HospitalInspections.org

The hospital failed to require that the Organizational Structure:

(0241) had a governing body that assumed full responsibility for determining, implementing, and monitoring policies governing the CAH's total operation so as to provide quality health care in a safe environment.

This CONDITION is a repeat deficiency from the last Medicare recertification survey conducted 11/17/08 (NVES11).

The cumulative effect of this systemic problem resulted in the inability of the CAH to be in compliance with the federal regulation for ORGANIZATIONAL STRUCTURE which led to the increased potential for adverse outcomes.

Based on review of the governing board Bylaws and monthly meeting minutes, hospital policies and procedures, Partners in Quality Committee meeting minutes and interviews, it was determined the governing body failed to assume full responsibility for the total operation to ensure quality care to patients by not:

1. determining, reviewing and approving hospital policies and procedures;
2. reviewing quality performance reports on a quarterly report as stated in the plan of correction dated 6/17/09 (NVES12); and
3. assuring all patients are provided care by a medical staff member that is currently credentialed by the hospital.

This is a repeat deficiency from the Medicare recertification survey conducted 11/17/08 (NVES11).

Findings include:

1. The "Amended and Restated Bylaws" approved and adopted by the Board of Directors on 11/17/09, revealed: "3.3 Powers and Duties of the Board of Directors - The Board of Directors ("Board") shall have all powers of management and control of the corporation and shall be empowered to adopt such rules and regulations consistent with the law, the Articles of Incorporation and these Bylaws. The Board shall have authority to: 3.3.1 Establish policies and rules and regulations of NCCH (Northern Cochise Community Hospital)."

The policies and procedures observed in the departments of nursing, pharmacy, rehabilitation, radiology, respiratory, laboratory, medical records, emergency room, gastroenterology lab, infection control, quality assurance, and swing beds, did not have a signature(s) from any member of the Governing Board. There was no evidence the governing board had approved them.

The nursing department's Interim Director of Nursing was not available during this survey, however, the charge nurse stated there were no other policies with the governing board's approval. Managers from the other departments surveyed, stated their current policies did not have governing board signatures to approve the policies.

The sleep study department which began procedures in December 2009, had no written policies and procedures.

The Administrator stated the Medical Executive Committee usually reviews and approves policies, but they are not brought to the Governing Board monthly meetings.

The Chief of the Medical Staff was interviewed on 3/5/10. He stated the Medical Executive Committee is in the process of approving policies and procedures for all departments. He was not aware the governing board had to approve the policies.

2. The Board of Directors' Job Description included: "A hospital board of directors must fulfill certain fundamental or core responsibilities in overseeing the efforts of the organization. These responsibilities cluster around six major areas...2. Quality Oversight...The Board must review and carefully discuss quality reports that provide comparative statistical data, set measurable policy targets to ensure continual improvement in quality performance...Monitor programs and services to ensure that they comply with policies and standards relating to quality. Take corrective action to improve quality performance when appropriate and/or necessary."

The "Amended and Restated Bylaws" included: "Article IX - Quality Assurance 9.2 The Board of Directors shall assume an active role in the Quality Assurance/Quality Improvement Program of the hospital by providing such overview as is needed to conduct Quality Assurance/Quality Improvement activities and to regularly review objectively the quality of health care delivery provided by the facility. Such review shall include results of studies and on-going reviews established in conjunction with the Quality Assurance/Quality Improvement Program. Monthly reports of quality assurance/quality improvement activities will be submitted to the Board of Directors."

The plan of correction from the 5/11/09 (NVES12), follow-up survey included: "The Quality Assurance and Performance plan was reviewed and updated to include all departments and insure a yearly update with departmental indicators to be monitored monthly. These indicators will be presented to the Board on a quarterly basis as part of the Quality report."

The monthly Board of Directors meeting minutes were reviewed from 5/27/09 through January 26, 2010. They revealed:

The 5/27/09, meeting meeting minutes revealed the Director of Quality Assurance informed the board that each department will track indicators monthly.
The 6/24/09, meeting did not review quality report indicators.
The 7/28/09, meeting did review the quality report indicators of multiple departments.
The 8/04/09, meeting did not review quality report indicators.
The 8/25/09, meeting did not review quality report indicators.
The 9/29/09, meeting did not review quality report indicators.
The 10/27/09, meeting did not review quality report indicators.
The 11/17/09, meeting did not review quality report indicators.
The 12/29/09, meeting did not review quality report indicators.
The 1/26/10, meeting did not review quality report indicators.

There was no evidence the governing board reviewed quality indicators on a quarterly basis as noted in the plan of correction, or monthly quality reports as required by the bylaws. The governing board has not taken an active role in the quality assurance/quality improvement program and its activities as required by the bylaws.

