HospitalInspections.org

WV00016039 2016-3-082
Based on interview with staff and review of documents, it was determined the facility failed to measure, analyze, and track any quality indicators for the out-patient Sleep Laboratory service through the hospital-wide Quality Assurance/Performance Improvement (QA/PI) program. This has the potential for missed opportunities to improve quality of care and safety to all patients when the services are not assessed and monitored.

Findings include:

Review of the hospital's "Performance Improvement Evaluation" for the year 2015 and 2016 revealed there was no documented evidence of any data collected or reviewed for the out-patient Sleep Laboratory.

The Director of the Cardiopulmonary (CP) Department was interviewed on 7/19/16 at 8:50 a.m. She stated the Sleep Laboratory is an out-patient service provided under the organization of the CP Department. She stated the Sleep Laboratory does not participate in the hospital-wide QA/PI program and the services provided in the Sleep Laboratory are not monitored for quality. The Director of Performance Improvement was interviewed on 7/19/16 at 3:10 p.m. and also stated the Sleep Laboratory does not participate in the hospital-wide QA/PI program.

WV00016039 2016-3-082
A. Based on interview with staff and review of documents, it was determined the facility failed to ensure the Medical Director and the Director of the out-patient Sleep Laboratory service monitor for quality and safety through the Quality Assurance/Performance Improvement (QA/PI) program. This has the potential for missed opportunities to improve quality of care and safety to all patients when the services are not assessed and monitored.

Findings include:

Review of the "Position Description" for the "Director, Respiratory Therapy", last revised 2/17/1996, revealed the job description includes the following: "Major Activities" for the Director "Evaluate the quality and appropriateness of services being provided in the department through an on-going program of quality assurance".

Review of the "Position Description" for the "Medical Director - Cardiopulmonary Services", (signed as being effective 7/1/16), states "The Medical Director is responsible for assuring the monitoring and evaluation process as part of the hospital's performance improvement program are implemented in the Cardiopulmonary Services Department".

The Director of the Cardiopulmonary (CP) Department (also known as the "Respiratory Therapy" Department) was interviewed on 7/19/16 at 8:50 a.m. She stated the Sleep Laboratory is an out-patient service provided under the organization of the CP Department. She stated the Sleep Laboratory does not participate in the hospital-wide QA/PI program and the services provided in the Sleep Laboratory are not monitored for quality.

B. Based on observation and interview with staff it was determined the facility failed to ensure the individuals responsible for the Sleep Laboratory out-patient service provided current and appropriate written policies and procedures for the immediate use by the Sleep Laboratory staff when they are working on-site at the outpatient office. This has the potential for staff to not have complete direction when providing services to all patients who undergo testing at the Sleep Laboratory out-patient office.

Findings include:

The Sleep Laboratory office was visited and observed on 7/18/16 at 10:15 a.m. and again on 7/19/16 at 10:20 a.m. It was observed the office is located approximately five (5) miles from the hospital's main campus. The office clerk was the only staff member present during both visits. During the first visit the clerk stated that she works during the day time on paperwork, filing, scheduling of staff and patients and general cleaning procedures for the office. She stated there are two (2) Sleep Laboratory technicians who work at night time when patients are present for the sleep studies. During the second visit to the out-patient laboratory the policies and procedures were requested for review. The clerk stated there are no written policies kept on site. She stated the office has been located in the present location for approximately three (3) years and the policies have not been located there during that time frame.

WV00016039 2016-3-082
Based on observation and interviews with staff, it was determined the hospital failed to maintain the out-patient Sleep Laboratory office with acceptable standards of practice in regards to medical equipment, safety equipment and general cleanliness of the office. This has the potential for care to be provided in an unsafe and/or an unsanitary manner. Findings include:

The Sleep Laboratory office was visited and observed on 7/18/16 at 10:15 a.m. and again on 7/19/16 at 10:20 a.m. It was observed the office is located approximately five (5) miles from the hospital's main campus. The office clerk was the only staff member present during both visits.

During the visit on 7/18/16, the office was observed between 10:15 a.m. and 11:15 a.m. It was observed the office had four (4) patient rooms. Two (2) of the rooms had two (2) beds each and two (2) rooms had one (1) bed each. The clerk who was present stated a total of four (4) beds are used for patient use only and the extra beds were used for family members who may need to stay with young patients or patients with special needs. It was observed all surfaces in the office, including the headboards of every bed, were covered with a layer of dust.

