HospitalInspections.org

The Governing Body failed to ensure the quality of services provided to patients.

On 8/15/2011 at 9:10 AM, a hospital tour was conducted with the DON (Director of Nursing). During the tour, the DON stated that the nursing supervisor for day shift worked on the Labor and Delivery Unit on the night shift and she was on her way home.

The Labor and Delivery Unit did not have any inpatients. However, there was one obstetric outpatient waiting for an ultrasound.

During the tour, the DON stated that the Obstetric/Labor and Delivery Unit was intended only to do spontaneous vaginal delivery with minimal or no complications. She also indicated that with no surgeons and anesthesia services to support an emergency cesarean section, the patient will have to be transferred out. When the DON was asked what will happen if the fetus heart rate drops with no return to baseline, the DON indicated that the patient will have to be transferred to the nearest hospital approximately 40 miles away.

On 8/15/2011 at 10:30 AM, an interview with RN charge nurse in the Labor and Delivery was conducted. She informed the surveyor that the nurses feel uncomfortable working in a unit where they can't do anything other than a normal delivery. According to the RN charge nurse, if the fetus heart rate drops down with no return to baseline, they have to prepare the patient for transfer to the nearest hospital and it does not always go well due to changes in the weather. She proceeded to express how she felt as a nurse that have been trained to do more for her obstetrical patients. She completed her statement by saying: "we put people life's at tremendous risk.".

On 8/16/2011 at 8:15 AM, an interview with the hospital Medical Director was conducted. He stated that the hospital has a group of Family Practice physicians that are comfortable doing labor and delivery. However, several doctors had expressed their concern on not doing enough deliveries to keep themselves competent in the skill. The Family Practice physicians had also indicated to the medical director that they would like to rotate to another hospital as part of their obstetrical training but this rotations have not been scheduled.

The Medical Director stated that he understand the inability of the doctors and nurses to do more for the labor and delivery patients specially with the pregnant women in active labor because there is no surgeon or anesthesia service at the hospital. He indicated that Family Practice doctors can't apply forceps or order Pitocin augmentation. The Medical Director stated that they can apply the vacuum if they need to assist with the presentation descend. None of the Family Practice can repair 4th degree vaginal laceration. In cases of 4th degree lacerations, the doctors have to pack it and transfer the patient to the nearest hospital.

The Medical Director stated that for the last six months the census of OB inpatients had been going down and he feels that the patients are not comfortable delivering at this hospital. He also indicated that the board of directors want the Labor and Delivery Unit to stay open, even when they know that is not a safe place to be at this time.

During the interview, the Medical Director also indicated that the Pediatricians are not comfortable with the neonatal resuscitation because they don't have enough experience. They had also requested a rotation to another hospital to keep themselves proficient. He indicated that he is in total agreement with the surveyors' determination in this area and he is willing to do what is necessary to bring good medical practices to the hospital.

The following medical records were reviewed pertaining to labor and delivery:
1. Patient # OB1 had a gestational age of 33 weeks (premature). Record indicated this patient did not have prenatal care. When the patient arrived at the ED, she was in active labor. She delivered and the baby was immediately transferred to the nearest hospital.

2. Patient # OB2 had a gestational age of 40 4/7 weeks (term). Record review indicated that the patient came in to the hospital on 4/4/2011 with contractions. Her cervical examination on admission (2:40 PM) was 1 cm dilatation, 80% effacement and -3 station. Possible rupture of membrane according to the patient was a 2:20 PM on that day. At 2:00 am (4/5/2011), 12 hours after the rupture of membranes, her cervix examination was: 7 cm dilation and 0 stations. The fetal heart rate monitor tracing indicated the presence of variable decelerations (early signs of fetal distress). At 4:10 am, she was 8 cm dilated with isolated late decelerations (placenta insufficiency/fetal distress). The patient had complete cervix dilatation at 6:30 am. She had a temperature of 100.6 F (at 8:00 am). Record indicated that the patient have 18 hours of maternal fever. The doctors attempted to transfer the patient to the nearest hospital but they were unsuccessful.

