HospitalInspections.org

Based on review of the hosptial's policy/procedure, documents, and interviews, it was determined that the governing body failed to require that an institutional plan (operational budget and capital expenditures), was reviewed annually. This deficient practice poses a risk to the health and safety of the patients, when the governing body has no oversight, to ensure that the institutional plan was prepared by representatives of the governing body, administrative staff, and the medical staff, providing input to the services and/or equipment needed for patient care.

Findings include:

Policy titled "Responsibilities of the Board of Directors" (#LD.003; 05/2020), revealed: "...Board of Directors (Governing Board) has ultimate responsibility for the safety, quality of treatment, and the operation authority for Talas Harbor...provides for internal structures and resources...the responsibilities of the Talas Harbor...Governing Board include...provide for organization management and planning...provide for resources needed to maintain safe, quality care, treatment, and services...."

Document titled "Rules & Regulation of the Governing Board of Talas Harbor at Bullhead City" (approved 06/10/2020), revealed: "...The Governing Board of Talas Harbor at Bullhead City hereby adopts the following Rules and Regulations...Purpose...purpose of the Governing Board is to recommend and implement hospital policy, promote patient safety...provide for organizational management and planning of the hospital...Article VIII...Governing Board Operation...Section 1...General Functions...the Governing Board shall have responsibility for the business and affairs of the hospital...Section 4...Planning Function...Governing Board shall participate in and support an institutional planning process...Section 8...Facility Plans and Budgets...Governing Board, together with the hospital Senior Executive Officer, shall develop short-term, and long-term financial management plans including, but not limited to...annual operating budget...a long-range capital expenditure plan...such plans shall be submitted to the Board of Directors...for review and approval...."

Document titled "Talas Harbor at Bullhead City, Profit and Loss" (as of date: 07/08/2020), revealed a report for Operating Expenses, Other Income, and Net Income (Loss) for the dates 08/31/2019 through 07/31/2020...."

Document titled "Talas Harbor at Bullhead City Capital Budget" (no date), revealed a report for Year 1, Year 2, Year 3, and Notes, but the report had no specific dates, and/or years on the report.

Documents titled "Governing Board Meeting Minutes and Agenda", revealed the following:
i. 12/02/2019 (Agenda): no documented evidence of an institutional plan;
ii. 12/02/2019 (Minutes): no documented evidence of meeting minutes;
iii. 01/06/2020 (Agenda): Standing Reports: Financial Report listed;
iv. 01/06/2020 (Minutes): no documented evidence of approval of an institutional plan under Standing Reports: Financial Report;
v. 02/26/2020 (Agenda): Standing Reports: Financial Report listed;
vi. 02/26/2020 (Minutes): no documented evidence of approval of an institutional plan under Standing Reports: Financial Report.

Documents titled "Committee of the Whole (COW)", revealed the following:
i. 06/02/2020 (Minutes): no documented evidence of approval of an institutional plan;
ii. 06/10/2020 (Agenda): no documented evidence of an institutional plan;
iii. 06/10/2020 (Minutes): no documented evidence of approval of an institutional plan.

The surveyor requested documented evidence of the Governing Body meeting minutes, showing evidence of approval of an institutional plan (operational budget and capital expenditures), and none was provided.

Personnel #3 confirmed during a telephone interview conducted 07/15/2020 (1045), that the institutional plan (operational budget and capital expenditures), was approved during the 12/02/2019 Governing Board meeting, and that the report should be in a binder or in the executive laptop, both located at the hosptial.

Personnel #1, and Personnel #2 both confirmed during a combined interview conducted 07/15/2020 (1545), that the requested evidence of approval of the institutional plan (operational budget and capital expenditures), was unable to be located.

Based on review of the hospital's policies/procedures, documents and interviews, it was determined that the Governing Body failed to require that all services provided under contract, were evaluated annually or included in the QAPI plan. This deficient practice poses a risk to the health and safety of the patients, when the Governing Body fails to ensure that contracted services are assessed and evaluated to determine quality compliance.

Findings include:

Policy titled "Performance Improvement" (#PC061; 06/2020), revealed: "...the plan is current and describes actual practices in the psychiatric hospital...plan addresses...reporting on key quality indicators...affect health outcomes, patient safety, and quality of care...it is the policy of Talas Harbor Hospital that the governing body, the Executive Director, physician, and hospital leadership ensure...an on-going program for quality improvement and patient safety...it is also the policy of the hospital to monitor contracted services by establishing expectations for the performance of those contracted services...results of the performance indicators will be reviewed annually and before renewal of the contract with the entity...."

Policy titled "Responsibilities of the Board of Directors" (#LD.003; 05/2020), revealed: "...Board of Directors (Governing Board) has ultimate responsibility for the safety, quality of treatment, and the operation authority for Talas Harbor...."

