PRINTED: 01/20/2016 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES NO. 0938?0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 430084 3- 1111912015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PHS INDIAN HOSPITAL AT ROSEBUD 400 SOLDIER CREEK ROAD Ix ROSEBUD, SD 57570 (x4) ID SUMMARY STATEMENT OF in PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL - PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A 000 INITIAL COMMENTS A 000 A hospital recertification survey was conducted at PHS Indian Hospital at Rosebud in South Dakota from 11/16/15 through 11/19/15. The hospital was not in compliance with seven Conditions of Participation (COP): Governing Body at A0043, Patient Rights at A0115, Quality Assurance and Performance improvement (QAPI) at A0263. Medical Staff at A0338, Medical Record Service at A0431, Physical Environment at A0700, and Emergency Services at A01100. The facility was not in compliance with 42 CFR part 482. The hospital census was three inpatients. Sample size was 52. A 043 482.12 GOVERNING BODY A 043 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legaily responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body - This CONDITION is not met as evidenced by: Based on staff interviews, review of medical records, hospital policies and observations it was determined the hospital failed to meet the Condition of Participation (COP) for Governing Body when they failed to ensure there was an effective Governing Body that was legally responsible for the conduct of the hospital. Findings include: See the following for details: A0049 Standard: The Governing Body failed to LABORATORY OR REPRESENTATIVES SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the ?ndings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited. an approved plan of correction is requisite to continued program participation. FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 1 of 82 PRINTED: 01/20/2016 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE 8: MEDICAID SERVICES OMB NO. 0938?0391 STATEMENT OF (X1) (X2) MULTIPLE CONSTRUCTION (xa) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 430084 3- 1111912015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 (x4) ID SUMMARY STATEMENT OF DEFECIENCIES ID PROVIDERS PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG To THE APPROPRIATE DATE . DEFICIENCY) A 043 Continued From page 1 A 043 ensure the medical staff committee reviewed the hospital's contracted medical staff accountability and the quality of patient care they performed. A0115 Condition of Participation: Patient Rights - The Hospital failed to ensure that patient rights requirements were met in relation to unauthorized release of patient?s medical record information and ensuring privacy of information with provision of care. A0263 Condition of Participation: Quatity Assessment and Performance Improvement (QAPI) Program - The Hospital faited to ensure that the QAPI program was fully functioning and effective with quality reviews and programs for all areas of the Hospital. Departments had not turned in monitoring reports for the past year. They failed to ensure a hospital-wide, effective QAPI program. A0338 Condition of Participation: Medical Staff - The Hospital failed to ensure that the physicians were accountable for the quality of care provided to the patients and had current bylaws under which to act. A0700 Condition of Participation: Physical Environment - Based on observation and interview, the facility failed to comply with the 2000 NFPA 101 Life Safety Code as required. A0724 Standard: Facilities, Supplies, Equipment Maintenance - The Hospital failed to ensure that the facility, supplies, and equipment were maintained at an acceptable level for safety and quality. Numerous issues were identified during the observations made on the initial tour of the FORM Previous Versions Obsolete Event ID: NO3E11 Facility ID: 430084 If continuation sheet Page 2 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938-0391 ACCOUNTABILITY [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This STANDARD is not met as evidenced by: Based on record review and interview, the Governing Body failed to ensure the medical staff committee reviewed the hospital's contracted medical staff accountability and the quality of patient care they provided. Additionally, the Governing Body faiied to ensure that the medical staff was accountable for the quality of care which was provided to the patients in the Emergency Department (ED), as evidenced by the immediate jeopardy (IJ) findings related to the care for patients in the ED. Findings include: 1. Review of the past years quarterly Governing Body minutes dated 11/14/14 through 04/24/15, revealed no documented evidence of contracted medical staff chart/peer reviews or the provider?s accountability for patient care. The Governing STATEMENT OF (x1) (x2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 430084 WING 11I19I2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE I DIAN PIT 400 SOLDIER CREEK ROAD HS OS AL AT R0 EBUD ROSEBUD, SD 57570 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A 043 Continued From page 2 A 043 Hospital. A1100 Condition of Participation: Emergency Services - The Hospital failed to meet the emergency needs of the patients in accordance with acceptable standards of practice, including failing to provide a dedicated Emergency Department, that provided care in a timely manner or as ordered by the physician/0MP, to ensure the accuracy and adequacy of triage assessments and appropriate care. A 049 MEDICAL STAFF - A 049 FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation Sheet Page 3 of 82 PRI TED: [2 O1 DEPARTMENT OF HEALTH AND HUMAN SERVICES 01 0/2 6 FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A COMPLETED 430084 3- 1111912015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD PH NDIAN HOSPITAL AT ROSEBUD I ROSEBUD, SD 57570 (x4) .9 SUMMARY STATEMENT OF DEFICIENCIES TD PROVIDERS PLAN OF CORRECTION (X5) PREFIX (EACH MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A 049 Continued From page 3 A 049 Body lacked documented evidence they met in July, 2015 to discuss the previous quarter (April, May, June 2015) medical staff peer review and 2. During an interview on 11/19/15 at 10:30 AM, the Acting Chief Executive Officer (ACEO) confirmed the Governing Body minutes lack-ed documentation Of medical staff performing chart review/peer review for the contracted medical staff and patient care servicesprovided. 3. The Governing Body failed to ensure medical staff were held accountable to ensure the patients evaluated and treated in the emergency department (ED) were provided appropriate, timely, and safe medical care based on acceptable standards of practice. This failure represented a failure tO provide appropriate emergency care for four patients #39, #42, and #47) who presented with cardiac events, preterm labor and delivery, or trauma after a motor vehicle accident and constituted an Immediate Jeopardy (lJ) situation. Refer tO A1100 for patient specific details. 