HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the outpatient department, respiratory services, anesthesia services, and contracted services were part of the quality assessment and performance improvement program and failed to ensure the emergency department quality assessment was effective. The findings included:

The hospital performance improvement meeting minutes for 4/19/2011 outlined the schedule for reporting. The outpatient department, respiratory services, anesthesia services, and the 9 contracted services were not scheduled to report from 4/2011 to 9/2011 and were not otherwise noted.

The hospital failed to assign one individual to be responsible for the outpatient department, to adequately staff the outpatient department, and to ensure integration between emergency department and outpatient services. See A1076 Condition of Particiaption, Outpatient Services.

The hospital failed to have an effective program that ensured the development and implementation of new Code Blue procedures and ensure patients were assessed timely and appropriately in the emergency department. See A1100 Condition of Participation, Emergency Services.

Based on staff interview, it was determined that Hospital was not performing Utilization Review (UR) and did not have an arrangement with the Quality Improvement Organization (QIO) to perform any type of review. The findings included:

On 10/19/11 at 4:30 PM, in an interview with the Chief Operating Officer (CEO) and the Director of Nursing (DON), they verified that there was a person designated as the lead for UR. However, they stated that no UR activities had occurred in the last year.

The Hospital failed to perform any UR.

Based on observation, record review and staff interview, it was determined that the outpatient services provided by the hospital failed to meet the needs of the patients. The Condition of Participation for Outpatient Services was not met as evidenced by the following findings:

The Hospital failed to implement policies and procedures that appropriately integrated Outpatient Services with other Hospital departments. Cross reference Tag A-1077.

The Hospital failed to assign one individual to be responsible for all outpatient services and maintain appropriate professional personnel to provide outpatient services. Cross reference Tag A-1079.

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Based on record review and patient, family, and staff interview, it was determined that the Hospital failed to have adequate, qualified Medical Staff and/or nursing staff to ensure that the needs of seven of 30 sample patients (#1, #19, #4, #3, #6, #7, and #8) were met and that patients were assessed and treated in a timely manner when they presented to the Emergency Department (ED). The findings included:

On 10/18/11 at 10:30 PM, in an interview with nurse L, she verified that the ED staff were using the "Emergency Severity Index" (ESI) for triage of patients seen in the ED. She confirmed

Review of manual for the ESI process, Chapter 3. Introduction to the Emergency Severity Index revealed:
"(ESI) is a simple to use, five-level triage instrument that categorizes emergency department patients by evaluating both patient acuity and resources. Initially the triage nurse assesses only acuity level. If a patient does not meet high acuity level criteria (ESI 1 or 2), the triage nurse then evaluates expected resource needs to help determine a triage level (ESI level 3, 4, or 5). ... Acuity is determined by the stability of vital functions and potential for life, limb, or organ threat. The triage nurse estimates resource needs based on previous experience with patients presenting with similar injuries or complaints...."

The ESI Conceptual Algorithm shows that:

ESI = 1, patient dying
ESI = 2, shouldn't wait
ESI = 3, vital signs
ESI = 4 one resource
ESI = 5 no resource.

Review of the documentation for the 30 sampled ED patients evidenced the following ESI ratings:

ESI 1 - 0 of 30 patients

ESI 2 - 1 of 30 patients

ESI 3 - 13 of 30 patients (included GI bleed, difficulty breathing, active labor who was changed from 3 to a 4, closed head trauma with loss of consciousness)

ESI 4 - 6 of 30 patients (included psychotic/suicidal)

ESI 5 - 2 of 30 patients (included past date pregnancy with signs and symptoms of labor, infected knee stump)

No "E.R. Record" for 4 of 30 patients

Couldn't read 3 of 30 patients record to determine the ESI level.

Review of 30 patients' medical records for the ED visits evidenced that the patients were triaged such that their assigned ESI levels were not equivalent to their needs or the required amount of care. The inaccurate use of the ESI rating could result in patients with significant medical/psychological problems not being seen timely.

During an interview with the Chief Executive Officer (CEO) and the Director of Nursing (DON) on 10/19/11 at 3:15 PM, the ED nurses' use of the ESI scale was discussed. The DON indicated that all nurses were required to do the new online training for the ESI process by 11/01/11.

Patient #1

1. Review of the patient #1's "E.R. Record" evidenced that the patient was a 57 year old female who presented at the ED on 8/24/11 at 10:38 AM as an "ER walk-in" patient. (Note: Per the Hospital's policy, patients without assigned clinic appointments were seen in the ED as walk-ins.) The patient's chief complaint was of "difficulty breathing. States she may pass out". The patient was assessed to be at an ESI (Emergency Severity Index) rating of "3", indicating that the patient was assessed to not be dying or in the shouldn't wait category. At a rating of "3", the patient would require vital signs be done. The review further evidenced that at 10:40 AM, the patient "pt fell outside of ER nurses station and hit head on floor, seizing".

a. The physician noted that "Pt collapsed as she was signing into the ED; "I was on the scene within 30 seconds of her collapse", she was unresponsive with fixed pupils and no pulse; she immediately was taken by gurney to room 9 where resuscitation efforts began. Pt was an uncontrolled diabetic with a1c 11.5 and recently seen in clinic 8/22/11 for her DM (diabetes)." The physician noted that ACLS protocols were followed. See flow sheet... Airway: Oxygen applied by mask as Intubation equipment prepared. Paramedics called; IV established in right EJ(external jugular). BS 295. Monitor showed Sinus bradycardia/agonal rhythm (PEA). Pt intubated x 2 attempts using BURP with 7.5 ETT(endotracheal tube)... Breath sounds (??no description), Atropine 1 mg IV given. CPR (nothing noted), Epi (epinephrine) 1 mg IV x 2. HCO3 1 amp given. Dextrose 1 amp given IV. Pt became mottled, eyes remained fixed and dilated. Resuscitation efforts started at 10:40 AM and Resuscitation efforts called at 1107 (11:07 AM). Visit Diagnoses: cardiopulmonary arrest."

b. Review of the physician's 8/29/11 chart review notation revealed that "cause of death myocardial infarction due to uncontrolled diabetes, hypertension, and tobacco abuse."

c. Review of the patient's 8/22/11 visit (to clinic two days prior to her death in the ED) evidenced that the patient came "for follow up of type 2 diabetes and htn (hypertension). morning glucoses are running in the 200-250 range on 55 units Levemir bid (twice a day). no episodes of hypoglycemia....also c/o (complained of) worsening sinus pressure with purulent discharge for three days. she has chronic sxs (signs and symptoms) of rhinitis, including congestion and runny nose. no fevers or shortness of breath. ... Visit diagnoses acute sinusitis, Uncontrolled type 2 diabetes, benign hypertension."

