HospitalInspections.org

Based on review of medical staff bylaws, medical staff record review, and personnel interview, the facility failed to ensure medical staff bylaws were followed for one member of the medical staff (D1) whose DEA certificate had expired.

Findings:

1. Medical Staff Bylaws were reviewed on 10/16/12 at 5:00 PM, indicated on pg. 51, under section 12.3.2 Drug Enforcement Administration (DEA), point a., "Revocation or Expiration: Whenever a practitioner's DEA certificate is revoked or has expired, he shall immediately and automatically be divested of his right to prescribe medications covered by the certificate."

2. Review of medical staff records on 10/16/12 at approximately 4:51 PM, indicated DEA certificate of D1 had an expiration date of 9/30/12.

3. Personnel P6 was interviewed on 10/16/12 at approximately 5:13 PM and confirmed, provider D1 does not have a valid Drug Enforcement Agency (DEA) certificate. It expired 9/30/12. An application for renewal was submitted online on 10/16/12 at approximately 2:58 PM. Medical Staff Bylaws were not followed related to ensuring a valid DEA license is in place for this member of the medical staff.

Based on policy and procedure review and medical record review, the facility failed to ensure drugs are administered in accordance with the orders of the practitioner responsible for the patient's care for 1 of 5 (N1) closed patient medical records reviewed.

Findings:

1. Policy No.: C.88, titled "General Medication Administration", was reviewed on 10/16/12 at 3:33 PM and indicated on pg. 5, bulleted list, "Each dose of medication administered must be properly recorded in the patient's medical record."

2. Review of closed patient medical records on 10/16/12 at approximately 12:25 PM, indicated patient N1:
A. per Physician's Orders dated:
a. 5/20/12 at 12:30 PM, Lasix 40 mg IV (intravenous) between units of blood.
b. 5/24/12 at 21:30 PM, 5 mg Vitamin K, SQ (subcutaneous) now.
B. per Medication Administration Records dated 5/20/12 through 5/24/12:
a. lacked documentation of administration of Lasix 40 mg IV between units of blood.
b. lacked documentation of administration of Vitamin K 5 mg, SQ now on 5/24/12.

Based on policy and procedure review, medical record review, and personnel interview the facility failed to ensure medical record entries are legible, complete, dated, timed, and authenticated by the person responsible for providing or evaluating the service provided for 5 of 5 (N1, N2, N3, N4 and N5) closed patient medical records reviewed.

Findings:

1. Policy No.: II-C.7, titled "Blood Administration", was reviewed on 10/16/12 at 3:33 PM and indicated on pg.:
A. 1, under Policy section, "All administration of blood or blood products will be documented by RN (Registered Nurse) after informed consent."
B. 3, under Procedure section, points 16. and 24., "Monitor and document vital signs for the first 15 minutes. After the first 15 minutes, monitor and document vital signs hourly until unit is infused...Document procedure in the patient record...and on Blood Transfusion Flow Sheet."

2. Policy No.: III-A.9, titled "Timeliness of Medical Record Completion", was reviewed on 10/16/12 at 3:33 PM and indicated on pg. 1, under Procedure section, point 1., "All medical record entries must be legible, complete, dated, timed and authenticated promptly, in written and electronic form, by the person (identified by name and discipline) who is responsible for ordering, providing, or evaluating the service furnished."

3. Review of closed patient medical records on 10/16/12 at approximately 12:25 PM, indicated patient:
A. N1, per Record of Blood Issued Forms (BI) and Blood Transfusion Documentation (BTD) Forms dated 5/24/12:
a. at 10:50 AM, 1st unit of PRBC's started infusing.
b. BI form lacked: "recipient ID # per wristband, date/time stopped, signature of person discontinuing blood, 15 minutes after start of infusion vital signs, post-transfusion vital signs, and whether or not a transfusion reaction occurred.
c. BTD form lacked: time of pre-infusion vital signs, time of completion, and time of post-infusion vital signs.
d. at 14:50 PM, 2nd unit of PRBC's started infusing.
e. BI form lacked: recipient ID # per wristband, date/time stopped, signature of person discontinuing blood, pre-transfusion vital signs, 15 minutes after start of infusion vital signs, post-transfusion vital signs, and whether or not a transfusion reaction occurred.
f. BTD form lacked: time of completion and post-infusion vital signs.

B. N2, per BI and BTD Forms dated 4/16/12:
a. at 10:15 AM, 2nd unit of PRBC's started infusing.
b. BI form lacked: time stopped and signature of person discontinuing blood.
c. BTD form lacked: correct time of vital signs 30 minutes after transfusion start. Transfusion started at 10:15 AM per BI form and vital signs 30 minutes after transfusion start was documented as 11:00 AM, should have been 10:45 AM. This made the times of the vital signs at 1 hour after, 2 hours after, and 3 hours after incorrect as well.

