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Based on the number and nature of deficiencies, the facility failed to be in compliance with the Condition of Participation of Governing Body. Specifically, the governing body failed to ensure the facility was in compliance with the other Conditions of Medical Staff Services and Quality Assurance/Performance Improvement (QAPI). In addition, the governing body failed to ensure the contract hospitalist physician group responded timely to urgent pages by nursing. The facility failed to take timely action to investigate and correct the identified problem with hospitalist response. The facility failed to ensure the contracted hospitalist group had timely notification of the response problem and had internal quality assurance activities to track performance failures. In addition, the facility's governing body failed to maintain an up-to-date contract for the hospitalist group that addressed performance expectations related to clinical care and internal quality assurance activities. The facility failed to ensure the policy/procedure regarding methods for notifying physicians about patient care issues accurately addressed the hospitalist group practice.

After further administrative review of findings after the survey, and in consultation with the CMS Regional Office, it was determined that an Immediate Jeopardy situation existed. The administrator, chief medical officer, chief nursing officer, vice presidents for nursing and clinical services and the directors of quality and compliance were notified by telephone conference call on 12/2/10 at approximately 8:30 a.m. that an Immediate Jeopardy situation had been declared at the facility. They were notified that a letter outlining the specific finding related to the Immediate Jeopardy situation would be completed and forwarded to CMS Regional Office for review. The Immediate Jeopardy findings letter, after approval by CMS, would be sent to the facility to expedite timely correction of the Immediate Jeopardy situation. The receipt of an acceptable plan to remove the Immediate Jeopardy situation would then trigger an on-site visit by state surveys to review the facility's corrective action and determine the Immediate Jeopardy situation could be removed. Per the final CMS letter sent to the facility, the termination date is 12/23/10.

The facility failed to meet the following Standards under the Condition of Governing Body:

Tag A 0049 Medical Staff Accountability
The Governing Body failed to ensure all standards of care outlined in the medical staff bylaws/rules and regulations included a standard for a timely response to calls from nursing related a change of condition or need for new orders. Specifically, the medical staff failed to ensure medical staff requirements included standards for timely response to calls regarding patient care.

Tag A 0084 Contracted Services
The Governing Body failed to evaluate and review all contracted services provided by a contracted group of hospitalist physicians and other groups of contracted physicians, including emergency services and remote radiological services, to ensure services were provided in a safe and effective manner.

Based on staff/physician interviews and review of facility documents and medical records, the medical staff failed to ensure the contract hospitalist physician group responded to urgent pages by nursing timely. The facility failed to take timely action to investigate and correct the identified problem with hospitalist response for sample patient #1. The failure created the potential for negative patient outcome.

The findings were:

1. Review on 11/29/10 of the medical record of sample patient #1 revealed the following, in pertinent parts:

On 11/8/10, the patient's assigned day shift nurse, a charge nurse and a unit secretary made multiple calls to the hospitalist answering service attempting to obtain an order for placement of a central line, because the patient's condition was deteriorating. The nurse was unable to make contact with a hospitalist for approximately 35 minutes, at which time an order for placement of a central line was obtained. A central line was immediately inserted by a surgeon present on the unit. The patient's condition continued to decline and the patient expired approximately an hour after the order was obtained.

Based on the 11/30/10 interview with the hospitalist group, it was later determined the practice answering service first paged Physician #1, whose shift ended in one minute. The service then attempted to contact Physician #2, who was not on duty, and was, in fact, on vacation. The service then attempted to contact Physician #3, who responded to the call at 7:35 a.m.

2. An interview was conducted on 11/30/10 at approximately 11:00 a.m. with Physician #2 (head of the hospitalist group) and Physician #1 (the nocturnist on duty on 11/7/10 to 11/8/10 from 7 p.m. to 7 a.m.) Physician #2 stated s/he had not been notified of this incident until 11/29/10 (the day the surveyors arrived at the facility.) Physician #2 also stated this was not acceptable. Furthermore, Physician #2 was not on the schedule for 11/8/10 due to being out of town on vacation and did not understand why the answering service would be paging him/her. Physician #2 informed his/her secretary that these incidents and the over-all performance of the Hospitalist Service needed to be tracked. Physician #1 stated there had been occasions when s/he did not receive the first page from the answering service. Physician #2 stated, "Oh, I thought that was just happening to me." Physician #1 recounted the events of 11/8/10: "I was the nocturnist on duty and received a number of calls from ICU regarding this patient, the last one being at 6:30 a.m. At 7:00 a.m., I was off duty and left the hospital and went right to bed. Woke up at approximately 11:00 a.m. and checked my pager. Noticed I had a page at 6:59 a.m. and called the answering service to make sure it was not a STAT, which it wasn't and assumed the answering service had called the hospitalists that were on days." Physician #2 again stated the whole incident was unacceptable and was very upset s/he had not heard of it sooner.

