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Based on interview and document reviews the hospital failed to have an effective governing body legally responsible for the conduct of the hospital as an institution. Failure to have an effective governing body has the potential to contribute to ineffective leadership and management within the facility and can potentially lead to negative patient healthcare outcomes and high readmission rates.

Findings include:

1. The Governing Body of the hospital failed to ensure the development, implementation, and maintenance of an effective quality assessment and performance improvement program (A0263, A0286, A0309 and A1000).

2. The Governing Body of the hospital failed to: ensure a medical staff member had one of their credentials validated before being approved for a specific privilege (A0341); and ensure the medical staff bylaws were being enforced (A0353).

3. The Governing Body failed to have an organized nursing service that meets the needs of the patients (Refer to A0385, A0396, A0405 and A0410).

4. The Governing Body failed to have a radiological services that meets professionally approved standards for safety and personnel qualifications (Refer to findings at A0528).

5. The Governing Body failed to ensure the hospital was arranged and maintained to ensure the safety of the patient. Additionally, the Governing Body failed to ensure the maintenance of the facilities and equipment in a manner to provide for the diagnosis and treatment of patients receiving services ( Refer to A0700, A0710 and A0724 (cross reference the Life Safety Code [LSC] survey finding dated 04/27/2018).

6. The Governing Body failed to ensure the hospital had a discharge planning program that applied to all patients (Refer to A0799, A0800, A0806, A0807, A0812, A0820 and A0843).

7. The Governing Body failed to ensure the Anesthesia Services Department was integrated into the hospital wide quality assessment process improvement program (A1000).

The cumulative effect of these systemic practices resulted in the failure of the hospital to provide care and services in accordance with the regulatory requirements related to Governing Body.

Based on observation, interview, record review, and review of facility policy the hospital failed to implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The facility failed to ensure performance improvement activities of the hospital tracked adverse patient events, analyzed the cause of the adverse event, and implemented preventive action. In addition, the facility failed to ensure the hospital-wide QAPI efforts addressed facility improvements directly impacting the quality of care and patient safety in 12 out of 40 departments of the hospital.

Findings include:

1. Based on interview, record review, and review of facility documentation, it was determined the hospital failed to ensure that it's performance improvement activities tracked adverse patient events, analyzed the cause of the adverse event, and implemented preventive action. The facility's failure affected the ability of the hospital to identify an adverse event in which Patient (P) 8 received intravenous (IV) iodine-based contrast in error during a medical procedure. This failure to track, analyze, and prevent adverse patient events had the potential to affect all patients receiving care at this facility (Refer to A-0286 and A-0410).

2. Based on interview, review of facility records, and a review of facility policy, it was determined the facility failed to ensure the hospital-wide Quality Assessment and Performance Improvement (QAPI) efforts addressed facility improvements directly impacting the quality of care and patient safety, and failed to ensure 12 out of 40 departments of the hospital provided reports related to QAPI activities and programs within their departments. For additional information (Refer to A-0309).


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3. Based on interview and document review the hospital failed to ensure the Anesthesia Services was integrated into the hospital-wide data-driven quality assessment and performance improvement program (Refer to A1000).

The cumulative effect of these systemic practices resulted in the failure of the hospital to provide care and services in accordance with the regulatory requirements related to Condition Quality Assessment and Performance Improvement.

Based on interview, record review, and review of facility documentation, it was determined the hospital failed to ensure the performance improvement activities of the hospital tracked adverse patient events, analyzed the cause of the adverse event, and implemented preventive action. The facility's failure affected the ability of the hospital to identify an adverse event in which Patient (P) 8 received intravenous (IV) iodine-based contrast in error during a medical procedure. This failure to track, analyze, and prevent adverse patient events had the potential to affect all patients receiving care at this facility.

Findings include:

On 04/24/2018 at 2:30 PM, a review of P8's medical record, "Emergency Department Record", revealed the patient presented to the Emergency Department (ED) of the hospital on 04/17/2018 at 1:32 AM with a complaint of abdominal pain and was triaged by the ED staff 04/17/2018 at 2:04 AM. The record further revealed ED Physician31 ordered a CT scan of P8's abdomen and pelvic area with oral contrast. In addition, the record revealed the patient was given an oral contrast, "per the instruction of the CT scan technician" on 04/17/2018 at 3:30 AM. P8 finished drinking the oral contrast at 4:30 AM and a CT scan of the patient's abdomen and pelvic area was performed on 04/17/2018 at 5:30 AM. On 04/17/2018 at 6:10 AM, the record documented ED Physician31 was notified the patient was given intravenous (IV) contrast prior to the completion of the CT scan. ED Physician31 noted in the record P8 was given IV contrast by mistake and required P8 to be admitted to the hospital. Additional review of P8's record, "Nephrology Consult Note," dated 04/19/2018, revealed P8 was diagnosed with, "Acute Kidney Injury (AKI) on Chronic Kidney Disease (CKD) 4: secondary to contrast-induced nephropathy." Further review of the "Nephrology Consult Note" revealed the document was signed by Nephrologist32 on 04/19/2018.

Review of the hospital's policy titled, "Quality Assessment Performance Improvement Plan" (QAPIP), dated 04/12/2018, revealed the QAPIP is responsible for ensuring the hospital assesses and evaluates the quality of patient care by collecting data, tracking quality indicators, and identifying opportunities for improvement to patient safety and quality, to include addressing, "medical errors and adverse patient events, wherein the hospital must analyze their causes, and implement preventative actions and mechanisms that include feedback and learning throughout the hospital."

Review of hospital documentation titled, "Position Description" for the Administrator of Quality, Patient Safety, and Regulatory Compliance, revealed the QAPI Administrator was responsible for providing, "leadership for the Sentinel Event process" and for the, "identification and prioritization of cases with appropriate leadership, and case write-up and summation."

During an interview on 04/25/2018 at 9:17 AM, Risk Management Director (RMD) 28 stated all facility staff are required to submit a "Patient Safety Form" when a medical error occurs and the form is submitted to the Risk Management Department of the hospital. The RMD further stated medical errors are investigated by the Risk Management Department when a "Patient Safety Form" is submitted. However, the RMD stated a "Patient Safety Form" had not been received related to any medical errors occurring on 04/17/2018 and the RMD did not have any knowledge of the medical error involving P8 at the time of the interview. In addition, RMD28 stated data related to medical errors and adverse events were not reported to the QAPI department of the hospital.

During an interview on 04/27/2018 at 8:30 AM, QAPI Coordinator23 stated the Risk Management Department was responsible for collecting "Patient Safety Forms" used in reporting adverse events and medical errors. However, the Coordinator added the Risk Management Department of the hospital did not report data related to tracking, analyzing, and providing corrective action for adverse events occurring in the hospital.

During an interview on 04/27/2018 at 1:50 PM, QAPI Administrator17 stated the Risk Management Department does not report to the QAPI department of the hospital regarding adverse events and medical errors. However, QAPI Administrator17 added he/she has requested data from the Risk Management Department for adverse events and medical errors. Administrator17 could not provide an explanation for why the data had not been collected and analyzed for corrective action.

During an interview on 04/27/2018 at 10:00 AM with the Chief Medical Officer (CMO), Chief Nursing Officer (CNO), and the Chief Executive Officer (CEO), the CMO acknowledged during the interview that the Risk Management Department of the hospital had failed to provide data related to adverse events and medical errors during the past 12 months.

Based on interview, review of facility records, and a review of facility policy, it was determined the facility failed to ensure the hospital-wide Quality Assessment and Performance Improvement (QAPI) Program's efforts addressed facility improvements directly impacting the quality of care and patient safety, and failed to ensure 12 of 40 departments of the hospital provided reports related to QAPI activities and programs within their departments.

Findings include:

A review of the hospital's policy titled, "Quality Assessment Performance Improvement Plan" (QAPIP), dated 04/12/2018, revealed the hospital's Governing Body is responsible for, "ensuring the quality and safety of care provided at the hospital." In addition, the policy stated, "The Performance Improvement Committee (PIC) of the hospital is responsible for the oversight of systems to monitor, evaluate, and improve the quality of care given to hospital patients. The PIC is responsible for the oversight of quality improvement programs and responsible for making recommendations to the governing body of the hospital related to compliance with Centers for Medicaid and Medicare Services (CMS) conditions of participation."

During an interview on 04/27/2018 at 8:30 AM, QAPI Coordinator23 identified that 12 of the hospital's 40 departments failed to provide QAPI reports related to the collection of data, the analysis of data, and/or the identification of QAPI program activities in their respective departments. The departments identified during the interview were as follows: Intensive Care Unit (ICU), Utilization Review (UR), Risk Management (RM), Communications, Environmental Services Department, Patient Education Department, Surgical Unit Department, Special Services Department, Telemetry, Urgent Care, Education Department, and the Medical Staff Department.

During an interview on 04/27/2018 at 1:50 PM, QAPI Administrator17 confirmed there were departments of the hospital that were inconsistent in providing information related to QAPI activities with their respective departments. In addition, QAPI Administrator17 provided electronic communications related to requests for data, analysis, and program activities to be forwarded to the QAPI Department.

During an interview on 04/27/2018 at 10:00 AM with the Chief Medical Officer (CMO), Chief Nursing Officer (CNO), and the Chief Executive Officer (CEO), the CMO, CNO, and CEO acknowledged the hospital had failed to ensure QAPI program activities were conducted in 12 departments during the last 12 months. In addition, the CMO stated the hospital's administration is trying to implement improvements to the hospital-wide QAPI. The CNO stated staffing shortages at the hospital contributed to inconsistent reporting of QAPI programs to the QAPI Department.

