HospitalInspections.org

Based on review of the Hospital Bylaws Article 10, Medical Executive committee meeting minutes and interviews, it was determined that the hospital medical staff leader failed to participate in leadership meetings and consult directly with the Governing Body (GB). This failure presents the potential for a compromise in the quality of care provided to the patients at that hospital.

Findings include:

Hospital Bylaws Article 10 revealed: "...Section 10.1 Authority of the Administrator....shall act as the duly authorized representative of the board...To oversee hospital operations to ensure compliance with State and Federal regulations...to serve as the liaison officer and channel of communications...between the board ... and the Medical Staff...to take all the reasonable steps to conform to all applicable federal, state and local laws...."

Review of the Arizona General Hospital Board of Directors Meeting minutes dated: 12/19/2014; 03/30/2015; 06/24/2015; 09/29/2015 identified that the President of the Medical staff (Medical Staff # 2) failed to be present and take part in the Board of Director meetings.

The CEO and the CNO both confirmed during confidential interviews on 12/03/2015 that the hospital designated a medical staff leader that failed to attend the Board of Director meetings identified above and have a direct consultation with the GB, from the hospital's initial state licensure to the above date.

Based on review of hospital policies/procedures, documents, job descriptions, medical records and interviews, it was determined that the hospital failed to meet the emergency needs of patients as evidenced by:

(A1103) 1. failing to operate emergency services as a single, integrated department of the hospital. The potential risk is that patients who require emergent care in a free-standing ED will not receive the same services available in the hospital;

2. failing to ensure adequate hospital beds to meet the needs of patients admitted to the emergency department who require inpatient admission. The potential risk is that the required inpatient services will not be available to patients; and

3. failing to ensure integration of emergency services, provided at the free-standing EDs, with pharmacy, laboratory and respiratory services. The potential risk is that the required medication, laboratory services and/or respiratory services required for emergency care of a patient will not be available.

(A1112) failing to provide staff to meet the care needed for patients for continuous observation for two of two behavioral health patients (Patients #2 and #3).
This failure poses risk of endangerment to self and others.

The cumulative effect of these systemic problems resulted in the hospital's failure to meet the requirements of the Condition of Participation for Emergency Services.

Based on review of hospital policies/procedures, documents, job descriptions, medical record and interviews, it was determined that the hospital failed to operate its emergency service as a department within the hospital and integrate with its other departments, as evidenced by:

1. failing to operate emergency services as a single, integrated department of the hospital. The potential risk is that patients who require emergent care in a free-standing ED will not receive the same services available in the hospital;

2. failing to ensure adequate hospital beds to meet the needs of patients admitted to the emergency department who require inpatient admission. The potential risk is that the required inpatient services will not be available to patients; and

3. failing to ensure integration of emergency services, provided at the free-standing EDs, with pharmacy, laboratory and respiratory services. The potential risk is that the required medication, laboratory services and/or respiratory services required for emergency care of a patient will not be available.

Findings include:

Review of the hospital policy/procedure titled Plan for the Provision of Care revealed: "...Patient Care Departments and Services:...Patient Care areas: a. Inpatient b. Perioperative c. Emergency...Leadership Responsibilities:...Ensuring uniform delivery of patient care services provided throughout the organization...Ensuring that systems are in place which promote the integration of services to support the patient's continuum of care needs...Ensuring staffing resources are available to appropriately meet the needs of the patients served...."

1. Review of hospital document titled Dignity Health Arizona General Hospital Organizational Chart revealed: the free-standing EDs are listed as "Outpatient Emergency Rooms" separate from the "Emergency Department". The Emergency Department, Inpatient Services, Laboratory Services and Pharmacy Services are all listed as reporting to the Chief Nursing Officer, who reports to the CEO. The Outpatient Emergency Rooms are listed separately with each respective administrator, and listed as reporting directly to the CEO.

Facility RN Administrator # 21 confirmed, during interview conducted on 12/3/15, that the Organizational Chart was the current and correct reflection of the reporting relationships and organizational structure of Arizona General Hospital (AGH).

2. At the time of the survey, direct observation and review of hospital documents revealed that the hospital had 16 inpatient medical/surgical beds. The main hospital ED has 8 bays/beds and the four currently licensed free-standing EDs have 7 bays each, for a total of 36 bays/beds.

Facility RN Administrator # 12 confirmed during interview conducted on 12/2/15, that if all of the Emergency Department bays, including free-standing ED bays, were full and all of the patients required admission to AGH, the hospital would not have the capacity or capability to provide the inpatient hospital care required.

Refer to Initial Comments, Tag 000, for statistics regarding the number of ED visits in each free-standing ED and the hospital ED.

The Chief Nursing Officer (CNO) confirmed, during an interview conducted on 12/3/2015, the validity of the data. These statistics revealed that the hospital does not primarily provide inpatient services.

3. Review of the job description titled Director of Pharmacy, revealed: "...responsible for daily operations, personnel management and regulatory compliance of pharmacy services for the facility...Oversees and leads the Pharmacy department...Manage drug procurement and Inventory process...Responsible for Board of Pharmacy annual controlled substance Inventory and ongoing monitoring activities as the Pharmacist-In-Charge...."

Review of the job description titled Facility Administrator revealed: "...Assures compliance with all policies and procedures and governmental regulations pertaining to: Controlled substances and medications...Maintains lab in accordance with CLIA, COLA, and TJC standards...Knowledgeable of operation of lab instruments, including but no limited to, Medonic, Triage, Piccolo, UA instruments, IStat (turning on/shutting down, running samples, reporting results)...."

The hospital was unable to provide policies/procedures regarding the integration of pharmacy and laboratory services with the free-standing EDs.