The patient pushed for 5 hours before delivery by vacuum was done. The hospital records showed how sick this patient was at the time of delivery and the outcome for the new born that was transferred to NICU (Neonatal Intensive Care Unit) with thick meconium aspiration. According to the records, the pediatrician attempted tracheal intubation but they were not successful.

The patient sustained a 4th degree perineal laceration. She was transferred to a hospital in Albuquerque. The family Practice MD does have the skill to repair a 4th degree perineal lacerations.

3. Patient OB3 had a gestational age of 39 weeks. Gravida 1, Para 1. She was admitted to the hospital in active labor on 1/9/2011. Cervical examination was 4-5 cm dilated, 80% effacement and -2 station. The 22 year old patient had a slow progress into labor. She was 25 hours in the first stage of labor. She delivered on 1/10/2011 at 8:40 am. Her baby weight 9 Lb and 5 oz. The patient had several vaginal lacerations. Record showed post partum hemorrhage of 1000 cc. According to medical notes, they attempted to transfer this patient out but it was snowing in Crownpoint.

Based on record reviews and interviews, it was determined that this facility does not have a formal process to inform each patient how to file a grievance with the facility. This failure had the potential to cause each patient mistreatment, mental distress, and/or harm.

An interview with the facility's Compliance Officer and Patient Advocate Officer on 8/16/2011 at 1:45 PM revealed that the patient's grievance process was not included in the facility's Patient's Right Hand Book (both new and old drafts). Also, the Patient Advocate stated, " A poster had been developed but had not printed or posted as yet. "

Based on interviews and record reviews on 8/15/2011 and 8/16/2011, it was determined that the facility did not review, investigate and resolved each patient's grievance within five days in accordance with the facility's policies. The failure had the potential to cause each patient mistreatment, mental distress and/or harm.

The facility's Advocacy Program (Revised 3/3/2011) stated, " K. Submit departmental findings and all supporting documentation within five working days after receipt of the complaint to the Patient Advocate Officer .... "

Review of the facility's grievance file audit conducted by the facility's Grievance Officer revealed that 14 of the 28 complaints received since 1/1/2011 reflected that complaints were not being investigated and/or resolved within 5 days. An interview with the facility's Patient Advocate on 8/16/2011 in the AM stated, "Responses to patient grievances received from the Emergency Room, Laboratory, Outpatient Department and the Medical Director were not being answered promptly."

Based on record reviews and interviews, it was determined that the hospital failed to ensure the competency of staff.

On 8/16/2011 at 10:00 AM a personnel file review was completed for the nursing staff. During the review it was evident that the nursing performance review were not completed for nurses in the inpatient units. The hospital currently has a Labor and delivery Unit and a Medical/Pediatric Unit.

During a medical record review of a patient admitted to the Medical Unit with a diagnosis of Acute Pancreatitis, Alcohol Abuse, Seizure Disorder, Myocarditis and Hypothyroidism there was no comprehensive Care Plan to reflect the nursing needs of the patient. On 8/15/2011 at 11:00 am, an interview with the RN taking care of the patient indicated that he always forget to ensure the Care Plan is in the medical record.

The RN also informed the surveyor that there is a travel nurse on staff and do not remember if he have a performance review in his personnel record.

On 8/16/2011 at 1:00 PM, an interview with the Director of Nursing (DON) was conducted. During the interview, the DON stated that she depended on the unit supervisor to complete the performance evaluation. However, there had been changes on the staff and the performance evaluation are not being done. The DON indicated that she does not have the time for oversight of the nursing supervisors to ensure that they are completing those evaluations.

The DON indicated on this interview that the nurses working in the Labor and Delivery Unit had expressed their concerns of the lack of experience working with difficult situations. The DON stated she has not meet with the current supervisor to discuss the nursing staff concern. The DON stated that at this time the hospital does not have an Education Department Coordinator that can evaluate the training needs of the nursing staff in the Labor and Delivery Unit or in any other unit.

