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Based on record review and interviews, the Governing Body failed to ensure that all services provided by contract and agreement were evaluated to identify quality and performance problems and/or implement appropriate corrective or improvement activities to ensure the monitoring and sustainability of those contracted services. This failed practice was evidenced by no documented evidence of quality indicators developed for contracted services, inclusion of contracted services in the Quality meeting minutes, and confirmation by interview that no quality indicators for each contracted clinical service had been developed or initiated for the evaluation of services provided by contract or agreement.
Findings:


Review of Quality Assurance documentation revealed no quality indicators for services provided by contract or agreement. No documentation of evaluations of services provided by contract or agreement was provided.

In an interview 8/8/18 at 3:05 p.m. S6PM and S7Consult reported that contracted services were not evaluated annually.

In an interview 8/8/18 at 3:00 p.m. S3QAIC verified the quality program did not develop indicators for the evaluation of clinical services provided by contract or agreement. S3QAIC reported the hospital did not periodically evaluate the quality of services provided by each contracted clinical service, so those services were not integrated into the quality program.

Based on record reviews and interview, the hospital failed to ensure it implemented its grievance policy related to the grievance rights and grievance resolution as evidenced by failure to have the resolution letter to include the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for 4 of 4 (R1, R2, R3, R4) grievances reviewed from grievances reviewed from December 2017 through August 5, 2018.
Findings:

Review of policy RM-003 titled: Patient's Grievance Rights and Grievance Resolution represented as current policy, revealed in part the purpose is to ensure that the patient is afforded reasonable expectations of care and services and that the facility will address those expectations in a timely, reasonable, and consistent manner.
In its resolution of the grievance, Hospital shall provide the patient with written notice of its decision that contains the name of the contact person, steps taken on behalf of the patient to investigate the grievance, results of the grievance process, and the date of completion.

Patient #R1
Review of the document titled Grievances 1Q 2018 related to Patient #R1 revealed on 4/18/18 an issue regarding discharge process in recovery. Further review revealed a letter dated 4/30/18 which indicated Patient #R1 was not completely satisfied with the discharge process, this was discussed in a meeting and the staff was informed regarding Patient #R1's concerns. Further review revealed no documentation that written notification of the steps taken to investigate or the results of the investigation was to the patient or his representative.

Patient #R2
Review of the document titled Grievances 1Q 2018 related to Patient #R2 revealed on 6/11/18 an issue regarding pre-op wait time communication. Further review revealed a letter dated 6/19/18 which indicated Patient #R2 was not completely satisfied with the preoperative setting, this was discussed in a meeting and the nursing staff was informed regarding Patient #R2's concerns. Further review revealed no documentation that written notification of the steps taken to investigate or the results of the investigation was to the patient or his representative.

Patient #R3
Review of the document titled Grievances 1Q 2018 related to Patient #R3 revealed on 7/17/18 an issue regarding discharge call backs. Further review revealed a letter dated 7/25/18 which indicated Patient #R3 was not completely satisfied with the discharge call back process, this was discussed in a meeting and the nursing staff was informed regarding Patient #R3's concerns. Further review revealed no documentation that written notification of the steps taken to investigate or the results of the investigation was to the patient or his representative.

Patient #R4
Review of the document titled Grievances 1Q 2018 related to Patient #R4 revealed on 12/19/17 an issue regarding questions with pre-op medications. Further review revealed a letter dated 1/10/18 which indicated Patient #R4 was given Versed and Fentanyl, the dosages, ant the start and stopped times of procedure. Further review revealed no documentation that written notification of the steps taken to investigate or the results of the investigation was to the patient or his representative.

On 8/8/18 at 2:00 p.m. in an interview with S3QAIC, she revealed she does not have a log for patient grievances, she does not keep a copy of the actual complaint, and she does not give the patient any more detailed information including the steps taken on behalf of the patient to investigate the grievance or results of the grievance process.

38777

Based on record reviews and interviews, the facility failed to ensure all staff received hospital-specific training during orientation and ongoing training regarding abuse and neglect and related reporting requirements including prevention, intervention, and detection for 8 ( S2DON, S3QAIC, S12SPD, S15RN, S18RN, S19RN, S22HIM, S25RT) of 9 (S2DON, S3QAIC, S12SPD, S15RN, S18RN, S19RN, S22HIM, S25RT, S27DM) employed staff's personnel files reviewed for abuse and neglect training.
Findings:

Review of the personnel files of S2DON, S3QAIC, S12SPD, S15RN, S18RN, S19RN, S22HIM, and S25RT failed to reveal documented evidence of training during orientation and ongoing training regarding abuse and neglect and related reporting requirements including prevention, intervention and detection of abuse and neglect.

In an interview on 08/08/18 at 8:40 a.m., S2DON presented documentation of courses taken through Healthstream (an online education source used by the hospital). She indicated the courses are generic courses that could be taken by another agency's employee who logs on to the Healthstream system. She confirmed the courses were not based on this hospital's specific policies and procedures.

In an interview on 8/8/18 at 2:45 p.m., S23HR indicated she didn't have documentation to present that revealed staff received training regarding abuse and neglect and related reporting requirements including prevention, intervention and detection of abuse and neglect.

Based on records review and interviews, the hospital failed to meet the requirements of the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) as evidenced by:

1) Failure to ensure the Quality Assurance/Performance Improvement program measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of services and quality of care. This deficient practice was evidenced by:
a.) Failure to provide documentation of data collected, analyzed, and tracked for quality indicators as outlined in their Quality Assurance plan (patient falls, restraint use, medication errors, adverse drug reactions, blood utilization, or cardio-pulmonary arrests);
b.) Failure to provide documented evidence the frequency and detail of data collection was specified by the hospital's governing body (See Findings in A-0273).

2) Failure of the Governing Body to ensure the QAPI program reflected the complexity of the hospital's services as evidenced by failing to include all hospital services in the QAPI program. This deficient practice was evident by failing to include: Dietary and Food Services, Laboratory Services, Medical Services, Pharmacy Services, Radiology Services, Respiratory Services, Physical Therapy, Outpatient Services, and all hospital services provided by contract or agreement in the hospital's QAPI program (See Findings in A-0308).

3) Failure to provide adequate resources for measuring, assessing, improving, and sustaining the hospital's performance. This deficient practice was evidenced by having a single staff member (S3QAIC) designated to conduct the QAPI functions of the hospital, while the same staff member was also designated responsibility for the Infection Control Program, Employee Health, Case Management, UR, Risk Management, Emergency Preparedness, and Staff Education, and being unable to provide documented evidence of a fully implemented and ongoing Quality Assurance Program (See Findings in A-0315).

