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Based on review of the Quality Assurance/Performance Improvement (QA/PI) Plan, QA data and interviews, the hospital failed to meet the Condition of Participation for Quality Assurance/Performance Improvement as evidenced by failing to: 1) ensure that all departments of the hospital participated in the hospital-wide quality assurance program as evidenced by the hospital not implementing quality indicators for all contract services, medical records, pharmacy services to include tracking of medication errors, infection control, grievances and falls and 2)have documented evidence that nursing services and psychiatric services formulated and implemented preventative actions for indicators that did not reach their own benchmark of 100 percent (A0267).

The hospital failed to meet the Condition of Participation for Physical Environment as evidenced by:
Based on observation, review of Governing Body meeting minutes, patient interview and interview with staff, the hospital failed to provide a functional heating system that became completely inoperable 9/2010. An immediate jeopardy situation was called as a result of the hospital not having heat as evidence by the temperature in the patient rooms being between 58 degrees and 68 degrees on 12/14/10. The hospital failed to ensure that there were available blankets in the hospital at the time of the immediate jeopardy. The hospital also failed to recognize the potential patient safety issues after providing portable heaters with long cords in the rooms of patients with psychiatric diagnoses.
These findings were identified and the Administrator and DON were notified on 12/13/10 at 5:15 PM. On 12/15/10, 2 new boilers were installed and heat was restored to the first floor of the hospital. A maintenance employee reported to the survey team there could be an "air lock" in the duct system preventing the warm air from being circulated to the second floor where Seaside Health System was located. The company installing the 2 boilers and Entity A maintenance staff continued to work on the heating system. On 12/16/10, an onsite inspection by the survey team of Seaside Health System revealed the heating system was completely restored and the immediate jeopardy was lifted on 12/16/10 at 9:40 AM. The deficient practice was reduced to a standard level once the heating system had been restored.
Findings:
During initial tour on 12/13/10 at 8:45 am observation revealed staff and patients wearing jackets in the day room. Observation in patient rooms revealed there was a heating unit on the wall that was encased in an expanded metal cage so that patients did not have access.
On 12/13/10 at 10:50 AM, patient # 1 requested to speak with the surveyors. Patient # 1 complained to the survey team that the building was cold, especially at night. Patient #1 stated the nurse brought a portable heater into her room at night but removed it in the morning and locked it up. Patient #1 also stated she nearly froze when it was time to bathe because there was not enough heat.
On 12/13/10 at 11:10 AM, patient #2 also asked to speak with the survey team. Patient #2 confirmed electric portable heaters were provided at night as the only source of heat. On 12/14/10 at 7:45 AM, Patient #2 stated he was really cold this morning.
On 12/13/10 at 11:20 AM an interview with S3 activity director revealed the temperature was controlled from a central location but currently there was no heat for the building.
Interview on 12/13/10 at 11:30 AM with S6 revealed he worked for Entity A, who leased the building, as a maintenance worker and he worked at 3 separate hospitals. S6 stated he was not sure how long the heat had been out, maybe since October 2010. S6 stated when the boiler goes out, the hospital does not have any heat. S6 also stated he did not know when the owner of the building was notified that the boiler was inoperable.
Interview on 12/13/10 at 11:40 AM with S7 revealed he worked for Entity A and provided maintenance services for this hospital and 2 others. S7 stated the hospitals in which he worked had 2 boilers, one to run and the other for back up. S7 stated that one of the boilers broke approximately 1 1/2 years ago, so that there was not a back up for the second boiler. S7 indicated the only functional boiler broke the first or second week in September 2010, so there was no back-up system for heat. S7 stated Entity A was well aware when the second boiler became non functional, but that it was "all about the money", so the boiler was not replaced right away. S7 stated he was in the process of working with a company to replace both boilers but could not guarantee when there would be heat in the building, hopefully by the end of the week. S7 stated Entity A provided electric portable heaters for patient rooms.
On 12/13/10 at 11:50 AM, observation in the equipment storage room revealed 20 portable heaters were stored there. The electric heater was a radiator type that circulated heated oil through it and the cord to the heater was approximately 5-6 feet long.
On 12/13/10 at 1:00 PM, interview with S1 Administrator revealed this hospital had a contract to sublease this floor of the hospital from Entity A. S1 confirmed the boiler for the heat system had been broken since early September 2010 and the radiator type portable electric heaters were bought by Entity A to provide heat for individual patient rooms. S1 confirmed the electric heaters had very long cords and that the current patient population had psychiatric diagnoses that included attempted suicide. S1 also confirmed the heaters were placed in each patients' room for the night and removed the next day. S1 also stated the Lease Contract between Entity A and the owner of the building provided that Entity A would be responsible for building and equipment maintenance. S1 confirmed the hospital failed to ensure the physical environment was maintained.
On 12/14/10 at 1:15 PM, ambient room temperatures were obtained in each of the patient rooms by maintenance personnel. The average room temperature was 64.3 degrees Fahrenheit. (highest temperature: 68; lowest temperature: (58)
On 12/14/10 at 5:15 PM, observation of each patient room revealed there was a portable heater that was on and the bed had 2 thin cotton spreads over the sheet. Further observation revealed patients that were in bed were wrapped up in the covers and indicated they were cold. At that time, S1 administrator and S2 DON indicated they had requested more blankets the previous night but confirmed they did not evaluate the blankets to determine how effective they would be in keeping the patients warm. After the survey team made this observation, the administrative staff made the decision to buy blankets for the patients.

