HospitalInspections.org

Based on interview and record review, the governing body failed to maintain Truman Medical Center (TMC)-Lakewood as a hospital that was separate and distinct from other entities encompassing the TMC Health System. The Conditions of Participation were integrated with other separately certified hospitals within the health system. The facility census was 58.

Findings include:

1. Review of the hospital provided documents titled, "Board of Director's Meeting Minutes", dated 03/2021 through 06/2021, showed that business from both TMC-Lakewood and Hospital B (separately certified hospital), as well as other TMC Health System entities, were consistently integrated within the meeting minutes, and failed to address which actions applied specifically to TMC-Lakewood. Co-mingled topics routinely included the reappointment of medical staff members, quality assessment reports, and financial information from all sources within the TMC Health System.

During an interview on 07/22/21 at 4:00 PM, Staff III, Board Member, stated that until 06/21/2021, he had been the Board Chair for the previous four years. He stated that he was aware the TMC-Lakewood and Hospital B were separately certified hospitals. He stated that board meetings were essentially "a high-level operational review of what was happening within the hospital" and that the meetings were "generally viewed as a holistic approach, but items took on a more specific nature, if they were relevant to a specific campus". He stated that there were not individual board meetings for each separately certified hospital.

2. During an interview on 07/22/21 at 3:20 PM, Staff HHH, Board Member, stated that the governing body was responsible for the oversight of TMC-Lakewood, as well as the other entities within the TMC Health System. He further confirmed that the hospitals within the TMC Health System operated under the same set of written governing body bylaws and that there was one medical staff who functioned under one set of medical staff bylaws. He stated that there were not separate board meeting for each individual hospital. He also verified that the Chief Executive Officer (CEO) for TMC-Lakewood was appointed by TMC Health System's governing body and was responsible for all entities within the Health System.

These deficient practices resulted in the hospital's non-compliance with specific requirements found under 42 CFR 482.12 COP: Governing Body, with the potential to negatively impact the care provided to patients who receive care at the hospital. The hospital census was 58.

Based on interview and record review, the Chief Executive Officer (CEO) failed to recognize that the there must be one registered nurse (RN) responsible for the oversight of the nursing services within the hospital, and failed to recognize that the hospital's nursing services could not be operationally integrated with the nursing services of more than one separately certified hospital at the same time. This failure had the potential to negatively affect all patients throughout the Truman Medical Center (TMC) Health System. The hospital census was 58.

Findings included:

1. Review of an undated document titled, "Organizational Chart," showed that the TMC-Lakewood's Associate Chief Nursing Officer (CNO) position was vacant. The vacant position reported directly to the Corporate CNO, Staff CCC, who held corporate responsibility for the nursing services at TMC-Lakewood, Hospital B (separately certified hospital), and other entities within the health system.

Review of the undated organizational chart titled, "Lakewood," showed that the hospital's Corporate CNO did not report directly to the hospital's CEO. The Corporate CNO, Staff CCC, reported to a corporate Chief Operating Officer, who reported to a corporate Executive Chief Clinical Officer, who reported to the corporate President/CEO. The organizational chart indicated that the nursing services for the individually certified hospitals were operationally integrated.

During an interview on 6/16/21 at 2:55 PM, Staff CCC, RN, CNO, stated that she was responsible for the oversight of nursing services throughout all campuses. She stated that an available position for an Associate CNO at TMC-Lakewood had been vacant since 01/2021, and had not been filled due to budget-related issues. She also stated that since that position was vacant she had been dividing her time between the two hospitals, and that she spent two days a week at TMC-Lakewood, and three days a week at Hospital B.

During an interview on 06/17/21 at 10:38 AM, Staff FFF, CEO, stated that he was not aware that the CNO could not serve both hospitals simultaneously in that capacity.

During an interview on 07/22/21 at 3:20 PM, Staff HHH, Board Member, stated he assumed that the CNO would be responsible for nursing services at both locations, as TMC Health System did not have a CNO for TMC-Lakewood and a separate CNO for Hospital B.






























41865

Based on interview, record review and policy review, Truman Medical Center (TMC)-Lakewood failed to ensure full-time oversight by a registered nurse who was responsible for the nursing practice exclusive to TMC-Lakewood (A-036), and failed to ensure that nursing staff followed their policy for insulin (medication that regulates the amount of sugar in the blood) administration, when staff failed to have a second nurse verify the dosage prior to administration for one patient (#43) of one patient reviewed who received multiple doses of insulin (A-405).

These deficient practices resulted in the hospital's non-compliance with specific requirements found under 42 CFR 482.23 Condition of Participation: Nursing Services, and placed all patients at risk for their health and safety. The hospital census was 58.

