HospitalInspections.org

Based on observation, interview, record review and policy review, the hospital's Governing Body failed to ensure:
- The Chief Executive Officer (CEO) provided adequate oversight when policies and procedures were not followed (A-0057);
- The hospital provided care in a safe setting due to the lack of Code Blue (emergency situation where a patient's heart or breathing has stopped, and staff quickly respond to attempt to restore the heartbeat or breathing) buttons and ventilator access panels connected to the patient call light system, which resulted in an Immediate Jeopardy (IJ) (A-0144);
- Nursing staff appropriately documented and treated patient wounds (A-395);
- Staff followed the medication administration policy for administering time critical medications (medications that when administered early or late may cause harm or have a negative impact to the intended therapeutic effect) for three patients (#17, #24, and #25) of three patients observed with time critical medications (A-0405); and
- The hospital had an effective hospital wide infection control program (A-0749).

These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital. The hospital census was 22.

The severity and cumulative effect of these systemic practices resulted in the hospital's non-compliance with 42 CFR 482.12 Condition of Participation: Governing Body.

Based on observation, interview, record review and policy review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital, including accountability for the effective oversight of staff to comply with the requirements under:
- 42 CFR 482.12 Condition of Participation (COP): Governing Body;
- 42 CFR 482.13 COP: Patient's Rights;
- 42 CFR 482.23 COP: Nursing Services;
- 42 CFR 482.42 COP: Infection Prevention and Control and Antibiotic Stewardship Programs. These failures had the potential to affect the quality of care and safety of all patients. The hospital census was 22.

Findings included:

Review of the hospital's document titled, "Medical Staff Bylaws," dated 02/2023, showed that the CEO was responsible for the overall management of the hospital.

Review of the hospital's undated document titled, "Landmark Hospital of Columbia Organizational Chart," showed that all administrative leaders reported to Staff A, CEO.

During an interview on 07/27/23 at 12:50 PM, Staff A, CEO, stated that she was responsible for the hospital and the staff.