4. The Governing Body failed to ensure that the medical staff completed medical records timely and accurately and had full access to patients' electronic health records and scanned documents (VISTA) to provide care to the patients. Refer to A0449 A 092 EMERGENCY SERVICES A 092 If emergency services are provided at the hospital, the hospital must comply with the requirements Of ?482.55. FORM Previous Versions Obsolete Event ID: N03E11 Facility ED: 430084 If continuation sheet Page 4 of 32 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRENTED: 01?20?2016 FORM APPROVED CENTERS FOR MEDICARE SERVICES OMB NO. 0938-0391 STATEMENT OF (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. COMPLETED 430084 3- WING 1111912015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD ROSEBUD, SD 57570 PHS INDIAN HOSPITAL AT ROSEBUD (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDERS PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE DEFICIENCY) A 092 Continued From page 4 A 092 This STANDARD is not met as evidenced by: Based on staff interviews and review of medical records and hospital policies and procedures, the Governing Body failed to ensure that Emergency Services provided to the patients who were evaluated and treated in the emergency department (ED) were provided appropriately, timely, safely and that the medical care was based on current acceptable standards of practice. This failure represented a failure to provide appropriate emergency care for four patients #39, #42, and #47) who presented with cardiac events, preterm labor and delivery, or trauma after a motor vehicle accident and constituted an Immediate Jeopardy (IJ) situation. Refer to A1100, A1103, A1104, and A1112 for specific patient/staff concerns. A 115 482.13 PATIENT RIGHTS A115 A hospital must protect and promote each patient's rights. This CONDITION is not met as evidenced by: Based on record review and staff interview, it was determined that the hospital's Governing Body failed to implement grievance policy and procedures to protect and promote each patient's rights. Findings include: See the following for details: A0118 Standard: The hospital failed to follow policies and procedures that had been established for a process for prompt resolution and communication between the hospital, patient or representative who had filed grievances. A0119 Standard: The hospital's Governing Body failed to follow policy and procedures that they FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 5 of 82 PRI D: 01/ 0/2 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES 2 0 6 FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 430084 3- WING 11I1 9/2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE DEFICIENCY) A 115 Continued From page 5 A 115 must review and resolve grievances for 87 of 148 patients iisted on the hospital's grievance log without a date Of resolution of the grievance. A0131 Standard: The hospital failed to ensure that consent forms including those for treatment as inpatient, surgery, and emergency room treatment were completed by not ensuring that the consents contained one or more of the foilowing, the patient?s signature, witness signature, or time and date. A0144 Standard: The hospital failed to ensure that patient call lights were kept in an operating manner and the temperature/cleaning of the Hydrocollator (a liquid heating device that was used in physical therapy clinics to heat and store hot packs for therapeutic uses) and the paraffin wax bath (used to apply heat for relief Of pain in the hands, joints and feet) in the physical therapy department was maintained. A 118 PATIENT RIGHTS: GRIEVANCES A118 The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to fiie a grievance. This STANDARD is not met as evidenced by: Based 'on observation, staff interviews, and review Of the hospital policy and procedures, the hospital failed to follow the policy and procedures that had been established for a process to ensure prompt resolution and communication between the hospital and the patient or patient's representative for 87 Of 148 patients who filed grievances. Findings include: FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation Sheet Page 6 of 82 PRINTED: 01/20/2016 DEPARTMENT OF HEALTH AND HUMAN SERVICES . FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES (x1) (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 430084 3- 11/1 912015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 (x4) ID SUMMARY STATEMENT OF DEFICIENCEES ID PROVIDERS PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A 118 Continued From page 6 A118 Review of the hospital policies and procedures revealed a document titled, "Patient Complaint/Grievance Policy, Revised: 2/15" which provided the following information: close out letter will be sent to the patient/representative within twenty one (21) days after the Patient Grievance Coordinator receives the grievance. The letter will explain the hospitals plan to correct or address the grievance. The letter will be Signed by the Chief Executive Officer (CEO) and Patient Grievance Coordinator A. Review of the hospital's "Grievance Log" from 10/20/14 to 9/22/15 revealed the following: 1) a grievance dated and received on 4/10/15 concerning delayed/inappropriate care had a resolution dated of 9/30/15 or 151 days past the required resolution date of 21 days. 2) Agrievance dated 5/27/15 received on 6/2/15 concerning bad treatment in the emergency room (ER) had a resolution date of 7/2/15 or 10 days past the required resolution date of 21 days. 3) A grievance dated 5/29/15 received on 5/29/15 concerning unprofessional behavior by an ER Doctor had a resolution date of 9/30/15 or 102 past the required resolution date of 21 days. 4) A grievance dated 6/17/15 and received on 6117/15 concerning issues with a legal name of a newborn baby had a resolution data of 9/30/15 or 83 days past the required resolution date of 21 days. 5) Agrievance dated 7/1/15 received on 8/31/15 concerning unprofessional behavior by medical staff had a resolution date of 9/30/15 or nine days past the required resolution date of 21 days. 6) Eighty two grievances had no completion date listed in the column title "Date of Response". FORM Previous Versions Obsolete Event ID: NO3E11 Facility ED: 430084 If continuation sheet Page 7 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938?0391 GRIEVANCES [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance] The hospital's governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This STANDARD is not met as evidenced by: Based on review of the hospital grievance log, staff interviews, and review of the hospital policy and procedures, the Governing Body failed to follow policy and procedures to review and resolve grievances for 82 of 148 patients listed on the hospital's grievance log. Findings include: Review of the hospital policies and procedures revealed a? document titled, "Patient Complaint/Grievance Policy, Revised: 2/15, APPROVED BY: Executive Staff and Governing Body, 2/17/15? which provided the foliowing information: patient complaint data will be consolidated by the Patient Grievance STATEMENT OF DEFICIENCIES (x1) (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A COMPLETED 430084 3- 