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Based on record review and interview, the CAH failed to ensure the governing body implemented and monitored policies governing the CAH's total operation. This deficient practice was evidenced by
1) failure to ensure the Medical Staff Bylaws, Rules and Regulations were enforced as evidenced by the Medical Staff failed to address incomplete medical records when medical staff members failed to date/time/authenticate physician orders;

2) failure of the governing body to appoint a Director of the hospital's Radiology Services as required by the Louisiana Hospital Licensing Standards; LAC 48:1. Chapter 93;Subchapter E. Radiological Services, Section 9361.B General Provisions;

3) Failure of the governing body to appoint a Director of the hospital's Laboratory Services as required by the Louisiana Hospital Licensing Standards:LAC 48:1. Chapter 93; Subchapter F. Laboratory Services, 9371.A , Organization and Staffing and 9365.A Personnel; and

4) failure to ensure all contracted physicians providing care and services in the hospital were privileged and credentialed as per the Medical Staff Bylaws for 3 (S18MD,S19MD, S20MD) of 6 (S18MD, S19MD, S20MD, S21MD, S28MD, S29MD) physicians' credentialing files reviewed.

Findings:
1) Failure to ensure the Medical Staff Bylaws, Rules and Regulations were enforced as evidenced by the Medical Staff failed to address incomplete medical records when medical staff members failed to date/time/authenticate physician orders:

Review of the monthly quality indicator reports for 2016 and the last quarter of 2015 revealed the quality indicator for Dating/Timing/Signing physician orders was below the benchmark of 100%.

In an interview on 05/04/16 at 9:40 a.m., S12Director of Medical Records confirmed there had been ongoing problems with physicians timing/signing orders. When asked what corrective actions had been to address the problem, she stated that was a question for S1CEO. She stated she collected the data and gave it to S1CEO and he took it to the Medical Staff meetings.

In an interview on 05/04/16 at 10:05 a.m., S1CEO stated the incomplete medical records were addressed in the Medical Staff meetings and was also reported in the Governing Body meetings. S1CEO confirmed this issue had been a problem for quite some time. S1CEO stated it had been a challenge to go through the medical staff. S1CEO confirmed the only action taken had been to discuss it at the medical staff and Governing Body meetings. S1CEO confirmed the corrective actions taken thus far had been ineffective and they had not implemented any other corrective actions.



2) Failure of the governing body to appoint a qualified member of the medical staff as Director of Radiology Services.

Review of the Louisiana Hospital Licensing Standards; LAC 48:1. Chapter 93;Subchapter E. Radiological Services, Section 9361.B., General Provisions revealed in part: "Radiological services shall be supervised by a qualified radiologist on either a full-time, part-time or consulting basis. Further review of Section 9365.A, Personnel revealed, in part: "A qualified full-time, part-time, or consulting radiologist must supervise the ionizing radiology services... The radiologist shall have clinical privileges delineated by the medical staff.

In an interview on 05/04/16 at 2:55 p.m. S1CEO indicated the Governing Body had not appointed a medical director of Radiology Services.



3) Failure of the governing body to appoint a qualified member of the medical staff as Director of Laboratory Services.

Review of Louisiana Hospital Licensing Standards:LAC 48:1. Chapter 93; Subchapter F. Laboratory Services, 9371.A , Organization and Staffing and 9365.A., Personnel, revealed in part: "...Laboratory services shall be directed by an individual who meets appropriate qualifications of a director and is credentialed by the medical staff.

In an interview 05/04/16 at 2:55 p.m. S1CEO indicated that S19MD was the Medical Director of Laboratory Services, and had been for many years. S1CEO further indicated that no documented evidence could be provided of an appointment of S19MD as the Medical Director of Laboratory Services, or any agreement with S19MD for the position or responsibilities as medical director over Laboratory Services.

Review of the credentialing file for S19MD revealed no documented evidence that his privileges on his most recent reappointment included supervision of laboratory services. Further review revealed S19MD's reappointment to the hospital's medical staff had expired as of 04/10/16.


4) Failure to ensure all contracted physicians providing care and services in the hospital were privileged and credentialed as per the Medical Staff Bylaws.

Review of the Medical Staff Bylaws, Rules and Regulations, and Ethics Manual revealed the following, in part: "... Article VII: Procedure for Reappointment/Renewal of Clinical Privileges A. Application for Appointment /Clinical Privileges 1. All applications for appointment/clinical privileges...will be submitted in the form designated by the MEC and approved by the Board...The application will request information including, but not limited to: a documentation of professional qualifications, including medical education; b information as to professional licensure...2. In order to continue appointment and clinical privileges the practitioner shall reapply and be reviewed at least every two years... 3. All applications for reappointment to the Medical-Dental Staff will be submitted in the form designated by the Medical Executive Committee and approved by the Board. The reappointment application will request information including, but not limited to:.. i. continuing medial education to comply with Louisiana requirement for medical licensure and Medical Executive Committee requirements...B. Reappointment/Renewal Process: 1. The Medical Staff Office will review each application for completion and verification...The complete application will be transmitted to the Chief of Staff and then to the Credentials Committee.

S18MD
Review of the credentialing file for S18MD revealed the last approved reappointment was dated 07/11/14. Further review of the credentialing file revealed no documented evidence of CME since 2010.

In an interview on 05/04/16 at 1:20 p.m., S23Adm Assist stated for the credentialing process they obtained the practitioner's CME or a signed attestation. After reviewing the credentialing file for S18MD, she confirmed there was no documented evidence of CME or an attestation since 2010.

S19MD
Review of the credentialing file for S19MD revealed his last approved reappointment was approved and effective 04/11/14 through 04/10/16. Further review revealed a reappointment application for S19MD dated 8/13/15. No current approved reappointment or privileges were found in the file.

In an interview 5/4/16 at 1:10 p.m. S23Adm Assist reported she was responsible for the coordination of credentialing of medical staff. S23Adm Assist reported that S19MD had not been reappointed to the Medical Staff, and his appointment had expired 4/10/16. S23Adm Assist confirmed the file for S19MD contained an application for reappointment, but could not provide a reason that his credentialing process had not been completed, reviewed, and completed by the Medical Staff and the Governing Body.

S20MD
A review of the credentialing file for S20MD revealed no current CDS or DEA license, or Proof of Insurance.

