HospitalInspections.org

Based upon review of Medical Staff Bylaws and interviews, the Governing Body failed to ensure the current Medical Staff Bylaws were in compliance with all requirements of Medicare hospital Conditions of Participation for Medical Staff. Findings:

Review of the current Medical Staff Bylaws revealed they failed to address all requirements under Medicare hospital Conditions of Participation for Medical Staff. (see information in A0355)

Interview, 11/20/13 at 3:00 p.m., with S1 Assistant Administrator/Governing Body Member confirmed the Medical Staff Bylaws were not complete and did not meet the requirements under the Condition of Participation for Medical Staff.

Based upon reviews of Credentialing files, and interviews, the Governing Body failed to ensure the physicians/practitioners providing telemedicine services to the hospital's patients were granted current/active privileges.
Findings:

Review of Credentialing files revealed there failed to be documented evidence the hospital had obtained/prepared credentialing files (for the telemedicine practitioners/physicians), and after review of their files, granted the telemedicine physicians/practitioners privileges. The scope of the privileges in the hospital must reflect the provision of the services via a telecommunications system and there failed to be documentation that indicated the hospital and Governing Body ensured this was completed.

Interview, 11/20/13 at 11:00am, with S1 Assistant Administrator and S27 Chief Executive Officer/Administrator revealed the hospital utilized telemedicine services from Contract C. Continued interviews confirmed the Governing Body had not granted privileges to the telemedicine physicians/practitioners.

Based upon reviews of Governing Body/Medical Staff Bylaws and meeting minutes, list of contracted services, Quality Assurance/Performance Improvement (QA/PI) data, and interviews, the hospital failed to ensure all services provided by contract/agreements were evaluated through the hospital's QAPI Program to ensure compliance with all applicable conditions of participation and standards for the specified contracted services. Findings:

Review of Governing Body/Medical Staff Bylaws and meeting minutes revealed there failed to be documented evidence contracted services were to be evaluated as required by regulations.

Review of QA/PI data revealed there failed to be documented evidence that any of the hospital's contracted services were evaluated through the QA/PI Program and reported to the Governing Body and Medical Staff.

Interview, 11/19/13 at 2:50 p.m., with S1 Assistant Administrator (a member of the Governing Body) confirmed contracted services had not been evaluated through the hospital's QA/PI to ascertain if the services performed were in compliance with all regulations.

Based upon reviews of a list of contracted services, Quality Assurance/Performance Improvement (QA/PI) Program/data and meeting minutes, and interviews, the hospital failed to ensure services provided by contract/agreements were evaluated through the hospital's QA/PI Program to assure the services performed were provided in a safe and effective manner. Findings:

Reviews of a list of contracted services and QA/PI data revealed none of the contracted/agreement services had received evaluations through the hospital's QA/PI Program.

Review of the QA/PI meeting minutes revealed there failed to be documentation that indicated contract/agreement services were evaluated and reported to the Governing Body/Medical Staff.

Interviews, 11/20/13 at 3:45pm, with S1 Assistant Administrator and S16 Licensed Practical Nurse (LPN) QA/PI confirmed the services the hospital received through contract/agreement services were not evaluated through the hospital's QA/PI Program. S1 Assistant Administrator agreed all services were to be evaluated through QA/PI and reported to the Governing Body/Medical Staff.

Based upon record review and interview the hospital failed to ensure that a comprehensive list of all contracted services, including the scope and nature of the services to be provided, was maintained as evidenced by a lack of a comprehensive documented list.
Findings:

A list of all contracted services (which was to include the scope and nature of services provided) was requested from the S1 Assistant Administrator. Review of the list of contracted services provided by S1 Assistant Administrator revealed that Respiratory Care Services (a contracted service) and Telemedicine Services (also a contracted service) were not included on the list.

Interview, 11/19/13 at 1:45PM, with S1 Assistant Administrator confirmed Respiratory Care Services was not included in the list of contracted services.

