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Based on interviews, review of documentation and policies it was identified that the facility's governing body failed to maintain its legal responsibility for the conduct of the hospital.

The findings include:

Based on interviews and the review of ten (10) contracts it was determined that the governing body failed to maintain the responsibility for services furnished and the actions taken through the hospital's QAPI program for contractors in the hospitals : Cross Reference Tag: 0083.

Based on interviews, review of ten (10) contracts it was determined that the governing body failed to ensure that contracted services are provided in a safe and effective manner: Cross Reference Tag: 0084.

Based on interviews and the review of ten (10) contracts it was determined that the hospital failed to outline the supervisory role of the hospital and the contractor role & responsibilities: Cross Reference Tag: 0085.

Based on interviews, observation and review of documentation the hospital failed to protect & promote patient rights for accurate State complaint hotline telephone numbers

The findings include:

Based on interview, observation, and review of documentation the patient's patient Bill of Rights in the admission package and hanging on the 1st floor wall contains a non-toll free telephone number not as an acceptable listing for contacting the complaint division at the state Office Of Licensure and Certification to lodge a complaint: Cross Reference Tag:0118.

Based on interview and documentation the hospital failed to protect the patient personal information from outside the hospital setting : Cross Reference Tag: 0143.

Based on interviews, observation, review of documents, five (5) patient clinical records and agency policies the facility failed to provide and meet patient care needs safely (patient #14, 15 &18): Cross Reference Tag: 0144.

CONDITION

Based on interviews, review of documents, clinical records and policies the hospital failed to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital failed to reflect the complexity of the hospital's organization and services of all the hospital departments and services (including those services furnished under contract or arrangement) in the hospital'sQuality Assurance Performace Improvement (QAPI) program.

The findings include:

Based on staff interview and review of the facility's quality assessment performance improvement (QAPI) program the facility failed to measure, analyze, and track quality indicators to monitor the effectiveness and safety of services and quality of care for patients: Cross Ref. Tag: 073.

Based on interviews and review of documentation the hospital Quality Improvement program failed to incorporate, analyzing and identified high risks and problems from the Adverse Event and 24 hour Daily Reports: Cross Ref. Tag: 083.

Based on observations and two (2) patient interviews it was determined the hospital staff failed to maintain sanitary patient conditions that avoids the transmission of infections and/or communicable diseases.

The findings include:

On 2/10/2013 at 08:30pm Patient #15 was interviewed in the patient's room. Patient #15 recalled in this interview the fall that occurred 12/22/13. Patient #15 recalled thinking that the bed rail was left down (points to left lower side bed rail). Patient #15 stated that when rolled over in the bed "I think I just rolled right out & off of the bed onto the floor." Patient #15 stated that someone found me on the floor but not clear on everything that happened. Patient #15 stated that the ambulance had to be called to be taken to the emergency room. Patient #15 stated that the there were broken bones that the doctors could not fix but want to keep them from moving around." Patient #15 confirmed that there is no identification at the bedside that patient #15 is at risk for falling. Patient #15 confirmed there is a call bell to use when in need of a nurse. Patient #15 stated that the call bell is not answered promptly that "it seems to take forever especially if I have a bowel movement.""I don't think they want to have to take care of it." " It depends on some days who is working then they may have a nice attitude other times not." I call the Respiratory Therapy the most or suctioning & they are prompt. I don't have a problem with the Respiratory Therapist. But, to get help from the Nurses is a problem & especially when I need to have to use the bathroom. But, I need to have a bowel movement it comes to a halt and takes what seems forever."

On 2/11/2014 patient #18 requested an interview with the Medical Facilities Inspector (MFI). An interview was conducted with patient #18 in the patient's room. Patient #18 unable to talk due to tracheotomy with O2 infusion. Patient #18 uses a dry erase board to write as preferred methods of communication. Patient #18 told the MFI length of stay at Lake Taylor Hospital has been 4 years. Patient #18 stated that there has been little change in condition. Patient #18 stated that to reach a nurse or Respiratory Therapist patient #18 uses a call bell. Patient #18 stated that the Respiratory Therapist response is usually prompt but, the nursing response is not. Requested of patient #18 to provide the MFI with an example when Nursing fails to act promptly when uses the call bell. Patient #18 stated that when has a bowel movement it is retained in diaper and takes a while to get someone willing to change the diaper. Asked if patient #18 knew how long the time lines have been to wait for changing the diaper after notification of having a bowel movement. Patient #18 responded the time line can vary from immediately but on average 20 to 40 minutes.
On 2/12/14 between 9:00am to 11:00am a follow up visit was conducted with patient #18. Present in Patient #18 room was a Respiratory Therapist and Nursing. An escort from the QA department was with the MFI on this visit to Patient #18. Patient #18 had a yankauer suction in the right hand & to self suction oral secretions. Observed Patient #18 raise the O2 mask covering the tracheotomy and slid the yankauer self suctioned into the trachea stoma region and self suction. The removed the yankauer self suctioned and immediately put into the mouth & suction. The Respiratory Therapist immediately approached the patient to educate not to cross over use of the yankauer self suctioned in the tracheotomy to avoid risk of infection. Interviewed patient #18 and inquired if this was a routine of the patient. Patient #18 acknowledged it was routine and stated "often I do this." Patient #18 acknowledged frequently suctions back and forth between the tracheotomy and mouth using the same yankauer suction catheter.

Based on interviews and the review of ten (10) contracts it was determined that the governing body failed to maintain the responsibility for services furnished and the actions taken through the hospital's QAPI program for contractors in the hospitals.

The findings included:

On 2/6/14 between 10:00am to 12:00 pm the Vice President Of Patient Services (VPPS, RN, employee #36) provided that the hospital has contracts with ten (10) companies for services used by the hospital. The following Services provided by a contractor are:
Respiratory Therapy
Rehabilitation Services
Laboratory Services
Pharmacy Services & subcontract through the pharmacy contract IV services. The pharmacy provides IV medications and the subcontracting for infusion company through the pharmacy provides for the IV Nursing Services.
Three (3) Supplemental Nursing Services for: RN, LPN & CNA
Equipment Services
DiVita ESRD Services

On 2/3/14 between 2:00pm and 6:00pm the Respiratory Therapy Supervisor (RRT Supervisor, employee #6) was interviewed in the 1st floor conference room. The RRT Supervisor acknowledged that all of the Respiratory Therapy services are through a contract. The RRT Supervisor acknowledged that the Respiratory Therapy services provided at the hospital are controlled by the contractor not the hospital directly.

