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Based on review of Medical Staff Meeting Minutes, Governing Body Meeting Minutes, Medical Staff Bylaws, Governing Body Bylaws and interviews with staff the facility failed to credential and privilege medical staff through the governing body processes.

Findings:

1. Review of Governing Body Bylaws indicate the Governing Body meets twice a year. The most recent documented meeting was February of 2011. Dr G 's credentialing file indicates credentialing and privileging occurred in July of 2011. There was no documentation the Governing Body reviewed and approved Dr. G's credentials and privileges.

2. On 12/8/2011 Staff A told surveyors Dr. I had temporary privileges to practice in the facility. There was no documentation the Governing Body granted temporary privileges to Dr I.

Surveyor: Cason, Karla J.
Based on review of hospital documents, medical records and interviews with hospital staff, the hospital's governing body failed to ensure quality care is provided by and/or in accordance with orders of a practitioner who has been granted privileges by the hospital.

Findings:

1. Pt#1-34 year old male admitted 11/11/11 with a diagnosis of "unstageable coccyx wound" and admitting service was listed as "wound management". Hospital Pre-Admission Assessment 11/10/11 stipulates "primary reason for admission to LTACH (long term acute care hospital) wound, need debridement, wound care, PT (physical therapy), OT (occupational therapy), low air loss". Facility "admission criteria" dated 11/13 stipulates with a "X" written by "wound/Skin" and in Staff C's writing "debridement planned, fragmin, tele (telemetry)". The patient was admitted to the care of Dr M. Orders written 11/11/11 requested a Dr.G to consult. Dr. G provided a wound management consult on on 11/15/11. On 11/23/11 a progress note written by Staff D indicates a call was placed to Staff I for wound consultation. There is no documentation Dr. M was notified the consulting physician would not be available until 11/28 or 11/29/11. On 11/23 an order was written by Dr. M to consult Dr. I for wound management. According to Staff D the patient's mother did not want to continue with the wound management program ordered by Dr. G and told Dr. M she wanted another physician to consult. There is no documentation in the chart Dr. G was notified the patient's family no longer wanted Dr. G to consult on the wound. Dr. M the attending physician did not notify Dr. G he was no longer consulting on the patient. There is no documentation any physician assessed the patients wound management care from 11/15/11 until discharge. Documentation in the chart indicates Dr. I told staff he would consult but did not come to the facility.

On 12/8/11 Staff D told surveyors calls were placed on two later days to Dr.I and on 11/30/11 Dr. I told staff his schedule would not allow him to see the patient until 12/2/11. Documentation on 12/1/11 indicates the patient's mother requested a transfer to another facility for surgical debridement. The patient was transferred out of the facility on 12/1/11.

In an interview 12/8/11 with Staff D, the wound care nurse, Staff D told surveyors Dr. G sees wound patients one time a week (Tuesdays). Staff G stated the facility has two wound care nurses and they are available Monday through Friday. Staff D told surveyors the wound care nurses assess wounds with woundvacs three times a week and patients without wound vac's are assessed once a week. Staff D also told surveyors the nurses caring for patients provide whatever wound care is ordered when the wound care nurses are not caring for the patient. Staff D told surveyors during the course of Patient #1's wound management care the patient's mother had removed the ordered dressings and replaced with other dressings and treatments. Staff D told surveyors she did not complete an incident report or document the family's dissatisfaction with care through the grievance process. Staff D told surveyors Dr. G was not notified because they had been told Dr. G had been fired by the family. Staff D told surveyors Dr. M was not notified because he was not in charge of the patient's wounds. There was no documentation Dr. M coordinated care for the patient's primary diagnosis.

2. Dr. G's credentialing and privilege file reviewed 12/8/11 did not indicate Dr. G. had been credentialed and privileged in wound management. Dr. G's privileges indicated core "orthopedic surgery" privileges were granted. There was no documentation in Dr. G's file of current competency or training in wound management.

3. On 12/18/11 Staff A, B, and D told surveyors Dr. I was granted temporary privileges. Credentialing files for Dr. I did not include any temporary privilege information.