Based on review of the current Medical Staff Bylaws and interview with S12 medical records clerk, S2 administrator failed to ensure the hospital followed the Medical Staff Bylaws relative to suspension of physicians who have delinquent medical records. Findings:

Observation on 12/14/2010 at 2:15 PM revealed S12 medical records clerk indicated 113 medical records were delinquent from 3/2010 to 10/2010. She confirmed that the medical records were not completed by the admitting psychiatrist who is also the medical director. S12 stated that written reminders had not been sent to the psychiatrist, but they had given him verbal reminders.

Review of the Medical Staff Bylaws revealed, "Practitioners must complete their patients' medical record within 30-days of each patient's discharge." Further review revealed that "Medical records that the Practitioner fails to complete within the 30 day period will be considered delinquent. The Medical Records department Supervisor/Director shall notify Practitioners in writing of incomplete records nearing delinquent status. This notification shall remind the Practitioner that his or her Clinical Privileges will be automatically suspended in the event that he does not complete the medical records with five (5) days following receipt of notice. If the Practitioner fails to complete medical records after such notification, all of his clinical privileges will be automatically suspended". S1 administrator stated in an interview on 12/14/2010 at 3:00 PM that "We don't suspend doctors here"

Based on staff interview the governing body failed to ensure that a contractor of services furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. Findings:
Interview with S1 administrator on 12/13/10 at 1:00 PM revealed this hospital had a contract to sublease this floor of the hospital from Entity A. S1 confirmed that one of the two boilers for the heating system had been broken since 9/2010. S1 also stated the Lease Contract between Entity A and the owner of the building provided that Entity A would be responsible for building and equipment maintenance. S1 confirmed the hospital failed to ensure the physical environment was maintained when the 2ND boiler broke in early September 2010 and was not replaced/repaired as soon as possible prior to the cold winter months. The failure of the governing body to ensure that Entity A replaced the boiler for the heating system resulted in Seaside Health Systems being without heat during November and December 15, 2010.
Review of the Governing Body Meeting Minutes dated 3/1/10 revealed repair or replacement of the first broken boiler was not discussed at that meeting. Review of the meeting minutes dated 10/8/10 revealed no documented evidence of a plan to restore the heating system boiler. The over-night low temperatures 12/12 and 12/13/2010 were near or below freezing (32 degrees Fahrenheit).

