HospitalInspections.org

Based on record review and interviews with hospital staff, the hospital does not ensure a list of all contracted services is maintained with the scope and nature of the services provides. This was verified on 04/19/12 in the afternoon with Staff.

Based on interviews with hospital staff and hospital record review, the hospital failed to provide specific privileges and limitations for each practitioner credentialed by the hospital. This occurred in one (O) of two (M) allied health professionals' (AHP) credential files reviewed and one (K) of four (J,K,L,N) physicians' credential files reviewed.

Findings:

1. One (O) allied health professional (AHP) credential file reviewed did not contain specific privileges or limitations authorized by the hospital that the AHP may perform when working in the emergency department. The allied health professional was licensed as a physician assistant (PA).

2. Another AHP's (M) credential file reviewed contained a job description listing the duties/limitations that the AHP may perform. A job description was not contained in the credential file of AHP (O).

3. One (K) physician's credential file did not contain what specific privileges the physician had been granted/authorized to perform in the hospital.

4. Hospital staff verified on 04/19/12 in the afternoon that the credential files for these practitioners did not record what specific duties/privileges they were authorized to perform in the hospital.

Based on record review and interviews with hospital staff, the hospital does not ensure the consultant pharmacist evaluates the performance and competency of pharmacy personnel who provide pharmacy services when the consultant pharmacist is not on the premises. Two (P & Q) of two pharmacy personnel files did not contain evidence of orientation to the pharmacy, performance evaluations, or job descriptions. Staff (B) who was designated as the Drug Room Supervisor did not have evidence in her file of orientation to the drug room or a job description that included Drug Room Supervisor as part of her duties.

Based on review of policy and procedure and interviews with staff the facility failed to ensure radiology exams were provided in a safe manner.
Findings:

1. The facility did not have documentation stipulating staff were licensed, trained, and competent in radiation safety.

2. Radiology staff did not have departmental orientation and training. There was no documentation radiology staff were competent in radiation safety techniques for themselves and patients.

3. There were no current clinical performance evaluations of radiology staff.

4. There was no documentation the contracted ultrasound service had been oriented to the facility. There was no documentation the ultrasound personnel were licensed, trained, and competent to provide services.

5. This finding was reviewed with administration at the exit conference. No further information was provided.

Based on review of policies, and interviews with staff, the hospital failed to ensure a qualified radiologist supervises the radiology services. On the afternoon of 4/19/12 Staff R told surveyors the facility did not have a specified radiologist that supervised radiology services. These findings were discussed with administration at the exit conference 4/19/12.

Based on review of policies, personnel files, and interviews with staff the facility failed to designate competent, qualified radiology personnel.

Findings:
1. There were no current policies or documents reviewed and approved by the medical staff and radiologist indicating personnel competent to use the radiological equipment and administer procedures.
2. The facility did not have documentation stipulating staff were licensed, trained, and competent in radiation safety.
3. Two of two radiology staff (R,S) did not have departmental orientation and training.
4. There was no documentation (R,S)were competent in radiation safety techniques for themselves and patients.
5. There were no clinical performance evaluations of (R,S) in the personnel files.

Based on review of medical records, policies and procedures, dietary consultation reports, and interviews with staff, the facility failed to ensure dietary services were provided in an organized manner and policies, procedures, and processes were reviewed, approved and implemented.

Findings:


1. On 4/18/2012 in the morning, dietary policies and procedures were provided to surveyors. There was no documentation indicating the policies had been reviewed and approved through the hospital's medical staff or governing body since 2005. There was no documentation menus had been reviewed by the dietitian and approved by the medical staff. No formalized policy for nutritional screening and nutritional assessment were provided. There were no nursing policies regarding nutritional screening.

2. Dietary personnel files were reviewed. There was no dietary departmental specific training included. The dietitian indicated in the monthly consultation report training topics for the month. There was no documentation indicating how staff hired after a particular training was provided would obtain the information they needed. There was no formalized orientation and training plan provided. There was no evidence a formalized orientation, training and competency program had been developed based on dietary policies, procedures, and processes.

3. On 4/18/2012, surveyors reviewed dietary consultation reports. The dietitian (Staff U) listed in the report did not have documentation of a current license, orientation, training, and evaluation.

Based on review of hospital documents and interviews, the hospital failed to ensure a qualified dietitian supervises the nutritional aspects of patient care. Staff U was listed as the consulting dietitian. There was no contract personnel file for Staff U. There was no evidence Staff U had current licensure and registration. There was no documentation Staff U had been oriented, trained, and evaluated to work in the facility.

Based on review of policies, personnel files, and interviews, the hospital failed to provide adequate training and oversight to dietary personnel.

Findings:

1. On 4/19/2012 surveyors reviewed dietary personnel records (Staff T and V). There was no documentation, policy, procedure, or process in place stipulating how new dietary department employees would be trained on the inservice material presented before they were hired. There was no documentation the employees had been oriented and trained to the facility and specific dietary department.

2. Dietary documents did not include a departmental specific orientation and training for each dietary job description. The facility did not have evidence the dietary department employees were trained to perform the duties each were hired/assigned to do.

