HospitalInspections.org

Based on document review and staff interviews, it was determined that the facility failed to include contracted services, including the scope of service, in the QAPI program (A0267), failed to review and follow up on incident reports to identify opportunities for improvement and changes that would lead to improvement (A0276 and A0289) and failed to ensure the CEO monitored its QAPI activities to assure review and follow-up action was taken on reported issues (A0309).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure monitoring of the effectiveness and safety of service and quality of care.

Based on document review, observations and staff interviews, it was determined that the facility failed to ensure an RN supervised the care (A0395) to patients on the behavioral health unit (BHU).

The effect of this problem resulted in the hospital's inability to ensure the provision of quality healthcare in a safe environment.

Based on document review and staff interviews, it was determined the facility failed to ensure radiology services were available to meet the needs of 4 of 4 patients that were ordered radiology services as identified on Event Report Quality Improvement/Peer Review forms(A0529).

The effect of this systemic problem resulted in the hospital's inability to ensure the provision of quality healthcare.

Based on document review and staff interviews, it was determined the facility failed to ensure the hospital had an agreement with a Quality Control Improvement Organization (QIO) and there are no CMS-approved State required plans for utilization review (A0653), failed to have a utilization review committee (A0654), failed to ensure a member of Utilization Review (UR) committee determined the medical necessity of patient admission and/or continued stay (A0656) and failed to ensure Utilization Review (UR) committee reviewed professional services provided (A0658). It could not be determined that outlier cases were identified and reviewed by the utilization review (UR) committee (A0657).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe environment.

Based on document review and interview, the governing body failed to ensure the CEO fulfilled his/her responsibilities for managing the hospital.

Findings included:

1. The Quality Assurance/Performance Improvement (QAPI) committee minutes were reviewed for 9/2009 through 8/2010. In all 12 months, the departments were reporting incidents from their departments. The minutes did not reveal recommendations or action plans on resolving direct patient care issues (see tag 0276).

2. There was evidence of STAT radiology orders and other radiology procedures not being done in a timely manner due to lack of staff available (see tag 0529).

3. The facility environment was not maintained at a level of acceptable quality and safety (see tags 0701 and 0724).

4. The contracted services list did not include scope of services and none of the contracted services were included in the QAPI program.

5. In interview with AD4 on 9/16/10 at 2:00 PM, AD4 indicated he/she is also CEO of another hospital in another state.

6. AD1 confirmed that AD4 works every other week at this facility.

Based on document review and interview, the Governing Body failed to include all contracted services in the QAPI program, thereby failing to assure services were furnished in compliance with applicable conditions and standards.

Findings included:

1. Listed contracted services of emergency physicians, dietician, CRNA, medical director (quality improvement), professional services, sleep specialist, psychiatric services, path lab, health rehab, speech pathologist and radiology services were not included in the QAPI program.

2. Unlisted contracted services of American Red Cross, pest control and HVAC, for which no contract was provided, were also not included in the QAPI program.

3. By interview with AD8 on 9/16/10, there were contracts with the entities of American Red Cross, pest control and HVAC.

4. Contracts for American Red Cross, pest control and HVAC were not provided by time of exit.

Based on document review and interview the facility failed to notify patients in writing of the outcome of complaint investigation.

Findings:

1. Review of hospital "Complaint Policy," last revised 7/09, outlined the steps to complaint resolution and indicated under procedure #2, "Once resolution is obtained, the hospital will provide the patient with written notice of its decision."

2. By interview at 1:30 PM on 9/16/2010, staff member AD1 indicated not all patients receive written notice of decision.

3. Documentation of a written notice of decision for patients 100-114 listed on the Complaint Log (7/5/09 through 8/29/10) was requested and none were provided by time of exit.

Based on document review and interview, the governing body failed to ensure the CEO
monitored its QAPI activities to assure review and follow-up action was taken on reported issues.

Findings included:

1. Event Report Quality Improvement form for patient A21 dated 6/1/2010 at 5:30 PM in Med Surg indicated "IVABx given before Bld cultures drawn because lab did not draw culture till 1730 pt admitted @ 1300." There was no review or follow-up action documented.

2. Event Report Quality Improvement form for patient A22 dated 6/1/2010 with no time marked indicated cardiac enzymes ordered timed, were missed by lab by several hours. The report noted a delay in procedure. There was no review or follow-up action documented.

3. Event Report Quality Improvement form for patient A23 dated 6/1/2010 at 1730 PM indicated "lab unable to draw bld cultures. Nsg had to draw in order to be compliant..." There was no review or follow-up action documented.

4. Staff #12 indicated in an e-mail that lab staff has been cut drastically over the last year, from 9 full time employees (FTE) to 6 FTEs leading to difficulty in meeting turn around times and keeping up with maintaining procedures.

5. Event Report Quality Improvement form for patient A24 for occurrence dated 6/11/2010 indicated patient had central line at 4:00 PM, labs needed to be drawn but were not completed until the morning of 6/12. There was no review or follow-up action documented.

