HospitalInspections.org

Based on policy and procedure review, clinical record review, and interview, it was determined the Governing Body was not effective as follows:
1. Nursing Service did not assure the nursing care was delivered to one of one (#1) patient by one of one (#5) Registered Nurse (RN) to protect the health and safety of the patient in that Vecuronium Bromide (Paralytic) was administered without an authorized physician order. The failed practice of not having an order for Vecuronium Bromide placed the patient at risk of receiving a wrong dose which had the likelihood to cause injury, impairment, or death. The failed practice had the likelihood to affect all patients who received Vecuronium Bromide. See A385 and A405 for details.

2. Nursing Service did not assure one of one (#1) Licensed Practical Nurse (LPN) did not administer Vecuronium Bromide to one of one Patient (#1) which was against Vecuronium Bromide policy in that a RN was to administer it. There was no evidence provided that LPN #1 was competent to perform the task as assigned to administer Vecuronium Bromide to protect Patient #1's health and safety. The failed practice had the likelihood to impact Patient #1 by a administering Vecuronium Bromide intravenous push (IVP) without an assessment by an RN. The failed practice had the likelihood of affecting all patients who receive Vecuronium Bromide. See A405 for details.

3. Medical records were not accurate or complete for 14 of 14 (#1-14) patients in that verbal orders were frequently used, were not dated, timed, and signed within 48 hours, and were not dated and timed by Physician #1 to authenticate the accuracy and completeness of the order. The failed practice did not ensure Physician #1 had ongoing assessment of the patient's health status. See A431 and A454.

The failed practices of the Governing Body placed all patients at risk for injury, impairment, or death.

Based on policy and procedure review, clinical record review, and interview, it was determined:
1. Nursing Service did not assure the nursing care delivered to one of one (#1) patient by one of one (#5) Registered Nurse (RN) protected the health and safety of the patient in that Vecuronium Bromide (Paralytic) was administered without an authorized physician order. The failed practice of not having an order for Vecuronium Bromide placed the patient at risk of receiving a wrong dose which had the likelihood to cause injury, impairment, or death. The failed practice had the likelihood of affecting all patients who receive Vecuronium Bromide. See A405 for details.

2. Nursing Service did not assure one of one (#1) Licensed Practical Nurse (LPN) did not administer Vecuronium Bromide to one of one Patient (#1) which was against Vecuronium Bromide policy in that a RN was to administer it. There was no evidence provided that LPN #1 was competent to perform the task as assigned to administer Vecuronium Bromide to protect Patient #1's health and safety. The failed practice had the likelihood to impact Patient #1 by a administering Vecuronium Bromide intravenous push (IVP) without an assessment by an RN. The failed practice had the likelihood of affecting all patients who receive Vecuronium Bromide. See A405 for details.

Based on policy and procedure review, clinical record review, physician file review, and interview, it was determined:
1. One of one (#1-Attending and Medical Director) physician did not authenticate verbal orders within 48 hours for 11 (#1- #13) of 14 (#1-#14) patients.
2. One of one (#1) physician did not date and time verbal orders to authenticate accuracy and completeness.
3. One of one (#1) physician did not assure verbal orders were used infrequently.
The failed practices did not ensure Physician #1 had ongoing assessment of the patient's health status. See A454 for details.

Based on Medical Staff Rules and Regulations review, clinical record review, physician file review, and interview, it was determined the Governing Body failed to uphold Medical Staff Rules and Regulations in that one of one (#1) physician (Attending and Medical Director) failed to fulfill responsibilities for signing orders within 30 days of patient discharge. The Governing Body failed to monitor and implement medical staff rules to suspend Physician #1's staff privileges and had the likelihood to impact patients' health and safety. The failed practice had the likelihood to affect all patients admitted to the facility. Findings follow:

A. Review of Medical Staff Rules and Regulations showed, "All physicians are responsible for completing their medical records within 30 days of a patient's discharge. Failure to complete incomplete records by the suspension date will result in the record becoming delinquent and the physician will be suspended of any and all privileges including admitting, emergency room, consults, etc. Suspension Day will be every other Thursday of every month. Three (3) thirty-day suspensions in one calendar year will result in referral to the Executive Committee for review."

