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Based on record review and interview, the hospital failed to conduct Utilization Review tasks to determine medical necessity for Medicare and Medicaid patients as evidenced by:

A. Failure to establish and maintain a committee including at least 2 physicians to perform UR functions (see A0654); and

B. Failure to review patient admissions, extended stays, and professional services to determine medical necessity of care (see A0655).

This failed practice had the potential to cause patients to receive medically unnecessary care, resulting in higher costs.

Based on record review and interview, the hospital failed to ensure contracted services were provided in a safe and effective manner.

This failed practice had the potential to affect all current patients due to the lack of evaluation of the safety and effectiveness of services provided by contracted services.

Findings:

A document titled "Contracts" listed services provided to the hospital under contract including professional services, lease agreements, management services, consultant and administrative services. The document showed no evaluation of the safety and effectiveness of the services provided by the contracted staff.

On 10/20/17 at 1:45 pm, Staff F stated there was no documented review of contracted services for safety and effectiveness.

Based on observation and interview, the hospital failed to provide a safe environment for 1 (Patient #1) of 1 patients observed in the operating room by placing a warming device hose wrapped in a blanket on the patient.

FINDING:

On 10/18/17 at 8:44 am, Staff A was observed wrapping a warming device hose in a blanket on a low setting and laying the blanket on the patient. The surveyor asked if this was a standard practice. Staff A and Staff M stated that on occasion the warming device hose would be wrapped in a blanket allowing horizontal air flow for "a few minutes" and the blanket and warming device would be removed prior to draping of the patient. Staff A stated he understood this was against the manufacturer's guidelines and that the practice should not be done.

Based on record review and interview, the hospital failed to ensure nursing staff administered IV medications per policy for 1 (Patient #10) of 20 records reviewed.

This failed practice had the potential to result in adverse effects from medications going untreated.

Findings:

A policy titled "Moderate (Conscious) Sedation" stated if a reversal agent (a medication to counteract effects of sedation such as decreased pulse, respiratory effort, and decreased level of consciousness) was administered in the ER, the patient must remain in the ER for monitoring for an hour after returning to pre-procedural state.

Patient #10

The patient was treated in the ER for a puncture wound with a protruding foreign body to the left foot. A review of the clinical record showed the following documentation:

1. At 3:30 pm, the patient's pulse was 75 bpm, respiration rate 18 per minute, oxygen saturation 100%, and pain level 5 out of 10.
2. At 3:48 pm, the patient was given Versed (a sedative) 2mg IVP.
3. At 3:55 pm, Staff N documented "Pt very relaxed. Vitals good..."
4. At 4:00 pm, the patient's pulse was 78 bpm, respiration rate 18 per minute, oxygen saturation 100%, and pain level 0 out of 10.
5. At 4:15 pm, the patient was given Demerol (narcotic pain medication) 25mg IVP.
6. At 4:30 pm, the patient's pulse was 57 bpm, respiration rate 16, oxygen saturation 99%, and pain level 0 out of 10. The foreign body was removed from the foot at that time without difficulty.
7. At 4:54 pm, Staff N documented the patient was calm and sleeping.
8. At 5:00 pm, the patient's pulse was 56 bpm, respiration rate 16 per minute, oxygen saturation 99%, and pain level 0 out of 10.
9. At 5:30 pm, the patient's pulse was 58, respiration rate 16, oxygen saturation 98%, and pain level 0 out of 10.
10. At 5:46 pm, the patient was given Romazicon (medication to reduce sedation from benzodiazepines) 0.5mg IVP.
11. At 5:52 pm, the patient was given Narcan (medication to reduce effects of opioid pain medication) 0.4mg IVP.
12. At 5:55 pm, Staff N documented the patient's response to the administration of Romazicon as "symptoms have improved the patient feels better."
13. At 5:58 pm, Staff N documented the patient's response to Narcan as "symptoms have improved the patient feels better" and disposition was "improved and stable" and left the ER with family members by private vehicle.

Documentation showed 12 minutes had elapsed from the administration of the first reversal agent to the time the patient left the facility; and no additional vital signs were obtained prior to the patient leaving the facility.

