HospitalInspections.org

Based on interview and record review, the facility's governing body failed to develop the medical staff rules and regulations. This deficient practice limited the governing body's ability to provide effective oversight of the medical staff.

Findings:

During an interview on 8/23/16 at 8 am , the facility's Program Director (PD) stated "I don't know about Rules and Regulations, all I have is that binder with the medical staff Bylaws...".

During an interview on 8/23/16 at 9:45 am, the Chief of Medical Staff (MD 1) was asked about the medical staff rules and regulations, and he stated "We have medical staff bylaws, it is a matter of semantics...what rules and regulations are you referring to?...".

During a follow up interview on 8/23/16 at 10:30 am, MD 1 was shown two sections in the facility provided copy of medical staff bylaws that made reference to medical staff "Rules and Regulations", "Section 12 D." and "Article XIII". MD 1 acknowledged the references and stated: "Well, we don't have those rules and regulations. We need to separate the rules and regulations from our bylaws...".

Based on interview and record review, the facility's governing body failed to evaluate the quality of each contracted service. There was no evidence that the facility's contracted services were incorporated into and evaluated by the hospital wide quality assessment and performance improvement (QAPI) program. The deficient practice limited the facility's ability to identify and correct problems with their contract services.

Findings:

During an interview on 8/23/16 at 9 am with the facility's Program Director (PD) and the Unit Manager (UM); when asked about how the facility's contracted services performance was evaluated, PD stated "I don't know about that..."

During an interview on 8/24/16 at 2:30 PM with PD, UM and the Chief Nursing Officer (CNO) to review the Quality Assurance Performance Improvement QAPI program, CNO stated "We get reports from some of the contractors like pharmaceutical services, but we do not have an agenda item regarding the evaluation of their services..."

Record review of a facility list of contracted services provided by PD on 8/24/16 at 10:30 am, indicated there were 10 contractors under agreement.

Record review of the QAPI monthly meeting agenda from 2/26/15 to 7/20/16 indicated no reference to the evaluation of contracted services.

Based on interview and record review, the facility failed to maintain a list of all contracted services including the scope and nature of the services provided.

Findings:

During an interview on 8/23/16 at 9 am with the facility's Program Director (PD) and the Unit Manager (UM); PD provided a four pages list of contracted services that included contract number and brief description. PD was asked about two randomly selected contractors from the list involving pharmacy and laboratory services. PD stated: "Those are no longer under contract, we have different providers...This is not a current list."

Record review of a facility list of contracted services provided by PD on 8/24/16 at 10:30 am, indicated there were 10 contractors. The contract for "X-ray and EKG Service" indicated a "Contract End Date 11/18/15". During a concurrent interview PD stated "Yes it is expired, we are trying to renew it...". The list of contracted services did not include transportation services.

Record review of a four pages contract copy for radiological services indicated a facility's signature on 3/25/15 and the contractor's signature line was blank.

During an interview on 8/25/16 at 10:30 am, the Chief Nursing Officer CNO stated: "Yes, I understand the radiology services contract expired...we are in the process of renewing it...".

During an interview on 8/24/15 at 11:05 am, UM stated "We use ambulance services from a company we have a contract with".

During an interview on 8/25/16 at 10 am, PD stated "We use transportation from a company the skilled nursing facility in the building has a contract with...but you are right, our psychiatric hospital is not listed in the contract...".

Record review of a copy of a contract for "Medical Transportation Services Agreement" signed on 3/17/11, did not list the psychiatric hospital as a recipient of services.

Based on interview and record review, the facility failed to prevent the frequent use of verbal orders when 3 of 20 sampled patients had Physician Orders containing 12 verbal orders, representing a pattern of frequent use. This could have resulted in miscommunication regarding treatments.

Findings:

1. Patient 1 was admitted with diagnoses including psychosis (mental disorder characterized by disconnection from reality) and dementia (disorder of cognition and memory).

During a record review on 8/22/16 of Patient 1 ' s Physician Orders, six verbal orders dated 6/28/16 (two), 6/30/16, 7/13/16, 7/19/16, and 7/27/16 were noted. These verbal orders included the 6/28/15 Admitting Physician ' s Orders, which were not signed by MD 1.

An interview on 8/22/16, at 1 pm, with the Program Director, confirmed the six verbal orders and also confirmed the 6/28/15 Admitting Physician ' s Orders were not signed by MD 1.

2. Patient 4 was admitted with diagnoses including schizophrenia (brain disorder in which people abnormally interpret reality) and hypertension.

During a record review on 8/22/16 of Patient 4 ' s Physician Orders, four verbal orders dated 7/13/16, 8/1/16, 8/4/16, and 8/22/16 were noted.

An interview on 8/22/16 at 1 pm with the Unit Manager confirmed the four verbal orders.

3. Patient 8 was admitted with diagnoses including psychosis and dementia.

During a record review on 8/23/16 of Patient 8 ' s Physician Orders, two verbal orders dated 2/12/16 and 2/13/16 were noted.

An interview on 8/23/16, at 3:35 pm, with the Program Director, confirmed the two verbal orders.

A record review on 8/22/16 of facility policy and procedure, " Physician Orders " , indicated, " 3. The physician shall sign telephone/verbal orders within 48 hours. "