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Based on staff interview, tours/observations and review of facility documents, the chief executive officer (CEO) failed to ensure that all contracted services were provided in a safe and effective manner and that the organization structure for the outpatient services complied with the requirement that all outpatient services were accountable to a single individual who directs the overall operation of the hospital's entire outpatient services (all locations, all outpatient services).

The findings were:

Reference Tag A 084 - Governing Body - Contracted Services - for findings related to the hospital's failure to ensure that contracts for mental health evaluations, general preventive maintenance, laundry and elevator preventive maintenance and repair.

Reference Tag A 1079 - Outpatient Services - Outpatient Services Personnel - for findings related to the hospital's failure to ensure that all outpatient services were accountable to a single individual who directs the overall operation of the hospital's entire outpatient services (all locations, all outpatient services), including outpatient surgery, the infusion center, physical therapy/rehabilitation and the sports medicine center.

Based on staff interview, tours/observations and review of facility documents, the chief executive officer (CEO) failed to ensure that all contracted services, including those for mental health evaluations, general preventive maintenance, laundry and elevator preventive maintenance and repair, were provided in a safe and effective manner.

The findings were:

1. Mental Health Evaluations:

Reference Tag A 464 - Medical Records - Content of Records - Consults - for findings related to the failure of contracted mental health evaluators to provide a written report of their psychiatric evaluations/consultations for the medical record, as required.

2. General Preventive Maintenance:

Reference Tag A 724 - Physical Environment - Facilities, Supplies, Equipment Maintenance - for findings related to failure to ensure that the preventive maintenance contractor had inventoried all equipment and conducted preventive maintenance, as required.

3. Laundry Services:

On 10/18/11 at approximately 10:00 a.m., the director of plant operations and the environmental services (housekeeping) supervisor were interviewed about the previously identified problems with the hospital linen coming back from the laundry with brown stains that made the linen appear soiled. They stated that the stains were due to a chemical interaction with the chlorhexidine (disinfecting agent) and the soaps/chemicals used by the laundry. They stated that they were looking at buying a 6-cycle washing machine that would eliminate the staining problem and do laundry on sight in another building recently acquired by the facility. They stated that they had been working with the contracted laundry to make sure that they took stained or damaged linen out of the returning loads of clean linen. They stated the laundry was now returning the stained/damaged linen in separate labelled bags so the hospital could determine whether to use them or discard them. They stated that they had stepped up the level of vigilance of the housekeeping staff to inspecting 100% of the linen returned from the laundry to ensure that stained/damaged linen did not go to patient use areas. They stated that they still had a new 6-month contract with the laundry and were hoping to purchase the new equipment to set up their own in-house laundry. In the interim, the housekeeping staff were unfolding and inspecting each piece of laundry as it was returned to the facility. They acknowledged that they did not have a laundry sorting area that they could use to ensure that linen was inspected and re-folded for patient use, to maintain optimums cleanliness during the inspection and re-folding process. The hospital has not made a firm decision to correct the linen situation with an improved linen sorting/re-folding area or purchase of a new 6-cycle washer and set up of a new in-house laundry with a target date of operation. No actions or decisions have been made to permanently and effectively correct the problem.

4. Elevator Preventive Maintenance and Repair:

On 10/19/11 at approximately 10:00 a.m., the director of plant operations was interviewed about the elevator service contract. S/he state that the elevator services contractor had been coming to the facility to conduct inspections and for repairs more timely, but the contractor was not providing any written documentation or report of their findings. S/he told me the contractor had last been to the facility approximately one month before to repair a switch on one of the elevators, but did not provide any documentation of their work or findings. When asked to contact the contractor to attempt to obtain a report of the work performed, s/he agreed to contract the elevator company. S/he returned at 10:50 a.m., with a copy of the 5-year inspection that the company had done that year, but had no other documentation. S/he stated that the company had refused to provide routine documentation after services or repairs were performed. S/he stated that the issue had been discussed with the CEO, and that/she had suggested looking for a different contractor, who might provide more timely services and cooperate with providing written reports of work done. The director of plant operations stated that they had begun to explore working with another company, but could not change until next May (2012), because of the terms of the contract. S/he stated that they would have to give their current contractor notice in January (2012) to get out of the current contract. When asked if s/he could get help from the CEO to communicate directly with the contractor to improve cooperation, including written reports of work done, with the current contractor until they could make a change. S/he said s/he was not sure if the CEO would get involved to help with that.

