HospitalInspections.org

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Based on review of medical staff by-laws, credential file review, and staff interview, the facility failed to ensure 4 of 6 active medical staff (PA-C #1, MD #1, MD #2, CRNA #1) had been approved by the governing body for current medical staff privileges. The findings were:

1. Review of the credential file for PA-C #1 showed the last approval letter granting privileges to practice medicine in the hospital was dated 5/29/12.

2. Review of the credential file for MD #1 showed the last approval letter granting privileges to practice medicine in the hospital was dated 8/25/14.

3. Review of the credential file for MD #2 showed the last approval letter granting privileges to practice medicine in the hospital was dated 8/25/14.

4. Review of the credential file for CRNA #1 showed the last approval letter granting privileges to practice medicine in the hospital was dated 11/30/11.

5. Review of the medical staff by-laws dated March 24, 1997 showed "3.3-9 Reappointments shall be for a period of two (2) Medical Staff years."

6. Interview with the Chief Executive Officer on 11/2/16 at 4:20 PM verified these medical staff practitioners were active staff who provided care at the hospital. He further verified the process of maintaining the credentialing files had been recently reassigned, and these medical staff needed the approval of the governing body to have their privileges renewed.
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Based on staff interview and review of meeting minutes and policies and procedures, the facility failed to ensure a policy development advisory group was established to review existing policies annually, and make recommendations on patient care policies. The findings were:

Review of patient care policy and procedure manual revealed multiple policies were categorized in each of the following sections: (1) Surgical Services Administration, (2) Infection Control, (3) Emergency Preparedness, (4) Operating Room Policies, and (5) Special Operating Room Considerations. Further review revealed no evidence the policies had been reviewed by a policy development advisory group, and the most current review date for the policies occurred in 2013. Review of the February 2016 to October 2016 minutes for QA, managers, and department head meetings also revealed no evidence of a policy development advisory group. During an interview on 11/2/16 at 4:20 PM, the Chief Executive Officer verified the facility did not have a policy development advisory group and the policies had not been reviewed annually.
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Based on observation and staff interview, the facility failed to ensure a maintenance schedule to keep 2 of 3 ice/water dispensers (emergency room, medical floor) sanitary. The findings were:

Observation on 11/2/16 at 10:30 AM showed the ice/water dispensers located in the emergency room and the medical unit had a build-up of whitish matter on the interior of the plastic shoot where the ice and water was dispensed. Interview with the dietary manager on 11/2/16 at 10:24 AM verified she was responsible for the ice machine located in the kitchen and was not sure who maintained the machines elsewhere in the hospital. Interview with the maintenance director on 11/2/16 at 3:15 PM verified there was no cleaning or sanitizing schedule for the two dispensers. He stated they were cleaned when there was a need for service or repair. Further, he verified there was no policy and procedure related to the cleaning and sanitation of the ice and water dispensers.
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Based on review of agreements and staff interview, the facility failed to ensure a list was maintained for 6 of 6 services provided under agreements (Occupational Therapy, Speech Therapy, Pathologist, Radiologist, Registered Dietitian, Sterile Processing). The findings were:

Review of service agreements showed patient care services were provided under contract/agreement for the following areas: Occupational Therapy, Speech Therapy, Pathology, Radiology, Sterile Processing, and Registered Dietitian services. Interview with the RN manager on 11/2/16 at 9:12 AM verified the facility did not keep or maintain a listing of these services provided under contract or agreement which included a description and the nature and scope of the services provided.
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Based on medical record review and staff interview, the facility failed to ensure nursing staff followed physician orders or notified the physician when orders were not followed for 1 of 20 sample patients (#14) who had orders for laboratory tests. The findings were:

