HospitalInspections.org

Based on review of policies and procedures and interviews with key staff on October 24 and 25, 2012, it was determined that the facility failed to ensure that the chief executive officer was responsible for assuring that staff are evaluated per hospital policy.

Findings include:

1. A review of the St. Mary ' s Regional Medical Center policy titled, ' 90 Day Evaluation ' , stated, " All employees new to a position, regardless of their status, will receive a 90 Day Evaluation ... "

2. During a review of personnel files on October 24, 2012, there were three (3) personnel files of nineteen (19) that did not contain documentation that a 90 Day Evaluation had been completed.

3. During an interview with the Director Human Resources/Learning on October 25, 2012, she stated that there was no documentation that these evaluations had been completed.

Based on review of information provided, review of policies and procedures and interviews with key staff on October 25, 2012, it was determined that the facility policy for complaints and grievances included a statement that allowed the facility to make the determination regarding if complaints could have been handled while the patient was hospitalized and therefore would not be grievances.

Findings include:

1. A review of the St. Mary's Regional Medical Center policy titled ' Patient Complaint and Grievance Procedure ' stated, " Complaints about patient care received via telephone from a patient or a patient representative post discharge are also considered grievances unless the complaint would routinely have been handled by staff during the stay/visit. "

2. During the review of Complaint A, on October 25, 2012, the information included concerns about the patient's discharge.

3. During an interview with the Patient Satisfaction Coordinator on October 25, 2012, she stated that Complaint A should have been a grievance, as the issues were related to discharge and could not have been handled by the staff during the stay/visit.

4. During the interview on October 25, 2012, with the Patient Satisfaction Coordinator, she confirmed that the statement included in the policy allowed for the hospital to make decisions regarding if complaints could have been handled by staff during the stay and that the hospital would really have no way of determining that.

Based on review of information provided and interviews with key staff on October 25, 2012, it was determined that the facility failed to follow its established grievance process in two (2) of three (3) grievances. (Grievances A and C)

1. A review of the St. Mary's Regional Medical Center policy titled ' Patient Complaint and Grievance Procedure ' stated, " .....All grievances are responded to within 7 days if possible depending upon the nature of the grievance. For more complicated grievances requiring extensive investigation and analysis, the person responsible for the primary response to the grievance sends the complainant a written interim response stating that the hospital is still working on the response, which the complainant can expect within 30 days if at all possible. "

2. During a review of Grievances A and C, on October 25, 2012, there was no documentation that these grievances were responded to within seven (7) days and there was also no documentation that a written interim response was sent to the complainants.

3. During an interview with the Patient Satisfaction Coordinator on October 25, 2012, she confirmed that these findings were correct.

Based on review of information provided and interviews with key staff on October 25, 2012, it was determined that the facility failed to consistently provide the patient with written notice of its decision in the resolution of the patient 's grievance, that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion in one (1) of three (3) grievances. (Grievence A)

Findings include:

1. Grievance A was reviewed on October 25, 2012. The documentation failed to include evidence that a written notice had been sent to the patient.

2. During an interview with the Patient Satisfaction Coordinator on October 25, 2012, she stated that she had not treated that concern as a grievance, rather as a complaint. She agreed that in retrospect, the concerns should have been handled as a grievance, and as such, a letter should have been sent to the complainant.

Based on an interview with the Chief Medical Officer on October 25, 2012, it was determined that the facility had failed to ensure that all physicians and other Licensed Independent Practitioners authorized to order restraints or seclusion, by hospital policy, had a working knowledge of the hospital policy regarding the use of restraints and seclusion.

Findings include:

1. During an interview with the Chief Medical Officer on October 25, 2012 at 9:00 a.m., he stated that there was no documented evidence that physicians and Licensed Independent Practitioners who were authorized to order restraints had a working knowledge of the hospital policy regarding the use of restraints and seclusion.

2. During the interview with the Chief Medical Officer on October 25, 2012, he stated that as of 6:30 a.m. that morning, the policy had been sent via email to all physicians and Licensed Independent Practitioners authorized to order restraints and seclusion.

Based on observation and interview, the facility failed to ensure that unauthorized individuals were not able to access patient records.

Findings include:

1. On October 23, 2012, at 10:45 A.M., a surveyor observed medical records in the reception area of the outpatient Surgical Services Suite 303 at 99 Campus Ave. During an interview with the staff in the reception area, this surveyor was told that the housekeeping staff come to the practice unsupervised in the evening to conduct their cleaning duties and have access to the medical records.

2. On October 24, 2012, at 1:05 P.M., a surveyor observed medical records in the reception area of the outpatient Cancer Center on Unit C4. During an interview with the staff in the reception area, this surveyor was told that the housekeeping staff come to the practice unsupervised in the evening to conduct their cleaning duties and have access to the medical records.

3. On October 24, 2012, at 4:15 P.M., this surveyor observed medical records in the reception area of outpatient Internal Medicine on the 3rd floor of 100 Campus Ave, Suite 203. During an interview with the staff in the reception area, this surveyor was told that the housekeeping staff come to the practice unsupervised in the evening to conduct their cleaning duties and have access to the medical records.

4. These findings were confirmed with the Director of Environmental Services at the time of discovery.

Based on record review and interview with key personnel on October 23, 2012, it was determined that the facility failed to document in the patients' medical records that a list of Home Health Agency's (HHA's) and Skilled Nursing Facilities was provided to the patients who needed such services.

Findings include:

1. Record F failed to contain documentation that the patient had been given a list of available HHA's in the patient's living area, in order to choose which agency he/she wanted to utilize.

2. During an interview with the Coordinator of Joint Center, on October 23, 2012, she confirmed that no written information was given to the patients informing them of their choices of HHA's in their area. She noted that it is her practice to discuss the options with the patient ahead of time, and stated," But I do read off a list to them."

Based on review of medical records and interviews with key staff on October 24, 2012, it was determined that the facility failed to ensure that the Operative Reports were complete.

Findings include:

1. Surgical Services Records CCC, DDD, EEE, FFF, GGG, HHH and KKK were reviewed on October 24, 2012, and found to be incomplete.

a.Surgical Services Records CCC, DDD, EEE, FFF, GG and HHH failed to document the times of surgery/procedure.
b.Surgical Services Records CCC and DDD failed to include documentation of a pre-operative diagnosis.
c.Surgical Services Records CCC, DDD, EEE and GGG failed to document the post-operative diagnosis.
d.Surgical Services Records HHH and KKK failed to document of the type of anesthesia administered during the surgery/procedure.

2. These findings were confirmed with Surgical Services Staff on October 24, 2012.