HospitalInspections.org

Based on document review, observation and interview, the facility does not comply with applicable federal laws, specifically; the provision of staff education related to advance directives and the posting of mandated notices in the Emergency Department (ED).

Findings include:

Review of staff education files on October 29, 2020 revealed no documentation to indicate education related to advance directives was provided to patient care staff (T), (W), (X), (Y) and (Z).

Observation in the ED on 10/29/20 revealed no evidence of a posted notice stating that a doctor of medicine or a doctor of osteopathy is not present 24 hours per day, 7 days per week and how the medical needs will be met for any patient with an emergency medical condition.

Interview with Staff (A), Compliance Officer on 10/29/20 verified the above findings.

Based on document review and interview, the governing body has not ensured that all members of the medical staff are re-appointed in accordance with medical staff bylaws.

Findings include:

Review of the Medical Staff bylaws revealed reappointments shall be made by the Board of Directors after there has been a recommendation from the Credentialing Committee and Medical Staff for a period of not more than 24 months.

Interview with Staff (BB), Medical Staff Coordinator on 10/30/20 revealed Staff (Q) has not been re-appointed during the last four years.

Review of the credential file for Staff (Q), Medical Director revealed no documentation to indicate Staff (Q) has been re-appointed during the last four years.

Interview with Staff (BB), Medical Staff Coordinator on 10/30/20 verified the above findings.

Based on document review and interview, the facility does not ensure that there are written policies which cover the health care services furnished by the CAH, specifically, the procedures followed by teleradiology services and next day in-house radiology services for interpreting readings and reporting discrepancies.

Findings include:

Interview with Staff (C), Director of Radiology on 10/28/20 at 11:00 AM revealed that an off-site teleradiology company provides preliminary radiologic readings on radiologic procedures performed overnight and next day in-house radiologist performs a final interpretation of the exam. If discrepancy is noted, the teleradiology company is notified and a quality assurance report filed. Review of Department of Radiology policies and procedures/protocols revealed no evidence of an existing policy/protocol describing procedure for interpreting readings and reporting discrepancies between teleradiology and in-house radiology.

Interview with Staff (A), VP Risk Quality on 10/30/20 at 10:00 AM verified the above finding.

Based on medical record review, document review and interview, informed consent for operative procedures and administration of anesthesia are not documented in accordance with the facility's policy and procedure in 7 of 7 operative records reviewed.

Findings include:

Review of facility's Policy and Procedure entitled "Informed Surgical and Anesthesia Consents" effective 9/13 revealed that the informed consent is the discussion between patient and physician of all information relevant to a proposed procedure, treatment or surgery. The consent form must be appropriately documented. The information on the surgical consent form must include name of the surgeon and procedure to be performed in a manner understood by the patient. Abbreviations are not acceptable. The information on the anesthesia consent form must include procedure to be performed in a manner understood by the patient, the type of anesthesia proposed, the name of the person(s) explaining and administering anesthesia.

Medical record review on 10/30/20 at 11:00 AM of Anesthesia Consents for Patient's #1, 5, 6, 7, 8, 9, and 10 revealed name of person administering anesthesia and surgical procedure to be performed were illegible and medical abbreviation was used in description of surgical procedure for Patient #7. Review of Surgical Consents for Patient's #5, 6, and 7 revealed name of surgeon and procedure to be performed were illegible and not documented in a manner that would be understood by the patient.

Interview with Staff (F), Director of Surgical Services and Staff (M), Director of Nursing on 10/30/20 at 11:30 AM verified above findings.