3. The "Credentialing Policy" revealed: "1.3 The Governing Body and any committees of the Medical Staff and/or of the Governing Body which conduct Professional Review Actions and/or Professional Review Activities hereby constitute themselves as professional Review Bodies as defined in the Act and in Arizona law...2.7 Duration of Medical Staff Appointments to the Medical Staff are for a period of not more than two (2) years."

A random selection of ten active medical staff members' credentialing and privileges were reviewed. Active staff member #1, a family nurse practitioner, was last credentialed and granted privileges in November 2006.

The Medical Staff Coordinator stated she did not have this staff member credentialed as required every two years.

Based on medical record review, policies and procedures, and staff interview, it was determined the facility did not ensure the anatomical gift donation form was completed for 7 of 10 expired patients reviewed (Patient's #23, #24, #25, #26, #28, #31, and #32).

Findings include:

Northern Cochise Health System Policy/Procedure: Anatomical Donations, reviewed October 6th, 2008, included: "Policy: It is the policy of Northern Cochise Community Hospital to present to all families the option of organ, tissue and eye donation for transplantation and/or research at or near the time of the patients' death."

Procedure: "1. At or near the time of death and within one hour of death, nursing personnel should make a reasonable effort to find evidence of a person's consent to donate...2. Nursing personal will call the Donor Network of Arizona (DNA)...for the evaluation and determination of type of donation possible for that patient. Document this response on the 'Arizona Record for Donation of Anatomical Gift' form (see attached)...

3. If a person has not executed a Document of Gift nor legally refused to make an anatomical gift before his or her death, a trained requester may obtain consent to donate from that person's decision-maker. Consent should be attempted from the following persons in the stated order or priority: a. The person's designated agent is a health care power of attorney. b. The person's court appointed guardian. c. The person's spouse unless legally separated...If no trained requester is available, the nurse will not approach the patient's decision maker. Donor Network of Arizona will make contact with the decision maker if donation is appropriate. The trained requestor will document acceptance or declination on the 'Arizona Record for Donation of Anatomical Gift' (see attached)."

The Director of Medical Records verified Patient's #23 and #24 did not have an Anatomical Donation form or a progress note in their medical record's notifying the Arizona Donor Network of the patient's imminent death and identifying the representative they notified.

Patient #25 had a progress note in the medical record that included: "___ (name of Hospice RN) here, donor network notified, patient is signed up for donation with mortuary. Mortuary here for body pickup, ____ with Hospice making all arrangements." The progress note was written by a trained requestor, but there was no Anatomical Record for Donation form in the medical record.

Patient #26 had an Anatomical Record for Donation in the medical record that only included: Donor Network of Arizona (DNA) was notified and the donor accepted for the donation of eyes. The remainder of the form was not filled out stating who would obtain the consent of the family; the trained requestor at the facility or a representative of the DNA.

Patient #28's medical record included: "The Donor Network was also notified. reportedly, patient is an organ donor, and they feel they will harvest his eyes. Patient's brother was notified of the death and he wanted me to also contact patient's life long friend and roommate. Several attempts were made to do this, but no answer to the phone calls, The body was released to the mortuary and the representative was advised that the organ donor network has plans to harvest his eyes." There was no Arizona Record for Donation of Anatomical Gift form found in Patient #28's medical record.

Patient #31's medical record included: "1345, Donor Network called, declined donation of any part of patient after history given. Spoke with (name of DNA representative). No Anatomical Gift Notification Form was found in the medical record for Patient #31."

Patient #32's medical record progress note included: Call to Pharmacy and Organ Donor Network by ___, RN at 1643 and spoke with (Donor Network representative) and Donor Network declined any donations at this time. Director of Nursing. The Anatomical Gift Notification form was not found in Patient #32's medical record.

The Charge Nurse acknowledged during an interview conducted on 03/05/10, the medical-surgical (med-surg) floor only had the first page of the Anatomical Gift Donation form. The second page of the form includes the areas completed by the trained requestor when obtaining consent.

The consulting Director of Nursing verified the facility needed a current list of trained requestors for the nurses to notify when a death is imminent to ensure the forms are completed.

Based on record review and staff interviews, it was determined the facility failed to require the swing bed patients were provided activities that reflected their interests, abilities, culture, and religion with outcomes identified in the progress notes for 5 of 5 patients reviewed (Patient #5, 10, 11, 18, and 19).

Findings include:

The Northern Cochise Community Hospital, Inc. Swing Bed Policies and Procedures: Swing Bed Activities include: "Purpose: All patients in the Swing Bed Unit at Northern Cochise Community Hospital (NCCH), Inc. will be encouraged to engage in various types of recreational activities. Policy: Swing Bed Unit at Northern Cochise Community Hospital, Inc. will provide activities for swing bed patients to include: games, equipment and supplies so that all needs for all patients will be met. Responsibility: The Social Services Coordinator will be responsible for promoting activities. They will encourage all employees to take an active interest in the social needs of the patients."

