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Based on review of facility documents, committee meetings minutes, and staff interviews, the facility failed to thoroughly measure, analyze, and track quality indicators, including adverse patient events and other aspects of performance that assessed processes of care, hospital services, and operations. Specifically, the facility failed to ensure that complaints and grievances were handled in an efficient manner and integrated into the Quality Assessment and Performance Improvement Program. This failure created the potential for a negative patient outcome and did not ensure identified patient issues were addressed in a quality manner.

The findings were:

A list of patient complaints was requested on 8/15/11. The Manager of Patient Relations, who also works as a Patient Representative/Advocate, stated that such a list was not possible to print at that facility. A list of grievances was requested, provided, and reviewed. This list did not contain the name of sample patient #3.

A tour of one of the facility's outpatient offsite urgent cares was conducted on 8/16/11. In an interview with the urgent care's manager at approximately 9:15 a.m., s/he stated that a "complaint" had been filed in regards to sample patient #3. Later review of the complaint revealed documentation within by the facility's other Patient Rep/Advocate of correspondence with the Urgent Care's Manager stating that the complaint was a grievance. However, follow through and letters were never completed according to the facility's grievance policy.

On 8/16/11 at approximately 12:50 p.m., the facility Chief Medical Officer (CMO), who also acts as the Patient Safety Officer, was asked about the grievance regarding sample patient #3. S/he stated, "I never was sent the letter [from the complainant which was addressed to the CMO]. That is a breakdown in our system... Clearly I should have gotten a copy of that letter... There was more in it than the bill and it looks like that piece (regarding physician care) was totally dropped..." The CMO explained that up until 18 months ago, the Pt Representatives had reported to the CMO and that they now report to the Vice President of Customer Experience. He stated, "It would be expected that if [s/he] had an issue like this it would go to more than [his/her] department. Most of this information will get bounced off [the Chief Nursing Officer] or myself. The big breakdown here is that I was not involved..."

An interview with the Manager of Patient Relations was conducted on 8/16/11 at approximately 1:20 p.m. When asked about follow-up of each grievance, s/he stated, "I keep a folder and [the other Patient Rep] does and we look through it weekly. At the end of the month, we look to see if any are outstanding." When asked about how this process ensures the timely resolution of grievances, s/he stated that the computer program currently used for complaints only allows access by both of the Patient Reps. S/he stated, "We are the ones dogging the managers... sometimes we make daily phone calls." When asked how a grievance is resolved if it is related to more than one department, s/he stated, "If it is a multi-faceted grievance, we stay on top of it and write the letter... but if it is a simple one that a manager can turn around, they do the investigation and letter... but honestly, we don't have time [to write letter for each grievance]. They know their staff..." It was confirmed that the Patients Reps still need to physically follow-up and track each complaint/grievance within their computer system. When asked specifically about sample #3's grievance, s/he stated, "I would have counted this as a grievance..." The Manager of Patient Relations confirmed all the timeframes of the grievance process and knowledge of the urgency of patient relations and written correspondence.

When the CMO was asked what process occurs if the grievance is related to the medical care of patient, s/he stated, "If we have a grievance related to a physician, either he [the Medical Director] will get it or I'll get it... Medical Directors are frequently in the position to get information very quick..." It was noted that each complaint and/or grievance may necessitate input from several different individuals and require coordination of such. Further interview was conducted with the CMO at approximately 5:00 p.m. The CMO, as the Patient Safety Officer, was the chair of the Grievance Committee. When asked about the committee's process, s/he stated that the Manager of Patient Relations "provides a list of complaints and breaks it down into categories... so we can see physician complaints, nursing complaints, billing issues..." S/he continued, "Then we go through a list of specific complaints or grievances and address..." When asked if s/he actually sees each complaint, the CMO stated, "Apparently we don't have a spreadsheet about grievances or complaints except the number of them in each category... We use the Patient Rep Summary Report to look for trends." A Summary Report was provided by the CMO and reviewed. The categories listed the type of complaint, number in each category over a certain time period, and percentage total.

