HospitalInspections.org

Based on interview and policy review the hospital's governing body failed to carry out its responsibilities for the conduct of the hospital. The Chief Executive Officer (CEO) failed to ensure professional oversight for the review and/or revision of the hospital's policy and procedures in a timely manner (A0057) and the facility's list of contracted services was incomplete and did not specify the scope of contractor responsibility. (A0085)

This failure had the potential to adversely affect the quality of care and safety of all patients in the hospital. The hospital census was 12.

The severity and cumulative effect of these systematic failures resulted in the hospital's noncompliance with 42 CFR 482.12 Condition of Participation: Governing Body and resulted in the hospital's failure to ensure quality healthcare and safety.

Based on observation, interview and policy review the Governing Body failed to ensure that the Chief Executive Officer (CEO) was responsible for the management of the entire hospital, including accountability for effective oversight of staff to comply with the requirements under 42 CFR 482.12 Condition of Participation (CoP): Governing Body. This failure had the potential to affect the quality of care and safety of all patients. The hospital's census was 12.

Findings included:

Review of the hospital's policy titled, "Development and Review of Policies and Procedures," dated 08/28/20, showed that organizational and departmental policy will be reviewed at least every three years except where defined by law or regulatory standards. The following departments are required to conduct annual review: home care (wide range of health care services that can be given in your home for an illness or injury), rehabilitation services (an inpatient area staffed and medically supervised in the care and treatment of the physical restorative needs of patients), respiratory care (discipline specializing in the promotion of heart and lung function, health and wellness), surgery (the branch of medical practice that treats injuries, diseases, and deformities by the physical removal, repair, or readjustment of organs and tissues, often involving cutting into the body), and cardiac and pulmonary rehabilitation (a service that aims to reduce the risk of complications in people with heart and lung conditions).

Review of the hospital's report titled "Past Due Policies," dated 06/28/23, showed that there were 54 policies and procedures that had past due review dates.
-14 policies and procedures in the category of Housekeeping had last reviewed dates between 06/01/17 and 05/15/19.
-11 policies and procedures in the category of Nursing had last reviewed dates between 12/26/17 and 06/19/20.
-Eight policies and procedures in the category of Facilities Management had last reviewed dates between 09/18/17 and 08/17/18.
-Four policies and procedures in the category of Behavioral Health had last reviewed dates between 05/12/20 and 06/01/20.
-Four policies and procedures in the category of Environmental Services had last reviewed dates between 03/24/15 and 04/15/20.
-Three policy and procedures in the category of Emergency Room had last reviewed dates between 06/30/17 and 12/18/19.
-Two policies and procedures in the category of Patient Safety had last reviewed dates of 12/15/19 and 06/17/20.
-Two policies and procedures in the category of Social Services had a last reviewed date of 07/31/19.
-One policy and procedure in the category of Infusion had a last reviewed date of 10/14/19.
-One policy and procedure in the category of Swing bed had a last reviewed date of 10/01/18.
-One policy and procedure in the category of Health Information Management had a last reviewed date of 12/28/17.
-One policy and procedure in the category of Employee Management had a last reviewed date of 12/13/19.
-One policy and procedure in the category of Administration had a last reviewed date of 06/28/20.
-One policy and procedure in the category of Business Office had a last reviewed date of 06/30/17.

During an interview on 06/29/23 at 11:40 AM, Staff OO, CEO, stated that the facility had "about 50 polices past due for review." She stated that she was aware of the importance of ensuring policies and procedures were updated properly. The Quality Director informed her of policies and procedures past due for review/revision every month at the Quality Meetings. She stated that she is "ultimately responsible to ensure policies are current." She expected managers to have followed the policy and procedure to review/revise policies and procedures before they had expired. She was unaware that managers had been informed of policies and procedures due for review/revision at 30, 60 and 90 days prior to the review/revision dates. She stated that she could not say how nursing staff gave safe and quality care based on outdated policies and procedures.

During an interview on 06/29/23 at 10:15 AM, Staff BB, Director of Nursing (DON), stated that she has received email notifications regarding policies and procedures past due for review/revision. She was unable to identify how often she had received those notifications. She stated that the hospital did have a policy committee, and she was responsible for Nursing policies and procedures. She stated that her expectation was for all policies and procedures to be current. She was aware that when she came into this role, one year ago, that the facility had policies and procedures past due for review/revision. She stated that the facility was in need of a process to quickly and efficiently update policies and procedures. She stated that she had kept a nursing resource book in her office. Security could escort nursing staff to her office when she was not available. The last time a nurse used that resource book was over a year ago in regards to a procedure that did not have a written policy and procedure in place. She was unable to provide information on how nursing staff would be aware of current evidence based practice guidelines. She could not ensure that staff were providing safe and quality care.

