HospitalInspections.org

Based on staff interviews and facility documentation review it was determined the facility staff failed to ensure an effective quality assurance program that included contracted dialysis services.

The findings were:

The facility's quality council minutes from January 2014 through May 2014 were reviewed on both June 19 and 20, 2014 by one surveyor. No evidence of quality data from their contracted dialysis services was noted.

The director of nursing (DON) was interviewed on 6/19/14 related to the facility's quality program and he/she did not recall the dialysis center's quality data being presented at the quality council meetings. At the end-of-day conference on 6/19/14, the administrator stated he/she believed the facility would need to request the dialysis center's quality data; the data was not automatically sent to the facility for review at this point.

The facility's agreement for acute dialysis services was reviewed on 6/20/14. The document identified the dialysis center's ongoing Quality Management Program activities and stated the facility "may request" that information for review.

Based on staff interviews and review of facility documentation it was determined the facility staff failed to have an agreement with an outside entity to review the appropriateness of the diagnosis and treatment provided by each medical doctor/doctor of osteopathy (MD/DO) as part of their quality assurance program.

The findings were:

The facility's quality council meeting minutes and medical staff meeting minutes between January 2014 through May 2014 were reviewed on both June 19 and 20, 2014. The documentation did not provide evidence of an outside entity review of MD/DO diagnosis and treatment appropriateness.

During the end-of-day conference with the director of nursing (DON) and the facility's administrator on June 19, 2014, the DON informed the survey team the facility's contracted corporate physician provided peer review and physician oversight as well as overall quality review for the organization as a whole. The DON stated the contracted corporate physician visited the facility on a regular basis (approximately every three months) to review records and meet with physicians to provide suggestions and feedback. However, the facility was unable to show evidence how that physician would satisfy the requirement that the outside entity be either 1) a hospital that was a member of the same rural health network as the facility (the facility was not a member of any rural health network according to the DON), 2) a Medicare Quality Improvement Organization, or its equivalent; or 3) another entity identified in the State's Rural Health Plan.

Based on a Life Safety Code Validation survey, completed on July 9, 2014, the CONDITION of Physical Plant and Environment was not met. Those deficient practices and the associated regulations can be found in the respective Life Safety Code survey.

Based on staff interview, clinical record review and review of facility policy and procedures, it was determined that the facility's clinical records failed to include a discharge summary following an inpatient stay but prior to a swing-bed admission for 4 (four) of 4 (four) patients in the survey sample. Patients #3, #4, #6 and #7.
The findings were:
1. Surveyor review of clinical records on 6/19/14 failed to reveal a discharge summary for Patients #3, #4, #6, and #7 after their discharge from CAH (critical access hospital) acute care services and prior to their admission to swing-bed services.
2. In an interview with the facility's Director of Medical Records on 6/20/14 at 10:00 a.m., when asked about discharge summaries for patients when they were discharged from acute care services and then admitted to swing-bed services, he/she replied that the physicians did not complete a discharge summary after the acute care admission but completed a discharge summary when the patient was discharged from swing-bed services that covers both the acute care and swing-bed admissions. He/she stated that it had "always been done that way."
3. In an interview with the Director of Nursing on 6/20/14 at 11:00 a.m. when asked about discharge summaries for patients when they were discharged from acute care services and then admitted to swing-bed services, he/she replied that the physicians did a discharge summary after the patients were discharged from swing-bed services that was meant to cover discharge from acute care services and from swing-bed services. He/she also acknowledged that it had "always been done that way."
4. Review of facility document titled, "Converting A Resident From Acute Care To Swing Bed" revealed the following statement, "Documentation will be done in accordance with federal guidelines when converting a resident from acute to the swing bed status."