6. Event Report Quality Improvement form dated 5/26/2010 at 0830 for D1 identified ACU department called down to the Radiology (RAD) Department that ACU was ready for a RAD tech to come to ACU and operate the C-arm for facet injections for patient D1. There was not a tech available due to the decrease in staff. The identified ordering physician stated there was a delay in treatment. There was no review or follow-up action documented.

7. Event Report Quality Improvement form dated 5/29/2010, no time, identified patient D2 "had a CT head w/o contrast. The report from.....recommended a MRI head which couldn't be done because there wasn't a MRI tech here." There was no review or follow-up action documented.

8. D2's medical record identified a MRI head test to be conducted which could not be done because there was not a MRI tech available. The medical record indicated the test was done on 5/30/2010 at 7:37 PM.

9. Event Report Quality Improvement form dated 6/7/2010, 1530, identified a mammogram patient (D3) had to be rescheduled due to reduction in staff. The report identified the technologists will not be available on the day the patient is scheduled which resulted in delayed treatment and inconvenience to the patient.

10. D3's medical record identified the scheduled date was marked through and date 6/27/2010 was written in the box. The patient's records indicated a previous right mastectomy for breast cancer and nodule noted in the left breast on previous mammogram.

11. Review of patient #N13 medical record indicated the following: The patient had an order written on 7/8/10 for a stat chest x-ray at 4:35 a.m. The x-ray was not completed until 5:57 a.m.

12. The July radiology employee schedule revealed there was no one on schedule at the hospital between 3:00 AM and 6:00 PM on 7/8/10.

13. At 2:00 PM on 9/14/2010, staff member AD6 indicated the Radiology Department staff technologists were reduced by 2 staff members which resulted in a 3 hour time frame during the night without someone at the hospital. However, a staff member would be on call. The hospital does not have a radiology on-call policy when no RAD techs are onsite.

14. At 3:30 PM on 9/16/2010, staff member AD9 indicated he/she was on call to perform chest x-rays if needed on 7/8/10 and he/she lives 30 minutes from the hospital. Staff member AD9 indicated a report was sent to the Radiology Department for a stat x-ray on the patient in question. The staff member indicated he/she never received a call from the hospital to perform an x-ray.

15. Staff member AD9's payroll records identified the he/she reported to work at 5:55 AM on 7/8/2010.

16. The Technologist List policy reference number XR101.4 states staff member AD9 works full time from 7:00 PM to 7:00 AM. The July radiology employee schedule and employee payroll records identified the staff member worked from 3:00 PM to 3:00 AM. The time schedule in the policy did not match the actual time worked for the employees in the month of June and July.

17. Operating Policies-Radiology Department policy number XR1301.2 states, "STAT procedures will be performed as soon as possible, a representative of the department will be sent to escort the patient immediately upon receipt of the request, and the attending physician will be notified as soon as the film has been read and interpreted." The policy also stated, "Emergency Room procedures will take precedence over routine inpatient and outpatient examinations."

18. At 4:00 PM on 9/16/2010, staff member AD1 indicated staff was cut severely in June. Certain departments do not have 24/7 coverage within their department. Radiology and the laboratory are the areas that have been affected by staff reduction.

19. QAPI minutes from May through July 2010 were reviewed. Only 3 of the 8 previously listed events (incidents) were reported. No recommendations or follow-up actions were noted in the minutes.

20. Quality Assurance Plan (QAPI) reference #1002 last revised December 2009 states, "Focus upon what is performed throughout the facility, and how well it is performed to provide healthcare. To facilitate this goal, emphasis is place upon 'dimensions of performance'. These dimensions of performance include: Efficacy of the procedure or treatment in relation to the patient's condition; appropriateness of a specific test, procedure or service to meet patient's needs; Availability of a needed test, procedure or service to meet patient who needs it.; Timeliness with which a needed test, procedure, treatment or service is provided to the patient; Effectiveness with which tests, procedures, and treatment and services are provided'

21. Policy Test Prioritization reference #GN-250 Department of Laboratory states, "The test designated as STAT will receive priority. STAT tests are used in emergency situations, when a patient's life or limb may be at risk.

Based on document review, observation and interviews, the facility failed to ensure a registered nurse evaluated/supervised the care provided to 2 of 7 behavioral health (BHU) patients (#N13 and N21).

