HospitalInspections.org

Based on document review and staff interview, it was determined the hospital governing body failed to ensure all contracted services were provided according to Medicare Conditions of Participation and evaluated through the quality assurance and performance improvement process. Findings:

Quality assurance and performance improvement (QAPI) meeting minutes and governing body meeting minutes were reviewed for 2011 and 2012. There was no documentation of a review of all contracted services to ensure those services were provided in a safe and effective manner according to acceptable standards of practice.

On 12/04/12, hospital leadership confirmed that contracted services were not included in the QAPI process.

Based on staff interview and record review, it was determined the hospital failed to ensure all contracted services were evaluated for quality assurance and performance improvement to ensure services were provided in a safe and effective manner. Findings:

Quality assurance and performance improvement (QAPI) records for 2011 and 2012 did not include documentation that all contracted service providers were included in the QAPI program.

Staff C was asked if the contractor for item reprocessing was evaluated by the surgery department for quality and performance. She stated they were not.

On 12 04/12, hospital leadership confirmed contracted services were not evaluated by the QAPI process.

Based on record review and staff interview, it was determined the hospital failed to maintain an accurate and up to date list of contracted services with documented delineation of contractor responsibility. Findings:

On 12/03/12, the hospital was asked to provide a list of contracted services. A complete and accurate list was not available. Staff were asked who was responsible to evaluate various contracted services. They stated they were not certain who was responsible to evaluate contracted services.

There was no documentation the quality assurance and performance improvement process evaluated contracted services and there was no documentation the governing body evaluated these services.

Based on record review and interviews with hospital staff, the hospital does not ensure that medication is administered as the physician has ordered. One (# 6) of one patient record reviewed that had cataract surgery did not have evidence that the eye drops ordered were given as ordered. The record did not document each eye drop with the name of the medication, number of drops administered, time administered and the person administering.

Findings:

1. Seven different eye drops were ordered to be admininstered as follows; one drop of each, times three times every 5 minutes.

2. Documentation in the patient record had the following: "eyedrops started 0825." Other documentation was "0835 eyedrops given."

3. Hospital staff verified on 12/04/12 in the afternoon that the medication was not documented with name of the drug, amount of drug administered, time administered and person administering.

Based on record review and interviews with hospital staff, the hospital does not ensure that all entries in the medical record are legible, complete, dated, timed and authenticated in written of electronic form by the person person providing the service. One (#7) of one patient record did not have a history and physical (H & P) that was legible. Two of two hospital nursing employees could not read what the physician had written when asked by the surveyor. One (#6) of one patient record did not have documentation of specific medications given with the name, date, time and person administering the medications. One (#6) of one surgery patient record had a photocopied order sheet, but did not have a physician's signature with the date when it was signed.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure surgical complications were documented in the clinical record. Findings:

Patient #10 was admitted to the hospital for a surgical procedure. The discharge summary, completed by the surgeon, did not document any complications related to the surgical procedure.

A review of the entire clinical record included documentation from other physicians (consultant specialists, hospitalists and radiologists) of a surgical complication. There was no documentation by the surgeon in the clinical record of a surgical complication.

Staff F was asked to review the discharge summary and other findings within the clinical record. She was asked if surgical complications should have been documented on the discharge summary and elsewhere in the medical record by the surgeon.

She stated they should.

Based on record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure:

a. flash sterilization was used only under circumstances recommended by nationally accepted standards; and

b. flash sterilization cycle documentation included all information necessary to track flash sterilized items to individual patients. Findings:

1. Surgery department records of flash sterilization were reviewed. There was documentation of 26 flash cycles in October 2012 and 28 flash cycles in November 2012. Individual instruments and complete sets of instruments were flashed sterilized. There was no documentation of why flash cycles were used in each of those cases.

Staff C stated the hospital used flash cycles during time constraints between cases (non-emergency turn-over) and due to limited numbers of individual instruments or sets.

2. Surgery surgery department sterilization policies did not adequately address flash sterilization to include the limits set in national standards.

3. Flash sterilization cycles were not adequately documented to include the item processed, the cycle parameters used, the date and time the cycle is run, the person who performed the flash cycle and the reason for the flash cycle. The documentation did not include if the items were flashed in an open container, closed container, wrapped or peel-packed.

4. Surgery department sterilization policies did not adequately address flash cycle documentation requirements.