On 10/19/11 at approximately 11:15 a.m., the CEO was interviewed about contract performance problems related to mental health evaluations, preventive maintenance, elevator service and repair and laundry/linen services. S/he acknowledged that if a contractor was not providing quality services and/or meeting the terms of the contract, that ultimately s/he was accountable and responsible to improve performance or change the contractor. S/he acknowledged that s/he had not been aware of the extent of the problems that the managers were struggling with to get acceptable standards of contract performance from the contractors. S/he stated that s/he needed to work with managers to not be willing to accept "good enough" contract performance. S/he stated the managers needed to know that it was "okay" to involve him/her with contract performance problems, and that s/he would be conveying that message to the managers going forward.

Based on review of the hospital's policies/procedures, staff interview, and review of the hospital's internal documents the facility failed to ensure that in its resolution of patient grievances that the hospital provided a written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

The findings were:

A review of the hospital's policy titled "Patient Complaint/Grievance" last revised August 2011, revealed the following, in pertinent part:
"...Step 3: Investigation
a.) The Risk Manager will investigate the grievance and respond to the patient, on average, within seven (7) working days, but up to fifteen (15) working days of the submittal of the grievance...
b.) After investigation, which may include a meeting with the patient and his/her family, and appropriate input from management and others, the Risk Manager will provide the patient with a written report o(r) personal phone call regarding the hospital's decision regarding the grievance, which includes:
i.) The name of the Risk Manager or other hospital contact person;
ii.) The steps taken by the hospital on behalf of the patient to investigate the grievance.
iii.) The results of the grievance process
iv.) The date of completion..."

A review of a sample of the hospital's grievances that had been resolved were reviewed with the risk manager on 10/18/2011 at approximately 2:30 p.m. The review included three complaints/grievances. Upon discussion with the hospital's Risk Manager regarding follow-up on the grievances, s/he stated that out of the three complaints, only one was sent a letter. S/he stated that "we don't send formal letters, we usually meet them [patients or the patient's representatives with grievances] in person." When asked if the facility could provide the letter for review, s/he stated that the facility was unable to do so, because a copy had not been retained.

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Based on review of facility documents and staff interviews, the facility failed to ensure that performance activities, which identified potential risk to patients, staff and visitors, included a system to track actions taken and resolution of identified risks situations. Specifically, the hospital failed to institute an organized system to track risk conditions that were identified during "environment of care" inspections to ensure that actions were taken to correct the risk conditions and to track resolution of the problems identified. In addition, other problems were identified in the "environment of care" meetings, but there was no evidence of follow-up or resolution of the problems in subsequent meeting minutes.

The findings were:

1. On 10/18/11, the meeting minutes for the hospital's "Environment of Care" Committee for July 21, 2011, August 31, 2011 and September 28, 2011 were reviewed and revealed the following findings:

Review of the minutes revealed that although there were categories in the meeting minutes for recommendations/actions and follow-up, resolution of the issues or actions taken were not in the meeting minutes and not reflected in subsequent meeting minutes. There was no evidence from meeting to meeting of resolution or "closure" of problems/risk conditions.

Findings that required actions were contained in the meeting minutes and in attached "environment of care" rounds reports. Issues identified included, the following;
-housekeeping was not changing wash water between rooms and not changing mop heads daily, causing more cross-contamination risks from patient room to patient room.
-minor repairs of tiles, appliance handle, cleaning of appliances and specific areas.
-improper storage related to infection control, fire safety and safe egress in hallways.
-improper use of disinfectant wipes.
These issues were not addressed in subsequent meeting minutes and there was no indication of actions taken or final resolution of the problem areas.

2. On 10/18/11 at approximately 11:00 a.m., the quality improvement and infection control officers were interviewed about the lack of evidence of tracking and correction of issues identified on "environment of care" rounds. They stated that they would have to try to reconstruct what actions were taken to correct situations by looking for e-mail correspondences from various department managers. They felt that things were getting corrected most of the time, but acknowledged that there was no organized system that tract resolution of identified problem areas. They discussed options for documenting more of what was inspected, including areas without problems, to better standardize the process and to track actions and resolutions on meeting minutes and subsequent "environment of care" inspection reports.

Based on review of medical records, facility documents and staff/physician interviews, the facility failed to ensure that contracted mental health consultants provided documentation of all consultative evaluations in the medical record. This failure created the potential for negative patient outcomes:

The findings were:

1) Sample patient #2 was a 23 year old, who presented to the emergency department on 9/10/11 at 4:24 p.m. because s/he was hearing voices. The Emergency Nursing Record noted: "16:45 (4:45 p.m.) Mental Health person here to see patient." The After Care Instructions for the patient stated: "Follow up with mental health Specialist at Alamosa ....Call NOW to arrange." The patient's medical record did not contain a note from the mental health consultant; there was no documentation of an assessment, evaluation or recommendation for a plan of care from a consultative visit with a mental health professional.

