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Based on review of hospital documents, policy and procedure, and medical records and interviews with staff, the governing body failed to ensure patients received care by or under the direct supervision of medical staff physicians. Hospital staff provided medical care to patients without direct supervision or consultation of the licensed physician. This occurred in two patient care records reviewed for variances.

Findings:

1. The policy "Plan for the Provision of Care" stipulates: e. Oversight a) The governing body will ensure that the medical staff as a group is accountable to the governing body for the quality of care provided to patients. The governing body is responsible for the conduct of the hospital and this conduct includes the quality of care provided to patients. c) All patient care is provided by or in accordance with the orders of a practitioner who meets the medical staff criteria and the procedures for the privileges granted, and who has been granted privileges in accordance with the criteria established by the governing body. It further stipulates: The medical staff is responsible for the quality of medical care provided to patients by the hospital. Further in the document it stipulates, IV. Care of Patients A.3. All patient care is provided by or in accordance with the orders of a practitioner who meets the medical staff criteria and procedures for the privileges granted, who has been granted privileges in accordance with those criteria by the governing body, and who is working with the scope of those granted privileges.

Another policy Rapid Response Team stipulates criteria for initiating the RRT: any, or all of the criteria meets the guidelines for initiating the RRT. The key to using the guidelines appropriately, is early identification of the following: Staff member worried/concerned about patient, acute change in systolic blood pressure (SBP) less than 90 mmHg or greater than 170 mmHg, acute and persistent change in saturation less than 90%, acute change in mental status/level of consciousness. The RRT structure is a group of clinicians who will bring critical care expertise to the declining patient at bedside. The RRT will consist of an ACLS advanced cardiac life support-trained RN, an ACLS trained respiratory Therapist (RT), and the floor nurse caring for the patient. Rapid Response Team assignments will be made each shift. The policy further stipulates when RRT is called, the team will respond within two minutes, The RN is deemed the Team leader and will perform the Initial Assessment and assist the floor nurse with physician communication, obtaining appropriate orders, initiation of physician orders. The respiratory therapist will perform a complete respiratory assessment and initiate intervention, as appropriate, per policy guidelines. The RRT RN will communicate the assessment and findings and recommendations of the team to the physician. The respiratory therapist may initiate the following prior to physician contact: 12 lead electrocardiogram, oxygen application, oral nasal, tracheal, or artificial airway suctioning, arterial blood gas puncture, placement of an oral nasal airway (intubation will be performed by calling CODE BLUE). Staff A told surveyors when code blue is called ACLS protocols are utilized. Staff A told surveyors the medical staff approved the use of ACLS protocols. There was no policy provided indicating what staff were to do during the code. Documentation in the RRT record is to be completed by the RN House Supervisor, Charge RN or designee. The nurse will properly transcribe physician orders in the patient Chart and MAR (medication administration record) , as indicated. All Rapid response team records will be reviewed by MD in same manner as code evaluations to identify opportunities for education and/or management.

Patient #1 - The patient, a 75 year old, was admitted on 10/13/11 with a diagnosis of acute versus chronic respiratory failure, moderate protein/calorie malnutrition, and severe debility. On the morning of 10/24/11, staff documented the patient was not doing as well. At 1735 documentation indicates the patient's condition had deteriorated and Staff R (LPN) notified the charge nurse. There is no documentation in the chart the charge nurse or a registered nurse (RN) assessed the patient or provided oversight of the patient's care on 10/24/11. On the morning of 10/25/11 documentation at 0400 in the nursing narrative indicates the patient's arterial blood gases were abnormal and a physician was notified and orders to intubate were received by respiratory. There was no documentation of the orders received from the physician on the order sheet. At around 430 AM the documentation indicates a code blue was called and seven attempts by Staff F of respiratory to intubate were unsuccessful. There was no documentation a registered nurse had been involved in the patient's care on 10/24/11 and 10/25/11 until two registered nurses names were listed on the code sheet. Multiple medications given during the code blue did not have physician orders and were outside of advanced cardiac life support protocols. There was no evidence a registered nurse assessed patient care needs according to hospital policy. The documentation on the code blue sheet indicates the first attempt to notify a physician the patient was in a critical situation and unable to be intubated was thirty minutes after the RRT was called and the fourth attempt at intubation by Staff F a certified respiratory technician (CRT) The CRT attempted intubation seven times in fifty minutes unsuccessfully. At 0515 within fifteen minutes of being called, a physician responded and intubated the patient . There is no documentation of an assessment of the patient by the RN as directed in policy. There are no orders for the medications given. The physician dictation regarding the code and intubation was not signed. The physician dictation regarding the events of the day was not signed. There was no documentation the physicians were involved in review of the care. There was no documentation indicating physician involvement in review of the incidents preceding the code blue and eventual death of the patient.

