HospitalInspections.org

Based on review of the Lincoln County Healthcare Quality Update,a review of randomly selected clinical records, review of departmental policies and procedures, review of the St. Andrews Hospital Medical Staff Bylaws, review of the CMS 2010 Inpatient and Outpatient Quality Indicators Summary, review of the Performance Improvement & Safety Plan 2010/2011, review of the Performance Improvement Council Committee meeting minutes, review of the Patient Care Committee meeting minutes, review of the Board of Trustee meeting minutes, and interviews with the Chief Executive Officer, the Chief Nursing Officer, Emergency Department physicians and the Performance Improvement Director on February 7-9, 2011, it was determined that the hospital's Governing Body failed to be totally responsible for the conduct of the CAH as an institution, as evidenced by:


1. The Governing Body failed to assume full legal responsibility for determining, implementing and monitoring policies (Tag C - 0302);

2. The Governing Body failed to ensure that the medical staff was accountable to the Governing Body for the quality of care provided to patients (Tag C-0330);

3. The Governing Body failed to ensure that the policies were administered so as to provide quality health care in a safe environment (Tag C- 302); and

4. The Governing Body failed to institute processes and systems to ensure periodic appraisal of the medical staff evaluation of patient care services at every patient care location (Tag C-0330).


The cumulative effects of these deficient practices resulted in this Condition of Participation being out of compliance.

Based on surgical record review, review of surgical policies and interviews with the Director of Surgical Services on February 8, 2011, it was determined that the hospital failed to have complete and accurately documented medical records in four (4) of eight (8) records. (Records: KK, LL, PP and QQ).

Findings include:

1. The hospital's policy "Surgical Suite Scheduling" specified under "Medical Record" that " Surgery is performed only after a history physical examination ...

2. A review of Record KK revealed that the record failed to have a history and physical documented in the clinical record prior to an Out patient surgical procedure that was completed on March 4, 2010.

3. The Hospital's policy, "Consents" specified under "B. Specific Informed Consent 1." that "The practicer who will perform the procedure is responsible for explaining to the patient the risks and benefits of the procedures for which specific informed consent must be obtained ..."
4. A review of Records LL and PP revealed that these records failed to have the Risk and Benefit section of the Surgical Consent form completed.

5. A review of Record QQ revealed that the record failed to have the type of Anesthesia (MAC) documented on the patient's Anesthesia Consent form.

6. These findings were confirmed with the surgical services staff on February 8, 2011.

Based on review of St. Andrews Emergency Department Daily Statistics, review of the St. Andrews Hospital Medical Staff Bylaws, review of the Emergency Department Performance Improvement Plan, review of the Emergency Department meeting minutes, review of the Surgical Service meeting minutes, review of the Patient Care Committee meeting minutes, review of the Performance Improvement & Safety Plan 2010/2011 and interviews with the Chief of Emergency Medicine, the Director of Performance Improvement, the Director of Nursing and the Director of Anesthesia Services February 7-8, 2011, it was determined that the CAH failed to ensure that the quality improvement activities were sufficient to assess the CAH care of patients. The case identification mechanisms for key quality initiatives were insufficient to identify cases for review. Furthermore, the CAH did not ensure that high risk, high volume and problem prone aspects of patient care, in the Emergency Department, the Swing Bed Unit, Surgical Services and in Anesthesia Services, were reviewed and that appropriate action was taken to improve patient care outcomes and services.

Findings include:
1. The St. Andrews Hospital " Performance Improvement & Patient Safety Plan 2010/2011 " stated, " To ensure that monitoring activities and prioritization of performance improvement and patient safety activities take into consideration ... high risk, high volume, and problem prone areas. "

2. The plan also stated, " The Medical Staff, ... is responsible for taking a leadership role in processes that are the primary responsibility of physicians and actively participate in organization-wide performance improvement activities. " and, " Projects will focus on high risk, high volume or problem prone areas and will consider the incidence, prevalence and severity of problems in those areas that affect patient safety. "

3. The St. Andrews Hospital Medical Staff Bylaws stated, " 2-2 THE RESPONSIBILITIES OF THE MEDICAL STAFF ARE TO: Account to the Board of Trustees for the quality, appropriateness, and efficiency of patient care provided by all practitioners authorized to practice in the Hospital through the following measures: continuous systematic monitoring and evaluation of patient care practices and provide opportunity to improve patient care and resolve identified problems; ... "

