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Based on interview, record review and policy review, the facility failed to implement and maintain an effective, ongoing, hospital-wide, data driven Quality Assurance/Performance Improvement (PI) program. The Governing Body failed to ensure that the program involved all departments of the hospital's organization and to focus on indicators which could reduce medical errors and improve patient care. This affects the quality of care for all patient services. The facility census was seven.

See the following citations:

A275 regarding failure of the facility to include infection control data as part of the quality assurance program to improve patients' quality of care.

A276 regarding failure of the facility to ensure relevant and correct data was collected and evaluated to identify opportunities for improvement and changes leading to improvement for the departments of radiology, physical therapy, contracted services and the Behavioral Health Unit.

A285 regarding failure of the facility to assess the departments of radiology, physical therapy, contracted services and pharmacy for high volume or problem prone areas and to consider the potential severity of problems in the departments which affect patient safety as part of the quality assurance process.

A310 regarding failure of the Governing Body, Medical Staff, and leadership to ensure an ongoing program for quality improvement is implemented and maintained for all departments of the hospital.

A315 regarding failure of the Governing Body, Medical Staff, and leadership to ensure the department of Pharmacy had adequate resources to assess and improve services as part of a quality assurance program.

The cumulative effect of this systemic practice resulted in the facility's non-compliance with 42 CFR (Code of Federal Regulations) 482.21 Condition of Participation: Quality Assessment and Performance Improvement Program.

Based on interview and policy review, the facility's governing body failed to delegate the responsibility of the grievance process to a grievance committee rather than one individual. The facility census was seven.

Findings included:

Record review of the facility's policy titled "Patient Complaints and Grievances," dated 12/2010, showed the Quality Management Department had been designated as the coordinator of the complaint/grievance process by the Board of Trustees. However, during an interview on 04/14/11 at 3:50 PM, Staff C, Director Quality Assurance and Risk Management, stated that the Quality Management Department consisted of only one person and that one person was Staff C.

Based on interview and policy review, the facility failed to ensure physicians had training regarding hospital policies related to restraint and seclusion. The facility census was seven.

Findings included:

1. Record review of the facility policy titled"Restraint and Seclusion R/S (Physical and/or Drug)", dated 05/2010, showed training for the physicians was through the Medical Staff meeting as changes occur with the restraint and seclusion policy. This occurs after their initial orientation to the hospital's policy with specific emphasis on physician documentation and assessment of the patient.

2. During a telephone interview on 04/13/11 at 3:50 PM, Staff U, Medical Director Behavioral Health Unit, stated that the facility had not provided any training on restraint/seclusion to physicians. Staff U stated that his/her restraint/seclusion knowledge is from experience and training received in other facilities.

3. During an interview on 04/14/11 at 1:05 PM, Staff B, Director of Nursing, stated that the physician training was discussed in the policy, but the facility had not implemented training as per the facility policy.

Based on interview and record review, the facility failed to implement first aid training related to incidents and nursing care required while the patient is restrained or in seclusion (e.g., a patient choking on food while restrained, or a patient who needs to toilet while in seclusion, etc.). The facility census was seven.

Findings included:

1. Record review of the facility booklet titled "The CMS Restraint Training Requirements Handbook," dated 06/2007, showed no staff education for first aid techniques related to incidents and nursing care while the patient was in restraints or seclusion.

2. During an interview on 04/14/11 at 1:05 PM, Staff B, Director of Nursing, stated that staff did not receive any first aid training or education related to restraints and seclusion.

Based on interview, policy review, and review of quality improvement data, the Governing Body, Medical Staff, and other leadership failed to ensure the Pharmacy Department had enough staff to sustain their quality improvement program. Without an on-going quality improvement program the Pharmacy cannot identify problems with medication errors and adverse drug reactions. This can adversely affect the quality of care for all patients in the facility. The facility census was seven.

Findings included:

1. Review of the facility policy titled "Plan of Care" revised 01/11 showed:
- The hospital organizational structure is an integration of all hospital departments. Each department functions as a key element within the organization and is comprised of professional and non-professional staff directly and indirectly responsible for providing care and services to patient and other users of the organization's services.

- The Administrative Team, consists of the Administrator, the Chief Financial Officer, Director of Nursing, Quality/Risk management Director, Director of Patient Services, Director of Pharmacy, ER Supervisor, Director of Ancillary Services, Director of Therapy, Director of Behavior Health, Director of Home Health, and Clinic Administrator which are responsible to the governing board.
- The department managers collaborate with the staff to coordinate, implement and evaluate a delivery of care for a variety of services including, but not limited to medical and/or clinical health care, surgical care, geriatric care, emergency response and treatment, outpatient diagnostic, cardiopulmonary, physical therapy, home health, behavior health and radiology.

2. Review of the Pharmacy Department performance improvement data showed the department collected data from January 2010 through October 2010. There is no evidence of any data collection after October 2010.

During an interview on 04/13/11 at 3:00 PM, Staff S, Director of Pharmacy, stated that he/she has been at the facility for approximately three weeks and is unfamiliar with the quality improvement process in the pharmacy. Staff S stated the person who knows about the Pharmacy quality improvement program is out on an extended sick leave. Staff S stated that with staff turnover he/she felt the Pharmacy quality improvement program was put on hold several months ago.

During an interview on 04/15/11 at 10:30 AM, Staff C, Quality Assurance Coordinator stated that the Pharmacy Department has not reported any data since 09/10. Staff C stated that a couple of months ago the pharmacy technician, who is out on sick leave, stated that he/she didn't have the time to collect data for the quality improvement program due to a staffing shortage. Staff C stated that he/she spoke with the pharmacist about the lack of data collection and pharmacy staff not having the time to collect the data for an on-going performance improvement program. Staff C stated he/she did not report the lack of data collection by Pharmacy to the Medical Staff.

Based on interveiw, review of the organizational chart, and review of the contracted service, the facility failed to ensure all nursing service is under the direction of one registered nurse since the nurse manager on the psychiatric unit does not report to the hospital's director of nursing. The facility census was seven.

Findings included:

1. Review of the facility organizational chart revised 12/13/10 showed Staff N, Nurse Manager Behavioral Health, reports directly to the Administrator. The organization chart does not show Staff N reporting to the Director of Nursing.

2. During an interview on 04/13/11 at 1:45 PM, Staff B, Director of Nursing, stated that the Nurse Manager for Behavioral Health does not report to him/her, but directly to the Administrator. Staff B stated that the Behavioral Health Nurse Manager has directly reported to the Administrator since the Behavioral Health Unit opened on 01/01/11.

3. During an interview on 04/13/11 at 3:45 PM, Staff N, Nurse Manager for the Behavioral Health Unit, stated that he/she does not report to the Director of Nursing and hasn't since the unit opened on 01/01/11. Staff N stated that he/she reports to the facility Administrator and to a vice president with the contracted company.