B. Review of clinical records showed Physician #1 failed to sign all orders within 30 days of discharge for 14 of 14 (#1-#14) of Patients.

C. Review of Physician #1's credential file showed there was no evidence of action taken by the of Governing Body for the physician's delinquent records and if suspension of privileges was considered.

D. During interview on 06/02/22 at 2:15 PM, the Administrator verified the above findings in A, B, and C.

Based on policy and procedure review, clinical record review, and interview, it was determined:
1. One of one (#5) Registered Nurse (RN) administered Vecuronium Bromide (Paralytic) to one of one (#1) patient without an authorized physician order. The failed practice of not having an order for Vecuronium Bromide placed the patient at risk of receiving a wrong dose which had the likelihood to cause injury, impairment, or death.

2. One of one (#5) RN failed to follow the policy titled, "Vecuronium Bromide," dated 04/2019, for the dosing range for administration for one of one (#1) patient. The failed practice had the likelihood to impact Patient #1 by administering a dose Vencuronium Bromide above 0.05 to 0.1 mg/kg (milligram/kilogram) intravenous push (IVP).

The failed practices had the likelihood to affect all patients who recieve Vecuronium Bromide. Findings follow:

A. Review of policy titled "Acknowledging, Coordinating, and Implementing Diagnostic & Therapeutic Orders," revised June 2019, showed that implementation of orders must be coordinated by the licensed nurse and documented accurately to describe the implementation of the order.

B. Review of policy titled "Vecuronium Bromide (Norcuron)," dated 04/2019, showed the dosing procedure for initiation/bolus dose was 0.05 to 0.1 mg/kg (milligram/kilogram) IVP.

C. Review of the clinical record for Patient #1 (ventilator dependent) showed on 10/17/21 at 3:13AM, RN #5 administered Vecuronium 10 mg (milligrams) IVP to a sedated (Dilaudid, Lorazepam, Midazolam, Fentanyl, Propofol, Clonazapam, and Morphine) patient with no physician order. The patient's weight was documented as 72.12 kg, making the dose 2.8 mg above policy range. There was no evidence RN #5 had assessed the patient prior to the administration of Vecuronium Bromide or after administration to determinine its effectiveness to assess the patient's health status.

D. Review of the clinical record for Patient #1 showed there was no evidence the physican was notified prior to given the 10 mg of Vecuronium Bromide nor was there evidence the physician had assessed the patient before administering Vecuronium Bromide with other sedating medications.

E. During an interview on 06/02/22 at 9:45 AM, the Director of Quality confirmed the above findings in A, B, C and D.




44854

Based on policy and procedure review, clinical record review, and interview, it was determined one of one Licensed Practical Nurse (LPN) #1 administered Vecuronium Bromide (Paralytic) to one of one Patient (#1) which was against Vecuronium Bromide policy in that a Registered Nurse (RN) was to administer it. There was no evidence provided that LPN #1 was competent to perform the task as assigned to administer Vecuronium Bromide to protect Patient #1's health and safety. The failed practice had the likelihood to impact Patient #1 by administering Vecuronium Bromide intravenous push (IVP) without an assessment by an RN. The failed practice had the likelihood to affect all patients who receive Vecuronium Bromide. Findings follow:

A. Review of policy titled, "Acknowledging, Coordinating, and Implementing Diagnostic & Therapeutic Orders," revised June 2019, showed implementation of orders were to be coordinated by a licensed nurse and documented accurately to describe the implementation of the order.

B. Review of policy titled, "Vecuronium Bromide (Norcuron)," dated 04/2019, showed it was the responsibility of the Registered nurse.

