HospitalInspections.org

Based on record reviews and interviews the hospital failed to have bylaws that define the organization's statement of governance and to define who was responsible for the conduct of the hospital's operation. The lack of the governing body providing oversight of the hospital operations put every patient at risk for lack of services.

Findings:

1. Governing body failed to ensure members of it's medical staff have current appointments and reappointments to the medical staff with specific privileges delineated before providing patient care. (see Tag A0046, A0353)

2. Governing body failed to ensure the medical staff had bylaws approved.

3. Governing body failed to ensure each patient's right to care in a safe setting. (see Tag A0144)

4. Governing body failed to evaluate and monitor the care provided under contracted services through the hospital's QAPI program. (see Tag A0273)

5. Governing body failed to ensure the medical staff had periodic appraisals and bylaws formulated. (see Tags A0338, A0340, A0353, A0354)

6. Governing body failed to ensure radiology services were provided. (see Tag A0528, A0529, A0584)

7. Governing body failed to ensure dietary services were provided under the direction of a dietitian, there was an approved therapeutic dietary manual. (see Tag A0618, A0620, A0621, A0629, A0631)

8. Governing body failed to ensure there was an effective infection control program. (see Tag A0747, 0749)

9. Governing body failed to ensure an Organ Procurement Organization agreement, written policies and procedures, staff education, and Tissue and Eye Bank agreement. (see Tag A0884, A0885, A0886, A0887, A0891)

Based on records review and interview the governing body failed to ensure they approved privileges of all applicants who provided care to patients of the hospital as evidenced by a lack of approval on 3 of 5 healthcare providers.

Findings:

Review of the credentialing files on Staff #s I, J, O revealed a form titled "...Reapplication for privileges". Continued review of the form revealed the applicant was to place a mark by the psychiatric privileges they were requesting and then the requested privileges would be accepted or denied.

Review of Staff #I's credentialing file revealed the reapplication for privileges was not signed by the governing body. The date the Medical Director signed the reapplication was 1/14/19. Continued review of Staff #I's file revealed a "MEMORANDUM" stating: "Your Clinical Privileging Application has been approved without condition from 12/7/16 to 12/6/18". Staff #I was allowed to continue caring for inpatients without having active privileges approved by the governing body.

Review of Staff #J's initial application for privileges revealed the request for psychiatric privileges had been left blank; no request had been made by Staff #J. Further review of the application revealed a date of 2/3/17. The Medical Director had approved the application 2/3/17 but the governing body had not signed their approval. The governing body allowed Staff #J to care for patients without approval.

Review of Staff #O's file revealed the governing body had not approved the requested privileges and allowed Staff #O to continue caring for patients without approval.

Based on record review and interview the governing body failed to ensure the medical staff had bylaws and operate under the bylaws.

Findings:

Surveyors requested the medical staff bylaws, rules, regulations for review. Staff #B stated there were none if the surveyor could not locate them in the policy book.

Review of the policy book revealed there failed to be any documentation of medical staff bylaws, rules and regulations.
The surveyors asked Staff #B to review the policy book to see if there were medical staff bylaws; Staff #B stated, "there are no medical staff bylaws".

Based on record reviews and interview the governing body failed to enured the medical staff was operating under bylaws, rules and regulations.

Findings:

Surveyors requested the medical staff bylaws, rules, regulations for review. Staff #B stated there were none if the surveyor could not locate them in the policy book.

Review of the policy book revealed there failed to be any documentation of medical staff bylaws, rules and regulations.
The surveyors asked Staff #B to review the policy book to see if there were medical staff bylaws; Staff #B stated, "there are no medical staff bylaws".

Based on record review and interview the governing body failed to ensure all required services were provided by either hospital staff or contract services and that those services were assessed through the hospital's QAPI program as evidenced by a lack of documentation of the quality of services provided or any other monitoring or evaluation of contracted services.

Findings:

Review of the hospital's Performance Improvement (PI) program revealed there lacked documentation that contracted services provided to the hospital and patients were monitored, evaluated for performance issues, or the quality of services provided.

Interview, 06/25/19 at 2:00 PM, with Staff #B confirmed contracted services provided to the hospital/patients were not evaluated through the hospital's PI program.

Continued interview, 06/26/19 at 10:40 AM, with Staff #B and #C confirmed laboratory and radiology services were not offered at the hospital and if any patient required such service, the patient would be sent to area hospitals.

