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Based on interviews, a review of meeting minutes, Hospital #1's Medical Staff Bylaws Rules and Regulations, Hospital #1's policies and procedures, the Amended and Restated Adult Oncology Inpatient Clinical Services Agreement, contracted services and a review of the physician credentialing process, the Governing Body of Hospital #1 failed to establish or maintain a separate and distinct Hospital from Hospital #2. The Conditions of Participation were integrated with Hospital #2; therefore, the Condition of Participation of Governing Body was not met. Failure to provide the independent oversight by Hospital #1 placed all potential patients at risk to receive poor quality of care.

Findings include:

The Governing Body failed to separately and independently examine the credentials and privileges to providers requesting membership or privileges to the medical staff of Hospital #1.

Please refer to A 341

The Governing Body failed to assess that all services provided under contract were separately and independently reviewed by the Governing Body to ensure quality care.

Please refer to A 263 and A 273

The Governing Body failed to separately and independently approve policies and procedures governing care provided to patients.

Please refer to A 118, A 398 and A 409

The Governing body failed to ensure that patients' rights were met.

Refer to A 116

The Governing Body failed to ensure that Hospital #1 had a medical record service that was separate from Hospital #2.

Refer to A-431

Based on observations, records reviewed and interviews, the Hospital failed for 3 of 14 sampled patients (Pt #6, #12 and #13), to have patient rights information and complaint/grievance policies that were independent from Hospital #2 and exclusive for patients of Hospital #1.

Findings include:

Hospital #1's Complaint Policy and Procedure regarding patient complaints and grievances, dated 2/2016, indicated that Hospital #1's policy excluded complaints from Hospital #1's inpatient units (5A, 5B and 6C).

Hospital #1 used Hospital #2's policy and procedure regarding complaints for Hospital #1's inpatients without appropriately adopting Hospital #2's policy and procedures.

Hospital #1's Welcome Packet, provided to Hospital #1's inpatient units 5A, 5B and 6C have the name and logo of Hospital #2 on the booklet.


Please refer to A-116

Based on record review and interviews, Hospital #1 failed to have its own exclusive Quality Assessment/Performance Improvement Program (QAPI) that was independent from Hospital #2 to ensure the quality of services for the patients of Hospital #1.

Findings included:


1. Based on records reviewed and interviews, Hospital #1 failed to have an independent Quality Assurance Performance Improvement (QAPI) Plan that: measured, analyzed and tracked quality indicators and other aspects of performance and that assessed processes of care, hospital service and operations, defined and incorporated quality indicator data according to definitions of the Governing Body that specified the frequency and detail of the data collection and monitored the effectiveness and safety of services and quality of care.

See A 273

2. Based on records reviewed and interviews, Hospital #1 failed to take actions through the hospital's QAPI program to: assess those services provided under contract, identify quality and performance problems, implement appropriate corrective or improvement activities and ensure the monitoring and sustainability of those corrective or improvement activities.

See A 308

3. Based on records reviewed and interviews, Hospital #1 failed to have an independent QAPI program that: identified and reduced medical errors and adverse patient events, analyzed their causes and implemented preventative actions and mechanisms that included feedback and learning throughout Hospital #1.

See A 286


4. Based on records reviewed and interviews, Hospital #1 failed to: have a performance improvement program separate from Hospital #2 whose efforts addressed priorities for improved quality of care and patient safety, ensure that all improvement actions were evaluated and failed to determine the number of distinct improvement projects that would be conducted annually.

See A 309

5. Based on records reviewed and interviews, Hospital #1 failed to allocate hospital resources to measure, assess, improve and sustain Hospital #1's performance and reduce risks to patients. Instead Hospital #1 relied upon Hospital #2, its contracted service, to perform these functions and took no independent responsibility to see that quality and performance improvement were maintained and sustained.

See A 315

The Governing Body failed to enforce the Medical Staff Bylaws to ensure that the Bylaws applied equally to all staff as it relates to credentialing and privileging.

See A 341

Based on records reviewed and interview, Hospital #1 failed to create an independent organized nursing service department separate from Hospital #2's nursing services to ensure that nursing service needs were met for the patients of Hospital #1.

Findings included:

Hospital #1 failed to provide administrative nursing oversight for Hospital #1's thirty inpatient beds including the determination of the types and numbers of nursing personnel and staff necessary to provide nursing care to patients on these units.

