HospitalInspections.org

Based on record review, interview, and observation, the Governing Body failed to ensure:

I. Policies were approved and appropriate for the specific services and functions provided by the hospital for seven of seven policies reviewed. The policies were written for a sister facility (an acute care hospital) and not specific to the LTACH being surveyed. Staff C stated the LTACH had "few" policies designated for the LTACH.

This failed practice had the likelihood for the staff not to implement the standards of practice expectations of the Governing Body for the services the hospital provided. (Refer to findings below).


II. Quality improvement committees clearly identified performance improvement issues and quality indicators specific to the hospital, minutes and discussion topics were separate and distinct from the sister facility during the quality improvement committee meetings, and recommendations with identified issues were moved forward from the committee to the Governing Body.

This failed practice had the likelihood for patient safety and quality of care issues to go unrecognized, unpursued and result in missed opportunities for improvement for patients admitted to the LTACH. (Refer to Tag A-0273, A-0283, A-0286, A-0297, and A-0309).


III. Direct formal consultations between the CEO (or President) and the Chief of Staff occurred at a minimum biannually from 05/17/17 to 04/18/18 on topics that included, but were not limited to: scope and complexity of hospital services, patient population served, and identified patient safety issues and quality of care that required participation and input of the Medical Staff. President of the hospital stated, there were no formal consultations with the Chief of Medical Staff on a scheduled basis.

These failed practices had the likelihood for issues that required Medical Staff input to go unrecognized and unpursued, and result in missed quality opportunities to improve patient health and safety outcomes. (Refer to Tag A-0053)


IV. services that were provided by the hospital's sister facility were contracted, met acceptable standards of practice, and evaluated for safety and effectiveness. The hospital received services including food services, linen, bio-waste, laboratory and speech therapy services from the sister facility.

This failed practice had the potential to affect all current patients' safety and quality of care. (Refer to Tag A-0083, A-0084)


V. the hospital had policies and procedures for services provided for the appraisal of emergencies including but not limited to: initial treatment, physician and staff responsibilities, stabilization, referral, and RN competency for initial assessment of patients, visitors and/or staff who experience an emergent medical condition. The hospital had policies and procedures for a "dedicated emergency department" but did not have a "dedicated emergency department". There was no evidence of RN qualification to respond and assess an emergent condition for nine of nine RN personnel files.

This failed practice had the likelihood for increased staff confusion and delay in patient triage, assessment, and referral to main hospital for all patients, visitors and/or staff who experience an emergent medical condition, and increased risk to patient safety and adverse health outcomes. (Refer to Tag A-0093)


VI. the hospital failed to provide written response of the investigational steps, results of investigation, completion date of process, and notice of decision for two (Patient #21 and 22) of two grievance records reviewed. The hospital director stated, prior to the Director of Quality and Risk Management's involvement in grievances the written response was a form letter and did not include the investigational steps and results, completion date of investigation, and decision.

This failed practice resulted in two (Patient #21 and 22) to receive no communication regarding steps taken by the hospital to investigate or the results of the investigation and had the potential for all patients who filed grievances to receive no evidence of resolution. (Refer to Tag A-0123)


VII. full responsibility and oversight of the QAPI program by prioritizing, discussion, analyzing, and evaluating performance improvement efforts and quality indicators. Governing Body minutes from 07/19/17 to 04/18/18 (electronic and in-person) did not reflect discussion, analysis and/or evaluation of the QAPI program, quality improvement projects and/or quality indicators including adverse events and delay in patient treatment. Staff C stated the Board discussed quality of care and medical quality projects and adverse events were not brought to Governing Body for discussion. (Refer to Tags A-0273, A-0283, A-0286, A-0297, A-0309)


Findings:

On 05/14/18 at 10:00 am, the surveyors requested the policies and procedures for the hospital, Staff A and Staff C provided multiple policies throughout the course of the survey for which the hospital entity listed was that of a sister facility and not the hospital being surveyed.

Examples of these policies included, but were not limited to the following:

*"Adverse Drug Event Reporting (6/14)"

*"Sentinel Event (date 05/15)"

*"Environment of Care Management (date 09/17)"

*"Emergency Operation of Care (date 08/17)"

*"Emergency Operation Plan (date 08/17)"

*"Organ and Tissue Donation (date 12/16)"

*"Organ and Tissue Donation after Cardiac Death (date 12/16)"


05/15/18 at 10:14 am, Staff C stated, the hospital had few policies designated for the hospital being surveyed, but most policies were "corporate" from the sister facility.

Based on record review and interview, the hospital failed to ensure:

I. quality improvement committees clearly identified performance improvement and quality indicators specific to the hospital, minutes and discussion topics were separated from the sister facility, and recommendations were provided to move identified issues forward from review of the Medical Quality Committee meeting minutes from 07/05/17 to 04/11/18. Staff C stated, quality improvement efforts were discussed in Leadership Council and minutes were not taken for these meetings.

This failed practice had the likelihood for patient safety and quality of care issues to go unrecognized, unpursued and result in missed opportunities for improvement for patients admitted to the hospital. (Refer to findings below)


II. ensure the QAPI programs involved all hospital services, including contracted services. QAPI program did not discuss, analyze, and determine risk to patient safety for three of three identified adverse events. QAPI Plan for 2018 failed to include evaluation of contracted services and Medical Quality Committee minutes from 07/05/17 to 04/11/18 failed to show evidence contracted services were assessed, monitored and evaluated.

This failed practice had the likelihood to affect patient safety and result in adverse health outcomes to all patients admitted to the hospital. (See findings below).


III. a quality improvement program specific to the hospital that included tracking, analysis, and monitoring of hospital specific quality indicators for effectiveness to improve patient care and outcomes. Review of Medical Quality Committee minutes from 07/05/17 to 04/11/18 did not contain strategies for improvement for quality indicators. Medical Executive Committee (MEC) minutes from 05/03/17 to 05/09/18 did not provide movement of the data and quality indicators forward for discussion, analysis, or conclusions, and Governing Body minutes from 07/19/17 to 04/18/18 (both electronic or in-person) failed to show evidence of the continued forward movement from MEC to Governing Body for discussion, analysis and conclusions of data and quality indicators.

This failed practice had the likelihood to increase the risk to patient safety to all long term care patients and reduce the hospital's ability to timely opportunities for improvement in quality indicators and implement best practice standards. (Refer to Tag A-0273)


IV. the QAPI committee identified opportunities for improvement, action plans, and tracked the improvements specific to the hospital to determine the sustainability of efforts. Meeting minutes from Medical Quality Committee from 07/05/17 to 04/11/18, MEC from 05/03/17 to 05/09/18 and Governing Body from 07/19/17 to 04/18/18 (electronic and in-person) showed no documentation of identified opportunities for improvement, action plans and discussion specific to the hospital to determine the sustainability and effectiveness of the facility's PI activities. Staff C stated minutes did not reflect all the discussion, action plans and/or conclusions that were discussed and all of the quality improvement activities the hospital staff were involved in.

