HospitalInspections.org

Based on document review and interview, the facility failed to have the governing body appoint the chief executive officer (CEO), resulting in less than optimal outcomes. Findings include:

On 8/18/15 at approximately 1500, interview with the facility Director, Vice President (VP) Care Transitions, and Chief Legal counsel (via phone), revealed that the governing body structure and membership were under transition. The Director stated that he attended previous governing body meetings to present information with the Medical Director. A request for the governing body documentation specifying the CEO and/or Director was made. On 8/18/15 at approximately 1600, The VP stated that they had no such documentation. The VP presented a conditional job offer letter dated 5/13/13 signed by the 'Recruiter' of the health system. There was no evidence that the governing body appointed the CEO or the Director to manage the hospital.

Based on document review and interview, the facility failed to document evaluation of data and interventions for performance improvement, resulting in the potential for continued poor outcomes. Findings include:

Interview with the Performance Improvement Coordinator, on 8/18/15 at approximately 1300, revealed that the facility's top three priorities for performance improvement were "readmissions within 30 days, patients leaving against medical advise (AMA), and timely psychiatrist evaluations."

On 8/19/15 at approximately 0900, review of the performance improvement documents provided revealed much data, but lacked documented evaluations of the data, documented action plans, interventions, and re-evaluations. Further interview with the Performance Improvement Coordinator, on 8/19/15 at 1000, revealed that performance improvement measures were discussed at the monthly business management meetings, but specifics were not documented. It was noted that data were trending down for timely completion of psychiatrist evaluations, without documented analysis or interventions. This was verified by the Performance Improvement Coordinator and Chief Nursing Officer on 8/19/15 at 1130.

Based on document review and interview, the facility failed to have Medical Staff Bylaws that documented the medical history and physical time frame requirements, resulting in potential for untimely patient assessment. Findings include:

On 8/18/15 at approximately 1100, review of the facility document titled, "Amended and Restated Bylaws of the Medical Staff [Facility A], dated 2015," revealed no documentation regarding the patient history and physical requirements. Interview with the Medical Staff Representative #O and the Medical Staff Administrative Assistant #P, on 8/18/15 at approximately 1400, verified that the within 30 days before or 24 hours after admission requirement for the patient history and physical was not documented in the Bylaws.

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 483.70(a), Life Safety from Fire, and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include

See the individually and below cited K-tags dated August 27, 2015.

K-0018
K-0025
K-0029
K-0076

Based on observation and interview the facility failed to ensure that outdated supplies are maintained at an acceptable level of safety and quality resulting in the potential for poor patient outcomes. Findings include:

On 8/17/15 at approximately 1035 during a tour of the supply room in the main hospital a box (quantity 10) of safety scalpels were labeled "expired on 12/2010" and available for patient use.

On 8/17/15 at approximately 1035 during an interview with staff B it was confirmed that the safety scalpels were expired.

On 8/17/15 at approximately 1100 during a tour of the Medical Services Building it was discovered in the medication room that the following supplies were expired and available for patient use:
~ One box of 1 ml Syringes labeled expired 5/2015
~ Five boxes of Anti-Microbial Telfa Dressings were labeled expired 4/2012
~ One tube of white petroleum labeled expired 6/2015
~ One bottle of Hydrogen Peroxide labeled expired 4/2013

On 8/17/15 at approximately 1100 during an interview with staff B it was confirmed that the supplies were expired.

Based on document review and interview, the facility failed to have the governing body appoint the chief executive officer (CEO), resulting in less than optimal outcomes. Findings include:

On 8/18/15 at approximately 1500, interview with the facility Director, Vice President (VP) Care Transitions, and Chief Legal counsel (via phone), revealed that the governing body structure and membership were under transition. The Director stated that he attended previous governing body meetings to present information with the Medical Director. A request for the governing body documentation specifying the CEO and/or Director was made. On 8/18/15 at approximately 1600, The VP stated that they had no such documentation. The VP presented a conditional job offer letter dated 5/13/13 signed by the 'Recruiter' of the health system. There was no evidence that the governing body appointed the CEO or the Director to manage the hospital.

Based on document review and interview, the facility failed to document evaluation of data and interventions for performance improvement, resulting in the potential for continued poor outcomes. Findings include:

Interview with the Performance Improvement Coordinator, on 8/18/15 at approximately 1300, revealed that the facility's top three priorities for performance improvement were "readmissions within 30 days, patients leaving against medical advise (AMA), and timely psychiatrist evaluations."

On 8/19/15 at approximately 0900, review of the performance improvement documents provided revealed much data, but lacked documented evaluations of the data, documented action plans, interventions, and re-evaluations. Further interview with the Performance Improvement Coordinator, on 8/19/15 at 1000, revealed that performance improvement measures were discussed at the monthly business management meetings, but specifics were not documented. It was noted that data were trending down for timely completion of psychiatrist evaluations, without documented analysis or interventions. This was verified by the Performance Improvement Coordinator and Chief Nursing Officer on 8/19/15 at 1130.

Based on document review and interview, the facility failed to have Medical Staff Bylaws that documented the medical history and physical time frame requirements, resulting in potential for untimely patient assessment. Findings include:

On 8/18/15 at approximately 1100, review of the facility document titled, "Amended and Restated Bylaws of the Medical Staff [Facility A], dated 2015," revealed no documentation regarding the patient history and physical requirements. Interview with the Medical Staff Representative #O and the Medical Staff Administrative Assistant #P, on 8/18/15 at approximately 1400, verified that the within 30 days before or 24 hours after admission requirement for the patient history and physical was not documented in the Bylaws.

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 483.70(a), Life Safety from Fire, and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include

See the individually and below cited K-tags dated August 27, 2015.

K-0018
K-0025
K-0029
K-0076

Based on observation and interview the facility failed to ensure that outdated supplies are maintained at an acceptable level of safety and quality resulting in the potential for poor patient outcomes. Findings include:

On 8/17/15 at approximately 1035 during a tour of the supply room in the main hospital a box (quantity 10) of safety scalpels were labeled "expired on 12/2010" and available for patient use.

On 8/17/15 at approximately 1035 during an interview with staff B it was confirmed that the safety scalpels were expired.

On 8/17/15 at approximately 1100 during a tour of the Medical Services Building it was discovered in the medication room that the following supplies were expired and available for patient use:
~ One box of 1 ml Syringes labeled expired 5/2015
~ Five boxes of Anti-Microbial Telfa Dressings were labeled expired 4/2012
~ One tube of white petroleum labeled expired 6/2015
~ One bottle of Hydrogen Peroxide labeled expired 4/2013

On 8/17/15 at approximately 1100 during an interview with staff B it was confirmed that the supplies were expired.