See A 386

Hospital #1 failed to ensure that contract nursing staff met all licensing, education and certification requirements of Hospital #1.

See A 394

Hospital #1 failed to ensure that contracted nursing staff adhered to Hospital #1's policies and procedures or that Hospital #1 provided supervision and evaluation of the clinical activities of each contracted staff person.

See A 398

Hospital #1 failed to establish policies to govern the use of blood products.

See A 409

Based on records reviewed and interviews, for 14 of 14 patients sampled patients, Hospital #1 failed to have an independent medical record services department that was exclusive to the facility and independent from Hospital #2's medical record service.

Findings included:

Fourteen of 14 medical records reviewed indicated that the Hospital created a continuous electronic medical record across two identified hospitals, Hospital #1 and Hospital #2.

Please refer to A 450

Based on records reviewed and interviews, for 14 of 14 sampled patients, the Governing Body failed to ensure that services provided under contact and/or agreement were separate and independent from Hospital #2 to ensure care was provided safely and independently from Hospital #2.

Findings include:

Refer to A 263

Based on observations, records reviewed and interviews, for 3 of 14 sampled patients (Pt #6, #12 and #13), Hospital #1 failed to separately and independently inform all patients of their rights.

Findings include:


During a tour of 6C on 8/1/16, the Surveyor observed 10 of Hospital #1's 30 licensed inpatient beds. The ten rooms were numbered 51-60 and those patient beds were within the building of Hospital #2.


The Surveyor interviewed the Access Services Manager, employed by Hospital #2, at 10:30 A.M. on 8/4/16. Hospital #2's Access Services Manager said that for planned admissions, Hospital #2's Welcome Packet would be mailed to a patient by Hospital #2, not Hospital #1. Hospital #2's Access Services Manager said for those patients with an unplanned admission to Hospital #1's unit 5A, 5B and 6C, Hospital #2's Access Staff would go directly to Hospital #1's inpatient units and ensure those patients receive Hospital #2's Welcome Packet.


During the tour, the Surveyor interviewed Patient #6 at approximately 2:00 P.M. Patient #6 said he/she did not receive a copy of patient rights and was not informed how to file a complaint if he/she needed to file one.

The Surveyor interviewed Hospital #2's Nurse Director during the tour of 6C on 8/1/16. The Nurse Director said she was not sure, but she thought the Patient's Rights were given to patients when they checked into the Admitting Office or the Patient Rights were mailed to patients by the Admitting Office of Hospital #2.

During a second tour of 6C at 9:50 A.M. on 8/4/16, the Surveyor interviewed Patient #12. Patient #12 said he/she did not receive a copy of his/her rights as a Hospital #1 patient.

The Surveyor interviewed Patient #13 at 10:00 A.M. on 8/4/16. Patient #13 said he/she did not receive a copy of his/her rights as a Hospital #1 patient.

During both tours of 6C on 8/1 and 8/3/16, the Surveyor observed and reviewed Patient #6, #12 and #13's medical records that were in a binder type note book as well as their electronic record. Patient #6, #12 and #13's medical record did not indicate that Hospital #1 informed Patient #6, #12 and #13 of their Patient Rights and Responsibilities.

Based on records reviewed and interviews, for 3 of 14 sampled patients (Patient #6, #12 and #13), Hospital #1 failed to have complaint and grievance policies that were independent from Hospital #2 and were exclusive for the Patients at Hospital #1.

Finding include:

Hospital #1's policy and procedure titled Patient Complaint/Grievance/Request Management Process, dated 2/2016, indicated Hospital #1 developed a policy and procedure that excluded Hospital #1's inpatient units, 5A, 5B and 6C. Hospital #1's policy and procedure titled Patient Complaint/Grievance/Request Management Process, dated 2/2016, indicated that every effort will be made to resolve a grievance in 7 days and provide a written response of resolution to the complainant. The policy indicated that if a resolution was not possible in 7 days, then it was resolved within 30 business days.

The Surveyor interviewed Hospital#1's Patient and Family Program Manager at 8:30 A.M. on 8/3/16. The Patient and Family Program Manager said that that she was responsible for coordinating outpatient complaints and responding back to complainants. The Patient and Family Program Manager said that the complaints for the inpatients are the responsibility of staff at Hospital #2.

