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Based on review of Governing Body By-Laws and Medical Staff By-Laws, the Governing Body failed to comply with their by-laws. The staff failed to ensure that Medical Staff appointments were timely and that all Medical Staff Members had an approved delineation of privileges according to their scope of practice at this hospital. The Governing Body also failed to ensure that contracted services were performed safely and competently.

The findings include:

1. Cross-reference to 046, 083, 084.

Based on staff interview and facility document review the facility failed to have an ongoing Quality Assessment and Performance Improvement Program for the acute care hospital.

The Findings Include:

Please cross reference:
Tags 0263 through 0267,
Tags 0273 through 0277,
Tag 0283,
Tags 0285 through 0291,
Tags 0297 through 0303 and
Tags 0309 through 0317.

Based on review of twelve credential files, and interview with the CEO and the Director of Credentialing, it was determined that the facility failed to comply with the Governing Body By-Laws and Medical Staff By-Laws for the delineation of clinical privileges and current appointment for Medical Staff members.

The findings include:

1. The Governing Body By-Laws (as amended July 23, 2008) read, "6.3 Appointment. Reappointment to the Medical Staff shall be for periods of two (2) years and be based upon the applicant's professional performance, current competence, ethical qualifications, absence of disruptive behavior, judgement, health status, and when appropriate, technical skills."

2. The Medical Staff By-Laws, as revised 05/28/2003, read, "Procedures for Appointment and Reappointment: (iv) Submit a written report of its findings, including recommendations regarding the granting or denial of Staff privileges to the applicant, to the Board within sixty (60) days of receipt of a completed application. 4.2 Active Staff. The Active Staff shall consist of those physicians to whom the Board has granted privileges. Consulting Staff. Members of the Consulting Staff will have all the privileges of the Hospital with the exception of admission privileges." The By-Laws also read, "Terms of Appointment. 2. Consulting Staff. Initial appointments to membership on the Consulting Staff shall be effective until the end of the Medical Staff year. Thereafter appointment shall be effective for two (2)
years."

3. Review of twelve physician credential files revealed no written documentation of a delineation of clinical privileges (DOP) for these physicians. In a March 7, 2012, afternoon interview with the CEO and Director of Credentialing, both confirmed they were not aware they needed to have specified clinical privileges.

4. One physician reviewed had been reappointed 01/27/2010. The By-Laws state that reappointments are effective for two years. In the above interview with the Director of Credentialing, she stated to the surveyor, "This physician is late returning his application." When asked if he currently sees patients at the hospital, she replied, "Yes."

Based on observation, review of policies, documents and logs, and interview it was determined that the facility failed to ensure that their Infection Control Officer was trained in infection control, that there was an Infection Control Committee as required in the Medical Staff By-Laws, and that cleaning of clinical surfaces, handling of linen and cleaning of toys were adhered to according to policy and appropriate infection control standards.

The findings include:

1 Cross-reference to 748 and 749.

Based on review of twelve physician credential files and interview with the Director of Credentialing and the Chief Executive Officer (CEO), it was determined that twelve of the twelve physicians reviewed, had no delineation of privileges as required by the Governing Body By-Laws. The facility also failed to ensure that all physicians currently practicing at this facility had a current medical staff appointment or re-appointment. and that one of the twelve physician's reviewed, who was currently practicing at the facility, was overdue in his reappointment.

The findings include:

1. The Governing Body By-Laws read, "6.8 Medical Care Recommendations. The Medical Staff, through its appropriate committees, shall make recommendation to the Authority regarding the medical care provided by Medical Staff members including (1) appointments, reappointments, and other changes in the Medical Staff status, (2) the scope of clinical privileges to be granted,"

2. Review of twelve physician credential files revealed that in twelve of the twelve files reviewed, there was no written evidence of delineation of privileges. For one physician reviewed, his reappointment had expired on January 27, 2012.

3. In a March 7, 2012, afternoon interview with the Director of Credentialing and the CEO, both confirmed that they were not aware that a delineation of privileges was required. In reference to the physician whose reappointment had expired, the Director of Credentialing said, "He is late getting his application back." When asked if he is currently active seeing patients at the hospital, she replied, "Yes he is."