Findings include:

1. Review of patient #N13 medical record indicated the following:
(A) The patient had an order written on 7/8/10 for a stat chest x-ray at 4:35 a.m. The x-ray was not completed until 5:57 a.m.
(B) Behavioral health nurse notes dated 7/8/10 at 9:00 p.m. indicated the patient was sitting quietly at the nurse station with a congested cough noted. His/her O2 sats were 97% on 2.5 liters of oxygen. Antibiotics were started. The notes at 2:00 a.m. stated "Slept in room until this time- awoke- states shes "dying"- O2 84% on 3 L- congested cough present. Tylenol po given for generalized discomfort. The medical record lacked documentation that a physician was notified of the decreased O2 saturation level despite the increase in oxygen to 3 L.
(C) Behavioral health nurse notes dated 7/11/10 at 8:00 p.m. indicated the patients O2 saturation was 92% and breath sounds were diminished. Narrative notes at 12:30 a.m. stated "In bed with O2 maintained. HOB elevated 45 (symbol for degrees) expiratory wheezes audible. 3+ pitting edema to all extremities. Lungs wet. Breathe sounds diminished. Resp shallow & irregular. O2 sat 87%. The medical record lacked documentation that a physician was notified of condition and decreased O2 saturation expiratory wheezing.
(D) The physician was contacted at 10:40 a.m. on 7/12/10 of the patient's condition and the patient was transferred out the of unit to the medical/surgical unit at 11:00 a.m. on 7/12/10. Physician progress notes after the transfer indicated the patient had acute congestive heart failure, hyperkalemia, and hypoxemia.
(E) The patient was transferred to the intensive care unit (ICU) at 4:20 a.m. on 7/13/10 after a successful code. He/she had a critical high D-Dimer test of 2170 (normal 0.0-600) on 7/13/10. The results were called to nursing at 5:29 a.m.. The record lacked evidence that the nurse paged the M.D. to report the critical high D-Dimer.
(F) The patient passed away on 7/16/10.

2. Review of patient #N21 medical record indicated the following:
(A) An order was written on 9/11/10 for Clonidine .1 mg po if B/P > than 150. The medication administration record (MAR) indicated to give the Clonidine if the patient's systolic B/P was > 150. The patient's blood pressure was 157/85 at 8:00 a.m. on 9/13/10, 172/93 at 8:00 p.m. on 9/13/10 and 157/87 at 8:00 a.m. on 9/15/10. The Clonidine was not administered per order for the increased blood pressure.

3. Staff member #3 verified the medical record documentation for patient #N13 beginning at 5:30 p.m. on 9/16/10.

4. Staff member #2 verified in interview at 11:30 a.m. on 9/16/10 that the medication was not documented as administered for patient #N21.

Based on document review and staff interview, the facility failed to ensure medical records were completed within 30 days of discharge for 6 of 20 patients (#N7, N15-N18, and N20).

Findings include:

1. Patients #N7 and N15-N18 medical record lacked documentation of a discharge summary. Discharge dates were:
(A) Patients #N7, N15, and N18, discharged 8/9/10.
(B) Patient #N16, discharged 8/4/10.
(C) Patient #N17, discharged 7/15/10.

2. Patient #N20 was discharged 8/4/10. His/her discharge summary was not dictated until 9/11/10.

3. Staff member #3 verified the above beginning at 5:30 p.m. on 9/16/10.

Based on observation and staff interview, the facility failed to ensure staff stored medications according to acceptable principles for 1 of 1 anesthesia cart observed and 1 of 1 medication cart on the behavioral health unit (BHU).

Findings include:

1. During observation of the medication cart on the BHU beginning at 12:00 p.m. on 9/16/10, the following was observed:
(A) Internal meds were stored with external ointment medications including, but not limited to, opened tubes of triple antibiotic ointment and an opened tube of "butt paste" belonging to a patient that had been discharged >7 days prior to survey.

2. Observation of the facility's anesthesia cart at 2:00 p.m. on 9/16/10 (Thursday) indicated the following:
(A) A prefilled syringe was found in the top drawer with 2 cc of a clear substance. A sticker on the syringe indicated the substance was Vecuronium Bromide. The sticker did not contain a date when the medication was drawn up, who drew it up or when the medication expired.
(B) The cart also contained a pump type dispenser of lotion and an open zip type baggie of candy.

3. Staff member #ST1 indicated in interview at 12:40 p.m. on 9/16/10 that there were no surgeries in the operating room (OR) this week, therefore the syringe of medication would have been in the cart > 1 week.

Based on observation, the facility failed to ensure medications were secure and locked, when appropriate, for 2 of 4 units toured (med/surg, ICU).

Findings include:

1. During tour of the medical/surgical unit beginning at 1:00 p.m. on 9/16/10 the following was observed:
(A) No staff members were at the nurses station area for a period of 10 minutes.
(B) The door to the medication room toward the back of the nurses station was open. The room could be accessed in two (2) areas from the public hallway. The room contents include, but is not limited to, two (2) unlocked medication carts stocked with patient medication and a shelving unit with medications.

2. During tour of the intensive care unit (ICU) beginning at 1:15 p.m. on 9/16/10 the medication cart stocked with medications was observed unlocked outside the nurses station. The cart would not be visible to the nurse if he/she were providing care in a patient room.

Based on document review and interview, the facility failed to ensure radiology services were available to meet the needs of the patient for 4 (D1-3 and N13) of 4 patients that were ordered radiology services as identified on Event Report Quality Improvement/Peer Review forms.