4. Record review of the Service Agreement dated 07/27/10 between the facility and the contracted company managing the Behavioral Health Unit showed the Nurse Manager of the Behavioral Health Unit shall be responsible to the appropriate member of the Hospital administration staff and shall function in a departmental head capacity. The Nurse Manager shall comply with all reporting requirements of the Hospital administration and shall be accountable to the Hospital administration in the same manner as any department of the Hospital.

Based on interview, record and policy review, the facility failed to ensure verbal and telephone orders on the tele-psychiatry Behavioral Health Unit are used infrequently and are not a common practice for six
(#6, #16, #17, #18, #11 and #12) of six Behavioral Health records reviewed. The facility census was seven and the Behavioral Health Unit census was one.

Findings included:

1. Record review of the facility's policy titled "Physician Responsibilities", dated 01/01/11, showed: following the individual patient session, the attending Psychiatrist, viewing the patient via telemedicine communication (not an onsite visit), will fax new MD (medical doctor) orders, MD certification or recertification form, if applicable and updated treatment plans or reviews. A psychiatrist is onsite only every other weekend.

Record review of facility's policy titled "Medication Policies (Proper Administration Method for Nursing)", dated 04/2011, showed direction for facility staff that verbal orders are to be limited to non-existent. Nurses should request that doctors write or place as a computer physician order any patient orders needed. When an emergency occurs such as a code, verbal orders can be received from the physician.

2. Review of the physician's orders for current Patient #6 showed 19 out of 22 physician's orders to be telephone orders.

3. Review of the physician's orders for discharged Patient #16 showed 13 out of 17 physician's orders to be telephone or verbal orders.

4. Review of the physician's orders for discharged Patient #17 showed four out of six physician's orders to be telephone or verbal orders.

5. Review of the physician's orders for discharged Patient #18 showed seven out of 12 physician's orders to be telephone or verbal orders.


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6. Review of discharged Patient #11's physician's orders showed 11 out of 11 physician's orders to be telephone or verbal orders.

7. Review of discharged Patient #12's physician's orders showed five out of 14 physician's orders to be telephone or verbal orders.

8. During an interview on 04/13/11 at 3:50 PM, Staff U, Psychiatrist, stated that he/she dictates the patient orders to the nurse in the room during the tele-psychiatry session. Staff U stated that the nurse writes the orders and faxes them to him/her for signature and that Staff U faxes the signed orders back to the nurse. Staff U stated that he/she could write the orders during or immediately after the tele-psychiatry session and fax them to the facility.

Based on record review, policy review and review of the Medical Staff Rules and Regulations, the facility failed to ensure all entries in the medical record are dated and timed for five patients (#6, #16,#17, #11 and #12) of 22 records reviewed. The facility census was seven.

Findings included:

1. Record review of the Medical Staff Rules and Regulations, revised 12/10, showed that all clinical entries in the patient's medical record shall be accurately dated and authenticated.

Record review of the facility's policy titled "Physician Responsibilities," dated 2009, showed direction for facility staff that all medical records include date, time, and signature.

2. Record review of the history and physical for current Patient #6 showed the patient was admitted on 04/08/11 for treatment of depression. Review of a cranial nerves (12 pair of nerves that emerge directly from the brain) assessment dated 04/8/11 showed the physician signed the assessment, but failed to time the entry.

Record review of the progress notes for current Patient #6 showed Staff GG, LCSW (Licensed Clinical Social Worker), co-signed the review of the other social worker's entries in order to evaluate the services offered by the Social Services Department. Staff GG signed, but did not date and time the entries dated 04/12/11 and 04/13/11.

3. Record review of the progress notes for discharged Patient #16 showed Staff GG co-signed the review of the other social worker's entries in order to evaluate the services offered by the Social Services Department. Staff GG signed, but did not date and time the entries dated 02/28/11, 03/01/11, 03/02/11 and 03/07/11.

4. Record review of the progress notes for discharged Patient #17 showed Staff GG co-signed the review of the other social worker's entries in order to evaluate the services offered by the Social Services Department. Staff GG signed, but did not date and time the entries dated 02/07/11, 02/08/11 and 02/10/11.





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5. Review of discharged Patient #11's progress notes showed Staff GG co-signed the review of the other social worker's entries, but failed to date and time entries on 02/25/11, 02/28/11, 03/01/11, 03/02/11, 03/07/11, and 03/08/11.

6. Review of discharged Patient #12's progress notes showed Staff GG co-signed the review of the other social worker's entries, but failed to date and time entries on 12/20/10, 12/21/10, 12/22/10 12/23/10, 12/24/11, and 12/27/11.

7. During an interview on 04/13/11 at 10:55 AM and 11:05 AM, Staff N, Nurse Manager, Behavioral Health Unit, confirmed that the entries of a co-signature by Staff GG were not dated or timed.

Based on interview, record review, and facility policy review, the facility failed to ensure physician orders were authenticated (signed, dated, and timed) for two patients (#3 and #5) of 22 records reviewed. The facility census was seven.

Findings included:

1. Review of the facility policy titled "Medication Policies (Proper Administration Method for Nursing)", revised 04/11, showed the following direction:
-Written Orders: Physician orders should be legible, timed, dated and authenticated (at the time the order is written or within 48 hours after a verbal has been given).

2. Review of Patient #3's current medical record showed the following physician's orders were not timed:

-On 04/11/11 telemetry with pulse ox (measures oxygen level), oxygen to keep saturation levels at 92% and EKG (electrocardiogram-measures electrical activity of the heart) on 04/12/11.

3. Review of Patient #5's current medical record showed the following physician's orders were not timed:

-On 04/11/11 discontinue nebulizer treatments, ventolin inhaler (used for breathing difficulty), two puffs four times a day as needed and advair 100/50 inhaler (used for breathing difficulty), one puff two times a day.

-On 04/11/11 may have regular coffee, nicorette patch (patch to help stop smoking), ativan (anxiety medication) 0.5 mg orally two times a day as need for anxiety, discontinue intravenous, Methicillin-resistant Staphylococcus aureus (MRSA) precautions.

During an interview on 04/12/11 at 2:35 PM, Staff B, Director of Nursing, confirmed the physician had not timed his/her orders for Patient's #3 and #5 and stated all physician orders should be timed.

4. See also the deficiency at A0457 regarding the facility's failure to ensure all telephone/verbal orders were signed, dated and timed by the physician for six (#6, #16, #17, #18, #11 and #12) of 22 records reviewed.

Based on interview, record and policy review, the facility failed to ensure all telephone/verbal orders were signed, dated and timed by the physician for six (#6, #16, #17, #18, #11 and #12) of 22 records reviewed. The facility census was seven.

Dating and timing of entries in the patient's medical record is a patient safety measure to ensure timely care and services.

Findings included:

1. Record review of the facility's policy titled "Physician Responsibilities," dated 2009, showed direction for facility staff that all medical records include date, time, and signature.