Based on record review and interview, the hospital failed to ensure the Quality Assurance/Performance Improvement program measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of services and quality of care. This deficient practice was evidenced by:
1) Failure to provide documentation of data collected, analyzed, and tracked for quality indicators as outlined in their Quality Assurance plan (patient falls, restraint use, medication errors, adverse drug reactions, blood utilization, or cardio-pulmonary arrests);
2) Failure to provide evidence that all services/departments were included in the Qaulity Improvment Program.. No indicators or data was provided for Dietary Services, Laboratory Services, Medical Records Services, Pharmaceutical Services, Radiology Services, Respiratory Services, Rehabilitative Services(Therapy), Outpatient services, or clinical services provided by contract and/or agreement. Further review revealed no documentation related to indicators outlined in the hospital policy, "Performance Improvement Plan" such as patient falls,/100 patient days.
3) Failure to provide documented evidence the frequency and detail of data collection was specified by the hospital's governing body.
Findings:


Review of hospital policy#PI-010 titled "Performance Improvement Plan", provided by S3QAIC as the current hospital Quality Plan, revealed the hospital would maintain an integrated and comprehensive Performance Improvement Plan. Further review revealed in addition to the Performance Improvement Priorities leadership, through the Quality Assurance Committee committee would monitor the following important functions on an ongoing basis: 1) root cause or focus reviews of significant events, 2) provisions of care, Treatment and services, 3) medication management, 4) Blood and Blood Product use (daily monitoring, 5) restraint use, 6) Operative and Invasive Procedures (daily monitoring), 7) Adverse Events during Moderate Sedation, 8) Utilizations management, 9) Quality Control, 10) Surveillance, Prevention, and Control of Infections, 11) Unexpected returns to hospital and/or surgery, and 12) Department specific PI indicators. Components or steps for Quality Control were listed as :a) Evaluate actual performance, b) Compare actual performance to quality goals, c) act on the difference, and d) departmental quality control activities largely monitored through the administrative side of the organizational structure for improving performance. Further review revealed no specifics related frequency and detail of data collection. No indicators were found for Dietary Services, laboratory services, medical record services, radiological services, respiratory services, therapy services, outpatient services, or contracted services.

Review of Quality Improvement Committee meeting minutes provided by S3QAIC for the last year revealed minutes for 3 meetings dated 08/23/17, 05/03/18, and 07/19/18. Further review of the meeting minutes revealed indicators discussed were documented as : Surgery, Anesthesia, Central Sterile, Pre-Op, PACU, and Medical Surgical. Documentation under "Action/Discussion" for each of these areas revealed revealed no information related to data collected, analyzed, or tracked. Target dates included: for August 2017 meeting target dates were 07/19/17 (earlier than the meeting), and 08/31/17 ( 7 days after the QA Committee Meeting), and for the 07/19/18 meeting target dates were documented as July 19, 2017, August 1, 2017, and July 25, 2017. The plan for follow-up documented on each of the 3 meeting minutes provided was the same: "New Excel spread sheets would be created and monthly data would be added to the indicators", "Managers requested to start data collection the beginning of Aug, They want to educated the staff for the indicators and data collection quality indicator worksheets.", and "New data collection work sheets will be designed to be kept in Surgery and medical surgical unit to help ease data collection process. 30 charts will be reviewed per month. Managers asked to start goal at 80% and after first month, increase to 90% then 95%." Further review revealed no discussion of quality data collected or analyzed for Dietary Services, Laboratory Services, Medical Records Services, Pharmaceutical Services, Radiology Services, Respiratory Services, Rehabilitative Services(Therapy), Outpatient services, or clinical services provided by contract and/or agreement, patient falls, restraint use, medication errors, adverse drug reactions, blood utilization, or cardio-pulmonary arrests/100 patient days.

In an interview 8/8/18 from 2:30 p.m. to 3:00 p.m. S3QAIC verified she was the person responsible for coordination of the hospital's Quality Assurance program. D3QAIC verified the hospital could not provide documentation of data collection, analyzation, and tracking for quality indicators that included all departments and services provided, or for each quarterly meeting.

Based on record reviews and interviews, the governing body failed to provide adequate resources for measuring, assessing, improving, and sustaining the hospital's performance by having insufficient staff designated to conduct the QAPI functions of the hospital. This deficient practice is evidenced by responsibility assigned to the Quality program, and to the same individual was assignment to Infection Control, Employee Health, Case Management, UR, and Emergency Preparedness, and Staff Education.. The hospital did not provide documentation of the collection, analyzing, and tracking of quality indicators for Dietary Services, Laboratory, Medical Services, Pharmaceutical Services, Radiology Services, Respiratory Services, Rehabilitative Services(Therapy), Outpatient services, or clinical services provided by contract and/or agreement. The hospital provided no documentation of data collected, analyzed, or tracked related to indicators outlined in the hospital policy, "Performance Improvement Plan" such as patient falls, restraint use, medication errors, adverse drug reactions, blood utilization, or cardio-pulmonary arrests.
Findings:

Review of hospital's policy #PI-010 titled, "Performance Improvement Plan", provided by S3QAIC as current, revealed in part that Sterling Surgical Hospital would maintain an integrated and comprehensive Performance Improvement Plan. Further review revealed Leadership would set priorities for Performance Improvement activities. Establishing the Performance Improvement Plan was the responsibility of leadership, and was guided by leadership. Further review revealed in addition to the Performance Improvement Priorities leadership, through the Quality Assurance Committee committee would monitor the following important functions on an ongoing basis: 1) root cause or focus reviews of significant events, 2) provisions of care, Treatment and services, 3) medication management, 4) Blood and Blood Product use (daily monitoring, 5) restraint use, 6) Operative and Invasive Procedures (daily monitoring), 7) Adverse Events during Moderate Sedation, 8) Utilizations management, 9) Quality Control, 10) Surveillance, Prevention, and Control of Infections, 11) Unexpected returns to hospital and/or surgery, and 12) Department specific PI indicators.

Review of Quality Improvement Committee meeting minutes provided by S3QAIC for the last year (August 2017-August 6, 2018) revealed minutes for 3 meetings dated 08/23/17, 05/03/18, and 07/19/18. Further review of the meeting minutes revealed indicators discussed were documented as : Surgery, Anesthesia, Central Sterile, Pre-Op, PACU, and Medical Surgical. Documentation under "Action/Discussion" for each of these areas revealed revealed no information related to data collected, analyzed, or tracked. Target dates included: for August 2017 meeting target dates were 07/19/17 (earlier than the meeting), and 08/31/17 ( 7 days after the QA Committee Meeting), and for the 07/19/18 meeting target dates were documented as July 19, 2017, August 1, 2017, and July 25, 2017. The plan for follow-up documented on each of the 3 meeting minutes provided was the same: "New Excel spread sheets would be created and monthly data would be added to the indicators", "Managers requested to start data collection the beginning of Aug, They want to educated the staff for the indicators and data collection quality indicator worksheets.", and "New data collection work sheets will be designed to be kept in Surgery and medical surgical unit to help ease data collection process. 30 charts will be reviewed per month. Managers asked to start goal at 80% and after first month, increase to 90% then 95%." Further review revealed no discussion of quality data collected or analyzed for Dietary Services, Laboratory Services, Pharmacy Services, Radiological Services, Respiratory Services, Medication Administration errors, Infection control, Therapy services, Laboratory services, services provided by contract or agreement, patient falls, restraint use, medication errors, adverse drug reactions, blood utilization, or cardio-pulmonary arrests/100 patient days as per the Performance Improvement Plan policy and procedure.

In an interview 08/08/18 from 2:30 p.m. to 3:00 p.m. S3QAIC verified she was the person responsible for coordination of the hospital's Quality Assurance program, and verified the above noted findings. S3QAIC verified the hospital could not provide documentation of data collection, analyzation, and tracking for quality indicators that included all departments and services provided. S3QAIC stated, "I just don't have time to do it all; I'm just one person." S3QAIC verified she was responsible for multiple areas, that included Quality Assurance, Infection Control and Employee Health, Risk Management, Case Management/UR, Emergency Preparedness, Licensing, and Staff Education.

