HospitalInspections.org

Based on review of governing body bylaws, meeting minutes and staff interview it was determined the governing body failed to ensure the accountability for the quality of care provided to patients. This failure creates the potential for the quality of care for all patients to be adversely affected. Findings include:

1. The Bylaws of Highland Hospital Association, amended 9/24/01, were provided for review. The Bylaws state, in part, under section 10.2 "Standing Committees: The composition and responsibility of the various standing committees of the Board of Trustees shall be as follows..." Quality Management Committee: Shall consist of at least three Trustees, one of whom shall be designated by the chairperson, appointed by the Chairman. The responsibility of this Committee shall be to consistently reinforce the ultimate accountability of the Board of Trustees for the quality of care provided in the hospital, and to ensure that the hospital is effective in assessing and improving the quality of patient care. The Committee shall meet at least quarterly, and report its findings, conclusions, recommendations, and actions to the Board of Trustees."

2. The Board of Trustees Meeting Minutes were reviewed for the past year. The minutes reflected a quality report was given twice, on 4/26/10 and 9/28/10. The report was not included in the minutes and the minutes lacked any documentation of findings, conclusions, recommendations or actions taken related to quality.

3. An interview was conducted with the Chief Executive Officer (CEO) in the afternoon of 1/5/11. These bylaws and meeting minutes were discussed. He agreed with these findings.

A. Based on document review and staff interview it was determined the hospital failed to provide a response to all patients/representatives who file complaints/grievances, describing the results and conclusion of the grievances process. This deficient practice affected three (3) of seven (7) grievances reviewed from July 1, 2010 to December 31, 2010 (complaints #1, #2 and #3). Failure to comply with the grievances process can result in a violation of a patient's rights when the hospital does not inform the patient of their investigational findings and conclusions.
Findings include:

1. Seven (7) written hospital Complaints/grievances were reviewed from July 1, 2010 to December 31, 2010. Three (3) grievances one of which was dated 8/16/10 (complaint#1), one dated 10/21/10 (complaint #2) and one dated 11/5/10 ( complaint #3) lacked documentation of any investigational findings or resolution.

2. The Quality Management Director reviewed the above complaints on 1/4/10 in the afternoon. She agreed the above grievances lacked documented responses.

B. Based on document review and staff interview it was determined the hospital failed to provide a written response to all patients/representatives who file complaints/grievances that are to be completed within thirty (30) days as specified by hospital policy. This deficient practice affected three (3) of seven (7) complaints reviewed from July 1, 2010 to December 31, 2010 (complaints #3, #4 and #5). Failure to comply with the hospitals policy for the thirty (30) day completion of grievances can result in a violation of a patient's rights when they have not been informed of a complaint investigation and findings within the hospital's required time frame.
Findings include:

1. Review of hospital policy entitled Complaint Process (Reviewed 10/18/10) states in part the following: Documentation of review and follow-up on complaints will be presented to complainant in writing either in person or by mail within thirty (30) days of receipt of the complaint.

2. Seven (7) written hospital Complaints/grievances were reviewed from July 1, 2010 to December 31, 2010. Three (3) of the complaints had a written response which exceeded the thirty (30) day hospital policy for completion of the complaint process. Complaint #4 was submitted on 7/26/10 had a written response that was dated 9/27/10 which was sixty-two (62) days after complaint submission. Complaint #5 was submitted on 8/3/10 and had a written response dated 9/27/10 which was fifty-five (55) days from when the complaint was submitted. Complaint #6 was submitted on 8/9/10 and had a written response dated 9/27/10 which was forty-nine (49) days from when the complaint was submitted.

3. The Quality Management Director reviewed the above complaints on 1/4/10 in the afternoon. and agreed the written response to these complaints had not been completed in the required thirty (30) days.

Based on document review and staff interview it was determined the hospital failed to provide to the patient/representative who files a grievance a written response that describes the actions taken to investigate the grievance and the results/findings of this process. This deficient practice was found in three (3) of three (3) grievances filed from July 1, 2010 to December 31, 2010 that received a written response (Complaints #4, 5 and 6). Failure to inform the patient/representative of the investigation findings and efforts made to resolve the grievance can result in a violation of a patient's rights. Findings include:

1. Review of the written complaints/grievances from July 1, 2010 to December 31, 2010 revealed three (3) complaints that had written responses. Complaints #4, 5 and 6 had written responses which documented the complaint had been formally reviewed and investigated by a program director and will be reviewed by Performance Improvement Committee and Board of Directors on 9/28/10. These written responses did not contain the findings and conclusions of the investigations and any efforts that were made to resolve the complaint.

