HospitalInspections.org

Based on observation and interview, the hospital failed to ensure that each patient had the right to receive care in a safe setting. This deficient practice was evidenced by the failure to keep the patient environment free from ligature risks.
Findings:

On 09/18/17 at 10:20 a.m., a tour of the boys bathroom in the dining hall revealed the toilet pipes were exposed, presenting a ligature risk.

On 09/18/17 at 10:30 a.m., a tour of facility dorm B revealed the following ligature risks:
The style of the sink fixtures (faucets/knobs) allowed for the possibility that material could be looped and tied around them, presenting a hanging risk in rooms B-1, B-5, B-6, B-10, B-12 and B-16.
The toilet pipes were exposed in rooms B-10 and B-11.

On 09/18/17 at 1:00 p.m., a tour of the girls bathroom in the gymnasium revealed the grab bars next to and behind the commode had space between the bar and the wall that presented a ligature risk. The faucet handles on the sink allowed for the possibility that material could be looped and tied around them, presenting a hanging risk. The handle on the inside of the door allowed for the possibility that material could be looped and tied around it, presenting a hanging risk.

On 09/18/17 at 1:30 p.m., a tour of dorm A revealed the following ligature risks:
The style of the sink fixtures (faucets/knobs) allowed for the possibility that material could be looped and tied around them, presenting a hanging risk in rooms A-9, A-10, A-11 and A-12.

The bathroom in the dayroom area of dorm A revealed the commode pipes, door hinges, door knob, faucets, and grab bars presented ligature risks.

The door handles on all of the patient rooms were not of the safety type and posed a ligature risk to patients.

Inspection of the "hopper" room revealed the door was unlocked and there was an exposed pipe approximately 4 feet off the floor; the hopper sink had rubber hoses attached to detergent chemicals.

On 09/18/17 at 1:45 p.m., an interview with S1Administrator confirmed the above findings presented ligature risks.


20310

Based upon record review and interviews, the hospital failed to meet the Condition of Participation for Quality Assurance/Performance Improvement as evidenced by:

1) The failure to identify and report opportunities for improvement related to health outcomes, patient safety, and quality of care, and the failure to take actions related to performance improvement, implement corrective actions, and track performance to ensure improvements were sustained. {See findings at Tag A0273};

2) The failure to ensure the Quality Assurance/Performance Improvement (QA/PI) Program was ongoing and measured, analyzed, and tracked activities. Review of the QA/PI Program data revealed the only month the indicators were tracked was in June 2017. {See findings at Tag A0286};

3) The failure of the Governing Body to ensure the hospital's QA/PI Program was maintained, on-going and involved all departments and services from January 2017 through May 2017 and July and August 2017. {See findings at Tag A0308};

4) The failure of the Governing Body, Medical Staff, and Administrative Staff to assume responsibility for the Quality Assurance/Performance Improvement Program and ensure the program was implemented and maintained to ensure quality indicators were reviewed and addressed priorities for improved quality of care and patient safety. {See findings at Tag A0309}.

Based upon record review and interviews, the hospital failed to ensure data was collected and reported through the Quality Assurance/Performance Improvement (QA/PI) Program. This was evidenced by the failure to identify and report opportunities for improvement related to health outcomes, patient safety, and quality of care and the failure to take actions related to performance improvement, implement corrective actions, and track performance to ensure improvements were sustained.
Findings:

Review of the hospital's Quality and Compliance Plan revealed C. 2. Monthly Critical Incident and Medication Error Summary. Each program is required to submit a monthly critical incident and medication error summary report to the CEO, COO, and the Director of Quality Compliance. This report provides a cumulative review of all incidents that have occurred at the facility over the past month. The Director of Compliance reviews the reports in detail to determine any negative patterns or trends at a single facility and/or system-wide. When trends are identified, the Director of Compliance will work with the program directors and/or the COO to determine what next steps are needed to reduce or eliminate future incidents. This plan was for the years 2015 and 2016. There failed to be an updated Quality and Compliance Plan for the year 2017.

Interview with S2CNO on 09/18/17 at 11:05 a.m. revealed she was the director of the QA/PI Program. On 09/19/17, the QA/PI data was requested. Provided for review was performance measures; however, the only data collected and reported for 2017 was for the month of June. Further review of the QA/PI data identified in June 2017 revealed the areas for Infection Control, Human Resources, Medical Records, Complaints/Grievances, Disciplines/Services, Outpatient Services, and patient satisfaction was not reviewed.

Based upon record review and interviews, the hospital failed to ensure the Quality Assurance/Performance Improvement (QA/PI) Program was ongoing and measured, analyzed, and tracked activities. Review of the QA/PI Program data revealed the only month the indicators were tracked was in June 2017.
Findings:

Review of the Performance Measures revealed from January through May 2017 and the months of July and August 2017, there failed to be documented evidence Quality Assurance activities were measured and tracked. Review of the June 2017 performance measures revealed the areas for Medical Records, Infection Control, Social Services, and Outpatient Services were left blank with no documentation of review.

