HospitalInspections.org

Based on document review and interview, the facility failed to follow the manufacturer's recommendation and facility requirement to make daily checks of 1 automated external defibrillator.

Findings:

1. Review of an offsite facility (RMH Healthcare Associates Medical Professional Building)document entitled Daily Defibrillator Check Sheet, Month: Dec 1/4 North indicated checks were not made on 10 of 21 days the facility was open, as follows:
December 8 through December 12
December 17 through December 19
December 24
December 26

2. In interview on 1-28-2015 at 2:00 pm, facility staff confirmed checks were made each day the building was open and the building was not open on weekends. No other documentation was provided prior to exit.

Based on observation, it could not be determined the facility followed the manufacturer's instruction to store contrast media within the proper temperature range in 1 instance.

Findings:

1. On 1-26-2015 at 1:30 pm, in the presence of employee #A6, Director of Maintenance, it was observed in the CT (computerized tomography) Scanner Room, there were 9 bottles of Iso-Vue 370 contrast media, 300 ml each, in a warming box. The manufacturer's label on each bottle indicated to store at temperature 68-77 degrees Fahrenheit. It was also observed there was no thermometer or other method to determine the temperature of the warming box.

2. In interview on the above date and time, employee #A8, Radiology Director, confirmed the above, provided no temperature log, and no other documentation was provided prior to exit.

Based on document review and interview, the hospital failed to ensure contractors met standards for 2 of 8 services (social services, teleradiologist) provided by the contractors.

Findings:

1. Review of the facility's QAPI program for calendar year 2014 indicated it did not include monitors and standards for the contracted service of social services.

2. In interview, on 1-28-2015 at 10:50 am, employee #A4, VP Operations/Risk & Compliance, confirmed the above for social services and no further documentation was provided prior to exit.

3. Review of 6 medical staff credential files reviewed indicated file MD#2, a contracted teleradiologist, did not have any documentation of outcome oriented performance evaluation.

2. In interview, on 1-27-2015 at 3:20 pm, employee #A7, Medical Staff Coordinator, provided a document for MD#2 which indicated the type and number of procedures interpreted. The document did not indicate any standards to be met by the contractor.

Based on observation, the facility failed to ensure medical records were adequately protected
from damage due to water and fire in 1 instance.

Findings:

1. On 1-26-2015 at 1:45 pm, in the presence of employee #A6, Director of Maintenance, it was observed in the medical record storage area, the room was unsprinklered. It was also observed there were 24 shelves of medical records which were on open shelves and not protected from damage due to water and fire.

Based on interview, the facility failed to ensure the provision of routine dental services.

Findings:

1. In interview, on 1-26-2015, employee #A1, President/CEO, indicated the facility did not provide dental services.