2. The Quality Management Director reviewed the above written complaint responses on 1/4/10 in the afternoon. She agreed the above written responses did not convey the findings of the investigations and any steps taken to resolve the complaint.

Based on review of training records and staff interview it was determined the hospital failed to ensure nursing staff maintain current certification in the use of cardiopulmonary resuscitation (CPR). This failed practice impacted two (2) of three (3) nurses reviewed (Employees #1 and #4). This failure creates the potential for an adverse impact on the condition of all patients who require emergency resuscitation. Findings include:

1. Review of the training record for Employee #1, who is a Registered Nurse (RN), revealed his CPR certification expired in December of 2010.

2. Review of the training record for Employee #4, who is a Licensed Practical Nurse (LPN), revealed his CPR certification expired in August of 2010.

3. These files were reviewed with the Director of Nursing (DON) in the afternoon of 1/5/11. He agreed with the findings.

Based on review of documents and interview with staff, it was determined the hospital's Quality Assessment Performance Improvement (QAPI) program failed to set measurable indicators and failed to show evidence any indicators could improve health outcomes. This has the potential to have a QAPI program which fails to improve the quality of care and improved outcomes for all patients. Findings include:

1. Review of the "Performance Improvement Plan 2010" and the "Performance Improvement Indicators and Oversight 2010" forms revealed there were no expected outcomes in measurable format listed. The "Indicators and Oversight" form only listed "Focus Area (i.e. restraints, order authentication's, etc.), Departments/Disciplines, Report/Analysis, Responsible Reporting (department or person), Analysis Oversight (committee), Frequency (of reporting), and Follow up (person responsible)". For all areas listed, there were no expected outcomes listed in any format, measurable or otherwise. There was no information in either the Plan or the Indicators form which indicated how any of the QAPI activities throughout the year 2010 was expected to improve health outcomes.

2. The Quality Management Director was interviewed throughout the survey. On 1/5/11 in the afternoon, she concurred the 2010 QAPI Plan failed to include any measurable indicators and failed to list any information on how the activities were expected to improve health outcomes.

Based on review of documents and interview with staff, it was determined the hospital's Quality Assessment Performance Improvement (QAPI) program was not approved by the hospital's governing body. This has the potential to adversely affect the program and the governing body's oversight of all performance improvement activities. Findings include:

1. Review of the "Performance Improvement Plan 2010" and the "Performance Improvement Indicators and Oversight 2010" forms revealed there were no signatures on either form to show who had approved the plan.

2. Review of the minutes to the hospital's governing body meeting minutes from December 2009 through December 2010 revealed there was no discussion listed for QAPI plan approval.

3. The Quality Management Director and the hospital administrator were both interviewed in the afternoon on 1/5/11. They both concurred the hospital's governing body failed to have input or give approval to the plan for 2010.

Based on review of documents and interview with staff, it was determined the hospital's Quality Assessment Performance Improvement (QAPI) program failed to consider high-risk, high-volume or problem-prone areas when determining activities for the 2010 year. This has the potential to have an ineffective QAPI program by not improving health outcomes, patient safety and quality of care for all patients. Findings include:

1. Review of the "Performance Improvement Plan 2010" and the "Performance Improvement Indicators and Oversight 2010" forms revealed there was no information included which indicated which areas in the hospital or in patient care that may be considered to be "high-risk, high-volume or problem-prone" areas which should be targeted areas to study. Review of those documents and of the QAPI Committee (the Performance Improvement Steering Committee) activities conducted throughout the 2010 year revealed there was no evidence provided which showed improvement on any health outcomes, patient safety or quality of care. Reviews of minutes to all meetings of the Performance Improvement Steering Committee during the 2010 year revealed that information had been submitted relative to data gathered, but there was no documented evidence the data had been used to determine how health outcomes, patient safety and quality of care could be improved for all patients.

2. The Quality Management Director was interviewed throughout the survey. On 1/5/11 in the afternoon, she concurred the 2010 QAPI plan and activities failed to specifically consider high-risk, high-volume or problem-prone areas. She stated most of the activities had "continued" from previous years. She also concurred the activities had failed to show improvement on health outcomes, patient safety or quality of care based on the information provided in the minutes to the QAPI meetings conducted throughout the 2010 year.