d. The Administrative staff were requested to provide copies of the patient's entire medical record (electronic documentation and hard copy) related to the 8/24/11 ED visit. Review of these records revealed the following:

e. The "Adult" form for CPR was noted to be started at 10:40 AM when the patient fell. At 10:42 AM the patient was moved to room 9. At 10:45 AM, LI was placed. At 10:49 AM, oxygen with a non-rebreather was in place. At 10:52 AM the patient was noted to be on the cardiac monitor, the patient's rhythm was PEA, and the patient was intubated with breath sounds being bilateral. At 10:53 AM, 1 mg IV (intravenous) Atropine was administered. At 10:55 AM, 1 mg IV Epinephrine was given. At 11:01 AM, "Bicarb IV" (no amount) and at 11:02 AM D 50 (Dextrose 50%) (no amount) was noted. CPR with a bag was started at 11:02 AM (22 minutes after the patient collapsed). At 11:03 AM, the patient was noted to be in PEA rhythm, was given 1 mg Epinephrine, and was receiving CPR by bag. At 11:04 AM, the patient's rhythm was PEA and CPR was noted by bag. No other notations were made in the flow sheet section of this form. The bottom of the form the Resuscitation Event ended at 11:07 AM with the patient noted as "dead" based on medical futility and no sustained ROC (return of circulation). There were no signatures on this page (Recorder, Nurse, Physician).

f. The "Consent to Treatment" form was marked "pt unable to sign" and was signed on 8/29/11 by the physician.

g. Review of the patient's medical record evidenced that there were no Critical Care Notes, or cardiac monitor strips results found in the record.

h. On 10/19/11 at 10:03 AM, in an interview with ED physician who was involved with this patient's care, he verified that:

1) The patient was not placed on a back board (to facilitate resuscitation).

2) There was no monitor in room 9, so one was taken off another patient who was in room 7 and about to be discharged. The physician confirmed that there were monitor strips for this patient and these were used to be determine "PEA" rhythm.

3) The crash cart had to be brought from another room. The crash cart was not missing items, but the staff were not familiar with where to find the items.

4) Things were not done timely.

5) Lot of new nurses were working at the time and items took time to find.

6) CPR was started late.

7) The accuracy of the Glucometer was questioned by the physician.

8) A Code Blue was not called (announced).

i. On 10/18/11 and 10/21/11, all five nurses who were working on 8/24/11 when the patient was in the ED were interviewed. The following information was communicated:

1) The monitor was moved from room 7 to room 9. There were monitor strips made during the resuscitation process.

2) The crash cart was moved from room 8 to room 9.

3) Requested items were actually on the crash cart but couldn't be located.

4) Critical flow sheets were utilized for documenting the events.

5) The nurses were not all aware of the Hospital's after death care policy/procedure.

6) All five nurses were not listed on the "E.R. Record" initial signature block.

7) There was a debriefing after the Code Blue for patient #1, but the analysis(RCA - root cause analysis) information was not shared or discussed with the nurses who were involved with the Code Blue.

j. In interviews on 10/19/11 at and 10/21/11 at with the Director of Medical Records, she verified that there were no monitor strips or Critical Care flow sheets in this patient's record. The Director indicated that the record had been secured immediately after the event so she was not able to leave the record for review, but provided a copy of the entire record.

k. On 10/19/11 at 10:03 AM, in an interview with ED Medical Staff Director patient #1's care while in the ED was discussed. Additionally, the physician was asked about the changes/follow up to the debriefing immediately after the event and the evaluation (RCA - root cause analysis) of patient #1's care. He talked about the training that had occurred, including CPR and BLS training. The Director said that mock codes(Code Blue) were being held. He commented that the Medical Staff bylaws don't mandate ACLS or PALS for the physicians, but since these are Standards of Practice, the bylaws are being modified.

l. Review of the mock codes which have been held since 8/24/11 evidenced the following:

a. On 9/8/11 at 7:00 AM in the ED. "The scenario was similar to the code that we had in the ED a few weeks ago. The mock pt (60 y/o male) was pulseless and found on the floor of the ED." The areas of improvement that were identified included:

1) "Need Ambu bags visibly hanging in the room 7 and 8 and not in crash cart. Staff not able to find the Ambu bags.

2) The compression board was placed under the gurney mattress.

3) Orient staff to the compression board in room 8.

4) Place the LMA's (laryngeal masked airway) in each crash cart and train staff on use.

5) Team leader assign duties, staff verbally acknowledge orders and repeat once order completed.

6) Recorder verbally repeat all orders once completed."

b. On 9/8/11 at 12:05 PM in the hallway outside the west team's office. The mock code was terminated to discuss the equipment shortfalls. Most nurses knew that the Central and East team had AED's (automated external defibrillator) but did not know where they were located. It was discovered that the following equipment was not available on the 3 rd floor:

Crash cart with Ambu bags
Backboard
Gurney
Suction.

The areas for improvement identified included:

1) "Place backboard in medicine room on 3 rd floor.

2) Place gurney in 3 rd floor medicine room.

3) Purchase STAT KIT Z-1000 Emergency Medical Kit and place in 3 rd floor medicine room or addition crash cart.

4) Consider using a specific code number (811) for mock code blue/code blue and maybe stat critical labs that will transmit over the telephone speaker phones as well as overhead.

5) Ensure all AED's are operational and staff is trained on proper use and they are accessible."

c. 9/29/11 at 8:40 AM at 2 2nd floor nurse's station.

The areas for improvement identified included:

1) "No history asked regarding mock pt (Dialysis pt visiting family member missed last 2 dialysis appt).

2) Blood sugar not checked early in the code.

3) Consensus that it is difficult to hear overhead page in work areas.

4) Still need to equip 3 complete code carts and one training code cart (Nursing still requests/requires training on the code cart medication and equipment organization....)"

d. 10/13/11 60 year old male with difficulty breathing. Hx of asthma and COPD, out of his nebulizer and progressive dyspnea on exertion.

The areas for improvement identified included:

1) Move LMAs into a gallon zip lock bag and place in bottom drawer of code cart with all other airway supplies.

2) Ensure all staff aware of LMAs location in airway drawer.

3) Ensure all staff aware that racemic epinephrine is in the refrigerator in the supply room.

4) You can use epinephrine 1:1000 with a saline bullet for racemic epinephrine if needed.