In an interview 5/4/16 at 1:10 p.m. S23 Adm Assist verified that the insurance, CDS license, and DEA license in S20MD's credentialing file were expired. S23Adm Assist left and returned with a copy of S20MD's current proof of insurance, but did not provide a current CDS or DEA license. S23Adm Assist indicated that S20MD was currently providing care and services in the hospital..






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Based on record reviews, observations, and interviews, the CAH (Critical Access Hospital) failed to ensure health care services were furnished in accordance with written policies as evidenced by:

1) failing to ensure safe and effective care was provided to patients presenting to the hospital's ED (Emergency Department) who were a potential threat to themselves or others as set forth per hospital policy. This deficient practice was evidenced by failing to ensure that Visual Observation (Line of Sight) was maintained for a PEC (Physician Emergency Certificate) patient in the ED according to hospital policy for 2 of 2 (#15, #16) current sampled PEC'd ED patients reviewed;

2) failing to develop and implement written policies and procedures for Intermittent Cardiac Monitoring, and;

3) failing to develop and implement written policies and procedures for Observation Services.

Findings:

1) Failing to ensure safe and effective care was provided to patients presenting to the hospital's ED (Emergency Department) who were a potential threat to themselves or others as set forth per hospital policy:

A review of the hospital policy titled "Physician Emergency Commitment (PEC) and the Care of the Suicidal Patient", provided by S2DON as the most current policy, revealed in part: To establish guidelines for observation of the high risk behavioral patient who is placed under a Physician Emergency Certificate (PEC) to protect and plan appropriate care for individuals at risk for suicide while receiving care. Level 2- Visual Observation: The patient remains within visual range of trained staff as indicated to prevent patients from injuring themselves. Visual Observation (Line of Sight) includes the following elements: The patient should be within visual range of the assigned staff. Documentation will be recorded on the Patient Observation Record every 15 minutes.

Patient #16
A review of Patient #16's medical record revealed that the patient was a 15 year old female who presented to the ED on 05/02/16 at 12:58 p.m. with a diagnoses of Suicidal Ideation (SI) and Depression and at 1:54 p.m. a PEC was signed. The patient was placed on Visual Observation (Line of Sight) at 1:54 p.m.

An observation on 05/02/16 at 2:10 p.m. of Patient #16 revealed that the patient was sitting on a stretcher in a ED room that was diagonally across from the nurse's station (approximate distance of 10 feet) with the door ajar. A further observation revealed 3 (three) staff members (S9RN, S8CNA, S7WardClerk) behind the nurse's station with no observation of anyone observing the PEC Patient #16 in the ED room. All 3 staff members were observed performing various tasks and were observed with their backs to the patient or their heads down doing other patient's paperwork.

In an interview on 05/02/16 at 2:15 p.m. with S9RN, S8CNA, S7WardClerk they were asked about Patient #16. S8CNA said that Patient #16 was a PEC patient from the ED. They were asked who was assigned to monitor (Visual Observation -Line of Sight) Patient #16. S8CNA indicated that the 3 of them were supposed to be monitoring the patient and she (S8CNA) indicated that no one person was designated that assignment. She indicated that S9RN was taking care of the patient. S7WardClerk indicated that S9RN had the patient's medical record and was going to talk to the patient's family in another area.

In an interview on 05/02/16 at 2:30 p.m. with S1CEO and S2DON that were made aware of the surveyor's observation of Patient #16 (PEC patient in the ED). S2DON indicated that one person should be assigned (Visual Observation -Line of Sight) and that staff were not following hospital policy.


Patient #15
Review of the medical record for Patient #15 revealed the patient was a 35 year old male who presented to the ED on 05/02/16 at 7:29 p.m. with Agitation and Hallucinations. At 8:00 p.m. a PEC was signed and the patient was placed on Line of Sight observation.

An observation on 05/03/16 at 10:15 a.m. of Patient #15 revealed the patient was in Exam Room 3 in the ED. S16Security was observed to exit the exam room and close the door with Patient #15 inside the room, resulting in no line of sight observation of Patient #15. S3IC was observed at this time walking in the hallway in front of the nurse's station. S3IC called to S16Security and told him he could not shut the door and he must go into the room with the patient. S16Security was then observed to enter the exam room with Patient #15.

In an interview on 05/04/16 at 2:15 p.m. S1CEO was made aware of the surveyor's observation of Patient #15 (PEC patient in ED). S1CEO confirmed the security staff were not following hospital policy for line of sight observation.


2) Failing to develop and implement written policies and procedures for Intermittent Cardiac Monitoring:

Review of the medical records for Patients #3, #19, and #20 revealed the physician ordered "Intermittent Cardiac Monitoring." Review of the records revealed monitor strips were recorded in the patients' records, but there was no interpretation of the rhythm and no pattern of the intervals the strips were recorded.

In an interview on 05/02/16 at 4:22 p.m., S27RN stated they do not do continuous telemetry monitoring. She stated they do, "Intermittent Cardiac Monitoring." A telemetry monitor was observed in the nurse's station above the desk where S27RN was seated. S2DON arrived in the nurse's station at this time and stated the hospital has a medical unit and not a telemetry unit. She stated they do have cardiac monitoring but they do not have telemetry techs and do not monitor continuously. The hospital's policy for "Intermittent Cardiac Monitoring" was requested for review.

Review of the policy titled, Intermittent Cardiac Monitoring (NOP-009) provided by S2DON revealed the following: In order to provide better care through the use of technology, [Hospital] will use remote telemetry transmitters to provide intermittent cardiac monitoring where appropriate.
Definitions: (Left Blank).
Policy/Procedure Guidelines:
1. Physicians may order intermittent cardiac monitoring.
2. When an order for intermittent cardiac monitoring is received, the nurse will select an appropriate telemetry monitor box and apply to the patient.
3. The nurse will monitor the rhythm intermittently. If the nurse notes any changes in the patient's cardiac rhythm, the physician will be notified.

Review of the policy revealed no provisions for how often the intermittent monitoring was to be done, how often monitor strips were to be recorded and what interpretation of the strip was required. The policy did not include a definition of "intermittent." There were no provisions for the discipline or competency level of the staff that would be assigned to perform the monitoring.

In an interview on 05/03/16 at 8:30 a.m., S2DON confirmed the policy did not include specific provisions for how the Intermittent Cardiac Monitoring was to be carried out. She confirmed the policy did not provide direction to the staff for how often to monitor the cardiac monitor, how often to record monitor strips, or what interpretation was required. S2DON stated when the staff uses Intermittent Cardiac Monitoring the patient is placed on a telemetry monitor and they stay on the monitor until it is discontinued by the physician. S2DON stated no one watches the monitor, and stated the alarms are on and will alert staff.


