HospitalInspections.org

Based on document review and interview the facility failed to ensure that it had an organized, individualized governing body responsible for the conduct of the hospital as an institution. Findings include:

During document review of the care continuum board of trustees meeting minutes on 4/24/12 and 4/25/12 it was found that this board was a combined governing body responsible for conduct of several different facilities simultaneously and that the hospital reported all information in relation to the different committees within the hospital to a care continuum board an affiliated hospital.

During an interview on 4/25/12 at approximately 0900, the above findings were explained to this surveyor by staff F, G and I. They confirmed the hospital has no independent governing body responsible for this facility.

Based on record review and interview the facility failed to ensure that all medical records were complete within 30 days of discharge. Findings include:
On 4/23/12 at approximately 1415 during medical record review it was identified that there were 182 incomplete medical records beyond the 30 days of the patients discharge from the facility. During an interview with Staff E these findings were confirmed.

Based on interview and record review the facility failed to designate, in writing, an infection control officer. Findings include:

On 4/25/12 at approximately 1045 during infection control interview with staff J and K revealed that the infection control program was, until recently under the direction of St. Johns Health and that staff J reported to staff K until last month. Staff K was the "regional infection control person". "The facility has been undergoing some reorganization so reporting structures have changed". Staff J now reports to Brighton Hospital's Chief Nursing Officer.

When asked for the designation of the infection control officer for Brighton Hospital, a document was produced that revealed "Infection Control Policy 1-3 Infection Control Statement of Authority: Infection Control" with an effective date of August 1986 with review dates through 4/12 "Purpose to define the authority of the Providence Hospital Infection Control Committee or its designee...President & Chief Executive Officer Robert F. Casalou, Director Infection Control Services J. Blair... The Medical Staff and Administration of Providence Hospital and Medical Centers recognize the authority of the Infection Control Committee or its designee...". Interview with staff J and K regarding the provided document and whether Brighton Hospital's governing body was represented on the approval of the document to which she responded "They are not".