When the CMO was asked about integration of complaints and grievances into the Quality Assessment and Performance Improvement Program, s/he stated, "We sort things out as to if this is really a RCA, what actually happened..." S/he stated that they look at trends by the number of complaints in each category. However, it was noted that there were only forty categories for the entire 522 bed facility health system, therefore many complaints may not necessarily be entered into the correct broad category, leaving room for error in trending unless each complaint is looked at specifically. When asked who's responsibility it was to report to one of the Quality Assurance committees, s/he stated, "It would be me. Often it is already reviewed by [the DON] or myself. If there is any investigation, it will involve [the Quality Director]. Those that uncover a system issue, would be taken to CEC or Patient Safety Committee." The CMO was also the chair of the Patient Safety Committee.

An interview with the Director of Clinical Effectiveness was conducted on 8/16/11 at approximately 5:00 p.m. When asked about his/her involvement with grievances, as s/he is the head of the facility's entire QAPI program, s/he stated, "I don't participate in the grievance committee. You'd have to ask [the CMO.] There is no trigger to get QA involved unless [the Manager of Patient Relations] identifies it... It only goes to our department if triggered by [the Manager] or if discussed at the Grievance Committee and brought to us."

An additional interview was conducted with the CMO the following day, 8/17/11 at approximately 8:45 a.m. When asked about the grievance that fell through the system, s/he stated, "It makes us look at our entire grievance process. It is not reliable. There clearly needs to be better record keeping." Maybe the structure needs more clinical input. "I look at complaints as one of a variety of sources to improve our processes." When asked further the Quality and Patient Safety Committee, which the CMO chairs and is where grievances would be reported should they go further, s/he stated, "We are less involved in the grievance portion... The main connection between grievances and Quality is [the CNO] or myself." It was confirmed that the Director of Clinical Effectiveness (QAPI) did not attend the meetings. When asked about grievances which eventually did get incorporated into Quality, s/he stated, "We had a big grievance that we changed our processes and I don't know where that is documented..." In further clarification about review of complaints by someone other than the Patient Representative, s/he stated, "There is not a single repository where everything can go together and we can see when it is in the process." It was confirmed that only the patient representatives see every complaint that comes into the facility until they are delegated to other individuals.

A review of the Quality and Patient Safety Committee meeting minutes from the past two months revealed that grievances and complaints were not an agenda on any of the meetings. Additionally, review of the CEC (Clinical Effectiveness Council) meetings, where Quality and Patient Safety Committee funnels to, for the past four months revealed that grievances and complaints were not addressed at those meetings either.

In summary, the facility failed to have a readily accessible complaint log, a usable integrated complaint and grievance documentation system, distinct quality oversight of patient complaints and grievances, and an efficient manner in which to ensure each complaint was identified and treated as a grievance when such was the case.

Based on review of facility documents, meeting minutes, policy/procedure, and staff interviews, the facility failed to use data collected to identify opportunities for improvement and changes that would lead to improvement. Specifically, the facility failed to clearly integrate their Patient Safety and Performance Improvement Programs as well as ensure Patient Safety documents were consistently available to reflect the final resolution of their processes. These failures created the potential for a negative outcome.

The findings were:

On 8/15/11, a review of the "Performance Improvement Flowchart" within the facility's "Organizational Performance Improvement and Patient Safety/ Risk Management Plan" revealed that the three following committees were each separate from each other: Department Indicator Specific CQI Team, CEC Council, and Quality/ Patient Safety Committee. The Plan described the Clinical Effectiveness Committee (CEC) as "a leadership committee that is delegated responsibility by the Community board for ongoing oversight of safety improvement activities via periodic reports from individuals or groups accountable for implementation of quality and patient safety efforts at Medical Staff, Quality Improvement, Nursing leaders, and clinical ancillary department leaders..." The Plan described the Quality/ Patient Safety Committee (QPSC) as follows: "The CEC delegates quality and patient safety improvement efforts to the QPSC. The QPSC is an organization-wide multidisciplinary committee with representation from departments with responsibility for aspects of patient and employee safety. The QPS responsibilities include the following: ...Coordinates and oversees data collection, analysis, reporting (internal and external), improvement, and follow-up activities related to quality and patient safety... Reports activities on an on-going basis to the CEC..."

