HospitalInspections.org

Based on review of information provided and interviews with key staff on December 1 and 2, 2001, it was determined that the hospital failed to be in compliance with the Federal Regulations 482.13(a)(2)(ii) and (iii), which required that in its resolution of the grievance, the hospital must provide the patient with written notice of the steps taken on behalf of the patient to investigate the grievance and the grievance process must specify time frames for the review of the grievance and the provision of a response.

Findings Include:

1. On December 2, 2010, complaint investigations were reviewed. Three (3) of five (5) letters to the patient related to complaints/grievances did not contain the steps taken to investigate the complaint.

2. On December 2, 2010, complaint investigations were reviewed. Four (4) of the five (5) letters to the patient were beyond the timeframe of seven (7) days as outlined in the hospital policy.

3. These findings were confirmed by the Chief Nursing Officer on December 2, 2010.

Based on tours of the hospital and interviews with the Facilities Manager on December 1, 2010, it was determined that the hospital failed to ensure that the preventative maintenance program maintained all essential mechanical and electrical equipment in safe operating condition.

Findings include:

1. On December 1, 2010, the dishwasher wash water temperature was measured at 140 degrees Fahrenheit. The manufacturer's specifications require a minimum of 150 F.

2. On December 1, 2010, the range hood screens were observed to be greasy and the surveyor was told that they had been cleaned the month prior.

3. These findings were confirmed with the Facilities Manager on December 1, 2010.

Based on review of the Complaint/Grievance Log for a year, review of randomly selected clinical contracts, review of the Medical Staff Bylaws, review of the Annual Department Performance Improvement Plans, review of the Fiscal Year 2011 Performance Improvement & Safety Plan, review of the Quality and Professional Affairs Committee meeting minutes, review of the Quality Committee meeting minutes, review of the Board of Trustee meeting minutes, review of the Blue Hill Memorial Hospital Medical Staff Quality Improvement Plan FY 2011, and interviews with the Chief Executive Officer, the Chief Nursing Officer/Risk Manager, and the Performance Improvement Director on December 1 and 2, 2010, it was determined that the hospital's Governing Body failed to be totally responsible for the conduct of the CAH as an institution, as evidenced by:


1. The Governing Body failed to assume full legal responsibility for determining, implementing and monitoring policies (Tags C -0151, C-0241, C-0279 and C-0334);

2. The Governing Body failed to ensure that the medical staff was accountable to the Governing Body for the quality of care provided to patients (Tags C-022, C-0241, C-0279, and C-0330);

3. The Governing Body failed to ensure that the policies were administered so as to provide quality health care in a safe environment (Tags C- 0222, C-0241, C-0279 and C-0330);

4. The Governing Body failed to institute processes and systems to ensure periodic appraisal of the medical staff evaluation of patient care services at every patient care location (Tags C- 0241 and C-0330); and

5. The Governing Body failed to ensure that the hospital was in compliance with all Federal Regulations (Tags C- 0151 and C-0241).


The cumulative effects of these deficient practices resulted in this Condition of Participation being out of complaince.

Please see Tag C- 0334 for additional information regarding the emergency policies and procedures.

Based on a tour of the kitchen and interviews with the Food Service Manager on December 1, 2010, it was determined that the procedures/policies for ensuring that the nutritional needs of the patients were in accordance with accepted dietary practices were not being consistently followed. The following did not meet Food and Drug Adminstration's food safety requirements.

Findings include:

1. On December 1, 2010, one (1) can of "Campbell's Tomato Soup" was observed to be dented to such an extent that the top ridge of the seal was cracked.

2. On December 1, 2010, it was observed that six (6) cans of "Glucerna" had passed their expiration date of July 10, 2010.

3. On December 1, 2010, it was observed that a case of "Promote" had also passed its expiration date.

4. These findings were confirmed with the Food Service Manager on December 1, 2010.

Based on clinical record review and interviews with key staff on December 1, 2010, it was determined that the clinical records were not complete in six (6) of ten (10) Emergency Department records and not legible in (5) five of (5) five Surgical records. (Records: B, D, F, H, I, J, BBB, CCC, DDD, EEE and FFF).

Findings include:

1. On December 1, 2010, six (6) randomly selected clinical records (Records: B, D, F, H, I and J), of patients who were transferred to another facility from the Emergency Department, failed to have complete "Transfer Forms." These forms failed to have either the Risks and/or Benefits or both not completed. In addition, Record D failed to have both the Risks and/or Benefits and the Reason for the transfer documented.

2. On December 2, 2010, five (5) randomly selected Surgical records (Records: BBB, CCC, DDD, EEE and FFF) revealed that it was not possible to determine from a signature, the name of the practitioner performing the procedure and the name of the person who explained the procedure to the patient.

3. On December 1 and 2, 2010, these findings were confirmed by the Emergency Department Nurse Manager and the Surgical Services Nurse Manager.

Based on review of Departmental Performance Improvement initiatives for the Medical Staff, Medical Staff Peer Review Report, Emergency Department and Surgical Services and interview with key staff on November 30, December 1 & 2, 2010, it was determined that the CAH failed to ensure that the quality improvement activities were sufficient to assess the CAH care of patients. The case identification mechanisms for key quality initiatives were insufficient to identify cases for review. Furthermore, the CAH did not ensure that high risk, high volume and problem prone aspects of patient care, both in the Emergency Department and in Surgical Services, were reviewed and that appropriate action was taken to improve patient care outcomes and services.