4. Although hospital staff conducted a review on Patient #1's medical record surveyors were told no physician was involved in the review. This was confirmed by Staff A,B, and D on 12/8/2011. Medical staff meeting minutes did not reflect the medical staff had conducted a review of the quality of medical care provided of either patient or review of the medical supervision for the care provided.

5. These findings were reviewed with administration at the exit conference. No further documentation was provided.

Based on review of Medical Staff Meeting Minutes, Governing Body Meeting Minutes, Medical Staff Bylaws, Governing Body Bylaws and interviews with staff the facility failed to credential and privilege medical staff through the governing body processes.

Findings:

1. Review of Governing Body Bylaws indicate the Governing Body meets twice a year. The most recent documented meeting was February of 2011. Staff G 's credentialing file indicates credentialing and privileging occurred in July of 2011. There was no documentation the Governing Body reviewed and approved Staff G's credentials and privileges.

2. On 12/8/2011 Staff A told surveyors Staff I had temporary privileges to practice in the facility. There was no documentation the Governing Body granted temporary privileges to Staff I..

Based on review of hospital policies and the grievance and complaint log, selected grievances and complaints, and interviews with hospital staff, the hospital failed to ensure the hospital's established grievance process was implemented.

Findings:

1. The hospital's grievance policy, entitled "Complaint and Grievance Process ," with an issue date of 11/11 defined a grievance as "a formal or informal written or verbal complaint that is made to the hospital by a patient, or patient's representative, regarding the patient's care. According to the policy " 4. the hospital staff member receiving the complaint will address the concerns that are appropriate to that individual's area of responsibility, expertise, state practice guidelines, experience and knowledge and can be addressed immediately (e.g. modification of treatment plan room temperature, environmental noise, etc.) 5. If a complaint cannot be resolved immediately in the same hour by the Hospital staff member, staff member shall notify his/her supervisor and complete the complaint/grievance form. The Complaint Grievance Form will then be forwarded to the Hospital's Chief Clinical Officer (CCO). The CCO, DQM, or CEO will investigate the circumstances surrounding the concern or complaint or grievance and review the issues with the Hospital's Chief Executive Officer (CEO). The Director of Quality Management (DQM) will assist with the investigation as needed and ensure the investigative procedure has been completed, corrective action has been taken and a written response sent within 7 days of receipt of the grievance." Although the hospital's policy correctly defines a grievance, the hospital failed to educate, train staff, and implement the policy.

2. The hospital failed to identify grievances: The surveyors reviewed two recent grievances regarding wound care. Two grievances (1,2) did not have a letter written to the complainant with all required elements.

Grievance #1 (Pt#1) -
According to the patient's medical record and hospital documents the Director of Nurses (DON) reviewed concerns the patient's mother had regarding wound care the day the patient was admitted 11/11/11. The patient's mother left notes on 11/15, 11/16,11/21,11/22,11/23, 11/28, regarding care concerns. Documentation in the chart from case management (11/14) indicates the patient's father was concerned about the patient's care and lack of wound management oversight. No formal grievance process was initiated until 11/30/2011. According to the CEO and the Director of Quality they were not aware of the concerns until 11/30/11. On 12/8/11 surveyors were told by wound management nurse and case management they were aware of patient complaints but did not initiate a formal grievance.

Grievance #2 (Pt#2)-
According to hospital documents the patient's spouse complained to the DON about patient care. Documents indicate an investigation was necessary to resolve the entire concern. There was no documentation a letter was written or the hospital grievance policy was followed. Documentation a second meeting was held with the complainant and issues from the first concern were identified as unsatisfactory. There was no documentation the Hospital grievance process was followed.

3. The hospital does not ensure the written response to the complainant contains all of the required elements. All of the grievances listed on the log were reviewed by surveyors. Not all of the complainants received letters. Not all of the letters to the complainants included what was done to investigate or what actions were taken to resolve the grievance.

Based on interviews with hospital staff and hospital record review, the hospital failed to provide specific privileges and limitations for each practitioner credentialed by the hospital. This occurred in two of three medical staff files reviewed.