Further review of the Performance Measures revealed for patient safety, indicators were to be tracked for patient incidents/injuries, monitoring of patient observation sheets related to incidents, adequate staffing, facility safety checklists, and medical equipment were to be monitored; however, there failed to be documented evidence these measures were reviewed except for the month of June 2017.

Review of the Quality Assurance Committee Meeting Minutes revealed the only meeting presented for review was dated August 2017. Further review of the meeting minutes revealed no evidence to indicate the committee identified the missing quality indicators.

Interview with S2CNO on 09/18/17 at 4:10 p.m. revealed when asked about the missing documentation of the performance measures, her response was "I know".

Based upon record review and interview, the governing body failed to ensure the hospital's QA/PI Program was maintained, on-going and involved all departments and services. This was evidenced by the failure to conduct ongoing monitoring of quality indicators from January 2017 through May 2017 and July and August 2017.
Findings:

Review of the Quality Assurance Performance Improvement activities revealed data had only been collected for the month of June 2017. Further review of the June 2017 data revealed Infection Control, Grievances/Complaints, Medical Records, Outpatient Services, Radiological Services, Pharmaceutical Services, Environmental Services was blank with no indication these services were reviewed.

Review of the 2015-2016 Quality and Compliance Plan revealed III. Infrastructure: Vice President, Office of Quality, Compliance, Access and Retention: The Vice President of Client Access and Retention services as the overarching leader for Quality Assurance activities; Director, Office of Quality, Compliance and Accreditation: The Director of Quality, Compliance, and Accreditation oversees Quality Improvement and Compliance activities to ensure that all sites are performing at the highest standards possible.

During an interview with S2CNO on 09/18/17 at 4:10 p.m., it was revealed the hospital did not have a Quality Assurance Plan for the year 2017. Further interview with S2CNO revealed when asking about the missing Quality Assurance data from January to May 2017 and August and September 2017, her response was "I know".

Based upon record review and interview, the governing body, Medical Staff, and Administrative Staff failed to assume responsibility for the Quality Assurance/Performance Improvement Program and ensure the program was implemented and maintained. This was evidenced by the failure to ensure quality indicators were reviewed on an on-going basis and addressed priorities for improved quality of care and patient safety.
Findings:

Review of the QA/PI Program data revealed quality indicators were developed; however, the data was only collected for the month of June 2017. Further review of the June 2017 data revealed the indicators for Outpatient Services, Contracted Services, Medical Records, Social Services, Infection Control, Medication Errors, and Patient Accidents/Incidents was not identified.

On 09/19/17, when asked if the hospital had Quality Assurance Committee Meeting Minutes, S2CNO presented meeting minutes dated August 9th, 2017. Review of the Committee Members present at the meeting revealed S1Administrator and S2CNO were present. Review of the meeting minutes revealed there failed to be documented evidence the missing Quality Assurance data had been collected and reported.

Based on record review and interview, the hospital failed to meet the requirements of the Condition of Participation for Medical Staff as evidenced by:

1. Failing to ensure the medical staff conducted periodic appraisals of its members for 5 of 5 credentialing files reviewed (S17MD, S21MD, S22MD, S23MD, S24MD). {See findings at Tag A0340};

2. Failing to ensure the medical staff examined the credentials of candidates of the medical staff membership and made recommendations to the governing body for appointment/reappointment for 5 of 5 credentialing files reviewed (S17MD, S21MD, S22MD, S23MD, S24MD). This was evidenced by:
A) Failing to ensure the appointment/reappointment of practitioners which resulted in them providing care and treatment to patients in the hospital without delineation of privileges and written approval for appointment/reappointment to the medical staff and
B) Failing to ensure credentialing files contained all supporting documents for examination by failing to obtain peer references, CDS and DEA licenses or proof of liability insurance. {See findings at Tag A0341};

3. Failing to ensure the medical staff enforced the by-laws adopted by the medical staff as evidenced by failing to ensure that an effective system was in place for addressing approximately 300 delinquent medical records greater than 30 days. {See findings at Tag A0353}.

Based on record review and interview, the hospital failed to ensure the medical staff conducted periodic appraisals of its members for 5 of 5 credentialing files reviewed (S17MD, S21MD, S22MD, S23MD, S24MD).
Findings:

Review of the Medical Staff By-laws provided by S1Administrator as the hospital's current Medical Staff By-laws revealed in part the following:
2.3 Responsibilities of the medical staff -the chief of staff will develop and implement methods for retrospective patient care audits and on-going monitoring of clinical practice..and account to the governing board for the quality and efficiency of patient care through regular reports and recommendations concerning the implementation, operation and results of the quality review, evaluations and monitoring activities.

Review of the credentialing files for S17MD, S21MD, S22MD, S23MD and S24MD revealed no evidence of an appraisal by the medical staff.

On 09/20/17 at 1:45 p.m., S1Administrator confirmed that he was unable to provide any documented evidence related to periodic appraisals for the above credentialing files.