The 8/24/11 death in the ED was reviewed and numerous action plans, including education of staff, resulted from that death. The four mock code practice reviews, which were documented from 9/8/11 to 10/13/11, revealed numerous ongoing concerns with the staff's abilities to perform in a Code Blue situation. Also the lack of or availability of the equipment continued to be an issue.

m. On 10/20/11 at 2:10 PM, in an interview with the Director of Nursing (DON) and the Supervisor in the ED, they verified that the Code Blue policy needed to be updated. There was a current policy in place and they were working on a draft new policy.

n. On 10/21/11 at 10:25 AM, in an interview with the DON, she confirmed that all nurses were required to be BLS certified and there was a PMAP (performance plan ) for them to have ACLS as a requirement.

Patient #19

2. Review of patient #19's 9/28/11 at 7:15 PM "E.R. Record" revealed that the patient was a 48 year old female who presented to the ED with "complaints of nausea and vomiting x 3 days on and off. Started Sun PM, Mon OK, Slept 14 hrs Tues and Wed - vomiting. Diarrhea - dk (dark) army green. vomit - yellow; can't eat or drink." "Pt placed in WC (wheelchair) on arrival." The patient reported a pain level of 10/10. The patient was triaged as an ESI = 3. The patient was moved to an exam room at 10:40 PM. The MSE was done at 11:35 PM. The patient left the ED at 1:10 AM on 9/29/11 with a "Medical Report of Duty Status", indicating that she could return to work on 10/1/11.

a. Review of the Critical Care Flow Sheet evidenced that it was started on 9/28/11 at 11:43 PM and documented the following information:

1) At 11:43 PM - Phenergan 50 mg IM; IV started; labs were drawn out of port; one liter normal saline IV at 999 ml/hr; pt has some nausea after injection.

2) At 12:12 AM (9/29/11) - Vital signs Blood Pressure (BP) 92/57, Pulse (P) 87, Respirations (R) 18, Temperature (T) 98.4 degrees Fahrenheit (F), pain 2/10. (Note: VS on triage were BP 116/78, P 102, R 18, T 99.)

3) At 12:45 AM - Zofran 8 mg dissolved on tongue per order. Prepain 0/10 at 12:44 AM.

4) At 12:46 AM - Toradol 30 mg IVP over 1 min stop at 12:47 AM for comfort.

5) At 12:57 AM - Urge to urinate. IV discontinued.

6) At 1:08 AM - BP 102/63, P 90, R 16, T 98.3, pain 0/10. - denies pain/nausea.

7) At 1:13 AM - Given bottle for collection of stool at home. Pt refused offer to use bathroom.

8) At 1:15 AM - Left floor ambulating with steady gait.

b. Review of the patient's MSE revealed that the patient thought food that she ate at Taco John's did not taste right. The provider noted the visit diagnoses as "Nausea/vomiting; diarrhea; Presumptive Food Poisoning". The plan was for the patient "to stay home from work the next 2 days and may return on 10/1/11. Pt will take meds as needed and will return for any further concerns."

c. Review of the patient's lab results timed on 9/28/11 at 11:41 PM revealed the following abnormal results:

RBC - 2.83 M/uL (normal 3.9 - 5.3)
HCT - 23.1 % (normal 35 - 46)
HGB - 8.1 g/dL (normal 12 - 17)
Urea Nitrogen 32 (normal 7- 22).

There was no evidence found to indicate that the low HCT/HGB were evaluated by the provider before discharging the patient or that any follow up on these values occurred after discharge. Although the patient's MSE included obtaining laboratory blood work, this information as not used in assessing the patient or making a determination of the patient's actual diagnosis. Additionally, the provider prescribed a medication (Ibuprofen) which would be contraindicated for a patient with a gastrointestinal (GI) bleed (patient's correct diagnosis made on 9/30/11 ED visit).

d. On 9/30/11 at 9:41 AM, the patient returned to the ED "C/O continued nausea, vomiting since she was here 9-28-11. She states she has had some blood in her emesis. Her triage vital signs were BP 104/62, P 142, R 20, T 101.2, pain 10/10. Her triage level was ESI of "3". The patient was placed in an exam room at 9:48 AM. The MSE was done at 10:10 AM. The patient was diagnosed as having a GI bleed, was given fluids, and an EKG was done (sinus tachycardia). At 11:00 AM, she was transferred to another hospital to receive blood.

e. Review of the Critical Care Flow Sheet evidenced that it was started on 9/30/11 at 9:43 AM included the following information:

1) At 9:43 AM - Pt to room; pain 10/10.

2) At 9:45 AM - Has emesis x 1 with dark blood.

3) At 9:50 AM - Labs drawn.

4) At 10:00 AM - EKG done.

5) At 11:00 AM - Departed with EMS. Stable condition.

f. Review of the patient's lab results timed on 9/30/11 at 9:41 AM revealed the following abnormal results:

RBC - 1.89 M/uL (normal 3.9 - 5.3)
HCT - 15.8 % (normal 35 - 46) Critical value reported to the physician
HGB - 5.6 g/dL (normal 12 - 17)
Urea Nitrogen 36 (normal 7- 22).

g. On 10/20/11 at 12:55 PM, in an interview with patient #19, she revealed that she had been seen in the ED on 9/28/11 at 6:30 PM with complaints of not feeling well and vomiting dark coffee colored liquid. When she was asked if the emesis was tested for blood, she replied "No". She indicated that she was placed in a wheelchair in the hallway. At 10:30 PM, she was seen and received an IV. She was discharged at on 9/29/11 at 1:30 AM with nausea and Ibuprofen. She was told that she had a diagnosis of food poisoning.

The patient said that on 9/30/11 at home at 12:30 AM, she blacked out and sat on the floor. Her son brought her back to the ED at 8:00 AM to 8:30 AM. She commented that she was not told about or treated for the ulcer. She said that she had a bleeding ulcer and her blood count was very low. On this visit they checked the emesis for blood and did lab work. The patient was transferred to another hospital where she was a patient for seven days, received an endoscope and antibiotics and was diagnosed with C-diff.

She was in the Hospital the day of this interview trying to get into the clinic because her appointment had been cancelled. The patient needed to get a return to work permit but was still unable to return to work.

h. On 10/21/11 this patient's care on 9/28/11 was discussed with ED Medical Staff Director. He was the physician who saw the patient on 9/30/11 so he was aware of and verified the failure to review the laboratory findings before discharge from the ER on 9/28/11. He indicated that the provider who saw the patient on 9/28/11 had been counseled and that this case would be presented to the Medical Staff.

