HospitalInspections.org

Based upon observations, interviews, and document reviews, it was determined that the hospital failed to have an effective Governing Body that demonstrated accountability and responsibility for the conduct of the hospital as evidenced by:

1. The Governing Body failed in ensure that the medical staff was accountable to the Governing Body and that safe quality care was provided in the psychiatric unit. Please refer to A 0049.

2. The Governing Body failed to ensure resources were adequate to reduce the risk of harm to patients. Please refer to A 0956 and A 0315.

3. 482.55 - Emergency Services: The hospital to provide the appropriate numbers of qualified staff to meet patient needs in the Emergency Department. Please refer to A 1112.

Based upon interviews and hospital document reviews, the Governing Body did not hold the medical staff accountable for the care provided in the psychiatric unit by allowing patients to be admitted to the unit after it was closed due to safety concerns and the inability to meet patient needs. Evidence includes the following:

1. Document review of a hospital press release notice and information shared with CMS indicated that on 11/2/12, the psychiatric unit was to be immediately closed to inpatient admissions for a period of ninety (90) days. The indications for the closure was to "improve the quality of care in the unit and to ensure continued compliance with CMS". It further indicated that the unit would be "evaluated and renovated".

In addition, a news article dated 11/6/12 indicated that SP #9 reported that the hospital had stopped accepting new admissions and that renovations would be costing $300,000. This was to be done before the CMS visit scheduled in February, 2013. SP #9 was quoted as saying the closure was "pre-emptive...taking care of potential problems before the federal officials came in".

The trigger for the closure of the unit was actually due to a series of adverse events suffered by an inpatient on the unit which had included more than thirty (30) falls. The staff assigned to the psychiatric unit failed to respond appropriately and provide the necessary interventions.

2. At no time was the public informed that the significance of the closure of the unit was directly related to the inability of staff to safely care for and monitor the patients.

Based upon an internal review of the events on the psychiatric unit, the hospital leadership determined that policies related to fall reporting were not followed, adherence to requirements for restraint and seclusion were not maintained, the staff was neglectful in their monitoring of the patient, the staff failed to document in accordance with acceptable standards and had identified staff sleeping on the job.

Based upon these failures, the hospital determined that the unit was to be immediately closed.

The survey team during a meeting on 1/23/13 with the Hospital Board of Directors and hospital staff, addressed the misleading information provided to the community and to staff including the reported ninety (90) day time line the hospital established to re-open the unit. It was reported to the board the the concern was about patient safety and not about renovations to the unit.

3. Although the unit was closed to new admissions, a review of daily census reports noted that on 11/3/12, two (2) patients were admitted to the psychiatric unit after it was closed on 11/2/12 for inpatient admissions. Review of the census report for 11/6/12 noted that the hospital staff admitted one (1) other patient to the psychiatric unit.

4. Review of the Quality Assessment Performance Improvement minutes of 11/7/12 regarding the psychiatric unit included statements from hospital leadership that "we have been taking patients in the interim".

Another notation indicated the " the press says the unit has been closed so then how do we link, relate or justify the action"? When questioned about who was caring for the patients on the unit the response was recorded as the "current staff."

5. Interview with SP #5 at approximately 1:30 p.m. verified that patients had been admitted to the psychiatric unit after the decision had been made to close the unit for new admissions.

6. Although the unit had been closed and staff had been identified as not meeting the needs of the patients and providing safe care, the hospital chose to continue to admit patients placing them at risk.

Based upon interview and document review, the hospital continued to fail to ensure that supplies necessary for care are provided timely. Evidence includes the following:

1. During the survey conducted on 9/28/12, the hospital failed to ensure that anesthesia supplies were readily available. During a tour of the unit at that time and interview, it had been determined that the anesthesia department did not have endo tracheal tubes in several sizes and a piece of specialized equipment for difficult airway intubations was not available.

2. During interview with MD #1 on 1/25/13, it was revealed that the hospital still did not provide supplies and necessary equipment for safe care.

By letter dated 1/14/13, hospital leadership was provided with a list of "urgent needs". Included on this list were pediatric face masks size 3, fiberoptic glidescope for difficult airway management, full set of functional fiberoptic laryngoscope blades and handles for five (5) operating rooms and pediatric size oral airways size 50/60/70. The hospital leadership was also notified that supplies previously ordered weeks ago had still not been delivered.

