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Based on interview and record review the hospital failed to ensure the all departments understood the hospitals expectation related to their Quality Assessment Performance Improvement (QAPI) projects and/or that the department was allotted adequate human resources to ensure their QAPI task were complete. Failures to a lot adequate resources for the completion of expected task can lead to a failures to complete the task.

Findings include:

1. During an interview with all the Discharge Planning staff on 02/06/2019 it was validated that since the last survey (which ended on 04/27/2018) no data had been collected to improve outcomes of care associated with the discharge planning process. The Discharge Planning team acknowledged that a single team member had not been delegated and allotted the time to complete the specific task associated with QAPI.

2. The hospital failed to ensure that anesthesia services was meaningfully integrated into the hospital wide quality assessment and performance improvement program (cross refer A1000). During interview with anesthesia Staff 12 and Staff 13 it was acknowledged that generally the Anesthesia Department staff are typically tasked to provide direct anesthesia services 100% of the time. Quality initiatives and revision of policies was not an ancillary duty assigned to any one department staff individual to complete.

Based on record review and interview, the medical staff was not organized and accountable to the governing body for the quality of medical care provided to the patients.

Finding includes:

Review of the hospital's medical staff bylaws (revised 12/27/18) revealed that the acute hemodialysis unit was under the purview of the Special Care Committee (SCC), one of 13 committees of the medical staff. The SCC, accordingly, had several responsibilities including the development and recommendations of policies and procedures relative to the care of patients in the special care units including hemodialysis; and recommending methods of training physicians, nurses, and ancillary personnel on the specialized care of patients.

Further record review and interview revealed that the SCC did not delegate or identify a physician (or physicians) responsible for organizing and coordinating all activities and aspects of the provision patient care unit-wide, including providing medical consultation and services as needed; establishing and ensuring that policies and procedures were correctly implemented; conducting annual reviews of policies and procedures; teaching and supervising nurses and technical personnel on the unit to ensure that the use of biomedical equipment, including hemodialysis machines was safe and effective; collecting and analyzing clinical data required for evaluating patient care; and participating in quality assessment and performance improvement activities.

In addition, the SCC did not specify a medical staff member responsible for reviewing and signing-off on results of water cultures and water analysis results, for example, to ensure they meet quality and safety standards; as well as providing consultations regarding evaluation of new products such as dialyzers, catheters, and disinfectants.

During separate interviews on the hemodialysis unit on 2/04/19, licensed staff stated that while they were able to contact attending nephrologists for concerns or issues specific to the nephrologist's patients, the staff were unsure as who to notify when concerns or issues involved the unit a a whole, as no one individual has been formally designated.

Further, while the SCC convenes monthly meetings which include the special care units including the ICU/CCU, interventional radiology, infection control, and nephrology, licensed staff on the hemodialysis unit stated that there could be issues that could not wait until the next monthly meeting for resolution or action. On 1/25/19, for example, licensed staff stated that the hospital's water softener had a breakdown affecting their portable hemodialysis machines. The breakdown triggered alarms built into the machines because of the rise in pH conductivity rendering dialysis treatments unsafe. According to staff, telephone calls were made to the hospital's facilities management department and chief financial officer for information and assistance and when dialysis can resume for all scheduled patients.

Review of safety logs including water cultures and water analysis reports further revealed that monthly sign-offs were not always done timely. Water analysis results from October 2018, for example, had not been signed (indicating they had been reviewed). In the same interview on 2/04/19, a licensed staff member (NM1) stated that there had not been any individual assigned to conduct product evaluation for new dialyzers; oversee and conduct training when there is a new dialysis machine or new staff; as well as resolve issues regarding availability of dialysis supplies, or develop a back-up plan for emergencies. According to NM1, these were some of the responsibilities of the medical director when the unit had one.

2. Review of the medical staff by-laws also revealed that the composition of the special care committee would include the medical director of the hemodialysis unit.

Record review and staff interview revealed that the hemodialysis unit did not have a medical director. During an interview on 2/06/19, the hospital's medical officer (CMO) stated that the current medical staff bylaws (revised 12/27/18) was being reviewed and revised to change the composition of the special care committee to remove the language pertaining to the inclusion of the hemodialysis medical director as a member of the SCC.

Based on interview and electronic record review the hospital failed to ensure that the Anesthesia Services Department had current and/ or existing policies and procedures. Failing to have current policies and procedures may lead to provider practices that are not consistent with the expectations of the hospital.

Findings include:

On 02/05/2019 during additional interview and policy review with Certified Registered Nurse Anesthetist (CRNA) Staff 12 it was revealed that multiple of the Anesthesia Department policies and procedures were still being revised and had not been processed for revision or review as she was not sure if the practices were still being performed at the hospital. During the concurrent interview and electronic policy review she acknowledged there were no Anesthesia Department policies or procedures to address: (a) patient consent, (b) protocol for supportive life functions such as cardiac and respiratory emergencies and (c) reporting requirements. During further inquiry with Staff 12 and her supervisor it was acknowledged that generally the Anesthesia Department staff are typically tasked to provide direct anesthesia services 100% of the time. Quality initiatives and revision of policies is not an ancillary duty assigned to any one department staff individual to complete.