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Based on interview and record review the Governing Body failed to ensure that the hospital maintained the QAPI program in that 1)The nursing department did not evaluate 3 of 3 contracted (agency nurses) (Agency Nurse #43, #44 and #45) and 2) Did not evaluate and/or address pharmacy reported medication removal of (6) total doses of prednisone from the ED (emergency department) pyxis by (Personnel #31 and #32) without a physician order and given to (Personnel #36 DO) and 3) 2 of 2 patients ( Patient #12 and #13) who had adverse surgical responses to procedures performed by Personnel #13 MD. The above events were not addressed in the QAPI program.

Findings Included:

1) On 03/28/14 at 12:45 the hospital provided the following non-employed (agency files) of staff who had worked in March 2014:

Agency Nurse #43's file reflected the agency provided competency skills documentation only. There was no evidence of hospital verified competencies, hospital orientation and/or evidence the hospital evaluated the agency nurses work performance.

Agency Nurse #44's file reflected an evaluation of agency personnel form dated 03/15/14 which was left unsigned. The post test and confidentiality statement were signed by Personnel #44 without evidence of hospital staff verification. The agency orientation checklist and Tour of Unit reflected Personnel #44's signature only and the space provided for supervisor/charge nurse signature and date was left blank. The file further reflected no evidence of hospital orientation attendance and/or evidence the hospital evaluated the agency nurses work performance.

Agency Nurse #45's file reflected the agency orientation checklist was not signed by a hospital supervisor. The file further reflected no evidence of hospital orientation attendance and/or evidence the hospital evaluated the agency nurses work performance. No documentation was found in the quality assessment performance improvement program which addressed the nursing contracted services and/or identified concerns with performance.

On 03/27/14 at 01:30 PM, Personnel #26 denied agency nurses were provided with hospital orientation. Personnel #26 stated she did not know if any events which involved agency nurses were reported to quality.

2) The 02/06/14 occurrence report reflected, "Personnel #32 entered (Personnel #36's) name into the pyxis machine as a patient and removed prednisone 20 mg (3) doses at (Personnel #36's) request for own use...Personnel #31 also removed (3) prednisone 20 mg tablets at (Personnel #36's) request... (Personnel #36) was not admitted to the hospital as a patient..." The event report did not indicate an investigation was completed and/or the event was addressed in the quality assessment performance improvement program.


On 03/28/14 at 02:00 PM, Personnel #29 was interviewed. Personnel #29 said he was aware of the event. Personnel #29 was asked what the facility did about the event. Personnel #29 said he spoke with the nurses. The surveyor referred to the event report with no follow-up, corrective action, risk management/quality review and/or documentation regarding the outcome of the event. Personnel #29 verified the above findings.

On 04/04/14 at 11:45 AM, Personnel #3 was interviewed. Personnel #3 was asked by the surveyor what was done regarding the prednisone being removed from the pyxis by nursing and given to the physician for personal use. Personnel #3 verified no quality follow-up and/or involvement was done. Personnel #3 verified quality was lacking.

3) Patient #12's Discharge Summary dated 05/13/13 reflected, "Degenerative Disk Disease at L3-L4...axial mechanical back pain, global lumbar spondylosis...there was some bleeding and significant blood loss from the L3 vertebral body...hemostased by placing the vertebral body screw back in the drilled hole in the correct position...blood loss was treated with fluids and blood products..."

Patient #13's 06/14/13 physician progress note timed at 12:40 PM, reflected, "Complains of left shoulder pain and numbness to left upper extremity...temperature 101.7...on vancomycin...crepitus noted to neck...x-ray...surgical sponge to left of midline in C5-C6 level...patient requires a higher level of care...at 15:00 PM...transferred to....hospital."

On 03/26/14 at 04:00 PM, Personnel #6 was interviewed. Personnel #6 stated nothing related to Personnel #13's cases which involved Patient #12 and Patient #13 were addressed in quality.

