HospitalInspections.org

Based on review of policies and procedures, review of information provided and interviews with key staff November 16-17, 2011, it was determined that the facility failed to be in compliance with the Federal Condition of Participation: Patient's Rights 482.13, as required by the Maine "Rules for the Licensing of Hospitals" section 3.2 as evidenced by:

1. The CAH failed to ensure that the hospital's governing body approved and was responsible for the effective operation of the grievance process, unless it delegated the responsibility in writing to a grievance committee (see Tag C-0151 for further information );

2. The CAH failed to provide the patient with written notice of its decision regarding a grievance, 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. (see Tag C-0151 for further information);

3. The CAH failed to ensure that each patient receive care in a safe setting (see Tag C-0151 for further information);

4. The CAH failed to identify a patient's basic rights, ensure patient safety, and eliminate the inappropriate use of restraint or seclusion (see Tag C-0151 for further information);

5. The CAH failed to include in their restraint and seclusion policy the definitions as described in the Federal Condition of Participation: Patient's Rights (see Tag C-0151 for further information);

6. The CAH failed to ensure that restraints or seclusion would only be used when less restrictive interventions had been determined to be ineffective to protect the patient, a staff member, or others from harm (see Tag C-0151 for further information);

7. The CAH failed to provide resource to assist clinicians in identifying less restrictive restraint or seclusion interventions (see Tag C-0151 for further information);

8. The CAH failed to implement the use of restraints or seclusion in accordance with safe and appropriate restraint and seclusion techniques (see Tag C-0151 for further information );

9. The CAH failed to implement its policy and procedure regarding restraints and seclusion (see Tag C-0151 for further information );

10. The CAH failed to prevent possible injury or death to patients by allowing untrained staff to monitor the condition of the patients who were restrained or secluded (see Tag C-0151 for further information );

11. The CAH failed to specify the training requirements of physicians and other licensed independent practitioners in hospital policy (see Tag C-0151 for further information );

12. The CAH failed to train staff to identify the most appropriate intervention to perfectly manage a patient's condition or symptom(s) (see Tag C-0151 for further information );

13. The CAH failed to ensure the safe implementation of restraint or seclusion by trained staff (see Tag C-0151 for further information );

14. The CAH failed to identify the training intervals necessary for staff regarding the application of restraints and the implementation of seclusion (see Tag C-0151 for further information );

15. The CAH failed to establish a training program based on techniques to identify staff and patient behaviors, events, and environmental factors that might trigger circumstances that would require the use of a restraint or seclusion (see Tag C-0151 for further information );

16. The CAH failed to require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in the use of nonphysical intervention skills (see Tag C-0151 for further information );

17. The CAH failed to require appropriate staff to have education, training and demonstrated knowledge based on the specific needs of the patient population in choosing the least restrictive intervention based on an individualized assessment of the patient's medical, or behavioral status or condition (see Tag C-0151 for further information );

18. The CAH failed to require appropriate staff to have education, training and demonstrated knowledge based on the specific needs of the patient population in the safe application and use of all types of restraint or seclusion used in the hospital (see Tag C-0151 for further information );

19. The CAH failed to require appropriate staff to have education, training and demonstrated knowledge based on the specific needs of the patient population in clinical identification of specific behavioral changes that indicate that restraint or seclusion is no longer necessary (see Tag C-0151 for further information );

20. The CAH failed to require appropriate staff to have education, training and demonstrated knowledge based on the specific needs of the patient population in monitoring the physical and psychological well-being of the patient who is restrained or secluded (see Tag C-0151 for further information );

21. The CAH failed to require appropriate staff to have education, training and demonstrated knowledge based on the specific needs of the patient population in the use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic Re-Certification (see Tag C-0151 for further information );

22. The CAH failed to provide staff training by individuals who were qualified as evidenced by education, training, and experience in techniques used to address patient's behaviors (see Tag C-0151 for further information ); and

23. The CAH failed to ensure documentation in staff personnel records that the training and demonstration of competency regarding restraints and seclusion were successfully completed (see Tag C-0151 for further information ).