3) Failing to develop and implement written policies and procedures for Observation Services:

Review of the medical records for Patients #9 and #14 revealed the patients were admitted under observation services.

In an interview on 05/04/16 at 9:00 a.m., S2DON confirmed the hospital did not have any policies and procedures related to observation services for patients. She stated they take their lead from the physician and the business office.

Based on record reviews and interviews, the CAH (Critical Access Hospital) failed to ensure the dispensation and administration of drugs and biologicals were implemented according to accepted professional principles as evidenced by failing to ensure its policies, procedures and hospital practices for dispensing and administering medications and biologicals included the pharmacist would review medication orders prior to the first dose being administered to the patient, except in emergencies. The hospital policies and practices allowed medications to be administered prior to the pharmacist review in the emergency department, and when the pharmacy was closed or the pharmacist was not available. Findings:

Review of the Louisiana Administrative Code, Title 46, Part LIII, Professional & Occupational Standards Pharmacists, effective 01/01/2004, revealed the following:
1511. Prescription Drug Orders
A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial dose of medication, except in cases of emergency.

Review of the CAH policy titled, Medication Administration of Medications (Pharm-001) revealed in part the following: A pharmacist must review all medication orders prior to administration with the following exceptions:
a. A situation exists whereby a Physician controls the medication process such as in the emergency department. In these circumstances the physician is present and available to oversee the components of the medication process.
b. An emergency situation exists and stat meds have been ordered. If clinical status could be compromised by the delay, these stat meds may be given prior to a pharmacist's review.
c. In urgent situations, when the delay of medication administration would harm the patient or when the patient experiences a sudden change in clinical status, the nurse may administer prior to the medication review by pharmacy.

In an interview on 05/02/16 at 3:00 p.m., S11RPh, Pharmacy Director stated the pharmacy hours were 7:30 a.m. to 4:00 p.m. and stated there was a pharmacist on-call after hours. S11RPh confirmed there were a large number of non-emergent patients seen in the hospital's emergency room. S11RPh confirmed all meds given in the emergency room were not in emergent situations. S11RPh confirmed he did not review the medication orders prior to the first dose for medications ordered in the emergency room that were non-emergent. S11RPh stated the physicians or the nurses may call or ask him questions regarding medications. S11RPh stated that he comes into the hospital after hours for admits and sets up the MARs, enters orders, and supplies medications.

Review of the medical record for Patient #3 revealed the patient was an 85 year old sent from a skilled nursing facility to the ER on 04/03/16 at 9:48 p.m. with complaints of altered mental status, lack of appetite, and incontinent of bowels and bladder. The triage assessment revealed the patient was oriented to person, place, and time, and was in no acute distress with a normal breathing pattern. Review of the record revealed the patient was given Rocephin 1gm. IVPB at 10:34 p.m. and Cipro 400 mg. IV at 11:53 p.m. by S25RN (Both are antibiotics). The record also revealed Lovenox (Anti-coagulant) 40 mg. SQ was administered at 2:00 a.m. on 04/05/16, and Duoneb (Breathing treatment) was administered at 4:00 a.m. There was no documented evidence that a review of the medication orders was done by the pharmacist.

In an interview on 05/02/16 at 5:15 p.m., S25RN stated the pharmacist does not come in and review medication orders in the ER and stated the pharmacist reviews the medication orders the next day when he comes in. She stated she called the pharmacist if she has any questions on how to mix a medication or any other concerns. S25RN stated, "If early enough, I call the pharmacist and he comes and does the MARs." S25RN stated if it was 2:00 a.m. she does the MAR and gives the medications, but does not call the pharmacist. S25RN confirmed there was no review by the pharmacist of the medication orders for Patient #3 prior to the medication administration in the ER.

In an interview on 05/04/16 at 9:00 a.m., S2DON stated the pharmacist review of the medication orders prior to the first dose was not consistently being done and there was no current process in place to document when the review was done. S2DON stated the nurses do call the pharmacist if they have any questions.

Based on record reviews, observations, and interviews the CAH failed to maintain a comprehensive and ongoing Infection Control Program designed to prevent, control, and investigate infection control practices by failing to maintain a sanitary environment to avoid sources and transmissions of infections as evidenced by:
1) failing to have a hospital policy, according to acceptable industry standards of practice and CDC (Centers for Disease Control and Prevention) guidelines, for the washing of hospital linens and patient ' s personnel clothing being laundered in the hospital Laundry Room by housekeeping staff
2) failing to have a designated/dedicated Decontamination Room for the decontamination of scopes (flexible sigmoid scopes and laryngoscopes) and reusable instruments used in patient ' s sterile procedures, and
3) failing of staff to follow hospital policy and acceptable infection control practices and the MFU (manufacturer ' s recommendations for use) for the HLD (high level disinfectant) solutions for semi-critical medical devices.


Findings:
A review of the CAH policy titled "Infection Prevention Plan" provided by S3IC as the most current, revealed in part: The purpose of the Infection Control Plan is to establish a hospital-wide, inter-disciplinary program using effective guidelines and methods to identify, control, and prevent infections and transmissions.

1) failing to have a hospital policy, according to acceptable industry standards of practice and CDC (Centers for Disease Control and Prevention) guidelines, for the washing of hospital linens and patient ' s personnel clothing being laundered in the hospital Laundry Room by housekeeping staff

A review of the CAH policy titled "Linen" provided by S3IC as the most current, revealed in part: To provide clean linen and handle soiled linen safely and aseptically. There was no documented evidence of a policy relating to the Laundry Department following any industry established guidelines and/or acceptable standards/guidelines used by staff in the washing and drying of hospital linens and patient ' s personnel clothing.

An observation of the Laundry Room revealed 2 (two) commercial washers and 2 (two) commercial dryers. Signage noted by the washers revealed MFU directions for the commercial washers for detergent and water temperatures. There was no signage noted by the dryers.

In an interview on 05/04/16 at 1:35 p.m. with S24Hker (housekeeper) she indicated that the housekeeping department was responsible for the cleaning of all hospital laundry, to include patient ' s personnel clothing. S24Hker indicated that the housekeeping department followed the MFU for the washers for temperature and detergent use and the housekeepers used " operator " discretion for the dryers. She further indicated that she was not aware of any policy regarding industry guidelines/standards for the washing and drying of hospital linens and patient ' s personnel clothing.