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by:

1) Failing to ensure the RN supervised and evaluated the nursing care for each patient as evidenced by:

a) Failing to develop a policy and procedure for the RN assisting the anesthesiologist with peripheral nerve blocks by aspirating and pushing the plunger of a syringe containing anesthetic agents in accordance with the LSBN's declaratory statement for 2 (#15, #18) of 3 (#15, #18, #20) patient records reviewed that had a peripheral nerve block performed in Pre-op prior to a surgical procedure from a sample of 31 patients. Observation on 08/07/18 at 10:15 a.m. in Pre-op revealed S15RN assisted S16MD with a peripheral nerve block to the right thigh on Patient #15 by aspirating and pushing the plunger of a syringe containing anesthetic agents with no documented evidence she had received training and education and had an evaluation of competency by a qualified professional for performing this procedure (see findings in tag A0395).

b) Failing to have documented evidence that patients receiving IV conscious sedation for a nerve block were monitored in accordance with the LSBN's declaratory statement for 3 (#15, #18, #20) of 3 patient records reviewed that included the administration of IV conscious sedation from a sample of 31 patients. Observation on 08/07/18 at 10:15 a.m. in Pre-op revealed S15RN assisted S16MD with a nerve block on Patient #15 by aspirating and pushing the plunger of a syringe containing anesthetic agents. Continuous observation revealed a second RN or CRNA was not present to monitor Patient #15 who received IV conscious sedation for the nerve block procedure (see findings in tag A0395).

2) Failing to ensure the RNs assigned the nursing care of each patient had the appropriate education, competence, and specialized qualifications to provide the nursing skill as evidenced by failure to have documented evidence of training, education, and an evaluation of competency in assisting the anesthesiologist with peripheral nerve blocks by aspirating and pushing the plunger of a syringe containing anesthetic agents in accordance with the LSBN's declaratory statement and/or monitoring patients receiving IV conscious sedation in accordance with the LSBN's declaratory statement for 3 (S15RN, S18RN, S18RN) of 3 RN personnel files reviewed for education, training, and competency evaluation for assisting with nerve blocks and monitoring IV conscious sedation from 10 personnel files reviewed (see findings in tag A0397).

Based on observations, record reviews, and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care for each patient as evidenced by:
1) Failing to develop a policy and procedure for the RN assisting the anesthesiologist with peripheral nerve blocks by aspirating and pushing the plunger of a syringe containing anesthetic agents in accordance with the LSBN's declaratory statement for 2 (#15, #18) of 3 (#15, #18, #20) patient records reviewed that had a peripheral nerve block performed in Pre-op prior to a surgical procedure from a sample of 31 patients. Observation on 08/07/18 at 10:15 a.m. in Pre-op revealed S15RN assisted S16MD with a peripheral nerve block to the right thigh on Patient #15 by aspirating and pushing the plunger of a syringe containing anesthetic agents with no documented evidence she had received training and education and had an evaluation of competency by a qualified professional for performing this procedure.
2) Failing to have documented evidence that patients receiving IV conscious sedation for a nerve block were monitored in accordance with the LSBN's declaratory statement for 3 (#15, #18, #20) of 3 patient records reviewed that included the administration of IV conscious sedation from a sample of 31 patients. Observation on 08/07/18 at 10:15 a.m. in Pre-op revealed S15RN assisted S16MD with a nerve block on Patient #15 by aspirating and pushing the plunger of a syringe containing anesthetic agents. Continuous observation revealed a second RN or CRNA was not present to monitor Patient #15 who received IV conscious sedation for the nerve block procedure.
3) Failing to ensure the RN's assessment of a patient preoperatively included an assessment of heart and lung sounds for 1 (#15) of 1 patient observed pre-operatively on 08/07/18 at 9:16 a.m. from a sample of 31 patients.
Findings:

1) Failing to develop a policy and procedure for the RN assisting the anesthesiologist with peripheral nerve blocks by aspirating and pushing the plunger of a syringe containing anesthetic agents in accordance with the LSBN's declaratory statement:
Observation on 08/07/18 at 10:15 a.m. in Pre-op revealed S16MD presented to perform a peripheral nerve block to Patient #15's right thigh. Continuous observation revealed time out was called by S15RN at 10:25 a.m. She administered Versed 2 mg IV at 10:26 a.m. and Fentanyl 50 mcg IV at 10:36 a.m. as ordered by S16MD. Continuous observation revealed S15RN assisted S16MD by pushing the anesthetic block medications while S16MD held the ultrasound probe and needle which S16MD had inserted under ultrasound guidance. Continuous observation revealed during the procedure S16MD told S15RN to aspirate and inject 1 ml of the anesthetic block medication, then told her to aspirate and inject 1 ml at 10:28 a.m., then told her to aspirate and inject "4 or 5 ml" and take a picture (from the ultrasound machine). S16MD then instructed S15RN to connect the second prepared syringe of anesthetic block medication to the needle and to aspirate and inject 5 ml and instructed her to aspirate and give the remaining 5 ml of anesthetic block medication.

Review of the LSBN's "Declaratory Statement On The Registered Nurse Assisting With Peripheral Nerve Blocks" revealed it is within the role and scope of RNs to assist anesthesia providers in the administration of anesthetic agents during the performance of a peripheral nerve block provided the RN is under the direct supervision of the anesthesia provider and the RN has the requisite knowledge, skills, and abilities to do so. Institutional policy should establish specific parameters for the RN's role and duties in assisting with peripheral nerve blocks as well as processes for RN training, education, and ongoing competency.

Review of the hospital policy titled "Special Anesthesia Procedure", presented as a current policy by S2DON, revealed the purpose of the policy was to provide guidelines for observation of, assistance with, and documentation of care related to administration of regional anesthetics or special anesthesia procedures performed by the anesthesiologist. Further review revealed the RN was to place the patient on the cardiac monitor, pulse oximetry, and automatic blood pressure monitor. The RN was to assess vital signs initially, during the procedure, and every 15 minutes post procedure until the patient was discharged from PACU. The RN was to remain available to assist the physician during the procedure and evaluate and document how the patient tolerated the procedure and the outcome. There was no documented evidence that the policy addressed specific parameters for the RN's role and duties in assisting with peripheral nerve blocks as well as processes for RN training, education, and ongoing competency.

Patient #15
Review of Patient #15's medical record revealed S15RN documented time out was called on 08/07/18 at 10:25 a.m. for a right lower extremity peripheral nerve block per S16MD. Further review revealed S15RN documented at 10:41 a.m. that the procedure was done, and the patient tolerated it well. There was no documentation that included S15RN's aspirating and pushing of the nerve block medication.

Patient #18
Review of Patient #18's medical record revealed he had a peripheral nerve block on 07/30/18 at 9:32 a.m. in Pre-op performed by S26MD. Further review revealed S19RN administered Versed 2 mg IV at 9:25 a.m., Fentanyl 50 mcg IV at 9:28 a.m., and Fentanyl 50 mcg IV at 9:38 a.m. Further review revealed S19RN documented that a time out was called at 9:35 a.m., the nerve block was started, the nerve block was completed at 10:00 a.m., and Patient #18 tolerated the procedure well with vital signs stable. There was no documented evidence that S19RN included her assistance of aspirating and pushing of the nerve block medication.

