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Based upon reviews of Governing Body meeting minutes, Quality Assurance Performance Improvement (QAPI) Plan and associated data, and interviews, the Governing Body failed to ensure all contracted services were evaluated to show that the contracted services were delivered in a safe and effective manner as evidenced by a lack of documentation that contract services were evaluated. Findings:

Review of Governing Body meeting minutes, dated May 2012 to May 2013, revealed there failed to be documentation that contracted services had been evaluated to ensure the services they supplied/performed were delivered in a safe and effective manner.

Review of the hospital's QAPI Plan and data, dated May 2012 to May 2013, revealed a lack of documentation the contracted services supplied/performed at the hospital had been evaluated to ascertain if they were delivered in a safe and effective manner.

Interviews, 06/12/13 at 11:00AM, with S1 RN (Registered Nurse) CNO (Chief Nursing Officer) and S8 Administrator/CEO, revealed the hospital had monthly meetings with Contract A (the company who supplied the hospital with Emergency Room physicians) and discussed issues that had arisen in the Emergency Room (ER) relative to the contracted ER physicians; however, when S8 Administrator/CEO was asked if the information was evaluated through the hospital's QAPI program, he replied that he thought it was. S1 RN CNO confirmed to the surveyors and S8 Administrator/CEO that the contract for ER physicians nor had any of the other contracted services been evaluated through the QAPI processes and had them reported to the Governing Body for their evaluation.

S1 RN CNO and S8 Administrator/CEO confirmed for the surveyor that contracted services had not been evaluated by the Governing Body to ensure that they were provided in a safe and effective manner.

Based upon review of the hospital's list of contracted services and interviews, the hospital failed to ensure a list of all contracted services was maintained as evidenced by a contract agreement with an acute care hospital for the purpose of transferring patients and the contract was not on the list of contracted services and included other contracted services which were no longer valid or were terminated. Findings:

Review of the list of contracted services maintained by the hospital revealed it had not been kept up to date as some of the services were discovered to be no longer used or the contract had been terminated. There was another contract (Contract B) that was discovered by the surveyor which served as a transfer agreement between the two hospitals; however, Contract B was not included on the list of contracted services which was maintained by the hospital.

Interview, 06/12/13 at 1:45PM, with S11 Risk Management/Compliance revealed she maintained the list and the contracts. When questioned if the list was complete and/or up to date, S11 Risk Management/Compliance stated she thought it had been updated; however, following the discussion with the surveyors, she agreed it was not current as all contracts had not been listed and some contracts that were listed were no longer in effect.

Based upon review of contract services, Quality Assurance/Performance Improvement (QA/PI) program and data and interviews, the governing body failed to ensure all contracted services were evaluated through the QA/PI Program. This was evidenced by failure of the QA/PI Program to evaluate any of the contracts that provided patient care services to ensure these services were provided in a safe and effective manner. Findings:

Review of the list of contracted services revealed there failed to be documented evidence that any of the contracts that provided patient care services were evaluated through the QA/PI Program.

Review of the QA/PI Plan revealed there failed to be documented evidence contracts were identified and required evaluation.

Interviews, on 06/12/13 at 11:20AM, with S1 Chief Nursing Officer and S8 Chief Executive Officer, confirmed contracted services were not reviewed through the QA/PI Program.

Based on medical record review, hospital policy and staff interview, the hospital failed to ensure documentation in the medical record was legible, complete and that hospital approved abreviations were used as evidenced by 4 of 4 anesthesia records (patient # 1, 2, 3, and 4) documentation not being clearly legible, that the document was not complete, and that hospital approved abeviations were used.

Findings:

Review of the preanesthesia evaluation record and the anesthesia intraoperative record for patient #1, #2, #3 dated 6/11/13 and #4 dated 6/12/13 revealed the documentation was not clearly legible and easily understood. Review of each preanesthesia evaluation record revealed preoperative vital signs were not entered in the area specifically designated for these. Further review revealed the question related to family history of anesthesia complications was not answered.

Interview with S5RN on 6/11/13 at 10:00 a.m. confirmed the documentation by S6CRNA was difficult to read and often had to request clarification to understand what was documented.

Interview with S13HIM Director on 6/12/13 at 11:15 a.m. confirmed the documentation on the anesthesia intraoperative record for patient #1, 2, 3, and 4 was not legible. S13HIM also confirmed the preanesthesua anesthesia evaluation record was not complete on these records.

Review of a hospital policy, #III 01.02.01 Version #1, titled " Use of Abbreviations, Acronyms, and Symbols, Acceptable and Unacceptable (Do Not Use) " , revealed this was the hospital-wide policy used relative to the use of abbreviations. Continued review of the above policy revealed: " Policy: To establish guidelines for the use of abbreviations in the medical record, as well as a list of unacceptable abbreviations, acronyms and symbols that will NOT be used. Use of a standard, nationally recognized publication is deemed appropriate for reference to abbreviations ...Text of policy: 1. Clinical abbreviations, acronyms and symbols may be used only if found in 'Stedman ' s Abbreviations, Acronyms and Symbols ' and will be taken in the context of the relevant body system ... "
Interviews, on 06/12/13 at 11:05AM, with S13 Director of HIM (Health Information Management) and S14 Director-In-Training of HIM, revealed the hospital policy stated that only approved abbreviations were to be used in medical records. Surveyors asked S13 Director of HIM to review an Anesthesia Intra-operative note that S6 CRNA (Certified Registered Nurse Anesthetist) had documented the following information in Patient # 3s medical record: " OAWO/P" Also documented on this record were abreviations that were not legible and were not on the hospital approved list according to S13 Director of HIM.
Interview, on 06/12/13 at 11:00AM, with S6 CRNA revealed when questioned what the abbreviations (referenced above) meant he stated, " I have used these abbreviations for 35 years. OAWO/P means oral airway with oral pharynx " . S6 was further questioned if the abbreviations he used were approved for use; S6 CRNA did not respond.
Continued interview, on 06/12/13 at 11:05AM, with S13 Director of HIM (who was present during the interview with S6 CRNA) confirmed the abbreviations used by S6 CRNA were not approved for use.

Based on anesthesia record review and staff interview, the hospital failed to ensure anesthesia consents were properly executed as evidenced by 2 of 2 (patient #3 and #4) anesthesia records not having the type of anesthesia selected and by not authenticating 1 of 1 (patient #4) anesthesia consents as evidenced by lack of CRNA signature in a total of 4 anesthesia records reviewed. Findings:

1. Review of the medical record for patient #3 revealed the patient had 2 procedures performed the morning of 6/11/13: a tonsilectomy and a diagnostic laparoscope. Review of the anesthesia consent record after patient #3 was transferred to the medical surgical floor revealed the type of anesthesia was not selected. Interview with S4RN on 6/11/13 at 9:25 a.m. confirmed the type of anesthesia was not selected prior to the surgical procedure.

2. Review of the medical record for patient #4 revealed she was a patient in labor on the obstetric floor. Review of the anesthesia consent form after the delivery revealed the type of anesthesia was not selected and that the space for the "Signature of Anesthesia Provider" was not signed. Interview with S1RN CNO (Chief Nursing Officer) on 6/12/13 at 3:15 p.m. confirmed the anesthesia consent form was not complete.