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Based on interviews and record review, the hospital's governing body failed to ensure the Surgical Review Committee monitored cases that met their standards for review of unexpected deaths, surgical complications and nosocomial infections. Patient #1's case was not reviewed despite reflecting surgical complications, multiple infections, transfer to a higher level of care, and unexpected death in another facility. The failure to evaluate current physician performance exposed future patients to potential harm. The findings are:

A. On 10/04/16 at 11:15 am during interview, the Medical Director was asked which cases are reviewed by the Surgical Review Committee. She stated, "We will review deaths, surgical complications and infections." She was asked why the hospital experience of Patient #1 was not reviewed since it met all three criteria. She responded,"We have not gotten to it."

B. On 10/04/16 at 09:30 am during interview, the mother of Patient #1 stated Patient #1 was air lifted to a hospital in Albuquerque on 05/11/16. She stated, "My daughter had 14 more surgeries while there." The transferring hospital at that time diagosed Patient #1 with necrotizing fasciitis, an infection caused by bacteria which can destroy the body's soft tissue.

C. Record review of the hospital's Surgical Committee Meeting minutes for 06/01/16 indicated no review of any cases including Patient #1. This was the only meeting since the death of Patient #1 on 05/30/16.

D. Record review of the Hospital's Policy titled "Plan for Peer Review/Focus Review," effective date of 09/13/2005 and not reviewed since, indicated the following, "Focused Professional Practice Review: Intensified (focused) review of an individual practitioner or specialty is triggered by PIC [Process Improvement Committee], Medical Executive Committee, member of hospital administration, of the Board, at anytime or during the course of the Peer Review Process as described above and/or otherwise upon any of the following occurrences:
1. Unexpected patient death;
2. Emergency transfer following inpatient admission;
3. Sentinel Events as defined by TJC (the Joint Commission)...
4. A pattern of trend in issues regarding patient safety and/or negative patient outcomes is identified during the course of On-Going Professional Practice review as identified by the appropriate Medical Staff Committee."

E. Record review of the facility's Quality Summary did not include any data regarding medical or surgical case reviews.

F. Record review of Patient #1's history and physical dated 05/07/16 indicated the following:
1. repair of a vaginal fistula (repair of an abnormal development of a hole between either the rectum or vagina or between the bladder and vagina) in September 2013
2. upper endoscopy (procedure consisting of the use of a scope to view the inside of the upper digestive tract) and colonoscopy (procedure consisting of the use of a scope to view the inner lining of the large intestine) in May 2015
3. left rectal sphincterotomy (surgical procedure consisting of cutting or stretching the sphincter muscles; used as a treatment for patients that suffer from tears in the lining of the rectum) in May 2016

G. Review of the discharge summary dictated 05/11/16, the day of the discharge and tranfer to a higher level of care for Patient #1 indicated the following:
1. "Final diagnosis: Abscess of the buttock with necrotizing fasciitis up the buttock and down the left leg."
2. "Hospital course: Patient [#1] was admitted to the hospital with cellulitis [reddened area of infection] on her buttock. We examined the cellulitis treated it for 24 hours with the IV antibiotics. Once the antibiotics had been used, the cellulitis continued to progress. We opened the buttocks and found necrotizing fasciitis extending into a localized area. We debrided that fairly aggressively, but in the ensuing 36-48 hours her left leg appeared to become more edematous [swollen]. We went ahead and obtained a CT [computed tomography, or use of specialized x-ray equipment to produce cross-sectional images] scan of her pelvis and left leg. CT scan showed air all the way down to her ankle. She was taken to the operating room emergently and we unroofed [surgically removed] medially, laterally in all areas that we could identify as infected and the areas that we felt were specific with pathology of the CT scan."

Based on interview and record review, the hospital failed to develop a comprehensive infection control program. The facility's infection control nurse failed to evaluate the complexity of Patient #1's wounds and infections. This ultimately contributed to her transfer to a higher level of care. The findings are:

A. On 10/04/16 at 9:20 am during interview, the Infection Control Nurse confirmed the following:
1. In tracking infections, "I only follow the lab results." He was asked whether he reviews charts, follows diagnoses, or discusses cases with the physicians or pharmacists. He stated "No."
2. He was asked if he tracked discharges to a higher level of care. He responded "No."
3. He was asked if he tracked special diagnoses such as necrotizing fasciitis, an infection caused by bacteria which can destroy the body's soft tissue. He stated, "I don't track diagnoses."

B. Record review of the facility's policies for infection control revised 02/13/14 confirmed that the infection control nurse did not track:
1. Cases of sepsis (global infection of the blood).
2. Discharges to a higher level of care and sentinel events.
3. Surgical complications data from the Surgical Review Committee and other data from medical review committees was also not reviewed by the infection control nurse for infections.

C. Record review of the facility's infection control policy did not cite operating room surveillance policy and/or dietary surveillance by the infection control nurse. No collaboration with the pharmacist or physicians on appropriate antimicrobial use (use of drugs, chemicals, or other substances that kill microorganisms or inhibits their growth) was recommended or followed in the policy.

Based on interviews and record review, the hospital's quality program did not track cases of sepsis, discharges to a higher level of care, sentinel events, and surgical complications data from the Surgical Review Committee. The hospital's quality program also failed to review data from other medical review committees to solve problems and improve quality. These failures could reduce the quality of care offered by the hospital. The findings are:

A. On 10/04/16 at 11:00 am during interview, the Risk Manager, who also is responsible for quality, was asked to review the facility's quality dash board. She confirmed that the dash board and current program did not track cases of sepsis, discharges to a higher level of care, sentinel events, surgical complications data from the Surgical Review Committee and other data from medical review committees. She also confirmed that the hospital quality program was "incomplete" and she "had not been long working on the program." She agreed that these topics would be important clinical data points for a robust hospital quality program. She was asked if any events in the last 6 months had been evaluated through a Root Cause Analysis (RCA). She stated "No." She also could not produce a review of the hospital's services by an outside quality organization.

B. On 10/04/16 at 9:20 am during interview, the Infection Control Nurse confirmed the following:
1. In tracking infections, "I only follow the lab results." He was asked whether he reviews charts, follows diagnoses, or discusses cases with the physicians or pharmacists. He stated "No."
2. He was also asked if he tracked discharges to a higher level of care. He responded "No."

C. Record review confirmed that the infection control nurse did not track cases of sepsis, discharges to a higher level of care, sentinel events, surgical complications data from the Surgical Review Committee and other data from medical review committees.

D. Record review confirmed that the dash board and current quality program did not track cases of sepsis, discharges to a higher level of care, sentinel events, surgical complications data from the Surgical Review Committee and other data from medical review committees.

E. The facility's infection control policy's performance measures did not include operating room surveillance, dietary surveillance, collaboration with physicians or pharmacists, or reviews of cases by physician and surgical committees.