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Based on record review and interview the hospital failed to ensure medical staff enforced bylaws by allowing two physicians with greater than 3 suspensions in one year to remain on staff at the hospital when bylaws indicate the third suspension would result in an automatic voluntary resignation of the physician (Physicians #14 and S15): Findings:
Review of the hospital's "Medical Staff Bylaws, Rules, (and) Regulations; Current Revision: 9/25/08 " presented by the hospital as current revealed in part, " (page 27/ Bylaws of the Medical Staff) An automatic suspension shall be imposed after warning of delinquency for failure to complete medical records within thirty (30) days following a patient's discharge from the Medical Center. Such suspension shall take the form of withdrawal of a practitioner's admitting or consulting privileges and shall be effective until the medical records are completed. . . Three suspensions within any twelve month period for failure to complete or prepare records will be deemed a voluntary resignation from the Medical Staff. Practitioners who so resign may immediately submit a formal application for appointment . . . ( page 9/Rules and Regulations of the Medical Staff) Such suspension will not affect the practitioner's ability to treat any patient who is currently admitted to his care in the hospital however, such practitioner may not electively admit patients, perform surgeries or other in-patient or out-patient procedures on patients who were admitted by other practitioners during the suspension, or act as a consultant in other emergency situations. (page 10/ Rules and Regulations of the Medical Staff) Any period of automatic suspension lasting twenty one days shall be counted separately, each as one full suspension."
Review of a list of " Physicians on Suspension "presented by the hospital as current revealed Physician S14 was placed on suspension dated 4/22/2010. Further review revealed the "number of suspension periods since 4/01/09 (12 month range)" to be 4 (four).
Review of a list of "Physicians on Suspension" presented by the hospital as current revealed Physician S15 was placed on suspension dated 4/15/2010. Further review revealed the "number of suspension periods since 4/01/09 (12 month range)" to be (4) four. Review of the credentialing file for Physician S15 revealed the last reappointment review to be for the period from 11/26/06 - 11/26/2008. Further review revealed Physician S15 had a total of 98 days of suspension at the time of the 11/26/2008 review.
During a face to face interview on 4/27/2010 at 1:35 p.m., Health Information Manager S16 indicated Physicians S14 and S15 remained on staff at the hospital; although both were on suspension for delinquent medical records at the time of the interview. S16 confirmed that both physicians had been on suspension 4 times during the past 12 months (exceeding the three suspensions that would result in automatic voluntary resignation for these physicians). S16 indicated she sent out a list weekly of all physicians on suspension. S16 indicated the Medical Staff Department was on the weekly mailing list.
During a face to face interview on 4/28/2010 at 10:05 a.m., President of Medical Staff, Physician S18 indicated he was aware that the bylaws had not been enforced as written regarding the mandatory voluntary resignation for all physicians at the time of their third suspension during any 12 month period for failure to complete delinquent medical records. Physician S18 indicated according to the bylaws, both Physician S14 and Physician S15 should have been classified as voluntarily resigned. Physician S18 indicated the hospital was in the process of enforcing their bylaws (Current Revision 9/25/2008) but had not yet completed implementation/enforcement. Physician S18 indicated the hospital had sent a letter to Physician S15 on 4/16/2010 to begin the process of enforcement of bylaws. Review of this letter revealed in part, " As of today, the information provided to us by the . . . Health Information Management Department indicates that you have 5 suspensions in the last 12 months (one more suspension than documented on the hospital list of "Physicians on suspension" / two more than required by bylaws for voluntary resignation). At its last meeting the MEC (Medical Executive Committee) voted for zero tolerance in regards to medical records suspension, effective May 1, 2010. . . . You are currently on medical record suspension and must complete all of your medical records prior to May 1, 2010."

Based on record review and interview the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient by:

1. failing to follow their policy and procedure for patients on telemetry monitors as evidenced by setting the alarm limit for low heart rate at 20 beats per minute for 1 of 1 patients reviewed on telemetry in a total sample of 20 patients (#3).

Observation on 04/26/10 at 10:50 a.m. revealed the telemetry monitor low heart rate alarm limit was set at 20 beats per minute for Patient #3.

In interview on 04/26/10 at 10:50 a.m. S12, Telemetry Monitor Technician, confirmed that the low heart rate alarm limit was set at 20 beats per minute. S12 had no explanation as to why the low heart rate alarm limit was set at 20 beats per minute. S8, RN, Telemetry Director, was present and confirmed the alarm setting on the monitor.

Review of the hospital policy titled: "Telemetry Monitoring, Policy #: K81715-PC109, Last revised: 10/01/06" revealed, in part, "Arrhythmia Alarm Unit Settings- HR (Heart Rate) Limits: Adult: High > 120 b/min (beats per minute) and Low < 50 b/min".