Patient #2- The patient, a 85 year old, was admitted on 8/25/11 with a diagnosis of colorectal fistual repair and post operative ventilator dependent respiratory failure. On admission nursing documentation indicates the patient had five (5) skin wounds documented on the initial nursing assessment. The patient was discharged to a nursing home on 11/17/11. Throughout the patient stay there was no documentation indicating nursing had assessed all of the wounds listed on admission including the hospital's designated wound care nurse. The patient was discharged to a nursing home at which time the receiving facility notified the hospital the patient's skin condition was not reported accurately and the patient had a large undocumented pressure ulcer on the lower leg and heel. Several days during the patient admission the patient did not receive a physical assessment by a RN. Documentation of skin status by the RN, LPN, and Wound Care Nursing staff throughout the stay did not address all of the skin wounds documented on admission. There was no documentation the physicians or the mid-level practitioners were aware of all wound sites. Orders at discharge did not indicate a physician oversaw the wound care treatment and protocols. There was no review of the chart through a quality or medical staff. This finding was confirmed with Staff A and B on the afternoon of 2/8/12. No further documentation was provided.

2. Review of governing body and medical staff meeting minutes for 2010 and 2011 did not indicate the physicians participated in root cause analysis (RCA) meetings and provide oversight in review and analysis of catastrophic events.

3. Documentation at the facility reflects a staff member acts as a "physician extender" at the facility. There is no job description with specific duties defining responsibilities for the physician extender. Review of personnel files of the nurse called a physician extender did not have specific duties defining the responsibilities of a physician extender. Hospital staff stated on 02/08/12 in the afternoon that the nurse was a physician extender that worked for a specific physician (V). The duties according to hospital staff included gathering all the physician's paperwork and accompanying him on rounds to see patients. The physician extender also writes orders as directed by the physician either as a verbal or telephone order. The nurse's personnel file did not have any job description that defined these physician extender duties. The only job description in the nurse's file was for a staff registered nurse. Medication error reports documented several incomplete/wrong medication orders attributed to the physician extender. The physician extender was counseled by administration and the evaluation stated there was lack of oversight by the physician on the physician extenders documentation. There is no documentation indicating the physician was informed of the lack of oversight.

4. The above findings were reviewed with administration at the time of the exit conference. No further information was provided.

Based on review of medical records,and interviews with hospital staff, the hospital failed to ensure the registered nurse (RN) supervised the nursing care for each patient. The supervisory nurse failed to ensure physicians' orders and hospital policies were followed. This occurred in two of four patient charts (Patients #1 and 2).

Findings:

1. According to the hospital policy "the plan for the provision of care", 6. Patient assessment and reassessment a) A RN must supervise the nursing care for each patient. A RN must evaluate the care for each patient upon admission and at least every 24 hours on an ongoing basis in accordance with accepted standards of nursing practice. b) Evaluation includes assessing the patient's care needs, patient's health status /conditioning, as well as the patient's response to interventions.

