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Based on a review of the Parkview Adventist Medical Center Quality Plan, Medical Staff Bylaws, Medical Staff Quality improvement indicators, meeting minutes for the Departments of Medicine and the Department of Surgery for 2011, the Performance Improvement Council from January 2011 through January 2012, and interviews with key staff, it was determined that the hospital failed to have an effective governing body that ensured that all areas of the hospital were participants in the hospital wide Quality Improvement Plan for 2011 and 2012.

Findings include:

1. The Governing Board failed to ensure that Patients' Rights requirements were met (see Tags A-0123, A-0165, A-0168, A-0173, and A-0184)

2. The Governing Board failed to recognize that the medical staff did not perform meaningful case reviews (see Tag A-0338).

3. The Governing Board failed to recognize that all Departments and Services did not have Performance Improvement indicators that were involving all Medical Staff Departments and Services and focused on indicators related to improved health outcomes and safety as these indicator were at there performance target, had no date , or did not involve all services provide by PMC (See Tag A-0338).


The cumulative effect of these deficient practices resulted in this Condition of Participation being out of compliance. Additionally, these are repeat deficient practices identified and cited during the onsite Federal Survey completed April 29, 2010.

Based on review of meeting minutes, review of the Quality Plan, review of Quality data and interviews with hospital staff March 6-8, 2012, it was determined that the governing body failed to ensure that the Medical Staff had an effective quality assurance and performance improvement program reflecting the complexity of the hospital's organization and services; involving all Medical Staff Departments and Services and focused on indicators related to improved health outcomes and the prevention and reduction of medical errors.

Findings include

1. The Medical Staff did not consistently have performance improvement initiatives as their indicators were either already at, or above, their performance targets, were found to be "hard to accurately measure," or were unrelated to their practice. [For more details, see Tag A-338]

2. The Medical Staff did not have minutes of meaningful case review in order to find opportunities for improvement. Furthermore, the Medical Staff did not review their case review indicators to determine if they were sufficient to find opportunities for improvement. [For more details, see Tag A-338]

The cumulative effect of these deficient practices is that this Condition of Participation is out of compliance. These deficient practices were identified and documented in a Statement of Deficiencies dated April 29, 2010 and represent recurrent deficiencies.

Based on a review of the CMS Form -2567 (Statement of Deficiencies) dated April 29, 2010 and the Plan of Correction submitted by Parkview Adventist Medical Center, and the Parkview Adventist Medical Center Quality Plan, Medical Staff Bylaws, Medical Staff Quality improvement indicators, meeting minutes for the Departments of Medicine and the Department of Surgery for 2011, the minutes from the Performance Improvement Council from January 2011 through January 2012, and interviews with key staff, it was determined that the Parkview Adventist Medical Staff continued to fail to take responsibility for the quality of care provided to patients and failed to perform meaningful case review in order to find opportunities for improving health outcomes.

Findings include:

Previous Survey Results

1. A Statement of Deficiencies dated April 29, 2010 noted that the Conditions of Participation, "Medical Staff" (tag A-338), "QAPI [Quality Assurance, Performance Improvement]" (tag A-263), and "Governing Body" (tag A-043) were out of compliance. The findings documented included that certain departments, including Anesthesia and Emergency Medicine, had either no quality improvement indicators or indicators that were already at their targets.

2. The Plan of Correction provided following the April 29, 2010 survey stated, "discussion at these meetings [PIPS, PI Council, department meetings of the medical staff and of the Board of Directors] will focus on those indicators not meeting target, indicators needing to be added and indicators needing to be dropped and the plans of corrective action for indicators not meeting targets."

Medical Staff Bylaws and Quality Plan

3. The Medical Staff Bylaws defines three departments, Medicine, Surgery, and Radiology. Emergency Medicine is part of the Department of Medicine. Anesthesia is part of the Department of Surgery.

4. The Medical Staff Bylaws, Article X, Section 10.5.3 " General Duties " states: "The purpose of the Medical Staff and Medical Center-wide Performance Improvement Council is to establish and maintain an ongoing, comprehensive, and effective performance improvement program which monitors the clinical performance of the medical center's Practitioners and resulting patient care outcomes ... "

5. The Medical Staff Quality Plan states, "The Medical and Professional Staff identify quality indicators reflecting monitoring of high risk, high volume or problem prone areas of clinical practice; including consideration of incidence, prevalence, severity, appropriateness of care and complications; opportunity to improve health outcomes, process improvement, and reduction of medical errors and/or patient safety. "

6. The document titled "2011 Data Dashboard Medical Staff (Updated 1/17/12)" was presented at the time of the survey as the list of medical staff quality improvement indicators and results.

