HospitalInspections.org

Based on review of documents and staff interview the hospital failed to have the governing body (re)appoint two (2) "locum tenens" physicians to the medical staff within the reappointment period allowed in the medical staff bylaws. This has the potential to limit the quality of patient care by failing to review the physicians' qualifications timely and to limit the ultimate responsibility that is placed upon the governing body. Findings include:

1. A review of the credentials files of twelve (12) physicians revealed that at least two (2) locum tenens physicians were "appointed" to the medical staff by the Chief of staff (by letter) but without the approval (appointment) of the governing body.

2. One (1) of the two (2) locum tenens physicians not appointed by the governing body "had privileges" as of 5/14/08. The hospital normally appoints locum tenens physicians for three (3) month periods.

3. During interview with the Medical Staff Secretary (throughout the survey) she indicated that the hospital utilizes locum tenens physicians (Physicians hired for short periods but without full medical staff privileges) frequently and agreed that a process will need to be established that will include their appointments by the governing body. She further indicated that the hospital may use the standard appointment process for all locum tenens physicians since their tenure is often long-term.

Based on review of documents and staff interview, the hospital failed to provide available evidence to indicate that all departments are participating in the Quality Assurance/Performance Improvement (QA/PI) Program. This has the potential to limit the quality of those services not participating in the QA/PI process and limits the quality of patient care provided by those services. Findings include:

1. The hospital's QA/PI Plan (dated 2009) indicated that the "Scope of Service" includes each department. A review of QA/PI minutes for the year 2009 reflected there was no evidence that Anesthesia Services was participating in the QA/PI Program.

2. The QA/PI Plan further indicated (in part) it is the hospital's expectation for QA/PI to be interdisciplinary, however, Anesthesia and Dietary are not reflected as active participants in the QA/PI minutes. The Plan further indicated that Administration will promote the participation of the appropriate members of professional and technical staff and departments, however, their participation was not reflected in the department minutes.

3. During interview with the QA/PI Coordinator on 1/7/10 in the a.m. she agreed that Anesthesia Services has not been participating in the QA/PI Program. She further indicated that Dietary Services has a new department manager and Dietary has not participated in the QA process for the past six (6) months. She indicated that QA/PI continues to be a work in progress and agreed that these departments (in the future) will be included in the program.

Based on review of documents and staff interview the hospitals governing body failed to reappoint three (3) physicians within the two (2) year (re)appointment period in accordance with the Medical Staff Bylaws/Rules and Regulations (revised 6/19/08). This affects three (3) out of thirteen (13) credential files reviewed. This has the potential to limit the quality of patient care by failing to review the credentials of the physicians within the medical staff's two (2) year reappointment time frame. Findings include:

1. A review of the medical staff bylaws/rules and regulations indicated that (re)appointment of members of the medical staff is for a period of two (2) years. A review of thirteen (13) medical staff credential files revealed that three (3) physicians who were permitted to actively practice at the hospital were not (re)appointed to the medical staff every two (2) years as specified in the Medical Staff Bylaws/Rules and Regulations (revised 6/19/08)

2. One (1) of the three (3) physicians who was not (re)appointed within the two (2) year (re)appointment period was permitted to continue working at the hospital since 4/2009 when his privileges had expired.

3. During interview with the Medical Staff Secretary on 1/7/10 in the a.m. she agreed that three (3) physicians had not been included in the (re)credentialing process as outlined in the medical staff bylaws. She indicated that this omission would be corrected soon.

Based on document review, medical record review and staff interview the hospital failed to ensure the medical staff enforces its Bylaws, Rules and Regulations in regards to documenting the progress notes daily in one (1) of two (2) Intensive Care Unit (ICU) medical records (Patient #19) reviewed. This has the potential to negatively impact all patient care by not promoting continuity of care. Findings include:

1. Welch Community Hospital Medical Staff Bylaws, Rules and Regulations, last revised 6/19/07, states in part "...d. Observations:
Progress notes by the Medical and Dental Staff shall be written no less frequently than every day..."

