HospitalInspections.org

Based on document review and interview the Chief Executive Officer (CEO) failed to carry out the responsibilities for assuring that the Hospital is in conformity with the requirements of planning, regulatory and inspecting agencies; reviewing, advising, and acting promptly upon the reports of such agencies. The CEO failed to provide the Medical Staff with the 01/31/2017 survey findings affecting patient care. The report was withheld from the Medical Staff. The Medical Staff was unable to review and evaluate activities to assess, preserve and improve the overall quality and efficiency of patient care in the Hospital. The Medical Staff did not make recommendations to the Board. The Board was not able to consider the recommendations of the Medical Staff and the other health care professionals providing patient care services. As a result the Board was unable to consider Medical Staff's recommendations. The Board did not receive the required findings and recommendations in writing, signed by the persons responsible for conducting the review activities, and supported and accompanied by documentation upon which the Board can take informed action.

A review of the document titled Medical Executive Committee Minutes and dated March 22. 2017 revealed starting on page 2 of 5, the Agenda Topic: Outside Audits/Surveys, Discussion: Discussed the final report from State survey. Corrections being addressed. Recommendation/Action: Blank no documentation, Follow-up: Blank no documentation.

A review of the document titled Board of Trustees dated February 7, 2017 revealed Agenda Topic: Outside Audits/Surveys, Discussion: We had state surveyor here January 23rd-26th. They were here for a return visit from a patient complaint that originated back in November ... We will continue to wait on final reports and get action plans started. Recommendation/Action: None, Follow-up: Blank no documentation.

A review of the document titled Board of Trustee Bylaws revealed on page 2, Definition 4, "Chief Executive Officer" or "CEO" means the individual appointed by the Corporation to provide for the overall management of the Hospital.

Article VI Chief Executive Officer
5.1, Appointment of the Chief Executive Officer.
The CEO shall be selected and employed by Corporation, after consultation with the Board, and shall be its direct executive representative in the management of the Hospital. The CEO shall have authority, and be held responsible for administering the Hospital in all of its activities, subject only to such policies as may be adopted and such orders as may be issued by Corporation. He/She shall act as the authorized representative of the Board and Corporation...

5.3 Chief Executive Officer's Responsibility
The authority and duties of the CEO shall include responsibility for the following:

5.3(i) Cooperating with the Medical Staff and others concerned with the rendering of professional services, to the end that optimal achievable care may be rendered to patients, and identifying the proper mix of programs and services of the Hospital;

5.3(m) Being responsible for assuring that the Hospital is in conformity with the requirements of planning, regulatory and inspecting agencies; reviewing, advising, and acting promptly upon the reports of such agencies;

Article VIII Medical Care Evaluations
7.1 Board Responsibility for the Quality of Professional Services
After considering the recommendations of the Medical Staff and the other health care professionals providing patient care services, the Board shall implement specific review and evaluation activities to assess, preserve and improve the overall quality and efficiency of patient care in the Hospital. The Board, through the CEO, shall provide whatever administrative assistance is reasonably necessary to support and facilitate activities contributing to continuous quality assessment and improvement.

7.3 Professional Accountability to the Board
The Medical Staff and the other health care professional staffs providing patient care services shall conduct, and be accountable to the Board for conducting activities that contribute to the preservation and improvement of the quality and efficiency of patient care provided in the Hospital. These activities shall include these functions;

7.3(b) On-going review, evaluation and monitoring of patient care practices through a systematic process of overall quality assessment and improvement;

7.3(g) Review the competency of care providers who are not subject to the Medical Staff privilege delineation process; and reporting to the governing body of findings with regards to such care providers;

7.3(i) Such other measures as the Board may, after receiving and considering the advice of the Medical Staff, the other professional services, and the CEO, deem necessary for the preservation and improvement of the quality and efficiency of patient care.

7.4 Documentation
The Board shall consider and act upon the findings and recommendations from the required review, evaluation, and monitoring activities. All findings and recommendations shall be in writing, signed by the persons responsible for conducting the review activities, and supported and accompanied by documentation upon which the Board can take informed action.

An interview on 04/05/2017 in the CEO's office, in the presence of the CEO and the Chairman of the Governing Board, the Chief of Staff confirmed the Medical Staff was not provided a copy of the survey results for the 01/31/2017 survey. The Chief of Staff confirmed the details of the report were not conveyed by the CEO.

An interview on 04/05/2017 in the CEO's office, in the presence of the CEO and the Chairman of the Governing Board, the Chief of Staff confirmed the Medical Staff and the Board had no interactions and/or discussions regarding the 01/31/2017 survey. The Chief of Staff and the Chairman of the Governing Board confirmed the results of the 01/31/2017 survey had only been made available to them on 04/04/2017. The Chief of Staff and the Chairman of the Governing Board confirmed the Medical Staff and The Board of Trustees did not participate or review the Plan of Correction that was submitted to the State on Friday, March 03, 2017 12:43 PM.

An interview on 04/05/2017 in the CEO's office, in the presence of the CEO, with the Chairman of the Governing Board confirmed during the meeting on 2/7/2017 the Board was notified the State had been in the facility. No State report was available and no action was taken by the board. The Chairman of the Governing Board confirmed there was not another meeting of the Governing Board until 04/04/2017. The Governing Board was provided a copy of the State findings and the Plan of Correction (POC) on 04/03/2017, a day before meeting.