C. Review of the clinical record for Patient #1(ventilator dependent) showed:
1. Review of a physician verbal order dated 10/17/21 at 3:40 AM showed Vecuronium 5 mg IVP PRN every 4 hours. The order did not include the instructions for use nor was it authenticated by the physician.
2. Review of the Medication Administration Record (MAR) on 10/17/21 At 8:07 AM, LPN #1 administered Vecuronium Bromide (Paralytic) 5 mg (milligram) IVP to Patient #1. There was no evidence an RN had assessed the patient's health status prior to administration of Vecuronium Bromide or after to assess its effectiveness.

D. Review of the clinical record for Patient #1 showed there was no evidence the RN or physician was notified prior to giving the 5 mg of Vecuronium Bromide. There was no evidence the physician had assessed the patient before the administration of the Vecuronium Bromide for possible drug to drug interaction with other sedating medications.

E. Interview on 06/02/22 at 9:45 AM, the Director of Quality was asked how LPNs were trained to administer Vecuronium Bromide. The Director of Quality stated that the LPNs took a 20 hour online course. A request was made to the Director of Quality for evidence the facility had deemed LPN #1 competent to administer Vecuronium Bromide. The Director of Quality stated that they did not have any written evidence to show LPN #1's competency to administer Vecuronium Bromide.

F. During an interview on 06/02/22 at 9:45 AM, the Director of Quality confirmed the above findings in A, B, C, D, and E.


Based on policy and procedure review, clinical record review, and interview, it was determined two of two (#1 and #2) LPNs administered Neuroblocking agents, Intravenous (IV) drip sedation and pain and vasopressors medications to 5 (#1-#3, #9, and #13) of 14 patients (#1-#14). The failed practice did not ensure the LPNs were supervised by a Registered Nurse (RN) for the assessment and monitoring of patients for effectiveness and safe administration of the medications. The failed practice had the likelihood to affect all patients who receive Neuroblocking agents, IV drip sedation and pain medications and vasopressors. Findings follow:

A. Review of the following policies on 06/03/22 showed the RN was the responsible party of the administration and monitoring of the following:
1) "Vecuronium Bromide [Paralytic],"revised April 2019;
2) "Propofol [Sedation]," revised August 2015;
3) "Midazolam Hydrochloride [Sedation]," revised July 2019;
4) "Fentanyl Continuous Infusion [Pain]," revised March 2020;
5) "Vasopressin Drip [Vasopressor]," revised March 2022; and
6) "Levophed [Vasopressor]," revised March 2022.

B. During the interview on 06/03/22 at 2:30 PM the Director of Quality confirmed the above findings in "A."

C. Review of Patient #1's clinical record showed LPN #1 administered and monitored the administration of Vecuronium Bromide. For example: Vecuronium 5 mg IV was administered on 10/17/21 at 8:07 AM. The findings of C were confirmed in an interview with the Charge Nurse on 06/03/2022 at 9:15 AM.

D. Review of Patient #2's clinical record showed an LPN#2 administered and monitored three of three (Propofol, Fentanyl, Levophed) medications. For example:
1) Propofol IV drip dated 10/22/21 at 11:41 AM.
2) Fentanyl IV drip dated 10/22/21 at 11:42 AM.
3) Levophed IV drip dated 10/25/21 at 7:38 AM.
4) The findings of D were confirmed in an interview with the Charge Nurse on 06/03/22 at 9:30 AM.

E. Review of Patient #3's clinical record showed an LPN #1 administered and monitored two of two (Midazolam and Fentanyl) medications. For example:
1) Midazolam IV drip dated 10/08/21 at 4:03 AM.
2) Fentanyl IV drip dated 10/08/21 at 6:45 AM.
3)The findings of E were confirmed in an interview with the Charge Nurse on 06/03/22 at 9:45 AM.

F. Review of Patient #9's clinical record showed an LPN #1 administered and monitored two of two (Vasopressin and Vecuronium) medications. For example:
1) Vasopressin IV drip dated 11/26/21 at 4:53 PM.
2) Vecuronium IV drip dated 11/26/21 at 2:08 PM.
3) The findings of F were confirmed in an interview with the Charge Nurse on 06/03/22 at 10:50 AM.

