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Based on facility policy review, observation and interview, the facility failed to protect patient's rights to privacy by placing patient names in public view on the spines of medical records in the Critical Care Unit (CCU). This affected all five patients in the CCU. The facility census was 14.

Findings included:

Review of the facility's policy titled, "Chart Labels," reviewed 07/20/06, showed the following direction:
- Staff will label chart with patient's name, room number, physician name, allergies, and other needed clinical information.

Observation during a tour of the CCU on 02/16/11 at 12:35 PM, showed a sticker on the spine of each patient's medical record. The patients' full last name and full first name were written in large, black letters and were easily visible to anyone who entered the unit.

During an interview on 02/16/11 at 12:40 PM, Staff R, Medical/Surgical Unit Manager, stated the stickers were colored coded to indicate the patient's physician and facilitated finding the correct medical record.

Based on observation, record review and interview, the facility failed to provide a safe environment for patients and visitors to the facility by:
- Failing to secure a room within the Respiratory Therapy Department which contained hazardous materials, hazardous waste, and hazardous gases that could be accessed by anyone within that area of the facility; and
- Failing to check and maintain safe temperatures for therapy devices utilized for Inpatients and Outpatients accessing care in the Rehabilitation Services Department. The facility census was 14.

Findings included:

1. Observation during a tour of the Respiratory Therapy Department on 02/16/11 at 9:15 AM, showed a room where arterial blood gas (ABG - a test to determine levels of oxygen and other gases in the blood) specimens were analyzed. A large waste can sat on the floor just inside the door. The waste can was labeled hazardous waste, and contained discarded laboratory specimen tubes of blood, and other contaminated materials used in testing blood gases. A sharps disposal container, approximately 11 inches by 11 inches by five inches, sat on the countertop just inside the room. The door to this room was open to a main corridor within the facility. There were no Respiratory Services employees in the immediate vicinity until the Director was paged to come to this area.

During an interview on 02/16/11 at 9:35 AM, Staff BB, Respiratory Director, stated the door to the ABG room had a locking mechanism, but the door was routinely left open.

2. Observation during a tour of the Rehabilitation Department on 02/16/11 at 10:15 AM, showed a room with a Paraffin Bath (a device used to heat wax which is used during treatment of arthritic joints and other conditions) and a Hydrocollator (a machine that heats packs for therapy in hot water). Each piece of equipment had a temperature log. Temperatures were recorded on the logs every three to four days. Recorded temperatures on the Paraffin Bath ranged from 117? F. to 128? F. Recorded temperatures on the Hydrocollator machine ranged from 140? F. to 155? F.

During an interview on 02/16/11 at 10:45 AM, Staff P, Rehabilitation Services Director, stated he/she did not know what temperature was considered optimal for each piece of equipment. Staff P stated the Department did not have a policy addressing either the frequency of temperature checks, or what to do if temperatures were not correct.

On 02/16/11 at 2:40 PM, Staff P stated that the temperature range for the Paraffin bath should be 125? F. to 135? F., and the temperature range for the Hydrocollator machine should be 160? F. to 166? F. Review of the Hydrocollator manual, page 2, confirmed the recommended operating temperature of 160? F. to 166? F.

Review of the form titled, "Daily Temperature Log - Paraffin," showed temperature checks from 12/10/10 to 02/15/11. During that time period of 67 days, 19 temperatures were recorded. Of these 19 recordings, 10 temperatures were recorded at less than 125? F. as follows:
- 12/14/10 - 122? F.
- 12/17/10 - 120? F.
- 12/21/10 - 118? F.
- 12/31/10 - 124? F.
- 01/04/11 - 118? F.
- 01/07/11 - 117? F.
- 01/11/11 - 124? F.
- 01/14/11 - 124? F.
- 01/21/11 - 124? F.
- 02/04/11 - 123? F.

Review of the form titled, "Daily Temperature Log - Hot Pack," showed temperature checks from 12/10/10 to 02/15/11. During that time period of 67 days, 19 temperatures were recorded. Of these 19 recordings, all temperatures were recorded at less than 160? F. as follows:
- 12/10/10 - 140? F.
- 12/14/10 - 152? F.
- 12/17/10 - 152? F.
- 12/21/10 - 146? F.
- 12/28/10 - 152? F.
- 12/31/10 - 152? F.
- 01/04/11 - 150? F.
- 01/07/11 - 151? F.
- 01/11/11 - 154? F.
- 01/14/11 - 155? F.
- 01/18/11 - 154? F.
- 01/21/11 - 153? F.
- 01/25/11 - 153? F.
- 01/28/11 - 149? F.
- 02/01/11 - 153? F.
- 02/04/11 - 152? F.
- 02/08/11 - 152? F.
- 02/11/11 - 152? F.
- 02/15/11 - 154? F.

During an interview on 02/16/11 at 3:00 PM, Staff P stated that the packs are wrapped after removal from the heater, and 6 to 8 layers of toweling are between the pack and the patient. Staff P stated that hot packs typically cool in approximately 30 minutes, and that hot packs at temperatures that were below the optimal ranges would cool faster.

Based upon observation and interview, the facility failed to prevent unauthorized access to patient medical records by:
- Leaving components of medical records in an unsecured area of the Respiratory Department; and
- Failing to log out of an open electronic medical record in an unsecured area of the Critical Care Unit before leaving the work station.

These failures affected all patients receiving arterial blood gas (ABG - a test to determine levels of oxygen and other gases in the blood) analysis from the Respiratory Department, and potentially affected all patients receiving care at the facility who had electronic medical records. The facility census was 14.

Findings included:

1. Observation during a tour of the Respiratory Department on 02/16/11 at 9:15 AM, showed a room within the Respiratory Department where ABG specimens were analyzed. The door to this room was open to a main corridor within the facility. There were no Respiratory Services employees in the immediate vicinity until the Director was paged to come to this area. A two and a half inch binder was lying on a desk in the room and contained approximately 100 patient ABG reports. Each report listed a patient's name, date of birth, and test results.

During an interview on 02/16/11 at 9:35 AM, Staff BB, Respiratory Director, stated information in the binder in the unsecured room represented patient test results for the months of January and February, 2011. The reports were duplicates of the information placed in patient records, and were kept in the Department as a reference when tests were repeated. Staff BB stated the door had a locking mechanism, but the door was routinely left open.

