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Based upon review of contract services, Quality Assurance/Performance Improvement (QA/PI) program and data and interviews, the hospital failed to ensure all contracted services were evaluated through the QA/PI Program. This was evidenced by failure of the QA/PI Program to evaluate 53 of the 96 contracts that provided patient care services to ensure these services were provided in a safe and effective manner. Findings:

Review of the list of contracted services revealed there failed to be documented evidence 53 of the 96 contracts that provided patient care services were evaluated through the QA/PI Program.

Review of the QA/PI Plan revealed there failed to be documented evidence contracts were identified and required evaluation.

Interview with S6, Executive Director of Ancillary Services, on 04/02/13 at 1:05 PM, confirmed contracted services were not reviewed through the QA/PI Program.

Based upon reviews of contracts, policy/procedures, and interviews the hospital failed to ensure a list of all contracted services, that included the nature and scope of the services to be provided, was maintained as evidenced by a lack of documented contracts with hospitals for patient transfers and a school for radiology technicians. Findings:

Review of a list of contracted services maintained by the hospital revealed there failed to be documentation relative to contracts with hospitals utilized to transfer patients for treatment at a higher level of care and/or to evacuate patients during a disaster.

During the survey of the Radiology Department, on 03/28/13, there was an individual identified as a radiology technician student. Review of the list of contracted services revealed there failed to be a contract listed for school/s of radiology for technicians.

Interview, on 04/02/13 at 2:30pm, with S5 Emergency Preparedness (EP) Director, revealed when questioned which hospitals were utilized for evacuated patients, S5 EP Director replied he was not certain and needed to check.

Interview, on 04/02/13 at 2:45pm, with S1 CEO, revealed when questioned if the hospital had contracts with hospitals for patient transfers, S1 CEO replied yes. Upon further questioning, in regard to the list of contracted services, S1 CEO confirmed the hospital did have contracts but agreed they were not listed on the list of contracted services.

Further interview, 04/02/13 at 2:45pm, with S1 CEO also confirmed Contract B was for a school of radiology for technicians and this contract also failed to be listed on the contract list that was maintained by the hospital.

Based upon record reviews and interviews the hospital's Governing Body failed to ensure the grievance process was operated effectively by the Grievance Committee as evidenced by: 1) lack of the Grievance Committee providing 16 patients/family/representative with written responses to their grievances; and 2) failing to report grievances to the hospital Quality Assurance Performance Improvement (QA/PI) committee for reporting possible quality of care issues. Findings:

Review of 16 patient grievances/complaints, dated 06/12 to present (04/02/13), revealed there failed to be documented evidence a written response had been sent to the patient relative to the resolution of their grievance/s.

Review of QAPI data revealed there failed to be evidence the Grievance Committee reported patient grievances for evaluation; nor, was there documented evidence the Governing Body was aware of the patient grievances.

Interview, on 04/02/13 at 4:00pm, with S1 Interim CEO confirmed the 16 patient grievances were not reported to the QAPI committee, Medical Staff and Governing Body.

Based upon reviews of the hospital's grievance policy, 16 complaints/grievances filed with the hospital (via written correspondence and/or by telephone), and interviews the hospital failed to ensure the grievance policy was followed and the 16 patients/complainants were provided a written response and that it included the name of the hospital's contact person, steps taken to investigate the grievance, the results of the grievance process, and the completion date. Findings:

Review of the hospital's grievance policy revealed patients were to receive written notification from the hospital that included: the name of the hospital contact person, steps taken on behalf of the patient to investigate the grievance, the results and the date of completion.

Review of typed and hand written complaints, dated 06/12 through 02/13, revealed the hospital did not provide the patient/family member with a written response of the grievance resolution; nor, did they make certain the required components, contained in their grievance policy, was followed.

Interviews, on 04/02/13 at 4:00pm, with S21 Patient Advocate and S1 Interim CEO confirmed none of the patients who filed complaints/grievances with the hospital from 06/12 to present (04/02/13) received written notification of the results of the hospital's investigation.
There were 16 complaints/grievances filed and presented to and for review by the surveyor.

Continued interview, 04/02/13 at 4:00pm, with S21 Patient Advocate revealed she had not provided patients with written response relative to their grievance/s.

Based upon review of Quality Assurance/Performance Improvement (QA/PI) Program data, QA/PI Plan, and staff interview, the hospital failed to ensure medical errors were reviewed through the program. Findings:

Review of the QA/PI Plan revised 08/10 revealed on pages 11 and 12 of 17 "Performance measures for processes that are known to jeopardize the safety of the individuals served or associated with sentinel events will be routinely monitored. At a minimum performance measures related to the following processes, as appropriate to the care and services provided are monitored with the approval, and at the suggested frequency of the Performance Improvement Committee..." "Medication use (including significant medication errors and adverse drug reactions."

Review of the QA/PI Program data from July 2012 through March 2013 revealed there failed to be documented evidence medication errors were evaluated through the program. Interview on 04/02/13, 1:05 PM, with S6, Executive Director of Ancillary Services, revealed when asked if medication errors were reviewed through the QA/PI Program, S6 replied "no".

Review of the incident/accident reports from October 2012 through February 2013 related to medication errors revealed the following medication errors per month: 10/12 (8), 11/12 (2), 12/12 (4), 1/13 (8), and 2/13 (6).

