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Based on clinical record review and staff interview, the hospital failed to ensure that the patient's response to the physical restraints used, including the rationale for continued use of the intervention, was documented for three of three patients (#8, 20, and 21) that were placed in restraints between January 2011 and August 2012. This failed practice could lead to patients being in restraints longer than necessary. The findings are:

A. Review of Patient #8's clinical record revealed a Medical/Surgical Restraint Order dated 08/13/12 at 11:45 am for bilateral soft wrist restraints.
1. Review of Patient #8's Critical Care Flow Sheet dated 08/13/12 revealed no documentation that the patient continued to need to be in physical restraints.
2. Review of the patient's clinical record revealed the patient was given 1 milligram of Dilaudid at 5:20 pm on 08/13/12. By 5:40 pm, the nurse noted, "[Patient] resting, no longer pulling."
3. Review of the patient 's Restraint 24 Hour Flow Sheet dated 08/13/12 revealed no evidence from documentation that between 1:45 pm on 08/13/12 and 11:45 am on 08/24/12 the patient was agitated; the documentation indicated instead that the patient was calm and resting.
4. On 08/22/12 at 3:45 pm, during an interview, the Operations/ Quality Director confirmed that no documentation of rationale for the continued use of the physical restraints for Patient #8 was completed by the hospital staff.

B. Review of Patient #20's clinical record revealed a Medical/Surgical Restraint Order dated 07/04/11 at 6:15 am for bilateral wrist restraints and the reason listed is "vent" (ventilator).
1. Review of the patient's clinical record revealed no documentation for the rationale for the continued use of the physical restraints.
2. On 08/23/12 at 4:45 pm, during an interview, the Operations/ Quality Director confirmed there was no documentation for the rationale for the continued use of the physical restraints.

C. Review of Patient #21's clinical record revealed a handwritten order dated 01/17/11 at 5:45 pm that read, " Wrist Restraints." This was after a surgical procedure and the patient was coming back on a ventilator.
1. Review of the patient's clinical record revealed no documentation for the rationale for the continued use of the physical restraints.
2. On 08/23/12 at 4:45 pm, during an interview, the Operations/ Quality Director confirmed there was no documentation for the rationale for the continued use of the physical restraints.

Based on record review and staff interview, the hospital failed to ensure patients were released from restraints as soon as possible for one of three patients (#8) that were placed in restraints between January 2011 and August 2012. This failed practice could lead to patients being in restraints longer than necessary. The findings are:

A. Review of Patient #8's clinical record revealed a Medical/Surgical Restraint Order dated 08/13/12 at 11:45 am for bilateral soft wrist restraints.

B. Review of Patient #8's Critical Care Flow Sheet dated 08/13/12 revealed the following information:
1. The patient was given 1 milligram of Dilaudid at 1:30 pm. By 1:45 pm, the nurse noted, "[Patient] resting, no longer pulling."
2. The Nurse noted at 3:30 pm, "[Patient] resting."
3. The patient was given 1 milligram of Dilaudid at 5:20 pm. By 5:40 pm, the nurse noted, "[Patient] resting, no longer pulling."

C. Review of the patient's Restraint 24 Hour Flow Sheet dated 08/13/12 revealed no evidence from documentation that between 1:45 pm on 08/13/12 and 11:45 am on 08/24/12 the patient was agitated, but rather calm and resting.

D. On 08/22/12 at 3:45 pm, during an interview, the Operations/Quality Director confirmed that Patient #8 was not removed from the restraints at the earliest possible time.

Based on record review and staff interview, the hospital failed to ensure that the ICU staff did not automatically request physical restraints when a patient gets placed on a ventilator for two of three patients (#20 & 21) that were placed in restraints between January 2011 and August 2012. This failed practice could lead to patients being in restraints when they do not have to be. The findings are:

A. Review of Patient #20's clinical record revealed a Medical/Surgical Restraint Order dated 07/04/11 at 6:15 am for bilateral wrist restraints and the reason listed is "vent" (ventilator).
1. Review of the patient's clinical record revealed no behaviors, such as pulling at tubes, as a rationale for the restraints.
2. On 08/23/12 at 4:45 pm, during an interview, the Operations/Quality Director confirmed there was no rationale for the patient to be in physical restraints.