2. Record review of the undated facility policy titled "Medical Record Guideline for Physicians" showed direction for facility physicians that all medical record entries must be timed, dated, and authenticated (signed).

3. Record review on 04/14/11 of the physician orders for current Patient #6 showed the following telephone orders:
04/10/11 at 12:40 PM - Klonopin (used to treat anxiety) 0.5 mg PO BID
Lorazepam (used to treat anxiety) 0.5 mg PO BID
Lorazepam 0.5 mg PO every 6 hours prn (as needed ) [for] severe anxiety
The physician's signature on the above orders lacks a date and time.

04/08/11 at 9:30 PM - Zyprexa (used to treat schizophrenia, mental disorder that makes it difficult to tell the difference between real and unreal experiences) 7.5 mg PO @ (at) bedtime
Klonopin 1 mg Q A.M. (every morning) 0.5 mg PO @2:00 PM and 2 mg at bedtime
The physician's signature on the above orders lacks a date and time.

4. Record review on 04/13/11 of the physician order for discharged Patient #16 showed the following telephone/ verbal orders:
03/01/11 at 9:15 AM - Lexapro 10 mg PO Q day (every day) in the AM (morning)
The physician's signature lacks a date and time.

03/04/11 at 8:30 AM - a verbal order for Risperdal 0.5mg PO TID
The physician's signature lacks a date and time.

03/05/11 at 9:30 AM - DC (discontinue) Epson salt soaks
The physician's signature lacks a date and time.

5. Record review on 04/13/11 of the physician order for discharged Patient #17 showed the following telephone/ verbal orders:
02/05/11 at 11:00 AM - Risperdal 0.25 mg PO TID
Ativan (used to relieve anxiety) 0.5 mg PO TID
Nemanda (used to treat the symptoms of Alzheimer's disease) 5 mg PO QHS (at bedtime)
Haldol 2 mg PO or IM Q4h (every four hours) prn for agitation
Ativan 0.5 mg PO or IM Q4h for agitation
The physician's signature lacks a date and time.

6. Record review on 04/13/11 of the physician order for discharged Patient #18 showed the following telephone/ verbal orders:
01/06/11 at 9:30 AM - a verbal order for an EKG now, obtain records fro (name of facility) previous EKG
01/07/11 at 11:40 AM - Mechanical soft diet
The physician's signature lacks a date and time.








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7. Record review on 04/12/11 at 2:50 PM, of physician's orders for current Patient #11 showed the following telephone orders:
-02/24/11 at 11:00 PM - Amoxil (an antibiotic) 250 mg PO (by mouth), TID (three times a day) for five days, and D/C (discontinue) PT/OT (physical therapy and occupational therapy). The physician's signature lacks a date and time.
-02/25/11 at 3:30 PM - DC Requip (A medication used to treat Parkinson's Disease) 1.5 mg(milligrams) every HS (hour of sleep). The physician's signature lacks a date and time.
-02/26/11 at 12:30 PM - Requip 1.5 mg PO at bedtime-if not available patient may take medication from home. The physician's signature lacks a date and time.
-03/02/11 at 8:45 AM - Requip 1 mg every AM, PO, and Requip 1.5 mg every HS, PO. The physician's signature lacks a date and time.
-03/02/11 at 8:50 AM - Increase Seroquel to 100 mg PO at HS. The physician's signature lacks a date and time.
-03/02/11 at 12:00 PM - BMP (lab test) today. The physician's signature lacks a date and time.
-03/02/11 at 3:00 PM - Saline nose spray, one spray to each nare (one nostril) BID (twice a day) and prn (as needed). The physician's signature lacks a date and time.
-03/03/11 at 1:30 PM - After patient has . . . not to exceed four doses. The physician's signature lacks a date and time.
-03/06/11 at 2:30 PM - Chloraseptic (An over the counter medication used to relieve pain of a sore throat.) spray every two hours prn for a sore throat. The physician's signature lacks a date and time.
-03/07/11 at 7:50 AM - Discharge to Rivermist Nursing Home. . . Fall Precautions. The physician's signature lacks a date and time.

8. Record review on 04/13/11 at 9:45 AM, of physician's orders for current Patient #12 showed the following telephone orders:
-12/18/10 at 9:00 PM - Toprol XL (A medication to treat high blood pressure) 50 mg PO every AM . . . PO every six hours prn pain. The physician's signature lacks a date and time.
-12/19/10 at 10:30 AM - Regular diet-chopped meats-yogurt -with breakfast. The physician's signature lacks a date and time.
-12/21/11 at 4:55 PM - for 1x now dose . . . with breakfast meal. The physician's order lacks a signature, date, and time.
-12/21/10 at 7:30 AM - Risperdal (A medication used to treat mental illnesses of Schizophrenia and Bipolar Disorder) . . . every day. The physician's signature lacks a date and time.
-12/22/10 at 10:35 AM - decrease Celexa (A medication used to treat the mental illness of Depression.) to 20 mg PO daily. The physician's signature lacks a date and time.
-12/27/10 at 4:40 PM - May discharge in AM . . . Chem. 14 and CBC (lab tests) on 12/29/10. The physician's signature lacks a date and time.
-12/28/10 at 8:50 AM - Toprol XL . . . discharge today on above medications. The physician's signature lacks a date or time.

9. During an interview on 04/13/11 at 10:55 AM and 11:05 AM, Staff N, Nurse Manager, Behavioral Health Unit, confirmed that the physician orders had not been dated or timed.

Based on interview, record and policy review, the facility failed to ensure staff obtained a properly executed informed consent prior to an outpatient procedure for three patients (#13, #14 and #15) of 22 records reviewed when the form was not signed by the patient or dated prior to the medical procedure. The facility census was seven.

Except in a medical emergency The informed consent form needs to be signed and dated prior to the medical procedure to ensure patient consent before it is performed since most procedures involve some risk to the patient.

Findings included:

1. Record review of the facility's policy titled "Consent for Procedures, Consent, Informed, and Implied", reviewed 05/10 did not direct staff on the minimum elements of an informed consent. The policy did not require the patient or the patient's legal representative to date and time their signature on the consent.

2. Review of Patient #13's discharged medical record showed a consent for excision (removal) of lesion on 04/7/11. The form included neither the date nor time of the patient's signature.

3. Review of Patient #14's discharged medical record showed a consent for an excision of two lesions on 03/10/11. The form included neither the date nor time of the patient's signature.

4. Review of Patient #15's discharged medical record showed a consent for excision of lesion on 03/10/11. The form included niether the date nor time of the patient's signature.

During an interview on 04/14/11 at 3:20 PM, Staff K, Medical Records Staff, stated the informed consent policy does not state the patient must date and time his/her signature. Staff K confirmed Patient's #13, #14 and #15 did not date and time their signature on the informed consent. Staff K stated that all signatures in the medical record should be dated and timed.