Based on observation of two patients receiving hemodialysis, interview with the two dialysis contract nurses, and review of dialysis documents, the contracted dialysis service staff failed to ensure that appropriate water checks for chlorine/chloramine levels were performed prior to the initiation of hemodialysis, and failed to ensure that the strips for total chlorine testing were within the acceptable date for use. The on-site dialysis RN lacked awareness that she needed to supervise the dialysis LPN who was working with her, thus failing to fulfill the requirements of the dialysis contract.

The findings include:

1. The contract for hemodialysis services at this facility, dated August 1, 2002, reads, "4. Staff, 4.2 Treatment. Whenever patients are receiving services, -----(contractor's name) shall provide on duty at least one (1) nurse currently licensed in the State of Virginia and experienced in rendering Services (the 'Registered Nurse') to oversee the provision of Services and such additional Staff to maintain an appropriate patient/staff ratio."

2. During a March 7, 2012, 11.00 AM observation of hemodialysis in room 205, accompanied by the Chief Executive Officer (CEO), the patient was receiving hemodialysis treatment through a femoral catheter. During interview with the Licensed Practical Nurse (LPN) who was performing the hemodialysis, the surveyor asked what water tests she performed prior to starting the dialysis. She replied, "I check the conductivity and the PH", and showed the surveyor the conductivity meter. Then the surveyor asked about chlorine/chloramine testing and the LPN replied, "I use the residual chlorine test strips to check for chlorine after the machine has been bleached." The LPN showed the surveyor two bottles of test strips, one for residual chlorine, and one for total chlorine (chlorine/chloramines), and said she used only the one for residual chlorine to test the water prior to dialysis. The bottle of total chlorine strips had an expiration date of 12/2011. The surveyor then asked to see documentation of the nurse's water checks that she had performed prior to starting this patient's dialysis that day. The LPN showed the surveyor a water check sheet which contained request for chlorine/chlorine testing along with other test results, and there was nothing documented for March 7, 2012.

3. The surveyor and CEO then went to room 210, where the contract Registered Nurse (RN) was preparing the dialysis machine to begin dialysis for another patient. The surveyor asked the RN to explain her dialysis set-up procedure, including water checks. She explained the machine set-up, and said she did chlorine/chloramine testing prior to dialysis. The RN showed the surveyor the total chlorine strips she used. This bottle of test strips was expired, as of 01/2012. When asked about supervision of the LPN who was working with her, the RN replied that she did not supervise her. She said, "I don't supervise her because she was trained the same as I was."

Based on observation, interview and review of water documents, it was determined that the dialysis services provided by the contractor, failed to ensure water testing safety measures, and failed to provide supervision to their on-site staff.

The findings include:

1. Cross-reference to 0083.

Based on staff interview and review of the facility's quality improvement program the facility failed to document their data collection.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify how they were collecting data for the acute hospital.

Based on staff interview and review of the facility's quality improvement program the facility failed to identify the activities of the quality improvement program.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify what activities the quality improvement program was working on.

Based on staff interview and review of the facility's quality improvement program the facility failed to track medical errors and adverse patient events.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify medical errors and adverse patient events in the acute hospital.

Based on staff interview and review of the facility's quality improvement program the facility failed to conduct performance improvement project(s) in the hospital.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify how the hospital was conducting performance improvement projects in the acute hospital.

Based on staff interview and review of the facility's quality improvement program the governing body, medical staff and administrative staff for the facility failed to ensure an ongoing program for quality improvement was defined, implemented, and maintained for the hospital.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify how the hospital's governing body, medical staff and administrative staff were responsible for the ongoing program for quality improvement and how it was defined, implemented, and maintained in the acute hospital.

Based on staff interview and review of the facility's quality improvement program the governing body, medical staff and administrative staff for the facility failed to ensure an ongoing program for quality improvement was defined, implemented, and maintained in the hospital.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify how the hospital's governing body, medical staff and administrative staff were responsible for the ongoing program for quality improvement and how it was defined, implemented, and maintained in the acute hospital.

