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Based on interview and record review, the facility failed to conduct an accurate enumeration of its performance improvement (PI) projects. The deficient practice eliminated a mechanism by which the facility leadership could know what projects were underway and prioritize its efforts.

Findings:

Review of the findings of the hospital's full validation survey completed on 5/16/11 indicated an accurate determination of the number of PI projects had not been done as of that date. Review of the facility's plan of correction dated 8/12/11 indicated that on 8/4/11, the facility's senior leadership had identified 22 PI priorities, 133 PI indicators tracked in a performance improvement monitoring system (PIMS), and 7 PI projects.

Review of the hospital's "Performance Improvement Plan (5.2)" approved 8/11/11 indicated Appendix A was titled "ORGANIZATIONAL PERFORMANCE IMPROVEMENT PRIORITIES DATA PLAN - FY 2012" and specified what data would be collected to monitor performance in the 22 priorities. Appendix A concluded with the statement, "Based on results of monitoring, potential impact on patient care outcomes, and identified high volume, problem prone processes, the organization will undertake the following performance improvement projects (detailed in Appendix B of PI Plan) for FY '12: TRANSFORMATIONAL CARE INITIATIVES: Operating Room (OR) Efficiency, OR Pre-admission Testing Services, Outpatient Registration, Inpatient Discharge; IMPROVE CARE OF SEPSIS PATIENTS; OPERATING ROOM SAFETY; IMPROVE PATIENT CARE EXPERIENCE".

Review of the PI Plan further indicated "PIMS measures are selected by department leaders based on assessment with regulatory readiness/requirements as well as individual department PI initiatives... Many hospital departments have department specific performance improvement activities and quality monitoring activities..."

Review of the hospital's "PIM QUARTERLY PERFORMANCE DASHBOARD" (undated but including data through 3rd quarter 2011) and the hospital's "(PIMS) DEPARTMENT SPECIFIC MEASURES" (dated 8/2011) indicated that neither document specified which, if any, of the measures was associated with a PI project and which was not.

In an interview on 9/13/11 at 12:43 p.m., Staff C stated the PIMS was a database of department level performance indicators whereas the PI projects were those which had a team initiated to look at an issue. She stated that some PIMS were stable, but that others could have issues addressed as they come up and that the process was intended to be fluid. She stated the PIMS constantly have an action plan but that the facility had called out "PI projects" on issues requiring time, resources, and a team approach. She stated that the PIMS did not include PI projects.

Review of the facility's Quality Assessment and Performance Improvement Committee (QAIC) minutes indicated the two meetings preceding the 8/4/11 enumeration of PI projects were on 6/27/11 and 7/25/11. Review of the QAIC minutes dated 6/27/11 indicated that the facility had convened a "Multi-Disciplinary Task Force" regarding duplicate medical records "to help identify trends and develop/implement solutions." The minutes indicated that the QAIC made duplicate medical records a standing agenda item to be discussed at every meeting. The 6/27 QAIC minutes also indicated the facility had conducted a failure modes and effects analysis (FMEA) on Fall Prevention in 2010 which would expand through 2011 and which would next focus on reducing variability of assessments and "the definition of injuries related to falls."

Review of the QAIC minutes dated 7/25/11 indicated that the FMEA on falls would continue through 2011 and that the "project team nurses" were working on "a process to decrease variability in the fall risk reassessments between shifts". The minutes also noted that "the total number of duplicate medical records had decreased by 50% from May 2011 and that aggressive steps were being put in place to address the issue." The minutes indicated that the facility's goal was to have no duplicate medical records and that the topic would continue to be a standing agenda item.

Comparison of the the QAIC minutes to the facility's list of 7 PI projects indicated that neither the FMEA on falls nor duplicate medical records were included as PI projects, even though the QAIC minutes indicated the FMEA had a "Multi-Disciplinary Task Force" and "project team nurses" developing new processes, that "aggressive steps were being put in place" regarding duplicate medical records, and that duplicate medical records would be addressed by the QAIC at every meeting.