2. Review of the medical record for Patient #19 revealed the patient was admitted to the ICU on 12/30/09. There was no documented evidence of an admission note on 12/30/09 nor a progress note for 12/31/09.

3. During an interview in the afternoon of 1/5/10 with the Unit Manager (UM) of the ICU, the medical record was reviewed and the UM agreed with the above findings.

Based on document review, medical record review and staff interview the hospital failed to ensure the medical staff follows the Bylaws, Rules and Regulations and hospital policy in regards to completing the required history and physical in one (1) of two (2) Intensive Care Unit (ICU) medical records (Patient #19) reviewed. This has the potential to negatively impact all patient care by not providing complete patient information to all potential practitioners. Findings include:

1. Welch Community Hospital Medical Staff Bylaws, Rules and Regulations, last revised 6/19/07, states in part "...b) History and Physical
A complete history and physical examination for all cases shall be dictated or written within twenty-four (24) hours after admission, and no longer than seven (7) days prior to admission, by the attending physician..."

2. Welch Community Hospital Admission To ICU policy, last revised 6/08, states in part "...7. History and Physical must be on the chart within twenty-four (24) hours after admission..."

3. Review of the medical record for Patient #19 revealed the patient was admitted to the ICU on 12/30/09. As of the date of review of the record, 1/5/10, there is no documented evidence of the History and Physical.

4. During an interview in the afternoon of 1/5/10 with the Unit Manager (UM) of the ICU, the medical record was reviewed and the UM agreed with the above findings.

Based on review of records, observation and interviews, it was determined the nursing staff failed to develop and keep current a care plan for at least one (1) of two (2) Intensive Care Unit (ICU) medical records reviewed for nursing care (Patient #1). This has the potential to negatively affect the quality of nursing care provided to all patients. Findings include:

On 1/5/10 in the afternoon, review of medical record #1 revealed the sixty-four (64) year old female patient was admitted on 12/26/09. The patient was admitted with loss of appetite, weakness, and weight loss. The patient was noted to have pneumonia and a possible bronchial tumor. It was noted at the time of admission the patient weighed less than one-hundred (100) pounds. The patient was observed and interviewed in the afternoon on 1/5/10. It was noted the patient had an intravenous infusion, oxygen by cannula and a chest tube. It was noted the patient had edema in the lower extremities and on one arm. The patient was noted to be very emaciated. The patient stated she could only get out of the bed if she had assistance.

Review of the patient's medical record revealed the nursing care plan consisted of a plan for "COPD" (chronic obstructive pulmonary disease). There was no other care plan in the record.

Review of the nursing notes revealed the patient was frequently being medicated for complaints of pain. The nursing documentation of the assessment of the patient's pain level was inconsistent and was generally based upon the administration of medication, and not necessarily based on a routine assessment of pain levels. There was no care plan relative to the patient's level of comfort.

Review of the initial nursing assessment and of nursing shift assessments revealed there was no method for the staff to assess the patient's risk for skin breakdown. Any preventative measures were inconsistently documented. Although it was noted the patient was nutritionally at risk, receiving pain medications, had more than one invasive line and required assistance with mobility, the patient did not have any care plan relative to prevention of skin breakdown.

Review of the initial nursing assessment and of nursing shift assessments revealed the assessments for the risk of a fall were very inconsistent from shift to shift. Although some staff documented the patient was at risk, there was no care plan initiated relative to the risk.

Staff ICU nurses were interviewed at the time of the record reviews on 1/5/10 in the afternoon. They concurred with the findings in the medical record.