On 2/6/14 the Consulting Pharmacist (RPh, employee #24) was interviewed in the first floor conference room. The RPh acknowledged the hospital contracts out the pharmacy services and through the pharmacy contract sub-contracts out for the IV infusion services. The RPh acknowledged that the Pharmacy and Iv Infusion services provided at the hospital are controlled by the contractor not the hospital directly.

On 2/6/2014 between 10:00am and 5:00pm the Director of Quality Development (employee # 2, LPN) provided the 1/4ly Quality Assurance Performance Improvement minutes. The 1/4ly meetings were conducted on 1/16/13, 4/17/13, 7/17/13 and 10/16/2013 with minutes. The QAPI program failed to review the contracted services are provided in a safe and effective manner. The VPPS provided the Executive Committee Hospital Authority of Norfolk meeting minutes held on 10/23/2013. The minutes failed to contain the evidence that the Executive Committee Hospital Authority coordinates and supervises the contractors or received a QAPI report related to the contractors.

On 2/6/2013 at 10:25am an interview was conducted with the Vice President Of Patient Services (VPPS) in the 1st floor conference room. The VPPS acknowledged that the contractors provide services for both the hospitals adults and pediatrics units. The VPPS acknowledged that the hospital has no evidence how the hospital is responsible to coordinate and supervise the contractors servicing the hospital.

Based on interviews, review of ten (10) contracts it was determined that the governing body failed to ensure that contracted services are provided in a safe and effective manner.

The findings included:

On 2/6/14 between 10:00am to 12:00 pm the Vice President Of Patient Services (VPPS, RN, employee #36) provided that the hospital has contracts with ten (10) companies for services used by the hospital. The following Services provided by a contractor are:
Respiratory Therapy
Rehabilitation Services
Laboratory Services
Pharmacy Services & subcontract through the pharmacy contract IV services. The pharmacy provides IV medications and the subcontracting for infusion company through the pharmacy provides for the IV Nursing Services.
Three (3) Supplemental Nursing Services for: RN, LPN & CNA
Equipment Services
DiVita ESRD Services

On 2/3/14 between 2:00pm and 6:00pm the Respiratory Therapy Supervisor (RRT Supervisor, employee #6) was interviewed in the 1st floor conference room. The RRT Supervisor acknowledged that all of the Respiratory Therapy services are through a contract. The RRT Supervisor acknowledged that the Respiratory Therapy services provided at the hospital are controlled by the contractor not the hospital directly.

On 2/6/14 the Consulting Pharmacist (RPh, employee #24) was interviewed in the first floor conference room. The RPh acknowledged the hospital contracts out the pharmacy services and through the pharmacy contract sub-contracts out for the IV infusion services. The RPh acknowledged that the Pharmacy and Iv Infusion services provided at the hospital are controlled by the contractor not the hospital directly.

On 2/6/2014 between 10:00am and 5:00pm the Director of Quality Development (employee # 2, LPN) provided the 1/4ly Quality Assurance Performance Improvement minutes. The 1/4ly meetings were conducted on 1/16/13, 4/17/13, 7/17/13 and 10/16/2013 with minutes. The QAPI program failed to review the contracted services are provided in a safe and effective manner.

On 2/6/2013 at 10:25am an interview was conducted with the Vice President Of Patient Services (VPPS) in the 1st floor conference room. The VPPS acknowledged that the contractors provide services for both the hospitals adults and pediatrics units. The VPPS acknowledged that the hospital has no evidence how the hospital ensures that services performed under a contract are provided in a safe and effective manner.

The VPPS provided the Executive Committee Hospital Authority of Norfolk meeting minutes held on 10/23/2013. The minutes failed to contain the evidence that the Executive Committee Hospital Authority coordinates and supervises the contractors and their services in a safe and effective manner within the the hospital.

Based on interviews and the review of ten (10) contracts it was determined that the hospital failed to outline the supervisory role of the hospital and the contractor responsibilities.

The findings included:

On 2/6/14 between 10:00am to 12:00 pm the Vice President Of Patient Services (VPPS, RN, employee #36) provided that the hospital has contracts with ten (10) companies for services used by the hospital. The following Services provided by a contractor are:
Respiratory Therapy
Rehabilitation Services
Laboratory Services
Pharmacy Services & subcontract through the pharmacy contract IV services. The pharmacy provides IV medications and the subcontracting for infusion company through the pharmacy provides for the IV Nursing Services.
Three (3) Supplemental Nursing Services for: RN, LPN & CNA
Equipment Services
DiVita ESRD Services

On 2/3/14 between 2:00pm and 6:00pm the Respiratory Therapy Supervisor (RRT Supervisor, employee #6) was interviewed in the 1st floor conference room. The RRT Supervisor acknowledged that all of the Respiratory Therapy services are through a contract. The RRT Supervisor acknowledged that the Respiratory Therapy services provided at the hospital are controlled by the contractor not the hospital directly.

On 2/6/14 the Consulting Pharmacist (RPh, emplyee #24) was interviewed in the first floor conference room. The RPh acknowledged the hospital contracts out the pharmacy services and through the pharmacy contract sub-contracts out for the IV infusion services. The RPh acknowledged that the Pharmacy and Iv Infusion services provided at the hospital are controlled by the contractor not the hospital directly.

On 2/6/2014 between 10:00am and 5:00pm the Director of Quality Development (employee # 2, LPN) provided the 1/4ly Quality Assurance Performance Improvement minutes. The 1/4ly meetings were conducted on 1/16/13, 4/17/13, 7/17/13 and 10/16/2013 with minutes. The QAPI program failed to review the contracted services are provided in a safe and effective manner.

On 2/6/2013 at 10:25am an interview was conducted with the Vice President Of Patient Services (VPPS) in the 1st floor conference room. The VPPS acknowledged that the contractors provide services for both the hospitals adults and pediatrics units. The VPPS acknowledged that the hospital has no evidance how the hospital is responsible to coordinate and supervise the contractors servicing the hospital.

The VPPS provided the Executive Committee Hospital Authority of Norfolk meeting minutes held on 10/23/2013. The minutes failed to contain the evidence that the Executive Committee Hospital Authority coordinates and supervises the contractors and their services in a safe and effective manner within the the hospital.