On 10/18/17 at 12:45 pm, Staff N stated the patient's father requested to take the patient home while he/she was "in and out of sleep". The physician ordered the reversal medications, they were administered, and the father again requested to leave. Staff N notified the physician of the request, and the patient was released to go home with family.

Based on record review and interview, the hospital failed to maintain a committee with at least 2 physicians to conduct UR functions.

This failed practice had the potential to cause patients to receive medically unnecessary care, resulting in higher costs.

Findings:

A review of UR committee meeting minutes from 2016, Governing Board minutes for 2017, and monthly QAPI reports for 2017 showed no documentation of meetings of the UR committee since May of 2016. There was no documentation of current UR committee members appointed by the Governing Board.

On 10/24/17 at 9:50 am, Staff Q (an RN) stated UR "is behind" and the facility has not had a UR committee since May of 2016; he/she was the only person involved in UR functions currently.

Based on record review and interview, the hospital failed to review patient records to determine medical necessity of services provided to Medicare and Medicaid patients.

This failed practice had the potential to cause patients to receive medically unnecessary care, resulting in higher costs.

Findings:

A review of UR committee meeting minutes from 2016, Governing Board minutes for 2017, and monthly QAPI reports for 2017 showed no documentation of review of patient admissions, length of stay, or professional services since May of 2016. There was no documentation of current UR committee meetings or findings.

On 10/24/17 at 9:50 am, Staff Q (an RN) stated UR "is behind" and the facility has not had a UR committee since May of 2016; he/she reviews patient readmissions for quality purposes, but no one is reviewing records to determine medical necessity currently.

Based on observation and interview, the hospital failed to maintain acceptable safety and quality by having an unsecured oxygen tank, a janitor closet with no door handle hardware, and unused equipment stored in the Cardiology room.

FINDINGS:

On 10/17/17 during a tour of the hospital, the following was observed:

a. an unsecured oxygen tank in the Radiology Department Dressing Room #1. The area was open to the general public. The unsecured tank could fall damaging the tank, cause a rupture or cause the tank to become an airborne hazard.

On 10/17/17 at 10:25 am, Staff R stated the tank should not be unsecured in the department.

b. a janitor closet with no handle hardware in the Cardiology room. This room is used to provide testing for cardiology patients and has the potential for visitors to be in the room. The janitor closet stores cleaning equipment and supplies.

On 10/17/17 at 10:28 am, Staff F stated she was unaware why the door handle was missing.

c. unused equipment including a body warming device, an infant radiant warmer and a Neopuff Resuscitator (Trademark) (an infant resuscitator) were stored in the Cardiology room. There was no indication if the equipment was clean or had been used and not cleaned.

On 10/17/17 at 10:30 am, Staff F stated the equipment was stored for use by the ED and was unsure if the equipment was clean or not.

Based on record review and interview the hospital failed to maintain acceptable humidity levels in the operating rooms.

Findings:

See Life Safety Code survey Tag K-0323

Based on observation and interview, the hospital failed to maintain a sanitary hospital environment increasing the risk of infections by failing to assess the hospital and ensure an active and investigative control of possible infectious exposures.

FINDINGS:

During tours of the hospital, the following observations were made:

1. containers on the floor and shelving with no solid lower shelf in the Anesthesia Closet. Plastic tubs were observed on the floor in the Supply Cabinet. This practice does not allow the cleaning of the floors.
2. single patient-use package of adult incontinence products being stored under the sink in the emergency room.
3. wallpaper and walls in the front hallway and in the patient rooms in the emergency room were cracked and peeling prohibiting the cleaning of the walls.
4. patient use equipment (not marked clean or dirty) was stored in the clean Cardiology room

On 10/17/17 at 10:30 am, Staff F stated the equipment was stored for use by the ED and was unsure if the equipment was clean or not; patient use products should not be stored under the sink.

On 10/18/17 at 9:30 am, Staff M stated they knew not to put cartons on the floor.

On 10/24/17 at 2:00 pm, Staff E stated he was aware of the damage to the walls in the hospital.