HospitalInspections.org

Based on record review and interview, the governing body failed to:

A. develop a 2013 institutional plan and budget for the facility. The governing body also failed to develop a 3-year capital expenditure plan.

Refer to tag A0073

B. provide a method to monitor contracted services. The contracted dietary services and linen and laundry services were not part of the hospital's Quality Program. There was not a process that would ensure services were being provided in a safe and effective manner.

Refer to tag A0084

C. ensure all patients received information about their rights in advance of receiving care. There was no evidence that 3 (#4, 5, and 6) of 11 patients received information regarding their rights at admission.

Refer to tag A0117

D. ensure all patients received information regarding whom to contact to file a grievance. There was no evidence that 3 (#4, 5, and 6) of 11 patients received information regarding whom to contact to file a grievance.

Refer to tag A0118

E. ensure all patients consented to medical treatment prior to receiving treatment. 3 (#4, 5, and 6) of 11 patient charts had no documented general consent to medical care.

Refer to tag A0131

F. ensure all patients received information regarding advance directives. There was no evidence that 3 (#4, 5, and 6) of 11 patients received information regarding advance directives.

Refer to tag A0132

G. maintain its infant abduction security system in working order. The governing body also failed to maintain its general facility security contract.

Refer to tag A0144

Based on records review and interviews, the facility failed to:

A. ensure that all patients received information about their rights in advance of receiving care. There was no evidence that 3 (#4, 5, and 6) of 11 patients received information regarding their rights at admission.

Refer to tag A0117

B. ensure that all patients received information regarding whom to contact to file a grievance. There was no evidence that 3 (#4, 5, and 6) of 11 patients received information regarding whom to contact to file a grievance.

Refer to tag A0118

C. ensure that all patients consented to medical treatment prior to receiving treatment. There was no documented general consent to medical care in 3 (#4, 5, and 6) of 11 patient charts.

Refer to tag A0131

D. ensure that all patients received information regarding advance directives. There was no evidence that 3 (#4, 5, and 6) of 11 patients received information regarding advance directives.

Refer to tag A0132

E. maintain its infant abduction security system in working order. The facility also failed to maintain its general facility security contract.

Refer to tag A0144

Based on document review and interview, the governing body failed to provide a method to monitor contracted services. The contracted dietary services and linen and laundry services were not part of the hospital's Quality Program. There was not a process that would ensure services were being provided in a safe and effective manner.
A review of the governing body's meeting minutes from the time line of January 2012 until present revealed no evidence the board had reviewed or evaluated the contracted companies that provide services within the facility.
A review of the facility's Quality Assurance Performance Improvement Program provided no evidence the contracted dietary service and the contracted linen and laundry service were being monitored for quality or safety of services provided.
An interview on 03/03/2013 at 10:57 in the conference room with staff #1 confirmed the governing body had not reviewed or evaluated facility's contracted services.
An interview with staff #4 in her office on 03/3/2013 at approximately 10:30AM confirmed the contracted dietary service and the contracted linen and laundry lervice were not being monitored for quality or safety of services provided.

Based on record review and interview, the governing body failed to develop a 2013 institutional plan and budget for the facility. The governing body also failed to develop a 3-year capital expenditure plan.

Findings include:

Review of facility records revealed no approved institutional plan and budget for 2013. Review of facility records also revealed no 3-year capital expenditure plan.

Review of Governing Body meeting minutes from January 2012 to present revealed no approval of a 2013 institutional plan and budget. Review of Governing Body Meeting minutes from January 2012 to present also revealed no 3-year capital expenditure plan.

During an interview on 3/03/13 at 10:57am in the conference room, staff #1 reported there was no Governing Body approved 2013 institutional plan and budget. Staff #1 also reported there was no Governing Body approved 3-year capital expenditure plan.

Based on document review and interview, the governing body failed to provide a method to monitor contracted services. The contracted dietary services and linen and laundry services were not part of the hospital's Quality Program. There was not a process that would ensure services were being provided in a safe and effective manner.
A review of the governing body's meeting minutes from the time line of January 2012 until present revealed no evidence the board had reviewed or evaluated the contracted companies that provide services within the facility.
A review of the facility's Quality Assurance Performance Improvement Program provided no evidence the contracted dietary service and the contracted linen and laundry service were being monitored for quality or safety of services provided.
An interview on 03/03/2013 at 10:57 in the conference room with staff #1 confirmed the governing body had not reviewed or evaluated facility's contracted services.
An interview with staff #4 in her office on 03/3/2013 at approximately 10:30AM confirmed the contracted dietary service and the contracted linen and laundry service were not being monitored for quality or safety of services provided.

Based on records review and interviews, the facility failed to ensure that all patients received information about their rights in advance of receiving care. There was no evidence that 3 (#4, 5, and 6) of 11 patients received information regarding their rights at admission.