Document titled "Rules & Regulation of the Governing Board of Talas Harbor at Bullhead City" (approved 06/10/2020), revealed: "...The Governing Board of Talas Harbor at Bullhead City hereby adopts the following Rules and Regulations...Purpose...purpose of the Governing Board is to recommend and implement hospital policy, promote patient safety...Article VIII...Governing Board Operation...Section 1...General Functions...the Governing Board shall have responsibility for the business and affairs of the hospital...Section 5...Performance Improvement (PI)...Governing Board shall require...staffs of the hospital departments/services to implement and report on the activities and mechanisms for monitoring and evaluating the quality of patient care...Governing Board shall consider and if necessary, act upon the results reported from PI activities, which activities shall strive to satisfy...quality patient care provided by...all others who provide patient care services at the hospital...."

Document titled "Performance Improvement (PI) Plan, Talas Harbor at Bullhead City" (06/14/2020), revealed: "...purpose of the plan is to ensure the delivery of quality care to all patients...accomplished through consistent monitoring...activities of the PI Plan are reported at least quarterly to the Committee of the Whole (COW) meeting...hospital plan will be reviewed at least annually and revised as necessary...Function...identify the important aspects of care related to the clinical services...the Executive Director or designee is responsible for the review and submission of all reports to the COW...Governing Board of Talas Harbor has authorized the Executive Director to implement and monitor the PI Plan...Executive Director or designee is responsible for facilitating the completion of PI activities defined by the scope of this plan...Goal...to ensure quality patient care and appropriateness of clinical services...."

Document titled "Performance Improvement Initiatives, Talas Harbor at Bullhead City" (no date), revealed no documented evidence that "contracts" was listed for review.

Documents titled "Governing Board Meeting Minutes and Agenda", revealed the following:
i. 12/02/2019 (Agenda): no documented evidence that PI review of contracts was listed;
ii. 12/02/2019 (Minutes): no documented evidence that PI review of contracts was discussed.

Personnel #8 confirmed during an interview conducted 07/14/2020 (1430), that s/he is familiar with the PI Plan, and that contracts is not listed on the 2020 PI Plan. Additionally, Personnel #8 revealed that s/he was not aware that the review of contracts is required annually, and should be evaluated for performance.

Personnel #3 confirmed during an interview conducted 07/15/2020 (1045), that s/he thought that PI review of contracted services had been previously reviewed at the 12/02/2019 Governing Board Meeting.

Personnel #1, and Personnel #2 both confirmed during a combined interview conducted 07/15/2020 (1545), that the requested documented evidence of PI review of contracted services by the Governing Board at the 12/02/2019 Governing Board Meeting was not available.

Based on review of the hospital's policy/procedure, documents and interviews, it was determined that the Governing Body failed to maintain a list of all contracted services, to include the scope and services provided. This deficient practice poses a risk to the health and safety of the patients, when all contracted services are not identified, or readily available for review, should a negative patient safety outcome arise.

Findings include:

Policy titled "Responsibilities of the Board of Directors" (#LD.003; 05/2020), revealed: "...Board of Directors (Governing Board) has ultimate responsibility for the safety, quality of treatment, and the operation authority for Talas Harbor...."

Document titled "Rules & Regulation of the Governing Board of Talas Harbor at Bullhead City" (approved 06/10/2020), revealed: "...The Governing Board of Talas Harbor at Bullhead City hereby adopts the following Rules and Regulations...Article X11...Review of Documents... Section 2...Professional Service Contracts...Governing Board shall review at least annually, the quality of service rendered by...other professional service contractors...the need for and selection of such...professional service contractors...Governing Board shall...review and make recommendations on any contractual matter referred to it by the Board of Directors...."

Documents titled "Governing Board Meeting Minutes and Agenda", revealed the following:
i. 12/02/2019 (Agenda): no documented evidence of contract listed;
ii. 12/02/2019 (Minutes): no documented evidence of contracts discussed.

Personnel #3 confirmed during an interview conducted 07/15/2020 (1045), that contracts were approved by the Governing Board during the 12/02/2019 Governing Board Meeting Minutes.

Personnel #1, and Personnel #2 both confirmed during a combined interview conducted 07/15/2020 (1545), that the requested documented evidence of an approved contract list by the Governing Board at the 12/02/2019 Governing Board Meeting was not available. Personnel #1, and Personnel #2 both revealed that the contract list provided at the time of survey, did not list the scope and nature that the contract services provided, nor was the list complete. Additionally, Personnel #1 confirmed that the hospital has agreements with the Organ Donor Network, and World Wide Staffing, but that these were not included on the contract list.

