HospitalInspections.org

Based upon record review and interviews, the hospital failed to provide, in writing, the patient or the patient's representative a phone number and address for lodging a grievance with the state agency. Findings:

Review of the information packet given to each patient upon admission revealed there failed to be documented evidence the telephone number and address of the State Agency was provided to lodge a grievance.

Interview with Staff A on 01/18/23 at 9:45 a.m. revealed the state agency information was located on the wall at the admission desk. Staff A confirmed this information was not included in the admission packet information.

If the patient did not look on the wall during the admission process and copy down this information they would not be aware of the phone number and address of the State Agency

Based upon review of physician credential files, Medical Staff ByLaws, and interview, the Medical Staff failed to follow their Medical Staff ByLaws to ensure each practitioner who was granted clinical privileges maintained current professional liability insurance. Review of 5 of 6 (Staff U, V. W, X, and Y) physician credential files revealed the professional liability insurance was expired. Findings:

Review of the physician credential files revealed the professional liability insurance was expired for the following physicians:
Staff V expired 09/01/22;
Staff W expired 01/01/22;
Staff X expired 01/01/22;
Staff Y expired 02/25/21.

Review of the Medical Staff ByLaws Rules and Regulations approved on 10/25/21, revealed the following in part: "Article 12 General and Other Provisions; 12.7 Professional Liability Insurance: Each Practitioner granted Clinical Privileges in the Hospital shall maintain in force professional liability insurance...A current certificate of insurance for the professional liability must be provided to the Chief Executive Officer..."

Interview on 01/19/23 at 11:00 a.m. with Staff A revealed the hospital used an outside entity for physician credentialing which was completed every 2 years. If the physician's liability insurance had expired during this two year period it would not be identified until their next re-appointment.

Based upon record review and interview the hospital failed to ensure a qualified director was appointed to manage the dietary services. This was evidenced by the failure of the identified dietary manager to have the appropriate qualifications, education and training to manage the food service operations. Findings:

Review of the Organizational Chart revealed Staff B and Staff D were identified as over the Dietary Services.

Interview with Staff B on 01/19/23 at 11:00 a.m. revealed Staff F was identified as the Dietary Manager. Review of the personnel file for Staff F revealed she was a licensed Registered Nurse and the Job Description was for Case Manager. There failed to be documented evidence her responsibilities included being the Dietary Manager.

During a tour of the Dietary Department on 01/19/23 at 1:30 p.m. interview with Staff D revealed she identified herself as the Dietary Manager and her position was for a Dietary Clerk II. Further interview with Staff D revealed she had completed the dietary certification training but would have to take a refresher course prior to taking the certification test.

Based upon record review and interview the hospital failed to ensure the therapeutic dietary manual was approved by the dietician. Findings:

Review of the Dietary Manual revealed there failed to be documented evidence the manual was approved by the Dietician.

Interview with Staff A on 01/19/23 at 2:45 p.m. confirmed the Dietician had not approved the Therapeutic Dietary Manual.

Based upon record review and interview, the hospital failed ensure a doctor of medicine or osteopathy was appointed as the director of respiratory care services. Findings:

Review of the Medical Staff Meeting Minutes from June 2022 through December 2022 revealed there failed to be documented evidence a physician had been appointed as the director of Respiratory Care Services.

Interview with Staff A on 01/18/23 at 3:00 p.m. revealed respiratory care was provided by Staff Z and the nursing staff. When asked if a physician had been appointed as the director of the service, she replied "no".