Findings included:

1. Event Report Quality Improvement form dated 5/26/2010 at 0830 for D1 identified ACU department called down to the Radiology (RAD) Department that ACU was ready for a RAD tech to come to ACU and operate the C-arm for facet injections for patient D1. There was not a tech available due to the decrease in staff. The identified ordering physician stated there was a delay in treatment. There was no review or follow-up action documented.

2. Event Report Quality Improvement form dated 5/29/2010, no time, identified patient D2 "had a CT head w/o contrast. The report from.....recommended a MRI head which couldn't be done because there wasn't a MRI tech here." There was no review or follow-up action documented.

3. Event Report Quality Improvement form dated 6/7/2010, 1530, identified a mammogram patient (D3) had to be rescheduled due to reduction in staff. The report identified the technologists will not be available on the day the patient is scheduled which resulted in delayed treatment and inconvenience to the patient.

4. D3's medical record identified the scheduled date was marked through and date 6/27/2010 was written in the box. The patient's records indicated a previous right mastectomy for breast cancer and nodule noted in the left breast on previous mammogram.

5. Review of patient #N13 medical record indicated the following: The patient had an order written on 7/8/10 for a stat chest x-ray at 4:35 a.m. The x-ray was not completed until 5:57 a.m.

6. The July radiology employee schedule revealed there was no one on schedule at the hospital between 3:00 AM and 6:00 PM.

7. At 2:00 PM on 9/14/2010, staff member AD6 indicated the Radiology Department staff technologists were reduced by 2 staff members which resulted in a 3 hour time frame during the night without someone at the hospital. However, a staff member would be on call. The hospital does not have a radiology on-call policy when no RAD tech are onsite.

8. At 3:30 PM on 9/16/2010, staff member AD9 indicated he/she was on call to perform chest x-rays if needed on 7/8/10 and he/she lives 30 minutes from the hospital. Staff member AD9 indicated a report was sent to the Radiology Department for a stat x-ray on the patient in question. The staff member indicated he/she never received a call from the hospital to perform an x-ray.

9. Staff member AD9's payroll records identified that he/she reported to work at 5:55 AM on 7/8/2010.

10. The Technologist List policy reference number XR101.4 states staff member AD9 works full time from 7:00 PM to 7:00 AM. The July radiology employee schedule and employee payroll records identified the staff member worked from 3:00 PM to 3:00 AM. The time schedule in the policy did not match the actual time worked for the employee in the month of June and July.

11. Operating Policies-Radiology Department policy number XR1301.2 states, "STAT procedures will be performed as soon as possible, a representative of the department will be sent to escort the patient immediately upon receipt of the request, and the attending physician will be notified as soon as the film has been read and interpreted." The policy also stated, "Emergency Room procedures will take precedence over routine inpatient and outpatient examinations."

12. Policy Test Prioritization reference #GN-250 states, "The test designated as STAT will receive priority. STAT tests are used in emergency situations, when a patient's life or limb may be at risk."

Based on document review and interview, the facility failed to ensure the hospital had an agreement with a Quality Control Improvement Organization (QIO) and there are no CMS-approved State required plans for utilization review.

Findings included:

1. At 11:45 AM on 9/14/2010, staff member AD1 indicated the hospital does not have an agreement with a QIO.

2. The Utilization Management (UR) plan does not identify the hospital having an agreement with a Quality Control Improvement Organization.

Based on document review and interview, the facility failed to have a utilization review committee.

Findings included:

1. At 11:00 AM on 9/15/2010, staff member AD1 indicated the hospital does not have an Utilization Review committee or a contracted service that monitors the Utilization review of the hospital. The staff member indicated the hospital cannot meet Utilization Review Condition of Participation.

2. At 4:30 PM on 9/16/2010, staff member AD5 indicated the hospital had an Utilization Review committee; however, the previous CNO discontinued the committee because she felt the hospital had too many committees.

3. Utilization Management policy last reviewed December 2009 states, "Utilization Management is the function within the Case Management Plan that focuses on the Utilization of Clinical Resources. This Contributes to the overall purpose of the Case Management Plan. Reports Quarterly at the QCRC." The policy identified Utilization Review Nurse and a Utilization Review Physician comprise the Utilization Review Committee.

4. The policy fails to address the requirement of a minimum of 2 committee members being doctors of medicine or osteopathy.

Based on document review and interview, the facility failed to ensure a member of Utilization Review (UR) committee determined the medical necessity of patient admission and/or continued stay.

Findings included:

1. At 11:00 AM on 9/15/2010, staff member AD1 indicated the hospital does not have an UR committee or a contracted service that monitors the UR of the hospital. The staff member indicated the hospital cannot meet UR Condition of Participation.

2. At 11:30 AM on 9/15/2010, staff member AD1 and staff member AD6 indicated the hospital does not have UR committee; therefore, there was no documentation and/or meeting minutes to provide for review.

3. The Utilization Management UR process indicates the UR committee is to review for medical necessity and discharge planning. Any patients that do not meet criteria are to be discussed. The hospital does not have an Utilization Review Committee; therefore, this process was not done.