Based on observation, interview, policy and record review, the facility failed to ensure home medications ordered by the physician and brought into the facility by patients are verified by the pharmacist prior to administration of the medication for one patient (#2) of one home medication orders reviewed. The facility census was seven.

Review of home medications brought to the hospital is a patient safety concern, to ensure that the medication is the medication and dosage the physician has ordered, and that the medication has not been altered, substituted, or shows signs it may not be safe to take.

Findings included:

1. Record review of the facility policy titled "Patient Home Medications not on Hospital Formulary", reviewed 05/10, showed the following direction:
-Pharmacy requests that a list be made of home medications with pill counts of each medication that is taken by the patient, and that the Home Medications List is signed by the patient and the charge nurse. The medications are verified by the hospital Pharmacist prior to dispensation.

2. Observation on 04/14/11 at 6:15 AM showed Staff Y, Licensed Practical Nurse (LPN), tried to administer Patient #2's home medication Plaquenil (a medication used for arthritis). Patient #2 refused the medication. Patient #2 stated, "I take it with my breakfast."

Review of Patient #2's current medical record showed a Physician's Order dated 04/11/11 at 2:30 PM for Plaquenil 200 milligrams (mg).

Review of Patient #2's Medication Administration Record showed Plaquenil 200 mg administered on 04/14/11 at 8:01 AM and on 04/15/11 at 8:24 AM.

Review of Patient #2's Non-Formulary Home Medication list showed Patient #2's signature and the signature of the Registered Nurse. However, the Pharmacist Verification of Medications signature line was blank.

Interviews revealed:

-On 04/15/11 at 9:05 AM, Staff Z, LPN stated he/she did administer Patient #2's home medication Plaquenil this morning. Staff Z stated he/she did not review the Non-Formulary Home Medication list to see if the Pharmacist had verified the medications. Staff Z stated the medications were in the medication cart and thought that meant they had been verified.

-On 04/15/11 at 9:15 AM, Staff X, LPN stated he/she did administer Patient #2's home medication Plaquenil on the morning of 04/14/11. Staff X stated he/she did not check to see if the Pharmacist had verified the medication before administering the medication.

-On 04/15/11 at 10:30 AM, Staff S, Pharmacist stated he/she verified Patient #2's home medication Plaquenil this morning. Staff S stated the mediation was not verified prior to Staff X and Staff Z administering the medication to Patient #2 on 04/14/11 and 04/15/11.

Based on interview and review of meeting minutes, the facility failed to ensure the Director of Pharmacy is an active member of the Pharmacy and Therapeutics committee. The facility census was seven.

Findings included:

1. During an interview on 04/13/11 at 3:00 PM, Staff S, Director of Pharmacy, stated that he/she is the only facilty Pharmacist and although the Pharmacy and Therapeutic Committee is generally lead by the Pharmacist, he/she has not attended any Pharmacy and Therapeutic meetings since coming to the facility approximately three weeks ago. Staff S stated that he/she did not know when the last meeting was held and has no schedule for the next meeting. The facility employs only one pharmicist.

2. During an interview on 04/15/11 at 9:30 AM, Staff C, Quality Assurance Coordinator and Risk Manager, stated that there has not been a Pharmacy and Therapeutics committee meeting since October 2010 and no meeting is currently scheduled. Staff C stated that the meetings should be held on a monthly basis.

3. Review of the Pharmacy and Therapeutics committee meeting minutes showed the last documented minutes were dated October 2010. The Pharmacy and Therapeutics Committee meets periodically in order to establish and review the facility's medication formulary (list of medicines available at the hospital), establish and review policies for pharmacy and other areas of care, such as Medical Nutrition Therapy, therefore it is important that a Pharmicist actively participate in the committee.

Based on interview, record review and policy review, the facility failed to ensure the pharmacy quality improvement activities address high-risk, high-volume or problem prone areas, and failed to ensure the Director of Pharmacy is aware of medication errors and adverse drug reactions. These failures resulted in the facility's inability to assess if their medication error reporting system and their quality indicator data effectively identifies medication errors and adverse drug reactions. This has the potential to affect the safety and quality of care for all patients. The facility census was seven.

Findings included:

1. Record review of the facility's policy titled "Drug Distribution and Administration", revised 08/30/10, showed medication errors and adverse drug reactions shall be reported immediately to the practitioner who ordered the drug, the appropriate nursing supervisor and pharmacist (pharmacy).

Record review of the facility's policy titled "Adverse Drug Reactions", revised 05/10, showed an adverse drug reaction form should be completed and turned into the supervisor immediately. This form is to be reviewed by the DON (director of nursing), Pharmacy, Risk Management and Peer Review as indicated.

2. During an interview on 04/13/11 at 3:00 PM, Staff S, Director of Pharmacy, stated that he/she has been at the facility for approximately three weeks and is unaware of any medication errors and has no documentation of medication errors or adverse drug reactions. Staff S stated that he/she is unfamiliar with the quality improvement process in the pharmacy.

3. Review of a quality control process completed by nursing for 2010 showed a total of 18 medication errors. There is no evidence these medication errors were reported to the Director of Pharmacy.

4. Review of the Pharmacy Department performance improvement data showed data collected from January 2010 through October 2010. The data monitored by the Pharmacy Department included the following:

-Allergies documented on patient profiles, admission orders and patient face sheets;
-Physician's timing all written orders;
-Correct abbreviations;
-Time IV (into the vein) discontinued;
-Verbal orders;
-Medication administration record in the correct place in the medical
record; and
-Checking the time when a patient status changes from an observation patient to an in-patient.

However, review of the data collection showed no data related to medication errors, adverse medication reactions or high-risk areas.

Based on interview and record review, the facility failed to ensure that the Medical Director of the Radiology department provided supervision of the department by either onsite or offsite review of documents, evaluation of services provided to patients, and evaluation for safety of patients and personnel. The facility census was seven.

Findings included:

1. Record review of the agreement titled "Radiology System Access Agreement" and the credentialing file for Staff W, Medical Director of Radiology, showed that there were no specific definitions for the responsibilities of the Medical Director of Radiology other than interpretation of images. The Medical Staff Bylaws did not further define this position. Review of a memo to the personnel director indicated that the Medical Director of the radiology department was Staff W, Radiology Physician.

2. Review of an undated policy titled "job description/scope of practice" for radiology showed that for the radiology consultant (Staff W) the job duties will include, but not be limited to the following:
-Serve as director of radiology services of the hospital.
-Be responsible for implementing the rules of medical staff governing the quality scope of radiology services and safety precautions to protect patients and personnel.
-Participate in reviewing the quality control and quality improvement implemented in the radiology department.
-Verify the competency of technologists performing radiologic exams and review this competency annually.

3. Observation on 04/14/11 showed that the radiographic table was removed from the facility. This was the only permanent radiographic unit/room at the facility.

