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Based on record review and staff interview, it was determined that the hospital failed to investigate when and how a broken right humerus occurred for Patient #50 after the patient's family noticed some pain in the right upper arm (refer to A-0145). The hospital further failed to notify the State Agency about the injury of unknown origin for Patient #50 and the possible neglect by a local nursing home of Patient #51 for the infected surgical site noted upon admission from a local nursing home (refer to A-0145). The cumulative effect of these systemic practices resulted in the hospital's inability to ensure the safety of the patients.

Based on record review and staff interview, the hospital failed to investigate when and how Patient #50 broke her right humerus during her stay in the hospital between 06/28/11 through 07/09/11. During the patient's stay, the family noticed the patient was having some pain in her right arm. An x-ray of the arm showed nondisplaced fracture. As the result of this failed practice, the hospital is likely to have more injuries of unknown origin that continue to be not investigated. The hospital further failed to report the injury of unknown origin of Patient #50 and the neglect of Patient #51 by a local nursing home to the proper authority, the State Agency. The findings are:

A. Review of the patient's "Death Summary" dated 07/09/11 indicated, "[Patient #50 came] in [the hospital] with a stroke and then developed aspiration pneumonia and went into respiratory distress which then required intubation. ...The family had seen that the patient had developed some pain in her right arm and somehow it had been discovered that she had a fracture in her arm, unsure of the cause, but the patient was placed in a splint."
1. Review of the patient's Radiologist Report dated 07/07/11 for an x-ray on 07/06/11 indicated, "There is a radiolucent [bright] line through the right humeral surgical neck highly suspicious for the presence for a nondisplaced fracture."
2. Review of the patient's Emergency Room Physicians Notes dated 06/28/11 revealed no indication of any pain or swelling to the patient's right arm.
3. On 11/04/11 at 11:00 am, during an interview, the Director of Risk Management stated that she did remember this patient. When asked about if the hospital had investigated for Patient #50's fracture, she stated that no investigation had been done.

B. Review of Patient #51's Discharge Summary dated 08/21/11 read, "The patient was in [from a local nursing home] was forgot to [be] brought [back] in for staple removal and [sic] from his previous day hospitalization [by the local nursing home], he was prompted [with] an advice to bring back [sic] for staple removal but it was not done and the patient presented with [a] severe infection. He was later diagnosed to have MRSA [Methicillin-resistant Staphylococcus aureus] positive and Proteus mirabilis positive..."

C. Review of Patient #50 and #51's clinical records revealed no notes to indicate the State Agency -- the Health Facility Licensing and Certification Bureau (HFLC) -- had been been notified about the possible abuse of Patient #50 and the probable neglect of Patient #51.

D. On 11/04/11 at 11:10 am, during an interview, the Director of Risk Management stated that the hospital had not notified HFLC regarding Patient #50's injury of unknown origin and #51's neglect by the local nursing home.

E. Review of the hospital's policy and procedure titled, "Abuse and Neglect," last reviewed on May 2011, indicated, "II. Policy
All incidents of, or suspected incidents of, abuse and/or neglect will be reported by the hospital staff according to this established policy.

"III. Procedure
...All staff members have the responsibility to report suspected abuse and/or neglect cases.

"Assessment:
...When a patient presents with the following, abuse or neglect should be suspected.
1. Has an unexplained injury.
4. Shows evidence of overall poor care.

"Referral/Reporting:
2. A referral (a report to a department or agency) will be made immediately upon assessment of a suspected or actual child/adult abuse by [name of facility] staff member...The member must notify the Department of Health."

Based on document request, document review and interview, the hospital failed to ensure that the Quality Assessment & Performance Improvement (QAPI) program was ongoing, hospital-wide, and data-driven. The following services were not integrated into the hospital's QAPI program: Discharge Planning, Anesthesia Services, Nuclear Medicine Services, Outpatient Services, and Respiratory Services. The hospital further failed to include the data of injuries of unknown origin into its QAPI program after Patient #50 broke her right humerus during her stay in the hospital. The hospital's failure to evaluate patient care resulted in the likelihood that it did not provide services to meet the needs of the patients. The findings are:

Based on document request, document review and interview, the hospital failed to ensure that the Quality Assessment & Performance Improvement (QAPI) program incorporated quality indicator data including patient care and other relevant data. The following services were either not collecting any QAPI data or were not providing the data to the QAPI program: Discharge Planning, Anesthesia Services, Nuclear Medicine Services, Outpatient Services, and Respiratory Services. The hospital's failure to evaluate the these services resulted in the likelihood that the hospital would be unable to determine if these services met the needs of the patients. (Refer to A-274)

Based on record review and staff interview, the hospital failed to investigate when and how Patient #50 broke her right humerus during her stay in the hospital between 06/28/11 through 07/09/11. During the patient's stay, the family noticed the patient was having some pain in her right arm. An x-ray of the arm showed nondisplaced fracture. As the result of this failed practice, the hospital is likely to have more injuries of unknown origin that continue to be not investigated. The hospital further failed to report the injury of unknown origin of Patient #50 and the neglect of Patient #51 by a local nursing home to the proper authority, the State Agency. (Refer to A-145)