Based on document review and interview, it could not be determined that outlier cases were identified and reviewed by the utilization review (UR) committee.

Findings included:

1. At 11:00 AM on 9/15/2010, staff member AD1 indicated the hospital does not have an Utilization Review committee or a contracted service that monitors the utilization review of the hospital. The staff member indicated the hospital cannot meet Utilization Review Condition of Participation.

Based on document review and interview, the facility failed to ensure Utilization Review (UR) committee reviewed professional services provided.

Findings included:

1. At 11:00 AM on 9/15/2010, staff member AD1 indicated the hospital does not have an Utilization Review committee or a contracted service that monitors the Utilization review of the hospital. The staff member indicated the hospital cannot meet Utilization Review Condition of Participation.

Based on observation and interview, the facility failed to maintain the hospital environment in such a manner that the safety and well-being of patients are assured.

Findings included:

1. At 1:37 PM on 9/16/2010, The fire EXIT door in the MRI observation room was observed with a 6-foot artificial palm tree obstructing it, preventing easy access in case of evacuation.

2. At 1:45 PM on 9/16/2010, the patient hallway adjacent to the Radiology Department was observed with an outlet cover plate exposing electrical wiring.

3. At 1:45 PM on 9/16/2010, staff member AD8 indicated a cart hit the plate couple of weeks ago and it has not been repaired.

4. At 2:00 PM on 9/16/2010, the 3rd floor pantry next to the Sleep Lab was inspected. The floor in the pantry was observed soiled with dirt and other debris. The under counter microwave was observed with a paper towel in it caked in grease. The paper towel dispenser had no paper towels. Soiled paper towels were observed on the pantry counter. The sink was observed heavily soiled with dirt, grease and other soil debris.

5. At 2:40 PM on 9/16/2010, the third floor Room #357 was inspected. The room was disorganized with office supplies on bed and the floor was observed heavily soiled. The sharps biohazard container was completely full giving the appearance the room was utilized for patients.

Based on record review, review of the policies and procedures, laboratory studies, observation and staff interview, the facility failed to ensure supplies and equipment were maintained at an acceptable level of safety and quality in csix (6) areas ((laboratory, behavioral health unit, basement hallway, bulk tank storage room and chiller room).

Findings included:

1. The policy, "Body Fluid Analysis", effective 3/15/08, read: "Cerebrospinal Fluids (CSF) should be divided into 4 samples and collected in sequentially tabled sterile plastic or silicone coated tubes. Tube 3 is used for gross examination and cell count. Differential: Place the setting on Time: 4-8 minutes and RPMs on 2200. Perform cell count as described by Procedure for cell count."

2. Review of the laboratory's centrifuge log from 2010 indicated that the centrifuge, used to spin CSF for differential examination, had no documentation for either rpm (2200) or timers (4-8 minutes) check.

3. On 9/15/10 at 2:00 p.m., staff member # 12 acknowledged the above-listed missing documentation.

4. The Beckman LH 500 policy, "Linearity Limits", effective 1/95, read:
"Linearity Limits
Parameter Linearity Range (upper)
WBC x 106th cell/uL 86.3
RBC x 10 6th cells/uL 6.3
Hgb g/dL 20.85
Plt x 10 3th cells/uL 734

Legend:
cells/uL: cells per microliter
g/dL: grams per deciliter

5. In interview on 9/15/10 at 10:00 a.m., staff member # 12 acknowledged that there was no upper linear documentation for the four complete blood count (CBC) indices listed above.

6. The Beckman DXC 600 policy, "Linearity Limits", read:
"Linearity Limits
Parameter Linearity Actual
Range report*
BUN mg/dL 5-95 78.0
Creatinine mg/dL 0.30-25.0 23.7
Triglyceride mg/dL 5-920 786.3

* upper tested actual ranges too low

7. In interview on 9/15/10 at 10:00 a.m., staff member # 12 acknowledged that the upper linear documentation for the above-listed three chemistry reportable ranges were too low.

8. The following was observed during tour of the BHU beginning at 10:45 a.m on 9/16/10:
(A) The floors adjacent to the lounge area and in front of the nurse station were very soiled and included a black sticky substance throughout the area that could be removed with an alcohol prep pad.
(B) The walls throughout the lounge/hall area near the nurse station were marred.
(C) Paint was chipped from doorways throughout the lounge/nurse station area.
(D) The corner strip of the nurse station was falling off and was heavily taped to secure it.

9. Facility policy titled "Cleaning Behavioral Health Unit" last reviewed/revised 7/08 stated under policy on page 1: "The Environmental Services personnel will clean all areas of the Behavioral Health Unit daily,
.....".

