HospitalInspections.org

Based on a review of facility documentation and staff interviews, the facility failed to establish a process for prompt resolution of patient grievances and a process/policy which meets the spirit of regulatory requirements for such resolution.

The findings were:

Facility policy #2080, "Patient/Visitor Comments," last revised 3/10, stated in part:
"Policy...
when a patient(s) and or visitor(s) have positive or negative comments, these comments are documented on the top portion of the Situation Form, an investigation is performed by the designated personnel and the action is decided on by the Patient Comments Committee...The policy and procedure process is monitored by the Patient Comments Coordinator and the Risk Manager...
Procedure
1. When an employee receives a verbal or written comment from a patient(s) and/or visitor(s) whether positive or negative, that employee will complete the top portion of the Situation Form...
2. The Patient Comments Coordinator will forward the Situation Form to the appropriate department manager...
3. The department manager will investigate the comment(s) and completes the top section of the back page of the Situation Form ("Investigation")...
5. The Patient Comments Committee...will meet monthly as scheduled by the Patient Comments Coordinator. The reviews comments, applicable documentation, and the department managers' investigation and determines what action, if any, needs to be initiated regarding the comment(s)...
6. Once appropriate action has been determined by the committee, it will be carried out and documented on the action portion of the Situation Form, by the Patient Comments Coordinator.
7. Once the comment has been completely reviewed, within a reasonable amount of time, but no later than 60 days of the receipt of the comment, the Patient Comments Coordinator will provide the patient with written notice of the action, if any, taken..."

A review of facility "Situation Forms" for the previous 12 months revealed patient comment/complaint forms completed in 9/13 and 10/13. The action portion of the form completed in 9/13 included only the following: "Will call pt." The action portion of the form completed in 10/13 included only the following: "Will refer to CEO." The facility could provide no further documentation of investigation or resolution of these patient complaints.

In an interview with Staff #2 and #5 on the morning of 6/25/14 in the facility conference room, they stated the facility could provide no further documentation regarding the above patient complaints, though they believed further action had occurred.

The above findings were again confirmed in an interview with the facility Chief Executive Officer and other administrative staff on the afternoon of 6/25/14.

Based on credentialing file review, policy review, and staff interview the facility failed to ensure physicians and allied health professional updated their delineation of privileges request form in the reprivileging process. 8 of 8 credentialing files were deficient.

The findings were:

Review of credentialing files for physicains and allied health professionals (#12, 13, 14, 15, 16, 17, 18, and 19) on 6/24/14 revealed the practioners did not follow their own policy in the reappointment and reprivileging process. The practitioner did not submit an updated delineation of privileges form with their reapplication. Some of the practitioners had not updated their delineation of privileges since 2007. Staff #17 had resigned and returned with no new application and delineation of privileges form filled out and was reappointed to the medical staff as an allied health professional based on an old application.

Facility policy titled "Medical Staff Bylaws" states, in part "The technical process for reprivileging is the same as for initial privileging." "Initial Privileging Process: The medical staff will review the requested privileges and certify that the practitioner is qualified in the requested areas."

In an interview with the CEO, CNO, and credentialling specialist on 6/24/14 and 6/25/14 all confirmed the current recredentialling process did not include the physician and allied health care providers to update their delineation of privileges form. They also acknowledged the delineation of privileges form was not included in the packet reviewed by the medical staff during consideration of recredentialling of the physicians and allied health staff.

Based on a review of facility documentation and staff interview, the facility failed to complete and document an updated examination of each patient prior to surgery or a procedure requiring anesthesia when the medical history and physical examination was completed within 30 days before the procedure.

The findings were:

A review of medical records of patients who had surgery or a procedure requiring anesthesia services revealed that for 1 of 3 patients [Patients #1], the facility could provide no documented evidence of an update to the history and physical examination prior to the procedure. Patient #1 underwent a history and physical examination on 6/19/14 in his physician's office. He had surgery on 6/24/14 at Pecos County Memorial Hospital.