2. During electronic medical record review on 02/16/11 at 1:55 PM, in a small room in a hallway near the Critical Care Unit (CCU), Staff R, Medical/Surgical Manager, was paged to a different area of the facility. The electronic medical record of Patient #19 remained open on the computer screen for approximately 10 minutes before the screen blackened, obscuring the medical information. Observation showed that moving the mouse automatically brought the information back for further review. Anyone entering the room who was familiar with computers could have easily viewed the patient's personal information.

During an interview on 02/16/11 at 2:05 PM, Staff R stated, "I should have closed the screen before walking away from it." Staff R stated the electronic medical record closes itself when it senses no activity after approximately 10 minutes, but indicated the time frame was much shorter for nursing staff working on patient units than it was for management level staff.

The facility failed to comply with the right of the patients to confidentiality of his/her clinical records when 14 of 14 patient records had the patients' names visible from the hall by the public at the medical/surgical nurse's station. The facility census was 14.

Findings Include:

Observation on 02/16/11 at approximately 12:30 PM, showed the following:
All patient charts have the patient's last name written on the spine of the medical record in large, bold, black lettering. The patients' names can be read when walking past the nurse's station and affected 100% of the current patient census 14 of 14 clinical records, Patients #1, #2, #3, #6, #9, #13, #14, #16, #22, #35, #36, #37, #38, #39.

Based upon facility policy review, record review and interview, the facility failed to ensure that there was an effective, ongoing, hospital-wide quality assurance/performance improvement program, responsible to the Governing Body of the hospital, which would lead to reduced medical errors and improved patient care. This applied to all patient services. The facility census was 14.

The severity and cumulative effect of this systemic practice resulted in the facility's non-compliance with 42 CFR (Code of Federal Regulations) 482.21 Condition of Participation: Quality Assessment and Performance Improvement Program.

See related citations at A0264, A0273, A0285, A0309, and A0310.

Based upon facility policy review, record review and interview, the facility failed to:
- Assure that there was an effective, ongoing, hospital-wide quality assurance and performance improvement program that showed measurable improvement in indicators for which there is evidence that it would improve patient health outcomes;
- Measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital service and operations. These failures applied to all patient services. The facility census was 14.

Findings included:

1. Record review of the facility's document titled, "Quality Assessment and Performance Improvement Plan," reviewed 05/20/10, showed the following:
- PURPOSE: The organizational program, established by the Medical Staff and Interdisciplinary Quality Assessment and Performance Improvement Committee, with support and approval from the Governing Board, has the responsibility for monitoring every aspect of patient care and services (including contracted services), from the time the patient enters the hospital through diagnosis, treatment, recovery and discharge in order to identify and resolve any breakdowns that may result in less than optimal patient care and safety, while striving to continuously improve and facilitate positive patient outcomes.
- SCOPE OF ACTIVITIES: Monitoring and evaluation activities for those components of care/service with the greatest impact on patient outcomes will be continuous. Other monitoring and evaluation activities will periodically change if results show continuous acceptable quality and the department/service wishes to focus their improvement projects on another key activity.

Record review of the facility's policy titled, "Quality Assessment and Performance Improvement Reporting Guidelines," approved 02/19/09, showed the following direction:
- Hospital departments will conduct and report Quality Assessment and Performance Improvement activities in accordance with state and federal regulations.
- The Department Manager will be ultimately responsible for their department's QAPI projects including compliance with state and federal regulatory requirements.

2. Review of current quality monitoring revealed surveillance in various areas of the facility, but there was no evidence of analysis and systematic performance improvement applications. Department Directors were asked to submit their data, but were not required to maintain evidence of the data collected, collection tools, or other methodology of review and analysis. Several Departments within the facility had no Quality Improvement (QI) surveillance in place, or had ineffective QI activities.
- The Pharmacy participated in several collaborative QI projects, but did not conduct their own QI projects and were not represented in the quarterly reports.
- Medication errors were tabulated and reported to the Governing Body, Medical Staff, and Safety Committee by the Quality Improvement Coordinator, but were not identified as a QI projects.
- A total of ten medication errors were reported during calendar year 2010. There was no evidence that the data was reviewed to determine whether errors were being under-reported.
- The Emergency Department participated in QI projects, but discontinued projects before showing evidence of sustained improvement, and discontinued continuous projects that were required by Missouri law.
- The Rehabilitation Department submitted evidence of QI projects that were not conducted as defined in their project plans, and did not meet established goals in any quarter of 2010.
- There was no evidence that each service provided through contract participated in quality improvement activities.

3. During an interview on 02/17/11 at 1:40 PM, Staff S, QI Director, stated the following:
- Department Directors developed their own QI projects for the year, including determination of quality indicators, measurement criteria and goals, without input from the Governing Body, the Medical Staff, the Quality Improvement Committee, or the Quality Improvement Coordinator.
- QI projects chosen by each Department Director did not require approval prior to implementation and were not reviewed prior to implementation.

Based upon review of facility policy review, record review, and interview, the facility failed to:
- Incorporate quality indicator data including patient care data and other relevant data to monitor the effectiveness of services and quality of care;
- Identify opportunities for improvement and changes that would lead to improvement; and
- Develop an ongoing hospital-wide quality program, for which the Governing Body had specified the frequency and detail of data collected. These failures applied to all patient services. The facility census was 14.

Findings included:

1. Record review of the facility's document titled, "Quality Assessment and Performance Improvement Plan," reviewed 05/20/10, showed the following:
- PURPOSE: The organizational program, established by the Medical Staff and Interdisciplinary Quality Assessment and Performance Improvement Committee, with support and approval from the Governing Board, has the responsibility for monitoring every aspect of patient care and services (including contracted services), from the time the patient enters the hospital through diagnosis, treatment, recovery and discharge in order to identify and resolve any breakdowns that may result in less than optimal patient care and safety, while striving to continuously improve and facilitate positive patient outcomes.
- GOALS: That clinical and administrative staffs monitor and evaluate the quality and appropriateness of patient care and clinical performance, resolve identified problems, and report information necessary for the Governing Board to assist in fulfilling its responsibility to the quality of patient care.
- ASSIGNED RESPONSIBILITY AND AUTHORITY: The Governing Board of Bates County Memorial Hospital shall support and have the final authority and responsibility for the assessment of a flexible, comprehensive and integrated Quality Assessment and Performance Improvement Program and will delegate the authority and accountability for the operation of the program to the Administration and Medical Staff.
- ORGANIZATION: Bates County Memorial Hospital shall organize a committee to be named the Quality Assessment and Performance Improvement Committee. This committee shall be responsible for monitoring, assessing, and evaluating hospital-wide quality assessment and performance improvement activities. This committee shall be composed of the following:
- Governing Board members appointed yearly by the President of the Governing Board.
- Medical Staff members appointed yearly by the Chief of the Medical Staff.
- SCOPE OF ACTIVITIES: Monitoring and evaluation activities for those components of care/service with the greatest impact on patient outcomes will be continuous. Other monitoring and evaluation activities will periodically change if results show continuous acceptable quality and the department/service wishes to focus their improvement projects on another key activity.

