HospitalInspections.org

Based on record review and interview, the facility failed to ensure that a practitioner with training and experience in emergency care was on call and immediately available on site within 30 minutes for six (Patient #11, 12, 13, 14, 15, 16) of 16 patients.

This failed practice has the likelihood to prevent access to care. Thereby, delaying emergent treatment to patients. (See Tag 201)


Based on record review, observation, and interview the facility failed to ensure emergency equipment was operable and in working order for one of one cardiac monitors.

This failed practice has the likelihood to result in incomplete assessment resulting in delay in treatment and poor quality of care.
(See Tag 204)

Based on record review and interview, the facility failed to ensure that a practitioner with training and experience in emergency care was on call and immediately available on site within 30 minutes for six (Patient #11, 12, 13, 14, 15, 16) of 16 patients.

This failed practice has the likelihood to prevent access to care. Thereby, delaying emergent treatment to patients.


Findings:

A Review of Records Showed:
A review of a policy titled "Scope of Service" read in parts "If the practitioner is on call they will have a 20 minute response time" and "Patients shall not be denied evaluation, screening, testing, treatment of stabilization on the basis of their presenting complaint, condition, or lack of physician on the medical staff of this hospital."

Patient #11
A review of the records for Patient #11 showed:
1. Patient #11 arrived to the emergency room on 10/23/19 at 10:30 pm. Staff U was notified at 11:00 pm and did not come to the emergency room to examine the patient.

2. A document titled "Verbal Order"on 10/23/19 at 11:00 pm read, "Is this an emergency medical contition?" "No" was circled, and stated "Per VO" (verbal order) by Staff U.

3. A document titled "Narrative Note" on 10/23/19 at 11:10 pm read, "Patient is non-emergent per Staff U and is to return to the emergency room in the am or follow-up with Staff U at his office."

4. On 11/19/19 at 1:35 pm, Staff D stated Patient #11 was told to come back in the morning.

Patient #12
A review of the records for Patient #12 showed:
1. Patient #12 arrived to the emergency room on 11/11/19 at 8:55 am. Staff U was notified at 9:05 am and arrived at emergency room at 11:40 am (155 minutes later).

2. A document titled "Telephone Order" on 11/11/19 at 9:05 am read, "Is this an emergency medical condition?" "No" was circled and stated the telephone order was read back to Staff U.

3. A document titled "Emergency Care Record" read in part,"Staff U notified at 9:05 am and arrived at 11:40 am."

Patient #13
A review of the records for Patient #13 showed:
1. Patient #13 arrived to the emergency room on 10/21/19 at 4:40 pm. Staff U was notified at 4:45 pm. Staff U arrival time to the emergency room was not documented and the patient was seen at 6:15 pm (90 minutes later).

Patient #14
A review of records for Patient #14 showed:
1. Patient #14 arrived to the emergency room on 10/28/19 at 11:15 pm. There was no documentation of the time Staff U was notified and arrived at the emergency room.

2. A document titled "Narrative Note" on 10/28/19 read, "Instructed patient to seek medical attention at facility that has x-ray."

Patient #15
A review of the record for Patient #15 showed:
1. Patient #15 arrived to the emergency room on 10/11/19 at 6:30 pm. The time Staff U was notified and arrived at the emergency room was not documented.

Patient #16
A review of the record for Patient #16 showed:
1. Patient #16 arrived to the emergency room on 09/28/19 at 12:43 am. Staff U was notified at 12:55 am. The arrival time to the emergency room and time patient was treated was not documented.

Interview
On 11/15/19 at 2:20 pm, Staff D stated Staff U had a clinic across the street from the facility and lived a few blocks away.

Based on record review, observation, and interview the facility failed to ensure emergency equipment was operable and in working order for one of one cardiac monitors.

This failed practice has the likelihood to result in incomplete assessment resulting in delay in treatment and poor quality of care.


Findings:

A Review of Records Showed:
A policy titled "Scope of Service" read in part, "Patients shall not be denied evaluation, screening, testing, treatment of stabilization on the basis of their presenting complaint, condition, or lack of physician on the medical staff of this hospital."


