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Based on review of facility documents and staff interviews (EMP), it was determined that J. C. Blair Memorial Hospital failed to have any documented evidence that their Grievance process is reviewed and analyzed and failed to show evidence of any oversight of their Grievance process.

Findings:

A Review of Administrative Policy 38, "Patient Representation/Complaints, ... Revision: ... 9/20/12 ... Scope: All Personnel ... II. Purpose: To define the procedure for handling patient complaints (or grievances - term used by DOH and CMS) through the Patient Representative. III. Text: A. It is the policy of J. C. Blair Memorial Hospital to fully investigate and resolve all complaints registered in a systematic and expeditious manner to determine appropriate course of action. By approval of this policy, the Board of Directors has delegated the responsibility for reviewing and resolving patient grievances to the Administrative Team, which will act as the patient Grievance Committee. ... The hospital will strive to resolve all grievances as soon as possible. The Patient Representative will forward patient grievances with their documented investigation and resolution to the V. P. of Quality Improvement for Administrative review. D. Procedure: ... 4. Administrative Responsibilities: It is the responsibility of the Hospital Administrative Team to determine if adequate investigation has been conducted by the appropriate individuals and approve the response to the patient. Timely referral of patient quality of care or premature discharge concerns will be made to the appropriate Medical Staff Department Quality Management Committee. ... ."

A review of Administrative Policy 44, "J.C. Blair Memorial Hospital Quality Management / Performance Improvement Program 1. Purpose:J.C.Blair Memorial Hospital, through the Board of Directors, Medical Staff. Performance Improvement Team and Administration, is dedicated to the provision of quality, appropriate and efficient care. An ongoing, planned and systematic Quality Management/Performance Improvement Program has been established as the mechanism to continually monitor and assess the quality of care and services; the efficient and efficacious utilization of resources and to seek opportunities for continuous performance improvement. Performance improvement activities are directed toward the mission, vision and strategic plan of J.C. Blair Memorial Hospital. II. Objectives To endeavor to deliver quality patient care within the available resources and consistent with achievable goals through objective care evaluation and other monitoring activities. ... To establish a mechanism to identify and correct problems specifically as they relate to clinical aspects of care or services, by assessing their cause and scope and implementing actions to resolve them. ... To ensure communication and reporting among Administration, Department Directors, Service leaders, Medical Staff and the Board of Directors. ... V. Scope and Methodology ... The Medical Staff, Departments and Services, and all stakeholders, whose activities have a direct or indirect impact on the quality of patient care and/or services provided, will participate in the Quality Management/Performance Improvement Program. ... The process used by each Department/Service will include: ... evaluation of data to identify opportunities for improvement - Actions taken to improve care/services or resolve problems, and evaluation of effectiveness of those actions ... VI. Data Sources: Many data sources may be used in performance improvement. The following are samples of data sources which may be used. This list should not be considered as all inclusive. ... Chart Event Report Forms and Trending Reports ... Patient Questionnaire survey results /Complaints/Compliments ... ."

1. A review of J.C. Blair Memorial Hospital Grievance Log for September, October and November 2012, revealed that the facility had identified 21 Grievances.

2. An interview was conducted with EMP2 on December 18, 2012 at 10:22 AM. "We probably had 20 Grievances in the past three months. We do not have a Grievance Committee, we have a Administrative Team that meets weekly. This team is comprised of the CEO, CFO, and VPs. We don't keep minutes from the Administrative Team weekly meetings. I can not provide you with any trending or patterns of Grievances. The only thing that goes to the Board of Directors is the Patient Satisfaction surveys. Te only other Quality data that goes to the Board of Directors for review, related to the Grievance process, is the timeliness of the Grievance response letters to the complainants.


Cross Reference with:

482.21 QAPI

Based on review of facility documents and staff interviews (EMP), it was determined that J.C. Blair Memorial Hospital failed to implement and maintain an effective, ongoing, hospital-wide, data-driven Quality Assessment and Performance Improvement Program by failing to measure and analyze quality indicators for all hospital Departments (A0267), by failing to collect data in order to monitor the effectiveness and safety of services and quality of care (A0275), and by failing to identify opportunities for improvement and changes that would lead to improvement (A0276) and by failing to ensure the frequency and detail of data collection was specified by the hospital's Governing Body (A0277), to include Outpatient Nursing Services and the Complaint/Grievance process.