Review of the personnel files of S15RN and S19RN revealed no documented evidence of training, education, and ongoing competency evaluations in assisting with peripheral nerve blocks.

In an interview on 08/07/18 at 10:45 a.m., S15RN confirmed the peripheral nerve block for Patient #15 was done under IV conscious sedation. She indicated "that's how we always do it" (meaning one RN assisting the anesthesiologist with aspirating and pushing the nerve block medication and also monitoring the patient for IV conscious sedation).

In an interview on 08/08/18 at 10:24 a.m., S2DON confirmed the hospital policy related to special anesthesia procedures did not include specific parameters for the RN's role and duties in assisting with peripheral nerve blocks as well as processes for RN training, education, and ongoing competency. She indicated she did not know the RN had to have special education and be evaluated for competency in pushing nerve block medication for the anesthesiologist.

2) Failing to have documented evidence that patients receiving IV conscious sedation for a nerve block were monitored in accordance with the LSBN's declaratory statement:
Observation on 08/07/18 at 10:15 a.m. in Pre-op revealed S16MD presented to perform a peripheral nerve block to Patient #15's right thigh. Continuous observation revealed time out was called by S15RN at 10:25 a.m. She administered Versed 2 mg IV at 10:26 a.m. and Fentanyl 50 mcg IV at 10:36 a.m. as ordered by S16MD. Continuous observation revealed S15RN assisted S16MD by pushing the anesthetic block medications while S16MD held the ultrasound probe and needle which S16MD had inserted under ultrasound guidance. Continuous observation revealed at 10:25 a.m. S15RN had to leave the room to get a 25 gauge needle for S16MD. Continuous observation revealed there wasn't a second RN or CRNA present during the nerve block procedure to provide monitoring of Patient #15 who had received IV conscious sedation for the procedure.

Observation on 08/07/18 at 10:45 a.m. revealed S15RN looked at the print out of Patient #15's vital signs from the monitor to document the vital signs for the time during the block procedure.

Review of the LSBN's "Declaratory Statement On The Role And scope Of Practice Of The Registered Nurse In The Administration Of Medication And monitoring Of Patients During The Levels of Intravenous Procedures/Conscious Sedation (Minimal, Moderate, Deep, And Anesthesia) As Defined Herein" revealed the RN (non-CRNA) monitoring the patient will have no additional responsibility that would require leaving the patient unattended or would compromise continuous monitoring during the procedure. Further review revealed documentation and monitoring of physiologic measurements, including but not limited to blood pressure, respiratory rate, oxygen saturation, cardiac rate and rhythm, and level of consciousness shall be recorded pre-procedure and at least every 5 minutes during the therapeutic, diagnostic, or surgical procedure and at a minimum every 15 minutes during the recovery period or as deemed appropriate by the authorized prescriber. Further review revealed the non-CRNA RN shall have documented education and competency to include the following: knowledge of sedative drugs and reversal agents, their dosing, onset, duration, potential adverse reactions, drug compatibility, contraindications, and physiologic effects; ACLS and/or neonatal Resuscitation Program, PALS, Emergency Nursing Pediatric Course based on the patient's age; skill in establishing an open airway, head-tilt, chin lift, use of bag-valve-mask device, oral and nasal airways; and emergency procedures including rescuing a patient that may progress beyond deep sedation; demonstration of acquired knowledge of anatomy, physiology, pharmacology, and basic cardiac arrhythmia recognition, ability to recognize complications of undesired outcomes related to sedation/analgesia, appropriate interventions in compliance with standards of practice, emergency protocols or guidelines; demonstration of the knowledge of age specific considerations in regard to assessment parameters, potential complications, and appropriate interventions according to institutional protocol or guidelines; possession of the requisite knowledge and skills to perform and evaluate pre-procedure baseline, intra-procedure, and post-procedure clinical assessment of the patient undergoing sedation/analgesia; demonstration of the ability to use oxygen delivery devices, applying the principles of oxygen delivery and respiratory physiology; demonstration of the knowledge of the standards of practice and licensure related to the sedation/analgesia; application of the principles of accurate documentation in providing a comprehensive description of patient responses and outcomes. Competencies will be measured initially during orientation and at least on an annual basis.

Review of the hospital policy titled "IV Conscious Sedation-Administration Guidelines", presented as a current policy by S2DON, revealed the skill level included Anesthesiologist, CRNA, and RN. Further review revealed education and competency is required as well as ACLS or PALS. The RN monitoring the patient will have no additional responsibilities, and a physician will be present during conscious sedation. Documentation and monitoring of physiologic measurements were to include but not be limited to blood pressure, respiratory rate, oxygen saturation, cardiac rate and rhythm, and level of consciousness and shall be recorded at least every 5 minutes during the therapeutic, diagnostic, or surgical procedure and at a minimum of every 15 minutes during the recovery period or as deemed appropriate by the authorized prescriber. There was no documented evidence the policy included the specific education and competencies required in accordance with the above-listed declaratory statement.

Patient #15
Review of Patient #15's medical record revealed S15RN documented time out was called on 08/07/18 at 10:25 a.m. for a right lower extremity peripheral nerve block per S16MD. Further review revealed S15RN documented Versed 2 mg IV was administered at 10:26 a.m., and Fentanyl 50 mcg IV was administered at 10:36 a.m. She documented at 10:41 a.m. that the procedure was done, and the patient tolerated it well. Review of the documentation of vital signs revealed no documentation of Patient #15's level of consciousness from 10:20 a.m. through 11:20 a.m. as required by the LSBN's "Declaratory Statement On The Role And scope Of Practice Of The Registered Nurse In The Administration Of Medication And monitoring Of Patients During The Levels of Intravenous Procedures/Conscious Sedation (Minimal, Moderate, Deep, And Anesthesia) As Defined Herein."

Patient #18
Review of Patient #18's medical record revealed he had a peripheral nerve block on 07/30/18 at 9:32 a.m. in Pre-op performed by S26MD. Further review revealed S19RN administered Versed 2 mg IV at 9:25 a.m., Fentanyl 50 mcg IV at 9:28 a.m., and Fentanyl 50 mcg IV at 9:38 a.m. Further review revealed S19RN documented that a time out was called at 9:35 a.m., the nerve block was started, the nerve block was completed at 10:00 a.m., and Patient #18 tolerated the procedure well with vital signs stable. Review of the vital signs documented revealed vital signs were documented every 5 minutes from 9:25 a.m. through 9:55 a.m. with no documented evidence of an assessment of Patient #18's level of consciousness every 5 minutes during the procedure and no documented evidence of an assessment of vital signs that included the level of consciousness at a minimum of every 15 minutes during the recovery period in accordance with the LSBN's declaratory statement listed above.

Patient #20
Review of Patient #20's medical record revealed he had a peripheral nerve block performed on 11/07/17 at 7:24 a.m. by S26MD with the assistance of a CRNA. Further documentation by S18RN revealed procedure started at 7:24 a.m. and ended at 7:55 a.m. Review of the vital signs documented revealed vital signs were documented every 5 minutes from 7:24 a.m. through 7:54 a.m. with no documented evidence of an assessment of Patient #20's level of consciousness throughout the procedure. There was no documented evidence of an assessment of vital signs with an assessment of level of consciousness at a minimum of every 15 minutes during the recovery period in accordance with the LSBN's declaratory statement listed above.

