HospitalInspections.org

Based on record review and interviews with hospital staff, the governing body does not ensure the services provided by contract or arrangement are evaluated through the quality assessment perormance improvement (QAPI) program to assure the services are provided in a safe manner. Review of QAPI and governing body meeting minutes for 2012 and 2013 did not have evidence that contracted services are evaluated to ensure they are provided in a safe and effective manner. Staff A stated on 11/18/13 in the afternoon that contracted services have not been evaluated by the QAPI program.

Based on record review and interviews with hospital staff, the hospital does not ensure a list of all contracted and shared services is maintained with the scope and nature of the services provided. The hospital did not have a list of all contracted services with the scope and nature of the services provided.

Findings:

1. The hospital provided a book of contracts for surveyor review.

2. The shared service contract with the host hospital did not specifically document which services the host hospital would provide for the hospital.

3. The contract book provided for review also did not have all of patient care services provided by contract and their scope.

4. These findings were verified on 11/18/13 in the afternoon.

Based on medical record review and staff interview the hospital failed to inform patients and/or their representatives of all patient ' s rights. This occurred in six (# 7 through 12) of seven medical records reviewed for patient ' s rights information.

Findings:

Medical records #7 through 12 did not contain documentation patients were given patient ' s rights information. A hospital document, which included the acknowledgment of patient rights, did not contain a signature from the patient and/or their representative. This was confirmed by Staff A and D during medical record review.

On the afternoon of 11/18/13, Staff D stated the hospital document is part of the admission paperwork and not all the nurses have the patient and/or their representative sign the form.

Based on review of hospital documents, medical records and staff interviews, the hospital failed to ensure restraints were used in accordance with physician's orders. This occurred in three of three patient records (Records #1, 9 and 11) reviewed for restraint information.

Findings:

The hospital's "Plan for the Care of Patients in Restraints" policy, stated, " The use of a restraint must be in accordance with the order of a physician or other LIP (licensed independent practitioner) " ...A restraint order is effective for up to 24 hours. "

Review of medical record #1 documented the patient was in restraints 6/24/13 through 7/19/13. The orders were not complete. The pre-printed order form did not contain the time the order was written and the physician signature on the following dates: 6/24/13 through 6/26/13, 6/28/13, 7/6/13, 7/8/13 through 7/12/13 and 7/19/13. The restraint orders were not signed by the physician on 7/4/13, 7/14/13 and 7/18/13. On 6/27/13, the order did not contain the time the order was written.

Record #9 documented restraints were applied in an emergent situation on 10/7/13 the preprinted restraint order form did not contain the physician and nurse ' s signature, date and time the order was written.

Review of medical record # 11 documented the patient was in restraints 10/29/13 through 11/1/13. Record #11 contained pre-printed restraint order forms that was not complete. The restraint order did not contain the physician signature, date and time the order was written on the following dates 10/29/13, 10/31/13 and 11/1/13. The restraint order for 10/30/13 did not contain the date or time the order was written.

The above findings were reviewed and confirmed with Staff A during the chart reviews.

Based on record review and interviews with hospital staff, the governing body does not ensure the Quality Assessment Performance Improvement (QAPI) program includes contracted or shared services. There was no evidence that all contract or shared services were evaluated by the QAPI program. Review of governing body meeting minutes and QAPI meeting minutes for 2012 and 2013 did not have evidence of review of services provided by shared service agreement with the host hospital or individual contract. This was verified by hospital staff on 11/18/13 in the afternoon.

Based on review of hospital documents personnel files, and medical records and interviews with hospital staff, the hospital failed to ensure nursing staff are adequately trained to provide care to meet the needs of the patients.

Findings:

The hospital is a long term acute care hospital that cares for patients eighteen years and older who are medically complex. The hospital has a four bed High Intensity Unit (HIU) staffed by registered nurses.