Based on review of the hospital's policies/procedures, documents, medical records, and interview, it was determined that the hospital failed to require that verbal/telephone orders were authenticated within the required forty-eight (48) hours. This deficient practice poses a risk to the health and safety of the patients, when the provider does not authenticate verbal/telephone orders in a timely manner, to ensure that the verbal/telephone order(s) was correct, and ordered for the right patient.

Findings include:

Policy titled "Verbal & Telephone Orders (#RC.006; 05/2020), revealed: "...To provide staff with direction to ensure safe patient care when telephone or verbal orders are given by a privileged medical staff member ...Authentication of orders...all verbal and telephone orders must be authenticated and countersigned by the prescriber or other responsible practitioner within forty-eight (48) hours (per Medical Staff Rules & Regulations)...."

Policy titled "Medication Ordering, Preparation, Dispensing & Administration" (#MM.018; 05/2020), revealed: "...all medications dispensed will follow all regulations and standards...telephone and verbal orders are required to be signed off by the physician or Licensed Independent Practioner (LIP) within forty-eight (48) hours...."

Document titled "Rules & Regulations of Medical Staff, Talas Harbor at Bullhead City" (06/10/2020), revealed: "...5.4 Member Orders...5.4.1...physicians making verbal or telephone orders shall countersign...within forty-eight (48) hours..."

Medical record review conducted 07/14/2020, and 07/15/2020, revealed the following:

i. Telephone/Verbal Orders: Eleven (11) out of seventeen (17) medical records contained verbal/telephone orders that had not been authenticated.

Personnel #7 confirmed during an interview conducted 07/13/2020 (1415), that verbal/telephone orders are required to be signed by the physician (MD) or Nurse Practitioner (NP) with forty-eight (48) hours.

Based on review of the hospital's policy/procedure, document, medical records, and interview, it was determined that the hospital failed to required that a psychiatric evaluation was completed within the required sixty (60) hours. This deficient practice poses a risk to the health and safety of patients, when the healthcare provider fails to complete a psychiatric evaluation, for the purpose of determining a patient's diagnosis, and treatment for care at a hospital specializing in psychiatric services.

Findings include:

Policy titled "Interdisciplinary Assessment Overview" (#PC.014; 05/2020), revealed: "...goal of the assessment is to determine the appropriate care, treatment, and services to meet a patient's initial needs while in the psychiatric program...all patients admitted to the program receive the following assessments...Psychiatric Evaluation....:

Document titled "Rules & Regulations of Medical Staff, Talas Harbor at Bullhead City" (06/10/2020), revealed: "...Admission...2.1...patients may be admitted to the facility only by members with clinical privileges to do so...all admissions to the facility must meet the facility's admission criteria as defined in these Rules & Regulations...2.7...the Psychiatric Evaluation and Mental Status Examination shall, in call cases, be completed...and recorded in the chart within sixty (60) hours after admission of the patient, unless one has been performed within the last thirty (30) days...."

Review of medical records conducted 07/14/2020, and 07/15/2020, revealed the following:

i. Psychiatric Evaluation: Four (4) out of seventeen (17) medical records did not contain a Psychiatric Evaluation within the required sixty (60) hours.

Personnel #5 confirmed during an interview conducted 07/14/2020 (1530), that a Psychiatric Evaluation by the provider is required to be completed within sixty (60) hours of the patient's admission.

Provider #1 confirmed during a telephone interview conducted 07/15/2020 (1700), that a Psychiatric Evaluation is required within sixty (60) hours of the patient's admission.

Based on review of the hospital's document, medical records, and interview, it was determined that the hospital failed to required that a discharge summary was completed within the required fifteen (15) days after the patient was discharged. This deficient practice poses a risk to the health and safety of patients, when the healthcare provider fails to complete a discharge summary, for the purpose of continuity of care, and evaluation the patient's mental health, and physical status at the time of discharge.

Findings include:

Document titled "Rules & Regulations of Medical Staff, Talas Harbor at Bullhead City" (06/10/2020), revealed: "...Medical Records...5.9...Completion of Medical Records...5.9.1...all discharge summaries...shall be completed within fifteen (15) days following the patient's discharge...incomplete records exceeding fifteen (15) days following discharge will be considered delinquent...."

Review of medical records conducted 07/14/2020, and 07/15/2020, revealed the following:

i. Discharge Summary: Four (4) out of fourteen (14) closed medical records, of discharged patients, did not contain a Discharge Summary within the required fifteen (15) days.

Personnel #5 confirmed during an interview conducted 07/14/2020 (1535), that a Discharge Summary by the provider, is required to be completed within fifteen (15) days after the patient's discharge.

Provider #1 confirmed during a telephone interview conducted 07/15/2020 (1710), that a Discharge Summary is required within fifteen (15) days of the patient's admission.