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Based on review of medical records, policies and procedures, and staff interview it was determined that the facility failed to ensure physician orders were documented upon the transfer of 3 out of 3 patients (Patient #7, Patient #8, Patient #9) to the multi-organized service unit (MOSU) for a higher level of care per facility policy. Failure to complete physician orders after transfer to a higher level of care may jeopardize the health and safety of the patients if physician orders for the treatment, intervention, and monitoring of patients are not documented.

Findings include:

Patient #7's physician orders revealed an order to transfer patient to MOSU/Telemetry on 01/07/2019 at 1350 hours. No subsequent physician orders were written upon transfer.

Patient #8's nursing documentation, dated 05/08/2019 at 2230 hours, revealed: "...Patient transferred to MOSU...due to patient sodium level and hypertonic saline drip...." No physician order was documented.

Patient #9's physician orders revealed an order to admit patient to MOSU/Telemetry on 11/26/2018 at 1430 hours. No subsequent physician orders were written upon transfer.

Review of policy titled, "Multi-Organized Service Unit" revealed: "...I. A Categorical model defines criteria for patients admitted in MOSU:...Category 3 - Telemetry Status. Moderate physiologic instability requiring continuous cardiac rhythm monitoring...IV - At the time of transfer to Category 3 or Category 4 level of care, all previous physician's orders will be automatically canceled....V - Continuous cardiac monitoring will be performed on all Category 3 and Category 4 patients.

Facility policy on continuous cardiac monitoring was requested. No policy was provided.

RN #14 verified, in an interview conducted on 06/18/2019, that patients #7 and #8 did not have new orders documented by a physician upon transfer to the MOSU, and patient #8 did not have a physician order to transfer to the MOSU.

RN #14 identified, in an interview conducted on 06/18/2019, that physicians do not document new orders when a patient is transferred to MOSU, nor do they document and order for continuous cardiac monitoring. RN #14 identified, in same interview, that it is just assumed that patients should be placed on continuous cardiac monitoring when transferred to MOSU.

The Quality Manager identified, in an interview conducted on 06/19/2019, that the facility does not have a policy on continuous cardiac monitoring.

Based on review of policies and procedures, facility documents, and staff interview, it was determined that the facility failed to enact their utilization plan through the medical executive committee per facility policy. Failure to do so prevents the facility from potentially identifying and evaluating clinical care issues in order to improve upon patient care services.

Findings include:

Policy and procedure titled, "Utilization Review/Case Management Plan 2019" revealed: "...The purpose of this plan and committee is: A. To assure high quality patient care with effective and efficient utilization of the Hospital's facilities, services, and resources. B. To assist in the promotion and maintenance of high quality care through the analysis, review, and evaluation of clinical practices within the hospital...Policy Statement...The Case Management function is the responsibility of the Medical Executive Committee (MEC)...UTILIZATION REVIEW...2. Responsibility for the day to day Utilization program function including: admission review, observation status, continued stay reviews, education/teaching, and referrals to Physician Advisor...PHYSICIAN ADVISOR RESPONSIBILITIES...1. The Physician Advisor (PA) is the physician member of the MEC who is assigned responsibility for performing certain functions under the Utilization Plan...Functions...A. The function of the MEC may be carried out a whole...B. The functions shall include, but not limited to: 3. Identification of utilization-related problems, including the appropriateness and medical necessity of admissions, continued stays and over/under scheduling of said services and identification and referral of quality of care issues...Documentation and Reports...A. Documentation and records shall be kept of all activities for which the MEC is responsible...Method of Review...A. The MEC will review the admissions and continued status of patients on a concurrent basis...."

Medical executive committee meeting minutes, dated 11/14/2018, 12/19/2018, 01/16/2019, 02.20/2019, 03/20/2019, and 04/17/2019, revealed no documentation related to utilization review.

The Quality Manager confirmed, in an interview conducted on 06/19/2019, the medical executive committee acts as the utilization review committee. The Quality Manager identified, in the same interview, that utilization review is not discussed in the Medical Executive Committee.(MEC)

Based on observations and staff interview, it was determined the facility failed to ensure all supplies met an acceptable level of quality, as evidenced by 20 out of 22 blood specimen collection tubes were expired. Failure to discard of expired blood tube supplies may pose a potential risk of inaccurate blood test results thus jeopardizing the health and safety of patients.