Based on review of documents and interview with staff, it was determined the hospital's Quality Assessment Performance Improvement (QAPI) program failed to identify any specific performance improvement project in the 2010 year. This has the potential to have an ineffective QAPI program by not having any projects identified to specifically improve health outcomes, patient safety and quality of care for all patients. Findings include:

1. Review of the "Performance Improvement Plan 2010" and the "Performance Improvement Indicators and Oversight 2010" forms revealed there was no specific project listed to be worked on by one or more area or department of the hospital during the 2010 year.

2. The Quality Management Director stated during interview in the afternoon on 1/4/11 that there was no specific project done in 2010. She stated that the use of restraints had been studied as a project in the 2009 year. She stated the special committee which reviewed the restraints was discontinued in 2009. She stated that during the 2010 year, it was determined by the Performance Improvement Steering Committee that the restraint team should be re-formed and a new project should be put into place, but that had not occurred as discussed in the committee meetings.

Based on review of documents and interview with staff, it was determined the hospital's Quality Assessment Performance Improvement (QAPI) program was not approved by the hospital's governing body, medical staff and administrative officials. This has the potential to adversely affect the program and oversight of all performance improvement activities. Findings include:

1. Review of the "Performance Improvement Plan 2010" and the "Performance Improvement Indicators and Oversight 2010" forms revealed there were no signatures on either form to show who had approved the plan.

2. Review of the minutes to the hospital's governing body meeting minutes from December 2009 through December 2010 revealed there was no discussion listed for QAPI plan approval.

3. The Quality Management Director and the hospital administrator were both interviewed in the afternoon on 1/5/11. They both concurred the hospital's governing body, medical staff and administration failed to have input or give approval to the plan for 2010.

Based on document review and staff interview it was determined the medical staff failed to enforce the requirement in the medical staff rules and regulations that specifies an admission summary will be completed by the attending physician within twenty-four (24) hours of admission. This deficient practice was identified in four (4) of four (4) medical records reviewed in which physician #1 was the attending (#4, 8, 12, 18). Failing to complete an admission assessment within twenty-four (24) hours can result in missed psychiatric/mental conditions needing immediate treatment, potentially resulting in negative patient outcomes for all patients of physician #1. Findings include:

1. The medical staff rules and regulations (revised 10/09) state, in part, under the admission summary the following: "The admission summary will be completed within 24 hours of admission to the hospital. It is the responsibility of the attending physician to assure an admission summary is completed within 24 hours of admission."

2. Review of medical record #8 revealed the patient was admitted on 12/28/10 and discharged on 1/4/11. At the time of review on 1/4/11 in the afternoon the medical record did not contain an admission summary. The above record was reviewed with the Program Manger of the Childrens program on 1/4/10 in the afternoon and she agreed the record did not have an admission summary. Additionally dictation was called, at this time, and it was reported they did not have a dictated admission summary on patient #8.

3. Review of medical record #12 revealed the patient was admitted on 12/29/10. At the time of review on 1/4/11 the record did not have an admission summary. The above record was reviewed with the charge nurse on the Childrens unit on 1/4/11 in the afternoon. He agreed the record did not have an admission summary.

4. Review of medical record #4 revealed the patient was admitted on 12/30/10. At the time of review on 1/4/11 the record lacked an admission summary. This record was reviewed with the Licensed Practical Nurse (LPN) around noon on 1/4/11. He acknowledged the record lacked an admission summary. A phone interview was conducted with the medical records transcriptionist in the early afternoon of 1/4/11. She stated the admission summary (psychiatric evaluation) had not been dictated.

5. Review of medical record #18 revealed the patient was admitted on 1/2/11 at 5:00 p.m. At the time of the review on 1/5/11 at 9:50 a.m., there was no admission summary (psychiatric evaluation) on the record. The Registered Nurse (RN) confirmed there was no psychiatric evaluation documented on the record. The transcriptionist was called at the same time, and she confirmed that the psychiatric evaluation had not been dictated as of that time.

Based on document review and staff interview it was determined the hospital failed to ensure that infection control and the problems/issues identified by this program are addressed in the quality assurance program and the formulation of recommendations and/or corrective action is initiated by the quality assurance committee. Failure to integrate infection control problems and issues in the quality assurance program can result in a failure to identify any needed corrective actions which would improve patient outcomes and reduce or eliminate patient/staff infections.
Findings include:

1. The Performance Improvement Steering Committee minutes were reviewed from December 14, 2009 to present. The minutes did not contain any documented reports, monitoring studies or issues relative to infection control.

2. During an interview with the Quality Management Director on 1/5/10 at 1330 hours she stated that infection control does not report infection control issues to the performance improvement committee. She added because infection control has their own committee she felt it was not necessary for that program to report to performance improvement since a lot of the same members are on both committees.