The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

HSHS GOOD SHEPHERD HOSPITAL INC 200 S CEDAR ST SHELBYVILLE, IL 62565 May 24, 2011
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on a review of the Hospital's Performance Improvement Plan, complaint files, physician credential file, and staff interview, it was determined that the Hospital's QAPI program failed to ensure all negative events/outcomes were documented with corrective action taken, which is necessary for performance review of medical staff.

Findings include:

1. The Hospital's Performance Improvement Plan was reviewed. It indicated under "IV. Structure and Procedure A. Structure 4. Medical Executive Committee This committee which consists of all medical staff members...meets not less than every 2 months and its duties include but are not limited to: a. Overseeing the quality of care provided by the Medical Staff, overseeing the performance improvement activities of the Medical Staff. b. Recommending to the Board all matters relating to...clinical privilege and corrective actions...."

2. The Hospital's complaint files for Jan, Feb, and [DATE] were reviewed. It was noted that a complaint filed on 2/17/11 indicated that a peer review of the medical record by the Emergency Services Medical Director which questioned the discharge of Pt #1 by P-1 to home. Documentation to a complaint filed on 4/26/11 involved P-1 and his rounding of Hospital patients. Internal documentation attached to the complaint indicated that the Emergency Services Medical Director would address this issue with P-1.

3. Physician credential file for P-1 was reviewed on 5/24/11 at 11:00 AM. There was no documentation of any corrective measures/actions that had taken place with P-1.

4. During an interview with the Emergency Services Medical Director, conducted on 5/24/11 at 1:15 PM, he stated that he had reviewed the complaint record related to the incident that occurred on 2/15/11 and that there were questions related to the discharge of Pt #1. He asked that the medical record be sent to the contract services of P-1 for further review and determination if corrective action was needed. He stated that he had spoken with P-1 regarding his rounding on his hospital patients. It was verbalized that there was no documentation that substantiated any corrective actions or that it was reported to the Board.

5. During a staff interview, conducted with the Risk Management/Quality Assurance Coordinator and the Chief Nursing Executive on 5/24/11 at 2:00 PM, the above finding were confirmed.
VIOLATION: CONTRACTED SERVICES Tag No: A0084
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on a review of ER physician contract, review of physician credential files, and staff interview, it was determined that in 1 of 2 (P-2) credential files reviewed, that the Hospital failed to ensure all physicians provided by the contract service had all required certifications.

Findings include:

1. The contract agreement for Emergency Department Services between the Hospital and Emergency Staffing Solutions, Inc. (ESS) was reviewed on 5/24/11. It indicated on page 3 "4. Conditions to Status as Emergency Physician. A. ...Each physician granted privileges under this Agreement shall have current certification in Advanced Cardiac Life Support (ACLS), Advanced Trauma Life Support (ATLS) and Pediatric Advanced Life Support (PALS)...."

2. The credential file of P-2 was reviewed. It indicated that P-2 services were provided through ESS and was granted ER privileges. There was no documentation that indicated P-2 was certified in ATLS and PALS.

3. During a staff interview with the Chief Nurse Executive and the Risk Management/Quality Assurance Coordinator, conducted on 5/24/11 at 2:00 PM the above findings were confirmed

B. Based on a review of ER physician contract, complaint documentation log, and staff interview, it was determined that in 1 of 2 (Pt #1) complaint documentation log that the Hospital failed to ensure that concerns addressed with the contract service are resolved.

Findings include:

1. The contract agreement for Emergency Department Services between the Hospital and Emergency Staffing Solutions, Inc. (ESS) was reviewed on 5/24/11. It indicated on page 4 "Dispute Resolution. Hospital agrees to advise ESS promptly of any questions which arise concerning the professional qualifications, clinical performance, or interpersonal problems associated with any Emergency Physician. ESS agrees to use its best efforts to attempt to resolve any such questions promptly to the satisfaction of Hospital including, without limitation, meeting and/or counseling with the Emergency Physician...."