Based on document review, medical record review and staff interview the hospital failed to ensure intravenous (IV) medications are administered only by approved nursing personnel, per hospital policy, in one (1) of two (2) Intensive Care Unit (ICU) medical records (Patient #1) reviewed. This has the potential to negatively impact all patient care by unqualified nursing personnel administering IV medications incorrectly. Findings include:


1. Welch Community Hospital Nursing Policy titled LPN: Advanced IV Therapy, last revised 6/08, states in part "...LPN's (Licensed Practical Nurses) with at least two (2) years nursing experience who are practicing in the Emergency Department or Intensive Care Unit and have successfully completed the Advanced IV Therapy Program may administer selected IV medications...IV therapy procedures which may be delegated to LPN's include IV administration of Lasix, Decadron, Solu-Medrol, Solu-Cortef, Pepcid, 50% Dextrose, Bumex, Reglan..."

2. Review of the medical record for Patient #1 revealed on 1/3/10 at 2143, an LPN administered Demerol 25mg, IV, which is not on the approved list for LPN IV administration.

3. During an interview in the morning of 1/6/10, the medical record was reviewed with the Staff Educator and Acting Chief Nursing Officer and both agreed with the above findings.

Based on observation and staff interview, the hospital failed to ensure the anesthesia staff is maintaining non-controlled drugs in a secure area while each surgical room is not in use for patient care. This has the potential to negatively impact all patient care by unauthorized persons to have access to the medications. Findings include:

1. During a tour of the Surgical Services Department at about 3:00 p.m. on 1/04/10, the anesthesia cart in Suite #3 was observed to be unlocked. When opened, the drawers were full of non-controlled IV (intravenous) medications. On top of the cart was a stack of unlocked boxes with small sliding drawers full of non-controlled IV medications as well. In Suite #2 the anesthesia cart was locked except the second drawer which, when opened, was full of IV medications. As with the first room, on top of the cart was a stack of unlocked boxes with small sliding drawers full of non-controlled IV medications. It was noted that at the time of the tour, neither room was currently in use for patient care. The Surgical Services Manager confirmed that there were no surgery cases scheduled to occur that afternoon.

Also on a shelf in the unlocked storage room were a box of vials of Vasopressin IV, a box of vials Heparin Lock Flush, and two (2) boxes of vials of Bupivacaine 0.25%.

2. During an interview with the Surgical Services Manager, while touring the department, she stated only the controlled medications get locked in the medication room. She also stated the Surgery Department itself, but not the individual surgery suites, is locked after-hours but the Nursing Supervisor and Security personnel have access to the department if needed.

Based on observations, record review and performance testing during the survey conducted from January 04-07, 2010, the volume of deficiencies issued to the Hospital for non compliance with the 2000 Edition of the Life Safety Code, deficiencies generated relating to the physical plant and hospital failure to correct deficiencies issued during a survey conducted April 06-08, 2009 it is determined the hospital failed to ensure the safety of patients, staff and the public. Therefore, the condition is not met. (A701, A722, K062, K070 and K147)

Based on documentation review, observation and staff interview it was determined the hospital failed to maintain facilities in a safe, functional and sanitary environment. This has the potential to adversely affect the safety of all hospital patients and staff. Findings include:

1. On 01/04/10 at approximately 1:00 p.m., a hospital survey report prepared by the Office of Health Facility Licensure and Certification and dated 04/08/09 was reviewed. This report indicated that the hospital was cited for the following finding:

a. Two (2) scrub sinks located in the OR (operating room) area had rusted areas and peeling paint. The hospital plan of correction dated 05/19/09 was to replace sinks and completion date was no later than 05/29/09.

b. During a tour of the OR area on 01/04/10 at approximately 2:00 p.m., two (2) scrub sinks were observed to have rusted areas with peeling paint. An interview with the OR nurse manager on this same date and time confirmed that the two (2) scrub sinks identified on the 04/08/09 report had not been replaced.