G. Review of Patient #13's clinical record showed an LPN #2 administered and monitored two of two (Fentanyl and Propofol) medications. For example:
1) Fentanyl IV drip dated 05/20/22 at 7:42 AM.
2) Propofol IV drip dated 05/20/22 at 10:25 AM.
3) The findings of G were confirmed in an interview with the Charge Nurse on 06/03/22 at 11:40 AM.


Based on clinical record review, policy and procedure review and interview, it was determined PRN (as needed) medications were not administered in accordance with physician's orders and policy and procedure as follows:
1. In 14 of 14 (#1-#14) patients, there was no evidence the licensed nurse assessed and recorded the need for the medication.
2. In 14 of 14 (#1-#14) patients, there was no evidence the licensed nurse assessed and recorded the effectiveness of the PRN medication
The failed practice did not ensure the appropriate medications were administered for the reason ordered. The failed practice to ensure the medication was effective for patient's health status. The failed practice had the likelihood to affect all patients receiving PRN medications. Findings follow:

A. Review of the policy titled, "Documentation/Electronic Medical Record (EMR) Utilization," revised February 2021, showed documentation occurred following any provision of care, medication administration, education, or routine nursing visits.

B. The findings of "A" were confirmed in an interview with the Charge Nurse on 06/03/22 at 2:10 PM. The Charge Nurse stated that the time frame in which the outcome of the medication would be assessed was generally between 30 minutes to 1 hour after giving the PRN medication.

C. Review of Patient #1's Medication Administration Record (MAR) 10/15/21 through 10/17/21 showed PRN medications administered did not include reason for administration or its effectiveness. For example:
1) Dilaudid (Pain) 1 mg was to be administered IVP. Dilaudid was documented as given on 10/15/21 at 6:43 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
2) Lorazepam (Anxiety) 2 mg was to be administered IVP. Lorazepam was documented as given on 10/15/21 at 6:43 PM There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
3) Midazolam (Sedation) 50 mg/10ml was to be administered IV drip. Midazolam was documented as given on 10/15/21 at 6:43 PM There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
4) Fentanyl (Pain) 2500 mcg/50 ml was to be administered IV drip. Fentanyl was documented as given on 10/15/21 at 7:51 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
5) Propofol (Sedation) 10 mg/10ml was to be administered IV drip. Propofol was documented as given on 10/15/21 at 9:45 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
6) Vecuronium (Paralytic) 5 mg was to be administered IVP. Vecuronium was documented as given on 10/17/21 at 7:18 AM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
7) Levophed (Hypotension) 2 mg/250 ml was to be administered IV drip. Levophed was documented as given on 10/17/21 at 3:05 AM There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
8) The findings of C were confirmed in an interview with the Charge Nurse on 06/03/22 at 9:15 AM.

D. Review of Patient #2's MAR 10/13/21 through 10/26/21 showed medications administered did not include reason for administration or its effectiveness. For example:
1) Hydrocodone/APAP (Pain) 5/325 mg was to be administered PO (orally). Hydrocodone/APAP was documented as given on 10/14/21 at 00:57 AM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
2) Dilaudid (Pain) 0.5 mg was to be administered IVP. Dilaudid was documented as given on 10/17/21 at 8:20 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
3) Propofol (Sedation) 10 mg/10ml was to be administered IV drip. Propofol was documented as given on 10/20/22 at 2:42 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
4) Fentanyl (Pain) 2500 mcg/50 ml was to be administered IV drip. Fentanyl was documented as given on 10/22/22 at 11:42 AM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
5) Levophed (Hypotension) 4 mg/250 ml was to be administered IV drip. Levophed was documented as given on 10/25/22 at 7:38 AM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
6) The findings of D were confirmed in an interview with the Charge Nurse on 06/03/22 at 9:30 AM.