Review of the Mental Health Consult log kept by the Director of the Emergency Department documented in reference to attempting to obtain consultation notes for this patient, "9/15/11 contacted mental health will fax consult. 9/16/2011 left message for the doctor. 9/20/2011 Consult in the chart." The patient was discharged from the Emergency Department 9/10/11 at 1755 p.m. (5:55 PM).

There was a mental health note added to the patient medical record containing the patient's presenting problem, mental status examination, assessment and plan. This documentation was faxed to the facility on 9/15/11, five days after the patient had been discharged.

2) Sample patient #4 was a 55 year old, who was brought by the police to the emergency department on 10/05/11 with altered mental status, desiring to hurt her/himself. A review of the EMERGENCY PHYSICIAN RECORD documented the time patient was seen as 01:20 a.m. The record also documented: "Mental Health -present." The patient was transferred from the facility's emergency department to the Colorado State Hospital for inpatient mental health treatment. In a review of the Mental Health Consult log kept by the Emergency Department Director, the director documented: "patient transferred to Colorado Mental Health Institute-Mental Health provider in ED and made arrangements." When the patient medical record was reviewed during the hospital survey on 10/18/11, there was no notation in the patient record of the mental health consultation. There was no documentation of an assessment, evaluation or recommendation for a plan of care from a consultative visit with a mental health professional.

An interview was conducted on 10/17/11 at approximately 4:00 p.m. with the Director of the Emergency Department. When asked about the contract between San Luis Valley Regional Medical Center (Hospital) and the Community Health Center (Center), the contract stated in pertinent part: "Center staffs will document these services in the hospital chart according to normal operating procedure." The Director of the Emergency Department responded: "I took it upon myself to take this to mean as soon as you finish seeing the patient you should talk to the provider and document in the patient record. That probably needs to be spelled out more." In reviewing the Plan Of Correction submitted by the Hospital with the Director of the Emergency Department it stated: "The Director of the ER will provide the Medical Records department a daily log of all Mental Health visits to alert the Medical Record staff of an incoming fax or to contact mental health if no fax is received." The Director stated: "I didn't start keeping a log until September because I didn't know I was suppose to." In another interview conducted on 10/19/11 at 9:00 a.m., the Director of the Emergency Department stated: I was called by the Director of Risk Management and told that I needed to audit the Mental Health consult visits. When asked if s/he had seen the Plan of Correction and told what her/his responsibilities were, s/he stated: "I have not seen a copy of the Plan of Correction. If I would have gotten this information I would have done this. I spoke with the HIM (Health Information Management) Director yesterday and s/he asked me if I was aware I was to send a log? I do not feel medical records should be involved because I as a nurse or any other person providing a service to the patient should document in the patient record before leaving the unit, two or three days later is too late because the patient has already been discharged and there is no plan in the chart."

An interview was conducted on 10/18/11 at approximately 1:00 p.m. with the Director of HIM (Health Information Management). When discussing the Plan of Correction that involved the Medical Records Department's role in follow-up of Mental Health consultations, s/he did not have a policy or procedure to show how this process change had been implemented. When the HIM Director was asked how staff was made aware of process/procedure changes s/he stated: "I tell them." When the Director was asked if there was documentation in departmental meeting minutes, there was no response from the Director. When the HIM Director was asked how the new process for requesting, obtaining and filing mental health consults was working, there was no response from the Director. S/he later answered, "I haven't heard of any problems." Review of the medical record of sample patient #2 revealed the same consultative note had been received on two different days and filed in two different locations of the patient medical record; one copy with date and initials of the person who received the fax. When asked which procedure was correct there was no response from the HIM Director. When asked about receiving a daily log of all Mental Health visits the Director was unaware of a log, and s/he would have to ask the staff that was directly involved.

An interview on 10/18/11 at approximately 2:25 p.m. with the Director of Risk Management. When asked how this new process for mental health consultations was working, s/he answered, "I wish I would have left Medical Records out of the process. We should have the expectation that they (mental health consultants) see the patient, discuss with the physician and write a note." When the Risk Management Director was asked why the expectation for these consultants is not the same as for other providers, s/he stated: "they do not have advanced degrees, they are not physicians." The Director then agreed that this would make the documentation perhaps more vital to be available after the assessment. S/he stated:
"there have been cases/news articles of known adverse outcomes with patients discharged from the ER (Emergency Room)." When asked about the process for the HIM Director to communicate to her/his staff about the changes outlined in the Plan of Correction s/he stated, "s/he was to communicate to her/his staff in a meeting." During an interview with the Risk Manager on 10/19/11 at approximately 7:45 a.m., when asked about how the Plan of Correction for Mental Health consults had been monitored, s/he stated, "I talked to the Director of ED and s/he is doing a log." When asked if the log is getting to Medical Records, s/he stated, "It's suppose to." When asked how s/he is monitoring this Plan of Correction , there was no response.

