HospitalInspections.org

Based on review of hospital data, Governing Authority Meeting Minutes, medical staff bylaws, rules and regulations, and staff and physician interviews, it was determined the medical staff failed to ensure the medical staff bylaws/rules and regulations for conducting peer review were documented and implemented.

Findings include:

The hospital's Governing Authority Bylaws, revised 05/27/11, included: "...Ensure that the medical staff is accountable to the governing body for the quality of care provided to patients...Medical Staff...The Governing Authority is ultimately responsible for the quality of care provided at the Hospital...the Medical Staff shall be responsible for the continual measurement, assessment and improvement of the quality of patient care services and the clinical performance of medical staff members within the Hospital...."

The hospital's Bylaws of the Medical Staff, revised 04/22/11, included: "...The Quality Council will meet at least quarterly and will report its findings and plan of action as indicated, to the Medical Executive Committee and the Governing authority at least quarterly...."

A review of the Governing Authority Meeting Minutes revealed on 03/12/2010, the agenda indicated there was a peer review report, however, no report was attached for review. The next Governing Authority Meeting conducted on 09/23/10, did not have peer review reports.

No peer review was reported to the Governing Authority for 2011.

Employee # 4 confirmed the Governing Authority findings on 10/14/11, at 1035 hours.

On 08/23/11, Medical Staff met to discuss the Transition of Peer Review Process. In this meeting it was noted that the current indicators (for peer review) were reviewed and discussed. Those indicators included, H&P completion on time, elements included in the H&P, legibility, dating & timing of orders and progress notes, and authentication of telephone and verbal orders. All of these components were being conducted by nurses and medical record personnel. Physicians were not involved in the collection of this data, only nurses and medical record personnel who are not peers of physicians. Employee #4 confirmed on 10/14/11 at 1035 hours, the documentation reviews were conducted by nursing and the medical records personnel.

A telephone interview with Physician #5, was conducted on 10/14/11 at 1000 hours. She confirmed no issues had "fallen out" for her to review.

The hospital could not demonstrate physicians conducted peer review.

Based on review of hospital policy/procedure, documents, and staff interviews, it was determined that the hospital failed to require a registered nurse was present or immediately available at the bedside on each inpatient pod, when patients were present.

Findings include:

The hospital has 3 patient pods (total 60 beds) each with a nurses' station, reception area, and offices. The hospital shares pharmacy and dietary services with the separately certified adjoined long term care facility.

The hospital policy titled Acuity Staffing Plan #CMS110 requires: "...The daily staffing pattern for each unit is determined by the RN in Charge...."

The patient census was 21 at the time of survey; 11 higher acuity patients in pod B3 staffed with RNs, LPNs, and CNAs, and 10 lower acuity patients in pod B2 staffed with LPNs and CNAs. Pod B1 was closed.

The Chief Nursing Officer (CNO) confirmed during an interview conducted on 10/12/11 at 0900, that B2 was staffed with 2 LPNs, 1 CNA, and no RN. The CNO stated that the B3 RN had 4 - 5 patients of her own, and covered the 2 LPNs assigned the 10 patients on B2. The CNAs float between units. The CNO stated, "the 3 pods are considered 1 unit." However, each "Pod" operates separately and is separated physically from the other units (pods). The central nursing station which connects all three units/pods is not being utilized as a nursing station and was vacant.

Both B2 LPNs #2 and 12, confirmed during interviews conducted on 10/12/11, that the B3 RN has a patient assignment on B3, and also provides LPN oversight, and coverage for breaks and lunches. During a return visit to B2, the surveyor confirmed that 1 LPN remained when the other LPN went to lunch, with no RN on the unit. The LPN stated that if the RN was needed, s/he would call her over from B3. No RN

The CNO confirmed B2 Nursing Assignments Daily Data Forms patient/staff assignments as follows:

10/01/11 7AM - 7PM 10 patients (pts). 2 LPNs, 1 CNA
10/02/11 7PM - 7AM 10 pts. 2 LPNs, 1 CNA
10/06/11 7PM - 7AM 10 pts. 2 LPNs, 1 CNA
10/07/11 7AM - 7PM 10 pts. 2 LPNs, 1 CNA
10/07/11 7PM - 7AM 9 pts. 2 LPNs, 1 CNA
10/08/11 7AM - 7PM 10 pts. 3 LPNs, 1 CNA
10/08/11 7PM - 7AM 10 pts. 2 LPNs, 1 CNA
10/10/11 7AM - 7 PM 12 pts. 2 LPNs, 1 CNA
10/10/11 7PM - 7 AM 12 pts. 2 LPNs, 2 CNA
10/11/11 7PM - 7AM 10 pts. 2 LPNs, 1 CNA

RNs are not staffed and immediately available at the bedside on each patient unit.