On 11/19/19 at 2:00 pm a cardiac monitor was observed in a nurses station that was not in use. The cardiac monitor was observed to not turn on after staff attempted to power on the monitor.

On 11/19/19 at 2:00 pm Staff A and Staff B continued to work with the cardiac monitor in an attempt to get it powered on and stated, they were not sure what the problem was with the machine.

Based on record review and interview the governing body failed to ensure the governing body identified categories for the medical staff, completed appointement of staff responsible for operation of the facility, and approved medical staff bylaws.

This failed practice has the likelihood to affect the ability of the facility to provide quality medical care to patients. (See Tag 241)


Based on record review and interview, the facility failed to report a change in the medical director to the state.

This failed practice has the likelihood to place patients at increased risk for poor quality of care provided. (See Tag 244)

Based on record review and interview the governing body failed to ensure the governing body identified categories for the medical staff, completed appointement of staff responsible for operation of the facility, and approved medical staff bylaws.

This failed practice has the likelihood to affect the ability of the facility to provide quality medical care to patients.

Findings:

A Review of Records Showed:
A review of the governing body minutes dated 07/16/19 showed no appointment of the CEO.

On 11/15/19, 11/18/19 and 11/19/19 Governing body minutes were requested for 2017, 2018 and 2019. Medical Staff bylaws were requested and documentation of CEO appointment was requested.

Interviews
On 11/18/19 at 12:50 pm Staff A stated the CEO was appointed in April 2019 and July 2019 was the only meeting.

On 11/15/19 at 2:45 pm Staff A stated the previous managing group must have taken the medical staff bylaws, and there were none.

On 11/19/19 at 12:50 pm, Staff A stated the last governing board meeting was in July 2019 and the governing board was replaced by a trustee of the bankruptcy court in North Carolina. Documentation showed no governing body pariticpation in the July 2019 meeting.

Based on record review and interview, the facility failed to report a change in the medical director to the state.

This failed practice has the likelihood to place patients at increased risk for poor quality of care provided.

Findings:

A Review of Contracts Showed:
A document titled "Physician PRN (as needed) Employment Agreement" between the previous managment company and Staff U was signed on 04/14/2014.

A document titled "Physician PRN (as needed) Employment Agreement" between the previous management company and Staff V was not signed and dated.

A document titled "Physician PRN (as needed) Employment Agreement" between the previous management company and Staff W was not signed and dated.

Interviews:
On 11/19/19 at 12:50 pm, Staff A stated Staff V was the covering physician when Staff U was out of town.

On 11/19/19 at 1:35 pm, Staff D stated Staff U has worked in the emergency room as a volunteer since the layoff on 10/03/19.

Based on record review and interview the facility failed to ensure a doctor of medicine or osteopathy was available to furnish patient care services at all times.

This failed practice has the likelihood to result in harm to the patient by failing to provide services to patients requiring urgent/emergent care. (See Tag 254)


Based on record review and interview the facility failed to ensure a doctor of medicine or osteopathy provided overall medical direction, consultation, and supervision of the healthcare services furnished.

This failed practice has the likelihood to affect the quality of patient care that could influence patient recovery, functional status, and quality of life. (See Tag 261).

Based on record review and interview the facility failed to ensure a doctor of medicine or osteopathy was available to furnish patient care services at all times.

This failed practice has the likelihood to result in harm to the patient by failing to provide services to patients requiring urgent/emergent care.


Findings:

A Review of Contracts Showed:
A document titled "Physician PRN (as needed) Employment Agreement" between the previous managment company and Staff U was signed on 04/14/2014.

A document titled "Physician PRN (as needed) Employment Agreement" between the previous management company and Staff V was not signed and dated.


A Review of Policies Showed:
A policy titled "Scope of Service" read in part: "Patients shall not be denied evaluation, screening, testing, treatment of stabilization on the basis of their presenting complaint, condition, or lack of physician on the medical staff of this hospital."


Interviews:
On 11/19/19 at 12:50 pm, Staff A stated Staff V was the covering physician when Staff U was out of town.