The medical record of sample patient #2 was reviewed with the Director of Risk Management and s/he was aware of this ED visit and stated, "s/he had spoken with the provider/physician and was told that the Mental Health consultant did not discuss the patient assessment with her/him." The note that had been faxed 10/18/11 was reviewed by the Director of Risk Management for the lack of content. S/he took the faxed document to the Chief Medical Officer for her/his review.

An interview was conducted on 10/19/11 at 8:15 a.m. with the Director of HIM in regard to the implementation of the Plan of Correction (POC), s/he stated, "I did not receive a copy of the POC. I should have been calling Mental Health for the records but I don't see how they are able to leave the ED without writing a note." The HIM Director admitted s/he was not aware of the Mental Health consultation follow-up to be done by Medical Records and the role the department was to have in this process change. A draft of Policy Title: Emergency Room Patient with Mental Health Consultation was submitted during this hospital survey.

An interview was conducted on 10/19/11 at approximately 12:50 p.m. with the Director of the ED. S/he stated, "the Mental Health staff does know about the expectation that the consultant talk with the provider/physician and write a note because I have talked with the Medical Director and gave them the information that needs to be done and/or documented when the patient is seen. There should be a note to inform the team and the provider/physician about the patient diagnosis and plan of care. If we receive after the visit, the patient has already been discharged from the ED."

In summary, the Mental Health consultants failed to fulfill their contract agreement with the hospital. Consultation notes were not consistently being provided at the time of service and some notes provided were not complete as evidenced by the omission of the patient assessment, evaluation, plan of care and a discussion with the Emergency Department provider/physician.

The facility also failed to implement, monitor and revise as needed their submitted Plan of Correction.

Based on tours/observations, staff interviews and review of facility documents, the hospital failed to ensure that facilities, supplies and equipment, including physical therapy equipment, infusion pumps, hospital linen and the facility elevators, were maintained to ensure acceptable level of safety and quality. The findings created the potential for negative outcomes for patients, staff and visitors to the facility.

The findings were:

1. Malfunctioning Equipment:

On 10/18/11 at approximately 2:30 p.m., during a tour of the outpatient rehabilitation clinic, a piece of equipment on a cart in a patient treatment room was observed with a sign attached saying "Do not use infrared." The machine had a preventive maintenance sticker indicating that the machine had been inspected within the last few months. When one of the physician practice administrator was asked to find out about the sign on the machine, s/he went and spoke to a staff member in the clinic, who had stated that the equipment needed to be inspected by biomedical equipment.

On 10/19/11 at approximately 8:30 a.m., the director of nursing for the facility, who was working with staff to follow-up on paperwork requests and other survey tasks was asked to follow-up with the manager of the outpatient rehabilitation clinic to get more specific information about why the equipment needed to be inspected by biomedical equipment, if the equipment had malfunctioned, had a patient been harmed by the equipment and had the event been reported. S/he agreed to contact the clinic manager and attempt to get more information.

On 10/19/11 at approximately, the clinic manager contacted the surveyor and stated that s/he was not aware of the equipment problem, but would follow-up with his/her staff and provide more information. That interaction occurred in the presence of the chief operating officer (COO), the person responsible for oversight of the outpatient services areas. The clinic manager was asked to provide the result of his/her follow-up investigation to the COO, who would then provide it to the surveyor.

At approximately 10:30 a.m., the COO provided the following e-mail, which s/he had received from the clinic manager explaining what had occurred with the equipment in the rehabilitation clinic:

"Last Thursday (10/13/11), (a staff member) was applying infrared to the shoulder of a patient. The patient complained of the probe being too hot and the staff member discontinued the treatment. The machine display was flashing "HOT" and it would not work at that time. The staff member inspected the patient skin and found no redness or other indications of injury. The patient had no further redness or other indications of injury. The patient had no further complaints. The staff member put a note on the machine indicating the infrared part of the machine was not working. These machines contain infrared, ultrasound and e-stim in one unit. A call was placed to biomed to report the defective machine. A biomed work order is in place and biomed has been notified by phone again and will reassess the machine today. We did our own informal inspection and the machine is apparently working properly. We think the machine did overheat, at least to that particular patient, and it had to reset itself, for now it is working normally. I will turn in an incident report with follow up. The machine is now in my office awaiting biomed inspection, I have sent an email to staff asking that any equipment failure or patient complaint is reported immediately to me so proper notifications are sent."