B. Review of Patient #21's clinical record revealed a handwritten order dated 01/17/11 at 5:45 pm that read, "Wrist Restraints." This was after a surgical procedure and the patient was coming back on a ventilator.
1. Review of the patient's clinical record revealed no behaviors, such as pulling at tubes, as a rationale for the restraints.
2. On 08/23/12 at 4:45 pm, during an interview, the Operations/Quality Director confirmed there was no rationale for the patient to be in physical restraints.









18749

Based on record review and staff interview, the hospital failed to ensure that the ICU staff tried other less restrictive interventions before placing patients in restraints for two of three patients (#20 & 21) that were placed in restraints between January 2011 and August 2012. This failed practice could lead to patients being in restraints when they do not have to be. The findings are:

A. Review of Patient #20's clinical record revealed a Medical/Surgical Restraint Order dated 07/04/11 at 6:15 am for bilateral wrist restraints and the reason listed is "vent" (ventilator).
1. Review of the patient's clinical record revealed no documentation that less restrictive alternatives attempted before placing the patient in restraints.
2. On 08/23/12 at 4:45 pm, during an interview, the Operations/Quality Director confirmed there was no documentation that less restrictive alternatives were attempted before placing the patient in restraints.

B. Review of Patient #21's clinical record revealed a handwritten order dated 01/17/11 at 5:45 pm that read, "Wrist Restraints." This was after a surgical procedure and the patient was coming back on a ventilator.
1. Review of the patient's clinical record revealed no documentation that less restrictive alternatives were attempted before placing the patient in restraints.
2. On 08/23/12 at 4:45 pm, during an interview, the Operations/Quality Director confirmed there was no documentation that less restrictive alternatives were attempted before placing the patient in restraints.

Based on record review and staff interview, the hospital failed to ensure hospital staff updated the patient's plan of care when the patient is placed in restraints for one of three patients (#8) that were placed in restraints between January 2011 and August 2012. This failed practice could lead to patients being in restraints longer than necessary. The findings are:

A. Review of Patient #8's clinical record revealed a Medical/Surgical Restraint Order dated 08/13/12 for bilateral soft wrist restraints.

B. Review of Patient #8's clinical record revealed no update to the patient's plan of care regarding the use of restraints.

C. On 08/22/12 at 3:45 pm, during an interview, the Operations/Quality Director confirmed that Patient #8's plan of care was not updated to reflect the use of restraints.





18749

Based on record review and staff interview, the hospital failed to ensure hospital staff updated the patient's plan of care when the patient is placed in restraints for one of three patients (#8) that were placed in restraints between January 2011 and August 2012. This failed practice could lead to patients being in restraints longer than necessary. The findings are:

A. Review of Patient #8's clinical record revealed a Medical/Surgical Restraint Order dated 08/13/12 at 11:45 am for bilateral soft wrist restraints.

B. Review of Patient #8 ' s Critical Care Flow Sheet dated 08/13/12 revealed the following information:
1. The patient was given 1 milligram of Dilaudid at 1:30 pm. By 1:45 pm, the nurse noted, "[Patient] resting, no longer pulling. "
2. The Nurse noted at 3:30 pm, "[Patient] resting. "
3. The patient was given 1 milligram of Dilaudid at 5:20 pm. By 5:40 pm, the nurse noted, "[Patient] resting, no longer pulling. "

C. Review of the patient's Restraint 24 Hour Flow Sheet dated 08/13/12 revealed no evidence from documentation that between 1:45 pm on 08/13/12 and 11:45 am on 08/24/12 the patient was agitated; the documentation indicated instead that the patient was calm and resting.

D. On 08/22/12 at 3:45 pm, during an interview, the Operations/ Quality Director confirmed that Patient #8 was not removed from the restraints at the earliest possible time.

Based on clinical record review and staff interview , the hospital failed to ensure that the patient's response to the physical restraints used, including the rationale for continued use of the intervention was documented for three of three patients (#8, 20, and 21) that were placed in restraints between January 2011 and August 2012. This failed practice could lead to patients being in restraints longer than necessary. The findings are:

A. Review of Patient #8's clinical record revealed a Medical/Surgical Restraint Order dated 08/13/12 at 11:45 am for bilateral soft wrist restraints.
1. Review of Patient #8's Critical Care Flow Sheet dated 08/13/12 revealed no documentation that the patient continued to need to be in physical restraints.
2. Review of the patient's clinical record revealed the patient was given 1 milligram of Dilaudid at 5:20 pm on 08/13/12. By 5:40 pm, the nurse noted, "[Patient] resting, no longer pulling."
3. Review of the patient's Restraint 24 Hour Flow Sheet dated 08/13/12 revealed no evidence from documentation that between 1:45 pm on 08/13/12 and 11:45 am on 08/24/12 the patient was agitated; the documentation indicated instead that the patient was calm and resting.
4. On 08/22/12 at 3:45 pm, during an interview, the Operations/Quality Director confirmed that no documentation of rationale for the continued use of the physical restraints for Patient #8 was completed by the hospital staff.

