HospitalInspections.org

Based on document review and interview, in four (4) of eight (8) disciplines reviewed, the hospital did not ensure performance improvement actions were delivered to all applicable disciplines and providers.

The lack of timely performance improvement action may place patients at risk for harm or injury.

Findings:

The facility's new policy and procedure (P&P) titled, "Vendor/Observer Access to Peri-Operative Locations," was first issued on 01/29/2024.

The facility's Education Attestation Logs for education on the new Vendor/Observer Access Policy revealed that the following four (4) disciplines did not have completed education attestations dated before 04/24/2024, prior to survey start:

- Pulmonology: Attestations were dated 04/24/2024; three (3) of four (4) providers had not attested to have reviewed/understood the new policy.
- Cardiology: Attestations were dated from 04/26/2024 to 05/01/2024; seventeen (17) of twenty-two (22) providers had not attested to have reviewed/understood the new policy.
- Neurology: Attestations were dated 05/01/2024; seven (7) of fifteen (15) providers had not attested to have reviewed/understood the new policy.
- Urology: No attestations were found.

During interview of Staff DD (Director of Regulatory Affairs) on 05/03/2024 at 02:30PM, Staff DD confirmed these findings.