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Based on interview, record and document review, the hospital's Governing Body failed to ensure that the hospital retained professional and administrative responsibility for the contracted services. The hospital's contract service agreements had not specified who retained professional and administrative responsibility for those services and for the quality oversight of the services provided. These failures had the potential to affect the overall quality, evaluation and control of the services provided.

Findings:

1. During the investigation of a State authorized entity reported incident, an interview was conducted, on 11/26/14 at 7:10 A.M., with Registered Nurse (RN) 40. RN 40 stated that the written results of patient diagnostic radiology examinations (x-ray reports) could take up to 24 hours if the exam had not been ordered stat (as soon as possible).

During an interview on 12/10/14 at 9:00 A.M., Medical Doctor (MD) 2 stated that he provided care and ordered tests and treatments for patients at the facility. MD 2 stated that routine x-ray reports were expected within the same day unless he had ordered the x-ray stat or if the x-ray revealed a critical finding. MD 2 stated that he was not aware of the radiology service contracted time parameters for the receipt of the x-ray reports.

During an interview on 12/10/14 at 10:15 A.M., RN 37 stated that patient x-ray procedures were provided at the facility and sent out for interpretation. RN 37 was unable to state the expected time parameters for receipt of the x-ray reports.

During an interview on 12/10/14 at 2:00 P.M., the Radiology Manager (RM) stated that the facility provided x-ray procedures and that an offsite contracted service provided x-ray interpretation reports through an electronic system. The RM stated the expected time interval for x-ray reports was "1 to 1 1/2 hours for a stat" and "up to 24 hours for a routine report."

During a subsequent interview and joint document review on 12/11/14 at 9:30 A.M., the RM stated that the facility currently used the hospital's Radiology Track and Trend and PI (performance indicator) form, to monitor monthly radiology services. The collected/monitored data from June 2014 through November 2014 was reviewed. The form collected data which included the report time interval for stat and routine x-rays. The form indicated that the data monitored stat x-ray results, which were obtained in less than or greater than 30 minutes, and routine x-ray results which were obtained in less than 24 hours. In addition, the quarterly Radiology Department PI Report forms, for the same time interval, were reviewed and indicated that the x-ray report time interval monitored was less than or greater 24 hours.

On 12/11/14 at 10:00 A.M., a document review of the facility's radiology Service Agreement (contract), dated 10/18/12 was conducted. The contract included "General Terms and Conditions...b. Company shall use best efforts to have a median final report turnaround time of nine (9) hours or less after the Company's receipt of complete transmission of images and faxed requisition. Company also shall use best efforts to provide from Practice a preliminary STAT report in thirty (30) minutes after Company's receipt of complete transmission images and Client's call to Company identifying the study as STAT."

During a joint interview and document review on 12/11/14 at 10:30 A.M., the facility's radiology Service Agreement (contract), dated 10/18/12 was reviewed with the Director of Respiratory Therapy (DRT) and Director of Quality and Risk Management/Infection Preventionist (DQRM/IP). The DRT stated that she had provided oversight for the facility radiology services for the past "1-2 years...until 2 months ago." The DRT and DQRM/IP stated that they were not aware of the specific time parameters which were included in the radiology services contract agreement. The DRT and DQRM/IP acknowledged that the facility had monitored data that was not reflective of the contract service agreement and that the data monitored had not captured the desired quality indicators for the timeliness of x-ray reports.

During an interview and joint document review on 12/11/14 at 10:30 A.M., the Chief Financial Officer (CFO) stated that he was responsible for the review of facility contracts. The CFO acknowledged that the facility's current contract for radiology services had not specified that the facility retained professional and administrative responsibility for those services and the quality of the services provided.


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2. An interview was conducted with the Chief Financial Officer (CFO) on 12/15/14 at 4:20 P.M. The CFO stated that the hospital had 44 contracted services. Additionally, he stated, twenty one of the 44 contracts were patient care contracts.

Five of the 44 contracts were reviewed with the CFO. He acknowledged that those 5 contracts did not specify that the hospital retained professional and administrative responsibility for the services. In addition, the CFO stated that the remaining 39 contracts also, did not specify that the hospital retained professional and administrative responsibility for the services.