Record review of the facility's policy titled, "Quality Assessment and Performance Improvement Reporting Guidelines," approved 02/19/09, showed the following direction:
- Hospital departments will conduct and report Quality Assessment and Performance Improvement activities in accordance with state and federal regulations.
- The Department Manager will be ultimately responsible for their department's QAPI projects including compliance with state and federal regulatory requirements.

2. Review of current quality monitoring revealed surveillance in various areas of the facility, but there was no evidence of analysis and systematic performance improvement applications. -Department Directors were asked to submit their data, but were not required to maintain evidence of the data collected, collection tools, or other methodology of review and analysis. -Several Departments within the facility had no quality improvement surveillance in place, or had ineffective quality improvement activities.
- The Emergency Department participated in QI projects, but discontinued projects before showing evidence of sustained improvement, and discontinued continuous projects that were required by Missouri law.
- The Rehabilitation Department submitted evidence of QI projects that were not conducted as defined in their project plans.
- There was no evidence that each service provided through contract participated in quality improvement activities.

3. Review of the Bates County Memorial Hospital Continuous Quality Improvement Committee meeting minutes for calendar year 2010 showed the following:
- Minutes of each Continuous Quality Improvement Committee meeting showed evidence of review and discussion regarding employee suggestions, review of event reports, review of regulatory compliance, and review of quality improvement reports for the quarter of the year under discussion.
- Minutes of each Continuous Quality Improvement Committee meeting failed to provide evidence of what was discussed during review of quality improvement reports, whether questions or concerns were raised, or whether guidance was offered.

4. During an interview on 02/17/11 at 1:40 PM, Staff S, Quality Improvement Director, stated the following:
- The QI Program was based upon retrospective review. Quarterly QI data was submitted to the QI Department for inclusion in summary reports that are presented to the facility's QI Committee, Medical Staff, and Governing Body at quarterly meetings. Members of the various groups were given an opportunity to review the data and request clarification, but "very rarely" asked questions or gave direction.
- Department Directors developed their own QI projects for the year, including determination of quality indicators, measurement criteria and goals, without input from the Governing Body, the Medical Staff, the QI Committee, or the QI Coordinator.
- QI projects chosen by each Department Director did not require approval prior to implementation and were not reviewed prior to implementation.

Based on Quality Improvement document review and interview, the facility failed to collect and analyze data related to high-risk or problem-prone areas to monitor the effectiveness and safety of services, including quality of services provided by the Pharmacy and the quality of care provided in the Emergency Department (ED). The facility census was 14.

Findings include:

1. Record review of the facility's policy titled, "Quality Assessment and Performance Improvement Reporting Guidelines," approved 02/19/09, showed the following direction:
- Hospital departments will conduct and report Quality Assessment and Performance Improvement activities in accordance with state and federal regulations.
- The Department Manager will be ultimately responsible for their department's QAPI projects including compliance with state and federal regulatory requirements.

2. Review of Quality Improvement (QI) project for the Pharmacy showed that the Pharmacy participated in several collaborative QI projects, but did not conduct their own QI projects and were not represented in the quarterly reports.

During an interview on 02/18/11 at 11:15 AM, Staff AA, Pharmacy Director, stated he/she was uncertain of what QI projects to do, didn't know how to set them up, and had not requested or received guidance.

3. Review of the "Quality Assessment and Performance Improvement Tracking Forms" for the 2010 ED projects showed each QI project undertaken by the ED was conducted over the course of three months, and then discontinued. Limited data was available for review in regard to length of stay, appropriateness of transfers, physician response time, provision of written instructions, timeliness of diagnostic studies, appropriateness of treatment rendered in the emergency department, and mortality - QI projects required by Missouri law.

The project titled "Chart Review," showed data for the months of January, February, and March, 2010. The QI goals were: Length of stay < two hours 75% of the time, Dr. response time < 30 minutes 90% of the time, and Discharge Instructions Given to 100% of patients. A total of 14 medical records were reviewed each month.
- The indicator of "Length of stay < two hours" was measured at 93% in January, 71% in February, and 86% in March.
- The indicator of "Dr. response time < 30 minutes" was measured at 71% in January, 64% in February, and 86% in March.
- Despite the varied results, the project was discontinued. A note on the form stated, "Will stop CQI and Continue PRN (First quarter of each year.)"
- There was no evidence that the data collected in any of the indicators was analyzed to determine a cause for variance in the measure of success.
- There was no evidence that performance was tracked to ensure sustained success.

The project titled, "Transfers," showed data for the months of April, May and June, 2010. The QI indicators were: Transfer information complete, Appropriate risk/benefits, Consent signed, Orders written, Vital signs within 15 minutes of discharge, and Cert. time (meaning unknown) within 15 minutes of discharge. The goal for all indicators was 100%. A total of 37 medical records were reviewed in April, 30 in May, and 41 in June.
- The indicator of "Transfer information complete" was measured at 97% in April, 90% in May, and 93% in June.
- There was no indication of level necessary to achieve success, but a note stated, "Improvement needed specifically in cert.time within 15 minutes of transfer."
- Despite the varied results, the project was discontinued. A note on the form stated, "Will stop CQI and Continue prn. Will review Second quarter 2011."
- There was no evidence that the data collected in any of the indicators was analyzed to determine a cause for variance in the measure of success.
- There was no evidence that performance was tracked to ensure sustained success.

The project titled, "Mortality," showed data for the months of July, August and September, 2010. The QI indicators were: Organ donation form complete, Death record complete, Hospital guideline/policy followed, and Needs medical review. The goal for all indicators was 100%. There were no deaths to review in July. One medical record was reviewed in August, and one in September.
- All indicators were measured at 100% for the three months reviewed.
- A note states, "Will stop CQI at this time and continue prn."