Findings include:

The facility document titled, "Patient Rights and Responsibilities," contained information regarding the following topics:

-patient rights and responsibilities;
-complaint/grievance process;
-advance directives.

Review of patient medical records #4, 5, and 6 revealed no evidence that these patients received a copy of "Patient Rights and Responsibilities."

During an interview on 3/03/13 at 10:18am on the Medical Surgical Unit, staff #7 confirmed there was no evidence patients #4, 5, and 6 received a copy of "Patient Rights and Responsibilities."

Based on records review and interviews, the facility failed to ensure that all patients received information regarding whom to contact to file a grievance. There was no evidence that 3 (#4, 5, and 6) of 11 patients received information regarding whom to contact to file a grievance.

Findings include:

The facility document titled, "Patient Rights and Responsibilities," contained information regarding the following topics:

-patient rights and responsibilities;
-complaint/grievance process;
-advance directives.

Review of patient medical record #4, 5, and 6 revealed no evidence that these patients received a copy of "Patient Rights and Responsibilities." Therefore there was no evidence these patients received information regarding whom to contact to file a grievance.

During an interview on 3/03/13 at 10:18am on the Medical Surgical Unit, staff #7 confirmed there was no evidence patients #4, 5, and 6 received a copy of "Patient Rights and Responsibilities." Staff #7 confirmed there was no evidence these patients received information regarding whom to contact to file a grievance.

Based on records review and interview, the facility failed to ensure that all patients consented to medical treatment prior to receiving treatment. There was no documented general consent to medical care in 3 (#4, 5, and 6) of 11 patient medical records.

Findings include:

Review of the facility document titled, "Inpatient /Outpatient Conditions of Admission and Consent to Medical Treatment," revealed that it is a document to be signed by the patient, indicating the patient was aware of and agreed to the following:

-assignment of insurance benefits;
-cost of a private room;
-responsibility for personal valuables;
-general consent for tests and treatment;
-advance directive acknowledgement.

Review of patient medical records #4, 5, and 6 revealed no "Inpatient /Outpatient Conditions of Admission and Consent to Medical Treatment," signed or unsigned.

During an interview on 3/03/13 at 10:18 am on the Medical Surgical Unit, staff #7 confirmed that there was no "Inpatient /Outpatient Conditions of Admission and Consent to Medical Treatment," signed or unsigned, for patients #4, 5, and 6. Staff #7 reported this document should be in all patient medical records.

Based on record review and interview, the facility failed to ensure that all patients received information regarding advance directives. There was no evidence that 3 (#4, 5, and 6) of 11 patients received information regarding advance directives.

Findings include:

The facility document titled, "Patient Rights and Responsibilities," contained information regarding the following topics:

-patient rights and responsibilities;
-complaint/grievance process;
-advance directives.

Review of the facility document titled, "Inpatient /Outpatient Conditions of Admission and Consent to Medical Treatment," revealed that it is a document meant to be signed by the patient, indicating the patient was aware of and agreed to the following:

-assignment of insurance benefits;
-cost of a private room;
-responsibility for personal valuables;
-general consent for tests and treatment;
-advance directive acknowledgement.

Review of patient medical record #4, 5, and 6 revealed no evidence that these patients received a copy of "Patient Rights and Responsibilities." Review of patient medical record #4, 5, and 6 also revealed no "Inpatient /Outpatient Conditions of Admission and Consent to Medical Treatment," signed or unsigned.

During an interview on 3/03/13 at 10:18am on the Medical Surgical Unit, staff #7 confirmed there was no evidence patients #4, 5, and 6 received a copy of "Patient Rights and Responsibilities." Staff #7 also confirmed that there was no "Inpatient /Outpatient Conditions of Admission and Consent to Medical Treatment," signed or unsigned, for patients #4, 5, and 6. Staff #7 reported there was no further evidence in the charts that the patients received information regarding advance directives.

Based on records review and interview, the facility failed to maintain its infant abduction security system in working order. The facility also failed to maintain its general facility security contract. These deficiencies have the potential to allow harm to all patients and staff within the facility.

Findings include:

During an interview on 3/02/13 at 2:50pm in the Maternal Child Department, staff #5 reported that the facility's infant abduction security system (designed to alert staff if an infant is taken out of the department) was not functioning due to the expiration of the contract and bills not being paid. Staff #5 reported that the system had not been functioning for 3 weeks. Staff #5 reported that the department handled 25-40 births per month. Staff #5 further reported there had been no general hospital security (security guards) for about a week.

Review of the infant abduction security system purchase order confirmed the contract expired on 2/28/13.

During an interview on 3/03/13 at 11:32, staff #2 confirmed that the infant security system had been non-functional for three weeks. Staff #2 also confirmed the facility had lost its security guard coverage due to lack of payment to the contracted company. There was no alternative security measures in place.