2. Patient #1 - The patient, a 75 year old, was admitted on 10/13/11 with a a diagnosis of acute versus chronic respiratory failure, moderate protein/calorie malnutrition, and severe debility. On the morning of 10/24/11, staff documented the patient was not doing as well. At 1735 documentation indicates the patient's condition had deteriorated and Staff R (LPN) notified the charge nurse. There is no documentation in the chart the charge nurse or a registered nurse (RN) assessed the patient or provided oversight of the patient's care on 10/24/11. On the morning of 10/25/11 documentation at 0400 in the nursing narrative indicates the patient's arterial blood gases were abnormal and a physician was notified and orders to intubate were received by respiratory. There was no documentation of the orders received from the physician on the order sheet. At around 430 AM the documentation indicates a code blue was called and seven attempts by Staff F of respiratory to intubate were unsuccessful. There was no documentation a registered nurse had been involved in the patient's care on 10/24/11 and 10/25/11 until two registered nurses names were listed on the code sheet. Multiple medications given during the code blue did not have physician orders and were outside of advanced cardiac life support protocols. There was no evidence a registered nurse assessed patient care needs according to hospital policy. These findings were addressed with Staff A, B, and C. No further documentation was provided.

3. Patient #2- The patient, a 85 year old, was admitted on 8/25/11 with a diagnosis of colorectal fistula repair and post operative ventilator dependent respiratory failure. On admission nursing documentation indicates the patient had five (5) skin wounds documented on the initial nursing assessment. The patient was discharged to a nursing home on 11/17/11. Throughout the patient stay there was no documentation indicating nursing had assessed all of the wounds listed on admission including the hospital's designated wound care nurse. The patient was discharged to a nursing home at which time the receiving facility notified the hospital the patient's skin condition was not reported accurately and the patient had a large undocumented pressure ulcer on the lower leg and heel. Several days during the patient admission the patient did not receive a physical assessment by a RN. Documentation of skin status by the RN, LPN, and Wound Care Nursing staff throughout the stay did not address all of the skin wounds documented on admission. This finding was confirmed with Staff A and B on the afternoon of 2/8/12. No further documentation was provided.

Based on review of medical records, hospital documents, personnel files, and interviews with hospital staff, the hospital failed to ensure that the nurse (Staff J). designated as the lead wound care nurse was trained, qualified, and competent to asses, develop, and manage the wound care of each patient with these specialized needs.

Findings:

1. The employee roster listed Staff J as the Lead Wound Care Nurse. The personnel file for Staff J did not contain evidence of specialized training in wound care assessment, development and management of wounds. The evaluation/competency for this nurse was a self-evaluation/completed by Staff J himself.

2. On the afternoon of 02/08/2012, Staff B and D told the surveyors that Staff J was not certified in wound care management and did not have any specialized training since hired at the hospital. Staff A, B and D verified that the physician director or another individual, qualified to assess Staff J's skills had verified Staff J's competency for wound care management.

3. Patient #2- The patient, a 85 year old, was admitted on 8/25/11 with a diagnosis of colorectal fistula repair and post operative ventilator dependent respiratory failure. On admission nursing documentation, completed by Staff U, indicated the patient had five (5) skin wounds, documented on the initial nursing assessment. The patient was discharged to a nursing home on 11/17/11. Throughout the patient stay there was no documentation indicating nursing had assessed all of the wounds listed on admission including the hospital's designated wound care nurse (Staff J). The patient was discharged to a nursing home at which time the receiving facility notified the hospital the patient's skin condition was not reported accurately and the patient had a large undocumented pressure ulcer on the lower leg and heel. This finding was confirmed with Staff A and B on the afternoon of 02/08/12. No further documentation was provided.

Based on record review and interviews with hospital staff, the hospital does not ensure that persons who are taking and transcribing orders for physicians are authorized to do so by hospital policy and as part of their job description. One ( P ) of one nurse who is called a physician extender did not have specific job duties authorized by the medical staff or the governing body defining duties above and beyond that of a staff nurse.