4. During an interview on 04/14/11 at 2:30 PM, Staff P, Radiology Technician and Supervisor, stated that recently the radiographic table had been out of service and images were obtained by a portable radiographic device. A new radiographic table was to be installed at the facility on May 9th. The facility does not provide fluoroscopic services and prior to the removal of the radiographic table the facility did not provide fluoroscopic services due to lack of an onsite radiologist. Staff P stated that the only quality assurance review done by the medical director was potentially the review of image quality when the medical director provided interpretations of images and this physician provided the majority of image interpretation. Staff P stated that the Medical Director of Radiology had not been onsite at the facility. Staff P stated that to his/her knowledge the medical director had not reviewed the policies and procedures of the department.

5. During an additional interview on 04/15/11 at 10:15 AM, Staff P stated that to his/her knowledge any safety reports or annual competency evaluations for the radiology staff or the dosimeter (measures exposure to radiation) badge reports for employees had not been reviewed by Staff W. Staff P was not aware how long Staff W had been medical director, but that Staff W had been the medical director since the facility had become aware of the need to have one.

6. Review of the quality assurance data provided to the quality assurance committee from the radiology department showed that the only data provided was the number of tests performed annually at the facility for computerized tomography (CT) examinations. This information is not an evaluation of the quality of services provided.

Based on interview and policy review, the facility Utilization Review plan failed to have detailed information regarding the qualifying stay admission criteria for the Behavior Health Unit. This had the potential to affect all patients in the Behavior Health Unit. The facility census was seven, and the census for the Behavior Health Unit was one.

Findings included:

1. Review of the policy, "Utilization Management Plan, Policy No. 100-01", revised 01/12/11, showed the following: "The initial review should determine if the patient is at the appropriate level of care to support current medical needs, and if the patient meets medical necessity for admission to acute care." The policy failed to show admission criteria for the Behavior Health Unit.

During an interview on 04/14/11 at 2:30 PM, Staff H, Director of Utilization Review/ Discharge Planning (UR/DC Plan), stated that the service of UR/DC Plan did not have admission criteria available for the new (open since December, 2010) Behavior Health Unit. Because the facility lacked a contract for outside Utilization Review, Staff H stated that he/she was the main person responsible to review each patient case and he/she was not sure if the patient(s) were appropriate for admission and care in the Behavior Health Unit.

Based on observation and interview, the facility:

- failed to ensure outdated and/or expired supplies were removed from the crash cart on the acute care unit. This had the potential to affect all patients needing immediate emergent care; and
- failed to ensure that hot water temperatures remained within a safe range for one patient room and one shower room utilized for patients.

The facility census was seven.

Findings included:

1. Observation on 04/12/11 at 10:05 AM showed the crash cart on the acute care unit contained four expired oral airways, two expired arterial blood gas sample kits and eight expired tracheal tubes.

During an interview on 04/12/11 at 10:05 AM, Staff B, Director of Nursing, stated that while nursing staff check the crash cart daily and ensures the supplies are on the cart, staff do not check the supplies for outdates. Staff B stated the Respiratory department should be checking the respiratory supplies for outdates.


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2. Record review of the facility policy titled "Domestic Water Temperature", dated 04/29/03, showed that water temperatures for hot water are to be recorded weekly on the water temperature control log. Review of the temperature control log showed that temperatures were recorded weekly (except for week prior to 04/13/11) and the documented temperatures were within a safe range.

3. Observation of temperatures taken by thermometer on 04/13/11 showed that at 11:13 AM, the water temperature in the hand wash sink of room 101 was 140 degrees Fahrenheit. The facility utilized one shower area for patient use and the water temperature of the shower was 132 degrees Fahrenheit. Room 101 was not occupied by a patient at the time of the temperature. The facility was informed of the water temperatures and adjusted the temperature of the main hot water supply. The temperature was again measured on 04/13/11 at 12:25 PM, and in room 101 the hand wash sink was 118 degrees Fahrenheit. The facility measured the temperatures of the hot water daily subsequent to the initial temperature reading and the hot water temperatures remained below 120 degrees Fahrenheit after the initial readings on 04/13/11.

Review of a document titled "guidelines for determining immediate jeopardy regarding hot water temperatures" showed that at at 131 degrees Fahrenheit injury can occur in 30 seconds. At 140 degrees Fahrenheit injury can occur in five seconds.

Based on observation, interview and record review, the facility

- failed to ensure that processes were in place to prevent contamination during the soiled linen and clean linen processing and for one ice machine.
- failed to perform hand hygiene during medication pass for one patient (#1) of five patients observed during medication administration, and
- failed to prevent cross contamination of wounds by changing gloves during wound care for two patients (#2 and #5) of two patients observed for wound care.

This had the potential to affect all patients. The facility census was seven.

Findings included:

1. Observation on 04/12/11 at 11:10 AM showed a laundry area with a single entrance/exit to the processing area. Soiled linen and clean linen entered and exited the area through the one doorway. Upon entry to the processing area which contained the washers and dryers the first machine was a washer (considered soiled processing), the second a dryer (considered clean linen) and a third machine was a washer (considered soiled) all in a row. A second dryer (considered clean linen) was approximately six feet away in the corner of the area. Therefore, to process the linens the washer and dryer locations all shared the same central space and staff would sort soiled and clean linens in this central area either before or after processing. The shared space prevented any separation between handling clean and soiled linen (considered soiled), potentially contaminating clean linens. Next to the dryer (within two feet) in the corner were six tubs (identified by red color for bio-hazardous) used for infectious waste storage. This area was noted to have one tub with infectious waste and five tubs which were empty and waiting to be filled.

During an interview on 04/12/11 at 1:45 PM, Staff V, Housekeeping Supervisor, and Staff B, Infection Control Nurse, stated that there were no housekeeping policies or infection control policies related to the handling of the linens and the separation of clean and soiled linens. Staff V stated that the area next to the dryer in the corner was used for storage of the infectious waste (medical waste contaminated with blood/body fluids and considered potentially contaminated) until an outside company picked them up and they could potentially have five or six tubs of infectious waste in this area. Staff V stated that staff bring infectious waste (identified by red bags) from the nursing areas into the laundry area by the single entrance and place them in the red tubs.

2. Observation on 04/12/11 at 10:50 AM, of the ice machine near the nurse's station showed that there were two drain lines, one from the lower end of the machine and one from the upper end of the machine joined to a single pipe which was continuous to a drain in the floor. Observation found no gap between the piping and the surface of the floor drain, needed to prevent a back flow of waste water back into the machine or to ensure that all water drained from the ice machine would freely drain from the piping.

During an interview on 04/12/11 at 10:50 AM, Staff Q, Maintenance Director, stated that there was no apparent backflow device or system to prevent the water which may accumulate in the floor drain from entering the drain pipes and re-entering into the ice machine.