In an interview on 08/07/18 at 10:45 a.m., S15RN confirmed the peripheral nerve block for Patient #15 was done under IV conscious sedation. She confirmed no other RN was assigned to monitor the patient while she assisted the MD with the block. She indicated "that's how we always do it."

In an interview on 08/08/18 at 10:24 a.m., S2DON confirmed the hospital policy related to IV conscious sedation did not include specific education and competency requirements for RNs performing IV conscious sedation as required by the LSBN's declaratory statement on monitoring IV conscious sedation. She indicated she did not know the RN had to have special education and be evaluated for competency in monitoring IV conscious sedation.

3) Failing to ensure the RN's assessment of a patient preoperatively included an assessment of heart and lung sounds:
Observation on 08/07/18 at 9:16 a.m. revealed Patient #15 arrived, and S15RN had him sign his anesthesia and surgical consents. Continuous observation revealed S15RN assessed Patient #15 but did not auscultate his heart and lung sounds.

Review of the hospital policy titled "Pre-op Assessment", presented as a current policy by S2DON, revealed hospital policy required patients be provided an appropriate screening prior to a scheduled procedure. Further review revealed a patient assessment will be obtained from the patient prior to the surgical procedure to determine the care required to meet the patient's initial needs as well as the needs as they change in response to care. A preoperative nursing assessment which includes physical, psychological, and social status will be obtained from the patient and/or guardian by the nurse. It will be completed when the patient pre-registers if possible. If pre-registration is done by phone, the nurse will call the patient at home the day prior to the procedure to obtain the needed information. Pre-op patient care needs will be identified during the pre-op assessment. The pre-op assessment will be used by the anesthesiologist and/or CRNA prior to the administration of anesthesia. The pre-op assessment is individualized and age specific. There was no documented evidence the policy addressed the requirements of a physical assessment with documentation of the assessment by a RN at the time of admission to Pre-op.

Review of the policy titled "Assessment of Pre Op and PACU Patient", presented as a current policy by S2DON, revealed the purpose of the policy was to provide guidelines for the assessment of post anesthesia care for all patients admitted to the PACU. There was no documented evidence that the policy addressed the guidelines for the assessment of Pre-op patients.

In an interview on 08/07/18 at 10:55 a.m., S15RN confirmed she didn't auscultate Patient #15's heart and lungs as part of her pre-op physical assessment. She further indicated "we don't auscultate heart and lungs until the patient gets to PACU unless the patient has a history of respiratory problems."

38777


Based on record reviews and interview, the hospital failed to ensure medical records were accurately written and timed, promptly completed, and properly stored as evidenced by:
1) Failing to ensure all staff accurately documented the same site for a surgical procedure and/or timed medical record entries for 5 (#4, #8, #10, #11, #15) of 13 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #15) patient records reviewed for accuracy and timing of signatures from a sample of 31 patients.
2) Failing to ensure all medical records were promptly completed in accordance with the hospital's policies for completion of medical records and failing to enforce consequences for delinquent medical records in accordance with the hospital's Medical Staff Bylaws.
3) Failing to ensure all medical records were properly stored in secure locations where they were protected from potential water damage in the event the sprinkler system was activated.
Findings:

1) Failing to ensure all staff accurately documented the same site for a surgical procedure and/or timed medical record entries:
Review of the policy titled "Medical Record Creation/Content and Distribution" presented as a current policy by S7Consult" revealed all clinical entries shall be accurately dated, timed, and authenticated by written signature or identifiable initials and professional title or initials indicating the professional credential. Further review revealed guidelines for medical record entries included accuracy.

Patient #4
Review of Patient #4's "Intraoperative Nursing Record" dated 07/18/18 revealed no documented evidence of the type of surgical prep used. Review of her "Discharge Summary" dated 07/19/18 revealed no documented evidence of the time the physician signed the discharge summary.

Patient #8
A review of Patient#8's medical record revealed a Pre- Operative Questionnaire with the procedure scheduled identified as left eye Cataract. The consent identified the left eye. The Physicians Pre and Post-Operative diagnosis was identified as Cataract of the left eye. The Intraoperative Report note stated the right eye was prepped with Betadine Solution/Normal Saline, and the implant was to the right eye.

Patient #10
A review of Patient #10's medical record revealed no documented evidence of the time the pre-operative evaluation was performed by the physician on 08/06/18.

On 08/07/18 at 9:40 a.m. in an interview with S2DON, she verified Patient #10's medical record had no documented time on his Preoperative Evaluation Form.

Patient #11
A review of Patient #11's medical record revealed the consent for refusal to permit the use of blood and or blood components, the patient consent to medical treatment or surgical procedure, the acknowledgement of receipt of medical information, and the Pre-Operative Questionnaire revealed no documented evidence of a time of the signatures.

Patient #15
Review of Patient #15's "Post-Operative Evaluation" revealed it was signed by S16MD on 08/07/18 at 8:00 a.m. prior to Patient #15's surgical procedure. Review of the "Intraoperative Nursing record" revealed the procedure began at 12:03 p.m. on 08/07/18.

In an interview on 08/07/18 at 2:30 p.m., S2DON verified the above inaccurate patient record documentation and incomplete documentation.

2) Failing to ensure all medical records were promptly completed in accordance with the hospital's policies for completion of medical records and failing to enforce consequences for delinquent medical records in accordance with the hospital's Medical Staff Bylaws:


39791


Review of the hospital Policy No. IM-030 titled "Chart Completion" revealed, in-part:
-Policy states hospital will utilize standardized HIM procedures for determining incomplete medical records for determining when an incomplete medical record has reached a delinquent status.
-Purpose is to ensure the chart completion fully and accurately reflects a patient's care and is in accordance with federal and state requirements.

Review of Policy No. IM-050 titled "Delinquent Physician List" revealed, in-part:
-Policy stated a list will be used as a mechanism of tracking those physicians having delinquent records.
-Purpose stated the medical staff rule and regulations define medical record delinquency as: Failure to fully document a H&P in the patient's chart within 24 hours of patient admission, or Failure to fully document a dictated or handwritten operative report within 24 hours of the procedure, or Failure to fully complete any other required record in the patient chart within 30 days following patient discharge.
-Procedure includes an analysis of incomplete and or delinquent records will be performed by the Medical Records Department on the 1st and 15th of each month. Letter #4 "Suspension of Privileges" (delinquent 30 days or more, notice of temporary suspension and hold placed on scheduling new surgery cases.
-On the 1st and 15th of each month, the Delinquent Physician List will be forwarded to the CEO.

Review of the Medical Staff Rules and Regulations, presented as the current rules and regulations by S7Consult, revealed:
Medical Records Suspension: A Practitioner whose charts are incomplete may be subject to corrective action in addition to temporary suspension of Privileges.
Delinquency Criteria:
a) Failure to fully document a H&P in the pt's chart prior to surgery or within 24 hours of patient admission, or
b) Failure to fully document a dictated operative report within 24 hours of the procedure, or
c) Failure to fully complete any other required record in the patient chart within 30 days following patient discharge.