Findings:

1. Review of governing body and medical staff meeting minutes for 2010 and 2011 and personnel files of the nurse called a physician extender did not have specific duties defining the responsibilities of a physician extender.

2. Hospital staff stated on 02/08/12 in the afternoon that the nurse was a physician extender that worked for a specific physician (V). The duties according to hospital staff included gathering all the physician's paperwork and accompanying him on rounds to see patients. The nurse also writes orders as directed by the physician either as a verbal or telephone order.

3. The nurse's personnel file did not have any job description that defined these physician extender duties. The only job description in the nurse's file was for a staff registered nurse.

4. Medication error reports documented several incomplete/wrong medication orders attributed to the physician extender. The physician extender was counseled by administration and the evaluation stated there was lack of oversight by the physician on the physician extenders documentation.

Based on review of hospital documents, respiratory policies and procedures, and personnel files and interview with hospital staff, it was determined the medical staff failed to enforce hospital policies and procedures. In one of one medical record record (Record #1) reviewed, a respiratory tech (Staff F), who had not been designated as qualified/competent to perform intubation, attempted intubation procedures on the patient.

Findings:

1. According to the medical record for Patient #1, Staff F unsuccessfully attempted to intubate the patient seven times on 10/25/2011 before a physician arrived and intubated the patient.

2. The hospital's policy, RT-05-001, indicated intubation could be performed by respiratory therapists, but stipulates that "intubation will be performed only by those individuals approved by the Medical Director of Respiratory Therapy Services.

3. Although the policy states qualified/approved respiratory therapist could intubate, review of meeting minutes, medical staff, governing body and quality council, for 2011, job descriptions for respiratory staff positions and five respiratory personnel files (Staff E, F, G, H, and I) did not contain evidence the Respiratory Medical Director had approved any individuals as qualified to perform intubation.

4. These findings were reviewed with administrative staff at the exit conference on 02/08/2012. No additional data was provided.

Based on review of medical records, hospital documents and personnel records, and interviews with hospital staff, the hospital failed to designate in writing those individuals who were qualified to perform intubation. This occurred for five of five respiratory personnel (Staff E, G, H, and I), whose files were reviewed.

Findings:

1. According to the medical record for Patient #1, on 10/25/2011 Staff F attempted seven times to intubate the patient without success. A physician arrived and was able to intubate the patient.

2. The hospital's policy, RT-05-001, indicated intubation could be performed by respiratory therapists, but stipulates that "intubation will be performed only by those individuals approved by the Medical Director of Respiratory Therapy Services.

3. Review of medical staff, governing body and quality council meeting minutes for 2011 did not contain evidence the Respiratory Medical Director had approved any individuals as qualified to perform intubation.

4. The surveyors reviewed the job descriptions for the different respiratory positions. The job descriptions did not designate any of the staff positions as capable to perform intubations.

5. Review of five respiratory staff personnel files (Staff E, F, G, H, and I) did not contain documentation of competency by the Respiratory Medical Director. Four of the personnel files (Staff E, G, H, and I) did not contain any training or competency in intubation until January 2012.

6. On 02/08/2012 at 1700, Staff E stated the Respiratory Medical Director had not performed competency or documented any approval of any respiratory therapists to perform intubation.

7. These findings were reviewed with administrative staff at the exit conference on 02/08/2012. No additional data was provided.

Based on record review and interviews with hospital staff, the hospital does not ensure that data collected is analyzed to monitor the effectiveness, safety of service and quality of care provided. Review of Quality Council meeting minutes for 2010 and 2011 did not document the conclusions or evaluation of data collected concerning patient care issues.

Findings:

1. Medication errors identified are not analyzed and a plan implemented to prevent their reoccurrence.

2. New policies and procedures implemented have not been evaluated for effectiveness as part of the hospital's quality program.

3. Inservices and training conducted as a result of some adverse events have not been documented and evaluated through the hospital's quality program.

4. Quality Council meeting minutes did not document specific projects with data, analyzation of data and evaluation of the data.