Patient #3

3. Review of patient #3's record for the 12/18/10 at 5:17 PM ED visit revealed that the patient was an 18 year old female. She presented to the ED with a chief compliant of "is 9 months pregnant with EDC (expected date of confinement) 12/23/10 .... 40 min ago water broke and began to have contractions now at 5-6 min apart". The patient was triaged at an ESI of "3" and then it was written over to be "4".

The provider's documentation stated that the patient was an "18 yo female 9 months pregnant in active labor" and included the following information:

Abdomen - pregnant with FHTs (fetal heart tones) at 144

Extremities - no swelling

Perineum with mucous dischg (discharge). No vaginal bleeding - No head presentation.

The provider failed to complete an adequate assessment to determine the patient's status and to determine a plan of action/care based on that assessment. No vaginal/cervical exam was done to determine the stage of labor.

Patient #4

4. Review of patient #4's "E.R. Record" for the 8/21/11 11:30 AM ED visit revealed that the patient was a 30 year old G3 (grava) P2 (para) female who presented to the ED with her chief complaint being "pregnant (1 week overdue) here to speak with ER MD". At 11:42 AM, it was noted that the FHT were 132 and the patient's pain was 8/10 with ctx (contractions). The patient was triaged as an ESI "5". There was a note that the patient left AMA at 11:49 AM, was a third trimester pregnancy, and was stable with a provider signature.

a. On 10/21/11 at 7:45 AM, in an interview with the ED Medical Staff Director, patient #4's care was discussed. He was not aware of this patient's care. He verified that the provider had not done an electronic health record (EHR). At 9:08 AM, he said that he spoke with the nurse who said that the patient just said she was leaving.

b. Review of the ED log for the morning of 8/21/11 evidenced that during the time period when the patient was in the ED, there were at least six other patients in the ED or waiting to be seen in the ED. Patient #4 and two other patients who were present during the patient's visit left AMA or LWBS(left without being seen).

There was no evidence to show that the patient was stable as noted on the E.R. Record. It was unclear why a patient in labor would not be assessed at a higher priority, especially since the patient would be transferred for delivery.

Patient #7

5. Review of patient #7's "E.R. Record" for the 3/3/11 12:23 AM ED visit revealed that the patient was a 36 year old male who presented to the ED (per the ambulance personnel) "states pt 'feels like killing himself', pt states not taking meds x 2 wks, pt nods yes, et not verbal". The patient was noted to have a history of schizophrenia/depression. The patient was triaged as an ESI of "4". At 12:31 AM, the patient refused to answer questions and to have vital signs done et "took off jacket et threw at nurse."

a. The MSE was done at 1:23 AM (time listed on the EHR) and as 1:30 AM (on the E.R. Record). The provider listed the diagnoses as psychosis/suicidal and the plan was to transfer the patient to another hospital via ambulance. The time of the transfer was listed as 12:42 AM with the patient being stable. The reason for the discrepancy in time was not evident in the record.

b. Review of the Out-of-Hospital Transfer Record dated 3/3/11 documented that he was to be transferred by ambulance and that he was on a 72 hour hold.

No evidence was found in the patient's record to show that he was on a 72 hold or that the police were present for the transfer of this patient with psychosis and suicidal ideation.

c. On 10/21/11 at 9:46 AM, in an interview with the DON and the ED Supervisor, the patient's 72 hold was discussed. They verified that no security was noted and that there was no evidence of a hold being placed on the patient. They indicated that they would check with the ED Medical Staff Director. In a discussion with the Director, he confirmed that it was appropriate to rapidly transfer this patient to a higher level of care. He did verify that there should have been police involvement with the transfer.

Patient #6

6. Review of patient #6's EHR for the ER walk-in visit on 3/2/11 at 3:43 PM evidenced that her chief complaint was "central cp, vxl, dxl". The provider noted that the visit diagnosis was chest pain and resolved tachycardia but due to the lab variances the patient's mother wanted her evaluated further. The provider arranged to have her transferred to another hospital via ambulance.

No "E.R. Record" or transfer forms were found for this patient prior to the surveyors leaving the hospital.

Patient #8

7. Review of patient #8's EHR for the ER walk-in visit on 10/15/10 at 5:30 PM evidenced that she was a 58 year old female "in tears - sobbing with long wait in ER - reports sinus pressure past x 4 days -- wants refill on Robaxin for leg cramps and flu vaccine - not sure why she has had to wait so long -- tried to contact east team today but doctor (physician name) not on duty -- many concerns and complaints". The provider's assessment and plan was sinusitis, leg cramps with medications ordered. The patient was to follow up with the East team.

No"E.R. Record" form was found for this patient as of the time of the exit.

For both patients #6 and #8, the ED was functioning as an outpatient clinic. The providers did not complete ED paperwork.

Based on record review and interview, the governing body did not appoint members of the medical staff for temporary privileges from 2009 to 2011. The findings included:

During an interview on 10/20/2011 at 8:30 AM, the program assistant, staff K, stated that the chief executive officer (CEO) under the governing body by-law 3.01.03 granted temporary clinical privileges for a limited period of time, not to exceed 120 days.

During an interview on 10/20/2011 at 12:15 PM, the CEO stated that the CEO had been delegated authority for privileging and credentialing temporary privileges in the governing body by-laws.

The governing body by-laws signed by the CEO on 2/25/2009 was provided on 10/20/2011 at 7:45 AM. Section 3.02.03 titled CEO stated "The Area Director, as Chair to the Governing Body delegates authority for the CEO for the following: 3.02.03.01 Granting of temporary Clinical Privileges, for a limited period of consecutive days".

Governing body delegation to the CEO for temporary privileges does not replace governing body appointment of the medical staff.

Based on record review and interview, the governing body did not ensure the criteria for selection of the medical staff included individual judgment and character from 2009 to 2011. The findings included:

The current medical staff by-laws for 2009 to 2011 were provided on 10/19/2011 at 8:45 AM. Character and judgment were not included in the medical staff by laws, Section 5.11, Reappointment, as a basis for recommendation for reappointment of medical staff.

During an interview on 10/21/2011 at 8:15 AM, the acting clinical director stated that the peer recommendation letters for medical staff provided information on character and judgment. The letters were kept in personnel files and not in the medical staff privileging and credentialing file. These letters were not available for the medical staff to review for the selection process.

Based on record review and interview, the chief executive officer (CEO) was not responsible for managing one hospital department, behavioral health from 8/06/2010 to 10/21/2011. The findings included:

The organizational chart for the hospital dated 8/06/2010 was received on 10/19/2011 at 8:45 AM. The behavioral health department was identified as managed and supervised by the area office.