The Surveyor reviewed four patient complaints, dated from January 2016 to July 2016. The investigations from the outpatient complaints did not include a written response of resolution as required by Hospital #1's policy and procedure. The two complaints from the inpatient log were in a file that belonged to Hospital #2.


The Surveyor reviewed Hospital #1's Complaint Log, dated January 2016 to July 2016, two complaints from the Outpatient Log and two complaints from the Inpatient Log were reviewed. Hospital #1's Complaint Log indicated three complaints were not resolved within 30 business days as indicated in Hospital #1's policy and procedure.

Further review of Hospital #1's policy and procedure titled "Patient Complaint/Grievance/Request Management Process", dated 2/2016, did not contain the procedure of how a patient was to contact the Quality Improvement Organization if they had a complaint regarding quality of care or disagree with a coverage decision (for example discharge).

Based on record review and interview, Hospital #1 failed to have an independent Quality Assurance Performance Improvement (QAPI) Plan that: measured, analyzed and tracked quality indicators and other aspects of performance and that assessed processes of care, hospital service and operations, defined and incorporated quality indicator data according to definitions of the Governing Body that specified the frequency and detail of the data collection and monitored the effectiveness and safety of services and quality of care.

Findings included:

1. Review of Hospital #1's Quality Improvement Plan and Quality Assurance contract with Hospital #2 did not identify any indicators of quality or aspects of performance for monitoring and evaluation regarding Hospital #1.

Review of the inpatient clinical services agreement, updated in April 2016, indicated Hospital #1 contracted with Hospital #2 to jointly provide Quality Assurance to facilitate achievement of excellence in clinical care delivery in the inpatient clinical units using a reliance on a partnership with the clinical and administrative leaders of Hospital #2 to prioritize, support, lead and evaluate clinical improvement activities. Hospital #2 would provide program structure such as quality measurement, reporting and improvement, patient safety teams, performance improvement and decision support and internal and external reporting. Hospital #2 would serve as a member on Hospital #1's Joint Committee on Quality Improvement and Risk Management (JQRIM) and on Hospital #1's Quality Leadership Council.

Under the agreement, Hospital #2 would define and measure key performance indicators of quality, safety and operations of Hospital #1's inpatient population. Hospital #2 would oversee safety reporting systems, safety culture and just culture systems and would facilitate performance improvement projects. Metrics were to be sent to Hospital #1's Quality Improvement Department to compile and present to the Quality Leader Council group which is a sub-committee of the board level JQRIM committee.

The Surveyor review the minutes of the Quality Leadership Council, dated 7/3/2015 and 12/3/2015 (January 3, 2016 meeting minutes were requested but not provided). In the 12/3/2015 minutes, under Quality Improvement, results of a Press Ganey Survey (patient satisfaction survey) were discussed that reflected combined survey results of both Hospital #1 and #2. Results indicated that the inpatient pods of Hospital #1 were performing as a slightly lower rate when compared to inpatient pods at Hospital #2 regarding the patients overall rating the hospital, recommendation of the hospital and communication with nurses and doctors. The minutes indicated an internal investigation was ongoing to determine why there was a difference between Hospital #1 and Hospital #2's inpatient pods satisfaction rates. The next steps would be an internal improvement process. There was no further documentation to indicate that a performance improvement was planned or provided.

The Joint Committee on Quality Improvement and Risk Management minutes indicated that under data and performance measures, review of dashboard quarterly reported data focused on patient experience, patient events (falls with injury) and the integrated electronic health record as well as pediatric satisfaction scores from the outpatient and associated oncology services from other hospitals. It also indicated that a quick review of a "more detailed quarterly departmental report" was reportedly done with no other areas requiring a focused review.

The Joint Committee on Quality Improvement and Risk Management minutes indicated the 2015 Infection Control Plan data was not available for presentation at that time and only staff flu vaccination compliance was reviewed.

When the Surveyor requested quarterly data for just the inpatient pods of Hospital #1, it took three days after the request for Hospital #1 to produce the data. During an interview on 8/3/2016 at 8:00 A.M., Hospital #1's Risk Manager said that the data was combined with Hospital #2's but could be separated down to each pod for Hospital #1.