Based on review of the Governing Body By-Laws and the Medical Staff By-Laws, and review of twelve physician credential files, it was determined the Governing Body failed to ensure that all physicians were reappointed every two years.

The findings include:

1. The Governing Body By-Laws read, "Reappointment to the Medical Staff shall be for periods of two (2) years, and be based upon the applicant's professional performance, current competence, ethical qualifications, absence of disruptive behavior, judgement, health status, and when appropriate technical skills."

2. Review of twelve physician credential files revealed that the reappointment of one of the twelve physicians reviewed had expired in January 2012. There was no paperwork in evidence for reappointment.

3. In an afternoon interview with the CEO and Director of Credentialing, on March 7, 2012, the Director of Credentialing stated, "This physician is late with submitting his application." When asked if he is currently active in caring for patients at the hospital, she replied, "Yes."

Based on review of twelve physician credential files and interview with the CEO and Director of Credentialing, the facility staff failed to ensure that all physicians practicing at the hospital had a current appointment or reappointment and clinical privileges.

The findings include:

1. Cross-reference to 338 and 340.

Based on review of twelve physician credential files and interview with the CEO and the Director of Credentialing, the facility failed to ensure that the medical staff had written duties and scope of medical staff privileges for each category of practitioner.

The findings include:

1. Based on review of twelve physician credential files, there was no written evidence of delineation of clinical privileges for the practitioners.

2. In a March 7, 2012, afternoon interview with the CEO and Director of Credentialing, both confirmed that they were unaware that clinical privileges with scope of practice for this hospital were required.

3. Cross-reference to 338, 340 and 341.

Based on observation, staff interview, review of the facility Medication Room/Cart Inspection forms, review of the facility Medication Cart Audit forms and facility policy review the facility failed to ensure medications repackaged by the pharmacist were labeled with the date the medication would expire and the lot number from which the stock medications were removed from, medication were labeled on the box as well as the bottle within the box, medications having been discontinued were no longer available for use and medications for a discharged patient were no longer available for use.

The Findings Include:

On 3/6/12 during the initial tour of the facility the "A" medication cart was inspected. The medication cart contained the following items:
1 a brown plastic pharmacy dispensing container labeled with: patient name, Topiramate 15 mg (milligrams), filled 4/2/11. It did not contain information related to when the medication would expire or what lot number the capsules was a part of.

2 brown plastic pharmacy dispensing container bottles labeled with patient name, calcium carbonate 1250 mg/5 ml (milliliters), dated filled (2/5/12), both bottles also had a 3 digit number with a dot between the first and second number and another number ending in a letter. These 2 numbers did not indicate what their significance was.

1 container with patient name, Constulose 10 G (grams)/15 ml filled on 1/9/11 and expired on 2/12 had been discontinued and remained in the cart available for use.
1 container with patient name, sulfamethoxazole 200-400 mg/5 ml, 10 ml twice a day for 7 days until 10/26/11, filled on 10/9/11. Employee #4 stated, "Both of those have been discontinued." Both medications remained in the cart available for use.

2 boxes opened labeled with patient name, one box Poly-vitamin with iron with fluoride 0.5 mg/ml filled on 4/2/11 and one box simethicon oral suspension 20 mg/0.3 ml filled on 1/4/12 neither bottle within the boxes had a patient name or instructions for administering on the bottle.
1 bottle (not in a box) of Poly-vitamin with iron had no label on the bottle as to which patient it was for or instructions for administering .

1 stick of silver nitrate was found in "A" cart and the remainder of the medications for this patient were in another cart. The silver nitrate had patient name, apply for 2 days, filled on 5/22/11 was available for use. Employee #4 stated, "Oh, that belongs in another cart and it has been discontinued."

In a syringe drawer of medication cart "A" the following capsules/tablets were found in blister packs some of which were partially opened but non contained a patient name of instructions for administering the medications: three 12.5 mg hydrochlorothazide capsules, three spironolactone 12.5 mg tablets, one of which was broken in half and one Prevacid 15 mg capsule.

Liquid items were found stored in plastic bottles with administering syringes in the bags. The inside and some of the outside of the bags were sticky.

There were multiple medications carts observed on the various units.