3. On 4/18/2012 Staff A told surveyors the Dietary Manager was Staff T. There was no documentation the Food Services Director had oversight by the dietitian for clinical aspects of nutritional services. There was no evaluation of the Food Services Director for clinical nutritional competency by the dietitian. Review of patient medical record at times included a "nutritional care plan" signed by Staff T. There was no documentation Staff U reviewed these forms. There were no recommendations on any of the plans reviewed by surveyors. There was no documentation the dietitian oversaw the clinical aspects of the Dietary Manager's job.

Based on review of infection control data and meeting minutes containing infection control, and hospital documents, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner developed and maintained a comprehensive system for reporting, analyzing and controlling infections and communicable diseases among patients and staff and ensuring a sanitary environment.

Findings:

The hospital did not have an infection control plan. This was confirmed with Staff B on 04/19/2012. The hospital's infection control program/policies did not specify the types and frequencies of surveillance/monitoring activities. The program did not specify how the surveillance activities would be evaluated. It did not specify that corrective actions would be developed if needed, to ensure infection control policies and recognized aseptic practices were followed. Meeting minutes containing infection control data, Infection Control Committee and Quality Council (Quality), did not reflect that, except for patient infections and protective equipment, the hospital monitored, reviewed practices, developed corrective actions for problems/concerns and conducted follow-up to ensure a safe and sanitary environment was provided for patients and staff.

1. The meeting minutes did not contain any mention of topics relating to staff or the analysis of any patient infections and/or communicable diseases related to staff illness/infections.
a. The infection control log only contained patient infections and meeting minutes only recorded patient communicable diseases.
b. Employee files contained documentation of illness. On 04/19/2012, Staff B stated she did not report employee illness to infection control or Quality.
c. The infection control program did not evaluate all staff and credentialed personnel for immunization status as recommended by the CDC(Centers for Disease Control and Prevention) and its Advisory Committee on Immunization Practices. Four of four physicians' and two of two allied health files reviewed did not contain complete immunization histories. Two of eight employee personnel files reviewed did not contain complete immunization histories. The hospital did not track immunization histories for contract staff.
d. These findings were reviewed with administrative staff on the afternoon of 04/19/2012.

2. The meeting minutes did not contain review and approval of the hospital's disinfectant to ensure it was appropriate, or contain evidence the infection control program monitored the application of the disinfectant to ensure it was applied, and remained wet, according to the manufacturer's guidelines.
a. This finding was reviewed and confirmed with Staff B on 04/19/2012. She stated she talked with the head of housekeeping who said the prior staff responsible for infection control had said it was appropriate.
b. Staff I, housekeeping staff whose personnel file was reviewed, did not contain a job description. The personnel file did not contain evidence of competency training for the housekeeping duties. The file did not contain evidence Staff I had been orientated to the hospital, or her expected duties. The surveyors ask if additional data was available; none was provided.

3. Monitoring activities, provided for review, did not include active surveillance of the practices to ensure staff adhered to the policies to avoid possible transmission of infections. On 04/19/2012, Staff B confirmed that only personal protective equipment, which included handwashing, was monitored.
a. On the afternoon 04/18/2012, one surveyor attempted to use the hand sanitizer outside a bathroom that did not contain a hand washing sink. The sanitizer was empty.
b. On the afternoon of 04/19/2012, one surveyor observed laboratory staff did not have hand sanitizing capability, either hand washing facility or hand sanitizer, available at the file where the personnel performed specimen draws.
c. This was discussed with administrative staff on the afternoon of 04/19/2012.

Based on review of hospital documents, personnel files and interview with staff, the hospital failed to ensure that respiratory services/procedures were administered by trained staff with each respiratory therapy procedure performed by each employee designated in writing, including the amount of supervision required when performing each procedure. This occurred for two of three nursing staff (Staff D and F of Staff D, F, and G), whose personnel files were reviewed and who were identified through medical record review as providing respiratory services.

Findings:

1. Six patient medical records reviewed, Records #4, 13, 16, 17, 18, and 19, contained documentation that nursing staff administered handheld nebulizer treatments to patients.

2. Review of nursing personnel files did not demonstrate staff had been trained/competency evaluated by the respiratory therapist in providing each respiratory service with a designation of the amount of supervision required for each individual providing the service.

3. On the afternoon of 04/19/2012, Staff B confirmed that nursing staff did administer respiratory treatments and stated that the respiratory therapist had not provided training/competency evaluation on all nursing staff who provided the respiratory treatments.

4. The personnel file for the respiratory therapist, Staff H did not contain documentation of orientation to the department or verification of competency by the physician director.

Based on review of medical records, policy and procedure, and interviews with staff the facility failed to provide nutritional services that met the needs of the patient. On 4/18/2012 Staff A told surveyors the patient population varied and several types of patients were served by the facility. Review of the patient's medical records indicate patients had varying comorbidities. Several records reviewed indicated patients had disease processes which would increase their nutritional risk. There was no documentation current menus had been reviewed and revised by a clinical dietitian to meet the needs of the types of patients the facility cared for. There was no documentation the supplements and parenteral nutrition were reviewed and approved by the dietitian. There was no documentation modified diets were reviewed and revised by the dietitian. There was no documentation nutritional care plans were reviewed with recommendations for nutritional care provided to patients.