HospitalInspections.org

Based on records reviewed and interview the Governing Body failed to assess the performance of the Hospitals contracted services.

The Surveyors reviewed the Patient Care Assessment Committee Meeting Minutes and the Board of Directors Meeting Minutes for 2017. There was no evidence that contracted services were reviewed by either of these committees.

The Surveyors interviewed the Chief Medical Officer at 1:00 P.M. on 2/12/18. The Chief Medical Officer said that his goal was to identify two measurable indicators by 7/1/2018. The Chief Medical Officer provided a draft grid, dated 2/12/18, of the contract service metrics that the Hospital would be measuring. The Chief Medical Officer said he did not believe that any contract service review had been conducted by the Committee this past year.

Based on interview, the Hospital failed to ensure that remedial education proved effective in achieving expected competencies for one of three Hospital staff who had been directly involved in a Serious Reportable Event (SRE).

The Surveyors reviewed the Clinical Leader for the Neurosurgical service line educational training records at 2:00 P.M. on 2/7/18. The Clinical Leader's training records indicated that she had signed the Operating Room attestation of reading the assigned documents/policies including the letter from the Chief Medical Officer, the policies on Universal Protocol, Operating Room Attire, Prevention of Surgical Site Infections and the Chain of Command and a review of the job description for the Surgical Technologist on 1/10/18. Additionally the Clinical Leader had completed an on-line module titled "A Culture of Safety and Teamwork" on 1/30/18.

The Surveyors interviewed the Clinical Leader for the Neurosurgical service line at 8:45 A.M. on 2/8/18. Despite being asked three separate times about what the Clinical Leader would do if she witnessed a like occurrence, she was only able to say that a like occurrence would "never happen again".

Based on records reviewed and interview the Hospital failed to set clear and timely patient safety expectations for two of four Hospital staff involved in a Serious Reportable Event in Surgical Services.

The Surveyors reviewed Neurosurgeon #1's credential file on 2/7/18. Neurosurgeon #1's file indicated that directly following the event, Neurosurgeon #1 was provided with timely clinical observation by the Chief Medical Officer. Neurosurgeon #1 was counseled about the limitations of the Informed Surgical Consent. Neurosurgeon #1 contacted Patient #1 and made full disclosure of the event and documented an addendum report into Patient #1's medical record. Neurosurgeon #1 was notified that he was in violation of the Hospital's Bylaws, Rules and Regulations and that subsequent action was under review by the members of the Medical Executive Committee.

The Surveyor reviewed the personnel record of Scrub Technician #1 on 2/7/18. Scrub Technician #1 record indicated that she had received a disciplinary action on 1/15/18 and additional training.

The Surveyor reviewed the personnel record of the Clinical Leader for the Neurosurgical service on 2/7/18. The Clinical Leader's record indicated that she had received additional training.

The Surveyor reviewed the personnel record of the Operating Room Nurse Manager on 2/7/18. The Operating Room Nurse Manager record indicated that she had received additional training.

The Surveyors interviewed the Chief Nursing Officer at 9:00 A.M. on 2/12/18. The Chief Nursing Officer said that she had provided a verbal warning to the Clinical Leader for the Neurosurgical service and the Clinical Leader was aware that at the conclusion of the investigation additional disciplinary action may be forthcoming.

The Chief Nursing Officer said using the principles of a just culture, the remediation plan for the Nurse Manager was still being considered.

Based on observation and interview the Operating Room (O.R.) at the Haverhill campus failed to have a tracheostomy kit available in the O.R. Suite.

During the tour of the OR Suite the Surveyor requested to view the tracheostomy set that is required to be available in the Operating Room.

The Surveyor interviewed the Operating Room Nurse Manager at the Haverhill campus at 3:30 P.M. on 2/12/18. The Nurse Manager of the OR said there was no tracheostomy set in the OR but there was one in the Intensive Care Unit.

The Hospital failed to follow policy when a post-anesthesia assessment by the Anesthesia Department was not documented on two of ten post-procedure patients (Patient #4 and Patient #9) requiring a post-anesthesia assessment.

Patient #4 was postoperative from a spinal procedure. There was no post-procedure note from Anesthesia to review vital signs, respiratory status, level of consciousness and level of pain post- procedure as required.

Patient #9 was postoperative from a spinal procedure. There was no post-procedure note from Anesthesia to review vital signs, respiratory status, level of consciousness and level of pain post- procedure as required.

The Risk Manager was unable to locate any additional documentation.