HospitalInspections.org

Based on review of hospital policies and procedures, medical records, hospital documents, and interviews, it was determined the hospital failed to have an effective governing body as evidenced by:

A115: failure to comply with the provisions of Patient's Rights, related to care in a safe setting and grievances;

A263: failure to demonstrate compliance with the provisions of Quality Assessment and Performance Improvement, and failing to provide documentation from the RCA for review regarding a patient's death in the lobby; and

A385: failure to demonstrate compliance with the provisions of the Nursing Services.

The cumulative effect of these systemic deficient practices resulted in the hospital's failure to meet the requirements for the Condition of Participation for Governing Body.

Based on review of hospital policies, procedures, medical records, hospital documents, and interviews, it was determined the hospital failed to comply with the provisions of Patient's Rights, related to care in a safe setting and grievances, as evidenced by:

A0144: failure to ensure 4 of 4 Emergency Department (ED) patients received care in a safe setting (Patients # 42, 31, 32, and 33); and

A0118: failure to document the grievance process for 3 of 3 patient complaints/grievances (Patients #39, 40 and 41).

The cumulative effect of these systemic deficient practices resulted in the hospital's failure to meet the requirements for the Condition of Participation for Patient Rights.

Based on review of hospital policies/procedures, complaint/grievance documents, and interviews, it was determined that the hospital failed to document and maintain their grievance process for 3 of 3 patients as demonstrated by failure to require documentation verifying complete investigations for 3 of 3 closed complaints/grievances (Patients #39, 40 and 41).

Findings include:

Review of facility "Grievance and Complaint Policies" dated 7/08, revealed: "...The Director of Risk/Quality Management (or his/her designee) shall conduct and (sic) investigation of the complaint to determine its validity. This investigation may be informal, but it must be thorough...The Director of Risk/Quality Management will maintain the files and records of the Hospital relating to such grievances...Each patient or family member that expresses concern regarding their care shall be encouraged to complete a 'Patient Complaint Form.' If the patient or family member is hesitant to complete the form, the member of Administration or the Quality/Risk Department that conducts the interview shall document the complaint in writing and forward it to the Director of Risk/Quality Management and applicable Department Director...Each complaint shall be investigated and the results of the investigation documented. A written response to the patient complaint shall be completed...VVMC (Valley View Medical Center) will make every effort to investigate, resolve, and when appropriate report back to the complainant within 7 days...."

The Director of Quality Risk Management provided closed complaint/grievance investigations including all related documentation, on 5/12/11 at 0900, as follows:

Patient # 39: complainant's letter, dated 3/18/11, regarding an allegation related to nursing services during an 02/11 inpatient admission. The Director of Quality Risk Management confirmed during an interview conducted on 5/12/11 at 1440, that the documentation of any discussion with the complainant, investigation or any follow up activity "was not retained."

Patient # 40: complainant's letter, dated 3/25/11, regarding an allegation related to outpatient services during an outpatient admission. The Director of Quality Risk Management confirmed during an interview conducted on 5/12/11 at 1440, that the documentation of any discussion with the complainant, date of outpatient visit, investigation or any follow up activity "was not retained."

Patient # 41: complainant's letter, dated 4/6/11, regarding an allegation related to nursing services during an emergency room visit on 3/31/11. The Director of Quality Risk Management confirmed during an interview conducted on 5/12/11 at 1440, that the documentation of any discussion with the complainant, investigation or any follow up activity "was not retained."

The Director of Quality Risk Management confirmed during an interview conducted on 5/12/11 at 1440, that documentation for complaint/grievance investigations "were not retained" and did not demonstrate what the complaints were, how the investigations were conducted to determine what processes were considered for corrective action, monitoring performed and what if any follow up processes were determined and implemented.

Based on review of Emergency Department (ED) staffing schedules, policies/procedures, ED logs and interview with staff, it was determined the hospital failed to ensure ED patients # 42, 31, 32, and 33 received care in a safe setting, as evidenced by:

1. Patient #42, a 34 year old arrived in the ED prior to 2251 hours on 02/15/11, and required cardiopulmonary resuscitation (CPR) around 2315 hours, while waiting in the ED lobby for triage. The patient expired;

2. Patient #31, a 71 year old, arrived in the ED on 02/15/11 around 1414 hours, with complaints of chest pain--atraumatic and left the ED at 1730 hours without triage/nursing or provider evaluation;

3. Patient #32, a 43 year old, arrived in the ED on 02/15/11 around 1758 hours, with complaints of blood in stools, and left the ED at 1913 hours without triage/nursing or provider evaluation; and

4. Patient #33 arrived in the ED on 02/15/11 around 1426 hours, with complaints of vomiting and diarrhea, and left the ED at 1730 hours without triage/nursing or provider evaluation.