1111912015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE DEFICIENCY) A 118 Continued From page 7 A 118 B. An interview on 11/18/15 at 3:00 PM with the hospital's Patient Grievance Coordinator verified the grievance log column titled "Date of Response" was when the hospital sent the close out letter to the patient or representative. The Coordinator confirmed the log lacked close out dates or timely dates as required by hospital policy for 87 grievances between the dates of - 10/20/14 to 9/22/15. . A119 PATIENT RIGHTS: REVIEW OF A 119 FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 8 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES 01?20?2016 FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 430084 3- WING 11I1 9I201 5 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD ROSEBUD, SD 57570 PHS INDIAN HOSPITAL AT ROSEBUD (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (X5) pREFix (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A119 Continued From page 8 A 119 Coordinator to be reviewed at the Quality Assessment/Performance Improvement meeting and Executive meeting an annual basis the Coordinator will report to the Area Governing Body a summary of the types of grievances received and the status Of efforts to resolve them recommendations regarding any improvements and Changes may reduce and prevent grievances in the future." A review of the hospital's "Grievance Log" between the dates of 10/20/14 to 9/22/15 revealed the hospital Patient Grievance Coordinator failed to send 82 patients or their representative a close out letter explaining how the grievance was corrected or addressed. Five additional patient grievances did not include a close out letter within the required 21 day time frame. An interview on 11/19/15 at 4:00 PM with the Patient Grievance Coordinator verified there was no documented evidence of information concerning patient grievances was taken to the Quality Assessment/Performance Improvement meeting, Executive meeting, or the Governing Body for review. A131 PATIENT RIGHTS: INFORMED A131 CONSENT The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patients rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be FORM Previous Versions Obsolete Event ID: ID: 430084 if continuation sheet Page 9 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER: 430084 (X2) MULTIPLE CONSTRUCTION A. BUILDING (x3) DATE SURVEY COMPLETED B. WING 11/19/2015 NAME OF PROVIDER OR SUPPLIER PHS INDIAN HOSPITAL AT ROSEBUD STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD ROSEBUD, SD 57570 (X4) ID PREHX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE A131 A144 Continued From page 9 construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This STANDARD is not met as evidenced by: Based on a review of 52 patient consents and staff interview, the hospital failed to ensure that four patients? #17, #37, and #19) consent forms, including those for treatment as inpatient, surgery, and emergency room treatment, were completed by not ensuring that the consents contained one or more of the following: the patient's signature, witness signature, or date. Findings include: 1. Review of the inpatient consent for Patient #16 revealed that the consent was signed by the patient?s daughter but there was no documented evidence of a witness signature. 2. Review of the inpatient consent for Patient #17 revealed that there was no date that the consent was signed. 3. Review of the Emergency Department (ED) Consent for Treatment for patient #37'3 4/23/15 ED visit revealed that the consent was signed by the patient but there was no documented evidence of a witness signature and no date. 4. Review of the Emergency Department (ED) EHR (electronic health record) for patient #19's 10/1/15 ED visit revealed that no consent for treatment was present. This record had been reviewed by the Area CD, who determined there were no other documents found for this patient's PATIENT RIGHTS: CARE IN SAFE SETTING The patient has the right to receive care in a safe setting. A131 A144 FORM Previous Versions Obsolete Event ID: Facility ID: 430084 If continuation Sheet Page 10 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/20/2016 FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 430084 B. WING 11/1 9/201 5 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A144 Continued From page 10 A 144 This STANDARD is not met as evidenced by: Based on observation, staff and patient interviews, review of hospital documentation and review Of poiicy and procedures, the hospital failed to ensure that patient call lights were kept in an Operating manner and the temperature/Cleaning of the Hydrocollator (a liquid heating device that was used in physical therapy clinics to heat and store hot packs for therapeutic uses)and the paraffin wax bath (used to apply heat for relief of pain in the hands, joints and feet) in the physical therapy department was maintained. Findings include: 1.During an interview on 11/16/15 at 2:05 PM, Patient #3 stated that he had gone into the bathroom in his hospital room on the second floor on 11/15/15 and pulled the emergency call light cord but that it did not work. On 11/16/15 at 2:10 PM, the surveyor went into Patient #3's bathroom and attempted to activate the emergency call light cord and the call Iight did not work. Interview on 11/16/15 at 2:25 PM with Employee (K) revealed that the patient call light system had not been operating for a week. Employee (K) further stated that a work order had been submitted, however, "nothing had been done? and patients were using the phones in their rooms to call the nurses. Employee (K) also revealed if the patients could not use the phone. an alarm button was provided to them. A request was made for review of the work order for the patient call tights, but Employee (K) and Biomedical Staff (G) were unable to find any record of the work order that had been submitted at the time the call lights stopped Operating. FORM Previous Versions Obsolete Event ID: NO3E11 Facility ID: 430084 If continuation sheet Page 11 of 82 1 D: 01/ DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTE 20/2016 FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 430084 3- 1111912015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD PH INDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 (x4) (D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A 144 Continued From page 11 A 144 During an interview on 11/18/15 at 10:45 AM, Employee (T) stated she had put in a work order but was unable to find it, and had been told that if she did not have a correct number when she placed the work order, it would not have gone through and would not have been received by Biomedical. An email dated 11/13/15 that was provided revealed the contracted company had been notified to repair the nurse call system for the "Inpatient" area. Review of an additional email dated 11/17/15 indicated a call would be made to the company as to when they could be expected to arrive and the contracted company indicated they would be at the facility on 11/23/15 to make the repairs. On 11/18/15 at 1:00 PM, an email dated 11/4/15 at 7:17 AM from Employee (K), to the Assistant Director of Nursing was provided and stated "The call light system is still down phone in the I room to call is OK for most but not all will need some manual bells if the system is going to be down much longer. I will Check with (name of staff) and follow up with you. Thanks." No further emails were provided. 