HospitalInspections.org

Based on document review and interview, it could not be determined if a discharge log had followed hospital policy for 1 of 1 defibrillators

Findings:

1. Review of hospital policy Section Number: 904, entitled Emergency (Crash) Carts, revised 7/2011, indicated the staff members assigned to the departments which house the emergency carts are responsible for performing readiness assessments (crash cart checks) per departmental policy.

2. Review of a document entitled Crash Cart Drug and Supply List 2012, located in the Cardiac Rehab area, indicated there was a checkmark for the date 7-23-12, for a line entitled Monitor with electrodes/Defib pads/ ped and adult. It was vague as to the meaning of the word "Monitor". Also, there was no signature or initials as to who had made the checkmark. Thus, it could not be determined if the defibrillator had been tested for performing readiness assessment and by whom.

3. In interview, on 7-23-12 at 11:10 am, hospital staff indicated there was no other documentation of testing of the defibrillator and no other documentation was provided prior to exit.

Based on document review and interview, the hospital failed to provide evidence of preventive maintenance (PM) for 3 pieces of equipment.

Findings:

1. Review of documentation of PM on a portable x-ray machine indicated the most recent PM occurred on 12-8-10.

2. In interview, on 7-24-12 at 11:20 am, employee #A4 indicated there was no current documentation and no other documentation was provided prior to exit.

3. Review of documentation of PM on a mammography scanner indicated the most recent PM occurred on 4-23-09.

4. In interview, on 7-24-12 at 11:20 am, employee #A4 indicated there was no current documentation and no other documentation was provided prior to exit.

5. Review of documentation of PM on a sleep study machine indicated all patient related equipment in the Rush-Hancock Sleep Disorders Center has been checked as of 5-31-12. The report did not indicate which specific equipment was checked and what specific checks were done.

6. In interview, on 7-24-12 at 11:15 am, employee #A4 indicated there was no documentation of which specific equipment was checked and what specific checks were done and no other documentation was provided prior to exit.

Based on transfusion record review, training record review, and staff interview, the facility failed to have documented training on transfusion administration as required consistent with applicable State law for one of five registered nurses reviewed who initiated one of seven transfusion records reviewed.

Findings included:
1. On 7/24/12 between 12:00 p.m. and 2:00 p.m. during transfusion record review, transfusions T#1 to T#7 were reviewed and found to have been initiated by staff persons SP#16 through SP#20.
2. On 7/24/12 between 2:00 p.m. and 3:00 p.m. training records for transfusion administration were requested for the above nurses and were obtained for all except SP#20.
3. In interview on 7/24/12 at 2:30 p.m., staff person #3 stated there was no documented training for SP#20 who initiated T# 2 without required special training consistent with applicable State law.

Based on document review and interview, the facility failed to ensure that the patient care policies were reviewed at least annually by at least one or more doctors of medicine or osteopathy of the medical staff, one or more nurse practitioners, who are members of the CAH Medical Staff, and at least one member who is not a member of the CAH staff.

Findings include:

1. Review of the Patient Care Policy Manual and facility documentation lacked documentation that a physician or nurse practitioner non medical staff member reviewed the Patient Care Policy Manual on the last annual review.

2. On 07-24-12 at 1130 hours staff #40 confirmed that the Patient Care Policy Manual is reviewed annually by members of the CAH Medical Staff and do not have documentation that at least 1 physician or nurse practitioner who is not a member of the CAH Staff reviewed the patient care policies.

Based on document review and interview, the hospital failed to include monitors and standards for 1 service directly-provided by the hospital and 1 service provided by a contractor as part of its comprehensive quality assessment and performance improvement (QAPI) program.

Findings:

1. Review of the facility's QAPI program indicated it did not include monitors and standards for the directly-provided rehabilitation services.

2. In interview on 7-24-12 at 4:00 pm, employee #A2 indicated there was no documentation for directly-provided rehabilitation services and none was provided prior to exit.

3. Review of the facility's QAPI program indicated it did not include monitors and standards for the contracted telepsych service.

4. In interview on 7-24-12 at 3:45 pm, employee #A2 indicated there was no documentation for the telepsych service and none was provided prior to exit.