HospitalInspections.org

Based on review of information provided and interviews with key staff August 23-25, 2011, it was determined that the hospital failed to be in compliance with the Patient's Rights Federal Regulations 482.13(a)(2)(ii) and (iii), which required that in its resolution of the grievance, the hospital must provide the patient with written notice of the steps taken on behalf of the patient to investigate the grievance.

Findings include:

1. On August 24, 2011 a review of MRH Patient Complaint and Grievance Policy was conducted. Under Chief Quality Officer/Senior Management, it stated, "a member of Senior Administration will provide the patient with a written notice ...of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion."

2. In the documentation of 4 of 5 (four of five) grievances reviewed on August 24, 2011, there was no written notification in Grievances A, B, C and E.

3. This was confirmed with the Chief Executive Officer on August 24, 2011.


Based on medical record review, policy review, and interview with key personnel on August 24, 2011, it was determined that the facility failed to be in compliance with the Patient's Rights Federal Regulation 482.13(e)(16) (iii), which required that when restraints are used, there must be documentation in the patient's medical record of alternatives or other least restrictive interventions attempted.

Findings include:

1. The policy titled 'Policy for Patient Restraints' was reviewed on August 24, 2011 and there was no requirement that least restrictive measures be documented in the patient's medical record.

2. In 1 of 2 (one of two) restraint records reviewed ( Record W) on August 24, 2011, there was no documentation of least restrictive measures tried.

3. This was confirmed with the Chief Executive Officer on August 24, 2011.



Based on medical record review, policy review, and interview with key personnel on August 24, 2011, it was determined that the facility failed to be in compliance with the Patient's Rights Federal Regulation 482.13(e)(4), which required that the use of restraints must be in accordance with a written modification to the patient's plan of care.

Findings include:

1. The policy titled 'Policy for Patient Restraints' was reviewed on August 24, 2011 and there was no requirement that the use of restraints was in accordance with a written modification of the patient's plan of care.

2. In 2 of 2 (two of two) restraint records reviewed (Records V and W), there was no modification to the plan of care relate to restraint use.

3. This was confirmed with the Chief Executive Officer on August 24, 2011.


Based on medical record review, policy review, and interview with key personnel on August 24, 2011, it was determined that the facility failed to be in compliance with the Patient's Rights Federal Regulation 482.13(e)(9), which required that restraints must be discontinued at the earliest possible time, regardless of the length of time identified in the order.

Findings include:

1. The policy titled 'Policy for Patient Restraints' was reviewed on August 24, 2011 and there was no requirement that restraints be discontinued at the earliest possible time.

2. In 1 of 2 (one of two) restraint records reviewed (Record W), there was documented evidence that the patient was sleeping, calm and restraints were still applied.

3. This was confirmed with the Chief Executive Officer on August 24, 2011.


Based on personnel record review, policy review, and interview with key personnel on August 24-25, 2011, it was determined that the facility failed to be in compliance with the Patient's Rights Federal Regulation 482.13(f)(1), which required that the hospital must document in the staff personnel records that the demonstration of restraint competency had been successfully completed.

Findings include:

1. On August 24, 2011 a review of " Policy for Patient Restraint " was conducted. Under "Training Requirements" it stated, "All staff designated as having direct care responsibilities, including contract and agency personnel, must be trained and demonstrate competency in the application of restraints .... "

2. Sixteen (16) personnel records were reviewed on August 25, 2011 and there was no documentation that restraint competency had been completed.

3. This was confirmed with the Chief Executive Officer on August 24, 2011.

Based on tours of the facility and interviews with key personnel on August 23-25, 2011, it was determined that the facility failed to maintain the facility to ensure the safety of patients.

Findings include:

1. During a tour on August 24, 2011, the following was observed:

a. stained and ill fitting ceiling tiles in the sterile area of Central Supply;

b. broken floor tiles in the laboratory;

c. cracked floor tiles in the second floor hallway and the Emergency Department.