During an interview on 10/19/2011 at 5:30 PM, the hospital CEO stated that " The deputy area director was the supervisor of behavioral health. Behavioral health was on the organizational chart to show administrative oversight. ..... Behavioral health is under the area office deputy area director. The CEO is not over behavioral health except for administrative oversight. "

Based on record review, the hospital failed to provide a list of contracts that included the scope and nature of the services provided for nine of nine current contracted services listed. The findings included:

A list of nine contracted services was provided on 10/20/2011 at 11:30 AM. The list did not delineate the contractor responsibility for the nine contracted services listed.

During the survey exit conference on 10/21/2011 at 11:30 AM, a list of contracted services that included the scope and nature of the services provided was again requested. The list was not received prior to when the surveyors exited the Hospital.

Based on interview and record review, the hospital failed to inform patients in advance of furnishing or discontinuing patient care of all patient rights. The findings included:

The patient information packet titled "Rapid City Indian Health Service Hospital and Clinics" was provided by the Performance Improvement Coordinator (PIC) on 10/20/2011 at 2:30 PM. She reported that this was the information packet was provided to inpatients on admission.

Interview with patient #39 on 10/19/11 at 5:30 PM had confirmed she had received the information packet on admission to the hospital. However further review found the information to be incomplete.

Review of the patient information packet section titled "Your Rights" revealed that the following patient rights were not included as required:

To have a family member and the patient's physician promptly notified of an inpatient admission

To be free from all forms of abuse or harassment

To ensure confidentiality of his or her clinical records.

Based on staff interview and record review, the hospital failed to provide written notice to all patients that a doctor of medicine (M.D.) or doctor of osteopathy (D.O.) was not in the hospital 24 hours a day, seven days a week (24/7) and how the hospital will meet the emergency needs of a patient who develops a emergency medical condition (EMC). The findings included:

During an interview on 10/19/2011 at 9:20 AM, the radiology technologist, staff (G), stated that generally a PA covered the emergency department at night.

During an interview on 10/21/11 at 8:15 A.M., the clinical director confirmed that a physician assistant (PA) covered the emergency department as the only provider in the evenings.

On 10/19/11 at 8:45 AM, the performance improvement coordinator provided the hospital provider schedule for 10/09/11 to 10/22/11. The scheduled was titled "PP 22 (pay period) Clinical Schedule - Dates". MDs and DOs were scheduled for clinic from Monday to Friday from 9:00 AM to 12:00 PM and 1:00 PM to 5:00 PM. A physician assistant,not a MD or DO, was scheduled in the emergency department for the 7:00 PM to 7:00 AM evening shift from 10/09/11 to 10/22/11 for 8 of 14 days (10/15/11 to 10/22/11).

The patient information packet titled "Rapid City Indian Health Service Hospital and Clinics" was provided by the Performance Improvement Coordinator (PIC) on 10/20/11 at 2:30 PM. The information packet was provided to inpatients on admission. The information packet did not include written notice that an MD or DO was not in the hospital 24/7 or how the hospital will meet the emergency needs of the patient who develops an EMC.

During an interview on 10/21/11 at 11:00 AM, the chief executive officer confirmed that a written notice was not provided to patients.

Based on record review and interview, the hospital had not defined the training interval for training of all staff for competency in the application of restraints, monitoring, assessment, and providing care for patients in restraints. The findings included:

During an interview on 10/20/11 at 2:30 PM with the director of nursing (DON) and the emergency department supervisor, staff training for restraints was discussed. The DON reported the hospital had not defined a training interval for staff competency. The emergency department nurse supervisor stated that nurses receive restraint training with orientation. Soft wrist and soft ankle restraints were the only restraints used in the hospital.

On 10/20/11 at 8:30 AM, the DON provided the annual nursing education and competencies documentation for 27 nursing staff. Training on soft wrist and soft ankle restraints was not included in the nursing education and competencies.

Based on record review and staff interview, it was determined that the Hospital failed to ensure that the medical records were accurate, complete, and documented the care provided to 4 of 39 patients(#1, #4, #6, and #8). The findings included:

On 10/18/11 during the entrance conference, the Administrative staff revealed that the Hospital had partially implemented the electronic health record (EHR) system. They stated that the Emergency Department (ED) records were not fully electronic, but outpatient and inpatient records were electronic.

1. Review of the patient #1's "E.R.(emergency room) Record "evidenced that the patient was a 57 year old female who presented at the ED on 8/24/11 at 10:38 AM as an "ER walk-in" patient. The patient's chief complaint was of "difficulty breathing. States she may pass out". The review further evidenced that at 10:40 AM, the "pt fell outside of ER nurses station and hit head on floor, seizing".

The physician noted that "Pt(patient) collapsed as she was signing into the ED; 'I was on the scene within 30 seconds of her collapse', she was unresponsive with fixed pupils and no pulse; she immediately was taken by gurney to room 9 where resuscitation efforts began..."

The physician noted that "ACLS(advanced cardiac life support) protocols were followed. See flow sheet... Monitor showed Sinus bradycardia/agonal rhythm (PEA). ... Breath sounds (??no description), Atropine 1 mg IV given. CPR (nothing noted), Epi 1 mg IV x 2. HCO3 1 amp given. Dextrose 1 amp given IV.... Resuscitation efforts started at 10:40 AM and Resuscitation efforts called at 1107 (11:07 AM). Visit Diagnoses: cardiopulmonary arrest."

Review of the physician's 8/29/11 chart review notation revealed that "cause of death myocardial infarction due to uncontrolled diabetes, hypertension, and tobacco abuse."

The Administrative staff were requested to provide copies of the patient's entire medical record (electronic documentation and hard copy) related to the 8/24/11 ED visit. Review of these records revealed the following:

The "Adult" form for CPR was noted to be started at 10:40 AM when the patient fell. At 10:42 AM the patient was moved to room 9. At 10:45 AM, LIJ(left internal jugular) was placed. At 10:49 AM, oxygen with a non-rebreather was in place. At 10:52 AM the patient was noted to be on the cardiac monitor, the patient's rhythm was PEA, and the patient was intubated with breath sounds being bilateral. At 10:53 AM, 1 mg IV (intravenous) Atropine was administered. At 10:55 AM, 1 mg IV Epinephrine was given. At 11:01 AM, "Bicarb IV" (no amount) and at 11:02 AM D50 (Dextrose 50%) (no amount) was noted. CPR with a bag was started at 11:02 AM (22 minutes after the patient collapsed). At 11:03 AM, the patient was noted to be in PEA rhythm, was given 1 mg Epinephrine, and was receiving CPR by bag. At 11:04 AM, the patient's rhythm was PEA and CPR was noted by bag. No other notations were made in the flow sheet section of this form. The bottom of the form the Resuscitation Event ended at 11:07 AM with the patient noted as "dead" based on medical futility and no sustained ROC. There were no signatures on this page (Recorder, Nurse, Physician).