When asked for policies and procedures relative to radiology and laboratory services the surveyors were given the policy book. Staff #B stated if there was a policy for either service it would be in the book.

Review of the policy book supplied by Staff #B revealed a lack of documentation for any radiology services and the only laboratory policies related to how reports were to be reviewed and waived testing procedures. The only waived testing performed by hospital staff was Urine Drug Screen.

There lacked documentation the hospital had contracts to provide the required laboratory and radiology services.

Based on observation, record review and interview the governing body failed to ensure services performed under a contract are provided in a safe and effective manner by failing to monitor inmates as addressed in the contract.
Findings:

On 06/25/19 at 9:00 AM a tour of the dietary kitchen was conducted and the the cook, director of nursing services and two inmates were the only staff observed in the dietary kitchen.

A review of the contract dated 05/14/14 signed and notarized, "Guidelines And Rules For Supervisors Of Public Works Programs" revealed "all supervisors will remain in the area with their inmates at all times".

In interview on 06/26/19 at 08:45 AM, Staff E stated he had worked at this hospital as a construction supervisor for twenty-three years. He reported his job was to supervise inmates and that he does have to be with them (inmates) at all times. He also that he only has to do a head count at 10:00 AM, noon and 2:00 PM.




41735

Based on record review and interview the governing body failed to ensure all services provided under contracted services were monitored and evaluated through the hospital's QAPI program.

Findings:

Review of the hospital's QAPI data revealed there failed to be documented evidence all services provided by contracted services/providers had been evaluated for quality of care, and to ensure the services received were in a safe manner.

Interview, 06/26/19 at 9:15 AM, with Staff #B confirmed the contracted services had not been reviewed through the QAPI program.

Based on review of the hospital's list of contracted services and interviews, the hospital failed to ensure the list of contracted services included the scope and nature of the services provided by the contract.

Findings:

Review of the list of contracted services, supplied to the surveyors by Staff #D, revealed the name of the contracted company and/or individual name of contractor.

Continued review of the contract list revealed Staff #P was listed as a contractor; however, the service/s to be provided by Staff #P was listed as Telemed services

Interview, 06/24/19 at 5:00 PM, with Staff #D revealed she was responsible for maintaining the list of contracted services.

Interview, 06/25/19 at 4:30 PM, with Staff #s C and D revealed when they were questioned as to where/who would perform radiologic services for patients, Staff #C stated Hospital A would.

Interview, 06/26/19 at 1:15 PM, with Staff #s C and D revealed when questioned again about radiologic services and laboratory services, Staff #C stated it would be Contract Provider B.

During the exit conference Staff #C stated Hospital C was where they typically sent their patients for lab studies and/or X-Rays; Staff #D stated there had not been a bill submitted from Hospital C, "so maybe they are billing the patient directly".

There failed to be a current contract that included the required services for Radiologic and Laboratory Services.

Based on observations and interviews the hospital failed to ensure all patients received care in a safe environment as evidenced by: 1. ligature risks consisting of exposed door hinges in every bathroom and room door in the inpatient rooms (4 female inpatient rooms P1-2, P3-4; 10 male inpatient rooms A1-8 and B1-2); and 2. unprotected light fixtures in every inpatient room that could be accessed by the patient to cause self-harm or harm to staff/other patients.

Findings:

Observations made, 06/24/19 at 1:40 PM, on the inpatient unit revealed 2 female double occupancy rooms (P1-2 and P3-4). The 2 female double occupancy rooms had bathroom doors and the doors leading to the hallway. These doors all had exposed hinges, some only had 2 hinges the rest all had 3 hinges. These hinges were also noted on the bathroom and room doors on the 5 male inpatient double occupancy rooms.

Patients admitted with suicidal ideation/attempts would be at risk as the hinges posed a ligature risk.

Further observations, 06/24/19, of the female and male inpatient rooms revealed all light fixtures were unprotected and could be accessed by the patients who may use the broken plastic covers or the glass light bulbs as a means to cause self-harm or harm to other patients/staff.

Interview, 06/24/19 at 1:55 PM, with Staff #s A and C revealed they "were unaware the hinges could be used as ligature risks". Staff #C confirmed the door hinges posed a safety risk as did the unprotected light fixtures.