E. Review of Patient #3's MAR 09/24/21 through 10/17/21 showed medications administered did not include reason for administration or its effectiveness. For example:
1) Lorazepam (Anxiety) 1 mg was to be administered IVP. Lorazepam was documented as given on 09/25/21 at 10:20 AM There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
2) Labetalol (Hypertension) 10 mg was to be administered IVP. Labetalol was documented as given on 09/28/21 at 00:30 AM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
3) Dilaudid (Pain) 0.5 mg was to be administered IVP. Dilaudid was documented as given on 10/16/21 at 1:35 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
4) Propofol (Sedation) 10 mg/10ml was to be administered IV drip. Propofol was documented as given on 10/16/21 at 9:41 PM There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
5) Fentanyl (Pain) 2500 mcg/50 ml was to be administered IV drip. Fentanyl was documented as given on 10/16/21 at 11:04 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
6) Levophed (Hypotension) 4 mg/250 ml was to be administered IV drip. Levophed was documented as given on 10/17/21 at 12:00 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
7) The findings of E were confirmed in an interview with the Charge Nurse on 06/03/22 at 9:45 AM.

F. Review of Patient #4's MAR 04/11/22 through 06/07/22 showed medications administered did not include reason for administration or its effectiveness. For example:
1) Morphine (Pain) 4 mg was to be administered IVP. Morphine was documented as given on 04/18/22 at 3:10 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
2) Lorazepam (Anxiety) 2 mg was to be administered IVP. Lorazepam was documented as given on 04/18/22 at 3:12 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
3) Levophed (Hypotension) 2 mg/250 ml was to be administered IV drip. Levophed was documented as given on 04/28/22 at 8:05 AM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
4) Oxycodone (Pain) 5 mg was to be administered PO. Oxycodone was documented as given on 05/1/22 at 9:50 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
5) Propofol (Sedation) 10 mg/10ml drip was documented as given on 05/24/22 at 8:00 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
6) The findings of F were confirmed in an interview with the Charge Nurse on 06/03/22 at 10:00 AM.

G. Review of Patient #5's MAR 05/18/22 through 06/02/22 showed medications administered did not include reason for administration or its effectiveness. For example:
1) Morphine (Pain) 4 mg was to be administered IVP. Morphine was documented as given on 05/18/22 at 10:45 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
2) Ondasteron (Nausea) 4 mg was to be administered IVP. Ondasteron was documented as given on 05/28/22 at 9:35 AM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
3) Oxycodone (Pain) 5 mg was to be administered PO. Oxycodone was documented as given on 05/30/22 at 2:15 AM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
4) Ketorolac (Pain) 30 mg was to be administered IVP. Ketorolac was documented as given on 05/30/22 at 11:08 AM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
5) Dilaudid (Pain) 0.5 mg was to be administered IVP. Dilaudid was documented as given on 05/31/22 at 9:30 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
6) Levophed (Hypotension) 4 mg/250 ml was to be administered IV drip. Levophed was documented as given on 06/01/22 at 00:00 AM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
7) Midazolam (Sedation) 50 mg/10ml was to be administered IV drip. Midazolam was documented as given on 06/02/22 at 9:13 AM There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
8) Vasopressin (Hypotension) 20 units/10ml was to be administered IV drip. Vasopressin was documented as given on 06/02/22 at 8:04 AM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
9) The findings of G were confirmed in an interview with the Charge Nurse on 06/03/22 at 10:10 AM.

H. Review of Patient #6's MAR 05/28/22 through 6/5/22 showed medications administered did not include reason for administration or its effectiveness. For example:
1) Meperidine (Pain) 25 mg was to be administered IVP. Meperidine was documented as given on 05/27/22 at 2:43 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
2) Hydrocodone/APAP (Pain) 5/325 mg was to be administered PO. Hydrocodone/APAP was documented as given on 05/28/22 at 2:28 AM There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
3) Morphine (Pain) 3 mg was to be administered IVP. Morphine was documented as given on 05/29/22 at 9:05 AM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
4) Hydrocodone/APAP (Pain) 7.5/325 mg was to be administered PO. Hydrocodone/APAP was documented as given on 06/02/22 at 7:19 AM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
5) Oxycodone (Pain) 10 mg was to be administered PO. Oxycodone was documented as given on 06/03/22 at 22:59 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
6) Promethazine (Nausea) 25 mg was to be administered IVP. Promethazine was documented as given on 06/04/22 at 11:02 AM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
7) The findings of H were confirmed in an interview with the Charge Nurse on 06/03/22 at 10:15 AM.