2. Complaint documentation log for Pt #1 was reviewed on 5/24/11 at 10:00 AM. Pt #1 was admitted on [DATE] with the diagnosis Chronic Obstructive Pulmonary Disease (COPD). Hospital complaint documentation log indicated on 2/25/11 that P-2 reviewed Pt #1's medical record, and that the Hospital was "sending the information to the agency that employs the physicians that staff our ER for a physician on their staff to review the case...."

3. During an interview with the Emergency Services Medical Director, conducted on 5/24/11 at 1:15 PM, it was verbalized that he asked that the medical record of Pt#1, that P-1 was the physician for, be sent to the contract services for further review and determination if corrective action was needed.

4. During an interview with the Risk Management/Quality Assurance Coordinator, conducted on 5/24/11 at 2:00 PM, she verbalized that the record was sent to the contract services. However, there was no feedback from the service and after several phone calls it was determined the contract service did not know where the medical record was at present, if it had been reviewed, or if corrective actions were needed.

5. During a staff interview with the Chief Nurse Executive and the Risk Management/Quality Assurance Coordinator, conducted on 5/24/11 at 2:00 PM the above findings were confirmed.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on a review of policy and procedure, review of 2 of 2 (Pts # 1, #11) complaint documentation logs, and staff interview, it was determined that the Hospital failed to provide, and failed to include in their policy that written notification of decisions/outcome be provided to the patient upon resolution.

Findings include:

1. The Hospital policy and procedure titled, "Patient Complaints" was reviewed. It indicated under, "I. PROCEDURE: 6. The Risk Manager will always make a follow-up phone call to the patient explaining what the outcome of the complaint was. 7. If it is deemed necessary or at the patient's request, a meeting with the Administrator and/or CNE can be scheduled.... 8. If no meeting is required, the Risk Manager will write a follow-up letter explaining what the outcome was to the Administrator and CNE, and will include all necessary paperwork, where it will be reviewed and filed." There is no requirement in the policy for a written notification to be provided to the patient on the decision/outcome of the grievance upon resolution.

2. Complaint documentation log for Pt #1 was reviewed on 5/24/11 at 10:00 AM. Pt #1 was admitted on [DATE] with the diagnosis Chronic Obstructive Pulmonary Disease (COPD). The Hospital complaint was received on 2/17/11. There was no documentation that written notification of grievance resolution was provided to the patient.

3. Complaint documentation log for Pt #11 was reviewed on 5/24/11 at 10:00 AM. Pt #11 was admitted on [DATE] with the diagnosis Hyperglycemia. The Hospital complaint was received on 4/26/11. There was no documentation that written notification of grievance resolution was provided to the patient.

4. During an interview with the Risk Management/Quality Assurance Coordinator, conducted on 5/24/11 at 2:45 PM, the above finding was confirmed.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on a review of the Hospital's Performance Improvement Plan, complaint files, physician credential file, and staff interview, it was determined that the Hospital's QAPI program failed to ensure all negative events/outcomes were documented with corrective action taken, which is necessary for performance review of medical staff.

Findings include:

1. The Hospital's Performance Improvement Plan was reviewed. It indicated under "IV. Structure and Procedure A. Structure 4. Medical Executive Committee This committee which consists of all medical staff members...meets not less than every 2 months and its duties include but are not limited to: a. Overseeing the quality of care provided by the Medical Staff, overseeing the performance improvement activities of the Medical Staff. b. Recommending to the Board all matters relating to...clinical privilege and corrective actions...."

2. The Hospital's complaint files for Jan, Feb, and [DATE] were reviewed. It was noted that a complaint filed on 2/17/11 indicated that a peer review of the medical record by the Emergency Services Medical Director which questioned the discharge of Pt #1 by P-1 to home. Documentation to a complaint filed on 4/26/11 involved P-1 and his rounding of Hospital patients. Internal documentation attached to the complaint indicated that the Emergency Services Medical Director would address this issue with P-1.