Based on review of the current Medical Staff Bylaws and interview with S12 medical records clerk, the Medical Staff failed to adhere to their bylaws by not: 1) completing medical records within 30 days of discharge and 2) ensuring the Medical Records Department notified the physician regarding incomplete medical records before they reach delinquent status (over 30 days). Findings:

Observation on 12/14/2010 at 2:15 PM revealed S12 medical records clerk indicated 113 medical records were delinquent from 3/2010 until 10/2010. She confirmed that the records needed to be completed by the medical director who also is a staff psychiatrist. S12 stated that written reminders had not been sent to the psychiatrist, but they had given him verbal reminders.

Review of the Medical Staff Bylaws revealed, "Practitioners must complete their patients' medical record within 30-days of each patient's discharge." Further review revealed that "Medical records that the Practitioner fails to complete within the 30 day period will be considered delinquent. The Medical Records department Supervisor/Director shall notify Practitioners in writing of incomplete records nearing delinquent status. This notification shall remind the Practitioner that his or her Clinical Privileges will be automatically suspended in the event that he does not complete the medical records with five (5) days following receipt of notice. If the Practitioner fails to complete medical records after such notification, all of his clinical privileges will be automatically suspended". S1 administrator stated in an interview on 12/14/2010 at 3:00 PM that "We don't suspend doctors here"

Based on record review and staff interview, the hospital failed to ensure the registered nurse supervises the nursing care for each patient and evaluates the patient care needs as well as the patient's response to interventions. Findings:

1. Review of the medical record for patient # 5 revealed he was admitted 11/29/10 with physician orders dated 11/30/10 for Albuterol nebulizer treatment to be administered every 6 hours while awake for wheezing. Review of the December 2010 MAR (medication administration record) revealed S9 LPN administered the treatment on 12/4 and 12/5/10. Further review of the medical record failed to reveal the nurse assessed the patient prior to or following the treatment to determine the patient's response to the medication and the effectiveness of the treatment.

Interview with S9 LPN on 12/14/10 at 2:20 PM revealed she worked the day shift and provided weekend coverage. S9 LPN confirmed she administered Albuterol nebulizer treatments to patient #5 on 12/4 and 12/5/10 and did not assess or document the patient's response to the treatment in the patient's medical record.

2. Review of the medical record for patient #6 revealed he was admitted 12/01/2010 with physician orders dated 12/2/10 for Ventolin 2 puffs every 6 hours as needed for wheezing.
Review of the December 2010 MAR and interview with S11 Registered Respiratory Therapist on 12/14/10 at 2:20 PM revealed the nurses provided respiratory treatments to patients during the night and on weekends but that there was no evaluation by the nurse of patient #6's respiratory status before or after the treatment to determine the patient's response to the treatment.

Interview on 12/14/10 at 2:50 PM with S2 DON confirmed the nurses provided respiratory treatments to patients on weekends and during the night. S2 DON stated the nurses should be evaluating the patients' response to respiratory treatments.

Based on review of incomplete medical records and interview with the medical records clerk, the hospital failed to ensure all medical records were completed within 30 days of patient discharge from the hospital.
Findings:

Observation of the medical records department on 12/14/07 at 2:15 PM revealed there were 113 incomplete medical records. These records were from 3/2010-9/2010. An interview was held at that time with S12 medical records clerk who also functions as the administrative assistant, human resource director, and billing clerk, who confirmed that these records were over 30 days delinquent. When asked by the survey team regarding her training S12 stated she trained herself to perform the duties of a medical records clerk. The survey team also asked S12 were there letters sent to the psychiatrist regarding his delinquent medical records and she replied "No". S12 further stated that the reason the letters were not sent to the psychiatrist regarding his delinquent records because the contract RHIA (registered health information administrator) did not instruct her to send a written notice to the physician. Review of the medical records policy and procedures failed to address delinquent records.