Interview, 11/20/13 at 11:00am, with S1 Assistant Administrator and S27 Chief Executive Officer/Administrator revealed the hospital utilized Telemedicine Services (provided by an area University Hospital) from Contract C. S1 Assistant confirmed that Telemedicine Services were not included on the contracted services list.

Based upon observations and reviews of Physicians Orders, policies/procedures, incident reports and interviews, the hospital failed to ensure policies and procedures for pediatric patient safety were formulated and implemented relative to the administration of intravenous fluids (IV) as evidenced by a 1000 mL (milliliter) bag of IV fluids infusing into a 4 month old infant (Patient #2) without the use of a locked infusion pump and/or a drip regulator on the IV tubing that could have caused fluid overload in the patient. Findings:

Observations conducted, 11/18/13 at 2:30 p.m., of patient room #103 revealed Patient #2, a 4 month old male, was lying in a baby crib with an IV of solution of 1000 mL of 5% Dextrose/Water (D5W)/0.45% Normal Saline (1/2 NS), with an added 10 mEq (millieqvalents) of Potassium, infusing into his right foot. Continued observations revealed there failed to be a drip regulator on the IV tubing; nor was the infusion pump locked.

Review of nursing policies/procedures relative to medications/IV fluid administration revealed there failed to be formulated, implemented and documented policies/procedures in regard to pediatric patients, and specifically the safe administration of IV fluids.

Interviews, 11/18/13 at 2:45 p.m., with S1 Assistant Administrator (Asst Admin) and S2 Director of Nursing (DON) revealed when questioned if the hospital had policy/procedures for pediatric patients, S2 DON stated, "No". Further interviews with S1 Asst Admin and S2 DON revealed they were unaware patient #2, a 4 month old infant, had a 1000mL bag of IV fluids infusing without the use of a locked infusion pump and drip regulator on the IV tubing.

S2 DON agreed an infant/pediatric patient should have a locked infusion pump or buretrol to used to administer IV fluids.

S2 DON initiated an incident report in regard to the 1000mL bag after the surveyors questioned the safety of the unlocked infusion pump and lack of drip regulator on the IV tubing. If anyone had removed the IV line from the infusion pump,(and with the lack of a drip regulator), the IV fluids would have infused at a very fast rate and caused fluid volume overload and avoidable pain at the infusion site secondary to the Potassium that was added to the IV solution.

Based upon reviews of the hospital's QAPI Program/Data (Quality Assurance Performance Improvement) and interviews the governing body failed to ensure all contracted services were evaluated through the QAPI Program as evidenced by a lack of documented evaluations on contract services. Findings:

Review of the QAPI data revealed there failed to be documentation contract services were evaluated.

Interview, 11/20/13 at 3:30 p.m., with S16 Licensed Practical Nurse/QAPI and S1 Assistant Administrator (member of the Governing Body), confirmed the services supplied by all contracted services were not evaluated through the hospital's QAPI Program.

S1 Assistant Administrator agreed contracted services should have been evaluated and reported through the QAPI Program.

Based upon reviews of credentialing files, list of contract/agreement services, and interviews the medical staff failed to ensure telemedicine physicians/practitioners had their credentials examined and were recommended for appointment by the governing body prior to providing patient care. Findings:

Review of 7 of 7 credentialing files (S8, S12, S14, S23, S28, S29, S30), revealed there failed to be credentialing files for telemedicine physicians/practitioners that indicated what privileges were granted.

Review of a list of contract/agreement services revealed telemedicine services were provided by Contract C.

Interview, 11/20/13 at 3:00 p.m., with S1 Assistant Administrator (Asst Admin) confirmed the physicians/practitioners who provided telemedicine services were not credentialed; nor were they granted privileges.