The Performance Improvement Plan for 2013 with a date of 07/31/13 reflected, "Priorities for Improvement...to increase desired patient outcomes, by assessing and improving the processes that most affect outcomes...identify opportunities to improve patient care and services...review information needed to educate the members of MEC to their responsibility for the quality of patient care...assessing the delivery of care through reporting...reviewing results and actions taken for performance improvement opportunities...adverse events..."

Based on interview and record review the Chief Nursing Officer failed to ensure non-employee licensed nurses 3 of 3 (Agency Nurse #43, #44 and #45 ) were adequately oriented and/or evaluated by the hospital nursing department.

Findings Included:

On 03/28/14 at 12:45 the hospital provided the following non-employee (agency files) of staff who had worked in March 2014:

1) Agency Nurse #43's file reflected the agency provided competency skills documentation non-dated. There was no evidence of hospital verified competencies, hospital orientation and/or evidence the hospital evaluated the agency nurse's work performance.

2) Agency Nurse #44's file reflected an evaluation of agency personnel form dated 03/15/14 which was left unsigned. The post test and confidentiality statement were signed by Personnel #44 without evidence of hospital staff verification. The agency orientation checklist and Tour of Unit reflected Personnel #44's signature only and the space provided for supervisor/charge nurse signature and date was left blank. The file further reflected no evidence of hospital orientation attendance and/or evidence the hospital evaluated the agency nurse's work performance.

3) Personnel #45's file reflected the agency orientation checklist was not signed by a hospital supervisor. The file further reflected no evidence of hospital orientation attendance and/or evidence the hospital evaluated the agency nurse's work performance.

During an interview on 03/27/14 at 1:30 PM Personnel #26 denied agency nurses were provided with hospital orientation and stated, " We trust what they send us."

Based on interview and record review, the hospital failed to ensure medications removed by (Personnel #31 and #32) from the ED (emergency department) pyxis machine were physician ordered for inpatient use. (Personnel #31 and #32) removed (6) total doses of prednisone 20 mg (milligram) tablets at the request of (Personnel #36 DO) without an order.

Findings Included:

The pyxis report dated 02/06/14 for the ED timed at 02:38 AM, reflected, "Personnel #32 removed (3) prednisone 20 mg tablets for Personnel #36." The report listed Personnel #36's name as the patient.

The pyxis report dated 02/06/14 for the ED timed at 07:38 AM, reflected, "Personnel #31 removed (3) prednisone 20 mg tablets for Personnel #36." The report listed Personnel #36's name as the patient.

On 03/28/14 at 02:00 PM, Personnel #29 was interviewed. Personnel #29 said he was aware of the event. Personnel #29 was asked what the facility did about the event. Personnel #29 said he spoke with the nurses. The surveyor referred to the event report with no follow-up, corrective action, risk management and/or documentation regarding the outcome of the event. Personnel #29 verified the above findings.

On 03/28/14 at 02:40 PM, Personnel #36 DO was interviewed. Personnel #36 was shown the pyxis records which recorded his name and (6) total doses of prednisone which were removed. Personnel #36 said he knew nothing about this and said no one had spoken to him about the event.

On 04/04/14 at 12:29 PM, Personnel #29 stated he reviewed the ED records for fourteen ED patients who were seen by Personnel #36 MD from 02/05/14 to 02/06/14. Personnel #29 stated none of the patients had orders for prednisone.

On 04/08/14 at 10:15 AM, Personnel #31 was interviewed by telephone. Personnel #31 verified Personnel #36 asked her for three 20 mg prednisone tablets. Personnel #31 acknowledged she gave Personnel #36 the prednisone tablets but did not know what he did with the medication.

On 04/09/14 at 05:30 AM, Personnel #32 was interviewed by telephone. Personnel #32 stated Personnel #36 asked her for prednisone. Personnel #32 acknowledged she removed (3) prednisone tablets from the ED pyxis and gave them to Personnel #36.

