HospitalInspections.org

Based on review of hospital policy, documents (contracts), observations and interviews, it was determined the Governing Body failed to assume responsibility for all hospital operations as determined by non-compliance with the provisions for the Governing Body requiring accountability for the overall care of patients receiving contracted dialysis service. This deficient practice posed the significant risk to patients' health and safety, as demonstrated by:

A-0043: failure to require the contractor provided dialysis policies/procedures (as mutually agreed by contract); failure to require hospital staff performed tracheostomy suctioning for patients undergoing dialysis; failure to require patients undergoing dialysis were under the care and supervision of an RN; failure to require patients weights were obtained and documented pre/post dialysis per physician orders; and failure to require the hospital staff accompanied/attended the patient in transporting to the dialysis area.

The cumulative effect of this systemic deficient practice(s) resulted in the hospital's failure to meet the requirements for the Condition of Participation for the Governing Body.

Based on hospital policies, documents, and staff interviews, it was determined that the hospital failed to comply with the provisions of Quality Assurance Performance Improvement (QAPI). This deficient practice posed the significant risk that issues are not identified and addressed that impact health outcomes, patient safety, and quality of care, as demonstrated by:

A-0273: failure to require and implement corrective action for identified hospital-wide practices that were consistently reported at less than acceptable benchmarks, and failure to investigate and/or identify corrective action for Incident Reports.

The cumulative effect of these systemic deficient practices resulted in the hospital's failure to meet the requirements for the Condition of Participation for Quality Assurance Performance Improvement.

Based on review of hospital policy, documents (contracts), observations, and interviews, it was determined that the governing body failed to require the hospital was responsible for the overall care of the patients receiving contracted dialysis services. This deficient practice posed the significant risk to patients' health and safety, as demonstrated by:

1. failure to require the contractor provided dialysis policies/procedures (as mutually agreed by contract);

2. failure to require hospital staff performed tracheotomy suctioning for patients undergoing dialysis;

3. failure to require patients undergoing dialysis were under the care and supervision of an RN;

4. failure to require patients weights were obtained and documented pre/post dialysis per physician orders; and

5. failure to require the hospital staff accompanied/attended the patient in transporting to the dialysis area.

Findings include:

The hospital policy titled Governing Body #3559130 (last revised 05/2017) requires: "...Governing Body...is responsible for the overall operation of the hospital...."

The hospital policy titled Weight Measurement #3675099 requires: "...Weight measurement is scheduled...before and after dialysis treatment...."

The Master In-Hospital Dialysis and Apheresis Services Agreement between the hospital (HOSPITAL) and [name of the Dialysis Corporation providing Hemodialysis services] (PROVIDER) signed by both parties on 08/2016, requires: "...PROVIDER shall provide policies, procedures, and techniques pertaining to the methods by which the Services are rendered at HOSPITAL pursuant to this Agreement...PROVIDER staff shall not be responsible for providing any nursing, or other medical treatment and/or procedures to patients of HOSPITAL, in any way undertake the practice of nursing, or in any way interact with Patients. PROVIDER and Provider Staff shall not...be required to undertake the practice of medicine...HOSPITAL shall transport the Patient to and from such space for treatment...HOSPITAL has full medical responsibility for it's Patients...during the provision of the Services and agrees to supervise its Patients accordingly...."

The hospital has 4 floors. Patients are housed on the 4th floor only. The hospital's Intensive Care Unit (ICU) on the 3rd floor is closed to admitting patients, however, the hospital uses the space to provide contracted hemodialysis services. The patients from the 4th floor are transported to the 3rd floor for treatment then returned to their rooms post treatment.

The surveyor interviewed the staff and observed patients undergoing hemodialysis in the unit on 06/23/17, 06/26/17 and 06/28/17, as follows:

1. The surveyor asked contracted dialysis RN #39 for the dialysis policies/procedures. RN #39 replied that s/he did not have access to the policies, and that the policies were "stored and locked in a room on the 2nd floor."

2. Contracted RN #39 suctioned tracheotomies for patients in the dialysis area, as confirmed in the following interviews:

Respiratory Therapist (RT) #33 indicated on 06/26/17: "...dialysis (staff) will page us - or they will suction the tracheotomy...."

RT #6 indicated on 06/28/17: "...suctioning is in the scope of practice for the dialysis nurse. If the patient needs suctioning - most of the time (RN #39) will suction...."

