HospitalInspections.org

Based on interviews and record reviews the hospital, an LTAC (Long Term Acute Care Hospital) failed to ensure that patients admitted to the hospital received a written disclosure notice indicating that the hospital did not have a Medical Doctor on-site at the hospital at all times. This failed practiced was evidenced by no documentation of a written disclosure notice that the hospital did not have a Medical Doctor on-site at the hospital at all times in 3 of 3 (#1, #2, #3) closed patient medical records and 2 of 2 (#4, #5) active patient medical records reviewed. The hospital had a total census of 4 patients out of a 15 patient capacity.

Findings:
A review of the medical records for Patients #1, #2, #3, #4, #5, revealed no evidence that the patients received a written disclosure notice indicating that the hospital did not have a Medical Doctor on-site at the hospital at all times.

In interviews on 9/30/14 at 11:15 a.m. with Patient #5 and on 9/30/14 at 11:30 a.m. with Patient #4's family, they indicated that they did not receive a written notice indicating that the hospital did not have a Medical Doctor on-site at the hospital at all times.

In an interview on 9/29/14 at 4:00 p.m. with S2DON she indicated that a Medical Doctor was not on-site 24 hours a day and that the Medical Doctors at the hospital had an on-call schedule for 24 hour patient care coverage. S2DON was asked if patients were given a written disclosure notice indicating that the hospital did not have a Medical Doctor on-site at the hospital at all times. S2DON indicated that the disclosure notice was probably in the admission packet information that was reviewed with the patient by the Admission Coordinator.

In an interview on 9/30/14 at 1:25 p.m. with S8AdmCoord, a patient admission packet was reviewed in the presence of S8AdmCoord. S8AdmCoord indicated that she was responsible for the admission packet information that was given to all patients upon admit. The patient admission packet, provided by S8AdmCoord as a complete packet, revealed no evidence of a written disclosure notice to patients that the hospital did not have a Medical Doctor on-site at the hospital at all times. S8AdmCoord indicated that she was not aware that the hospital had to provide a written disclosure notice to patients indicating that the hospital did not have a Medical Doctor on-site at the hospital at all times.

Based on interviews and record reviews, the hospital failed to ensure that patients who received dialysis services in an outpatient Dialysis Center, received care in a safe setting by failing to have policies and procedures in place that clearly delineated what care was to be provided by each provider (the hospital and/or the outpatient Dialysis Center) for the patients who received dialysis services to ensure continuity of patient care. This failed practice was evidenced by no documented policies and procedures in the hospital's Policy and Procedure Manual regarding patients who received dialysis services in an outpatient setting outside of the hospital. The hospital had a total of 7 (seven) patients (discharged) from 01/2014 to present who had received outpatient dialysis services during their admission at the hospital and 0 (zero) active patients at present receiving outpatient dialysis services. The hospital had a total census of 4 patients out of a 15 patient capacity.

Findings:
A review of the patient census roster from 01/2014 to present revealed that 7 (seven) patients (discharged) had received outpatient dialysis services during their admission at the hospital and 0 (zero) active patients at present were receiving outpatient dialysis services.

A review of the hospital's Policy and Procedure Manual, provided by S1Adm as the most current, revealed no policies and procedures in place that clearly delineated what care was to be provided by each provider (the hospital and/or the outpatient Dialysis Center) for the patients who received dialysis services to ensure continuity of patient care.

In an interview on 9/29/14 at 4:00 p.m. with S2DON, she was asked for the policies and procedures that delineated what care was to be provided by each provider (the hospital and/or the outpatient Dialysis Center) for the patients who received dialysis services to ensure continuity of patient care. S2DON indicated that there were no policies and procedures in place, at present, that delineated what care was to be provided by which provider (the hospital and/or the outpatient Dialysis Center) for the patients who received dialysis services to ensure continuity of patient care.

In an interview on 9/30/14 at 1:45 p.m. with S1Adm he was asked about the hospital's admission criteria for patients who required dialysis services since the hospital had no inpatient dialysis department. S1Adm indicated the hospital followed McKesson LTAC criteria which allowed the hospital, an LTAC, to accept patients who had ESRD, as a secondary diagnosis, and who required maintenance dialysis services. S1Adm indicated that the hospital (LTAC) had a contract with the outpatient Dialysis Center across the street. S1Adm further indicated that the hospital did not presently have any patients on dialysis and was not utilizing the services of the Dialysis Center across the street at the present time. S1Adm indicated that he had recently contacted DHH and CMS, regarding outpatient dialysis services for LTAC patients, and was awaiting a response from CMS.