Based on interview, observation, and review of documentation the patient's patient Bill of Rights in the admission package and hanging on the 1st floor wall contains a non-toll free telephone number not as an acceptable listing for contacting the complaint division at the state Office Of Licensure and Certification to lodge a complaint.


The findings include:

On 02/11/2014 between 10:20am to 10:55am the facility's President provided the patient's admission package. The patient's admission package was reviewed and it contained the patient's Bill of Rights. The patient's Bill of Right's contained a non-toll free telephone number not an acceptable listing for contacting the complaint division at the state Office Of Licensure and Certification to lodge a complaint. The hospital President took the Medical Facility Inspector in the hallway on the 1st floor. The hospital President showed an enlarged Patient Bill of Rights framed on the wall. The enlarged patient's Bill of Rights hanging on the 1st floor wall contained a non-toll free telephone number (different from the one in the admission package) but, not an acceptable listing for contacting the complaint division at the state Office Of Licensure and Certification to lodge a complaint.

The facilities President acknowledged the findings that the patient Bill of Rights in the admission package and hanging on the 1st floor wall contained different non toll free telephone numbers to the complaint unit of the Office of Licensure and Certification.

On 2/3/2014 an entrance conference was conducted at 10:30am with the hospital President (employee #1) and the Director of the Quality Assurance Department (LPN, employee #2) in the 1st floor conference room by two (2) Medical facilities Inspectors. A request was made to review the hospitals documented complaints and resolutions and how they are received and recorded/logged. On 2/10/2013 at 8:00pm the hospital President asked the Medical Facilities Inspector (MFI) in the 2nd floor nurses station if anything "was needed." A 2nd request was then made to review the documented complaints by patients &/or caregivers with their resolutions. On 2/12/2013 between 8:30 am and 10:30am a 3rd request for the hospitals documented complaints was placed to the VPPS (RN, employee #36). The VPPS stated that the hospital documents complaints that need additional work towards a resolution as grievances. The VPPS stated that the delay in providing the grievance reports was that the MFI asked to see the facility complaints and not the facilities grievances. The VPPS stated that the grievances require documented investigations & followed through by the hospital's grievance committee. The VPPS stated that grievances are reviewed and documented in the minutes by the Grievance Committee. The last Grievance Committee Meeting was held on 1/8/2014.

On 2/12/2013 between 8:30 am and 10:30am a request was made to the VPPS (RN, employee #36) for the hospital's grievance policy. The VPPS (RN, employee #36) acknowledged that the hospital failed to have a grievance policy.

Based on interview and documentation the hospital failed to protect the patient personal information from outside the hospital setting.

The findings include:

On 2/6/2014 an interview was with a contract employee (interviewee #23) in the hospital 1st floor conference room. Interviewee #23 provided a copy of an email letter dated 1/2214 to the two Medical Facilities Inspectors. The letter contained evidence that the letter was emailed to seventy five (75) email addresses. Seventy two (72) out of seventy five (75) email address were not through the hospital's email encrypted email server. Interviewee #23 acknowledged that the email letter dated 1/22/14 was sent to the contract corporate offices and different members in Administration. The 1/22/14 email letter contained content regarding hospital patient concerns. Additional content included but not limited to the lack of supervision to patient concerns identified, safety related to care and/or lack of care of patients, areas of severity related to concerns identified and reported and the state of taking/receiving physician orders, etc .Interviewee #25 stated that staff working at the hospital are aware that the hospital has an email system for use in communication access.

On 2/12/14 between 9:00am and 12:00pm an interview was conducted with the Respiratory Supervisor (RRTS, employee # 6) in the1st floor conference room. The RRTS acknowledged that the hospital has has an internal email system that is encrypted. The RRTS stated that when not working the staff have access thru calling the RRTS's cell phone anytime. The RRTS stated that when not onsite at the hospital there have been occasions that the respiratory staff may need to make contact related to a patient concern. The RRTS acknowledged that the respiratory staff have sent via text on the RRTS cell phone patient names and identified patient problems.

On 2/12/14 between 9:00am and 12:00pm an interview was conducted with the hospital President in the first floor conference room. The hospital President confirmed that the hospital uses email as a form of communication between internal staff and the system is security protected. The hospital President was provided a copy of the email letter page dated on 1/22/14 (sender name removed) listing the seventy five (75) email addresses. The hospital President acknowledged that there were email address that were not through the hospital secure web site.

Based on interviews, observation, review of documents, five (5) patient clinical records and agency policies the facility failed to provide and meet patient care needs safely (patient #14, 15 &18).

The findings include:

From February 5 to 7, 2014 the Director of Quality Development (employee # 2, LPN) provided the 24 hour Daily Reports for December 2013 of the two adult patient units on 2 East & 3 East. The 24 hour Daily Reports contained the following findings for 3 East: *12/16/2013: 7am to 7pm: Room 305A: Code Blue.*12/26/2013: 7am to 7pm: Room 316B: ER transport for nephrology tube replacement.
The December 2013's monthly adult 24 hour Daily Reports for adult patient unit on 2 East contained the following statistics: *12/01/2013: 7am to 7pm: Room 203D: 2nd Day" unresponsive episode: no episode today Temp=100. *12/05/2013: 7am to 7pm: Room 208B: Temp=102.2 last night 100.5 this morning. *12/06/2013: 7pm to 7am: Room 211B: Negative Pressure Wound Therapy (NPWT) machine malfunction.*12/07/2013: 7pm to 7am: Room 207B: Spoke with daughter reassured no contact will be made by CNA in question. Pt removed from the CNA assignment. Apologized to patient's daughter. On rounds spoke with patient who was able to talk for short time. Reinforced that CNA was reassigned.*12/16/2013: 7pm to 7am: Room 231C: Patient found on floor unable to tell how patient got onto floor. Appears to have hit head at right brow.* 12/22/2013: 7pm to 7am: Room 212A: Patient fell onto floor. Admitted to Sentara Leigh Memorial Hospital. At 15:35 (3:35pm) patient fell out of bed onto the floor. Respiratory Therapist reported having suctioned food from/through tracheostomy. *7pm to 7am: Room 207B: Patient with foley catheter: Thick foul smelling discharge from penis yellow brown with request for assessment on MD sheet.*12/23/2013: 7am to 7pm: Room 205B: Sent to Sentara Leigh Memorial Hospital ER due altered mental state. Patient admitted into the hospital.*7pm to 7am: Room 201A: at 18:00 zx(6:00pm) NG tube came out. Doctor notified. *12/24/2013: No 24 Daily Report Form provided for this date.*12/25/2013: 7pm to 7am: Room 203C: Seizure activity while up in chair approximately 30 seconds. Patient did not loose consciousness. Nurse & family present.*12/26/2013: 7am to 7pm: Room: 203C: Patient de-cannulation; 7am to 7pm: Room: 205A: Patient de-cannulated; 7pm to 7am: Room: 203D: Desaturated to 48%, decrease level of consciousness. (RT) Respiratory Therapy ambu-bagged therapy ("RT Bagged ") suctioned, Reinflated trachea cuff, patient deflating cuff. Saturation level back up to 98%. Awake requesting suctioning. Respiratory Therapy ambu-bagged therapy ("RT Bagged") suctioned, Re-inflated trachea cuff, patient deflating cuff. Saturation level back up to 98%. Awake requesting suctioning. 7pm to 7am: Room: 211B: Resumed Negative Pressure Wound Therapy. 7pm to 7am: Room: 202B: Peg tube ruptured. Tube feeding on hold. *12/27/2013: 7am to 7pm: Room: 213A: Admitted from Sentara Leigh Memorial Hospital. Status Post (S/P) fall in Lake Taylor Hospital (12/22/2013).7pm to 7am: Room: 202B: Peg Tube out. Reinserted with X-ray placement check. 7pm to 7am: Room: No room number listed (patient name listed & with held for HIPPA) Admit 7:05pm. At 2300 (11:00pm) found by Respiratory Therapy sitting on the floor beside the bed, 4 side rails up. No injuries, denies pain, able to move upper & lower extremities. MD & spouse notified. 7pm to 7am: Room: 203D: Periods of Un-responsiveness. Bagged by Respiratory Therapy FiO2 increased to 100% via ventilator. Back to old self. Physician & family member notified. *12/28/2013: 7am to 7pm: Room: 205B. Patient fell the night of 12/27/2013 and un-witnessed.. Sent to Sentara Leigh Memorial Hospital (SLMH) - ER - @ 12:00pm on 12/28/2013 for CT Scan & eval. Returned at 17:15pm(5:15pm). Call from SLMH CT scan normal. 7am to 7pm: Room: 231A: Hgb night 12/27/13=8.2 on this shift decrease to 7.5 1 unit PRBC ordered. Completed 1 unit PRBC at 02:30am. 7am to 7pm: Room: 203D: Type & Cross v2 units PRBC. 7pm to 7am: Room: 203D:Episode of unresponsiveness for 2-3 minutes. FiO2 increase to 50%, came back with good color/alert. Begging to be suctioned & ice to chew. Completed 1st unit of PRBC @ 03:40am, 2nd unit of PRBC in process, tolerating.*12/29/2013: 7pm to 7am: Room: 203D: No reaction status post blood transfusion.*12/30/2013: 7pm to 7am Room: 203D: Status post blood transfusion no adverse reaction.*12/31/2013: 7pm to 7am Room: 207A: Sentara Leigh Memorial Hospital (SLMH) admit: Sepsis.
On 2/10/2014 at 8:00pm began the review of the clinical record for patient #14 in the 2nd floor nurses station. The hospital President asked if the MFI had any needs. Showed to the hospital President that patient #14's clinical record received to review ended on Dec. 12, 2013 but, this patient's last date of service was 1/2/14. Request to review the complete clinical record for patient#14 through 1/2/14. On 02/11/2014 the complete clinical record for patient #14 was not provided. A 2nd request for a complete clinical record of patient #14 was made to the Director of Quality Assurance Department on 2/12/14. The completed file for patient#14 was located within the Vice President of Patient Services office and upon request the clinical recordwas provided for review.
Patient #14 had entry's in the December 2013 24 hour Daily Reports for the following dates: 12/1/13: 7am to 7pm: T-100 2nd day post "unresponsive episode" no episodes today. 12/27/13: 7pm to 7am: "Period of unresponsiviness. Bagged by RT (respiratory therapist) FiO2 increased to 100% via vent. Back to old self. Physician & family notified." 12/28/13: 7pm to 7am: "Episode of unresponsiveness for 2-3 minutes. Suctioned and Fi02 increase to 50%. Came back with good color/alert. Begging to be suctioned & ice to chew. Completed 1st unit of PRBC at 0340. 2nd unit of RPBC in process. Tolerating.

On 2/12/2014 at 11:25am Patient #14's clinical record was reviewed in the 1st floor conference room. Patient #14 had recorded documentation being last seen without problems at 0600 on 1/2/14. Lab work was drawn at 4:35 am. Patient #14's clinical record contained documentation that patient #14 was found unresponsive at 7:53am on the cardiopulmonary arrest record dated 1/2/14 & contained in the clinical record. The clinical record contained documentation that patient #14's began having interventions for being unresponsive with CPR and Ventilating started by the hospital staff at 7:53am & continued onto 9:09am when the paramedics arrived. Lab studies drawn at 4:35am had critical levels for Potassium= 6.2 & CO2=10 with critical results called at at 9:16am from the lab to this RN being interviewed. The RN stated the results were faxed & given directrly to the MD still present for patient #14.

On 2/12/14 at 9:45am an interview was conducted with RN (employee # 39) in the 1st floor conference room. The RN acknowledged being present and participating during this event with patient #14. The RN went thru the details that took place from 7:53am to 9:09am administered for patient #14. The RN stated that staff present was 2 Respiratory Therapist, 2 LPN's, 1 CNA, 2 RN's, the patient's physician, Vice President of Patient Services (VPPS), Director of Nursing (DON) and Nursing Manager. The RN acknowledged that the intervention began at 7:53 am, the physician was called 7:57am with status report on patient #14 and orders received. The RN stated that the MD instructed that the RN was not to send the patient out of the hospital and to wait as the MD was coming to the patient (because the MD was in the hospital). The RN stated that the MD arrived at 7:59am present in the patient's room and physician said not to call a Code Blue. The RN stated this was confusing as the patient was a full code. At 8:10 the MD took the patients chart to add additional orders to ones already given by telephone. A chext X ray order was received 1/2/14 at 8:36am, obtained & read 1/2/14 at 8:50am. The physician did not give the RN an order to call 911 until 09:00am. The RN acknowledged that 911 was called & arrived at 9:09am but, the secreations. EMT arrived at 0909am and took over compressions. RT continued bagging. Multiple rounds of ALCS meds and five shocks produced no results CPR stopped. TOD: 09:24am.patient was not transported off the unit.

