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.

Based on document review, interview, review of the hospital's quality and performance improvement program, and review of the hospital's plan of correction, the hospital failed to monitor for successful correction of deficiencies found during a federal and state complaint investigation in July 2019.

Failure to systematically identify problems, implement corrective action plans, and monitor for improvement limits the hospital's ability to provide high quality patient care and improve patient outcomes.

Findings included:

1. Review of the hospital's Quality and Patient Safety Plan 2020 showed the hospital's quality assurance/quality improvement program will measure and monitor quality outcomes and implement changes using a reporting structure to perform ongoing risk assessment. This guideline includes having a systematic collection, measurement, assessment of data on process, and outcomes related to patient care and organizational functions which are reviewed monthly.

2. On 12/03/20 at 1:30 PM, Investigator #3 and the hospital's Regulatory and Risk Manager Compliance Officer (Staff #304), reviewed the hospital's plan of correction which was developed in response to a federal and state complaint investigation for practice deficiencies involving ventilated patients. Chart audits were implemented to ensure all orders were documented prior to a patient being placed on a ventilator or upon changes in ventilator settings. The review showed that monthly audits for changes in the ventilator settings were not evaluated, or documented for inpatients for the months of February 2020 to present (10 months total).

3. At the time of the review, Investigator #3 interviewed the hospital's Regulatory and Risk Manager Compliance Officer (Staff #304), about the absence of audits for physician orders for changes made in ventilator settings. Staff #304 confirmed the audits only reflected initial ventilator settings and not when changes in settings were made.

4. On 12/03/20 at 3:03 PM, Investigators #3 and #7, interviewed the hospital's Regulatory and Risk Manager Compliance Officer (Staff #304), and the Chief Medical Officer (Staff #305) about the monthly ventilator chart audits. Staff #305 stated that a Hospitalist provider (Staff #306), performs monthly audits on all inpatients who are ventilated. The results of those audits are reported in the monthly hospitalist group meetings which is attended by the Chief Medical Officer. Any deviations from the standard are discussed with the individual provider. Staff #305 stated that no report of those audits are forwarded to the Medical Executive Committee or Quality Improvement Committee. Staff #304 acknowledged that these reports should have been sent to the Hospital Quality Committee for monitoring and tracking of compliance.

5. On 12/03/20 at 3:24 PM, Investigators #3 and #7, with the hospital's Regulatory and Risk Manager Compliance Officer (Staff #304), interviewed the Hospitalist provider (Staff #306), who performs the monthly ventilator chart audits. Staff #306 stated that he started doing ventilator chart audits this year. He reports his findings to the monthly Hospitalist group meetings. Investigator #3 asked Staff #306 why there were no audits for changes in ventilator settings, Staff #306 stated he was told to only look at initial orders and not changes in ventilator settings.
Based on document review, interview, and review of hospital policy and procedures, the hospital failed to ensure that staff members were oriented to their assigned work area for 2 of 4 human resource records reviewed (Staff #302, Staff #303).

Failure to ensure hospital staff members are oriented to their job responsibilities risks inappropriate and/or ineffective patient care and poor patient outcomes.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Competency: Assessment and Maintenance," no policy number, last approved 12/03/19, showed that the manager or director will provide all staff with a department-specific orientation. This orientation is designed to educate and train new staff to the department's functions, policies, practices, and their individual responsibilities. The human resources department maintains the documentation of completion of the hospital-wide and departmental orientations.

2. On 12/03/20 at 12:25 PM, Investigator #3 reviewed the personnel files of four hospital staff members, with the assistance of the hospital's Human Resources Manager (Staff #301). The review showed:

a. Staff #302 was a contracted respiratory therapist who had a start date of 02/20/20. There was no evidence of unit orientation documentation in Staff #302's file to show that he had been oriented to the duties and responsibilities in the Respiratory Therapy department.

b. Staff #303 was the supervisory coordinator for the Respiratory Therapy department with a start date of 08/17/20. Record review showed that the department orientation checklist was incomplete with the latest date of annotation as 08/25/20.

3. At the time of the review, Investigator #3 interviewed the Human Resource Manager (Staff #301), about the missing and incomplete unit orientation files for the hospital staff members. Staff #301 confirmed the above findings and was unsure of the location of the missing files.