Based on record reviews and interviews, it was determined that the facility's medical records system was not consistently reviewed and revised as needed. This failure could cause the patients to have inaccurate medical records thereby creating miscommunication of information.

Review of the facility's Medical Records policies and procedures on 8/15/2011 at 8:30 AM, revealed the newest revised copy of the facility's policy and procedures of medical records had not been approved by the medical committee. The new draft lacked signatures except for the Medical Records Director. The Medical Record Director signed the new draft on 4/11/2011. The last time the Medical Records policies and procedures were revised was on 6/29/2006.

Based on observations, interviews and record reviews, it was determined that the facility failed to ensure that clinical records were complete, dictated promptly and accurately documented for two (Patient # IP1 and # IP2) of five patient records reviewed. This failure could cause the patients to have inaccurate medical records thereby creating miscommunication of information.

Patient # IP1 was discharged on 3/28/2011 with a diagnosis of Reactive Airway Disease. Review of his clinical record revealed his discharge summary was dictated on 4/26/2011, approximately one month after discharge. The facility's medical records policy (revised 6/29/2006) requires: V. Discharge Summaries /Narratives Discharge Summaries are to be completed within 15 days of discharge.

Patient # IP2 was transferred to an Albuquerque area hospital with a diagnosis of Sepsis on 4/13/2011 without a physician's order for discharge. The facility's medical records policy (revised 6/26/2006) requires: III. Orders: There will be a written order for admission and discharge.

Upon interview, this information was confirmed by Medical Records Tech #1 and #2 on 8/15/2011 at 8:30 AM.

The facility failed to ensure that pharmaceutical services were administered in accordance with accepted standards of practice.

On 8/15/2011 at 3:30 PM, an inspection was completed for the crash carts in the Adult/Pediatric Medical Unit and the Labor and Delivery Unit. During the inspection of these areas it was confirmed by the duty nurse that Pharmacy Department is in charge of the maintenance and integrity of the medication tray in the crash carts.

Observations:

Adult/Pediatric Medical Unit:

1. Pediatric crash cart: The crash cart was sealed with a red tag lock. On top of the cart there was a list of the medications with expiration dates that are inside of the crash cart. By reading the medication list 4 medications were expired in 2010. The nurse conformed that Pharmacy is responsible to keep the crash cart medications integrity. He indicated that he has seen the list inside the crash cart and none of the medications are expire.

2. Adult crash cart: The crash cart was sealed with a red tag lock. On top of the cart there was a list of the medications with expiration dates. From 25 medications 23 appear to be expired. The duty nurse confirmed that he had seen the list inside the cart and none of the medications are expired.

3. In the Labor and Delivery Unit crash carts, (adult and pediatric) the same observation was made. In which the list of medication posted outside of the carts were expired.

On 8/16, 2011 the crash carts were opened by the pharmacist. It was noted that a list of updated expiration dates were inside the medication tray for the inpatient unit's crash carts.

On 8/16/2011 at 12:00 PM, an interview with the Pharmacist confirmed that facility pharmacists are assigned to different patient care unit and they are responsible to keep the medications updated inside the crash carts. When he was inform of the practice of having a list of expired medication posted out of the crash cart he indicated he was not aware of the discrepancies.

The current practice failed to ensure that the nursing staff were aware of the expiration dates in the medication in the crash carts. The pharmacy do not have internal controls to prevent the possibility of expired medications inside the crash carts.

The facility failed to ensure that all patient care equipments are routinely checked to ensure safety for patients and operators and that those equipments are in good working order.