A review of the medical records for the 5 swing bed patients revealed no comprehensive activity assessments or activity programs were documented in the patients medical records.

Patient #5 was admitted to a swing bed from an acute hospital on 02/03/10. Patient #5 acknowledged in an interview conducted on 03/03/10, at 08:45 a.m., he didn't know of an activity program, but the case manager had brought cards and dominoes one day that he hadn't used.

Patient #10 was admitted to a swing bed from an acute hospital on 01/05/10. The medical record did not include an activity's assessment, activity plan or documentation of activities in which the patient participated.

Patient #11 was admitted to a swing bed from an acute hospital on 02/02/10. Patient #11's medical record did not include an activity assessment, an activity plan or a list of activities that included Patient #11's participation.

Patient #18 was admitted to an acute hospital bed at the facility on 02/16/10, and transferred to a swing bed on 02/20/10. A review of the medical record did not include an activity assessment, activity plan or documentation of participation in activities.

Patient #19 was admitted to an acute hospital bed in the facility on 11/05/09, and transferred to a swing bed on 11/08/09. A review of the medical record revealed there was no activity assessment or activity plan. A December 2009 Individual Resident Daily Participation Record was found for Patient #19's participation in current events, exercise, family/friend visits, and television. There were no further monthly activities in the record.

The Case Manager for the Swing Bed Unit acknowledged in an interview conducted on 03/03/10, the hospital had not had an activities coordinator or provided activities to the swing bed patients since the previous social services coordinator had quit several months ago. She verified that the hospital did not have a calendar of events/activities. The calendar posted by the cafeteria did not include scheduled activities and was done by the nursing home personnel.

The representative from Human Resources verified in an interview conducted on 03/04/10, that the previous Social Services Coordinator had left employment at the facility on 08/21/09.

Based on record review and staff interview, it was determined the facility failed to require the comprehensive care plan was prepared by the interdisciplinary team including the physician and reviewed weekly for 4 out of 5 patients reviewed (Patient #5, #10, #11, and #19).

Findings include:

Northern Cochise Community Hospital Policy /Procedure: Med/Surg Department: Care Plan included: "Purpose: To facilitate planning to best meet the needs of the patient and family, and to help assure a smooth transition along the continuum of care. Responsibilities/Procedures: 1. It is the responsibility of the admitting Registered Nurse (RN) to initiate the Care Plan. The Care Plan will generate a Worklist in the HMS (electronic record) system. 2. The RN will coordinate activities to ensure timely completion of the Worklist tasks. 3. The worklist tasks will be completed and documented in a timely fashion by either the nurse, or nurse assistant as appropriate. 4. The care plan for an Acute patient should be reviewed every shift, and updated as necessary. The care plan for a Swing patient should be reviewed weekly, and updated as indicated."

Patient #5's care plan included the date the plan was initiated on 02/05/10, and an expected achievement date for the patients goals of 03/07/10. It was reviewed by the RN on 03/02/10, without any changes to the care plan. No further updates were reflected in the care plan.

Patient #10's care plan included the date nursing diagnoses were assigned by the RN, 01/10/10. It was reviewed by the RN on 03/02/10, without any changes to the plan of care. The expected achievement date given was 02/28/10. No further updates were included in the care plan.

Patient #11's care plan was initiated on 02/02/10, with an expected achievement date for goals of 03/31/10. The care plan was reviewed on 02/27/10, by the RN, without any changes in the plan. No further updates were included.

Patient #19 's care plan was created on 11/11/09, and updated on 12/24/09, with the expected achievement of goals on 02/27/10. The nursing diagnosis of inadequate tissue perfusion was removed on 12/23/09. The care plan was reviewed on 01/31/10, without any changes. No further updates were included for the plan of care.

The Charge Nurse acknowledged during an interview conducted on 03/05/10, at 08:30 a.m., the HMS system for the care plan was not very user friendly. The Care Plan included sections for Physical Therapy and Occupational Therapy that were not used. The surveyor was shown where the nurse can make a comment in one of the diagnoses, but none of the care plans reviewed contained any comments when printed.

The Dietician, Physical Therapist, Occupational Therapist and Speech Therapist included their goals for the patients in their assessments and evaluations but not in the care plan.

A review of the Case Managers Interdisciplinary Care Plan notes for February included attendee's: Case Manager, Physical Therapy, Physical Therapy Assistant, Occupational Therapy, Respiratory Therapy, the Director of Nursing and the Case Manager Assistant. The Case Manager acknowledged in an interview conducted on 03/04/10, at 4:00 p.m., the physician did not attend the Interdisciplinary Care Plan Meetings.