The project titled, "AMA (Against Medical Advice)," showed data for the months of July, August and September, 2010. The QI indicators were: Patients decision making, patients reason for leaving, Appropriate risks/benefits, and Discharge instructions given. The goal for all indicators was 100%. There were 11 medical records reviewed in July, seven in August, and 11 in September.
- The indicator of "Discharge instructions given" was measured at 91% in July, 43% in August, and 82% in September.
- Despite the varied results, the project was discontinued. A note on the form stated, "Will stop CQI at this time and continue PRN (Third quarter of each year.)"
- There was no evidence that the data collected in any of the indicators was analyzed to determine a cause for variance in the measure of success.
- There was no evidence that performance was tracked to ensure sustained success.

The project titled, "Chest Pain Review for Timeliness of Diagnostic Studies," showed data for the months of October, November and December, 2010. The QI indicators were: Lab results returned within one hour of arrival, EKG (electrocardiogram - a test monitoring the electrical activity of the heart) within 15 minutes of arrival, and CXR (chest x-ray) within 30 minutes of arrival. The goal for all indicators was 85%. A note states, "Will review all charts on patients admitted or transferred with chest pain for timeliness of diagnostic studies as defined above. Admissions will assist with gathering of data." There were 11 medical records reviewed each month.
- The indicator of "Lab results within one hour of arrival" was measured at 64% in October, 82% in November, and 91% in December.
- The indicator of "EKG within 15 minutes of arrival" was measured at 82% in October, 92% in November, and 100% in December.
- The indicator of "CXR within 30 minutes of arrival" was measured at 73% in October, 92% in November, and 91% in December.
- Despite the varied results, the project was discontinued. A note on the form stated, "Will continue to monitor prn."
- There was no evidence that the data collected in any of the indicators was analyzed to determine a cause for variance in the measure of success.
- There was no evidence that performance was tracked to ensure sustained success.

The project titled, "Appropriateness of Treatment Rendered," showed data for the month of April, 2010. The QI indicator was: The ED Medical Director will approve of treatment rendered by Emergency Room (ER) physician no less than 90% of the time. One Physician's medical care was evaluated in April. Five routine ED medical records were reviewed for treatment in the ED, and five medical records were reviewed for patients who transferred to another facility, were admitted, or left AMA.
- The chart reviews were rated at 100% approval.
- A note states, "Will stop CQI at this time."
- No other physicians were evaluated for appropriateness of treatment rendered in 2010.

4. During an interview on 02/15/11 at 2:15 PM, Staff B, ED Nurse Manager, stated the following:
- The determination to abstract ED QI data on an annual basis was the result of a conversation with Staff S, QI Director, in which state and federal regulations were discussed. According to Staff B, the regulations did not specify how frequently QI data had to be collected, so annual collection was considered to be sufficient.
- The ED Medical Director reviews two physicians per year for appropriateness of treatment rendered.

5. Review of the proposed 2011 ED QI projects showed the following:
- 1st Quarter - Chart Review CQI: Review First 14 charts of month (Non Admit, Transfer, AMA) - Includes Length of Stay, Dr. Response Time, and Receipt of Discharge Instructions;
- 2nd Quarter - Transfer: Review First 30 Transfers of Each Month;
- 3rd Quarter - AMA and Mortality: Review all AMA and Deaths;
- 4th Quarter - Chest Pain: Review Chest Pain Charts (On Admits and Transfers Only); and
- Medical Director - Ongoing Appropriateness of Treatment Rendered of ER Doctors.

There was no indication of the quality indicators, goals, or analysis methodology.

6. During an interview on 02/17/11 at 1:40 PM, Staff S, QI Director, stated the following:
- Department Directors developed their own QI projects for the year, including determination of quality indicators, measurement criteria and goals, without input from the Governing Body, the Medical Staff, the QI Committee, or the QI Coordinator.
- QI projects chosen by each Department Director did not require approval prior to implementation and were not reviewed prior to implementation.
- The reason the ED looked at QI indicators on a quarterly basis and then discontinued the project was "because Staff B was struggling to get the data abstracted. Staff B was looking at every indicator every month. If the data isn't showing improvement, Staff B needed to keep reviewing the data for at least at six months."
- The QI Program was based upon retrospective review. Quarterly QI data was submitted to the QI Department for inclusion in summary reports that were presented to the facility's QI Committee, Medical Staff, and Governing Body at quarterly meetings. Members of the various groups were given an opportunity to review the data and request clarification, but "very rarely" asked questions or gave direction.
- The ED Medical Director did some chart reviews when patient complaints were investigated, but any data derived from those chart reviews was not shared with the QI Director.

Based upon policy review and interviews, the facility failed to ensure that:
- The Governing Body, the Medical Staff, and the Administrative staff are responsible for the Quality Assessment/Performance Improvement Program;
- The program had clear definition, including ongoing program priorities for improving quality of care and patient safety; and
- All improvement actions are evaluated. These failures applied to all patient services. The facility census was 14.

Findings included:

1. Record review of the facility's document titled, "Quality Assessment and Performance Improvement Plan," reviewed 05/20/10, showed the following:
- PURPOSE: The organizational program, established by the Medical Staff and Interdisciplinary Quality Assessment and Performance Improvement Committee, with support and approval from the Governing Board, has the responsibility for monitoring every aspect of patient care and services (including contracted services), from the time the patient enters the hospital through diagnosis, treatment, recovery and discharge in order to identify and resolve any breakdowns that may result in less than optimal patient care and safety, while striving to continuously improve and facilitate positive patient outcomes.
- GOALS: That clinical and administrative staffs monitor and evaluate the quality and appropriateness of patient care and clinical performance, resolve identified problems, and report information necessary for the Governing Board to assist in fulfilling its responsibility to the quality of patient care.
- ASSIGNED RESPONSIBILITY AND AUTHORITY: The Governing Board of Bates County Memorial Hospital shall support and have the final authority and responsibility for the assessment of a flexible, comprehensive and integrated Quality Assessment and Performance Improvement Program and will delegate the authority and accountability for the operation of the program to the Administration and Medical Staff.
- ORGANIZATION: Bates County Memorial Hospital shall organize a committee to be named the Quality Assessment and Performance Improvement Committee. This committee shall be responsible for monitoring, assessing, and evaluating hospital-wide quality assessment and performance improvement activities. This committee shall be composed of the following:
- Governing Board members appointed yearly by the President of the Governing Board.
- Medical Staff members appointed yearly by the Chief of the Medical Staff.