The "Consent to Treatment" form was marked "pt unable to sign" and was signed on 8/29/11 by the physician.

On 10/18/11 and 10/21/11, all five nurses who were working on 8/24/11 when the patient was in the ED were interviewed. The following issues were identified:

The monitor was moved from room 7 to room 9 inorder to place the patient on cardiac monitor. There were monitor strips made during the resuscitation process, .

Critical Care flow sheets were utilized for documenting the events.

Review of the patient's medical record evidenced that no Critical Care flow sheets,or cardiac monitor strips were found in this record.

In interviews on 10/19/11 and 10/21/11 with the Director of Medical Records, she verified that there were no cardiac monitor strips or Critical Care flow sheets in this patient's record. The Director indicated that the record had been secured immediately after the event so she was not able to leave the record for review, but provided a copy of the entire record.

2. Review of patient #4's "E.R. Record" for the 8/21/11 11:30 AM ED visit revealed that the patient was a 30 year old G3(grava) P2(para) female who presented to the ED with her chief complaint being "pregnant (1 week overdue) here to speak with ER MD". At 11:42 AM, it was noted that the FHT(fetal heart tones) were 132 and the patient's pain was 8/10 with ctx (contractions). The patient was triaged as an ESI(emergency severity index) "5". There was a note that the patient left AMA(against medical advice) at 11:49 AM, was a third trimester pregnancy, and was stable with a provider signature.

On 10/21/11 at 7:45 AM, in an interview with the ED Medical Staff Director, patient #4's care was discussed. He was not aware of this patient's care. He verified that the provider had not done an electronic health record (EHR). At 9:08 AM, he said that he spoke with the nurse who said that the patient just said she was leaving.

3. Review of patient #6's EHR for the ER walk-in visit on 3/2/11 at 3:43 PM evidenced that her chief complaint was "central cp(chest pain), vxl , dxl". The provider noted that the visit diagnosis was chest pain and resolved tachycardia but due to the lab variances the patient's mother wanted her evaluated further. The provider arranged to have her transferred to another hospital via ambulance.

No "E.R. Record" or transfer forms were found for this patient prior to the surveyors leaving the hospital.

4. Review of patient #8's EHR for the ER walk-in visit on 10/15/10 at 5:30 PM evidenced that she was a 58 year old female "in tears - sobbing with long wait in ER - reports sinus pressure past x 4 days -- wants refill on Robaxin for leg cramps and flu vaccine - not sure why she has had to wait so long -- tried to contact east team today but doctor (physician name) not on duty -- many concerns and complaints". The provider's assessment and plan was sinusitis, leg cramps with medications ordered. The patient was to follow up with the East team.

No"E.R. Record" form was found for this patient as of the time of the exit.

For both patients #6 and #8, the ED was functioning as an outpatient clinic. The providers did not complete ED paperwork.

Based on observation, staff interview, policy review, and record review, the hospital failed to periodically check the radiation exposure for one of four radiology technologists (staff E). The findings included:

On 10/18/2011 at 5:40 PM in the radiology department, the surveyor noticed the radiology technologist, staff (E), lacked a dosimeter badge. At that time, staff (E) confirmed that there was not a radiation exposure badge assigned to him.

On 10/19/2011 at 9:20 AM, radiology technologist, staff (F), stated radiation exposure badges are replaced quarterly and there were new badges on 10/01/2011.

On 10/20/2011 at 11:00 AM radiology technologist staff (G) confirmed that staff (E) was not issued a radiation exposure badge and was the only one without a badge.

Staff (E) was not listed on the Occupational Radiation Exposure Report for 9/30/2011.

The current radiology policy, radiation exposure badges, dated 01/01/2011, stated "... Chapter 21 requires Radiology employees wear film badges to track exposure to ionizing radiation. ... Radiation badges shall be worn at all times employee is on duty."

Based on interview and record review, the medical staff had not approved policies for the ionizing radiology service. The findings included:

On 10/19/2011 at 9:20 AM, the radiology technologist, staff (G), stated the radiologist had not approved the ionizing radiology polices.

On 10/19/2011 at 10:20 AM, the radiologist stated the radiology supervisor would only ask for comments on radiology polices and had not approved policies.

The radiology policy, "Routine X-Ray Policy" (undated), was not signed by a medical staff member.

Based on record review and interview, the hospital failed to have a policy approved by the medical staff and a pathologist for tissue specimens that described requirements for macroscopic and macroscopic examination. The findings included:

The policy for tissue specimens (undated) was provided on 10/18/2011 at 2:25 PM by the laboratory supervisor. The policy stated, "All tissues removed in the hospital, with the exception of that tissue or procedures on the official "No Tissue List", shall be sent to the reference laboratory who shall make such examinations considered necessary to identify the tissue and pathology involved." The laboratory supervisor stated that this was the only policy for tissue specimens.

Based on observation and staff interview, it was determined that the facility failed to maintain the hospital physical plant and environment to provide for the overall safety and well-being of patients. The findings included:

Call System:

1. On 10/18/11 at 4:35 PM, during the initial walk through tour of the Emergency Department (ED) with Director of Nursing (DON) and the Performance Improvement Coordinator (PIC), ED room 8 was observed. The DON indicated that this was an ER (Emergency Room) examination room. She commented that the bathroom in this room was the only bathroom in the ED. Observation revealed that there was no call light in the room. If a patient used the bathroom and needed assistance, there was no system in place to call for help.

2. Observation and interview of the environment during a tour of the Emergency Department and Laboratory Department on 10/19/11 at 9:45 AM to 11:45 AM revealed that patient bathrooms did not have emergency call lights.

Preventative Maintenance:
3. During a tour on 10/20/11 at 11:00 AM to 12:15 PM of the dental clinic with the head of the Facilities' Management, an issue with the preventative maintenance was identified with the x-ray (radiologic imaging) equipment.

a. A check of the equipment in the dental clinic found that the stickers on the x-ray arms/units were noted to be for 2/11 (2011). A provider in the dental clinic reported that the sticker was to indicate when the units were to have their preventative maintenance (PM) checks done. He reported there were 13 x-ray/radiologic units in the dental bays which were in need of the PM inspections since these were past due. Additionally, he had been concerned with the two Panorex x-ray machines which had not been checked so he had an independent contractor come to the facility to check the machines. The invoice was for the inspection of one unit which was dated 06/17/11. The second Panorex was not currently being used.