RT #10 indicated on 06/28/17 regarding RN #39: "...I know s/he suctions patients in dialysis...(dialysis Patient #10) is comfortable having (RN #39) suction - it's a shared responsibility...."

3. Observation on 06/23/17 at 0930 revealed that contracted RN #39 left the 3rd floor dialysis area, and went to the 4th floor to retrieve patients, while leaving 3 dialyzing patients with the contracted Certified Hemodialysis Technician (CCHT) #48. A second surveyor was interviewing RN #5 on the 4th floor at the same time when contracted RN #39 presented and spoke to the surveyor and RN #5.

CCHT #48 confirmed during an interview and observation of the name badge that s/he was the technician, although the Dialysis Treatment Summary recorded "RN" after the name. The Arizona Board of Nursing website (www.azbn.gov) does not list an RN by the name on CCHT #48's name badge.

4. The Hemodialysis Physician Orders (in the patients' medical records for dialysis patients) requires: "...Crit Line:...Other _(blank)______ must be completed by ordering Nephrologist if the Crit-Line is not used...Pre and Post weights required if Crit-Line not used...."

Contracted RN #39 stated that s/he did not weigh dialysis patients pre/post treatment because "we don't use the Crit-line and the hospital's scales are broken...we're guests of the hospital - it's the hospital staff responsibility to weigh the patients..we've asked the staff to record the weights several times - it doesn't get addressed...I don't know how long the scales haven't worked...if they (hospital staff) don't get the weights, we (contracted dialysis staff) don't need to..it's the nephrologists' (sic) orders...."

In addition, the contractor's Area Administrator #49 spoke with the surveyor onsite on 06/26/17, and stated that the dialysis patients do not require weighing because "we don't go by weights - we go by how the patient tolerates the treatments based on their response, blood pressure, etc."

The surveyor observed/confirmed the following with the contracted RN #39 and CCHT #48 on 06/23/17 at 1000:

Patient #2 began dialyzing at 0845. The patient was in a hospital bed equipped with a bed scale, however, no pre-dialysis weight was recorded. When the surveyor inquired, the CCHT #48 obtained and recorded the weight.

Patient 5 began dialyzing at 0910. The patient was in a bed, and no pre-dialysis weight was recorded. The patient gets up with physicial therapy when on the inpatient unit, and the surveyor confirmed during the tour conducted on 06/23/17 that the wheelchair/standing scales functioned, but the patient was never weighed.

Patient #14 began dialyzing at 0940. The patient was seated in a chair. The patient is ambulatory. No pre-dialysis weight was recorded.

The Dialysis Treatment Summary records in the medical records revealed the following:

Patient #5: no recorded pre/post or dry weights: 06/23/17, 06/21/17, 06/19/17, 06/16/17, 06/14/17, and 06/12/17.

Patient #2: no recorded pre/post or dry weights: 06/05/17 and 06/07/17

In response to the staff not obtaining the patients pre/post dialysis weights, Nephrologist DO #1 indicated during an interview conducted on 06/28/17: "...there's room for improvement...the staff is going by clinical experience...."

5. The following interviews revealed:

RT #33 on 06/26/17identified: "...the dialysis nurse and the floor nurse transport patients to/from dialysis...."

Nursing Supervisor RN #3 on 06/28/17 stated: "...the dialysis RN comes to the unit to get the patient to take to dialysis. If the patient has oxygen needs the hospital Respiratory Therapist goes with the patient also...."

Unit Secretary #51 on 06/28/17, stated the same statement as RN #3.

RT #6 on 06/28/17 indicated that the respiratory therapist accompanies the patient to dialysis - and stated: "...usually the dialysis nurse comes upstairs and both accompany the patient downstairs...if there are other patients dialyzing downstairs, the dialysis technician stays with the patients...."

There was no evidence that the hospital verified/monitored the contracted dialysis services.

Based on review of hospital policies, documents, and staff interviews, it was determined that the hospital failed to require the Quality Improvement Plan (QI) 2017 included corrective action. This deficient practice posed the high risk that issues were not identified and addressed that impact health outcomes, patient safety, and quality of care, as demonstrated by:

1. failure to require corrective actions for items that fell below benchmarks; and

2. failure to investigate and/or identify corrective action for Incident Reports.

Findings include:

1. The Quality Improvement (QI) Plan 2017 requires: "...Before making a change to the process, participants will need to know the whole process from start to finish...Analyze data collected...Develop actions from the analysis of data...Monitoring results is essential...Hospital leadership will actively analyze, trend and address plans for improvement on a continuous basis...."