2. Review of facility documents showed that the core administrative body failed to be responsible and involved in the Quality Improvement (QI) Program, and that the current QI Program failed to have specific priority focus for improving patient safety so that all improvement actions were evaluated.

Review of the Bates County Memorial Hospital Continuous QI Committee meeting minutes for calendar year 2010 showed the following:
- Review of members attending the February 9, 2010 meeting showed that there were no representatives of the Governing Body in attendance. One member of the Medical Staff attended.
- Review of members attending the May 11, 2010 meeting showed that there were no representatives of the Governing Body in attendance. One member of the Medical Staff attended.
- Review of members attending the August 10, 2010 meeting showed that there were no representatives of the Governing Body in attendance. One member of the Medical Staff attended.
- Review of members attending the November 16, 2010 meeting showed that there were no representatives of the Governing Body or Medical Staff in attendance.
- Minutes of each Continuous QI Committee meeting showed evidence of review and discussion regarding employee suggestions, review of event reports, review of regulatory compliance, and review of QI reports for the quarter of the year under discussion.
- Minutes of each Continuous QI Committee meeting failed to provide evidence of what was discussed during review of QI reports, whether questions or concerns were raised, or whether guidance was offered.

3. During an interview on 02/17/11 at 1:40 PM, Staff S, QI Director, stated the following:
- The QI Program was based upon retrospective review. Quarterly QI data was submitted to the QI Department for inclusion in summary reports that were presented to the facility's QI Committee, Medical Staff, and Governing Body at quarterly meetings. Members of the various groups were given an opportunity to review the data and request clarification, but "very rarely" asked questions or gave direction.
- Department Directors developed their own QI projects for the year, including determination of quality indicators, measurement criteria and goals, without input from the Governing Body, the Medical Staff, the QI Committee, or the QI Coordinator.
- QI projects chosen by each Department Director did not require approval prior to implementation and were not reviewed prior to implementation.

The hospital's governing body failed to ensure an ongoing program for quality improvement when the nursing services department and the infection control department failed to have quality improvement activities defined and implemented for 2011.

The facility census was 14.

Findings Included:

During an interview on 02/17/11 at approximately 10:45 AM, with Nursing Supervisor, Staff R, showed the following:
-He/she confirmed nursing services had not developed QAPI (Quality Assurance/Performance Improvement) indicators for year 2011;
-He/she confirmed no QAPI monitoring had been done thus far in 2011;
-He/she confirmed monitoring and collection data sheets had not been retained for 2010; and
-He/she confirmed the governing body had been involved in the approval for the QAPI for 2011.

During an interview with the Infection Control Coordinator, Staff CC, on 02/18/11 at approximately 9:30 AM, showed the following:
-He/she confirmed the infection control department had not developed QAPI (Quality Assurance/Performance Improvement) indicators for year 2011;
-He/she confirmed no QAPI monitoring had been done thus far in 2011; and
-He/she confirmed the governing body had not been involved in the approval for the QAPI for 2011.

Based on interview, and policy review the facility failed to promptly retrieve and secure medical records from the outpatient clinic. The number of patients seen in the clinic was 39. The facility census was 14.

Findings Included:

Record review of the facility policy titled, "Outpatient/Emergency Room Records," revised 08/12/98 showed the following direction:
-An outpatient/emergency room record is initiated on any person asking for/or receiving treatment in the outpatient/emergency department.
- The outpatient/emergency records are picked up each morning in the emergency/outpatient offices.

During an interview on 02/16/11 at 2:35 PM, Staff T, Admission Clerk, stated that a face sheet (A sheet that has the patients date of birth, social security number, address, phone number, family or friend name and contact phone number, insurance, physician, and diagnosis), physician orders sheet, and a consent for treatment on each patient seen for the day were put together, placed in a folder, secured with a rubber band, and placed in an unsecured, open, wire basket. The next morning a staff from medical records would pick up these medical records.

During an interview on 02/16/11 at 2:38 PM, Staff N, Clinical Supervisor of Outpatient Clinic, stated housekeeping came in at night to clean the clinic and the medical records remained in the unsecured wire basket until the next morning. This allowed housekeeping employees access to information about each of the patients seen in the clinic that day.

Based on record review and interview, the facility failed to ensure the policy and procedure manuals for pharmaceutical services were reviewed and revised according to facility policy. This had the potential to affect all patients accessing care in the facility. The facility census was 14.

Findings included:

Record review of the Pharmacy "Policy and Procedure" manual on 02/18/11 at 8:50 AM, showed policies too numerous to count that were revised and approved in June, 2008.

During an interview on 02/18/11 at 11:00 AM, Staff AA, Pharmacy Director, stated the Pharmacy policies have/been scanned into the computer and he/she reviewed and updated them in the computer. Staff AA stated the goal was to review the policies annually, but the policy and procedure manual available to Pharmacy staff had not been kept current.

Based on observation and interview, the facility failed to ensure medications are kept in a secured area to prevent access by unauthorized persons. This had the potential to affect all patients accessing care in the Emergency Department (ED) and five patients in the Critical Care Unit (CCU). The facility census was 14.

Findings included:

1. Observation during a tour of the ED on 02/15/11 at 2:15 PM, showed a rolling cart containing IV (intravenous) catheters and a rack of prefilled normal saline syringes sitting on the visitor side of the ED nursing station. The cart was accessible to anyone entering the ED.

During an interview on 02/15/11 at 2:20 PM, Staff A, Emergency Department Director, stated the cart was set-up to roll into ED exam rooms so that nurses would have easy access to supplies necessary to start IV's. Staff A stated the normal saline syringes had not been considered medication, therefore access was not restricted.

2. Observation during a tour of the CCU on 02/16/11 at 12:45 PM, showed an open supply closet. Items noted in this supply closet were two disposable enemas containing Bisacodyl (used to treat constipation) and two disposable enemas containing Mineral Oil (also used to treat constipation).

During an interview on 02/16/11 at 12:55 PM, Staff R, Medical/Surgical Manager, stated the "clean" patient supplies are kept in the storage closet and the door was generally left open. Staff R stated the enemas were considered part of floor stock, and were supplied by the Central Supply Department. Staff R stated the enemas were not considered medication, but agreed that access should be restricted.