Review of a sample of 8 (#22, #23, #24, #25, #26, #27, #28, #29) of 38 delinquent medical records, provided by S22HIM as current delinquent medical records, revealed the procedure dates dated back to 06/20/17. These included:
1 record greater than 390 days delinquent;
1 record greater than 330 days delinquent;
1 record greater than 300 days delinquent;
2 records greater than 30 days delinquent;
2 records greater than 21 days delinquent.
1 record presented as delinquent was not delinquent.

On 08/07/18 at 3:30 p.m. in an interview with S22HIM, S22HIM indicated she considers an operative report delinquent if it's not signed within 24 hours from surgery. She further indicated there should be a H&P in the patient's chart when the patient is having surgery, or updated within 24 hours. When asked about delinquent medical records, S22HIM stated the policy is to review the delinquent medical records on the 1st and 15th of the month and to send letters to the physicians who were delinquent. She stated the physicians were to be suspended after 60 days (30 days following delinquency), but she never sent a physician a letter of suspension. When asked who she was to notify regarding her list of delinquent physicians she finds on the 1st and 15th of the month, she stated she does not report these findings to anyone. She stated if she was asked, then she would inform them of the physician's delinquent records. She stated she does send suspension letters to physicians. When asked to see a log book/hospital's medical record deficiency report, she stated she cannot locate it due to the move, but will look for it to present to the surveyor. When asked to show copies of the letters she has sent, she provided 4 letters dated April 2018 to August 2018. When asked if these are the longest delinquent physician unsigned charts and incomplete charts, she responded "No". The charts were pointed to on a shelf, and she stated there were records delinquent since March 2017. When asked if the privileges of the physician with delinquent charts since March 2017 had been suspended, she stated no, and her reasoning was because it has been so long, she doesn't think he will return. She also stated she has not reported a list of delinquent physicians to her administrator. The delinquent records were counted out loud in the presence of the surveyors, S22HIM, and S24HIM with a total of 38 records being counted as delinquent at this time.

On 08/07/18 at 4:30 p.m. in an interview with S22HIM, she indicated she could not locate the log book with the evidence of the letters of delinquency that had been sent to physicians with delinquent records. She further indicated she was not successful in locating the log.

In an interview on 08/08/18 at 8:30 a.m., S22HIM was asked by the surveyor if she had located the log book with the evidence of the letters of delinquency sent to the physicians, and she stated she had not located it as of this time.

3) Failing to ensure all medical records were properly stored in secure locations where they were protected from potential water damage in the event the sprinkler system was activated:
Review of the hospital Policy No. IM-030 titled "Chart Completion" revealed, in-part:
Procedure stated administration shall enforce the standards defined in this policy. Regardless of the state of completion of the medical record, all medical records are stored in a secure environment and that records and information are protected against loss, destruction, tampering, and unauthorized access or use. Storage of medical records must be kept separate from non-clinical records to ensure confidentiality and restricted access. Care shall be taken at all times to ensure that unauthorized individuals do not have access to medical records.

Observation of the medical record department on 08/06/18 at 10:15 a.m. revealed the current location of the department is temporary. The hospital was undergoing renovations. Observation revealed the present location of the patient medical records was in a room that had sprinklers in the ceiling. There was no observation of a covering that protected the records from potential water damage in the event the sprinkler system was activated.

On 08/06/18 at 10:20 a.m. in an interview with S24HIM, she indicated the area where charts are usually stored is an appropriate area with no sprinklers. She stated she was currently scanning medical records. She stated there is no plan at the moment to protect the unprotected medical records in the event a sprinkler goes off. She stated she voiced this concern to her manager.

On 08/07/18 at 3:30 p.m. in an interview with S22HIM, she indicated the number of records needing to be scanned into the system were 138 patient records. She further confirmed the approximate number of records without protection from potential water damage was 176.

Based on record review and interview, the hospital failed to ensure the Utilization Review committee consisted of at least two doctors of medicine or osteopathy who do not have a direct financial interest in the hospital or was professionally involved in the care of the patient whose case was being reviewed. The hospital did not have two such physicians designated as physicians on the Utilization Review committee.
Findings:

Review of the policy titled "Utilization Review Plan 2018", presented as a current policy by S2DON, revealed a committee consisting of two or more practitioners must carry out the utilization review function. At least two members of the committee must be doctors of medicine or osteopathy and who have no direct financial interest in the hospital or was professionally involved in the care of the patient whose case was being reviewed.

In an interview on 08/08/18 at 1:00 p.m., S3QAIC confirmed the hospital doesn't presently have 2 physicians who don't have financial interest in the hospital on the utilization review committee.

Based on observations, record reviews, and interviews, the hospital failed to meet the requirement of the Condition of Participation of Infection Control. The the infection control officer failed to develop and/or implement a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel as evidenced by:

1) Failing to implement surgery-related risk mitigation measures contributing to healthcare-associated infections as evidenced by:
a) Failure to ensure safe injection practices were implemented. Observation in Pre-op on 08/07/18 at 9:00 a.m. revealed the warmer (top shelf) had 16 bags of 500 ml LR that had been spiked with tubing attached with no label indicating which nurse spiked the solution and what time and date the bags were spiked as well as the expiration date and time of the fluids in the warmer. Observation on 08/07/18 from 10:00 a.m. to 10 25 a.m. in OR "a", during a surgical procedure on Patient #17, revealed 3 different medications pre-drawn into single syringes that were labeled with only the drug names and strength were placed on a rolling cart in OR "a" during a procedure, and reported by staff to be for other patients scheduled to have procedures in OR "a" after the procedure in progress/being observed was completed (see findings in tag A0749).

1b) Failure to ensure hand hygiene practices were implemented in accordance with hospital policy or AORN guidelines as evidenced by observation of breaches in hand hygiene during observations on 08/06/18 and 08/07/18. The infection control officer had no documented evidence of the specific staff members who were observed during hand hygiene surveillance to be used for tracking and trending of deficient practice (see findings in tag A0749).

2) Failing to maintain a sanitary hospital environment as evidenced by failure to ensure refrigerator temperatures, OR temperatures, and OR humidity were maintained at the proper levels and that action was taken and documented when temperatures and humidity were outside acceptable ranges (see findings in tag A0749).

3) Failing to implement hospital staff-related measures related to training in infection control as evidenced by failing to have documented evidence of regular update training in preventing and controlling healthcare-associated infections and methods to prevent exposure to and transmission of infections and communicable diseases for 8 (S2DON, S3QAIC, S12SPD, S15RN, S18RN, S19RN, S22HIM, S25RT) of 9 (S2DON, S3QAIC, S12SPD, S15RN, S18RN, S19RN, S22HIM, S25RT, S27DM) staff personnel files reviewed for infection control updates (see findings in tag A0749).

4) Failing to have developed infection control quality indicators to be included in the quality assessment performance improvement report (see findings in tag A0749).

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Surgical Services as evidenced by:


1) Failing to ensure a medical history and physical examination was completed and documented no more than 30 days before or 24 hours after admission or registration, and an updated examination of the patient, including any changes in the patient's condition, was completed and documented within 24 hours after admission or registration when the medical history and physical examination was completed within 30 days before admission or registration. Observation on 08/07/18 at 11:15 a.m. in Pre-op revealed S10MD did not perform a history and physical examination of Patient #15 but documented that it was performed (see findings in tag A0952).