A review of the Quality and Patient Safety Committee Meeting minutes revealed that several issues and incidents were discussed at each meeting. However, the minutes did not fully reflect process flow, performance improvement actions, and monitoring for each item addressed at the meeting. A review of the CEC Meeting minutes revealed that each item addressed at the QPSC meeting were not addressed or taken up to the CEC meeting. For example, the meeting, dated 5/18/11, stated the following in the "Data Review- Patient Safety section: Information provided but not discussed due to time constraints." Additionally, the "Actions taken" portion of the minutes stated "Ongoing discussion" in each section." The only section that had a "Person(s) responsible for follow-up" assigned was "Drug Shortages." There was no evidence as to how Patient Safety issues were incorporated into the Quality Assessment and Performance Improvement Program for follow through and monitoring.

On 8/15/11 at approximately 2:20 p.m., the Director of Clinical Effectiveness was asked if the Quality Program had any further meeting minutes or committees that could be reviewed. S/he stated, "We stop at CEC for our Quality and then the CMO, CNO, etc go to JC (Centura Joint Council) at Centura." At approximately 3:10 p.m., several incidents from the QPSC were reviewed with the Director of Clinical Effectiveness, as the meeting minutes did not reflect a complete QAPI process. The Director had some knowledge of the issues, but referred the surveyor to the Patient Safety/ Risk Manager for further data and follow through.

An interview with the Patient Safety/ Risk Manager was conducted on 8/16/11 at approximately 11:30 a.m. Several cases were discussed at length in order for the surveyor to understand the follow-through and actions taken. When asked about monitoring for one case, a telemetry box issue, s/he stated, "They put in an occurrence report anytime an incorrect tele box is done... We did not set up auditing as one of our action items..." When asked about the QPSC meetings, which the Chief Medical Officer is the chair, and minutes, which were not fully reflective of the issues, s/he stated, "A lot of verbal and overhead projector information is at the meetings...." When informed that this information is not evident, s/he stated, "I can talk with our minutes person... All of these points have hand outs that go with them... We are very specific as to what Patient Safety does... We've had adverse events related to all of these PI issues..."

Another interview was conducted with the Director of Clinical Effectiveness on 8/16/11 at approximately 4:10 p.m. When asked about monitoring due to the issue with the tele box, s/he stated that monitoring would be done by incident reports (which staff report after the incident). S/he continued, "Once this gets established [further education/ processes] and all done, the tracking piece will be part of this... We can't do it electronically, so we do SBARQ (Situation Background Assessment Response Questions) audits. We can do chart reviews only retrospectively but can monitor the PACU prospectively." The Director was able to provide evidence of a plan to essentially check-out each tele box in the PACU. The Director also found documentation that the final "done date" was to be 8/23.

When asked further about the integration of Patient Safety items into the QAPI program, s/he stated, "We cover outstanding RCA info at Pt Safety... the [CNO] and [CMO] are there... I don't do PI projects on all of them." S/he stated that they deal with the issues each differently and may conduct process changes, data collecting, or monitoring. When asked further about the QPSC meeting, s/he stated, "We only meet two times per month... We don't go through every action item or every follow-up unless we are missing information." S/he stated that the type of incident which occurred would determine where the incident is dealt with and monitoring, for example patient identification issues would "go through Red Rules Committee." The facility had a very large and comprehensive Performance Improvement (PI) Program which was clearly evidenced via documentation and data, however, the Director was asked to describe some issues which were identified as a problem within the facility wherein active PI and monitoring were being conducted. S/he listed pain, sterilization, and falls, which had all been issues with the facility. When asked about the oversight the Director provides, s/he stated that s/he was over three staff in Patient Safety/ Risk, six staff in Regulatory/ Quality Assurance, and three staff in Infection Control. The Director was further asked about the integration of Patient Safety items into the QAPI program. S/he stated that s/he did sit at the QPSC meetings and that "we have so much that we address at these meetings and are trying to go more paperless..."