Lack of Meaningful Indicators in Emergency Services

7. The Chief Nursing Officer, in a meeting on March 7, 2012, said the Emergency Department saw between 10,000 and 11,000 patients per year, and that Anesthesiology and Emergency Medicine were both high risk and high volume services at Parkview Hospital.

8. According to the "2011 Data Dashboard Medical Staff (Updated 1/17/12)," there were four Quality improvement initiatives for the Emergency Physicians. These indicators did not identify "...opportunity to improve health outcomes, process improvement, and reduction of medical errors and/or patient safety ... " as stated in the Medical Staff Quality Plan, since they were: not related to physician care; were at, or exceeded their targets for all measurement periods; were "hard to accurately measure;" or had no data available.

a. The first indicator was, "Arrival of patient to first encounter by physician, within 30 minutes, 80%." There was no evidence of performance improvement as this indicator exceeded the target for all three quarters for which data was available.

b. The second emergency physician indicator was, "Pain medication administered to patients with fractures prior to x-ray, Department goal, 80% " . . The results for the first quarter were "no data available." The results for the second and third quarter were 62% and the results for the fourth quarter were "no data available." This indicator was discussed at the September 2011 Performance Improvement Council meeting. The minutes stated, "ER [Emergency Room] indicator of pain med [medication] administered to patients with fractures prior to x-ray is hard to accurately measure. Conclusion is to retire this indicator. Question of a new measure to replace: pain assessment prior to x-ray for patients with probable fractures." These minutes do not indicate whether this new indicator would be a nursing or a physician indicator. Despite the failure to demonstrate improvement, and the difficulty "to accurately measure" the indicator, there was no evidence that a new indicator was adopted.

c. The third indicator was, "Time of arrival to first EKG for patients with CP/AMI [Chest Pain/Acute Myocardial Infarction] within 10 minutes." The results of this indicator was 100% for all three quarters for which data was available. During a meeting with the Chief Executive Officer and the Chief Nursing Officer on March 7, 2012, the Chief Nursing Officer confirmed that this indicator was related to the practice of nurses, and not physicians.

d. The fourth indicator was, "Time of arrival to time of ASA [aspirin] administration for patient with CP/AMI, within 24 hours." The results of this indicator were 100% for all three quarters for which data was available.

Lack of Meaningful Indicators in Anesthesiology and Surgery

9. The Chief Nursing Officer, in a meeting on March 7, 2012, said that Anesthesiology and Emergency Medicine were both high risk and high volume services at Parkview Hospital.

10. According to the "2011 Data Dashboard Medical Staff (Updated 1/17/12)," there were five Quality improvement initiatives for the Anesthesiology.

a. The first indicator was, "Anesthesia awareness from patient feedback, 0% (0 incidents)." Results for the three quarters of data available were 0%.

b. The second indicator was, "100% of prophylactic ax, [antibiotics] administered within 1 hr of incision, 100%." The results for all four quarters of data available was 100%.

c. The third indicator was, "100% CPOE [Computer Physician Order Entry] use in epidural cases, Department goal 100%." The results for all three quarters for which data were available was 100%.

d. The fourth indicator was, "100% compliance with CPOE epidural/ intrathecal narcotic precautions, Department goal 75%." There were no eligible cases for the three quarters reported at the time of the survey.

e. The fifth indicator was, "0% headache related to inadvertent dural puncture during epidural placement, National standard is <3%." The results for all three quarters reported at the time of the survey were 0%.

11. The minutes of the Department of Surgery dated June 3, 2011, stated, "Medical Staff Dashboard: [Chief Nursing Officer] presented. All indicators are being met, so new indicators need to be created."

12. The August 1, 2011 minutes of the Department of Surgery stated, "Med Staff Dashboard Q2 2011: [Chief Nursing Officer] presented the Q2 data for surgery, anesthesia and gastroenterology. All anesthesia indicators are at 100%. New indicators need to be created, Action Accepted and approved."

13. During a meeting on March 6, 2012, the Chief Nursing Officer stated that no new Anesthesia or Surgery indicators were added to the Medical Staff Dashboard as suggested in the minutes of the Department of Surgery.

14. In a meeting with the Chief of Anesthesia on March 8, 2012, he stated that he could not demonstrate process improvement as all the indicators were at their targets, or had no data, throughout the entire measurement period.

Lack of Meaningful Indicators in Radiology

15. Two (2) of the four (4) Department of Radiology indicators were at their targets for the entire year, and one (1) indicator was at target for the first 2 measurement periods. The fourth indicator did not involve physician performance, according to the minutes of the Department of Radiology from September 13, 2011, which stated, "One of the PI indicators being tracked is "time out" before procedures. The rate of compliance is low, but it is a documentation issue. The technologists have been notified to improve documentation. Action: Informational."

