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Based on review of documents and interview it was determined that the hospital did not organize the governing body so that it was separate and distinct for the hospital, and from the other associated entities affiliated with the hospital.

Findings include:

Review of governing body meetings and structure found that the substance of these meetings included issues that are not specific to the hospital. There is evidence in the Governing Body meeting minutes that items and issues regarding other corporate entities, such as the Nursing Home, the outpatient clinic, an apartment house, a housing company, and other various corporate entities were discussed concurrently during the Hospital Governing Body meetings.
Specific references are made to the 2/16/12 meeting minutes of the Board of Trustees during which the following entities: Linroc Community Services Corporation, Schulman and Schachne Institute for Nursing and Rehabilitation, The Samuel & Bertha Schulman Institute for Nursing & Rehabilitation Fund INC., Amboy Properties Corporation, Linden Foundation, Rockreal Corporation, Brookdale Family Care Centers, Brookdale Hospital Hegeman Housing Company, Brookdale Residency Housing Development Fund Corporation, The Arlene and David Schlang Pavilion, LCSC Holdings Incorporated, and Brookdale Research Foundation, were discussed concurrently with hospital matters. This was evident for governing body meetings over a one year period.

At interview with the administration of the hospital it was stated that the minutes of the meetings involve all the issues both in common with all or some facilities and that the members of that governing body are integrated into all the other corporate entities.

Based on record review it was not evident that the appointment of the Chief Executive Officer (CEO) was made by the governing body.

Findings include:

Review of governing body minutes for 2011 and 2012 did not find any evidence of the appointment of the CEO by the governing body. The facility was not able to produce any record of a meeting that included this appointment.

Based on document review and interview it was evident that the facility contracted out the functions of the CEO and other temporary employees but did not provide evidence that this contract would be implemented in such a fashion to ensure compliance with all conditions of participation.

Findings include:

Review of a draft document dated 4/4/12 was incomplete in that while it was stipulated that the CEO would be under the supervision of the Board of Trustees (aka the governing body) it did not delineate how the supervision would be implemented or evaluated. Specific reference is made to page 3 of this document that it is agreed that some of the services listed may or may not be performed depending on "facts and circumstances that may emerge during the course of the engagement".

Furthermore under the title "staffing" it was referenced that "temporary staff " would be provided by the contractor at any level (including managerial). Further reference is made to the contractor as leading communication with outside constituents including regulators. No reference regarding patient care is found in this document.

The facility did not provide any additional documentation.

Based on review of grievance records, procedures, and staff interviews, it was determined that the hospital did not ensure consistent adherence to procedures for inclusion of findings resulting from departmental reviews in order to justify effective grievance resolution.

Findings include:

Written grievance investigations were incomplete for either inclusion of findings resulting from departmental investigations or omission of complainant notification response. Review of 5/11 grievance and complaint files on 4/13/12 for the period after October 2011 found that the facts and results of internal department-specific investigations were not consistently included in grievance records in order to support the hospital's decisions and actions taken.

This was not in accordance with the Hospital's Complaints/Grievances policy and flowchart which requires that departmental managers, directors, and chairpersons shall initiate immediate investigations to report outcomes to Patient Relations within 48 hours.

Examples include:

MR # 1
The wife of a patient who expired in the ED on 10/9/11 had complained that she found him unresponsive and that nursing staff left him unattended. The written response provided to the complainant indicated that a qualitative review performed had determined the care was deemed appropriate. However, the file did not include documentation of the departmental investigation results. In addition, the file lacked results of follow up interviews with medical and nursing staff involved in the care of the patient, which had been referenced in the complainant's response letter and Nursing e-mail correspondence. The investigation lacked any evidence of review to ascertain if the cardiac monitor alarm was functioning.


MR # 2
Patient complained on 3/26/12 of multiple issues during a visit to the psychiatric ED for treatment. Response letters were sent to the patient which referenced reviews by Psychiatry and Performance Improvement , and concluded some missed opportunities for improved communication. However, the reviews from these departments and specific results were not included in order to explain what happened and to support the determination of the specific communication failures that occurred.

MR #3
Complaint was received on 12/2/11 about the mother of a pediatric patient who reportedly sustained a bedbug bite. The complainant was offered medical treatment but had refused the treatment. The area was immediately exterminated but the file lacked evidence of departmental review by Building Services to assess extent of the problem, if any.


MR # 4
The daughter of a patient complained on 2/22/12 that her mother sustained a stage 3 pressure ulcer and a burn on one of her hands while in the hospital. Patient relations staff reviewed charts and also spoke with the patient's daughter to inform her that decubitus stage 2 was present in the emergency department. Grievance committee minutes on 3/7/12 noted that there was a referral to Risk management. However, no response letter was provided to the complainant and the case was closed on 3/29/12.

MR # 5
On 1/24/12 the AOD received a complaint from a psychiatric inpatient who was hospitalized during January 2012, who complained of being choked with a sheet by a Psychiatric technician staff member. The concerns were forwarded to Psychiatry for investigation as noted in a 1/27/12 letter to the complainant. However, the file lacked evidence of a departmental review by the Department of Psychiatry staff. Grievance Committee documents noted that the complaint was discussed on 2/1/12. Attempts to contact the patient on 2/6/12 resulted in her hanging up the phone. A third letter dated 3/7/12 was sent to the complainant requesting that she call the hospital staff. No departmental follow up was evident to review the record for quality of care or interview with staff .

Interview with staff found that the patient had made the same complaint in 2010 against the same staff member, for which a complete investigation was conducted at that time and which was not substantiated. However, it was not evident that a departmental investigation for the current 2012 allegation was initiated to ascertain the facts.

Based on review of records and staff interviews, it was determined the hospital's personnel did not ensure consistent assessment of outpatient needs and risk factors in order to identify problems and facilitate continuity of outpatient care.

Findings include:

It was determined that 2/4 ambulatory OB/GYN records lacked appropriate or accurate psychosocial assessment for evident needs.

Two of four applicable outpatient high-risk obstetrical/GYN records reviewed on 4/12/12 found that social assessment was either missing or inaccurate.

Examples:

MR # 6
39 year old pregnant female with multiple issues including prior gestational diabetes and who was a late registrant for care on 2/3/12 did not receive psychosocial assessment for evident needs. The patient tested high-risk for Trisomy 18 and was also found to have atypical cells on pap smear. Despite having missed multiple appointments for medical and genetic testing, was not evaluated for social and emotional needs. Interview with the outpatient social worker found the patient was never assessed.

MR # 7
Record reviewed for a 27 year-old pregnant female seen in high risk clinic on 4/12/12. The physician's clinic notes documented history of sexual abuse at age 9 years. Patient first presented for care on 11/8/11 when this history was noted and social work referral was made. Social work assessment dated 11/8/11 found no reference to the reported history of sexual assault. The risk assessment checked negative for history of sexual assault. Interview with the clinic social worker on 4/12/12 found that the worker was unaware of this matter despite the physician's repeat notation of this history in 4 areas of the record. There was lack of evident care coordination to assess this risk factor.