HospitalInspections.org

Based on record review and interview, the facility had two people appointed as Chief Executive Officer (CEO).

Findings include:

Review of the facility ' s organizational chart (revised April 2011) revealed that staff #34 was CEO of the Harlingen campus and staff #10 was CEO of the Brownsville Campus.

Review of staff #34 ' s personnel file revealed a letter written August 4, 2008, which states the following: " I am very pleased to announce staff #34 as our new Chief Executive Officer for Solara Hospital Harlingen and Brownsville Campuses effective Monday, August 11, 2008. "

Review of staff #10 ' s personnel file revealed a letter written December 20, 2010, which states the following: " As Chief Executive Officer, your primary responsibilities will be to direct and oversee all Solara Hospital-Brownsville operational, clinical, marketing, staffing and financial activities to ensure that this hospital is successful in all of these respects. "

During an interview on 7/12/2011 at 8:50am in the conference room, staff #34 confirmed that there were two CEOs for the facility, as listed on the organizational chart.

Based upon record review and interview, the facility failed to ensure patients received a clear explanation of how to submit a complaint or grievance to the facility.

Review of a three page form in the admission packet titled "Patient Rights and Responsibilities" revealed the following: "You have the right to present any conflicts or complaints you have in regard to admission, treatment, discharge or the quality of care. Any complaint or concern may be presented by contacting the nursing supervisor at the Team Station. All issues will be reviewed, investigated, and responded to in a timely manner." This form has a signature line for the patient to sign that they received and understand the rights and responsibilities.

Review of the policy titled "Patient Rights and Responsibilities" that was reviewed on 3/18/10 revealed the same statement as the form given to patients in the admission packet.

An interview was conducted with the Quality Manager on 7/13/11 at 10:30 am. in the conference room. The Quality Manager confirmed that the "Patient Rights and Responsibilities" form was the only information provided to the patient..

Based upon record review and interview, the facility failed to include time frames for reviewing and responding to complaints in the information provided to the patients.

Review of a three page form in the admission packet titled "Patient Rights and Responsibilities" revealed the following: "You have the right to present any conflicts or complaints you have in regard to admission, treatment, discharge or the quality of care. Any complaint or concern may be presented by contacting the nursing supervisor at the Team Station. All issues will be reviewed, investigated, and responded to in a timely manner." The form did not contain any time frames for reviewing or responding to complaints.

Review of the complaint log containing information related to the complaints revealed no written responses by the facility of the facilities response to the grievance.

Review of the policy titled "Patient Complaints" revealed the following statement: "Responses and appropriate resolutions to all complaints will be made within 48 hours."

An interview was conducted with the Quality Manager on 7/13/11 at 10:30 in the conference room. The Quality Manager confirmed that written responses and resolution were not being provided to the patients after the complaint was investigated.

Based upon record review and interview, the facility failed to ensure written notice was provided to the complainant of the review, response and resolution of all grievances.

Review of the facility's policy and procedure #PSC-09-005 titled "Patient Complaint"revealed one statement regarding responses to the complainant: "Responses may be written or verbal, depending on the situation."

Review of the complaint log containing information related to the complaints revealed no written responses by the facility of the facilities response to the grievance.

An interview was conducted with the Quality Manager on 7/13/11 at 10:30 in the conference room. The Quality Manager confirmed that written responses and resolution were not being provided to the patient or complainant after the complaint was investigated.

Based on record review and interview the facility failed to involve the patient or family in the weekly team conferences.

Review of Policy Numbered NCD-03-005, Titled: Care Plans, revealed "The Care Plan will be updated every week at the team conference for that patient using the Evaluation/Progress Note. Input for setting goals will come from discussions between all staff members, the attending physician, and other consultants, as well as the patient and his family. The Plan will be updated more frequently as necessary, when the patient ' s condition warrants. "

Interview on 07/11/2011 at 2:00PM in the nurses break room with CCO, staff #38 and staff #39 and confirmed that the patient and family were not being involved in the weekly team conferences.

Based on record review and interview the facility failed to ensure the Medical Director of Dialysis Unit reviewed the results of the water quality testing and directed corrective action when indicated. Citing 6 of 6 month of equipment and machinery laboratory report results reviewed.

