HospitalInspections.org

Based on observation, interview and review of policies, procedures, contracts, and other documents it was determined that the governing body had not been responsible for all services provided by the hospital, including those furnished under contracts. All services provided by the hospital, including those provided at offsite locations and contracted services, were not clearly and consistently identified, and all services provided at offsite, non-hospital locations were not provided under a contract.

Findings include:

1. The hospital's offsite locations and services provided at those locations were described in the following documents reviewed:

a. A document dated "12/11/13", provided by hospital administration under the heading of "Hospital Services & list of satellite locations", was reviewed. The document identified the hospital's "Off-campus site" locations and services as:

Barger Medical Clinic, 4010 Aerial Way, Eugene, Oregon. The document indicated that the following services were provided at this location:
* Senior Health & Wellness Center
* Outpatient Therapy

RiverBend Annex, 123 International Way, Springfield, Oregon. The document indicated that the following service was provided at this location:
* Inpatient Pharmacy

b. The hospital's State of Oregon license application submitted for license renewal and dated 12/11/2013 identified the sites and services under a. above as its off-campus locations.

c. The "Exhibit 286 - Hospital Database Worksheet", submitted by the hospital administrator on 01/09/2014, identified the sites and services under a. above as its off-campus locations.

2. The hospital's contracted services were inconsistently identified in the following documents reviewed:

a. A document dated "12/11/13", provided by hospital administration under the heading of "Hospital Services & list of satellite locations", was reviewed. The document identified the hospital's "Contracted Services" as:
* Emergency Room Physicians
* Radiology Physicians
* Dialysis

b. A document provided by hospital administration under the heading of "Contracted Services" was reviewed. The document identified the hospital's "Contracted Services" and contained a summary of quality improvement activity for the listed services. The following services were identified:
* Radiology Associates'
* Eugene Emergency
* Fresenius Medical Care
* Hospice
* Hospitalist
* Interpretation Services
* Physiatrists

c. A document titled "Quality and Patient Safety Plan" for the period September 1, 2013 through August 31, 2014 was reviewed. Final approval of the plan was reflected by the governing board on 09/10/2013.
On page 7 the document reflected that the plan "...integrates all departments within the Medical Center, including outsourced and contracted services." On page 9 the document contained a section titled "Contracted Services" and reflected "Contracted services are fully integrated into the quality management system and evaluated at least annually using criteria set forth in each individual contract. The following services/processes have been outsourced.
* Emergency Room Physicians
* Radiology Physician
* Anesthesia Services
* Laboratory (No written contract because it is an operating division of PeaceHealth, Inc.)
* Blood Bank (same as above)
* Laundry
* Radiation Therapy
* EKG/Echo Interpretation
* Dialysis"

d. The "Exhibit 286 - Hospital Database Worksheet" submitted by the hospital administrator on 01/09/2014 identified the hospital's services provided fully or in part by arrangement or agreement as:
* Emergency Department
* MRI
* Radiology Services - Diagnostic

3. During tour of the ED on 01/08/2014 at 1030 a machine identified as an "InstyMed" was observed. The ED nurse manager and medical director described the function of the machine as medication dispensing. The machine was put into use in August of 2013. It was designed to dispense certain medications directly to patients from prescriptions written by ED physicians. This service is available 24 hours a day in lieu of patients having their prescriptions filled at a retail pharmacy. During the interview about the machine, it was revealed that the InstyMed company is in Minnesota. The medication inventory in the machine is monitored electronically by the company and replacements overnight shipped to the hospital each day. The hospital pharmacy staff re-stock the machine upon arrival of the medications.

This service was not identified on the contracted services lists under finding 2 above.

During interview with the Administrator and the Regional Director of Quality on 01/10/2014 at 1515, they indicated that there was a contract for services with this company and that it would be added to the contracted services list.

4. During tour of the outpatient rehabilitation department on 01/08/2014 at 1330, the Director of Rehabilitation Services was interviewed. He/she stated that department staff conducted one-to-one and group patient evaluations for hospital patients at an off-campus site located at Oregon Neurology Associates clinic in an adjacent city.