The Clinical record of patient #14had a Respiratory Therapy "Discharge Report" date 1/2/14 was contained within the clinical record of patient #14. This report contained under the section "Comments/Goals" the following content: "At 0:858 Code Blue called. CPR began with bagging at 100%Fi02. Suctioning copious bloody

The Clinical record of patient #14 contained a Death Summary by the physician dated with discharge date 1/2/14. The first four (4) Death Diagnosis listed were: Cardiac Arrest, History of Chronic Repiratory Failure, on mechanical ventilatory support, Guillain-Barre Syndrom & other diagnosis listed. This report by the MD included the following written content: "The time spent at the bedsiode, face to face with the patient as well as coordnating car and dictating this note was 1 hour and 38 minutes."

Patient #14 had 3 episodes of unresponsivness within 30 days of the DOD 1/2/14. On 2/28/13 had 1 unit PRBC infused start time 2340 to 0340. No Post Transfusion Vital signs were recorded on the Transfusion Monitoring Sheet that was to be obtained and be recorded evey 4 hours for 24 hours.

On 2/10/2014 at between 7:30pm to 8:30pm the clinical record of patient #15 was reviewed in the 2 East nurses station. The clinical record contained the following:
A)"Physician/Nurse Communication Form page(s) 1 & 2 dated: 12/22/13 with the content: "Patient Found on the floor next to the bed with legs found under the patient sitting on left hip. Recommendation: Send to SLH (hospital) ER for evaluation and treatment. At 1400 patient possibly aspiratedon small piece of bread from lunch RT suctioned out bread breathing well. 1535: Patient was found on the floor next to bed with legs under patient sitting on left hip was found by team leader & charge nurse after team leader called for charge nurse to come to room. Attempted to lift into bed not able to patient's weight." 1545:Hoyer placed under patient & lifted to bed using hoyer lift. Upon examination found right knee slightly swollen more than previous to fall........1555: On Call Nurse Practioner notified of fall out of bed. Asked if patient could be seen by Sentara Leigh Memorial Hospital. ER for evaluation & possible treatment on-call prepared to send to ER. 1620: EMR called to to transport patient to be transport in 30-40 minutes. 1650: EMR arrived to transport patient to SLH ER. 1658: Patient departs via stretcher by EMR transport to SLH ER." B) "12/22/2013 Signed Physician Verbal Order at 1555: Post Fall Send Patient to SLH ER for evaluation & Treatments." C) "Discharge Summary: dated 12/22/2013 contained the following: "Section: Course In Hospital (W/Complications, if Any) And Discharge Plan:.......on the day of transfer to acute care, the patient, apparently, fell off the bed and fractured her left foot, for which reason she was immediately transferred to the Sentara Leigh Hospital Emergency Room from where she was admitted as inpatient." D) On 12/27/2013 a "Readmission Patient/Resident History and Physical contained the following content: History Of Present Illness: Patient #15 came from Sentara Leigh Hospital. Patient #15 was taken last week after a fall. She had an elbow epicondylar fracture and femur fracture. E) "On 12/27/2013 a Social Worker note the contained the following content: "On 12/26/13 patient #15 was admitted to Lake Taylor Transitional Care Hospital from Sentara Leigh Memorial Hospital with the admitting diagnosis of: s/p fall, right distal femur fracture, Right elbow fraxture, PN, UTI, sepsis, DM, CHF, trach, ESRD." F) "On 12/31/13 Pulmonary Consult: Patient #15 was admitted to Lake Taylor Transitional Care Hospital transferred from SLMH where she was admitted after a fall and fractures in the elbow and femur. She was treated conservatively. While in the hospital patient 315 was diagnosed with sepsis secondary to UTI."
An Adverse Event Report was documented with the following content dated for:12/22/2013: At 1535 Patient found on floor by Respiratory Therapist who was walking by room. Notified the Team Leader and LPN, who then called for the charge nurse to room 212A. Patient on floor with legs under patient sitting on Left hip. Nurses attempted to return to been but not able due to patient s weight & position. Patient was returned to bed. Patient complained of pain to right knee/ left elbow ad lower back." This report continues with nursing assessment.
On 2/10/2013 at 08:30pm Patient #15 was interviewed in the patient's room. Patient #15 recalled in this interview the fall that occurred 12/22/13. Patient #15 recalled thinking that the bed rail was left down (points to left lower side bed rail). Patient #15 stated that when rolled over in the bed "I think I just rolled right out & off of the bed onto the floor." Patient #15 stated that someone found me on the floor but not clear on everything that happened. Patient #15 stated that the ambulance took her to the emergency room. Patient #15 stated that the there were broken bones that the doctors could not fix but want to keep them from moving around." Patient #15 confirmed that there is no identification at the bedside that patient #15 is at risk for falling. Patient #15 confirmed there is a call bell to use when in need of a nurse. Patient #15 stated that the call bell is not answered promptly that "it seems to take forever especially if I have a bowel movement.""I don't think they want to have to take care of it." " I depends on some days who is working then they may have a nice attitude other times not ."' I call the Respiratory Therapy the most & they are prompt. I don't have a problem with the Respiratory Therapist. Nursing is a problem & when I need to have to use the bathroom but, when I need to have a bowel movement it comes to a halt."
Between 02/3-7/2014 the hospital provided a policy titled: Fall Risk/Fall Prevention: The policy does not identify a universal bedside identification system for identifying the high risk fall patients. The policy does not have a system to identify the high risk fall patients directly to all types of staff receiving patient staffing assignments. Patients safety is compromised with no policy developed for a notification system allowing all staff to identify a high risk fall patient at the bedside.
On 2/11/2014 patient #18 requested an interview with the Medical Facilities Inspector (MFI). An interview was conducted with patient #18 in the patient's room. Patient #18 unable to talk due to tracheotomy with O2 infusion. Patient #18 uses a dry erase board to write as preferred methods of communication. Patient #18 told the MFI length of stay at Lake Taylor Hospital has been 4 years. Patient #18 stated that there has been little change in condition. Patient #18 stated that to reach a nurse or Respiratory Therapist patient #18 uses a call bell. Patient #18 stated that the Respiratory Therapist respond usually is prompt but, the nursing response is not. Requested of patient #18 to provide the MFI with an example when Nursing fails to act promptly when uses the call bell. Patient #18 stated that when has a bowel movement it takes a while to get someone willing to change the diaper. Asked if patient #18 knew how long the time lines have been to wait for changing the diaper after notification of having a bowel movement. Patient #18 responded the time line can be 20 to 40 minutes.
On 2/12/14 between 9:00am to 11:00am a follow up visit was conducted with patient #18. Present in Patient #18 room was a Respiratory Therapist and Nursing. An escort from the QA department was with the MFI on this visit to Patient #18. Patient #18 had a yankauer suction in the right hand & to self suction oral secretions. Observed Patient #18 raise the O2 mask covering the tracheotomy and slid the yankauer self suctioned into the trachea stoma region and self suction. The removed the yankauer self suctioned and immediately put into the mouth & suction. The Respiratory Therapist immediately approached the patient to educate not to cross over use of the yankauer self suctioned in the tracheotomy to avoid risk of infection. Interviewed patient #18 and inquired if this was a routine of the patient. Patient #18 acknowledged it was routine and stated "often I do this." Patient #18 acknowledged frequently suctions back and forth between the tracheotomy and mouth using the same yankauer suction catheter.