B. Review of Patient #20's clinical record revealed a Medical/Surgical Restraint Order dated 07/04/11 at 6:15 am for bilateral wrist restraints and the reason listed is "vent" (ventilator).
1. Review of the patient's clinical record revealed no documentation for the rationale for the continued use of the physical restraints.
2. On 08/23/12 at 4:45 pm, during an interview, the Operations/Quality Director confirmed there was no documentation for the rationale for the continued use of the physical restraints.

C. Review of Patient #21's clinical record revealed a handwritten order dated 01/17/11 at 5:45 pm that read, "Wrist Restraints." This was after a surgical procedure and the patient was coming back on a ventilator.
1. Review of the patient's clinical record revealed no documentation for the rationale for the continued use of the physical restraints.
2. On 08/23/12 at 4:45 pm, during an interview, the Operations/Quality Director confirmed there was no documentation for the rationale for the continued use of the physical restraints.

Based on document request, document review, and interview, the hospital failed to ensure that an effective, ongoing hospital-wide, data-driven quality assessment and performance improvement (QAPI) program was developed, implemented and maintained. The hospital's QAPI program did not incorporate the Conditions of Participation (COP's) for Radiology, Food & Dietary, Physical Environment, Organ, Tissue & Eye, Anesthesia, Nuclear Medicine, and Outpatient Services. As a result, no data was collected, analyzed or acted upon, and the hospital did not evaluate these seven COP's to determine how to improve patient health outcomes and reduce medical errors. The findings are:

A. On 08/21/12 at 8:30 am the Director for Quality/Risk Management and the Quality Coordinator were asked to show where the data for the COP's for Radiology, Food & Dietary, Physical Environment, Organ, Tissue & Eye, Anesthesia, Nuclear Medicine, and Outpatient Services were to be found since they were not included in the requested QAPI data provided by the hospital. The Director for Quality/Risk Management stated that the hospital had not been collecting any indicators or data for these seven COP's.

B. On 08/24/12 at 9:25 am the Quality Coordinator was again asked to verify that the COP's for Radiology, Food & Dietary, Physical Environment, Organ, Tissue & Eye, Anesthesia, Nuclear Medicine, and Outpatient Services were not incorporated into the hospital's QAPI program. She confirmed that no data or indicators were being collected on these seven COP's.

Based on document request, document review, and interview, the hospital failed to ensure that an effective, ongoing hospital-wide, data-driven quality assessment and performance improvement (QAPI) program was developed, implemented and maintained. The hospital's QAPI program did not incorporate the Conditions of Participation (COP's) for Radiology, Food & Dietary, Physical Environment, Organ, Tissue & Eye, Anesthesia, Nuclear Medicine, and Outpatient Services. As a result, no data was collected, analyzed or acted upon, and the hospital did not evaluate these seven COP's to determine how to identify and reduce medical errors.The findings are:

A. On 08/21/12 at 8:30 am the Director for Quality/Risk Management and the Quality Coordinator were asked to show where the data for the COP's for Radiology, Food & Dietary, Physical Environment, Organ, Tissue & Eye, Anesthesia, Nuclear Medicine, and Outpatient Services were to be found since they were not included in the requested QAPI data provided by the hospital. The Director for Quality/Risk Management stated that the hospital had not been collecting any indicators or data for these seven COP's.

B. On 08/24/12 at 9:25 am the Quality Coordinator was again asked to verify that the COP's for Radiology, Food & Dietary, Physical Environment, Organ, Tissue & Eye, Anesthesia, Nuclear Medicine, and Outpatient Services were not incorporated into the hospital's QAPI program. She confirmed that no data or indicators were being collected on these seven COP's.