Findings include:

Observations, during a tour of the Medical Surgical unit on 06/14/2019, revealed 20 expired blood specimen collection tubes in a cabinet with other blood drawing supplies within the medication room.

The Quality Manager and RN #29 confirmed, in an interview conducted on 06/14/2019, the blood tubes were expired.

Based on review of medical records, facility documents, and staff interviews, it was determined the facility failed to follow accepted standards of anesthesia care for 10 out of 10 patients as evidenced by, the postanesthesia evaluation was completed in its' entirety at the same time of the patients' point of movement from the operative area to the designated recovery room. Failure to complete post anesthesia evaluations within designated timeframes (up to 48 hours post procedure and not at the point of movement post procedure) poses the risk that the patient may not be sufficiently recovered from anesthesia to participate in the evaluation, which may jeopardize an accurate assessment of the patient's recovery from anesthesia, and potentially risk the health and safety of the patient. (Patients #7, #8, #9, #10, #14, #15, #16, #17, #18, #19)

Findings include:

Review of anesthesia documentation for Patients #7, #8, #9, #10, #14, #15, #16, #17, #18, and #19 revealed the postanesthesia evaluation was completed on each patient at the same time the immediate recovery room note was completed.

"Core Institute Specialty Hospital General Rules and Regulations" for the medical staff revealed: "...X. PREANESTHESIA AND POSTANESTHESIA CARE...B. Standard for Delivery of Services...3. The post-anesthesia evaluation for anesthesia recovery must be completed in accordance with Arizona State law and with hospital policies and procedures that have been approved by the medical staff, and that reflect current standards of anesthesia care...."

The Interim CNO/Director of Perioperative Services and the Quality Manager confirmed, in an interview conducted on 06/19/2019 at 0900 hours, the postanesthesia evaluation is always completed in its' entirety at the same time in which the patient enters the recovery room. In the same interview the Interim CNO/Director of Perioperative Services and the Quality Manager verified that this practice does not follow accepted standards of anesthesia care.

Based on review of the facility emergency plan, and staff interview, it was determined the facility failed to develop and implement a policy and procedure for sheltering in place during an emergency. Failure to adequately shelter in place during an emergency could potentially lead to harm to both patients and staff, if the facility does not have processes and supplies readily available to institute when patients and staff cannot leave the facility.

Findings include:

The Chief Operating Officer (COO) and the surveyor reviewed the facility's Emergency Plan on 6/18/19. The Emergency Plan (EP) did not identify a process for sheltering patients and staff during an emergency.

The COO confirmed on 6/18/19, the facility EP plan did not identify a process for sheltering patients and staff during an emergency.

Based on review of the facility Emergency Plan, facility record review, and interview, it was determined the facility failed to develop and implement emergency preparedness policies and procedures to describe its role in providing care at alternate care sites during an emergency. Failure to develop emergency policy and procedure at alternative care sites may cause harm to the residents during an emergency.

Findings include:

The COO and the surveyor reviewed the facility's Emergency Plan on June 18, 2019. The plan did not include policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.

The COO acknowledged during the exit conference on June 18, 2019, the facility EP plan did not include policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.
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Based on review of the Emergency Plan, record review, and staff interview, it was determined the facility failed to develop a means for sharing information on occupancy, needs, and it's ability to provide assistance to the authority having jurisdiction. Failure to develop a means to report occupancy levels and/or needs may result in residents not receiving care and services as needed.

Findings include:

The COO and the surveyor reviewed the facility's Emergency Plan on June 18, 2019. The Emergency Plan did not include a method for sharing occupancy levels and/or facility needs to other facilities or to the authority having jurisdiction or the Incident Command Center.

The COO acknowledged during the exit interview on June 18, 2019, the Emergency Plan for the facility did not include a method for sharing occupancy levels and/or facility needs to other facilities or to the authority having jurisdiction or the Incident Command Center.