Based on record review and interview, the hospital did not ensure the medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates in accordance with the medical staff bylaws, rules, and regulations.

Finding includes:

Review of the hospital's medical staff bylaws, rules, and regulations revealed that one of the responsibilities of the medical staff was to account "for the quality and appropriateness of patient care rendered by all practitioners and allied health professionals" through several measures such as a "credentials program, including mechanisms for appointment and reappointment, and the matching of clinical privileges to be exercised or of specified services to be performed, with verified credentials and demonstrated current competence of the applicant, staff member, or allied health professional."

The medical staff bylaws further required that an application for appointment should include detailed information concerning the applicant's professional qualifications including the names and complete addresses of at least two physicians "who have had extensive experience in observing and and working with the applicant and who can provide information pertaining to the applicant's present professional competence and character." In addition, the bylaws required that the applicant shall have the burden of producing adequate information for a proper evaluation of his/her competence, and of "providing evidence that all the statements made and given on the application are factual and true."

Review of Physician A's credential file revealed that an application for initial medical staff membership was completed on 7/27/16. The application included requests for several pediatric privileges including peritoneal dialysis which Physician A claimed to have completed "50" cases. A recommendation was made by the chief of the pediatrics department to grant the request on 9/08/16, and approval was formally conveyed in a letter dated 10/21/16 to Physician A by a hospital administrative staff (Staff 27).

Further review of the credential file including Physician A's curriculum vitae, however, revealed the lack of documentation that Physician A had background training, proctoring, or experience in pediatric peritoneal dialysis. In addition, there was no indication that Physician A had provided evidence or information to support the request for the privilege so that a "proper evaluation" of competency could be made. Also, no attempts were made by the hospital to verify and/or inform Physician A to provide documentation or additional information.

During the credential file review (on 4/27/18), a letter from the hospital dated 3/06/18 was sent to an off-island hospital (Hospital 1) requesting information regarding Physician A's training in "the performance of privileges" in pediatric peritoneal dialysis. In response, Hospital 1, identified as where Physician A completed a fellowship program, noted that the physician had training in the management of patient on peritoneal dialysis, but "not management of PD (peritoneal dialysis)." In a follow-up email dated 3/08/18, Hospital 1 clarified that while Physician A completed training (at Hospital 1), the physician however, "was not trained to fulfill the traditional role of a nephrologist in managing PD (peritoneal dialysis) directly (writing PD orders etc)."

During an interview on 4/27/18, a medical staff coordinator (Staff 10) stated that the letter was sent to Hospital 1 to verify Physician A's credentials. Staff 10 added that no further follow-up was made because the response from Hospital 1 was clear (about Physician A). When asked why the letter was not sent earlier on during the initial application period, Staff 10 was unable to respond.

On 4/27/18 during the survey, Physician A's application for active membership (reappointment) to the medical staff was also reviewed. The application dated 6/29/17 which was approved by Staff 27 in a letter dated 8/31/17 included the granting of several requests for pediatric privileges including peritoneal dialysis. The completed application noted that Physician A had "40" pediatric peritoneal dialysis cases.

There was no documentation that the hospital verified the number of cases claimed by Physician A during the initial provisional period.

In a separate interview on 4/27/18, the chairperson of the pediatrics department stated that the hospital did not have a lot of pediatric peritoneal dialysis cases.

During another interview on 4/27/18, Staff 27 was informed about the privilege granted to Physician A without an evaluation and determination to verify training and competency during the initial application and subsequent reappointment. Staff 27 stated that he was aware of the situation and explained that the medical staff bylaws were being reviewed to ensure that the incident did not occur again.

Based on interview and record review the hospital failed to ensure the medical staff enforced its bylaws. Failure to enforce the medical staff bylaws may infer governing body approval for practices by Physicians or Allied Health Professionals that may not be consistent with the medical staff bylaws and/or territory laws. The aforementioned could potentially allow medical staff providers to practice outside their licensed capacity or the approved privileges granted by the governing body.

Findings include:

The GMHA Medical Staff Bylaws (last revised 11/16/2017) under Article V which addresses Appointment and Reappointments to the Medical Staff indicates ...The application shall contain a request for specific Clinical Privileges desired by the applicant and shall require detailed information concerning the applicant's professional qualifications including:
- "Information as to whether the applicant's membership in local, state, territory or national professional societies or his/her license to practice any profession in any state, territory or his/her Guam Controlled Substance license (GCSL) or Drug Enforcement Administration (DEA) license has ever been suspended, modified or terminated".

- "Applicant has up to 180 days to submit GCSL and DEA licenses, or must show just cause in a written statement why DEA or GCSL has not been submitted which will be reviewed by the Chairperson of the Credentials Committee. Failure to comply with the above may result in termination or limitation of hospital privileges".

The same Medical Staff Bylaws under Article VII, which pertains to Allied Health Professionals and their responsibilities indicates. "Allied Health Professionals must practice within the scope of their license and scope of practice agreement as well as the privileges granted them by the board". They must:
-"Abide by the relevant sections of the Medical Staff bylaws and other lawful standards, policies and rules of the Guam Memorial Hospital Authority".

The GMHA policy titled Medication Orders last reviewed/revised 03/23/2018 states under Definitions related to Prescribing Privileges .... "Only advanced practice nurses who are licensed by the DEA are authorized to write orders for controlled substances".

The Guam Code Annotated, Title 10 Health and Safety (website address http://www.guamcourts.org/Compileroflaws/GCA/10gca/10gc012.PDF) indicates
"(g) The Advance Practice Registered Nurse (APRN) shall hold a current Guam license to practice as a registered nurse, a current national or state board certification in nurse practitioner, nurse midwife, nurse anesthetist or clinical nurse specialist, and a Board certification to practice as an APRN on Guam.
(h) The APRN shall be authorized to prescribe and dispense drugs for administration to, and use by, other persons within the national scope of practice, and the rules and regulations adopted by the Board. The Prescriptive Authority Advisory Committee shall establish the rules for the ordering and prescribing of schedule drugs.
(j) The APRN shall secure and maintain a Federal Drug Enforcement Agency ('DEA') registration number, and comply with all state and Federal laws and regulations APRN prior to prescribing 'Schedule Drugs II-V'".

On April 25 and April 26, 2018 select Medical Staff and Allied Health Professionals credential and privileging files were reviewed with Staff 10. During the review Staff 10 validated the hospital currently has:

- 7 Certified Nurse Midwives on staff and 3 of the 7 have no DEA licenses in their files and

- 4 Certified Registered Nurse Anesthetist (CRNA) and none of the CRNAs have DEA licenses in their files.

During the review there was no evidence of a written statement indicating why a DEA or GCSL had not been submitted with the application for appointment or reappointment to the medical staff.

Based on interview and record review, the facility failed to meet the Conditions for Participation (CoP) for Nursing Services. The facility failed to ensure a biological (iodine-based intravenous (IV) contrast was administered in accordance with the orders of the practitioner and the accepted standards of practice for one of 30 patients who received care in the facility. In addition, the facility failed to ensure the staff followed the policy for reporting an error in the administration of intravenous (IV) contrast to one of 30 sampled patients. The administration of the iodine based IV contrast resulted in P8 being admitted to the hospital and requiring hemodialysis. Refer to A-0405 and A-0410.

Findings include:

On 04/24/2018 at 2:30 PM, a review of P8's "Emergency Department Record" revealed the patient presented to the Emergency Department (ED) of the hospital on 04/17/2018 at 1:32 AM with a complaint of abdominal pain and was triaged by the ED staff 04/17/2018 at 2:04 AM. ED Physician31 ordered a CT scan of P8's abdomen and pelvic area without contrast. The documentation revealed the patient was given an oral contrast agent, "per the instruction of the CT scan technician," on 04/17/2018 at 3:30 AM. P8 finished drinking the oral contrast at 4:30 AM and a CT scan of his/her abdomen and pelvic area was performed on 04/17/2018 at 5:30 AM. Further review of the documentation revealed the ED Physician31 was notified on 04/17/2018 at 6:10 AM, that the patient was given intravenous (IV) contrast prior to the completion of the CT scan. ED Physician31 noted in the record that P8 was given IV contrast by mistake and required admission to the hospital. Review of a "Nephrology Consult Note," dated 04/19/2018, revealed P8 was diagnosed with, "Acute Kidney Injury (AKI) on Chronic Kidney Disease (CKD) 4: secondary to contrast-induced nephropathy." Further review of the "Nephrology Consult Note" revealed the document was signed by Nephrologist32 on 04/19/2018.

During an interview on 04/26/2018 at 8:05 AM, Registered Nurse (RN) 33 stated P8 presented to the ED on 04/17/2018 at 1:32 AM, and was triaged by the ED staff 04/17/2018 at 2:04 AM. RN33 stated he/she inserted an IV line in P8's arm obtain blood for ordered laboratory tests. RN33 stated he/she reviewed an order for P8 for a CT scan procedure and verified the procedure required oral contrast to administered to P8. RN33 further stated he/she was notified by ED Physician31 that Staff19 administered IV contrast to P8 after the procedure was completed. In addition, RN33 stated he/she was informed Staff19 would fill out a "Patient Safety Form" to report the error to the Risk Management Department of the hospital. However, RN33 stated the error was not reported on the nurses' 24-hour report and was not reported to the House Supervisor of the hospital. In addition, RN33 stated he/she did not advise Staff 19 to complete a "Patient Safety Form."

