HospitalInspections.org

Based on record review and interview, the hospital's governing body failed to ensure the appointment and re-appointment of members of the medical staff was in accordance with the medical staff bylaws. This deficient practice is evidenced by failure to appoint a Radiologist to serve as director for the hospital's Radiological Services.

Findings:

Review of the Medical Staff By-Laws, dated January 30, 2019, revealed in part: Appointment To The Medical Staff 4.1 General (a), Appointment to the Medical Staff is a privilege which shall be extended only to professionally competent physicians, dentists, psychologists, and podiatrists who continuously meet all of the qualifications, standards and requirements set forth in these by-laws and in such policies as are adopted from time to time by the Board.

Review of the MEC meeting minutes, dated 12/2021, revealed S12RadMgr, who is not a radiologist, had been appointed as Radiology Supervisor.

Review of credentialing files on 07/13/2022 at 9:00 a.m. with S7DirCred confirmed that there was no appointed Radiologist to serve as director of the hospital's Radiological Services.

In an interview on 07/13/2022 at 10:00 a.m. with S1Adm, she confirmed the Governing Body had not designated a Radiologist to serve as the director of the hospital's Radiological Services.

Based on record review and interview, the hospital failed to ensure the QAPI program identified, analyzed, and implemented preventive actions for all medication errors. This deficient practice was evidenced by failure to identify a medication error related to administration of sliding scale insulin for 1 (#11) of 3 (#11, #19, #22) sampled patients reviewed with medication errors from a total patient sample of 30.

Findings:

Review of Patient #11's electronic medical record, navigated by S2DON, revealed the patient was admitted on 06/24/2022.

Further review revealed the patient was receiving Insulin Aspart via the following sliding scale:
151-200 mg/dL: pre-meal - 2 units; 10:00 p.m. - 1 unit;
201 -250 mg/dL: pre-meal - 4 units; 10:00 p.m. - 2 units;
251- 300 mg/dL: pre-meal - 6 units; 10:00 p.m. - 3 units;
301 -350 mg/dL: pre-meal - 8 units; 10: 00 p.m. - 4 units; and
Greater than 350 mg/dL: pre-meal - 10 units; 10:00 p.m.- 5 units.

Additional review of Patient #11's electronic medical record revealed on 07/10/2022 at 9:00 p.m., the patient was administered 8 units of Insulin Aspart for a capillary blood glucose of 321 mg/dL. According to the sliding scale dosing order 4 units should have been administered for a capillary blood glucose of 321 mg/dL that was not resulted prior to meals.

Review of Patient #11's electronic medical record, navigated by S2DON, revealed there was no entry explaining why 8 units of insulin was administered instead of 4 units for the above referenced capillary blood glucose of 321mg/dL.

In an interview on 07/11/2022 at 2:00 p.m. with S2DON, he verified there was no entry in the patient's electronic medical record to explain why the patient received 8 units of insulin per sliding scale instead of 4 units of insulin for a capillary blood glucose of 321 mg/dL obtained at 9:00 p.m.

Review of Risk Management documentation for 7/1/2022 - 7/11/2022 revealed no documented evidence that the incorrect dose of sliding scale insulin had been identified as a medication error to be addressed through Risk Management/QAPI.

In an interview on 07/13/2022 at 1:00 p.m. with S2DON, he verified the above referenced medication error had not been logged as a medication error until 07/13/2022. He further verified this was after the error had been noted, by the surveyor, during Patient #11's electronic medical record review on 07/11/2022.

Based on record reviews and staff interview, the hospital failed to ensure a qualified full-time, part-time or consulting radiologist supervised the hospital's Radiology Services.

Findings:

Review of the hospital's staffing list and physicians with privileges list failed to reveal a radiologist appointed to supervise the hospital's radiology services.

In an interview on 07/13/2022 at 10:00 a.m. with S1Adm, she confirmed the hospital does not have an appointed radiologist to supervise the hospital's Radiology Services.

Based on interview and record review, the hospital failed to ensure the person designated as the Infection Control Officer had acquired specialized training in infection control. This deficient practice is evidenced by S2DON (Interim Director of Nursing)/Infection Control Officer having no documentation of specialized training in infection control.

Findings:

Review of S2DON's personnel file revealed no documentation of specialized training in infection control/establishing and managing an infection control program.

In an interview 07/13/2022 at 10:30 a.m. with S2DON, he confirmed he was the hospital's Infection Control Officer. S2DON further confirmed he had no specialized training in infection control/establishing and managing an infection control program. He indicated his infection control knowledge was based on basic infection control training that all nursing staff received.

Based on observation and interview the hospital failed to ensure the infection prevention and control program employed methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings. This deficient practice was evidenced by S6RN failing to perform hand hygiene when removing dirty gloves and donning clean gloves while initiating a dialysis treatment for 1 (#6) of 1 patients observed for initiation of a dialysis treatment.

Findings:

An observation on 07/11/2022 at 11:05 a.m. of S6RN initiating Patient #6's dialysis treatment revealed S6RN removed dirty gloves and donned clean gloves multiple times. Further observation revealed S6RN failed to perform hand hygiene with each glove change.

In an interview on 07/13/2022 at 10:30 a.m. S2DON verified hand hygiene should have been performed between each glove change while initiating a dialysis treatment.