On 11/19/19 at 1:35 pm, Staff D stated Staff U had worked in the emergency room as a volunteer since the layoff on 10/03/19.









41372

Based on record review and interview the facility failed to ensure a doctor of medicine or osteopathy provided overall medical direction, consultation, and supervision of the healthcare services furnished.

This failed practice has the likelihood to affect the quality of patient care that could influence patient recovery, functional status, and quality of life.


Findings:

A Review of Policy Showed:
A review of a policy titled "Scope of Service" read in part: "patients that present to the facility seeking emergency care shall receive a medical screening exam by an emergency department physician" and "patients shall not be denied evaluation, screening, testing, treatment of stabilization on the basis of their presenting complaint, condition, or lack of physician on the medical staff of this hospital."

A Review of Contracts Showed:
A document titled "Physician PRN (as needed) Employment Agreement" between the previous managment company and Staff U was signed on 04/14/2014.

A document titled "Physician PRN (as needed) Employment Agreement" between the previous management company and Staff V was not signed and dated.

A document titled "Physician PRN (as needed) Employment Agreement" between the previous management company and Staff W was not signed and dated.


Interview
On 11/19/19 at 12:50 pm, Staff A stated Staff V was the covering emergency room physician when Staff U was out of town.

Based on record review and interview, the hospital failed to maintain an ongoing infection control program that includes active surveillance, early detection, control, and education consistent with nationally recognized infection control practices or guidelines.

These failed practices has the likelihood to create an ineffective infection control program and increased the infection control risk to the hospital's inpatients and outpatients. (See Tag 278)

Based on record review and interview the facility failed to provide clinical laboratory services, diagnostic imaging, and x-ray services.

This failed practice has the likelihood to place patients at an increased risk for poor quality of care and worsening medical conditions by not aiding in the diagnosis of medical conditions. (See Tag 282)

Based on interview the facility failed to provide radiology services.

This failed practice has the likelihood to place patients at an increased risk for poor quality of care and worsening medical conditions by not aiding in the diagnosis of medical conditions (See Tag 283)

Based on record review and interview the facility failed to ensure Plans of care were kept current for three (Patient #8, #9, and #10) of three patients.

This failed practice has the likelihood to result in patients not receiving care indivdually designed to improve patient health and outcomes. (See Tag 298)

Based on record review and interview, the hospital failed to maintain an ongoing infection control program that includes active surveillance, early detection, control, and education consistent with nationally recognized infection control practices or guidelines.

These failed practices has the likelihood to create an ineffective infection control program and increased the infection control risk to the hospital's inpatients and outpatients.


Findings:

On 11/15/19 at 2:20 pm, Surveyors requested Infection Control Culture Logs and sign-in sheets for monthly meetings for the past 12 months. Requested documents were not provided.

On 11/15/19 at 2:20 pm, Staff C stated the 10/19 Infection Control Meeting was not held due to the layoff of infecton control staff.

Based on record review and interview the facility failed to provide clinical laboratory services, diagnostic imaging, and x-ray services.

This failed practice has the likelihood to place patients at an increased risk for poor quality of care and worsening medical conditions by not aiding in the diagnosis of medical conditions.


Findings:

A Review of Records Showed:
A review of administrative records showed no contracts for labs, x-ray, or diagnostic imaging.


On 11/15/19 at 2:20 pm, Staff A stated after 10/03/19 there were no contracts in place for lab or x-ray services. Staff A stated they have a lab but were not able to staff it and patients requiring lab and/or x-ray services were sent or transferred to another facility.

Based on interview the facility failed to provide radiology services.

This failed practice has the likelihood to place patients at an increased risk for poor quality of care and worsening medical conditions by not aiding in the diagnosis of medical conditions.


Findings:

A Review of Records Showed:
A review of administrative records showed no contracts for labs, x-ray, or diagnostic imaging.

On 11/15/19 at 2:20 pm, Staff A stated after 10/03/19 there were no contracts in place for lab or x-ray services. Staff A stated patients requiring lab and/or x-ray services were sent or transferred to another facility.

Based on record review and interview the facility failed to ensure Plans of care were kept current for three (Patient #8, #9, and #10) of three patients.