The cumulative effects of these deficient practices resulted in the Condition of Participation being out of compliance.

Based on review of personnel records, review of policies and interviews with key staff on November 16, 2011, it was determined that the facility failed to comply with the Federal Condition of Participation: Patient Rights 482.13(f) (4), Training Documentation, which required that the hospital must document in the staff personnel records that the demonstration of competency for restraint application was successfully completed.

Findings include:

1. A review of the hospital policy titled ' Documentation of Education Training ' on November 16, 2011, revealed no requirement that personnel demonstrate competency of the application of restraints.

2. A review of the hospital policy titled 'EMH/CA DEAN RESTRAINTS AND SECLUSION POLICY' stated, "Staff will be competency trained in the use of least restrictive alternatives and standard restraint equipment application."

2. Ten (10) personnel records were reviewed on November 16, 2011. None of the records contained documentation of competency regarding the use of least restrictive alternatives and standard restraint equipment application.

3. During an interview with the Chief Nursing Officer on November 16, 2011, it was confirmed that there had been no competency training for the application of restraints in 2008, 2009 and 2010. It was further stated that competency training regarding the application of restraints had only begun several weeks ago due to "the bath salts crisis. "
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Based on review of credential files, review of policies and interviews with key staff on November 16, 2011, it was determined that the facility failed to comply with the Federal Condition of Participation: Patient Rights 482.13(f) (2), Training Content, which required that the hospital must require appropriate staff to have education, training and demonstrated knowledge based on the specific needs of the patient population.

Findings include:


1. A review of the hospital policy titled ' Documentation of Education Training ' on November 16, 2011, revealed no requirement that physicians and other licensed independent practitioners have at a minimum, a working knowledge of the hospital policy regarding the use of restraint and seclusion.

2. Eight (8) credential files were reviewed on November 16, 2011. There was no documentation that at a minimum, physicians and other licensed independent practitioners authorized to order restraint or seclusion by hospital policy in accordance with State law, had a working knowledge of hospital policy regarding the use of restraint and seclusion.

3. During an interview with the Human Resources Coordinator on November 16, 2011, it was confirmed that there was no system in place to ensure that physicians and other licensed independent practitioners, at a minimum had a working knowledge of the hospital policy regarding the use of restraint and seclusion.

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Based on review of complaints and interviews with key staff on November 16, 2011, it was determined that the facility failed to comply with the Federal Condition of Participation: Patient Rights 482.13 (a)(2)(iii), which required that in its resolution of the grievance, the hospital must provide the patient with written notice of the decision that contains 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.

Findings include:

1. On November 16, 2011, a review of the hospital policy titled, ' Complaints by Patients, Residents, Legal Representative ' was completed. It stated, " PURPOSE: D. .... they shall take appropriate corrective action where indicated and submit a written response to the individual filing the complaint.. "

2. The review of the same policy revealed that there was no documentation of the specific information that needed to be included in the written notification to the patient/complainant.

3. During an interview with the Executive Administrative Assistant on November 17, 2011, she stated that the Chief Executive Officer hand wrote the responses, sealed the envelopes and mailed them. She further stated that there were no copies kept and she could not verify the content of these letters .

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Based on review of governing body meeting minutes for January 2009 and interviews with key staff on November 17, 2011, it was determined that the facility failed to comply with the Federal Condition of Participation: Patient Rights 482.13 (a)(2), which required that the governing body had approved and was responsible for the effective operation of the grievance process, and had reviewed and resolved grievances, unless it had delegated the responsibility in writing to a grievance committee.

Findings include:

During an interview with the Executive Administrative Assistant on November 17, 2011, she stated that she could not find any documentation from the governing body where they had taken on the responsibility of grievances or had delegated that responsibility to others.

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Based on review of information provided and interviews with key staff on November 17, 2011, it was determined that the facility failed to comply with the Federal Condition of Participation: Patient Rights 482.13(e), which required that restraint or seclusion could only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.