Based on document request, document review and interview, the hospital failed to ensure that the Quality Assessment & Performance Improvement (QAPI) program incorporated quality indicator data including patient care and other relevant data. The following services were either not collecting any QAPI data or were not providing the data to the QAPI program: Discharge Planning, Anesthesia Services, Nuclear Medicine Services, Outpatient Services, and Respiratory Services. The hospital's failure to evaluate the these services resulted in the likelihood that the hospital would be unable to determine if these services met the needs of the patients.
The findings are:

A. The hospital failed to ensure that Case Management Services had been collecting Quality Assessment & Performance Improvement (QAPI) data or indicators and providing them to the Quality/Patient Safety Committee. This committee was designated by the hospital as its QAPI committee.

1. On 11/02/11 at 2:00 pm, the surveyor reviewed the QAPI data provided by the hospital. There was no evidence of any data or indicators being collected or reported for Case Management Services.

2. On 11/03/11 at 10:45 am, the Director of Quality Management/Regulatory Compliance was interviewed. He was asked where the data for Case Management Services could be found in the QAPI data that had been provided. He stated that the hospital had no data for Case Management Services in the database for the Quality/Patient Safety Committee.

B. The hospital failed to ensure that the Anesthesia Services was collecting Quality Assessment & Performance Improvement (QAPI) data or indicators and integrating them into the Quality/Patient Safety Committee, the committee designated by the hospital as its QAPI committee.

1. On 11/02/11 at 2:00 pm, the surveyor reviewed the QAPI data provided by the hospital. There was no evidence of any data or indicators being collected or reported for Anesthesia Services.

2. On 11/03/11 at 10:45 am, the Director of Quality Management/Regulatory Compliance was interviewed. He was asked where the data for Anesthesia Services could be found in the QAPI data that had been provided. He stated that the hospital was not collecting data or indicators for Anesthesia Services and that no data would be found in the database for the Quality/Patient Safety Committee.

C. The hospital failed to ensure that the Quality Assessment & Performance Improvement (QAPI) data or indicators collected by the Nuclear Medicine Services were provided to the Quality/Patient Safety Committee, the committee designated by the hospital as its QAPI committee.

1. On 11/02/11 at 2:00 pm, the surveyor reviewed the QAPI data provided by the hospital. There was no evidence of any data or indicators being reported for Nuclear Medicine Services.

2. On 11/03/11 at 10:45 am, the Director of Quality Management/Regulatory Compliance was interviewed. He was asked where the data for Nuclear Medicine Services could be found in the QAPI data that was provided. The Director stated, "The data being collected on Nuclear Medicine Services does not go to the Quality/Patient Safety Committee, but goes instead to the Environment of Care Committee."

3. On 11/02/11 at 2:45 pm, the Nuclear Medicine technician, who managed the Nuclear Medicine Services, stated that the data collected by Nuclear Medicine Services goes first to the Radiation Safety Committee and then goes on to the Environment of Care Committee. She confirmed that the Nuclear Medicine data is not provided to the Quality/Patient Safety Committee.


D. The hospital failed to ensure that Outpatient Services was collecting Quality Assessment & Performance Improvement (QAPI) data or indicators and providing them to the Quality/Patient Safety Committee. This committee was designated by the hospital as its QAPI committee.

1. On 11/02/11 at 2:00 pm, the surveyor reviewed the QAPI data provided by the hospital. There was no evidence of any data or indicators being reported for Outpatient Services.

2. On 11/03/11 at 10:45 am, the Director of Quality Management/Regulatory Compliance was interviewed. He was asked where the data for Outpatient Services could be found in the QAPI data that was provided. The Director stated, "Outpatient Services was reorganized in July 2011 under a new director and no data or indicators have been collected."

E. The hospital did not meet acceptable standards of practice by failing to ensure that Respiratory Care Services was collecting Quality Assessment & Performance Improvement QAPI data or indicators and providing them to the Quality/Patient Safety Committee, the designated QAPI committee.

1. On 11/02/11 at 2:00 pm, the surveyor reviewed the QAPI data provided by the hospital. There was no evidence of any data or indicators being collected or reported for Respiratory Care Services.

2. On 11/03/11 at 10:45 am, the Director of Quality Management/Regulatory Compliance was interviewed. He was asked where the data for Respiratory Care Services could be found in the QAPI data that had been provided. He stated that the hospital had no data for Respiratory Care Services in the database for the Quality/Patient Safety Committee.