This failed practice had the likelihood to affect patient safety and health outcomes for all patients admitted to the hospital and reduce the hospital's ability to timely opportunities for improvement in quality indicators and implement best practice standards. (Refer to Tag A-0283)


V. Based on record review and interview the hospital failed to establish an on-going quality improvement program that measured, analyzed the cause of medical errors and adverse patient events, implemented preventive actions, and tracked performance to ensure sustainability of improvements. QAPI Plan 2018 provided no evidence of performance improvement activities for medical errors. Incident Log for 07/24/17 to 04/14/18 showed incidents including but not limited to 15 falls, two unexpected deaths, one delay in care, one medication error, and one adverse event. Review of Pharmacy and Therapeutic Committee minutes from 04/20/17 to 04/14/18, Medical Quality Committee from 07/05/17 to 04/11/18, MEC from 05/03/17 to 05/09/18 and Governing Body from 07/19/17 to 04/18/18 (electronic and in-person) showed no evidence adverse events and medical errors were analyzed and evaluated. Staff C stated, he/she was aware the minutes did not provide an accurate assessment of the discussions, action plans and conclusions that were being discussed during Medical Quality Committee, MEC and Governing Board meetings.

This failed practice had the likelihood to affect the safety and health outcomes of all patients receiving care in the hospital due to the hospital's failure to identify risks and quality improvement opportunities and implement action plans to improve patient outcomes. (Refer to Tag A-0286)


VI. Based on record review and interview the hospital failed to conduct annual quality improvement projects designed to improve the safety and quality of care. Quality improvement projects provided by the hospital that included medication reconciliation, patient falls, low employee engagement and satisfaction, antibiotic stewardship and nutritional screening failed to have continued actions, assessments and outcomes to show evidence of improvement towards a sustainable goal. Three of the six quality improvement projects identified in the QAPI Plan 2018 failed to show they were related to the hospital.

This failed practice had the likelihood to affect the safety and health of all patients receiving care at the hospital due to the hospital's failure to identify annual quality improvement opportunities, perform continued assessments, and analyze performance towards goal to determine effectiveness and sustainability. (Refer to Tag A-0297)


VII. full responsibility and oversight of the QAPI program by prioritizing and evaluating performance improvement efforts. Governing Body minutes from 07/19/17 to 04/18/18 (electronic and in-person) did not reflect discussion, analysis and/or evaluation of the QAPI program, quality improvement projects and/or quality indicators including adverse events and delay in patient treatment. Staff C stated, the Board discussed quality of care and medical quality projects and adverse events were not brought to Governing Body for discussion.

This failed practice had the likelihood to affect the safety and health of all hospital patients due to the Governing Body's failure to be actively involved in the evaluation of QAPI performance improvement activities and implementation of action plans to improve patient outcomes. (Refer to Tag A-0309)


Findings:


I. Quality Minutes and Indicators

Review of hospital documents titled "Medical Quality Summary" showed the document had the sister facility logo and failed to identify the hospital and evidence of discussion topics, data, quality improvement activities and/or action plans relevant to the hospital.


Review of hospital document titled "Medical Quality Committee" meeting minutes from 05/09/18 showed a "P&T Summary Report, dated 04/19/18" that failed to clearly separate data and clinical information for the hospital and the sister facility. The report discussed a drug diversion committee formed to investigate suspected diversion that was not relevant to the hospital according to Staff T. ADE Quarterly report did not separate data for the hospital and the sister facility, making it difficult for the committee to identify data relevant to the hsopital.


Review of hospital document titled "Medical Staff Bylaws, dated 08/16/17" provided a vague statement "continuous and ongoing monitoring process utilized by the Medical Center...by monitoring Medical Staff critical indicators, and others as appropriate ..." The Bylaws referenced Medical Center which was synonymous with the sister facility and failed to specifically identify the Medical Staff's responsibilities for the hospital.


Review of hospital document titled "Quality Assessment and Performance Improvement Plan (QAPI) Plan - CY (Calendar Year) 2018" showed a multidisciplinary leadership forum council was a standing committee responsible for the following activities:

*Analyze performance of the LTACH PI activities, including contract services

* "reduce unacceptable performance variation"

*ensure improvements are made and sustained


Surveyors requested minutes from the leadership forum council. Staff C stated, minutes were not taken for this committee.


On 05/15/18 at 10:00 am, Staff C stated, performance improvement activities were reviewed, discussed, and recommendations made at the Leadership Council meetings.


On 05/16/18 at 12:30 pm, Staff C stated, the Medical Quality Committee, MEC, and Governing Board meeting minutes did not reflect all of the quality improvement activities the hospital were doing. Staff C stated, he/she was aware the minutes did not provide an accurate assessment of the discussions, action plans and conclusions that were being discussed during Medical Quality Committee, MEC, and Governing Board meetings.


II. Hospital/Contracted Services


Review of hospital document titled "Medical Staff Bylaws, dated 08/16/17" identified two committees: Medical Executive Committee (MEC) and the Medical Quality Committee. None of the committees' responsibilities included development, implementation and maintenance of an on-going QAPI program that involved all the hospital service lines (including contract services.)


Review of hospital document titled "Quality Assessment and Performance Improvement Plan (QAPI) Plan - CY (Calendar Year) 2018" failed to show evidence of involvement of all the hospital service lines (including contracted services) in the QAPI program.


Review of hospital documents titled "Medical Quality Committee" meeting minutes from 07/05/17 through 04/11/18 failed to show evidence contracted services utilized by the hospital were incorporated to the QAPI-CY 2018, assessed, monitored, and evaluated including: dialysis, speech therapy, dietary/meal service, linen and bio-waste. There was no evidence these contracted services and other clinical contracts were reviewed.


Review of document titled "Fourth Quarter 2017 Quality Assessment and Performance Improvement Report for [not named] LTACH" dated 01/28/18 showed two adverse events, first event was a dialyzer clotted but was able to return blood and second event was clotted access requiring placement of a catheter. Two treatment delays were reported in 10/17 secondary to transport. No evidence of discussion and analysis of the adverse events and delay in treatment by the Medical Quality Committee or the Governing Board to determine the risk to patient safety and health outcomes.


Review of hospital documents titled "Board of Directors" meeting minutes showed electronic meetings were held for 07/19/17, 09/20/17, 10/18/17, 01/17/18, 02/21/18, 03/21/18, and 04/18/18. In person meetings were conducted for 05/17/17, 08/16/17, and 11/29/17. There was no discussion in the meeting minutes to reflect the involvement of the hospital contracted services in the QAPI program. No evidence the Governing Body discussed, analyzed, and evaluated the adverse events and delay in treatment identified by the dialysis contracted service.


On 05/16/18 at 11:45 am, Staff C stated, the dialysis "issues" were discussed in Medical Quality but he/she was not aware if there were any recommendations from the committee regarding this service. Staff C stated, the adverse events were not brought to Governing Body for discussion.

Based on record review and interview, the hospital failed to:

I. ensure an organ, tissue, and eye procurement policy was developed and addressed the facility's responsibility of notification per their organ procurement agreement requirement of within one hour of the patient's death), and had the likelihood to contribute to Patient #15 and # 18 delayed organ procurement notification of 1 hour 45 minutes and two hours and 40 minutes, respectively. (Refer to Tag A-0885)

II. ensure an organ, tissue, and eye procurement agreement was in place with an Organ Procurement Organization that contained CMS required elements which including, but was not limited to" timely notification" within one hour of the patient's death, which had the likelihood to contribute to Patient #15 and # 18 delayed organ procurement notification of 1 hour 45 minutes and two hours and 40 minutes, respectively. (Refer to Tag A-0886)

III ensure two (Staff LL and Staff KK) had organ, tissue and eye procurement training and four (Staff GG, HH, III, JJ) of six RN staff had no instructions regarding organs or eyes procurement. (Refer to Tag A-0891).