The hospital failed to ensure that the medical staff examined the credentials of candidates of the medical staff membership and made recommendations to the governing body for appointment/reappointment for 5 of 5 credentialing files reviewed (S17MD, S21MD, S22MD, S23MD, S24MD). This was evidenced by:
1) Failing to ensure the appointment/reappointment of practitioners which resulted in them providing care and treatment to patients in the hospital without delineation of privileges and written approval for appointment/reappointment to the medical staff and
2) Failing to ensure credentialing files contained all supporting documents for examination by failing to obtain peer references, CDS and DEA licenses or proof of liability insurance.
Findings:

Review of the Medical Staff By-laws provided by S1Administrator as the hospital's current Medical Staff By-laws revealed in part the following:
7.1-1 Members shall be required to have reappointments to the staff every two years. The completed application for membership shall be presented to the Director of Health Information. It shall be the responsibility of the Health Information Department to obtain 2 peer references on the applicant...and obtain verification of current licensure...current Federal and State DEA certificates.
7.1-2 The organized medical staff is responsible for planning and implementing the privileging process to include the following: a) developing and improving a delineation of privileges, b) processing the application, c) evaluating the applicant in regards to specific information...The application shall be referred to the Medical Executive Committee. The organized medical staff will review the information on each new applicant prior to submitting to the Governing Board for final approval for privileges to the medical staff.

On 09/18/17 at 2:00 p.m., the sampled credentialing files were requested from S1Administrator. He stated that all credentialing files were at the corporate office and would have to be scanned over to the hospital.

On 09/18/17 at 10:10 a.m., the credentialing files were presented to the survey team. This consisted of each physicians scanned information being paperclipped together. There was no order to the information. Upon reviewing the first credentialing file, the review revealed that the information was outdated/expired and did not contain all required documents. The survey team requested to speak to the employee responsible for credentialing files.

On 09/18/17 at 10:30 a.m., telephone interview with S8Human Resources was conducted. She stated that she was responsible for the credentialing files. The surveyor informed her of the required documents that the survey team needed to review for each credentialing file. S8Human Resources stated that the information would be scanned to the hospital.

On 09/20/17 at 9:00 a.m., S1Administrator provided all information scanned over from S8Human Resources. Review of the this information included:

S17MD
The application was dated 02/23/17. There was no documented evidence of peer references or DEA license. There was no evidence that the physician had been appointed to the medical staff and no documentation of delineation of privileges.

S21MD
The application was dated 09/02/16. There was no documented peer references, DEA or CDS license or proof of liability insurance. There was no evidence that the physician had been appointed to the medical staff and no documentation of delineation of privileges.

S22MD
The application was dated 05/02/17. There was no documented peer references or DEA license. There was no evidence that the physician had been appointed to the medical staff and no documentation of delineation of privileges.

S23MD
The application was dated 02/23/17. There was no documented peer references. There was a form titled Delineation of Privileges Request Form dated 02/25/17 with specific privileges requested by the physician. The form was signed by the chair of the medical board and governing body but the box that indicated approval or disapproval was blank. There was no evidence that the physician had been appointed to the medical staff.

S24MD
The application was dated 07/31/17. There was no documented peer references of CDS license. There was a form titled Delineation of Privileges Request Form dated 04/25/17 with specific privileges requested by the physician. The form was signed by the chair of the medical board and governing body but the box that indicated approval or disapproval was blank. There was no evidence that the physician had been appointed to the medical staff.

On 09/20/17 at 1:45 p.m., S1Administrator confirmed that he was unable to provide any further information related to the above credentialing files. He further confirmed the above missing information.

Based on record review and interview, the hospital failed to ensure the medical staff enforced the by-laws adopted by the medical staff as evidenced by failing to ensure that an effective system was in place for addressing approximately 300 delinquent medical records greater than 30 days.
Findings:

Review of the Medical Staff By-laws revealed in part, All medical records shall be completed by the attending physician within 30 days of discharge...Health records that are not completed within 30 days shall be brought to the Governing Board Committee Meeting for resolution and possible reprimand.

On 09/18/17 at 2:00 p.m., S11RHIA provided a list dating back to 01/09/17 of deficient medical records (approximately 300). The list included patient names and the discharge dates. Some of the patient names indicated the physician name, but most were blank. The form did not indicate what was deficient in each medical record. The following physicians and/or Nurse Practitioners were indicated on the above form as having medical record deficiencies greater than 30 days:

S23MD had 17 deficient medical records
S24MD had 41 deficient medical records
S25NP had 32 deficient medical records, dating back to 01/02/17
S26NP had 25 deficient medical records, dating back to 03/22/17

Further interview with S11RHIA at this time confirmed that the delinquent medical records date back to January 2017. She revealed that she was hired in June 2017 and she is doing the best she can to get the records completed. When asked for the policy/procedure regarding the steps to follow when physicians have delinquent medical records, she stated that to her knowledge, there was no policy. She further stated that she tries to catch the physicians when they come to the hospital to get them to complete their delinquent medical records.

On 09/20/17 at 1:45 p.m., interview with S1Administrator and S2CNO confirmed that they were aware of the multiple delinquent medical records. They were unable to provide any documented evidence that the governing body or medical staff was aware of and had addressed the issue.

Based on record review and interview, the hospital failed to ensure that nurses, who were responsible for providing respiratory care services, were competent to provide those services.
Findings:

Review of the Consulting Services Agreement dated 02/22/17 between the hospital and the Respiratory Therapist revealed the responsibilities of the respiratory therapist included: 1) nursing staff education and competencies for respiratory services will be provided when requested; and 2) provide guidance to staff when needed regarding respiratory services.

