HospitalInspections.org

At the time of the revisit on 05/28/14, this deficiency was not corrected.

Based on staff interview, review of hospital documents, and observation of hospital clinical equipment, the hospital failed to have a preventative maintenance program to ensure the hospital's medical devices and equipment were maintained in safe operating condition.

Findings:

The hospital does not perform any surgical procedures, but maintains a autoclave for cleaning instruments that are used in the emergency room and the medical-surgical unit. On the morning of 05/29/14, Staff A was asked if preventative maintenance had been completed on the autoclave, she stated only maintenance checked the autoclave, not the manufacturer (Amsco).

Review of the temperature wheel for the autoclave did not contain documentation of the cooling times for the different loads. Staff A stated no work order had been requested for the autoclave.

At the time of the revisit on 05/28/14, this deficiency was not corrected.

Based on review of hospital documents and interviews with staff, the governing body does not ensure all services provided by contract or agreement are evaluated by the hospital's quality program. Review of the hospital's quality/compliance, governing body and medical staff committee meetings for 2013 and contract personnel files did not have evidence of review and evaluation through the QA/PI (quality assessment and performance improvement) program of the services provided by contract.

Findings:

There was no evidence rehabilitative, dietetic and radiology services provided by contract are evaluated by the hospital's QA/PI program.

No additional information was provided by hospital staff during the survey concerning contract services evaluation by the QA/PI program.

At the time of the revisit on 05/28/14, this deficiency was not corrected.

Based on record review and interviews with hospital staff, the hospital does not ensure the annual program evaluation had determined whether the utilization of services were appropriate, established policies were followed and any changes were needed. The program evaluation did not have evidence that any changes to hospital services or policies were added or revised because of information from the annual program evaluation. This was verified by hospital staff during the survey.

At the time of the revisit on 05/28/14, this deficiency was not corrected.


Based on record review and interviews with hospital staff, the hospital does not ensure that the quality assurance (QAPI) program evaluates the hospital's patient care services to ensure patient health and safety. Services provided by contract were not evaluated by the QAPI program

The above information was presented to the administrative staff during the exit interview.

At the time of the revisit on 05/28/14, this deficiency was not corrected.

Based on record review and interviews with hospital staff, the hospital does not ensure that the physician assistant providing patient care is evaluated by a physician member of the medical staff of the hospital. There was no evidence in five (Patients# 1,2, 5, 6, and 7) of seven patient medical records reviewed of evaluation of the care provided by the physician assistant.

Findings:

Medical records were reviewed on 05/29/14, with Staff C and U.

Review of the medical records did not contain evidence the physician(s) reviewed and signed the patient care provided by Staff M. This was confirmed by Staff U during medical record review.

Staff U stated she was unaware the physician(s) had to sign or co-sign the history and physical and discharge summaries that were completed by Staff M.

At the time of the revisit on 05/28/14, this deficiency was not corrected.

Based on record review and interviews with hospital staff, the hospital does not document the outcome of any remedial action taken. Quality Assurance Performance Improvement (QAPI), medical staff and Board of Trustees meeting minutes for 2013 did not have evidence any remedial action taken to address any deficiencies identified by the QAPI program.

At the time of the revisit on 05/28/14, this deficiency was not corrected.


Based on review of the hospital's medical records and interviews with hospital staff, the hospital failed to ensure the activity program was directed by a qualified staff member.

Findings:

On 05/29/14, Staff B stated the previous activities director is no longer employed by the hospital.

Staff B, who is a RN(registered nurse), stated she has taken on the role of the activities director. Staff B was asked if she completed the activities director course, she stated no.