During an interview on 04/26/2018 at 1:15 PM, the Chief Nursing Officer (CNO) stated he/she was not aware of the incident related to P8 until 04/25/2018. The CNO stated he/she reviewed P8's medical record on 04/25/2018 and stated the incident was not reported on the nursing 24-hour report. In addition, CNO stated the incident was not reported to the hospital's House Supervisor on duty on 04/17/2018.

Based on observation, interview and record review, the hospital failed to ensure nursing staff develops, and keeps current, a nursing care plan for 1 of 30 sampled patients (P19) reviewed for care plans on the Intensive care unit. Specifically, the facility failed to develop a nursing care plan that were comprehensive and reflected problems and interventions in response to identified nursing care needs for a patient on contact isolation and who received multiple blood transfusions. These failures increased the risk of failing to identify unmet patient care needs and/or failing to identify potential complications. In addition a nursing care plans will provide and opportunity to promote, maintain, or restore health.

Findings include:

During a record review concurrent an interview on 4/23/18 at 12:30 p.m., with Staff # 45 in regards to P19, he was admitted on 4/21/2018 with diagnoses of anemia, congestive heart Failure and chronic kidney disease. Clinical record reveals that P19 had received multiple red blood cell transfusions due to anemia and had been placed on contact isolation precautions for possible fungal and viral infections. Further review of the record identified that there were no care plans initiated for the isolation precaution maintenance and potential blood transfusion reactions. Staff # 45 acknowledged that a care plan should have been imitated for P19 as per policy and could not provide any evidence of the nursing care plan documentation.

On 4/26/2017 at 2:00 p.m., during an interview with Staff # 40 she indicated her expectation was for the nurses to implement a care plan for all patients receiving blood transfusion and any patient placed on all types of isolation precautions.

On 4/27/2018 at 11:00 a.m., during an interview with Staff # 44 she indicated she had failed to implement a care plan for P19 who was receiving blood transfusion and placed on isolation precautions per policy.

On 4/27/2018 the facility policy Title "Electronic Based Documentation Guidelines" revise dated on 5/2015 was reviewed and it reveals in section IV. Nursing Care Plans - The nursing Care Plans may need to be individualized to each patient needs; The nursing Care Plan including nursing diagnosis, expected outcomes, and nursing interventions; During the hospital stay, it should be used to conduct an individualized plan of care for the patient. It can be used when giving shift report, as a guide to evaluate what has been done, and what should be documented.

Based on observation, interview, and record review, the facility failed to ensure a biological (iodine-based IV contrast agent) was administered in accordance with the orders of the practitioner and accepted standards of practice for one of 30 patients, (Patient (P) 8) receiving care at the facility. The administration of the iodine-based IV contrast agent resulted in P8's admission to the hospital for hemodialysis treatments.

Findings include:

On 04/23/2018 at 10:55 AM, an observation conducted during the initial tour of the hospital revealed P8 was receiving hemodialysis treatment in the inpatient hemodialysis unit of the facility. At the time of the observation, seven hospital patients were observed receiving dialysis treatment.

On 04/24/2018 at 2:30 PM, a review of P8's "Emergency Department Record" revealed the patient presented to the Emergency Department (ED) of the hospital on 04/17/2018 at 1:32 AM and was triaged by the ED staff 04/17/2018 at 2:04 AM. The record stated P8 presented to the ED with a complaint of abdominal pain and the ED Physician (later identified as ED Physician31) ordered a CT scan of P8's abdomen and pelvic area with oral contrast. The documentation indicated P8 was given an oral contrast agent, "per the instruction of the CT scan technician" on 04/17/2018 at 3:30 AM and had finished drinking the oral contrast at 4:30 AM. The CT scan of P8's abdomen and pelvic area was performed on 04/17/2018 at 5:30 AM. Further review of the documentation indicated on 04/17/2018 at 6:10 AM, ED Physician31 was notified that P8 received intravenous (IV) contrast prior to the completion of the CT scan. ED Physician31 noted in the record that P8 received IV contrast by mistake, and the patient required hospital admission. Additional review of P8's record revealed a "Nephrology Consult Note," dated 04/19/2018, that read, "[P8 was diagnosed with] Acute Kidney Injury (AKI) on Chronic Kidney Disease (CKD) 4: secondary to contrast-induced nephropathy." Further review of the "Nephrology Consult Note" revealed the document was signed by Nephrologist32 on 04/19/2018.

During an interview on 04/26/2018 at 7:30 AM, Staff19 stated P8 presented to the ED of the hospital on 04/17/2018 at 1:32 AM and he/she received an order from ED Physician31 to perform a CT scan without contrast of P8's abdomen and pelvic area. Staff19 stated he/she contacted ED Physician31 to verify that the order for the CT scan was to be performed without IV contrast and to verify that P8 would receive a water soluble oral contrast for the procedure. In addition, Staff19 stated he/she prepared the patient for the CT scan procedure and instructed the patient to drink the oral contrast on 04/17/2018 at 3:30 AM. Staff19 further stated he/she verified P8 finished drinking the oral contrast at 5:45 AM and the CT scan of P8' s abdomen and pelvic area was performed on 04/17/2018 at 5:54 AM. Staff 19 stated he/she administered an IV contrast at the beginning of the procedure and immediately realized the procedure did not require IV contrast to be administered. Staff19 stated he/she estimated he/she had administered approximately 50 cubic centimeters (cc) of the IV contrast to P8 in error. However, Staff19 could not provide an explanation why he/she administered the IV contrast after he had verified with ED Physician31 that the procedure was to be performed without IV contrast.

During an interview on 04/26/2018 at 2:55 PM, ED Physician31 stated he/she ordered a CT scan of the abdomen and pelvic area without IV contrast for P8 because the patient had a diagnosis of CKD. ED Physician31 stated administering IV contrast was potentially harmful to patients with CKD. ED Physician31 stated Staff19 informed him/her that P8 was administered IV contrast during the ordered procedure and he/she immediately consulted with an admitting physician of the hospital and Radiologist6 to admit P8 to the hospital for observation. ED Physician31 stated he/she informed P8 that admission to the hospital would be necessary because of the error of administering IV contrast during the CT scan procedure.

During an interview on 04/26/2018 at 8:05 AM, Registered Nurse (RN) 33 stated P8 presented to the ED on 04/17/2018 at 1:32 AM and was triaged by the ED staff 04/17/2018 at 2:04 AM. RN33 stated he/she inserted an IV line in P8's arm and obtained blood for ordered laboratory tests. RN33 stated he/she reviewed an order for P8 for a CT scan procedure and verified the procedure required oral contrast to administered to P8. RN33 further stated he/she was notified by the "Doctor on Duty" (DOD) that Staff19 had administered IV contrast to P8 after the procedure was completed. RN33 stated the error was not reported on the nurses 24-hour report and was not reported to the House Supervisor of the hospital.

During an interview on 04/26/2018 at 1:15 PM, the Chief Nursing Officer (CNO) stated he/she was not aware of the incident related to P8 that occurred on 04/17/2018. The CNO stated he/she reviewed P8's medical record on 04/25/2018 and that the incident was not reported on the nursing 24-hour report, nor was the incident reported to the hospital's House Supervisor on duty on 04/17/2018.

Based on observations, interview, and record review, it was determined the facility failed to report an error in the administration of intravenous (IV) contrast agent to one of 30 sampled patients, (Patient (P) 8). On 04/17/2018, staff administered an iodine-based IV contrast agent to P8 during a computed tomography (CT) scan procedure of the patient's abdomen and pelvic area. However, the physician's order for the procedure directed the staff to conduct the test without the administration of an IV contrast agent. The administration of the iodine-based IV contrast agent resulted in P8's admission to the hospital for unscheduled hemodialysis treatments. This failed practice resulted in Immediate Jeopardy.

On 04/25/2018 at 11:45 AM, the CEO, CMO, CNO, Risk Management Officer, and QAPI Administrator were notified that Immediate Jeopardy existed at A-0410. The facility provided an acceptable plan for removal of the Immediate Jeopardy on 04/27/2018 at 12:00 PM. The facility's plan for removal of the Immediate Jeopardy included an investigation of the incident that occurred on 04/17/2018, training all facility staff on reporting adverse events, and conducting an analysis of the investigation to ensure future occurrences are reported and monitored.

The survey team validated that the condition which constituted Immediate Jeopardy was removed on 04/27/2018 at 1:00 PM following the facility's implementation of the plan for removal of Immediate Jeopardy. On 04/27/2018 at 4:30 PM, the CEO, CMO, and CNO were notified that the condition which constituted Immediate Jeopardy at A-0410, had been removed and the Immediate Jeopardy at A-0410 had been abated.

Findings include:

Observations on 04/23/2018 at 10:55 AM, during the initial tour of the hospital revealed P8 was receiving hemodialysis treatment in the inpatient hemodialysis unit of the facility. At the time of the observation, seven hospital patients were receiving dialysis treatment.

On 04/24/2018 at 2:30 PM, a review of P8's "Emergency Department Record," dated 04/17/2018 (no time), revealed P8 presented to the Emergency Department (ED) of the hospital on 04/17/2018 at 1:32 AM with a complaint of abdominal pain and was triaged by the ED staff 04/17/2018 at 2:04 AM. The record indicated the ED physician (later identified as ED Physician31) ordered a CT scan of the patient's abdomen and pelvic area without IV contrast. On 04/17/2018 at 3:30 AM, P8 was given an oral contrast agent, "per the instruction of the CT scan technician." P8 finished drinking the oral contrast agent at 4:30 AM and a CT scan of his/her abdomen and pelvic area was performed on 04/17/2018 at 5:30 AM. The record indicated ED Physician31 was notified on 04/17/2018 at 6:10 AM that the patient was given IV contrast prior to the completion of the CT scan. ED Physician31 noted in the record that P8 was given IV contrast by mistake and subsequently required admission to the hospital.

