HospitalInspections.org

Based on interviews, and document review, the governing body failed to:

a. determine the eligibility categories for appointments to the medical staff (See tag A-0045)

b. appoint qualified members to the medical staff (See tag A-0045),

c. establish medical staff bylaws (See tag A-0047),

d. approve the medical staff bylaws and medical staff rules and regulations (See tag A-0048),

e. ensure medical staff was accountable for quality of care to patients (See tag A-0049),

f. directly consult the individual responsible for organization and conduct of medical staff as related to quality of care matters (See A-0053),

g. appoint the chief executive officer who is responsible for the management of the entire hospital. (See tag A-0057),

h. ensure all contracted services were evaluated for compliance with the applicable Conditions of Participation and evaluated through the hospital's QAPI program (See tag A-0083), and

i. ensure all contracted services were performed in a safe and effective manner. (See tag A-0084)


Without effective Governing Body oversight, all patients admitted to hospital were potentially at risk for sub-optimal care.


Findings:


On 02/13/17 at 1:00 pm, the Chief Executive Officer provided the surveyors with a written statement documenting that as of December 13, 2016, the hospital had changed ownership.


On 02/13/17 at 9:55 am, in an interview, the Director of Quality Management stated an out-of-state management company employed the clinical and administrative staff. She stated that transfer of ownership had involved legal actions, some vendors had not been paid by the former owner, and had been "challenging" times.


On 02/13/17, surveyors requested the bylaws, rules and regulation, meeting minutes, policies and procedures, quality program activities implemented by the current Governing Body, and evidence of Governing Body approval for the current medical staff; none were provided.

Based on interviews and document review, the Governing Body failed to determine the categories of practitioners who were eligible for candidacy for appointments to the medical staff.


Findings:


On 02/13/17 at 1:00 pm, the Chief Executive Officer provided the surveyors with a written statement documenting that as of December 13, 2016, the hospital had changed ownership.


On 02/13/17 at 1:28 pm, surveyors requested the Medical Staff bylaws adopted by current Governing Body and the current Governing Body meeting minutes, and none were provided.


On 02/13/17 at 9:55 am, in an interview, the Director of Quality Management stated the current Governing Body had not adopted Medical Staff bylaws.


(Bylaws outline categories of practitioners who are eligible for candidacy for appointments to the medical staff, such MD, DO, and non-physician practitioner).

Based on interviews and document review, the Governing Body failed to appoint qualified members to the medical staff.


Findings:


On 02/13/17 at 1:00 pm, the Chief Executive Officer provided the surveyors with a written statement documenting that as of December 13, 2016, the hospital had changed ownership.


On 02/13/17 at 1:28 pm, surveyors requested the Medical Staff bylaws adopted by the current Governing Body and the current Governing Body meeting minutes, and none were provided.


On 02/13/17 at 9:55 am, in an interview, the Director of Quality Management stated the current Governing Body had not appointed and privileged the Medical Staff.

Based on interviews and document review, the Governing Body failed to approve medical staff bylaws and medical staff rules and regulations.


Findings:


On 02/13/17 at 1:00 pm, the Chief Executive Officer provided the surveyors with a written statement documenting that as of December 13, 2016, the hospital had changed ownership.


On 02/13/17 at 1:28 pm, surveyors requested the Medical Staff bylaws and medical staff rules and regulations adopted by the current Governing Body, and the current Governing Body meeting minutes, and none were provided.


On 02/13/17 at 9:55 am, in an interview, the Director of Quality Management stated the current Governing Body had not adopted medical staff bylaws and medical staff rules and regulations.

Based on interviews and document review, the Governing Body failed to ensure that the medical staff was accountable to the governing body for the quality of care provided to patients.


Findings:


On 02/13/17 at 1:00 pm, the Chief Executive Officer provided the surveyors with a written statement documenting that as of December 13, 2016, the hospital had changed ownership.


On 02/13/17 at 1:28 pm, surveyors requested the Medical Staff bylaws and medical staff rules and regulations adopted by the current Governing Body, and the current Governing Body meeting minutes, and none were provided.


On 02/13/17 at 9:55 am, in an interview, the Director of Quality Management stated the current Governing Body had not adopted medical staff bylaws and medical staff rules and regulations or Governing Body meeting minutes.

Based on interviews and document review, the Governing Body failed to directly consult with the individual assigned the responsibility for the organization and conduct of the hospital's medical staff, or his or her designee.


Findings:


On 02/13/17 at 1:00 pm, the Chief Executive Officer provided the surveyors with a written statement documenting that as of December 13, 2016, the hospital had changed ownership.


On 02/13/17 at 1:28 pm, surveyors requested the current Governing Body meeting minutes, and none were provided.


On 02/13/17 at 9:55 am, in an interview, the Director of Quality Management stated the current Governing Body had no meeting minutes that appointed the Chief of the Medical Staff.

Based on interviews and document review, the Governing Body failed to appoint a chief executive officer who is responsible for managing the hospital.