I. Review of Patient #7's MAR 05/18/22 through 06/06/22 showed medications administered did not include reason for administration or its effectiveness. For example:
1) Propofol (Sedation) 10 mg/10ml was to be administered IV drip. Propofol was documented as given on 05/24/22 at 8:00 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
2) Morphine (Pain) 2 mg was to be administered IVP. Morphine was documented as given on 05/21/22 at 9:19 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
3) The findings of I were confirmed in an interview with the Charge Nurse on 06/03/22 at 10:20 AM.

J. Review of Patient #8's MAR 04/29/22 through 06/05/22 showed medications administered did not include reason for administration or its effectiveness. For example:
1) Temazepam (Insomnia) 15 mg was to be administered PO. Temazepam was documented as given on 05/04/22 at 10:30 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
2) Morphine (Pain) 2 mg was to be administered IVP. Morphine was documented as given on 05/02/22 at 11:10 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
3) Cyclobenzaprine (Muscle Spasms) 10 mg was to be administered PO. Cyclobenzaprine was documented as given on 05/31/22 at 1:00 AM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
3) Oxycodone (Pain) 5 mg was to be administered PO. Oxycodone was documented as given on 04/29/22 at 4:30 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
4) Ketorolac (Pain) 30 mg was to be administered IVP. Ketorolac was documented as given on 05/12/22 at 8:15 AM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
6) The findings of J were confirmed in an interview with the Charge Nurse on 06/03/22 at 10:30 AM.

K. Review of Patient #9's MAR 11/11/21 through 12/2/21 showed medications administered did not include reason for administration or its effectiveness. For example:
1) Fentanyl (Pain) 2500 mcg/50 ml was to be administered IV drip. Fentanyl was documented as given on 11/11/21 at 11:29 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
2) Vecuronium (Paralytic) 3 mg was to be administered IVP. Vecuronium was documented as given on 11/15/21 at 2:00 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
the medication.
3) Levophed (Hypotension) 2 mg/250 ml was to be administered IV drip. Levophed was documented as given on 11/15/21 at 2:35 AM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
4) Midazolam (Sedation) 50 mg/10ml was to be administered IV drip. Midazolam was documented as given on 11/17/21 at 2:45 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
5) Vasopressin (Hypotension) 20 units/10ml was to be administered IV drip. Vasopressin was documented as given on 11/29/21 at 10:47 AM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
6) Vecuronium (Paralytic) 50 mg/250 ml was to be administered IVP. Vecuronium was documented as given on 11/27/21 at 4:36 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
the medication.
7) The findings of K were confirmed in an interview with the Charge Nurse on 06/03/22 at 10:50 AM.

L. Review of Patient #10's MAR 01/18/22 through 01/30/22 showed medications administered did not include reason for administration or its effectiveness. For example:
1) Morphine (Pain) 4 mg was to be administered IVP. Morphine was documented as given on 01/28/22 at 1:39 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
2) Benzonatate Cap (Cough) 100 mg was to be administered PO. Benzoate Cap was documented as given on 01/18/22 at 9:07 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
3) Tramadol (Pain) 50 mg was to be administered PO. Tramadol was documented as given on 01/21/22 at 1:30 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
4) Lorazepam (Anxiety) 1 mg was to be administered IVP. Lorazepam was documented as given on 01/20/22 at 9:52 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
4) Ketorolac (Pain) 30 mg was to be administered IVP. Ketorolac was documented as given on 01/28/22 at 8:40 AM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
6) The findings of L were confirmed in an interview with the Charge Nurse on 06/03/22 at 11:00 AM.

M. Review of Patient #11's MAR 03/01/22 through 03/05/22 showed medications administered did not include reason for administration or its effectiveness. For example:
1) Morphine (Pain) 4 mg was to be administered IVP. Morphine was documented as given on 03/1/22 at 10:05 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
2) Lorazepam (Anxiety) 1 mg was to be administered IVP. Lorazepam was documented as given on 03/02/22 at 7:32 AM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
3) The findings of M were confirmed in an interview with the Charge Nurse on 06/03/22 at 11:10 AM.