In an interview on 05/03/16 at 8:30 a.m. with S3IC she indicated that she was the designated Infection Control Officer for the CAH and that the CAH followed CDC and APIC (Association for Professionals in Infection Control and Epidemiology) guidelines for the hospital and SGNA (Society of Gastroenterology Nurses and Associates) guidelines for the Special Procedure Room. S3IC indicated that the only Laundry and Linen policies in place related to handling and transporting soiled linen safely and aseptically. S3IC indicated that she tried to look into Laundry (Industry) standards of practice /guidelines for the hospital setting at one time and never followed up with it.

2) failing to have a designated/dedicated Decontamination Room for the decontamination of scopes (flexible sigmoid scopes and laryngoscopes) and reusable instruments used in patient ' s sterile procedures, and

A review of the SGNA (Society of Gastroenterology Nurses and Associates) Guideline 2012 on guidelines for safety in the gastrointestinal unit revealed in part: The SGNA standards are to be used for all settings where endoscopy is practiced. Reprocessing of contaminated patient equipment must be done in an area designated and dedicated for this function. This must be a room separate from where endoscopic procedures are performed. Local, state, and federal guidelines should be incorporated in the design or designation of any reprocessing area. Considerations include adequate space for reprocessing activities, proper airflow and ventilation requirements {FGI- Facilities Guideline Institute: The decontamination area should have a negative airflow with a minimum number of 6 (six) air exchanges per hour and a temperature of 60 - 65 degrees F (Fahrenheit) and humidity between 20% - 60%. The preparation and clean areas should have a positive airflow with a minimum number of 10 air exchanges and a temperature of 68 - 73 degrees F and humidity between 20% - 60%.}, work flow patterns (dirty to clean workflow), work surfaces, lighting, adequate utilities, hand washing station, eye washing facilities, air drying capability, and storage.
Infection control measures that need to be considered include in part: disinfection, proper use of PPE (personnel protective equipment), engineering controls, cleaning and disinfecting of environmental surfaces, administrative monitoring and support, training and competency skills and continuing education, and written protocols/policies.

An observation on 05/02/16 at 3:30 p.m. with S6RN was made of the Special Procedure Room and Sterile Processing Room. The Special Procedure Room (where the Flexible Sigmoidoscopies were performed) was observed to contain supplies and equipment used in the decontamination and HLD of the Flexible Sigmoid scope. The Sterile Processing Room was observed to contain clean supplies and equipment.

In an interview on 05/02/16 at 3:30 p.m. with S6RN she indicated that she and S25RN were responsible for the Special Procedure Room and the Sterile Processing Room and in assisting the physician with Flexible Sigmoidoscopy procedures. S6RN indicated that the decontamination and the HLD of the scope were performed in the Special Procedure Room. S6RN indicated that the CAH did not have a designated Decontamination Room and they used the Special Procedure Room where the Flexible Sigmoidoscopy procedures were performed to decontaminate the flexible sigmoid scope after use and then perform HLD on the scope. S6RN further indicated that the Respiratory staff and the Nursing staff used the Sterile Processing Room to decontaminate soiled reusable laryngoscope blades and the non-disposable soiled sterile instruments from Emergency Room patient procedures.

In an interview 05/02/16 at 4:50 p.m. with S25RN she indicated that she was the main staff person responsible for the Special Procedure Room, the Sterile Processing Room and the Infection Control measures for those 2 rooms. S25RN indicated that the CAH followed the SGNA guidelines for Endoscopy. She indicated that she was not aware that the Special Procedure Room could not be used for the decontamination and reprocessing of the endoscope and that there should be a designated/dedicated Decontamination Room for that purpose.

In an interview on 05/03/16 at 8:30 a.m. with S3IC she indicated that she was the designated Infection Control Officer for the CAH and that the CAH followed CDC and APIC (Association for Professionals in Infection Control and Epidemiology) guidelines and SGNA (Society of Gastroenterology Nurses and Associates) guidelines for the Special Procedure Room. S3IC indicated that she depended upon S25RN ' s knowledge of Endoscopy and SGNA guidelines to assist her in the Infection Control measures for the Special Procedure Room and Flexible Sigmoidoscopy procedures. She indicated that the CAH did not have a designated/dedicated Decontamination Room.


3) failing of staff to follow hospital policy and acceptable infection control practices
and the MFU (manufacturer ' s recommendations for use) for the HLD (high level disinfectant) solutions for semi-critical medical devices

A review of the SGNA (Society of Gastroenterology Nurses and Associates) Guideline 2012 on guidelines for safety in the gastrointestinal unit revealed in part: The SGNA standards are to be used for all settings where endoscopy is practiced. Enzymatic detergent refers to low-foaming detergents which add enzymes capable of digesting organic material such as blood and mucous. HLD refers to a chemical germicide disinfectant capable of destroying all viruses, bacteria, fungi and some bacterial spores. MEC (Minimum Effective Concentration) refers to the lowest concentration of active ingredient necessary to meet the label claim on a HLD solution.
The Spaulding classification system is universally used to determine what type of disinfectant/sterilization is appropriate for medical devices. The 3 classes are critical, semi-critical and non-critical and stratify the risk of infection associated with each device. Critical devices break the mucosal barrier and should be sterilized (reusable biopsy forceps, reusable surgical instruments). Semi-critical devices (endoscopes, laryngoscopes) come in contact with mucous membranes or non-intact skin and should be sterilized or HLD. Non-critical devices (blood pressure cuffs, stethoscopes) come in contact with intact skin and can be disinfected with a low-level EPA registered disinfectant (i.e., Virex). Endoscopes are considered semi-critical and should receive at least HLD with a FDA approved HLD (i.e., Cidex OPA). Endoscopy areas should follow MFU for HLD solutions when HLD is used for endoscopes.

A review of the CAH policy titled " Disinfection and Sterilization " , provided by S3IC as the most current, revealed in part: Semi-critical devices that require HLD include: Endoscopes and Respiratory equipment (laryngoscopes). Critical medical devices (reusable surgical instruments) that require sterilization will be sent to the contract hospital for sterilization.

A review of the CAH policy titled " Decontamination and Sterilization of Reusable Instruments " , provided by S3IC as the most current, revealed in part: At the point of decontamination, instruments must be rinsed of all visible debris and blood, wrapped in a towel and brought to the workroom (Sterile Processing Room) to be further cleaned with an enzymatic cleanser. After drying, they will be sent to the contract hospital for sterilization.