These failed practices had the likelihood for procurement opportunities to be missed for the 13 patients who expired from 01/01/18 to 05/10/18.

Based on record review and interview, the Governing Body failed to ensure:

I. a policy was implemented that required the Chief Executive Officer (CEO or President) and the Chief of Staff to conduct formal consultations that occurred at a minimum biannually from 05/17/17 to 04/18/18 on topics that included, but were not limited to: scope and complexity of hospital services, patient population served, and identified issues patient safety and quality that required participation and input of the Medical Staff.


II. consultative sessions were conducted between the Chief Executive Officer (CEO or President) and the Chief of Staff per policy. President of the hospital stated, there were no formal consultations with the Chief of Medical Staff on a scheduled basis.

These failed practices had the potential for issues that required Medical Staff input to go unrecognized and unpursued, and result in missed quality opportunities to improve patient health and safety outcomes.


Findings:

I. Policy

On 05/16/18 at 10:35 am, surveyors requested a policy that designated the requirements of formal consultations between the Chief Executive Officer (CEO or President) and the Chief of Staff, the topics to include, but not limited to: scope and complexity of hospital services, patient population served, and identified issues with patient safety and quality of care that required participation and input of the Medical Staff, and none was provided.

Review of hospital document titled "Medical Staff Bylaws, dated 08/16/17" showed the duties of the Chief of Staff, which did not include consultative sessions with the CEO (or President) at a minimum biannually.

On 05/16/18 at 11:44 am, Staff C stated the hospital did not have a policy regarding formal consultative sessions between himself/herself and the Chief of Staff.


II. Consultative Sessions

Review of hospital documents titled "Board of Directors" from 05/17/17 to 04/18/18 showed no formal consultative sessions between the CEO (or President) and the Chief of Staff regarding scope and complexity of hospital services, patient population served, and identified issues with patient safety and quality of care that required participation and input of the Medical Staff.


On 05/16/18 at 11:44 am, Staff C stated he/she met with the Chief of Staff informally regarding patient safety and quality of care issues. Staff C stated there were no minutes or notes taken at these meetings.

Based on record review and interview, the governing body failed to ensure services that were provided by the hospital's sister facility were contracted and met acceptable standards of practice. The hosptal received services including food services, linen, bio-waste, laboratory and speech therapy services from the sister facility. This failed practice had the potential to affect all current patients' safety and quality of care.

Findings:

Review of hospital document titled "Board of Directors Electronic Meeting, dated 03/21/18" showed review and approval by the board of directors of a "Contracted Services Listing". There was no evidence of review and approval by the Board of Directors for services contracted with the sister facility including laboratory, food service, speech therapy, linen and bio-waste.

On 05/16/18 at 11:55 am, Staff C stated he/she and the Board of Directors were not aware the sister facility was a contracted service and did not have contracts for services provided by the sister facility to the hospital.

Based on record review and interview, the Governing Body failed to ensure services that were provided by the hospital's sister facility were contracted and evaluated for safety and effectiveness. The hospital received services including food services, linen, bio-waste, laboratory and speech therapy services from the sister facility. This failed practice had the potential to affect all current patients' safety and quality of care.

Findings:

Review of a hospital document titled "Contracted Services Listing, dated 03/20/18" failed to show evidence of contracted services between the hospital and the sister facility for food service, linen, bio-waste, laboratory and speech therapy services.

Review of hospital document titled "Board of Directors Electronic Meeting, dated 03/21/18" failed to show evidence of review and approval by the Board of Directors for services between the hospital and the sister facility for food service, linen, bio-waste, laboratory and speech therapy services.

On 05/16/18 at 11:50 am, Staff C stated he/she did not view the services provided between the hospital and the sister facility as a contracted service. Staff C stated there would not be any discussion in the Board of Director minutes regarding the shared services between the hospital and the sister facility because they were not contracted services.

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

I. the hospital had policies and procedures for services provided for the appraisal of emergencies including but not limited to: initial treatment, physician and staff responsibilities, stabilization, referral and RN competency for initial assessment of patients, visitors and/or staff who experience an emergent medical condition. The hospital had policies and procedures for a "dedicated emergency department" but did not have a "dedicated emergency department".

II. qualified and competent RNs capable of initial assessment and stabilization for patients, visitors and/or staff who experienced an emergent medical condition. There was no evidence of RN qualification to respond and assess an emergent condition for nine of nine RN personnel files.

This failed practice had the likelihood for increased staff confusion and delay in patient triage, assessment, and referral to main hospital for all patients, visitors and/or staff who experience an emergent medical condition, and increased risk to patient safety and adverse health outcomes.


Findings:

During a tour on 05/14/18 at 10:43 am, surveyors observed a room identified as the emergency room on the first floor located in the Occupational Health Clinic. The Occupational Health Clinic was located just inside the main entrance of the facility. The clinic was staffed by clinic nurses and providers. The Occupational Health Clinic was closed after 4:30 pm Monday through Friday and on weekends. A red phone located on the wall with a sign for emergencies use the phone to call for assistance. The hospital was located on the second floor of the facility.


I. Policies and Procedures

Review of hospital document titled "Rules and Regulations, dated 07/19/17" failed to identify the role of the physicians and licensed independent practitioners at the hospital for patients who may need emergent medical treatment and referral.


Review of hospital ED policy titled "Patient Care and Transfers - EMTALA (Emergency Medical Treatment and Active Labor Act), dated 01/01/18" failed to identify the process for immediate appraisal, treatment and transfer, and staff responsibilities specific to the hospital that does not have an emergency department offering emergency services.


Review of hospital ED policy titled "Providing Care, dated 01/03/18" showed an initial assessment was to be performed immediately by "qualified staff" for patients seeking emergency care. Prior to transfer the on-call physician was to be contacted. Qualified staff were responsible for securing an accepting hospital/physician, patient consent to transfer and completion of the transfer form. The policy failed to identify who "qualified staff" were, responsibilities of RN and medical staff, and required assessment elements for the initial appraisal of an emergency.


On 05/15/18 at 11:45 am, Staff PP (clinic staff) stated, the "hospital staff was in charge of the ED room". Staff PP stated, he/she was responsible for taking the patient into the ED room and obtaining vital signs until the hospital nursing staff could arrive with the crash cart from the second floor. Staff PP stated, the RN from the hospital was responsible for performing and documenting the patient assessment because the clinic was not set up to document those types of assessments. Staff PP stated, the hospital nurse was responsible for entering the patient into the ED log that was maintained in a cabinet in the ED room.


On 05/15/18 at 12:00 pm, Staff UU (clinic staff) stated, the ED room was in the clinic. Staff UU stated, clinic staff were "more like first responders," the staff would provide immediate assistance to the patient by getting the patient to the ED room and notify hospital nurse and provider to evaluate and transfer patient.


On 05/15/18 at 1:11 pm, Staff HH (hospital staff) stated, clinic nurse staff were responsible for patients presenting for emergency treatment during the day. Staff HH stated, if a patient was critical, a charge nurse from hospital would respond with the crash cart. Staff HH, stated after the clinic closed and on weekends the hospital nursing staff were responsible for patients seeking emergency care. Staff HH stated, he/she would "notify 911 and take care of the patient until EMS arrived to transfer to the main hospital".