Based on document request, document review and interview, the hospital failed to ensure that an effective, ongoing hospital-wide, data-driven quality assessment and performance improvement (QAPI) program was developed, implemented and maintained. The hospital's QAPI program did not incorporate the Conditions of Participation (COP's) for Radiology, Food & Dietary, Physical Environment, Organ, Tissue & Eye, Anesthesia, Nuclear Medicine, and Outpatient Services. As a result, no data was collected, analyzed or acted upon, and the hospital did not evaluate these seven COP's to determine how to improve patient health outcomes and reduce medical errors. The findings are:

A. On 08/21/12 at 8:30 am the Director for Quality/Risk Management and the Quality Coordinator were asked to show where the data for the COP's for Radiology, Food & Dietary, Physical Environment, Organ, Tissue & Eye, Anesthesia, Nuclear Medicine, and Outpatient Services were to be found since they were not included in the requested QAPI data provided by the hospital. The Director for Quality/Risk Management stated that the hospital had not been collecting any indicators or data for these seven COP's.

B. On 08/24/12 at 9:25 am the Quality Coordinator was again asked to verify that the COP's for Radiology, Food & Dietary, Physical Environment, Organ, Tissue & Eye, Anesthesia, Nuclear Medicine, and Outpatient Services were not incorporated into the hospital's QAPI program. She confirmed that no data or indicators were being collected on these seven COP's.

Based on document request, document review, and interview, the hospital failed to ensure that the Quality Assessment and Performance Improvement (QAPI) program failed to track medical errors and and adverse patient events for seven Conditions of Participation (COP's): Radiology, Food & Dietary, Physical Environment, Organ, Tissue & Eye, Anesthesia, Nuclear Medicine, and Outpatient Services. The failure to incorporate these seven COP's into the QAPI program resulted in the hospital not being able to track and analyze medical errors and adverse patient events for these COP's. The findings are:

A. On 08/21/12 at 8:30 am the Director for Quality/Risk Management and the Quality Coordinator were asked to show where the data for the COP's for Radiology, Food & Dietary, Physical Environment, Organ, Tissue & Eye, Anesthesia, Nuclear Medicine, and Outpatient Services were to be found since they were not included in the requested QAPI data provided by the hospital. The Director for Quality/Risk Management stated that the hospital had not been collecting any indicators or data for these seven COP's.

B. On 08/24/12 at 9:25 am the Quality Coordinator was again asked to verify that the COP's for Radiology, Food & Dietary, Physical Environment, Organ, Tissue & Eye, Anesthesia, Nuclear Medicine, and Outpatient Services were not incorporated into the hospital's QAPI program. She confirmed that no data or indicators were being collected on these seven COP's.

Based on document request, document review and interview, the hospital's Governing Body, administrative officials and medical staff all failed to ensure that an ongoing program for quality improvement was defined, implemented, and maintained. The hospital failed to incorporate seven Conditions of Participation (COP's): Radiology, Food & Dietary, Physical Environment, Organ, Tissue & Eye, Anesthesia, Nuclear Medicine, and Outpatient Services into the Quality Assessment & Performance Improvement (QAPI) program. By not including these seven COP's in the QAPI program, the hospital could be unaware of failures that could compromise the hospital's ability to improve patient care and reduce medical errors. The findings are:


A. On 08/21/12 at 8:30 am the Director for Quality/Risk Management and the Quality Coordinator were asked to show where the data for the COP's for Radiology, Food & Dietary, Physical Environment, Organ, Tissue & Eye, Anesthesia, Nuclear Medicine, and Outpatient Services were to be found since they were not included in the requested QAPI data provided by the hospital. The Director for Quality/Risk Management stated that the hospital had not been collecting any indicators or data for these seven COP's.

B. On 08/24/12 at 9:25 am the Quality Coordinator was again asked to verify that the COP's for Radiology, Food & Dietary, Physical Environment, Organ, Tissue & Eye, Anesthesia, Nuclear Medicine, and Outpatient Services were not incorporated into the hospital's QAPI program. She confirmed that no data or indicators were being collected on these seven COP's.

Based on staff interview, the hospital failed to ensure that patients' records from the hospital's outpatient clinics were integrated and maintained by the hospital's medical record department. This failed practice could lead to patients not getting all of the services needed to improve their health. The findings are:

A. On 08/21/12 at 11:00 am, during an interview, the Medical Records Supervisor stated that the patients' medical records at the hospital's clinics are not integrated or maintained by the hospital's medical record department.

B. On 08/21/12 at 2:45 pm, during an interview, the Operations/Quality Director confirmed that the patients' records at their outpatient clinics are not integrated or maintained by the hospital's medical records department.