Findings:


On 02/13/17 at 1:00 pm, the Chief Executive Officer provided the surveyors with a written statement documenting that as of December 13, 2016, the hospital had changed ownership.


On 02/13/17 at 1:28 pm, surveyors requested the current Governing Body meeting minutes, and none were provided.


On 02/13/17 at 9:55 am, in an interview, the Director of Quality Management stated the Governing Body did not appoint a chief executive officer.

Based on interviews and document review, the Governing Body failed to ensure contracted services were furnished to comply with all applicable conditions of participation and standards for the contracted services, and evaluated through QAPI.


Findings:


On 02/13/17 at 1:00 pm, the Chief Executive Officer provided the surveyors with a written statement documenting that as of December 13, 2016, the hospital had changed ownership.


On 02/13/17 at 9:55 am, in an interview, the Director of Quality Management stated the current Governing Body did not approve or evaluate contracted services.

Based on interviews and document review, the Governing Body failed to evaluate contracted services were furnished in a safe and effective manner.


Findings:


On 02/13/17 at 1:00 pm, the Chief Executive Officer provided the surveyors with a written statement documenting that as of December 13, 2016, the hospital had changed ownership.


On 02/13/17 at 9:55 am, in an interview, the Director of Quality Management stated the current Governing Body did not evaluate contracted services.

Based on review of documents and interview, the hospital failed to adhere to their process for resolution of patient grievances.


Findings:


On 02/13/17, the surveyor requested complaints/grievances log and the policy and procedures for complaints/grievances.


During the review of the documents, there was documentation to support grievances are being treated as a complaint.


The Hospital policy #LM-LD-H-0049 states in part "...formal or informal written or verbal complaint...regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present...Any written or telephonic complaint whether from an inpatient, outpatient, released or discharged patient or their representative is considered a grievance..."


A document titled "Specialty Hospital of Midwest City 2016 Hospital Report Card" was reviewed by the surveyor. The document lists a total of 33 complaints between June and December 2016. Of the 33 complaints, 11 were found to meet the hospital's stated policy definition of a grievance. A written response with follow up actions was not provided to the 11 patients (Patients #22 through 32).


During interview with Staff A and Staff B on 02/13/17, both confirmed the 11 complaints should be treated as a grievance.

Based on document review and staff interview, the hospital failed to provide documentation of written notice to each patient reporting the grievance resolution, steps taken in the investigation, results, and completion date for ten of eleven records (Patient #23, 24, 25, 26, 27, 28, 29, 30, 31, and 32) reviewed.


Findings:


On 02/13/17, a document titled "Specialty Hospital of Midwest City 2016 Hospital Report Card" was reviewed by the surveyor. The document lists a total of 33 complaints between June and December 2016. Of the 33 complaints, 11 were found to meet the hospital's stated policy definition of a grievance. The complaints/grievances did not contain a letter or verification that a letter had been created to report results of the internal investigation for ten of eleven records (Patient #23, 24, 25, 26, 27, 28, 29, 30, 31, and 32) reviewed.


On 02/13/17, surveyor requested documentation of written responses to patient's grievances; none were provided.


On 02/13/17, an interview was conducted with the CEO, Director of Quality, and the Director of Nursing who reported no written notice were provided to each patient regarding their grievance.

Based on interviews and document review, the Governing Body failed to ensure that the QAPI's programs reflected the complexity of the hospital's organization and services, and involve all hospital departments and services.


Finding:


On 02/13/17 at 1:00 pm, the Chief Executive Officer provided the surveyors with a written statement documenting that as of December 13, 2016, the hospital had changed ownership.


On 02/13/17 at 1:28 pm, surveyors requested the quality program's approved by current Governing Body, and none were provided.


On 02/13/17 at 9:55 am, in an interview, the Director of Quality Management stated the current Governing Body had approved not the hospital's quality program.

Based on observations, interviews, and document review, the hospital failed to:

a. to identify and segregate in-use and out-of-use equipment, and

b. perform an annual preventive maintenance for medical equipment.


These deficient practices could affect all patients in the hospital by causing injury as a result of equipment malfunction of failure.


Findings:


a. On 02/13/17 at 1:42 pm, during a tour of a equipment room, the surveyors observed a large, unorganized room filled with dozens of pieces of medical equipment. Staff M stated the equipment in the room was newly acquired equipment from recently closed facility.


The surveyor asked which equipment in the room was in-use, and Staff M identified an IV pump. The inspection sticker of that IV pump was dated 11/14. There was no segregation for in-use or out-of use equipment, and no method to communicate ( such as signs or tags) to staff what equipment was in and out of use.


b. On 02/13/17 at 11:12 am., in the accompaniment of the Infection Control Preventionist, the surveyor toured multiple patient rooms. The following equipment was in-use and connected to patients, and had no inspection sticker or an expired inspection date:

~Room 501- Kangaroo feeding pump- expired 1/14, and Kangaroo feeding and IV pumps with no stickers.

~Room 504- IV pumps with no stickers.

~Room 506- Kangaroo feeding with no sticker.