Based upon reviews of Medical Staff Bylaws, 7 of 7 credentialing files (S8, S12, S14, S23, S28, S29, S30), and interviews, the governing body failed to ensure the Medical Staff Bylaws included the duties and privileging process of the medical staff. Findings:

Review of the Medical Staff Bylaws revealed there lacked documentation relative to the scope/duties and privileges of each category of practitioner who made application for membership to the Medical Staff.

Review of S8, S12, S14, S23, S28, S29 and S30's Credentialing files revealed there failed to be documented evidence relative to each physicians' privileges and scope of duties.

Interview, 11/20/13 at 1:30 p.m., with S1 Assistant Administrator confirmed the credentialing files lacked documentation relative to the physicians' privileges and the scope of their duties.

Continued interview, with S1 Assistant Administrator, revealed the Medical Staff Bylaws lacked information relative to privileges and the scope of duties for physicians/practitioners who were eligble to apply for membership in the Medical Staff.

Based upon review of the Medical Staff Bylaws and interview, the Medical Staff failed to ensure description of the qualifications and the criteria for privileging/appointment to the Medical Staff were documented in the Bylaws. Findings:

Review of the Medical Staff Bylaws revealed there lacked documentation relative to the description of qualifications and the criteria required for appointment to the Medical Staff. The Medical Staff Bylaws failed to describe the privileging process that was to be used.

Interview, 11/19/13 at 3:00 p.m., with S1 Assistant Administrator confirmed the Medical Staff Bylaws lacked requirements/criteria for appointment to the Medical Staff.

Based upon review of Medical Staff Bylaws and interview, the Medical Staff failed to ensure each patient received a completed and documented medical history and physical examination within the required 24 hours after admission. Findings:

Review of the Medical Staff Bylaws revealed physicians must complete and document a medical history and physical examination within 48 hours. The requirement of 24 hours for completion and documentation of a medical history and physical examination after admission was not met based on the Medical Staff's timeframe of 48 hours.

Interview, 11/19/13 at 10.30 a.m., with S1 Assistant Administrator confirmed the Medical Staff Bylaws stated 48 hours for documentation and completion of patients' medical history and physical examination after admission; and therefore did not met the requirement of 24 hours per regulation.

Based upon review of Medical Staff Bylaws and interview, the Medical Staff failed to ensure each patient received an updated documented examination within 24 hours of admission, when the medical history and physical examination was obtained 30 days prior to admission. Findings:

Review of the Medical Staff Bylaws revealed physicians must complete and document a medical history and physical examination within 48 hours of admission. The requirement of an updated examination within 24 hours (when the medical history and physical examination was completed 30 days prior to admission), was not met based on the Medical Staff's criteria of 48 hours.

Interview, 11/19/13 at 10.30 a.m., with S1 Assistant Administrator confirmed the Medical Staff Bylaws stated 48 hours for documentation and completion of patients' medical history and physical examination; and therefore did not met the requirement of 24 hours per regulation.

Based upon reviews of Governing Body/Medical Staff Bylaws, 7 of 7 credentialing files (S8, S12, S14, S23, S28, S29, S30), and interviews, the Medical Staff and Governing Body failed to ensure the Medical Staff Bylaws included a procedure for applying the criteria; and the criteria used for determining the granting of privileges to individual practitioners who performed or treated hospital patients as evidenced by a lack of documentation of granted current privileges for all physicians/practitioners and the procedure used to apply the criteria. Findings:

Review of Medical Staff Bylaws revealed there failed to be documented evidence the Medical Staff had determined the criteria used to grant privileges to physicians/practitioners who requested privileges; nor was there a documented procedure for the application of the criteria for privileges.

Interview, 11/19/13 at 10:45 a.m., with S1 Assistant Administrator (member of Governing Body) confirmed the Medical Staff Bylaws lacked the procedure and criteria used to grant privileges. S1 Assistant Administrator (member of Governing Body) agreed that credentialing files for physicians #s S8, S12, S14, S23, S28, S29, S30 and all telemedicine physicians/practitioners (who were unidentified due to numbers and specialties represented) all lacked evidence of granted privileges.