Further review of P8's record revealed a "Nephrology Consult Note," dated 04/19/2018, that read, "[P8 was diagnosed with] Acute Kidney Injury (AKI) on Chronic Kidney Disease (CKD) 4: secondary to contrast-induced nephropathy." Further review of the "Nephrology Consult Note" revealed the document was signed by Nephrologist32 on 04/19/2018.

During an interview on 04/25/2018 at 9:17 AM, Risk Management Director (RMD) 28 stated all facility staff are required to submit a "Patient Safety Form" when a medical error occurs. The "Patient Safety Form" is then submitted to the Risk Management Department of the hospital. The RMD further stated that medical errors are investigated by the Risk Management Department when a "Patient Safety Form" is submitted. However, the RMD stated a "Patient Safety Form" had not been received related to any medical errors occurring on 04/17/2018 and the RMD had no knowledge of the medical error involving P8 at the time of the interview.

During an interview on 04/25/2018 at 9:33 AM, the Radiology Department Manager (RM) 20 stated that Radiologist6 informed him/her that Staff19 administered IV contrast to P8 on 04/17/2018, but a "Patient Safety Form" had not been received from Staff19 related to the incident on 04/17/2018. RM20 could not provide an explanation for why the error had not been reported or why Staff19 administered IV contrast to P8 without an order.

During an interview on 04/25/2018 at 9:45 AM, Radiologist1 stated ED Physician31 notified him on 04/17/2018 that Staff19 administered IV contrast to P8 in error. Radiologist1 further stated he discussed the medical error with ED Physician31, and P8 was admitted to the hospital for observation because the patient had a diagnosis of chronic kidney failure and would need to be monitored because the IV contract agent was administered in error and had the potential to cause an adverse reaction.

During an interview on 04/25/2018 at 2:00 PM with P8 and P8's spouse in the patient's hospital room, P8 stated he/she was admitted to the hospital on 04/17/2018 and received his/her first dialysis treatment on 04/23/2018. P8 stated he/she has received a second dialysis treatment on 04/24/2018 and was scheduled for a third dialysis treatment on 04/26/2018. P8 further stated he/she had never received dialysis treatments prior to his/her admission to the hospital on 04/17/2018.

On 04/25/2018 at 4:00 PM, a review of a blank "Patient Safety Form" revealed the instructions on the form directed hospital staff to report incidents affecting patient safety. The form stated, "If the incident is a serious injury or an unexpected death, notify the Risk Communications Center." In addition, the document instructed hospital staff that the form, "should be received by the Risk Management Program Officer no later than 72 hours post incident."

During an interview on 04/26/2018 at 7:30 AM, Staff19 stated that P8 presented to the ED of the hospital on 04/17/2018 at 1:32 AM, and he/she received an order from ED Physician31 to perform a CT scan without contrast for the abdomen and pelvic area. Staff19 stated he/she contacted ED Physician31 to verify that the order for the CT scan was to be performed without IV contrast and to verify that P8 would receive a water soluble oral contrast for the procedure. In addition, Staff19 stated he/she prepared P8 for the CT scan procedure and instructed the patient to drink the oral contrast on 04/17/2018 at 3:30 AM. Staff19 further stated he/she verified P8 finished drinking the oral contrast at 5:45 AM and the CT scan of P8's abdomen and pelvic area was performed on 04/17/2018 at 5:54 AM. Staff19 stated he/she administered an IV contrast at the beginning of the procedure and immediately realized the procedure did not require IV contrast to be administered. Staff19 stated he/she estimated he/she had administered approximately 50 cubic centimeters (cc) of the IV contrast to P8 in error. However, Staff19 could not provide an explanation why he/she administered the IV contrast after he/she verified with ED Physician31 that the procedure was to be performed without IV contrast. In addition, Staff19 stated during the interview that he/she did not report the error in administering IV contrast to P8 without an order. Staff19 stated he/she informed ED Physician31 that P8 was given intravenous (IV) contrast prior to the completion of the CT scan, but did not complete a "Patient Safety Form" to report the error.

During an interview on 04/26/2018 at 2:55 PM, ED Physician31 stated he/she ordered a CT scan of the abdomen and pelvic area without IV contrast for P8 because the patient had a diagnosis of CKD. ED Physician31 stated administering IV contrast was potentially harmful to patients with CKD. ED Physician31 stated when Staff19 informed him/her that P8 received IV contrast during the ordered procedure, he/she immediately consulted with an admitting physician of the hospital and Radiologist1 to admit P8 to the hospital for observation. ED Physician31 stated he/she informed P8 that admission to the hospital would be necessary because he/she received IV contrast in error during the CT scan procedure. ED Physician31 further stated he/she did not instruct Staff19 to fill out a "Patient Safety Form" because he/she assumed Staff19's direct supervisor would ensure the form would be filled out and the error would be reported to the hospital's Risk Management Department. ED Physician31 stated he/she did not fill out a "Patient Safety Form" regarding the error.

During an interview on 04/26/2018 at 8:05 AM, Registered Nurse (RN) 33 stated P8 presented to the ED on 04/17/2018 at 1:32 AM, and was triaged by the ED staff on 04/17/2018 at 2:04 AM. RN33 stated he/she inserted an IV line in P8's arm and obtained blood for ordered laboratory tests. RN33 stated he/she reviewed an order for P8 for a CT scan procedure and verified the procedure required oral contrast be administered to P8. RN33 further stated the "Doctor on Duty" (DOD) notified him/her that Staff19 administered IV contrast to P8 after the procedure was completed. In addition, RN33 stated he/she was informed Staff19 would fill out a "Patient Safety Form" to report the error to the hospital's Risk Management Department. However, RN33 stated the error was not reported on the nurses' 24-hour report nor was the medication error reported to the hospital's House Supervisor. In addition, RN33 stated he/she did not advise Staff19 to complete a "Patient Safety Form."

During an interview on 04/26/2018 at 1:15 PM, the Chief Nursing Officer (CNO) stated he/she was not aware of the incident related to P8 that occurred on 04/17/2018. The CNO stated he/she reviewed P8's medical record on 04/25/2018 and that the incident was not reported on the nursing 24-hour report, nor was the incident reported to the hospital's House Supervisor on duty on 04/17/2018. The CNO acknowledged that the medical error had not been documented on a "Patient Safety Form."

During an interview on 04/26/2018 at 2:55 PM, Nephrologist32 stated he/she conducted a consult with P8 on 04/19/2018, and added that the IV contrast administered to P8, "played a major role in the patient having to be dialyzed."

Based on observation and interview and policy review, the hospital failed to ensure that all drugs and biologicals storage areas and or carts were securely stored and locked and made available to only authorized professional health care employees. This failure was evident in the Operating room #2 and the PACU.

Findings include:

On 4/24/2018 at 9:30 a.m., during a tour of the operation room #2 concurrent with an interview with Staff 46, she acknowledged that the medication cart was left unlocked, and the expectation is for the cart to be locked all times. The anesthesia medication cart contained a total of 40 different type of medications in various forms. The PACU unit medication storage area was unsecured and open with over 100 medications accessible and visible to everyone. Staff 46 validated that everyone including housekeeping and the technician had access to the unlocked medication cart and PACU. Staff 46 validated that the housekeeping and technician should not have access to the medication cart, and only authorized license personnel.

On 4/24/2018 at 9:35 a.m., interview with Staff 50, she indicated that her duty is to stocks the anesthesia medication cart with supplies. She demonstrated how she locks and opens the anesthesia medication cart. She further explained that although she have a direct link to the medication she does not touch the medication draws. Staff 50 explained that she last entered the cart at 8:30 a.m. in order to stock it and did lock the medication cart afterwards.

On 4/24/2018 at 9:40 a.m., interview with Staff 51 he indicated that the anesthesia medication cart should be locked at all time. He further explained that the staff are aware that the medication cart should remain lock.

On 4/24/2018 at 9:45 a.m., interview with Staff 52 and he indicated that he completed the medication cart count this am at 7:30 a.m., and locked the medication cart after. He validated that the expectation is to keep the medication cart locked all the time.

On 4/24/2018 at 9:46 a.m., during a concurrent interview and a record review with Staff # 53, he validated that the expectation per policy is keep the medication cart locked at all time. He provided a copy of the monthly audit title "Pharmacy Self Evaluation Report" conducted by the pharmacy department. The review revealed that the pharmacy has identified the medication carts being open and has reported the concern to management. He further explained that this concern was previously identified and has done in-services to the operating room team. In addition he stated, that the same concern was identified on a the previous survey. Staff 53 provided a written deficient practice plan of correction that was put in place for the hospital to secure the medication carts from the previous survey.

On 4/26/2018 at 10:00a.m., interviewed with Staff 40, she indicated that the expectation and policy of the hospital is to have all medication secured and locked

On 4/26/2018 reviewed the Hospital policy titles "Storage and Security of Drugs dated 3/26/18 and it reveals that:
Purpose: To ensure that medications and chemicals are stored in a proper and safe manner so that their integrity, stability and effectiveness are maintained
Policy: Medication in the entire hospital are to be stored under proper conditions and security.
Procedure: All medications at nursing stations shall be in a lockable storage at all times. Medications are stored either in a lockable medication cart or medication room. When unattended the medication carts and medication room are to be locked. Only the authorized nursing personnel and pharmacist or authorized personnel from pharmacy are allowed to access it.