Findings include:

A review of Administrative Policy 44, "J.C. Blair Memorial Hospital Quality Management/Performance Improvement Program. 1. Purpose:J.C.Blair Memorial Hospital, through the Board of Directors, Medical Staff. Performance Improvement Team and Administration, is dedicated to the provision of quality, appropriate and efficient care. An ongoing, planned and systematic Quality Management/Performance Improvement Program has been established as the mechanism to continually monitor and assess the quality of care and services; the efficient and efficacious utilization of resources and to seek opportunities for continuous performance improvement. Performance Improvement activities are directed toward the mission, vision and strategic plan of J.C. Blair Memorial Hospital. II. Objectives: To endeavor to deliver quality patient care within the available resources and consistent with achievable goals through objective care evaluation and other monitoring activities. ... To establish a mechanism to identify and correct problems specifically as they relate to clinical aspects of care or services, by assessing their cause and scope and implementing actions to resolve them. ... To ensure communication and reporting among Administration, Department Directors, Service leaders, Medical Staff and the Board of Directors. ... V. Scope and Methodology: ... The Medical Staff, Departments and Services, and all stakeholders, whose activities have a direct or indirect impact on the quality of patient care and/or services provided, will participate in the Quality Management / Performance Improvement Program. ... The process used by each Department/Service will include: ... evaluation of data to identify opportunities for improvement - Actions taken to improve care/services or resolve problems, and evaluation of effectiveness of those actions ... VI. Data Sources: Many data sources may be used in Performance Improvement. The following are samples of data sources which may be used. This list should not be considered as all inclusive. ... Chart Event Report Forms and Trending reports ... Patient Questionnaire Survey results /Complaints/Compliments ... ."

Review of "Bylaws J.C. Blair Memorial Hospital, Revised: September 4, 2008, revealed, "...14.4 Quality of Care and Administrative Support. The Board of Directors, through the Chief Executive Officer, shall assure that the Medical Staff is provided with the Administrative assistance necessary to conduct quality assurance activities in accordance with the Hospital's Quality Management Plan. This includes the services of the Medical Records Department, as well as any other Administrative, Advisory, or Technical Assistance, as necessary and appropriate, to facilitate the staff's conduct of quality assurance activities. The nature and frequency of submission of required reports shall be in accordance with the Hospital's Quality Assurance Plan and the Medical Staff Bylaws, Rules and Regulations. ... ."

A Review of Administrative Policy 38, Patient Representation/Complaints, ... Revision: ... 9/20/12 ... Scope: All Personnel ... II. Purpose: To define the procedure for handling patient complaints (or grievances - term used by DOH and CMS) through the Patient Representative. III. Text: A. It is the policy of J. C. Blair Memorial Hospital to fully investigate and resolve all complaints registered in a systematic and expeditious manner to determine appropriate course of action. By approval of this policy, the Board of Directors has delegated the responsibility for reviewing and resolving patient grievances to the Administrative Team, which will act as the patient Grievance Committee. ... The hospital will strive to resolve all grievances as soon as possible. The Patient Representative will forward patient grievances with their documented investigation and resolution to the V. P. of Quality Improvement for Administrative review. D. Procedure: ... 4. Administrative Responsibilities: It is the responsibility of the hospital Administrative Team to determine if adequate investigation has been conducted by the appropriate individuals and approve the response to the patient. Timely referral of patient quality of care or premature discharge concerns will be made to the appropriate Medical Staff Department Quality Management Committee. ... ."

Review of the facility's Outpatient Care Unit policy entitled "Scope of Service/Mission Statement", dated March 2012, revealed, "... III. Goals: J.C. Blair Memorial Hospital is committed to organization wide continuous improvements of quality and performance which takes into account the needs of patients, physicians, employees, payors, communities, and anyone else associated with the organization ... ."

A review of policy "Organizational Narrative" revised April 2003 revealed, "The Outpatient Care Unit is an ambulatory care unit. The average daily census varies with the number of Pre-Admission Testing patients, also the number of outpatient procedures scheduled by physicians. ... Physical Characteristics: The Department consists of a Waiting Room, three Interview/Exam rooms, a four-bed Bay Area, a Soiled Utility room, office, and a bathroom. ... ."