The Chief Executive Officer (CEO) confirmed during an interview conducted on 06/28/17, that RN #2 was the appointed Chief Quality Officer for both hospital campuses.

Chief Quality Officer RN #2 provided the untitled 2017 data collections sheets for both hospitals that indicated the categories and compliance percentages for each month January 2016 through May 2017 as follows: Case Management, Compliance, Nutrition, Health Information Management, Hospital Wide, Human Resources, Infection Control, Employee Health, Nursing, Wound Care, Outcomes, Pharmacy, Patient Satisfaction, Quality/Risk Management, Rehab Therapy, Respiratory Therapy, Radiology, and Worker's Comp.

Chief Quality Officer RN #2 confirmed the following during an interview conducted on 06/28/17:

The data sheets reflect Corporate requirements. The hospitals provide a monthly report to the Corporate office, in turn, the Corporate office provides the hospitals with "what to look at." Corporate determines benchmarks based on "all" hospitals in the system (12 total to include Arizona, Massachusetts, Oklahoma, and Louisiana).

Infection Control: D-Diff benchmark: 0 occurrences. The Infection Control LPN collects data and reports to the Chief Quality Officer who reports to "Quality and Med Exec." The Phx. hospital reported 1 case in May 2017. The Chief Quality Officer confirmed "we've not identified any need for corrective action."

Case Management Documentation: benchmark (10 chart audits/month). Benchmark 95% (of audits conducted). The Phx. hospital reported 63% compliance for the 1st quarter, and 0% for April and May 2017. "We had a new Case Manager started in April and...wasn't doing the audits...I met with (him/her) last week to show how to do the audits."

Nutrition: Documentation audit 10 chart audits/month). Benchmark 95% (of audits conducted). April and May 2017 both 0%. "We had a changeover...we're currently interviewing for a new dietician...we haven't had someone to do the audits." No corrective action.

Health Information Management: Charts completed within 30 days. Benchmark 100%. First quarter (January, February, March 2017) 2% compliance. April and May 2017 both 2% compliance. "We had a changeover." No corrective action.

Health Information Management: Discharge summary documented (10 chart audits/month). Benchmark 95%. First quarter: 7%. April 2017 90% and May 2017 20%. No corrective action.

Hospital Wide - Regulatory Rounding audits (5 rounds/month): Benchmark 95%. First quarter 55%. April 2017 75%. May 2017 0%. "This is for leadership rounds...they round different areas of the hospital...we haven't utilized the form...we just started our leadership committee - they're assigned to do the rounding...." No corrective action.

Outcomes: Unplanned Return to Acute (RTA). Benchmark 0. First quarter 8 cases. April 2017 3 cases, May 2017 3 cases. No corrective action. "we review case-by-case...some of those are unavoidable...Phx hospital April/May no trends to speak of...Northwest Hospital...I spoke with Quality and physicians...we're looking at practices and protocols to see what we can do the catch sepsis early and prevention. We identified that we need an RTA committee..we've been brainstorming but haven't formed a committee yet...."

Pharmacy: Total Medication Occurrences. Benchmark 0. First quarter 15 occurrences. April 2017 8 occurrences and May 2017 12 occurrences. "We're under reporting; worked on education regarding reporting process...we've had an increase in reporting...we're having a skills fair in September." No corrective action.

Respiratory Therapy: Wean Rate. Benchmark - unclear. First quarter 53%. April 2017 80%. May 2017 70%. "It's the percent of patients reported as weaning off the ventilator...the way we're reported...it's the number of patients currently being weaned." It was unclear what the benchmark was or action taken or required.

2. The hospital policy titled Incident Report #3653694 (last revised 11/2016) requires: "...All incidents must be acted upon within 24 hours of occurrence...."

The Incident Report form requires the following documentation: Type of incident i:e: fall, acute care transfer, medication variance, equipment-related, patient death, miscellaneous, code blue, injury sustained, and medical treatment, and requires Description of Incident/Treatment Administered and Investigation Comments to include the investigator's signature, name and title.

Phx hospital Incident Reports revealed the following:

Patient #5 on 06/06/17: Medication omission 3 doses of Vancomycin missed on 05/31/17 and 2 doses on 06/01/17. The Investigation Comments included "...no reason was given...as to why the...doses were not given....". The Chief Quality Officer signed the report. There was no documented evidence of investigation or corrective action.

Patient #4 on 05/29/17: Wrong medication. The nurse twice administered an unordered medication. The Chief Quality Officer documented under Investigation Comments: "No side effects noted related to medication administration." There was no documented evidence of investigation or corrective action.

