HospitalInspections.org

Based on interview and record review, the facility failed to ensure practitioners providing telemedicine services were appointed to the facility's medical staff and granted privileges associated with the provision of telemedicine services. Findings include:

Review of the credentialing file for staff member AA failed to show current documentation of the Governing Board's approval of staff member AA's membership on the medical staff, and the granting of the necessary privileges for the provision of telemedicine services. Staff member AA's most recent Governing Board approval was dated December of 2021. The current approval should have been completed by December of 2023.

Review of the credentialing file for staff member BB failed to show current documentation of the Governing Board's approval of staff member BB's membership on the medical staff, and the granting of the necessary privileges for the provision of telemedicine services. Staff member BB's most recent Governing Board approval was dated January of 2021. The current approval should have been completed by January of 2023.

Review of the facility's teleradiology services agreement, dated 8/11/23, showed, "Each Physician ...shall be appointed to the Facility's Medical Staff, ... and thereby obtain clinical privileges to carry out the duties described herein ..."

Review of the facility's Medical Staff By-Laws. dated 9/29/22, showed, "1. Telemedicine Service Physicians shall be considered Courtesy Staff under these By-Laws ..."

During an interview on 5/9/24 at 9:05 a.m., staff member A stated he had reviewed the minutes from the Governing Board, dated from January of 2023 through April of 2024. Staff member A stated he was not able to find current Governing Board approval for staff members AA and BB.

47752

Based on interview and record review, the facility failed to complete a comprehensive, person-centered care plan for inpatient admissions for 9 (#s 1, 2, 7, 12, 13, 14, 21, 40, and 42) of 21 sampled patients admitted into inpatient status. This deficient practice had the potential to affect all patients admitted to the hospital as an inpatient. Findings include:

Review of patient #1's EMR, dated 5/3/24 to 5/6/24, showed patient #1 was admitted to inpatient status with the diagnoses of nausea, vomiting and weakness. Patient #1 was discharged on 5/6/24. No comprehensive, person-centered care plan was implemented and failed to identify or address the areas of nausea, vomiting or weakness.

Review of patient #2's EMR, dated 4/9/24 to present, showed the patient was admitted with end-stage liver disease, ascites, heart failure, community-acquired pnuemonia, and multi-system organ failure. The care plan focus areas were for pain management and fall prevention. The care plan failed to identify the liver disease, the need for frequent paracenteses to drain the re-occurring ascites, antibiotic usage, and respiratory issues related to the pneumonia.

Review of patient #7's EMR, dated 4/6/24 to 4/7/24, showed patient #7 was admitted to inpatient status with the diagnoses of alleged assult, rib fracture, alcohol intoxication, seizures, perinephric hematoma, and intravenous drug use. Patient #7 was discharged on 4/7/24. No comprehensive, person-centered care plan was implemented and failed to identify or address the areas of alleged assult, alcohol intoxication, perinephric hematoma, or intravenous drug use.

Review of patient #12's EMR, dated 11/21/23 to 11/24/23, showed the patient was admitted with diagnoses of community-acquired pneumonia, chronic kidney disease, a urinary tract infection, bilateral lower extremity cellulitis, and metabolic encephalopathy. The patient's care plan failed to identify any of the problem areas listed above.

Review of patient #13's EMR, dated 10/16/23 to 10/24/23, showed the patient was admitted with altered mental status, a urinary tract infection, sepsis, and dehydration. The patient's care plan identified fall prevention and VTE prophylaxsis. The care plan failed to identify any of the focus areas from the patient's diagnoses.

Review of patient #14's EMR, dated 10/13/23 to 10/16/23, showed the patient was admitted with bladder cancer with questionable metastasis and a urinary tract infection. The patient's care plan failed to identify the genitourinary system.

Review of patient #21's EMR, dated 9/13/23 to 9/22/23, showed the patient was admitted with diagnoses of end-of-life care, metastatic liver cancer, and HIV. The patient's care plan failed to identify any of the focus areas associated with his diagnoses.

Review of patient #40's EMR, dated 5/4/23 to 5/7/23, showed patient #40 was admitted to inpatient status with the diagnosis of abdominal pain. Patient #40 was discharged on 5/7/23. No comprehensive, person-centered care plan was implemented and failed to identify or address the area of abdominal pain.

Review of patient #42's EMR, dated 4/7/24 to 4/8/24, showed patient #42 was admitted to inpatient status with the diagnoses of alcohol abuse and detoxing. Patient #42 was discharged on 4/8/24. No comprehensive, person-centered care plan was implemented and failed to identify or address the areas of alcohol abuse or detoxing.