The Facility RN Administrator # 12, confirmed, during interview conducted on 12/2/15, that s/he orders all medications for the free-standing ED stock supply and Code Cart. S/he stated that the administrators of the other free-standing EDs also order their medications and Code Cart supplies. S/he confirmed that the Director of Pharmacy oversees the ordering of medications and restocking of the Code Cart for the hospital ED. The formulary for the free-standing EDs is different from the formulary for the hospital, and any changes require approval by the regional/system organization.

The hospital Director of Pharmacy confirmed, during interview conducted on 12/3/15, that he has direct responsibility over the medication procurement and control of medications in the hospital. He serves in a consultant role for the free-standing ED's. He audits charts and "checks" the medication rooms at the free-standing EDs. The free-standing EDs do not operate under the hospital pharmacy license. He explained that the Board of Pharmacy does not allow him to be a pharmacist in charge at multiple sites. If the free-standing EDs had their own pharmacies, they would each have a pharmacist in charge who would be under his supervision. Medications are administered from the medication rooms at the free-standing EDs. The ordering of medications in the free-standing EDs is under the supervision of the free-standing ED Medical Director. The Medical Director is required to "sign" for receipt of all controlled drugs in the free-standing EDs. The Medical Board oversees medication processes of the free-standing EDs. In contrast, every medication/drug administered in the hospital "falls under the pharmacy license."
He also confirmed that there are some differences between the hospital formulary and the formulary for the free-standing EDs.

Pt # 14 was seen at the Chandler Freestanding ED on Ray Rd.

Pt # 14's medical record contained documentation that the Freestanding ED did not have opiates available to control her pain in order to re-pack wounds which were a result of removal of pelvic external fixations conducted at another facility.

The Facility Administrator confirmed during an interview conducted on 12/3/15, that nursing and medical staff were "locked out" of the automated system used for dispensing of opiates on 11/7/15. They were "locked out" for several hours and had to wait until the security system was corrected to allow access by the staff. This system had not been permanently corrected at the time of the survey. Opiate medication was not obtained from the hospital pharmacy. Pt # 14 was transferred to another facility for care.

All free-standing EDs are not integrated with the hospital pharmacy services.

The Facility RN Administrator # 21 confirmed, during interview conducted on 12/3/15, that lab tests which cannot be completed on-site are completed at a local acute medical center's lab. Specimens are sent to the local acute medical center laboratory, by courier. Specimens are not sent to the Arizona General Hospital lab. The freestanding EDs are unable to type and cross-match blood, whereas the hospital is able to type and cross-match blood and administer blood transfusions. Lab tests that are unable to be performed at the free-standing EDs in the East Valley are performed at a local acute medical center. Arizona General Hospital (AGH) has the capability to perform the same tests and also has a laboratory technician who can complete microscopic exams of specimens, however, specimens are not sent to AGH from the East Valley free-standing EDs.
Lab tests that are not able to be performed at the Glendale free-standing ED are sent to AGH when AGH has the capability to perform the lab tests.

The main hospital does not provide laboratory services to the East Valley free-standing EDs.

Review of hospital policy/procedure titled Emergency Services Scope of Services revealed: "...Unit Operation/Staffing Plan...Arizona-licensed registered nurses and respiratory therapists are available in the facility 24 hours per day, seven days per week and are trained to respond to an urgent or emergent patient presentation...."

Facility RN Administrator # 12 confirmed, during interview conducted on 12/2/15, that the free-standing EDs do not have ventilators available or respiratory therapy services available. If a patient requires intubation and a ventilator, the free-standing EDs have a "Vortran transferring device." The device does not require "vent settings." The MD sets the Positive End-Expiratory Pressure (PEEP).

The hospital ED has respiratory therapy available and the ability to place a patient on a ventilator if required.

The free-standing EDs are not integrated with hospital respiratory therapy services.

Based on review of the medical records, hospital's policy and procedures and direct observations and interviews, it was determined that the hospital failed to provide staff to meet the care needed for two of two behavioral health patients (Patients #2 and #3), requiring continuous observation. Failure to ensure continous observation when determined necessary poses risk of endangerment to self and others.

Findings include:

Patient #2 medical record revealed on 12/2/15 at 1107, nursing documentation: "...suicidal precautions in place...."

Policy and procedure titled Case and Management of the Suicide Patient, Policy Code: PC-1005, Effective Date: 11/2014 requires: "...Suicidal Precautions-continuous Observation of patient in a safe, protected environment...will be in constant site (sic) of the designated sitter/caregiver... remove all hazardous items....placed on Suicide Precautions...and will be cared for on one staff member per one patient ration (sic)...."

Patient #3 medical record revealed on 12/2/15 at 0117 nursing documentation: "...Est (establish) 1:1 obs (observation)...."

Policy and procedure titled Sitters policy, Policy Code: PC-1068, Effective Date: 11/2014 requires: "...for 1:1 observation...keep the patient in view all times...do not leave the patient unattended at any time...."

Observation conducted on 12/3/2015 at 0900 revealed seven (7) ED patients.

Patients #2 and #3 were observed simultaneously by the same CNA #20 in ED rooms numbered five (5)and six (6). At 0940 CNA #20 (sitter) left room #5 and walked to the opposite side of the ED to retrieve a blanket. There was no staff in the hallway, or in rooms 5 and 6 to continuously observe the patients.

Director of the ER, RN #4 stated during the interview on 12/3/15, it was fine for the CNA to get a blanket because both patients were sleeping.

Review of the personnel file of CNA #20, revealed that she is a registry employee, who was scheduled for her second day to work in the hospital, on 12/03/2015. The hospital was unable to provide documentation of CNA #20's orientation to the hospital, competency to function in an emergency room, or orientation to the hospital's sitter policy.