An interview with members of the Governing Body was conducted on 12/15/14 at 4:35 P.M. The Chief of Staff (COS), President and Board Chairman (PCOB), Regional Quality Director (RQD), Compliance Officer (CO), Chief Executive Officer (CEO), Chief Clinical Officer (CCO), Director Quality Risk Management/Infection Preventionist (DQRM/IP), Director Business Development (DBD) and Chief Financial Officer (CFO) were present. The COS acknowledged that the Governing Body was responsible and had oversight over all the hospital's conduct and function:

The COS stated that the Governing Body was not aware that the hospital's contracted service agreements failed to specify who retained professional and administrative responsibility for those services, in an effort to ensure that the quality of services provided met the needs and expectations of the patients and hospital.
Additionally, the PCOB stated that the Governing Body was not aware that the contracts did not specify that the hospital retained professional and administrative responsibility for the services. He stated that the Governing Body reviewed the hospital's contracts annually; however, the contracts are initially executed by the CEO.

Based on interview and document review, the hospital failed to identify quality indicators and collect outcome related data for outpatient services in an effort to ensure that processes of care and services in those areas were assessed for performance improvement opportunities. Failure to establish quality indicators and collect data in outpatient services did not ensure that the hospital focused on areas that were high risk, high volume or problem prone. In addition, there were no identified performance improvement activities developed to measure, track and sustain performance.

Findings:

An interview with members of the Governing Body was conducted on 12/15/14 at 4:35 P.M. The Chief of Staff (COS), President and Board Chairman (PCOB), Regional Quality Director (RQD), Compliance Officer (CO), Chief Executive Officer (CEO), Chief Clinical Officer (CCO), Director Quality Risk Management/Infection Preventionist (DQRM/IP), Director Business Development (DBD) and Chief Financial Officer (CFO) were present. The COS acknowledged that the Governing Body was responsible and had oversight over all the hospital's conduct and function related to outpatient services.

The COS stated that the Governing Body was not aware that the hospital's quality indicators were not developed for outpatient services. In addition, the COS stated that "The hospital looks at the number of procedures by specialty, determines if there are any problems, and that the hospital would deal with any concerns on a (case by case) basis." The COS acknowledged that the hospital had not identified any quality indicators or collected data pertaining to outpatient services in an effort to identify potential performance improvement activities. He further stated that in the past, the hospital previously looked at Electroconvulsive Therapy ECT(providing electric shock treatments to the brain for certain behavior and mood disorders), Dental and Bronchoscope procedures; however, there was not current data.

On 12/15/14 at 12:00 P.M., an interview was conducted with the Chief Executive Officer (CEO), Chief Clinical Officer (CCO), Director Quality Risk Management/Infection Preventionist (DQRM/IP), Director Plant Operations (DPO) and Director of Pharmacy (DOP).

The CEO, COO and DQRM/IP acknowledged that the hospital's outpatient services included ECT (electrode shock therapy ) procedures, dental procedures, bronchoscope (lung images via scope) procedures, rehabilitation and CT (x-rays of body structures) scan. A review of the hospital's procedural case volume report for 2014 was conducted on 12/15/14. Per the report, 657 out of 936 procedures performed (or 70%) at the hospital were done on an outpatient basis. Of the 657 outpatient procedures performed, 243 were dental procedures and 247 were ECT procedures.

The hospital's current Performance Improvement Plan (PI Plan) dated 2014, did not reference any activities pertaining to outpatient services.

The CEO, CCO and DQRM/IP acknowledged that the hospital did not collect outcome driven data on outpatient service to ensure that the quality of those services met the needs of the patients.

Based on interview and document review, the hospital failed to ensure that it's Organizational Performance Improvement Plan (OPIP) was reviewed and approved by the Governing Body (GB). The lack of the GB oversight of the hospital's OPIP failed to demonstrate accountability by the GB to ensure that the hospital's overall Quality Assessment Performance Improvement (QAPI)program addressed priorities for improved quality of care and patient safety, as well as the complexity of the departments and services provided. In addition, the hospital's GB failed to ensure that multiple action items in a Plan of Correction (POC) from a Federal Complaint Validation Survey conducted in August of 2014 were implemented.

Findings:
1. An interview with members of the GB was conducted on 12/15/14 at 4:35 P.M. The Chief of Staff (COS), President and Board Chairman (PCOB), Regional Quality Director (RQD), Compliance Officer (CO), Chief Executive Officer (CEO), Chief Clinical Officer (CCO), Director Quality Risk Management/Infection Preventionist (DQRM/IP), Director Business Development (DBD) and Chief Financial Officer (CFO) were present.
The COS acknowledged that the GB was responsible and had oversight over all the hospital's conduct and function:
On 12/15/14 at 5:40 P.M., the COS stated that the hospital's current OPIP dated 2014, had not been reviewed and approved by the GB. Furthermore, the COS stated that the OPIP should be reviewed and approved by the Medical Executive Committee and GB to ensure that quality indicators and monitoring mechanisms were in place.
An interview was conducted with the CEO, CCO and DQRM/IP on 12/16/14 at 9:00 A.M. The DQRM/IP stated that the current 2014 OPIP was developed in May 2014, prior to his role in the current DQRM/IP position.

