HospitalInspections.org

Based on a review of the facility's policies and procedures, medical staff bylaws, quality assurance (QA) data and staff interview, it was determined that the governing body failed to ensure that an organized and effective QA mechanism existed for review of physicians and anesthesia providers in eleven (11) of eleven (11) sampled credential files (#'s 1, 2, 3, 5, 6, 7, 8, 9, 10, 11 and 12).

Findings were:

Review of the facility's policy entitled Medical Staff Peer Review, approved 04/25/2002, revealed that the facility would ensure that the medical staff assessed the performance of individuals granted privileges and utilized the results of such assessments to: 1. Improve the quality of care provided by the medical staff; 2. Monitor the performance of the medical staff; 3. Identify areas for performance improvement and 4. Monitor significant trends by analyzing aggregate data. The policy indicated that ongoing review was to be conducted and reported to the appropriate committee for review and action with information reported to the medical executive committee (MEC) and the board of directors at least quarterly.

Review of the Medical Staff Bylaws (11.4-1), last approved 2012, entitled Description of Functions of Peer Review Committee revealed that the duties involved in coordinating and reviewing patient care audits and Continuous Quality Improvement areas were to adopt specific programs and procedures for reviewing, evaluating and continuously improving the quality and efficiency of patient care within the hospital.

Review of the sampled credential files and QA data failed to reveal documented evidence that an organized and thorough quality review of physicians and anesthesia providers was established and ongoing in order to monitor the performance of the medical and allied health staff (non physician practitioners). Review of quality assurance/performance improvement (QAPI) data revealed that physician blood usage and surgical complications were some of the areas being monitored, but this limited review failed to include other important quality indicators and failed to include the entire medical and allied health population.

During an interview on 01/31/2013 at 11:30 a.m. in the administrative office, the chief executive officer (CEO) confirmed that the facility did not have a formal physician quality review process. He/she stated that several hospital departments were monitoring results and complications, but that there was no data accumulated on each practitioner's performance and no action plan. He/she stated that if an unexpected or negative outcome occurred, this would be brought to the Peer Review Committee, then to the MEC and then to the governing body (GB).

Based on review of the facility's policies and procedures, Quality Assurance and Performance Improvement (QAPI) documents and staff interviews, it was determined that the governing body failed to assure that all of the facility's services including contract services were reflected in the QA/PI program of the hospital.

Findings were:

Review of the facility's policy titled Contract Review, effective date 11/2012, revealed that it was the policy of the facility to establish a process for the annual review of contracted services to assure that contract services were safe and effective. Additionally, it was the responsibility of the governing body to evaluate and select contracted services.

Review of the facility's Performance Improvement Plan, last reviewed 07/12, revealed that the scope of the plan included all departments.

Review of the facility's documents failed to demonstrate that quality assurance and performance improvement activities and data for all contracted services had been provided to the QA/PI committee and governing body.

Review of the PI committee meeting minutes for three (3) quarters of 2012 failed to reveal QA/PI reports from contract services. The minutes list the quarter but not the date of the actual meetings. Additionally, the minutes reflected that six (6) hospital departments failed to report monitors as scheduled.

During an interview on 1/29/2013 at 3:35 p.m. in the administrative conference room, the Chief Executive Officer (CEO) and the QA Director confirmed that QA/PI information for contracted services had not been provided to the facility and/or the governing body.

Based on review of the facility's radiology services documentation, policies and procedures, tour and staff interview, it was determined that the facility failed to have a system in place to control infections in patients receiving exams where transvaginal ultrasound probes are utilized.

Findings were:

Review of the department's documentation failed to reveal that logs were being maintained related to the cleaning of transvaginal ultrasound probes.

Review of the departments policy entitled "Infection Control," effective 11-20-1995, no revision date, revealed that instruments used in the department were to be soaked in a hospital approved solution, and then washed and sterilized.

During a tour of the department on 01/30/2013 at 10:00 a.m., there was not an area observed for sterilization of instruments used in the department nor was there solution for the soaking of these instruments.

During an interview in the ultrasound department on 01/30/2013 at 10:15 a.m., the radiology director (employee #3) stated that he/she depended on the ultrasound technicians to guide him/her in what they needed in their area. The radiology director further stated that he/she recently ordered high-level disinfectant for this use as requested by the ultrasound technician.

During an interview on 01/30/2013 at 10:20 a.m. in the ultrasound department, the ultrasound technologist (employee # 21) confirmed that he/she did not have a log documenting the cleaning of transvaginal probes. He/she stated that the cleansing of the transvaginal probes involved the use of a sheath during the exam. This was removed after an exam and the probe was wiped down with a sani-wipe plus.