There were two (2) fire extinguishers in the office. The last date of checks on each were 9/2014 and 12/2012.

There were two (2) Purell hand sanitizer containers mounted on the wall. The sanitizer had an expired date of 3/2015 in both. There were three (3) new sanitizer containers on the supply shelf and the expired dates on those were 8/2015.

There was electrical equipment in the office including three (3) oxygen concentrators, four (4) bedside "head boxes" (used for the sleep studies) and four (4) bipap machines at each bedside. There were no biomedical stickers on any equipment to show they had been checked for safety.

The office clerk was present during all observations and she concurred with the findings.

The hospital's Engineering Manager was interviewed on 7/18/16 at 12:00 p.m. He stated the maintenance department has not been involved in the maintenance or biomedical checks of the safety equipment or electrical equipment in the Sleep Laboratory office. He stated the last fire safety drill in that office was in 2014.

A. Based on record review, document review and staff interview it was determined the hospital failed to ensure the nursing staff followed the established triage policy for two (2) of six (6) medical records reviewed (patients #1 and #11). Failure to follow the established triage policy has the potential to negatively affect the patient.

Findings include:

1. Review of the hospital policy entitled "Triage in the Emergency Department", reviewed on 4/18/13, revealed the policy stated: "All patients presenting to the Emergency Department for treatment will be evaluated within five (5) to ten (10) minutes by a Registered Nurse (goal five (5) minutes)".

2. Review of patient #1's medical record revealed he/she arrived at the Emergency Department (ED) on 6/12/16 at 1:55 p.m. and was triaged on 6/12/16 at 2:57 p.m. On 7/20/16 at approximately 11:50 a.m. Registered Nurse (RN) #1 concurred with this finding.

3. Review of patient #11's medical record revealed he/she arrived at the ED on 6/12/16 at 8:43 a.m. and was triaged on 6/12/16 at 10:29 a.m. On 7/20/16 RN #1 concurred with this finding.

B. Based on record review, document review and staff interview it was determined the hospital failed to ensure the nursing staff followed the established triage policy for four (4) of six (6) medical records reviewed (patients #1, #3, #4 and #11). Failure to follow the established triage policy has the potential to negatively affect the patient.

Findings include:

1. Review of the hospital policy entitled "Triage in the Emergency Department", reviewed 4/8/13, revealed the policy states: "Triage levels...three (3). Moderate Risk-Described as "Urgent."...Vital Signs are required Q 2 hours and as needed. four (4). Low Risk...Described as "Non Urgent."...Vital signs will be done Q 2 hours and as needed".

2. Review of patient #1's medical record revealed he/she was a triage level three (3) and his/her vital signs were documented on 6/12/16 at 2:57 p.m., 6/12/16 at 11:04 p.m., 6/13/16 at 12:56 a.m., 6/13/16 at 3:39 a.m. and 6/13/16 at 4:42 a.m. On 7/20/16 at approximately 11:50 a.m. Registered Nurse (RN) #1 concurred with this finding.

3. Review of patient #3's medical record revealed he/she was a triage level three (3) and only one (1) set of vital signs were documented for him/her on 6/12/16 at 1:20 p.m. On 7/20/16 at approximately 11:50 a.m. Registered Nurse (RN) #1 concurred with this finding.

4. Review of patient #4 medical record revealed he/she was a triage level four (4) and his/her vital signs were documented on 6/12/16 at 9:47 p.m., 6/13/16 at 3:40 a.m. and 6/13/16 at 6:11 a.m. On 7/20/16 at approximately 11:50 a.m. Registered Nurse (RN) #1 concurred with this finding.

5. Review of patient #11's medical record revealed he/she was a triage level four (4) and his/her vital signs were documented on 6/12/16 at 10:29 p.m., 6/13/16 at 4:34 a.m., 6/13/16 at 6:35 a.m., 6/13/16 at 8:00 a.m. and 6/13/16 at 9:45 a.m. On 7/20/16 at approximately 11:50 a.m. Registered Nurse (RN) #1 concurred with this finding.