2. In August of 2014 a Federal Complaint Validation Survey was conducted. A Statement of Defiencies was issued to the hospital and a Plan of Correction (POC) was received on 11/17/14.

Per the POC, the following action items were to be implemented by the hospital:

a. Portable oxygen tanks: Per the POC, portable oxygen tanks were to be visualized and monitored for remaining psi (pounds per square inch). The oxygen tanks were to be changed out when the psi dropped to 1000 psi. The completion date was 9/13/14.

b. Rooms for compatible for hemodialysis: Per the POC, the Charge Nurse Shift Report form would identify rooms that were non compatible for the administration of hemodialysis. The Charge Nurses were to utilize this form when assigning hemodialysis patients to a room. The completion date was 8/19/14.


c. Physical environmental rounding: Per the POC, environmental rounding was added as an indicator to the environmental tour checklist was implemented. The completion date was 9/3/14.

d. Maintaining egress free from obstruction: Per the POC, an egress indicator was added as an indicator to the environmental tour checklist. The completion date was 9/3/14.

On 12/15/14 at 12:35 P.M., the DPO, CEO and CCO acknowledged that the hospital's "Environmental Tour Checklist" was not implemented to ensure that power strips were removed from the hospital. In addition, the CEO, CEO, DPO and DQRM/IP stated they were not aware that the hospital's portable AC units were not approved for hospital use; however, they acknowledged that the equipment was brought in to their hospital and that risk assessments for safety an appropriate use were not conducted on the equipment.

On 12/15/14 at 12:35 P.M., the DPO, CEO and CCO acknowledged that the hospital's "Environmental Tour Checklist" was not implemented to ensure that power strips were removed from the hospital. In addition, the CEO, CEO, DPO and DQRM/IP stated they were not aware that the hospital's portable AC units were not approved for hospital use; however, they acknowledged that the equipment was brought in to their hospital and that risk assessments for safety an appropriate use were not conducted on the equipment.

On 12/14/15 at 12:50 P.M., the DQRM/IP acknowledged that the OR dehumidifiers were not monitored. In addition, the DQRM/IP stated that the hospital made the decision to monitor the water levels in the dehumidifiers; however, he was not aware of any oversight to staff accountability in monitoring the water levels in the dehumidifiers.

On 12/15/14 at 1:30 P.M., the CEO, CCO and DPO acknowledged that their POC following a Complaint Validation Survey in August 2014, related to room environment risk assessments for patients receiving hemodialysis, was not implemented. The CEO, CCO and DPO acknowledged that the rooms were documented on the hospital's "Charge Nurse Shift Reports" however; the rooms frequently changed and staff were not consistent with describing the process of hemodialysis room placement. The DPO stated that an initial risk assessment had not been formulated and acknowledged that it was done on 12/12/14, after it had been identified during the current revisit survey.
On the same day at 1:40 P.M., The CCO, CEO and DQRM/IP acknowledged that their POC following a Complaint Validation Survey in August 2014, related to oxygen E and H tank monitoring was not implemented when, a patient receiving oxygen was observed with a psi level below the hospital's POC.

Based on interview, record and document review, the hospital failed to maintain the medical record as required for 1 of 30 sampled patient records (43). A physician progress note regarding the patient's change of condition, was entered into the medical record without a date and with an illegible time entry. In addition, the same physician progress note had not included specific information with regard to the patient's sudden change in condition, which had required emergency interventions by the physician. The progress note had not described the physician's emergency interventions and outcomes, which had occurred during the resuscitation process, in a complete manner. The hospital's System Observation Data Collection form (a 24 hour nursing assessment record maintained for each patient) had not been completed as required. This failure reduced the continuity of care needed for the assessment of patient condition changes.

Findings:

1. A joint interview and record review was initiated on 11/20/14 at 2:10 P.M., with the Chief Clinical Officer (CCO), when an State authorized entity reported incident investigation was initiated.