A joint interview was conducted with the Director of Clinical Effectiveness and the CMO on 8/17/11 at approximately 9:00 a.m. The organizational flow of the facility's entire QAPI Program was discussed. The Director was asked was occurred if issues/ incidents addressed at the Patient Safety meeting needed further PI monitoring, s/he stated, "I would delegate to Infection Control, Core Measures, etc... When asked what happened if it was an issue that didn't fall into one of those categories, s/he stated, "Then I would address the issue." The CMO stated, "...With Patient Safety, we spend the majority of our time with incidents." The Director stated that the Patient Safety team is effective in that they all divide up the work list and then each have a ten minute meeting everyday to address the issues, however this flow and process was not evidenced. The Director of Clinical Effectiveness and the Patient Safety/ Risk Manager then obtained their laptop computer to show the "Patient Safety Summary Sheet" that is displayed on an overhead during each meeting. When asked about different items, they both explained that some were delegated to Infection Control, some under "Claims folder," some information in the RCA form, etc. When asked where the complete documentation could be found on each item, they described the different areas it would be found, such as the "Claims folder, infection control folder, RCA form," etc. The Patient Safety/ Risk Manager stated, "A lot of the discussion happens at the Patient Safety Committee... A representative from each department is present as well as [the CNO and CMO]," indicating that most departments are knowledgeable of the issues.

In summary, the facility failed to ensure that Patient Safety and Performance Improvement were clearly integrated. The facility's QAPI program policy stated the QPSC would "follow-up activities related to quality and patient safety" and such was not easily evidenced. If a patient incident/ issue occurred, was identified by the facility, required quality follow-through, and did not fit into one of the pre-determined PI programs, the QAPI Director would have to address and deal with the issue. Despite that the Director of Clinical Effectiveness/ QAPI Director and Patient Safety Officer/ CMO both attend the Quality/ Patient Safety Committee, there was no otherwise clear channel of identified opportunities for improvement into the Performance Improvement program. Instead, the QPSC and PI programs reflected as separate entities, whether due to a poor documentation system and coordination of projects or due to the lack of integration is not fully known.

Based on review of facility documents, committee meetings minutes, and staff interviews, the facility failed to ensure adequate resources were allocated for measuring, assessing, improving, and sustaining the hospital's performance. Specifically, the facility failed to have an efficient process to review complaints and grievances. This failure created the potential for a negative outcome.

The findings were:

Cross Reference to A0267 - Qapi Quality Indicators for findings related to the facility's failure to thoroughly measure, analyze, and track quality indicators, including adverse patient events and other aspects of performance that assess processes of care, hospital services, and operations.

Based upon review of the facility policies and procedures, medical records and staff interviews it was determined that the facility failed to ensure the legibility of medical records. This failure created the potential for negative outcomes and continuance of potential deficient practices.

The findings were:

The policy and procedure regarding legibility reads as follows:
PENROSE-ST. FRANCIS HEALTH SERVICES INTERDISCIPLINARY PRACTICES
SUBJECT: Legibility Issues with effective date 9/09 states in PERTINENT part: "PRACTICES: B. If two (2) people cannot read handwritten documentation, it is illegible."