II. RN Competencies


Review of hospital ED policies titled "Patient Care and Transfers - EMTALA dated 01/01/18" and "Providing Care, dated 01/03/18" failed to show education and training/competencies required for the Occupational Health Clinic and hospital RN staff identified as "qualified staff" and responsible for responding to the ED room and performing initial appraisal of persons with emergencies.


Nine (Staff GG, HH, II, JJ, KK, LL, OO, PP and QQ) out of a total sample of nine RN staff personnel files had no evidence of education training and/or competencies to perform an initial assessment and provide care for a patient experiencing a medical emergency.


On 05/15/18 at 11:45 am, Staff PP stated, he/she had not received any education on the ED process including RN responsibilities for initial assessment and evaluation, documentation, and transfer of patient. Staff PP stated, the only training he/she had was BLS (basic life support) training and "how to get the patient into the ED room".


On 05/15/18 at 1:11 pm, Staff HH stated, he/she had not received education or training on the RN's responsibility for initial assessment and evaluation of a patient seeking emergency medical services.


On 05/15/18 at 1:46 pm, Staff NN (Clinical Education Manager) stated, he/she had not provided education and/or training for the initial assessment and evaluation by the RN for a patient seeking emergency medical services at the hospital.

Based on record review and interview, the hospital failed to provide written response of the investigational steps, results of investigation, completion date of process, and notice of decision for two (Patient #21 and 22) of two grievance records reviewed. The hospital director stated, prior to the Director of Quality and Risk Management's involvement in grievances the written response was a form letter and did not include the investigational steps and results, completion date of investigation and decision.

This failed practice resulted in two (Patient #21 and 22) to receive no communication regarding steps taken by the hospital to investigate or the results of the investigation and had the potential for all patients who filed grievances to receive no evidence of resolution.


Findings:

Review of hospital policy titled "Receiving and Responding to Patient Complaints and Grievances, revised 10/16" showed "written responses shall include notice of decision ...steps taken to investigate ...results of investigation ...date of completion of the process".


Patient #21 filed a grievance with the hospital on 03/31/17 regarding incorrect medication dosage. Investigation included interview of physician, nursing, chart audit and education of nursing staff. A letter was provided to Patient #21 on 04/15/17 with no evidence of notice of decision, investigational process and date of completion of the process.


Patient #22 filed a grievance with the hospital on 01/04/18 regarding difficulty maintaining blood sugar and no shower provided for several days. Investigation included interview of dietician, nursing staff, physician, and chart audit. Review of grievance file showed no evidence of a written response provided to Patient #22.


On 05/17/18 at 8:49 am, Staff A stated, prior to Staff U's involvement with review of grievances, the written response letter was a form letter. Staff A stated, the written response now included the investigational process and hospital's decision. Staff A stated, after review of the grievance filed on 01/04/18 it was determined it was not a grievance because it was resolved at the time of the patient's discharge, and a written response was not provided.

Based on record review, interview, and observation, the hospital failed to post written notice and obtain a signed acknowledgement from a sample of six (Patient #2, 3, 4, 5, and 6) of six inpatients at admission that there was no physician on-site at the hospital twenty-four hours a day, seven days a week. Staff C stated, the hospital did not notify patients and families there was not a physician on-site 24 hours, seven days a week.

This failed practice had the potential to affect all patients admitted to the hospital to make informed decisions regarding their healthcare.


Findings:

Review of hospital admission packet provided to patients at time of admission provided no information explaining to the patient that a physician was not present on the hospital premises 24 hours a day, seven days a week.

Review of six (Patient #2, 3, 4, 5, and 6) of a sample of six patient medical records showed no evidence of signed acknowledgement notifying patients at the time of admission there was no physician on-site at the hospital 24 hours a day.

On 05/14/18 at 10:43 am, Staff QQ stated, the hospital does not have a physician on-site 24 hours a day, seven days a week. Staff QQ stated, the hospital has an on-call physician available.

On 05/16/18 at 11:38 am, Staff C stated, the hospital did not notify patients and families a physician was not on-site 24/7.

On 05/14/18 at 10:42 am, surveyor toured hospital entrances, patient care areas and reviewed information posted. There was no documentation or notice communicating to patients and families the hospital did not have a physician available on-site 24 hours a day, seven days a week.

On 05/14/18 at 4:00 pm, surveyors toured and reviewed information posted in public areas. There was no documentation or notice communicating to patients and families the hospital did not have a physician available on-site 24 hours a day, seven days a week.

Based on record review and interview, the hospital failed to create a quality improvement program specific to the hospital that included tracking, analysis, and monitoring of hospital specific quality indicators for effectiveness to improve patient care and outcomes. Review of Medical Quality Committee minutes from 07/05/17 to 04/11/18 did not contain strategies for improvement for quality indicators. Medical Executive Committee (MEC) minutes from 05/03/17 to 05/09/18 did not provide movement of the data and quality indicators forward for discussion, analysis or conclusions, and Governing Body minutes from 07/19/17 to 04/18/18 (both electronic or in-person) failed to show evidence of the continued forward movement from MEC to Governing Body for discussion, analysis and conclusions of data and quality indicators.

This failed practice had the likelihood to increase the risk to patient safety to all long term care patients and reduce the hospital's ability to timely opportunities for improvement in quality indicators and implement best practice standards.


Findings:


Review of hospital document titled "Committee Reporting Structure, undated" attached to the Medical Quality Committee meeting for 01/02/18, showed the following committees for the hsopital: the Grievance, Infection Control and P&T committees reported directly to the Medical Quality Committee. Medical Quality Committee reported to the Medical Executive Committee (MEC) and the MEC reported to the Governing Board.


Review of hospital document titled "Quality Assessment and Performance Improvement Plan (QAPI) Plan - CY (Calendar Year) 2018" showed the staff, medical staff, leadership, and board were committed to continual performance improvement to provide a safe environment for all patients, staff and visitors. "Board of Directors Quality Committee" were delegated the responsibility of "planned, systematic, organizational-wide, approach to process design and performance measurement, analysis and improvement" by the Governing Board. On 05/15/18 at 3:00 pm, surveyors requested all quality meeting minutes. No Board of Directors Quality Committee meeting minutes were provided. This committee was not part of the Committee Reporting Structure identified by the hospital leadership.


Review of hospital document titled "Medical Staff Bylaws, dated 08/16/17" showed the MEC committee was responsible for participation in performance improvement activities and "to consider and recommend action to the President on all matters of medico-administrative nature". The Medical Quality Committee was responsible for assessment and improvement of patient care activities including but not limited to: departmental indicator monitoring and evaluation, infection control, grievances, patient safety, risk management, and other monitoring functions.


Pharmacy and Therapeutics


Review of hospital documents titled "P&T Committee" meeting minutes for 07/20/17, 10/26/17 and 04/19/18 showed agenda items that included separate data for ADE (Adverse Drug Event) performance measure indicators for the hospital and sister facility, and combined data for the number of ADEs reported with corresponding level of injury. The minutes for 04/19/18 documented 21 ADEs, 10/26/17 minutes documented 26 ADEs and 07/20/17 minutes documented 13 ADEs. There was no documented discussion regarding at what location the ADEs occurred, causes of the ADEs, actions taken and/or follow-up.


