HospitalInspections.org

Based on observation, interview and record review the governing body did not ensure that medical staff are following the policies and procedures of the facility, for handwashing and authentication of verbal orders in 3 of 6 patients (ID#8, 9, 10) that were transferred to a higher level of care.

Findings Include:

Record review of the facility policy "Hand Hygiene" dated 06/2022 stated, all staff and persons will perform hand hygiene before entering and when leaving the patient's room every time.

Record review of the facility policy of "Medical Staff, Rules & Regulations", dated 2019 stated, all verbal orders must be dated, timed, and authenticated within 48 hours by the prescriber or another practitioner who is responsible for the care of the patient and has been credentialed by the medical staff and granted privileges ...

Observation and interview on 12/30/2022 at 1015 in the intensive care unit revealed physician (ID#59) going in and out of patient room 202 (pt.#15) who was on contact isolation with Candida Auris without performing hand hygiene or cleaning his stethoscope as he attempted to move into the next patient room 204 (pt.#16), who was also on contact isolation with a multidrug resistant organism (MDRO).

Interview on 12/30/2022 at 1015 with staff (ID#52) who observed and verified physician (ID#59) had not performed hand hygiene when he entered and left room 202 after examining patient (ID#15) and attempted to enter the next patient's (ID#16) without cleansing his hands or stethoscope.

Record review of medical records of 3 of 6 patients (ID#8,9,10) that transferred out of the facility to a higher level of care revealed the following:

Patient (ID#8) was transferred to a higher level of care, on 11/18/2022, per telephone ordered by physician (ID#62). The order was not authenticated and until 12/15/2022.

Patient (ID#9) was ordered to transfer per telephone on 10/13/2022 to Methodist hospital by physician (ID#55). The order was not authenticated by physician (ID#55) until 10/24/2022.

Patient (ID#10) was transferred to a higher level of care, on 12/20/2022 at 1008 per telephone by the physician (ID#63) and as of 12/30/2022, the order had not been authenticated.

Interview on 12/30/2022 at 1405 with staff (ID#53), who confirmed that verbal orders should be authenticated within 48 hours.