Based on record review, interview and facility policy and procedure, the facility failed to document (one) 1 hour post blood transfusion vital signs (VS) for 5 of 9 (#21, 26, 51, 52 & 53) and failed to document any VS for 1 of 9 (#25) patient records that received blood transfusions. This failed practice resulted in the likelihood that staff would not discover a severe medical problem while patients were receiving blood transfusions. The findings are:

A. Record review of the blood transfusion records revealed the following missing documentation:
1. Patient #21 received blood transfusions as follows:
a. On 10/01/11 at 1605 (4:05 pm) one unit was started and finished at 18:30 (6:30 pm). No 1 hour post VS were documented.
b. On 10/02/11 at 5:10 am, one unit was started and finished at 7:40 am. No 1 hour post VS were documented. Another unit was started at 1738 (5:38 pm) and finished at 1953 (7:53 pm). No 1 hour post VS were documented.
2. Patient #26 received a blood transfusion on 10/29/11 at 1330 (1:30 pm) and completed the transfusion at 1540 (3:40 pm). The transfusion record had no 1 hour post VS documented.
3. Patient #51 received a blood transfusion on 08/17/11 at 12:00 pm, and completed the transfusion at 1308 (1:08 pm). The transfusion record had no 1 hour post VS documented.
4. Patient #52 received a blood transfusion on 05/05/11 at 1355 (1:55 pm) and completed the transfusion at 1800 (6:00 pm). The transfusion record had no 1 hour post VS documented.
5. Patient #53 received a blood transfusion on 10/10/11 at 12:50 pm, and completed the transfusion at 1445 (2:45 pm). The transfusion record had no 1 hour post VS documented.
6. Patient #25 received 4 units of packed blood cells on 10/14/11 with the first unit started at 1300 (1:00 pm) and the last unit at 13:50 (1:50 pm). The transfusion records had no VS documented. Written on the records was the following, "See OR [operating room] record."


B. During an interview, the Director of Nursing (DON) on 11/04/11 at 9:20 am stated that the blood transfusion sheets were not complete. She stated that they do not have all the VS documented. At 10:05 am, the DON further stated that she interviewed the laboratory director who was responsible for the review of the blood transfusions. He informed her that the one hour post VS were no longer required and he had been "letting that go" but failed to change the facility policy.

C. Review of the facility policy/procedure titled "Blood Products General Policy" dated 03/1992 and last revised on 06/2009 revealed on page 6, "#3. Take post vital signs one hour after the transfusion is complete and record on the transfusion record."

Based on staff interview and record review, the hospital failed to ensure the staff that make the determination that an admission or continued stay is not medically necessary is a member of the Utilization Review (UR) committee. This failed practice was likely to cause patients to be charged for unnecessary services. The findings are:

A. On 11/02/11 at 4:00 pm, during an interview, the Health Information Management Director, a member of this committee, stated that the case managers inform the doctors if a patient can be admitted and when the patient has to be discharged. When asked if the case managers are part of the Medical Records (MR)/UR Committee, she stated that they are not part of this committee.

B. Review of the MR/UR Committee members revealed no case managers on the committee.

Based on record review and staff interview, the hospital failed to ensure the Utilization Management committee reviewed the professional services provided by the hospital to promote the most effective use of offered service. This failed practice resulted in the likelihood that the most efficient use of available health facilities and services was not promoted. The findings are:

A. Review of the "Medical Records/Utilization Review (MR/UR) Committee" meeting minutes between 01/26/11 through 07/28/11 revealed no review of the hospital's professional services.

B. On 11/02/11 at 2:45 pm, during an interview, the Health Information Management Director, a member of this committee, confirmed that this committee does not review the professional services for effectiveness of these services.

Based on document review and interview, the hospital failed to ensure that the infection control officer had been designated in writing as the appointed infection control officer. This failed practice results in the likelihood that infection control issues are not effectively addressed. The findings are:

A. Review of the infection control program did not indicate that the acting infection control officer had been designated in writing as the appointed infection control officer.

B. On 11/03/11 at 3:40 pm, during an interview, the Quality Management/Regulatory Compliance Director stated, "We do not have evidence that she has been designated."

Based on interview, the hospital failed to ensure that the in-house preparation of radio pharmaceuticals was performed by, or directly supervised by, a registered pharmacist or MD/DO, who was qualified through education, experience and training in the preparation of radio pharmaceuticals. The failure to have in-house preparation of radio pharmaceuticals performed or supervised by a qualified pharmacist or MD/DO resulted in the likelihood that a medical error could occur. The findings are:

A. On 11/02/11 at 2:45 pm, the Nuclear Medicine technician who managed the Nuclear Medicine services was asked if the hospital-prepared in-house radio pharmaceuticals was being directly supervised or performed by a registered pharmacist or MD/DO, who was qualified through education, experience and training in the preparation of radio pharmaceuticals. She stated, "No, there is no supervision when we [nuclear medicine technicians] prepare in-house radio pharmaceuticals."

Based on record review and staff interview, the hospital failed to have a doctor of medicine or osteopathy as the director of respiratory care services. This failed practice is likely to cause patients not to receive appropriate care from the respiratory staff. The findings are:

A. Review of the facility's organizational chart revealed that the Director of Respiratory and Cardiopulmonary Services was not a doctor.

B. On 11/03/11 at 3:00 pm, during an interview, the Director of Respiratory and Cardiopulmonary Services confirmed that he was not a doctor, but a radiology technician.