In an interview with the Director of Nursing on the morning of 6/25/14 in the facility conference room, she stated she could not locate any section of the Medical Staff Bylaws which addressed the need for an updated examination prior to a patient's surgery if the history and physical was completed within 30 days before the procedure; i.e., if the history and physical was not completed in the hospital on the date of surgery. She also confirmed that the medical record of Patient #1 did not contain documentation of an updated examination prior to his procedure.

The above findings were again confirmed in an interview with the Chief Executive Officer and other administrative staff on the afternoon of 6/25/14 in the facility conference room.

Based on record review and staff interview the facility failed to ensure a single pharmacist supervised and coordinated all activities of the hospital pharmacy service.

The findings were:

Review of documentation of pharmacy record review and pharmacy and therapeutics committee meeting minutes revealed that the pharmacist in charge had not reviewed or provided documentation of review of status reports or meeting minutes since March 2014.

Interview with the CEO, pharmacy technician, and contract pharmacist revealed the pharmacist in charge had other pharmacists coming in on a weekly basis to oversee the pharmacy operations but she had not reviewed any documentation of weekly or quarterly review since March 2014 and had not been in the facility since March 2014.

Based on a review of facility documentation and staff interview, the facility failed to follow its own fire control plan in regard to conducting the number of required annual fire drills.

The findings were:

A review of fire drill documentation for 2013 and 2014 revealed the facility could provide no documented evidence of fire drills having occurred on the night shift in the 2nd and 4th quarters of 2013.

Facility policy 100.10 entitled, "Fire Drill Reports & Record Keeping LFS," last revised 11/10, stated in part:
"POLICY:
To standardize and provide guidance for maintaining and recording the results of fire drills...
PROCEDURE:
1) Establish a schedule for conducting drills, ensure compliance with established requirements..."

In an interview with the facility Safety Officer on the afternoon of 6/24/14 in the facility conference room, she stated the schedule adopted by the hospital for conducting fire drills was once per shift per quarter as required by regulations.

The above findings were confirmed in an interview with Chief Executive Officer and other administrative staff on the afternoon of 6/25/14 in the facility conference room.

Based on observation, policy review, and staff interview the facility failed to ensure personnel followed their own policies in regard to handwashing and infection control.

The findings were:

During observation in the surgical suite of the facility on 6/24/14 staff #20, 30, & 31 did not wash or disinfect hands after procedure completed and gloves removed. Staff #20 was observed during the disinfection process of the endoscope and colonoscope and hands were not washed or disinfected between tasks and with glove changes.

Facility policy titled "Hand Hygiene for Health Care Workers" states, in part "All staff should decontaminate their hands: after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; after removing gloves; and after handling any object or piece of equipment used by a patient."

In an interview with staff #20 on 6/24/14 she confirmed none of the three staff members washed their hands coming out of the procedure in the surgical suite and she never washed or sanitized her hands during the scope cleaning process. She further stated if she washed her hands every time she changed her gloves she would be washing her hands all the time.

Based on a review of facility documentation and staff interview, the facility failed to complete and document a pre-anesthesia evaluation performed within 48 hours prior to surgery or a procedure requiring anesthesia services for each patient.

The findings were:

A review of medical records of patients who had surgery or a procedure requiring anesthesia services revealed that for 3 of 3 patients [Patients #1-3], the area on the anesthesia record indicating a pre-anesthesia assessment was not timed. Thus the facility could provide no documented evidence the pre-anesthesia evaluation was performed within 48 hours prior to the procedure for these patients.

Facility "Rules and Regulations of the Medical Staff of Pecos County Memorial Hospital (PCMH)" stated in part, "The anesthesia/post anesthesia service shall be directed by the CRNA with the medical director being the Chief of Surgery...responsibilities shall include at least:
A. Participate in the pre-anesthesia evaluation required by the Rules and Regulations of PCMH..."

In an interview with the Director of Nursing and two facility registered nurses on the morning of 6/25/14 in the facility conference room, they agreed the area on the anesthesia record indicating a pre-anesthesia assessment was not timed. Thus when the assessment had occurred could not be determined.

The above findings were again confirmed in an interview with the Chief Executive Officer and other administrative staff on the afternoon of 6/25/14 in the facility conference room.