Patient 43 was admitted to the facility on 11/12/14 with diagnoses which included seizures versus ETOH (alcohol) withdrawal versus epilepsy (a brain disorder which can cause seizure activity) per the Patient Registration Form. A joint review of the Nursing Progress Note Page, dated 11/13/14 at "0047" (12:47) A.M., indicated that Patient 43's monitored heart rate was observed "going down to SB ( sinus bradycardia. An abnormally slow heart rate. Normal range 60-80.) 30's...checked patient...unresponsive and no pulse...called code (emergency resuscitation team)". A review of the hospital Resuscitation Record, dated 11/14/14 at 12:47 A.M., included "Intubation (tube placed into trachea to assist breathing)Time: 0106 (1:06 A.M.)...attempted-unsuccessful". A joint record review of the handwritten Physician Progress Notes included an un-dated, illegible time entry which read "Death Note. Patient became asystolic (absence of pulse), attempts to resuscitate was unsuccessful. Patient pronounced dead at 0145 (1:45 A.M.). Family/significant other notified." The handwritten note had been signed by Medical Doctor(MD) 1. There were no further Physician Progress Notes found in the patients' record or the hospital electronic dictation system. The CCO stated the expectation that entries made in the patient medical record were to be legible, dated, and complete. The CCO further stated that medical record entries were utilized for quality assurance and peer review activities. and that incomplete and illegible entries interfered with the quality review and improvement process.

A review of the hospital policy and procedure entitled Medical Record Documentation, dated 12/19/12, included "The medical record is maintained for the following purposes...to document evidence of the course of the patient's medical evaluation, treatment, response to treatment and change in condition during an inpatient hospital stay...To provide information required for peer review and quality assurance activities...All members of the medical staff and designated hospital staff are responsible for documenting in the medical record the personal and identifiable services they render." In addition, the same policy and procedure included "Full dates, including the year shall be recorded. Each entry shall be timed and dated...Entries must be neat and legible."

During an interview and joint record/document review on 12/11/14 at 4:30 P.M., the CCO acknowledged that the hospital had not maintained Patient 43's medical record in a complete and legible manner. The CCO further stated that medical record entries were utilized for quality assurance and peer review activities and that incomplete and illegible entries interfered with the quality review and improvement process.

2. A joint interview and record review was initiated on 11/20/14 at 2:10 P.M., when a State authorized entity reported incident investigation was initiated. Patient 43 was admitted to the facility on 11/12/14 with diagnoses which included seizures versus ETOH (alcohol) withdrawal versus epilepsy (a brain disorder which can cause seizure activity) per the Patient Registration Form. A review of the patient's System Observation Data Collection form, dated "11/13", included nursing assessments for 24 hours of care. The date was not documented in a complete manner and portions of the assessment form had been left blank. The patient's status with regard to level of consciousness, behavior, speech, eye appearance/reaction and mouth status were not documented as having been assessed on "7 AM-7 PM" 12 hour shift. In addition, the handwritten entry in Nursing Progress Note Page of the form had not been signed by the Registered Nurse (RN) for the "7 AM-7 PM" shift.

During an interview conducted on 11/26/14 at 7:15 A.M., RN 40 stated that she had provided care to Patient 43 on the day shift of 11/13/14. RN 40 stated that the System Observation Data Collection form, was used to document patient assessments and occurrences during each 12 hour shift. RN 40 acknowledged that she had not completed, dated or signed the form as expected.

A review of the hospital's policy and procedure entitled, Assessment/Reassessment, Interdisciplinary, included "Nursing shall reassess the patient each shift (reference policy 24 Hour Care Record."

A review of the hospital policy and procedure entitled Medical Record Documentation, dated 12/19/12, included "The medical record is maintained for the following purposes...to document evidence of the course of the patient's medical evaluation, treatment, response to treatment and change in condition during an inpatient hospital stay...To provide information required for peer review and quality assurance activities...All members of the medical staff and designated hospital staff are responsible for documenting in the medical record the personal and identifiable services they render." In addition, the same policy and procedure included "Full dates, including the year shall be recorded. Each entry shall be timed and dated...Entries must be neat and legible."

During an interview and joint record/document review on 12/11/14 at 4:30 P.M., the CCO acknowledged that the hospital had not maintained Patient 43's medical record in a complete and legible manner.

Based on observation, interview and record review the Directory of Quality Risk Management/ Infection Preventionist (DQRM/IP) failed to demonstrate oversight of the hospital's infection control program by not ensuring that infection control policies and procedures were implemented by environmental service staff and contracted hemodialysis staff.

