HospitalInspections.org

Based on review of the list of contracted services and interviews the hospital failed to ensure the list of contracted services included the scope and nature of the contracted services along with the contractor responsibility.

Findings:

Review of the list of contracted services revealed the hospital failed to have the scope and nature of the conrtract service to be provided to hospital patients documented on the list and the contract themselves were not specific as to what services would be provided to the hospital's patients.

Interview, 06/28/2019 at 10:00 AM, with Staff #X, confirmed the scope and nature of all contracted services provided to hospital patients was not documented on the contract list. Staff #X further confirmed by review of the list of contracted services one could not ascertain what service was to be provided.

Based on record reviews and interview the hospital failed to ensure their grievance process was followed as evidenced by not notifying all patients and/or the patient's representative of the resolution of the grievance.

Findings:

Review of the hospital's grievance log revealed 10 of 10 grievances filed by patients seen in the Emergency Department (04/18/19 through 05/30/19), did not have the results of the grievance investigation and results/resolution documented.

Interview, 06/27/2019 at 2:20 PM, with Staff #K revealed when questioned as to where the results of the grievance investigations relative to the Emergency Department (ED) patients could be found; Staff #K stated the ED patients grievances were forwarded to the Director of the Contracted ED Physician Services (Contract #1). Further questioning of Staff #K confirmed the hospital had not received any notification if the ED grievances had been investigated and resolved to the patients satisfaction.

Based on record review and interview the QA/PI (Quality Assurance/Performance) coordinator failed to measure and track indicators by not having action plans for identifiers and "data analysis".
Findings:

A review of the QA/PI (Quality Assurance/Performance Improvement) Meeting Minutes for 07/26/18, 08/23/18, 09/20/18, 10/25/18, 12/27/18, 01/24/19, 02/28/19, 03/28/19 and 04/25/19 revealed the QA/PI coordinator failed to document action plans for identifiers and "data analysis".

In an interview on 06/27/19 at 10:00 AM the QA/PI coordinator confirmed that she did not document action plans for identifiers and the "data analysis" she documents.

Based on record reviews and interview the hospital failed to ensure the contracted pharmacist: 1. had qualifications established by the medical staff and had been granted privileges as a pharmacist; 2. the consultant pharmacist would be responsible for developing, supervising and oversee all activities of pharmaceutical services.

Findings:

Review of the contract agreement for the hospital pharmacist revealed there lacked documentation that the pharmacist would serve as the director of pharmacy services and provide oversight/supervision of all pharmacy related activities. The hospital utilizes a drug room in lieu of a pharmacy and Staff #U was acting as the drug room supervisor.

Review of Staff #U's personnel file revealed a lack of documentation for training of duties for work in the drug room, job description describing the duties in the drug room and had been oriented to drug room prinicples by the consultant pharmacist.

Based on observation, interview and record reviews the hospital failed to ensure there were adequate numbers of pharmacy personnel availabe to provide pharaceutical services 24 hours a day/7 days a week.

Findings:

Observations, made 06/27/19 and 06/28/19, revealed the hospital utilized a Drug Room and not a pharmacy.

Interview, 06/28/19 at 2:45 PM, with Staff #U confirmed the Drug Storage room was used by the hospital as the pharmacy. Continued interview with Staff #U revealed the supervisor of the drug storage room was Staff #U. During the interview, 06/28/19 at 2:45 PM, with Staff #U it was confirmed that the charge nurses on the inpatient unit had access to the drug storage room keys should a patient require a medication that was not available through the automated drug dispensing machine.

Review of Staff #R contract for pharmacy services revealed there lacked documentation in the contract that Staff #R would serve as the Supervisor of Pharmacy services.

Review of Staff #U's personnel file revealed a lack of documented evidence Staff #U had received training in drug room duties, had a job description describing duties in the drug room, and had been oriented to drug room priniciples by the consultant pharmacist.

Review of personnel records (10/10), revealed none of the Registered Nurses files (Staff #s B, E, F, I, J, K, L, U, V, W) contained documented evidence of training in drug room duties.

Based on observations, record review and interviews the hospital failed to ensure out of date medications/drugs were not available for patient use as evidenced by 4 bags of Dopamine HCL in 5% Dextrose with expiration dates of 1 June 2019 which were available for use in the Emergency Department Bays 4 and 5.

Findings:

Observations made, 06/28/19 at 1:50 PM, of Bay 4 in the Emergency Department revealed 2 foil wrapped bags of Dopamine HCL in 5% Dextrose hanging on the wall. Review of the expiration date revealed they were both expired as of 1 June, 2019. Review of 2 foil wrapped bags of Dopamine HCL in 5% Dextrose located in the cabinet in Bay 5 revealed they had also expired on 1 June, 2019.

Review of the crash cart data sheet (included information such as drugs available, defibrillator checks, etc), dated June 2019 revealed nurses had placed check marks by all the medications.

Interview, 06/28/19 at 2:10 PM, with Staff #U confirmed the 4 bags of Dopamine HCL had expired on 1 June 2019 and should have been removed.

Based on record review and interview the infection control officer failed to develop a system for investigating and controlling infections by not ensuring the infection control officer was evaluating the effectiveness of antibiotic treatments.
Findings:

A review of the infection control log from July 2018 through May 2019 revealed the infection control officer failed to evaluate the effectiveness of antibiotics after patients have completed their treatments to find out if signs and symptoms of infection were present.

In an interview on 06/27/19 at 10;00 AM the infection control officer stated she does not evaluate the effectiveness of antibiotics against infectious organisms.