HospitalInspections.org

Based on review of contracted service agreements, the hospital's Quality Assurance/Performance Improvement (QAPI) data and meeting minutes, policy titled "Contracted Services" (#HR 2.30 approved 12/27/2010) and interview with the DON (Director of Nursing Services) and Administrator, the Governing Body failed to evaluate all contracted services to ensure the services were provided in a safe and effective manner. Findings:

Review of the hospital's QAPI data and meeting minutes failed to reveal documented evidence that contracted services related to patient care had been evaluated to ensure they were provided in a safe and effective manner. Review of policy "Contracted Services" revealed the purpose of the policy was to ensure patient safety and quality services provided by contract which would be accomplished by documenting licensure, training, experience, clinical competence and performance evaluation of the services. In an interview on 12/06/2011 at 10:45 AM the DON and the Administrator confirmed there failed to be documented evidence that the Governing Body had evaluated contracted services to ensure they were provided in a safe and effective manner.

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Based on record review, policy review, and interview, the hospital failed to ensure the hospital had an " Advanced Directive " policy, failed to ensure the patients were given the opportunity to formulate Advanced Directives, and failed to ensure hospital staff implemented and complied with the Advanced Directive as evidenced by 4 of 7 surgical records reviewed were missing Advanced Directives (#1, #3, #5, #23) and 1 of 30 clinical records reviewed, (#25). Findings:

There was no "Advanced Directive" policy provided during the survey conducted from 12/05/11 through 12/07/11.

Review of medical records for Patient #1, #3, #5 and #23 revealed the patients had surgical procedures performed on 12/05/11. Further review revealed there was no documented evidence whether the patients had formulated an Advanced Directive noted in their medical records. Review of the computer generated preadmission scanned data for Patient #1, #5 and #23 revealed they did not have Advanced Directives formulated. Further an Advanced Directive was requested for Patient #3 on 12/01/11. Patient #3 was admitted and discharged to home without the hospital staff able to implement and comply with the patient's wishes.

In interviews on 12/07/11 at 9:35 a.m., at 9:40 a.m., at 9:45 a.m. and at 9:50 a.m., S1DON verified Patient #1, #3, #5 and #23 had surgical procedures performed on 12/05/11. The DON confirmed the medical records for Patient #1, #3, #5 and/or #23 had no information regarding whether the patients had formulated an Advanced Directive. S1DON indicated the hospital staff would not be able to implement and comply with Patient #3's wishes. Further S1DON indicated the hospital did not have a policy for staff to implement and comply with for Advanced Directives.

Record review of patient #25's clinical record revealed the face sheet was missing information related to whether the patient had formulated an Advanced Directive. In an interview on 12/7/11 at 10:00 a.m. with S1DON, she confirmed the clinical record had no information regarding patient #25's Advance Directive; therefore, the hospital staff would not be able to comply with patient #25's wishes.