2. On 11/16/15 at 11:55 AM during an observation of the Physical Therapy (PT) department revealed a hydrocollator and a paraffin wax bath located in the supply room. The temperature logs were hanging on the wall above each appliance. Review of the hydrocollator log revealed the most recent date staff had documented the unit was Cleaned and documented a temperature (159 degrees) was on 12/16/14. A review of the paraffin wax bath log revealed staff last cleaned the unit on 4/18/14. FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 12 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER: 430084 NAME OF PROVIDER OR SUPPLIER PHS INDIAN HOSPITAL AT ROSEBUD (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A144 A147 Continued From page 12 During an interview on 11/16/15 at 12:00 PM, Physical Therapist (A) verified they have patients scheduled weekly who use the hot packs and wax therapy. Staff (A) confirmed they had not cleaned or recorded the temperature of the hydrocollator and had not replaced or cleaned the paraffin wax bath since the previous physical therapist left the position at the end of December 2014. Review of the hospital's policies and procedures revealed a document titted, effective 3/1/01 which provided the following information: "The hydrocollator will be cleaned once a month, or more if needed, to maintain cleanliness of hot Review Of the policy and procedure titled PARAFFIN effective 9/1/01 provided the following information: "Cleaning of the unit is to be done once a month, or as needed when used excessively for that month PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS The patient has the right to the confidentiality of his or her clinical records. This STANDARD is not met as evidenced by: Based on patient, family and staff interviews, review of the medical record request form, and review Of policy and procedure, the hospital failed to maintain the confidentiality of patients clinical records. This reiated to the unauthorized release of patient's medical information and not following (x2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY A. BUILDING COMPLETED 3- ?me 1111 912015 STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD ROSEBUD, SD 57570 ID PROVIDERS PLAN OF CORRECTION (x5) PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG TO THE APPROPRIATE DATE DEFICIENCY) A 144 A 147 FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 13 of 82 PRINTED: 01/20/2016 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938~0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 430084 3- NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 (x4) .9 SUMMARY STATEMENT OF DEFICI-ENCIES Io PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE common TAG REGULATORY OR IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE DEFICIENCY) A 147 Continued From page 13 A 147 the facility's policies and procedures protecting of information in patients' medical record from unauthorized disclosures. Findings include: A. On 11/17/15 a patient came into the facility to file a grievance/complaint which involved unauthorized release of medical information. At 10:45 AM the complainant and family then asked to speak to the survey team to file concerns. 1) The patient reported he had been seen in the ED (Emergency Department) and ED staff had called the police and released medical information concerning patient lab reports without the patient's consent. 2) The ED record had a "yes" where it asked if consent was given to treat. 3) The hospital release the copy Of the patient medical record without checking the patient's identification before giving out the record. 1) The patient presented an email from the police department. The email was entitled, "Incident Report Rosebud Police Department Sgt. It stated, few hours later I was advised by emergency room staff that (patient name_) was only one that registered alcohol from lab results. I was advised by staff that called the police department that (patient name_) blood alcohol was over 300. I advised that once the (person/gender) was done with medical attention he/she would be transported to the Rosebud jail for 2) Review of patient #223 ED record identified concerns with lack of monitoring and signed consent. The patient was brought into the ED by ambulance on 11/7/15 at 5:35 PM. The ED record FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 14 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: 430084 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (x3) DATE SURVEY COMPLETED 11I1912015 NAME OF PROVIDER 0R SUPPLIER PHS HOSPITAL AT ROSEBUD STREET ADDRESS, STATE, ZIP CODE 400 SOLDIER CREEK ROAD ROSEBUD, SD 57570 (X4) ID noted the patient had been involved in a MVA (motor vehicle accident). "Patient odorous Of ETOH, garbled speech, poor historian and uncooperative. Patient was reported to have loss of consciousness at scene. Patient alert upon arrival hollering and attempting to take straps off backboard and head support C?collar." The section "is consent to treat been signed" was marked as However, further review found no signed consent. A"Critical Care Fiow Sheet" was initiated on this patient. However, the record was incomplete. The flow sheet showed one full set of vital signs at 1735 (5:35 PM) and then a partial set at 1810 (6:10 PM). There were no other vital signs documented and the patient was released on 11/8/15 at 1:40 AM. There was no indication in the medical record that when the patient was brought into the ED, the patient was on a "Police Hold" or in "Police Custody". The discharge note showed the patient was released on 11l8/15 at 1:40 AM. The note stated, notified that patient was medicaily cleared for release to adult corrections. Pt. driver of a 2 car motor vehicle accident. Pt. out of ER with RPD Officer B. Interview on at 9:50 AM, Employee (Z) revealed when an individual completed a form for release of medical records, she obtained the information requested, and when the individual returned to pick up the copy of the medical record, Employee (2) would give it to them and confirmed there was no request for the individual to provide identification. When Employee (Z) was asked why no identification was requested, she SUMMARY STATEMENT OF ID PLAN OF CORRECTION (x5) pREle (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETEON TAG REGULATORY OR LSC IDENTIFYING TAG CROSS-REFERENCED To THE APPROPRIATE DATE DEFICIENCY) A 147 Continued From page 14 A147 FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 15 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORMAPPROVED OMB NO. 0938-0391 stated she "had been there for 30 years and knew almost everyone. The only time identification may be requested is if someone else is picking up the medical record for the person who had requested the information." C. Review of the form "Authorization For Use or Disclosure of Protected Health information" revealed