3. Physician credential file for P-1 was reviewed on 5/24/11 at 11:00 AM. There was no documentation of any corrective measures/actions that had taken place with P-1.

4. During an interview with the Emergency Services Medical Director, conducted on 5/24/11 at 1:15 PM, he stated that he had reviewed the complaint record related to the incident that occurred on 2/15/11 and that there were questions related to the discharge of Pt #1. He asked that the medical record be sent to the contract services of P-1 for further review and determination if corrective action was needed. He stated that he had spoken with P-1 regarding his rounding on his hospital patients. It was verbalized that there was no documentation that substantiated any corrective actions or that it was reported to the Board.

5. During a staff interview, conducted with the Risk Management/Quality Assurance Coordinator and the Chief Nursing Executive on 5/24/11 at 2:00 PM, the above finding were confirmed.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
A. Based on a review of internal documentation and staff interview, it was determined that in 1 of 2 complaints which involved P-1, the Hospital failed to ensure it identified areas for improvement and implemented changes that would lead to improvement.

Findings include:

1. Internal documentation that included hand written notes (related to a peer review of a medical record), analysis of a complaint, and e-mails were reviewed on 5/24/11. It indicated that there was a questionable discharge related to a complaint that occurred on 4/15/11. The hand written notes of a peer review indicated that there were numerous questions related to the discharge of the patient versus admission. Written notes of the QA Coordinator indicated the peer review identified several areas of concern such as "Questionable physical exam findings on ER chart - no findings on general appearance." and "No treatment for COPD exacerbation"

2. During an interview with the Emergency Services Medical Director (which was attended by the Risk Management/Quality Assurance Coordinator), conducted on 5/24/11 at 1:15 PM, it was verbalized that no corrective actions were put into place to ensure the questionable issues related to care and discharge of the patient were addressed with the practitioner so as to prevent further care problems.

3. During a staff interview with the Chief Nurse Executive and the Risk Management/Quality Assurance Coordinator, conducted on 5/24/11 at 2:00 PM the above findings were confirmed.
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on medical record review and staff interview, it was determined in 2 of 10 (Pts #1, #8) medical records reviewed, the Hospital failed to ensure verbal orders were put into writing and signed by the physician.

Findings include:

1. The medical record of Pt #1 was reviewed on 5/24/11. Pt #1 was admitted on [DATE] with the diagnosis COPD. On 2/15/11 at 9:31 PM, nursing documentation indicated "Notified doctor of patient's Accucheck was 456. Said to go and give regular insulin 8 units at this time." On 2/16/11 at 5:54 AM, nursing documentation indicated "Notified doctor that blood sugar was 433 and sliding scale stops at 8 units. Doctor stated to give the 8 units for now." On 2/16/11 at 9:18 AM, nursing documentation indicated "Regular insulin dosage clarification. Doctor said to hold this AM dose of Regular insulin pending discharge this afternoon." There was no documentation to indicate these verbal orders were placed into writing and signed by the physician.

2. The medical record of Pt #8 was reviewed on 5/24/11. Pt #8 was admitted on [DATE] with the diagnosis Hyperglycemia. On 4/25/11 at 11:31 AM, nursing documentation indicated "Notified physician patient's blood sugar of 85 and sherbet given. Phone order received to hold scheduled Lispro, give scheduled Levemir at 12:00 PM, and recheck blood sugar after lunch, orders read back successfully." On 4/25/11 at 8:18 PM, nursing documentation indicated "Notified doctor regarding glucose from lab is 458. Gave order to give supper insulin dose and bedtime dose at this time. Which is Lispro 20 units and Levemir 23 units. Continue with Accucheck at 10:00 PM tonight and has lab glucose ordered at 11:00 PM. At this time Dr. O will be taking over patient's care." There was no documentation to indicate these verbal orders were placed into writing and signed by the physician.

3. During a staff interview, conducted with the Risk Management/Quality Assurance Coordinator and the CNE on 5/24/11 at 2:00 PM, the above findings were confirmed.