Findings include:

1. During an interview with the Chief Nursing Officer on November 16, 2011, it was confirmed that there was no restraint or seclusion training program for staff, physicians or other licensed independent practitioners. She further stated that there was no training program in 2009 or 2010 .

2. Therefore, due to the lack of training for those authorized to order and/or apply restraints, the intent to eliminate the inappropriate use of restraints and seclusion and to ensure patient safety could not be verified.

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Based on review of information provided and interviews with key staff on November 17, 2011, it was determined that the facility failed to comply with the Federal Condition of Participation: Patient Rights 482.13(e)(2), which required that restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm.

Findings include:

Please see the above deficiency for additional information about the lack of a training program and therefore a potential lack of caregivers who are skilled in individualized assessment and tailoring interventions after taking into consideration such factors as the patient's condition and the patient's behaviors.

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Based on review of information provided and interviews with key staff on November 17, 2011, it was determined that the facility failed to comply with the Federal Condition of Participation: Patient Rights 482.13(e)(3), which required that the type or technique of restraint or seclusion must be the least restrictive interventions that will be effective to protect the patient, a staff member or others from harm.

Findings include: Please see other tag C-151 deficiencies for additional information about the lack of a training program and therefore a potential lack of resources to assist the clinicians in identifying less restrictive restraint or seclusion interventions. __________________________________________________________________

Based on review of information provided and interviews with key staff on November 17, 2011, it was determined that the facility failed to comply with the Federal Condition of Participation: Patient Rights 482.13(e)(4)(ii), which required that the use of restraint or seclusion must be implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law.

Findings include:

1. A review of the hospital policy titled 'EMH/CA Dean Restraints and Seclusion Policy' was reviewed on November 17, 2011. The policy stated, " Staff will be competency trained in the use of least restrictive alternatives and standard restraint equipment application."

2. During an interview with the Chief Nursing Officer on November 16, 2011, it was confirmed that currently there is no restraint or seclusion training program for staff, physicians or other licensed independent practitioners. She further stated that there was no training program in 2009 or 2010. ___________________________________________________________________

Based on review of information provided and interviews with key staff on November 17, 2011, it was determined that the facility failed to comply with the Federal Condition of Participation: Patient Rights 482.13(e)(9), which required that the restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order.

Findings include:

1. A review of the hospital policy titled 'EMH/CA Dean Restraints and Seclusion Policy' was reviewed on November 17, 2011. The policy stated, " Restraints shall be the least restrictive type to accomplish the intended purpose, and will be discontinued at the earliest possible time."

2. During an interview with the Chief Nursing Officer on November 16, 2011, it was confirmed that there was no restraint or seclusion training program for staff, physicians or other licensed independent practitioners. She further stated that there was no training program in 2009 or 2010 . ______________________________________________________________________

Based on review of information provided and interviews with key staff on November 17, 2011, it was determined that the facility failed to comply with the Federal Condition of Participation: Patient Rights 482.13(e)(10), which required that the condition of the patient who is restrained or secluded must be monitored by a physician, other licensed independent practitioners or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy.

Findings include:

1. A review of the hospital policy titled 'EMH/CA Dean Restraints and Seclusion Policy' was reviewed on November 17, 2011. The policy did not include training criteria and the intervals identified by the hospital.

2. During an interview with the Chief Nursing Officer on November 16, 2011, it was confirmed that there was no restraint or seclusion training program for staff, physicians or other licensed independent practitioners. She further stated that there was no training program in 2009 or 2010 . ______________________________________________________________________

Based on review of information provided and interviews with key staff on November 17, 2011, it was determined that the facility failed to comply with the Federal Condition of Participation: Patient Rights 482.13(e)(11), which required that physician and other licensed independent practitioner training requirements must be specified in hospital policy. At a minimum, physicians and other licensed independent practitioners authorized to order restraint or seclusion by hospital policy in accordance with State law must have a working knowledge of hospital policy regarding the use of restraint or seclusion.

Findings include:

1. A review of the hospital policy titled 'EMH/CA Dean Restraints and Seclusion Policy' was reviewed on November 17, 2011. The policy did not include training criteria and the intervals identified by the hospital.

2. During an interview with the Chief Nursing Officer on November 16, 2011, it was confirmed that there was no restraint or seclusion training program for staff, physicians or other licensed independent practitioners. She further stated that there was no training program in 2009 or 2010.

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Based on review of information provided and interviews with key staff on November 17, 2011, it was determined that the facility failed to comply with the Federal Condition of Participation: Patient Rights 482.13(f), which required that the patient had the right to safe implementation of restraint or seclusion by trained staff.

Findings include:

During an interview with the Chief Nursing Officer on November 16, 2011, it was confirmed that there was no restraint or seclusion training program for staff, physicians or other licensed independent practitioners. She further stated that there was no training program in 2009 or 2010 .
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Based on review of information provided and interviews with key staff on November 17, 2011, it was determined that the facility failed to comply with the Federal Condition of Participation: Patient Rights 482.13(f)(1), which required that staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for the patient in restraint or seclusion.


Findings include:

During an interview with the Chief Nursing Officer on November 17, 2011, she stated that there was no training program as of yet. The facility had just started to identify what the staff's training needs would be, related to restraints and seclusion based on" the bath salt crisis".

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Based on review of information provided and interviews with key staff on November 17, 2011, it was determined that the facility failed to comply with the Federal Condition of Participation: Patient Rights 482.13(f)(2)(ii), which required that the hospital must require appropriate staff to have education, training, and demonstration knowledge based on the specific needs of the patient population in at least the following: (ii) The use of nonphysical intervention skills.


Findings include:

During an interview with the Chief Nursing Officer on November 17, 2011, she stated that there was no training developed in the areas of nonphysical intervention skills.

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Based on review of information provided and interviews with key staff on November 17, 2011, it was determined that the facility failed to comply with the Federal Condition of Participation: Patient Rights 482.13(f)(2)(iii), which required that the hospital must require appropriate staff to have education, training, and demonstration knowledge based on the specific needs of the patient population in at least the following: (iii) Choosing the least restrictive interventions based on an individualized assessment of the patient's medical, or behavioral status or condition.


Findings include:

During an interview with the Chief Nursing Officer on November 17, 2011, she stated that there was no training developed in the area of choosing the least restrictive interventions.
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Based on review of information provided and interviews with key staff on November 17, 2011, it was determined that the facility failed to comply with the Federal Condition of Participation: Patient Rights 482.13(f)(2)(iv), which required that the hospital must require appropriate staff to have education, training, and demonstration knowledge based on the specific needs of the patient population in at least the following: (iv) The safe application and use of all types of restraint or seclusion used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress (for example: positional asphyxia).


Findings include:

During an interview with the Chief Nursing Officer on November 17, 2011, she stated that there was no training developed in the area of recognizing and responding to patient signs of physical and psychological distress.

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Based on review of information provided and interviews with key staff on November 17, 2011, it was determined that the facility failed to comply with the Federal Condition of Participation: Patient Rights 482.13(f)(2)(v), which required that the hospital must require appropriate staff to have education, training, and demonstration knowledge based on the specific needs of the patient population in at least the following: (v) Clinical indication of specific behavior changes that indicate that restraint or seclusion is no longer necessary. The safe application and use of all types of restraint or seclusion used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress (for example: positional asphyxia).


Findings include:

During an interview with the Chief Nursing Officer on November 17, 2011, she stated that there was no training developed in the area of identification of behavioral changes that indicate the need for restraint or seclusion.

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Based on review of information provided and interviews with key staff on November 17, 2011, it was determined that the facility failed to comply with the Federal Condition of Participation: Patient Rights 482.13(f)(2)(vi), which required that the hospital must require appropriate staff to have education, training, and demonstration knowledge based on the specific needs of the patient population in at least the following: (vi) Monitoring the physical and psychological well-being of the patient who is restrained or secluded, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any requirements specified by hospital policy associated with the 1-hour face-to-face evaluations.