Based upon review of the Quality Assurance/Performance Improvement (QA/PI) Plan and associated program data, and staff interview, the hospital failed to ensure the QA/PI Plan was followed related to analyzing and tracking quality indicators. This was evidenced by the QA/PI Committee's failure to meet monthly and analyze and track the quality indicators submitted by the hospital departments. Findings:

Review of the QA/PI Plan, revised 08/10, revealed on page 8 of 17 "With designated responsibility from the Performance Improvement Committee, the PI Team will operate as a functional grouping of individuals in the organization who meet to evaluate and improve a specific process or system within the hospital. The PI Team is comprised of departmental leaders, medical staff on an as needed basis and those individuals designated from each department, as appropriate, who may have the highest degree of knowledge regarding a given PI topic...The organizational PI Team meets on at least a monthly basis to review and prioritize issues throughout the organization, which may benefit from a PI small team endeavor."

Review of the QA/PI data from July 2012 through March 2013 revealed for the quarters of July, August and September 2012 and October, November and December 2012, the data was collected but not analyzed. Interview with S6, Director of Ancillary Services, on 04/02/13 1:05 PM, revealed the quarterly information was "still in progress" and the PI Committee had not met since November 2012.

Based upon review of contract services, Quality Assurance/Performance Improvement (QA/PI) program and data and interviews, the governing body failed to ensure all contracted services were evaluated through the QA/PI Program. This was evidenced by failure of the QA/PI Program to evaluate 53 of the 96 contracts that provided patient care services to ensure these services were provided in a safe and effective manner. Findings:

Review of the list of contracted services revealed there failed to be documented evidence 53 of the 96 contracts that provided patient care services were evaluated through the QA/PI Program.

Review of the contracts revealed Contract A (Pharmacy), effective July 1, 2006 revealed "IV. Term: This agreement shall be effective as of the effective date and shall continue for a period of 3 years. Thereafter, shall both parties agree, this agreement shall renew for successive one year terms on the same terms and conditions unless 90 day written notice of intent to terminate this agreement is provided by either party." There failed to be documented evidence the hospital's governing body identified the pharmacy contract had expired and required an update.

Review of the QA/PI Plan revealed there failed to be documented evidence contracts were identified and required evaluation.

Interview with S6, Executive Director of Ancillary Services, on 04/02/13 at 1:05 PM, confirmed contracted services were not reviewed through the QA/PI Program.

Based on review of hospital Policy and Procedures, medical record review, hospital occurence reports and staff interview, the hospital failed to ensure medication administration errors were reported to the QA program and that medication administration errors were promptly recorded in patient records (patient #8 and #32). Findings:

During an interview on 4/2/2013 at 9:00 a.m., S1 Interim CEO stated medication error incidents were recorded by the nurse on an Occurence Report, the nurse manager reviewed the report, and then the report was given to the DON; then reported to the Pharmacy and Therapeutics Committee. S1 Interim CEO stated the pharmacist was supposed to report omissions and nursing reported the actual incident. S1 Interim CEO confirmed medication administration errors were not reported to the QA committee.

Review of electronic medical records with S37 RN revealed medication errors documented on occurence reports for patient #8 on 9/27/2012 and patient #32 on 1/27/2013 were not entered into the medical record for either patient.

Review the hospital Policy and Procedure MM-6.20-01 page 3 of 5 effective date 4/01/04 related to medication errors revealed the druge administered in error or ommited in error and the action taken shall be properly recorded in the patient's medical record.

Based on interview with hospital staff and review of hospital occcurence records, the pharmacist failed to report abuses and losses of controlled substances to Federal Authorities when narcotic diversion by nurse staff was detected. Findings:

Interview with S12Registered Pharmacist on 3/26/13 at 10:15 a.m. revealed the hospital detected narcotic diversion last year when it was brought to his attention by nursing service that they suspected a licensed practical nurse had removed narcotics from the Omnicel but did not record the administration. When asked if this was reported, S12 Registered Pharmacist stated since it was a small quantity of narcotics, he did not file a report with Federal Authorities (Drug Enforcement Agency).

Review of the hospital occurence report revealed Morphine Sulfate 5 mg/1ml vial was removed from the Omnicel 9 times between 9/19/12 and 10/04/12 by 1 nurse that were not charted as administered and/or wasted. Further review revealed 5 Lortab 10/325 had been removed from the Omnicel that were not charted as given or wasted by the same nurse.

Interview with S1 Interim CEO on 4/3/13 at 9:00 a.m. revealed through the nursing service investigation, they had determined Morphine Sulfate 5mg/1ml had been diverted (not given to a patient) and was under the impression that pharmacy had reported the abuse/loss of the narcotics.

Based on record reviews and staff interviews, the hospital failed to ensure the Medical Staff recommended and the Governing Body appointed S30 Physician as Director of Respiratory Services. Findings:

A review of the Medical Staff Bylaws stated the Respiratory Therapy Services Director must be appointed annually.

Review of the Medical Staff and Governing Body meeting minutes revealed S30 had not been recommended nor appointed.

Interview, on 04/01/13 at 11:00 with S9 Respiratory Therapist Manager, revealed when questioned who the Medical Director of the Respiratory Therapy Service was, she replied S30 Physician.

Interview, 04/02/13 at 2:00pm with S1 Interim CEO, confirmed there failed to be documented evidence S30 Physician was appointed as Medical Director of Respiratory Therapy Services.