HospitalInspections.org

Based upon review of physician credential files and staff interviews, the Medical Staff failed to ensure each physician was evaluated for the quality of patient care and the clinical performance relative to the physicians approved clinical privileges. There failed to be documented evidence for 4 of 6 credential files for physicians and allied health personnel that the clinical performance related to the approved clinical privileges was appraised and an evaluation of the quality of patient care was evaluated. Findings:

Review of physicians S17, S18, S20, and allied health Physician Assistant S16 was appraised relative to clinical privileges during the re-appointment process. There also failed to be documented evidence an the physicians were evaluated as related to the provision of quality of patient care provided.

Interview with Registered Nurse S11 on 07/20/10, 11:20 AM, revealed she no longer was responsible for physician credentialing; however, when she was doing credentialing, the evaluation process was conducted. Interview with Licensed Practical Nurse, S12, revealed since she had taken over physician credentialing, no evaluations had been completed.

Based upon reviews of 5 of 5 outpatient medical records (patient #s 14, 15, 16, 17, 18), policies and procedures, and staff interviews the hospital failed to ensure that all outpatients (#s 14,15, 16, 17, 18) evaluated and/or treated in the outpatient/specialty clinics of the hospital had their medical records maintained and monitored by the hospital's Health Information Management section. Findings:

During the tour, 07/19/2010, 2:15 PM, of the Outpatient Specialty Clinic the surveyor discovered the medical records for outpatient cardiology patients were not maintained by the hospital. Interview with Licensed Practical Nurse (LPN) S13 revealed when questioned as to how the medical records were maintained, she replied the cardiologists maintain, on their personal laptop computers, the patients' progress notes and then the face sheet (sheet containing the patients' demographic information) was sent to the medical records department (Health Information Management).

Review of patient #s 14, 15, 16, 17, and 18's medical records revealed the only information in their respective records were the face sheets which contained the patients' demographic information (name, address, insurance information,etc). There lacked documentation relative to their evaluations, testing results, treatments, interventions and care (etc.).

Interview, 07/22/2010, 3:30 PM, with Registered Health Information Administrator (RHIA) S14, revealed she was not aware outpatients who were evaluated by cardiology did not have their medical records kept at the hospital. Further interview revealed she discovered the cardiologists had maintained the progress notes (including testing results, interventions, outcomes) on their personal laptop computers after her discussion with LPN S13.

There lacked documented evidence that all outpatient medical records were monitored and maintained through the hospital's Health Information Management Department.

Based upon observations, reviews of 10 of 10 dietary staff personnel files (S4, 22, 23, 24, 25, 26, 27, 28, 29, 30), policies and procedures, and staff interviews, the hospital failed to ensure annual competency evaluations were completed on dietary staff members, (S4,22,23,24,25,26,27,28,29 and 30) as evidenced by a lack of documentation in each of the dietary staff members' respective personnel files, to ensure that they were competent to perform their assigned duties. Findings:

Review of Dietary Manager (DM) S4's personnel file revealed there lacked documented evidence a competency evaluation was obtained upon S4's hire in July 2009. Continued review of DM S4's personnel file revealed there lacked documented evidence of any competency evaluation.

Review of dietary staff members, S22, 23, 24, 25, 26, 27, 28, 29, and 30's, personnel files revealed there failed to be documented evidence that any of them had received a competency evaluation, either upon hire or annual re-evaluation of competency. Continued review of their personnel files revealed there were competency forms located in the staff members files which had the following titles: "Cook, Dishwasher, Nutritional worker I, II, or III, Dietary Manager, and Registered Dietitian". Located on each of these competency forms were specific duties and questions relative to each area (i.e. cook, dishwasher, etc); however they had not been completed.

Review of a hospital policy titled "NUTRITIONAL SERVICES DEPARTMENT SAFETY, REFERENCE # 6001 POLICY: The Certified Dietary Manager is responsible for maintaining safety standards, developing safety rules, supervising and training personnel in departmental standards..."

Interview, 07/22/2010, 2:00 PM, with DM S4 confirmed she had not completed competency evaluations on dietary staff prior to them performing their assigned duties. The surveyor questioned DM S4 why staff were allowed to perform duties without documented competency evaluations; she replied a lot of the staff had been employed prior to her hire and she just had not got around to the evaluations. The surveyor noted that none of the dietary staff had received competency evaluations prior to their performance of assigned duties.

Based upon review of 8 of 8 emergency department Registered Nurses personnel files (S #s 3, 8, 9, 31, 32, 33, 34, 35), and staff interviews the hospital failed to ensure all Registered Nurses (RN) working in the Emergency Department (#s 3,8,9,31,32,33,34,35) had their emergency skills/competencies evaluated at least upon hire and annually thereafter as per hospital policy and procedure, prior to the performance of assigned emergency department duties. Findings:

Review of the personnel files for RNs S#s 3, 8, 9, 31, 32, 33, 34, and 35 revealed all 8 were assigned to work in the Emergency Department (ED). Continued review of the individual personnel files of the above RNs revealed they all lacked documented evidence that unit specific (in this instance, the Emergency Department) competencies were evaluated at least annually or upon hire in the case of RN S9 (hire date of 06/29/2010).

Continued review of the personnel files revealed job descriptions for the ED and evaluations which stated the competencies were to be evaluated annually.

Review of general nursing policies and procedures revealed all competencies were to be evaluated upon hire and annually to ensure compliance with assigned job duties.

Interview, 07/22/10, 10:30 AM, with Emergency Department Director RN S3 confirmed the nurses (RN and Licensed Practical Nurses) working in the ED had not had unit specific competencies evaluated.