A review of the CAH policy titled " Gluteraldehyde (Cidex OPA) Solution and Cidex OPA test strips for HLD " , provided by S3IC as the most current, revealed in part: Cidex OPA 14 day solution is prepared/activated according to manufacturer ' s instructions. The Cidex OPA solution test strips are used to monitor the concentration of the Cidex solution and are to be used according to the manufacturer ' s recommendations. After immersing the clean instruments in the Cidex OPA solution, cover the Cidex OPA with a secure lid. Soak for a minimum of 12 minutes at 20 degrees C (Celsius) to achieve results.

A review of the MFU label on the Cidex OPA (HLD solution) bottle revealed in part: Cidex OPA is a HLD with an immersion time of 12 minutes at 20 degrees Celsius and is a reusable product with a maximum reuse life of 14 days. MEC testing is required with Cidex OPA specific tests strips. The HLD activation is effective at the specific MEC testing and at 20 degrees C.

An observation of the Sterile Processing Room revealed that Cidex OPA was used for HLD of semi-critical medical devices (endoscopes and laryngoscopes).

A review of the HLD solution logs from January 2016 to present revealed no documented evidence that the temperature of the HLD was monitored prior to each use. The review of the HLD log further revealed no documented evidence that the medical devices were immersed for at least 12 minutes.

In an interview on 05/02/16 at 3:30 p.m. with S6RN she indicated that she and S25RN were responsible for the Special Procedure Room and the Sterile Processing Room. She was asked about the HLD log for the HLD solution of the endoscope after patient use. S6RN indicated that she and S25RN monitored the MEC before each use and checked for the solution expiration date, but was not monitoring the temperature of the solution before each use (as noted on the MFU on the Cidex OPA label). S6RN indicated that she was not aware that the MFU indicated that the temperature of the solution had to be monitored before each use and that the HLD solution temperature had to be at least 20 degrees C. S6RN indicated that she timed the endoscope after immersion for 12 minutes with her watch and did not document an " in and out " time on the HLD log to ascertain that the endoscope was immersed for at least 12 minutes.

In an interview 05/02/16 at 4:50 p.m. with S25RN she indicated that she was the main staff person responsible for the Special Procedure Room, the Sterile Processing Room and the Infection Control measures for those 2 rooms. S25RN indicated that she monitored the HLD solution ' s MEC before each use and checked for the solution expiration date, but was not monitoring the temperature of the solution before each use (as noted on the MFU on the Cidex OPA label). S25RN indicated that she was not aware that the MFU indicated that the temperature of the solution had to be monitored before each use and that the HLD solution temperature had to be at least 20 degrees C.

In an interview on 05/03/16 at 10:35 a.m. with S13CRT (Certified Respiratory Therapist) she indicated that the CAH had disposable and non-disposable laryngoscope blades. S13CRT indicated that after a non-disposable laryngoscope blade was used, she washed the blade with soap and water in the Sterile Processing Room ' s sink and then soaked the blade in Cidex OPA solution for about an hour. S13CRT indicated that she does not perform a MEC test or a temperature check on the HLD solution prior to use and was not aware of any hospital policy on decontamination and reprocessing of the non-disposable laryngoscope blades. She further indicated that she was not documenting in the HLD log when she used the HLD solution for the laryngoscopes.

In an interview on 05/03/16 at 2:30 p.m. with S6RN and S14RN they indicated that soiled sterile instruments used for patient procedures in the ED (Emergency Department) were cleaned in the Sterile Processing Room ' s sink with soap and water and then left to dry before sending them to the contract hospital for sterilization.

In a phone interview on 05/03/16 at 5:15 p.m. with S25RN she indicated that the soiled sterile instruments used for patient procedures in the ED (Emergency Department) were supposed to be cleaned in the ED or in the Sterile Processing Room ' s sink with an enzymatic cleaner or left in the Sterile Processing Room ' s sink for her to decontaminate.

In an interview on 05/03/16 at 8:30 a.m. with S3IC she indicated that she was the designated Infection Control Officer for the CAH and that the CAH followed CDC and APIC (Association for Professionals in Infection Control and Epidemiology) guidelines for the hospital and SGNA (Society of Gastroenterology Nurses and Associates) guidelines for the Special Procedure Room. S3IC indicated that she thought that staff were to decontaminate soiled instruments at the point of contact (i.e., ED) and then bring them to the Sterile Processing Room for eventual transport to the contract hospital for sterilization. S3IC indicated that the Respiratory Therapists were responsible for decontaminating and reprocessing the soiled reusable laryngoscope blades according to their policy. S3IC indicated that staff were not following hospital policy on HLD. S3IC further indicated that some infection control policies and procedures needed to be reviewed and revised to assure that they follow acceptable infection control practices.

Based on record review and interview, the CAH failed to ensure a registered nurse (RN) assigned the nursing care of each patient to other nursing personnel according to the needs of the patient and the qualifications and competence of the available staff. The ED RN delegated the line of site observation of patients to contracted security guards who had not received training and had not been assessed for competency in crisis prevention and interventions for 2 of 2 ( S16Security and S17Security) contracted security guards. Findings:

Review of the personnel records for S16Security and S17Security contracted security revealed no documentation of Crisis Prevention and Interventions training and no competencies for monitoring of a psychiatric patient with physician's observation orders for line of sight.

An interview was conducted with S2DON on 5/04/16 at 2:00 p.m. S2DON reported S16Security and S17Security were provided by the contract security agency to provide line of sight monitoring to patients when it is ordered by the physician. She further reported she had instructed the contract security company on the training that was needed for the security guards and the contract agency was suppose to provide the training to their personnel.

26351

Based on record review and staff interview, the CAH failed to ensure all medications were administered by accepted standards of practice for 3 out of 3 inpatients (#14, #19, #20) reviewed for medication administration out of a total sample of 20. Findings:

Review of the hospital policy titled Administration of Medications (Pharm-001) revealed no documented evidence of provisions for the monitoring of medications other than documenting the patient's response to medications given in the nursing notes.


Patient #14
Review of medical record for Patient #14 revealed the patient was admitted on 03/23/16 and discharged on 03/26/16 with the diagnosis of Right Upper Lobe Pneumonia.

Review of the MAR (Medication Administration Record) revealed the patient was being administered Cozaar (Antihypertensive) 25 mg oral once a day at 9:00 a.m. Further review of the MAR, Nursing Focus Notes and the Graphic Record for 03/23/16, 03/24/16, 03/25/16 and 03/26/16, revealed no documentation of monitoring the patient's blood pressure prior to administration of the Cozaar.