Based upon review of documentation of nursing personnel licensure information and interviews, the hospital failed to ensure the licenses for Licensed Practical Nurses (LPN's) S24 and S26, who provided Endoscopy assistance, were verified. Findings:

Interview with S2 RN/DON on 11/19/13 at 2:15 p.m. revealed LPN S24, and LPN S26 accompanied S8 Physician and provided assistance with the endoscopies in the Emergency Department. According to S2 RN/DON, these nurses were employed by Hospital A.

Review of the list of nursing personnel licensure verifications revealed LPN S24 and LPN S26 failed to be identified.

Further interview with S2 RN/DON revealed when the licensure verification for LPN S24 and LPN S26 was requested, a faxed copy dated 11/19/13, timed 2:25 p.m. from Hospital A, of the licenses for LPN S24 and LPN S26 was produced. The hospital failed to ensure the licenses for LPN S24 and LPN S26 was verified prior to these nurses providing endoscopy assistance.

31206

Based on record review and interview the hospital failed to ensure a RN (registered nurse) must supervise and evaluate the nursing care for each patient as evidence by failing to ensure IV(Intravenous) sites were assessed for flow and patency every 2 hours for 8 (#1, #3, #13,#14,# 15, #16, #17, & #18) of patient's records reviewed for IV assessments out of a total sample of 21 patient's records reviewed. Findings:

Review of the Hospital Policy titled "IV Therapy" presented as current (no date) reads in part: Documentation of IV assessment will be done at least every shift. All IV's will be checked for flow and patency every 2 hours.

Review of electronic medical records for patients #1, #3, #13, #14, #15, #16, #17, & #18 revealed documentation of site assessments on MARs (medical administration records) once per shift which included an initials of the nurse who performed the assessment. Continued review of the electronic records revealed a lack of documented evidence the flow and patency was checked every 2 hours.

In a face to face interview, on 11/20/13 at 2:00 p.m., S10 RN indicated IVs are assessed initially at the beginning of each shift and periodically throughout the day, documented in the nurses progress note and written on the MARs as site assessments. S10 RN indicated IV sites were assessed for redness and swelling with the findings documented in the nurse's progress notes. S10 RN reviewed the nurse's progress notes for patient's#1, #3, #13, #14, #15, #16, #17, & 18 and confirmed there was no documented evidence of IV assessment checks performed for flow and patency of the IV every 2 hours but there should have been.

In a face to face interview, 11/20/13 at 2:30 p.m., S2 DON confirmed IV assessments, which included flow rate and patency, were not being documented every 2 hours as stated in the hospital's policy on IVs and should have been.

Based upon review of personnel files, nursing license verifications, observations, and staff interviews, the hospital failed to ensure Licensed Practical Nurses (LPN's) S24 and S26 and Registered Nurse (RN) S25 had the specialized qualifications and competencies to assist S8 Physician in endoscopies and cleaning of the endoscopy scopes. Findings:

Observations in the Emergency Department on 11/19/13 at 9:30 a.m. revealed a closet where upper and lower endoscopes were being stored. Interview with S2 RN/DON on 11/19/13 at 10:05 a.m. revealed once every two weeks, S8 Physician, a Gastroenterologist, does endoscopes in the Emergency Department and brings an RN to assist with the endoscopic procedure and monitor the patient, and an LPN to clean the endoscope. A hospital RN was also in the endoscopy room to record the patient monitoring. When asked if these nurses were employees of the hospital or provided these services under contract, S2 RN/DON identified S24 LPN, S26 LPN and S25 RN by name and stated these nurses were employed at Hospital A.

Review of the list of verifications for licensure revealed there failed to be documented evidence the licenses for S24 LPN and S26 LPN were verified. Further interview with S2 RN/DON on 11/19/13 at 2:15 p.m. revealed there were no personnel files for S24 LPN, S25 RN, and S26 LPN. When the license verification for S24 LPN and S26 LPN was requested, a faxed copy, dated 11/19/13 and timed 2:35 p.m., from Hospital A was provided.

