HospitalInspections.org

Based on personnel file review and staff interview, it is determined the hospital has failed to assure that the manager of the Health Information Management Department meets applicable standards required by State regulations.

Findings include:

Section 27.0, Medical Records, of the Rules and Regulations of Licensing of Hospitals (R23-17-HOSP) states:

"27.1 The medical record service shall be under the full-time direction of a registered medical record administrator or a registered health information administrator (RHIA) who is certified by the American Health Information Management Association or who possesses equivalent training and experience."

Review of the personnel file, on 8/18/2011, for the Assistant Director of Health Information Management, who holds responsibility for the day-to-day activities for the Health Information Management (HIM) Department, revealed no credentials of either a registered medical record administrator, nor a registered health information administrator. Interview with the Assistant Director of HIM, on 8/15 and 8/18, reveals she is enrolled in a program which will begin in September.

Based on surveyor observation, staff interview, and review of portable X-ray unit calibration records, it was determined that the hospital failed to ensure periodic inspections of all portable radiographic units, in accordance with the Rhode Island Rules and Regulations for the Control of Radiation (R23-12.3-RAD).

Findings are as follows:

According to the Rhode Island Rules and Regulations for the Control of Radiation (R23-12.3-RAD), section F.5.1 (e) states:

"An evaluation of the light field versus X-ray field alignment and actual vs indicated settings be performed at least every 6 months".

Review of maintenance records revealed no evidence that testing for "alignment and actual versus indicated settings" had been conducted within a 6 month period per State regulation. In addition, during an interview on 8/16/11 at 1:00 PM with the Manager of Diagnostic Radiology, she was unable to provide evidence that this required testing had been performed.

Based on surveyor observation, monitoring records, and staff interview, it was determined that the hospital failed to submit control badges with appropriate monitoring badges to determine accurate personnel radiation exposure, from February 2011 through July 2011, in accordance with the Rhode Island Rules and Regulations for the Control of Radiation (R23-12.3-RAD).

Findings are as follows:

According to the Rhode Island Rules and Regulations for the Control of Radiation (R23-12.3-RAD), section F.5.7 (a) states:

"A control badge must be returned with the proper monitoring badges".

During a review of the above 5 months of monitoring records, it was determined that no control badge had been sent with personnel monitoring badges to be evaluated.

During an interview on 8/16/11 at 1:00 PM with the Manager of Diagnostic Radiology, she was unable to produce evidence that radiation workers were checked for accurate radiation exposure by use of control badges per State regulations.

Based upon surveyor observation and staff interview it was determined the hospital failed to maintain supplies to ensure an acceptable level of safety and quality, relative to food storage.

Findings are as follows:

1. Surveyor observation of the kitchen on 8/15/11 revealed two bins with dry goods, rice and flour. The outside of the bins, including around the openings, were not clean to either sight or touch. During interview on 8/5/11 at 11:25 PM, the operations manager indicated that the bins should be cleaned.

2. Surveyor observation on 8/15/11 of the juice dispensing machines in the nourishment kitchens, utilized by patients, on the fourth floors of the main building and south pavilion, revealed the dispensing tubes of these machines were not protected from contamination since these dispensing tubes could touch the inside of a cup and/or the liquid in the cup.

During interview on 8/16/11 at 2:50 PM, the food service director confirmed the juice dispensing machines (tubes) could become contaminated.

Based upon review of the agreement with the designated Organ Procurement Organization (OPO), and staff interview, it was determined that although an agreement exists, the hospital has failed to implement all parts of the agreement.

Findings are as follows:

The agreement dated 2/1/2010, between the OPO and the hospital, under Duties of the Donor Hospital states NEOB (New England Organ Bank will provide the following services:

"3.13 Conduct periodic death record reviews as indicated in conjunction with the Donor Hospital Medical Records Department to assess the effectiveness of the Donor Hospital's organ, tissue and eye donation program and policies"; and under,

"3.14 Conduct periodic in-service education programs on organ, tissue and eye donation"; and,

"4.4 Train the members of its medical staff with the current medical standards...."

Interviews with the Director of Patient and Family Support and the Risk Manager on 8/18/11 revealed that the hospital could not produce evidence of either reviews noted above, or of medical staff training in accordance with the agreement.

Based upon surveyor interview on 8/17/11 and 8/18/11 it was determine that the hospital has failed to designate a trained individual who is an organ procurement representative or a designated requestor to approach potential donor families and request organ or tissue donation.

Findings are as follows:

On 8/17/11, at 8:45 AM, and on 8/18/11, at 9:15AM, during interviews with the Director of Patient and Family Support, she was unable to produce evidence that staff have completed a course offered or approved by the Organ Procurement Organization (OPO,) which is designed in conjunction with the tissue and eye bank community, regarding the methodology for approaching potential donor families and requesting organ or tissue donation.

Based upon staff interviews on 8/17/11 and 8/18/11 it was determined that the hospital has failed to work with the designated Organ Procurement Organization (OPO), tissue bank and eye bank in educating staff on donation issues.

Findings are as follows:

During interviews with the Director of Patient and Family Support, the Assistant Vice President of Patient Care Services, and the Risk Manager on 8/17/11 and 8/18/11, it was determined that the hospital could not produce evidence of staff training being conducted on donation issues.

Based on record review, it was determined that the hospital failed to ensure that Operative Reports include the times of surgery for 7 of 7 relevant sample records (ID #'s 2, 3, 4, 5, 6, 8, and 9).

Findings are as follows:

A review of the Operative Reports for patient ID #'s 2, 3, 4, 5, 6, 8, and 9 revealed no evidence that the times of surgery were included in these reports.