An interview was conducted with S2DON on 5/03/16 at 4:10 p.m. S2DON confirmed the nurses did not document the patient's blood pressure prior to administration of Cozaar.

Review of the information on Cozaar in Nursing 2016 Drug Handbook revealed under Nursing Considerations, monitor patient's blood pressure closely to evaluate effectiveness of therapy.


Patient #19
Review of the medical record for Patient #19 revealed the patient was admitted on 04/13/16 and discharged on 04/16/16 with the diagnosis of Chest Pain, Rule Out Sepsis, and Diabetes Mellitus.

Review of the MAR revealed the patient was being administered Lopressor 25 mg oral twice a day at 9:00 a.m. and 9:00 p.m. Further review of the MAR, Nursing Focus Notes and the Graphic Record for 04/13/16, 04/14/16, 04/15/16, and 04/16/16 revealed no documentation of monitoring the patient's apical pulse prior to administration of the Lopressor.

In an interview on 05/03/16 at 4:15 p.m. S2DON reviewed the medical record for Patient #19 and confirmed the nurses did not document the patient's pulse prior to administration of Lopressor.

Review of the information on Lopressor in Nursing 2016 Drug Handbook revealed under Nursing Considerations, always check patient's apical pulse rate before giving drug. If it's slower than 60 beats/minute, withhold drug and call prescriber immediately.



Patient #20
Review of Patient #20 medical record revealed she was admitted on 2/01/16 and discharged on 2/04/16 with the diagnosis of Paroxysmal Atrial Fibrillation with Rapid Ventricular Response.

Review of her MAR (Medication Administration Record) revealed she was being administered Lopressor 25 mg oral twice a day at 9:00 a.m. and 9:00 p.m. Further review of the MAR, Nursing Focus Notes and the Graphic Record for 2/01/16, 2/02/16 and 2/04/16 revealed no documentation of monitoring the patient's apical pulse prior to administration of the Lopressor.

An interview was conducted with S2DON on 5/04/16 at 9:30 a.m. She reported the Drug Reference book used by the nurses was Nursing 2016 Drug Handbook. S2DON further reported the CNAs perform vital signs check on the patients and with review of the medical record confirmed the nurses did not document the patient's pulse prior to administration of Lopressor.

Review of the information on Lopressor in Nursing 2016 Drug Handbook revealed under Nursing Considerations, always check patient's apical pulse rate before giving drug. If it's slower than 60 beats/minute, withhold drug and call prescriber immediately.

26351

Based on record review and interview, the hospital failed to ensure that the nursing staff developed and kept current a nursing care plan for each patient as evidenced by failing to individualize the patient's nursing care plan to include all of the patient's medical diagnoses for which the patient was being treated for 6 of 6 (Patient #3, #7, #14, #18, #19, #20) inpatient records reviewed out of a sample of 20 patients. Findings:

Review of the hospital policy titled Nursing Care Plan (NOP-017) provided by S2DON as current policy, revealed in part the following: An RN will initiate the plan of care, interdisciplinary teaching plan, and discharge plan after completing the admit assessment. The plan of care will be based on the assessment and be consistent with the attending practitioner's plan for medical care. The plan of care will contain nursing diagnoses, measurable nursing care goals, expected outcomes and appropriate nursing interventions based on the patient's nursing care needs. Nursing care goals should contain short and long term goals where relevant. The goals must be congruent, realistic, measureable, and have time period for achievement. The care plan will be updated each shift and at discharge.


Patient #3
Review of the medical record for Patient #3 revealed the patient was admitted on 04/04/16 from the ED with a diagnosis of Healthcare-Acquired Pneumonia. Review of the History & Physical revealed the patient had diagnoses of Diabetes Mellitus, Dementia, Hypertension, Aortic Valve Replacement, and Atrial Fibrillation.
Review of the physician orders revealed Intermittent Cardiac Monitoring, Foley to gravity, and sliding scale insulin was ordered.
Review of the Nursing Focus Goal List (Nursing Care Plan) revealed the only nursing diagnosis was Imparied Gas Exchange related to diffusion of oxygen secondary to inflamatory process in lungs. There was no documented evidence that the patient's identified problems of Diabetes Mellitus (Sliding Scale Insulin administration), Atrial Fibrillation (Intermittant Cardiac monitoring), or the Foley Catheter were included in the plan of care.

In an interview on 05/03/16 at 4:15 p.m., S2DON reviewed the medical record for Patient #3 and confirmed the plan of care did not include all of the patient's diagnoses and problems that were treated during his hospital stay.

Patient #7
A review of the medical record for Patient #7 revealed the patient was admitted on 04/18/16 with a diagnosis of Diarrhea, Nausea, Hematechezia. A review of the History & Physical revealed the patient had diagnoses of Hypertension, Chronic Cystitis, Gastric Reflux, Osteoporosis, prior Cerebral Vascular Accident with left sided weakness, Supraventricular Tachycardia and Hyperlipidemia. A review of the Nursing Focus Goal List (Nursing Care Plan) revealed the only 2 (two) nursing diagnoses that were care planned were: #1 Fluid Volume Deficit relating to diarrhea and #2 Nausea with Abdominal Cramping. There was no documented evidence that the patient's other identified problems of Hypertension, Chronic Cystitis, Gastric Reflux, Osteoporosis, prior Cerebral Vascular Accident with left sided weakness, Supraventricular Tachycardia and Hyperlipidemia were included in the plan of care.

In an interview on 05/04/16 at 9:30 a.m. with S2DON she indicated that the nurses should have care planned Patient #7's other diagnoses.

Patient #14
Review of the medical record for Patient #14 revealed the patient was admitted on 03/23/16 from the ED with a diagnosis of Right Upper Lobe Pneumonia with Hypoxemia and Bronchospasm, Hyperglycemia Secondary to Steroid-Induced Diabetes, and Syndrome of Inappropriate Antidiuretic Hormone Secretion.

Review of the physician orders revealed sliding scale insulin was ordered.

Review of the Nursing Focus Goal List (Nursing Care Plan) revealed the only nursing diagnosis was Imparied Gas Exchange related to Bronchospasm and Potential for Falls related to history of falls. Review of the goals section revealed the goals for both identified problems were not individualized and did not have time frames for achievment. There was no documented evidence that the patient's identified problems of Steriod Induced-Diabetes Mellitus (Sliding Scale Insulin administration) or the Syndrome of Inappropriate Antidiuretic Hormone Secretion were included in the plan of care.