Based on record review and interview the hospital failed to track and evaluate services by not having documented evidence that the hospital's contracted services were monitored through the QA/PI (Quality Assurance/Performance) process.
Findings:

A review of the hospital's Quality Assurance/Performance Improvement (QA/PI)) data failed to reveal the Governing Body monitored and evaluated contracted services that were provided to the hospital.

In an interview on 06/25/19 at 2:00 PM, Staff #B confirmed contracted services provided to the hospital/patients were not evaluated through the hospital's QA/PI program.

Based on record review and interview the hospital failed to ensure the medical staff operated under bylaws approved by the governing body as evidenced by a lack of written and approved medical staff bylaws, rules and regulations.

Findings:

Review of hospital policy manual revealed there lacked documentation of medical staff bylaws, rules and regulations.

Interview, 06/26/19 at 9:30 AM, with Staff #B revealed if the medical staff had bylaws written they would be located in the hospital's policy manual. Staff #B was asked to review the policy manual to check for documented medical staff bylaws.

Staff #B confirmed the hospital did not have medical staff bylaws.

Based on record review and interview the medical staff failed to conduct periodic appraisals of its members.

Findings:

Review of 5 of 5 credentialing files (#F,I,J,O,P) revealed there failed to be documented evidence the medical staff had conducted periodic appraisals. The credentialing files for Staff #s F, I, J, O, P revealed there lacked documented evidence of any type of appraisals.

There was not appraisal of each practitioner's qualifications and demonstrated competencies relative to the privileges for which they requested.

There lacked Medical Staff Bylaws, rules and regulations to review to ascertain what types of information relative to each provider that would be appraised.

Based on record review and interview, the medical staff failed to adopt and enforce bylaws.

Findings:

Review of a policy book, identified as containing governing body bylaws and medical staff bylaws, revealed there failed to be documentation of any medical staff bylaws, rules and regulations. Staff #B was questioned if the medical staff bylaws, rules and regulations were located somewhere else; Staff #B responded "if they are not in there, then we don't have them".

Staff #B was asked to review the policy book to ensure medical staff bylaws had not been overlooked.

Staff #B confirmed the medical staff did not have bylaws, rules and regulations available for review and was not certain if they existed.

Based on record review and interview the governing body failed to ensure the medical staff had bylaws and operate under the bylaws.

Findings:

Surveyors requested the medical staff bylaws, rules, regulations for review. Staff #B stated there were none if the surveyor could not locate them in the policy book.

Review of the policy book revealed there failed to be any documentation of medical staff bylaws, rules and regulations.
The surveyors asked Staff #B to review the policy book to see if there were medical staff bylaws; Staff #B stated, "there are no medical staff bylaws".

Based on record/document reviews and staff interviews it was determined the hospital failed to ensure:
1. documentation pertaining to the scope and complexity of radiology services received by the hospital was under approved standards for safety and personnel qualifications;
2. the medical staff and governing body approved the scope and complexity of the radiology services obtained; and
3. the radiology services provided were included in the hospital wide QAPI process (Tag 0273)
Findings:

On 06/26/19, the Executive Director was informed of the findings. The Executive Director was not aware the medical staff and governing body, as well as the QAPI program should have evaluated radiology services. It was also confirmed the hospital did not have a contract with a radiology services provider.

Based on record review and interview the hospital failed to ensure the scope and complexity of diagnostic radiological services were specified in writing.

Findings:

Review of the hospital's policy and procedure manual revealed there failed to be radiology services documented. There lacked documentation of the scope and complexity of diagnostic radiological services.

Interview, 06/25/19 at 10:30 AM, with Staff #A confirmed the lack of documentation for any radiology services.

Interview, 06/26/19, at 11:00 AM, with Staff #C and D confirmed it was questionable if the hospital had a contract with another hospital to provide radiological services. Staff #C and D stated they "send patients out to other hospitals for radiology if needed".

Review of the list of contracted services failed to have radiological services listed.

Based on record review and staff interviews the hospital failed to ensure emergency laboratory services were available 24 hours/day, 7 days a week as evidenced by a lack of laboratory services provided by the hospital or by a contract for laboratory services.

Findings:

Review of the list of contracted services revealed there was a provider (name of Contract Provider B) listed for "lab services and blood work".

Review of the hospital's policy/procedure for laboratory services failed to address emergency laboratory services.

