HospitalInspections.org

Based on personnel record review, attempted policy and procedure review, and staff interview, the facility failed to be in compliance with federal, state and local laws by failing to ensure seven (7) of 16 employees received a criminal history record check prior to employment. Employee #1, #4, #5, #8, #9, #10 and #12.


Findings Include:


Review of personnel records revealed no documented evidence of a criminal history record check for Employee #1, #4, #5, #8, #9, #10 and #12 prior to employment at the hospital.


During an interview on 1/06/16 at 2:30 p.m. the Administrator stated, "The employee personnel files are kept in my office, however the Director of Nurses (DON) is in charge of keeping them up to date."


On 1/06/16 at 4:10 p.m. the DON was asked about the lack of employee criminal history record checks in the seven (7) personnel files. She stated, "The personnel files are kept in the Administrator's office. You will have to ask her. She is in charge of them."


The facility failed to submit a policy and procedure regarding employee criminal history record checks prior to the end of the survey. On 1/06/16 at 4:30 p.m. the DON stated that they do not have a policy and procedure regarding employee personnel files but would be putting one in place.

Based on record review, failed policy and procedure review, and staff interview, the facility failed to ensure their patient's right to formulate advance directives for six (6) of six (6) closed charts and 6 (six) of 6 (six) open charts reviewed. (Patient #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, and #36)


Findings Include:


Review of closed records for Patient #31, #32, #33, #34, #35, and #36, and open records for Patient #25, #26, #27, #28, #29, and #30 revealed no documented evidence that these 12 patients had been asked about advance directives at any time during their hospital stay.


During an interview on 1/07/16 at 9:30 a.m. these findings were discussed with the Administrator. She confirmed the findings and stated that the facility did not have a policy on Advance Directives.

Based on observation, review of hospital documentation, and staff interview, the facility failed to maintain the hospital environment and rights of patients in a manner that protected the safety and well-being of patients, as evidenced by call lights (communication system for patients) not functioning in the Behavior Health Unit (BHU). Eight (8) out of 18 rooms, Rooms #19, #20, #21, #22, #23, #24, #25, and #26, were without call lights.


Findings Include:


Cross Refer to A0700 /482.41 for the facility's failure to ensure the safety of the patients in the BHU.

Based on Quality Assurance Committee meeting minutes review, policy and procedure review, and staff interview, the facility failed to maintain and demonstrate an effective, ongoing, hospital-wide, data-driven Quality Assessment and Performance Improvement (QAPI) program involving all hospital departments and services focusing on indicators related to improved health outcomes and the prevention and reduction of medical errors.


Findings Include:


Review of the facility's Quality Assurance Committee meeting minutes revealed no documented evidence of any indicators being tracked throughout the last 12 month period, data collection used to identify opportunities for improvement and changes, or measurable progress achieved on Performance Improvement projects.


Review of Infection Control documentation revealed no documented evidenced that problems identified in the infection control program are addressed in the hospital QAPI program (i.e., development and implementation of corrective interventions, and on ongoing evaluation of interventions implemented for both success and sustainability).


Review of the facility's Quality Assurance program revealed no documented evidence of their discharge planning being reviewed on an on-going basis.


Review of the facility's "Quality Assurance and Performance Program (QAPI)" policy, last reviewed by the hospital's Medical Staff on November 14, 2014, revealed: "Policy Statement. This facility shall develop, implement, and maintain an ongoing program designed to monitor and evaluate the quality of patient care, pursue methods to improve quality care, and to resolve identified problems. Purpose - The primary purposes of the Quality Assurance and Performance Program are: ...2. To establish and provide a system whereby a specific process, and the documentation relative to it, is maintained to support evidence of an ongoing Quality Assurance Program, encompassing all aspects of patient care including safety, infection control, and quality of life applicable to patients ...".


During an interview on 1/07/16 at 11:35 a.m., the Director of Nursing/Quality Assurance Coordinator confirmed there was no documented evidence of any Quality Assurance indicators being monitored for the QAPI program at this time or during the last 12 months.



During an interview on 1/07/16 at 11:40 am the Director of Nurses stated, "I do not include discharge planning in my Quality Assurance."

Based on review of the minutes of the Quality Assurance Committee, policy and procedure review, and staff interview, the facility:
1. failed to have a Quality Assessment and Performance Improvement (QAPI) program that includes, but is not limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes or measure, analyze, and track quality indicators and other aspects of performance that assess processes of care, hospital service and operations; and
2. failed to incorporate quality indicator data including patient care data, and other relevant data, submitted to, or received from, the hospital's Quality Improvement Organization.


