HospitalInspections.org

Based on record review and interviews with hospital staff, the hospital does not ensure all services provided by contract or arrangement are evaluated through the hospital-wide quality assessment and performance improvement (QAPI) program. Contracted services that perform both clinical and non-clinical services such as biomedical checks of equipment, laundry services, off site radiology and off site food/meal providers were not included in the QAPI evaluations of services provided by contract.

Findings:

1. Review of contracted services lists provided by the hospital, the Hospital Performance Council meeting minutes and Governing Body and Medical Staff meeting minutes did not include evaluations of all these services.

2. Outside contract food/meal providers were not included on the first list provided for review. These providers are either restaurant or catering businesses. There was no evidence that these providers were periodically evaluated for quality and food safety.

3. Contracted radiology services were not evaluated by the hospital's QAPI program.

4. Contracted services which were not designated by the hospital as clinical were not evaluated for quality and safety.

5. Linen services were not included on the first contracted services list provided by the hospital. These services were not evaluated for quality and infection control practices.

These findings were verified by hospital staff during the survey.

Based on record review and interviews with hospital staff, the hospital does not ensure the Pharmacist in Charge (PIC) supervises and evaluates the performance and competency of pharmacy personnel who provide pharmacy services. Four (Y, Z, BB and CC) of five pharmacists' personnel files reviewed did not have evidence of job descriptions, competency evaluations and orientation specifically for Lakeside Women's Hospital by the Pharmacist in Charge.

Findings:

1. Staff Y, Z, BB and CC who work part time did not have job descriptions and orientation by the PIC specific for the duties they performed in the pharmacy by the Pharmacist in Charge. They also did not have orientation to the hospital

2. Staff Z did not have evidence of a competency evaluation by the PIC.

These findings were verified by hospital staff .

Based on document review, personnel file review, observation, and staff interview, the hospital failed to:

1. Document in writing the scope and complexity of radiology services offered by the hospital.

On 04/24/14, the director of risk/quality and radiology supervisor was asked to provide a written scope of services for radiology services offered. The radiology manager provided written scope of services on the afternoon of 04/25/14 that did not have all radiology services offered.

On the afternoon of 04/24/14, surveyors reviewed the black binder that was labeled "Policy and Procedure Manual" provided by the operating room (OR) manager. A "DEQ Form ..." documented, "...a license is hereby issued authorizing the licensee to receive, acquire, possess, and transfer the source(s) of radiation..."

On the afternoon of 04/24/14, the radiology supervisor, OR manager, and Director of Risk/Quality verified that the hospital provides nuclear medicine services.

2. Ensure the medical staff and the governing body approved the scope and complexity of the radiology services offered.

There were no meeting minutes that documented the medical staff and governing body approved the scope of nuclear medicine services.

3. Develop comprehensive policies and procedures for the radiology department based on nationally recognized standards of practice.

The radiology policies and procedures reviewed were from multiple contracted services that the hospital contracted with. There was no evidence that the medical staff and governing body approved/adopted contracted radiology services' policies and procedures, and did not have references to national standards of practice.

4. Include radiology services in the hospital-wide QAPI process.

On the morning of 04/24/14, the radiology supervisor told the surveyors she did not know what QAPI was.

On the afternoon of 04/25/14, the radiology supervisor told surveyors that each contracted employee reports to their supervisor (contracted company that employs them) and follows their company's policies and procedures.

5. Implement radiology policies, procedures and practices that ensured safety for patients and personnel.

The radiology did not have documentation of policies and procedures that described how radiation hazards were prevented in the department.

The radiology department did not have policies and procedures related to safety and emergency procedures specific to the radiology department.

On the morning of 04/24/14, the radiology manager stated there was no training or practice drills for emergencies in the radiology department.

On the morning of 04/25/14, Staff AAA told surveyors he was not aware that the radiology department that was located in a business occupancy (different building than the hospital) had to participate in emergency drills.

6. Ensure radiology personnel had documented evidence of specialized training, education, qualifications, and certification necessary for work in the radiology department.

On the afternoon of 04/23/14, the radiology supervisor was unable to verify what equipment staff in the radiology department were qualified to operate.

There was no documented evidence that radiology contracted personnel and hospital staff performing/working with nuclear medicine, had necessary training, education, qualifications, and certification.

The medical staff had not designated qualified staff to operate the radiological equipment and to administer procedures in the radiology department.

7. Ensure a qualified radiologist supervised all radiology services.

The director of medical staff services, director of risk/quality, and the CEO stated the hospital had not appointed a supervising radiologist.