Hospital policy titled "CLIA Waived Testing for Consumers Not Requiring Physician Oversight", Policy # II-B-10 did not address emergency laboratory services.

Review of hospital policy "PROCESSING LABORATORY REPORTS", Policy # III-D-9 addressed how laboratory reports would be reviewed.

However, interviews with Staff #s C and D (06/26/19 at 11:00 AM) revealed the hospital used other providers not listed on the list of contracted services. Staff #C stated patients had blood work done at (name of Hospital C); and Staff #D stated patients had blood work done at (name of Hospital A).

Interview, 06/26/19 at 2:30 PM, with Staff # C, D, I revealed "if labs were needed on the weekends we could wait until Monday and then do it". Staff #C stated if a patient required laboratory studies after hours and weekends they would send them to an area hospital. The hospital failed to ensure emergency laboratory services were made available to patients should the need occur.

Based on policy/procedure, document review, and interview the hospital failed to ensure the policy/procedures included the description of all laboratory services provided, including the laboratory studies provided on routine and stat basis. This was evidenced by a lack of a written contract (with an outside laboratory that provided laboratory services) that had a description of all services/types of blood testing and other specimen testing to be performed and what constituted routine and stat tests.

Findings:

Review of Policy # II-B-10, titled "CLIA Waived Testing for Consumers Not Requiring Physician Oversight", date reviewed/revised: ...08/18. "...PROCEDURE ...D. The following staff are responsible for supervising waived testing: i. Inpatient - Director of Nursing, Nurse Care manager and the Infection Control Nurse..."

Continued review of the above policy, Policy # II-B-10, revealed it did not contain the descriptions of all laboratory services provided by an outside laboratory.

Interview, 06/26/19 at 11:00 AM, with Staff #s C and D revealed when questioned if the hospital had an active contract/agreement with any laboratory to supply laboratory services to patients; Staff #C stated "think it is with (name of Hospital C)". Staff #D stated "I thought it was with (name of Hospital A). The surveyor again asked if the list of contracted services was current and reflected all contracted services; again Staff #D stated it was the current list of contracted services.

Review of the list of contracted services revealed neither Hospital A or Hospital C was listed on the list of contracted services. There was a provider listed (name of Contract Provider B) for lab service and blood work. This was after the surveyor informed Staff #D the list of contracted services must include the scope and nature of the contract.

Based on record review and interview, the hospital failed to have organized dietary services that are directed and staffed by quality personnel by not :
1. having a full-time employee who serves as director of the food and dietetic
services responsible for daily management of dietary services and qualified by
experience or training,
2. having documented evidence that a contracted dietitian was providing
patient assessments, nutritional screenings and oversight for dietary services,
3. ensuring two of two patients (patient #5 and patient #6) diagnosed with type two
diabetes in a total sample of 8 patients received nutritional screening and
4. ensuring the dietitian and the medical staff approved a current therapeutic diet
manual
This failed practice had the potential to affect the nutritional and well being of all patients.

Based on record review and interview the hospital failed to have a full-time employee who serves as director of the food and dietetic services, responsible for daily management of the dietary services and qualified by experience or training.
Findings:

A review of the personnel file for Staff G revealed a job description signed and dated 08/20/14 titled "Food Service Specialist". Continued review failed to reveal Staff G position included managerial duties. Additionally, the personnel file did not include documented training for managing dietary services.

On 06/25/19 at 9:40 AM, Staff G stated she was the dietary manager and her duties were to cook, serve meals to patients and to manage food services. Staff G also stated she had not been trained or enrolled in a training program for dietary management.

Based on record review and interview the hospital failed to employ a qualified dietitian full time, part time, or on a consultant basis by not having documented evidence that a dietitian was providing:
1. nutritional screenings,
2. patient assessments and
2. oversight for dietary services.
Finding:

A review of contracted services revealed an agreement was signed on 2/28/19 between the hospital and a dietitian (Staff H). A review of dietary manuals, provided to the survey team by the dietary manager revealed no documented evidence that the dietitian was providing oversight of dietary services. Additionally there were no documents with the dietitian's signature or name on it.

In a telephone interview on 06/24/19 at 3:55 PM, Staff H stated he was the consultant dietitian and had not seen or performed nutritional screenings at the hospital since his contract was signed. He stated he was unaware he was suppose to assess and perform nutritional screenings for patients.