18749

Based on document request and interview the hospital failed to ensure that the Radiological Service had developed written policies to designate which personnel are qualified to use the radiological equipment and administer procedures. The hospital also failed to ensure that the written policies on qualified staff were approved by the medical staff. The failure to have written policies to designate which personnel are qualified to use the radiological equipment and administer procedures created the likelihood that a staff member or provider might use radiological equipment that they were not qualified to use, putting patients at risk. The findings are:

A. On 08/20/12 at 8:30 am the hospital was given a Request for Information for Radiological Services which included a request for "Radiological Services policies to designate which personnel are qualified to use the radiological equipment and administer procedures."

B. On 08/24/12 at 8:30 am the hospital was again asked to provide the policies requested on 08/20/12. The Director of Radiology was interviewed on 08/24/12 at 10:45 am. He stated that to his knowledge the hospital did not have such policies, but that he would look for them. By the end of the survey no policies were provided to surveyors.

Based on observation and interview, the facility failed to ensure that the kitchen had proper working equipment (dishwasher) and failed to repair areas (floor tile, dishwasher leak, cracked wall) that were damaged from water, which could produce an environment for mold to grow and release spores into the air in the kitchen. This failed practice could likely cause illness for staff and patients. The findings are:


A. On 08/23/12 at 10:47 am, observation of the facility's kitchen was conducted with the Dietary Manager (DM). The Dietary Aide (DA) was asked to run a cycle of the dish machine to determine the water temperature. After the completion of the cycle the DA used a hand thermometer to read the water temperature and received a reading of 116.9 and a second reading of 116.5. During interview, the Nutritional Service Coordinator stated that the gauge broke and it is to be replaced, but in the meantime they have to use a hand thermometer and sometimes they have to run the machine 3 or 4 times before the temperature is at 120 (the machine is a low temperature machine and the temperature is to be between 120 to 140 degrees).
1. During this observation, water was leaking into a bucket was placed on the floor under the dish machine. Four floor tiles under the bucket of water were loose and coming up, a piece of wall behind the dish machine had a 3-foot crack and appeared wet and moist, and green buildup was noted on the dishwasher connectors and the dishwasher piece that was leaking.
2. A pool of water was noted by the floor drain next to the dishwasher that was black and had an odor that smelled like the sewer.
3. Observation under the clean dish table (area where the clean dishes are received), revealed 8 floor tiles that were cracked and coming up, and black buildup was noted in the cracks. The table legs had black buildup around them on the floor.
4. The floor next to the DM's office which opened into the clean side of the dish room had an area measuring 1/4 of an inch wide and extending the length of the doorway that had no tile or similar surface and was covered with a black buildup.


B. During interview on 08/23/12 at 10:55 am, the DM was asked about the leak. She stated that the maintenance department knew about the leak and a work order had been completed. When asked about the other areas, she acknowledged them and stated that a remodel had been budgeted but she was not sure when it was to take place.


C. Review of the facility's "Environmental Tour" documentation dated 08/09/12 for the dietary department revealed the following:
1. The section for safety management revealed, "19. Tile and carpet are in good condition" and was coded a "1" in the yes column.
2. The section for equipment management revealed, "3. Is all equipment and furniture operating properly," and was coded a "1" in the yes column.


D. On 08/24/12 at 11:20 am, the Quality/Risk Management Compliance Officer was asked about the coding. She stated that a "1" meant nothing needed to be fixed. She stated that she did not understand why it was coded that way.


E. On 08/23/12 at 11:05 am, an interview was conducted with the Maintenance Manager. When asked how long the dishwasher leak had been a problem, he stated, "Ever since I have worked here." When asked how long he had been working for the facility, he stated, "Two years."

Based on observation, the hospital failed to maintain safe air handling systems in operating rooms, instrument processing rooms and isolation rooms. This failure to maintain safe air handling systems could result in the air-born contamination of patients receiving surgery, sterile packages being contaminated and air-born disease escaping isolation rooms. The findings are:

A. On 08/22/12 at 7:00 am surveyors inspected the operating suite. Both operating rooms #1 and #2 were determined to not have positive air pressure at doorways. The dirty instrument cleaning room was determined to not have negative pressure and the sterile processing room was determined to not have positive pressure. An isolation room in the recovery area was also determined to not have negative pressure.