On 8/16/11 at approximately 3:30 p.m., one of 20 medical records reviewed was not legible. The record was given to the CMO (Chief Medical Officer) and the DON (Director of Nurses) for review; neither could read the hand written documentation in the "PROGRESS notes" of the patient medical record. The DON enlarged the medical record document view by approximately one hundred percent but was still unable to read the handwriting. The DON then requested the assistance of a "senior" RN staff member to write the handwritten note, s/he was unable to re-write the note in its entirety. On 8/16/11 at approximately 12:30 p.m., the progress note was forwarded to the physician who documented in the medical record. During the telephone interview, on 8/16/11 at approximately 2:30 p.m., the physician stated, "this is hard for me to read."

Based on the nature of deficiencies, the facility failed to be in compliance with the Condition of Participation of Outpatient Services. Specifically, the hospital failed to ensure that outpatient services were organized and integrated in the functions of the hospital to ensure that the services meet the needs of the patients in accordance with acceptable standards of practice in the areas of nursing and laboratory services and the contracted cardiac catheterization lab.

The facility failed to meet the following Standards under the Condition of Outpatient Services:

Tag A 1077 Integration of Outpatient Services
The hospital failed to ensure that outpatient services were appropriately organized and integrated with hospital standards in the provision of nursing care and laboratory specimen collection and point-of-care testing in all outpatient services areas. The hospital also failed to maintain personnel files and a plan for provision of care/services for the contracted cardiac catheterization lab.

Tag A 1079 Outpatient Services Personnel
The hospital failed to ensure that one individual was responsible for all outpatient services, as required.

Based on a tours/observations, review of organizational charts, position descriptions, facility documents, personnel files and staff interviews, the hospital failed to ensure that outpatient services were appropriately organized and integrated with inpatient services in the provision of nursing care to outpatient services. Specifically, numerous outpatient services areas that relied heavily on nursing care to deliver patient services were not under the direct oversight of the department of nursing or in a direct reporting relationship to the chief nursing officer. In addition, the hospital failed to ensure adequate laboratory services oversight of supplies for blood specimen collection and point-of-care testing in an urgent care center and the contracted cardiac catheterization lab. The hospital also failed to ensure that the contracted cardiac catheterization lab was incorporated into the provision of services plan for the facility. Finally, the hospital failed to maintain personnel files that contained evidence of qualifications, licensure, orientation, and evidence of on-the-job training in the principals, the policies, the procedures, and the techniques involved in care of patients in a contracted cardiac catheterization lab, as required by state licensure regulations. The failures created the potential for negative patient outcomes.

The findings were:

1. Review of hospital organizational charts throughout the survey revealed that at least three different administrators were overseeing parts of the outpatient services of the hospital. The chief operating officer was responsible for the outpatient rehabilitation clinics, the cancer center, the cardiovascular services (including the contracted cardiac catheterization lab), all surgical services including outpatient surgical services, and the laboratory and radiology/imaging services, including their outpatient services. Review of the organizational charts further revealed that the urgent care clinics were under the oversight of the chief nursing officer. Per interview with the chief nursing officer, on 8/15/11 at approximately 2:10 p.m., s/he stated that s/he also had oversight over the wound care clinic and the infusion clinic. Per interview with the director of quality on 8/17/11 at approximately 8:15 a.m., s/he stated that the chief business development officer was in charge of women's services, which s/he later confirmed included the wound care clinic. S/he further confirmed that neither the chief operating officer nor the chief business development officer had any clinical professional training, including nursing.