2. These findings were confirmed with the Director of Plant Operations on August 23-25, 2011.

Based on review of the list of Complaints/Grievances for the year 2010, review of the Medical Staff Bylaws, review of the Quality Assurance & Performance Improvement Plan 2011, review of the Quality Reporting Tables for 2010 nad 2011, review of the Professional Affairs Committee meeting minutes, review of the policies and procedures, review of the Medical Staff Steering Committee meeting minutes, review of the Board of Trustee meeting minutes, review of the Peer Review Committee meeting minutes, and interviews with the Chief Executive Officer/Chief Nursing Officer, Chief Quality Officer/Risk Manager, and Medical Staff members on August 23-25, 2011, it was determined that the hospital's Governing Body failed to be totally responsible for the conduct of the CAH as an institution, as evidenced by:


1. The Governing Body failed to assume full legal responsibility for determining, implementing and monitoring policies (Tags C -0151 and C-0277);

2. The Governing Body failed to ensure that the medical staff was accountable to the Governing Body for the quality of care provided to patients (Tags C-0151, C-0330 and C-0337);

3. The Governing Body failed to ensure that the policies were administered so as to provide quality health care in a safe environment (Tag C- 0277 and C-0151);

4. The Governing Body failed to institute processes and systems to ensure periodic appraisal of the medical staff evaluation of patient care services at every patient care location (Tags C- 0330 and C-0337); and

5. The Governing Body failed to ensure that the hospital was in compliance with all Federal Regulations (Tag C- 0151).


The cumulative effects of these deficient practices resulted in this Condition of Participation being out of complaince.

Please see Tags C-0277 and C-0151 for additional information regarding the implementation and monitoring of polices by the governing body.

Based on review of the hospital ' s policy manual and interviews with key staff on August 24, 2011, it was determined that the policy that outlined how medication errors were to be documented was not complete and did not reflect the current practice.

Findings include:

1. The policy " MRH Medication Error and Intravenous Therapy Problems Policy" , issued March 8, 1980, last revised Sept 6, 2002, did not include a procedure for the documentation of the medication error in the patient ' s medical record.

2. This was confirmed by the Pharmacist on August 24, 2011.

Based on review of Departmental Performance Improvement initiatives, the " MRH Quality and Performance Improvement Plan 2010-2011, Medical and Allied Health Staff- Departments " indicator list, meeting minutes from the Departments of Medicine, Surgery, Emergency Medicine and Medical Staff Steering Committee, other documents as described below, and interviews with key staff on August 23-25, 2011, it was determined that the CAH failed to ensure that the quality improvement activities were sufficient to assess the CAH care of patients. The CAH did not ensure that high risk, high volume and problem prone aspects of patient care, in the Emergency Department, Surgical Services and the Provider Practices, were reviewed and that appropriate action was taken to improve patient care outcomes and services as evidenced by:

1. The Millinocket Regional Hospital Medical Staff Bylaws Article 2.2-1 (a) 1 state, " Each department and/or committee shall monitor patient care for high risk, high volume, and adverse outcomes, events, or procedures, and shall trend outcomes, events or procedures. "

2. According to the Chief Quality Officer, endoscopies are a high volume surgical procedure, accounting for forty-seven percent, (47%) of the surgeries at Millinocket Regional Hospital. There were no medical staff quality improvement indicators regarding endoscopies.

3. During a meeting with leaders of the Medical Staff on August 24, 2011 the Chief of Surgery stated that he was aware that there were national performance measures for endoscopy, and that he keeps a log of his performance, but does not report these statistics or require reporting by his colleagues.