Based on interview and record review the hospital failed to ensure the diagnostic radiological services were administered in a manner to ensure safety. Failing to ensure the radiological service is administered in a safe manner, and all errors fully investigated, may potentially lead to additional errors and/or adverse hospital acquired conditions.

Findings include:

1. Cross reference findings at A405 and A410.

2. On 4/25/2018 a record review of Patient 8 revealed that Patient 8 arrived in the Emergency Department (ED) at GMHA on 4/17/18 at 1:32 a.m. complaining of abdominal pain. The emergency room physician (MD) ordered a Computed Tomography (CT) of the abdomen and pelvic without intravenous (IV) contrast. The written sequence in the ER nursing notes disclosed that Patient 8 received oral contrast that was prepared by the radiological technician at about 3:30 a.m. At approximately 5:30 a.m., Patient 8 received the CT of the abdomen and pelvis with IV contrast without an MD order in error. The ED MD was informed of the error by the radiologist at approximately 6:10 a.m. As a result the ED MD admitted Patient 8 for observation and consulted an admitting physician. In addition Patient 8 had a consult with a nephrologist on 4/19/18 and it concluded that Patient 8 Acute Kidney Injury was a result of contrast-induced nephropathy.

3. During a concurrent interview and record review with Staff 20 on 4/25/18 at 9:33 a.m., he stated he was not informed of an aforementioned error. Staff 20 explained that usually if an error occurs the radiology staff are expected to fill out the patient safety form (blue form). The patient safety form is then submitted to management and management will conduct an investigation along with the risk management and other disciplinary team members at the hospital. Staff 20 also provided a copy of the patient screening form that should occur prior to administering of IV contrast to any patient. When asked if he could provide a copy of the form used for Patient 8 on 4/17/18, he stated that it was not available in the medical record. He further explained that the expectation is for the patient screening form to be scanned into the medical record within the next day of the radiological procedure completion. Staff 20 validated that an informed consent was not obtained prior to the IV intravenous contrast agent per policy. In addition, Staff 20 acknowledged Staff 19 did not follow the policy and procedure for IV Contrast Agents Administration.

4. On 4/25/18 at 9:45 a.m. during an interview conducted with Staff 53, Chief of the Department of Radiology, he validated he was informed by the radiology technician that he had administered the IV contrast to Patient 8 on 4/17/18 in error. He stated he informed the ED MD immediately and also requested that Staff 19 complete a patient safety form regarding the error. When asked if he had followed up with management in regard to the error reporting he indicated "No.. There was no direct supervision of the CT Technologist during the administration of the IV contrast to Patient 8. There was no departmental investigation regarding the aforementioned incident in an attempt to identify potential factors that could have contributed to the error or potential solutions to help prevent the reoccurrence of future errors.

5. On 4/26/2018 the radiology policy titled "IV Contrast Agents Administration" dated 10/28/2017 was reviewed. The policy indicates that:
- "IV contrast media may be administered by a CT Technologist. Informed consent must be obtained prior to the injection of contrast agents.

- Responsibility: "The license hospital radiology technologist is responsible for fulfilling the duties of administering IV contrast. The Chief and or Assistant Radiology will oversee the technologist to ensure compliance".

- Procedure: "All technologist shall be responsible for verifying physician orders in the patient's medical record or on the prescription with the printed requisition; Identify patient using 2 identifiers; Verify any allergies to medications, seafood or contrast media; Check the medical record or ask the patient about any history regarding "Renal Disease/Insufficiency"".

The cumulative effect of the aforementioned gaps in practice and the lack of following established facility procedures resulted in the failure of the hospital to provide services ensuring safety in accordance with the regulatory requirements related to the condition of Radiological Services.

Based on interview and record review the hospital failed to assure the agreement of an outside blood collecting establishment contained verbiage that would facilitate compliance with Centers for Medicare and Medicaid (CMS) regulations. Failure to ensure the timely notification requirements are met may potentially promote the transmission of a possible blood borne pathogen.

Findings include:

On April 23, 2018 all the sections of the laboratory services were inspected in the presence of the Staff 25. Later that same day multiple policies were also reviewed. During further investigation on April 24, 2018 Staff 25 was questioned further regarding the outside blood collecting establishment notification requirements. On April 25, 2018 during a concurrent interview and record review with Staff 25 she acknowledged that the outside blood collecting establishment agreement did contain verbiage that the parties to the agreement would comply with applicable laws and industry standards.... of the Food and Drug Administration, the American Red Cross, JCAHO (The Joint Commission), ETC. Staff 25 acknowledged the aforementioned agreement did not contain specific verbiage to ensuring compliance with the CMS regulatory notification requirements associated with blood and/or blood components collected from infectious donors with human immunodeficiency virus and/or hepatitis C virus infections.

Based on observation, interview and record review the hospital failed to ensure it must be constructed, arranged and maintained to ensure the safety of the patients, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community.

Findings include:

1. The hospital failed to maintain the physical plant and overall hospital environment to ensure the safety of patients, staff and visitors (A0701).

2. The hospital failed to ensure that equipment located in the kitchen are were maintained in a manner that would provide an acceptable level of safety well-being for patients, staff and visitors (A0724).

3. The hospital failed to ensure the Life Safety Code (LSC) requirements were met (A0710). Refer to the LSC finding dated April 27, 2018.

The cumulative effect of these systemic practices resulted in the failure of the hospital to provide care and services in accordance with the regulatory requirements related to the condition of Physical Environment.

Based on observation and staff interview, the facility had failed to ensure the second floor east and west side exterior exits were safe for use. The exits had balcony/walkways that extended along the wall about 40 feet on the east side and 30 feet on the west side of the building with each connected to a stair leading to the ground. On both the east and west side, the balcony handrailing was rusted through at the base, the concrete floor was missing pieces, and the steel support beams had severe rust deterioration. As a result, this created an Immediate Jeopardy situation that could result in personal injury if these hand railings were utilized and failed resulting in a one-story fall. This would affect anyone who used the stairways. The facility administration was notified of the Immediate Jeopardy on 04/24/2018 at 5:00 PM. The Immediate Jeopardy was removed 04/27/2018 at 12:00 PM.

Findings include:

On 04/23/2018 at 4:30 PM, two Fire Life Safety surveyors and the health survey team toured the exterior of the hospital. Observations during the tour revealed concerns with the weathering of the exterior of the hospital. On 04/24/2018 at 8:30 AM the survey team along with the Facility Maintenance Manager toured the areas identified by the Fire Life Safety surveyors.

Observations of the west side of the building second floor balcony revealed a walkway leading from an emergency exit to a stairwell to the ground floor. The balcony had visible deterioration in the cement coating, handrails, and steel beam structure coming out of the building, which supported the walkway. There were two, two-inch square tube sections welded to the building support and welded to the handrail to support the original handrail. During an interview on 04/24/2018 at 8:30 AM, the facility Maintenance Director (also a civil engineer) confirmed the welds appeared to be cold welds, which would fail if stressed. The handrails had rusted to a degree that they broke away from the concrete base. There were three doors that exited onto the balcony from the Labor and Delivery unit that would rely upon the corroded handrail.

Observations of the east side of the building's second-floor balcony revealed a walkway leading from the laboratory department exit to a stairwell leading to the ground floor. The balcony had visible deterioration in the cement coating with an 8-inch by 24-inch hole where the balcony connects to the stairwell. Rebar was visible inside the hole where the concrete had broken away. Along the edge of the walkway on the railing side, were 3-inch by 48-inch sections broken away. The metal handrail posts that were connected to the concrete walkway had severe rusting with one that was separated from the base. The structural steel beams beneath the walkway were rusting and pieces of rusted steel were found on the ground beneath them. The door that leads to the walkway was an exit from the laboratory.

During an interview on 04/24/2018 at 8:30 AM, the Facility Maintenance Manager stated he/she was aware of the walkway deterioration on the west side but not the one on the east side. He/she stated there was only one contractor interested in "mid 2017" in fixing the west side but they wanted "$75000.00 before they would do the work." The repair order was submitted at a level less than 5, (Note: level 5 was the designation given for highest priority of maintenance and/or repair) and there was no urgency to repair it, so nothing further was done. When asked when the last time the exit had been used, the Facility Maintenance Manager stated that he/she did not know, but thought it had been several years. However, he/she stated that housekeeping staff access from the outside to clean the stairs and walkway. The east and west walkways were designated for emergency use. The Facility Maintenance Manager was asked if he thought the balcony was a danger and stated that he/she felt both the east and west were dangerous.

During an interview on 04/24/2018 at 4:45 PM, the Environmental Chairperson was questioned about the "Environmental Risk Assessment." He/she indicated the west side had been identified in 2017, but it had not been put on the list for capital improvement so there was no plan to repair it. The east side balcony problem had not been identified until noted by the Fire Life Safety surveyors. There was no current plan for its repair.

The facility administration was notified of the Immediate Jeopardy on 04/24/2018 at 5:00 PM.

The Immediate Jeopardy was removed 04/27/2018 at 12:00 PM. The exits to both balconies were closed, emergency routes were changed to bypass the east and west balcony exits, and staff in-services were started in the laboratory, and in Labor and Delivery. Two surveyors toured the areas and confirmed the facility met the Immediate Jeopardy removal plan.

Based on observation, interview and record review the hospital failed to ensure compliance with all the Life Safety Code regulatory requirements.