2. Preventive Maintenance Inspections/Inventory of Equipment:

A tour of the medical/surgical patient care unit was conducted with the hospital's Chief Nursing Officer (CNO) on 10/17/2011 at approximately 3:00 p.m. It was observed that in a room that contained equipment for patient use there were two intravenous infusion pumps that did not have current biomedical engineering inspection tags. One pump was last inspected in October 2009 and the other pump was last inspected in June 2010. The hospital's CNO confirmed that the equipment did not have any indication that they were inspected when the rest of the facility's equipment was inspected and that it was expected that each pump was to be inspected annually. S/he removed the pumps from the room at that time to allow inspection by the contracted biomedical technicians.

An interview with the hospital's CNO on 10/18/2011 at approximately 4:20 p.m., revealed that the two infusion pumps that had not been inspected that were found on 10/17/2011 had been inspected by the biomedical engineering service on 10/18/2011.

An interview with the hospital's CNO on 10/19/2011 at approximately 8:40 a.m., revealed that the hospital did not have a log or current inventory of the equipment that needed biomedical inspection mostly in part to the equipment being leased and not purchased. S/he stated that the hospital was working on generating a list with the contracted service currently and that the hospital was developing a policy and process in which new equipment entering the facility would be provided inspection stickers before being put into service.

An interview with the hospital's Manager of Biomedical Engineering on 10/19/2011 at approximately 11:15 a.m., revealed that the two infusion pumps that were not inspected while the rest of the hospital's equipment had been inspected were not assigned asset numbers to be tracked until 10/18/2011 because they had not been located on the "initial sweep." S/he stated that the hospital would be able to generate a list of the equipment requiring service and equipment that could not be located once the database had each piece of equipment. S/he stated that the database needed to be developed as the hospital did not have a list of the current equipment when the new company came to the facility to service all of the equipment recently. The hospital's CNO was present during the interview and confirmed what the Manager of Biomedical Engineering had stated.

In summary, the facility did not have an accurate inventory of the equipment requiring service to identify equipment not yet serviced or to prevent non-serviced equipment from being used for patient care.

3. Laundry

Reference Tag A 084 - Governing Body - Contracted Services - for findings related to continued failure to take actions or make decisions to permanently and effectively correct the problem of stained and damaged linens being returned from the contracted laundry services.

4. Elevator Maintenance

Reference Tag 084 - Governing Body - Contracted Services - for findings related to the failure to ensure that the facility receives written reports of findings when the contracted elevator service inspects or repairs the facility's elevators.


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Based on staff interview, tours/observations and review of facility documents, the chief executive officer (CEO) failed to ensure that the organization structure for the outpatient services complied with the requirement that all outpatient services were accountable to a single individual who directs the overall operation of the hospital's entire outpatient services (all locations, all outpatient services), including outpatient surgery, the infusion center, physical therapy/rehabilitation and the sports medicine center.

The findings were:

1. On 10/18/11 at approximately 2 p.m., during a tour of the outpatient clinics, the clinic managers (physician services director of nursing and nurse manager and physician services practice administrator) stated that some clinics in the outpatient areas were not in under the chief operating officer (COO), who was identified by the facility and the organizational chart as the person responsible for oversight of all outpatient services. Specifically, they identified that the outpatient surgery, the infusion center, physical therapy/rehabilitation and the sports medicine center were not in a reporting relationship to the COO under the organization of the facility.

2. On 10/19/11 at approximately 9:15 a.m., the COO confirmed that the outpatient surgery, the infusion center, physical therapy/rehabilitation and the sports medicine center did not report to him/her. S/he stated that the outpatient surgery and infusion center were under the director of nursing and the physical therapy/rehabilitation and the sports medicine center areas were under the a manager that was listed on the organization chart as being in charge of clinical excellence for the facility, as well as being the CEO of an affiliated critical access hospital.

3. Review on 10/18/11 of the organization charts for the facility, the outpatient services area and the nursing department revealed that the outpatient surgery and infusion center were under the director of nursing rather than the COO. The organizational charts also showed that the physical therapy/rehabilitation and the sports medicine center areas were under the a manager that was listed on the organization chart as being in charge of clinical excellence for the facility, as well as being the CEO of an affiliated critical access hospital. The COO was listed as being the person in charge of all outpatient services. Multiple interviews with facility management staff during the survey confirmed that the COO was the person at the facility that had been designated as the person accountable for all outpatient services, as required. That was also confirmed by the COO during an interview about outpatient services on 10/17/11 at approximately 2:45 p.m.