Review of policy "Outpatient Department" revised November 2012 revealed, "... Department Policies: ... Patients: 1. Patients with a high potential for infection are handled during the period of least activity. ... 3. Isolation techniques are maintained according to hospital policy. ... Equipment and Supplies: Clean and Sterile Supplies: Clean supplies are kept in designated cupboards and drawers. ... ."

1. A review of J.C. Blair Memorial Hospital Grievance Log for September, October and November 2012, revealed that the facility had identified 21 Grievances.

An interview was conducted with EMP2 on December 18, 2012 at 10:22 AM. "We probably had 20 grievances in the past three months. We do not have a Grievance Committee, we have a Administrative Team that meets weekly. This team is comprised of the CEO, CFO, and VPs. We don't keep minutes from the Administrative Team weekly meetings. The only thing that goes to the Board of Directors is the Patient Satisfaction data. The only other Quality data that goes to the Board of Directors for review, related to the Grievance process, is the timeliness of the Grievance response letters to the complainant."

A review of the Performance Improvement Team, Surgical Quality and Medical Quality meeting minutes for the year 2012 failed to reveal any trending of all patient Grievances. (A0267), (A0275), (A0276), (A0277)

2) A tour of the Outpatient Unit was conducted on December 19, 2012 at approximately 11:00 AM. Observation of the four-bed Bay Area revealed that there were six patients in the Bay Area receiving intravenous therapy. The Bay Area was equipped to supply medical gases and suction for four patients. The Area was noted to lack adequate clearance around and between the patients, in order to respond in an emergency. It was observed that clean supplies were located on an uncovered, portable shelving unit. A patient's chair was observed to have direct contact with the clean supplies with no clearance between the patient and the supplies. It was observed that the door to the Soiled Utility room, located in the Bay Area, was propped open with a bedside commode.

A review of the Outpatient Log dated December 19, 2012 revealed that 16 patients had been scheduled between the hours of 7:00 AM and 4:00 PM. Six patients were scheduled for Vancomycin therapy and two patients were scheduled for blood transfusions

A review of Governing Body meeting minutes dated January 2012 to present revealed no documented evidence of discussion of the Outpatient Unit exceeding capacity.

An interview was conducted with EMP6 on December 20, 2012 at 10:12 AM. "We have outgrown the Outpatient Unit, we do not have space for our supplies. We are to have three chairs and one bed in the Bay Area. Yes, we had six patients from 8:00 AM to 12:00 PM, scheduled on Wednesday, December 19, 2012. We have two to three patients per day with MRSA. We are unable to schedule them last in the day because of the length of time required to infuse their antibiotics, so they are scheduled with other patients ... .I have talked with EMP7 about the schedule of patients and they said that as long as we are following standard precautions that was okay." (A0275), (A0276)

Cross Reference with:

482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.
482.42 (a)(1) Infection Control Officer Responsibilities
482.54 Outpatient Services

Based on review of facility documents and staff interview (EMP), it was determined that J.C. Blair Memorial failed to follow adopted Medical Staff Bylaws by failing to ensure the completion of Conflict of Interest statements.

Findings include:

A review of J.C. Blair Memorial Medical Staff Bylaws, dated December 2011, revealed, "... 2. Article II: Purpose and Responsibility of the Medical Staff ... 2.9 Conflict of Interest Statement shall be signed annually ... ."

1) A review of the facility's Active Medical Staff roster, provided to the surveyor, revealed the names of approximately 40 individuals. Review of the facility's Consulting/Courtesy Staff roster, provided to the surveyor, revealed the names of approximately 64 individuals.

2) Surveyor requested signed Conflict of Interest Statements on December 17, 2012, by the Medical Staff, for the years 2011 and 2012.
Interview with EMP9 on December 17, 2012, revealed that not all of their Conflict of Interest Statements had been received. A review of Conflict of Interest Statements provided to surveyor by EMP9 on December 17, 2012, revealed the facility had received six Conflict of Interest Statements to date for the year 2012. Theses six statements were noted to be dated December 17, 2012.

3) An interview was conducted with EMP9 on December 18, 2012. EMP9 revealed that the facility had no documentation of any signed annual Conflict of Interest of Statements for the year 2011.

Based on review of facility documents and staff interviews (EMP), it was determined that J. C. Blair Memorial failed to ensure the documentation of any product temperatures for approximately 39 of 90 meals in November 2012, and approximately 17 of 54 meals in December 2012, and failed to establish policies related to the recording/monitoring of product temperatures.