3. During an interview on 02/18/11 at 11:00 AM, Staff AA, Pharmacy Director, stated normal saline syringes and disposable enemas had not been considered medications in the past, therefore the security of these items had not been questioned. Staff AA indicated changes would be put into effect to ensure that these items were controlled and kept in secure locations to prevent tampering.




Based on observation and interview, the facility failed to ensure medications are kept in a secured area to prevent access by unauthorized persons. This had the potential to affect all patients accessing care in the Emergency Department (ED) and five patients in the Critical Care Unit (CCU). The facility census was 14.

Findings included:

1. Observation during a tour of the ED on 02/15/11 at 2:15 PM, showed a rolling cart containing IV (intravenous) catheters and a rack of prefilled normal saline syringes sitting on the visitor side of the ED nursing station. The cart was accessible to anyone entering the ED.

During an interview on 02/15/11 at 2:20 PM, Staff A, Emergency Department Director, stated the cart was set-up to roll into ED exam rooms so that nurses would have easy access to supplies necessary to start IV's. Staff A stated the normal saline syringes had not been considered medication, therefore access was not restricted.

2. Observation during a tour of the CCU on 02/16/11 at 12:45 PM, showed an open supply closet. Items noted in this supply closet were two disposable enemas containing Bisacodyl (used to treat constipation) and two disposable enemas containing Mineral Oil (also used to treat constipation).

During an interview on 02/16/11 at 12:55 PM, Staff R, Medical/Surgical Manager, stated the "clean" patient supplies are kept in the storage closet and the door was generally left open. Staff R stated the enemas were considered part of floor stock, and were supplied by the Central Supply Department. Staff R stated the enemas were not considered medication, but agreed that access should be restricted.

3. During an interview on 02/18/11 at 11:00 AM, Staff AA, Pharmacy Director, stated normal saline syringes and disposable enemas had not been considered medications in the past, therefore the security of these items had not been questioned. Staff AA indicated changes would be put into effect to ensure that these items were controlled and kept in secure locations to prevent tampering.

Based on observation and interview, the facility failed to ensure that expired medications were not available for patient use in the Rehabilitation Department of the facility. This affected all Inpatients and Outpatients accessing rehabilitation care at the facility. The facility census was 14.

Findings Included:

1. Review of the facility's Pharmacy policy titled, "Outdated (Expired) and Unusable Drugs and Devices," reviewed 06/08, showed the following direction:
- The Pharmacy shall identify outdated and other unusable drugs and devices and prevent their distribution and administration. The Director of Pharmacy or qualified designee shall survey for outdated and otherwise unusable drugs and devices during the monthly inspection of the facility.
- If an expiration date is expressed only as a month and year, the date of expiration shall be the conclusion of the last day of the stated month.

2. During a tour of the Rehabilitation Department on 02/16/11 at 4:00 PM, observation of a medication cabinet showed a bottle of Dexamethasone (a drug used to reduce inflammation) 2 mg (milligram, a unit of measure)/ (per) ml (milliliter, a unit of measure). The bottle was labeled as having once contained 480 ml, and had a label from the facility pharmacy. A second, smaller bottle with an identical label was fitted with a device that allowed a needleless syringe to be affixed to it so that a specific amount of medication could be withdrawn. Both bottles were labeled with an expiration date of 12/10. Approximately 100 ml of the solution remained in the bottle.

During an interview on 02/16/11 at 4:10 PM, Staff P, Rehabilitation Director, stated medication was transferred from the larger bottle to the smaller of the two bottles as needed. The smaller of the two bottles had a special cap that allowed the medication to be withdrawn from the bottle using a syringe. Withdrawn medication was then applied to a small pad that was placed against a patient's skin. Using a process called Iontopheresis, an electrical charge was used to deliver the medication through the skin without using a needle. Staff P stated that the procedure wasn't prescribed often, but that he/she had done the procedure on 02/15/11 for a patient, and did not notice the bottle of medication was expired.

Based on observation, interview, and policy review the facility failed to ensure that expired supplies were not available for use in patient care areas. The facility census was 14.

Findings Included:

1. Record review of the facility policy titled, "Outdated (Expired) and Unusable Drugs and Devices," reviewed 06/08 showed the following direction:
- Unusable drugs and devices include those that are:
-Expired;
-Recalled;
-Contaminated;
-Broken or deteriorated;
-Mislabeled (improper, illegible, missing, or worn);
-Otherwise unsuitable for administration or use.
- All supplies that expire or outdate should be monitored and replaced before depletion of stock.

Review of the facility's policy titled, "General Infection Control Policy," reviewed 06/30/08, showed the following direction: Equipment: Items that have an expiration date and that are outdated will be removed and sent to Central Sterile for disposal.

Review of the facility's policy titled, "Crash Cart: Daily Inventory," reviewed 09/01/10, showed the following direction: Nursing will replace any expired non-pharmaceutical supplies.

2. Observation on 02/16/11 at 10:15 AM, showed a glutaraldehyde (disinfectant solution for sterilization of non-heat-resistant equipment) sensor (used to check high levels of glutaraldehyde in the area.) in the Same Day Surgery Department refrigerator that expired on 12/10.

During an interview on 02/16/11 at 10:15 AM, Staff J, RN (Registered Nurse), Surgery Manager, confirmed that the Glutaraldehyde Sensor was expired.


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3. Observation of an unattended, unlocked wound care cart in the hall outside of room #235, on 02/16/11 at 3:05 PM, showed the following expired wound care supplies:
-Textile antimicrobien skin fold agent (a skin product used for healing wounds in skin folds) with expiration date of 12/2010; and
-Two Hydrophilic (an absorptive dressing) wound dressing packages with expiration date of 09/2009.

An interview on 02/16/11 at 3:05 PM, with Staff H, he/she confirmed the wound care supplies were outdated. He/she removed the outdated supplies from the wound care cart.



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4. During a tour of the CCU on 02/16/11 at 1:15 PM, the Broselow Resuscitation System Bag used for responding to pediatric emergencies was examined. Random inspection of several pockets within the bag revealed four intravenous (IV) catheters that were outdated. Two catheters outdated 04/10, and two outdated 05/10.

During an interview on 02/16/11 at 1:20 PM, Staff R, Medical/Surgical Manager, stated the crash cart and supplies are carefully checked on a monthly basis, but somehow these items were overlooked. Staff R confirmed the IV catheters were expired.

