presented to the OB unit for triage at 0610 on 11/26/12 where she was assessed. The physician was not notified of the initial assessment until 0650.

7. Patient #9 presented to the OB unit for triage at 1910 on 12/7/12 where she was assessed. The physician was not notified of the initial assessment until 2010.

8. Patient #10 presented to the OB unit for triage at 1902 on 9/30/12 where she was assessed. The physician was not notified of the initial assessment until 1945.

9. These medical records were reviewed with the Clinical Nurse Manager of the OB unit on 3/5/13 at 1545 and she agreed with the findings.