Based on staff interview and review of the facility's quality assessment performance improvement (QAPI) program the facility failed to measure, analyze, and track quality indicators to monitor the effectiveness and safety of services and quality of care for patients.

The findings include:

On 2/3/2014 between 10:30am to 11:30am an entrance interview was conducted with the Director of the Quality Assurance Department (DQAD, LPN, employee #2) and Hospital President (employee #1) in the first floor conference room. Two (2) Medical Facilities Inspector were present for the entrance interview. The Director of the Quality Assurance Department stated that the hospital keeps Adverse Event reports for patients that have an adverse medical event. The Director of the Quality Assurance Department stated that the Adverse Event reports are only kept for one year then they are destroyed. The Director of the Quality Assurance Department acknowledged that the Adverse Event reports contain the patient's adverse events, investigations and follow up documentation. The Director of the Quality Assurance Department stated that the information from the Adverse Event reports are a part of the QAPI's quarterly reports and they are provided to the annual Governing Body Meeting.

Adverse Event reports were received for the two (2) adult units (2 East and 3 East) and one (1) Pediatric unit (2 West) on June 3, 2013 at 3:04pm from the Director of the Quality Assurance Department in the 1st floor conference room. An observation was provided to the Director of the Quality Assurance Department that the Adverse Event reports were incomplete. The The Director of the Quality Assurance Department failed to provide either an explanation and/or additional information related to the incomplete Adverse Event reports received.

On 2/4/2014 between 9:49am and 1130am an interview was conducted with the Vice President of Patient Services (VPPS, RN, employee # 36) in the 1st floor conference room. Reviewed with the VPPS the Adverse Event reports received from the DQAD (LPN,employee # 2) on 2/3/2014 at 3:04pm. The observation was given to the VPPS that the Adverse Event reports appeared to be incomplete. The VPPS acknowledged that there was a 2nd page to the Adverse Event reports and that they were missing from the reports provided to the two (2) Medical Facility Inspectors on 2/3/2014 from the DQAD (LPN,employee # 2). The VPPS (RN, employee # 36) provided on 2/4/2014 the 2nd page to the Adverse Event Reports that had been received on February 3, 2013.

The VPPS (RN, employee # 36) acknowledged that there is a 1/4ly Quality Assurance meeting and that the Adverse Event reports are reviewed as a part of the meeting. The meeting minutes were reviewed on February 10, 2014 at approximately 4:45 pm. The Vice President of Patient Services and/or Director of the Quality Assurance Department did not offer additional evidence used by the hospital to measure, analyze, and track quality indicators to monitor the effectiveness and safety of services and quality of care for patients.

On 2/7/2014 at 12:35pm an interview was conducted with the Vice President of Patient Services and the DQAD (LPN, employee #2) in the 1st floor conference room with two (2) Medical Facilities Inspectors. The VPPS acknowledged that the hospital units use a 24 hour report form (form # LTTHC 13006) to communicate daily medical events and /or identified adverse events from the floor to the Director of Nursing. The VPPS acknowledged that the form has been "used for quite a long time." Both the VPPS and DON acknowledged that there was nor is inservice training to the staff on the proper use of the 24 hour Daily Report form (form # LTTHC 13006). The VPPS provided upon request the 24 hour Daily Report forms for the month of December 2013 on all hospital units.

On 2/7/2014 between 1:00pm to 3:00pm and from 2/10/2014 to 2/12/2014 the December 24 hour report forms were reviewed for the hospitals Adult units (2 East and 3 East). The findings for the December 2013 Adverse Event reports and the December's 2013 24 hour Daily report forms data did not coordinate. There was only one (1) Adverse Event report provided for the month od December 2013. December 2013 there were two (2) adverse events for the hospital adult unit 3 East and twenty three (23) adverse events for the hospital adult unit 2 East. The VPPS & DON failed to provide an explanation for the variance in the Adverse Event reports and those identified on the 24 hour Daily report forms for December 2013.

The VPPS acknowledged that the Governing Body receives an annual QA report from the 1/4ly QAPI reports. The VPPS acknowledged that the 1/4ly QA reports includes statistics from the Adverse Event reports. The VPPS acknowledged that the hospital does not keep past years Adverse Event reports and that previous years are "destroyed." The VPPS acknowledged that the hospital does not have the Adverse Event reports for the year 2012.

The 1/4ly QA minutes for the meetings held on 1/16/13, 4/17/13, 7/17/13 & 10/16/13 failed to contain data found in the following statistics from the Adverse Event reports from June 2013 to January 2014 of the following:
Total Falls: 3, Total Unplanned Decannualtion: 17, Total Wounds/skin tears: 9,Total Gastric Tube Out: 2, Total Negative Pressure Wound Treatment Machine not connect to deliver continuous care: 2, Total Medication Not Provided All Weekend: 1, Total Missed Accu Check (with negative patient impact): 1, Total Code (s): 2.
No statistics from the adverse events identified within the 24 hour report forms (form # LTTHC 13006) in December 2013 was included in the 1/4ly QA minutes regarding the documented medical events and /or identified adverse events from the hospital floors.