Based on observation, interview, and policy review, the facility failed to:
- Provide cleanable surfaces in the Operating Room and Rehabilitation Department, which affected all patients accessing these services;
- Maintain emergency equipment for immediate patient use; and
- Follow hand hygiene policy when providing care to two patients (#15 and #19) of 16 patients observing during nursing care. The facility census was 14.

Findings Included:

1. Record review of the Rehabilitation Department policy titled, "Infection Control Guidelines," reviewed 02/14/11, showed the following direction: Responsibilities of the Director and/or Assistant Director: Ensure proper maintenance and cleaning of all equipment.

Record review of the facility's policy titled, "Damaged Hospital Property," showed the following direction: All damage to hospital property will be reported and followed-up in a timely manner.

Record review of the facility's policy titled, "Hand Hygiene," reviewed 06/30/08, showed the following direction:
- Alcohol-based hand rubs should be used for routine decontamination in all other clinical situations if available. If not, hand washing with antimicrobial soap and water is an acceptable alternative. Decontamination of hands should be performed:
- Before and after having direct contact with patients;
- After contact with a patient's intact skin;
- After removing gloves or other Personal Protective Equipment;
- After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient;
- If moving from a contaminated-body site to a clean-body site during patient care;
- After contact with body fluids or excretions, mucous membranes, on-intact skin, and wound dressings if hand are not visibly soiled;
- Before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure; and
- Before donning sterile gloves when inserting a central intravenous catheter.
Glove Use:
- Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and non-intact skin could occur.
- Change gloves during patient care if moving from a contaminated body site to a clean body site.
- Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient, and do not wash gloves between uses with different patients.

2. Observation on 02/16/11 at 10:40 AM, in the GI (Gastrointestinal) Lab (an area where tests are performed using an illuminated optical instrument for visualization of interior body cavities) showed a pole used to suspend intravenous (IV) fluids. Rusted areas were noted around the circumference approximately two-thirds down from the top of the pole. The rusted areas ranged in size from approximately pin point to the size of a pencil eraser head. Just below the rust area was an area of adhesive residue, approximately the size of a quarter.

During an interview on 02/16/11 Staff J, Surgery Manager, confirmed the presence of the rust areas and the adhesive residue on the IV pole.

3. Observation on 02/16/11 at 10:55 AM, in operating room #1 showed two areas of adhesive residue on the operating room table pad in the following areas:
- On the left side of the middle table pad, measuring approximately five inches by 10 inches; and
- Ten pin point spots on the opposite (right) side of the same table pad.

During an interview on 02/16/11 at 10:55 AM, Staff J, confirmed the presence of the two areas of adhesive residue.

4. Observation on 02/16/11 at 11:05 AM, in operating room #2 showed the following:
- A total of 30 open areas around the perimeter of each of the three operating room table pads. The openings ranged from pin point to one and a half inches in length;
- Adhesive residue was noted to the left side of the middle operating room table pad, approximately one and a half inches by one and a half inches;
- A rolling IV pole showed rust around the pole where it attached to the pole base, and rust on five casters (metal that attaches wheels to the base of the IV pole);
- A Roller board (a device used to transfer patients between flat surfaces) had 52 open areas on one side, 54 open areas on the other side, and 15 open areas on the middle section of the material. All open areas were less than one centimeter in length; and
- Adhesive residue on both sides and the top surface of an arm board as showed the following:
- One side area was approximately 18 inches by two inches;
- A second side area was approximately 16 inches by two inches wide; and
- The top of the board showed five areas approximately the size of an eraser head of a pencil.

During an interview on 02/16/11 at 11:05 AM, Staff J, confirmed the presence of the 30 open areas and adhesive residue on the operating room table, the presence of rust on the IV pole and wheel casters, the open areas on the roller board, and the areas of adhesive residue on the sides and top surface of the arm board.

5. Observation on 02/16/11 at 2:00 PM, Staff I, Chief Nursing Officer, had gloves on to clean blood from Patient #15 after insertion of an intravenous catheter. Without removing his/her gloves, Staff I put his/her gloved right hand into his/her right pocket to obtain a pen. Staff I failed to perform hand hygiene after removing the gloves.

6. Observation on 02/16/11 at 2:45 PM, Outpatient Clinic room #6 showed an IV pole with rust ring around the pole approximately 1/4 inch in width, where the pole attaches to the base and tape approximately two inches wide by two inches long with the initials CT written on it on one of the legs of the base.
(How large was the area of rust on the pole?)

During an interview on 02/16/11 at 2:45 PM, Staff I and Staff N, Clinical Supervisor Outpatient Clinic, confirmed that the IV pole had a rusted area and tape was present on the pole.

7. Observation on 02/16/11 at 2:50 PM, in the Outpatient Clinic soiled utility room showed a defibrillator (a device that uses an electric shock to make the heart beat correctly.) for emergency patient use.
(Explain what a defibrillator is please.)

During an interview on 02/16/11 at 2:50 PM, Staff I and Staff N, stated that the defibrillator should not be stored in the soiled utility room and stated it would be cleaned and relocated to a clean area.

8. During an interview on 02/16/11 at 3:55 PM, Staff I stated that the facility did not have any policies regarding cleaning of adhesive residue from mattresses or removal and/or repair of mattresses when they have open areas.
(OK what is this example in regard to? Is it to the mattresses mentioned above in the OR rooms/areas? If so this needs to be and read more clearly to the reader or moved up to be place directly with the OR examples?)


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9. Observation in the Critical Care Unit (CCU) on 02/16/11 at 1:15 PM, showed Staff Q, Registered Nurse (RN), preparing an IV medication (medication administered directly into a vein) for Patient #19. The following actions were observed:
- Without performing hand hygiene, Staff Q entered the CCU Medication Room and prepared Patient #19's IV medication, which included puncturing the medication bag and priming IV tubing.
- Without performing hand hygiene, Staff Q applied gloves and went to the bedside to hang the medication. While untangling Patient #19's IV tubing, Staff Q lifted and untangled the foley catheter (a tube into the bladder to drain urine) tubing and bag, which had become tangled with the IV tubing. After this was accomplished, Staff Q re-hung the catheter bag on the side of Patient #19's bed.
- Without performing hand hygiene or changing gloves, Staff Q administered the IV medication by accessing a port on the IV tubing and connecting the two tubes.
- Without performing hand hygiene or changing gloves, Staff Q programmed the infusion pump to administer the medication.
- Without performing hand hygiene or changing gloves, Staff Q removed an IV catheter from Patient #19's other hand that was no longer functional, applied pressure to the insertion site, and applied a bandage.
- Staff Q then gathered all the used supplies from the room and disposed of them by using his/her gloved hand to raise the lid of the waste can in the room rather than depressing the foot pedal.
- Staff Q then disposed of his/her gloves and performed hand hygiene. Before leaving the room, Staff Q went back to the IV pump and reprogrammed it, then left the patient's room without performing hand hygiene and returned to the nursing station.