B. On 08/23/12 at 10:30 am the Director of Quality/Risk Management, the Quality Coordinator, and the Physical Plant Supervisor were advised that the surveyors had determined that none of the above listed rooms had the correct air pressure, which had been checked again on 08/23/12 at 8:15 am by the surveyor. The hospital was advised that if they wanted to challenge the surveyor's finding on air-handling that they needed to present their evidence or documentation. No evidence or documentation was provided by the end of the survey.

Based on staff and patient interview, the hospital failed to have a system to notify patients or their representatives that they could request a discharge planning evaluation. Two patients on the Medical/Surgical unit were interviewed (#17 and 19). This failed practice could result in the patient being discharged without all of the services being provided for continued health improvement. The findings are:

A. On 08/22/12 at 9:30 am, during an interview, the Discharge Planning Director stated that the hospital has no policy or procedures to notify patients or their representatives that they can request a discharge planning evaluation during their hospital stay.

B. On 08/23/12 at 1:50 pm, during an interview, Patient #19 reported no recollection of getting paperwork or having any discussions with the hospital staff about the possibility of requesting a discharge planning evaluation during the patient's hospital stay.

C. On 08/24/12 at 8:30 am, during an interview, Patient #17 and his wife were asked about discharge planning evaluations. When asked, they stated that no paperwork was given nor was a discussion offered with hospital staff with respect to either of them requesting a discharge planning evaluation during the hospital stay.



18749

Based on policy and procedure review and staff interview, the hospital failed to have a process to inform physicians that they could request a discharge planning evaluation anytime during the patient's hospital stay. This failed practice could result in the patient being discharged without all of the services provided for continued health improvement. The findings are:

A. On 08/22/12 at 9:30 am, during an interview, the Discharge Planning Director stated that the hospital has no policy or procedures to notify physicians that they can request a discharge planning evaluation during the patient's hospital stay.

B. On 08/10/12 at 10:00 am, during an interview, Physician #1 was asked if he knew of any hospital policies or procedures that stated that the patient's physician could request a discharge planning evaluation anytime during the patient's hospital stay. He stated that he did not know of any hospital policies or procedures that tell the physicians how they should do this.




18749

Based on staff interview and review of the hospital's quality assurance/performance improvement (QAPI) data, it was determined that the hospital failed to meet acceptable standards of practice by not ensuring that the departments that were offering outpatient services were integrated into the hospital's QAPI program (A-1077 & A-263). The hospital further failed to ensure that patients' records from the hospital's outpatient clinics were integrated and maintained by the hospital's medical record department (A-1077 & A-432). The cumulative effect of these systemic practices resulted in the hospital's inability to ensure that the patients' medical needs were provided in a safe and effective manner and could be accessible to all departments.



18749

Based on staff interview, the hospital failed to ensure that patients' records from the hospital's outpatient clinics were integrated and maintained by the hospital's medical record department. This failed practice could lead to patients not getting all of the services needed to improve their health. The findings are:

A. On 08/21/12 at 11:00 am, during an interview, the Medical Records Supervisor stated that the patients' medical records at the hospital's clinics are not integrated or maintained by the hospital's medical record department.

B. On 08/21/12 at 2:45 pm, during an interview, the Operations/ Quality Director confirmed that the patients' records at their outpatient clinics are not integrated or maintained by the hospital's medical records department.



Based on record review and staff interview, the hospital failed to ensure that outpatient services were integrated into the hospital's quality assurance/performance improvement (QAPI) program. This failed practice could lead to patients getting harmed during outpatient services. The findings are:

A. Review of the hospital's QAPI program revealed that the departments that offer outpatient services do not collect data for their outpatient programs. (See QAPI, A-263)

B. Review of the document request for Outpatient Services revealed a handwritten note -- next to the request for documentation that the hospital's outpatient services are integrated into its hospital-wide QAPI program -- that read, " Physician clinics (are) not integrated."

C. On 08/20/12 at 3:45 pm, during an interview, the Operations/Quality Director confirmed the departments that offer outpatient services do not collect data for outpatient for their outpatient programs and that the physician clinics are not part of the hospital-wide QAPI program.



18749

Based on review of credential file and staff interview, the hospital failed to ensure that the Medical Director of Respiratory Services had the knowledge and experience to administer this service properly. This failed practice could lead to patients not getting proper respiratory services. The findings are:

A. Review of the credentialing file for the Medical Director of Respiratory Services revealed that he did not have specialized training in respiratory care.

B. On 08/24/12 at 9:30 am, during an interview, the Medical Director for the hospital's respiratory services confirmed he did not have any specialized training in respiratory services.



18749