2) Failing to ensure policies governing surgical services were developed to achieve the maintenance of high standards of medical practice and patient care as evidenced by:
a) Failure to develop a system to assure the associated risk of fire from the the use of alcohol-based skin preparations in inpatient and outpatient anesthetizing locations was minimized. Alcohol-based skin preparations were used as the surgical prep with the use of the electrocautery system for surgical procedures performed on 2 (#15, #18) of 2 patient records reviewed for surgical skin preps from a sample of 31 patients;
b) Failure to develop policies and procedures for the use of the "One Tray" (a sealed sterilization container) related to retained moisture (see findings in tag A0951).

3) Failing to ensure surgical privileges were delineated for all practitioners providing surgical care. This deficient practice was evidenced by the hospital's practice of not including RN first assistants and unlicensed first assistants in the credentialing and privileging process of practitioners and allied health providers (see findings in tag A0945).

Based on record review and interview, the hospital failed to ensure surgical privileges were delineated for all practitioners providing surgical care. This deficient practice was evidenced by the hospital's practice of not including RN first assistants and unlicensed first assistants in the credentialing and privileging process of practitioners and allied health providers.
Findings:

Review of the medical record for Patient #9 revealed he was admitted to the hospital 08/03/18 and underwent a Left total knee arthroplasty. Further review revealed an Operative Report documented S21SAC as the assistant.

Review of the Medical Staff Bylaws revealed, in part under Article XII, 12.1, that Categories of Privileges that may be granted to LIPs and AHPs shall include : Clinical Privileges One-Case Privileges, Locum Tenens Privileges, Emergency Privileges, and Disaster Privileges. "Every LIP and AHP providing direct clinical services at this Hospital shall, in connection with such practice and except for Temporary Privileges, One-Case Privileges, and Emergency Privileges, be entitled to exercise only those Privileges or services specifically granted to him by the Governing Board. Said Privileges must be within the scope of the license authorizing the LIP or AHP to practice in this state and consistent with any restrictions thereon...Clinical Privileges shall be granted by the Governing Board, based on the recommendations of the MEC. Clinical Privileges may be granted for LIPs who have submitted applications for appointment or reappointment to the Staff consistent with these Bylaws or to LIPs and AHPs who have submitted a valid application hereunder...Prerogatives: Under establishing experience, training, and current competence, AHPs granted Privileges shall have the following prerogatives: (1) he Governing Board in consultation with the MEC shall determine the scope of the activities which each AHP may undertake..."

Review of hospital policy #SURG-51.2.4 titled "Operating Room RN First Assistant", provided by S7Consult as current, revealed in part that First Assistant functions should be performed only after the responsibility has been granted by a credentialing committee established by the facility.

A credentialing file was requested for S21SAC, and upon review it was revealed the file contained no evidence of a request for privileges or the approval and granting of privileges by the Medical Staff or the Governing Body.

Review of a list of RN and/or certified first assistants contracted through company "A" revealed 12 Surgical First Assistants

Review of a contract between Company "A" and the hospital revealed Company "A" would provide First Assistants for surgical first assist services.

In an interview 08/07/18 at 1:45 p.m. S7Consult reported there was not a credentialing file for S21SAC because the hospital did not credential and privilege any of the contracted first assistants.

Based on observation, record review, and interview, the hospital failed to ensure a medical history and physical examination was completed and documented no more than 30 days before or 24 hours after admission or registration, and an updated examination of the patient, including any changes in the patient's condition, was completed and documented within 24 hours after admission or registration when the medical history and physical examination was completed within 30 days before admission or registration. Observation on 08/07/18 at 11:15 a.m. in Pre-op revealed S10MD did not perform a history and physical examination of Patient #15 but documented that it was performed.
Findings:

Observation in Pre-op on 08/07/18 at 11:15 a.m. revealed S10MD visited Patient #15 to perform the history and physical examination/update prior to his procedure. Continuous observation revealed S10MD asked Patient #15 if there were "any last minute things for me? Alright we're going to fix you up." Further observation revealed S10MD asked Patient #15 which knee they were doing. Continuous observation revealed S10MD did not perform a physical examination or ask if there were any changes in his medical condition.

Review of the Medical Staff Rules and Regulations, presented as the current rules and regulations by S7Consult, revealed a complete admission history and physical examination, including all update notes when applicable, done by the physician shall be recorded within 24 hours of admission. This report should include all pertinent findings resulting from an assessment of all systems of the body. If a complete history has been recorded and a physical examination performed within 30 days prior to the patient's admission, a legible copy of these reports may be used providing these reports were recorded by a staff member. In such instances, an interval note should include a physical examination to update the patient's current medical status shall be completed within within 7 days prior to, or within 24 hours after admission. An appropriate history and physical examination and the preoperative diagnosis shall be recorded in the medical record prior to the performance of the surgery. When the history and physical examination are not recorded before an operation, the procedure should be canceled.

Review of Patient #15's "History & (and) Physical Record-S10MD revealed the documentation of the form did not include the date, time, and signature of the physician who performed the physical examination. Further review revealed the section "no change noted in patient's condition since History & Physical performed" did not have a check mark in the space provided before the written words, and S10MD signed this section on 08/07/18. There was no documented evidence that Patient #15 had a history and physical examination by S10MD prior to having his surgical procedure on his right knee on 08/07/18.

In an interview on 08/07/18 at 11:16 a.m., S15RN, who was present during the above observation, confirmed S10MD didn't ask Christian if there were any changes in his condition or allergies since his history and physical examination was done and didn't perform a physical examination of Patient #15.

Based on record reviews and interview, the hospital failed to ensure a properly executed informed consent for the operation must be in the patient's chart before surgery, except in emergencies, as evidenced by having incomplete anesthesia consents (a description and indication for the proposed surgery requiring anesthesia) in 5 (#9, #15, #17, #18, #20) of 15 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #15, #17 #18, #20, #21, #30) patient records reviewed for informed consent from a sample of 31 patients.
Findings:

Review of the Medical Staff Rules and Regulations, presented as the current Rules and Regulations by S7Consult, revealed all inpatient medical records shall include evidence of an appropriate informed consent. Further review revealed requirements prior to anesthesia and surgery include a preoperative evaluation and documentation review of the patient's informed consent forms. There was no documented evidence that the Rules and Regulations addressed the components of a properly executed informed consent.

Patient #9
Review of the "Anesthesia Consent for Patient #9 revealed Section 2, titled "Treatment/Procedure" failed to have documented the type of planned anesthesia to which the patient consented. Further review revealed Section 3, "Patient's Condition" referred to the patient's condition with the following statement: "Patient's diagnosis, description of the nature of the condition or ailment for which medical treatment, surgical procedure, or other therapy ... is indicated and recommended." There was no documented evidence that the patient's diagnosis or description of the nature of the condition for which anesthesia was recommended was included on the form as evidenced by having a blank space at the end of the statement. The consent was signed by Patient #9 and S9MD and timed prior to the patient's surgery 08/03/18. In an interview 08/08/18 at 10:40 a.m. S2DON verified the above findings.