On 06/25/19 at 9:40 AM an interview was conducted with Staff G, who stated she was the dietary manager. She stated Staff H comes to the hospital once a month for an hour but she does not have any documentation that shows the oversight he provides. Staff G stated she never calls him for anything and he does not see patients for any reason.

Based on record review and interview the hospital failed to ensure the nutritional needs of the patients were met in according to recognized dietary practices by not ensuring two of two patients diagnosed with type two diabetes recieved a nutritional screening in two of two patients (patient #5 and patient #6) in a total sample of 8.
Findings:

Review of the medical record for patient #5 and patient #6 revealed a diagnosis of type two diebetes. Further review revealed an order by the physician for both patients to receive a two thousand calorie ADA (American Diabetic Association) diet.

In an interview on 06/24/19 at 9:40 AM Staff G was asked by the survey team, what was on the menu for today (06/24/19) and she replied "hot dogs". A review of the 06/25/19 lunch menu revealed all patients were to receive hot dogs. Staff G was also asked how did she know the number of serving diebetics are suppose to receive. She stated there were two diebetics in the hospital and she did not measure food by servings. Additionally, she stated she was always told to give diabetics two winners and a piece of bread.

Based on record review and interview the hospital failed to ensure the dietitian and the medical staff approved a current therapeutic diet manual.
Findings:

A review of the hospital's dietary manual revealed the dietitian and the medical staff did not approve the manual. A review of the Medical Staff Meeting Minutes from for the last twelve months revealed the medical staff did not document that the dietary manual was approved.

In an interview on 06/25/19 at 10:00 AM the dietary manager (Staff G) stated she was unaware that the dietary manual had to be approved.

Based on observation, record review and interview the hospital failed to provide a sanitary environment to avoid transmission of infections by:
1. not evaluating patients after receiving antibiotics for continued signs and symptoms
of infections,
2. not ensuring strips used for testing the strength of chemicals, in water used to
sanitize pots and pans were in date.
3. failing to document dish water was test for activation of chemical used to sanitize
dishes,
4. by one of one inmates (inmate #1) working in the dietary kitchen with hair
extending down below his hair net and one of one inmates (inmate #2) wearing
no hair net in a total of 2 inmates working in the dietary kitchen and
5. inmate #2 dropping snacks on the floor, picking them up and placing them on the
tray with the clean snacks without cleaning the packages.
This failed practice had the potential to affect all patients and staff who chose to eat in the dietary kitchen.

Based on observation, record review and interview the infection control officer failed to develop a system for prevention of and controlling diseases by:
1. not evaluating patients after receiving antibiotics for continued signs and
symptoms of infections,
2. not ensuring strips used for testing the strength of chemicals, in water used to
sanitize pots and pans were in date,
3. failing to document dish water was test for activation of chemical used to sanitize
dishes,
4. by one of one inmates (inmate #1) working in the dietary kitchen with hair
extending down below his hair net and one of one inmates (inmate #2) wearing
no hair net in a total of 2 inmates working in the dietary kitchen and
5. inmate #2 dropping snacks on the floor, picking them up and placing them on the
tray with the clean snacks without cleaning the packages.
Findings:

1. A review of the hospital's infection control log for 07/20/18, 08/2018, 09/2018,
10/2018, 11/2018, 12/2018, 01/2019, 02/2019, 03/2019, 04/2019 and 05/2019 revealed the infection control log did not address evaluating patients after receiving antibiotics for continued signs and symptoms of infections.

In an interview on 06/24/19 at 8:45 AM, Staff C stated she was the Director of Nursing Services and was also the infection control officer. Staff C reviewed the infection logs and confirmed that she does did evaluate patients after they completed their antibiotic treatments.

2. On 06/24/19 at 9:30 AM, roll of tape strips used to test solution used to sanitize pots and pans were observed. Further observations showed the strips had an expiration date of 10/30/17 (1 year, 7 months and 7 days after expiration). A review of the clip board where the results of the sanitation solution were documented revealed staff only tested the water in the months of 03/2019 and 06/2019.

On 06/24/19 at 9:40 AM Staff G, dietary manager observed the date on the test strips and confirmed the strips had expired.

3. On 06/24/19 at 9:45 AM a bottle of test strips used to test sanitation solution for dishes was observed. Staff G, dietary manager was asked for documentation addressing the solution used to sanitize the dishes was being tested.

