HospitalInspections.org

Based on record review and interviews with hospital staff the governing body does not ensure that all services provided to patients in the hospital are provided in a safe and effective manner by personnel who are competent to provide those services and comply with all the applicable conditions of participation. The hospital does not provide oversight on services provided by a licensed retail pharmacy located in the licensed space of the hospital.

Findings:

1. Pharmaceutical services for the hospital are provided by a pharmacy licensed as a retail pharmacy and located within the licensed space of the hospital. The drugs are bubble packed by the pharmacy and dispensed as personal prescriptions for each patient in the hospital. The pharmacy also provides drugs for nursing homes according to hospital staff on 02/28/12.

2. Pharmaceutical services provided are not included in the hospital's quality assurance program and the hospital does not oversee the personnel working in the pharmacy.

3. Hospital staff W stated that the pharmacy was separate and was leased out to a pharmaceutical company.

4. The governing body must take actions through the hospital's QAPI program to: assess the services furnished directly by hospital staff and those services provided under contract, identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities.

Based on review of hospital policies and the grievance and complaint log, selected grievances and complaints, and interviews with hospital staff, the hospital failed to ensure the hospital's established grievance process was implemented.

Findings:

1. The hospital's grievance policy, entitled "Grievances-Families/Patients," with an issue date of 3/1/11 stipulates "B. Method of investigating and assessing the validity of a grievance or concern. 1. If at all possible the concern will be addressed immediately upon disclosure. However, should schedules prevent this, the nurse and/or grievance coordinator (Social Services Director) will arrange to meet with the concerned party within five (5) working days to hear the grievance. 2. Every effort will be made to resolve issues and reach a consensus with the concerned party on an informal basis within 15 days of the grievance. All efforts will continue until a satisfactory resolution is completed. 3. All grievances or concerns will be discussed with the supervisory personnel of the department involved. 4. Other personnel involved with the care of the patient, if necessary, will be consulted to determine all the facts. 5. The focus of the grievance will be observed first hand, i.e., cleanliness, diet. 6. If there is not a resolution the grievance will be directed to the Chief Executive Officer. 7. If the grievance continues to be contested, the facility Board of Directors will be advised." The hospital failed to develop, approve, implement a grievance policy or process which includes all the required elements.

2. On the morning of 2/28/12 surveyors were told by Staff F and D there were no grievances for the year 2011.

3. The hospital failed to identify grievances: On 2/28/12 and 2/29/12 surveyors reviewed two medical records (Medical record #11,16) in which patients family repeatedly complained about visitation issues, loss of patient's clothing, and physician orders. The hospital's social services documented multiple interventions with the family. All complaints required investigations and follow up with other staff. There was no documentation the patient's issues/concerns were addressed through the grievance process.

4. These findings were reviewed with administration at the time of the exit conference on 2/29/2012. No further documentation was provided.

Based on review of records, interviews with staff, review of hospital documents, and review of policies, the hospital does not ensure that all patient grievances are reviewed, resolved, and a written response sent through the hospital's grievance process. Two medical records ( 11,16 ) had incidents of complaints/grievances documented. The facility did not recognize these occurrences as grievances. There was no documentation the complaints/grievances had been reviewed through the governing body or the committee delegated to oversee grievances. These findings were reviewed at the exit conference. No further information was provided.

Based on review of policies and procedures and patient handouts and interviews with hospital staff, the hospital failed to develop a policy with mechanisms/methods defined that clearly describe the procedures to follow when a patient alleges abuse by a hospital employee or contract worker.

Findings:

1. The hospital provided three policies and the employee pamphlet for review that addressed abuse. No document provided for review contained all the components to prevent, screen, identify, train, and report/respond to allegations of abuse/neglect by an employee/contract worker. The documents did not clearly define the steps that would be taken concerning the employee/contract worker while the investigation was proceeding.

2. This finding was reviewed and verified with administrative staff, Staff B and F, on the afternoon of 02/28/2012..

Based on record review and interviews with hospital staff, the hospital does not ensure that performance improvement activities tracking discrepancies of scheduled drug counts are analyzed and evaluated. There was no documentation in Pharmacy and Therapeutic meeting minutes or Quality Assurance meeting minutes that these discrepancies were analyzed to see if any diversion was occurring or the patients were receiving the correct dosage.

Based on record review and interviews with hospital staff, the hospital does not ensure that all drugs are controlled and distributed in accordance with applicable Federal and State laws and regulations and applicable standards of practice. The hospital does not have Federal and State narcotic permits to allow them to have scheduled drug storage.

Findings:

1. Scheduled drugs are stored in a cabinet in the drug room for emergency dispensation. These drugs belong to the retail pharmacy within the hospital and are not specifically prescribed for individual patients.

2. The retail pharmacy according to staff W is leased out to a pharmaceutical company and the hospital does not have oversight of the pharmacy's operations.

Based on review of policy and procedure and interviews with staff the facility failed to ensure radiology exams were provided in a safe manner. The facility did not have documentation stipulating staff were licensed, trained, and competent in radiation safety. There was no documentation personnel utilized to assist in holding patients were competent in radiation safety techniques for themselves and patients.

Based on review of policies, and interviews with staff, the hospital failed to ensure a qualified radiologist supervises the radiology services, only personnel designated as qualified by the medical staff used the radiologic equipment and administered procedures.

Findings:

1. On the morning of 2/27/2012 staff F told surveyors radiology services were provided by employees and by contract personnel. Staff F also told surveyors at times nursing personnel were utilized to hold patients while an x-ray was performed. There was no evidence all personnel involved in x-ray procedures were trained and competent to provide services. There was no documentation all personnel had training on radiation safety. There were no current policies (reviewed and approved by medical staff and the supervising radiologist) indicating what services were provided at the facility. 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. On the afternoon of 2/28/2012 Staff F told surveyors the physician in charge of the radiology program was not a radiologist.

3. These findings were reviewed with administration at the exit conference.

Based on review of infection control data and meeting minutes 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:

1. Infection control meeting minutes for 2011 did not reflect the program contained review and analysis with plans of action and follow-up of monitoring:
a. Employee health and tracking of employee illness to ensure transmissions between staff and patients did not occur;
b. Infections and communicable diseases -
i. Identifying whether hospital acquired and
ii. The modes of possible transmission between individuals with analysis of measures taken to contain and prevent transmission and whether they were effective.
c. Except for handwashing and personal protective equipment (PPE) for isolation education, that staff followed established policies and procedures and standards of practice to prevent and control infections and maintain a sanitary environment.

2. 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 throughout the hospital, including the proper application of disinfectants. On the afternoon of 02/28/2012, Staff F stated she did monitor, but did not keep records.

3. These findings were reviewed with hospital administrative staff during the exit conference on the afternoon of 02/28/2012.