Findings include:

During an interview with the Chief Nursing Officer on November 17, 2011, she stated that there was no training developed in the area of monitoring the restrained patient.

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Based on review of information provided and interviews with key staff on November 17, 2011, it was determined that the facility failed to comply with the Federal Condition of Participation: Patient Rights 482.13(f)(3), which required that the hospital must require that individuals providing staff training must be qualified as evidenced by education, training, and experience in techniques used to address patient's behaviors.


Findings include:

During an interview with the Chief Nursing Officer on November 17, 2011, she stated that the facility had failed to identify the individuals who would be providing the training.

Based on document review and interview with key personnel on November 16, 2011, it was determined that the facility failed to maintain and ensure patient safety in the surgical suite. The findings include:

1. A sagging ceiling tile was observed in a clean storage area adjacent to the operating room.

2. The tile allowed air infiltration from the above space.

3. This was confirmed with the Facilities Manager on November 16, 2011. The Facilities Manager reported that the facility failed to have an organized surveillance program to identify damaged ceiling tiles. He relies on personnel to report issues.

4. The ceiling tile was replaced on November 16, 2011.

Based on review of the list of Complaints / Grievances for the year 2011, the Performance Improvement Plan, review of the meeting minutes of the Medical Staff Utilization Review and Performance Improvement Committee, Medical Staff meetings, and the Medical Staff Executive Committee, review of the policies and procedures, review of the Board of Trustee meeting minutes, and interviews with the Chief Executive Officer, Chief Operating Officer, Chief Nursing Officer, and the Chief of the Medical Staff, on November 15-17, 2011, it was determined that the hospital's Governing Body failed to be totally responsible for the conduct of the CAH as an institution, as evidence by:
1.The Governing Body failed to assume full legal responsibility for determining, implementing and monitoring policies (Tags C -0151 and C-0335);

2. The Governing Body failed to ensure that the medical staff was accountable to the Governing Body for the quality of care provided to patients (Tags C-0151and C-0330);

3. The Governing Body failed to ensure that the policies were administered so as to provide quality health care in a safe environment (Tags C-0151,C-0221, C-0335 and C-0338);

4. The Governing Body failed to institute processes and systems to ensure periodic appraisal of the medical staff evaluation of patient care services at every patient care location (Tag C- 0330 ); and

5. The Governing Body failed to ensure that the hospital was in compliance with all Federal Regulations (Tag C- 0151).

The cumulative effects of these deficient practices resulted in the Condition of Participation being out of compliance.

Based on document review and interviews with key personnel on November 16, 2011, it was determined that the governing body failed to assume full legal responsibility to assure that the hospital provided quality health care in a safe environment.

Please see Tags C-0331-C-0335 and C-0151 for additional information regarding the annual program evaluation and the implementation and monitoring of policies by the governing body.

Based on a review of the CA Dean Performance Improvement Plan, meeting minutes and other documents as described below, and interviews with key staff on November 15-17, 2011, it was determined that the CAH failed to carry out a periodic appraisal in order to ensure that quality improvement activities were sufficient to assess the CAH care of patients. The CAH did not ensure that high risk, high volume and problem prone aspects of patient care, in the Pharmacy, Emergency Department, and Surgical Services were reviewed and that appropriate action was taken to improve patient care outcomes and services as evidenced by:

1. The CAH failed to conduct an annual evaluation (Tag C-0331) that included a review of the number of patients served and the volume of services (Tag C-0332), a representative sample of active and closed records (Tag C-0333), a review of policies (Tag C-0334) and any changes needed (C-0335);

2. The CAH failed to track and trend complaints ( Tag C-0336); and

3. The CAH failed to implement an effective quality assurance and performance improvement program (Tag C-0336) that evaluated the quality and appropriateness of diagnoses and treatment furnished ( Tag C-0337) , and medication therapy (Tag C-0338);

The cumulative effects of these deficient practices resulted in the Condition of Participation being out of compliance.