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3. Record review of infection control quality improvement data showed the facility had gathered data related to infections, urinary tract infections, hand hygiene and glove usage.

During an interview on 04/15/11 at 9:55 AM, Staff B, Director of Nursing stated the facility gathers infection control data and makes observations for hand hygiene and glove usage. Staff B stated the data is reported to the infection control committee.

4. Observation on 04/12/11 at 09:15 AM during medication pass (administration of medications to patients) showed Staff X, Licensed Practical Nurse (LPN), entered Patient #1's room without performing hand hygiene and administered his/her medications.

During an interview on 04/12/11 at 10:55 AM, Staff X stated staff are to perform hand hygiene when entering and exiting patient rooms. Staff X confirmed he/she did not perform hand hygiene prior to administering Patient #1's medications.

During an interview on 04/12/11 at 11:15 AM, Staff B, Director of Nursing (DON) stated the facility policy on hand washing states between patient contact, but does not specifically address before and after providing care. Staff B stated the expectation is for staff to wash their hands with soap and water or use hand gel before and after providing patient care.

5. Observation on 04/14/11 at 1:30 PM during wound care showed Staff X wore gloves to remove a soiled dressing from Patient #2's right, lower leg. Staff X while wearing the same soiled/potentially contaminated gloves, picked up the bottle of wound cleaner and cleaned the wound on Patient #2's right, lower leg.

During an interview on 04/14/11 at 3:45 PM, Staff B stated staff should change gloves and perform hand hygiene after handling soiled material before they touch anything clean.

6. Observation on 04/13/11 at 10:35 AM, during wound care showed Staff X wore gloves to apply Mupirocin (antibiotic ointment) to Patient #5's lower left leg's open wound. Staff X while wearing the same gloves removed a wet gauze dressing and then applied Mupirocin to the open wound on the patient's right lower leg.

During an interview on 04/13/11 at 3:00 PM, Staff B stated the facility did not have a policy for glove change during wound care. Staff B stated staff should change gloves between clean and dirty procedures, and between wound care treatments to prevent cross contamination.

*See A0275 regarding lack of trending infection control data for quality improvement activities to improve patient care.

Based upon interview and record review, the facility failed to have policies for the Rehabilitation Department approved by the Administration, the Medical Staff and the Governing Body of the hospital following facility policy, and failed to have a scope of services available defined in writing. This has the potential to affect all patients receiving Rehabilitation Therapy, both inpatient and outpatient. The facility census was seven.

Finding included:

1. Review of the facility policy "Guidelines For Development and Review of Policies and Procedures, #200-01", effective 12/07/10, showed the policy regarding policy approvals as: "Quality Management will monitor when manuals are scheduled for review," and, "Each Department Leader will be responsible for the review/revision of their departmental policies and procedures."

2. Record review on 03/14/11 at 3:00 PM, of the Rehabilitation Department Policy and Procedure Manual showed the following: the approval signature page of the manual for the following required signatures of the Rehabilitation Director, the Medical Director, the Administrator, and the Governing Body Representative were all blank. The manual failed to have the required signatures.

3. During an interview on 03/15/11 at 9:00 AM, Staff A, the Administrator, stated that Staff J, Director of Rehabilitation Services, reported that he/she forgot to get the policy manual reviewed. The policy manual was revised January 2011, but failed to be reviewed by others and their required signatures documented.

4. Record review of the Rehabilitation Policy and Procedure manual on 04/14/11 at 3:00 PM, showed the policy manual did not include a written definition of the scope of services provided by the Rehabilitation Services. During an interview on 04/14/11 at 3:00 PM, Staff J agreed and confirmed the manual did not include a written definition for the scope of services.

Based on interview and record review, the facility:
-Failed to ensure infection control Performance Improvement (PI) data was used to monitor for effectiveness and implementation of effective actions and
-Failed to trend infection control quality data.

This failure affects the facility's ability to improve the quality of patient care. The facility census was seven.

Findings included:

1. Record review of infection control quality improvement data dated 11/10 showed the facility had gathered data related to infections, urinary tract infections (UTI), hand hygiene and glove usage.

Record review of the Daily Observation Compliance Totals for March 2011, showed the facility at 88% compliance for hand washing & hand gel in or out of patient rooms and at 98% compliance with glove usage. Nevertheless, see the deficiency at A0749 regarding the failure of staff to perform hand hygiene during medication pass for one patient (#1) of five patients observed during medication administration, and failure of staff to prevent cross contamination of wounds by not changing gloves during wound care for two patients (#2 and #5) of two patients observed for wound care.

During an interview on 04/15/11 at 9:55 AM, Staff B, Director of Nursing stated he/she had been gathering infection control data for infections and UTI's. Staff B stated observations were being made of staff for hand hygiene and glove usage. Staff B stated the data is reported to the infection control committee, but the gathered infection control data is not used for trending patterns and the facility had not been using the data to implement actions to improve patients' quality of care.

Based on interview and record review, the facility failed to ensure that relevant and correct data was collected and submitted identifying opportunities for improvement and changes that will lead to improvement for the radiology department, physical therapy, contracted services and the Behavioral Health Unit. The facility census was seven.

Findings included:

1. Review of the Policy Titled "Plan of Care" showed the details of the quality assurance process revised January of 2011. Section I. for organization of services stated that the hospital organizational structure is an integration of all hospital departments. Each department functions as a key element within the organization and is comprised of professional and non-professional staff directly and indirectly responsible for providing care and services to patient and other users of the organization's services.
The expanded management team consists of the administrative team and the department managers. They conduct monthly meetings to: strategically plan and provide feedback related to the assessed needs of patients, the organization and its customers; to review policies and develop action plans to achieve the identified goals, missions and vision of the hospital, and to meet at least monthly as the quality council. All team activities are reported to this group and it serves as a steering committee for all quality activities throughout the hospital.
Section II for "authority and responsibility" stated: The department managers have been empowered to oversee and are responsible for all activities within their assigned areas.

2. During an interview on 04/15/11 at 10:40 AM, Staff C, Quality Assurance Coordinator, stated that the radiology department does submit data to the quality assurance/performance improvement (QA/PI) committee, but that this data is only the number of radiology exams performed.

Record review for the data submitted by the radiology department for the year of 2010 showed that the only data submitted was the number of CT (computerized tomography) examinations performed during the year of 2010.

While this information demonstrates the use of the department by patients, it does not collect data showing the quality of patient care provided to or received by patients.

During an interview on 04/14/11 at 2:30 PM, Staff P (radiology technician and supervisor) stated that recently the radiographic table had been out of service and images were obtained by a portable radiographic device. A new radiographic table was to be installed at the facility on May 9th. Staff P stated that the only quality assurance review done by the medical director was potentially the review of image quality when the medical director provided interpretations of images and this physician provided the majority of image interpretation.

The change in services or other data necessary to identify opportunities for improvement were not identified as part of the quality assurance program.