2. During tour of the OR on 01/04/10 at approximately 2:15 p.m., humidity logs for OR rooms #2 and #3 were reviewed. At this time, the recorded humidity readings from 12/14/09 to 01/04/10 were from 12% to 20%. Acceptable humidity requirements for OR rooms must be between thirty (30) and (60) percent. An interview with plant operation director on 01/05/10 at approximately 9:00 a.m. indicated that repair parts were on order for the humidity unit for the OR rooms.

3. On 01/05/10 at approximately 10:50 a.m., the doors to airborne isolation rooms #213 and #215 were observed to have the required self-closing device removed.

Based on documentation review and staff interview it was determined the hospital failed to maintain adequate facilities for its services. This has the potential to adversely affect the safety of all hospital operating patients. Findings include:

a) On 01/04/10 at approximately 1:00 p.m., a hospital survey report prepared by the Office of Health Facility Licensure and Certification and dated 04/08/09 was reviewed. This report indicated the following finding was cited:

1) During a tour of the hospital operating room on 04/07/09 at approximately 2:00 p.m., a container of cidex solution was observed located in a semi-restricted corridor across from the scrub sink. The existing process for cleaning contaminated scopes would include wiping with a sponge type cleaner, from the procedure room into the restricted corridor, rinse in the scrub sink, place in the solution of cidex and returned. The cleaning of instrumentation would not allow the flow from the contaminated to clean and then to clean storage. Therefore, the patients are placed in surroundings where clean safe/clean conditions was not met. An interview with the OR nurse manager on this same date and time confirmed that proper flow of instrumentation could not be achieved from contaminated to clean and then to clean storage. The hospital plan of correction dated 05/19/09 was to construct a new scope processing area in the OR with a completion date of 05/29/09.

a) During a tour of the OR area on 01/04/10 at approximately 2:00 p.m., the new scope processing area was observed not to be completed. An interview with the OR nursing manager on this same date and time revealed that the contaminated scopes are processed in the same area of the OR that was cited during the 04/08/09 survey.

Based on review of medical records and other documents, interviews with staff and observations, it was determined the hospital failed to furnish and maintain anesthesia services in an appropriate and well organized manner in accordance with regulations, accepted standards of care and hospital policies. The hospital failed to establish a policy relative to a proper informed consent for anesthesia services, which potentially affected the rights of seven (7) of seven (7) cases reviewed for anesthesia services. (Patients #1, 2, 3, 5, 6, 21 and 22) These deficiencies have the potential to negatively affect the quality of care provided to all patients who receive anesthesia services. Findings include:

1. Review of hospital policy "Organization of Department of Anesthesia", last reviewed 3/07, states "The Anesthesia Services shall be under the director of the Chief of Anesthesia." The Medical Staff Secretary stated during interview in the morning on 1/6/10 that she did not know who the Chief of Anesthesia was. The Chief of Staff was interviewed on the morning of 1/6/10. He stated he thought he was the Chief of Anesthesia, but he did not think there is an "Anesthesia Department". He stated that generally the CRNA provided services under the direct supervision of the surgeon who was present on each case.

2. Review of hospital policy "Anesthesia", last reviewed 3/07, states "Because of the possible liability concerns a strong peer review system needs to be in place..." The Chief of Staff stated during interview on the morning of 1/6/10 that the CRNA's activities were not routinely reviewed under a peer review process.

3. Review of hospital policy in the anesthesia services policy and procedure manual "Annual Reviews", last dated review 3/07, states "All policies and procedures shall be reviewed annually by the medical staff." The policy also states "The Board of Directors shall review all polices and procedures annually."

Review of the policy and procedure manual for the Anesthesia services revealed there is a signature sheet with the signatures of two physicians, the Chief Nursing Officer, the hospital Administrator and two CRNAs (Certified Registered Nurse Anesthetists). There is no signature of a Board of Directors member. There are no dates on the signature page to reflect the date or even the year the policies were reviewed. On each individual policy, there are initials of one of the CRNAs and the date 3/07. There is no clear evidence the policies have been reviewed annually by the members of the group specified in hospital policy.