Interviews with the chief operating officer on 8/16/11 at 4:30 p.m., and the chief nursing officer on 8/15/11 at 2 p.m., and during subsequent interviews, confirmed that nursing did not have line authority to exercise control and oversight of the nursing care provided in many of the outpatient services areas, including the "service lines" of surgical services, cardiovascular services (including the contract cardiac catheterization lab) and the wound care clinic. The chief operating officer stated that the chief nursing officer was expected to maintain quality nursing care standards in those areas, despite the fact that the nurses in those "services lines" reported ultimately to non-clinical managers with a management or business background. Review of the written responsibilities of the "Manager RN" of the cardiovascular "service line" revealed that the "Manager RN"/nurse had no reporting responsibility to the chief nursing officer of the hospital. Review of the position descriptions for the surgical services "service line" revealed that they contained no reporting responsibility to the chief nursing officer. Interview with the chief nursing officer on 8/17/11 at approximately 10:15 a.m., revealed that the recent changes in the reporting structure for some of the outpatient services in which nursing care was provided did not incorporate reporting responsibility to him/her into the organizational charts and position descriptions. S/he reviewed the organizational charts of the cardiovascular and surgical services "service lines" and confirmed that although s/he did participate in some meetings with those "service lines," the nurses in those areas did not have a direct reporting relationship to him/her as the chief nursing officer and leader of the organization of nursing services for the hospital.

During the interview with the chief operating officer on 8/16/11 at 4:30 p.m., s/he stated that the surgical "service line" was going to be under a manager that did not have clinical training. S/he stated that that manager would have a director of nursing for surgical services that reported to that manager, rather than the chief nursing officer of the hospital. S/he stated that they had recently interviewed for and hired a nurse for the director of nursing position. S/he stated that the director would be starting later in the year. When asked s/he confirmed that the chief nursing officer of the hospital had participated in the interview process. During a subsequent interview, on 8/17/11 at approximately 10 a.m., with the chief nursing officer of the hospital, s/he confirmed that s/he had participated in the hiring of the director of nursing for surgical services. S/he stated that they were "up-front" during the interviewing process with applicants about the reporting relationships. S/he stated that they lost several strong applicants, because they were not comfortable taking the position since there was not a direct reporting relationship to the chief nursing officer of the hospital. When asked about his/her comfort level with the restructuring of reporting relationships for key areas that provided nursing care, s/he appeared reluctant to share his/her concerns, but did acknowledged that s/he felt responsible for those areas, but no longer had control to ensure that s/he received adequate information and inclusion in decisions that effected nursing care, and ultimately patient care.

2. On 8/16/11 at approximately 8:30 a.m., a tour of an urgent care clinic located in a mountain community west of the hospital was conducted. During the tour of the point-of-care testing/blood specimen collection room, several problems were observed related to labeling of lab test control/reagent bottles to track for expiration dates after the kits/bottles had been opened. The findings were:

In the lab refrigerator, a red-topped control/reagent bottle with a hand written label "opened 7/4/11" and a blue-topped control/reagent bottle with a hand written label "opened 7/7/11" were observed. The lab assistant stated that they were instructed by the hospital lab that the bottles expired 90 days after being opened, per manufacturer directions.
Two glucometer control bottles were observed with a hand written label "expired 8/23/11." It was unclear whether that reflected the 90-day expiration calculation or the 28-day expiration date which is the usual standard for expiration of multi-use vials and other testing supplies.
The chief nursing officer acknowledged during that lab observation that the two above examples reflected inconsistent label practices that could lead to confusion about accurate expiration dates.

The final problem with testing involved kits for rapid strep testing. The tests came in a box that contained 4 different control/reagent bottles lined up in a plastic tray. None of the bottles or the box/tray were labelled to identify when they were opened to calculate expiration dates. The box/tray also contained additional bottles of all four of the different controls/reagents. They were obviously not part of the kit that was contained in the box/tray because there was an indentation in the tray for each of the four bottles to be stored with the kit and ready for use. The extra bottles appeared to be "left-overs" from previous kits. They also were not labeled for open or expiration date. These findings were also confirmed with the chief nursing officer at the time of observation. S/he later provided information from the hospital lab that the boxes were supposed to be labeled when they were opened and that the strep test box we had observed had not been labeled, as required.