Review of the personnel files of the nursing staff revealed no documented evidence that the competency evaluation of respiratory services had been conducted by the respiratory therapist for the nurses within the last year.

On 09/18/17 at 11:00 a.m., an interview with S2CNO confirmed that the nurses provide respiratory services to the patients, including oxygen administration, nebulizers and inhalants. On 09/20/17 at 1:00 p.m., S2CNO confirmed there was no documented evidence that the nurses had been evaluated for competency in administering respiratory treatments and services.

Based on record reviews and interviews, the hospital 1) failed to ensure medical records for each patient were promptly completed within 30 days of discharge and 2) failed to ensure that medical records were protected from fire or water damage.
Findings:

1) Failed to ensure medical records for each patient were promptly completed within 30 days of discharge

Review of the Medical Staff By-laws revealed in part, All medical records shall be completed by the attending physician within 30 days of discharge...Health records that are not completed within 30 days shall be brought to the Governing Board Committee Meeting for resolution and possible reprimand.

On 09/18/17 at 2:00 p.m., S11RHIA provided a list dating back to 01/09/17 of deficient medical records (approximately 300). The list included patient names and the discharge dates. Some of the patient names indicated the physician name, but most were blank. The form did not indicate what was deficient in each medical record. The following physicians and/or Nurse Practitioners were indicated on the above form as having medical record deficiencies greater than 30 days:

S23MD had 17 deficient medical records, dating back to 07/25/17
S24MD had 41 deficient medical records, dating back to 05/30/17
S25NP had 32 deficient medical records, dating back to 01/02/17
S26NP had 25 deficient medical records, dating back to 03/22/17

Further interview with S11RHIA at this time confirmed that the delinquent medical records date back to January 2017. She revealed that she was hired in June 2017 and she is doing the best she can to get the records completed. When asked for the policy/procedure regarding the steps to follow when physicians have delinquent medical records, she stated that to her knowledge, there was no policy. She further stated that she tries to catch the physicians when they come to the hospital to get them to complete their delinquent medical records.


2) Failed to ensure that medical records were protected from fire or water damage

On 09/18/17 at 2:00 p.m., observation of the medical records room revealed open shelves that contained patient medical records dated 2016 to present. Further observations across the hall revealed more medical records were stored in an unused patient shower room. Patient medical records were observed on rolling carts and on open shelves in this room. Sprinkler heads were noted in the ceilings of the above rooms. Interview with S11RHIA, at this time, confirmed that the records were not protected from water, should the water sprinklers activate.

On 09/20/17 at 1:20 p.m., observations with S1Administrator of the gym revealed a room that contained patient medical records, dated 20017 to present. The records were on open wooden shelves. S1Administrator confirmed that the records were not protected from fire or water damage.

Based on record review and interview, the hospital failed to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed (review for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications).
Findings:

Review of the Louisiana Administrative Code, Title 46 Professional and Occupational Standards, Part LIII Pharmacist, Chapter 15 Hospital Pharmacy, Section: 1511: Prescription Drug Orders, Item A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial dose of medication, except in cases of emergency.

Review of the hospital's Exclusive Pharmaceutical Service Agreement with Pharmacy A revealed that orders for new patients and new drug orders after hours and on weekends should be faxed to the pharmacy. Once the order has been faxed to the pharmacy, the facility will need to call the pharmacist on-call. Further review revealed that for new patients, the facility will fax pharmacy all required new patient information (facility face sheet).

On 09/19/17 at 2:00 p.m., an interview with S6LPN confirmed that the hospital did not have an on-site pharmacy. She stated that when a new order is received after hours or on the weekend, the nurses call the parent to obtain consent. The order is faxed to the pharmacy, and the staff pulls the first dose of the new medication from the hospital's "night cabinet", which contains the most commonly prescribed medications.

On 09/19/17 at 2:15 p.m., an interview with S3RN revealed that when new patients are admitted after the pharmacy is closed and on weekends, the physician may write orders for medications to "start now." She stated in these cases, the first dose of a medication may be administered prior to review by the pharmacist.

Based on record review and interview, the hospital failed to meet the requirements for the Condition of Participation for Radiology Services as evidenced by:

1) The hospital failed to ensure the contract service for radiology identified what type of radiological services were offered. The contract also failed to identify the turn-around times for STAT radiological services. {See findings at Tag A0529};

2) The hospital failed to ensure a full-time, part-time or consulting radiologist supervised the radiological services. {See fndings at Tag A0546}.

Based upon record review and interview, the hospital failed to ensure the Contract Service for Radiology identified what type of radiological services were offered. The contract also failed to identify the turn-around times for STAT radiological services.
Findings:

Review of Hospital A contract revealed radiological services were included; however, there failed to be documented evidence the scope of services was identified. Further review of Hospital A contract revealed STAT radiological services related to the turn-around time was not identified.

Interview with S1Administrator and S2CNO on 09/19/17 revealed only Hospital A furnished Radiological Services.

