HospitalInspections.org

Based upon record review and interview, the hospital failed to meet the Condition of Participation for Respiratory Services as evidenced by:


1. Failure to define in writing the scope of therapeutic respiratory services offered by the hospital (See findings under tag A1152)

2. Failure to ensure there was a director of respiratory care services who is a doctor of medicine or osteopathy with knowledge, experience and capabilities to supervise and administer the service properly. (See findings under tag A1153)

3. Failure to ensure a respiratory therapist was available to provide respiratory care needs of the patients. (See findings under tag A1154)

4. Failure to
a) develop respiratory care policies and procedures for each type of respiratory treatments provided in the hospital,

b) develop the qualifications, education and training of the personnel authorized to perform the respiratory treatments, and

c) identify the type of personnel who were to provide direct supervision over respiratory care services. (See findings under tag A1161)

Based on record review and interview, the hospital's governing body failed to ensure the medical staff had written policies and procedures for appraisal of emergencies, initial treatment, and referral when appropriate, that was hospital-wide for the hospital, which did not have a dedicated Emergency Department.

Findings:

Review of the hospital's policy and procedure titled "Inpatient Care Unit-Emergency Procedures" (Policy #INPT.09) revealed in part that in the event of a life threatening emergency (i.e. cardiac arrest), the following phone calls will be made in the order listed:
1. 911
2. DON or CNO
3. Patient's admitting physician
4. Physician on call
5. Medical Director
6. Administrator

Further review of the above policy revealed no documented evidence of a procedure for the appraisal of emergencies, initial treatment or transfer as appropriate for emergency situations pertaining to staff, visitors, or walk-in persons entering the hospital with an emergency.

In an interview 8/20/15 at 3:45 p.m. with S2DON (Director of Nursing), she revealed that the hospital did not have a dedicated Emergency Room. She revealed that the hospital's policy on emergency procedures did not address the appraisal of persons with emergencies, initial treatment, and referral when appropriate, for emergency situations. Further interview with S2DON revealed that the above policy only addressed emergency situations that involved a hospital inpatient and that the policy did not address emergency situations involving staff, visitors, or walk-in persons entering the hospital with an emergency. She further stated that the medical staff had no other policy in place that addressed a hospital-wide policy for emergency situations involving any other emergency situations, other than inpatient emergencies.

Based on record review and interview, the hospital failed to ensure data collected for its QAPI (Quality Assessment & Performance Improvement) program was used to identify:
a) opportunities for improvement and changes that will lead to improvement, b) actions aimed at performance improvement, and implementing the actions, measuring its success, and tracking performance to ensure that improvements are sustained and c) documented evidence that the improvement activities focus on areas that are high risk (severity), high volume or problem prone. Findings:

Review of the Hospital's Policy titled "Performance Improvement and Safety Plan" presented as current read: "Measure and assess the effectiveness of performance and improving patient safety."

Review of the distinct quality indicators of Medication Reconciliation, Pain Management, & On time starts (surgery) revealed no interventions and/or evaluation of success of the interventions.

Review of the hospital's QAPI (Quality Assessment & Performance Improvement) data revealed no documented evidence that the hospital had selected the indicators based on high risk (severity), high volume or problem prone.

In an interview on 08/20/15 at 11:30 a.m., S2DON (Director of Nursing) indicated the hospital had no documented evidence that evaluations of interventions for Medication Reconciliation, Pain Management, and On-time start (surgery) were performed.

In an interview on 08/20/15 at 11:45 a.m., S20QA (Quality Assurance) indicated that after review of the hospital's QAPI data, there was no documented evidence that the improvement activities focused on areas that were high risk (severity), high volume, or problem-prone.

Based on record review and interview, the hospital failed to ensure that the hospital leadership set expectations for patient safety by not adopting policies supporting a non-punitive approach to staff reporting of adverse patient events and medical errors.

Findings:

Review of the Hospital's Policy & Procedure Manual revealed no documented evidence of the development and/or implementation of a policy for reporting of non-punitive approach to staff reporting of adverse patient events and medical errors.

In an interview on 08/20/15 at 12:00 p.m., S2DON (Director of Nursing) confirmed the hospital had no policy and procedure on staff reporting of adverse patient events and medical errors for review.

Based on record review and interview, the hospital failed to ensure that the QAPI (Quality Assessment & Performance Improvement) identified performance improvement projects as evidenced by: 1) Failure to conduct distinct improvement projects annually and 2) Failure to ensure that documentation of what quality improvement projects are conducted, the reason for conducting these projects and measurable progress achieved on these projects.

Findings:

Review of the QAPI Policy & Procedures, and Data collection revealed no documented evidence that identified distinct improvement projects were conducted annually. Further review revealed no documented evidence of what quality improvement projects are conducted, the reason for conducting these projects and measurable progress achieved on these projects.

In an interview on 08/20/15 at 12:00 p.m., S2DON (Director of Nursing) indicated the Hospital had no documented evidence of the number and scope of distinct improvement projects conducted annually or the quality of improvement, reason, and measurable progress achieved on the projects.