Findings include:

The hospital failed to ensure the Life Safety Code (LSC) requirements were met; refer to K-200 in the LSC survey dated April 27, 2018.

Based on observation, interview, and review of facility documentation, it was determined the facility failed to ensure eight pieces of equipment located in the kitchen area of the hospital were maintained in a manner that provided an acceptable level of safety and well-being of patients, staff, and visitors. This failure has the potential to affect all patients, staff, and visitors of the hospital.

Findings include:

1. An observation of the kitchen area of the hospital was conducted on 04/21/2018 at 10:20 AM during the initial tour of the hospital. The following pieces of equipment were identified as inoperable:

a. One dish machine was out of order and not being utilized to wash dishes;

b. The main freezer door had ice around the outside of the door and its framing, which prevented the door from completely shutting and sealing;

c. One convection oven had signage posted that indicated the equipment was out of order;

d. One double steamer had signage posted that indicated the equipment was out of order;

e. One two-door chiller had signage posted that indicated the equipment was out of order;

f. One portable warmer used for maintaining temperatures of food had signage posted that indicated the equipment was out of order;

g. One tilting skillet used for cooking had signage posted that indicated the equipment was out of order; and

h. One grill used for cooking had signage posted that indicated the equipment was out of order.

A review of undated facility documentation titled, "Dietary Services Department Inoperable Equipment," listed the eight items identified during the initial tour of the hospital's kitchen. According to the list in the document, the dish machine had been inoperable since 06/13/2016 and the double steamer used for steaming food had been inoperable since 11/08/2017.

During an interview on 04/24/2018 at 8:45 AM, the Dietary Supervisor (DS) 34 stated the inoperable equipment in the kitchen area had been reported to the administration of the hospital. However, repairs to the equipment had been delayed by a lack of funding, or the hospital was waiting on replacement parts to arrive. In addition, DS34 stated the hospital was still receiving bids from vendors for some of the equipment to either be repaired or replaced. DS34 further confirmed the dish machine had not been in operation since 06/13/2016 and the double steamer had been inoperable since 11/08/2017.

Based on record review and interview, the hospital did not have discharge planning that applied to all patients including identification at an early stage of hospitalization all patients who were likely to suffer adverse health consequences upon discharge if there was no adequate discharge planning (A800); did not provide discharge planning evaluation to patients that included an evaluation of the likelihood of a patient requiring post-discharge services, the availability of services, capacity for self-care, or the possibility of the patient being cared for in an environment from which the patient was admitted to the hospital (A806); did not ensure that a registered nurse, a social worker or other appropriately qualified personnel supervised the development of the discharge planning evaluation (A807); including the discharge planning evaluation in the patient's medical record for use in establishing an appropriate discharge plan (A812); did not arrange for the initial implementation of the patient's discharge plan (A820); and did not reassess its discharge planning process on an on-going basis that included a review of discharge plans to ensure that they were responsive to patient's discharge needs (A843). The cumulative effect of the non-compliance resulted in the failure of the hospital to provide statutorily mandated care and services in accordance with regulatory requirements under Discharge Planning.

Based on record review and interview, the hospital did not identify at an early stage of hospitalization all patients who were likely to suffer adverse health consequences upon discharge if there was no adequate discharge planning.

Finding includes:

The hospital's policy and procedure on Electronic Based Documentation Guidelines (revised 5/2015) outlined the purpose of the initial discharge assessment as an instrument by which the interdisciplinary care team identifies and obtains data on each patient, thus enabling the patient to develop a plan of care that meets the full range of the patient's healthcare needs."

Review of medical records revealed that while an initial discharge assessment was being completed upon admission by a registered nurse, there was no indication that the result of the assessment was used to identify discharge planning needs or other needs that could potentially result in adverse health consequences to the patient upon discharged if not identified.

Further, while the hospital's policy and procedure on Patient Discharge Planning Implementation on Acute Care Wards (6431-4B) noted that "Established indicators will be used to determine priority patients," there was no indication that this was being implemented or followed. Review of inpatient medical records, for example, did not identify indicators used or any applicable criteria to help identify patients who may need discharge planning.

During an interview on 4/26/18, social workers (Staff 1, 4, and 15) stated that the hospital's discharge planning policy and procedure did not outline specific criteria to help identify patients who may need discharge planning. A social service staff member (Staff 4) stated during the interview that the hospital's discharge planning policy and procedure was being revised to include criteria that could help identify vulnerable patients. (Reference Patients 3, 4, and 5)

Cross-refer to A806.

Based on record review and interview, the hospital did not provide a discharge planning evaluation to patients that included an evaluation of the likelihood of a patient needing post-discharge services; the availability of services; and capacity for self-care; or of the possibility of the patient being cared for in an environment from which the patient was admitted to the hospital.

Finding includes:

The hospital's policy and procedure (P&P) on Electronic Based Documentation Guidelines (revised 5/2015) outlined the purpose of the initial discharge assessment as an instrument by which the interdisciplinary care team identifies and obtains data on each patient, thus enabling the team to develop a plan of care that meets the full range of the patient's healthcare needs."

The P&P further noted that all patients, families, and significant others, as well as respective members of the interdisciplinary "shall participate in the admission/discharge planning/reassessment process" through a screening which shall be conducted by a registered nurse within 24 hours of admission "using criteria to determine risk of patients that would prompt a more in-depth assessment." Accordingly, the screen would include nutritional, functional, possible victims of abuse, discharge planning, risk of fall and skin assessment.

Further review of the hospital's policy and procedure (P&P) for Patient Discharge Planning Implementation on Acute Care Wards (64-31-B) indicated that the initial discharge planning assessment was to be conducted by a registered nurse within 24 hours of admission or as the medical condition or status of the patient changes. The same P&P noted that Nursing will the identify appropriate patient candidates to be presented at a care planning conference.

Review of inpatient medical records however, revealed that while an initial discharge assessment was being conducted by a registered nurse upon assessment, there was no indication that the results of the "assessment," which entailed completion of several data fields including patient contact information; cognitive status; functional status and activities of daily living; and whether the patient needed referral to other hospital services, were being used to conduct a "more-in depth assessment of the patient . In addition, there was no documentation that information following the screening or initial discharge assessment was being used to identify or determine which patients needed discharge planing.

For example:

1. Patient 3 was admitted to the hospital on 4/11/18 with several diagnoses including diabetes mellitus and a right diabetic foot infection. Review of the medical record revealed that the patient resided off-island where the infection was acquired and was admitted to the hospital for care and treatment, and because she had children on-island with whom she can stay with and could care for her. According to medical record, Patient 3 had been brought to the operating room on 4/13/18 for debridement of the wound requiring dressing changes; was placed on wound contact precautions, and was receiving intravenous antibiotics.

Further review of the medical record revealed that while the initial discharge assessment was completed by a registered nurse on 4/11/18, there was no indication that a follow-up evaluation of the patient was conducted to identify potential discharge needs early on during admission as well as emerging needs the patient may have during the inpatient stay. During an interview on 4/24/18, a licensed staff (Staff 16) stated that care conferences on the unit are conducted every Thursday by the discharge planning team. Staff 16 added that while direct care licensed staff are not involved in discharge planning, the RN charge nurse on duty as well as the social worker on the unit are responsible for documentation of items discussed during the care conference.

Review of Patient 3's medical record revealed the lack of documentation of any Thursday care conference meetings held or any discharge planning discussion.

During an interview on 4/24/16 at 11:40 a.m., Patient 3 stated that she was not aware of any discharge planning meeting or discussion with a licensed staff or social worker on the unit. The patient added that she had been in the hospital for about two weeks and was concerned about a lot of things which kept her awake at night, including financial and hospitalization costs, her desire to go home and return to her off-island residence, self-monitoring of blood glucose, the adverse effects of antibiotics on her kidney function, and wound care at home.

Patient 3 also stated that she was told earlier in the morning by her physician that she was going home and that she needs to have someone who could help her with wound care as it would be difficult to do on her own. The patient stated that she preferred her daughter-in-law since she had changed the dressing on her left foot wound when she lost a pinky in 2015; and because her husband and son would not do it. The only problem, according to the patient, was that her daughter-in-law worked during the weekday and was therefore unavailable.

During a separate interview on 4/24/18, Staff 16 was asked if social services had met with Patient 1 about her concerns. Staff 16 responded that a referral to the social worker needed a physician's order, hence the patient's concerns were not evaluated.

Further record review revealed at On 4/17/18, a physical therapy note documenting discharge from physical therapy noted that while Patient 3 was independent in bed mobility and transfers, the patient "needs (wheelchair) if possible with elevated leg rests." The note added that "Social worker consult (was) recommended to obtain (wheelchair)."

There was no indication that a social service referral was made in the medical record.

Patient 3 was discharged on 4/26/18 at 4:40 p.m. A nursing discharge note at 4:25 p.m. revealed that the patient's understanding of dressing change to the right foot was evaluated, and that the patient "was able to explain to (the registered nurse) on how to perform the dressing change on the right foot." There was no mention however, whether a caregiver was identified to assist the patient with wound care, or that attempts were made to involve the daughter-in-law who was preferred by the patient because of her experience.

Further review of the medical record revealed that on 4/26/18, a physician's progress note was made that the "SW (social worker) was not consulted as the patient is uninsured and wound care supplies or home health would then not be covered." While the note added that "Patient registration provides all patients with forms to apply for medical assistance," there was no indication that the patient was informed about the application process and whether she needed assistance. The same note added that the patient and "family are now trained in wound care, (and that) patient (was) given work excuse note and follow up arranged with endocrinology, podiatry, and nephrology."