In an interview on 9/14/11 at 3:10 p.m., Staff C stated that the FMEA on falls was included under the National Patient Safety Goals, which was one of the 22 PI priorities (but not one of the 7 PI projects). She stated that the issue of duplicate medical records had come up recently and that the PIMS was a fluid process intended to allow the facility to address issues as they came up, whereas the requirement for an enumeration of PI projects was once a year. When the surveyor pointed out that the issue of duplicate medical records had been discussed on 6/27/11 (prior to the 8/4/11 enumeration of projects), Staff C nodded her head in the affirmative.

Based on interview and record review, the facility failed to analyze whether 2 of 9 sampled medical staff members (Practitioners 4 and 7) were providing appropriate care when the physicians' quality profiles indicated higher than expected mortality rates (refer to A-340). The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on interview and record review, the facility failed to analyze whether 2 of 9 sampled medical staff members (Practitioners 4 and 7) were providing appropriate care when the physicians' quality profiles indicated higher than expected mortality rates. The facility also failed to maintain relevant quality data in 1 of 9 sampled credentials files (Practitioner 8). The deficient practices diminished the facility's efforts to hold its medical staff accountable for the quality of care being provided.

Findings:

1. Review of Practitioner 4's credentials file indicated she was a cardiologist reappointed to the facility's medical staff on 9/1/11. The undated "Physician Performance Evaluation/Profiling/Credentialing" data sheet indicated that from 6/1/10 to 2/28/11, Practitioner 4's "Overall Mortality Rate" was 10.345 and the "Overall Mortality Rate Expected" was 3.88. No units were specified for either rate. The same data sheet indicated that from 7/1/09 to 6/30/11, Practitioner 4's mortality rate was 4.76, and the expected rate was 2.49. The undated "QM - Physician Profile Report Peer Review Activity" for Practitioner 4 indicated that from 7/1/09 to 6/30/11, none of Practitioner 4's cases had been peer reviewed. Another undated "Physician Performance Evaluation/Profiling/Credentialing" data sheet in Practitioner 4's file also contained the mortality rates for 6/1/10 to 2/28/11 along with a notation which stated, "The mortality rates used in this OPPE [ongoing professional practice evaluation] report are calculated by the Midas database, which applies attribution only to the role of attending physician. Due to this limitation, we are also providing in this report a mortality rate which includes in the denominator both patients for whom you were the attending physician, and for whom you were the consultant. Based on this recalculation, the mortality rate is 2.2%." No statement was present indicating what the expected mortality rate would be once the group of patients was expanded or whether 2.2% was higher or lower than expected.

In an interview on 9/14/11 at 10:05 a.m., Staff E (the chief medical officer) stated "Not any mortality goes to peer review". Staff D (the director of medical staff administration) stated that she would bring the facility's peer review indicators. Staff E stated that the department chair had addressed Practitioner 4's mortality rate by requesting a recalculation. Staff E agreed, however, that the expected mortality rate for Practitioner 4 should have also been recalculated when her observed mortality rate was recalculated for a larger group of patients.

In an interview on 9/14/11 at 1:17 p.m., Staff E stated that the expected mortality benchmark was computed using only the group of patients for which the physician in question was the attending provider. He stated that peer review of Practitioner 4's patients who died "was not the judgment made at the time" and that his advice to department chairs had been to look at the data and decide how to proceed.

Review of 3 undated documents defining how the results in the physicians' quality profiles were calculated indicated that the document discussing "Overall Mortality Rate" had a section labeled "Provider attribution" which stated that the results were "Summarized by admitting provider unless the facility elected to summarize by attending provider". Review of the document regarding "Overall Mortality Rate Expected" indicated that it was a photocopy which had been enlarged and rotated so as to crop the section discussing provider attribution.