When the quarterly department report was received there was no data recorded for Hospital #1 since October 2015 for the areas of care coordination, nursing oncology, blood transfusion standards, central venous line related bacteremia, management of chemotherapy side effects, hand hygiene compliance, pain management to include completion of pain assessments, nutrition, and pharmacy measures to include median time to drug availability. There was no Catheter Associated Urinary Tract Infection (CAUTI) data since April 2015.

Review of the JQRIM (Governing Body level review) monthly minutes through 7/2016 did not indicate any mention of performance improvement activities related to the Press Ganey results of patient satisfaction on the inpatient pods.

Based on records reviewed and interviews, the Hospital failed to have an independent QAPI program that identified and reduced medical errors and adverse patient events, analyzed their causes and implemented preventative actions and mechanisms that included feedback and learning throughout the hospital.

Findings included:

Hospital #1 contracted with Hospital #2 to identify serious and/or unexpected patient outcomes through mechanisms such as safety reporting systems, quality measurement reports, medical record reviews and provider reports. Sentinel events would be reviewed by both Hospital #1 and Hospital #2's Risk Management (RM) staff and hospital committees to ensure that any and all necessary external reporting was completed per regulatory requirements under Hospital #1's license. Hospital #2 would serve as a member on Hospital #1's Medical Staff Executive Committee (MSEC), the combined Quality Improvement Committee and various other safety committees.

Hospital #2 would also report to Oncology leadership (made up of members from both Hospital #1 and Hospital #2), on falls, medication events (these metrics are reported to the Care Improvement Team and to the Joint QI/RM team) and SRE's (Serious Reportable Events), which are reported to the Joint QI/RM Committee.

Review of the Joint Committee on Quality Improvement and Risk Management (JQIRM) committee minutes, 12/18/2015, indicated that the committee was comprised of members from Hospital #1 and Hospital #2. Other events such as Central Line Acquired Blood Stream Infections (CLABSI) and oral chemotherapy safety in the pediatric cancer population was also discussed from three institutions (Hospital #1, Hospital #2 and the pediatric specialty Hospital #3).

The JQRIM minutes indicated that the Senior Director of Patient Safety, an employee of Hospital #2, presented to the JQRIM Committee the process on safety reporting in Hospital #2's computerized system. The presentation indicated that the reports were reviewed by department managers, risk management, patient medication safety officer at Hospital #2 and if the event caused any level of harm the report is automatically emailed to a senior leadership for review. Root cause analyses were conducted for serious or potentially serious events as well as selected near misses. An internal safety coding team reviewed all reports and standardized the event type and severity level coding. A multidisciplinary review committee which included nurses, pharmacists and representatives from all the relevant clinical areas reviewed the select cases for follow-up and trended data and the data was used to drive improvement.

Based on records reviewed and interviews, Hospital #1 failed to take actions through the hospital's QAPI program to: assess those services provided under contract, identify quality and performance problems, implement appropriate corrective or improvement activities and ensure the monitoring and sustainability of those corrective or improvement activities.

Findings included:

1. Review of the list of contracted services provided by Hospital #1 indicated that Hospital #1 had contracted for 33 services from Hospital #2 to include but not limited to: admitting and patient registration, care coordination/utilization review, central processing, clinical compliance and risk management, environmental services, food and dietary services, health information services; human resources; infection prevention and control; information systems, nutrition, patient care plans and nursing services, pharmacy services, physician services, quality assurance, radiology, rehabilitation services and respiratory care services.

According to the contracted service agreements, each fiscal year the department was to complete a standardized scorecard detailing performance in their quality metrics for the year and submit it to the Medical Director of Inpatient Medical Oncology Service and the Associate Chief Nurse of Oncology of Hospital #2. This staff would review the scorecards and determine any corrective actions and provide a summary to Oncology Leadership at Hospital #2. Each department would be scheduled for an annual report to Oncology Leadership forums, as appropriate, to the service provided. Presentations may be consolidated as needed (for example one consolidated in Patient presentation to JQRIM (Joint Committee on Quality Improvement and Risk Management) by the Medical Director of Inpatient Medical Oncology Service and the Associate Chief Nurse of Oncology from Hospital #2.

On 8/3/2016, at 8:00 A.M., Hospital #1's senior management team was asked to produce any documentation to indicate that the JQRIM (governing body) had assessed, through its QAPI program, all the contracted services for quality and safety as well as review of performance improvement programs for monitoring and sustainability in those services in the past two years. By the end of the day, the management team was unable to produce the requested information that Hospital #1's QAPI process had independently evaluated all the contracted services.