Even though S24 LPN, S25 RN and S26 LPN were allowed to assist with endoscopic procedures and endoscopy scope cleaning , there failed to be documented evidence these nurses were qualified and competent to perform these duties.

Based upon observations and interviews, the hospital failed to ensure periodic maintenance and testing was conducted on medical devices and equipment. This was evidenced by: 1) failure to annually inspect medical equipment in the Emergency Department (IV infusion equipment, cardiac monitors, defibrillators); and 2) failure to annually inspect medical equipment utilized on the patient units (automated vital sign machines, patient electronic scales, IV infusion pumps). Findings:

1) Observations during the environmental tour on 11/19/13 at 9:30 a.m. of the Emergency Department revealed the following:

Room #2: The last period inspection of the cardiac monitor had a yellow sticker identifying the date of inspection was documented as 12/07/11.

Room #3: Cardiac monitor and Welsh Allen Otoscope last inspected 12/7/11. The infusion flow meter pump last inspected 11/18/10.

Room #4: The last periodic inspection of the Sigma Spectrum flow meter and the Nohon Kohden cardiac monitor had a yellow sticker dated 12/07/11. The Welch Allen Otoscope, the EKG machine and the Phillips Defibrillator failed to have evidence it was ever inspected.

2) Observations conducted, 11/18/13 at 10:45 a.m., of the patient care units revealed:

Open storage area located between the two patient unit hallways, had 2 Mindray automatic vital sign machines. The maintenance sticker had due dates of 1/10 and 10/12.

The Electronic patient scale did not have a maintenance sticker, and the Director of Nursing (DON) did not know if it had been inspected.

Mindray Datascope Vital Sign machine did not have a maintenance sticker and the DON did not know if it had been inspected.

Patient room #103 had an IV infusion pump in current use on a patient. Review of the due date documented on the maintenance tag was 10/11 for the required maintenance.

Review of 3 other IV infusion pumps, Room # 101, #111, and Room #118 revealed the annual maintenance had not been performed. The last documented dates were 10/11, 9/10, and 10/12.

Interview, 11/20/13 at 5:45 p.m., with S2 DON confirmed that annual maintenance was to be conducted on all medical equipment. S2 DON agreed the medical equipment had not received annual maintenance inspections as per the hospital policy to ensure that all medical equipment functioned as it should and not potentially cause patient harm.

Based on record review and interview, the hospital failed to ensure the scope of diagnostic and/or therapeutic respiratory services offered by the hospital were defined in writing, and approved by the Medical Staff as evidenced by a lack of a documented policy & procedure for respiratory services.
Findings:

Review of the hospital's Policy & Procedure Manual revealed there lacked documented evidence the hospital had formulated and implemented a Policy/Procedure for Respiratory Care Services.

In a face to face interview, on 11/19/13 at 12:30 p.m., S10 RN (Registered Nurse) & S15 RN indicated respiratory treatment ordered by the physicians were provided by the RN & LPN (Licensed Practical Nurse), when S17 RT was not available. S10 RN & S15 RN both indicated the respiratory treatment included the collection of ABGs (drawing blood from an artery for testing: arterial blood gas sample) by RNs. S10 RN & S15 RN both indicated they had no formal training on ABGs specimen collection. According to both nurses the training which they received included observation of MT (medical technologist), performance with MT providing verbal instruction during collection and visually pointing out with proper hand positioning for location of artery.

In a face to face interview on 11/19/13 at 1:05 p.m. S2 DON indicated S17 RT was contracted (16 hours weekly) and RNs & LPNs were responsible for administering respiratory treatments ordered by the physician. S2 DON indicated the treatments included but were not limited to: nebulizer treatment, oxygen administration, trachea care, Bi-PAP (Bi-Level Positive Airway Pressure), CPAP (Continuous Positive Airway Pressure), mist tent (pediatric), chest percussion, and drawing ABGs. S2 DON confirmed the hospital did not have a policy /procedure for respiratory care services which were being provided by S17 RT or which addressed respiratory care of the patient, or a policy/procedure for collection of ABGs by RNs. S2 DON indicated there was no documented training or competency for the RN to perform ABGs, Bi-PAP, chest percussion, & mist tent (pediatric).