In an interview on 05/03/16 at 4:10 p.m., S2DON reviewed the medical record for Patient #14 and confirmed the plan of care did not include all of the patient's diagnoses and problems that were treated during his hospital stay. S2DON confirmed the identified problems did not have individualized goals and time frames for achievement.


Patient #18
Review of the Medical Record for Patient # 18 revealed he was admitted on 3/26/16 from the ED with diagnoses of Dehydration and Lung Cancer, and a presenting complaint of weakness. Patient #18 received medications, as ordered for restlessness, cough, and agitation (Dilaudid and Ativan), and respiratory problems (Atropine, Albuteral treatments). Further review of Patient #18's medical record revealed no care plan(s).

In an interview 5/4/16 at 1:10 p.m. S12Director of Medical Records confirmed there were no care plans in the medical record of Patient #18.


Patient #19
Review of the medical record for Patient #19 revealed the patient was admitted on 04/13/16 from the ED with a diagnosis of Chest Pain, Viral Syndrome, Dehydration, Diarrhea, Atrial Fibrillation with Rapid Ventricular Response. Review of the History and Physician revealed the patient's diagnoses included Fever of Unknown Origin, Rule Out Sepsis, Cellulitis Left Lower Extremity and Diabetes Mellitus, Type 2.

Review of the physician orders revealed Intermittent Cardiac Monitoring and sliding scale insulin was ordered.

Review of the Nursing Focus Goal List (Nursing Care Plan) revealed no documented evidence that the Diabetes Mellitus was included in the plan of care.

In an interview on 05/03/16 at 4:15 p.m., S2DON reviewed the medical record for Patient #19 and confirmed the plan of care did not include all of the patient's diagnosis of Diabetes Mellitus and the sliding scale insulin.


Patient #20
Review of Patient #20's medical record revealed she was admitted on 2/01/16 and discharged on 2/04/16 with the diagnosis of 1. Paroxysmal Atrial Fibrillation with Rapid Ventricular Response, 2. Noncompliance secondary to Cognitive Impairment from Vascular Dementia, 3. Azotemia and 4. Hyperglycemia secondary to #2.

Review of Patient#20's Nursing Focus Goal List revealed the only nursing diagnosis care planned was Decreased Cardiac Output.

An interview was conducted with S2DON on 5/03/16 at 2:00 p.m. She reported the nurses should have care planned Patient #20's other diagnoses, especially her cognitive impairment.



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30420

30420


Based on record reviews and interviews the hospital failed to ensure physicians dated and timed all entries in the medical record as per Medical Staff Rules and Regulations. This deficient practice was evidenced by physician orders that were not signed, and/or timed for 2 (#14 #18) of 6 (#3, #7, #14, #18, #19, #20) sampled inpatient records and 2 of 2 (#R1, #R2) random records reviewed for timed and authenticated physician orders from a total sample of 20.
Findings:

Review of the Medical Staff Bylaws, Rules & Regulations, revised date of 01/27/16, revealed in part the following:
C. Medical Records:
4. Diagnostic and Therapeutic Orders. All written orders for treatment must be legible, dated/timed and authenticated.


Patient #14
Review of the medical record for Patient #14 revealed the patient was admitted to the hospital as an inpatient on 3/22/16, from the ED. Further review revealed the Physician's Admission Orders for care and treatment were without a signature of the physician writing the orders, or documentation of a verbal order taken by a nurse. The admission orders had a date of 3/22/17 and a time of 8:00 p.m. documented.
Further review of the physician's orders revealed an order documented by S30MD dated 3/23/16 with no documentation of the time the order was written.

In an interview on 05/03/16 at 4:10 p.m., S2DON reviewed the medical record for Patient #14 and confirmed S30MD had not timed the orders dated 03/23/16. S2DON confirmed the hospital was aware of a problem with S30 MD documenting the time on his orders. S2DON stated the physician said timing the order was not necessary.

In an interview on 05/03/16 at 4:20 p.m., S12Director of Medical Records reviewed the above Admission Orders and identified the handwriting of the admission orders as that of S26MD. S12Director of Medical Records verified that the physician's orders were not signed. S12Director of Medical Records verified the physician order dated 3/23/16 was noted timed by the physician when it was written.



Patient #18
Review of the medical record for Patient #18 revealed he was admitted to the hospital as an inpatient on 3/26/16, from the ED. Further review revealed Physician's Admission Orders for care and treatment without a signature of the physician writing the orders, or documentation of a verbal order taken by a nurse. The admission orders had a date of 3/26/17 and a time of 3:45 p.m. documented.

In an interview 5/04/16 at 9:25 a.m. S12Director of Medical Records identified the handwriting of the admission orders as that of S26MD. S12Director of Medical Records verified that the physician's orders were not signed.


Patient #R1
Review of the medical record for Patient #R1 revealed the patient was admitted to the hospital as an inpatient on 01/03/16. Review of the physician's orders revealed an order dated 01/03/16, documented by S30MD that was not timed when written.

In an interview on 05/03/16 at 3:50 p.m., S2DON reviewed the medical record for Patient #R1 and confirmed S30MD had failed to time the order written on 03/26/16.



Patient #R2
Review of the medical record for Patient #R2 revealed the patient was admitted to the hospital as an inpatient on 03/24/16, from the ED. Review of the physician's orders revealed an order dated 03/26/16, documented by S30MD that was not timed when written.

In an interview on 05/03/16 at 3:50 p.m., S2DON reviewed the medical record for Patient #R2 and confirmed S30MD had failed to time the order written on 03/26/16.

Based on record review and staff interview, the CAH failed to ensure the Quality Assurance (QA) program was effective as evidenced by:

1) The QA program failed to include identified problems with PEC'd patients in the ED, and;

2) The QA program failed to include corrective actions for quality indicators that did not meet the identified goals. Findings:


1) The QA program failed to include identified problems with PEC'd patients in the ED:

Review of the hospital's Performance Improvement Plan 2015/2016 revealed in part the following: General subjects for ongoing measurements include the following: High volume, High-risk, and problem prone processes including patient rights....

An observation on 05/02/16 at 2:10 p.m. of Patient #16 revealed that the patient was sitting on a stretcher in a ED room that was diagonally across from the nurse's station (approximate distance of 10 feet) with the door ajar. A further observation revealed 3 (three) staff members (S9RN, S8CNA, S7WardClerk) behind the nurse's station with no observation of anyone observing the PEC Patient #16 in the ED room. All 3 staff members were observed performing various tasks and were observed with their backs to the patient or their heads down doing other patient's paperwork.