The Medication Room/Cart Inspection form, completed by a pharmacy tech did not indicate which cart was inspected only the unit. The form contains a section titled A. Medication Room/Cart which has 13 items to be reviewed. Number 13 ask "Spoons stored to ensure proper infection control when handling them." On all forms it is marked N/A (not applicable). The facility uses syringes to give oral medications to pediatric patients not spoons.

The section titled B. Medications has 10 items to be reviewed. On all the forms this is marked N/A with a note stating "not checked by pharmacy checked by (initials of facility) staff."

23 Medication Cart Audit forms, completed by the facility staff were reviewed, 9 of the forms indicated which medication cart was audited and 5 of the forms listed 2 carts reviewed on the same cart. If deficiencies were noted it did not indicate which cart had the deficiencies. The dates of the Medication Cart Audit forms did not correlate with the dates of the the Medication Room/Cart Inspection form.

An interview with the facility pharmacist was conducted on 3/7/12. The pharmacist stated, "Monthly inspections are conducted by a pharmacy extender which is a pharmacy tech. The pharmacy tech does not open drawers and inspect the drawers. On a quarterly basis a medication pass is observed by an LPN (licensed practical nurse). The LPN does not inspect the cart. The cart is inspected by the facility staff."

The pharmacist also stated, "All boxes and bottles should have a label on them to indicate which patient they belong to and should the bottle and box become separated it would still be labeled. It is the responsibility of the facility to dispose of medications of discharged patients that has been opened and accessed."

The facility's policy on Medication Administration was provided by the Vice President of Patient Services and was reviewed on 3/7/12.

Based on interview with the Infection Control Officer and the Vice President of Patient Services, it was determined that neither the Infection Control Officer or the Vice President of Patient Services was trained in Infection Control.

The findings include:

1. In a March 8, 2012, afternoon interview with the Infection Control Officer and the Vice President of Patient Services, both reported that they had not been trained in Infection Control.

2. In the above mentioned interview, the Infection Control Officer said she had responsibilities for Quality Assessment and Performance Improvement as well as Infection Control for both the 193 bed skilled nursing facility as well as this 104 bed long term acute care (LTAC) hospital.

Based on observation, review of policies and interview with the Infection Control Officer, Director of Rehabilitation and a Certified Nursing Assistant (CNA), it was determined that the facility failed to adhere to cleaning policies and lacked policies for which toys are appropriate to be shared and the cleaning procedure for them. Also, the scope of the infection control surveillance process with patients was not delineated in a plan or practice.

The findings include:

1. During a March 8, 2012 afternoon interview with the Infection Control Officer, and the Vice President of Patient Services, they reported that the hospital's surveillance for infection control with inpatients was targeted, but they lacked documentation and data of which patient diagnoses or medical devices were targeted and the outcomes.

2. During tour of the Pediatric Unit on 2 West on March 6, 2012, accompanied by the Director of Nursing, several stuffed toys were observed that did not belong to a specific child. One was sitting on a shelf that was easily accessible, and it was somewhat soiled. Another stuffed bear was observed laying on a wire basket full of "clean" clothes. In interview with the CNA on the unit, she said the bear belonged to a child who had been discharged several weeks earlier, and when asked about the clothes, she said the clothes belonged to several children and they were mixed together.

3. During an afternoon tour of the Rehabilitation Gymnasium on March 6, 2012, patients were observed receiving therapy treatments on mat tables. The surveyor asked the Director of Rehabilitation how often the tables and pillows were cleaned. She said the tables were cleaned 2-3 times a day with approved sanitizing wipes. She said the pillows were not wiped with the sanitizer, but they changed pillow cases between patients. Stacks of "clean" linen were observed laying on mat tables after a patient had left, and the table had not been disinfected.

4. The Cleaning and Disinfecting policy, revised 09/01/10, reads, "1.3 Non-critical items are objects that do not come into contact with mucus membranes, but do come into contact with intact skin. These items require cleaning between patient use. 4. Perform routine disinfection of items used in daily care practices. 4.2 Multi use equipment must also be cleaned/disinfected between patients. The Linen Handling policy dated 09/01/04 reads, "Maintain clean linen in a closed storage area. 1.1 Keep clean linen covered. 2. Transport clean linen in covered carts or bags."