During an interview on 5/8/24 at 1:10 p.m., staff member B stated care plans were started on admission by the nursing staff.

During an interview on 5/8/24 at 2:03 pm., staff member F stated when a patient was admitted to acute care, nursing staff started the care plans. Staff member F stated the care plans are also to be documented on for progression and completion of patient goals.

During an interview on 5/9/24 at 8:00 a.m., staff member F stated the EMR system did not provide a wide variety of options for care plan focus areas. Staff member F stated this made having comprehensive, patient-centered care plans difficult.

During an interview on 5/9/24 at 8:15 a.m., staff member B stated the EMR system had a limited amount of choices for care plan focus areas.

Review of a facility document titled, "Care Plans/IPOCs," with a revision date of 1/12/16, showed:

"It is the policy of [Name of Service] to provide an individualized interdisciplinary plan of care (IPOC) for all patient through the use of care planning...

A. Upon admission all patients shall have an IPOC generated by the admitting nurse under the supervision of the charge nurse."

Based on interview and record review, the facility failed to ensure an admission consent form was completely filled out at the time of admission for 1 (#8) of 21 sampled patients who were admitted to the hospital. This deficient practice had the potential to affect all patients admitted to the hospital. Findings include:

A review of patient #8's EMR, dated 3/9/24 to 3/12/24, showed patient #8 had signed the admission consent form. The admission consent form was not completely filled out with the required information. Patient #8's admission consent form did not contain a printed name, date of birth, mailing address, phone number, or the name of a primary provider.

During an interview on 5/8/24 at 1:30 p.m., staff member B stated all admission consent forms should be completely filled out by the staff member who was admitting the patient.

During an interview on 5/9/24 at 9:30 a.m., staff member W stated her department was responsible for making sure the medical records were complete. Staff member W stated, "We check medical records in our daily work. We check to make sure consents are properly filled out. I now realize this is not accurately being completed." Staff member W stated, "It is usually the admitting nurse or ward clerks responsibility to make sure documents are complete, but my department is supposed to double check for completeness before it is placed in the medical record."

Based on interview and record review, the facility failed to ensure properly executed informed consents were completed for procedures performed for 1 (#2) of 21 sampled patients who were admitted to the hospital. Findings include:

Review of patient #2's EMR showed the patient had multiple paracenteses, two of which occurred on 4/12/24 and 4/13/24. Review of patient #2's informed consents, dated 4/12/24 and 4/13/24, showed the provider who performed the procedure did not sign or date either of the consents.

During an interview on 5/9/24 at 9:35 a.m., staff member W stated it was the responsibility of the HIM department to ensure informed consents were completed properly. Staff member W stated they should have identified patient #2's informed consents, dated 4/12/24 and 4/13/24, were not properly completed.

47752

Based on interview and record review, the facility failed to ensure a physician co-signed the history and physical for acute inpatient admissions for 4 (#s 1, 8, 10, and 12) of 21 sampled patients who were admitted to the hospital. This deficient practice had the potential to affect all patients admitted to the hospital. Findings include:

Review of patient #1's EMR, dated 5/3/24 to 5/6/24, showed patient #1 was admitted to inpatient status on 5/3/24 by staff member O. No physician co-signature was noted on the admission history and physical.

Review of patient #8's EMR, dated 3/9/24 to 3/12/24, showed patient #8 was admitted to inpatient status on 3/9/24 by staff member Z. No physician co-signature was noted on the admission history and physical.

Review of patient #10's History and Physical form, dated 2/12/24, showed it was completed by staff member O, who was an APRN. The form failed to show an MD or DO co-signature.

Review of patient #12's History and Physical form, dated 11/21/23, showed it was completed by staff member O, an APRN. The form failed to show the co-signature of an MD or DO.

During an interview on 5/8/24 at 3:00 p.m., staff member Q stated he was responsible for co-signing acute inpatient history and physicals, and acute care notes. Staff member Q stated he provided oversight to the mid-level providers in the hospital. Staff member Q stated if he was notified through the medical record, he could sign off on documentation pretty quickly. He stated if he was not messaged through the medical record, it took a little longer to review and sign off on the documentation. Staff member Q stated if he was not notified directly through the medical record, the mid-level provider would call and notify him of admissions. Staff member Q stated, "I do not manage in real time, but I do get all of the notes and can answer any questions in real time."

Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for Infection Prevention and Control.

