HospitalInspections.org

Based on observation and interview the hospital failed to provide care in a safe setting. This deficiency is evidenced by the failure of the visible call bells to work simultaneously on the bed guardrails and the handheld remote.

Direct observation on 02/21/2022 at 8:34 a.m. while touring the facility it was revealed that the call bell on the bed and the remote cannot work at the same time. It was explained there is only one plug for the call bell. If the bed is plugged, only the call bell on the guard rails work. If the remote is plugged , the remote call bell works but the call bell on the bed does not.

In interview on 02/21/2022 at 8:35 a.m. S4CNO verified there were always call bells visible to the patient and their family that did not work depending on what was plugged in.

Based on record review and interview the hospital failed to accurately report quality indicators for the year of 2021. This deficiency is evidenced by inaccurate and incomplete information for: 1) return to OR in 24 hours; 2) transferred patients; and 3) readmissions.
Findings:

1) Return to the OR
Review of the list provided to the surveyor, Return to the OR in 24 hours, revealed patients were returned to the OR on 03/23/2021, 05/ 21/2021, 07/07/2021, 07/09/2021, 11/16/2021, and 12/29/2021.

Review of the summary of Quality Indicators 2021 under return to surgery within 24 hours revealed all months were filled in with 0%.

2) Transferred patients
Review of the list of transferred patients provided to the surveyor revealed patient transfers were reported on 03/15/2021, 05/21/2021, 10/28/2021, 10/09/2021, 11/22/2021, 12/06/2021, 12/07/2021, and 12/15/2021.

Review of the summary of Quality Indicators 2021 under transfers revealed all months were filled out with 0%.

Review of the summary of Quality Indicators 2021 under transfer to higher LOC revealed one in March, one in May, one in October and one in December. All other values were 0.

3) Readmissions
Review of the list of readmits in the last 12 months revealed patients were readmitted on 03/11/2021, 03/15/2021, 03/25/2021, 04/07/2021, 04/14/2021, 05/03/2021, 06/14/2021, 06/28/2021, 06/30/2021, 07/01/2021, 07/19/2021, 08/02/2021, 08/04/2021, and 10/28/2021.

Review of the summary of Quality Indicators 2021 under readmitted in 72 hours revealed one in May and one in October. All other values were 0.

Review of the summary of Quality Indicators 2021 under readmitted within 30 days revealed three in March, five in April, four in June, four in July, three in August, and one in September. There are no values for October, November, or December.

In interview on 02/22/2022 at 2:55 p.m. S4CNO and S5DQ verified the information in the year summary, Quality Indicators 2021, was inaccurate and incomplete.

Based on record review and interview the facility failed to periodically conduct appraisals of the medical staff. This deficiency is evidenced by evaluations greater than 24 months old in two (S7MD, S8MD) of four (S7MD, S8MD, S9MD, S10MD) members of the medical staff reviewed.
Findings:

Review of the AVALA Practitioner Quality Data Profile for S7MD revealed an evaluation date of 05/2017 through 05/2019.

Review of the AVALA Practitioner Quality Data Profile for S8MD revealed and evaluation date of 10/ 2017 through 10/ 2019.

In interview on 02/22/2022 at 1:50 p.m. S5DQ verified these were the most recent appraisals and the appraisals were supposed to be done every two years with reappointment.