HospitalInspections.org

Based upon record review and interview, the Governing Body failed to ensure contracted services were reviewed and assessed through the Quality Assurance Performance Improvement Program to ensure the services complied with standards of practice related to the provision of radiology, laboratory and dietary services. Findings:

On 06/12/23 at 12:15 p.m. interview with Staff E revealed Contract H was identified as providing acute care services for patient transfers, laboratory services, and radiology services. O 06/13/23, Contract H was requested for review. Staff G provided purchase orders for rendered services. Interview with Staff G on 06/13/23 at 10:30 a.m. revealed the hospital did not have an actual contract for H.

Interview on 06/24/23 at 11:40 a.m. with Staff A and Staff E revealed the Registered Dietician was provided by Contract I. Review of Contract I revealed this "Memorandum of Understanding" identified dietary evaluation and/or consultation, quarterly menu review, and inservice training to dietary staff was to be provided. Further review of the contract revealed it failed to identify a Registered Dietician was to provide the services or the name of the Dietician. Further interview with Staff A revealed the name of the Dietician was identified; however, there was no contract with a Registered Dietician.

Review of the Quality Assurance Performance Improvement Plan revealed no contract services were reviewed through the program to ensure the services furnished were in compliance with the contract.

Based upon record review and interview, the Governing Body failed to ensure contract services were reviewed through the hospital wide Quality Assessment Performance Improvement Program. This was evidenced by the failure to have a mechanism in place to review all contracts to ensure the services provided in a safe and effective manner. Findings:

Review of the Quality Assessment Performance Improvement Program data on 06/13/23 revealed contract services were not identified as being reviewed in the plan. Interview with Staff C on 06/13/23 at 1:20 p.m. confirmed contract services were not reviewed.

Based upon record review and interview, the hospital failed to ensure there was a qualified dietician on a full-time, part-time or consultant basis. This was evidenced by the failure to provide a personnel file, a valid contract for the dietician, or documentation of on-site supervision of the dietary staff or consultation for review of the patient's nutritional needs when required. Findings:

Interview on 06/14/23 at 11:40 a.m. with Staff A and Staff E revealed the Registered Dietician was provided by Contract I.

Review of Contract I revealed the contract did not identify a Registered Dietician was to provided oversight of the dietary service. Further interview with Staff A revealed the hospital did not a personnel file or any information on the dietician other than a name.

Based upon record review and interview, the hospital failed to ensure for 3 of 10 (#5, #8, #9) medical records reviewed, the active treatment plan identified planned treatment modalities related to the patient's medical problems. Findings:

Review of patient #5's medical record revealed an admission date of 06/07/23. According to the admission diagnosis, the patient had a medical history significant for Hypertension and Seizures. According to the nursing progress notes, the patient was placed on seizure precautions; however, the active treatment plan failed to identify a plan of treatment and approaches to be provided.

Review of patient #8's medical record revealed the patient was admitted on 03/03/23 and discharged on 03/16/23. According to the admission diagnosis the patient had a history of Asthma and required an Albuterol Inhaler. Review of the active treatment plan revealed a plan of treatment and approach was identified for the patient's history of Asthma which required an inhalant to relieve the symptoms.

Review of patient #9's medical record revealed the patient was admitted on 03/16/23 and discharged on 03/28/23. According to the admission diagnosis, the patient's medical history included Asthma and Seizures. Review of the Medication Administration Record revealed on 03/19/23 at 2:00 p.m., the patient required a hand held nebulizer inhalation treatment for the Asthma. Review of the active treatment plan revealed treatment modalities were not developed related to the medical problems of Asthma and Seizures even though the patient required treatment of the Asthma during the hospitalization.

Interview with staff E on 06/13/23 at 3:30 p.m. confirmed the active treatment plans did not identify modalities for the patients medical problems.