Based on interview and record review, the facility failed to:

-Ensure the individuals employed as the Infection Prevention and Control Specialists were qualified through education, training, experience, and/or certification in infection prevention and control practices. (See C1204)

-Ensure specific tracking and trending of infections were established for the Infection Prevention and Control Program. (See C1208)

-Ensure an antibiotic stewardship program was established and adhered to nationally recognized guidelines. (See C1221)

-Ensure the facility had a system in place for active surveillance, prevention, and control of all infections, to include antibiotic use. (See C1225)

-Ensure the individuals employed as the Infection Prevention and Control Specialists were qualified to develop and implement a facility wide infection control, surveillance, and prevention program based on nationally recognized guidelines. (See C1231)

-Ensure complete documentation of the infection prevention and control program, to include surveillance, and tracking of infections. (See C1235)

-Ensure the individuals employed as the Infection Prevention and Control Specialists provided competency-based training and education to all personnel and staff, including the medical staff, on the practical applications of antibiotic stewardship guidelines, policies, and procedures. (See C1250)

Based on interview and record review, the facility failed to ensure the individuals employed as the Infection Prevention and Control Specialists were qualified through education, training, experience, and/or certification in infection prevention and control practices. This deficient practice had the potential to affect all patients receiving care and staff providing care at the facility. Findings include:

During an interview on 5/7/24 at 2:06 p.m., staff members E and L stated they had not been doing Infection Prevention and Control for very long, and had no education, training, or certification in Infection Prevention. Staff member E stated her and staff member L were not appointed to their positions by the Governing Board. Staff member E stated, "The staff member that was hired for Infection Prevention left and now [Staff Member L Name] and I have taken it (Infection Prevention and Control Program) over. I am going to the APIC conference this week and hopefully I will learn more about Infection Prevention."

Record review of the facility's personnel files for staff members E and L did not show documentation of education, training, certification, or experience in Infection Prevention.

Based on interview and record review, the facility failed to ensure specific tracking and trending of infections were established for the Infection Prevention and Control Program. This deficient practice had the potential to affect all patients receiving care within the facility. Findings include:

During an interview on 5/7/24 at 2:03 p.m., staff member E stated there was not any documentation which tracked or trended infections or antibiotic use within the facility.

Review of a facility policy titled, "Infection Control Program," with a revision date of May 2024, showed:

" ... The program director has the responsibility for implementing, coordinating, and directing a program of surveillance, prevention, and control of infection and associated adverse events ..."

Based on interview and record review, the facility failed to ensure an antibiotic stewardship program was established and adhered to nationally recognized guidelines. This deficient practice had the potential to affect all patients receiving care at the facility. Findings include:

During an interview on 5/7/24 at 2:03 p.m., staff member E stated the facility did not have an established Antibiotic Stewardship Program.

During an interview on 5/7/24 at 2:05 p.m., staff member L stated there were no facility policies or procedures regarding antibiotic stewardship.

A request for the Antibiotic Stewardship policy and procedure was requested on 5/7/24 at 3:07 p.m., and was not received prior to the end of the survey.

Based on interview and record review, the facility failed to ensure they had a system in place for active surveillance, prevention, and control of all infections, to include antibiotic use. This deficient practice had the potential to affect all patients and staff within the facility. Findings include:

During an interview on 5/7/24 at 2:03 p.m., staff member E stated the facility did not have documentation of surveillance, tracking or trending of infections, or antibiotic use. Staff member E stated the facility was not using any criteria for antibiotic use. Staff member E stated she was not sure what criteria for antibiotic use was.

Review of a facility policy titled, "Infection Control Program," with a revision date of May 2024, showed:

" ...The program director has the responsibility for implementing, coordinating, and directing a program of surveillance, prevention, and control of infection and associated adverse events..."

Based on interview and record review, the facility failed to ensure the individuals employed as the Infection Prevention and Control Specialists were qualified to develop and implement a facility-wide infection control, surveillance, and prevention program based on nationally recognized guidelines. This deficient practice had the potential to affect all patients and staff providing care within the facility. Findings include:

During an interview on 5/7/24 at 2:03 p.m., staff members E and L stated they had not been doing Infection Prevention and Control for very long, and had no education, training, or certification in Infection Prevention. Staff member E stated she and staff member L were not appointed to their positions by the Governing Board. Staff member E stated, "The staff member that was hired for Infection Prevention left and now [Staff Member L Name] and I have taken it (Infection Prevention and Control Program) over. I am going to the APIC conference this week and hopefully I will learn more about Infection Prevention."

During an interview on 5/7/24 at 4:43 p.m., staff member A stated staff members E and L were not approved or appointed by the Governing Board.

A request was made for Govening Board minutes showing the approval of staff members E and L as the Co-Infection Prevention and Control Specialists, and was not received prior to the end of the survey.