Findings:

1. In one (Staff #G )of three medical staff (#G,H,I)credentialing files reviewed specific privileges granted indicated "Orthopedic Surgery". Documents provided to surveyors and interviews with staff indicate the physician was the "wound care program director". The credentialing file did not contain evidence of any education or training related to "wound management". The privilege form stipulated "Orthopedic Surgery Core". There were no requests documented for additional privileges. According to Pt #1's (the patient mentioned in the complaint) medical record Staff I provided "wound management" consultation.

2. According to Staff A, B, and D, Staff I was consulted to provide care for patients needing wound management. Staff A and B told surveyors 12/8/11 Staff I had temporary privileges. Pt #1's chart indicates an order was written for Staff I to consult for wound management on November 23, 2011. Review of Staff I's credentialing file includes an application to the medical staff. No temporary privileges were documented. There was no documentation provided to surveyors Staff I had temporary privileges.

3. This finding was reviewed with the administrator at the exit conference. No further documentation was provided.

Based on review of medical records, hospital documents, personnel files, and interviews with hospital staff, the hospital failed to ensure that wound assessment and care of each patient is assigned to nursing personnel who are trained, qualified, and competent to care for patients with these specialized needs. This occurred for two out of three nursing personnel charts for review.

Findings:

1. Staff D, E, and J's personnel files did not have evidence of yearly competencies or evaluation of skills for wound care to provide considerations for nursing personnel's qualifications and ability to provide care for the individual needs of each patient for which they are assigned.

2. Staff D and E were identified as wound care nurses. On the morning of 12/08/2011 staff B was asked to provide documentation of wound care staff's education, training, and qualifications. Staff D's and E's personnel files were reviewed. There was no evidence presented that identified staff D and staff E were wound care nurses - that they were trained and evaluated for competency of wound care evaluation and treatment according to current standards of wound care treatment. The file did not demonstrate continuing education was provided to ensure the wound care staff implemented comprehensive wound assessments, developed a plan of care including goals, implemented physician orders, and evaluated outcomes of treatment, based on the current standards of wound care treatment. This finding was reviewed with administrative staff on the afternoon of 1208/2011.

a. Staff D was identified to surveyors as the lead nurse for wound care treatment at the facility by administration on 12/08/2011. Staff D did not have a job description for lead wound care nurse signed and dated in their personnel file or in the wound care manual. The human resources personnel, Staff L, printed a job description from the computer titled "Lead Wound Care Nurse." Under the header "EDUCATION AND/OR EXPERIENCE:" the document records, "Minimum of (5) years of comprehensive wound management including wound assessment, formulation of treatment plan, recommendation of appropriate wound dressing, documentation, evaluation, education, data collection, surveillance and outcome data. Minimum one (3) year hospital Medical/Surgical or Rehabilitation experience. Knowledge of principles of infection control." Staff D was issued her registered nurse license on 9/17/2010 and has a hire date of 8/31/2010 at the hospital. Staff D did not have documentation present in her personnel file that a preceptorship occurred with the previous lead wound care nurse. No evidence was provided to surveyors that staff D had any training, experience, or qualifications in wound care treatment.

b. Staff E was identified as a wound care nurse by administration on the morning of 12/08/2011. Staff E told the surveyors on the morning of 12/08/2011 that she provided wound assessments, formulation of treatment plans and wound care when Staff D was not at the hospital. Staff E's personnel file was reviewed. Staff E did not have a job description for a wound care nurse signed and dated in their personnel file or in the wound care manual. Human resources personnel, Staff L stated the only job descriptions available for wound care were "Lead Wound Care Nurse" and "Wound Care Tech." Staff L stated that a job description for the role of Wound Care Nurse would have to be developed. Staff E did not have documentation present in their personnel file that a preceptorship with the previous wound care nurse occurred. No evidence was provided that staff E had any training, experience, or qualifications in wound care treatment. On the morning of 12/08/2011, Staff E confirmed that she did not have any specialized training in wound care.

3. The surveyors discussed these findings with administration during exit interview on 12/08/2011. No additional data was provided.