C. N3, per BI and BTD Forms dated 4/29/12:
a. at 05:30 AM, 1st unit of PRBC's started infusing.
b. BI form lacked: correct time of vital signs 15 minutes after transfusion start. Transfusion started at 05:30 AM per BI form and vital signs 15 minutes after transfusion start were documented as 05:50 AM, should have been 05:45 AM. This made the times of the vital signs on the BTD form at 30 minutes, 1 hour and 2 hours after incorrect as well.
c. at 08:20 AM, 2nd unit of PRBC's started infusing.
d. BI form lacked: recipient ID # per wristband.
e. BTD form lacked: correct time of vital signs 1 hour and 2 hours after transfusion start. Transfusion started at 08:20 AM per BI form and vital signs 1 hour after transfusion start was documented as 09:05 AM, should have been 09:20 AM. This made the times of the vital signs at 2 hours after incorrect as well.

D. N4, per BI and BTD Forms dated 4/30/12:
a. at 08:30 AM, 2nd unit of PRBC's started infusing.
b. BI form lacked whether or not a transfusion reaction occurred.

E. N5, per BI and BTD Forms dated 6/5/12:
a. at 04:30 AM, 1st unit of PRBC's started infusing.
b. BI form lacked: recipient ID # per wristband, date/time stopped, signature of person discontinuing blood, and whether or not a transfusion reaction occurred.
c. BTD form lacked: times of vital signs at pre-infusion, 15 minutes after start, 30 minutes after start, 1 hour after start, 2 hours after start, and time of completion.
d. at 12:50 PM, 2nd unit of PRBC's started infusing.
e. BI form lacked: recipient ID # per wristband and whether or not a transfusion reaction occurred.
f. BTD form lacked: times of vital signs at pre-infusion, 15 minutes after start, 30 minutes after start, 1 hour after start, 2 hours after start, and time of completion.

4. Personnel P2 was interviewed on 10/16/12 at approximately 2:01 PM and confirmed the the above-mentioned closed patient medical records lacked documentation as described on the BI and BTD forms, as required per facility policy and procedure.

Based on policy and procedure review and medical record review, the facility failed to ensure all orders, including verbal orders, are dated, timed, and authenticated promptly by the ordering practitioner for 5 of 5 (N1, N2, N3, N4 and N5) closed patient medical records reviewed.

Findings:

1. Policy No.: C.88, titled "General Medication Administration", was reviewed on 10/16/12 at 3:33 PM and indicated on pg. 4, bulleted list, "All medication orders are to be timed and dated by the authorized person writing the order."

2. Policy No.: III-A.9, titled "Timeliness of Medical Record Completion", was reviewed on 10/16/12 at 3:33 PM and indicated on pg.:
A. 1, under:
i. Policy section, "Physician Health Record Completion Responsibilities: Verbal Order completion time 48 hours."
ii. Procedure section, point 1., "All medical record entries must be legible, complete, dated, timed and authenticated promptly, in written and electronic form, by the person (identified by name and discipline) who is responsible for ordering, providing, or evaluating the service furnished...Orders written by the medical staff require writing the date and time of the order along with the signature of the person writing the order. Verbal or Telephone orders dictated to staff require co-signature along with writing the date and time the signature was written."
B. 2, under Procedure section, point 6., "Verbal orders and telephone orders must be authenticated within 30 days with the signature dated and timed."

3. Review of closed patient medical records on 10/16/12 at approximately 12:25 PM, indicated patient:
A. N1, per Physician's Orders dated:
a. 5/23/12 at (time blank), Re-start Coumadin 5/25 at 2.5 mg qd (daily). Lacked documentation of time of physician order.
b. 5/24/12 at:
i. (time blank), discontinue Coumadin...2 units FFP (Fresh Frozen Plasma). Lacked documentation of time of physician order.
ii. 0030 AM, stat CBC (complete blood count), type and screen. Telephone order, lacked date and time of physician authentication.
iii. 0510 AM, 2 units of PRBC's (Packed Red Blood Cells). Telephone order, lacked date and time of physician authentication.
B. N2, per Physician's Orders dated 4/15/12 (time blank), 2 units PRBC's (Packed Red Blood Cells) slow. Lacked documentation of time of physician order.
C. N3, per Physician's Orders dated 4/28/12 (time blank), transfuse 2 units PRBC's. Lacked documentation of time of physician order.
D. N4, per Physician's Orders dated 4/29/12 (time blank), 2 units PRBC's transfuse. Lacked documentation of time of physician order.
E. N5, per Physician's Orders dated 6/4/12 at 15:55 PM, telephone order read back and verified, for type & cross and transfuse 2 units PRBC's. Lacked date and time of physician authentication.

Based on policy and procedure review and medical record review, the facility failed to ensure properly executed informed consent form for blood transfusion for 1 of 5 (N5) closed patient medical records reviewed.

Findings:

1. Policy No.: II-C.7, titled "Blood Administration", was reviewed on 10/16/12 at 3:33 PM and indicated on pg. 1, under:
A. Policy section, "All administration of blood or blood products will be documented by RN (Registered Nurse) after informed consent."
B. Procedure section, point 2., "Obtain consent..."

2. Review of patient N5 medical record on 10/16/12 at approximately 12:25 PM, indicated :
A. per Record of Blood Issued Forms and Blood Transfusion Documentation Forms dated 6/5/12:
a. at 04:30 AM, 1st unit of PRBC's started infusing.
b. at 12:50 PM, 2nd unit of PRBC's started infusing.
B. per Consent for Transfusion of Blood and Blood Components, lacked the date and time of the patient's signature and the signature of the witness with date and time. Unable to determine if the consent was signed by the patient prior to administration of blood products.