Based on record review and interview, the governing body failed to determine the number of distinct improvement projects that would be conducted annually.

Findings:

Review of the hospital's policy titled "Performance Improvement and Patient Safety Plan", presented as a current policy revealed no documented evidence that the governing body determined the number of distinct improvement projects that would be conducted annually.

In an interview on 08/20/15 at 2:30 p.m., S2DON (Director of Nursing) confirmed that she could provide no documented evidence that the governing body had determined the number of distinct improvement projects that would be conducted annually.

Based on record review, and interview the hospital failed to ensure 14 Physicians (S3, S7, S8, S9. S1, S11, S12, S13, S14, S15, S16, S17, S18, and S19) followed Medical Staff By-laws and hospital policies and procedures related to completion of medical records that were delinquent for greater than 30 days.

Findings:

Review of the Medical Staff By-laws, ADMS.04 Section 5: Medical Records, 5.16, revealed in part: The record of discharged patients shall be completed thirty (30) days following discharge. The Chairman of the Continuous Quality Improvement Committee or his designee shall notify the practitioner that his admitting and surgical privileges shall be suspended seven (7) days from the date of the notice and such practitioner shall remain suspended until the records have been completed

Review of the policy Titled " Audit of Medical Records and Timely Completion: Number ADMR.02, revealed in part 3. All physician folders will be reviewed on a weekly basis. If charts have not been completed within 7 days from a patient ' s discharge, the physician will be called or a reminder sent requesting he/she come in to complete the charts. 4. If charts have not been completed within 3 weeks, the Medical Director will personally contact the physician and request the charts be completed.

Review of the Delinquent Charts Report by Physician for August 2015 revealed the following physicians had delinquent records over 30 days:

S3 Physician - # 28 records
S7 Physician - #2 records
S8 Physician - #8 records
S9 Physician - #1 record
S10 Physician - #1 record
S11 Physician - #1 record
S12 Physician - #2 records
S13 Physician - #19 records
S14 Physician - #1 record
S15 Physician - #1 records
S16 Physician - #11 records
S17 Physician - #1 record
S18 Physician - #1 record
S19 Physician - #1 record

In an interview on 08/19/15 at 2:30 p.m. with S4Medical Records Manager confirmed there were 14 physicians (S3, S7, S8, S9, S10, S11, S12, S13, S14, S15, S16, S17, S18, and S19) with delinquent medical records past 30 days. S4Medical Records Manager further revealed that the delinquent records were pulled and placed on the counter in the recovery area for the Physicians to complete. She was not aware if anyone contacted the Physicians for the delinquent records.

Interview on 08/19/15 at 2:50 p.m. with S2DON (Director of Nursing) confirmed that there was a problem with delinquent records not being completed timely. S2DON further confirmed that the Physicians names and delinquent records were being reported in the QI (Quality Improvement) meetings and the Governing Board meetings. S2DON was unaware if there was anyone following up with the incomplete records.

Based on record review and interview, the hospital failed to have an adequate number of personnel to ensure quality pharmaceutical services as evidenced by failing to have a pharmacist available 24 hours a day, seven days a week. Findings:

Review of the hospital policy titled, Pharmacy and Medication Review (Policy #PMME.14), revealed in part:

The facility shall have an agreement with a pharmacy organization to provide 24 hours, 7 days a week support in the required provisions of medication management program which will meet the needs of the patient.

Review of the contract (signed 08/14/13) between the hospital and S21Pharmacist revealed in part: (1.9) Be available to the facility on an as need basis in addition to regularly scheduled consults. There was no documentation to indicate that a licensed pharmacist would be available to staff on a 24/7 basis.

Review of the contract (signed 01/12/15) between the hospital and the local retail pharmacy who provides medications for the patients in the hospital revealed no documented evidence that the retail pharmacy would be available 24 hours a day, seven days a week to provide medications and/or pharmacy services to the hospital.

On 08/19/15 at 9:50 a.m., in an interview with S2DON (Director of Nursing), she revealed that S21Pharmacist was the pharmacy director of the hospital. S2DON further revealed that the pharmacist was not available 24/7 to the staff of the hospital because he also has another full time job. Further interview with S2DON revealed that the hospital uses a local retail pharmacy to acquire all of the patients' medications and their pharmacists were available during working hours.