Based upon record review and interview, the hospital failed to ensure a full-time, part-time or consulting radiologist supervised the Radiological Services.
Findings:

Review of the list of Medical Staff provided as current by S1Administrator revealed there failed to be evidence a Radiologist was staff at the hospital.

Interview with S2CNO on 09/19/17 at 10:30 a.m. revealed when asked who the hospital's Radiologist was, she replied an Internal Medicine physician was responsible for the service. When asked if there was a Radiologist on the hospital's medical staff, she responded "no".

Based upon record review and interview, the hospital failed to ensure there was a written description of laboratory services made available to the medical staff.
Findings:

Interview on 09/18/17 with S9Phlebotomist at 10:50 a.m. revealed when asked who provided laboratory services at the hospital, she replied laboratory specimens were processed by Contract B. When asked about STAT laboratory orders, S9Phlebotomist replied the specimens would be taken to the laboratory department at Hospital A.

Review of the list of contracted services revealed Contract B was not listed. Review of the contract for Hospital A revealed laboratory services were to be provided; however, the need for STAT services was not identified.

Based on observation and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in such a manner that the safety and well being of patients was assured.
Findings:

On 9/18/17 at 10:00 a.m., tour of the dining area with S1Administrator revealed the following observations:
The napkin dispensers, hand sanitizer dispensers and fork and spoon dispensers had a buildup of dirt and grime;
There was a buildup of dirt and grime on the doorways entering the kitchen;
24 of 30 chairs had ripped, torn seats;
Spider webs and dead bugs were noted in the back of the dining room by the window;
Spider webs were hanging from vents in the ceiling;
Exposed wiring was noted from the window air conditioning unit, freezer and overhead light;
The boys bathroom located by the dining area had spiders and spider webs in the windows, and had no toilet paper or paper towels available.

On 9/18/17 at 10:30 a.m., tour of the occupied dorm B with S1Administrator revealed the following observations:
Room B-2 had dead bugs in the window sill;
The electrical room in the hallway was unlocked;
Room B-5 had no curtain in the window; the bathtub was dirty with a buildup of grime and debris; there were dried spills and stains on the bedspread of bed a;
The exam table in the exam room had a large tear in the vinyl covering;
Room B-12 had no screen on the window;
Room B-14 had no screen on the window; dead bugs were on the curtain; a large hole was noted in the bedspread on bed a;
Room B-16 had a large hole in the bedspread of bed b; the screen was hanging off of the window;
Room B-18 had a window that was coated with a dark black substance; moisture was noted between the window panes; spider webs were in the windows;
The shower room in the hallway had a large hole with missing tile around the drain in the shower floor of one shower; the other shower had a hole where the drain should be with a piece of plastic piping with sharp edges put in the hole; spider webs were in the window sill;
There was a hole in the wall of the hallway with exposed piping and electrical plug (S1 Administrator stated this was from an old water fountain);
A strong sewage smell was noted in the hallway near the nurse station/day room area;
The bottom of the water machine by the nurse's station was coated with grime and a dark black substance;
All the rooms had buildup of dirt and debris in the corners and on door frames; hallway corners were noted with a thick buildup of dust and debris.

On 9/18/17 at 1:00 p.m., tour of the gymnasium with S1Administrator revealed the following observations:
A dried spill/spot of dark red substance was noted on the floor with tracks where someone had walked through it;
A large hair ball was noted on the bottom of a table;
Spider webs were all over the backs of the basketball goals;
A large broom with swept up trash, debris and paper was pushed up in a corner of the gym; The covers over the fire alarms on the walls were coated with spider webs;
Dead bugs, debris, spider webs and hair balls were built up all against the baseboards.

On 09/18/17 at 1:30 p.m., tour of dorm A with S1Administrator revealed the following observations:
Room A-8 had no bathroom light;
The seclusion room bathroom had a reddish brown substance on the top of the commode;

On 09/18/17 at 1:30 p.m., an interview with S1Administrator confirmed that the above areas were in need of cleaning, repair and maintenance.


20310

Based upon record review and interviews, the hospital failed to meet the Condition of Participation for Infection Control as evidenced by:

1) The failure to: a) designate in writing an individual as its infection control officer responsible for the infection prevention and control program; b) ensure the individual had ongoing education and training to oversee the infection control program; and c) implement hospital infection control policies.{See findings at Tag A0748};

2) The failure to: a) identify infections documented on the infection control log and indicate if the infections identified and treated were hospital acquired or community acquired; b) maintain a sanitary environment related to pest control; and c) maintain active infection control surveillance. {See findings at Tag A0749};

3) The failure of the Administrator, Chief Nursing Officer, Medical Staff and Director of Nursing to take responsibility for the QA/PI Program by: a) the failure to ensure the Infection Control Officer had the education and training to implement infection control activities as identified in the Infection Control Program and b) the failure to ensure Infection Control activities were included in the monthly QA/PI activities and a correction plan was implemented and evaluated to ensure infection control practices were followed. {See findings at Tag A0756}.