3. During an interview on 04/15/11 at 10:40 AM, Staff C stated that the physical therapy department does submit data to the QA/PI committee and only does this on an annual basis and not more frequently.

Record review of the data submitted by the physical therapy department showed nine indicators for which they collected data. Three of the specific data indicators labeled as "billing" and "documentation" were indicated as not applicable (blank) for the months of June through September and blank again in December.

The department did not routinely provide data to the quality assurance program and the data collected could not be used to identify opportunities for improvement, or the need for changes, or identify how the missing data affected the program.

4. Review of the contracted services list provided by the facility on 04/15/11 showed which services are related to patient care and not provided directly by the facility. During interview on 04/15/11 at 10:40 AM, Staff C was asked if any of the services were evaluated or assessed as part of the QA/PI program. Staff C stated that the following contracted services had no data collected or any other method to determine performance for, or establishment of assessed goals for:

a. Laboratory for the blood bank services,
b. Tele-radiology services and interpretation of images, a contracted radiology technician, and reading of ultrasounds (contracted company for service and interpretation)
c. Contracted physician services for the emergency department (six providers)
d. The bio-medical waste courier (transports the hazardous medical waste)
e. Hospice services for patients
f. The facility utilizes a service for the donation of tissue and organs which is under contract and is evaluated by the department of medical records, but the data collected is not part of the QA/PI program.

During an interview on 04/12/11 at 10:00 AM, Staff K, Lead Coder for Medical Records, stated that the contract for Organ Procurement was maintained with MTS (Mid-America Transplant Services). MTS requests the list of all deaths within the past year on an annual basis and provides the quality assurance monitor a comparison of the hospital list of deaths with the MTS list of deaths. The quality assurance compliance had been 100% for all calls made regarding patient deaths. However, Staff K stated that the report(s) were not submitted and included for the Hospital-wide Quality Improvement Committee review; and that the facility did not have a policy regarding the inclusion of quality data reports for Organ Procurement as a part of the Hospital-wide quality improvement program

5. The frequency of data collection submitted for the physical therapy department, lack of any data other than number of one modality performed by the radiology department and lack of reporting for any of the contracted services listed prevented any identification for improvement or changes needed for improvement in those areas.

There was no data collected or progam goals identified for the contracted services listed and opportunities for improvement or changes to those programs could not be identified.



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6. Record review for the data submitted by the Behavioral Health Unit for 01/11, 02/11 and 03/11 showed the quality indicator data for the physician to record a progress note at least five out of seven days for justification for continued stay was collected for seven patients. However, the data for two of those seven patients was incorrect since the documentation on the audit sheet showed the physician recorded a progress note five out of seven days for Patient #17 and Patient #18:

a. Record review of the progress notes showed the physician recorded a note for Patient #17 only one of six days of the patient's hospital stay
b. Record review revealed the physician recorded a note for Patient #18 only three of seven days of the patient's hospital stay.

The lack of the physician to record the patient's progress on a routine basis affects the guidance and source of information from the physician to all members of the treatment team.

- Record review for the data submitted by the Behavioral Health Unit for 01/11, 02/11 and 03/11 showed the quality indicator data for the psychiatric evaluation completed within 24 hours was collected for eight patients. The data for one of those eight patients was incorrect. The documentation on the audit sheets showed the physician dictated the psychiatric evaluation within 24 hours. However, record review of the psychiatric evaluation for Patient #17 showed the patient entered the facility on 02/05/11. The review showed the physician dictated the evaluation on 02/09/11. The physician discharged the patient on 02/10/11. The lack of a psychiatric evaluation until the day before discharge would affect the ability to accurately diagnose the psychiatric disorder.

- Record review for the data submitted by the Behavioral Health Unit for 01/11, 02/11 and 03/11 showed the quality indicator data for the psychiatric evaluation was that it was to include a medical history and data was collected for eight patients. The data for one of the eight patients was incorrect. The documentation on the audit sheets showed the physician dictated a medical history. However, record review of the psychiatric evaluation dated 01/06/11 for discharged Patient #18 showed the patient entered the facility on 01/05/11 for treatment of aggressive behavior. The psychiatric evaluation showed for medical history the physician dictated, "Please see complete history and physical for details." Other than a list of the patient's current medications, no other medical history is indicated in the evaluation. The omission of a medical history may impact the treatment and recovery of the patient.

- Record review for the data submitted by the Behavioral Health Unit for 01/11, 02/11 and 03/11 showed the quality indicator data for the psychiatric evaluation was to include the onset of psychiatric symptoms, a justification for admission, was collected for seven patients. The data for one of the seven patients was incorrect. The documentation on the audit sheets showed the physician documented the onset of illness and the circumstances leading to admission. However, record review of the psychiatric evaluation dated 02/09/11 for discharged Patient #17 showed the patient entered the facility on 02/05/11 for treatment of dementia. The psychiatric evaluation showed no documentation of the onset of Patient #17's illness. The physician did not document when the patient's symptoms began or what the chief complaint for admission was. This could impact the patient's treatment and length of stay.

Because the data collected was incorrect it could not be used to identify opportunities for improvement.

During an interview on 04/14/11 at 11:40 AM, Staff N, Nurse Manager for the Behavioral Health Unit agreed the data for Patients #17 and #18 was incorrect.

Based on interview and record review, the facility failed to ensure the departments of radiology, physical therapy and contracted services participated in the quality assurance/performance improvement (QA/PI) program to identify priorities that affect health outcomes and patient safety. The facility failed to collect and analyze data related to high-risk or problem-prone areas to monitor the effectiveness and safety of services provided by the Pharmacy. This has the potential to affect the safety and quality of care for all patients. The facility census was seven.

Findings included:

1. Review of the Policy Titled "Plan of Care" showed details of the quality assurance process revised January 2011. Review of Section I. for organization of services found it stated that the hospital organizational structure is an integration of all hospital departments. Each department functions as a key element within the organization and is comprised of professional and non-professional staff directly and indirectly responsible for providing care and services to patient and other users of the organization's services.

The expanded management team consists of the administrative team and the department managers. They conduct monthly meetings to: strategically plan and provide feedback related to the assessed needs of patients, the organization and its customers; to review policies and develop action plans to achieve the identified goals, missions and vision of the hospital, and to meet at least monthly as the quality council. All team activities are reported to this group and it serves as a steering committee for all quality activities throughout the hospital.

2. During an interview on 04/15/11 at 10:40 AM, Staff C, Quality Assurance Coordinator, stated that the departments of radiology and physical therapy collect data, but are not routinely providing this data to the QA/PI committee. Staff C further stated that physical therapy only turned in data at the end of the year for 2010 and because of this the progress on the data collected could not be evaluated. The department of radiology submits information quarterly, but the only information submitted is the total number of procedures. Staff C stated that he/she cannot make the departments submit the data more frequently and has reported the lack of information submitted to the administrator.