3. As of 1/25/13, these supplies had not been received. The failure to provide specific and necessary anesthesia equipment has continued to place patients at risk.

Based upon interviews and document reviews, the hospital failed to ensure that the bylaws included transfer agreements to meet Emergency Medical Treatment and Labor Act (EMTALA) obligations. Evidence includes the following:

1. During the survey of 9/28/12, the hospital failed to provide evidence
of the agreements that Governor Juan Luis Hospital has with receiving hospitals pertaining to EMTALA.

Although several documents were provided at that time, none of the agreements were signed. During that time, physicians stated that emergent cases may sometimes be transferred to Roy Schneider Hospital in St Thomas, to Centro Medico or HIMA Health in Puerto Rico or to a hospital in Florida. The physicians indicated at times there were delays with the receiving hospitals accepting the patients that had been transferred. Transfers were done on a "gentlemen's" agreement and at times the appropriate receiving hospital staff were not aware of the transfer.

2. On 1/23/13, the hospital leadership was asked to provide copies of their transfer agreements. The only agreement produced was with Fort Lauderdale Hospital and Atlantic Shores Hospital which was signed 11/16/12 and specifically for behavioral health.

3. Interview with MD #3 on 1/23/13 at 10:30 a.m. addressed the difficulty each time a transfer is required because there "are no transfer agreements in place". The physician on call must call multiple hospitals which can take as many as 3 hours of personal time and a total of 10 -12 hours to finalize the transfer.

In an interview with MD #4 on 1/24/13 at 8:25 a.m. another example of the delays with hospital transfers was for Patient #8. The patient was in need of transfer as established by the Emergency Room physician at 4:30 p.m. and not transferred until the following day at 8:00 a.m.

4. Interview with SP #8 confirmed that emergency transfers are complex and can take anywhere from 5 - 15 hours. It was reported that s/he was unaware of any transfer agreements and was surprised when shown the agreement with Fort Lauderdale and Atlantic Shores. It was reported that this agreement was in place specifically for behavioral health, those on the psychiatric unit that had been reported to be closed as of 11/2/12. The contract was never utilized for transfer of the patients on the psychiatric unit.

5. Review of the Quality Assessment Performance Improvement Committee minutes of December 4, 2012 noted that patient transfer agreements had been finalized and that the recommended action was all entities that Governor Juan Luis Hospital (GJLH) transfer patients to off- island will be required to sign the agreement and the due date was 12/30/12. As of 1/25/13, the hospital provided no evidence of any signed agreements.

Based upon interviews and document review, the hospital failed to ensure that essential anesthesia equipment was inspected and maintained for safe operation. Evidence includes the following:

1. Interview with PC #1 on 1/22/13 at 8:00 a.m. indicated that during an emergency meeting with operating room staff on 1/14/13, the status of the inspection of anesthesia machines had been discussed. Information provided to leadership about the inspection dates for the equipment had been misleading and contradictory. Without safe inspections of the life sustaining equipment, patients are a risk.

2. SP #2 was interviewed in the afternoon of 1/23/13 regarding equipment maintenance. It was reported that several anesthesia machines were overdue for inspection. and that the vendor would not come in to service the equipment timely due to the hospital not paying for prior services provided by the vendor.

3. Interview with MD #1 on 1/24/13 at 12:15 p.m. indicated the anesthesia equipment was inspected in December of 2011, again in June of 2012 but the vendor had not been paid for the services. The next scheduled maintenance visit would have been December, 2012 but was not done due to the failure of the hospital to pay the vendor.

4. Payment was arranged as a result of the 1/14/13 meeting but the vendor indicated they would not be able to conduct the inspections for three (3) days. The decision was made by hospital leadership to close the operating room for all elective surgeries until the equipment was inspected.

5. The hospital had used the equipment in the operating rooms for 17 days beyond the required inspection date.

6. Review of a maintenance report provided noted that on 1/17/13, the five (5) anesthesia machines delinquent since 12/31/12 were inspected.

Based upon interviews, observations and hospital document reviews, the hospital failed to ensure that emergent patient needs were addressed timely and the care was provided by qualified and competent staff as evidenced by:

1. The hospital failed to staff the emergency room with adequate staffing that were trained and competent to meet patient needs. Please refer to A 1112.

Based upon interviews and hospital document reviews, the hospital failed to staff the emergency department with qualified trained staff to meet patient emergent needs. Evidence includes the following: