HospitalInspections.org

Based on request for information and staff interview it was determined the hospital failed to have evidence of a written notice that is provided to all inpatients at the beginning of a planned or unplanned inpatient stay informing them the hospital does not have a physician present in the hospital twenty-four (24) hours a day for seven (7) days a week. When this notice is not provided to all hospitalized patients it can result in patients or caregivers making medical decisions without full knowledge of what medical services are available at all times in the facility.

Findings include:

During the entrance conference on 1/5/14 at 9:45 a.m. the administrator was questioned if there is a physician present in the hospital at all times and she stated they do not have a physician present at all times. She added there is always a physician on call.

Requests were made for the written notification that is provided to all hospitalized patients informing them a physician is not present in the hospital twenty-four (24) hours a day for seven (7) days a week.

On 1/14 at 2:30 p.m. the Director of Operations and Quality stated they do not have a written notification which is given to hospitalized patients informing them a physician is not present in the hospital all the time.

Based on document review and staff interview it was determined the facility failed to conduct an annual review of the Swing Bed Policy and Procedures manual. Failure of the professional group to review policies and procedures annually has the potential to allow problems with the delivery of health care services to go undetected and, therefore, uncorrected.

Findings include:

1. Facility Swing Bed Policies and Procedure Manual was reviewed on 1/7/15 and revealed, in part, the last date of review as November 2013.

2. An interview was conducted with the Director of Clinical Operations on 1/7/15 at 8:45 a.m. She stated she was aware of the regulation requiring an annual review of all facility policies. She agreed no annual review had been completed for the Swing Bed Policy and Procedure Manual for 2014.

Based on document review and staff interview, it was determined the facility failed to perform and document annual skills competencies of all personnel providing Radiology services. Failure to ensure all personnel are fully competent and knowledgeable related to safe practices and emergency procedures has the potential to place all patients receiving radiological testing at risk for injury.

Findings include:

1. Facility policy entitled "Competency Assessment", last reviewed 7/2014, was reviewed on 1/7/15. It states, in part, "Staff member competence is evaluated continuously and at least annually through the performance management process and competence validation".

2. Facility policy specific to the Radiology Department entitled "Scope of Services", last reviewed 7/2014, was reviewed on 1/7/15. It states, in part, "All technologists who provide technical diagnostic services are licensed or registered according to applicable state law and regulation, and have the appropriate training and competence."

3. Facility Radiology Policies and Procedure Manual, last reviewed 7/2014, was reviewed on 1/7/15. It revealed, in part an eighty-one (81) item checklist entitled "Annual Competency Clinical Skills Assessment/Evaluation of Clinical Performance/Imaging Services Technologist".

4. Multiple requests were made during the survey for documentation of the above-named Annual Competency for current Radiology personnel to both the facility Radiology Manager and the Director of Clinical Operations. No documentation of completed competencies were provided during the survey.

5. A joint interview was conducted with the Radiology Manager and the Director of Clinical Services on 1/7/15 at 8:40 a.m. Both stated they were aware of the policy regarding annual competency testing for Radiology personnel and both stated they were unable to locate documentation of the completion of these competencies.

Based on requests for the hospital's annual program evaluation it was determined the hospital failed to have evidence of a program evaluation which is completed on at least an annual basis. When hospitals do not perform annual evaluations it can result in a failure to identify management and patient care issues which could result in negative patient outcomes.

Findings include:

On 1/6/15 after multiple requests for the annual program evaluation the Director of Quality provided a program evaluation which was completed in June of 2013 and a second evaluation which was dated June 2012. There was not an annual program evaluation that had been completed in 2014 and the most currently available annual evaluation was completed eighteen (18) months ago.

The Director of Quality explained on 1/6/15 at 4:00 p.m. the annual report for 2014 has not been fully completed at the present time due to computer issues.

Based on request for policies and procedures relative to visitation rights of patients it was determined the hospital failed to have evidence of having visitation rights polices. Additionally, the hospital failed to have evidence of a process for notifying the patient or support person of their visitation rights prior to providing services when possible. When the hospital fails to have visitation rights policies with patient notification of these policies can result in patients not receiving the needed visits by the support person of their choosing,

Findings include:

A request was made for the hospitals visitation policies and patient notification of these rights which is provided prior to providing services.

On 1/7/15 at 2:20 p.m. the Director of Operations and Quality presented a visitation policy which describes the visitation hours and medically indicated restrictions. The Director agreed they did not have policies that covers all of the patients visitation rights and there is no written patient notifications of these rights.