Findings include:

1. The Emergency and Surgical Service Departmental Performance Improvement Plan for 2011 stated that there will be a " systematic and ongoing process to monitor, evaluate, and improve the quality of care and services provided by the ... Department. The goal is to insure that high risk, high volume and problem prone aspects of patient care are reviewed and appropriate action is taken to improve patient care outcomes and services. "

2. According to the hospital ' s annual report, the Emergency Department (ED) had 6500 visits per year. The Medical Staff Quality Initiatives for ED specified that the Emergency Department " evaluate and improve as needed the % [percent] of patients with initial EKG [electro-cardiogram] reviewed by a practitioner within thirty (30) minutes of presenting with or reporting onset of chest pain. " . During the calendar year 2010, this resulted in the review of (40) forty cases per month.

3. The Nurse Manager of the Emergency Department and the Chief Medical Officer, (CMO) both confirmed, in an interview, that no additional ED medical staff reviews were done, and that the percentage of cases reviewed reflected approximately 1`% of all cases seen in the Emergency Department. In addition, they confirmed that there was no review of high volume cases planned or completed for the year 2010.

4. The Nurse Manager stated, " We haven ' t found issues in surgery to review. "

5. The Nurse Manager stated that there were approximately (1500) fifteen hundred surgeries performed in the year 2010. The Nurse Manager also said that " 80% of their surgery was Out Patient. " In addition, out of those (1500) fifteen hundred surgical cases, (700) seven hundred cases consisted of endoscopies. However, they further stated that there were no reviews done on any of these Endoscopy or Outpatient cases.

6. During the same interview, the CMO and the Nurse Manager stated that they were confident that the care was of high quality because they hadn ' t received any patient complaints nor were they aware of any surgical complications.

7. The Nurse Manager of Surgical Services reported that the hospital tracks 100% of cases within the Surgical Quality Improvement measures for Surgical Quality.

8. This Nurse Manager provided the survey team with a copy of the report submitted to the hospital quality committee that listed a total of (13) thirteen patients whose care fell into the Surgical Quality Improvement measures and had been reviewed. Of these, only one patient was identified as having had a hysterectomy and the CMO stated, " I did more than (1) one hysterectomy... "

9. The Nurse Manager returned approximately thirty (30) minutes later and stated that he just pulled and completed a manual review of hysterectomy cases that fell into the Surgical Quality Improvement measures and found that there were twelve (12) hysterectomy cases that had not been identified or reported upon. He stated that their process for identifying cases " had a problem " and he surmised that there were other Surgical Quality Improvement cases that had not been identified or reviewed.


The cumulative effects of these deficient practices resulted in this Condition of Participation being out of compliance.

Based on interviews with the Emergency Department Nurse Manager, the Surgical Services Nurse Manager and the review of the Emergency Department Policy Manual and the Surgical Services Manuals on December 1, 2010, it was determined that there was no documented evidence that all of the Emergency Department policies and the Surgical Services Department policies were approved by the Governing Board on an annual basis.

Findings include:

1. On December 1and 2, 2010, the review of the Emergency Department "Title Page" which contained the "Approval and Revised/Reviewed" dates for each policy, revealed that several policies had not been updated on an annual basis. The oldest policy was not updated and/or approved since June 2005 (i.e. Trauma Nurse Core Curriculum).

2. On December 1 and 2, 2010, the review of the Surgical Services Department documentation regarding the annual review of the policies and procedures was not complete and lacked approval dates.

3. These findings were confirmed by both the Nurse Managers on December 1 and 2, 2010.

Please see Tags C-0330 and C-0337 for additional information about the evaluation of the quality of care provided to patients at the CAH.

Based on interviews with the Emergency Department Nurse Manager, the Swing Bed Coordinator, other key staff and review of the Quality Assurance Plan for both of these Departments on December 1, 2010, it was determined that the hospital failed to evaluate all patient care services affecting patient health and safety.


Findings Include:

1. A review of the Performance Improvement initiatives for 2010 for the Emergency Department on November 30, 2010 indicated that there were only two initiatives identified for evaluation of patient care services. Both of these Performance Initiatives failed to evaluate the clinical services provided to patients that affect their health and safety.

2. A review of the Performance Improvement initiatives on December 1, 2010, for the 2010 Swing Bed Program revealed that there were no initiatives that evaluated the effectiveness of the Swing Bed Program until September 2010. In addition, there was only one performance initiative identified , "Patient Satisfaction " which did not evaluate the clinical services and safety of patient care.

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Based on review of the Complaint/Grievance Log, review of five (5) randomly selected complaint investigations, review of the Performance Improvement & Safety Plan FY 2011, review of the Risk Management Complaint/Grievance Action Plan November 2010, review of the Blue Hill Memorial Hospital Risk Management Plan FY 2011, review of the Blue Hill Memorial Hospital FY 11 Annual Department PI Plans and interviews with the Chief Nursing Officerand the Performane Improvement Manager on December 1 and 2, 2010, it was determined that the hospital failed to incorporate the analysis of all complaints to establish trends and report the results through the Quality Management Program.

Findings include:


1. On December 2, 2010, a review of the Risk Management Complaint/Grievance Action Plan dated November 2010 was completed. There was no requirement that analysis and trends of the hospital complaints/grievances be reported through the Performance Improvement Program.

2. On December 2, 2010, a review of the meeting minutes of the Quality & Professional Affairs Committee from November 19, 2009 through October 21, 2010, revealed no discussion of the complaints/grievances received by the hospital and/or action taken regarding these complaints.

3. On December 1 and 2, 2010, a review of the Board of Trustees meeting minutes from April 5, 2010 through October 27, 2010, revealed no discussion of the complaints/grievances received by the hospital and/or action taken regarding these complaints/grievances.

4. During an interview with the Chief Nursing Officer on December 2, 2010, it was confirmed that there was no analysis and/or trending of complaints/grievances reported through the Performance Improvement Program and then to the Board of Trustees.

Please see Tags C-0330 and C-0337 for additional information related to appropriate remedial action taken to address deficiencies found through there quality assurance process.