Medical Quality Committee


Review of hospital documents titled "Medical Quality Committee" meeting minutes from 07/05/17 through 04/11/18 showed reoccurring agenda items for restraint documentation, pressure ulcers, medication reconciliation, medical record stats, pharmacy, wound care, falls, physician record completion, and no harm (risk management) indicators. The minutes did not contain analysis of the data provided. The minutes did not contain specific strategies for improvement. The meeting held on 04/11/18, agenda documented "March 2018 medical quality minutes" for approval, minutes provided to surveyors for this meeting were from 11/09/17.


In meeting minutes for 01/02/18 reports were provided for code blue, fall prevention, medication reconciliation, antimicrobial stewardship, restraints, medical record stats, and a pharmacy summary. The minutes did not contain discussion or analysis of the data provided in the multiple reports. There was no documentation the data was evaluated, outcomes identified, recommendations for improvement and/or follow-up were made.


In meeting minutes for 02/14/18 data for medication reconciliation, falls, pressure ulcers, falls, restraints, pharmacy, and medical record stats were reported. No documentation the data was discussed, analyzed, evaluated, outcomes identified, recommendations for improvement and/or follow-up were made.


In meeting minutes for 04/11/18 data for wound care, restraints and medical record stats were reported. No documentation the data was discussed, analyzed, evaluated, outcomes identified, recommendations for improvements, and/or follow-up were made.


Medical Executive Committee


Review of hospital documents titled "Medical Executive Committee Minutes" from 05/03/17 to 05/09/18 showed the Medical Quality Committee minutes were presented, reviewed and discussed. No documentation that topics were discussed in depth. No evidence data obtained from the Medical Quality Committee were analyzed, evaluated, and/or recommendations for improvement or follow-up were identified by MEC.


Governing Body


Review of hospital documents titled "Board of Directors" meeting minutes showed electronic meetings were held for 07/19/17, 09/20/17, 10/18/17, 01/17/18, 02/21/18, 03/21/18, and 04/18/18. In person meetings were conducted for 05/17/17, 08/16/17, and 11/29/17. The meeting minutes failed to show evidence of discussion, analysis, and/or evaluation of data provided by the Medical Quality Committee. Information and reports from Medical Quality Committee were not documented within the Governing Body meeting minutes.


On 05/16/18 at 10:30 am, Staff A stated, he/she agreed the minutes from those meetings did not consistently reflect discussion, action plans and/or conclusions that were discussed specific to the hospital during Medical Quality Committee, MEC, and Governing Board meetings.


On 05/16/18 at 12:30 pm, Staff C stated the Medical Quality Committee, MEC, and Governing Board meeting minutes did not reflect all of the quality improvement activities the hospital were doing. Staff C stated, he/she was aware the minutes did not provide an accurate assessment of the discussions, action plans and conclusions that were being discussed during Medical Quality Committee, MEC, and Governing Board meetings.


On 05/17/18 at 9:03 am, Staff U stated, the hosppital had a lot of quality activities in progress and there was in-depth discussion going on in the quality committees that was probably not getting documented in the meeting minutes. Staff U stated, meetings were held jointly between the hospital and the sister facility and it could be difficult to separate the discussions when taking minutes.

Based on record review and interview, the hospital failed to ensure the QAPI committee identified opportunities for improvement, action plans, and tracked the improvements specific to the hospital to determine the sustainability of efforts. Meeting minutes from Medical Quality Committee from 07/05/17 to 04/11/18, MEC from 05/03/17 to 05/09/18 and Governing Body from 07/19/17 to 04/18/18 (electronic and in-person) showed no documentation of identified opportunities for improvement, action plans and discussion specific to the hospital to determine the sustainability and effectiveness of the facility's PI activities. Staff C stated, minutes did not reflect all the discussion, action plans and/or conclusions that were discussed and all of the quality improvement activities the hospital staff were involved in.

This failed practice had the likelihood to affect patient safety and health outcomes for all patients admitted to the hospital and reduce the hospital's ability to timely opportunities for improvement in quality indicators and implement best practice standards.
.

Findings:


Review of hospital documents titled "Infection Prevention and Control Committee" dated 06/07/17 to 05/09/18 showed no meeting minutes for 06/07/17, 10/04/17 and 05/09/18. Meeting minutes for 02/14/18 showed discussion of one CLABSI for fourth quarter of 2017 with actions taken. No documentation of discussion of hospital acquired infections and surveillance activities.


Review of hospital documents titled "Medical Quality Committee" meeting minutes from 07/05/17 through 04/11/18 showed no documentation of identified opportunities for improvement, action plans and discussion specific to the hospital to determine the sustainability and effectiveness of the facility's PI activities.


Review of hospital documents titled "Medical Executive Committee Minutes" from 05/03/17 to 05/09/18 showed no documentation of identified opportunities for improvement, action plans and discussion specific to the hospital to determine the sustainability and effectiveness of the facility's PI activities.


Review of hospital documents titled "Board of Directors" meeting minutes showed electronic meetings were held for 07/19/17, 09/20/17, 10/18/17, 01/17/18, 02/21/18, 03/21/18, and 04/18/18. In person meetings were conducted for 05/17/17, 08/16/17, and 11/29/17. Review of the meeting minutes showed no documentation of identified opportunities for improvement, action plans and discussion specific to the hospital to determine the sustainability and effectiveness of the facility's PI activities.


On 05/16/18 at 10:30 am, Staff A stated, he/she agreed the minutes from those meetings did not consistently reflect discussion, action plans and/or conclusions that were discussed specific to the hospital during Medical Quality Committee, MEC, and Governing Board meetings.


On 05/16/18 at 12:30 pm, Staff C stated, the Medical Quality Committee, MEC and Governing Board meeting minutes did not reflect all of the quality improvement activities the hospital staff were doing. Staff C stated, he/she was aware the minutes did not provide an accurate assessment of the discussions, action plans, and conclusions that were being discussed during Medical Quality Committee, MEC, and Governing Board meetings.


On 05/17/18 at 9:03 am, Staff U stated the hospital had a lot of quality activities in progress and there was in-depth discussion going on in the quality committees that was probably not getting documented in the meeting minutes. Staff U stated, meetings were held jointly between the hospital and the sister facility, and it could be difficult to separate the discussions when taking minutes.

Based on record review and interview, the hospital failed to establish an on-going quality improvement program that measured, analyzed the cause of medical errors and adverse patient events, implemented preventive actions, and tracked performance to ensure sustainability of improvements. QAPI Plan 2018 provided no evidence of performance improvement activities for medical errors. Incident Log for 07/24/17 to 04/14/18 showed incidents including but not limited to 15 falls, two unexpected deaths, one delay in care, one medication error, and one adverse event. Review of Pharmacy and Therapeutic Committee minutes from 04/20/17 to 04/14/18, Medical Quality Committee from 07/05/17 to 04/11/18, MEC from 05/03/17 to 05/09/18 and Governing Body from 07/19/17 to 04/18/18 (electronic and in-person) showed no evidence adverse events and medical errors were analyzed and evaluated. Staff C stated he/she was aware the minutes did not provide an accurate assessment of the discussions, action plans and conclusions that were being discussed during Medical Quality Committee, MEC, and Governing Board meetings.

This failed practice had the likelihood to affect the safety and health outcomes of all patients receiving care in the hospital due to the hospital's failure to identify risks and quality improvement opportunities and implement action plans to improve patient outcomes.


