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Based on survey activities including document review and staff interviews, it was determined that the hospital was not in compliance with the condition of governing body. The conditions of nursing service, medical staff, QAPI, and EMTALA were found out of compliance. While it was apparent from committee minutes and interviews that the governing body was aware of the practices of these departments, no action was taken, nor was any plan presented upon surveyor request evidencing a systematic and thorough approach to addressing the problems with late and non-existent nursing performance appraisals and competencies, physician performance evaluations that lacked substance, and a quality assurance department that collected data but failed to analyze causative factors or plan for correction/improvement of metrics. Because neither the medical staff nor the nursing department were tracking patient outcomes, no analysis of cause and effect was made of any possible contribution of the staff training and credentialing deficits to patient outcomes. In addition, there was no evidence of oversight of the quality of care provided by the contracted emergency services entity that provides ED physician coverage, nor was there evidence that the governing body identified that the periodic performance appraisals completed by the contractor lacked substance and did not include utilization, patient outcomes, or complaints.

See deficiencies cited at A0263, A0338 and A0385

Based on a review of documentation and interviews with staff during the survey on August 7 and 8, 2017, it was determined that the condition of QAPI was not met. The hospital was tracking many quality indicators but presented no systematic or programmatic plans to address the findings of the quality indicators. The hospital has not performed a focused study and was not using quality data to drive change. In addition, high-risk and problem-prone processes were not identified. There was also no indication in committee minutes of substantive discussions of challenges, quality indicators, or intervention plans. For instance, the QAPI department was aware of the lack of/late performance evaluations and competencies for the nursing staff but had no plans to address the problems. The QAPI department was unaware of the lack of substantive quality appraisals of the medical staff.

On 8/8/2017, a review of Quality Assurance and Improvement Committee documentation and data revealed aggregate data on specified indicators was collected, but the hospital failed to develop and implement improvement programs from the data. Specifically, the hospital documentation revealed data rate collection inclusive of hospital re-admissions, critical values, and surgical cancellations, but showed no evidence of written documentation of the following:
· Identification and analysis of factors causing or contributing to rates of readmissions, surgical cancellations, or late notification of critical lab and diagnostic values.
· Identification of opportunities for improvement and changes that would lead to improvement of patient safety, health outcomes, and quality of care,
· Utilization of the data to develop system-wide programs or projects related to the analyzed data to improve patient safety or patient outcomes, or
· Any analysis of the possible effects on patient outcomes caused by staff lacking documented training and performance.

Based on documentation reviewed and interviews conducted during the on-site survey on August 7 and 8, 2017, it was determined that the condition of medical staff was out of compliance. There was no evidence of on-going appraisals of the quality of medical care. See Tag A-340.

Based on documentation reviewed and interviews conducted during the survey on August 7 and 8, 2017, it was determined that the condition of nursing services was out of compliance. The nursing staff had no process for verifying the competence of emergency department (ED) nurses. Nurses that floated to the ED had no ED-specific competency verification, and annual performance evaluations for two of five medical-surgical and emergency department nurses were more than one year old.

Please see Tag A397

Based on a review of the credentialing files of five members of the medical staff, it was determined that the hospital failed to meaningfully evaluate the care provided by all five members of the medical staff reviewed.

Two of the files reviewed were of emergency department physicians, which is a contracted service. The performance evaluations for the last re-credentialing period contained only the word "Excellent." There was no evaluation of service or resource utilization, patient volumes, patient outcomes, patient or staff complaints or any other indicators of quality.

The three remaining files contained patient volumes but no appraisals of utilization, patient outcomes, patient or staff complaints, or any other indicators of quality care.

During an interview 8/8/17 at approximately 9 AM,with the Chief Medical Officer (CMO) stated that the medical staff was 100% compliant with performance appraisals.

The hospital provided a policy for on-going and focused provider performance evaluations. The policy was dated 2010 and there was no evidence of implementation.

Based on review of 7 registered nurse (RN) personnel files and interviews with hospital staff, it was determined that the hospital failed to 1) have current annual performance evaluations for two RNs, 2) failed to have current annual competencies for 4 RNs and 3) failed to have unit specific competencies for the emergency department (ED).

RN #2, 3, and 4 were ED nurses. RN #2's last performance evaluation was February 2016. RN #3's last performance evaluation was May 2016. RN # 2, 3, and 4 did not have current competencies found in their files. RNs #6 and 7 were floater nurses to the ED. Neither had ED-specific competencies. RN #5 did not have current competencies for the medical surgical unit.

Interview with ED manager on 8/8/17 revealed there were no emergency department-specific competencies for the ED nurses. The ED manager, in an interview on 8/8/17 at 0830, indicated new competency and orientation check lists had been created. However, the checklist titled "New Hire Orientation Checklist Medical- Surgical, Emergency Department RN Staff" did not include important elements of the ED experience that should include at a minimum: triage, EMTALA, registration, and use of ED-specific equipment. Another form presented during the survey titled "RN Competency Validation" also did not include important ED elements and is nearly identical to the competencies used in the Medical Surgical unit. New RN hires into the ED have one year to achieve certification in advanced cardiac life support (ACLS) and pediatric-advanced life support (PALS).

According to documentation, there were times when there were only two RNs in house-one in the ED and one on the medical-surgical unit. Allowing new hires one year to gain life support certification without a formal process for initially verifying and intermittently testing competence placed ED patients at risk.