N. Review of Patient #12's MAR 03/14/22 through 04/6/22 showed medications administered did not include reason for administration or its effectiveness. For example:
1) Morphine (Pain) 4 mg was to be administered IVP. Morphine was documented as given on 03/27/22 at 1:50 AM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
2) Levophed (Hypotension) 4 mg/250 ml was to be administered IV drip. Levophed was documented as given on 03/17/22 at 9:40 AM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
3) Vasopressin (Hypotension) 20 units/10ml was to be administered IV drip. Vasopressin was documented as given on 04/06/22 at 6:43 AM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
4) Lorazepam (Anxiety) 1 mg was to be administered IVP. Lorazepam was documented as given on 04/06/22 at 3:59 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
5) The findings of N were confirmed in an interview with the Charge Nurse on 06/03/22 at 11:20 AM.

O. Review of Patient #13's MAR 05/18/22 through 05/24/22 showed medications administered did not include reason for administration or its effectiveness. For example:
1) Propofol (Sedation) 10 mg/10ml was to be administered IV drip. Propofol was documented as given on 05/24/22 at 11:23 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
2) Fentanyl (Pain) 2500 mcg/50 ml was to be administered IV drip. Fentanyl was documented as given on 05/19/22 at 3:00 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
3) Morphine (Pain) 4 mg was to be administered IVP. Morphine was documented as given on 05/22/22 at 10:28 AM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
4) Lorazepam (Anxiety) 1 mg was to be administered IVP. Lorazepam was documented as given on 05/22/22 at 11:44 AM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
5) The findings of O were confirmed in an interview with the Charge Nurse on 06/03/22 at 11:40 AM.

P. Review of Patient #14's MAR 04/18/22 through 05/31/22 showed medications administered did not include reason for administration or its effectiveness. For example:
1) Ondasteron (Nausea) 4 mg was to be administered IVP. Ondasteron was documented as given on 04/23/22 at 9:10 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
2) Hydrocodone/APAP (Pain) 10/325 mg was to be administered PO. Hydrocodone/APAP was documented as given on 04/26/22 at 1:30 PM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
3) Diphenhydramine (Itching) 25 mg was to be administered PO. Diphenhydramine was documented as given on 05/7/22 at 00:41 AM. There was no evidence of an assessment for administering the medication and no evidence of the outcome of administering the medication.
4) The findings of P were confirmed in an interview with the Charge Nurse on 06/03/22 at 11:50 AM.

Based on policy and procedure review, clinical record review, physician file review, and interview, it was determined
1. One of one (#1-Attending and Medical Director) physician did not authenticate verbal orders within 48 hours for 11(#1- #13) of 14 patients.
2. One of one (#1) physician did not date and time verbal orders to authenticate accuracy and completeness.
3. One of one (#1) physician did not assure verbal orders were used infrequently.
The failed practice did not ensure the Physician #1 protected the health and safety of patients by having knowledge of the patient's hospital course, medical plan of care, condition, and current status. The failed practice had the likelihood to affect all patients admitted to the facility. Findings follow:

A. Review of Medical Staff Rules and Regulations showed, "Within 48 hours, verbal orders must be dated, signed, and authenticated by the ordering practitioner or other practitioner who is responsible for the care of the patient."

B. Review of policy titled, "Verbal Orders," dated July 2015, showed verbal orders should be used infrequently.

C. Review of clinical records showed 10 (#1-9 and #13) of 14(#1-#14) verbal orders were not dated and timed as to when they were authenticated by the prescribing physician:
1) Patient #1- 107 of 107 orders dated 10/15/21-10/17/21;
2) Patient #2- 87 of 452 orders dated 10/12/21-10/25/21;
3) Patient #3- 299 of 441 orders dated 09/22/21-10/17/21;
4) Patient #4- 480 of 1911 orders dated 04/20/22-06/06/22;
5) Patient #5- 124 of 318 orders dated 05/17/22-06/03/22;
6) Patient #6- 72 of 104 orders dated 05/27/22-06/05/22;
7) Patient #7- 108 of 214 orders dated 05/18/22-06/06/22;
8) Patient #8- 102 of 264 orders dated 04/30/22-06/01/22;
9) Patient #9- 240 of 398 orders dated 11/11/21-12/02/21; and
10) Patient #13- 144 of 157 orders dated 05/18/22-05/24/22.

