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Based on record reviews and interviews, the hospital failed to ensure the contracted ambulance service was safe and effective as evidence by 1 (Pt.#2) of 5 (Pt. #1 - #5) sampled records reviewed revealed a delay in transport to an acute care facility. This failure may impact any patient requiring emergency transport services to an external provider.
Findings:

Review of the policy and procedure titled, "Transfer of Patient to External Facility" revealed, in part, Purpose: Identified patients, requiring a higher level of care due to medical condition, will transfer from the hospital to an external facility. Nursing Procedure revealed, in part, 9. Contact ambulance service with request for patient transport. Further review of the policy revealed no procedure if the ambulance response time was not timely.

Review of the Ambulance Contract revealed, in part, Continuous Performance Improvement. Supplier as part of the facility's Performance Improvement (PI) Program will ensure the quality and appropriateness of patient care services provided are monitored and evaluated, and identified problems are resolved. Supplier will have a planned and systematic process for the monitoring and evaluation of the quality and appropriateness of services provided to facility patients. This system shall be coordinated with the facility's performance improvement program and supplier shall report results on a quarterly basis when requested.

Review of the hospital's Quality Assurance (QA) meeting minutes for October 12, 2021, November 23, 2021 and July 18, 2022 revealed no topics or discussion related to the quality and appropriateness of patient care services provided by the contracted ambulance service.

Review of the medical record revealed on 11/07/2021 at 2:25 p.m., Patient #2's lab results revealed an elevated white blood cell count, elevated liver enzymes and purulent yellow drainage from the surgical site. Subsequently, at 3:50 p.m. an acute care hospital accepted Patient #2. At 4:00 p.m. the contracted ambulance service was contacted for transport. At 7:45 p.m. Patient #2 was still awaiting transport to an acute care facility.

In interview on 10/04/2022 at 1:55 p.m., S1CNO verified Patient #2 was transported out of the facility on 11/07/2021 at 8:00 p.m.

In interview on 10/04/2022 at 1:55 p.m., S11QA indicated the hospital did not monitor quality indicators related to the contracted ambulance service.

In interview on 10/04/2022 at 2:00 p.m., S1CNO indicated the hospital did not monitor or request any quality assurance monitoring from the contracted ambulance service.

Based on record review and interview, the hospital's governing body failed to ensure an effective grievance process was implemented when a 10/26/2021 entry was made on the log for 1 (Pt. #2) of 5 (Pt. #1 - Pt. #5) sampled patients. The grievance log further indicates the complaint is unresolved. This failure has the potential to impact any patient filing a complaint and/or grievance related to hospital care or services.
Findings:

Review of the policy and procedure titled, "Patient/Visitor Complaint/Grievance Process" effective 12/01/04 and last revised on 06/29/22 revealed, in part, it is the policy of the hospital to provide a systematic approach to resolve conflicts whereby patients and/or their significant others or representatives, can voice concerns about the quality of care received at the hospital. A "patient grievance" is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, when a patient issue cannot be resolved promptly by staff present or hospital management, it is to be considered a grievance. Patient grievances would also include situations where patients or the patient's representative call or write to the hospital about concerns related to care or services, who were not able to resolve their concern related to care or services, who were not able to resolve their concern during their stay or who did not wish to address their issue during their stay. The QA committee will provide oversight to assure the patient grievances were handled in a timely, reasonable, and consistent manner set forth in this policy. The employee should complete an occurrence report detailing the nature of the complaint or grievance. This occurrence report is forwarded to the Director of Quality, who in turn will route to the appropriate leader and convene the appropriate individuals to discuss resolution of the situation. The information provided to the patient includes: Time frames for review and resolution of complaint/grievance; The patient will receive a written notice of grievance determination. All efforts will be made to effectively and expeditiously resolve the patient's grievance. A written response is required for the initial acknowledgment of the grievance (which may or may not include the resolution within the timeframe of 7-10 business days). The hospital will follow up with another written response within a specified timeframe (depending on what actions the hospital may have to take). If the unresolved grievance is related to a quality of care concerns, the CEO, QA/PI, MEC and Governing Board will be notified and requested to intervene in a multidisciplinary approach towards resolution of the conflict. Grievance resolution will be in writing and directed to the patient. The grievance resolution shall include the following: Organization contact person, steps taken to investigate, the results of the grievance process and the date of the completion.