This off-campus location and the services were not identified on the off-campus site or contracted services lists under findings 1 and 2 above.

During interview with the Administrator and the Regional Director of Quality on 01/10/2014 at 1515, it was confirmed that hospital patients had been sent to this off-campus site to have rehabilitation evaluations conducted. It was further confirmed that there was not a contract for those services to be provided at that off-campus location.

5. During tour of the radiology department on 01/08/2014 at 1330 the radiology staff person present on the tour described the services provided by the department. He/she stated that the hospital did not have an MRI machine and that during regular business hours MRIs were conducted under agreement at the Oregon Imaging Center and after regular business hours SHUD patients were sent to another PeaceHealth hospital in the area.

These off-campus locations were not identified on the off-campus site lists or consistently identified on the contracted services lists under findings 1 and 2 above.

During interview with the Regional Director of Quality on 01/09/2014 at 1530, he/she indicated there was a contract with the Oregon Imaging Center for MRI services, confirmed that those services were not identified on the list of contracted services, and indicated that the evaluation of those services "will be" included in the radiology department quality improvement program and the "MRI piece strengthened". No information was provided related to MRI services rendered to SHUD patients at a second hospital.

An "Agreement For For (sic) Inpatient and Outpatient Magnetic Resonance Imaging Services" was reviewed. The contract was dated in January 2011 and was between Oregon Imaging Center, LLC and PeaceHealth Oregon Region. It reflected that the contract covered services provided for two separate PeaceHealth hospitals in the area, including SHUD. The contract reflected that the hospital "...desires to retain the services...to provide the technical component of magnetic resonance imaging ("MRI") services and certain other diagnostic imaging services for patients presenting at the Emergency Department...and for other...patients." In Exhibit A attached to the agreement the services provided to the hospital were identified as "MRI Services" and "Other Services". The "Other Services were listed as: "Digital Mammogram Screening...Digital Mammogram Diagnostic...Stereo Core Breast Biopsy...Needle Localization."

The "Other Services" identified in the agreement were not consistently identified on the contracted services lists under finding 2 above.

6. During a tour of the laboratory department on 01/08/2014 at 1500 the laboratory manager described the laboratory as a "stat lab", primarily conducting those tests that required urgent completion. The manager indicated that generally other tests were sent to the "core lab" which was identified as a PeaceHealth central lab located off-campus at the RiverBend Annex 123 site. The manager also indicated that the lab did not provide pathology services for tissue specimens.

The services were not identified on the off-campus site lists or consistently identified on the contracted services lists under findings 1 and 2 above.

During interview with the Administrator and the Regional Director of Quality on 01/10/2014 at 1515, they indicated that a signed agreement for laboratory services could not be located at that time but it was believed there was one.

On 01/13/2014, following the survey, a document was submitted to the HCRQI office which was titled "Service Level Agreement" between the PeaceHealth Laboratory and PeaceHealth Oregon West Network (referred to as the Client) was reviewed. The agreement was dated 11/19/2013. The document reflected that "The scope of services includes, but is not limited to, the provision of standard clinical laboratory and pathology coordination of services to Client." However, the agreement contained no specific language which reflected the specific testing and laboratory services to be conducted for SHUD.

7. During the tour of the laboratory department on 01/08/2014 at 1500 the laboratory manager additionally stated the hospital did not have a blood bank and that those services were provided by another PeaceHealth hospital in the area. The manager stated that blood was provided by the other hospital as needed.

This service was not consistently identified on the contracted services lists under finding 2 above.

During interview with the Regional Director of Quality on 01/09/2014 at 1530, he/she stated that there was no contract for those services because all blood bank services were performed at SHUD.

