HospitalInspections.org

Based on review of governing body meeting minutes and hospital documents and interviews with hospital staff, the hospital does not ensure the organizational structure of the hospital is effective to protect the safety of patients and staff.

Findings:

1. Review of governing body minutes did not reflect the new administrator/Chief Executive Officer (CEO) had been appointed by the governing body with the authority for day-to-day operation of the hospital. This findings was reviewed with the CEO on the afternoon of 07/16/2010.

2. The governing body failed to monitor to ensure care was provided in a safe environment by trained and qualified staff. Please refer to Tags # C-241 and C-383.

3. The governing body failed to monitor the Quality Assurance Program to ensure the quality and appropriateness of services are furnished safely. Please refer to Tag # C-330.

Based on review of governing body meeting minutes and hospital documents and interviews with hospital staff, the governing body failed to monitor and ensure care was provided in a safe environment.

Findings:

1. Review of dosimetry reports revealed the last time the radiological dosimeter badges were checked was May 2009.

2. Staff B stated on 07/16/2010 at 1230 that the department did not have badges. Staff B stated when new badges did not arrive in 2009, the administrator, that was there at that time, was notified. Staff B stated when the current administrator arrived in December 2009, Staff B notified that administrator that the department was providing radiological services without dosimetry badges to monitor/measure the amount of radiation that each employee received.

3. Review of governing body and medical staff (quality assurance part of medical staff) meeting minutes did not reflect this problem had been addressed with a corrective action identified and follow-up to ensure the problem was corrected.

4. The administrator stated on 07/16/2010 at 1250 that he was unaware the hospital still did not have dosimetry badges. He stated when he was made aware in December 2009, he called the corporate office and thought the bill had been paid. He stated he did not notify governing body or medical staff as he thought is was a "quick fix." He did not follow-up to ensure the problem had been corrected.

Based on policy and procedure manual review and interview with the radiology department manager, the hospital failed to ensure policies are reviewed at least annually.

Findings:

On the morning of 7/16/2010 surveyors were given copies of the Radiology Department policy and procedure manual. Policies and procedures were initially approved effective 1/05/01 and revised 03/15/05.

Based on policy and procedure manual review, review of hospital documents, and interviews with the radiology department manager, the hospital failed to maintain current dosimetry badges and monitoring . The hospital also failed to have documentation showing all the personnel operating the diagnostic x-ray equipment are qualified and trained.

Findings:

1. On the morning of 7/16/2010 surveyors were given copies of two dosimetry badge reading documents dated 5/2009. Later in an interview at approximately1215, Staff B was asked by surveyors if there were any other dosimetry readings for 2009 and 2010. Staff B told surveyors the 5/2009 reports were the last time there had been badge readings because of a vendor hold for payment. Staff B stated staff had not been given badges since 5/2009. Staff B stated she had advised the former administrator at the time and she had also advised Staff J in or around October. In a conversation later in the afternoon on 7/16/2010, Staff J stated he was not aware the badges had not been replaced. Staff J also stated he thought the vendor situation was taken care of.

2. In four of four ( Staff B, C, D, E) radiology personnel files there was no documentation they had been oriented to the hospital or had the appropriate training to operate x-ray equipment. In an interview on the afternoon of 7/16/2010 Staff B stated all of the employees (B,C,E) were on-the-job trained to take x-rays and computed tomography except for Staff D who was a certified American Registry of Radiology Technicians (ARRT). Surveyors asked Staff B to provide documentation of certification for Staff D. Staff B stated there were no documents to support the orientation and training specific to radiology in any of the employee's (B,C,D,E) personnel file. On the afternoon of 7/16/2010 at 1210 Staff B provided surveyors with a certification of Staff D as an (ARRT).

3. On the afternoon of 7/16/2010, Staff B was asked by surveyors if the magnetic resonance imaging (MRI) was provided by contract. Staff B brought the contract with contracted MRI personnel records. Staff B told surveyors none of the contracted workers had hospital orientation or radiology department training. When surveyors asked if there was emergency equipment and oxygen available in the MRI unit, Staff B stated she was unaware as she had not been in the MRI unit. Staff B stated the MRI staff were made aware of the location of the nearest hospital emergency cart.
0 of 7 contract personnel records (K,L,M,N,O,P,Q) indicated they had orientation to the hospital or the radiology department. 2 of 4 (N, Q) with certification in MRI did not have current certifications. Staff B was asked by surveyors which technicians were working in the CAH. Staff B stated she did not know the technicians because they worked on Saturdays and she did not work on Saturdays.

4. On the afternoon of 7/16/2010, surveyors asked Staff B if there was a Radiologist in charge of the department. Staff B indicated Dr. G was the physician in charge of the department and he is the person she would take most of the problems to. Staff B stated because the radiologist are contract, there is not a particular radiologist who is charge of the facility. Review of Dr. G's credentialing and privilege files indicate he is family medicine not a radiologist.

The hospital does not meet the Condition of Participation for Periodic Evaluation and Quality Assurance Review at CFR 485.641.

Based on record review and interviews with hospital staff, the hospital does not ensure that the quality assurance (QA) program evaluates patient care services to insure the health and safety of patients and provides this data to the Medical Staff and Governing Body. The hospital does not have a mechanism in place to evaluate the quality and appropriateness of the radiology services and radiology safety furnished by staff at the critical access hospital (CAH).

Findings:

1. On 7/16/2010 surveyors reviewed meeting minutes from Governing Body 2009-2010 and Medical Staff 2009-2010. There was no documentation to reflect the Governing Body or the Medical Staff had been apprised of problems or concerns with the radiology department. The quality assurance overview provided to the governance gave only total numbers of studies. No problems were monitored or reported. There was no review of competencies, education or training of radiology staff in any of the Governing Body, Medical Staff or Radiology Department meeting minutes. There was no radiation safety information presented at any of the Radiology Department, Medical Staff, or Governing Body meetings. In an interview on the afternoon of 7/16/2010 Staff J stated he had not reported the lack of dosimetry badges to the Governing Body or Medical Staff.

2. On 7/16/2010 surveyors reviewed radiology department policies. The radiology department policies were initially approved effective 01/05/01 in 2001 and revised 03/15/05. There had not been any review by Governing Body or Medical staff since 2005.