Findings include:

A review of the facility's adopted form entitled "HACCP (Hazard Analysis and Critical Control Points) Daily Taste Panel Chart", revealed, "... Product temperature must be recorded on this Log at 2 hour intervals during holding and serving. If products are held and served for less than two hours, product temperatures must be recorded at the beginning and end of service ... ."

During review of the form entitled "HACCP Daily Taste Panel Chart, it was also noted that the form contained areas to be completed, which included evaluation code, taste panel corrective action, and three areas to document time and temperature, per product.

1) A review of "HACCP Daily Taste Panel Chart" forms revealed no documentation of any temperature recordings for approximately 39 of 90 meals in November 2012, and no documentation of any temperature recordings for approximately 17 of 54 meals from December 1-18, 2012.

2) An interview with EMP8, on December 20, 2012, confirmed that all meal temperatures should be recorded, and confirmed the findings. EMP8 also confirmed that there is no policy related to the recording of information, as stated on the "HACCP Daily Taste Panel Chart".

Based on a Life Safety Code survey, the Condition for Physical Environment is not met based on the results of the Division of Safety Inspection survey completed on December 4, 2012, at J.C. Blair Memorial Hospital. Those deficient practices and associated regulations can be found on the respective Life Safety Code survey (HUI321)

Based on review of facility documents, observation, and staff interviews (EMP), it was determined that J.C. Blair Memorial failed to ensure that Infection Control policies were followed in the Outpatient Care Unit.

Findings include:

A review of the facility's policy entitled "Infection Prevention and Control Program", dated February 2012, revealed, "I. Goals. The goals of the infection prevention and control program are to A. Decrease the risk of infection to patients, visitors, and personnel ... C. Identify and correct problems relating to infection prevention and control practices ... II. Scope of The Infection Prevention and Control Program. The infection prevention and control program is comprehensive in that it addresses detection, prevention, and control of infections among patients, personnel, and visitors ... The major activities of the program include the following: ... C ... Staff and patient education focuses on risk of infection and practices to decrease risk. Policies, procedures, and aseptic practices are followed by personnel in performing procedures and in disinfection of equipment ... IV. Reporting Mechanisms For Infection Control ... C. Compliance with infection prevention and control practices is monitored and documented by a. Staff evaluation b. Observation of practices ... ."

A review of the facility's policy entitled "Outpatient Department", dated November 2012, revealed, "... Patients: 1. Patients with a high potential for infection are handled during the period of least activity. 2. Standard Precautions are used. 3. Isolation techniques are maintained according to hospital policy. Equipment and Supplies: Clean and Sterile Supplies: Clean supplies are kept in designated cupboards and drawers ... ."

Review of the facility's policy entitled "MultiDrug-Resistant Organism (MDRO) Policy", dated July 2012, revealed, "I. Purpose. To identify care and management issues for patients who are colonized or infected with an MDRO ... MDROs are introduced into the healthcare setting most often in two ways: 1. Via colonized or infected patients ... Patient-to-patient transmission of MDROs is usually via the unwashed hands of healthcare workers. Hands can easily become contaminated during the course of caring for a patient or having contact with environmental surfaces in close contact with the patient. Without appropriate hand hygiene and/or appropriate use of Personal Protective Equipment (PPE), i.e. gown and gloves, contact with colonized or infected patients or the environment of care may result in transmission of MDROs to other susceptible patients ... III. Definitions. Multidrug-Resistant Organisms (MDROs) are defined as microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents. MDROs include MRSA (Methicillin-Resistant Staphylococcus aureus,); VRE (Vancomycin-Resistant Enterococcus); CDI (Clostridium difficile Infection); ESBL (Extended-Spectrum Beta Lactamase) gram negative bacteria; and other multidrug-resistant gram negative bacteria ... IV. Policy ... D. Contact Precautions is is used whether the patient is known, has history of, or suspected of being colonized or infected with an MDRO ... V. Procedure ... D. Ambulatory Care Settings. 1. At a minimum, Standard Precautions should be followed in Outpatient service locations. 2. Gloves and gown should be used if contact with uncontrolled wound drainage, stool incontinence, and ostomy tubes and bags is anticipated. 3. MDRO-positive patients may wait in common Waiting areas for Outpatient services. 4. Cleaning and disinfection of exam rooms and patient equipment should be performed between patients, as per Standard Precautions ... ."