This failed practice has the likelihood to result in patients not receiving care indivdually designed to improve patient health and outcomes.

Findings:
Patient #8
A review of the patient record showed a progress note dated 10/02/19 that stated "still having some vomiting problems." There was no documentation to show vomiting as a patient problem, no expected outcomes, and no interventions or approaches documented in the patient care plan.

Patient #9
A review of the patient record showed orders for Chest x-rays dated 09/28/19, 09/29/19, and 09/30/19. There was no documentation to show patient problem or area of concern in relation to the chest x-rays as a patient problem, no expected outcomes, and no interventions or approaches documented in the patient care plan.

Patient #10
A review of the patient record showed a document title "Plan of Care" with Pain checked and dated 09/29/19, 09/30/19, and 10/01/19. There was no documentation of expected patient outcomes, interventions, or approaches.

On 11/19/19 at 1:23 PM Staff D stated record reviews had not been completed for that month.

Based on record review and interview, the facility failed to ensure medical records were complete, accurately documented, and readily accessible.

This failed practice has the likelihood for patients to be placed at risk of incomplete documentation of records. Thereby, affecting the quality of patient care. As the patient record provides communication of patient care in a sequential manner to provide timely assessment and intervention. (See Tag 301)


Based on record review and interview the physician failed to date and sign patient progress notes on three (Patient #8, 9, 10) of 10 patient records.

This failed practice has the likelihood to place patients at risk of having incomplete records. Thereby, affecting the quality of patient care; as the patient record provides communication of patient care in a sequential manner to promote timely assessment and invervention. (See Tag 306)


Based on record review and interview the hospital failed to ensure:

1. Documentation of a completed, signed, and dated medical history and physical exam (H & P) within 24 hours of admission for four (Patient #3, 8, 9, 10) of 10 patient records.

2. Documentation of a completed, signed, and dated discharge summary within 30 days following discharge for seven (Patient #1, 3, 4, 5, 6, 7, 8, 10) of 10 patient records.

3. Documentation of completed, signed, and dated progress notes within 30 days following discharge for three (Patient #8, 9, 10) of 10 patient records.

This failed practice has the likelihood to cause injury, delay in care, and worsening of health conditions due to lack of early intervention. (See Tag 307)

Based on record review and interview, the facility failed to ensure medical records were complete, accurately documented, and readily accessible.

This failed practice has the likelihood for patients to be placed at risk of incomplete documentation of records. Thereby, affecting the quality of patient care. As the patient record provides communication of patient care in a sequential manner to provide timely assessment and intervention.

Findings:

A Review of Records Showed:
On 11/19/19 at 10:55 am, the medical records for Patient #17 were not found.

Interview:
On 11/15/19 at 11:40 am, Staff A stated access to patient records in their EMR (electronic medical record) program was patchy and sometimes they cannot access patient records. Staff A stated the facility went back to paper charts on 03/16/19.

On 11/19/19 at 10:55 am, Staff L stated "I can't find the records on Patient #17, but I will keep looking."

Based on record review and interview the physician failed to date and sign patient progress notes on three (Patient #8, 9, 10) of 10 patient records.

This failed practice has the likelihood to place patients at risk of having incomplete records. Thereby, affecting the quality of patient care; as the patient record provides communication of patient care in a sequential manner to promote timely assessment and invervention.


Findings:

Patient #8
A review of the patient progress notes showed no physician date and signature for 09/27/19, 09/28/19, 09/29/19, 09/30/19, 10/01/19, and 10/02/19.

Patient #9
A review of the patient progress notes showed no physician date and signature for 09/28/19, 09/29/19, 09/30/19, 10/01/19, and 10/02/19.

Patient #10
A review of the patient progress notes showed no physician date and signature for 09/30/19, 10/01/19, and 10/02/19.

On 11/18/19 at 12:00 pm Staff C stated a review had not occured after staff lay offs.

Based on record review and interview the hospital failed to ensure:

1. Documentation of a completed, signed, and dated medical history and physical exam (H & P) within 24 hours of admission for four (Patient #3, 8, 9, 10) of 10 patient records.