However, a policy and procedure titled "Centralized Transfusion Services (CTS) Policy Overview..." was reviewed and contained contradictory information. The policy reflected that "Transfusion Service at Sacred Heart Medical Center at RiverBend (SHRB) performs all pre-transfusion testing for Sacred Heart Medical Center University District (SHMC)...and sends blood products to those locations when needed."

Another policy and procedure titled "Centralized Transfusion Services (CTS) Procedure.." was reviewed. It reflected that "PeaceHealth Transfusion Services at Sacred Heart RiverBend (SHRB) performs all pre-transfusion testing for Sacred Heart University District (SHMC)...patients and sends blood products to them."

Based on interview and review of policies, procedures, forms and patient information documents it was determined that the hospital failed to ensure that the written information in English and Spanish provided to patients about patient's rights, specifically related to grievance procedures, was accurate and available for use. Admission packets, brochures, consent forms, and other documents observed in multiple areas throughout the hospital contained inaccurate information about grievance procedures, including those required by the hospital's own policy. In addition, although written patient rights information was available in Spanish language it was not always provided to Spanish speaking patients.

Findings include:

1. A form titled "Rights and Responsibilities of Patients" with a version date of "060710" was observed in the outpatient rehabilitation department on 01/08/2014. The following was noted:
* Language on the form included that the patient had the right to "complain about hospital care...and if requested, to receive a written response from the hospital." That information was inaccurate based on hospital policy identified under finding 5 below.
* Language on the form informed patients that they could file a complaint with "the Joint Commission", the hospital's AO. However, effective 12/20/2013 the hospital has a different AO.
* The phone number provided for patients to file a complaint with CMS, the federal Medicare agency, 800-336-6016, is not accurate. A phone call to that number on 01/09/2014 revealed that number is for the State of Oregon Medicaid agency.

2. On 01/08/2014 and 01/09/2014 forms titled "Rights and Responsibilities of Patients" and "Conditions of Admission and Consent", with version dates of "12/04/13", "05/2013", "04/04/13", "032813", and "07/10/2012" were reviewed in documents provided by hospital administration, in a "Guide to Guest Services", and in departments throughout the hospital, including off-campus sites, such as outpatient rehabilitation and the senior health and wellness center. The following was noted:
* Language on the form informed patients that they could file a complaint with "the Joint Commission", the hospital's AO. However, that is not currently the hospital's AO.

3. A Spanish language form titled "Derechos y Responsabilidadesde los pacientes" (Rights and Responsibilities of patients) with a version date of "021712", and a Spanish language "Guia de Servicios" (Guide to Services) with a version date of "040212" was provided by hospital administration under the heading of "Patient Rights Policies". The following was noted in each:
* Language informed patients that they could file a complaint with "La Comision Conjunta (Joint Commission)", the hospital's AO. However, that is not currently the hospital's AO.

4. A policy and procedure titled "Patient Complaints/Grievances" with a version date of "02/09/2012" was provided by hospital administration under the heading of "Grievance/Complaint Policies Procedures". The following was noted:
* Paragraph 1.2.4 of the policy reflected that "Patients or patient's representatives may also file a complaint...with the Centers for Medicare & Medicaid Services at 1- (855) 994-6610..." A phone call to that number on 01/09/2014 revealed that number to be disconnected.

5. The policy and procedure titled "Patient Complaints/Grievances" with a version date of "02/09/2012" was reviewed. Language at section 1.3.1 of the policy required that a written response be provided to the patient or the patient's representative within 7 days when possible. The policy directed that if a response was not possible within 7 days that the patient or representative be informed that a written response would be provided within 30 days. There were no provisions in the policy for providing a written response only if the patient or representative requested one.

6. On 01/09/2014 at 1145 at the Barger Medical Clinic off-campus location, the use of Spanish language materials was discussed with the the hospital administrator. During the interview it was disclosed that there were no Spanish language versions of the "Rights and Responsibilities of Patients" and "Conditions of Admission and Consent" forms available at that location, that Spanish speaking patients received the English language version of the forms, and a Spanish language interpreter was used to translate the information on the forms.