Based on interview and record review, Truman Medical Center (TMC)-Lakewood failed to ensure full-time oversight by a registered nurse (RN) who was responsible for the nursing practice exclusive to TMC-Lakewood. Failure to ensure separate and independent organizational nursing services could impact the nursing care provided by TMC-Lakewood. The hospital census was 58.

Findings included:

1. Review of an untitled hospital document, dated 01/23/15, showed confirmation of Staff CCC, RN, in her new role as the Corporate CNO, effective 02/02/15.

Review of the hospital's undated document titled, "Organizational Chart," showed Staff CCC listed as the Corporate CNO, with a vacancy listed for the TMC-Lakewood Associate CNO position.

Review of the hospital's undated document titled, "Nursing", showed that TMC Health System co-mingled the administrative oversight of the nursing services provided by two separately certified hospitals, TMC-Lakewood and Hospital B, into a single organization. The CNO was responsible for the oversight of nursing care at both hospitals.

Review of the undated organizational chart titled, "Lakewood," showed that the hospital's Corporate CNO did not report directly to the hospital's Chief Executive Officer (CEO). Instead, the Corporate CNO, Staff CCC, reported to a corporate Chief Operating Officer, who reported to a corporate Executive Chief Clinical Officer, who reported to the corporate President/CEO.

Review of an undated document titled, "CNO Job Description", showed that the position was responsible for the following:
- Corporate administration of all aspects of the nursing service programs including the standards of nursing practice;
- Competencies and compliance with all applicable accrediting and regulatory requirements regarding inpatient, ambulatory and specialty programs;
- Administrative direction and support to the management of the department under the direction of this position;
- Collaborates with other administrators and assures accountability in the management and promotion of nursing standards of practices in other divisions where nursing practice is occurring; and
- Consults with the Chief Executive Officer (CEO) on issues of policy, development and revision.

During an interview on 6/16/21 at 2:55 PM, Staff CCC, RN, CNO, stated that she was responsible for the oversight of nursing services throughout all campuses. She stated that the Associate CNO position at TMC-Lakewood, had been vacant since 01/2021, and had not been filled due to budget-related issues. She stated that since that position was vacant she had been dividing her time between the two hospitals, and that she spent two days a week at TMC-Lakewood, and three days a week at Hospital B.

During an interview on 06/17/21 at 10:38 AM, Staff FFF, CEO, stated that he was not aware that the CNO could not serve both hospitals simultaneously in that capacity.

During an interview on 07/22/21 at 3:20 PM, Staff HHH, Board Member, stated he assumed that the CNO would be responsible for nursing services at both locations, as TMC Health System did not have a CNO for TMC-Lakewood and a separate CNO for Hospital B.





41865

Based on observation, interview, record review and policy review, the hospital failed to ensure staff prepared insulin (medication that regulates the amount of sugar in the blood) according to the hospital's medication administration policy, for one current patient (#43) of one current patient reviewed. This failure had the potential to cause harm to all patients within the facility who received insulin. The hospital census was 58.

Findings included:

1. Review of the hospital's policy titled, "Administration of Medication and Self-Administration of Medication," revised 02/13/19, showed that medications will be administered in a safe manner according to policies and procedures. The same policy instructed nursing staff to check the dosage of insulin prepared outside of the pharmacy with another nurse before insulin doses were administered to a patient.

Observation on 06/16/21 at 8:15 AM, showed Staff WW, Registered Nurse (RN), gathered medications for Patient #43, which included a scheduled dose of insulin and an additional sliding-scale insulin (the progressive increase in the pre-meal or nighttime insulin dose) dose, based on the patient's morning blood glucose result. Staff WW withdrew the insulin from the vial and administered the insulin to Patient #43 without verifying the dose with another nurse.

Review of Patient #43's medical record showed that he was admitted on 06/01/21, and received treatment for infected wounds on his left foot and diabetes (a disease that affects how the body produces or uses blood sugar, and can cause poor healing). The Medication Administration Record (MAR) dated 06/01/21 to 06/16/21, showed that the patient received 52 administrations of insulin. There was no documentation that the dosages of insulin administered were verified by a second nurse.

During an interview on 06/16/21 at 8:32 AM, Staff YY, RN, Clinical Team Manager, stated that she did not know whether the hospital's medication administration policy required insulin dose verification by a second nurse.

During an interview on 06/17/21 at 9:25 AM, Staff EEE, Pharmacy Clinical Manager, stated that she considered insulin a high risk medication, and it required dose verification by a second nurse before administration to a patient.

During an interview on 06/17/21 at 9:40 AM, Staff CCC, Chief Nursing Officer, stated that she reviewed the hospital's medication administration policy immediately prior to the interview, and verified that the policy required a second nurse verification before insulin was administered. However, nurses had been educated that this was no longer a current practice. Staff CCC added that she had oversight of all nursing policies and was responsible for any changes, updates and final approval of those policies.