10. Review of staff member #H1 monitoring for cleanliness of the BHU for 8/5/10- present (per Plan of Correction for survey of 7/6/10, the area is to be monitored M-W-F of each week) indicated the following:
(A) The monitoring was not completed on M-W-F per POC. There were several lapses in between days (more than 2 days) and what monitoring that was completed was not always on a Monday, Wednesday, or Friday.
(B) There were weeks (week of 8/23/10 and the week of 9/6/10) that the unit was monitored for cleanliness only 1 day.
(C) The monitoring did not include the entire unit but only random areas. The area cited in previous survey for cleanliness issues and again noted to be soiled, was only monitored 2 times since 8/5/10.

11. Staff member #11 indicated the following in interview at 4:45 p.m. on 9/16/10:
(A) He/she last buffed the floors on the BHU on Tuesday. The halls get buffed most of the time and the big T.V. area outside the nurses station may get buffed weekly "if lucky" because the patients are always in this area.
(B) Stripping and waxing of the floors on the BHU have not been stripped and waxed for > 2 years.

12. Staff member #8 indicated in interview at 5:00 p.m. on 9/16/10 that the painting of the door facings was not placed on the work order, therefore was not completed.

13. At 2:10 PM on 9/16/2010, utility room outside the Behavioral Health Department was observed. The room had a strong urine odor when the door was open. The mop sink was observed heavily soiled. There was blackish-mold like substance on the janitors's walls. The trash can was completely filled with trash and hairy fuzzy debris from a sweeper.

14. At 3:00 PM on 9/16/2010, the basement hallway near bulk tank storage was inspected. Four ceiling tile were observed missing and ceiling tile next to the ones missing had water stains on them. The hallway was completely soiled on the floor and walls. Six skids were standing upright in an unsafe position and also obstructing the door into bulk tank storage.

15. At 3:05 PM on 9/16/2010, the bulk tank storage room was inspected. The room was heavily caked in soil, loose debris, and unnecessary items such as broken O2 valves, loose shelving. The hand sink in the room was completely soiled.

16. Staff member AD8 indicated the room was the paint shop until the painter's position was eliminated.

17. The eye wash station in the Maintenance shop was observed being a resting spot for an empty can of soda pop. The unit was completely soiled and had cobwebs on the end of it.

18. At 3:20 PM on 9/16/2010, the chiller room was observed. A battery operated scrubber was observed plugged into a charger. The room did not have an eyewash station for the possible exposure to battery acid.

19. ANSI Standard Z358.1-2004 recommends, "...the emergency eyewash station must be within a 10 second walk to wherever the hazard is, and ...present in all areas where caustic or hazardous substances such as acid, solvents and other chemicals are present..."

20. Interview with AD8 at 2:15 PM on 9/16/10 confirmed that an eye wash station should be available.











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Based on interview, the hospital failed to assure that the director of respiratory services had complete documentation to assure that he/she was given the authority and responsibility for the operation of the hospital's respiratory department.

Findings included:

In interview on 9/15/10 at 9:00 a.m., staff member #5 acknowledged that there was no documentation that the physician who was in charge of respiratory services had been officially appointed by the hospital with both a fixed line of authority and with delegation of responsibility for the operation of respiratory services.

Based on review of personnel files and staff interview, the hospital failed to assure that the supervisor of respiratory services was qualified to provide direct supervision of the hospital's respiratory department.

Findings included:

1. Review of the respiratory supervisor's personnel file indicated that he/she failed to have sufficient education, training, licensure, or experience necessary to perform each type of respiratory care service within this department. The respiratory supervisor was a medical technologist without documented respiratory training or experience although he/she was responsible for the day to day operation of the hospital's respiratory department.

2. In interview on 9/15/10 at 10:15 a.m., staff member #12 acknowledged that he/she did not have the above-listed missing documentation.

Based on document review and interview, the facility failed to include contracted services, including the scope of service, in the QAPI program.

Findings included:

1. Listed contracted services of emergency physicians, dietician, CRNA, medical director (quality improvement), professional services, sleep specialist, psychiatric services, path lab, health rehab, speech pathologist and radiology services were not included in the QAPI program.

2. Unlisted contracted services of American Red Cross, pest control and HVAC, for which no contract was provided, were also not included in the QAPI program.

3. By interview with AD8 on 9/16/10, there were contracts with the entities of American Red Cross, pest control and HVAC.

4. Contracts for American Red Cross, pest control and HVAC were not provided by time of exit.

Based on document review and interview, the facility failed to review and follow up on incident reports to identify opportunities for improvement and changes that would lead to improvement.

Findings included:

1. Event Report Quality Improvement form for patient A21 dated 6/1/2010 at 5:30 PM in Med Surg indicated "IVABx given before Bld cultures drawn because lab did not draw culture till 1730 pt admitted @ 1300." There was no review or follow-up action documented.

2. Event Report Quality Improvement form for patient A22 dated 6/1/2010 with no time marked indicated cardiac enzymes ordered timed, were missed by lab by several hours. The report noted a delay in procedure. There was no review or follow-up action documented.

3. Event Report Quality Improvement form for patient A23 dated 6/1/2010 at 1730 PM indicated "lab unable to draw bld cultures. Nsg had to draw in order to be compliant..." There was no review or follow-up action documented.