Findings include:

The hospital policy titled Nursing Acuity Staffing Plan, effective 08/09, required: "...Emergency Department...There are always 2 RN's from 7am--7pm, 2 RN's 7pm--7am. A split -shift nurse will be assigned during peak hours. Occasionally, a critical patient may require (2) RN's to stabilize. During these times, the ED Director or House Supervisor will assist with direct patient care. In addition, there are Unit Clerks/ ER techs during peak hours, and may be adjusted at the Director's discretion. These individuals will be utilized according to their documented competencies to assist with patient care. In the event the Emergency Department receives a sudden influx of patients, and/or the acuity increases due to trauma or critical patients, the ED Director and/or Administrative Supervisor calls off-duty staff and requests assistance, and/or 'floats' competent staff as available to assist with patient care. The ED schedule will maintain an on-call list for that day and also list it on the daily staffing sheet...."

Review of ED staffing schedules for 02/15/11, revealed the following staff were working on the 7am--7pm (Days) shift: 2 RN's, 1 ED tech and 1 unit secretary. The 7pm--7am (Nights) shift had 2 RN's, 1 ED tech from 1600-0000 hours and 1 ED tech 7pm--7am.

Review of the ED log for 02/15/11, revealed a total of 16 patients left the ED without treatment (LWOT). The times these patients presented to the ED began at 12 noon and the last patient presented at 2301. According to the Interim Chief Nursing Officer (CNO) the total number of patients leaving without treatment for February 2011 was 126 patients, representing 7.7% of the patients seen that month in the ED.

1. Review of patient #42's medical records revealed the following information:

Patient (#42) was seen three times in the Emergency Department (ED) beginning on 02/14/11 at 0812, again on 02/15/11 at 0807 and last on 02/15/11 at 2251, when the patient coded around 2315 hours, while waiting for triage, in the ED lobby. The patient expired.

The last visit occurred on 02/15/11, when the patient was registered at 2251 hours. The next documentation for the patient indicated the patient had been found in the ED waiting room at 2315, after the fiance kicked the door to the ED treatment room, and yelled for help. Nursing did not triage or assess the patient upon arrival to the ED. Nursing documented that the patient was found in the waiting room and had vomited copious amounts of blood and CPR was in progress.

According to interviews with Employees #3 and 41 conducted on 05/06/11 in the morning, Patient #42's fiance was heard in the lobby yelling and kicking at the door that enters into ED treatment area, which alerted the ED staff there was a problem with Patient #42. Both verified no triage nurse or registration personnel were in the lobby at the time and neither a registered nurse, or a physician had assessed the patient upon the patient's arrival in the ED.

The Director of Quality/Risk Management stated during an interview on 05/05/11, at 1600 hours, the patient had not been evaluated by a registered nurse (RN) or nursing personnel until cardiopulmonary resuscitation (CPR) was started in the lobby.

2. Review of patient #31's medical record revealed the following information:

Patient #31, a 71 year old, was registered into the computer by the registration personnel on 02/15/11 at 1414 hours. The ED registration personnel documented the chief complaint as "Chest Pain--Atraumatic." Documentation in the record indicated the patient left prior to triage. No triage assessment was documented. When the medical record was printed it indicated that the patient's triage time was 1730 hours. The Director of ED explained during an interview on 05/12/11, that the triage time was entered by the registration personnel to close out the record. She confirmed no nursing personnel had documented a triage assessment for this patient.

3. Review of patient #32's medical record revealed the following information:

Patient #32, was registered into the computer by the registration personnel on 02/15/11 at 1758 hours. The ED registration personnel documented the chief complaint as "Blood In Stools." Documentation in the record indicated that the patient's triage time was 1913 hours. No triage assessment was documented.

4. Review of patient #33's medical record revealed the following information:

Patient #33, was registered into the computer by the registration personnel on 02/15/11 at 1426 hours. The ED registration personnel documented the chief complaint as "Vomiting and Diarrhea--Adult (Mild)." Documentation in the record indicated the patient's triage time was 1730 hours. No triage assessment was documented.

The Director of ED explained during an interview on 05/12/11, that for patient's 31, 32, and 33, the ED registration personnel had to enter a time for triage to close the record out and print the record. She confirmed no nursing personnel had assessed these patients.