Patient #4 on 05/26/17: Wrong medication. The nurse administered Oxycodone SR 10 mg instead of Oxycodone IR 10 mg. Investigation Comments: blank. There was no signature from the Chief Quality Officer and no documented investigation or corrective action.

Patient #8 on 05/15/17: Acute Care Transfer...severe respiratory compromise. The Chief Quality Officer documented under Investigation Comments: "Acute care transfer required due to ALOC (altered level of consciousness) with respiratory distress not resolved with BiPap". No documented evidence of investigation or corrective action.

Patient #12 on 06/18/17: Medication wrong dose. The Chief Quality Officer documented un Investigation Comments: Reviewed process of contacting pharmacy with any questions related to medication administration via PCA pump...(staff) verbalized understanding." No documented evidence of investigation or corrective action.

Patient #24 on 05/25/17: Wrong medication. The nurse administered Oxycodone SR 10 mg instead of Oxycodone IR 10 mg. The Chief Quality Officer documented under Investigation Comments: "No side effects noted related to medication administration." There was no documented evidence of investigation or corrective action.

Patient #24 on 06/04/17: Acute Care Transfer...trach dislocation, bleeding sub cue (sic) air. The Chief Quality Officer documented under Investigation Comments: "Acute care transfer required related to respiratory distress with bleeding." There was no documented evidence of investigation or corrective action.

Patient #25 on 05/24/17: Medication omission. The patient missed one dose of Valtrex, and Miracle mouthwash. Investigation Comments: "...nurse spoke with (nurse)...did not see the order...." There was no documented evidence of investigation or corrective action.

Patient #26 on 05/15/17: Medication omission. Late administration of 2 medications. The staff documented under Investigation Comments: "day shift RN states...falling behind". The Chief Quality Officer documented: "Medications administered." No documented evidence of investigation or corrective action.

Based on review of hospital policy, documents, observations, and interviews, it was determined the nurse executive failed to obtain and document patient weights according to policy and physicians orders. This deficient practice posed the risk for accurate medication prescribing and fluid balance monitoring as evidenced by:

1. failure to weigh and document dialysis patients pre and post hemodialysis treatments

2. failure to weigh and document per doctors orders

Findings include:

The hospital policy titled "Weight Measurement" #3675099 (last revised 06/2017) requires: "...Weight measurement is scheduled as follows: 1. Weight within 24 hr of admission 2. Physician orders 3. Before and after dialysis treatment...."


1. (11 out of 12) inpatients sampled had no documentation of the ordered weights and eleven (11) of those patients had multiple weights missed or not documented.

Patient #10

Patient #10 was admitted to the hospital on 05/02/2017 with multiple diagnosis including Respiratory Failure, End Stage Renal Disease (ESRD) on dialysis, Cardiomyopathy, Diabetes Mellitus (DM). Doctors orders titled "Hemodialysis Physicians Orders" reads "1. Pre and post weights required if Crit-Line not used". Both Program Director #49 and RN # 39 confirmed no Crit-Line is used at this facility and they do not weight the patients at this facility. On the patient's flowsheet in the medical record titled "Weight Record" on 04/18/2017 one (1) entry was appreciated. Noted that this entry was from the previous admit in April before returning from the hospital. No other documentation was on this flowsheet. Dialysis treatment (run) sheets sampled with seven out of eight (7 of 8) sheets failed to document weights. Of these sheets one (1) run sheet had weight documention that only contained a pre (before) weight no post (after) weight was documented. The patient's treatment flowsheet titled "treatment record" for dates 6/3/2017 to 6/16/2017 has a category labeled "Current WT with PT" that had no documentation listed for those dates. From 5/2/2017 to 6/23/2017 forty six (46) weights were ordered and only one (1) was performed in that time frame.

Nursing supervisor #3 confirmed that one weight of the forty six (1 of 46) weights ordered was documented, and that there are no other areas where weights would be located.

Patient #13

Patient # 13 was admitted to the hospital on 06/14/2017 with a diagnosis of Congestive Heart Failure (CHF) Doubutamine dependent, Chronic Kidney Disease (CKD), DM, and others. This patient had daily weights ordered on admission on 06/14/2017. On the patient medical record flowsheets titled "Treatment Record" and "Weight Record" from 06/14/2017 to 06/23/2017 only seven out of twelve (7 of 12) weights were documented.