at the following statement at the bottom of the form; "This information is to be released for the purpose stated above and may not be used by the recipient for any other purpose. Any person who knowingly and willfully request or obtains any record concerning an individual from a Federal agency under false pretenses shall be guilty of a misdemeanor." The following section had a space titled next to that section is a section that had a space for NAME (Last, First, MI), RECORD NUMBER, ADDRESS, and DATE OF BIRTH. D. Review of the facility policy titled "Release of Information", Revised Date 9-2013, Reviewed Date 10/2015 stated: "Policy: The release of medical information may be made to an authorized agency or individual as identified. Purpose: To assure the privacy and confidentiality of patient information. Procedure: -A. Receipt: 1. All requests for medical information will be directed to the Medical Records Department. All requests will be date stamped as to the STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 430084 3- 11/19/2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE. ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, so 57570 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES u) PLAN OF CORRECTION (x5) pREle (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC TAG CROSS-REFERENCED TO THE APPROPRIATE DATE . DEFICIENCY) A 147 Continued From page 15 A 147 FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 16 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/20/2016 date received in the Release of Information Office. 3. The release information will be considered valid when the following elements are met. Addressed to the Rosebud Comprehensive Health Care Facility. Patient is identified by: name and either by, date of birth, social security number. Identification of individual or facility to whom the records will be disclosed to Note: signature will be compared with signature on file. lfvalidity is questionable, patient will be contacted. Specific information requested shall be indicated all outpatient visits of 1997). Search and Preparation of Document (5): 1. The patient registration system will be utilized to search for the patient &the health record. 2. The medical records is then retrieved from the permanent fiie area and reviewed for the requested information. 5. Photocopying of the record shall be performed by: Photocopy ONLY the information that has been requested. A copy of the original consent form will be made to be returned with the requestor. Assure photocopied documents are clear as possible no smudges, etc.). 6. Arrange the photocopied records in order Ambulatory records, Lab, Radiology, etc) 7. Photocopied records will be placed in a sealed secure envelope. The envelope will be labeled CONFIDENTIAL. -C. PRIORITIES AND TIME FRAMES: The foliowing priorities and time frames Shall FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 430084 8- WING 11I1 9/201 5 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 (x4) ED SUMMARY STATEMENT OF DEFICIENCIES ED PROVIDERS PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A147 Continued From page 16 A 147 FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 17 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER: 430084 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 11/19/2015 NAME OF PROVIDER OR SUPPLIER PHS INDIAN HOSPITAL AT ROSEBUD STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD ROSEBUD, SD 57570 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE A147 A 263 Continued From page 17 apply to release of medical information requests. Emergency request involving immediate emergency care of patient/customer: Process immediately. All other requests: within 10 workdays or soonen -D. ACCOUNTING OF DISCLOSURE: 1. Staff will stamp the original consent with the date of when it was received. . 2. Alt request will be entered into the Release of Information program within RPMS (Resource and Patient Management System) and tracked until completed. 3. All original written authorization and [or consent forms will be permanently filed in the patient record." E. During an interview on 11/18/15 at2200 PM the Clinical Director revealed he had become aware of the policy and procedure for releasing copies of medical records to patients and that the procedure "was not right" and needed to be changed. There was nothing in the policy and procedure that stated that the person requesting the release of their medical record information needed to provide any type of identification when picking up their copy of the medicai record. 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospitatuwide, data-driven quality assessment and performance improvement program. . The hospital's governing body must ensure that the program reflects the complexity of the A147 A 263 FORM Previous Versions Obsolete Event JD: N03E11 Facility ID: 430084 If continuation sheet Page 18 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/20/2016 FORM APPROVED CENTERS FOR MEDICARE 8. MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: BUILDENG COMPLETED 430084 3- WING 11I19l2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 (x4) ?3 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE DEFICIENCY) A263 Continued From page 18 A263 hospital's organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This CONDITION is not met as evidenced by: Based on interview, record review and review of policies and procedures, the facility failed to meet the Condition of Participation (COP) for Quality Assessment and Performance Improvement (QAPI) when they failed to meet and identify concerns throughout the hospital. The hospital failed to develop, implement, and maintain an effective, ongoing, hospital wide QAPI program that identified facility wide concerns with plans of action and measurable goals with time tables to ensure that the identified concerns would not continue in the future. They failed to develop interventions, plans of action and performance improvement plans for: 1) Care and services in the ED (Emergency Department) with identified concerns, 2) Patient complaints and grievances, 3) Patient medical records/EHR (electronic health record), 3) Maintenance and operation of essential equipment that included sterilizers, surgical instrument washer, dental equipment and kitchen equipment. Findings include: 1. An interview with the Acting QAPI Coordinator FORM Previous Versions Obsolete Event lD: N03E11 Facility ID: 430084 If continuation sheet Page 19 of 82 0/201 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED 01/2 6 FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING . COMPLETED 430084 B. WING 11/1 9/2015 NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL . PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A263 Continued From page 19 A263 on 11/19/15 revealed that the facility had four different QAPI groups that would rotate and meet each quarter. The QAPI Coordinator reported, each department had monitors they were supposed to be following to address problems and potential concerns. Then that information was to be discussed at the quarterly'QAPl meetings. However, she had difficulty