On 2/7/2014 an interview was conducted with the Vice President of Patient Services (VPPS, RN, employee # 36) between 1:55pm and 2:10pm. The VPPS acknowledged that "it was not identified as a problem to do a QAPI report on" for the problems as exampled identified of missing trach balloons and j/g tube problems on the Pediatric unit.

On February 10, 2014 at approximately 4:45 pm the Governing Body annual meeting of October 23,2013 were reviewed. The Governing Body minutes failed to contain evidence that the Governing Body incorporates quality indicator including patient care, adverse event findings, 24 hour Daily report adverse findings and grievances either obtained and/or reported by the hospital's Quality Improvement Program.


















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Based on interviews and review of documentation the hospital Quality Improvement program failed to incorporate, analyzing and identified high risks and problems from the Adverse Event and 24 hour Daily Reports.

The findings include:

During the week of 2/3-7/2014 interviews were conducted with the Director of the Quality Assurance Department and the Vice President of Patient Services. The Director of the Quality Assurance Department acknowledged that the Adverse Event reports contain documentation of high risk and problems related to patient care needs. The information of the adverse events contain the investigations and follow ups. The Vice President of Patient Services stated that the Adverse Event reports are only kept for one year then they are destroyed. The Vice President of Patient Services acknowledged that the hospital maybe unable to monitor for trends when the statistics are only maintained for 1 year.

The Director of the Quality Assurance Department stated that the information from the Adverse Event reports are a part of the QAPI's quarterly reports and are provided to the annual Executive Committee Meeting minutes. The 10/13 Executive Committee Meeting minutes were reviewed and failed to contain content from QAPI's quarterly meeting minutes to identify program data and activities on the high risk and problem areas based on the Adverse Event and 24 hour Daily Reports findings.

Between Feb. 3 to 7, 2014 and Feb. 10-12, 2014 the 1/4ly QA minutes were reviewed for the meetings held on 1/16/13, 4/17/13, 7/17/13 & 10/16/13. The 1/4ly QA minutes failed to integrate of analysis and identification of high risks problems through data analysis from the patient's Adverse Event and 24 hour Daily Reports.
A) The Adverse Event reports from June 2013 to January 2014 were reviewed & contained the following statistics: Total Falls: 3, Total Unplanned Decannualtion: 17, Total Wounds/skin tears: 9,Total Gastric Tube Out: 2, Total Negative Pressure Wound Treatment Machine not connect to deliver continuous care: 2, Total Medication Not Provided All Weekend: 1, Total Missed Accu Check (with negative patient impact): 1, Total Code (s): 2.
B) The 24 Hour Daily Reports forms (form # LTTHC 13006) for December 2013 were reviewed & contained the following statistics:
*The 24 hour Daily Reports contained the following findings for adult unit 3 East: *12/16/2013: 7am to 7pm: Room 305A: Code Blue.*12/26/2013: 7am to 7pm: Room 316B: ER transport for nephrostomy tube replacement.
*The 24 hour Daily Reports contained the following findings for adult unit 2 East:*12/01/2013: 7am to 7pm: Room 203D: 2nd Day" unresponsive episode: no episode today Temp=100. *12/05/2013: 7am to 7pm: Room 208B: Temp=102.2 last night 100.5 this morning. *12/06/2013: 7pm to 7am: Room 211B: Negative Pressure Wound Therapy (NPWT) machine malfunction.*12/07/2013: 7pm to 7am: Room 207B: Spoke with daughter reassured no contact will be made by CNA in question. Pt removed from the CNA assignment. Apologized to patient's daughter. On rounds spoke with patient who was able to talk for short time. Reinforced that CNA was reassigned.*12/16/2013: 7pm to 7am: Room 231C: Patient found on floor unable to tell how patient got onto floor. Appears to have hit head at right brow.* 12/22/2013: 7pm to 7am: Room 212A: Patient fell onto floor. Admitted to Sentara Leigh Memorial Hospital. At 15:35 (3:35pm) patient fell out of bed onto the floor. Respiratory Therapist reported having suctioned food from/through tracheostomy. *7pm to 7am: Room 207B: Patient with foley catheter: Thick foul smelling discharge from penis yellow brown with request for assessment on MD sheet.*12/23/2013: 7am to 7pm: Room 205B: Sent to Sentara Leigh Memorial Hospital ER due altered mental state. Patient admitted into the hospital.*7pm to 7am: Room 201A: at 18:00 zx(6:00pm) NG tube came out. Doctor notified. *12/24/2013: No 24 Daily Report Form provided for this date.*12/25/2013: 7pm to 7am: Room 203C: Seizure activity while up in chair approximately 30 seconds. Patient did not loose consciousness. Nurse & family present.*12/26/2013: 7am to 7pm: Room: 203C: Patient de-cannulation; 7am to 7pm: Room: 205A: Patient de-cannulated; 7pm to 7am: Room: 203D: Desaturated to 48%, decrease level of consciousness. (RT) Respiratory Therapy ambu-bagged therapy ("RT Bagged ") suctioned, Reinflated trachea cuff, patient deflating cuff. Saturation level back up to 98%. Awake requesting suctioning. Respiratory Therapy ambu-bagged therapy ("RT Bagged") suctioned, Re-inflated trachea cuff, patient deflating cuff. Saturation level back up to 98%. Awake requesting suctioning. 7pm to 7am: Room: 211B: Resumed Negative Pressure Wound Therapy. 7pm to 7am: Room: 202B: Peg tube ruptured. Tube feeding on hold. *12/27/2013: 7am to 7pm: Room: 213A: Admitted from Sentara Leigh Memorial Hospital. Status Post (S/P) fall in Lake Taylor Hospital (12/22/2013).7pm to 7am: Room: 202B: Peg Tube out. Reinserted with X-ray placement check. 7pm to 7am: Room: No room number listed (patient name listed & with held for HIPPA) Admit 7:05pm. At 2300 (11:00pm) found by Respiratory Therapy sitting on the floor beside the bed, 4 side rails up. No injuries, denies pain, able to move upper & lower extremities. MD & spouse notified. 7pm to 7am: Room: 203D: Periods of Un-responsiveness. Bagged by Respiratory Therapy FiO2 increased to 100% via ventilator. Back to old self. Physician & family member notified. *12/28/2013: 7am to 7pm: Room: 205B. Patient fell the night of 12/27/2013 and un-witnessed.. Sent to Sentara Leigh Memorial Hospital (SLMH) - ER - @ 12:00pm on 12/28/2013 for CT Scan & eval. Returned at 17:15pm(5:15pm). Call from SLMH CT scan normal. 7am to 7pm: Room: 231A: Hgb night 12/27/13=8.2 on this shift decrease to 7.5 1 unit PRBC ordered. Completed 1 unit PRBC at 02:30am. 7am to 7pm: Room: 203D: Type & Cross v2 units PRBC. 7pm to 7am: Room: 203D:Episode of unresponsiveness for 2-3 minutes. FiO2 increase to 50%, came back with good color/alert. Begging to be suctioned & ice to chew. Completed 1st unit of PRBC @ 03:40am, 2nd unit of PRBC in process, tolerating.*12/29/2013: 7pm to 7am: Room: 203D: No reaction status post blood transfusion.*12/30/2013: 7pm to 7am Room: 203D: Status post blood transfusion no adverse reaction.*12/31/2013: 7pm to 7am Room: 207A: Sentara Leigh Memorial Hospital (SLMH) admit: Sepsis.