Nursing supervisor #3 and RN #5 confirmed that five out of twelve (5 of 12) weights ordered were not documented, and that there are no other areas where weights would be located.

Patient #1

Patient #1 was admitted to the hospital on 2/11/2017 for Acute Renal Failure (ARF), Acute Respiratory Failure, and was status post heart cath. The patient was on dialysis from 2/11/2017 until 04/7/2017. An order for weights three times per week for dialysis was also written on admission.

Chief Quality Officer #2 confirmed there was no changes in orders for weights until 5/18/2017, that read "weekly weights".

From 4/7/2017 to 6/23/2017 twelve out of twenty one (12 of 21) weights were not documented in the patient's medical record.


2. Patients that had multiple undocumented weights as ordered by the physician were as follows:

Patient # 19 from 6/8/2017 to 6/26/2017 twelve of sixteen (12 of 16) weights were not documented. Pt was on dialysis and had physician orders for pre and post dialysis weights. The patient received dialysis three (3) times per week.

Patient # 7 from 5/18/2017 to 6/25/2017 twenty six out of thirty two (26 of 32) weights were not documented. Pt was on dialysis and had physician orders for pre and post dialysis weights. The patient received dialysis three (3) times per week.

Patient # 3 from 4/19/2017 to 6/23/2017 eight out of eleven (8 of 11) weights were not documented. Pt had physician orders for weekly weights.

Patient # 18 from 6/20/2017 to 6/27/2017 four out of six (4 of 6) weights were not documented. Pt was on dialysis and had physician orders for pre and post dialysis weights. The patient received dialysis three (3) times per week.

Patient # 12 from 6/7/2017 to 6/26/2017 fourteen out of sixteen (14 of 16) weights were not documented. Pt was on dialysis and had physician orders for pre and post dialysis weights. The patient received dialysis three (3) times per week.

Patient #15 from 6/2/2017 to 6/27/2017 two out of five (2 of 5) weights were not documented. The Patient had physician orders for weekly weights.

Patient #2 from 5/1/2017 to 6/26/2017 forty two out of forty eight (42 of 48) weights were not documented. Pt was on dialysis and had physician orders for pre and post dialysis weights. The patient received dialysis three (3) times per week.

Patient # 8 from 5/24/2017 to 6/23/2017 three out of five (3 of 5) weights were not documented. The patient had physician orders for weekly weights.

Patient # 4 from 4/7/2017 to 6/26/2017 eight out of twelve (8 of 12) weights were not documented. The patient had physician orders for weekly weights.

The surveyor interviewed Chief Quality Officer #2, Chief Compliance Officer #4, Chief Executive Officer #1, and Nursing Supervisors #3 and #12. All confirmed the ordered weights were not being documented in the patient medical record. Both Nursing Supervisor #3 and #12 verified there is no other place were weights would be documented other than the dialysis run sheets, the treatment sheet that stay with the nurses for a total of two (2) weeks, or the weight record flowsheet.

Based on review of hospital policy, documentation, observation, and interview, it was determined that the hospital's Infection Control Officer failed to implement the hospital's employee Tuberculosis (TB) testing policy. This deficient practice poses the significant risk to staff and patient's health and safety, as demonstrated by failure to require:

1. Ten of sixteen (10 of 16) employees that were employed for more than one year were screened annually for TB; and

2. One of one (1 of 1) TB test was not read prior to working at the hospital.

Findings include:

1. The hospital policy titled "TB Testing Guidelines" #3650721 (last revised 05/2017) requires: "...A. To reduce the spread of Tuberculosis...Tuberculosis screening...annually...."

Nine out of sixteen (9 of 16) employees sampled from staff roster failed to have a current Tuberculosis (TB) test or screening, as follows:

RN #41 and #20
Certified Nursing Assistant #40
Staffing Coordinator # 27
Environmental Service Aide #44
Monitor Technician #37
Data Processing Coordinator # 28
Food Service Manager #32
Registered Dietitian # 52

2. The hospital policy titled "TB Testing Guidelines" #3650721 (last revised 05/2017) requires: "...B Tuberculosis screening prior to employment...Employment will not begin until the test is read between 48 and 72 hours...."

Security Maintenance Technician #15 was employed on 6/5/2017 there was no documented evidence that TB screening performed on 6/5/2017 was read between 48 and 72 hours post placement as of survey date 6/23/2017.

Infection Control Officer LPN #19 confirmed during an interview on 06/26/2017 that all staff individually listed above were out of compliance with the hospital's TB policy.