Based on interview, documentation for 7 of 7 blood transfusions in 4 of 4 medical records reviewed (Patients 20, 21, 22, and 23) and review of policies and procedures it was determined that the hospital failed to fully develop and consistently implement its policies and procedures related to vital signs and monitoring of patients during blood transfusions.

Findings include:

1. Review of a Blood Transfusion Record in the medical record for Patient 20 reflected that a transfusion was started on 11/01/2013 at 1220. Vital signs were documented at 1235, 15 minutes after the start of the transfusion. In addition, the portion of the form for documentation of monitoring "every hour" during the transfusion was blank. The transfusion was completed at 1410. There was no documentation in the record that the patient's condition had been monitored every hour during the transfusion.

Review of a Blood Transfusion Record for Patient 20 reflected that a transfusion was started on 11/01/2013 at 1425. Vital signs were documented at 1435, 10 minutes after the start of the transfusion. In addition, the portion of the form for documentation of monitoring "every hour" during the transfusion was blank. The transfusion was completed at 1612. There was no documentation in the record that the patient's condition had been monitored every hour during the transfusion.

2. Review of a Blood Transfusion Record in the medical record for Patient 21 reflected that a transfusion was started on 10/29/2013 at 1405. Vital signs were documented at 1420, 15 minutes after the start of the transfusion. In addition, the portion of the form for documentation of monitoring "every hour" during the transfusion was blank. The transfusion was completed at 1550. There was no documentation in the record that the patient's condition had been monitored every hour during the transfusion.

Review of a Blood Transfusion Record for Patient 21 reflected that a transfusion was started on 10/29/2013 at 1605. Vital signs were documented at 1625, 20 minutes after the start of the transfusion. In addition, the portion of the form for documentation of monitoring "every hour" during the transfusion was blank. The transfusion was completed at 1745. There was no documentation in the record that the patient's condition had been monitored every hour during the transfusion.

3. Review of a Blood Transfusion Record in the medical record for Patient 22 reflected that a transfusion was started on 08/06/2013 at 1040. Vital signs were documented at 1055, 15 minutes after the start of the transfusion. In addition, the portion of the form for documentation of monitoring "every hour" during the transfusion was blank. The transfusion was completed at 1220. There was no documentation in the record that the patient's condition had been monitored every hour during the transfusion.

Review of a Blood Transfusion Record for Patient 22 reflected that a transfusion was started on 08/06/2013 at 1300. Vital signs were documented at 1325, 25 minutes after the start of the transfusion. In addition, the portion of the form for documentation of monitoring "every hour" during the transfusion was blank. The transfusion was completed at 1500. There was no documentation in the record that the patient's condition had been monitored every hour during the transfusion.

4. Review of a Blood Transfusion Record for Patient 23 reflected that a transfusion was started on 11/21/2013 at 1148. Vital signs were documented at 1200, 12 minutes after the start of the transfusion. In addition, the portion of the form for documentation of monitoring "every hour" during the transfusion was blank. The transfusion was completed at 1325. There was no documentation in the record that the patient's condition had been monitored every hour during the transfusion.

5. The hospital policy titled "Blood and/or Component Transfusion Administration Procedure" was reviewed. Under the section for "Monitoring Transfusion" the procedure required that once the transfusion has started, a set of vital signs be obtained "...after 15-20 minutes..." Therefore those vital signs taken at 10 minutes, 12 minutes, and 15 minutes after the transfusion was started were not taken in accordance with the policy. The policy did not specify how long "after 15-20 minutes" was acceptable to obtain the first set of transfusion vital signs.

In addition, although the Blood Transfusion Record form used in the medical records had space for checks of the patient "every hour", the policy and procedure did not address hourly patient monitoring during a transfusion.