A review of Patient #16's medical record revealed that the patient was a 15 year old female who presented to the ED on 05/02/16 at 12:58 p.m. with a diagnoses of Suicidal Ideation (SI) and Depression and at 1:54 p.m. a PEC was signed. The patient was placed on Visual Observation (Line of Sight) at 1:54 p.m.


In an interview on 05/02/16 at 2:15 p.m. with S9RN, S8CNA, S7WardClerk they were asked about Patient #16. S8CNA said that Patient #16 was a PEC patient from the ED. They were asked who was assigned to monitor (Visual Observation -Line of Sight) Patient #16. S8CNA indicated that the 3 of them were supposed to be monitoring the patient and she (S8CNA) indicated that no one person was designated that assignment. She indicated that S9RN was taking care of the patient. S7WardClerk indicated that S9RN had the patient's medical record and was going to talk to the patient's family in another area.


An observation on 05/03/16 at 10:15 a.m. of Patient #15 revealed the patient was in Exam Room 3 in the ED. S16Security was observed to exit the exam room and close the door with Patient #15 inside the room, resulting in no line of sight observation of Patient #15. S3IC was observed at this time walking in the hallway in front of the nurse's station. S3IC called to S16Security and told him he could not shut the door and he must go into the room with the patient. S16Security was then observed to enter the exam room with Patient #15.

Review of the medical record for Patient #15 revealed the patient was a 35 year old male who presented to the ED on 05/02/16 at 7:29 p.m. with Agitation and Hallucinations. At 8:00 p.m. a PEC was signed and the patient was placed on Line of Sight observation.


Review of the quality indicators for the emergency department revealed no documented evidence that PEC observation in the ED was included in the QA program.

In an interview on 05/04/16 at 10:45 a.m., S4Radiology Supervisor confirmed she was responsible for the hospital's QA program. When asked if PEC observation in the ED was included in the QA program, she stated the hospital was monitoring PEC observation, but it was discontinued in December after 100% compliance was achieved. S4Radiology provided the December, 2015 quality indicator which revealed only the following aspects were monitored: level of observation ordered by the physician, "Sad" person assessment, and use of bedside commode for suicidal patients. S4Radiology Supervisor confirmed there was no indicator evaluating staff compliance with the prescribed observations level.


2) The QA program failed to include corrective actions for quality indicators that did not meet the identified goals:

Review of the monthly quality indicator reports for 2016 and the last quarter of 2015 revealed the quality indicator for Dating/Timing/Signing physician orders was below the benchmark of 100%.

In an interview on 05/04/16 at 9:40 a.m., S12Director of Medical Records confirmed there had been ongoing problems with physicians timing/signing orders. When asked what corrective actions had been done to address the problem, she stated that was a question for S1CEO. She stated she collected the data and gave it to S1CEO and he brings it to the Medical Staff meetings.

In an interview on 05/04/16 at 10:05 a.m., S1CEO stated the incomplete medical records were addressed in the Medical Staff meetings and was also reported in the Governing Body meetings. S1CEO confirmed this issue had been a problem for quite some time. S1CEO stated it has been a challenge to go through the medical staff. S1CEO confirmed the only action taken has been to discuss it at the medical staff and Governing Body meetings. S1CEO confirmed the corrective actions taken thus far had been ineffective and they had not implemented any other corrective actions.

Further review of the quality indicators revealed the business office indicator for medicare secondary or primary payor had not met the benchmark consistently and the only corrective action documented was "reviewed errors and educated staff."
Review of the pharmacy indicator for medication error compliance revealed the benchmark of 100% had not been met for the month of March 2016. The only corrective action documented was, "Doctor notified, subsequent dose correction made." The pharmacy indicator for Verbal Orders in the ED for the Month of March 2016 was not met and there were no corrective actions documented.
Review of the Rural Health Clinic indicators revealed 3 of the 5 identified indicators were not met and there were not corrective actions documented other than the charts were sent to the nurses to correct.
Review of the hand hygiene indicator for March 2016 revealed the benchmark was not met and there were no corrective actions documented.

In an interview on 05/04/16 at 10:25 a.m., S4Radiology Supervisor was interview and confirmed she was responsible for the hospital's QA program. S4Radiology Supervisor stated she compiles the reports from the data submitted by the team leaders. She stated once the data is compiled into the report, the report is sent to the team leader and she requests they update and include their corrective actions.
After reviewing the above quality improvement reports and quality improvement indicators she confirmed the indicator for the business office had been an ongoing problem for months and the only corrective action was to educate the staff. S4Radiology Supervisor stated confirmed the medication error corrective action only included physician notification and not any actions to prevent reoccurrence of the error. S4Radiology Supervisor stated she did not know what the pharmacist was doing to address the verbal orders in the ED that did not meet the benchmark. S4Radiology Supervisor confirmed 3 of the 5 indicators in the hospital's rural health clinic were below the benchmark and she did not know what was being done to address the identified problems.

Based on record review and staff interview, the CAH failed to ensure the Quality Assurance (QA) program included all patient care services as evidenced by failing to include the contracted services of organ procurement and security services in the QA program. Findings:

Review of the hospital's Performance Improvement Plan for 2015/2016 revealed in part the following: Scope: The quality/performance improvement plan encompasses organization-wide activities....The hospital participates in hospital-wide, interdisciplinary monitoring of important functions....All PI activities are incorporated into a systematic, organizational-wide approach through integrated monitoring.

Review of the monthly quality improvement reports for 2015 and 2016, and the Clinical Contract Evaluation Dashboard Fiscal Year 2015 revealed no documented evidence of quality monitoring of the contracted services of organ procurement and security services.

During observations of the ED on 05/03/16 and 05/04/16, S16Security was observed providing Line of Sight observation of Patient #15 who was PEC'd and awaiting bed placement in a psychiatric facility.

In an interview on 05/04/16 at 10:25 a.m., S4Radiology Supervisor confirmed she was responsible for the hospital's QA program. S4Radiology Supervisor stated she made recommendations to the team leaders (department heads), and stated, "I am just a compiler of information." After reviewing the quality improvement records and the Clinical Contract Evaluation Dashboard Fiscal Year 2015, she confirmed the contracted services of organ procurement and security services were not included in the QA program. S4Radiology Supervisor confirmed the security services provided patient related services when assigned to monitor PEC'd patients in the ED.