Based on interview and record review, the facility failed to ensure complete documentation of the infection prevention and control program, to include surveillance, and tracking of infections. This deficient practice had the potential to affect all patients and staff within the facility. Findings include:

During an interview on 5/7/24 at 2:03 p.m., staff member E stated the facility did not have any documentation of the infection prevention and control program, surveillance, tracking or trending of infections or antibiotic use.

Review of a facililty document titled, "Infection Control Program," with a revision date of May 2024, showed:

"... Provide documentation of recognition and compliance..."

Based on interview and record review, the facility failed to ensure the individuals employed as the Infection Prevention and Control Specialists provided competency-based training and education to all personnel and staff, including the medical staff, on the practical applications of antibiotic stewardship guidelines, policies, and procedures. Findings include:

During an interview on 5/7/23 at 2:03 p.m., staff member E stated she had not done any kind of education with staff or providers. Staff member E stated any education was provided through employee education. Staff member E stated, "I do not do that." Staff member E stated she had never spoken with the medical staff or any staff about any type of antibiotic stewardship guidelines. Staff member E stated there were no policies, procedures, or guidelines in place for antibiotic stewardship.

Review of a facility document titled, "Infection Control Program," with a revision date of May 2024, showed:

"... Provide education and other services..."

Based on interview and record review the facility failed to initiate discharge planning for 3 (#s 6, 7, and 8) of 21 sampled patients who were admitted to inpatient status. This deficient practice had the potential to affect all patients that were admitted into acute care. Findings include:

Review of patient #6's EMR, dated 4/16/24 to 4/18/24, showed patient #6 was admitted to inpatient status on 4/16/24 and was discharged on 4/18/24. No documentation of discharge planning was found for patient #6.

Review of patient #7's EMR, dated 4/6/24 to 4/7/24, showed patient #7 was admitted to inpatient status on 4/6/24, and was discharged on 4/7/24. No documentation of discharge planning was found for patient #7.

Review of patient #8's EMR, dated 3/9/24 to 3/12/24, showed patient #8 was admitted to inpatient status on 3/9/24 and was discharged on 3/12/24. No documentation of discharge planning was found for patient #8.

During an interview on 5/8/24 at 2:03 p.m., staff member F stated the nurses did not usually do discharge planning. Staff member F stated, "We have two gals that do the discharge planning, but they do not work in the building. They are based out of [Hospital Name]." Staff member F stated if the discharge planners were not available, nursing staff went over any discharge instructions, discharged the patient, and set up any required follow up appointments.

During an interview on 5/8/24 at 4:03 p.m., staff member T stated she helped with discharge planning. Staff member T stated discharge planning was supposed to be started the day the patient was admitted, unless it was a weekend. Staff member T stated discharge planning was started on the next business day if an admission occured over the weekend. Staff member T stated the process for discharge planning for inpatients was to meet with the patient if needed, and talk with the nursing staff to find out what the patient's needs were. Staff member T stated she did not usually have to go to [Hospital Name] very often. Staff member T stated once discharge planning was implemented, all the paperwork and documentation was scanned into the patient's electronic medical record, and any notes or assessments were noted in the patient's medical record.

Review of the facility's policy titled, "Discharge of Patient - Planning, Summary, Implementation," dated December of 2017, showed discharge planning was the responsibility of nursing staff and was to be done for all inpatients.

Based on interview and record review, the facility failed to review death records with the OPO (Organ Procurement Organization) for 5 (#s 9, 12, 21, 22, and 34) of 8 sampled patients who expired in the facility. Findings include:

Review of patient #9's EMR, dated 2/15/24 to 2/16/24, showed the patient expired in the facility on 2/16/24. The electronic medical record showed the OPO was notified of the death in the facility.

Review of patient #12's EMR, dated 11/21/23 to 11/24/23, showed the patient expired in the facility on 11/24/23. The electronic medical record showed the OPO was notified of the death in the facility.

Review of patient #21's EMR, dated 9/13/23 to 9/22/23, showed the patient expired in the facility on 9/22/23. The electronic medical record showed the OPO was notified of the death in the facility.

Review of patient #22's EMR, dated 1/29/24 to 1/30/24, showed the patient expired in the facility on 1/30/24. The electronic medical record showed the OPO was notified of the death in the facility.

Review of patient #34's EMR, dated 3/8/24 to 3/8/24, showed the patient expired in the facility on 3/8/24. The electronic medical record showed the OPO was notified of the death in the facility.

During an interview on 5/8/24 at 8:42 a.m., staff member B stated she had not done any death reviews with the OPO. Staff member B stated, "The only time the death records are reviewed is when there was a problem." Staff member B stated she had received the monthly list of patients from the OPO but had never reviewed any of the deaths with the OPO.