Based on records reviewed and interviews, Hospital #1 failed to: have a performance improvement program separate from Hospital #2 whose efforts addressed priorities for improved quality of care and patient safety, ensure that all improvement actions were evaluated and determine the number of distinct improvement projects that would be conducted annually.

Findings included:


Hospital #1's QAPI plan was requested. A document titled "Quality Improvement Plan", revised in April 2016, indicated that each department is responsible for: reviewing new and existing processes and routines relevant to each performance area, developing, collecting and monitoring key quality indicator to measure performance, assessing and interpreting data collected to formulate recommendations, actions and evaluation, developing activities and processes to comply with external regulatory standard and reporting to appropriate oversight committee on results of quality improvement activities.

Each department manager was responsible and accountable for monitoring, evaluating and improving the care and services provided by their department and for those contracted services related to the provision of safe oncology care. Managers will ensure that quality improvement data was gathered, aggregated and reported to the appropriate oversight committee for review and corrective action was implemented in a timely manner.

The plan did not determine, for each department, what distinct improvement projects would be performed in 2016.

The Surveyor interviewed the Associate Chief Nurse for Hospital #2 at 2:00 P.M.on 8/3/2016. The Associate Chief Nurse for Hospital #2 said that performance improvement in nursing quality is done through nursing at Hospital #2 and encompasses the inpatient pods of Hospital #1. All data is collected and evaluated for all patient units including the inpatient areas of Hospital #1. When trends are noted, the nurse managers of the each pod are notified and are asked to address care issues. Each manager of Hospital #1's inpatient units were employees of Hospital #2 and managed other inpatient units of Hospital #2. Performance improvements for issues such as pressure sores, Catheter Associated Urinary Tract Infections (CAUTI) may be the same for all inpatient units for both hospitals and not specific to Hospital #1. The Associate Chief Nurse for Hospital #2 said that nursing quality issues were reviewed at Hospital #1.

Based on records reviewed and interviews, Hospital #1 failed to allocate resources to measure, assess, improve and sustain Hospital #1's performance and reduce risk to patients. Instead Hospital #1 relied upon Hospital #2, its contracted service, to perform these functions and took no independent responsibility to ensure that quality and performance improvement were maintained and sustained.

Findings included:

Hospital #1 contracted it quality assurance and performance improvement activities to Hospital #2 with little oversight.

Hospital #1 had appointed a Director of Quality and a Risk Manager who worked with Hospital #2. Hospital #2 reviewed all patient safety events, conducted investigations and root cause analyses when required which were shared with Hospital #1.

Although the Director of Quality and the Risk Manager attended Hospital #1's Joint Committee on Quality Improvement and Risk Management (JQRIM) and were members of Hospital #1's Quality Leadership Council, all the data was collected, analyzed and measured by Hospital #2. Hospital #2, the contracted service, presented all the data at these meetings. Performance measures were designed and implemented by Hospital #2.

Based on records reviewed and interviews Hospital #1 failed to provide a consistent, separate and independent process that applied equally to all staff as it related to credentialing and privileging.

Findings included:

The Surveyor interviewed the Chair of the Credentialing Committee at 3:15 P.M. on 8/2/16. The Chair of the Credentialing Committee said that there was overlapping of the credentialing processes between Hospital #1 and Hospital #2 and it was a symbiotic relationship.

The Surveyor interviewed the Credential Representative from Hospital #2. The Credential Representative said that Hospital #1 and #2 had a joint credentialing system in place for many years.

The Credential Representative provided the Surveyor with a copy of a letter from the State Board of Registration in Medicine (BORM), dated 12/1/2001. The BORM letter indicated a unified approach to credentialing would improve efficiency and reduce duplication.

The Surveyor interviewed the Credential Representative from Hospital #1 at 10:55 A.M. on 8/4/16. Credential Representative #1 said that Hospital #1 relied on Hospital #2 to provide to Hospital #1 a jointly credentialed candidate's primary source verification, education and training, hospital affiliations, professional references, board certifications, insurance information and claims, Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) and requests for clinical privileges for the candidates seeking credentials with the Medical Staff at Hospital #1. Credential Representative #1 said Hospital #1 would then provide primary source verification of the candidate for licensure, National Data Base information, and the System for Award Management before presenting the candidate to Hospital #1's Credential Committee for approval.

Credential Representative #1 said if the candidate was not to be jointly credentialed with Hospital #2, then Hospital #1 would compile all of the candidate's credential requirements for presentation to the Credential Committee.

Hospital #1's Cardio-Pulmonary Resuscitation (CPR) Manual, dated 6/2014, indicated a pediatric anesthesiologist from an adjoining Pediatric Specialty Hospital (Hospital #3) should perform pediatric intubations (the placement of a flexible plastic tube into the windpipe to maintain an open airway) for Hospital #1's pediatric patients.

The Surveyor interviewed the Manager of Quality and Safety at 4:20 P.M. on 8/3/16. The Manager of Quality and Safety said that while there were a number of credentialed Anesthesiologists from Hospital #3 who regularly provided services to the pediatric patient at Hospital #1 in an emergency, the responding Anesthesiologist from Hospital #3 might not have been credentialed or hold privileges at Hospital #1.

The Surveyor interviewed the Nurse Director of Hospital #1's Outpatient Satellite Treatment Center at 9:35 A.M. on 8/3/16. The Nurse Director of Hospital #1's Outpatient Satellite Treatment Center said when an emergency response (i.e. Code Team or Rapid Response) was needed by a patient receiving treatment at Hospital #1's outpatient center, the emergency response team working at adjoining Hospital #4 provides the emergency care to Hospital #1's patient. The Nurse Director of Hospital #1's Outpatient Satellite Treatment Center said the responders from Hospital #4 included the Chief of Medicine, a Critical Care Unit Nurse, the Nurse Educator or Nursing Supervisor, Anesthesia and Respiratory Therapy.


The undated Service Agreement (Code Team Services) indicated that Hospital #4 would provide emergency response (i.e. Code Team or Rapid Response) to Hospital #1's outpatient unit with staff performing services on behalf of Hospital #4.


The Surveyor interviewed the Nurse Director of Hospital #1's Outpatient Satellite Treatment Center at 9:35 A.M. on 8/3/16.
The Nurse Director of Hospital #1's Outpatient Satellite Treatment Center provided Hospital #4's policy for the Rapid Response Team, dated December 2012. The Nurse Director of Hospital #1's Outpatient Satellite Treatment Center said this policy was used during an emergency response at Hospital #1's outpatient satellite.


Hospital #4's policy indicated the response team included a critical care nurse, a medical house officer, and a respiratory therapist, all of whom worked for Hospital #4.

Based on records reviewed and interview Hospital #1 failed to create an independent and separate nursing service governed by accepted policies and procedures and fully responsible for the operation of the nursing service including the scheduling of nursing personnel to provide care for patients.

Findings included:


The Vice President of Adult Nursing and Clinical Services was interviewed at 8:40 A.M. on 8/1/16. The Vice President of Adult Nursing and Clinical Services said Hospital #1 had a joint contract with Hospital #2 to provide nursing care to the inpatient units.

The Surveyor interviewed Unit 5A Registered Nurse (RN) #1 at 9:00 A.M. on 8/1/16. RN #1 said she and all the staff working on the unit were employed by Hospital #2. RN #1 said Hospital #2 provided all of the services to the patients on the unit including care coordination, pharmacy, food, transport and infection control.

The Surveyor interviewed Unit 5B Registered Nurse (RN) #2 at 10:40 A.M. on 8/1/16. RN #2 said when a patient on the unit required a medical emergency response team i.e. the Code Team (Cardiac Arrest), the Rapid Response (a patient exhibiting signs of clinical deterioration) or a STAT Nurse (additional nursing staff), Hospital #2 provided these response teams. RN #2 said these were specially trained teams who would respond to emergencies on both Hospital #1 and #2's patient units located within the tower building.

The Surveyor interviewed the Risk Manager for Hospital #2 at 10:55 A.M. The Risk Manager for Hospital #2 said if a Hospital #1 patient required IV (Intravenous) therapy services or placement of a peripherally inserted central catheter (PICC), the nursing team working at Hospital #2 would be called to perform this specialized service.

The Surveyor interviewed the Interim Nursing Director at 11:40 A.M. on 8/2/16. The Interim Nursing Director said she was employed by Hospital #2 and provided supervision to Hospital #1's contracted nursing staff. The Interim Nursing Director said she was responsible for scheduling and evaluating the contracted nursing staff.


The Surveyor interviewed the Nurse Director of the Hospital #1's Outpatient Satellite Treatment Center at 9:35 A.M. on 8/3/16. The Nurse Director of the Hospital #1's Outpatient Satellite Treatment Center said when an emergency response (i.e. Code Team or Rapid Response) was needed by a patient being treated at Hospital #1's outpatient center, the emergency response team working at adjoinig Hospital #4 provided the emergency care to Hospital #1's patient. The Nurse Director of the Hospital #1's Outpatient Satellite Treatment Center said she only provided oversight to the eight (8) contract employees working in the Outpatient Center.

Based on records reviewed and interviews, the nursing service of Hospital #1 failed to ensure that contract nursing staff employed by Hospital #2 met all licensing, education and certification requirements of Hospital #1.

Findings included:

The Surveyor interviewed the Interim Nursing Director at 11:40 A.M. on 8/2/16. The Interim Nursing Director said she was employed by Hospital #2 and provided staff evaluation for Hospital #1's contracted nursing staff. The Interim Nursing Director said all newly hired contracted nurses were oriented at Hospital #2's new hire orientation program. The Interim Nursing Director said unit orientation was provided by the Nurse Educators from Hospital #2. The Interim Nursing Director said orientation to Hospital #1's nursing units was provided by the contracted nurses from Hospital #2.


The Surveyor reviewed six contract nurses personnel and education records for Hospital #1's contracted staff at 3:00 P.M. on 8/2/16. The Interim Nursing Director assisted in the review. The records indicated the annual nursing review was completed by the Interim Nursing Director and the education was an on-line program furnished by Hospital #2.

Contract RN #1's orientation summary, dated 1/28/14 thru 4/11/14, indicated the orientation to Hospital #1 was provided by Hospital #2, including orientation to Hospital #2's Clinical Practice Manual, Patient Education Material and Blood Transfusion policy.

The Surveyor interviewed the Float Pool Manager, employed by Hospital #2, at 2:30 P.M. on 8/2/16. The Float Pool Manager said there were fifty five (55) nurses eligible to be STAT or Code Nurses. The Float Pool Manager provided the Float Pool-Code RN Competency Schedule, dated 2015, to the Surveyor. The Float Pool-Code RN Competency indicated Hospital #2's code policies were used to evaluate competency.


The Surveyor interviewed the Nurse Director of Hospital #1's Outpatient Satellite Treatment Center at 9:35 A.M. on 8/3/16. The Nurse Director of Hospital #1's Outpatient Satellite Treatment Center said when an emergency response (i.e. Code Team or Rapid Response) is needed by a patient being treated at Hospital #1's outpatient satellite center, Hospital #4's emergency response team provided the emergency care to Hospital #1's patient. The Service Agreement indicated the response team members were to be employees in good standing from Hospital #4.

Based on records reviewed and interview, Hospital #1 failed to ensure that contracted nursing staff adhered to Hospital #1's policies and procedures or that Hospital #1 provided supervision and evaluation of the clinical activities for each contracted staff person.

Findings included:

The Surveyor interviewed Unit 5B Registered Nurse (RN) #3 at 8:40 A.M. on 8/2/16. RN #3. When RN #3 was asked to access the Hospital's nursing policies and procedures, RN #3 demonstrated the on-line policy manual labeled as Hospital #2's nursing policy manual.

The Surveyor interviewed the Associate Chief Nurse of Oncology, Medical and Integrative Nursing at 4:30 P.M. on 8/2/16. The Associate Chief Nurse of Oncology, Medical and Integrative Nursing said she was employed by both Hospital #1 and Hospital #2. The Associate Chief Nurse of Oncology, Medical and Integrative Nursing said she managed ten (10) Nursing Directors who in turn supervised the Oncology Service including the three (3) units licensed to Hospital #1. The Associate Chief Nurse of Oncology, Medical and Integrative Nursing said the ten Nursing Directors were employed by Hospital #2. The Associate Chief Nurse of Oncology, Medical and Integrative Nursing said the Nurse Educators were employed by Hospital #2 and provided education, training and competency evaluation for Hospital #1's contracted nurses. The Associate Chief Nurse of Oncology, Medical and Integrative Nursing said the policies used on the inpatient units were solely from Hospital #2 and Oncology specific policies were written dually by Hospital #1 and #2.