2. Patient 5 was admitted to the hospital on 4/07/18 with several diagnoses including repair of a left hip intertrochanteric fracture, and a history of alcohol use.

An initial discharge assessment conducted on 4/07/18 revealed that Patient 5 was admitted to the ward from the emergency department, that his alcohol usage was about 6 cans per day, and that he required extensive assistance with activities of daily living. The assessment further noted that the availability of help care and a supportive home environment for the patient upon leaving the hospital was "unknown," and that the patient had "some" medical needs because of chronic alcohol abuse, marijuana use, and because the patient was a chronic tobacco smoker.

Review of the medical record revealed the lack of indication that the initial assessment was used to determine whether Patient 5 needed discharge planning and evaluation, or that the need for an in-depth assessment was considered or conducted to identify potential discharge needs.

There was no indication that concerns identified during the initial discharge assessment were referred to the appropriate disciplines including nursing and social services.

Further, while the patient had been in the hospital for two Thursdays (two weeks), there was no documentation either from nursing or social services about any care conference held indicating ongoing assessment to identify other potential discharge needs so that these could be addressed at an early stage of the hospitalization.

During an interview on 4/24/18 at about 11:00 a.m., Patient 5 stated that he might go home the following day (on 4/25/18) and that he might be transferred to a skilled nursing facility. The patient added that he lived alone and did not have a permanent place to stay. Patient 5 also stated that his primary concern was being able to walk because he "liked walking" prior to his hospitalization.

Review of the medical record revealed that a social service referral was not made until 4/24/18 at 3:21 p.m. A progress note which was the first indication of social service engagement revealed the lack of social service participation in the discharge planning including placement, the need for further rehabilitation, timely renewal of public assistance benefits which had lapsed and was just being renewed, and other concerns identified during the initial discharge screening.

The medical record revealed that the patient was discharged on 4/25/18.

3. Patient 4 was admitted to the hospital on 4/16/18 with a diagnosis of ruptured appendix. An initial assessment dated 4/17/18 was completed following the resident's admission to the unit from the recovery room. The assessment noted that the patient was independent in activities of daily living, had her mother as the primary contact and support person, and that referral to other services was needed for health education as well as for "diabetic services/dietitian."

Review of the medical record revealed the lack of indication that the referrals were made to the appropriate services. In addition, there was no documentation that an evaluation of the patient's need for discharge planning was conducted and determined based on the initial assessment or screening. There also was no evidence that a care conference was conducted as there was no documentation that one was convened.

During an interview on 4/25/18, Patient 4 stated that he had a ruptured appendix that was repaired and that he could not take anything orally for a while but was receiving a special intravenous solution (total parenteral nutrition) to sustain him. The patient stated that he still had a drain to help remove fluid from his wound, but he was taking liquids well and had no post-operative pain. According to the patient's mother, the attending surgeon had told them that Patient 4 might be discharged when he continues to take food well orally.

In the same interview, Patient 4 and his mother stated that there had not been any conversation about discharge planning with either the nursing staff or the social worker, or any discussion about what they would need or prepare for after leaving the hospital, including wound care.

Based on record review and interview, the hospital did not ensure that a registered nurse, a social worker or other appropriately qualified personnel developed and supervised the development of the discharge planning evaluation.

Finding includes:

While the hospital's policy and procedure on Patient Discharge Planning Implementation on Acute Care Wards (6431-4B) identified several members of the care planning team which included the charge nurse or designee of the unit (co-chairperson), the social worker (chairperson), the attending physician, the utilization review coordinator, dietitian, and several others, it did not however, specify an individual responsible for the development of the evaluation.

Consequently, the result of the initial screening assessment was not always used to identify a patient's need for discharge planning.

Further, the hospital's policy and procedure (P&P) on Electronic Based Documentation Guidelines (revised 5/2015) noted that all patients, families, and significant others, as well as respective members of the interdisciplinary "shall participate in the admission/discharge planning/reassessment process" through a screening process which shall be conducted by a registered nurse within 24 hours of admission. The policy added that the screening, which uses criteria to determine risk of patients would prompt a more in-depth assessment."

There was no indication in the inpatient medical records reviewed that information from the initial screening was used to conduct a more in-depth assessment of the patient's discharge planning needs.

Medical record reviews also revealed the lack of documentation of "established indicators" that will be used to determine priority patients in need of discharge planning.

During an interview on 4/25/18, a licensed staff (Staff 37) stated that the unit charge nurse participated in discharge planning conferences when these were held every Thursday. According to Staff 37, the care conference was when discharge planning needs were also identified. When asked if documentation was made about items discussed specific to each patient during a conference, Staff 12 stated that social services staff made notes.

Review of the medical records revealed the lack of documentation when care conferences were held as well as discharge evaluations and planning discussed.

During the initial tour of the surgical unit on 4/23/18, a licensed staff (Staff 54) stated that the average length of stay (LOS) on the unit was about 5 - 7 days. When asked how discharge planning for patients was conducted so that needs were identified early on during the admission and care conference, and addressed before discharged, Staff 54 was unable to respond.

There was no indication based on record review that the development of the evaluation was being supervised to ensure they were conducted, completed, and documented timely; and that needs were identified and addressed to ensure a smooth transition post hospital care for the patient.

During an interview on 4/26/18, a social worker staff member (Staff 4) stated that she was the lead (chair) of the patient care planning conference but that all of the social workers had their own patient case load to manage. (Reference Patients 3, 4, and 5).

Based on record review and interview, the hospital did not include the discharge planning evaluation in the patient's medical record for use in establishing an appropriate discharge plan.

Finding includes:

The hospital's policy and procedure on Electronic Based Documentation Guidelines stated that the initial discharge assessment was an instrument by which the interdisciplinary care team identifies and obtains data on each patient, thus enabling the team to develop a plan of care that meets the full range of the patient's healthcare needs.

The P&P further noted that all patients, families, and significant others, as well as respective members of the interdisciplinary "shall participate in the admission/discharge planning/reassessment process" through a screening which shall be conducted by a registered nurse within 24 hours of admission using criteria to determine risk of patients that would prompt a more in-depth assessment." Accordingly, the screen would include nutritional, functional, possible victims of abuse, discharge planning, risk of fall and skin assessment.

Review of medical records revealed that while the initial discharge assessments were being completed by a registered nurse upon admission, there was no indication that discharge planning evaluations, as well as "in-depth" assessments following the screening conducted by nursing or social service staff, were maintained in the records.

In addition, there was no indication in the medical records that care conferences, where identification of the patients' discharge needs were supposed to be made by the patient care planning team, were being documented.

During an interview on 4/25/18, a licensed staff (Staff 37) stated that the unit charge nurse participated in discharge planning conferences when these were held every Thursday. When asked if documentation was made about items discussed specific to each patient during a conference, Staff 37 stated that social services staff made notes of what was discussed.

In a separate interview on 4/26/18, several social services staff members (Staff 1, 4, and 15) stated that discharge planning care conferences were being documented. None however, was presented during the survey, for review. (Reference Patients 3, 4 and 5)

Based on interview and record review, the hospital failed to implement a discharge plan for 9 of 28 sample patients (patients: 30, 29, 13, 14, 16, 18, 3, 5 and 4) who would most likely need post-hospital services after discharge. Failure to initiate a discharge plan may contribute to not identifying or timely meeting the physical and or psychosocial health care needs of the patient and/or family thereby leading to a potential readmission after discharge.

Findings include:

1. On 4/25/18 during a concurrent medical record review and interview with Staff 11 it was revealed that sample Patient 30 was born at the hospital on 4/19/18. Some of his identified problems included: being born premature, multiple congenital abnormalities; and cyst on the right kidney. During an interview with Staff 11 it was revealed that the parents lived off-island, that they are young, that there were four other young siblings at home, that the other siblings may have congenital problems as well, and that an initial discharge screening for this patient was completed by nursing. Further investigation revealed the discharge plan was not located within the paper medical records nor was there a discharge plan within the electronic medical records. During an interview with Staff 4 on 4/26/18, all the aforementioned was validated and it was acknowledged that a discharge plan did not exist. On 4/27/18, (six days after being admitted), Staff 4 provided a discharge plan for Patient 30.

2. On 4/25/17, during a concurrent medical record review and interview with Staff 11, it was revealed that sample Patient 29 was born at the hospital on 11/02/17. Some of his identified diagnoses included being born premature, congenital hydrocephalus, facial nerve paralysis, and shunt placement to address the hydrocephalus. During the interview with Staff 11 it was revealed that the parents lived off-island, that they young, that there were other young siblings at home, and that an initial discharge screening for this patient was completed by nursing. Further investigation revealed the discharge plan was not located within the paper medical records nor was there a discharge plan within the electronic medical records. During an interview with Staff 4 on 4/26/18, all the aforementioned was validated and it was acknowledged that a discharge plan did not exist. On 4/27/18, Staff 4 provided a discharge plan for Patient 29.

3. Patient 13 was admitted to the hospital on 4/01/18 with diagnoses of diabetes mellitus, end stage renal disease (ESRD), and gangrene of the fourth metatarsal (toe) of the left foot.

Medical record review found an "Initial Discharge Assessment" was completed 4/01/18 at 19:37 (7:37 p.m.) and documented the patient had no discharge needs. During the course of this hospitalization the gangrene progressed and the patient had to have a left below the knee amputation (LBKA) on 4/18/18. No assessment for discharge needs was completed after the amputation occurred. The patient interview identified multiple discharge needs.