Findings: Reviewed Microbiological Culture results in the conference room on 7/12/2011 at 3:00 pm.
Review of microbiological culture reports from 1/2011 thru 7/2011 revealed:

Harlingen Campus Water Culture reports for:
Hemodialysis(HD) machine 9KOS 140949, HD machine 9KOS 141021, HD machine 9KOS 141067, Aquaboss Reverse Osmosis(RO) 1002113, Aquaboss RO 1002147, and Aquaboss RO 1002357 revealed no documentation that Medical Director reviewed results and/or advised corrective action if one was required for abnormal test results.
Brownsville Campus Water Culture reports for:
HD Machine 9KOS 140907, HD Machine 9KOS 141939, HD Machine 9KOS 141055, Aquaboss RO 1002360, Aquaboss RO 1002356, and Aquaboss RO 1002149 revealed no documentation that the Medical Director reviewed results and /or advised corrective action if one was required for abnormal test results.

Interview with staff #1 on 7/12/2011 at 4:00 pm confirmed there was no documentation to confirm that the Medical Director had reviewed the microbiological reports.

Based on record review, the facility failed to assure medical records were complete within 30 days of patient discharge in 5 of 32 records (#4, 13, 14, 22, and 28).


Findings include:

Review of Medical Staff Bylaws section 7.4.4, titled, " Medical Records, " revealed the following: " Members of the medical staff are required to complete medical records within 30 days of a patient ' s discharge. "

Review of Medical Staff Rules and Regulations, section7.15, revealed the following: " Charts are required to be complete within 15 days of patient discharge. Incomplete charts greater than 30 days will result in the suspension of " admitting privileges " and " consultation privileges. " "

A review of patient charts revealed 5 that were incomplete greater than 30 days after discharge, as follows:

-Chart #4 had no discharge summary
-Chart #13 had no discharge summary
-Chart #14 had no discharge summary
-Chart #22 had no discharge summary
-Chart #28 remained incomplete, though the patient was discharged on 6/7/2011

Based on record review, the facility failed to assure physician signatures were affixed to 3 of 32 Admission Criteria notes (#6, 15, and 18), one (1) of 32 Discharge Summaries (# 11), and two of too numerous to count procedure consent forms (#28 and #29).

Findings include:

Review of medical records revealed no physician signatures on the following forms:
-Chart #6- Admission Criteria
-Chart #11- Discharge Summary
-Chart #15- Admission Criteria
-Chart #18- Admission Criteria
-Chart #28- Bronchoscopy Consent
-Chart #28- Peripherally inserted central catheter Consent

Based on record review, the facility failed to assure written orders were dated in 12 of 32 charts (#1, 2, 16, 18, 19, 20, 21, 22, 23, 26, 27, and 28). The facility also failed to assure written orders were timed in 16 of 32 charts (#1, 2, 6, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, and 29). The facility also failed to assure the ordering physician countersigned verbal orders in 12 of 32 charts (#1, 2, 6, 8, 9, 14, 16, 17, 18, 19, 23, and 29).

Findings include:

Review of medical records revealed the following charts with undated written orders, as follows (Chart# x number of orders lacking date):

Chart #1 x 2
Chart #2 x 2
Chart #16 x 7
Chart #18 x 7
Chart #19 x 2
Chart #20 x 2
Chart #21 x 1
Chart #22 x 2
Chart #23 x 2
Chart #26 x 1
Chart #27 x 4
Chart #28 x 1

Review of medical records revealed the following charts with written orders lacking time ordered, as follows (Chart# x number of orders lacking time of order):

Chart #1 x 2
Chart #2 x 2
Chart #6 x 13
Chart #16 x 8
Chart #17 x 1
Chart #18 x 8
Chart #19 x 3
Chart #20 x 2
Chart #21 x 2
Chart #22 x 2
Chart #23 x 4
Chart #24 x 5
Chart #26 x 2
Chart #27 x 4
Chart #28 x 4
Chart #29 x 2

Review of medical records revealed 12 charts where verbal orders were not countersigned, as follows (Chart# x number of verbal orders not countersigned):

Chart #1 x 4
Chart #2 x 2
Chart #6 x 4
Chart #8 x 11
Chart #9 x 5
Chart #14 x 2
Chart #16 x 7
Chart #17 x 8
Chart #18 x 19
Chart #19 x 1
Chart #23 x 1
Chart #29 x 2

Based on record review, the facility failed to assure verbal orders were authenticated by the ordering physician within 48 hours in 23 of 32 charts (#1, 2, 3, 4, 6, 7, 8, 9, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, and 29).

