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LATIMER COUNTY GENERAL HOSPITAL
MEDICAL STAFF - BYLAWS AND RULES
Tag No.: A0048
Based on document review and interview, the Governing Body failed to ensure Bylaws and Rules were current and approved.
Finding:
A review of the facility's bylaws and rules showed the Governing Body-review signature sheet was signed on 2/2014. The document control policy showed two year interval for review of bylaws. Director of Nursing (DON) confirmed the bylaws and rules were not current.
CONTRACTED SERVICES
Tag No.: A0084
Based on document review and interview, the Governing Body failed to
evaluate the quality of each contracted service and ensures that each contracted service is provided in a safe and effective manner.
Findings:
1) Licensed Dietitian was not on staff nor under contract or Memo of Understanding (MOU) for services provided.
2) Respiratory Therapist was not on staff nor under contract or MOU for services provided.
3) Laundry contract was expired.
4) There were no indications, in Governing Body meeting minutes, of evaluation of performance of services provided by the above.
The Director of Nursing (DON) confirmed the Governing Body failed to evaluate the quality of the above services.
CONTRACTED SERVICES
Tag No.: A0085
Based on document review and interview, the Governing Body failed to maintain a current list of all contracted services including the scope and nature of the services provided.
Findings:
Laundry contract was expired.
The Director of Nursing (DON) confirmed the Governing Body had failed to maintain a current list of all contracted services.
ORDERS FOR DRUGS AND BIOLOGICALS
Tag No.: A0409
Based on document review and staff interview, the facility failed to ensure staff was trained and competent to administer blood products.
Findings:
On 09/07/2016, a review of sixteen patient 's medical records documented two patients (Patient #15 and Patient #16 ) received blood transfusions.
A hospital policy titled, "Blood (or components) Transfusion," dated Aug 2015, did not contain documentation of guidelines for staff training and competencies.
Surveyor requested staff training and competencies for blood administration, none were provided. On 09/07/2016, Staff B stated nursing staff received blood administration training through policy review.