HospitalInspections.org

Based on record review and interviews with hospital staff the hospital does not ensure that all services provided for patients either by contract, agreement, shared services or joint venture are provided in compliance with the Medicare Conditions of participation and according to acceptable standards of practice. Services provided by St John Health System employees are not evaluated by St John - Owasso hospital through its QAPI program to monitor the quality and performance of these services.

Findings:

1. The dietitian providing oversight of the hospital's dietary services competency was evaluated by an outside source and not by St John - Owasso.

2. Radiological services were evaluated by an outside source and not by St John - Owasso.

3. Physical Therapy services and personnel were evaluated by an outside source and not by St John - Owasso.

4. Hospital staff stated that they did not have an agreement, contract or shared service agreement with the outside source.

Based on record review, policy and procedure review and staff interview, it was determined the hospital failed to identify a patient complaint as a grievance, and failed to provide written responses to patient grievances. Findings:

A hospital policy, titled "Patient Complaint and Grievances", documented, "... Complaint:... dissatisfaction with the care or services provided that is relatively minor in nature and can be resolved by the staff present*...

Grievance:... may be a written or verbal complaint that cannot be resolved by the staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution...

Grievances will be reviewed, thoroughly investigated, and resolved within reasonable time frames... If the grievance will not be resolved, or if the investigation is or will not be completed within seven days, the patient or the patient's representative will be informed in writing that the hospital is still working to resolve the grievance and to expect a written follow-up no later than 45 days from date of receipt..."

1. A variance form, dated 04/12/12, documented Patient #26 complained to hospital staff she was not medicated for pain and did not receive the services she requested while in the emergency room on 04/11/12.

The form also documented the patient had a dispute about an outstanding balance owed for previous services.

There was no documentation that indicated the patient's complaint was classified as a grievance and was investigated. There was no documentation the patient received a written response from the hospital.

2. A variance report, dated 02/22/12, documented a family member of Patient #10 filed a grievance regarding care received in the emergency room on 02/21/12.

There was no documentation of a written response to the grievance.

On 05/02/12, the hospital CEO stated the hospital did not identify the complaint made by Patient #10 as a grievance.

He stated the hospital had not completed the investigation and written response to the grievance alleged by Patient #10. He stated the hospital's written response would be completed and sent out that day.

Based on record review and staff interview, it was determined the hospital failed to ensure a registered nurse with a probationary license was competent to provide care. Findings:

On 05/02/12, the personnel file for Staff CC, a registered nurse, was reviewed for credentials, skills competency, hospital and departmental orientation and specialized training.

The file documented the registered nurse's license had been placed on a probationary status by the Oklahoma Board of Nursing in 2008.

The human resources manager stated the nurse was allowed to practice as a registered nurse with several stipulations, to include direct supervision by another registered nurse at all times, and periodic performance evaluations with reports to the Board of Nursing.

There was also a stipulation that required the hospital to report to the Board any and all verbal or written discipline or counseling incidents involving this nurse.

The personnel file contained a written notice from the DON dated 10/11/11, that documented Staff CC had failed to document narcotics she administered to a patient and failed to document pain assessments for the patient.

The medical-surgical services nurse manager was asked if the Board of Nursing had been notified of the written counseling by the DON. She stated she was not aware of the incident.

The human resources manager stated she had no documentation of a report to the Board of Nursing regarding the disciplinary issue.

Based on review of policies, hospital documents, and interviews with staff, the hospital failed to ensure a qualified radiologist supervises the radiology services. On the afternoon of 5/2/12 Staff A told surveyors the facility did not have a specified radiologist that supervised radiology services. These findings were discussed at the exit conference 5/2/12.

Based on review of infection control data and meeting minutes containing infection control for the past twelve months, and hospital documents, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner developed and maintained a comprehensive system for reporting, analyzing and controlling infections and communicable diseases among patients and staff and ensuring a sanitary environment.