Findings:


Review of hospital document titled "Quality Assessment and Performance Improvement Plan (QAPI) Plan - CY (Calendar Year) 2018" showed performance measures included but not limited to: adverse patient events and drug administration errors. The QAPI plan showed no evidence of performance improvement activities for medical errors.


Review of hospital policy titled "Adverse Drug Event Reporting, dated 06/14" showed the online "Patient/Visitor Safety (Incident) Report" was used to report all ADEs by healthcare providers and pharmacists. Pharmacists were responsible for reporting all ADE's classified as adverse drug reactions (ADR).


Review of untitled hospital document identified by Staff A to be the "Incident Log" showed from 07/24/17 to 04/14/18 there were the following:

*15 Falls

*Three Other - two skin tear injuries, one no medical equipment ordered at discharge requiring patient to return to ED

*Two Unexpected deaths

*One Medication Error

*One Adverse Drug Event

*One Lab Mislabel Event

*One Wound

*One Delay in Care

No evidence incidents were analyzed and evaluated for improvement opportunities.


Review of hospital document titled "P&T Committee Agenda, dated 04/19/18," showed no evidence of minutes and reporting of adverse drug events (ADE). The agenda showed a "Quarterly CMS data from System" for ADE's and "Summary of Local ADE's" were reported at the meeting. The minutes from 04/19/18 and ADE reports were not provided with the Agenda.


Review of hospital document titled "P&T Committee" meeting minutes from 04/20/17 through 01/18/18 showed ADE performance measures rates individually for the hospital and sister facility for INR ?5, Blood Glucose ?50mg/dL and use of Naloxone for Opioid Reversal Oversedation.

The meeting minutes failed to distinguish the hospital from the sister facility for the number of ADE's reported as evidenced by:

*01/08/18: one Level 0 (near miss), 11 Level 1 (no injury/system), and nine Level 2 (minor treatment)

*10/26/17: 23 Level 1, one Level 2, and 2 Level 3 (moderate treatment)

*07/20/17: four Level 0, six Level 1, and 3 Level 2

*04/20/17: none reported

No evidence ADEs were analyzed and evaluated for improvement opportunities.


Review of an untitled hospital document showed ADE data separated for the hospital and the sister facility from the second quarter of 2017 through the fourth quarter of 2017 and the first quarter of 2018l. The hospital had the following ADEs:

*CY2017 Q2: one Level 1

*CY2017 Q3: one Level 2

*CY2017 Q4: one Level 1

*CY2018 Q1: two Level 0

The "Incident Log" provided to the surveyors failed to include each of the ADEs identified by pharmacy for the LTACH per hospital policy. No evidence ADEs were analyzed and evaluated for improvement opportunities.


Review of hospital documents titled "Medical Quality Committee" meeting minutes from 07/05/17 through 04/11/18 showed, attached departmental reports from infection prevention, P&T, QAPI, No Harm (risk management), and administrative, which included numerical statistical information. No topics were discussed in depth. No identification of departmental and service line (including contract services) indicators and/or projects, and no establishment of goals and action plans. Data was not analyzed or action plans developed to move issues towards sustained improvement. Although the P&T Committee gave a report within this committee, ADE's the minutes did not reflect discussion and recommendations. The Incident Log and the ADE data reported by the P&T Committee were not discussed, trended or analyzed within this committee or other committees to determine the discrepancies between the Log and ADEs reported by P&T.


Review of hospital documents titled "Medical Executive Committee Minutes" from 05/03/17 to 05/09/18 showed, the Medical Quality Committee Report was presented, reviewed and discussed. No documentation that topics were discussed in depth. There was documentation as to causes of issues or directives for a comprehensive action plans to move performance measure indicators towards sustainability.


Review of hospital documents titled "Board of Directors" meeting minutes showed, electronic meetings were held for 07/19/17, 09/20/17, 10/18/17, 01/17/18, 02/21/18, 03/21/18, and 04/18/18. In person meetings were conducted for 05/17/17, 08/16/17, and 11/29/17. Meeting minutes did not reflect review and discussion of P&T committee minutes, and topics including medical errors and ADEs.


On 05/16/18 at 10:30 am, Staff A stated, committee meeting minutes from P&T were attached and provided to Medical Quality Committee, MEC, and Governing Board. Staff A stated, he/she agreed the minutes from those meetings did not reflect discussion, action plans and/or conclusions that were discussed during Medical Quality Committee, MEC and Governing Board meetings in regards to medical errors and ADEs.


On 05/16/18 at 12:30 pm, Staff C stated the Medical Quality Committee, MEC and Governing Board meeting minutes did not reflect all of the quality improvement activities the hospital staff were doing. Staff C stated, he/she was aware the minutes did not provide an accurate assessment of the discussions, action plans and conclusions that were being discussed during Medical Quality Committee, MEC, and Governing Board meetings.

Based on record review and interview, the hospital failed to conduct annual quality improvement projects designed to improve the safety and quality of care. Quality improvement projects provided by the hospital that included medication reconciliation, patient falls, low employee engagement and satisfaction, antibiotic stewardship, and nutritional screening failed to have continued actions, assessments, and outcomes to show evidence of improvement towards a sustainable goal. Three of the six quality improvement projects identified in the QAPI Plan 2018 failed to show they were related to the hospital.


This failed practice had the likelihood to affect the safety and health of all patients receiving care at the hospital due to the hospital's failure to identify annual quality improvement opportunities, perform continued assessments, and analyze performance towards goal to determine effectiveness and sustainability.


Findings:


Review of hospital document titled "Quality Assessment and Performance Improvement Plan (QAPI) Plan - CY (Calendar Year) 2018" failed to include current year 2018 performance improvement projects that included all departments and service lines (including contract services) to improve patient care. There was no documentation of key indicators for high risk, high volume or problem areas were identified in the plan for the current year.


Review of hospital documents titled "Medical Quality Committee" meeting minutes from 07/05/17 through 04/11/18 showed no identification of performance improvement projects for 2018, reasons for conducting each project chosen and measurable progress achieved.


On 05/15/18 at 1:00 pm, surveyors requested performance improvement projects being conducted for 2018 and were provided the following:

*Medication Reconciliation process not completed accurately on admission - started 06/17, no evidence action improved towards a sustainable goal.

*Patients falling related to not asking for assistance, no intentional rounding, left unassisted and neglecting to set chair/bed alarm - started 07/16, no evidence action improved towards a sustainable goal.

*Low employee engagement and satisfaction - start date not identified, no evidence action improved towards a sustainable goal.

*Hospital acquired pressure ulcers (HAPU) - start date not identified, no evidence action improved towards a sustainable goal.

*Nutritional screening that is completed during admission should identify patients with nutritional risk factors prompting dietary consult - start date not identified, no evidence action improved towards a sustainable goal.


Review of a hospital document titled "QAPI 2018" failed to identify three of six QAPI projects related to the hospital:

*How satisfied is staff

*Time frames for nutritional assessment and reassessments of nutritional risk

*Antibiotic stewardship


.
On 05/14/18 at 10:30 am, surveyors requested copies of the facility's performance improvement (PI) projects for the current year.


On 05/15/18 at 10:00 am, PI projects for the facility were provided to surveyors by Staff C. Staff C stated, individual PI projects were discussed and recommendations made in leadership council. Staff C stated, minutes were not kept for leadership council meetings.