On 06/24/19 at 9:47 AM, Staff G replied "staff did not document the results of the testing".

4. On 06/21/19 at 9:30 AM two inmates were observed working in the dietary kitchen. Inmate #1 was wearing braids and one of them was extending from under his hair net. Inmate #2 at that time was observed working without a hair net on his head. Continued observations showed inmate #2 dropped two packages of snacks on the kitchen floor, picked them up and placed them on the clean tray with the other snacks without cleaning the packages.

In an interview on 06/24/19 at 9:40 AM the dietary manager stated all staff must wear hair nets and all hair must be under the net. She also stated it is not sanitary to place packages that have fallen on the floor back with the clean packages.

Based on review of hospital policy/procedure, documents and interviews, the hospital failed to ensure:
1. Have and implement written protocols to address organ procurement responsibilities and duties (see Tag A-0885).
2. Have a written agreement/contract with an Organ Procurement Organization (OPO) (see Tag A-0886).
3. Provide a written agreement/contract with an Eye Bank (see Tag A-0887).
4. Hospital staff received annual training on their duties and responsibilities relative to organ/tissue and eye procurement (see A-0891).

Findings:

1.
Review of Policy #III-D-8, page 1 of 1, (date of reviewed/revised 08/18), revealed the following: "POLICY...The hospital shall utilize this agency to: 1. Identify potential organ and tissue donors; and 2. Contact family members to notify them of their options to donate or to decline donation...Consumers who may be potential organ donors will be referred to the network for evaluation. PROCEDURE 1. The Network shall be notified immediately after a consumer death by the RN on duty or the physician in attendance at the time of death...3. When tissue donation is requested...will arrange and provide for the retrieval of tissue."

The above referenced policy failed to have mention of imminent death, nor was there a definition for imminent death.

Interview, 06/26/19 at 1:30 PM, with Staff #B confirmed the hospital's policy/procedure (Policy # III-D-8) referenced above was the extent of written protocols that outlined the organ procurement organization's responsibilities.

2.
Review of the current list of contracted services failed to include a contract agreement with any organ procurement organization, tissue or eye bank for retrieval of organs, tissues and/or eyes.

3.
Interview, on 06/26/19 at 10:45 AM, with Staff #D confirmed the hospital did not have a contract with an Organ/Tissue procurement organization or eye bank.

4.
Review of 7 of 7 (Staff C, V, W, X, Y, Z, AA) Registered Nurse (RN) personnel files revealed a lack of documentation that 7 of 7 RNs had received training/education relative to donation and organ/tissue procurement that included what their responsibilities and duties would be for patients who wish to donate organs/tissues/eyes.

Interview, 06/26/19 at 10:20 AM, with Staff #B confirmed there lacked documentation that indicated hospital staff had received training on their responsibilities and duties relative to organ/tissue/eye donation.

Based on reviews of hospital policy/procedures, documents and interviews, the hospital failed to ensure there were written policies and procedures that addressed the responsibilities of the organ procurement organization.

Findings:

Review of Policy #III-D-8, page 1 of 1, (date of reviewed/revised 08/18), revealed the following: "POLICY...The hospital shall utilize this agency to: 1. Identify potential organ and tissue donors; and 2. Contact family members to notify them of their options to donate or to decline donation...Consumers who may be potential organ donors will be referred to the network for evaluation. PROCEDURE 1. The Network shall be notified immediately after a consumer death by the RN on duty or the physician in attendance at the time of death...3. When tissue donation is requested...will arrange and provide for the retrieval of tissue."

The above referenced policy failed to have mention of imminent death, nor was there a definition for imminent death.

Interview, 06/26/19 at 1:30 PM, with Staff #B confirmed the hospital's policy/procedure (Policy # III-D-8) referenced above was the extent of written protocols that outlined the organ procurement organization's responsibilities.

Based on policy/procedure review and interview the hospital failed to ensure there was: 1. an active contract with an Organ, Tissue, Eye Procurement Organization as evidenced by a lack of a contract; 2. policies and procedures developed and implemented relative to organ, tissue, eye procurement, that included the responsibilities and duties of hospital staff; 3. definition of what imminent death means; 4. interventions the hospital will utilize to maintain potential organ donor patients so that the patient organ remain viable; and 5. review of the organ, tissue and eye donation program through the hospital's QAPI program.