Based on review of the Medical Staff By-laws and interview, the hospital failed to ensure the Medical Staff appointed a Director for Respiratory Care Services that provided oversight/supervision for the respiratory department, and ensured patients received respiratory care by qualified, competent staff. Findings:

Review of S23 Medical Director's credentialing file revealed a documented, (not dated) that indicated he agreed to serve as Medical Director of Respiratory Therapy Services. The document contained no documented evidence of approval by the governing body or medical staff. S23 Medical Director's signature was the only one on the document; however, there failed to be a date that indicated when the signature was placed.

In face to face interview, on 11/20/13 at 9:30 a.m., S1 Administrator indicated S23 Medical Director as the Director of Respiratory Services and the acceptance letter with S23's signature should have been approved by the governing body and dated.

Based on record reviews and interview the hospital failed to ensure the amount of supervision required for personnel who performed specific respiratory procedures and the qualifications required to perform these procedures was designated in writing as evidenced by a lack of respiratory polices and procedures. Findings:

Review of the hospital's policy & procedure manual revealed there failed to be documented evidence a policy/procedure for respiratory services was formulated and implemented; nor was there documentation that indicated what qualifications/training the personnel, who provided respiratory services, must possess in order to provide respiratory treatments.

Interview, on 11/19/13 at 10:30 a.m., with S2 DON (Director of Nursing) revealed when questioned about respiratory services, he presented 2 documents (titled RNs & LPNs ) relative to respiratory services and training.

Review of the above mentioned documents revealed: "RNs may perform tasks promoting pulmonary hygiene or any respiratory tasks they have been trained or had proper inservice in. They are under the supervision of Chief of Staff (S23). Oxygen therapy, suctioning, CPT (chest percussion therapy), Aerosol therapy, croup tents..." Both documents were signed by S1 Assistant Administrator, S23 Medical Director, reviewed by S2 DON with a date of 6/1/04. S2 DON indicated these documents were the Respiratory Care Policy.

Review of the personnel file for S17 RT (Respiratory Therapist) (contracted service), revealed a lack of documented evidence that S17 RT received: 1) an orientation to the hospital's policies/procedures, and 2) had her license, training and competency/skills evaluated to ensure competency and active licensure.

Review of personnel files for S2 DON, S3RN, S4RN, S7RN, S10RN, S15RN, S16LPN, and S26RN revealed a lack of documented evidence they received training, evaluation of competencies on performing respiratory treatments, drawing ABGs (arterial blood gas samples), and oxygen therapy.

An interview, on 11/20/13 at 4:00 p.m., with S2 DON confirmed there lacked documented evidence the personnel received training, competency/skill evaluations relative to respiratory treatments and/or use of respiratory equipment. S2 DON further agreed the qualifications and the amount of supervision required to perform specific respiratory services was not designed in writing and approved by the Governing Body/Medical Staff.

Based upon observations, reviews of policy/procedures, and interviews, the hospital failed to ensure a married couple had the right to cohabit a room if a room was available and they chose to share the room as evidenced by a lack of a documented policy/procedure that addressed this right. Findings:

Observations of room numbers 223 through 228 revealed these rooms were utilized as swing bed rooms.

Review of the hospital's policy/procedures revealed there failed to be a documented policy/procedure that addressed the patients' rights to cohabit a room should they desire.

Interviews, 11/20/13 at 3:30 p.m., with S1 Assistant Administrator and S2 Director of Nursing confirmed the hospital did not have policy/procedures in place for married patients admitted to a swing bed room to cohabit the room if they desired to share the same room.