During an interview on 06/28/23 at 3:30 PM, Staff JJ, Director of Quality, stated that policies and procedures were to have been reviewed/revised every three years unless the policy required more frequent review/revision. The department managers had received notice of policies and procedures that had been due for review/revision at 30, 60 and 90 days prior to the due date via email. Once the policy and procedure had surpassed the required date for review/revision the quality assistant had printed a list of those policy and procedures past their due date and had distributed that list to each department manager with overdue policies and procedures every month. The Quality Committee had been informed of each policy and procedure that had passed the due date at every monthly Quality Committee meeting. The CEO had attended the Quality Committee meetings and was made aware of the total number of policies and procedures that had past due dates. The CEO was also made aware of the department managers that had the responsibility for those policies and procedures that were past due. She stated that "we needed a tighter process for this than what we had." 06/29/23 at 9:20 AM, staff JJ, stated that staff were relying on out dated policies and procedures that did not provide current evidence based practice guidelines.

During an interview on 06/27/23 at 3:15 PM, Staff G, Patient Safety Officer at Southeast Hospital in Cape Girardeau, stated that policy revision timelines were managed through the program called "Policy Manager." Some policies were reviewed more frequently if they had certain "certifications of service" requirements. She stated that, "it was unusual that policies and procedures had not been reviewed every three years."

During an interview on 06/28/23 at 2:00 PM, Staff EE, Director of Quality at Southeast Hospital in Cape Girardeau, stated that both hospitals (Southeast Hospital in Cape Girardeau and Southeast Hospital of Stoddard County) utilized the same policy manager process. The electronic program, "Policy Manager," had notified the department managers at 30, 60 and 90 days prior to the review/revision due date via email. She stated that review/revision of policies and procedures was, "extremely important and everyone needed to stay on top of them."

Based on interview and record review, the facility failed to maintain a complete list of contracted services including the scope and nature of services. This had the potential to impact the safety and appropriate care of all patients. The facility census was 12.

Findings included:

Record review of the list of contracted services provided by Staff BB, Director of Nursing, showed 45 contracted services of which approximately nine were clinical contracted services. The scope and nature was not included. Additionally, a list of 47 contracted services was provided by Staff BB which did not match the first list.

During an interview on 06/29/23 at 9:00 AM, Staff JJ, Quality Manager, stated that there were 57 contracted services.

Based on observation, interview and policy review, the hospital failed to ensure staff followed infection prevention policies when they failed to:
- Perform hand hygiene (washing hands with soap and water or alcohol-based hand sanitizer) and change gloves while administering medications and touching inanimate objects for 1 patient (#12) of 2 patients observed. (A-0749)
- Prepare a clean work surface prior to administration of medication for one patient (#12) of one patient observed. (A-0749)
- Ensure the proper storage of urinals at the bedside of one patient (#12) of one observed. (A-0749)
- Remove expired supplies from stock. (A-0749)
- Remove expired food items from stock in the patient nutrition room refrigerator. (A-0749)
- Ensure clean utensils were used when food was served. (A-0749)
- Remove a full sharps (a term used for a device with sharp points or edges that can puncture the skin) container out of one procedure room out of one observed. (A-0749)

These failures had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infection. The hospital census was 12.

The severity and cumulative effects of these systemic failures resulted in the hospital's non-compliance with 42 CFR 482.42 Condition of Participation: Infection Prevention and Control and Antibiotic Stewardship Programs and resulted in the hospital's failure to ensure quality health care and safety. Refer to A-749 for details.

48359

Based on interview and policy review, the facility failed to appropriately define "timely notification" of the death of a patient in their policy for organ donation. This could adversely affect the suitability of donor organs.

Findings Included:

Review of the hospitals policy titled, "Organ/Tissue Donation" dated 07/22/21, showed the definition of "timely notification" of a patient death as "should be done as soon as possible".

During an interview on 06/28/23 at 2:30 PM, Staff L, Registered Nurse (RN), stated that she would call the organ transplant provider after the death of a patient as soon as she could.

During an interview on 06/29/23 at 10:35 AM, Staff BB, Director of Nursing, stated that she considered timely notification of a death to be five to ten minutes but it could be interpreted differently by other nurses.