During an interview on 4/25/18 at 10:00 a.m., Patient 13 stated his concerns as follows:

a. He lived on the second floor of an apartment complex and had fifteen steps to climb;

b. He had not received a wheelchair that was ordered by the physician;

c. He felt he could no longer drive, and the amount of assistance he would need to get to the dialysis unit three days a week; and

d. He was being discharged on 4/25/18 and felt these issues were not resolved.

Review of the medical record showed there was no documentation of a discharge plan for the patient to have a smooth transition to home.

During an interview with three social workers on 4/26/18 at 11:00 a.m., the patient was discussed; however, no plan was developed that identified the patient's needs to achieve a successful discharge. There was no plan for resolving any of the patient's discharge needs.

4. Patient 14 was admitted to the facility on 3/05/17 with diagnoses of diabetes mellitus, ESRD, blindness, right above the knee amputation, and confusion due to dementia.

Review of Patient 14's medical record on 4/24/18 revealed that the patient had been in the hospital for 417 days and no plan had been developed for the patient's discharge. Documentation by the social worker on 2/15/18 and 3/14/18 indicated that the patient's situation was discussed with a son, but no plan was developed.

During an interview with three social workers 4/26/18 at 11:00 a.m., the patient was discussed; however, no plan was developed that identified the patient's needs to achieve a successful discharge. There was no plan for resolving any of the patient's discharge needs.

5. Patient 16 was admitted to the hospital on 4/19/18 with diagnoses of fluid overload, metabolic acidosis, and anemia.

Observation on 4/23/18 at 10:00 a.m. revealed the door to the patient's room had a sign on it for airborne isolation. The patient had a potential for tuberculosis infection.

Review of Patient 16's medical record revealed an "Initial Discharge Assessment," dated 4/20/18, which read: "Patient Concerns at admission: Transportation, support system, discharge options, other (need social worker)." The medical record did not contain a discharge plan.

During an interview with three social workers on 4/26/18 at 11:00 a.m., the patient was discussed; however, no plan was developed that identified the patient's needs to achieve a successful discharge. There was no plan for resolving any of the patient's discharge needs.

6. Patient 18 was admitted to the hospital 12/25/17 with a diagnosis of hemorrhagic cerebrovascular accident (stroke).

Review of the patient's medical record revealed an "Initial Discharge Assessment" dated 12/25/17. However, the document did not identify the patient's discharge needs. A review of the patient's care plan dated 3/31/18 revealed, "The patient had needs for "Financial Assistance/ Discharge Planning." The intervention was to "Continue home placement discussion with son."

The medical record revealed that Patient 18 had a Stage Four pressure ulcer on his coccyx (lower back) with multiple drug resistant organisms (MDRO) cultured from the wound bed. The patient had been in the hospital for 121 days at the time of the survey. The medical record did not include a discharge plan.

During an interview with three social workers on 4/26/18 at 11:00 a.m., the patient was discussed; however, no plan was developed that identified the patient's needs to achieve a successful discharge. There was no plan for resolving any of the patient's discharge needs.



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7. Patient 3 was admitted to the hospital on 4/11/18 with several diagnoses including diabetes mellitus and a right diabetic foot infection which required daily dressing changes. Review of the medical record revealed that while the initial discharge assessment was completed by a registered nurse on 4/11/18, there was no indication that a discharge plan was was initiated based on the results of the assessment.

In an interview on 4/24/16 at 11:40 a.m., Patient 3 stated that she was not aware of any meeting or discussion with a licensed staff or social worker on the unit about discharge planning. The patient added that she was concerned about a lot of things which kept her awake at night, including financial and hospitalization costs, her desire to go home and return to her off-island residence, self-monitoring of blood glucose, the adverse effects of antibiotics on her kidney function, and managing wound care when she's discharged home.

During the interview, Patient 3 stated that she informed earlier in the morning by her physician that she was going home and that she needs to have someone who could help her with wound care as it would be difficult to do on her own. The patient stated that she preferred her daughter-in-law since she had changed the dressing on her left foot wound when she lost a pinky in 2015; and because her husband and son would not do it. The only problem, according to the patient, was that her daughter-in-law worked during the weekday and was therefore unavailable.

Review of the medical record revealed that the concerns raised by Patient 3 were not addressed or care planned, or referred to appropriate hospital services.

During a separate interview on 4/24/18, a licensed staff (Staff 16) was asked if social services had met with Patient 1 about her concerns. Staff 10 responded that a referral to the social worker needed a physician's order, hence the patient's concerns were not evaluated.

8. Patient 5 was admitted to the hospital on 4/07/18 with several diagnoses including repair of a left hip intertrochanteric fracture, and a history of alcohol use.

An initial discharge assessment conducted on 4/07/18 revealed that Patient 5 was admitted to the unit following repair of the fracture, that he used alcohol to about 6 cans per day, and that he required extensive assistance with activities of daily living. The assessment further noted that the availability of help care and a supportive home environment for the patient upon leaving the hospital was "unknown," and that the patient had medical needs because of chronic alcohol abuse, marijuana use, and because the patient was a chronic tobacco smoker.

Review of the medical record revealed the lack of indication that the initial assessment was used to determine whether Patient 5 needed discharge planning and evaluation, or that the need for an in-depth assessment was considered or conducted to identify potential discharge needs. In addition, there was no indication that concerns identified during the initial discharge assessment were referred to the appropriate disciplines including nursing and social services.

Further record review revealed the lack of indication that the initial and in-depth assessment were used to develop an initial discharge plan to ensure that concerns identified, which could potentially affect post-hospital care transition, were addressed.

9. Patient 4 was admitted to the hospital on 4/16/18 with a diagnosis of ruptured appendix. An initial assessment dated 4/17/18 was completed following the resident's admission to the unit from the recovery room. The assessment noted that the patient was independent in activities of daily living, had her mother as the primary contact and support person, and that referral to other services was needed for health education as well as for "diabetic services/dietitian."

Review of the medical record revealed the lack of indication that a care plan was developed and implemented to ensure that the referrals were made to the appropriate services and addressed.

During an interview on 4/25/18, Patient 4 stated that he had a ruptured appendix that was repaired and that he could not take anything orally for a while. According to the mother, however, the patient was now taking liquids well and had no post-operative pain and might be discharged.

In the same interview, Patient 4 and his mother stated that there had not been any conversation about discharge planning with either the nursing staff or the social worker; or any discussion about what they would need or prepare for including wound care when Patient 4 leaves the hospital.

Based on record review or interview, the hospital did not reassess its discharge planning process on an on-going basis that included a review of discharge plans to ensure that they were responsive to patient's discharge needs.

Finding includes:

In an interview on 4/26/18, social service staff members (including Staff 1, 4 and 15) stated that the discharge planning committee did not collect information such as key indicators to measure the effectiveness of the hospital's discharge planning process. Staff 4 stated that the hospital's QAPI department (quality assessment and performance improvement) did the gathering of information for discharge planning. When asked what quality indicators were being collected by QAPI on behalf of discharge planning, the staff members were unable to respond,

During the survey, medical record reviews revealed the lack of evidence that while patient screening was being conducted, the results however, were not being used to identify patients who could benefit from discharge planning; were not being used to determine whether a more in-depth discharge planning assessment was needed; and that identified needs were evaluated, care planned, and addressed.

In addition, there was no indication that the effectiveness of the hospital discharge planning was being measured in terms of completeness of documentation, for example, ensuring that the process involved the patient and family members, that referrals to appropriate services were timely, and whether the process was effective in meeting the patients' discharge needs to ensure a smooth transition after the hospital admission.

In the same interview, none of the social staff members present were aware of the hospital's readmission rates.

Based on interview and facility record review, the hospital failed to ensure that anesthesia services was integrated to the hospital wide Quality Assessment and Performance Improvement (QAPI) program. Failing to have meaningful analysis and trending of data collected by the department may result in a failure to identify opportunities to improve outcomes of care and/or services provided by the department.

Findings include:

During a concurrent interview and record review on 4/26/2018 at 1:15 p.m., with Staff 47 he provided the data that was being submitted to the QAPI department regarding daily anesthesia cases. The anesthesia department does not have any evidence of a quality project for patient safety and performance improvements. Staff 47 validated the data being submitted by anesthesia is not being monitored for patterns, analyzed and /or trended for opportunities to improve care and/or services provided by the department. When asked if the other members of anesthesia services were involved in the quality improvement initiatives he stated "NO".

During an interview on 04/27/2018 at 8:30 AM, Staff 23 validated the information that is received from the anesthesia department is not being analyzed, when received it is filled monthly in a binder. She confirmed that there were no current projects being implement at this time within the anesthesia department and QAPI has no analytic data available.

On 4/27/2018 the Professional Service Agreement for the CRNAs was reviewed and in the section addressing Service Obligation it indicates:
- "CRNA will be responsible for administrative duties but not limited to, active participation in Quality Improvement, in Medical Staff Committees, in the establishment and implementation of procedures and policies to preserve and enhance the consistency and quality of all services provided".

- "CRNA shall assist, as requested by the GMHA, in the establishment and implementation of quality assurance and utilization review protocols, programs and procedures as necessary or appropriate to facilitate and enhance the GMHA's participation in managed care programs".

On 4/27/2018 reviewed the Medical Staff - Article 2- Purpose and Responsibility it disclosed:
- "Review and evaluation of the quality of patient care through valid and reliable quality improvement programs".

- "Account to the Board for the quality, efficiency, and safety of patient care rendered to patients in the hospital through regular reports and recommendations concerning the implementation, operation and result of quality improvement activities".