5. During the above mentioned tour of the Rehabilitation Department, the hydrocollator was observed and the water was cloudy. There was a manufacture label on the hydrocollator lid that stated the temperature of the water should be no higher than 165 degrees F. Review of the hydrocollator logs revealed that neither the temperature of the hydrocollator or cleaning of it had been recorded at all in 2012. The 2011 log revealed that the temperature of the hydrocollator ranged from 153 to 177 degrees F. There were no written parameters on the log sheet. The log sheet for 2011 revealed that the hydrocollator was cleaned 1 time per month and the temperature was documented 1 time per month.

6. Review of the policy for Application of Superficial Moist Heat dated 07/15/2009, reads: "3. The hydrocollator unit should be maintained according to manufacturer guidelines." The Chattanooga Group User Manual reads: "Maintenance: The tank should also be drained and cleaned systematically at minimum intervals of every two weeks. 6. Regularly clean and drain the tank every two weeks. Failure to properly maintain the unit will cause premature wear and will void the warranty." The Safety Precautions of this user manual reads: "Never adjust the thermostat too high. The thermostat is extremely sensitive and the slightest adjustment will alter the temperature several degrees. The recommended operating temperature is 160 degrees F to 165 degrees F."

7. During the March 6, 2012 morning and afternoon tours of the patient care areas, the surveyors noted tape on a number of pieces of equipment. One Medicine Cart had big pieces of tape on it holding s broken plastic shield together. IV poles were noted to have tape on them, even though they were in the clean equipment room. In the shower room on the third floor there were two containers for soiled diapers which should have been housed in the soiled utility room.

Based on staff interview and review of the facility's quality improvement program the facility failed to document what the scope of their program was.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify the scope of the quality program for the acute hospital.

Based on staff interview and review of the facility's quality improvement program the facility failed to document evidence that would improve health.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify specific ongoing programs that would show measurable improvement(s) that would improve health outcomes within the hospital.

Based on staff interview and review of the facility's quality improvement program the facility failed to identify and reduce medical errors.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify and show reduction of medical errors for the acute hospital.

Based on staff interview and review of the facility's quality improvement program the facility failed to measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital services and operations.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify how they were measuring, analyzing, and tracking quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital services and operations for the acute hospital.

Based on staff interview and review of the facility's quality improvement program the facility failed to document their data collection.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify how they were collecting data for the acute hospital and submitting the data to the Quality Improvement Program.

Based on staff interview and review of the facility's quality improvement program the facility failed to document their data collection which would allow them to monitor the effectiveness and safety of services and quality of care.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify how they were collecting data and monitoring its effectiveness for the acute hospital.

Based on staff interview and review of the facility's quality improvement program the facility failed to document their data collection which would allow them to identify opportunities for improvement and changes that would lead to improvement.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify how they were collecting data for the acute hospital to show opportunities for improvement.

Based on staff interview and review of the facility's quality improvement program the facility failed to ensure the governing body specified the frequency and detail of their data collection.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify how governing body specified the frequency and detail of data collection.

Based on staff interview and review of the facility's quality improvement program the facility failed to set priorities that focused on high-risk, high-volume or problem-prone areas.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify how the priorities set for its performance improvement activities that could affect health outcomes, patient safety and quality of care.

Based on staff interview and review of the facility's quality improvement program the facility failed to track medical errors and adverse patient events and analyze their cause.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify medical errors and adverse patient events and analyze their cause in the acute hospital.

Based on staff interview and review of the facility's quality improvement program the facility failed to track medical errors and adverse patient events, analyze their cause and implement preventive actions and mechanisms that include feedback and learning throughout the hospital.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify medical errors and adverse patient events, analyze their cause and implement preventive actions and mechanisms that include feedback and learning throughout the acute hospital.

Based on staff interview and review of the facility's quality improvement program the facility failed to take action aimed at performance improvement in the hospital.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify how the hospital would take actions aimed at performance improvement in the acute hospital.