Based on document review and interview with key personnel on November 15, 2011, it was determined that the facility failed to conduct an annual program evaluation. The findings include:

1. A review of the Charles A. Dean Memorial Hospital and Nursing Home Quality Assessment /Performance Improvement Plan was conducted on November 15, 2011. Appendix B states " The Performance Improvement Council ...Review annual overview of each performance improvement activity and approves initiatives for next year " .

2. A review of the Performance Improvement Council meeting minutes from October 21, 2010 through September 15, 2011 was conducted. There is no documentation that an annual program evaluation had been conducted.

3. This was confirmed with the Chief Nursing Officer on November 15, 2011. She stated, " ...this [annual program evaluation] was not done on a house wide basis " and " this is very frustrating, because pieces of it were done, but not all of it " .

Based on document review and interview with key personnel on November 15-16, 2011, it was determined that the facility failed to conduct an annual program evaluation which includes the utilization of services, the number of patients served and the volume of services provided . The findings include:

1. A review of the Charles A. Dean Memorial Hospital and Nursing Home Quality Assessment /Performance Improvement Plan was conducted on November 15, 2011. Appendix B states " The Performance Improvement Council ...Review annual overview of each performance improvement activity and approves initiatives for next year " and " The Professional Affairs Committee will review .... [in the] 4th Quarter Annual Reports ... "

2. A review of the Performance Improvement Council meeting minutes from October 21, 2010 through September 15, 2011 was conducted. There is no documentation that an annual program evaluation had been conducted, therefore, no compilation of data including the number of patients served and the volume of services provided has been performed.

3. This was confirmed with the Chief Nursing Officer on November 16, 2011. She stated, " This [annual program evaluation] has not been done. We will just have to take a hit on this " . She also noted that the Performance Improvement Council and the Professional Affairs Committee is one and the same.

Based on document review and interview with key personnel on November 15-16, 2011, it was determined that the facility failed to conduct an annual program evaluation which includes at least the number of patients served and the volume of services provided , and a representative sample of both active and closed clinical records. The findings include:

1. A review of the Charles A. Dean Memorial Hospital and Nursing Home Quality Assessment /Performance Improvement Plan was conducted on November 15, 2011. Appendix B states " The Performance Improvement Council ...Review annual overview of each performance improvement activity and approves initiatives for next year " and " The Professional Affairs Committee will review .... [in the] 4th Quarter Annual Reports ... "

2. A review of the Performance Improvement Council meeting minutes from October 21, 2010 through September 15, 2011 was conducted. There is no documentation that an annual program evaluation had been conducted, therefore, no compilation of data including a representative sample of active and closed records has been performed.

3. This was confirmed with the Chief Nursing Officer on November 16, 2011. She stated, " This [annual program evaluation] has not been done. We will just have to take a hit on this " .

Based on document review and interview with key personnel on November 15-16, 2011, it was determined that the facility failed to conduct an annual program evaluation which includes at least the number of patients served and the volume of services provided , a representative sample of both active and closed clinical records, and the CAH ' s health care policies. The findings include:

1. A review of the Charles A. Dean Memorial Hospital and Nursing Home Quality Assessment /Performance Improvement Plan was conducted on November 15, 2011. Appendix B states " The Performance Improvement Council ...Review annual overview of each performance improvement activity and approves initiatives for next year " and " The Professional Affairs Committee will review .... [in the] 4th Quarter Annual Reports ... "

2. A review of the Performance Improvement Council meeting minutes from October 21, 2010 through September 15, 2011 was conducted. There is no documentation that an annual program evaluation had been conducted, therefore, no review of policies has been conducted.

3. A review of the list of policies was conducted. At least three hundred (300) policies had not been updated as scheduled. The oldest was scheduled to be updated on October 27, 2009. Additionally, many of the policies reviewed contained language such as " long term care staff " , " long term care nurse " , and " long term care facility " , which is obsolete.