On 05/16/18 at 12:30 pm, Staff C stated, the Medical Quality Committee, MEC and Governing Board meeting minutes did not reflect all of the quality improvement activities the hospital staff were doing. Staff C stated, he/she was aware the minutes did not provide an accurate assessment of the discussions, action plans and conclusions that were being discussed during Medical Quality Committee, MEC, and Governing Board meetings.


On 05/17/18 at 9:03 am, Staff U stated, the LTACH had a lot of quality activities in progress and there was in-depth discussion going on in the quality committees that was probably not getting documented in the meeting minutes. Staff U stated, meetings were held jointly between the hospital and the sister facility and it could be difficult to separate the discussions when taking minutes.

Based on record review and interview, the Governing Body failed to assume full responsibility and oversight of the QAPI program by prioritizing and evaluating performance improvement efforts. Governing Body minutes from 07/19/17 to 04/18/18 (electronic and in-person) did not reflect discussion, analysis and/or evaluation of the QAPI program, quality improvement projects and/or quality indicators including adverse events and delay in patient treatment. Staff C stated, the Board discussed quality of care and medical quality projects and adverse events were not brought to Governing Body for discussion.

This failed practice had the likelihood to affect the safety and health of all hospital patients due to the Governing Body's failure to be actively involved in the evaluation of QAPI performance improvement activities and implementation of action plans to improve patient outcomes.


Findings:


Review of document titled "Fourth Quarter 2017 Quality Assessment and Performance Improvement Report for [not named] LTACH" dated 01/28/18 showed two adverse events, first event was a dialyzer clotted but was able to return blood and second event was clotted access requiring placement of a catheter. Two treatment delays were reported in 10/17 secondary to transport. No documentation of discussion and analysis of the adverse events and delay in treatment by the Medical Quality Committee or the Governing Board to determine the risk to patient safety and health outcomes.


Review of hospital document titled "Medical Quality Summary March - May 2018" failed to show discussion topics, data, and/or quality improvement activities relevant to the hospital. The summary noted stroke door to CT scan times improved and the Massive Transfusion Protocol, both were not services provided at the hospital. Code blue, severe sepsis and infection control data, benchmarks, and performance improvement efforts failed to separate the hospital from other system entities per CMS requirements. There was no documentation the Governing Body reviewed this summary and identified the hospital was not individually assessed in order for the Governing Body to evaluate the quality efforts.


Review of hospital documents titled "Board of Directors" meeting minutes showed electronic meetings were held for 07/19/17, 09/20/17, 10/18/17, 01/17/18, 02/21/18, 03/21/18, and 04/18/18. In person meetings were conducted for 05/17/17, 08/16/17, and 11/29/17. Meeting minutes did not reflect evaluation and discussion of the Medical Quality Committee minutes that included performance improvement activities. There was no evidence the Governing Body provided oversight of the QAPI program including the prioritization and determination of the number of PI projects for the current year. There was no documentation of in-depth discussion and recommendations by the Governing Body regarding any QAPI activities.


On 05/15/18 at 10:00 am, Staff C stated, the "Board" met in person every three months and had electronic meetings in-between monthly. Staff C stated, the Board discussed quality of care and medical quality projects. Staff C stated, the Board approved the QAPI plan annually.


On 05/16/18 at 11:45 am, Staff C stated, the dialysis "issues" were discussed in Medical Quality but he/she was not aware if there were any recommendations from the committee regarding this service. Staff C stated, the adverse events were not brought to Governing Body for discussion.


On 05/16/18 at 12:30 pm, Staff C stated, the Governing Board meeting minutes did not reflect all of the quality improvement activities the hospital staff were doing. Staff C stated, he/she was aware the minutes did not provide an accurate assessment of the discussions, action plans and conclusions that were being discussed during Governing Board meetings

Based on record review and interview the hospital failed to ensure:

I. documentation of a completed comprehensive (head-to-toe) nursing assessment each shift for eight (Patient #2, 3, 4, 5, 6, 18, 19, and 20) out of a total sample of 20 patient medical records reviewed. The hospital policy showed, nursing assessments should be performed at "regular" intervals but failed to identify a time frequency. Nursing staff stated assessments were to be performed each shift.

This failed practice had the likelihood for increased risk of delayed recognition for change in a patient's clinical condition for eight (Patient #2, 3, 4, 5, 6, 18, 19, and 20) out of a total sample of 20 patients admitted to the hospital.


II. written medical records reflected an accurate time and legible authentication by healthcare providers for one (Patient #1) out of a total sample of one emergency department (ED) patient medical record reviewed, to identify the person responsible for completing the assessment and the time when it occurred. The hospital policy for documentation did not provide requirements for written medical records. Patient #1's medical record did not have documentation of arrival time, time of assessment, who performed assessment, time vital signs taken, time report called to receiving hospital, and time of patient discharge.

This failed practice had the likelihood for patients to have inaccurate communication between healthcare providers as the medical record provides a sequential record of patient care promoting patient safety through timely assessments, interventions and ensuring quality patient care.


Findings:


I. Nursing Assessments

Review of hospital policy titled "Patient Assessment/Reassessment, dated 09/16" showed assessment was continuous throughout the hospital stay for inpatients. At regular intervals reassessments should be performed by nursing staff. The policy failed to identify the frequency of nursing assessments for patients admitted to the hospital. Interviews with nursing staff and administrative leadership showed a head to toe assessment of patients admitted to the hospital were performed every shift.

Eight (Patient #2, 3, 4, 5, 6, 18, 19, and 20) out of a total sample of 20 reviewed showed a comprehensive nursing assessment was not performed and documented in the patient's EMR each shift.

On 05/16/18 at 2:55 pm, Staff NN (Clinical Nurse Educator) stated, body systems were to be assessed and documented each shift. Staff NN stated, documentation of system assessment was covered in EMR training for nursing staff.

On 05/17/18 at 10:57 am, Staff A (Administrative Director) stated, his/her expectation was all patients admitted were to have a full assessment completed and documented in the EMR each shift.

On 05/17/18 at 12:34 pm, Staff ZZ stated, as a staff nurse he/she performed and documented a full head to toe nursing assessment each shift for each patient he/she was assigned.


II. Written Medical Record

Review of hospital policy titled "Documentation of Patient Care, revised 04/16" showed "all documentation is in accordance with legal, regulatory ...applying to all care providers." The policy failed to identify documentation requirements for all entries whether written or electronic medical records to ensure compliance with CMS requirements.

Hospital document titled "Rules and Regulations, dated 07/19/17" showed emergency service electronic medical record documentation should include, but not limited to: mode of arrival, arrival date and time, name of physician, history (to include chief complaint, present illness/past medical history, system review, and date and time of disposition. This document failed to identify documentation requirements for physicians and licensed independent providers for written records to ensure compliance with CMS requirements.


On 05/17/18 at 10:00 am, surveyors requested a policy for documentation related to date, time and authentication requirements for physicians, licensed independent practitioners and nursing staff for written and electronic medical records. None was provided.


Patient #1, a 50 year old male, presented to the hospital with a chief complaint of shortness of breath and chest heaviness on 04/05/17. Review of the ED medical record failed to show evidence of documentation for the following:

*Method of arrival to the hospital. The written record did not identify whether the patient came to the hospital seeking emergency medical services or was already at the hospital when the emergency arose.

*Time of arrival in the ED.

*Time assessment performed, and provider signature responsible for completing assessment

*Time vital signs were taken.