4. The following were indicators for the " Emergency Department Performance Improvement Plan " , and were confirmed during meetings with the Director of Performance Improvement and the Chief of Emergency Medicine on February 8, 2011. The 2010 indicators relating to physician care in the ED [Emergency Department] were, " 100% ASA, [aspirin] @ arrival, Lytic w/I [within] 30 minutes, EKG in 10 [minutes], ...BC [blood cultures] in ED prior to ABX [antibiotic] Abx w/I [antibiotic within] 6 hrs. [hours], 90% of eligible thrombotic stroke patients will receive Tissue Plasminogen Activator (tPA) in less than 3 hours from time of onset of symptoms. "

5. The Chief of Emergency Medicine in a meeting on February 8, 2010 stated that he did not consider " time to EKG " to be a physician indicator.

6. The Director of Performance Improvement stated that " Time to EKG " was a high volume indicator for the Emergency Department, but according to the Chief of Emergency Medicine, as has been described above, was not an indicator in which the physicians participated.

7. All of the physician indicators listed were at their targets throughout 2010. The pneumonia indicator, " ED blood culture prior to antibiotic " had only one patient in the first quarter of 2010 and there were no other patients in 2010.

8. The meeting minutes of the ED physicians for the calendar year 2010 were reviewed. In every instance the " Action " taken for " Quality " was deferred on two occasions, or, nothing to report or two occasions, " Annual Appraisal 2009 approved " on one occasion, and was, " Continue to monitor and report " on five occasions.

9. There was no evidence that the Emergency Physicians participated in, or took action on, high risk, high volume, or problem prone indicators, nor evidence that there was consideration of the incidence, prevalence and severity of problems in the indicators chosen, as there were no problems identified, nor action taken, in the entire year of measurement.

10. The surgical quality improvement indicators related to the work of surgeons was, " 95% compliance with Inpatient Patient, Out Patient and Office PQRI SCIP indicators, 100% Central Line Bundle Compliance in Perioperative Areas, 100% compliance with Surgical Safety Check list. "

11. In a report titled, " SCIP Indicators " , dated 01-25-2011, the report lists " No Patients " for 2010.

12. According to a document titled, " Surgical Safety Checklist Compliance " presented at the time of the survey, the checklist was used in 100% of cases reviewed throughout 2010.

13. The minutes of the Surgical Committee for the calendar year 2010 were reviewed. The June minutes regarding Central Line bundle were, " Rate was 50%. Forms not filled out on one case ...Action 1. Informational " . The compliance during all other time periods was " 100% " and the action was " Informational. "

14. The Anesthesia Performance Improvement plan for 2010 contained the initiatives " Compliance with Pre-Op Abx [antibiotic] Administered within 1 hr. [hour] Prior to Surgical Incision " , and " Compliance with Peri-Op Beta blocker". A review of the quarterly reports for the year 2010 indicated that the initiatives were " NA" (not applicable) for all four quarters. In addition, the Quality Assurance monitoring for Post Operative nausea and vomiting for the four quarters of 2010 was "N/A" or not applicable.


15. The minutes of the Surgical Committee for the calendar year 2010 were reviewed. In each instance in which the discussion item was " Quality " , the action item was, deferred in five instances, or, " 2009 Annual Appraisal approved " on one occasion, " Informational " on six occasions and, " Continue to monitor and report " on seven occasions.

16. There was no evidence that the Surgeons or Anesthetists participated in, or took action on, high risk, high volume, or problem prone indicators, nor evidence that there was consideration of the incidence, prevalence and severity of problems in the indicators chosen, as there were either no cases, or no problems identified, nor evidence of actions taken, in the entire year of measurement.

The cumulative effect of these deficient practices resulted in this Condition of Participation being out of compliance.

Please see Tag C - 0330 for additional information regarding the effectiveness of the hospital's quality assurance program.

Please see Tag - C0330 for additional information related to the evaluation of all patient care services affecting patient health and safety.

Please see Tag C-0330 for additional information related to appropriate remedial action taken to address deficiencies found through the quality assurance process.