4. Review of all anesthesia policies revealed there are no policies which specify the expected response for on-call time anesthesia personal for an emergency procedure. Random interviews with staff during a visit to the Obstetrical Department on 1/5/10 revealed the staff stated that the CRNA may take longer than one hour to arrive to the hospital when called for an emergency Cesarean section.

5. Interview with the Director of Quality Assessment and Performance Improvement (QAPI) during the afternoon on 1/7/10 revealed that the Anesthesia Department has not participated in the hospital wide QAPI program for the first three quarters of 2009. She stated the fourth quarter has not been submitted by the Department as of the time of the interview.

6. Review of hospital policy "Job Description for CRNA", last reviewed 3/07, states it is expected each CRNA will "Secure and maintain all necessary equipment, supplies, drugs, etc., which are necessary for the care of the patient."

During a tour of the Surgical Services Department at about 3:00 p.m. on 1/04/10, the anesthesia cart in Suite #3 was observed to be unlocked. When opened, the drawers were full of non-controlled IV (intravenous) medications. On top of the cart was a stack of unlocked boxes with small sliding drawers full of non-controlled IV medications as well. In Suite #2 the anesthesia cart was locked except the second drawer which, when opened, was full of IV medications. As with the first room, on top of the cart was a stack of unlocked boxes with small sliding drawers full of non-controlled IV medications. It was noted that at the time of the tour, neither room was currently in use for patient care. The Surgical Services Manager confirmed during the time of the tour that there were no surgery cases scheduled to occur that afternoon.

7. Review of the Anesthesia policy and procedure manual revealed there are no specific policies relative to the informed consent process. A total of seven (7) open and closed medical records were reviewed for patients who received anesthesia services, records # 1, 2, 3, 5, 6, 21 and 22. On all seven (7) records, the Operating Room Registered Nurse (RN) co-signed and witnessed the informed consent relative to anesthesia services. The CRNA and/or the Anesthesiologist had not signed any of the consents to witness they had been the one responsible for providing information for the informed consent process.

Based on review of medical records and physician credential files and interview with staff, it was determined the hospital failed to ensure that the anesthesiologist who provided services to one (1) of seven (7) patients reviewed for anesthesia services was appointed by the hospital's Governing Body to provide those services (patient #1). This has the potential to negatively affect the quality of anesthesia care provided to all patients. Findings include:

Review of the open medical record of patient #1 on 1/5/10 revealed the patient had a procedure done on 12/28/09 with general anesthesia. It was noted the anesthesia was provided by an anesthesiologist. Review of the anesthesiologist's credential file on 1/6/10 revealed that the locum tenens physician's medical staff privileges were not approved by the Governing Body of the hospital. The physician's file contained a letter from the Chief of Staff dated 12/21/09 which stated "You are hereby granted locum tenens privileges for a three month period."

The Medical Staff secretary confirmed that the Governing Body had not officially appointed the physician to the staff during interview in the morning on 1/6/10.

Based on review of medical records and hospital policy and interview with staff, it was determined the hospital failed to ensure a post-anesthesia evaluation occurred for one of two current intensive care unit (ICU) records reviewed for anesthesia services (patient # 1). This has the potential to negatively affect the quality of care provided to all patients when patients are not adequately assessed for response to anesthesia. Findings include:

Review of the current medical record for patient #1 on 1/5/10 revealed the patient had a surgical procedure with general anesthesia on 12/28/09. There was no post-anesthesia evaluation within 48 hours of the surgery. The ICU nurse reviewed the record in the afternoon on 1/5/10 and concurred with the findings. Also, the findings were discussed with the Nurse Manager of Surgical Services in the afternoon on 1/7/10.

Review of hospital policy, "Delivery of Anesthesia Care", last reviewed 3/07, states "The anesthetist is responsible for making a post-anesthetic visit, including at least one note describing the presence or absence of anesthetic complications."