On 8/15/11 at approximately 3 p.m., a tour of a contracted cardiac catheterization lab located within the hospital was conducted. During a tour of the cardiac catheterization lab, a tour of the point-of care lab testing area and inspection of related supplies was conducted. Inspection of blood collection tubes revealed three light green topped tubes with past-due expiration dates. One tube expired 5/2011, a second expired 6/2011, and the third tube expired 7/2011. A nurse from the lab stated that the hospital's lab supplied the equipment and supplies for the cardiac catheterization lab and that they checked supplies to ensure they were not expired. S/he stated that the hospital lab's point-of-care staff member came over monthly to oversee their point-of-care testing in the cardiac catheterization lab, to inspect supplies and insure controls were being done regularly and correctly.

3. Review on 8/16/11 of the hospital-wide manual titled "Plan For the Provision of Care or Service," which contained a scope of services for each area of the hospital, revealed that the manual contained no plan for the contracted cardiac catheterization lab. This finding was confirmed, on 8/17/11 at approximately 10 a.m., with the chief nursing officer, who stated s/he had been in contact with the contracted cardiac catheterization lab and they were unable to locate such a document for that area.

4. On 8/15/11 at approximately 3 p.m., a tour of a contracted cardiac catheterization lab located within the hospital was conducted. During a tour of the lab, a nurse was questioned about staff personnel file and the reporting relationships within the lab and with the hospital. S/he stated that the lab was a separate entity which maintained its own human resources department and maintained the staff personnel files there. S/he stated s/he was an employee of the cardiac catheterization lab, not the hospital. That was confirmed by the chief nursing officer of the hospital, who was accompanying the surveyor of the tour of the lab.

On 8/16/11 at approximately 4:30 p.m., the chief operating officer of the hospital was interviewed. During the interview it was confirmed that the chief operating officer was the hospital manager that had ultimate responsibility/oversight for the contracted cardiac catheterization lab. S/he confirmed that the personnel files for the clinical staff were maintained by the lab's human resources department. S/he stated that the hospital had an agreement that allowed the hospital to arrange for access to personnel files maintained by the lab, in necessary.

On 8/17/11, a sample personnel file from the contracted cardiac catheterization lab, which was provide by the lab, was reviewed. Review of the personnel file of the lab staff member, who was a registered nurse, revealed the following findings:
The file contained a job description/evaluation for the nurse. The job description/evaluation contained the letterhead of the contracted cardiac catheterization lab and was signed by the onsite manager of the lab. The file contained documentation of a current nursing license, and certifications for BLS (basic life support) and ACLS (advanced cardiac life support). The file contained some skills checklists related to conscious sedation and respiratory support. All skills tests contained no letterhead, so it was not clear whether they were lab or hospital documents. The file contained no evidence of orientation to the hospital, or ongoing participation in hospital competencies and policy/procedure updates. Those findings were confirmed with the chief nursing officer of the hospital on 8/17/11 at approximately 8:20 a.m.

Based on review of organizational charts, meeting minutes, job descriptions and staff interview and other facility documents, the facility failed to ensure that one individual was responsible for all outpatient services, as required.

The findings were:

1. Review of hospital organizational charts throughout the survey revealed that at least three different administrators were overseeing parts of the outpatient services of the hospital. The chief operating officer was responsible for the outpatient rehabilitation clinics, the cancer center, the cardiovascular services (including the contracted cardiac catheterization lab), all surgical services including outpatient surgical services, and the laboratory and radiology/imaging services, including their outpatient services. Review of the organizational charts further revealed that the urgent care clinics were under the oversight of the chief nursing officer. Per interview with the chief nursing officer, on 8/15/11 at approximately 2:10 p.m., s/he stated that s/he also had oversight over the wound care clinic and the infusion clinic. Per interview with the director of quality, on 8/17/11 at approximately 8:15 a.m., s/he stated that the chief business development officer was in charge of women's services, which s/he later confirmed included the wound clinic.

2. Interviews with the chief operating officer, on 8/16/11 at 4:30 p.m., and the chief nursing officer on 8/15/11 at 2 p.m., and during subsequent interviews, confirmed that no one person was responsible for oversight of all outpatient services, as required.