Findings Include:


Cross Refer to A263 / 482.21 for the facility's failure to have a QAPI program that includes an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes or measure, analyze, and track quality indicators and other aspects of performance that assess processes of care, hospital service and operations and failure to incorporate quality indicator data including patient care data, and other relevant data, submitted to, or received from, the hospital's Quality Improvement Organization.

Based on review of the minutes of the Quality Assurance Committee, policy and procedure review, and staff interview, the facility failed to set priorities for its performance improvement activities that focus on high-risk, high volume, or problem-prone areas.


Findings Include:


Cross Refer to A263 / 482.21 for the facility's failure to set priorities for its performance improvement activities that focus on high-risk, high volume, or problem-prone areas.

Based on review of the minutes of the Quality Assurance Committee, policy and procedure review, and staff interview, the facility failed to have performance improvement activities that track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital.

Findings Include:

Cross Refer to A263 / 482.21 for the facility's failure to have performance improvement activities that track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital.

Based on review of the minutes of the Quality Assurance Committee, policy and procedure review, and staff interview, the facility failed to document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.


Findings Include:


Cross Refer to A263 / 482.21 for the facility's failure to document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.

Based on medical record review, policy and procedure review, and staff interview, the facility failed to ensure all patient records are complete, dated, timed and authenticated by the person responsible for providing the service, consistent with hospital policies and procedures.


Findings Include:


Review of medical records revealed 18 Behavioral Health Unit (BHU) charts, five (5) Acute Care (AC) charts and nine (9) Out-patient (OP) charts with incomplete medical records. The delinquent medical records ranged from March 2015 to present and included incomplete physician orders and progress notes, nurse progress notes, group charting, discharge summaries, social worker progress notes, psychiatric evaluations, history and physicals, clinical participation notes, omitted dates, times and signatures.


Review of the facility's Rules and Regulations revealed: " ...3. The attending physician shall be responsible for the preparation of a complete and legible medical record for each patient ...This record shall include ...progress notes ...summary or discharge note ... 16. The patient's medical record should be completed at the time of discharge, including final diagnosis ...within fourteen days after discharge."


During an interview on 1/06/16 at 11:15 a.m. the Medical Records Director confirmed the 18 BHU, 5 AC and 9 OP delinquent medical records. She stated that she had submitted a delinquent chart report to the Administrator on December 22, 2015.

Based on record review, policy and procedure review and staff interview, the facility failed to ensure all orders, including verbal orders are dated, timed and authenticated.


Findings Include:


Cross Refer to A450 / 482.24(c)(1) for the facility's failure to ensure all orders, including verbal orders are dated, timed and authenticated.

Based on observation, review of hospital documentation, document review, and staff interview, the facility failed to maintain the hospital environment in a manner that protected the safety and well-being of patients. The call light communication system for patients was not functioning in the Behavior Health Unit (BHU) in eight (8) of 18 rooms, Rooms #19, #20, #21, #22, #23, #24, #25, and #26.


Findings Include:

Observations made with the Director of the Geri Psych Unit on 1/05/16 at 1:00 p.m. revealed that eight (8) patient rooms, Rooms #19, #20, #21, #22, #23, #24, #25, and #26, on the east wing side of the BHU did not have functional call lights. The unit's census on that day was nine (9) patients. No patients were in their rooms at that time.

Interview with the Director at 3:45 p.m. revealed that the patients in Rooms #19, #20 #21 and #26 were scheduled for discharge that day. The patients in Rooms #23, #24 and #25 would be moved to a room with a functioning call light system and if the hospital had to use a room with a non-functioning call light they would provide one (1) on one (1) observation 24/7 until call lights were repaired.


On 1/5/16 at 4:30 p.m. observation of the BHU revealed that the rooms with nonfunctional call lights did not have patients in them. The Director of the BHU confirmed that the four (4) patients scheduled for discharge had been discharged and other patients had been relocated to a room with a functioning call light.


Observation on 1/5/16 at 4:40 pm revealed maintenance staff working on the dysfunctional call light system.


On 1/6/16 at 8:00 a.m. the facility submitted a work order from an electric company showing they had repaired all nonfunctioning call lights on 1/5/16.


Review of documentation provided by the Administrator on 1/6/16 at 10:15 a.m. revealed a policy regarding the BHU's Call Light System. This policy was dated 1/6/16 and documented as their current policy. The facility did not submit any previous policy.