getting departments to report. Review of the department monitors tracking form from Oct. 2014 to Sept. 2015 showed some departments had not reported for the past 12 months. Those departments included: Administration, BioMed, Credentialing, Medical records, Medical Staff, Safety, Security and Finance. This facility wide report listed reporting compliance at 20%. She also confirmed that the facility did not have a Risk Manager" for approximateiy one year and they were bringing back the position next Monday. Additionally, the high vacancy rate and unfilled positions make it difficult to get the reporting completed. She also confirmed that the issues and concerns identified with medical records/EHR were not being tracked or addressed in QAPI. 2. Review of the QAPI meeting minutes revealed that the committee members did not analyze and track indicators relative to patient grievances and complaints; consequentiy, they did not develop plans of actions with measurable goals and timetables to ensure that the patient complaints/grievances would not continue in the future. Refer to A0273. 3. Review of the QAPI meeting minutes revealed that?the committee failed to review the documented issues and concerns from each QAPI meeting to ensure that there was an ongoing Performance Improvement (PI) Plan for each department of the hospital. The QAPI FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 20 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938-0391 program did not: 1) Analyze and track indicators relative to patient grievances and complaints, 2) Develop a plan of action relative patient care, Refer to A1100, 3) Develop a plan of action relative medical records and integration and use of EHR and 4) Monitor the operation and provide maintenance of essential equipment that included sterilizers, surgical instrument washer, dental equipment and kitchen equipment in a safe and timely fashion. Refer to A0724. 4. The Governing Body/Executive Committee failed to complete their responsibilities to oversee the QAPI to ensure that each member was represented at each meeting; consequently, the absent committee members could not develop a plan of action with measurable goals with timetables to ensure that the identified concerns could be prioritized, addressed and managed effectively. 5. Review of the facility?s policies and procedures revealed a document titled, Plan" signed by Governing Body on 3/2/15 which provided the following information: PURPOSE The purpose of the Quality Assessment Performance Improvement efforts is to ensure the delivery of the best care possible for patients. This is accomplished by assessing patient care and other support processes in a systematic, Ongoing manner, in order to identify improvement opportunities and act on them in a timely manner. The plan has as its aim, the continual improvement of key governance, managerial, clinical and supportive processes that are most important to the health and safety of the patients served. STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 430084 3- 11/19/2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, so 57570 (x4) ED SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (x5) PREFIX (EACH DEFICEENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A263 Continued From page 20 A263 FORM Previous Versions Obsotete Event ID: N03E11 Facility ID: 430034 If continuation sheet Page 21 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938-0391 The QAPI plan is designed to integrate the pursuit of the Rosebud Service Unit's Mission The Rosebud IHS Hospital is dedicated to providing the highest quality health care to the people we serve while being a vital part of this community and providing each other with a positive and fulfilling work environment. II. OBJECTIVES The objectives of the QAPI Program are: 1. To increase the probability of desired patient outcomes, including customer satisfaction,by assessing and improving governance, managerial clinical and support processes that most affect those outcomes. 2. To establish priorities and address opportunities for improvement by focusing on those with the greatest potential impact on patient care outcomes and customer satisfaction. 3. To assure that all employees are trained in assessing and improving the processes that contributes to improved organizational performance. 4.?To monitor provider performance for the purpose of credentialing, privileging and re- appointing. 5. To establish an effective communication system for reporting performance improvement activities throughout all levels of the organization. AUTHORITY The Governing Body has final authority and responsibility for assuring the quality and effectiveness of patient care services provided by its Medical Staff members and other professional and support staff. The organization's leaders set expectations, develop plans, and implement procedures to access and improve the quality of organizations' governance, management and STATEMENT OF (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION NUMBER: COMPLETED A. BUILDING 430084 3- . 11/19/2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZEP CODE PHS INDIAN HOSPITAL AT ROSEBUD 40? SOLDIER CREEK ROAD ROSEBUD, so 57570 (x4) ID SUMMARY STATEMENT OF ID PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR 1.30 IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A 263 Continued From page 21 A263 FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 22 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938~0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: 430084 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 11I1912015 NAME OF PROVIDER OR SUPPLIER PHS INDIAN HOSPITAL AT ROSEBUD STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD ROSEBUD, SD 57570 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPR DEFICIENCY) (X5) COMPLETION IATE DATE A 263 A 273 Continued From page 22 support B. Procedure Each department/service/employee is expected to be engaged in Ongoing measures include, but not limited to the measures reported to the Governing Body on a quarterly The facility was not following it's current policies and procedures for an effective hospital wide QAPI program. DATA COLLECTION ANALYSIS Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it wil! improve health outcomes (2) The hospital must measure, analyze, and track quality indicators and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data, for example, information submitted to, or received from, the hospital's Quality Improvement Organization. (2) The hospital must use the data collected to-- Monitor the effectiveness and safety of services and quality of care; and (3) The frequency and detail of data collection must be specified by the hospital's governing body. A263 A 273 FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 23 of 82 PRINTED: 01/20/2016 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 430084 B. WING 11I191201 5 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION x5 PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A273 Continued From page 23 I A 273 This STANDARD is not met as evidenced by: Based on interview, record review and review of