HospitalInspections.org

Based on review and interview the hospital failed to ensure the Medical Staff Bylaws were enforced by not ensuring the Medical Staff was conducting eleven meeting per year.
Findings:

A review of the Medical Staff Meeting Minutes showed the Medical Staff had one meeting from 04/29/18 through 04/29/19. Further review showed this meeting was held 04/29/19.

A review of the Medical Staff Bylaws showed that "meetings shall be held monthly or at least eleven months per year".

On 05/23/19 at 11:00 AM, an interview was held with Staff E, Staff E stated a few months ago, the hospital brought in a consultant to help the hospital with their problem. Staff E stated the Medical Staff did not know they were suppose to have meeting until the consultant told them.

Based on observations, interviews and record reviews the hospital failed to ensure 8 of 8 patient (#s 1-8) medical records were complete by failing to include the physician ordered observation of patient every 15 minutes that showed how the patient's condition was being monitored.

Findings:

Observations, 05/24/19 10:00AM through 11:15AM, revealed Mental Healthcare Technicians (MHT) had utilized clipboards with a form, titled "Patient Observation Record q [every] 15 minutes", that had the names of their patients. Further observations revealed the form was utilized to enter observations every 15 minutes on patients that indicated what activity the patient was involved with and how the patients' conditions were monitored.

Interview, 05/24/19 10:30AM, with Staff #G revealed when questioned how the every 15 minute checks were documented in the medical records Staff #G replied, "the forms on our clipboards is where we document our every 15 minute observations". The surveyor further questioned Staff #G as to when those forms were entered in the individual patient medical records and Staff #G replied, "they are not put in the patient's medical record". Staff #G was questioned how Staff members documented the 15 minute checks in the patients medical record; Staff #G stated would need to ask someone else as the form was the only place used to document this information.

Interview, 05/24/19 10:50AM, with Staff #E revealed the observation forms were collected daily and were kept on a computer spread sheet on the Director of Nursing's office computer. Staff #E was questioned as to when were the observation forms entered into the individual patients medical records; Staff #E stated they were not entered in the patient's medical records but if needed they could be retrieved off the computer spread sheet.

Interview, 05/24/19 3:00PM, with Staff #F revealed she was not aware this form was not included in the patients medical records. Staff #F agreed this information (Patient Observation q15 minute form) should be included in the medical record of all patients who had physician orders for every 15 minute observation/per policy. Staff #F agreed without the Patient Observation q 15 minute form the patient's medical record would not be complete and show required documentation of each patient's condition.

Review of Policy # 6600, "SUBJECT: PATIENT SUPERVISION LEVELS", revealed all patients would be observed at a minimum of every 15 minutes and this would be recorded on 15 minute observation form. Continued review of Policy #6600 revealed: "POLICY: It is the policy...to provide supervision of patients at the least restrictive level...Patient supervision levels are determined by the physician and treatment teams and are based on the individual needs and clinical status of patients...Procedure: 1. The physician shall order one of three levels of observation at time of admission, and may change the level of observation based on the patient's condition...6. Staff will complete the patient observation record as rounds are made, using the coding system described on the record...LEVELS OF OBSERVATION: Q [every] 15 MINUTE CHECKS This is the minimum level of observation for all patients. Staff will observe patient and document on the Patient Observation Record q 15 minutes..."

Hospital staff failed to ensure all patient documentation relative to the patient individual conditions were monitored and had the documentation to support the monitoring included in 8 of 8 patient medical records.

Based on record review and interviews, the hospital failed to ensure the current Therapeutic Diet Manual was approved by the Dietitian and Medical Staff.

Findings:

Review of the signature page contained in the current Therapeutic Diet Manual revealed a signature of the previous Dietitian and was dated March 2018.

Review of the Medical Staff meeting minutes, dated May 20, 2018 through 04/20/2019 revealed there failed to be documented evidence the Therapeutic Diet Manual had been approved.

Interview, 05/24/19 at 8:00 AM, with Staff #B confirmed she was unaware she had to approve the Therapeutic Diet Manual.

Interviews, 05/24/19 at 3:00 PM, with Staff #C and #D confirmed they were unaware the Dietitian and Medical Staff had to approve the Therapeutic Diet Manual.

Staff #s B, C, D confirmed the Therapeutic Diet Manual (TDM) should have been approved annually and that documentation should be present to confirm the TDM had been approved by both the Dietitian and Medical Staff.

Based on review and interview, the hospital failed to develop a system for identifying disease by not tracking and trending organisms that caused infections.
Findings:

A review of the infection control logs for 05/24/18, 06/28/18, 06/26/18, 09/27/18, 10/25/18, 11/29/18, 12/20/18, 01/24/19, 02/18/19, 03/28/19, 04/25/19 and 05/23/19 showed the hospital was not tracking and trending organism that caused infections.

On 05/23/19 at 04:55 PM an interview was held with Staff E, who stated she was the Director of Nursing Services and the Infection Control Coordinator. Staff E was question regarding causative organisms not being documented in the infection control data. Staff E stated she was unwarned infectious organisms were to be tracked.

Based on record reviews and interviews the hospital failed to ensure 8 of 8 patient's (#s 1-8) treatment plans contained long term and short term goals relative to the patients (#s1-8) problem being treated.

Findings:

Review of 8 out of 8 patient (#s 1-8) treatment plans revealed there failed to be short and long term goals established and documented on their individual treatment plans.

Review of patient #1-8's treatment plans revealed there lacked documentation to support that long and short term goals had been established and implemented by the multidisciplinary treatment team.

Interviews, on 05/24/19 at 2:40 PM, with Staff #sG, H, and C revealed they were unaware the treatment plans required long range and short term goals. Staff #G confirmed there lacked documentation on 8 of 8 (patients #1-8) patients treatment plans. Staff #G further stated the patients (#1-8) treatment plans should have had long and short term goals established, implemented and documented.