HospitalInspections.org

Based on review of facility documents and staff interview (EMP) it was determined that the Department of Anesthesia failed to present their Performance Improvement activities at the Performance Improvement Committee meetings.

Findings:

Review of Conemaugh Miners Medical Center Organizational Performance Improvement Plan, Approvals 2011 Adoption: This Organizational Performance Improvement plan has been reviewed, approved and adopted by the Board of Directors, the Medical Staff acting through its Medical Executive Committee and by the Hospital Administration as attested to by signatures below. .... Performance Improvement Oversight Responsibility. The outcome of review performed by the medical staff for the hospital functions will be submitted to the Continuous Quality Improvement Council and the Performance Improvement Committee for their analysis, as well as the Medical Executive Committee for their approval and action. The Medical Staff is responsible for the performance improvement monitoring, assessment and evaluation activities performed throughout the hospital as delegated by the Board of Directors. ... Through the responsibility delegated by the Performance Improvement Committee, the Continuous Quality Improvement Chairperson will facilitate and implement the performance improvement process, provide support and education as it relates to performance activities and the Organizational Performance Improvement Program as a whole. The Coordinator of Utilization Review/Quality Assurance through the responsibility delegated by the Performance Improvement Committee and the Medical Staff, will coordinate the medical staff review functions, performance improvement processes to assist in providing the Performance Improvement Committee with the information necessary to assess and evaluate the quality of care and patient services provided throughout the hospital. ....."

1) An interview was conducted with EMP13, on August 9, 2011, at approximately 2:45 PM, " The Department of Anesthesia has failed to provide the Performance Improvement Council with their performance projects. Anesthesia was to present to the Performance Improvement Committee at the November 2010 meeting. I have sent reminders to the Anesthesia Department requesting them to bring their performance activities for review. The Department of Anesthesia has not reported to date."

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure that verbal orders were authenticated within 48 hours for seven of 22 medical records reviewed. (MR1, MR7, MR13, MR15, MR18, MR19 and MR22).

Findings include:

Review of "Miiners Medical Center By-laws ... Article III Medical Orders ... " revealed " ... Section 3: Verbal Orders ... The order shall include the date, time, and full signature of the person taking the verbal order and shall be countersigned by the prescribing practioner within 24 hours. ... "

Review of "Miners Medical Center ... Subject Medication Orders ... " revealed " ... Procedures: Verbal Orders . Verbal medication orders may be taken from a physician by a registered nurse or a pharmacist. These orders must be countersigned by the physician within 24 hours. ... "

1) Review of MR1, MR7, MR13, MR15, MR18, MR19 and MR22 revealed verbal orders that were taken by personnel qualified according to medical staff by-laws. The orders included the date, time and full signature of the person taking the order. There was no evidence that the orders were co-signed by a practioner within 24 hours.

2) Interview with EMP11 confirmed the above findings and revealed "It's an on-going problem."

Based on review of facility documentation and staff interview [EMP], it was determined that the facility failed to follow facility policy/procedure for maintaining monthly checks on all retakes of X-ray films.

Findings include:

Review of "Miners Medical Center ... Policy Code RAD 27 ... Subject: Film Retakes ..." reviewed November 2010, revealed "Purpose: To establish a procedure for the retaking of x-ray films due to the first film not being of optimal quality. ... Procedure: ... D. A monthly check of all retakes is performed each month to determine the reason of the retakes."

1) Review of "Radiology/CT/MRI Departments 2011 Quality Assurance Plan" revealed no documented evidence of monthly checks on all retakes of X-ray films.

2) An interview was conducted with EMP6 on August 11, 2011, at 9:30 AM, "I have not kept any data on retakes since we went digital. I didn't think there was a need."