2. Documentation of a completed, signed, and dated discharge summary within 30 days following discharge for seven (Patient #1, 3, 4, 5, 6, 7, 8, 10) of 10 patient records.

3. Documentation of completed, signed, and dated progress notes within 30 days following discharge for three (Patient #8, 9, 10) of 10 patient records.

This failed practice has the likelihood to cause injury, delay in care, and worsening of health conditions due to lack of early intervention.

Findings:

1. A review of patient records showed no documentation of a completed, signed, and dated H & P within 24 hours of admission for four (Patient #3, 8, 9, 10) of 10 patients.

Patient #3 Admitted to the hospital on 06/31/19, the physician signature is not dated (142 days after admission).

Patient #8 Admitted to the hospital on 09/25/19 showed no documentation of a H & P (55 days after admission).

Patient #9 Admitted to the hospital on 09/28/19, the physician signature is not dated (52 days after admission).

Patient #10 Admitted to the hospital on 09/29/19, the physician signature is not signed and dated (51 days after admission).


2. A review of patient records showed no documentation of a completed, signed, and dated discharge summary within 30 days after discharge for eight (Patient #1, 3, 4, 5, 6, 7, 8, 10) of 10 patient records.

Patient #1 Discharged from the hospital on 10/01/19, the physician signature is not signed and dated (18 days after required date).

Patient #3 Discharged from the hospital on 06/24/19, the physician signature is not dated (118 days after required date).

Patient #4 Discharged from the hospital on 04/08/19, the physician signature is signed and dated on 05/26/19 (18 days after required date).

Patient #5 Discharged from the hospital on 08/19/19, the physician signature is not dated (61 days after required date).

Patient #6 Discharged from the hospital on 07/25/19, the physician signature is not dated (86 days after required date).

Patient #7 Discharged from the hospital on 09/28/19, the physician signature and date missing (22 days after required date).

Patienty #8 Discharged from the hospital on 10/02/19 and no documentation of a discharge summary (17 days after required date).

Patient #10 Discharged from the hospital on 10/01/19, the physician signature and date missing (18 days after required date).


3. Documentation of signed and dated progress notes within 30 days following discharge for three (Patient #8, 9, 10) of 10 patient records.

Patient #8 Progress notes dated 09/27/19 (22 days after the required date), 09/28/19 (21 days after the required date), 09/29/19 (20 days after the required date), 09/30/19 (19 days after the required date), 10/01/19 (18 days after the required date), and 10/02/19 (17 days after the required date) were not signed and dated.

Patient #9 Progress notes dated 09/28/19 (21 days after the required date), 09/29/19 (20 days after the required date), 09/30/19 (19 days after the required date), 10/01/19 (18 days after the required date), and 10/02/19 (17 days after the required date) were not signed and dated.

Patient #10 Progress notes dated 10/01/19 (18 days after the required date) and 10/02/19 (17 days after the required date) were not signed and dated.

Interview

On 11/18/19 at 12:00 pm Staff C stated a review had not occured after staff lay offs.

Based on record review and interview the facility failed to have an effective quality program that included identification, implementation, and evaluation of corrective actions approved by the Governing Body, who is responsible for total operation of the hospital and for ensuring quality health care in a safe environment is provided.

This failed practice has the likelihood to affect all current patients due to the lack of analysis of errors, lack of corrective actions, and lack of subsequent evaluation of corrective actions to improve quality of care. (See Tag 336)

Based on record review and interview the facility failed to have an effective quality program that included identification, implementation, and evaluation of corrective actions approved by the Governing Body, who is responsible for total operation of the hospital and for ensuring quality health care in a safe environment is provided.

This failed practice has the likelihood to affect all current patients due to the lack of analysis of errors, lack of corrective actions, and lack of subsequent evaluation of corrective actions to improve quality of care.


Findings:

On 11/15/19 at 2:20 pm, surveyors requested the Quality Policy and Procedure and QAPI meeting minutes for the past 12 months. No documents were provided.

On 11/15/19 at 2:30 pm, Staff C stated the facility stopped reporting patient falls when the hospital closed on 10/03/19.