Based on review of the Lincoln County Healthcare Quality Update,a review of randomly selected clinical records, review of departmental policies and procedures, review of the St. Andrews Hospital Medical Staff Bylaws, review of the CMS 2010 Inpatient and Outpatient Quality Indicators Summary, review of the Performance Improvement & Safety Plan 2010/2011, review of the Performance Improvement Council Committee meeting minutes, review of the Patient Care Committee meeting minutes, review of the Board of Trustee meeting minutes, and interviews with the Chief Executive Officer, the Chief Nursing Officer, Emergency Department physicians and the Performance Improvement Director on February 7-9, 2011, it was determined that the hospital's Governing Body failed to be totally responsible for the conduct of the CAH as an institution, as evidenced by:


1. The Governing Body failed to assume full legal responsibility for determining, implementing and monitoring policies (Tag C - 0302);

2. The Governing Body failed to ensure that the medical staff was accountable to the Governing Body for the quality of care provided to patients (Tag C-0330);

3. The Governing Body failed to ensure that the policies were administered so as to provide quality health care in a safe environment (Tag C- 302); and

4. The Governing Body failed to institute processes and systems to ensure periodic appraisal of the medical staff evaluation of patient care services at every patient care location (Tag C-0330).


The cumulative effects of these deficient practices resulted in this Condition of Participation being out of compliance.

Based on surgical record review, review of surgical policies and interviews with the Director of Surgical Services on February 8, 2011, it was determined that the hospital failed to have complete and accurately documented medical records in four (4) of eight (8) records. (Records: KK, LL, PP and QQ).

Findings include:

1. The hospital's policy "Surgical Suite Scheduling" specified under "Medical Record" that " Surgery is performed only after a history physical examination ...

2. A review of Record KK revealed that the record failed to have a history and physical documented in the clinical record prior to an Out patient surgical procedure that was completed on March 4, 2010.

3. The Hospital's policy, "Consents" specified under "B. Specific Informed Consent 1." that "The practicer who will perform the procedure is responsible for explaining to the patient the risks and benefits of the procedures for which specific informed consent must be obtained ..."
4. A review of Records LL and PP revealed that these records failed to have the Risk and Benefit section of the Surgical Consent form completed.

5. A review of Record QQ revealed that the record failed to have the type of Anesthesia (MAC) documented on the patient's Anesthesia Consent form.

6. These findings were confirmed with the surgical services staff on February 8, 2011.

Based on review of St. Andrews Emergency Department Daily Statistics, review of the St. Andrews Hospital Medical Staff Bylaws, review of the Emergency Department Performance Improvement Plan, review of the Emergency Department meeting minutes, review of the Surgical Service meeting minutes, review of the Patient Care Committee meeting minutes, review of the Performance Improvement & Safety Plan 2010/2011 and interviews with the Chief of Emergency Medicine, the Director of Performance Improvement, the Director of Nursing and the Director of Anesthesia Services February 7-8, 2011, it was determined that the CAH failed to ensure that the quality improvement activities were sufficient to assess the CAH care of patients. The case identification mechanisms for key quality initiatives were insufficient to identify cases for review. Furthermore, the CAH did not ensure that high risk, high volume and problem prone aspects of patient care, in the Emergency Department, the Swing Bed Unit, Surgical Services and in Anesthesia Services, were reviewed and that appropriate action was taken to improve patient care outcomes and services.

Findings include:
1. The St. Andrews Hospital " Performance Improvement & Patient Safety Plan 2010/2011 " stated, " To ensure that monitoring activities and prioritization of performance improvement and patient safety activities take into consideration ... high risk, high volume, and problem prone areas. "

2. The plan also stated, " The Medical Staff, ... is responsible for taking a leadership role in processes that are the primary responsibility of physicians and actively participate in organization-wide performance improvement activities. " and, " Projects will focus on high risk, high volume or problem prone areas and will consider the incidence, prevalence and severity of problems in those areas that affect patient safety. "

3. The St. Andrews Hospital Medical Staff Bylaws stated, " 2-2 THE RESPONSIBILITIES OF THE MEDICAL STAFF ARE TO: Account to the Board of Trustees for the quality, appropriateness, and efficiency of patient care provided by all practitioners authorized to practice in the Hospital through the following measures: continuous systematic monitoring and evaluation of patient care practices and provide opportunity to improve patient care and resolve identified problems; ... "