[The Panorex X-ray is a single picture of all your teeth and surrounding bones. Sometimes referred to as a single FMX, or full mouth X-ray, the Panorex provides a two-dimensional panoramic view of your mouth.]

b. Interview with the Head of the Facilities' Management during the tour reported that the area office had initiated new policies on the preventative maintenance and on the equipment inspections and labeling. He confirmed that there was no evidence to show that the PM of the equipment used for x-ray/radiologic imaging had been done. He reported he would provide the policies and follow up on manufacturer's recommendation for the dental equipment,

c. Review of the polices, dated April 2011, included Standard Operating Procedure for "Equipment Inspection Labeling" and PM Interval Assessment & Exemption".
They included: The purpose was to standardize equipment marking and stickers utilized by all Clinical Engineering (biomed) activities within Aberdeen Area Indian Health Services. All medical and dental devices and components of medical device systems (network) shall be labeled with a unique control number sticker ... " However there was no evidence to show that the dental x-ray units had been inspected in accordance with the manufacturer's recommendations.

The facility failed to ensure medical/dental equipment had required maintenance activities for maintenance, inspection and/or testing for patient health and safety.

Kitchen Sanitation:
4. On 10/19/11 at 10:00 AM to 10:45 AM, a tour of the kitchen was conducted with the Dietary Supervisor (DS). The DS reported the kitchen was currently serving meals to one inpatient, appropriately 35 breakfast meals and 60 noon meals for staff, and had an open tray line for the public. The following issues were identified:

a. During the tour an interview with the DS revealed issues with the procedure for the use of the three compartment sink. Staff reported that either "Clorox" or "Quat" (quaternary ammonium) could be used for sanitizer in the three compartment sink. The instructions posted on the sink stated, "15 gallons of water and 1 cup of Clorox". When the DS was asked how the sanitizer was tested to ensure the concentration of chemical that was being used was adequate, he reported it was not being tested. He then asked the cook if there were test stripes and where they were located. The DS returned with a bottle of test stripes to test Chlorine and reported, "These are the only test strips we have. I think it is supposed to be 200 ppm but I'm not sure. We don't have any way to test when the 'Quat' is used. I'm the one who uses it because the 'Clorox' is hard on my hands." The strips were checked and found they did not have an expiration date and staff was unsure how old the test strips were.

b. Staff was also noted to be using cleaning buckets in the kitchen. The DS reported that "Clorox" was also used in the cleaning buckets.

Interview with the dietary staff (who did not want to be identified) revealed the chemical concentration in the cleaning buckets was not tested. They were unsure of what the level of chemical concentration was and what was needed for proper sanitation. They stated, "We just put a capful of 'Clorox' in the bucket." The solution was being used to wipe down such things as counter tops, steam cart and tray line.

The facility failed to ensure that the manufacturer's instructions for chemical concentration for proper sanitation in the three compartment sink and food contact surfaces were being followed. The facility failed to have test kits specific for all sanitizers available for use.

Reference: FDA Food Code 2009
Chapter 4 4-302.14 Sanitizing Solutions, Testing Devices.
A test kit or other device that accurately measures the concentration in mg/l (milligrams/liter) of sanitizing solutions shall be provided.
[The sensitivity of the test strips may be affected by age, heat and humidity. Manufacturer's instructions should be followed with regard to their storage, use and replacement.]

4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization - Temperature, pH, Concentration, and Hardness.
A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times specified under ? 4-703.11(C) shall meet the criteria specified under ? 7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions... "
4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration.
Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device.

Based on staff interview, the hospital failed to have and implement written protocols for Organ, Tissue and Eye Procurement. The findings included:

Review of patient #1's medical record for the 8/24/11 Emergency Department (ED) visit revealed that the patient expired in the Emergency Department (ED) on 8/24/11. Review of the physician's electronic health record (EHR) documentation addendum on 8/24/11 at 12:41 PM evidenced "Drivers license confirms organ donor". There was no documentation found in the patient's record to show that the Hospital followed an organ donation protocol.

The five nurses and the physician involved with the care of this patient in the ED on 8/24/11 were interviewed on 10/18/11, 10/19/11, and 10/20/11. None of these interviewees indicated that they had contacted the organ procurement organization to report the death of this patient or utilized an organ donation protocol.

The Organ, Tissue and Eye Procurement written protocol was requested during the entrance conference on 10/18/2011 at 3:30 PM and during the exit conference on 10/21/2011 at 11:30 AM. The written protocol was not received by the surveyors prior to their exit from the Hospital.

Based on interview, the hospital failed to define the organization of the hospital anesthesia services to include the topical/local anesthesia. The findings included:

During an interview on 10/21/2011 at 10:30 AM, the emergency department medical staff director stated that "Mid-levels do topical and local anesthesia. There were no policies and procedures. The acting clinical director was in charge of Anesthesia services.

Based on interview with staff and patients and record review, it was determined that the hospital failed to implement policies and procedures that appropriately organized and integrated Outpatient Services with other hospital departments. The findings included:

1. On 10/18/11 during the entrance conference, the Administrative staff described their Hospital's clinic services as fitting three types:

Scheduled visits;

Same day appointments which were limited in number and were obtained by calling into the Hospital at 8:00 AM the day that the visit was requested;

Walk-in patients (not scheduled and not able to get same day appointments) were seen in the Emergency Department (ED). These patients did not have to have Emergency Medical Conditions (EMC) to be seen in the ED.

2. On 10/18/11 at 4:30 PM a tour with nurse (H) of the Outpatient Department located on the third floor of the hospital was completed. Nurse (H) reported;

There were three outpatient clinics located on the third floor of the hospital.

All three Outpatient Clinics received patients by scheduled appointments and that there was a small window of time each morning when patients could call into the clinic and try to get a same day appointment.

The facility did not have a walk in clinic or urgent care clinic.

The staff would attempt to work in some patients that came to the clinic without scheduled appointments. The example given was patient needing medication refills or vaccines.

The patients that could not get scheduled would be directed to go to the Emergency Department (ED) for care and treatment.

Nurse (H) also reported that they had received complaints from patients about not being able to get appointments and confirmed vacancies in nurse staffing and providers.

She also reported that the Outpatient Clinic was trying to return calls left on the answering machines within 48 hours. There was discussion that the time may be extended to 72 hours. The nurse was aware that patients had complained about not getting called back timely.