On 8/15/2011 at 2:00 PM a facility tour to the inpatient units was conducted. The following observations were made:

a) Adult Medical and Pediatric Unit:
1. Crash cart for the pediatric use last maintenance for the AED was 02/09/2009.
2. All beds in the unit were last service in March 2010.

b) Labor and Delivery Unit:
1. Toshiba-Natus ear test machine have no record of ever been service.
2. Neonatal/Pediatric defibrillator was last maintenance on 06/09/2010.
3. Infant weight scale have no record of ever been maintenance.
4. Baby warmers last maintenance was in 03/08/2010.
5. Baby oxygen meters were last maintenance in 03/08/2010.
6. Baby thermometers (4), were last maintenance in 10/19/2010.
7. Brand new baby hearing test machine have no record of ever been maintenance.
8. Suction machine last service in 04/2010.
9. Hug baby alarm system: Was confirmed that is not functioning in any of the areas that the alarm is to activate in a situation of a baby abduction situation.

On 8/15/2011 at 4:00 PM an interview with the facility maintenance/environment personnel was conducted. During the interview, they confirmed that the dates in each equipment mention above was the last day the equipment was maintenance and if the equipment does not have a dated sticker it means that it has not been check.

The environment coordinator also confirmed that the Hug alarm system has not work for over a year and the company that manufactured when out of business. He stated that the hospital is in the process to purchase a system out of Colorado.

Based in record reviews and interviews, it was determined that the hospital did not have systems and processes for an active infection prevention program.

On 8/15/2011 at 9:30 am, the Director of Nursing indicated that the Infection Control Coordinator (ICC) was participating in a continuing education class in Albuquerque, New Mexico. During the interview, she indicated that if we have specific questions for the ICC concerning the Infection Control Program, the ICC Supervisor and DON will provide the answers. She stated that the ICC will come back on Wednesday (8/17/2011).

The surveyor requested the Infection Control Logs and the minutes for the Infection Control meetings.

On 8/16/2011 at 4:10 PM, an interview with the Director of Nursing was conducted. During the interview, the DON was not able to explain what kind of monitoring the ICC have in place to prevent infection within the hospital. The DON was also asked, what is the infection rate in the hospital and how is this is addressed by the hospital-wide QAPI program. The DON was not able to provide an answer. Several question were asked regarding staff training on bioterrorism, infection control tracking and trending, what infection were being tracked in the outpatient clinics including the Emergency Department and inpatient unit. The DON informed the surveyor that she was not the right person to answer anything related to Infection Control.

On 8/17/2011 at 8:30 am, the supervisor for the ICC was interviewed. She indicated that the person assigned to do Infection Control has not been an effective employee in that position and she indicated that he had called sick for the day (8/17/2011). Similar questions were asked to assess the staff' understanding on the Infection Control Program. However, she was not able to provide answers and indicated that the ICC was the only person that knows about the program. She also confirmed that she have one statement on infections during a QA meeting but nothing else.

In reviewing the Infection Control Log it was discovered that from 1/06/2011 to 7/17/2011, the facility reported 32 MRSA (Methicillin Resistant Staphylococcus Aureus) cases. When the DON was asked how this infection was being tracked or what kind of surveillance was in place to reduce and control the spread of MRSA she responded by saying "I don't know."

During a record review of the hospital policies and procedure manual for the Infection Control Program, it was noted that the majority of the policies were written in 1997 and revised in 2001.

Based on interviews and record reviews, it was determined that the CoP for Infection Control Services was not met and the hospital is not in compliance with this requirement.

Based on interview and record reviews, it was determined that the hospital did not consistently reassess its discharge planning process on an on-going basis. This failure had the potential for patients to be ill prepared for discharge and prevent positive patient outcomes.

On 8/15/2011 at 9:00 AM, the Discharge Planning/Case Manager stated, "A Discharge Planning meeting was to be conducted weekly; however, in the last 8 months, only 5 meetings have been conducted. There were four in January and one in August. (The facility's current Discharge Planning/Case Manager was fired two weeks prior to the survey. The position has been vacant from February to July.

The facility's Utilization Review Program policy (dated 1/14/2011) dictated: Discharge Planning/Case Management ...Serve as the chairperson of the Discharge Planning meeting held every Tuesday afternoon.