Based on staff/physician interviews and review of facility documents and medical records, the governing body of the facility failed to ensure the contract hospitalist physician group responded to urgent pages by nursing timely. The facility failed to take timely action to investigate and correct the identified problem with hospitalist response. The facility failed to ensure the contracted hospitalist group had timely notification of the response problem and had internal quality assurance activities to track performance failures. In addition, the facility's governing body failed to maintain an up-to-date contract for the hospitalist group that addressed performance expectations related to clinical care and internal quality assurance activities. The facility failed to ensure the policy/procedure regarding methods for notifying physicians about patient care issues accurately addressed the hospitalist group practice. The findings created the potential for negative patient outcome.

The findings were:

1. Reference Tag A 0049 Governing Body - Medical Staff Accountability for findings related to the medical record for sample patient #1 and interview conducted with the hospitalist physician group.

2. Review on 11/30/10 of the contracts and amendments to the contract between the hospital and the contract hospitalist practice group revealed part of the contract was with a different physician practice group, a large additional contract only addressed the hospital provision of administrative staff for the practice group and some amended financial arrangements between the hospital and the current hospitalist group. None of the supplied contracts addressed the clinical expectation for hospitalist group, including response times and hand-off/transition from one hospitalist to the next. In addition, the contracts contained no expectations for quality assurance activities related to tracking reliability of electronic pagers and performance of the answering service.

Based on the nature of the deficiencies cited, the facility failed to comply with the Condition of Participation of Quality Assurance/Performance Improvement (QAPI). The facility failed to institute and maintain a quality assurance program that included standards for timely review, assignment of priority, investigation and corrective action for unusual/adverse events reported as incidents to the risk manager.

The facility failed to meet the following Standards under the Condition of Quality Assurance/Performance Improvement (QAPI):

Tag A 0288 QAPI Feedback and Learning
The facility failed to ensure incident reports, which were required to be forwarded to the risk manager, received timely review, assignment of priority, investigation and implementation of corrective action to maintain a safe patient care environment.

Based on staff/physician interviews and review of facility documents and medical records, the facility failed to ensure incident reports ("Events Report"), which were required to be forwarded to the risk manager, received timely review, assignment of priority, investigation and implementation of corrective action to maintain a safe patient care environment. The failure created the potential for negative patient outcomes.

The findings were:

1. Reference Tag A 0049 Governing Body - Medical Staff Accountability for findings related to the medical record for sample patient #1 and interview conducted with the hospitalist physician group.

2. An interview was conducted with the Interim Director of ICU on 11/30/10 at approximately 7:55 a.m. The Director stated the nurse (nurse #1), who cared for the patient on 11/8/10 was very concerned regarding the lack of immediate response from the hospitalist service and had reported it to him/her. The Director then completed an Events Report, electronically, regarding the incident on 11/8/10 and it was automatically forwarded to the Risk Manager. The Director further stated s/he thought it had been evaluated and action taken in regards to the issues; however, s/he had not received a response from the Risk Manager or anyone for that matter. (The Director did not know, prior to this interview, that no one had addressed the Events Report.)

Based on the nature of the deficiencies cited, the facility failed to comply with the Condition of Participation of Medical Staff Services. The facility failed to institute and maintain a quality assurance program that included standards for timely review, assignment of priority, investigation and corrective action for unusual/adverse events reported as incidents to the risk manager.

The facility failed to meet the following Standards under the Condition of Medical Staff Services:

Tag A 0347 Medical Staff Accountability
The Medical Staff failed to ensure all standards of care outlined in the medical staff bylaws/rules and regulations included a standard for a timely response to calls from nursing related to a change of condition or need for new orders. Specifically, the medical staff failed to ensure medical staff requirements included standards for timely response to calls regarding patient care.