6. On 01/10/2014 at 1245 the following individuals were interviewed or present during the interview: Outpatient infusion center charge nurse; clinical education manager; regulatory and accreditation manager; and emergency department manager. The infusion center charge nurse stated that although the paper Blood Transfusion Record had space for checks of the patient "every hour", that space on the form was not utilized. He/she confirmed that hourly monitoring of the patient during a transfusion was required and was to be recorded by the nurses in the electronic notes. During the interview the electronic transfusion records for Patients 20, 21, and 22 were accessed and reviewed. The electronic entries in all three records for the six transfusions were identical to the handwritten entries on the Blood Transfusions Records. There were no additional notes which reflected hourly monitoring for those transfusions.

Based on documentation in 21 of 22 medical records reviewed (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, 15, 16, 17, 18, 19, 20, 21, and 22) it was determined that the hospital failed to ensure that all entries on consent forms, ED records, discharge instructions, physician orders, death records, and blood transfusion records were legible, complete, dated, timed, or authenticated.

Findings include:

1. The medical record for Patient 5 reflected the patient was admitted to the ED on 11/12/2013.
* Pages 1 and 2 of the Conditions of Admission and Consent Form contained entries on the "Witness" space that were not legible.
* The consent obtained on the Conditions of Admission and Consent Form lacked a time.
* The patient mode of arrival was not evident on the ED Clinical Services Record as the patient name label was placed over a portion of the form where that information was noted.
* The ED Clinical Services Record lacked the date and time the form was signed by the MD.
* The "RN Staff Signature" space on the Discharge Instructions form was blank.
* The Emergency Physician Record form lacked the date and time the form was signed by the "Attending" MD.

2. The medical record for Patient 6 reflected the patient was admitted to the ED on 11/08/2013.
* The consent obtained on the Conditions of Admission and Consent Form lacked a time.
* The ED Clinical Services Record lacked the date and time the form was signed by the MD.
* The Emergency Physician Record form lacked the date and time the form was signed by the "Attending" MD.
* The Emergency Physician Record form lacked the date and time the form was completed by the "Scribe".

3. The medical record for Patient 7 reflected the patient was admitted to the ED on 11/08/2013.
* Pages 1 and 2 of the Conditions of Admission and Consent Form lacked signatures on the "Witness" space on each page.
* The consent obtained on the Conditions of Admission and Consent Form did not include a "Date" on page 2 and lacked a time.
* The ED Clinical Services Record lacked the date and time the form was signed by the individual who signed the "MD Signature" space.
* The patient signature and the "RN Staff Signature" spaces on the Discharge Instructions form were blank.
* The Emergency Physician Record form identified the name of a PA and an "Attending" physician signature. The form lacked the date and time the form was completed and signed by each of those providers.

4. The medical record for Patient 13 reflected the patient was admitted on 11/03/2013.
* The name of the patient was not recorded on either page 1 or page 2 of the Conditions of Admission and Consent Form dated 11/03/2013.
* The consent obtained on the Conditions of Admission and Consent Form by an individual other than the patient was dated 11/03/2013 and lacked a time. The space for "Relationship" to the patient was blank.
* A consent obtained on the Conditions of Admission and Consent Form by an individual other than the patient was dated 11/18/2013, the date of discharge, and lacked a time. The space for "Relationship" to the patient was blank.

5. The medical record for Patient 15 reflected the patient was admitted on 12/16/2013.
* The consent obtained on the Conditions of Admission and Consent Form lacked a time.
* Pages 1 and 2 of the Conditions of Admission and Consent Form contained entries on the "Witness" space that were not legible.

6. The medical record for Patient 17 reflected the patient was admitted on 11/16/2013.
* The consent obtained on Pages 1 and 2 of the Conditions of Admission and Consent Form by a patient representative was dated 11/22/2013, six days after admission, and was not timed.
* The "Witness" spaces on Pages 1 and 2 of the Conditions of Admission and Consent Form were blank.
* The Release of Body Record contained three different spaces on the form identified as "Filled out by" and a space to reflect who the body was "Transported to Morgue by". Those spaces were blank.
* The Consent to Procedures and Other Treatments form reflected a consent for a "Peripherally Inserted Central Catheter". The consent obtained by a patient representative was dated 11/22/2013 and not timed.