Based upon record review and interviews, the hospital failed to: 1) designate in writing an individual as its infection control officer responsible for the infection prevention and control program; 2) ensure the individual had ongoing education and training to oversee the infection control program; and 3) implement hospital infection control policies. Findings:

Review of the Infection Control, Prevention Strategy and Action Plan for 2016 and 2017 revealed "Infection Control Program and Infrastructure, Objective: The hospital will have a well structured and designed infection control program with evidenced based policies and will be led by an Infection Preventionist with specific training in Infection Control". Strategy: Infection Preventionist will have membership with APIC and attend the APIC academy this Spring whilst watching webinars, reading articles and completing other infection control courses of importance through APIC and other appropriate sources. This knowledge will be utilized in the review of policies and procedures to ensure that the infection control program is current and evidenced based. Preventionist to consult with person of expertise as necessary in order to make knowledgeable decisions."

On 09/18/17 at 4:10 p.m. interview with S2CNO revealed when asked who the Infection Control Officer was, she responded S5DON. On 09/19/17 at 1:25 p.m. a telephone interview was conducted with S5DON. When asked about her duties as the Infection Control Officer, S5DON replied she was not the Infection Control Officer. S5DON reported she had not been doing any infection control activities since her return to the hospital in February 2017. S5DON further indicated S9Phlebotomist was doing infection control activities.

Review of the personnel file for S9Phlebotomist revealed there failed to be documentation designating her as the Infection Control Officer, a job description for infection control, or any evidence of ongoing training or education in infection control. During an interview with S9Phlebotomist on 09/19/17 at 10:20 a.m. when asked her responsibilities for infection control, she stated she documents the patient's infection and antibiotic ordered in the infection control log.

Review of the contract services revealed the hospital had a contract with Contract Service A for Infection Control personnel; however, interview on 09/20/17 at 1:30 p.m. with S1Administrator revealed the hospital had contacted the entity three times and they never responded.

Based upon record review, interview and observation, the hospital failed to ensure the Infection Control Program was effective and implemented in accordance with the Infection Control Plan. This was evidenced by the failure to: 1) identify infections documented on the infection control log and indicate if the infections identified and treated were hospital acquired or community acquired; 2) maintain a sanitary environment related to pest control; and 3) maintain active surveillance.
Findings:

1) Review of the Infection Control, Prevention Strategy and Action Plan for 2016 and 2017 revealed in part "Areas that are monitored by the Infection Control Committee: Hospital/Community Acquired Infections."

Review of the Infection Control Log revealed each month a list of patient infections and antibiotic treatments were documented; however, the infections failed to identify if they were acquired during hospitalization or if the patient had the infection upon admission.

Review of the Infection Control Committee Meetings from May 2017 to August 2017 revealed the following:
May 2017: No documentation of infections were reviewed;
June 2017: Patient Infections: Difficult to analyze. Two infections, both patients had STDs that were reported to the CDC per guidelines;
July 2017: Patient Infections: We had 14 reported patient infections;
August 2017: Infection Control Record: Information was provided on a separate sheet by (S9Phlebotomist) and reviewed with the committee.

There failed to be documented evidence patient infections were identified as Hospital Acquired or Community Acquired.

On 09/19/17 at 1:30 p.m., S9Phlebotomist stated that she was over infection control activities at the hospital. She further confirmed that there was no documented evidence that infections were identified as Hospital Acquired or Community Acquired.

2) Review of the Infection Control, Prevention Strategy and Action Plan for 2016 and 2017 revealed "Investigating Potential Outbreak: Implement control and prevention measures...initiate or maintain surveillance...communicate findings"

Review of the Infection Control Committee Meeting Minutes dated 06/30/17 revealed for New Business: potential of bed bugs on the unit". The action plan was for a pest control company to be called to spray unit and maintenance was to remove and dispose of mattresses in the rooms that there had been complaints. Further review of the Meeting Minutes for July 2017 and August 2017 revealed there failed to be a follow-up evaluation conducted to ensure the insects were eradicated.

Observations made during the environmental tour on 09/18/17 at 10:00 a.m. revealed live and dead insects were seen throughout the in-patient units and administrative suites.

On 09/20/17 at 10:00 a.m., interview with S1Administrator confirmed that he was aware that the hospital had issues with bugs and insects.

3) Review Infection Control, Prevention Strategy and Action Plan revealed in part "Personal Protective Equipment (PPE), Objective: The hospital will have a competency based training program for use of PPE. Hospital will regularly audit adherence to proper PPE selection and use including donning and doffing. Strategies: Training will be provided to all personnel who use PPE upon hire and at least annually...Audits will be conducted bi-weekly through direct observation and intervention will e given when non-adherence is observed. Data will be collected and analyzed.

Review of the infection control audits revealed the only facility monitoring was for hand hygiene. No documentation related to the use and training related to PPE was completed as indicated in the Infection Control Program.

Based upon record review and interviews, the Administrator, Chief Nursing Officer, Medical Staff and Director of Nursing failed to take responsibility for the hospital-wide Quality Assessment/Performance Improvement (QA/PI) Program related to the Infection Control Program. This was evidenced by: 1) the failure to ensure the Infection Control Officer had the education and training to implement infection control activities as identified in the Infection Control Program and 2) the failure to ensure Infection Control activities were included in the monthly QA/PI activities and a correction plan was implemented and evaluated to ensure infection control practices were followed.
Findings:

Interview with S1Administrator and S2CNO on 09/18/17 at 1:35 p.m. revealed S5DON was identified as the Infection Control Officer. On 09/19/17 at 1:25 p.m. a telephone interview with S5DON revealed she had returned to hospital employment in February 2017, was not the Infection Control Officer and was not performing any infection control surveillance. Further interview with S5DON revealed she indicated S9Phlebotomist the responsible for Infection Control.