Finding:

1. On 12/8/14 at 10:37 A.M., an observation and interview was conducted with EVS 16. EVS 16 was observed with PPE in a room with a green colored contact precaution sign (color used for MRSA-methicillin resistant staphylococcus aureus, a bacterial infection that is resistant to numerous antibiotics) outside the door. EVS 16 stated that he had used "Neutral" (Brand name disinfectant) to clean the sink, table and other environmental items in the room including the floor. EVS 16 stated he would use this same product for a room with a contact isolation sign that was orange in color (C-Diff -clostridum difficile. An easily spread, highly contagious intestinal infection which causes severe diarrhea). EVS 16 was unable to state the difference between the two signs. EVS 16 stated he used the Clorox-(Brand name chlorine) wipes to clean patient rooms after the patient was discharged.

On 12/9/14 at 11:40 A.M., an interview was conducted with the Director of Quality Risk Management/Infection Preventionist (DQRM/IP). The DQRM/IP stated that the process for cleaning contact isolation rooms with known MRSA was that "CaviWipes (product that kills MRSA microorganisms)" were to be used to disinfect all patient care equipment, environmental surfaces and that the floors were to be cleaned with the "Neutral" disinfectant. The DQRM/IP stated that the process for cleaning contact isolation rooms with known C-diff was that "Clorox bleach wipes" were to be used to disinfect all patient care equipment, environmental surfaces and that the floors were to be cleaned with the a bleach dilution. The DQRM/IP stated that the Director of Plant Operation (DPO) had oversight of the EVS staff.

On 12/11/14 at 3:00 P.M., a review of the employee file for EVS 16 was conducted with the Director of Human Resources (DHR). EVS 16's education record did not included specific training with regard to proper cleaning procedures for cleaning patient rooms with known infectious diseases. The DHR stated that specific training was the responsibility of the EVS supervisor (DPO).

On 12/15/14 at 10:50 A.M., an interview was conducted with the DPO. The DPO stated that he had oversight to ensure that the correct cleaning agent was used to clean and disinfect isolation precaution rooms by the EVS staff. The DPO stated that he took over the responsibility of the EVS staff 2.5 months ago and that there was already a program in place. The DPO stated "A program that has been utilized your going to assume its ok." The DPO stated he was not aware that the EVS staff were not knowledgeable of the proper disinfectants to be used.

On 12/15/14 at 11:25 A.M., a review of the EVS staff education binder was conducted with the Director of Education (DOE). The DOE acknowledged that the binder had no documented evidence of education that had been given to any of the EVS staff since 10/11/12.

On 12/15/14 at 11:52 A.M., a Quality Assessment and Performance Improvement group meeting was conducted. The DQRM/IP acknowledged that the EVS training was not current. The DPO acknowledged that the EVS staff lacked the knowledge for the cleaning of isolation rooms.

The hospitals policy and procedure titled "Isolation Precautions" dated 12/19/12, indicated "Contact Precautions include the following: ...Cleaning/Disinfection - All environmental surfaces with the patient room will be cleaned utilizing the Caviwipes(Brand name bleach wipes) disinfectant... Floor surfaces within a contact isolation room shall be disinfected with the EnviroCare Neutral Disinfectant... C. diff Cleaning/Disinfection - All environmental surfaces with the patient room will be cleaned utilizing the Bleach wipes... Floor surfaces within a contact isolation room shall be disinfected with 10:1 bleach water dilution..." This policy was not followed when EVS 16 could not verbalize the correct cleaning agent used to clean and disinfect isolation precaution rooms.

While the DQRM/IP may have delegated EVS education and training to the DPO, the DQRM/IP failed to maintain oversight of the overall Infection Control and Prevention program to ensure that training was completed and staff were knowledgeable to ensure that the policies and procedures were implemented.

2. On 12/9/14 at 10:15 A.M., an observation and interview was conducted with the hemodialysis nurse (HDN). The HDN was observed in a room with a contact isolation sign posted outside the room. The HDN ripped open a hole in the PPE gown to expose his name badge. The HDN was not observed to have replaced the gown prior to providing care to the patient. The HDN stated that he was waiting until this surveyor left to change the gown. The HDN acknowledged that the patient was on contact precautions and in order to maintain infection control precautions, that he should have replaced the gown.