Based on patient record review and staff interview the hospital failed to ensure documentation of the patient transfer,
documented communication of patient information to the receiving healthcare institution for three (Patient #8, #9, ad #10) of three patients.

This failed practice has the likelihood to prevent a safe and effective transition of care. (see Tag 373)

Based on review of personnel files and interview the facility failed to ensure a background check was completed prior to employment of staff that might have patient contact for 11 (Staff M, J, C, N, D, O, P, Q, TR, S, T) of 11 staff.

This failed practice has the likelihood to place patients at risk for abuse, neglect, and exploitation of their property by employees who have been found guilty by a court of law for this behavior. (See Tag 381)

Based on record review and interview the facility failed to ensure medically related social services to attain or maintain the practicable physical, mental, and psychosocial well-being of each patient.

This failed practice has the likelihood to result in a change of patient condition who did not receive services prescribed for their medical condition. (See Tag 386)

Based on patient record review and staff interview the hospital failed to ensure documentation of the patient transfer,
documented communication of patient information to the receiving healthcare institution for three (Patient #8, #9, ad #10) of three patients.

This failed practice has the likelihood to prevent a safe and effective transition of care.


Findings:

Patient #8
A review of the patient record showed an order dated 10/02/19 that read in part "transfer patient." There was no documentation to show patient education or patient communication about the transfer, no documented transfer planning, and no documentation of transfer coordination with the receiving hospital.

Patient #9
A review of the patient record showed an order dated 10/02/19 for patient transfer. There was no documentation to show patient education or patient communication about the transfer, no documented transfer planning, and no documentation of transfer coordination with the receiving hospital.

Patient #10
A review of the patient record showed an order dated 10/02/19 for patient transfer. There was no documentation to show patient education or patient communication about the transfer, no documented transfer planning, and no documentation of transfer coordination with the receiving hospital.

On 11/19/19 at 1:23 PM Staff D stated record reviews had not been completed for that month.

Interview
On 11/18/19 at 1:00 pm, Staff S stated the swing bed patients were transferred when the facility closed on 10/03/19.

Based on review of personnel files and interview the facility failed to ensure a background check was completed prior to employment of staff that might have patient contact for 11 (Staff M, J, C, N, D, O, P, Q, TR, S, T) of 11 staff.

This failed practice has the likelihood to place patients at risk for abuse, neglect, and exploitation of their property by employees who have been found guilty by a court of law for this behavior.


Findings:

Staff M hired on 05/19/19 and background check was completed on 07/16/19 (68 days after hire date).

Staff J hired on 05/19/19 and background check was completed on 07/16/19 (68 days after hire date).

Staff C hired on 05/19/19 and background check was completed on 07/16/19 (68 days after hire date).

Staff N hired on 05/19/19 and background check was completed on 07/16/19 (68 days after hire date).

Staff D hired on 05/19/19 and no background check was completed (184 days after hire date).

Staff O hired on 05/19/19 and background check was completed on 07/16/19 (68 days after hire date).

Staff P hired on 05/19/19 and no background check was completed (184 days after hire date).

Staff Q hired on 05/19/19 and no background check was completed (184 days after hire date).

Staff R hired on 05/19/19 and no background check was completed (184 days after hire date).

Staff S hired on 05/19/19 and no background check was completed (184 days after hire date).

Staff T hired on 05/19/19 and no background check was completed (184 days after hire date).


On 11/19/19 at 1:00 pm, Staff G stated background checks were not completed prior to hiring these employees.

Based on record review and interview the facility failed to ensure medically related social services to attain or maintain the practicable physical, mental, and psychosocial well-being of each patient.

This failed practice has the likelihood to result in a change of patient condition who did not receive services prescribed for their medical condition.


Findings:

Review of a document titled "Haskel County Community Hospital Swing Bed Policy and Procedure" states the Haskell County Community Hospital will provide medically related social services when referral is needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in the swing bed program.

On 11/18/19 at 1:00 pm, Staff S stated the swing bed coordinator was laid off when the facility closed on 10/03/19.