Based on staff interview and review of the facility's quality improvement program the facility failed to take action aimed at performance improvement in the hospital and then measure the success of the hospital.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify how the hospital would take actions aimed at performance improvement and measure the success in the acute hospital.

Based on staff interview and review of the facility's quality improvement program the facility failed to take action aimed at performance improvement in the hospital, then measure the success and track performance to ensure the improvements were sustained within the hospital.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify how the hospital would take actions aimed at performance improvement, measure the success and track the performance to ensure the improvments were sustained in the acute hospital.

Based on staff interview and review of the facility's quality improvement program the facility failed to conduct performance improvement project(s) in the hospital that was proportioned to the scope and complexity of the services the hospital offered.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify how the hospital was conducting performance improvement projects relevant to the scope and complexity in the acute hospital.

Based on staff interview and review of the facility's quality improvement program the facility failed to document what quality improvement projects they are conducting.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify specific programs the hospital was conducting.

Based on staff interview and review of the facility's quality improvement program the facility failed to document what quality improvement projects they are conducting and what reason they choose the projects.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify specific quality programs the hospital was conducting and the reasons they choose the programs.

Based on staff interview and review of the facility's quality improvement program the facility failed to document what quality improvement projects were being conducted, the reasons for conducting these projects and the measurable progress achieved on these projects in the hospital.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify how the hospital had documented what quality improvement projects were being conducted, the reasons for conducting these projects and the measurable progress achieved on these projects in the acute hospital.

Based on staff interview and review of the facility's quality improvement program the facility failed to document what quality improvement projects were being conducted, the reasons for conducting these projects and the measurable progress achieved on these projects in the hospital.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify how the hospital had documented what quality improvement projects were being conducted, the reasons for conducting these projects and the measurable progress achieved on these projects in the acute hospital.

Based on staff interview and review of the facility's quality improvement program the governing body, medical staff and administrative staff for the facility failed to ensure an ongoing program for quality improvement was defined, implemented, and maintained in the hospital.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify how the hospital's governing body, medical staff and administrative staff were responsible for the ongoing program for quality improvement and how it was defined, implemented, and maintained in the acute hospital.

Based on staff interview and review of the facility's quality improvement program the governing body, medical staff and administrative staff for the facility failed to ensure an ongoing program for quality improvement was defined, implemented, and maintained including patient safety and medical errors in the hospital.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify how the hospital's governing body, medical staff and administrative staff were responsible for the ongoing program for quality improvement and how it was defined, implemented, and maintained in the acute hospital.

Based on staff interview and review of the facility's quality improvement program the facility staff failed to ensure the hospital wide quality assessment and performance improvement efforts addressed priorities for improved quality of care and that all improvements were evaluated in the hospital.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify how hospital wide quality assessment and performance improvement efforts addressed priorities for improved quality of care and that all improvements were evaluated in the acute hospital.

Based on staff interview and review of the facility's quality improvement program the facility staff failed to ensure the hospital wide quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient saftey and that all improvements were evaluated in the hospital.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify how hospital wide quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety and that all improvements were evaluated in the acute hospital.

Based on staff interview and review of the facility's quality improvement program the governing body, medical staff and administrative staff for the facility failed to ensure an ongoing program for that clear expectations for safety are established.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify how the hospital's governing body, medical staff and administrative staff were responsible for the ongoing program for quality improvement and how it was defined, implemented, and maintained in the acute hospital. They could not identify how clear expectations for safety are established.

Based on staff interview and review of the facility's quality improvement program the facility staff failed to ensure the hospital wide quality assessment and performance improvement efforts had adequate resources allocated for reducing risk to patients in the hospital.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify how adequate resources were allocated for reducing risk to patient care in the acute hospital.

Based on staff interview and review of the facility's quality improvement program the facility staff failed to determine the number of distinct improvement projects was conducted annually in the hospital.

The Findings Include:

On 3/8/12 an interview was conducted with the person designated as the Director of Quality (DOQ) and the Vice President of Patient Services (VPPS) regarding the quality program. The DOQ stated, "We don't have a separate program. The acute hospital and the nursing home program is all together."

The DOQ and the VPPS could not identify the number of distinct improvement projects conducted annually in the acute hospital.