On the afternoon of 04/24/14, Staff OO stated, "It would be inappropriate for a radiologist to be over the department. There is not a radiologist needed for bone density interpretation/readings, it is just numbers."

Based on record review and interviews with hospital staff, the hospital failed to ensure the consultant dietitian supervises the nutritional aspects of patient care. Review of patient records did not have evidence of planning and implementing of patient care strategies to meet the nutritional needs of patients.

Findings:

Meal service is a contracted service provided to the hospital by a restaurant. All meals are provided ready to eat. The Certified Dietary Manager (CDM) assembles the meals on trays and reheats if necessary.

1. Thirty-six ( 1 through 36) of 36 patient records reviewed did not have any evidence of any nutritional interventions by the consultant dietitian. All nutritional screens were done by nursing. The nutritional screens did not have a question concerning whether the patient had diabetes.

2. There were no monthly reports from the dietitian with evidence of supervision of dietary services. Day to day dietary supervision is performed by a Certified Dietary Manager. There was no evidence in patient records of the CDM providing any nutritional screens or counseling to patients.

3. The menus provided for review were not signed as approved by the dietitian.

4. There were no inservices provided by the dietitian to hospital staff to show collaboration in meeting the needs of the patients.

5. There was no evidence of the dietitian supervising the CDM and observing the day to day activities to assure safe food handling practices and menu oversight.

6. There was no evidence of evaluation of dietary services through the QAPI program to assure patients' safety and nutritional needs were met.

These findings were verified by hospital staff.

Based on record review and interviews with hospital staff, the hospital failed to ensure the current diet manual had been approved by the dietitian and the medical staff.

Findings:

1. The diet manual and medical staff meeting minutes for 2013 and 2014 did not have evidence of approval by both the dietitian and the medical staff.

2. Medical staff meeting minutes had evidence of approval by the medical staff, but not the Consultant Dietitian.

3. The dietary manual did not have a signature sheet in the front of the manual with the signatures of both the consultant dietition and medical staff representative showing approval of the manual.

Hospital staff verified these findings on 04/24/14 in the afternoon.

Based on observation, review of infection control data, surveillance activities, meeting minutes, hospital documents, staff interviews, and observation, the hospital failed to develop and maintain an ongoing comprehensive system for reporting, analyzing and controlling infections and communicable diseases among patients and staff.
Findings:
1. On the morning of 04/23/2014, hospital administrative staff was asked to provide infection control meeting minutes, infection control policies and procedures, all infection control surveillance activities and the name of the infection control officer.
2. On the afternoon of 04/23/2014, staff H was asked if the hospital's infection control committee and medical staff had approved the disinfectants that were used in the hospital. Staff H stated that the disinfectants had been approved five years ago.
3. A hospital policy titled, "Sterilization, Disinfectants and Cleaning agents", documented, "...All agents and supplies used for sterilization, decontamination, disinfection and cleaning the hospital shall be approved for use by the infection control committee..." The policy further documented, "...agents, supplies, and cleaning schedules in each department will be reviewed every two years ...."
4. There was no documentation that disinfectants used in the hospital for cleaning and disinfecting were approved by the infection control committee and the medical staff.
5. There was no documentation of any surveillance activities for infection control in the different hospital departments.
6. On the afternoon of 04/23/2014, staff H was asked if she conducted surveillance activities in all hospital departments. She stated that she did conduct surveillance activities in all departments. Staff H was asked if she had documented the surveillance activities. Staff H stated that she had not documented the surveillance activities.
7. On the afternoon of 04/23/2014, staff H was asked if she had a record of surgical site infections, and any investigative data. Staff H provided the surveyors with a form that contained documented information on surgical site infections but the form contained no documentation of any investigative actions taken or outcomes related to the surgical site infections.
8. On the afternoon of 04/23/2014, staff H was asked if she had a record of employee illnesses, and any investigative data. Staff H provided the surveyors with a form that contained names of employees, dates an employee called in sick, and the reason for calling in sick but the form contained no documentation of any investigative actions taken or outcomes related to the employee illness.
9. On the afternoon of 04/23/2014, staff H was asked who provided the hospital with linen service. Staff H stated that there was a contract with an outside linen company. Staff H was asked if she had conducted surveillance of the outside linen company. Staff H stated that she had conducted surveillance of the outside linen company but that she had no documentation of the surveillance.
10. On the morning of 04/23/2014, the operating room (OR) manager was asked who was responsible for cleaning the surgical department. The OR manager stated that housekeeping was responsible for cleaning the surgical department. She stated housekeeping cleaned each operating room after a surgical case and that housekeeping performed terminal cleaning of the surgical department at the end of the day.
Surveyors reviewed two surgical department cleaning policies. A policy titled, "Cesarean Operating Room Cleaning", documented,"...Housekeeper must wear surgical jump suit, shoe covers, and surgical cap..." A policy titled, "Surgical Suite Terminal Cleaning" documented, "...housekeepers must always enter the locker room to undress and put on scrubs and shoe covers ..." On the morning of 04/23/2014, surveyors observed a housekeeper cleaning an OR suite. The housekeeper was wearing scrubs that were not issued by the hospital and did not wear a surgical jump suit.
Two of two housekeeping personnel files reviewed (staff SS, & staff TT) did not contain operating room cleaning competencies.
11. Surveyors reviewed a policy titled, "Dress Code." The policy documented, "...personal cloth surgery caps may be worn but must be covered by a disposable surgical cap during patient care ..." On the morning of 04/23/2014, surveyors observed staff P, an operating room circulator, wearing a personal cloth surgery cap during a surgical procedure. Staff P did not have a disposable surgical cap covering the cloth cap.
12. On the afternoon of 04/24/2014 during preparation of patient food trays, surveyors observed staff A prepping the food trays. Staff A did not wash her hands prior to donning gloves. Staff A was observed changing gloves one time during the preparation of the trays and she did not wash her hands in between changing gloves.
13. On the afternoon of 04/24/2014, surveyors observed the food thermometer used to check food temperature was stored with pencils.
14. One of five pharmacist's (staff Y) personnel files reviewed did not contain documentation of immunization status or documentation of declination of immunizations.