Based on interview and record reviews the hospital's Medical Executive Committee (MEC), under the direction of the Medical Director, S11MedDir,
1) failed to ensure that the contract with the outpatient Dialysis Center was evaluated/re-evaluated and approved by the MEC; and
2) the hospital's MEC failed to ensure that the MEC had evaluated/re-evaluated the hospital's admission criteria for patients who required dialysis services. This failed practice was evidenced by no documentation in the MEC meeting minutes for 2013 -2014 that the MEC evaluated/re-evaluated and approved the contract with the outpatient Dialysis Center or evaluated/re-evaluated the hospital's admission criteria for patients who required dialysis services. The hospital had a total of 7 (seven) patients (discharged) from 01/2014 to present who had received outpatient dialysis services during their admission at the hospital and 0 (zero) active patients at present receiving outpatient dialysis services. The hospital had a total census of 4 patients out of a 15 patient capacity.
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Findings:
A review of the hospital's Medical Staff By-laws, provided by S1Adm as the most current, revealed that the MEC, under the Chief Medical Officer (Medical Director) was responsible for evaluating appropriate patient admissions, use of hospital services (to include hospital contracts) and all related factors relating to patient quality of care.

A review of the MEC meeting minutes, as provided by S1Adm as the complete MEC meeting minutes for 2013-2014, revealed no documented evidence that the MEC evaluated/re-evaluated and approved the contract with the outpatient Dialysis Center or evaluated/re-evaluated the hospital's admission criteria for patients who required dialysis services.

In an interview on 9/30/14 at 4:30 p.m. with S11MedDir he was asked about the MEC's responsibility in the hospital's admission criteria and the hospital contracts. S11MedDir indicated that the MEC was responsible for evaluating patient admission criteria and evaluating and approving hospital contracts. S11MedDir was asked if the MEC had evaluated/re-evaluated the hospital's admission criteria for patients who required dialysis services and if the MEC had approved the contract with the outpatient Dialysis Center. S11MedDir indicated that the MEC was aware of the contract with the outpatient Dialysis Center and had approved the contract "a while back". S11MedDir indicated that the hospital's admission criteria allowed patients who required maintenance dialysis services (due to a secondary diagnosis) to be admitted to the hospital, even though the hospital did not have an inpatient dialysis department because the hospital had obtained a contract with the outpatient Dialysis Center across the street. S11MedDir further indicated that S13Neph/MD was credentialed at the hospital and at the outpatient Dialysis Center and was responsible for the dialysis needs of the dialysis patients admitted to the hospital. S11MedDir indicated he remembered discussing the contract at one of the MEC meetings (during the summer months) with other physicians and/or with S1Adm. S11MedDir further indicated that the contract with the outpatient Dialysis Center was not the most optimal solution and that other dialysis service options needed to be discussed with the MEC.

Based on interviews and record reviews the hospital failed to ensure that contracted staff had received hospital orientation and had completed hospital competency skills checklists. This failed practiced was evidenced by no documentation of hospital orientation or a completed hospital competency skills checklists for 1of 1 (S17CNA/Contract) contracted employee file reviewed. The hospital's census was 4 patients out of a total capacity of 15.

Findings:
A review of the employee files on 9/30/14 in the presence of S2DON and S7OfficeMgr/HR revealed no employee file for the contracted CNA (S17CNA/Contract) who was on duty today (9/30/14).

In an interview on 9/30/14 at 3:30 p.m. with S17CNA/Contract she was asked if the hospital provided her with a hospital orientation and if she completed a hospital competency skills checklist prior to her being assigned patients. S17CNA/Contract indicated that she worked "on and off" at the hospital and that the first time she worked at the hospital, another CNA "showed her around" the hospital before she was assigned patients. S17CNA/Contract further indicated that she had not completed a hospital competency skills checklist with anyone here at the hospital prior to her being assigned patients.

In an interview on 9/30/14 at 12:45 p.m. with S2DON she was asked about the hospital's use of contracted staff. S2DON indicated that the hospital used contracted staff (RN, LPN, CNA) about once a week. S2DON was asked about the hospital's orientation and a hospital competency skills checklists for the contracted staff. S2DON indicated that the hospital did not have a formal orientation for contracted staff. S2DON indicated that a "first time" contracted staff would "be paired " with one of their employees for one or two days. S2DON further indicated that the hospital did not complete a competency skills checklists on contracted staff and assumed the Contract Agency completed competency skills checklists on their staff before sending them to work at the hospital. S2DON was asked if the Contract Agency sent a completed competency skills checklist to the hospital prior to the contracted staff working at the hospital. S2DON indicated, "no". S2DON further indicated that she could ask for one from the Contract Agency and they would probably send something to her.