Patient #17
Review of the "Anesthesia Consent for Patient #17 revealed Section 3, "Patient's Condition" referred to the patient's condition with the following statement: "Patient's diagnosis, description of the nature of the condition or ailment for which medical treatment, surgical procedure, or other therapy ... is indicated and recommended." There was no documented evidence that the patient's diagnosis or description of the nature of the condition for which anesthesia was recommended was included on the form as evidenced by having a blank space at the end of the statement. The consent was signed by Patient #17 and S16MD and timed prior to the patient's surgery 08/07/18. In an interview 08/08/18 at 10:40 a.m. S2DON verified the above findings.

Patient #15, #18, #20
Review of the "Anesthesia Consent" for Patients #15, #18, and #20 revealed the third part of the consent referred to the patient's condition with the following statement: "Patient's diagnosis, description of the nature of the condition or ailment for which medical treatment, surgical procedure, or other therapy ... is indicated and recommended." There was no documented evidence that the patient's diagnosis or description of the nature of the condition for which anesthesia was recommended was included on the form as evidenced by having a blank space at the end of the statement.

In an interview on 08/08/18 at 10:24 a.m., S2DON confirmed the above findings. She offered no explanation or reason for the informed consent not being complete prior to the patient being taken to surgery.



30420




39791

Based on record reviews and interview, the hospital failed to ensure an operative report describing techniques, findings, and tissue removed or altered was written or dictated immediately following surgery and signed by the surgeon as evidenced by failing to have documented evidence of a completed operative report in the patient's current medical record immediately after surgery before the patient is transferred to the next level of care in accordance with the Medical Staff Rules and regulations for 4 (#4, #9, #15, #20) of 11 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #15, #20) patient records reviewed for a complete operative report from a sample of 31 patients.
Findings:

Review of the Medical Staff Rules and Regulations, presented as the current rules and regulations by S7Consult, revealed a post-operative note shall be dictated or written immediately following surgery and shall contain the following elements: the name of the surgeon; description of the approach and findings; the technical procedures used; the specimen(s) removed; estimated blood loss; drains and packing left; suture and technique of closure of the various plains; the post-operative diagnosis; the patient's condition during and after the procedure. An operative report or hand written operative progress note must be promptly signed by the surgeon and made a part of the patient's current medical record immediately after surgery before the patient is transferred to the next level of care.

Patient #4
Review of Patient #4's hand-written "Surgical Progress Note/Operative Report" signed by the physician on 07/18/18 revealed no documented evidence (areas left blank) of the following items: specimen(s) removed; estimated blood loss; drains; complications; condition on arrival to recovery; patient transferred to floor (option of answering yes or no). Review of the dictated "Operative Report" revealed no documented evidence of the date it was dictated or transcribed, and the physician signed the report on 07/25/18 (7 days after the procedure).

Patient #9
Review of Patient #9's hand-written "Surgical Progress Note/Operative Report" signed by S10MD dated 08/03/18 at 10:30 a.m. revealed no documented evidence (areas left blank) of the following items: technique, specimen(s) removed, estimated blood loss, complications, condition on arrival to recovery (good, fair, guarded all blank) and "yes" and "no" choices for the patient's transfer to the floor. Review of the dictated "Operative Report" revealed it was dictated 08/03/18, transcribed 08/04/18, and electronically reviewed and signed 08/07/18 (4 days after the surgery).

Patient #15
Review of Patient #15's hand-written "Surgical Progress Note/Operative Report" dated 08/07/18 with no documented evidence of the date or time of of the physician's signature revealed no documented evidence (areas left blank) of the following items: technique; specimen(s) removed; estimated blood loss; drains; complications; condition on arrival to recovery; patient transferred to floor (option of answering yes or no). Review of the dictated "Operative Report" revealed no documented evidence of the time it was dictated or transcribed.

Patient #20
Review of Patient #20's hand-written "Surgical Progress Note/Operative Report" signed by the physician on 11/07/17 with no documented evidence of the time of his signature revealed no documented evidence (areas left blank) of the following items: technique; specimen(s) removed; estimated blood loss; complications; condition on arrival to recovery; patient transferred to floor (option of answering yes or no). Review of the dictated "Operative Report" revealed no documented evidence of the time it was dictated on 11/09/17 or transcribed on 11/10/17. S10MD signed the transcribed Operative Report on 12/14/17.

Review of the quality indicators for surgery presented by S3QAIC revealed no documented evidence that completion of an accurate operative report immediately after procedure was included in the list of surgery quality indicators.

In an interview on 08/08/18 at 10:24 a.m., S2DON confirmed the above findings. She offered no explanation for the operative reports not being accurately completed by the physicians.




30420

Based on observation, record review,and interview, the hospital failed to ensure a pre-anesthesia evaluation was completed and documented by an individual qualified to administer anesthesia performed within 48 hours prior to surgery or a procedure requiring anesthesia services that included an examination of the patient. Observation on 08/07/18 at 9:45 a.m. revealed no observation of S16MD performing a physical examination that included auscultation of heart and lungs when he performed the pre-anesthesia evaluation of Patient #15.
Findings:

Observation on 08/07/18 at 9:45 a.m. revealed S16MD presented to do the pre-anesthesia risk evaluation and sign the anesthesia consent for Patient #15. There was no observation of S16MD auscultating Patient #15's heart and lungs prior to surgery.

Review of the Medical Staff Rules and Regulations, presented as the current rules and regulations by S7Consult, revealed requirements prior to anesthesia and surgery included documentation of a pre-anesthesia evaluation by a physician done prior to coming to the operating suite.

Review of the policy titled "Preoperative/Postoperative Anesthesia Visits", presented as a current policy by S7Consult, revealed all patients scheduled for anesthesia will be interviewed by the anesthesiologist or anesthetist prior to the surgical procedure. All patients are evaluated immediately prior to being taken to the operating room for induction. There was no documented evidence of the components of the pre-anesthesia evaluation by the anesthesiologist.

In an interview on 08/07/18 at 10:50 a.m., S16MD confirmed he didn't auscultate Patient #$15's heart and lungs when he did his pre-anesthesia evaluation. He further indicated he doesn't always auscultate the heart and lungs if the patient is young and healthy.

38777

Based on record reviews and interviews, the hospital failed to ensure all staff received emergency preparedness training annually and demonstrated knowledge of emergency procedures as evidenced by failure to have documented evidence of annual emergency preparedness training and demonstration of knowledge of emergency procedures for 8 of 8 (S2DON, S3QAIC, S12SPD, S15RN, S18RN, S19RN, S22HIM, S25RT) staff personnel files reviewed for emergency preparedness training.
Findings:

Review of the personnel files of S2DON, S3QAIC, S12SPD, S15RN, S18RN, S19RN, S22HIM, and S25RT revealed no documented evidence of annual emergency preparedness training with demonstration of knowledge of emergency procedures.

In an interview on 08/08/18 at 8:40 a.m., S2DON presented documentation of courses taken through an online system used for staff education. She further indicated the courses in the online system were generic courses that could be taken by another agency's employee who logs on to the online system. She confirmed the courses were not based on this hospital's specific policies and procedures and emergency preparedness plan.

In an interview on 08/08/18 at 2:45 p.m., S23HR indicated she didn't have documentation to present that revealed staff received training on emergency preparedness annually and documentation of the staff's demonstration of knowledge of emergency procedures.