Medical record review showed patient #14 had signs and symptoms of a kidney infection and was admitted on 8/23/16. Further review revealed the physician's admission orders included antibiotic therapy and laboratory tests for blood and urine. The following concerns were identified:
a. Review of the laboratory urine culture results, dated 8/24/16, showed "mixed growth." Interview on 11/1/16 at 4:15 PM with the RN manager revealed the urine specimen was contaminated. She further stated a second urine culture was ordered, but staff did not do this.
b. Interview on 11/2/16 at 1:45 PM with the infection control manager revealed the facility protocols required staff to review all culture results for antibiotic susceptibility. He stated this information is important because the test results are used to determine whether the most effective antibiotic was prescribed.
c. Review of the medical record revealed the failure to follow the orders for the second urine test and lack of confirmed antibiotic susceptibility were not reported to the physician. Review of the physician's discharge orders, dated 8/4/16, revealed instructions for the patient to continue the same antibiotic that was initiated during the inpatient stay.
d. Review of the QA medical record review form showed a review of this hospital stay was completed on 8/24/16, and the reviewer determined all the ordered laboratory tests were done. During an interview on 11/3/16 at 10:30 AM, the QA manager verified the 8/24/16 QA medical record review was not accurate.
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Based on medical record review and staff interview, the facility failed to ensure a comprehensive care plan that addressed all patient concerns was developed for 13 of 20 sample patients (#1, #3, #6, #8, #10, #11, #12, #13, #14, #15, #16, #18, #23). The findings were:

1. Review of the medical record showed patient #1 was admitted on 6/7/16. The patient had identified needs related to pain/comfort and nausea. However, the care plan failed to show details related to the interventions. The interventions were general and showed, "medication administration, medication management, active listening, vital sign monitoring, nausea management..."

2. Review of the medical record showed patient #3 was admitted on 3/23/16. Review of the care plan showed the patient had identified care needs which included impaired gas exchange and activity intolerance. The interventions related to these areas were general and showed, "exercise promotion, exercise therapy: ambulation, oxygen therapy, activity therapy, fluid management, vital sign monitoring."

3. Medical record review showed patient #6 was admitted on 7/24/16 and diagnoses included anemia and pneumonia. Review of the care plan showed interventions were developed to address ineffective airway clearance, excess fluid volume, and acute pain. Further review showed the interventions were non specific, not individualized and without measurable goals.

4. Review of the medical record showed patient #8 was admitted on 1/25/16. Review of the care plan showed the patient had identified care needs which included acute pain and anxiety. The interventions related to the care plan were generic and showed, "Analgesic administration, anxiety reduction, calming technique, medication prescribing."

5. Medical record review showed patient #10 was admitted on 3/14/16 for treatment of pneumonia. Review of the care plan showed one of the identified problems was risk of aspiration. Further review revealed no interventions were developed to address this problem.

6. Medical record review showed patient #11 was admitted on 7/19/16 with a diagnosis of hypokalemia and hypomagnesium. Further review showed the admission physician orders included a urinary catheter and blood glucose checks four times daily. Review of the care plan showed interventions were developed to address activity intolerance and imbalanced nutrition. Further review showed the interventions did not include care of the urinary catheter or information about getting blood glucose levels.

7. Medical record review showed patient #12 was admitted on 2/1/16 for treatment of pneumonia. Review of the care plan showed identified problems were risk for activity intolerance and ineffective airway clearance. Review of the care plan showed pain management, oxygen therapy, positioning and emotional support were included in the interventions. However, further review revealed no information about tasks or actions for managing pain, providing oxygen therapy, and positioning; and what should be done to support the patient emotionally.

8. Medical record review showed patient #13 was admitted on 7/10/16 with diagnoses of nausea, vomiting, stomach pain, and diarrhea. Review of the care plan showed interventions were developed to address nausea and vomiting, but not the stomach pain.

9. Medical record review showed patient #14 was admitted on 3/14/16 for treatment for pyelonephritis. Review of the care plan showed one of the identified problems was risk of falls. Further review revealed no interventions were developed to address this problem.

10. Medical record review showed patient #15 was admitted on 11/4/16 after knee surgery. Review of the care plan showed interventions were developed to address impaired physical mobility and pain. Further review showed the interventions were non-specific, not individualized and without measurable goals.

11. Medical record review showed patient #16 was admitted on 9/9/16 with a diagnosis of congestive heart failure. Review of the care plan showed interventions were developed to address activity intolerance and acute pain. Further review showed the interventions were non-specific, not individualized and without measurable goals.

12. Medical record review showed patient #18 was admitted on 6/1/16 after knee surgery. According to the physician's admission history and physical and admission orders, the patient had a diagnosis of diabetes and required diabetic monitoring. Review of the care plan showed interventions were developed to address pain and impaired physical mobility. Further review revealed diabetic monitoring was not included.