Based in interviews and review of documentation it was determined that the hospital failed to maintain for a period of five (5) years a form that contains patient medical information known as the Patient Adverse Event.

The findings include:

On 2/3/2014 between 10:30am to 1:30pm an interview was conducted with the Director of Quality Assurance Program (DQAP, employee #2, LPN) in the 1st floor conference room. The DQAP provided to the Medical Facilities Inspector (MFI) page one of a two page Event Report. The DQAP stated that the Adverse Event Reports contains have patient information for Adverse Events. Reviewed with the DQAP the front page of the Adverse Events report. The DQAP failed to provide page 2 of the Adverse Events reports.

On 2/4/2014 between 9:49am to 11:30am an interview was conducted with the Vice President of Patient Services (VPPS, RN, employee #36) in the 1st floor conference room with two (2) MFI's. Reviewed with the VPPS the Event Reports received on 2/3/14 from the DQAP. The VPPS acknowledged that the MFI's did not receive page 2 of the report titled "Quality Assurance Tool." The VPPS provided page 2 to go with page 1 of the Event Reports provided to the two (2) MFI's on 2/3/14. The VPPS acknowledged that the Event Reports contain patient medical information & details related to an identified adverse event. A request was made to the VPPS for the 2012 Event Reports (pages 1 & 2). The VPPS stated that the hospital does not maintain past one (1) year of Event Reports. The VPPS acknowledged that the only available year for the Event Reports are for 2013.

Based on observation, documentation, and interview the facility failed to maintain a safe environment for hospital patients .

The findings included:
An interview was conducted with employee #27 (Security Guard) on the afternoon of February 6, 2014 by two Medical Facilities Inspectors in the first floor conference room. Employee #27 confirmed that the hospital has estimate 40 security cameras throughout the hospital and campus. Employee #27 stated that the camera monitors are behind the hospital main entrance operators desk. Employee #27 stated that after the operator leaves at 11:30pm no hospital staff watches the hospital security cameras when the required routine security checks are conducted. Employee #27 reported that security rounds are every 2 hours. Employee #27 reported that the security checks can take up to an hour or hour an a half each check. Employee #27 verified that the pediatric unit has a camera at the entrance hallway of the unit. Employee #27 confirmed that the pediatric and hospital units could be accessed unnoticed. Employee #27 acknowledged that the hospital cameras are not in patient rooms but are in the hallways.

On 02/05/2014 a RN (employee #18) was interviewed by two Medical Facilities Inspectors at approximately 3:15 pm in the first floor conference room. The RN reported other night staff from other areas in the hospital come for coffee onto the Pediatric Unit. The RN confirmed that on the pediatric unit access to POD 1 can occur unnoticed and it is this area where higher incidents occurred of detach and missing pilot balloons adverse events occurred. The RN confirmed POD 1 (area where multiple pediatric patients are in beds) is closest to the entrance to the Pediatric Unit. The RN acknowledged that there could be a time when all staff are busy caring for patients in another POD and that someone could enter the unit unnoticed. The RN acknowledged not being aware of other security systems going on off the hospital units.

On February 10, 2014 at approximately 7:00 pm two (2) Medical Facilities Inspectors were able to gain access to the hospital through an unsecured and unmonitored front entrance (not the main entrance). The two Medical Facilities Inspectors entered the hospital, walked the complete length of a first floor hallway to a back hallway. Then the two (2) MFI's walked the complete back hallway and access an elevator to the 2nd floor. The two Medical Facilities Inspectors were able to gain access to the 2nd floor Pediatric and Adult units without being stopped.

Based on interview and documentation the hospital failed to protect the patient's right to have their personal private and medical information remain confidential.

The findings include:

On 2/6/2014 an interview was with a contract employee (interviewee #23) in the hospital 1st floor conference room. Interviewee #23 provided a copy of an email letter dated 1/2214 to the two Medical Facilities Inspectors. The letter contained evidence that the letter was emailed to seventy five (75) email addresses. Seventy two (72) out of seventy five (75) email address were not through the hospital's email encrypted email server. Interviewee #23 acknowledged that the email letter dated 1/22/14 was sent to the contract corporate offices and different members in Administration. The 1/22/14 email letter contained content regarding hospital patient concerns. Additional content included but not limited to the lack of supervision to patient concerns identified, safety related to care and/or lack of care of patients, areas of severity related to concerns identified and reported and the state of taking/receiving physician orders, etc .Interviewee #25 stated that staff working at the hospital are aware that the hospital has an email system for use in communication access.

On 2/12/14 between 9:00am and 12:00pm an interview was conducted with the Respiratory Supervisor (RRTS, employee # 6) in the 1st floor conference room. The RRTS acknowledged that the hospital has has an internal email system that is encrypted. The RRTS stated that when not working the staff have access thru calling the RRTS's cell phone anytime. The RRTS stated that when not onsite at the hospital there have been occasions that the respiratory staff may need to make contact related to a patient concern. The RRTS acknowledged that the respiratory staff have sent via text on the RRTS cell phone patient names and identified patient problems.

On 2/12/14 between 9:00am and 12:00pm an interview was conducted with the hospital President in the first floor conference room. The hospital President confirmed that the hospital uses email as a form of communication between internal staff and the system is security protected. The hospital President was provided a copy of the email letter page dated on 1/22/14 (sender name removed) listing the seventy five (75) email addresses. The hospital President acknowledged that there were email address that were not through the hospital secure web site.