Review of the facility's credentials committee minutes dated 9/9/11 indicated that Practitioner 7 was an internist who had been recommended for reappointment by the committee. Review of the undated "Physician Performance Evaluation/Profiling/Credentialing" data sheet for Practitioner 7 indicated that from 7/1/09 to 6/30/11, Practitioner 7's "Overall Mortality Rate" was 8.474 while the "Overall Mortality Rate Expected" was 4.63. No units were specified for either rate. The undated "QM - Physician Profile Report Peer Review Activity" for Practitioner 7 indicated that from 7/1/09 to 6/30/11, none of Practitioner 7's cases had been peer reviewed. No further analysis of Practitioner 7's mortality rate was present in the credentials file.

In an interview on 9/14/11 at 2:22 p.m., Staff E stated that the department chair had reviewed Practitioner 7's quality data and signed off on the reappointment.

Review of the facility's undated "Criteria for Medical Staff Peer Review" indicated that there were 6 different care evaluation committees: Medical, Surgical, Psychiatric, Special Services, Blood Utilization, and Anesthesiology. The criteria stated that the "Medical Care Evaluation Committee" would review deaths. The criteria also stated that the "Medical Care Evaluation Committee" review of "Cases that do not meet Care Management Indicators" was "discontinued 2008". A list of indicators was attached, however, which were categorized as one of three types: review, rule, and rate.

In an interview on 9/15/11 at 10:17 a.m., Staff E stated that the indicators attached to the peer review criteria were "a list of indicators we track" and that those listed as "review indicators" would prompt a focused review while those listed as rate or rule indicators were tracked and trended over time but "I don't know that it triggers anything."

Review of the list of indicators revealed that the facility had a review indicator for all departments which was "Unanticipated death" and that for the "Medical" departments it included "Deaths of medical inpatients excluding... medical conditions with known expected death rates (e.g. CHF [congestive heart failure], acute AMI [acute myocardial infarction, a heart attack], pneumonia)..." The list indicated that for medical departments, the "Risk adjusted mortality index" was computed by "actual complications divided by expected complications" and was a rate indicator rather than a review indicator.

In an interview on 9/15/11 at 10:17 a.m., Staff E stated that the rates in the physician quality profiles came from those cases for which they were the attending physician. He stated that Practitioner 4's patients who had died had not been the target of a focused review. He stated that mortality would be reviewed by a nurse according to the criteria in the review indicators and only those cases which did not meet the exclusion criteria would go on to peer review. When the surveyor expressed concern that unusually high mortality rates for the diagnoses listed as exclusion criteria would not trigger peer review, Staff E stated that the purpose of having a nurse do the screening was to use the nurse's clinical judgment. He agreed, however, that the nurse would not be able to judge whether or not a physician's practice had been appropriate since those decisions would not be within the nurse's scope of practice.

2. Review of the facility's credentials committee minutes dated 9/9/11 indicated Practitioner 8 was an emergency medicine physician who the committee had recommended for reappointment. Review of Practitioner 8's credentials file indicated it included an undated "Physician Performance Evaluation/Profiling/Credentialing" data sheet which indicated Practitioner 8 had been the attending physician for 2075 inpatients for whom the mean length of stay had been zero days, the same as their expected length of stay. The profile indicated Practitioner 8's mortality rate was zero, which was the same as the expected mortality rate.

In an interview on 9/15/11 at 2:22 p.m., the surveyor asked Staff D to explain why Practitioner 8 (an emergency room doctor) had been the attending physician for thousands of hospital inpatients who didn't stay in the hospital. Staff D replied that an emergency room physician wouldn't have admissions, but that the emergency room did its own internal reviews to ensure quality.

In an interview on 9/15/11 at 3:10 p.m., Staff E stated that the facility had begun using new performance metrics for the emergency room physicians in February, that the facility had used the wrong template for Physician 8's quality profile, and that it would be redone and resubmitted to the credentials committee.

Based on interview and record review, the facility failed to enforce its medical staff bylaws when 1 of 9 sampled credentials files (Practitioner 6) had malpractice coverage which was for the wrong specialty. The deficient practice had the potential to limit resources available to pay malpractice claims.