The policy and procedure entitled, "Outpatient medication" with a review date of 02/01/14 reflected, "The patient must be an inpatient to receive medications..."

The policy and procedure entitled, "Medication Administration" with a review date of 02/01/14 reflected, "Medication should be ordered to treat patients specific medical condition...drugs should be administered to patients only upon receipt of the order from the prescriber that has clinical privileges...personnel will not administer drugs outside this sphere of practice..."

The hospital failed to ensure that medical record entries for six of six patients (Patients #4, #10, #11, #12, #14 and #15) were completed in written or electronic form by the person responsible for providing or evaluating the service provided in that physicians' orders and/or reports were not signed and/or dated and timed.

Findings Included:

1) Patient #4's pre-operative physician's orders dated 12/11/12 at 01:00 PM did not reflect a physician signature by Personnel #13 MD. Physician's post-operative orders were undated and not timed. The order sheet was left blank and did not carry a physician or nursing signature.

2) Patient #10 was admitted on 03/29/13 at 06:56 AM with an admitting diagnosis of Discectomy. The DVT Prophylaxis Based Upon risk Physician Orders dated 03/29/13 at 09:15 AM were left blank. The space left for a physician signature was left blank.

3) Patient #11 was admitted on 04/19/13. Patient #11's DVT Prophylaxis Based Upon Risk Physician orders did not have a nursing signature.

4) Patient #12 was admitted on 05/06/13 and discharged on 05/07/13. The patient's DVT Prophylaxis Based Upon Risk Physician Orders dated 04/06/13 at 11:36 AM were not noted and did not reflect a nursing signature.

The Blood Bank Transfusion Orders And Justification Form with the order to transfuse four units of blood was undated and untimed. The space for the "required doctor signature" was left blank.

Patient #12's Pressure Ulcer Prevention Protocol Orders document was undated, untimed and did not have a physician signature. Physician Orders dated 05/06/13 at 11:45 ordered Valium 5 mg IV every 6 hours and Lortab 10/325 mg one to two tablets by mouth every 6 hours whenever necessary for pain. The telephone order was not signed by Personnel #13 MD.

Patient #12's physician Discharge Summary dated 05/14/13 at 02:24 PM was not signed by Personnel #13 MD.

Patient #12's Operative Report dated 05/14/13 at 02:27 PM was not signed by Personnel #13 MD.

5) Patient #14 was hospital admitted on 03/13/14 at 00:12 AM. Admitting diagnoses included DVT (Deep Vein Thrombosis). Progress Notes dated 03/14/14 at 01:57 PM reflected physician notification about an abnormal lab value. The space provided for a physician's signature, date and time was left blank.

Patient #14's renal consultation report dated 03/14/14 at 02:20 PM was not signed by Personnel #42 MD.

6) Patient #15 was hospital admitted on 03/14/14 at 3:45 PM with an admitting diagnosis of Acute Bronchitis. The patient was discharged on 03/23/14. Patient #15's pressure ulcer prevention protocol orders dated 03/13/13 at 03:00 AM and the reconciled discharge medications document, undated and untimed, did not reflect physician signatures.

A verbal order for respiratory treatment with Atrovent 0.5 mg and Albuterol 25 mg dated 03/14/14 timed at 05:25 PM was not signed by the physician.

A telephone order dated 03/15/14 at 10:00 PM reflected an order to hold Advair 250/500. There was no evidence in the medical chart that the order was signed by the physician.

Patient #15's discharge summary dated 03/23/14 at 01:54 PM was not signed by Personnel #7 MD at the time of survey.

Patient #15's Radiology Report dated 03/14/14 at 04:31 PM was not signed by Personnel #40 MD.

The policy and procedure entitled, "Information Management Department Discharge Analysis/Completeness Review (HIM.005)" undated reflected, "A medical record shall be considered complete when it contains...documentation appropriate to the particular episode of care...proper authentication of all entries..."