On 1/07/16 at 11:20 a.m. the call light systems in all BHU patient rooms were tested and all were found to be functioning properly.

Based on review of hospital documentation, staff interview, and personnel record review, the facility failed to have an active program for the prevention, control, and investigation of infections and communicable diseases.


Findings include:



On 1/07/16 at 9:00 a.m. the Director of Nursing (DON) revealed that she was unable to obtain all of the Infection Control documentation because the Infection Control Nurse (Registered Nurse [RN] #4) was out on leave because of a death in her family.


On 1/07/16 at 9:15 a.m. review of RN #4's job description failed to reveal she was an Infection Control Officer. The Job description was signed by RN#4 on 11/5/15 and revealed her Job Title as "Registered Nurse-BHU/PHP (Behavioral Health Unit/Personnel Health Provider".


During an interview on 1/07/16 at 11:35 a.m., the Director of Nursing/Quality Assurance Coordinator confirmed that she could not provide any Infection Control information.

Based on review of hospital documentation, staff interview, and personnel record review, the facility failed to designate a infection control officer or officers to develop and implement policies governing control of infections and communicable diseases.


Findings Include:


Cross Refer to A0747 / 482.42 for the facility's failure to designate a infection control officer or officers to develop and implement policies governing control of infections and communicable diseases.

Based on review of hospital documentation, staff interview, and personnel record review, the facility failed to develop a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.


Findings Include:


Cross Refer to A0747 / 482.42 for the facility's failure to develop a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.

Based on review of hospital documentation, staff interview, and personnel record review, the facility failed to ensure that the hospital-wide Quality Assessment and Performance Improvement (QAPI) program and training programs address problems identified by the infection control officer or officers; and failed to be responsible for the implementation of successful corrective action plans in affected problem areas.



Findings include:


Cross Refer to A0263 / 482.21 for the facility's failure to address Infection Control in their QAPI program (i.e., development and implementation of corrective interventions, and on ongoing evaluation of interventions implemented for both success and sustainability).

Cross Refer to A747 / 482.42 for the facility's failure to develop a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.

Based on document review and staff interview, the facility failed to ensure the reassessment of their discharge planning on an on-going basis.


Findings Include:


Review of the facily's Quality Assurance program revealed no documented evidence of their discharge planning being reviewed on an on-going basis.


During an interview on 1/07/16 at 11:40 am the Director of Nurses stated, "I do not include discharge planning in my Quality Assurance."

Based on personnel record review, attempted policy and procedure review, and staff interview, the facility failed to ensure emergency service personnel requirements are met for five (5) of 16 emergency service personnel reviewed, Registered Nurses (RN) #1, #2, #3, #4 and #5; and failed to submit a policy and procedure for emergency service personnel requirements



Findings Include:


Review of emergency service personnel records revealed no documented evidence of Advanced Cardiac Life Support (ACLS) and Cardiopulmonary Resuscitation (CPR) for RN #1, #2, #3, #4 and #5.


During an interview on 1/06/16 at 12:00 p.m. the Director of Nurses stated, "All of our nurses are CPR certified and all of our Registered Nurses are ACLS certified."

A policy and procedure for emergency service personnel requirements was requested on 1/06/16 at 4:00 p.m. No policy was submitted for review.

Based on staff interview, personnel record review, and attempted policy and procedure review, the facility failed to submit a policy regarding emergency service personnel requirements.


Findings include:


Cross Refer to A1100 / 482.55 for the facility's failure to ensure the development of a policy and procedure regarding emergency service personnel requirements.

Based on personnel record review and staff interview the facility failed to ensure the emergency service personnel requirements are met for five (5) of 16 emergency service personnel records reviewed, Registered Nurse (RN) #1, #2, #3, #4 and #5.


Findings Include:


Cross Refer to A1100 / 482.55 for the facility's failure to ensure RN #1, #2, #3, #4 and #5 meet all necessary emergency service personnel requirements.

Based on personnel record review and staff interview the facility failed to have adequate nursing personnel qualified in emergency care to meet the needs anticipated by the facility by failing to ensure the emergency service personnel requirements are met for five (5) of 16 emergency service personnel records reviewed, Registered Nurses #1, #2, #3, #4 and #5.



Findings Include:


Cross Refer to A1100 / 482.55 for the facility's failure to have adequate nursing personnel qualified in emergency care to meet the needs anticipated by the facility.