4. Staff #12 indicated in an e-mail that lab staff has been cut drastically over the last year, from 9 full time employees (FTE) to 6 FTEs leading to difficulty in meeting turn around times and keeping up with maintaining procedures.

5. Event Report Quality Improvement form for patient A24 for occurrence dated 6/11/2010 indicated patient had central line at 4:00 PM, labs needed to be drawn but were not completed until the morning of 6/12. There was no review or follow-up action documented.

6. Event Report Quality Improvement form dated 5/26/2010 at 0830 for D1 identified ACU department called down to the Radiology (RAD) Department that ACU was ready for a RAD tech to come to ACU and operate the C-arm for facet injections for patient D1. There was not a tech available due to the decrease in staff. The identified ordering physician stated there was a delay in treatment. There was no review or follow-up action documented.

7. Event Report Quality Improvement form dated 5/29/2010, no time, identified patient D2 "had a CT head w/o contrast. The report from.....recommended a MRI head which couldn't be done because there wasn't a MRI tech here." There was no review or follow-up action documented.

8. D2's medical record identified a MRI head test to be conducted which could not be done because there was not a MRI tech available. The medical record indicated the test was done on 5/30/2010 at 7:37 PM.

9. Event Report Quality Improvement form dated 6/7/2010, 1530, identified a mammogram patient (D3) had to be rescheduled due to reduction in staff. The report identified the technologists will not be available on the day the patient is scheduled which resulted in delayed treatment and inconvenience to the patient.

10. D3's medical record identified the scheduled date was marked through and date 6/27/2010 was written in the box. The patient's records indicated a previous right mastectomy for breast cancer and nodule noted in the left breast on previous mammogram.

11. Review of patient #N13 medical record indicated the following: The patient had an order written on 7/8/10 for a stat chest x-ray at 4:35 a.m. The x-ray was not completed until 5:57 a.m.

12. The July radiology employee schedule revealed there was no one on schedule at the hospital between 3:00 AM and 6:00 PM on 7/8/10.

13. At 2:00 PM on 9/14/2010, staff member AD6 indicated the Radiology Department staff technologists were reduced by 2 staff members which resulted in a 3 hour time frame during the night without someone at the hospital. However, a staff member would be on call. The hospital does not have a radiology on-call policy when no RAD techs are onsite.

14. At 3:30 PM on 9/16/2010, staff member AD9 indicated he/she was on call to perform chest x-rays if needed on 7/8/10 and he/she lives 30 minutes from the hospital. Staff member AD9 indicated a report was sent to the Radiology Department for a stat x-ray on the patient in question. The staff member indicated he/she never received a call from the hospital to perform an x-ray.

15. Staff member AD9's payroll records identified the he/she reported to work at 5:55 AM on 7/8/2010.

16. The Technologist List policy reference number XR101.4 states staff member AD9 works full time from 7:00 PM to 7:00 AM. The July radiology employee schedule and employee payroll records identified the staff member worked from 3:00 PM to 3:00 AM. The time schedule in the policy did not match the actual time worked for the employees in the month of June and July.

17. Operating Policies-Radiology Department policy number XR1301.2 states, "STAT procedures will be performed as soon as possible, a representative of the department will be sent to escort the patient immediately upon receipt of the request, and the attending physician will be notified as soon as the film has been read and interpreted." The policy also stated, "Emergency Room procedures will take precedence over routine inpatient and outpatient examinations."

18. At 4:00 PM on 9/16/2010, staff member AD1 indicated staff was cut severely in June. Certain departments do not have 24/7 coverage within their department. Radiology and the laboratory are the areas that have been affected by staff reduction.

19. QAPI minutes from May through July 2010 were reviewed. Only 3 of the 8 previously listed events (incidents) were reported. No recommendations or follow-up actions were noted in the minutes.

20. Quality Assurance Plan (QAPI) reference #1002 last revised December 2009 states, "Focus upon what is performed throughout the facility, and how well it is performed to provide healthcare. To facilitate this goal, emphasis is place upon 'dimensions of performance'. These dimensions of performance include: Efficacy of the procedure or treatment in relation to the patient's condition; appropriateness of a specific test, procedure or service to meet patient's needs; Availability of a needed test, procedure or service to meet patient who needs it.; Timeliness with which a needed test, procedure, treatment or service is provided to the patient; Effectiveness with which tests, procedures, and treatment and services are provided'

21. Policy Test Prioritization reference #GN-250 Department of Laboratory states, "The test designated as STAT will receive priority. STAT tests are used in emergency situations, when a patient's life or limb may be at risk.

Based on document review and interview, the facility failed to review and follow up on incident reports to identify opportunities for improvement and changes that would lead to improvement.

Findings included:

1. Event Report Quality Improvement form for patient A21 dated 6/1/2010 at 5:30 PM in Med Surg indicated "IVABx given before Bld cultures drawn because lab did not draw culture till 1730 pt admitted @ 1300." There was no review or follow-up action documented.