Based on medical record review and staff interview, the hospital failed to ensure that a complete pre-anesthesia evaluation was completed on each patient prior to the administration of anesthesia. This occurred in three of twelve surgical charts reviewed. (#14, #31, & #34)
Findings:
1. On the morning of 04/25/2014, surveyors reviewed medical records of twelve surgical patients who received anesthesia. (#9, 10, 11, 12, 13, 14, 15, 27, 31, & #34). Three of the twelve records reviewed (#14, 31 & #34) did not contain documentation of a pre-anesthesia risk score.
2. This was verified upon exit on the afternoon of 04/25/2014 with staff B.

Based on observation, document review and staff interview, the hospital failed to:

1. Define the scope of nuclear medicine services provided.

On 04/24/14, the radiology supervisor and hospital leadership were asked to provide a written scope of services for nuclear medicine services. None was provided.

2. Appoint a qualified MD/DO as the director of nuclear medicine services.

On the afternoon of 04/24/14, the Director of Medical Staff Services told surveyors that Staff F and G do not have nuclear medicine privileges; have not requested nuclear medicine privileges; and do not have nuclear medicine training.

The director of risk/quality and the chief executive officer (CEO) verified that there is not an appointed director for nuclear medicine services.

The radiology supervisor told surveyors she was not aware that the hospital provided nuclear medicine services.

3. Show the staff were qualified and trained on their specific job responsibilities related to nuclear medicine.

The hospital had not determined what qualifications, specialized training, education, licensure or certification was necessary for the staff working in nuclear medicine.

None of the hospital personnel had qualifications and training for working with/in nuclear medicine.

4. Develop, approve, implement, and adopt policies and procedures for the preparation, labeling, use, transportation, storage and disposal of radioactive materials.

5. Include the nuclear medicine equipment in the preventive maintenance and biomedical engineering program.

6. Determine the policies related to nuclear medicine reporting requirements and a requirement for nuclear medicine reports to be stored for at least five years.

7. The hospital did not demonstrate nuclear medicine services were provided based on nationally recognized standards.

8. There was no documentation the staff had training or drills on nuclear medicine emergencies in that department.

9. Nuclear medicine services were not included in the hospital's QAPI program.

Based on review of medical staff meeting minutes, review of personnel files, and staff interview, the hospital failed to ensure there was a physician designated to serve as the director of respiratory care services.
Findings:
1. On the morning of 04/25/2014, staff GG was asked who the physician director of respiratory therapy services was. Staff GG stated that staff HH was the director of respiratory therapy services.
2. There was no documentation in the medical staff meeting minutes that any physician had been designated as the director of respiratory services.
3. Surveyors reviewed the personnel file for staff HH. There was no documented evidence that staff HH had been designated as the director of respiratory therapy services.
4. Staff II verified this at the time of record review.