On 11/15/13 Staff A stated that Diprivan is used in the HIU on intubated patients.
Review of the education and training files for Staff P, Q, R, S, T and U did not contain documentation of Diprivan education. Staff A stated the hospital did not provide training on Diprivan to the staff.

Based on medical record review and staff interview the hospital failed to ensure all medical records were promptly completed. This occurred in nine (#1, 4, 6, 7, 9, 12 and 21 through 23) of fifteen closed records reviewed.

Findings:
Medical records #1, 4, 6, 7, 9, 12, and 21 through 23 of patients who were discharged from the hospital thirty or more days prior to their admission date were not complete. The medical records contained electronic discharge summaries, progress notes and histories and physicals (h and p) that did not contain the date and time when the report was authenticated by the physician or licensed practitioner.
The above findings were reviewed and confirmed with Staff A during the chart reviews.

Based on medical record review and interviews with hospital staff, the hospital failed to ensure that all entries in the medical record contain the date and time when they were signed or authenticated in electronic or written form by the person responsible for the services provided. This occurred in nineteen (Records #1 through 12, 14, 15, 17, and #20 through 23) of twenty-three medical records reviewed.

Findings:

Medical records # 1 through 12, 21 and 23 contained electronic discharge summaries, progress notes and histories and physicals (h and p) that did not contain the date and time when the report was authenticated by the physician or licensed practitioner.

Medical records #14 contained a verbal physician order dated 11/14/13 that did not contain the physician signature. The h and p did not contain a signature by the physician or licensed practitioner. A physical therapy clarification order dated 11/15/13 did not contain the signature of the ordering physician or licensed practitioner.

Medical record #15 contained verbal physician orders dated 11/12/13 that did not contain the date and time the orders were authenticated by the physician or licensed practitioner.

The medical record #17 documented the patient was admitted on 11/15/13, the medical record did not contain an h and p by the admitting physician.

The h and p for medical record #20 did not contain the date, time and signature when the report was authenticated by the physician or licensed practitioner.

Three (Records #1, 9 and 11) of three medical records reviewed for restraints did not contain authentication by the physician or licensed practitioner on the restraint order. (See Tag 0168).

The above findings were reviewed and confirmed with Staff A during the chart reviews.

Based on review of infection control data, personal files, hospital documents, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner (ICP) developed and implement infection control measures related to hospital personnel. This occurred in eighteen (Record A, C, E through G, L through P, R, S, T, W, X and Y) of twenty-eight health files and three (EE, FF, and GG) of three physician files reviewed.

Findings:

Respiratory Isolation:

A hospital policy related to N-95 fit testing documented fit testing should be completed at least annually. The hospital did not perform annual N-95 fit-testing for employees. This occurred in sixteen of twenty-eight personnel files and one (EE) of three physician files reviewed.

On the afternoon of 11/18/13, Staff C stated the hospital had decided to only Fit Test core staff. When asked about a core staff Fit Testing policy, Staff C stated the hospital did not have one. When asked how core staff was determined, no answer was provided.

Health files for A, C, E, F, G, L, M, N, O, P, R, S, T, W, X, and Y did not contain documentation of an annual N-95 fit test.


Tuberculin Testing:

The Staff C was interviewed on 11/15/13 and 11/18/13.

On 11/18/13 at 1645, Staff C stated a tuberculosis (TB) Risk Assessment had not been completed for the hospital.

Twenty-eight hospital personnel files and three physician files were reviewed for documentation regarding a yearly screening for tuberculosis. Four of the twenty-eight personnel files and three of three physician files did not contain documentation regarding testing to screen for TB.

On 11/18/13 at 1645, Staff C stated, that in March or April of this year (2013), the hospital had decided to change from annual TB skin test to only doing TB tests upon hire and exposure.


Meeting minutes did not reflect employee health was part of the infection control program. Employee illnesses and immunizations were not review to ensure transmission of communicable diseases and infections were not transmitted between staff and patients.