Findings include:

Review of policy, " Medical Records: Verbal and Telephone Orders, " revealed the following: " Verbal orders shall be countersigned as soon as possible by the ordering practitioner with the following exception: verbal/telephone orders for restraints, Schedule II drugs and DNRs must be signed and dated by the ordering physician within 24 hours. "

Review of Medical Staff Bylaws section 6.3, revealed the following: " Verbal orders will only be accepted for urgent and emergent events. Such orders shall be authenticated within 48 hours by physician signature, date, and time. "

Review of medical records revealed 23 charts where the verbal order countersignature had not been dated; therefore, the facility could not assure the orders had been countersigned within 48 hours, per regulation. Findings were as follows (Chart# x number of undated verbal order countersignatures):

Chart #1 x 6
Chart #2 x 5
Chart #3 x 6
Chart #4 x 7
Chart #6 x 4
Chart #7 x 8
Chart #8 x 11
Chart #9 x 5
Chart #14 x 2
Chart #15 x 39
Chart #16 x 9
Chart #17 x 10
Chart #18 x 20
Chart #19 x 2
Chart #20 x 1
Chart #21 x 2
Chart #22 x 8
Chart #23 x 1
Chart #24 x 1
Chart #26 x 2
Chart #27 x 2
Chart #28 x 1
Chart #29 x 4

Review of medical records revealed 12 charts where verbal orders were not countersigned, as follows (Chart# x number of verbal orders not countersigned):

Chart #1 x 4
Chart #2 x 2
Chart #6 x 4
Chart #8 x 11
Chart #9 x 5
Chart #14 x 2
Chart #16 x 7
Chart #17 x 8
Chart #18 x 19
Chart #19 x 1
Chart #23 x 1
Chart #29 x 2

Based on record review, the facility failed to assure a history and physical (H&P) examination was completed and placed on patients ' charts within 24 hours of admission in 10 of 32 charts (#2, 3, 4, 5, 7, 10, 16, 19, 27, and 29).

Findings include:

Review of policy, " Timely Completion of Medical Records, " revealed the following: " A complete History and Physical Exam shall, in all cases, be documented in the medical record no later than 24 hours after admission of the patient. "

Review of policy, " Medical Records: Physician Requirements, " revealed the following: " History and Physical Examinations: Shall be completed within 24 hours of admission. "

A review of patient charts revealed ten history and physical notes were placed in the medical record more than 24 hours after admission (charts #2, 3, 4, 5, 7, 10, 16, 19, 27, and 29). In all cases, the history and physical note was transcribed greater than 24 hours after the patient ' s admission.

Based on record review and interview the Dietary Department of the facility failed to report the quality assessment and performance improvement indicators to the Performance Improvement Committee held quarterly by the Quality Management Department.

Review of meetings titled Performance Improvement Committee Meeting dated 6/16/2010, 8/25/2010, 3/24/2011, and 6/23/2011 revealed dietary had not reported to the Quality Management Department.

An interview with #36 on 7/13/2011 at 1:30 PM confirmed Dietary was not reporting quality issues to the Quality Management Department.

Based on record review and interview, the facility failed to assure the quality of its dietary, rehab, and housekeeping services. These three services did not report to the hospital ' s Performance Improvement Committee (PIC).

Findings include:

Review of the hospital ' s PIC minutes from June 2010 to June 2011 revealed that the dietary, rehab, and housekeeping departments were not reporting to the committee.

During an interview on 7/12/2011 at 12:52pm in the conference room, staff #36 confirmed that the dietary, rehab, and housekeeping departments were not reporting to the PIC.