3. On 10/18/11, an interview conducted with the hospital's Chief Executive Officer (CEO) revealed there was an issue with the Outpatient Department located on the third floor. He reported the facility had identified that there was a need for more providers and nursing staff to handle the volume of the patients needing and wanting to be seen. The Hospital currently did not have space to expand the Outpatient Department located on the third floor. He also reported that any walk in patients to the outpatient clinic without scheduled appointments were supposed to be processed and seen through the ED.

4. Review of filed complaints identified issues with care in the Outpatient Department which included:

a. Unable to get appointments timely in the outpatient clinics, walk in clinic patients sent to the ED,

b. Unable to get timely follow up on requests for referrals,

c. Lack of providers and staff in the outpatient clinics,

d. Phone calls not returned to patients when messages are left trying to get appointments.

5. Interviews with patients/complainants during the survey who did not want to be identified but came in to file complaints with the survey team. The complaints included issues with care in the Outpatient and Emergency Departments which included:

a. Staff not available to answer the phone in either the ED or outpatient departments and when message is left phone calls are not returned. "There is just not enough staff to care for all the patients who want to be seen in the outpatient clinic".

b. "The emergency room is used inappropriately. There is no walk in clinic or urgent care so they send clinic patients to the ER which means really sick people wait a long time."

c. "The departments do not communicate". The patient was sent for a urinalysis (UA) for possible urinary tract infection and lab did not run test as physician order was not put in to the system. The patient attempted to get outpatient clinic appointment as instructed by ED but was unable to get in. The patient ended up going to another hospital.

d. Patients who need referrals for care cannot get in to see case workers to get referrals set up.

e. "I tried to set up appointments with the outpatient department you call and call but either they don't answer or you leave a message. If they call back it takes a long time and you can never get an appointment on the same day because they are just too busy not enough staff."

f. Patient seen in ED was told to make an appointment to be seen the next day in the outpatient clinic "May have a clot". ED staff did not set up an appointment or assist the patient to ensure follow-up care. The patient called the outpatient clinic as instructed but did not get a return call or appointment. "It seems the departments just don't communicate."

6. Review of patient complaints filed with the hospital and review of the hospital complaints log on 10/20/11 the issues included:

a. Patients having issues getting appointments in the outpatient clinics,

b. Walk-in clinic patients sent to ED and long waits to be seen,

c. Patients not getting return phone calls timely,

d. Patient concerns with access to care including follow up for referrals,

e. Lack of providers and staff.

7. On 10/19/11 information on the staffing and number of patients seen through the main hospital's Outpatient Clinic was provided. The information provided and CEO confirmed the following vacancies included:

-The facility's Outpatient Clinic had vacancies for four providers, two registered nurses, case workers, and switchboard operators.

- A review of reports entitled "Number of Ambulatory Visits by Clinic Type" showed patients seen in the facility's Outpatient Clinic during the past four months was an average of 1300 outpatients.

During an interview on 10/19/2011 at 5:30 PM, the CEO described the phone service at the hospital. Outside of business hours telephone calls go to the Emergency Department. The hospital was recently approved for 5 positions in order to have the telephone answered by an operator 7 days a week from 7:00 AM to 11:00 PM. The current hospital switch board was staffed by one person 5 days a week from 7:30 AM to 5:00 PM. On a normal business day there was 150 people trying to call in.

The CEO confirmed the need for more providers and nursing staff to handle the volume of patients wanting to be seen in the outpatient clinics.

Based on record review and staff interview, it was determined that the Hospital failed to assign one individual to be responsible for all outpatient services and to maintain appropriate professional personnel available to provide outpatient services. The findings included:

1. A review of the Hospital's organizational structure,on 10/19/11, found the Hospital organization to include an Outpatient Department as part of its provided services. The Hospital outpatient services included an outpatient clinic in the main Hospital and other clinics (dental, optometry, public health and wellness) located outside of the main hospital building.

a. Interviews conducted with the Hospital's Chief Executive Officer (CEO) during the survey confirmed the Outpatient Department in the main hospital was managed by the DON (Director of Nursing). He also reported that the other clinics were each managed separately. Those administrators were each responsible for their individual clinics and all reported to the Chief Executive Officer (CEO) of the hospital. He confirmed that there was no single individual who was responsible for all of the Outpatient Services in the facility.

b. An interview with the DON on 10/19/11 at confirmed she was responsible for the facility's main Outpatient Department. The Outpatient Department was located on the third floor of the hospital and had three clinics. She also identified another nurse who was listed as Department Head for "Outpatient Nursing", but she was not present during the survey. The DON confirmed she was not responsible for the any of the outlying clinics that the facility provided as outpatient services. She stated that she reported to the facility CEO.

c. Interviews with staff from the dental clinic on 10/20/11 at confirmed that they operated separately from the main hospital Outpatient Clinic.

2. The hospital was asked on 10/19/11 to provide information on the staffing and number of patients seen through the main hospital's Outpatient Clinic. The information provided and CEO confirmed the following vacancies which included:

-The facility's Outpatient Clinic had vacancies for four providers, two registered nurses, case workers, and switchboard operators.

- A review of reports entitled "Number of Ambulatory Visits by Clinic Type" showed patients seen in the hospital's Outpatient Clinic during the past four months included:
July 2011 1311 outpatients seen,
August 2011 1412 outpatients seen,
September 2011 1486 outpatients seen,
October 2011 (until Oct 20 th) 1027 outpatients seen.

The review found that the Outpatient Clinic was seeing an increase in the average of patients per month.

The CEO expressed need for more providers and nursing staff to handle the volume of patients wanting to be seen and added there was approximately 150 new patients being added for care.

3. The information showed that the Outpatient Clinic's normal staffing was Monday through Friday from 8:00 AM to 5:00 PM. There were three outpatient clinics located on the third floor of the hospital. All three clinics were run by scheduled appointments and had a window of time each morning when patients could call into the clinic to get a "same day" appointment. However, the appointment times available for making "same day" appointments was very limited. The normal staffing schedule for the clinic did not include staffing for a walk in clinic. The "same day" appointments were placed between scheduled patients or into cancellations. The walk in patients went to the Emergency Department for care and treatment.

Based on interview, the hospital failed to have respiratory services in accordance with medical staff directives. The findings included:

On 10/20/11 at 6:05 PM, the sole hospital respiratory therapist was interviewed. He stated that the only respiratory service provided was outpatient pulmonary function testing. The interview also revealed the following:

a) The respiratory policy book had not been seen for a year.
.
b) The medical staff had approved the missing respiratory policy book.

c) There was nothing else to demonstrate the existence of respiratory policies or to show medical staff approval of respiratory therapy policies.

Respiratory services policies were not provided by exit on 10/21/11 at 11:30 AM.