Lack of Meaningful Indicators in Pathology

16. For the Department of Pathology, three (3) of the four (4) indicators were at their targets for the entire measurement period. Only the "Indication for blood product use is documented on the physician orders 100% of the time" indicator was not at the target for the entire year, but this indicator did not reflect the practice of the Pathologists who do not order blood transfusions.

Failure to Complete Peer Review

17. In an e-mail communication on March 7, 2012 the Director of Medical Staff Services identified the medical staff retrospective peer review indicators as: All deaths, Hospital acquired DVT, Hospital acquired Pulmonary emboli, Hospital acquired Pneumothorax, Hospital acquired Aspiration Pneumonia, Pediatric transfers to acute care facility (Dr. [pediatrician] to do), Post surgical respiratory failure (Anesthesia to do), Mechanical ventilator (intubation post surgical only) - Anesthesia will do, 30 day readmits, and Core Measure fails.

18. The Director of Medical Staff Services, on March 7, 2012, stated that the hospital could not supply a list of case reviews based on the retrospective peer review indicators, and unless the case was presented at the Department meeting, there would be no case discussion or minutes.

19. A review of the minutes of the Department of Medicine contained only one case review in March 2011, with a description of the case and issues for the medical staff to address. There was one other case review in August 2011 which was described as "for educational purposes," but there was no description of the case or the educational objectives. There were no other case discussions in the meeting minutes, and there was no discussion about revising the peer review indicators nor discussion regarding whether the existing peer review indicators were sufficient in identifying quality issues for improvement.

20. The minutes of the Department of Surgery for 2011 were reviewed. There were no cases "forwarded for review" at any meeting.

Failure in Medical Staff Quality

21. On March 6, 2012, the Chief Nursing Officer confirmed that many of the indicators on the 2011 Medical Staff Dashboard did not represent process improvement as they were already at their targets at the beginning of the measurement period, and the Medical Staff did not propose or modify any of the indicators that were already at their targets throughout the entire 2011 measurement period.

22. The minutes of the Medical Staff and Medical Center-wide Performance Improvement Council from January 2011 through January 2012 were reviewed. There was no evidence in the minutes that the Medical Staff and Medical Center-wide Performance Improvement Council established or maintained an, "ongoing, comprehensive, and effective performance improvement program" as there was no discussion about the absence of, performance improvement targets that could demonstrate "opportunity to improve health outcomes."


The cumulative effect of these recurrent deficiencies is that this Condition of Participation is out of compliance.

Based on record review, policy review and interview with key personnel on March 6, 2012, it was determined that the hospital failed to follow its policy "Grievance Policy for Resolving Patient Complaints", in three (3) of five (5) complaints reviewed.

Findings include:

1. The Parkview Adventist Hospital policy entitled "Grievance Policy for Resolving Patient Complaints", stated, "whenever possible, investigation in response to grievances that are not complex in nature shall be completed with a written response to the complainant within seven to ten business days." "If the grievance is not resolved and is still being evaluated , an initial written response shall be sent to the complainant within seven to ten business days." "The final written response shall include the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion."

2. Review of the complaint Record VV, indicated that the complaint was reported to the facility on March 16, 2011. Complaint Record VV contained a letter in response to the patient dated April 11, 2011. No other notes to the patient were found in the complaint record.

3. Review of the complaint Record XX, indicated that the complaint was reported to the facility on May 20, 2011. Complaint Record XX contained a letter in response to the patient dated July 8, 2011. No other notes to the patient were found in the complaint record.

4. Review of the complaint Record YY, indicated that the complaint was reported to the facility on September 12, 2011. Complaint Record YY lacked a letter to the patient with the resolution of the complaint; however, a note in the record indicated that the patient had been called on the phone on September 29, 2012.

5. The above findings were confirmed by the Chief Nursing Officer on March 6, 2012.

Based on record reviews and interviews with key personnel on March 6, 2012, it was determined that the facility failed to assure that physicians specified the type of restraints to be used in three (3) of five (5) patient records.

Findings include:

1. The physician's orders for Record KK, LL and RC contained physician orders for two point type restraint to be used.

2. While nursing documentation for restraint type indicated bilateral wrist (2 point), soft restraint, physician orders made no mention of the restraint being either soft or leather type restraint and failed to indicate if these were to be used on wrists, ankles, or on one wrist and one ankle.

3. These findings were confirmed with the Nurse Manager of the ICU (Intensive Care Unit) on March 6, 2012.

4. The deficiencies regarding the type of restraint was noted in the Statement of Deficiencies dated April 20, 2010 (A263 paragraph 3) and is a recurrent deficient practice.