Findings:

Review of hospital policy/procedure titled "Organ Donor Program", Policy # III-D-8, page 1 of 1, revealed the following: "POLICY...The hospital shall utilize this agency to: 1. Identify potential organ and tissue donors; and 2. Contact family members to notify them of their options to donate or to decline donation...Consumers who may be potential organ donors will be referred to the network for evaluation. PROCEDURE 1. The Network shall be notified immediately after a consumer death by the RN on duty or the physician in attendance at the time of death...3. When tissue donation is requested...will arrange and provide for the retrieval of tissue."

Review of the policy and procedure above lacked information as to what the hospital staff would do to maintain potential organ donor patients to ensure that the patient organs remain viable. Continued review of Policy #III-D-8 revealed there lacked documentation as to what responsibilities and duties hospital staff had relative to organ donation; nor was there a definition for imminent death.

Interview, 06/26/19 at 10:45 AM, with Staff D confirmed the hospital did not have a contract with an Organ/tissue procurement organization or Eye Bank.

Based on record review and interview the hospital failed to have an agreement with a tissue bank and/or an eye bank for retrieval of tissues/eyes that may be obtained from potential donors upon death.

Findings:

Review of the current list of contracted services failed to include a contract agreement with any organ procurement organization, tissue or eye bank for retrieval of organs, tissues and/or eyes.

Interview, on 06/26/19 at 10:45 AM, with Staff #D confirmed the hospital did not have a contract with an Organ/Tissue procurement organization or eye bank.

Based on record review and interview the hospital failed to ensure hospital staff received training on donation issues including their duties and responsibilities.

Findings:

Review of 7 of 7 (Staff C, V, W, X, Y, Z, AA) Registered Nurse (RN) personnel files revealed a lack of documentation that 7 of 7 RNs had received training/education relative to donation and organ/tissue procurement that included what their responsibilities and duties would be for patients who wish to donate organs/tissues/eyes.

Interview, 06/26/19 at 10:20 AM, with Staff #B confirmed there lacked documentation that indicated hospital staff had received training on their responsibilities and duties relative to organ/tissue/eye donation.

Based on record review and interview, the hospital failed to ensure the services of a Psychologist was available as evidenced by lack of an employed Psychologist nor was there a contract for the services of a Psychologist.

Findings:

Review of the list of contracted services and the list of personnel revealed there lacked documentation that a psychologist was an employee or contracted to provide psychological services to the hospital's patients.

Interview, 06/24/19 at 4:05 PM, with Staff #A revealed when questioned if the hospital had a psychologist as an employee or contract; the response was "no, most of the services could be provided by an LPC (Licensed Professional Counselor)".

Staff #A confirmed the hospital did not have the services of a psychologist.

Based on observations, record reviews and interviews the hospital failed to ensure a qualified therapeutic activity therapists was hired to restore and maintain optimal levels of physical and psychosocial functioning for all patients who participated in recreational activities by hiring one of one staff (Staff L) who did not quality as a recreational therapist.
This failed practice had the potential to hinder the psychosocial well beings of all patients.
Findings:

Observations from 06/24/19 to 06/26/19 during the survey, revealed Staff L was observed conducting recreational activities.

A review of the job description for Staff L revealed he was a recreational therapist. Further review revealed his job duties were to plan, organize, direct and conduct client therapy programs and "instruct or supervise clients in recreational activities as part of a therapeutic, psychiatric or medical treatment program". Continued review revealed to quality for the job the applicant had to have a bachelor's degree in recreational therapy, outdoor recreation, physical education or a closely related field; or an equivalent combination of education and experience".

A review of the job application for Staff L failed to reveal he had a degree of any kind. A review of the of the "Therapeutic Activity Services Screening" forms for patient #5 and patient #6 revealed Staff L performed the screenings and signed off as a "RT" (recreational therapist).

In an interview on 06/25/19 at 8:45 AM Staff L stated he had been a recreational therapist for fourteen years and had been in the activity department at this hospital for twenty-seven years. He stated he provides activities, order supplies and worked with the activity treatment team. He said he took the recreational therapist test at the unemployment office and had to have four years of experience to take the test. Staff L reported he performs all of the initial task screening at the hospital for activities. He also stated he does not have a degree but he qualifies for his job through years of education.