Based on staff/physician interviews and review of facility documents and medical records, the medical staff failed to ensure all standards of care outlined in the medical staff bylaws/rules and regulations included a standard for a timely response to calls from nursing related to a patient's change of condition or need for new orders. Specifically, the medical staff failed to ensure medical staff requirements included standards for timely response to calls regarding patient care. The failure created the potential for negative patient outcome.

The findings were:

1. Reference Tag A 0049 Governing Body - Medical Staff Accountability for findings related to the medical record for sample patient #1 and interview conducted with the hospitalist physician group.

2. Reference Tag A 0258 QAPI - Feedback and Learning for findings related to failure to do a timely review of the incident report ("Events Report")with notification of the medical staff/medical director and the hospitalist practice group, so medical staff investigation and corrective action could begin.

3. Reference Tag A 0084 Governing Body - Contracted Services for findings related to failure to participate with the governing body to evaluate and review all contracted services provided by a contracted group of hospitalist physicians and other groups of contracted physicians, including emergency services and remote radiological services, to ensure services were provided in a safe and effective manner.

Based on medical record review and staff interview, the facility failed to ensure medical record entries were consistently dated and timed in six (#2, #5, #7, #16, #17 and #19) of 20 medical records reviewed. This failure created the potential to adversely affect patient safety and quality of care.

The findings were:

The following medical records were electronically reviewed on 11/30/10 with the Director and Assistant Director of Accreditation/Medical Staff Services:

1. Patient sample #2 was admitted to the facility with a diagnosis of pneumonia on 11/7/10 and discharged on 11/9/10. The hospitalist admission orders written on 11/7/10 were not timed although the form was printed with "Date/Time" to prompt the physician. The adult inpatient pneumococcal and influenza vaccine administration form was not timed by the nurse completing the form although the form was printed with a space to insert the "Time." The hospitalist progress notes written on 11/8/10 and 11/9/10 were not timed.

2. Patient sample #5 was admitted to the facility with a diagnosis of cellulitis on 11/8/10 and discharged on 11/10/10. A physician order was written sometime after 11/10/10; however, the order did not have a date but it was timed.

3. Patient sample #7 was admitted to the facility with a diagnosis of chest pain on 11/9/10 and discharged on 11/11/10. Physician's order written on 11/9/10, 11/10/10 and 11/11/10 were not timed. Physician progress notes written on 11/10/10 and 11/11/10 were not timed.

4. Patient sample #16 was admitted to the facility with a diagnosis of seizures on 11/8/10 and discharged on 11/9/10. A physician admission order was written on 11/8/10 that was not timed. The discharge order written by a physician was not dated or timed and the nurse noting the order did not date it.

5. Patient sample #17 was admitted to the facility with a diagnosis of angina on 11/9/10 and discharged on 11/10/10. Physician orders written on 11/9/10 were not timed. There was a physician order written that was neither dated nor timed. Physician progress notes written on 11/9/10 and 11/10/10 were not timed.

6. Patient sample #19 was admitted to the facility with a diagnosis of nausea/vomiting on 11/7/10 and discharged on 11/8/10. The adult DVT (deep vein thrombosis) screening and prophylaxis orders were not timed by the physician. There was no signature, date or time noted by the RN (registered nurse). The hospitalist admission orders were not timed by the physician and also the nurse that noted the orders did not time it. There were physician orders noted by the RN on 11/7/10 and 11/8/10 that were not dated or timed. Physician progress notes written on 11/7/10 and 11/8/10 were not timed.

During the process of reviewing medical records, the Director stated that the dating and timing of physician orders have been monitored for some time; particularly the timing of orders. S/he further stated that the percentage of compliance among the physicians has significantly increased but there is still room for improvement.

Based on medical record review and staff interview, the facility failed to utilize the proper consent forms in 20 of 20 medical records reviewed. Specifically, the preprinted Admission Agreement and Treatment Consent forms did not request the timing of the document.

The findings were:

The medical records were reviewed electronically on 11/30/10 with the Director and Assistant Director of Accreditation/Medical Staff Services. It was noted during the review process that the Admission Agreement and Treatment Consent form did not prompt the patient or authorized representative to document the time when signing the consent form. The consent requested the "signature of patient or authorized representative" and the "date" only.

During the review of medical records on 11/30/10, the Assistant Director confirmed the facility was not in compliance with the current consent forms being used. S/he confirmed the consent forms must also be timed.