1) A tour of the Outpatient Unit was conducted on December 19, 2012 at approximately 11:00 AM. Observation of the four-bed Bay Area revealed that the clean supplies were located on an uncovered, portable shelving unit. A patient's chair was observed to have direct contact with the clean supplies with no clearance between the patient and the supplies. It was observed that the door to the Soiled Utility room, located in the Bay Area, was propped open with a bedside commode.

2) An interview was conducted with EMP6 on December 20, 2012 at 10:12 AM. "We have outgrown the Outpatient Unit, we do not have space for our supplies. We are to have three chairs and one bed in the Bay Area. Yes, we had six patients from 8:00 AM to 12:00 PM, scheduled on Wednesday, December 19, 2012. We have two to three patients per day with MRSA. We are unable to schedule them last in the day because of the length of time required to infuse their antibiotics, so they are scheduled with other patients ... .I have talked with EMP7 about the schedule of patients and they said that as long as we are following standard precautions that was okay."

Cross reference with:

482.21 QAPI

Based on review of facility documents, observation, and staff interview (EMP), it was determined that J.C. Blair Memorial Hospital failed to maintain their Outpatient Department in accordance with acceptable standards of practice, by failing to adopt policies related to Discharge criteria, and by exceeding the capacity of the Unit, and by failing to maintain a sanitary environment.

Findings include:

A review of policy "Organizational Narrative" revised April 2003 revealed, "The Outpatient Care Unit is an ambulatory care unit. The average daily census varies with the number of Pre-Admission Testing patients, also the number of outpatient procedures scheduled by physicians. ... Physical Characteristics: The Department consists of a waiting room, three interview/exam rooms, a four-bed bay area, a Soiled Utility room, office, and a bathroom. ... ."

A review of policy "Outpatient Care Unit Procedures Listing" revised March 2004 revealed, " ... To provide a comprehensive listing of procedures which can be performed in the Outpatient Care Unit. ... Procedures Performed by Physicians with Nurse Assistance: 1. Minor surgeries requiring local anesthesia only. 2. Bone marrow aspiration 3. Lumbar puncture 4. Paracentesis 5. Thoracentesis 6. Liver Biopsy 7. Tensilon testing ... ."

Review of policy "Outpatient Department" revised November 2012 revealed, "... Department Policies: ... Patients: 1. Patients with a high potential for infection are handled during the period of least activity. ... 3. Isolation techniques are maintained according to hospital policy. ... Equipment and Supplies: Clean and Sterile Supplies: Clean supplies are kept in designated cupboards and drawers. ... ."

1) A tour of the Outpatient Unit was conducted on December 19, 2012 at approximately 11:00 AM. Observation of the four-bed Bay Area revealed that there were six patients in the Bay Area receiving intravenous therapy. The Bay Area was equipped to supply medical gases and suction for four patients. The Area was noted to lack adequate clearance around and between the patients, in order to respond in an emergency. It was observed that clean supplies were located on an uncovered, portable shelving unit. A patient's chair was observed to have direct contact with the clean supplies with no clearance between the patient and the supplies. It was observed that the door to the Soiled Utility room, located in the Bay Area, was propped open with a bedside commode.

2) A review of the Outpatient Log dated December 19, 2012 revealed 16 patients had been scheduled between the hours of 7:00 AM and 4:00 PM. Six patients were scheduled for Vancomycin therapy and two patients were scheduled for blood transfusions.

3) An interview was conducted with EMP6 on December 20, 2012 at 10:12 AM. "We have outgrown the Outpatient Unit, we do not have space for our supplies. We are to have three chairs and one bed in the Bay Area. Yes, we had six patients from 8:00 AM to 12:00 PM, scheduled on Wednesday, December 19, 2012. We have two to three patients per day with MRSA. We are unable to schedule them last in the day because of the length of time required to infuse their antibiotics, so they are scheduled with other patients ... We do not have written Discharge criteria for our patients. We do not define Discharge criteria."

4) A review of Governing Body meeting minutes dated January 2012 to present revealed no documented evidence of discussion of the Outpatient Unit exceeding capacity.

5) A request was made for Outpatient Discharge criteria on December 19, 2012. None was provided.

Cross reference with:

482.21 QAPI
482.42 (a)(1) Infection Control Officer Responsibilities