Review of the Grievance Log 2021 revealed, in part, Date of Service 10/26/21 - Complaint: Patient #2 was transferred to an outside Emergency Department where she expired. Follow-Up was documented as: on-going.

In interview on 12/04/2022 at 1:50 p.m., S11QA verified an entry on the Grievance log dated 10/26/2021 regarding Patient #2's transfer to an acute care facility where she expired. S11QA further indicated this entry was made on the grievance log because she had a "gut feeling" that this was going to become an issue. S11QA indicated Pt. #2's representative was not sent an acknowledgement letter within 7-10 days of his initial phone call and was not sent a letter regarding resolution of the grievance.

Based on record reviews and interview, the hospital failed to ensure a medical record for 1 (Pt. #2) of 5 (Pt. #1 - Pt. #2) sampled patients contained accurate information related to credentials and prompt completion. This failed practice has the potential to affect any patient receiving services at the hospital.
Findings:

Review of the policy and procedure titled, "Medical Record Organization, Completion, and Confidentiality" last revised on 12/21/21 revealed, in part, the hospital has administrative responsibility for all medical records of the organization The hospital shall maintain an accurate completed medical record for each inpatient and outpatient which can be either written, electronic or a hybrid of the two. Further review revealed, once the patient is discharged, the chart is broken down and reviewed for completion and tagged for deficiencies. If not completed, the chart is put in the appropriate area for completion. For incomplete charts, 4. All records other than the operative report must be completed within 30 days of discharge or the physician's medical staff privileges will be suspended.

Review of a letter dated 01/26/2021 revealed S2MD recommended the approval of privileges for S5CSA.

Review of the letter of privileges dated 04/08/2021 revealed, in part, the provider's Governing Body approved S5CSA's request for AP-AHP privileges as Surgical Assistant sponsored by S2MD. Further review revealed the effective period of time for privileges as 01/26/2021 through 01/26/2023.

Review of the operative report for Patient #2 revealed, in part, S2MD's inaccurate dictated note documenting S5CSA as his Assistant and "M.D.".

Review of the Surgery Case Attendee record revealed, in part, on 09/13/2022 Patient #4 had a Laparoscopic Vertical Sleeve Gastrectomy. The Attendee was listed as S5CSA whose role was incorrectly documented as "Physician Assistant".

Review of the Surgery Case Attendee record revealed, in part, on 06/07/2022 Patient #5 had a Laparoscopic Vertical Sleeve Gastrectomy. The Attendee was listed as S5CSA whose role was incorrectly documented as "Physician Assistant".

Based on observation and interviews, the hospital failed to provide access to a current list of practitioner's surgical privileges in the operating rooms or surgical scheduling area. Failure to ensure that operating room staff and surgical schedulers have immediate access to a current list of practitioner's specific credentials for confirmation of surgical privileges may result in inaccurate documentation of the operation report.
Findings:

A tour of the surgical scheduling area on 10/04/2022 at 11:41 a.m., revealed no accessible roster listing each practitioner's name with the specific surgical privileges of all those identified as active, restricted, and suspended.

A tour of operating room number 2 on 10/04/2022 at 11:49 a.m., revealed no accessible roster listing each practitioner's name with the specific surgical privileges of all those identified as active, restricted, and suspended.

In interview on 10/04/2022 at 11:43 a.m., S7SS stated, "I do not have access to the credentialing files".

In interview on 10/04/2022 at 11:50 a.m., S6Dir2 indicated that surgical staff do not have access to credentialing files to verify credentials.

In interview on 10/04/2022 at 11:51 a.m., S8SSup confirmed that surgical staff do not have access to the credentialing information.

In interview on 10/04/2022 at 11:56 a.m., S1CNO indicated that there is no readily available roster with current surgical credentialing information available in the operating rooms.