4. This was confirmed with the Chief Nursing Officer on November 16, 2011. She stated, " This [annual program evaluation] has not been done. We will just have to take a hit on this " . She also acknowledged that there was a " systems problem " with the process of updating policies.

5. During an interview with the Chief Executive Officer on November 15, 2011, he confirmed that the hospital has not operated a nursing home for approximately one year, and acknowledged that the policies had not been updated.

Based on document review and interview with key personnel on November 15-16, 2011, it was determined that the facility failed to conduct an annual program evaluation which includes at least the number of patients served and the volume of services provided , a representative sample of both active and closed clinical records, the CAH ' s health care policies. The purpose of the evaluation is to determine whether the utilization of services was appropriate, the established policies were followed, and if any changes were needed. The findings include:

1. A review of the Charles A. Dean Memorial Hospital and Nursing Home Quality Assessment /Performance Improvement Plan was conducted on November 15, 2011. Appendix B states " The Performance Improvement Council ...Review annual overview of each performance improvement activity and approves initiatives for next year " and " The Professional Affairs Committee will review .... [in the] 4th Quarter Annual Reports ... "

2. A review of the Performance Improvement Council meeting minutes from October 21, 2010 through September 15, 2011 was conducted. There is no documentation that an annual program evaluation had been conducted, therefore, no review of established policies as conducted to determine if they were followed or needed revision.

3. A review of the list of policies was conducted. At least three hundred (300) policies had not been updated as scheduled. The oldest was scheduled to be updated on October 27, 2009. Additionally, many of the policies reviewed contained language such as " long term care staff " , " long term care nurse " , and " long term care program " , which is obsolete. Additionally, the letterhead on hospital documentation identifies the hospital as " Charles A. Dean Memorial Hospital & Nursing Home " .

4. During an interview with the Chief Executive Officer on November 15, 2011, he confirmed that the hospital has not operated a nursing home for approximately one year.

5. This was confirmed with the Chief Nursing Officer on November 16, 2011. She stated, " This [annual program evaluation] has not been done. We will just have to take a hit on this " . She also acknowledged that there was a " systems problem " with the process of updating policies, and that they needed to be reviewed and updated.

Based on review of complaints, incidences, other information provided and interviews with key staff on November 16 and 17, 2011, it was determined that there was no documented evidence that the quality assurance program was effective as evidenced by the lack of tracking and trending data related to complaints and incidences.

Findings include:

1. During interviews on November 16 and 17, 2011, with the Chief Nursing Officer and the Executive Administrative Assistant, they stated that there would be no documentation in the Quality Program related to complaints and incidences.

2. On November 16, 2011, a review of documentation of five (5) complaints was conducted. The documentation failed to contain a written response to the patient and/or complainant.

3. During an interview with the Chief Nursing Officer on November 16, 2011, she stated that she did collect some data but did not trend and analyze it, and did not include this information in the quality assurance program.

4. During an interview with the Executive Administrative Assistant on November 17, 2011, she stated that she did not track, trend or analyze complaint data.


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Based on a review of the CA Dean Performance Improvement Plan, meeting minutes and other documents as described below, and interviews with key staff on November 15-17, 2011, it was determined that the CAH failed to have an effective, on-going quality assurance and performance improvement program to evaluate the care of patients. The CAH did not ensure that case review or performance improvement activities including high risk, high volume and problem prone areas of patient care, such as the Emergency Department and Surgical Services were reviewed and that appropriate action was taken to improve patient care or patient outcomes.

Findings include:

1. The Hospital Quality Plan, " Policy # 100-004 " states, " Practitioner Profiles: - These will be compiled and reviewed at least annually. Feedback opportunities will be provided. Profiles will be confidential, and coded with a confidential numbering system to ensure confidentiality. The Chief of Staff will review these and report pertinent findings to the Executive Committee of the Active Medical Staff, which acts as a Credentialing Committee. "

2. The minutes of the Medical Staff Executive Committee from January 2011 through October 2011 were reviewed. There was no evidence of a review of practitioner profiles or any discussion of quality data review at the time of re-credentialing.