The Surveyor interviewed the Interim Nursing Director at 11:40 A.M. on 8/2/16. The Interim Nursing Director said she was employed by Hospital #2 and provided supervision to Hospital #1's contracted nursing staff including the performance evaluations for the contracted nursing staff.


The Surveyor interviewed the Nurse Director of Hospital #1's Outpatient Satellite Treatment Center at 9:35 A.M. on 8/3/16. The Nurse Director of Hospital #1's Outpatient Satellite Treatment Center said when an emergency response (i.e. Code Team or Rapid Response) is needed by a patient being treated at Hospital #1's outpatient center, adjoining Hospital #4's emergency response team, including nurses, provided the emergency care to Hospital #1's patient. The Nurse Director of Hospital #1's Outpatient Satellite Treatment Center said the responders from Hospital #4 included the Chief of Medicine, Critical Care Unit Nurse, the Nurse Educator or Nursing Supervisor, Anesthesia and Respiratory Therapy.


The undated Service Agreement between Hospital #1 and Hospital #4 related to the Code Team Response indicated the Emergency Response Team responded to Hospital #1's emergencies. The Service Agreement indicated personnel responding to the emergency were to follow Hospital #4's guidelines and response policy. The Agreement indicated the staff were performing services on behalf of Hospital #4.


The Nurse Director of the Hospital #1's Outpatient Satellite Treatment Center said she only provided oversight to the eight (8) contract employees working in the Outpatient Center.


The Surveyor reviewed the Service Agreement between Hospital #3 (a pediatric specialty hospital) and Hospital #1, dated 6/30/2009. The Agreement indicated that Hospital #3 would provide an emergency response team, including three senior nurses, in the event of a pediatric code at Hospital #1. The Agreement indicated that the nurses responding to the pediatric code would leave the pediatric specialty hospital and be met at a Hospital #1 entrance by Security Staff from Hospital #1 who would direct the pediatric code responders to the location of the emergency. The Agreement indicated that nurses would be duly licensed in the State, however, theses nurses were not on staff or contracted with Hospital #1.

Based on records reviewed and interviews, Hospital #1 failed to establish separate and independent policies to govern the use of blood products.

Findings included:

The Survey team requested the Hospital #1's policy on Blood Transfusion at the opening conference. The policy, titled Blood Products Administration, indicated the policy was from Hospital #2 with Hospital #2's approval dates and there was no evidence that Hospital #1 had reviewed or approved this policy for use in the inpatient units.

Based on records reviewed and interviews Hospital #1 failed to maintain a medical record service for the thirty (30) inpatient beds licensed to Hospital #1 that was exclusive to Hospital #1.

Findings included:

The Surveyor interviewed the Director of Health Information Services at 2:00 P.M. on 8/2/16. The Director of Health Information Services said the medical records for Hospital #1's patients was a joint venture with Hospital #2. The Director of Health Information Services said Hospital #2 will maintain Hospital #1's inpatient medical records.

The Surveyor interviewed the Nurse Educator for the Oncology service at 10:50 A.M. on 8/1/16. The Nurse Educator said if Hospital #1 received a patient request for their medical record, the patient would be sent to Hospital #2's medical record services.

Based on observations, records reviewed and interviews, Hospital #1 failed to ensure a completed medical record for 4 patients (Patient #3, #6, #7 and #8) in a sample of 14 patient records.

Findings include:


During a tour of 6C on 8/1/16 at approximately 2:00 P.M., the Surveyor observed that electronically generated medication orders were titled Protocol Regimen Orders and placed in the inside jacket binder of Patient #6, #7 and #8's medical record. The orders titled Protocol Regimen Orders were not identified with patient names for proper identification and may have lead to medical errors.

Patient #7's consent for placement of a tunneled catheter, dated 7/20/16 and to be performed in the interventional radiology department, was not timed.

Patient #8's consent for placement of a tunneled catheter, dated 7/8/16 and to be performed in the interventional radiology department, was not timed.

Patient #8's blood transfusion record, dated 8/1/16, did not contain the discipline of the staff member who verified the patient's informed consent and verified the unit of blood to the patient's identification.

Patient #3's blood transfusion record, dated 8/1/16, did not contain the discipline of the staff member who verified the patient's informed consent and verified the unit of blood to the patient's identification.