Review of Medical Staff Bylaws revealed, "Practitioners must complete their patients' medical record within 30-days of each patient's discharge." Further review revealed that "Medical records that the Practitioner fails to complete within the 30 day period will be considered delinquent. The Medical Records department Supervisor/Director shall notify Practitioners in writing of incomplete records nearing delinquent status. This notification shall remind the Practitioner that his or her Clinical Privileges will be automatically suspended in the event that he does not complete the medical records with five (5) days following receipt of notice. If the Practitioner fails to complete medical records after such notification, all of his clinical privileges will be automatically suspended". S1 administrator stated in an interview on 12/14/2010 at 3:00 PM that "We don't suspend doctors here".

Based on interviews, review of medication variance reports and minutes of the only P&T (Pharmacy and Therapeutic) meeting held from 3/2010 through 12/13/2010, the hospital failed to ensure drug errors were reported to the pharmacist who is responsible for supervising and coordinating all activities of pharmacy services. Findings:

Review of medication variances from 3/2010 through 12/13/2010 revealed there were 5 errors reported. In an interview on 12/14/2010 at 9:00 AM S2 DON stated she calls the contract pharmacist to discuss medication variances, but does not send a copy of the variance to him. S2 DON further stated she does not document any information regarding the calls.

Review of the 10/18/2010 P&T committee meeting minutes revealed medication variances were not addressed. In a telephone interview on 12/14/2010 at 10:15 AM the owner of the contract pharmacy reported to the survey team that the pharmacist is not informed when medication variances occur. The owner stated he repeatedly asked the hospital to call and send the pharmacist a copy of the medication variances so the pharmacist could determine the causative factors of the variances and implement corrective actions if needed.

Based on hospital policy and procedure review and interview, the hospital failed to develop in writing the scope and complexity of respiratory care services offered. Findings:

Review of the hospital's policy and procedure manual revealed the scope and complexity of respiratory care services was for more advanced, complex treatments not provided by this hospital. Further review revealed policies and procedures had not been developed to address the practices of the hospital which included administration of respiratory nebulizer treatments. There were no policies/procedures developed that stipulated expected assessment/evaluation of respiratory status when the respiratory treatments were provided by nursing staff.

On 12/14/10 at 2:20 PM, interview with S11 Registered Respiratory Therapist confirmed the hospital policies and procedures were for more complex procedures that were not provided at this hospital. S11 confirmed there was not a policy and procedure specifying expected nursing evaluation/assessment of patient respiratory status following breathing treatments administered by nursing staff.

Interview on 12/14/10 at 2:50 PM with S2 DON confirmed the policy and procedures for respiratory services failed to specifically define the scope and complexity of respiratory care services provided by the hospital and failed to address nursing staff administration and evaluation of respiratory status of patients following breathing treatments administered by nursing staff.

Based on review of the QA/PI (Quality Assurance/Performance Improvement) Program reports and interview with S2 DON, the hospital failed to ensure all departments of the hospital measured, analyzed and tracked quality indicators as evidenced by the failure to: 1) include contracted services (lab, respiratory, radiology, dietary, housekeeping), medical records, medication errors, infection control, grievances and falls in the hospital wide QA/PI, 2) have documented evidence that nursing services and psychiatric services formulated and implemented preventative actions for indicators that did not reach their benchmark which was 100 percent. Findings:

The hospital did not provide the survey team with QA/PI reports for 3/2010, 4/2010 and 5/2010. Review of the QA/PI reports for 6/2010 through 8/2010 revealed there were no indicators for contracted services, medical records, medication errors, infection control, grievances and falls. The reports also revealed that even though there were indicators for nursing services and psychiatric services, there failed to be documented evidence that the hospital formulated and implemented preventative actions for indicators that did not reach their target goals. In an interview on 12/15/2010 at 9:30 AM S2 DON stated she is the hospital QA/PI coordinator. The DON confirmed at that time that the hospital has had problems with patients falling but she did not have an indicator for falls. She also confirmed that she did not include include contracted services, medical records, inflection control, medication variances or grievances in the QA/PI program.