4. In an e-mail communication on August 25, 2011 regarding Otolaryngology Surgery, (ENT), the Chief Quality Officer wrote, " ENT is 6 % of our surgical volume ... I knew of no PI to be completed or in progress specific to ENT ... "

5. According to the Chief Quality Officer and the Chief Executive Officer, Outpatient Family Practice and Internal Medicine practices are hospital departments. According to the, " MRH Quality and Performance Improvement 2010-2011, Medical and Allied Health Staff- Departments " indicator list, and the Chief Quality Officer, the quality improvement initiative for the outpatient office staff was to measure Hemoglobin A1C. There were no additional quality improvement indicators regarding the medical care provided in the Outpatient Practices.

6. The minutes of the Division of Medicine from August 2010 through June 2011 were reviewed. There was no discussion of quality improvement indicators, or results of quality improvement activities for the Outpatient Practices.

7. According to the " MRH Quality and Performance Improvement 2010-2011, Medical and Allied Health Staff- Departments" indicator list and confirmed by the Chief of Emergency Medicine and the Chief Quality Officer in meetings on August 24, 2011, there were no indicators in the Emergency Department for high volume conditions.

8. A review of the Emergency Department meeting minutes from July 2010 through July 2011 did not demonstrate discussion of quality improvement indicators for high volume conditions.

9. In a meeting on August 24, 2011, the Chief of Emergency Medicine said the Emergency Department had developed a change in practice for a high-risk but low volume indicator. He said he believed the changes were successful, and they had not begun work on establishing a new high-risk indicator.

10. The Medical Staff Bylaws Article 11.2?1 (d) (2) states, " ...In addition to the above, the [Medical Staff Steering] Committee shall conduct quality improvement and peer review activities relating to the outcomes and processes of care which are not necessarily on an individual practitioner basis. These activities shall include systematic process and outcome-based quality improvement analyses [sic] with indicator based screening, quantitative review, trending, conclusions, and quality improvement interventions with assessment of ultimate efficacy of these interventions." And, Article 11.2-1 (h) " Fulfill the Medical Staff's accountability to the Board for the quality of the overall medical care rendered to the patients in the hospital, in accordance with the provisions of the hospital quality assessment and improvement plan, including organizing performance improvement activities and establishing a mechanism designed to conduct, evaluate and revise such activities, including serving as the hospital Quality Assurance and Quality Improvement Committee."

11. The minutes for the Medical Staff Steering Committee from June 2010 through May 2011, the Medical Executive Committee from June 2010 through June 2011, and the Medical Staff from June 2010 through June 2011, were reviewed. There was no evidence in these minutes that the committee conducted, " indicator based screening, quantitative review, trending, conclusions, and quality improvement interventions with assessment of ultimate efficacy of these interventions " nor evidence of " organizing performance improvement activities and establishing a mechanism designed to conduct, evaluate and revise such activities " as described in the Medical Staff Bylaws.


The cumulative effects of these deficient practices resulted in this Condition of Participation being out of compliance.

Please see Tags C-0330 and C-0337 for additional information about the evaluation of the quality of care provided to patients at the CAH.

Based on document review and interview with key personnel on August 24, 2011, it was determined that the facility failed to evaluate all patient care services and other services affecting patient health and safety.

Findings include::

1. The Quality Assurance & Performance Improvement Plan 2011 stated " Reporting Departments ...These ...[updates] will be provided quarterly to the CQO (Chief Quality Officer).The CQO will assure PI (Performance Improvement) activity is ongoing in each reporting unit. "

2. On August 24, 2011, a review of the Quarterly Quality Report 2010 was conducted. The Emergency Department failed to report for Quarters one, two and three; Pharmacy & Therapeutics (P&T) failed to report for Quarters two and four; and Discharge Planning / Social Services /Swing failed to report for Quarters one and two.

3. On August 24, 2011, the Quality Reporting Table 2011 was reviewed. Dietary /Nutrition failed to report in the first quarter.

4. This was confirmed with the Chief Executive Officer on August 24, 2011.


Please see Tag C-0330 for additional information regarding all patient care services being evaluated.

Please see Tags C-0330 and C-0337 for additional information related to appropriate remedial action taken to address deficiencies found through the quality assurance process.