13. Medical record review showed patient #23 was admitted on 7/11/16 after knee surgery. Further review showed the patient received physical therapy and as needed pain medications. Review of the care plan showed interventions were developed to address risk of infection. Further review revealed pain and immobility were not addressed

14. Interview with the RN manager on 11/3/16 at 10:39 AM verified the care plan interventions were not very descriptive and they could be improved upon.
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Based on staff interview, review of medical staff meeting minutes, and review of medical summary reports, the facility failed to ensure a periodic review of the hospitals total program was completed annually. The findings were:

Review of the Medical Summary Report 2015-2016 showed information was compiled related to the facility's patient admission numbers, types of admissions, length of stay, surgical cases, and radiological procedures. Review of the monthly medical staff meeting minutes from June to October 2016 showed "nothing" was written in under the category in the minutes for "Utilization Review." Interview with the QA Manager on 11/3/16 at 9:45 AM verified she kept the information on each patient stay, however, was not aware of any reports or formal evaluations done on an annual basis. Interview with the Chief Executive Officer on 11/2/16 at 4:20 PM verified a yearly evaluation covering the total program was not completed.
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Based on staff interview and review of patient care policies and procedures, the facility failed to evaluate, review, and/or revise the health care policies as part of a periodic yearly evaluation. The findings were:

Review of patient care policy and procedure manual revealed multiple policies were categorized in each of the following sections: (1) Surgical Services Administration, (2) Infection Control, (3) Emergency Preparedness, (4) Operating Room Policies, and (5) Special Operating Room Considerations. Further review revealed the most current review date for the policies occurred in 2013. During an interview on 11/2/16 at 4:20 PM, the Chief Executive Officer verified the policies had not been reviewed annually.
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Based on staff interview and review of QA activities, the facility failed to develop a QA committee for ongoing evaluation of care and services. The findings were:

Random review of QA meeting minutes, dated 3/17/15 and 1/13/16 showed various departments reported the QA projects for their individual department, but evidence of a committee evaluation, data review, project review, data analysis, evaluations of care and services, and identified measures to improve quality on a continuous basis was lacking. Review of the 3/8/16 and 8/16/16 managers' meeting minutes revealed staff did not have time to discuss QA. Interview with the Chief Executive Officer (CEO) on 11/2/16 at 4:20 PM revealed the facility did not have a formalized QA committee or process for periodic evaluation of care and services. He stated the problems with the QA program started after the previous QA director left in July this year. Interview on 11/3/16 at 9:30 AM with the QA Manager revealed she collected data and quality information from most of the departments, and communicated this to the CEO. She stated this data was not reviewed at every managers' meeting. She further stated the facility did not have a committee that reviewed the appropriateness of each project, correlated all QA activities, and determined overall effectiveness.
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Based on staff interview, QA information review, review of medical staff list, and review of contracts/agreements, the facility failed to ensure an evaluation of the quality and appropriateness of the diagnosis and treatment furnished by 2 MDs and 1 DO was completed. The findings were:

Review of the QA information failed to include information related to MD/DO evaluations. Review of the contracts and agreements provided by the facility failed to include an outside entity to review the appropriateness of the diagnosis and treatment provided by each MD and DO. The facility medical staff list included 2 MDs and 1 DO employed by the hospital. Interview with the Chief of Staff on 11/2/16 at 5 PM verified he was not aware if these evaluations continued to be done. He recalled in the past receiving notice of an evaluation that had been done. Interview with the RN manager on 11/3/16 at 11:45 AM verified the MD/DO evaluations were not being completed.
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Based on medical record review and staff interview, the facility failed to ensure comprehensive assessments were completed for 2 of 3 sample swing bed patients (#5, #20). The findings were:

1. Review of the medical record showed patient #20 was admitted to swing bed status on 5/17/16. Review of the 14 day assessment showed it was dated 6/1/16. The assessment was a collection of data related to a variety of areas. There was no summary or analysis of the data to determine if care planning was needed.

2. Review of the medical record showed patient #5 was admitted to swing bed status on 7/11/16 with a 22 day stay. Review of a data collection form showed information related to a variety of areas dated from 7/11 to 7/18/16. However, there was no summary or analysis of the data to determine if care planning was needed.

3. Interview with the QA Manager on 11/3/16 at 9:45 AM verified the assessment data had not been summarized or analyzed, and additional steps were needed for the data to be considered an assessment.


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