Based on record reviews and interviews with key personnel on March 6, 2012, it was determined that the facility failed to assure that the restraint used on a patient was ordered by a physician prior to use in one (1) of five (5) patient records.

Findings include:

The medical record of patient KK, contained a nursing note specifying that a restraint was initially applied on February 3, 2011 at 1645 (4:45 PM). The physician's order for this restraint was ordered on February 4, 2011 at 0845. The restraint was applied prior to an order being obtained by the physician. This finding was confirmed by the Nurse Manager of ICU (Intensive Care Unit) on March 6, 2012.

Based on record reviews and interviews with key personnel on March 6, 2012, it was determined that the facility failed to assure the continuous use of a restraint used on a patient was ordered by a physician prior to it's continued use for one (1) of five (5) patients.

Findings include:

The medical record of patient NN indicated that the patient had a restraint initially ordered on December 7, 2011 and the patient continued to be restrained on December 12, 2011. However, review of the medical record failed to contain a physician's order for a restraint on December 12, 2011. This finding was confirmed by the Nurse Manager of ICU (Intensive Care Unit) on March 6, 2012.

Based on record review, policy review and interview with key personnel on March 6, 2012, it was determined that the facility failed to assure that a patient was seen face-to-face by a physician or LIP (licensed independent practitioner) within one (1) hour after the initiation of a restraint in three (3) of five (5) patient records.

Findings include:

1. Parkview Adventist Hospital's restraint policy states, "Restraints may be applied after obtaining a valid Physician/LIP order for restraints. When restraints are used. . . the patient must be seen face-to-face within 1 hour after the initiation if the intervention by a physician or other licensed independent practitioner (LIP) in order to evaluate..."

2. The medical record of patient KK indicated that a restraint was ordered by the physician on March 4, 2011 at 0845 and lacked evidence that the physician had seen the patient face-to-face within 1 hour of the order.

3. The medical record of patient LL indicated that a restraint was ordered by the physician on April 19, 2011 at 1836 (6:36 PM), and lacked evidence that the physician had seen the patient face-to-face within 1 hour of the order.

4. The medical record of patient NN indicated that a restraint was ordered by the physician on December 7, 2011 at 1145, and lacked evidence that the physician had seen the patient face-to-face within 1 hour of the order.

5. The above findings were confirmed by the Nurse Manager of ICU (Intensive Care Unit) on March 6, 2012.

Based on record review and interview with key staff on March 5, 6, & 7, 2012, it was determined that the condition of the physical plant and the overall hospital environment were not developed and maintained in such a manner that the safety and well being of patients are assured.

Findings include:

1. In the Pharmacy Department, the floors were dirty and stained, the walls were gauged with pealing wall paper, the shelves holding medications were dusty and needed to be painted, areas in the main area lacked cove base, a ceiling vent had accumulated dust, chemical hood had rusted vents, and ceiling tiles were ill fitting and stained.

2. On March 5, 2012, the men and women's bathroom in the main corridor had no working sink and no alternative hand washing was available.

3. The hospital Sleep Lab had torn wall paper, the hallway walls were patched, and the counter top in the Sleep Lab Office was damaged and taped.

Based on a tour of the hospital facility and interview with key staff on March 5, 6, & 7, 2012, it was determined that not all equipment was maintained to ensure acceptable level of safety and quality.

Findings include:

1. In the Emergency Department, the pulse oximeter located in the triage room was last inspected on September 2010 and due for inspection on September 2011 by GE (General Electric). In addition, in exam room 6, a woods lamp was last inspected September 2010 and due for reinspection on September 2011 by GE.

2. In the Infusion Suite A, four IV pumps had no information regarding their last mechanical inspection.

3. In the Sleep Study area , room 206, had a VAP face mask lacked information regarding its last maintenance inspection.

4. In an interview with the Director of Maintenance, revealed that there was confusion between two contracting equipment inspection companies. Both companies failed to establish an adequate system of tracking and maintaining all patient equipment.

Based on record review and interview with key personnel on March 6, 2012, it was determined that the facility failed to assure a medical history and physical exam was completed and documented no more that 30 days before admission in two (2) of six (6) patient records.

Findings include:

1. Patient Record GG indicated that surgery was scheduled for February 29, 2012. The medical record of GG lacked a completed history and physical prior to surgery; however, the medical record of GG contained a history sheet, dated February 14, 2012, indicating that a history sheet had been reviewed and signed.

2. Patient Record JJ indicated that surgery was scheduled for February 29, 2012. The medical record of JJ lacked a completed history and physical prior to surgery; however, the medical record of JJ contained a history sheet, dated February 16, 2012, indicating that a history sheet had been reviewed and signed.

3. These finding was confirmed by the Chief Nursing Officer (CNO) on March 6, 2012.