Review of the personnel file for S9Phlebotomist revealed there failed to be documentation she was responsible for the Infection Control Program or had the necessary education and training in order to administer the program.

Review of the QA/PI program data revealed from January 2017 to August 2017 the only data collected and reported was in June 2017. Further review of the QA/PI data revealed for Infection Control HAI (Health-care Associated Infections) was to be monitored; however, there was no data documented.

Based on record review and interview, the hospital failed to have a director of respiratory care services who is a doctor of medicine or osteopathy with the knowledge, experience and capabilities to supervise and administer the service properly.
Findings:

Review of the hospital's organizational chart, medical staff minutes and governing body minutes revealed no documented evidence that a doctor of medicine or osteopathy had been identified or appointed as director of respiratory services.

On 09/20/17 at 1:30 p.m., an interview with S1Administrator confirmed there was no physician appointed as director of respiratory services.

Based on observations, record reviews and interviews, the hospital failed to meet the Condition of Participation specified in the following:

1. 482.21 (Quality Assurance/Performance Improvement)
A) Failure to identify and report opportunities for improvement related to health outcomes, patient safety, and quality of care, and the failure to take actions related to performance improvement, implement corrective actions, and track performance to ensure improvements were sustained. {See findings at Tag A0273};

B) Failure to ensure the Quality Assurance/Performance Improvement (QA/PI) Program was ongoing and measured, analyzed, and tracked activities. Review of the QA/PI Program data revealed the only month the indicators were tracked was in June 2017. {See findings at Tag A0286};

C) Failure of the Governing Body to ensure the hospital's QA/PI Program was maintained, on-going and involved all departments and services from January 2017 through May 2017 and July and August 2017. {See findings at Tag A0308};

D) Failure of the Governing Body, Medical Staff, and Administrative Staff to assume responsibility for the Quality Assurance/Performance Improvement Program and ensure the program was implemented and maintained to ensure quality indicators were reviewed and addressed priorities for improved quality of care and patient safety. {See findings at Tag A0309}

2. 482.22 (Medical Staff)
A) Failure to ensure the medical staff conducted periodic appraisals of its members for 5 of 5 credentialing files reviewed (S17MD, S21MD, S22MD, S23MD, S24MD). {See findings at Tag A0340};

B) Failure to ensure the medical staff examined the credentials of candidates of the medical staff membership and made recommendations to the governing body for appointment/reappointment for 5 of 5 credentialing files reviewed (S17MD, S21MD, S22MD, S23MD, S24MD). This was evidenced by:
a) Failing to ensure the appointment/reappointment of practitioners which resulted in them providing care and treatment to patients in the hospital without delineation of privileges and written approval for appointment/reappointment to the medical staff and
b) Failing to ensure credentialing files contained all supporting documents for examination by failing to obtain peer references, CDS and DEA licenses or proof of liability insurance. {See findings at Tag A0341};

C) Failure to ensure the medical staff enforced the by-laws adopted by the medical staff as evidenced by failing to ensure that an effective system was in place for addressing approximately 300 delinquent medical records greater than 30 days. {See findings at Tag A0353}

3. 482.26 (Radiology Services)
A) Failure to ensure the contract service for radiology identified what type of radiological services were offered. The contract also failed to identify the turn-around times for STAT radiological services. {See findings at Tag A0529};

B) Failure to ensure a full-time, part-time or consulting radiologist supervised the radiological services. {See fndings at Tag A0546}

4. 482.42 (Infection Control)
A) The failure to: a) designate in writing an individual as its infection control officer responsible for the infection prevention and control program; b) ensure the individual had ongoing education and training to oversee the infection control program; and c) implement hospital infection control policies.{See findings at Tag A0748};

B) The failure to: a) identify infections documented on the infection control log and indicate if the infections identified and treated were hospital acquired or community acquired; b) maintain a sanitary environment related to pest control; and c) maintain active infection control surveillance. {See findings at Tag A0749};

C) The failure of the Administrator, Chief Nursing Officer, Medical Staff and Director of Nursing to take responsibility for the QA/PI Program by: a) the failure to ensure the Infection Control Officer had the education and training to implement infection control activities as identified in the Infection Control Program and b) the failure to ensure Infection Control activities were included in the monthly QA/PI activities and a correction plan was implemented and evaluated to ensure infection control practices were followed. {See findings at Tag A0756}.