*Time report called to receiving hospital and name of person receiving report

*Time patient discharged and transferred to another acute care hospital for treatment of the emergent medical condition.


On 05/17/18 at 9:05 am, Staff A stated, written medical records were to be dated, timed, and signed by the nurse and/or physician who performed the assessment. Staff A stated, Staff QQ and Staff UU were the RN and medical provider in the Occupational Health Clinic on the day Patient #1 presented to the hospital.

Based on record review and interview, the hospital failed to ensure physicians and licensed independent practitioners completed a history and physical (H&P) within twenty-four (24) hours of admission for five (Patient #2, 3, 5, 19, and 20) of 20 patient medical records reviewed according to hospital policy and CMS requirements. LTACH "Rules and Regulations" (dated 07/19/17) showed, an H&P was to be completed and documented in the patient's medical record within 24 hours of admission.

This failed practice had the likelihood to affect medical treatment decisions, discharge planning, care plans and adversely affect patient health outcomes for five (Patient #2, 3, 5, 19, and 20) of 20 patient medical records reviewed.

Findings:

Hospital document titled "Rules and Regulations, dated 07/19/17" showed admitting physician or licensed independent practitioner was responsible for completing a history and physical (H&P) within 24 hours of patient admission, and documenting the H&P in the patient's medical record.

Five (Patient #2, 3, 5, 19, and 20) of 20 medical records reviewed showed, the H&Ps were not completed and documented in the patient's EMR within 24 hours.

On 05/17/18 at 11:30 am, Staff A stated, H&Ps were to be completed by medical staff within 24 hours of the patient's admission to the LTACH.

Based on record review and interview the facility failed to ensure:

I. medical gas and essential electrical system (EES) building system risk assessments were completed for their existing facility. (Refer to K-0901)

II. the sprinkler system was inspected, tested and maintained as required. (Refer to K-0353)

III. all patient care related electrical equipment was tested and inspected before being placed into service. (Refer to Tag K-0921)

IV. ventilation is in accordance with ASHRAE 170. (Refer to Tag-K-0223)

V. smoke detector sensitivity inspection, testing, and maintenance. (Refer to Tag- K0345)

Based on record review and interview the facility failed to include the transmission of a fire alarm signal on each fire drill. (Refer to K-0712)

Based on observation and interview the facility failed to ensure:

I. all patient care related electrical equipment was tested and inspected before being placed into service. (Refer to K- 0921)

II. initial and ongoing staff training on safety measures, handling, and specific hazards of medical gases usage/guidelines.
(Refer to K-0926)

Based on observation and interview the facility failed to ensure:

I. all patient care related electrical equipment was tested and inspected before being placed into service. (Refer to K- 0921)

II. initial and ongoing staff training on safety measures, handling, and specific hazards of medical gases usage/guidelines.
(Refer to K-0926)

Record review showed the facility ventilation documentation for isolation room #4228 did not include air exchanges per hour as required. (Refer to K-0323).

Based on record review and interview, the hospital failed to ensure an organ, tissue, and eye procurement policy was developed and addressed the facility's responsibility of notification within the required one hour timeframe as per their organ procurement agreement, and had the likelihood to contribute to Patient #15 and # 18 delayed organ procurement notification of 1 hour 45 minutes and two hours and 40 minutes, respectively.

These failed practices resulted in the organ procurement organization not receiving notification within the required one hour timeframe for two (Patient #15 and Patient #18) of two patients who expired (out of total patient sample of 20), and had the likelihood for procurement opportunities to be missed for the 13 patients who expired from 01/01/18 to 05/10/18.

Findings:

On 05/14/18 at 10:00 am, the surveyors requested the policies and procedures governing organ, tissue, and eye procurement. Staff C provided two policies titled, "Organ and Tissue Donation (date 12/16)" and "Organ and Tissue Donation after Cardiac Death (date 12/16)"; however, the hospital entity listed was that of a sister facility and not the LTACH being surveyed.

On 05/14/18 at 3:00 pm, Staff C stated, the hospital did not have an organ, tissue, and eye procurement policies.

A review of the medical record for Patient #15 documented the patient had expired on 11/17/17 at 2:30 am./ The organ procurement organization was notified at 11/17/17 at 4:19 am, which was greater than the one hour timeframe requirement.

A review of the medical record for Patient #18 documented the patient had expired on 02/15/18 at 4:50 am. The Organ Procurement Organization was notified on 2/15/18 at 7:40 am, which is greater than the one hour timeframe requirement.

On 05/17/18 at 12:30 pm, surveyors requested any other evidence of the time the organ procurement organization was notified for Patient #15 and Patient #18, and none was provided.

Based on record review and interview, the hospital failed to ensure an organ, tissue, and eye procurement agreement was in place with an Organ Procurement Organization that contained CMS required elements which including, but was not limited to" timely notification" requirement of within one hour of the patient's death, which had the likelihood to contribute to Patient #15 and # 18 delayed organ procurement notification of 1 hour 45 minutes and two hours and 40 minutes, respectively.

These failed practices resulted in the organ procurement organization not receiving notification within the required one hour timeframe for two (Patient #15 and Patient #18) of two patients who expired (out of total patient sample of 20), and had the likelihood for procurement opportunities to be missed for the 13 patients who expired from 01/01/18 to 05/10/18.

Findings:

On 05/14/18 at 10:00 am, the surveyors requested the organ, tissue, and eye procurement agreement. Staff C provided two documents titled, "Organ and Tissue Recovery Agreement (10/14)" and "Transplant Center Addendum (date 10/14). The document listed the hospitals represented by and joined to the agreement but the list did not include the hospital being surveyed.

On 05/14/18 at 3:00 pm, Staff C stated, the facility did not have an agreement with an organ procurement organization.

A review of the medical record for Patient #15 documented the patient had expired on 11/17/17 at 2:30 am. The organ procurement organization was notified at 11/17/17 at 4:19 am, which was greater than the one hour timeframe requirement.

A review of the medical record for Patient #18 documented the patient had expired on 02/15/18 at 4:50 am. The Organ Procurement Organization was notified on 2/15/18 at 7:40 am, which is greater than the one hour timeframe requirement.

On 05/17/18 at 12:30 pm, surveyors requested any other evidence of the time the organ procurement organization was notified for Patient #15 and Patient #18, and none was provided.

Based on record review and interview, the hospital failed ensure two (Staff LL and Staff KK) employees had organ, tissue and eye procurement training and four (Staff GG, HH, III, JJ) of six RN staff had no instructions regarding organs or eyes procurement.

These failed practices had the likelihood to contribute to Patient #15 and # 18 delayed organ procurement notification of 1 hour 45 minutes and two hours and 40 minutes, respectively, and for procurement opportunities to be missed for 13 patients who expired from 01/01/18 to 05/10/18.

Findings:

A review of the document titled, "Education/ Competency Validation Required Annually" showed "Tissue Donation" was required for all RN / LPNs except "ER/ICU".

A review of the curriculum for "Tissue Donation" training showed the material oriented to tissue and not organs and eyes.

A review of the six RN personnel files for OPO training showed two (Staff LL and Staff KK) employees failed to contain evidence of OPO training and four (Staff GG, HH, III, JJ) of six RN staff had no instructions regarding organs or eyes procurement.

On 05/14/18 at 3:45 pm, Staff A stated, the hospital staffs' annual training for organ procurement consisted of tissue donation and did not include organs or eyes.