On 12/15/14 at 10:25 A.M., an interview was conducted with the Director of Quality Risk Management/Infection Preventionist (DQRM/IP). The DQRM/IP stated that the HDN was required to follow the hospitals protocols with regards to contact isolation precautions. The DQRM/IP stated that "if gown is breached, new gown should be placed same as if there's a hole in the gloves, you replace them." The DQRM/IP stated that the Director of Education (DOE) was responsible to ensure that the contracted hemodialysis nurses had the education on the hospital's protocols.

The hospitals policy and procedure titled "Isolation Precautions" dated 7/2/13, indicated "3. Personal Protective Equipment (PPE) is used to protect healthcare workers from contact with infectious agents and to prevent healthcare workers from carrying these infectious agents from patient to patient... Gowns... To be worn when performing procedures that may likely generate splashes or sprays of blood, body fluids, secretions or excretions in order to protect the skin and to prevent contamination/soiling of clothing." This policy was not followed when the HDN did not replace his gown after it had a hole exposing his clothing.

While the DQRM/IP may have delegated contracted HD staff education and training to the DOE, the DQRM/IP failed to maintain oversight of the overall Infection Control and Prevention program to ensure that the training was effective, and that staff implemented those policies and procedures.

Based on observation, interview, record and document review, the hospital failed to ensure that respiratory services were implemented according to a plan of correction (POC) from a previous Federal Complaint Validation Survey in August 2014, in an effort to ensure that there was an adequate supply of oxygen for 1 of 20 sampled patients (1). Monitoring of portable oxygen E tanks was not implemented for 1 of 20 sampled Patients (1). Patient 1's portable oxygen E tank was observed at 900 psi (Pounds per square inch). The hospital did not replace the E tank at 1000 psi in accordance to their plan of correction (POC).

Findings:

During a FederalComplaint Validation Survey conducted in August 2014, the hospital was cited for a deficient practice related to their bulk oxygen supply. A POC was received which documented that the hospital was going to use portable oxygen tanks. The oxygen levels in those tanks were going to be monitored and checked every two hours, and changed if the oxygen level was less than 1000 psi. The completion date on the POC was 9/3/14.

A tour of the Medical Surgical Unit was conducted with Nurse Manager (NM) 1 on 12/11/14 at 11:35 A.M. Patient 1 was observed sitting in a wheelchair across from the nurses station. Patient 1 had an oxygen nasal cannula in place, and attached to an E tank which delivered oxygen at 2 liters per minute. The E tank was observed at 900 psi.

On 12/11/14 11:40 A.M., an interview was conducted with Registered Nurse (RN) 19. RN 19 stated that Respiratory Therapists (RT) check the E tanks every two hours and document the levels. In addition, she stated that the charge nurses and nurse managers check the H tanks 2 times each shift and report the psi levels to the RT, who then documents the levels.

On 12/11/14 at 11:45 A.M., an interview was conducted with the Director of Respiratory Therapy (DRT). The DRT stated that the RT's document the psi levels of H tanks every 2 hours and that there was no official documentation record of the E tank monitoring.

Patient 1's RT documentation was reviewed with the DRT. The DRT stated that she had been monitoring Patient 1's psi and that at 8:35 A.M., the psi was 1800 and at 10:15 A.M., the psi was 1200. The DRT acknowledged that at 11:35 A.M., the psi was at 900, and that the expectation was that oxygen cylinders were changed at 1000 psi. The DRT acknowledged that the hospital was to monitor portable oxygen closely due to the bulk liquid oxygen supply was no longer in existence. Additionally, she acknowledged that the lack of adequate oxygen monitoring placed patients at risk for medical safety.

The hospital failed to implement their POC when oxygen psi was not documented and changed at 1000 psi for Patient 1. The DRT acknowledged that the POC included documentation of psi level every 2 hours and oxygen tanks were to be changed at no lower than 1000 psi, all staff are responsible for monitoring oxygen tank psi, and that RT's will document the psi with every oxygen tank check.

An interview with members of the Quality Assessment Performance Improvement (QAPI) was conducted on 12/15/14 at 12:00 P.M. Chief Executive Officer (CEO), Chief Clinical Officer (CCO), Director Quality Risk Management/Infection Preventionist (DQRM/IP), Director Plant Operations (DPO) and Director of Pharmacy (DOP) were present. The CCO, CEO and DQRM/IP acknowledged that their POC following a Complaint Validation Survey in August 2014, related to oxygen E and H tank monitoring was not implemented when, a patient receiving oxygen was observed with a psi level below the hospital's POC.