Findings:

Review of the facility's medical staff bylaws dated 8/5/10 indicated, "Allied health professionals shall be required to provide documented evidence of professional liability coverage..."

Review of Practitioner 6's credentials file indicated she was a nurse practitioner (NP) and registered nurse first assistant (RNFA) whose privileges included "Management of the Neurosurgical Patient" and "Discharging the Neurosurgical Patient". Practitioner 6's malpractice certificate indicated it was for "Pediatric/Neonatal/Fam Practice Nurse Practit" (sic) rather than a neurosurgery NP or RNFA.

In an interview on 9/14/11 at 10:39 a.m., Staff D stated Practitioner 6's medical staff sponsor was a neurosurgeon. She agreed that the malpractice certificate stated it was for a pediatric, neonatal, and family practice NP and that Practitioner 6 was working in neurosurgery.

In an interview on 9/15/11 at 2:22 p.m., Staff E stated the facility had nothing in writing to indicate that Practitioner 6 was covered for neurosurgery.

Based on record review and interview, the facility failed to ensure that all patient medical record entries had the time documented where applicable when, one "Conditions of Admission and Treatment', did not have the time on the date of the patient's representative signature (Patient 1) and one "Consent to Transfusion of Blood Products" had no time on the date of the physician's informed consent and the patient's consent to blood transfusion (Patient 2 ). Failure to document the time on the records could create confusion for other staff caring for the patient and can affect patient safety and quality of care.

Findings:

1. Record review conducted on 9/14/11 at 10:45 AM, showed that Patient 1 was admitted to the facility on 9/9/11 with the diagnosis of gum bleeding.

Review of the "Conditions of Admission and Treatment" showed that the patient's legal representative signed the above form on 9/9/11. The space provided to record the time when signed was blank. The patient's legal representative signature was witnessed by a facility staff.

2. Record review conducted on 9/14/11 at 1:30 PM, showed that Patient 2 was admitted to the facility on 8/22/11 with the diagnosis of end stage renal disease (ESRD).

Review of the "Consent to Transfusion of Blood Products", showed that the physician signed the informed consent on 8/23/11 and the patient signed the consent to blood transfusion on 8/28/11 The time when signed was not indicated.

In an interview with the Director of Quality and Performance Improvement ( DOQPI) conducted on 9/15/11 at 11:10 AM, the DOQPI stated that it was facility's expectation to to record the time in the space designated on the form.






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Based on observation, interview and nursing document review, the hospital failed to ensure nursing staff followed correct infection control precautions to prevent cross contamination when delivering meal trays to patients.

Findings:

Patient 19 had diagnosis including lumbar axis and MRSA (methicillin resistant Staphylococcus Aureus). The entrance to Patient 19's room had a posted sign that read:

STOP
Wear Gloves
Wear gowns required for direct contact with patient or environment

At 12:18 p.m. on 9/13/11 during observations of lunch meal tray distribution, Nursing Staff A (NS A) was observed to bring lunch tray into Patient 19's room and set the tray on the overbed table. Patient 19 was standing at the bedside holding on to a walker and asked nursing staff A to wait while she used the rest room. Patient 19 gave her walker to NS A. Nursing Staff A was observed to take the walker with bare hands and push it to the foot of the bed, and then move the overbed table into position after Patient 19 re-entered the bed. Nursing Staff A then washed her hands in the patient sink and exited the room.
During an interview with the surveyor at 12:25 p.m. NS A stated she should wear gloves if she touched anything in the patient room when delivering meal trays.

At 1:00 p.m. during an interview, Infection Control Practitioner B stated that the patient environment included clothing and equipment and she would have expected nursing staff A to wear gloves when delivering the meal tray/ handling patient equipment and overbed tables. Hospital policy " Infection Control Precautions for Hospitalized Patients " approved 7/29/10 guided staff working with MRSA patients to wear gloves when touching patient, patient surroundings, or items likely to be contaminated with organism from the patient.