On 08/20/15 at 8:35 a.m., in an interview with S21Pharmacist, he stated that he was not the director of pharmacy, but was a consultant pharmacist for the hospital. S21Pharmacist verified that he was not available 24 hours a day, seven days a week due to his full time job. He further verified that should he go on vacation, there was no back up pharmacist to take over his duties at the hospital. Further interview with S21Pharmacist revealed that he had never reviewed the Federal regulations relative to the Pharmacy Services Condition of Participation.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice, consistent with state law. This deficient practice was evidenced by failing to ensure all medication orders were reviewed by a pharmacist, before the first dose was dispensed, for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications.
Findings:

Review of the hospital policy titled, Pharmacy and Medication Review (Policy #PMME.14), revealed in part:

7. Before dispensing, the pharmacy consultant and/or contracted pharmacy service organization shall review all prescriptions or medication orders for appropriateness. Review to include all "First Dose Orders". 8. Exceptions for review of all prescriptions or medication orders by a pharmacist at the time of dispensing will be made, (8.3) when the pharmacist is not on the premisis, a retrospecitve review of the orders as soon as he/she is available shall be conducted.


In an interview with S2DON (Director of Nursing) on 08/19/15 at 9:50 a.m., she stated that if nurses pull medications from the stock doses at the hospital, a first dose review by the pharmacist is not performed. S2DON stated that if this occurs, the nurse fills out a form titled Pharmacy First Dose Review, which includes the name of the medication that was administered and height, weight and allergies of the patient. The nurse places this form on the desk of the consultant pharmacist (S21Pharmacist) for him to review when he comes to the hospital on his next visit.


In an interview on 8/20/15 at 8:35 a.m. with S21Pharmacist, he stated that he was the consultant pharmacist for the hospital and also had another full time job. S21Pharmacist reported that he comes to the hospital approximately three to four times a week, after the hours of 5:00 p.m. S21Pharmacist further indicated that during these visits, he reviews the forms that the nurses had filled out regarding retrospective first dose reviews. S21Pharmacist verified that first dose reviews were not being performed prior to the initial doses of medications being dispensed and administered to the patients.

Based on record review and interview, the hospital failed to ensure Dietetic Services were currently under the direction of a qualified manager by failing to employ a qualified, full time Dietary Manager to serve as Director of Food and Dietetic Services. Findings:

Review of facility records revealed no evidence to indicate dietetic services were currently under the direction of a qualified manager.

In an interview on 08/19/15 at 11:10 a.m., S2DON (Director of Nursing) indicated the hospital had no qualified dietary manager.

Based on record review and interview, the hospital failed to ensure there was an organized respiratory care service. This was evidenced by the hospital's failure to define in writing the scope of therapeutic respiratory services offered by the hospital.

Findings:

Review of the hospital's organizational chart revealed Respiratory Services was not identified.
Review of the hospital's policies and procedures revealed there failed to be evidence that policies were developed that identified the scope of therapeutic respiratory services that were to be provided to the patients.

On 08/19/15 at 3:00 p.m., interview with S2DON (Director of Nursing) revealed the hospital did not have a respiratory therapy department; however, respiratory treatments were provided by the nursing staff. S2DON further revealed that the hospital did not have a director of respiratory services, did not have policies and procedures that addressed respiratory services, and did not have a respiratory therapist contracted to provide any respiratory services or training to the nursing staff.



10808

Based on record review and interview, the hospital failed to ensure there was a director of respiratory care services who is a doctor of medicine or osteopathy with knowledge, experience and capabilities to supervise and administer the service properly. Findings:

Review of the hospital's organizational chart revealed that the director of respiratory services was not addressed. Review of the governing body meeting minutes revealed no documented evidence that a director of respiratory had been appointed.

On 08/19/15 at 3:00 p.m., interview with S2DON (Director of Nursing) revealed the hospital did not have a respiratory therapy department; however, respiratory treatments were provided by the nursing staff. S2DON further added the hospital did not have a director of respiratory services.

Based on record review and interview, the hospital failed to ensure a respiratory therapist was available to provide respiratory care needs of the patients. Findings:

Review of the hospital's organizational chart revealed there failed to be documented evidence respiratory services was identified. Review of the list of contract services and list of hospital personnel revealed a respiratory therapist was not identified. Review of the hospital's policies and procedures revealed there were no respiratory therapy/treatment policies and procedures.

Interview with S2DON (Director of Nursing) on 8/19/15 at 3:00 p.m. revealed when asked about respiratory therapy services, S2DON replied the hospital did not have respiratory services and the nursing staff provided respiratory treatments as needed.

10808

Based on record review and interview, the hospital failed to develop 1) respiratory care policies and procedures for each type of respiratory treatment provided in the hospital, 2) identify the qualifications, education and training of the personnel authorized to perform the respiratory treatments and 3) identify the type of personnel qualified to provide direct supervision over respiratory care services. Findings:

Review of the hospital's organizational chart revealed respiratory care services was not identified. Review of the hospital's policies and procedures revealed the type of respiratory treatments, the personnel authorized to perform each type of treatment and the personnel qualified to provide direct supervision was not addressed.

Interview on 08/19/15 at 3:00 p.m., with S2DON revealed when asked about respiratory care services, S2DON replied the hospital did not have a respiratory department and the nursing personnel provided respiratory treatments.

Review of 4 (S22RN, S23RN, S24RN, S25RN) of 4 nursing personnel files revealed there failed to be documented evidence of competencies and training related to the provision of respiratory treatments.