2. Event Report Quality Improvement form for patient A22 dated 6/1/2010 with no time marked indicated cardiac enzymes ordered timed, were missed by lab by several hours. The report noted a delay in procedure. There was no review or follow-up action documented.

3. Event Report Quality Improvement form for patient A23 dated 6/1/2010 at 1730 PM indicated "lab unable to draw bld cultures. Nsg had to draw in order to be compliant..." There was no review or follow-up action documented.

4. Staff #12 indicated in an e-mail that lab staff has been cut drastically over the last year, from 9 full time employees (FTE) to 6 FTEs leading to difficulty in meeting turn around times and keeping up with maintaining procedures.

5. Event Report Quality Improvement form for patient A24 for occurrence dated 6/11/2010 indicated patient had central line at 4:00 PM, labs needed to be drawn but were not completed until the morning of 6/12. There was no review or follow-up action documented.

6. Event Report Quality Improvement form dated 5/26/2010 at 0830 for D1 identified ACU department called down to the Radiology (RAD) Department that ACU was ready for a RAD tech to come to ACU and operate the C-arm for facet injections for patient D1. There was not a tech available due to the decrease in staff. The identified ordering physician stated there was a delay in treatment. There was no review or follow-up action documented.

7. Event Report Quality Improvement form dated 5/29/2010, no time, identified patient D2 "had a CT head w/o contrast. The report from.....recommended a MRI head which couldn't be done because there wasn't a MRI tech here." There was no review or follow-up action documented.

8. D2's medical record identified a MRI head test to be conducted which could not be done because there was not a MRI tech available. The medical record indicated the test was done on 5/30/2010 at 7:37 PM.

9. Event Report Quality Improvement form dated 6/7/2010, 1530, identified a mammogram patient (D3) had to be rescheduled due to reduction in staff. The report identified the technologists will not be available on the day the patient is scheduled which resulted in delayed treatment and inconvenience to the patient.

10. D3's medical record identified the scheduled date was marked through and date 6/27/2010 was written in the box. The patient's records indicated a previous right mastectomy for breast cancer and nodule noted in the left breast on previous mammogram.

11. Review of patient #N13 medical record indicated the following: The patient had an order written on 7/8/10 for a stat chest x-ray at 4:35 a.m. The x-ray was not completed until 5:57 a.m.

12. The July radiology employee schedule revealed there was no one on schedule at the hospital between 3:00 AM and 6:00 PM on 7/8/10.

13. At 2:00 PM on 9/14/2010, staff member AD6 indicated the Radiology Department staff technologists were reduced by 2 staff members which resulted in a 3 hour time frame during the night without someone at the hospital. However, a staff member would be on call. The hospital does not have a radiology on-call policy when no RAD techs are onsite.

14. At 3:30 PM on 9/16/2010, staff member AD9 indicated he/she was on call to perform chest x-rays if needed on 7/8/10 and he/she lives 30 minutes from the hospital. Staff member AD9 indicated a report was sent to the Radiology Department for a stat x-ray on the patient in question. The staff member indicated he/she never received a call from the hospital to perform an x-ray.

15. Staff member AD9's payroll records identified the he/she reported to work at 5:55 AM on 7/8/2010.

16. The Technologist List policy reference number XR101.4 states staff member AD9 works full time from 7:00 PM to 7:00 AM. The July radiology employee schedule and employee payroll records identified the staff member worked from 3:00 PM to 3:00 AM. The time schedule in the policy did not match the actual time worked for the employees in the month of June and July.

17. Operating Policies-Radiology Department policy number XR1301.2 states, "STAT procedures will be performed as soon as possible, a representative of the department will be sent to escort the patient immediately upon receipt of the request, and the attending physician will be notified as soon as the film has been read and interpreted." The policy also stated, "Emergency Room procedures will take precedence over routine inpatient and outpatient examinations."

18. At 4:00 PM on 9/16/2010, staff member AD1 indicated staff was cut severely in June. Certain departments do not have 24/7 coverage within their department. Radiology and the laboratory are the areas that have been affected by staff reduction.

19. QAPI minutes from May through July 2010 were reviewed. Only 3 of the 8 previously listed events (incidents) were reported. No recommendations or follow-up actions were noted in the minutes.

20. Quality Assurance Plan (QAPI) reference #1002 last revised December 2009 states, "Focus upon what is performed throughout the facility, and how well it is performed to provide healthcare. To facilitate this goal, emphasis is place upon 'dimensions of performance'. These dimensions of performance include: Efficacy of the procedure or treatment in relation to the patient's condition; appropriateness of a specific test, procedure or service to meet patient's needs; Availability of a needed test, procedure or service to meet patient who needs it.; Timeliness with which a needed test, procedure, treatment or service is provided to the patient; Effectiveness with which tests, procedures, and treatment and services are provided'

21. Policy Test Prioritization reference #GN-250 Department of Laboratory states, "The test designated as STAT will receive priority. STAT tests are used in emergency situations, when a patient's life or limb may be at risk.