Based on record review and interview, the hospital failed to provide adequate numbers of qualified professional, technical and consultative personnel to formulate written individualized treatment plans for 5 of 5 patients' treatment plans reviewed in a total sample of 10 (Patient #1, 2, 3, 5, 7).
Findings:

Review of the hospital policy and procedure titled, Treatment Planning-Protocol for Interdisciplinary Individualized Master Treatment Plans, revealed in part that the initial treatment team shall be scheduled within 7 days of the patient's admission. Treatment planning meetings will be attended by the primary physician or designee, RN and LCSW/Therapist. Others such as pharmacy, nutritional services, activity/recreational therapists and medical consultants will attend as indicated. The LCSW/Therapist will facilitate the treatment planning meeting process. The treatment planning format includes: signature sheet which includes team signatures indicating approval of entire plan by the physician and treatment team members.

Patient #1
Review of Patient #1's Master Treatment Plan revealed that it was initiated on 09/09/17. There was no documented evidence that the physician was involved in the formulation of the initial treatment plan. Further review revealed the treatment plan was updated/reviewed on 09/13/17. There was no documented evidence that the Registered Nurse or physician was involved in the update of the master treatment plan.

Patient #2
Review of Patient #2's Master Treatment Plan revealed that it was initiated on 09/14/17. The treatment plan was signed by the activity therapist and the counselor. There was no evidence that the Registered Nurse or physician was involved in the formulation of the treatment plan.

Patient #3
Review of Patient #3's Master Treatment Plan revealed that it was initiated on 09/11/17 (admit). The treatment plan was signed by the RN and the activity therapist. There was no evidence that the LCSW/therapist or physician was involved in the formulation of the treatment plan. Further record review on 09/19/17 revealed that the master treatment plan had not been reviewed/updated since it was initiated on 09/11/17.

Patient #5
Review of Patient #5's Master Treatment Plan revealed that it was initiated on 09/13/17 (admit). There was no evidence that the physician or LCSW was involved in the formulation of the initial treatment plan.

Patient #7
Review of Patient #1's Master Treatment Plan revealed that it was initiated on 08/16/17 (admit). There was no evidence that the physician or LCSW was involved in the formulation of the initial treatment plan. Further review revealed no documented evidence that the treatment plan was updated or reviewed since it was initiated on 08/16/17.

On 09/19/17 at 10:30 a.m., interview with S3RN revealed that the registered nurses are supposed to be involved in the treatment team meetings, but are unable to routinely participate due to staffing issues. She further stated that she rarely gets to be involved in treatment team meetings.

On 09/19/17 at 3:45 p.m., interview with S4LCSW revealed that the Registered Nurse, physician and the patient should be involved in the development of the treatment plans. At this time, she reviewed the above treatment plans and confirmed that there was no documented evidence that all required staff was involved in the development or updates of the treatment plans. She further confirmed that there was no documented evidence that the patients were involved in the development of their treatment plans.







20310

Based on record review and interview, the hospital failed to ensure that inpatient psychiatric services were under the supervision of a clinical director, service chief, or equivalent who is qualified to provide the leadership required for an intensive treatment program.
Findings:

Review of the physician list provided by S1Administrator as current revealed that S27MD was listed as the Clinical Director of the hospital.

On 09/18/17 at 4:12 p.m., S1Administrator and S2CNO was asked by the survey team the name of the Clinical Director. They stated that S27MD was the Clinical Director as well as the Medical Director of the hospital. When asked if S27MD was board certified in psychiatry or neurology, they stated no. When asked if he was involved in treatment team leadership, on-call provisions of emergency psychiatric treatment or individual, group or family therapy, they stated no.

Based on record review and interview, the clinical director, service chief or equivalent must meet the training and experience requirements for examination by the American Board of Psychiatry and Neurology, or the American Osteopathic Board of Neurology and Psychiatry.
Findings:

Review of the physician list provided by S1Administrator as current revealed that S27MD was listed as the Clinical Director of the hospital.

On 09/18/17 at 4:12 p.m., S1Administrator and S2CNO was asked by the survey team the name of the Clinical Director. They stated that S27MD was the Clinical Director as well as the Medical Director of the hospital. When asked if S27MD was a board certified in psychiatry or neurology, they stated no. S1Administrator then stated that S17MD was the Clinical Director of the hospital.

Review of the credentialing file for S17MD revealed no documented evidence that she was appointed as Clinical Director of the hospital.

On 09/20/17 at 1:45 p.m., S1Administrator was asked to provide documented evidence that S17MD had been appointed and was acting as Clinical Director of the hospital and he stated that he had no evidence.

Based on record review and interview, the hospital failed to have available psychological services to meet the needs of the patients as evidenced by failing to have current credentialing documents for 2 of 2 psychologists contracted by the hospital (S18Psychologist, S20Psychologist).
Findings:

Review of the list of providers that are credentialed by the hospital revealed S18Psychologist and S20Psychologist were listed as current providers.

On 09/18/17 at 2:00 p.m. and on 09/19/17 at 10:30 a.m., requests were made to review the credentialing files for S18Psychologist and S20Psychologist.

On 09/20/17 at 9:00 a.m., the credentialing file for S18Psychologist was provided. Review of this file revealed the only included documents was an expired license and expired insurance.

On 09/20/17 at 1:45 p.m., S1Administrator confirmed that he was unable to provide any further information because the files were at the corporate office in another city and S8Human Resources had scanned everything over that she had. As of exit on 09/20/17, the file for S20Psychologist had not been provided to the survey team.