3. Eight (8) medical staff credentials files were reviewed, including seven, (7) files of members of the medical staff who had been recredentialed at least once. The hospital was unable to provide quality data or " profiles " for these members of the medical staff.

4. The Executive Assistant, Administration, who maintains the credentialing files, said she was not aware that the hospital compiles any quality data or " profiles " for any members of the medical staff. This was confirmed during an interview with the Chief of the Medical Staff on November 15, 2011, who said he only reviews the performance of providers in his specialty practice.

5. During this same interview with the Chief of the Medical Staff on November 13, 2011, he said that he compiles and reviews quality data on the mid-level providers that work with him, but there was no other quality data that would have been reviewed on members of the medical staff at the time of their reappointment.

6. According to the hospital ' s Performance Improvement plan, " Policy # 100-004 " , Medical Staff Committees will, " Maintain and permanently document meeting minutes including agenda, discussion, decisions, votes, remedial actions and follow-up to all issues. " This policy also states, " The Medical Staff via the Medical Records/Utilization Review and Medical Staff Performance Improvement Committee (MSPIC) shall conduct peer review activities. "

7. The minutes of the Medical Records/Utilization Review and Medical Staff Performance Improvement Committee, (MSPIC), meeting minutes from January 2011 through October 2011 were reviewed. These minutes were titled, " Utilization Review Committee " . There was no evidence of a discussion of, either performance or, peer review activities in these minutes.

8. During an interview with the Chief of the Medical Staff and the Chief Nursing Officer on November 13, 2011, the Chief of Staff confirmed that there were no minutes of peer review, and that there was no provider specific peer review available for members of the medical staff with the exception of the mid-level practitioners that work in his specialty.

Based on a review of the CA Dean Performance Improvement Plan, meeting minutes and other documents as described below, and interviews with key staff on November 15-17, 2011, it was determined that the CAH failed to ensure that all patient care services were evaluated.

Findings include:

1. The Hospital ' s PI Plan states, " The PI program must, reflect the complexity of CA Dean's organization and services, involve all departments and services, focus on indicators related to improving health outcomes and the prevention of medical errors. "

2. The hospital performs general surgery including endoscopic surgery, orthopedic, urologic, podiatric, and ENT surgery, and has an emergency department. According to the Chief of the Medical Staff and the Chief Nursing Officer, who also serves as the Director of Quality, there were no quality improvement initiatives relating to emergency medicine, endoscopy, general surgery, or any of the surgical sub-specialties provided at the hospital, such as orthopedics, urology, or podiatry.

3. The hospital ' s PI Plan, Policy# 100-004 states, " The Medical Staff via the Medical Records/Utilization Review and Medical Staff Performance Improvement Committee (MSPIC) shall conduct peer review activities. "

4. The minutes of the MSPIC from January 2011 through October 2011 were reviewed. These minutes were titled, " " Utilization Review Committee Meeting " . There was no evidence of peer review in any of these minutes. This was confirmed by the Chief of Staff who said that no case review was documented.

5. The Medical Staff meeting minutes, the Medical Staff Executive Committee minutes and the Medical Staff Performance Improvement Committee (MSPIC) minutes from January 2011 through October 2011 were reviewed. There was no evidence of ongoing quality assurance or performance improvement initiatives in any of these minutes.

6. The Chief Nursing Officer, who serves as the hospital ' s director of quality, confirmed that there was no medical staff quality initiatives for which evidence of performance improvement could be demonstrated.

Based on document review and interview with key personnel on November 16, 2011, it was determined that the pharmacy failed to participate in the hospital wide Quality Assurance Program that included a review of medication therapy. Findings include:

1. A review of the 2011 P&T meeting minutes was conducted. The minutes failed to include documentation that indicated the Pharmacy participated in an effective Quality Assurance Program which evaluates medication therapy.

2. The department 's failure to participate in the Quality Assurance Program was confirmed during an interview with the Director of Pharmacy on November 16, 2011.