D. Review of clinical records showed 10 (#2-#3, #5-#6, and #8-#13) of 14 (#1-#14) verbal orders were not authenticated by the prescribing physician within 48 hours:
1) Patient #2- 172 of 452 orders dated 10/12/21-10/25/21;
2) Patient #3- 23 of 441 orders dated 09/22/21-10/17/21;
3) Patient #5- 81 of 318 orders dated 05/17/22-06/03/22;
4) Patient #6- one of 104 orders dated 05/27/22-06/05/22;
5) Patient #8- 24 of 264 orders dated 04/30/22-06/01/22;
6) Patient #9- 19 of 398 orders dated 11/11/21-12/02/21;
7) Patient #10- 170 of 218 orders dated 01/18/22-01/31/22
8) Patient #11- 94 of 126 orders dated 02/23/22-03/04/22;
9) Patient #12- 258 of 825 orders dated 02/25/22-04/06/22; and
10) Patient #13- one of 157 orders dated 05/18/22-05/24/22.

E. Review of Physician #1's credentialing file showed a signed statement on Facility letterhead dated 12/14/21 stated "I, (Physician #1), hereby attest that I issued the foregoing verbal orders for this patient. I was prevented from individually authenticating the orders due to computer error." A copy of the signed statement was found in Patient #1 clinical record.

E. During an interview on 06/02/22 at 1:43 PM, Pharmacist #1 stated that physicians had access to EMR (Electronic Medical Record) medication ordering at all times. Pharmacist #1 stated that all patient's of Physician #1 prior to 12/14/21 had a copy of the statement placed in the clinical records.

F. During an interview on 06/02/22 at 02:45 PM, the Administrator confirmed the above findings in A, B, C, D, and E.

Based on review of the Centers for Disease Control and Prevention (CDC) COVID-19 guidelines, review of policy and procedure, observation, and interview, it was determined the facility did not conduct surveillance, prevent, and control infection in that visitors were not screened upon entrance for signs and symptoms of COVID-19 for 7 of 7 (05/26/22 through 06/01/22) days requested. The failed practice did not ensure visitors COVID-19 were not allowed to enter the facility. The failed practice had the likelihood to affect all patients, staff, and visitors. Findings included:

A. Review of the facility document titled, "CDC COVID-19 Interim Infection Prevention and Control Recommendations Management of Visitors to Healthcare Facilities in the Context of COVID-19: Non-US Healthcare Settings," updated September 15, 2020, showed the following:
1) Facilities should designate an entrance that visitors can use to access the healthcare facility.
2) Visual alerts, such as signs and posters, should be placed at facility entrances and other strategic areas instructing visitors not to enter as a visitor if they have fever or respiratory symptoms.
3) Signage should include signs and symptoms of COVID-19 and who to notify if visitors have symptoms.

B. Review of the policy and procedure titled, "Visitation Guidelines, Interim for COVID-19," dated August 2021, showed the following:
1) All visitors would be subject to the screening process; if they have fever or respiratory symptoms of COVID-19 visitors would not be allowed to enter.
2) All visitors were required to always wear a facemask while inside the facility and encouraged to wear their own mask.
C. Upon entering the facility on 05/31/22 through 06/06/22, showed no evidence of signage designating location for visitor to be screened for signs and symptoms of COVID-19; Surveyor #1 and Surveyor #2 were not screened upon entry to facility.
D. During the interview on 06/06/22 at 12:15 PM with the Chief Executive Officer, the findings were confirmed for A-C.