the policies and procedures, the hospital failed to ensure that their QAPI (Quality Assessment and Performance) committee had an ongoing program that indicated measurable improvements and outcomes for identified concerns. The program did not analyze and track indicators relative to: 1) Care and services in the ED (Emergency Department), 2) Patient complaints and grievances, 3) patient medical records/EHR (electronic health record), 4) Maintenance and operation of essential equipment that included sterilizers, surgical instrument washer, dental equipment and kitchen equipment. Findings include: 1. Based on staff interviews and review of medical records and hospital policies, it was determined the hospital failed to meet the Condition of Participation (GDP) for Emergency Services when they failed to ensure the patients evaluated and treated in the emergency department (ED) were provided appropriate, timely, and safe medical care based on acceptable standards of practice. This failure represented a failure to provide appropriate emergency care for four patients #39, #42, and #47) who presented with cardiac events, preterm labor and delivery, or trauma after a motor vehicle accident and constituted an Immediate Jeopardy (lJ) Situation. The Acting CEO, the Area Office Clinical Director, and the Area Office Nurse Consultant were notified of the immediate jeopardy on 11/19/15 at 2:10 PM. See FORM Previous Versions Obsolete Event ID: Facility ID: 430084 If continuation Sheet Page 24 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED 01/20/2016 FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 430084 B. WING 11/1 912015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 (x4) ID SUMMARY STATEMENT OF ID PLAN OF CORRECTION (st (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A273 Continued From page 24 A273 A1100 2. Review Of the hospital's "Grievance Log" from 10/20/14 to 9/22/15 revealed the facility failed to resolve grievances for 82 of 148 patients listed on the log. The log included: 1) a grievance dated and received on 4/10/15 concerning delayed/inappropriate care had a resolution dated Of 9/30/15 or 151 days past the required resolution date of 21 days. 2) A grievance dated 5/27/15 received on 6/2/15 concerning bad treatment in the emergency room (ER) had a resolution date of 7/2/15 or 10 days past the required resolution date of 21 days. 3) A grievance dated 5/29/15 received on 5/29/15 concerning unprofessional behavior by an ER Doctor had a resolution date Of 9/30/15 or 102 past the required resolution date of 21 days. 4) A grievance dated 6/17/15 and received on 5/17/15 concerning issues with a legal name of a newborn baby had a resolution date Of 9/30/15 or 83 days past the required resolution date Of 21 days. 5) A grievance dated 7/1/15 received on 8/31/15 concerning unprofessional behavior by medical staff had a resolution date of 9130/15 or nine days past the required resolution date of 21 days. 6) Eighty two grievances had no completion date listed in the column title "Date Of Response". 3. Review of the hospital policies and procedures revealed a document titled, "Patient Complaint/Grievance Policy, Revised: 2/15" which provided the following information: Close out letter will be sent to the patient/representative within twenty one (21) days after the Patient Grievance Coordinator receives the grievance. The letter will explain the hospitals plan to correct FORM Previous Versions Obsolete Event ED: N03E11 ID: 430084 If continuation sheet Page 25 of 82 . PRINTED: 01/20/2016 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A, BUILDING COMPLETED 430084 3- WENG 11/19/2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 (x4) ID SUMMARY STATEMENT OF DEFICEENCIES ID PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A273 Continued From page 25 A 273 or address the grievance. The letter will be signed by the Chief Executive Officer (CEO) and Patient Grievance Coordinator b. An interview on 11/18/15 at 3:00 PM with the hospital's Patient Grievance Coordinator verified the grievance log column titled "Date of Response" was when the hospital sent the close out letter to the patient or representative. The Coordinator confirmed the log lacked close out dates or timely dates as required by hospital policy for 87 grievances between the dates of 10/20/14 to 9/22/15. 3. Review of medical records and staff interviews the Hospital failed to ensure medical records were complete and contained information/documentation regarding evaluations. interventions and patient care provided. The hospital also failed to ensure patient medical record information was scanned into computerized medical records/EHR (electronic health record) was accessible and available to the physicians and other care providers to use in making decisions on the provision of care to the patients seen both in the emergency department and inpatients. a. The incomplete records for ED Patients included #39, #42, and Review of the medical records from patients seen in the ED (emergency department) which included both computerized medical record] EHR and paper portions were found to be incomplete. The surveyors found that numerous parts of the electronic health records (EHR) were missing. It was not possible to ensure that appropriate emergency care was provided with the lack of charting, including vital signs, critical care flow sheets, EKG monitor strips, fetal heart tone Previous Versions Obsolete Event ED: N03E11 Facility ID: 430084 If continuation sheet Page 26 of 82 I PRINTED: 01/20/2016 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION I (X3) DATE SURVEY AND PLAN OF CORRECTION EDENTIFICATION NUMBER: A BUILDING COMPLETED 430084 B- WING 11l19l2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PHS INDIAN HOSPITAL AT ROSEBUD 400 SOLDIER CREEK ROAD ROSEBUD, SD 57570 (x4) ID SUMMARY STATEMENT OF DEFICIEN-CIES ID PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE DEFICIENCY) A273 Continued From page 26 A273 monitoring strips, medication documentation, and orders. Each EHR was reviewed by the Area Office Clinical Director, who verified the records were incomplete. See A1100 b. During an interview with a Provider (I) on 11/19/15 at 10:15 AM ED cases were reviewed. The Provider expressed concerns with the EHR system and lack of access to records or reports that were supposed to be scanned into the EHR that could affect both ED and inpatients. Interview with Staff (K)(lnpatient Supervisor Nurse and CAC) was brought into the conversation. Staff (K) reported that they did have three computers set up that had the to view scanned documents. Provider I reported, "Then that is part of the problem because I did not know that or where those computers are." Staff (K) stated, "Then I think that is a training issue that we need to address and ensure everyone knows how to access and use the system." 