During an interview on 02/16/11 at 1:45 PM, Staff R, Medical/Surgical Manager, stated employees should wash hands or wear gloves during medication administration. Staff R stated Staff Q should have washed his/her hands and reapplied gloves after handing the catheter bag and prior to handling the IV fluid bag and administering medication. Staff R also stated Staff Q should have not used his/her hands to open the waste can to dispose of used supplies, and should have performed hand hygiene again prior to exiting Patient #19's room.

10. Observation on 02/16/11 at 4:15 PM, during a tour of the Rehabilitation Department showed a treatment table in the Wound Treatment room. Inspection of the table showed a one inch wide by two inch long piece of silk tape on the side of the table that was dark brown/black from an unknown substance. Inspection of a large therapy table in the Rehabilitation Department showed that the protective covering had been torn away from two of four corners revealing a second layer of clear plastic covering a white material. The area torn from one of the two corners was approximately one inch by one and a half inches. The area torn from the second corner was approximately one half inch by one inch.

During an interview on 02/16/11 at 4:20 PM, Staff P, Rehabilitation Director, stated the tables are wiped with Sani-Cleans wipes each day to remove bacteria and debris. Staff P agreed that the tables could not be effectively cleaned due to the tape, tape residue, and torn covering areas.

Based on record review and interview the facility failed to follow facility policy and assure integration and communication between outpatient services and medical surgical floor of the facility in four patients (#28,#29,#30, and #32) of seven discharged patients. The facility census was 14.

Findings Included:

Record review of the facility policy titled "Outpatient Record," revised 01/05/11 showed patients admitted from the outpatient department require a patient report to be called to the receiving care provider by the outpatient staff.

During an interview 02/17/11 at 1:35 PM, with Staff N, Clinical Supervisor Outpatient Clinic, stated that when a patient of the outpatient clinic is admitted to an inpatient status prior to the patient going to the floor as an inpatient, an outpatient nurse calls a report to the inpatient nurse.

Review Patient #28's outpatient record showed no documentation of a call between the outpatient nurse and the medical surgical nurse prior to Patient #28's admission to the medical surgical floor.

Review Patient #29's outpatient record showed no documentation of a call between the outpatient nurse and the medical surgical nurse prior to Patient #29's admission to the medical surgical floor.

Review Patient #30's outpatient record showed no documentation of a call between the outpatient nurse and the medical surgical nurse prior to Patient #30's admission to the medical surgical floor.

Review Patient #32's outpatient record showed no documentation of a call between the outpatient nurse and the medical surgical nurse prior to Patient #32's admission to the medical surgical floor.

During an interview on 02/17/11 at 2:35 PM, Staff N, stated the hospital did not have a tracking system to locate any more patient records of patient's that were admitted from the outpatient clinic to the hospital later than 2009 for review. Staff N confirmed that in the above four admissions no nurse to nurse calls were documented.

Based on record review and interview, the facility failed to ensure that medical care provided to patients was assessed on a continual basis.

The facility census was 14.

1. Record review of the facility's document titled, "Quality Assessment and Performance Improvement Plan," reviewed 05/20/10, showed the following:
- SCOPE OF ACTIVITIES: Data collection for Medical Staff quality assessment and performance improvement activities shall be overseen by the Quality Management Director, who with the Medical Staff may delegate data collection responsibilities as required. Results of data collection will be forwarded to the Medical Record Committee for review.

Review of Quality Improvement (QI) Data provided during the survey showed no evidence that this process occurred.

2. During an interview on 02/17/11 at 1:40 PM, Staff S, QI Director, stated the Medical Director reviews quarterly reports, but otherwise is not involved in QI activities.

3. Review of the Emergency Department (ED) Quality Improvement project titled, "Appropriateness of Treatment Rendered," showed data for the month of April, 2010.
- The quality indicator was: The ED Medical Director will approve of treatment rendered by ER physician no less than 90% of the time.
- One Physician's medical care was evaluated in April. Five routine ED medical records were reviewed for treatment in the ED, and five medical records were reviewed for patients who transferred to another facility, were admitted, or left AMA.
- The chart reviews were rated at 100% approval.
- A note states, "Will stop CQI at this time."
- No other physicians were evaluated for appropriateness of treatment rendered in 2010.

Based upon record review and interview, the Rehabilitation Department failed to have physician oversight for the quality and scope of rehabilitative services, including review of services provided, policies, and quality improvement activities. This affected all Inpatients and Outpatients accessing care from the Rehabilitation Department. The Rehabilitation Department is a contracted service of the hospital. The facility census was 14.

Findings included:

Record review of the facility's Rehabilitation Department "Policy and Procedure" manual showed that policies were not reviewed or signed by the Medical Director.

During an interview on 02/16/11 at 3:40 PM, Staff P, Rehabilitation Director, stated Staff Z, Medical Director, did not provide oversight of services provided by the Rehabilitation Department, did not review or contribute to Policies and Procedures, and did not review or contribute to QI activities. Staff P stated medical staff "rotate through the various departments as Medical Director," and Staff Z had been the Medical Director of the Rehabilitation Department for several years.

During an interview on 02/18/11 at 1:10 PM, Staff Z stated that he/she did not have experience with rehabilitative care, and in fact, was appointed by the Chief of Staff as Medical Director for Rehabilitation Services that same day during a Medical Staff meeting. Staff Z stated his/her training was in the field of Family Practice, and that his/her role as Medical Director was to meet with the Department either monthly or quarterly, and review charts as requested.

During an interview on 02/18/11 at 1:20 PM, Staff W, Administrative Assistant, stated minutes from Medical Staff meetings showed that Staff Z was the Medical Director of the Rehabilitation Department during the calendar year 2010.