3. Record review for the data for 2010 for the radiology department showed the only data available was for the total number of CT (computerized tomography) examinations done for patients during the year. While this provides information regarding the use of the department, it does not provide information regarding the quality of services provided to patients. Radiology is considered a high-risk area because of the use of services by many patients as well as the potential risk from repeated x-rays or other risks associated with radiology.

4. Record review for the data submitted by physical therapy for the year of 2010 revealed nine areas where data had been collected to assess the need for improvement. Two of the areas were labeled as "documentation" and "billing" which included three of the criteria and were blank for the months of June through September and December.

5. During an interview on 04/15/11 at 10:40 AM, Staff C, stated that all contracted services are not assessed as part of the QA/PI program. The list of contracted services was reviewed with Staff C and stated the following areas do not participate in the quality assurance program by data collection or assessment of any problem prone areas:

a. Laboratory for the blood bank services,
b. Tele-radiology services and interpretation of images, a contracted radiology technician, and reading of ultrasounds (another contracted company for service and interpretation)
c. Contracted physician services for the emergency department (six providers)
d. The bio-medical waste courier (transports the hazardous medical waste)
e. Hospice services for patients
f. The facility utilizes a service for the donation of tissue and organs which is under contract and is evaluated by the department of medical recordsm but the data collected is not part of the QA/PI program.


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6. Record review of the facility's policy titled "Drug Distribution and Administration" revised 08/30/10, showed medication errors and adverse drug reactions shall be reported immediately. The practitioner who ordered the drug, the appropriate nursing supervisor and pharmacist (pharmacy) shall be notified.

Record review of the facility's policy titled, "Adverse Drug Reactions" revised 05/10, showed an adverse drug reaction form should be completed and turned into the supervisor immediately. This form is to be reviewed by the DON (director of nursing), Pharmacy, Risk Management and Peer Review as indicated.

During an interview on 04/13/11 at 3:00 PM, Staff S, Director of Pharmacy, stated that he/she has been at the facility for approximately three weeks and is unfamiliar with the quality improvement process in the pharmacy.

Review of a quality control process completed by nursing for 2010 showed a total of 18 medication errors.

Review of the Pharmacy Department performance improvement data showed data collected from January 2010 through October 2010. The data monitored by the Pharmacy Department included the following:
-Allergies documented on patient profiles, admission orders and patient face sheets;
-Physician's timing all written orders;
-Correct abbreviations;
-Time IV (into the vein) discontinued;
-Verbal orders;
-Medication administration record in the correct place in the medical record and;
-Checking the time when a patient status changes from an observation patient to an in-patient.

Review of the data collection showed no data related to medication errors or adverse medication reactions, high-risk areas or problem prone areas.

Based on interview and record review, the facility's governing body, medical staff and other leadership failed to ensure that the hospital's quality assurance program was implemented and maintained for all departments by an ongoing system of data collection, monitoring and necessary action plans developed by participation in the quality assurance process. The facility census was seven.

Findings included:

1.Review of the Policy Titled "Plan of Care" details the quality assurance process revised January of 2011. Review of Section I. for organization of services found it stated that the hospital organizational structure is an integration of all hospital departments. Each department functions as a key element within the organization and is comprised of professional and non-professional staff directly and indirectly responsible for providing care and services to patient and other users of the organization's services.

The expanded management team consists of the administrative team and the department managers. They conduct monthly meetings to: strategically plan and provide feedback related to the assessed needs of patients, the organization and its customers; to review policies and develop action plans to achieve the identified goals, missions and vision of the hospital, and to meet at least monthly as the quality council. All team activities are reported to this group and it serves as a steering committee for all quality activities throughout the hospital.

Section II stated that the governing body has authority for all care and performance improvement activities within all services. The department managers have been empowered to oversee and are responsible for all activities within their assigned areas.

2. During an interview on 04/15/11 at 10:40 AM, Staff C, Quality Assurance Coordinator, stated that the departments of radiology and physical therapy are collecting data, but are not routinely providing this data to the QA/PI committee. Staff C further clarified that physical therapy only turned in data at the end of the year for 2010 and therefore monitoring and the need for action plans could not be evaluated throughout the year.

The department of radiology does submit information quarterly, but the only information submitted is the total number of procedures for one type of procedure. No other data was submitted regarding information related to the needs of patients or performance in other areas of the department.

Staff C stated he/she cannot make the departments submit the data more frequently and has reported the lack of information submitted or participation in the quality assurance process to the administrator.

Record review of the list of contracted services provided by the facility showed that he facility utilizes contracted services to provide patient care services under agreement with the hospital as approved by the governing body. During interview on 04/15/11 at 10:40 AM, Staff C was asked if any of the services from the list of contracted services were evaluated or assessed as part of the QA/PI program. Staff C stated that the following programs had no data collected or any other involvement in the quality assurance process:

a. Laboratory for the blood bank services,
b. Radiology for Tele-radiology services and interpretation of images, a contracted radiology technician, and reading of ultrasounds (contracted company for service and interpretation)
c. Contracted physician services for the emergency department (six providers)
d. The bio-medical waste courier (transports the hazardous medical waste)
e. Hospice services for patients
f. Organ procurement: the service is evaluated by the department of medical records but the data collected is not part of the QA/PI program.

3. Review of an undated policy titled "job description/scope of practice" for radiology showed that for Staff W, Radiology Consultant, the job duties will include, but not be limited to the following: Participate in reviewing the quality control and quality improvement implemented in the radiology department.

During an interview on 04/14/11 at 2:30 PM, Staff P, Radiology Technician and Supervisor, stated that the only quality assurance review done by the medical director was potentially the review of image quality when the medical director provided interpretations of images and this physician provided the majority of image interpretation. Staff P stated that the Medical Director of Radiology had not been onsite at the facility. Staff P stated that to his/her knowledge the medical director had not reviewed the policies and procedures of the department.

No staff interviewed throughout the survey was able to state when the current Medical Director of Radiology assumed the role as Director.



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4. Review of the Pharmacy Department performance improvement data showed the department collected data from January 2010 through October 2010. There is no evidence of any data collection after October 2010.

During an interview on 04/13/11 at 3:00 PM, Staff S, Director of Pharmacy, stated that he/she has been at the facility for approximately three weeks and is unfamiliar with the quality improvement process in the pharmacy. Staff S stated the person who knows about the Pharmacy quality improvement program is out on an extended sick leave. Staff S stated that with staff turnover he/she felt the Pharmacy quality improvement program was put on hold several months ago.

During an interview on 04/15/11 at 10:30 AM, Staff C, stated that the pharmacy department has not reported any data since 09/10. Staff C stated that he/she did not report the lack of data from the Pharmacy Department to the Medical Staff because he/she only reports problems found with the data collection. Staff C stated that the lack of reporting and data collection from the Pharmacy should have been reported by him/her.