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Based on record review and interview the hospital did not ensure that all contracted services are provided in a safe and effective manner. Findings are:

-Review of the hospital's Masters Services Agreement (MSA) conducted on 11/17/2015 indicated that Respiratory services are provided to the hospital by the collocated hospital.

-Review of the Burdett Care Center Quality Committee meeting minutes conducted on 11/18/2015 indicated that quality data regarding Respiratory services provided to Burdett Care Center patients was reported infrequently, i.e. at the 1/7/2014 quality committee meeting and then not again until the 10/27/2015 quality committee meeting, an interval of twenty-one months.

-The above findings were verified with the Executive Director, Chief Medical Officer, and the Quality Director of the Hospital on 11/18/2015 at approximately 2:00 PM.

Based on a review of medical staff credentials files, the hospital failed to ensure that there is a periodic review of the scope of procedures granted to all physicians and midlevel providers appointed to the staff in 1 of 7 provider files reviewed.

Findings:

-The credentials file of the Chief of Obstetrics was reviewed on 11/17/2015. Documentation in the file showed that the reappraisal process was not complete; the privileges list dated 5/20/2013 was annotated by the applicant as "same as previous request, " with no procedures specifically requested and approved for the review period. Documentation for a review in 2015 was not in the credentials file.

This was verified on interview with the hospital's Medical Staff Credentialing specialist on 11/17/2015 who confirmed that medical staff undergo a reappraisal every two years and also indicated that the physician was presently completing a privileges list for staff privileges for the 2015 reappointment period.

Observed 11/16/2015 at 1:35 PM: Clean and sterile supplies are being stored in the same room as external cardboard shipping containers. The Equipment Storage room is being used for clean and sterile supply storage. Sterile items include injection needles. Several external shipping containers are also being stored in this room. The Association for the Advancement of Medical Instrumentation, Standard 79, states that external shipping containers should not be used in clean storage areas for infection control purposes.

This finding was confirmed with the Infection Control Practitioner at the time of observation.

Observed 11/18/2015 at 2:15 PM: There is no tracheotomy set available to the Operating Room suites. Interview with the Obstetrics Technician at 2:15 PM confirmed that the crash carts do not contain this item, and that a request would need to be made to the collocated hospital should one be needed in an emergency. This finding was verified with the Executive Director during the exit interview on 11/18/15 at 2:30 PM.

Based on observation, interview and record review, one of one surgical tracer cases observed did not have an on site post anesthesia evaluation prior to discharge from the post anesthesia care unit (PACU). Findings:

Patient #13 was observed in the post anesthesia care unit (PACU). on 11/17/15, and the patient's medical record was reviewed. The patient underwent a gynecological procedure under general anesthesia on 11/17/15. Patient #13 was discharged from PACU without receiving a post anesthesia evaluation completed by an individual qualified to administer anesthesia.

Upon interview, the PACU RN (staff H ), confirmed that if the patient has no complications and meets the discharge criteria, the anesthesia provider does not "eyeball" the patient prior to discharge. These findings were also confirmed on 11/18/15 at 10:30 AM with the Chief of Anesthesiology (staff #O).