2. failing to thoroughly assess a patient's nutritional needs and consult the Registered Dietician for 1 of 1 patients with a nutritional consult (Patient #7) out of 20 sampled patients. Patient #7
The medical record for Patient #7 was reviewed. Documentation revealed Patient #7 was admitted on 04/15/10 with diagnoses of left femoral neck fracture, cerebral vascular accident. Documentation revealed "Height 5' 4" Weight 100 lbs." Review of the Nursing Admission Assessment, dated 04/15/10 and signed by the Registered Nurse, revealed the Nutritional Screening was incomplete. Documentation for other was checked with Diabetic. There was no documented evidence the Patient was assessed for significant weight loss or gain in the past 6 months as indicated in the screening. There was no documented evidence the patient was scored through assessment for a score of 4 or greater which would trigger a Nutrition Assessment. Under "Consult Dietician For Any Positive Findings" it was documented "04/23/10 0 (no) consult."
Review of the Progress Notes documented by the Registered Dietician on 04/23/20 at 1620 (4:20 p.m.) revealed in part, "0 consult sent on admit. Nutrition Intervention per MD consult. Underweight."

S4, Director of Accreditation reviewed the record for Patient #7. During a face to face interview on 04/26/10 at 10:40 a.m. S4 indicated the Registered Dietician consult did not trigger on the Nursing Admission Assessment and the nutritional assessment was incomplete.

S10, RN Charge Nurse of the Medical/Surgical Unit was interviewed on 04/26/10 at 10:45 a.m. S10 reviewed the record for Patient #7. S10 indicated the nutritional consult should have been requested on admission because the patient. had a diagnosis of Diabetes. Further the Nutritional Assessment was incomplete. Further the Admission Nursing Assessment form had been changed but was incorrect for triggering because there were no score protocols. Further S10 indicated the previous assessment form had protocols for scoring but the new form did not.

S11, Registered Dietician was interviewed face to face on 04/26/10 at 10:55 a.m. S11 reviewed the record for Patient #7. S11 indicated she had evaluated Patient #7's nutritional status on 04/23/10 per an MD order and had not received a consult request from the RN on admission.

Review of the hospital policy, #D006 with a revision date of 04/10, entitled "Clinical Nutrition Services Initial Assessment and Prioritization" revealed in part, "Nursing An initial assessment program is implemented to identify patients who may require medical nutrition therapy. * Based on results of initial assessment consults dietitian. Dietician * Acts on information/consults resulting from Nursing Assessment." There was no documented evidence in the policy of a protocol for scoring the patient's nutritional needs.

Based on observations and interview the Hospital failed to 1) maintain a sanitary environment by failing to ensure that glucometers used for obtaining blood glucose levels were cleaned and disinfected after each use for 3 of 4 glucometers observed on unit "a". 2) to ensure protocols, for the maintenance of a sanitary surgical environment, were implemented for disinfecting the environmental surfaces of a operating room after a completion of a surgery case. This practice had the potential to cause cross contamination of infectious diseases to the surgical patients in the operating room, (OR).
Findings:

1) maintain a sanitary environment by failing to ensure that glucometers used for obtaining blood glucose levels were cleaned and disinfected after each use for 3 of 4 glucometers observed on unit "a".

Observation on 04/26/10 at 10:45 a.m. revealed a dried bloody substance on the surface of 3 of 4 glucometers used for obtaining patient blood sugars.

In interview on 04/26/10 at 10:45 a.m. S8, RN, Director Telemetry, confirmed that the glucometers had dried blood on the surface and should have been cleaned and disinfected after every use.

Review of the hospital policy for glucometers, last reviewed 07/2009, revealed, in part, "B. Nursing Service Responsibilities- 9. The Nursing Staff: e. Inspects the monitor(s) daily to: 2. Inspect for cleanliness. Cleaning of instrument should be performed with disinfectant wipes. It is not recommended to use bleach. Disinfect after testing is done on contact isolation patient".


2) to ensure protocols, for the maintenance of a sanitary surgical environment, were implemented for disinfecting the environmental surfaces of a operating room after a completion of a surgery case.

Observation on 04/26/10 at 2:20pm revealed S9, Operating Room Assistant (ORA) cleaning a surgery room with Caviwipes after completion of a surgical case.

When the surveyor questioned S9 (ORA) regarding the contact time of the Caviwipes during the disinfection cleaning of the environmental surfaces in the operating room he indicated 1 to 3 minutes but he did not know the exact time. Review of the Caviwipes label revealed net time visibly wet 3 minutes.

S13, OR Director was interviewed face to face on 04/28/10 at 10:30am. S3 indicated the environmental surfaces in the OR should be visibly wet for 2 minutes. Further she indicated S13 should have know the correct contact time for the use of the Caviwipes.

Review of the hospital policy #K81160-EC101 entitled "Cleaning of Surgery" with a revision date of 04/2010 revealed in part, "Between Case Cleaning A. All flat surfaces are wiped down with a hospital approved cleaner, or cleaned by spraying hospital approved germicide solution onto the surface and wiping it off with a dry wipe."

Review of the "Surface Disinfection Using Caviwipes' instructions revealed in part, "B. Disinfect precleaned surface with towelette. Follow label instructions for appropriate contact times. Fast Action, Kills TB in 3 minutes and MRSA, HIV-1, HBV and HCV in 2 minutes."