7. The medical record for Patient 18 reflected the patient was admitted on 12/29/2013.
* The Release of Body Record form contained a space to record who the body was "Transported to Morgue by". That space was blank.

8. The medical record for Patient 19 reflected the patient was admitted on 11/14/2013.
* Pages 1 and 2 of the Conditions of Admission and Consent Form were dated 11/14/2013 but lacked the patient signature and time. The space for "Patient unable to sign at admission because" was blank.
* Pages 1 and 2 of the Conditions of Admission and Consent Form contained entries on the "Witness" space that were unclear.
* The Release of Body Record contained signatures and authentication that was unclear or illegible for spaces on the form identified as: "Filled out by"; "Notified by"; "Transported to Morgue by"; and "Hospital Representative".

9. The medical record for Patient 20 reflected the patient received two blood transfusions on 11/01/2013.
* The Blood Transfusion Record contained an entry for "Vital Signs...Before transfusion" for the time recorded as 1410 on 11/01/2013. The entry for blood pressure had been scratched out and was not readable. There was no identification of who scratched out the entry, why it was scratched out, and when that was done.
* The Blood Transfusion Record contained spaces for "Vital Signs...Every hour". Those spaces were blank.
* The Blood Transfusion Record contained a time recorded for "Vital Signs...At completion of Transfusion". A second time was written over the original time and rendered that entry unclear and illegible.
* The Blood Transfusion Record contained a time recorded for "Blood product completed/stopped". A second time was written over the original time and rendered that entry unclear and illegible.
* Similar findings were identified on the Blood Transfusion Record for the second transfusion conducted that day.

10. The medical record for Patient 21 reflected the patient received two blood transfusions on 10/29/2013.
* The Ambulatory Infusion Blood Products Orders were signed and dated by the physician but not timed.
* The consent obtained on the Blood or Blood Products Consent lacked the time.

11. Similar findings were identified in records for Patients 1, 2, 3, 4, 8, 9, 10, 11, 14, 16, and 22.

Based on observation, interview, and review of policies and procedures it was determined that the hospital failed to ensure that all potential hazards in the environment had been identified and addressed to ensure the safety and well-being of patients. Although hospital policy and procedure identified items that posed a potential risk to patients on the BHU, the physical environment on the BHU had not been fully evaluated to ensure that those same or similar items were not accessible to patients.

Findings include:

1. During tour of the BHU on 01/08/2014 at 1000 and on 01/10/2014 at 1030 a wall mounted television was observed in the common area on the "transition unit". The wall mount was affixed to the wall at a height approximately five to seven feet from the floor and the mount extended the television approximately two feet from the wall. Multiple cords and cables were observed connecting the television, other supplementary entertainment equipment, and electrical and cable outlets. The cords were loosely dangling and were within arms reach of an ambulatory individual.

Observations on the unit on 01/10/2014 at 1030 reflected that the area of the common room where the television was mounted could not be observed from all lengths of the hallways which extended out from the common area.

2. A policy titled "Contraband and Patient Search" dated 06/15/2011 described the BHU policy as: "We work to maintain a safe and therapeutic environment for patients, staff, and visitors..." Pages 3 and 4 of the document contained a "Contraband List". The items on the list included: clothing drawstrings, belts, neckties, string, rope, shoelaces. In addition, a note on the list referred to "All corded equipment" and indicated that the presence of such equipment required a suicide assessment every eight hours, 15 minute checks, physician orders, and a treatment team sign off.

3. During interview on 01/10/2014 at 1030 the RN manager referred to a new BHU currently under construction and indicated that the television on the new unit would be placed in a recessed area and all cords would be hidden in the walls.

During interview on 01/10/2014 at 1030 an RN charge nurse indicated that there had been an incident in December 2013 where a patient experiencing behaviors had accessed the television cords. The RN stated that staff had intervened to protect the patient and no injuries were incurred.