4. The following were indicators for the " Emergency Department Performance Improvement Plan " , and were confirmed during meetings with the Director of Performance Improvement and the Chief of Emergency Medicine on February 8, 2011. The 2010 indicators relating to physician care in the ED [Emergency Department] were, " 100% ASA, [aspirin] @ arrival, Lytic w/I [within] 30 minutes, EKG in 10 [minutes], ...BC [blood cultures] in ED prior to ABX [antibiotic] Abx w/I [antibiotic within] 6 hrs. [hours], 90% of eligible thrombotic stroke patients will receive Tissue Plasminogen Activator (tPA) in less than 3 hours from time of onset of symptoms. "

5. The Chief of Emergency Medicine in a meeting on February 8, 2010 stated that he did not consider " time to EKG " to be a physician indicator.

6. The Director of Performance Improvement stated that " Time to EKG " was a high volume indicator for the Emergency Department, but according to the Chief of Emergency Medicine, as has been described above, was not an indicator in which the physicians participated.

7. All of the physician indicators listed were at their targets throughout 2010. The pneumonia indicator, " ED blood culture prior to antibiotic " had only one patient in the first quarter of 2010 and there were no other patients in 2010.

8. The meeting minutes of the ED physicians for the calendar year 2010 were reviewed. In every instance the " Action " taken for " Quality " was deferred on two occasions, or, nothing to report or two occasions, " Annual Appraisal 2009 approved " on one occasion, and was, " Continue to monitor and report " on five occasions.

9. There was no evidence that the Emergency Physicians participated in, or took action on, high risk, high volume, or problem prone indicators, nor evidence that there was consideration of the incidence, prevalence and severity of problems in the indicators chosen, as there were no problems identified, nor action taken, in the entire year of measurement.

10. The surgical quality improvement indicators related to the work of surgeons was, " 95% compliance with Inpatient Patient, Out Patient and Office PQRI SCIP indicators, 100% Central Line Bundle Compliance in Perioperative Areas, 100% compliance with Surgical Safety Check list. "

11. In a report titled, " SCIP Indicators " , dated 01-25-2011, the report lists " No Patients " for 2010.

12. According to a document titled, " Surgical Safety Checklist Compliance " presented at the time of the survey, the checklist was used in 100% of cases reviewed throughout 2010.

13. The minutes of the Surgical Committee for the calendar year 2010 were reviewed. The June minutes regarding Central Line bundle were, " Rate was 50%. Forms not filled out on one case ...Action 1. Informational " . The compliance during all other time periods was " 100% " and the action was " Informational. "

14. The Anesthesia Performance Improvement plan for 2010 contained the initiatives " Compliance with Pre-Op Abx [antibiotic] Administered within 1 hr. [hour] Prior to Surgical Incision " , and " Compliance with Peri-Op Beta blocker". A review of the quarterly reports for the year 2010 indicated that the initiatives were " NA" (not applicable) for all four quarters. In addition, the Quality Assurance monitoring for Post Operative nausea and vomiting for the four quarters of 2010 was "N/A" or not applicable.


15. The minutes of the Surgical Committee for the calendar year 2010 were reviewed. In each instance in which the discussion item was " Quality " , the action item was, deferred in five instances, or, " 2009 Annual Appraisal approved " on one occasion, " Informational " on six occasions and, " Continue to monitor and report " on seven occasions.

16. There was no evidence that the Surgeons or Anesthetists participated in, or took action on, high risk, high volume, or problem prone indicators, nor evidence that there was consideration of the incidence, prevalence and severity of problems in the indicators chosen, as there were either no cases, or no problems identified, nor evidence of actions taken, in the entire year of measurement.

The cumulative effect of these deficient practices resulted in this Condition of Participation being out of compliance.

Please see Tag C - 0330 for additional information regarding the effectiveness of the hospital's quality assurance program.

Please see Tag - C0330 for additional information related to the evaluation of all patient care services affecting patient health and safety.

Please see Tag C-0330 for additional information related to appropriate remedial action taken to address deficiencies found through the quality assurance process.