Based on review of the ED logs, quality council meeting minutes, hospital documents, medical records and interview with staff, it was determined the hospital failed to demonstrate compliance with the provisions of Quality Assessment and Performance Improvement as evidenced by:

A0275: failure to monitor the effectiveness, safety and quality of ED care for 4 of 4 patients (Pt #42, 31, 32, and 33), presenting to the ED on 02/15/11, that included the death of patient # 42.

The cumulative effect of this systemic deficient practice resulted in the hospital's failure to meet the requirements for the Condition of Participation for Quality Assessment and Performance Improvement.

Based on review of the ED logs, quality council meeting minutes, hospital documents, medical records and interview with staff, it was determined the hospital failed to monitor the effectiveness, safety and quality of ED care for 4 of 4 patients (Pt #42, 31, 32, and 33), presenting to the ED on 02/15/11, that included the death of patient # 42.

Findings include:

A review of the ED logs for February 2011 was completed. It was discovered that Patient #42 had expired on 02/16/11 (Pt #42 arrived before midnight on 02/15/11).

Patient (#42) was seen three times in the Emergency Department (ED) beginning on 02/14/11 at 0812, again on 02/15/11 at 0807 and last on 02/15/11 at 2251, when the patient coded around 2315 hours, while waiting for triage in the ED lobby. The patient expired.

The last visit occurred on 02/15/11, when the patient was registered at 2251 hours. The next documentation for the patient indicated the patient had been found in the ED waiting room at 2315, after the fiance kicked the door to the ED treatment room, and yelled for help. Nursing did not triage or assess the patient upon arrival to the ED. Nursing documented that the patient was found in the waiting room and had vomited copious amounts of blood and CPR was in progress.

According to interviews with Employees #3 and 41 conducted on 05/06/11 in the morning, Patient #42's fiance was heard in the lobby yelling and kicking at the door that enters into the ED treatment area, which alerted the ED staff there was a problem with Patient #42. Both verified there was no triage nurse or registration personnel in the lobby at the time and neither a registered nurse or physician assessed the patient upon the patient's arrival in the ED.

The Director of Quality/Risk Management stated during an interview on 05/05/11, at 1600 hours, the patient had not been evaluated by a registered nurse (RN) or nursing personnel until cardiopulmonary resuscitation (CPR) was started in the lobby.

The Department could not determine the hospital evaluated the incident (death) for Patient #42.

Review of the Quality Council Meeting Minutes for 2010 and 2011 revealed the following:

According to the minutes for October 2010 the following information was reported during Quality Council: "...ER Physician Stats by Month September 2010 Stats...CNO reported that there 1503 patient (sic) treated in the ED for the month of September. LWOTS (left without treatment) and AMA's (against medical advice) have increased slightly, which is a reflection of the new Emergency Room Physicians that are currently being trained. There should be a decline in AMA's and LWOTS in the near future...Recommended Action...AMA, LWOT, Transfers...Physician statistics will continue to be reported monthly...."

Quality Council Meeting Minutes indicated there were no ED data reports for November and December of 2010, and no reports for January and February 2011.

Data regarding LWOTS and AMA's was not reported monthly as recommended by the Quality Council.

The Director of Quality and Risk Manager verified the meeting minutes available and verified there was no meeting in December 2010 and no other ED reports had been reported during the Quality Council Meetings for November and December 2010, and January and February 2011.

Review of the ED log for 02/15/11, revealed a total of 16 patients left the ED without treatment (LWOT). The times these patients presented to the ED began at 12 noon and the last patient presented at 2301. According to the Interim CNO the total number of patients leaving without treatment for February 2011 was 126 patients representing 7.7% of the patients seen that month in the ED.

Patient #31, a 71 year old, arrived in the ED on 02/15/11 around 1414 hours, with complaints of chest pain, (atraumatic) and left the ED at 1730 hours without any nursing or provider evaluation.

Patient #32, a 43 year old, arrived in the ED on 02/15/11 around 1758 hours, with complaints of blood in stools, and left the ED at 1913 hours without any nursing or provider evaluation.

Patient #33 arrived in the ED on 02/15/11 around 1426 hours, with complaints of vomiting and diarrhea, and left the ED at 1730 hours without any nursing or provider evaluation.

The Director of ED confirmed during an interview on 05/12/11, that patient's 31, 32, and 33, were not assessed by nursing personnel or a physician.

The facility failed to monitor the safety and quality of care for emergency service patients.

Based on review of the medical staff bylaws, credential files, and interviews with staff, it was determined the hospital failed to enforce its bylaws, ensuring 1 of 2 physicians with temporary privileges (Physician #4) had a national practitioner data bank query according to bylaw requirement before granting privileges.