Findings:

1. On 05/01/2012, administrative staff told the surveyors that infection control activities were part of the Quality (QMAC) program and meeting minutes.

2. Review of meeting minutes containing infection control and the infection control data provided for review, did not demonstrate analysis of the data presented with corrective action taken when indicated and follow-up to ensure the action taken was effective.
a. According to the data provided, the hospital had nosocomial/facility acquired infections for both acute care stay and surgical site. Data reviewed did not demonstrate analysis to identify if hospital policies and procedures and practices needed to be changed.
b. Employee Health entries only identified immunization practices of employees. The data provided did not contain employee illnesses or demonstrate review and analysis to determine if there was any correlation between employee and patient illness/organisms with corrective action taken when indicated.
c. Environmental rounds, conducted quarterly, identified deficits in practices. Meeting minutes did not address these problems or reflect follow-up to ensure any actions taken were effective.

3. Review of the data provided and meeting minutes did not demonstrate the infection control program conducted active surveillance of hospital practices, with the exception of monthly handwashing and quarterly walk through environmental rounds, to ensure infection control practices and policies were followed.

4. The infection control program did not include a review of surgical services' practice.
a. The hospital provides cataract surgery once every month. According to the surgery log, thirteen cataract surgeries were performed on 01/25/2012. On 05/02/2012, Staff N told the surveyors that the hospital had three sets of surgical instruments. The surveyors were told that for the first three cases, the instruments were put through a full sterilization and drying time cycle, but that for the rest of the cases, the instruments were put through a "flash"/shorten/immediate use cycle. At the end of the day the instruments were again sterilized through the complete cycle. Infection control activities and meeting minutes did not reflect a review of the practice to ensure the practice was appropriate according to the instrument manufacture guidelines or review to decrease the need for immediate use sterilization.
b. Monitor/surveillance activities and meeting minutes did not reflect the application of the disinfectant was monitored to ensure it followed the manufacturer guidelines. On the afternoon of 05/02/2012, Staff B and N could not tell the surveyors the amount of time the hospital's disinfectant needed to remain wet on the surfaces to be effective. Staff N stated she did not monitor staff to ensure they followed the manufacturer's guidelines for application and wet time.
c. On 05/02/2012 at 1520, Staff N told the surveyors that she did not provide/report any information to infection control about immediate use sterilization or disinfectant use/monitoring. Staff F told the surveyor on the afternoon of 05/02/2012 that the infection control program did not monitor and analyze either of these practices.

Based on personnel record review and staff interview, it was determined the hospital failed to ensure the surgery department was managed by a registered nurse experienced in the provision and management of surgical services. Findings:

On 05/02/12, the personnel record for the surgical department manager (Staff N) was reviewed for credentials, skills competency, departmental orientation and specialized training.

The record documented the surgery manager had been promoted from the position of a PACU staff nurse to OR department manager in June of 2010.

The nurse's resume had no documentation of experience in the operating room or of surgery management experience.

The DON was asked if the surgery manager had previous OR experience, had been oriented to the surgery department, had demonstrated competence in surgery, or was qualified to evaluate the performance of the OR staff.

He stated she did not have surgery experience, had no documentation of orientation to the OR, and had no documentation of OR skill competency.

He stated he understood this was an area of concern.

Based on record review and interviews with hospital staff, the hospital does not ensure that outpatient services provided have policies and procedures established to assure quality patient care. The hospital does not have policies and procedures established to define the procedure for admission to outpatient services for patients who are referred for outpatient procedures by a physician who is not on the hospital's medical staff.

Findings:

1. Hospital staff stated on 05/02/12 in the afternoon that they do not have policies and procedures defining the process for outpatient services ordered by a physician who does not have medical staff privileges.

2. The current process for the admittance of patients of physicians without medical staff privileges according to hospital staff is the patient is admitted by the hospitalist physician on duty.

3. There was no documentation in the records reviewed that the hospitalist may or may not have patient information to determine the appropriateness for the referral for the outpatient procedure.