Findings include:

The current Medical Staff Bylaws approved 12/07/06, required: "...Temporary Privileges...The CEO or his/her designee, upon recommendation of the Chief of Staff or Chairperson of the applicable department...completion of the required Data Bank query...may grant temporary privileges...In addition, the results of the NPDB (National Practitioner Data Bank) query must be obtained and evaluated before any grant of temporary privileges based on a pending application...."

Review of Physician #4's credential file revealed the physician was granted temporary privileges from 04/2010 through 06/10/2011. The credential file did not contain the NPDB query and results as required for review.

The CEO and Medical Staff Director were interviewed on 05/11/11. Both confirmed Physician #4's credentialing file did not contain the required NPDB query with results, and this information was not reviewed prior to granting temporary privileges.

Based on review of Emergency Department (ED) staffing schedules, policies, procedures, ED logs, medical records, and interview with staff, it was determined the hospital failed to demonstrate compliance with the provisions of the Nursing Services as evidenced by;

A0392: failure to have adequate numbers of personnel to provide nursing care for 4 of 4 patients (Patients #42, 31, 32, and 33) presenting to the ED on 02/15/11; and

A0395: failure to require a registered nurse supervised and evaluated the nursing care for 4 of 4 patients (Patients #42, 31, 32, and 33) presenting to the ED on 02/15/1.

The cumulative effect of these systemic deficient practices resulted in the hospital's failure to meet the requirements for the Condition of Participation for Nursing Services.

Based on review of Emergency Department (ED) staffing schedules, policies/procedures, ED logs and interview with staff, it was determined the hospital failed to have adequate numbers of personnel to provide nursing care for 4 of 4 patients presenting to the ED on 02/15/11, as evidenced by:

1. Patient #42 arrived in the ED prior to 2251 hours on 02/15/11, and required cardiopulmonary resuscitation (CPR) around 2315 hours, while waiting in the ED lobby for triage. The patient expired;

2. Patient #31, a 71 year old, arrived in the ED on 02/15/11 around 1414 hours, with complaints of chest pain (atraumatic) and left the ED at 1730 hours without triage/nursing or provider evaluation;

3. Patient #32, a 43 year old, arrived in the ED on 02/15/11 around 1758 hours, with complaints of blood in stools, and left the ED at 1913 hours without triage/nursing or provider evaluation; and

4. Patient #33 arrived in the ED on 02/15/11 around 1426 hours, with complaints of vomiting and diarrhea, and left the ED at 1730 hours without triage/nursing or provider evaluation.

Findings include:

Cross reference A144 482.13(c)(2)

Based on review of Emergency Department (ED) staffing schedules, policies/procedures, ED logs and interview with staff, it was determined the hospital failed to require a registered nurse supervised and evaluated the nursing care for 4 of 4 patients presenting to the ED on 02/15/11, as evidenced by:

1. Patient #42, a 34 year old arrived in the ED prior to 2251 hours on 02/15/11, and required cardiopulmonary resuscitation (CPR) around 2315 hours, while waiting in the ED lobby for triage. The patient expired;

2. Patient #31, a 71 year old, arrived in the ED on 02/15/11 around 1414 hours, with complaints of chest pain--atraumatic and left the ED at 1730 hours without triage/nursing or provider evaluation;

3. Patient #32, a 43 year old, arrived in the ED on 02/15/11 around 1758 hours, with complaints of blood in stools, and left the ED at 1913 hours without triage/nursing or provider evaluation; and

4. Patient #33 arrived in the ED on 02/15/11 around 1426 hours, with complaints of vomiting and diarrhea, and left the ED at 1730 hours without triage/nursing or provider evaluation.

Findings include:

Cross reference A144: 482.13(c)(2)

Based on review of medical records, policies and procedures and staff interviews, it was determined that the facility did not obtain a fully, completed anesthesia consent form for 3 of 7 patients (Patients #13,14 and 15).

Findings include:

Review of hospital "Anesthesia" policy dated 03/06, revealed: " An informed consent is obtained from the patient or responsible party...Documentation must include date, time and signature of anesthetist...."

Review of "ANESTHESIA INFORMED CONSENT" forms for Pts #13, 14, and 15, revealed that the date, time, and "I request and authorize Dr..." was left blank on all of the consents.

The Director of Quality Risk Management verified on 5/11/11 at 1420 hours, that the consent forms were not completely filled out prior to the patients signing the forms.