4. Based on observation, document review and staff interview, the hospital failed to ensure the equipment was maintained and repaired for the Surgical Department steam autoclaves and washer, the Outpatient Department vinyl covered exam tables, the Outpatient Dental Department steam autoclaves and washer/sterilizers, Dietary Department cook range hood and dish machine, and the Emergency Room (ER) bay oxygen leak, that would not provide patients with an acceptable level of safety and quality of care. See A0724. A 338 482.22 MEDICAL STAFF A 338 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the FORM Previous Versions Obsolete Event iD: N03E11 Facility ID: 430084 If continuation Sheet Page 27 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938?0391 quality of medical care provided to patients by the hosp?al This CONDITION is not met as evidenced by: Based on record and poiicy review and staff interviews, it was determined that the hospitai failed to meet the Condition of Participation for Medical Staff when they failed to evaiuate the care provided by the Medical Staff, including the contracted providers, and failed to ensure that Medical Staff provided quality care to the patients seen in the Emergency Department (ED), Outpatient Department, and on the Inpatient Unit. The findings included: A0049 Standard: The Governing Body failed to ensure the medical staff committee reviewed the hospital's contracted medical staff accountability and the quality of patient care they provided. Additionally, the Governing Body failed to ensure that the medical staff was accountable for the quaiity of care which was provided to the patients in the Emergency Department (ED). A0273 Standard: The hospital failed to ensure that their QAPI (Quai-ity Assessment and Performance) committee had an ongoing program that indicated measurable improvements and outcomes for identified concerns. The QAPI program did not analyze and track indicators relative to: 1) Care and services in the ED (Emergency Department), 2) Patient complaints and grievances, 3) patient medical records/EHR (electronic health record), 4) Maintenance and operation of essential equipment that included sterilizers, surgical instrument washer, dental equipment and kitchen equipment. STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTEON IDENTIFICATION NUMBER: COMPLETED A. BUILDING 430084 3- 11/19/2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A 338 Cpntinued From page 27 A 338 FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 28 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938-0391 ORGANIZATION ACCOUNTABILITY The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors Of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This STANDARD is not met as evidenced by: Based on record review and family and staff interview, it was determined that the hospital failed to ensure that the Medical Staff was accountable to the Governing Body for providing quality of care to patients. Examples of these failures were identified for patients #37, #31, and STATEMENT OF (x1) PROVIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF IDENTIFICATION NUMBER: A BUILDING COMPLETED . 430084 B- WING 11I1 9I2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD ROSEBUD ROSEBUD, SD 57570 (x4) SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A 338 Continued From page 28 A 338 A0347 Standard: The Medical Staff failed to be accountable for the quality Of care provided to patients. A 347 (2), (3) MEDICAL STAFF A 347 FORM Previous Versions Obsofete Event ID: N03E11 ID: 430084 If continuation sheet Page 29 of 82 PRINTED: 01/20/2016 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 430084 B. WING 11l19l2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZEP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 (X4) SUMMARY STATEMENT OF DEFICIENCIES PLAN OF CORRECTION X5 I PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A 347 Continued From page 29 A 347 #33. The findings included: 1. Record review for patient #37's 4/23/15 Emergency Department (ED) visit revealed a chief compiaint of chest pain. At 7:20 PM, during the nursing triage/assessment, the patient was put on the monitor, which showed a of SW (supraventricular) with a heart rate of 160. A stat EKG revealed Afib. The patient's pain level was 8 out of 10 with "pain through to the back". The physician was notified. The patient's MSE (medical screening exam) was started at 8:15 PM (55 minutes after the patient was triaged.) The physician (FF) noted the patient's chief complaint was "palpitation, dizziness and sob (shortness of breath) since last weekend. Pt previously healthy without hx of diabetes mellitis, hypertension or dyslipidemia?. The physician noted that the patient denied chest pain and shortness of breath and listed diagnoses as Atrial fibrillation, anxiety, and chest pain. The plan was to transfer the patient to Sioux Falls (signed by the physician at 8:50 PM), which was changed to Rapid City (signed by the physician at 9:17 PM). The charted transfer time was 11:55 PM. . - On 11/18/15 at 10:25 AM, in an interview with the patient's famiiy member (FM), the FM indicated the patient had a history of cardiomeglia and had an increased pulse rate for two years. The hospital providers had diagnosed the patient as having anxiety, not a cardiac probiem. The FM indicated that she was told the Sioux Falls hospital refused the transfer. The FM contacted the Sioux .Falls hospital and was told that they would not and did not refuse a cardiac transfer. The FM felt that the patient was not properly FORM Previous Versions Obsolete Event lD: N03E11 Facility ID: 430084 If continuation sheet Page 30 Of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES 01?20?2016 FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION NUMBER: A BUILDING COMPLETED 430084 B. WING 11/1 9/2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD PHS HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE DEFICIENCY) A 347 Continued From page 30 A 347 diagnosed, was not treated appropriately because of the anxiety diagnosis, and had a delayed transfer due to the physician's failures. A grievance was filed (4/24/15) but no final response had been provided at the time of the survey (seven and a half months later). 2. Review of the 3/3/15 ED record for patient #31 evidenced that this 2 year old was brought to the ED at 6:35 PM by his mother. The mother indicated that the child had a "fever with runny nose 7 days". The nursing triage assessment listed "fever, hands cramping, difficulty breathing - wheezing, ill x16 days, (2/27/15), difficulty breathinglfever/dehydrated." Provider (FF) charted that the child's external ear and TMS (tympanic membranes) were Clear and that the child had a viral The physician noted the history Of present illness included fever, runny nose, no sob (short of breath) and vomiting. There was no description of the vomiting or of dehydration The patient was discharged home at 7:05 PM (30 minutes after arrival in the ED). Review Of the patient?s medical record evidenced that he had been seen in the Outpatient clinic on 2/27/15 and was given amoxicillin and ear drops for possible otitis media (ear infection). Review of physician note for the patient?s ciinic visit which occurred on 3/4/15 revealed that the patient presented with "not eating or drinking fluids may be dehydrated hands (per the mother's report). The mother told the physician about the ED visit, the night before this clinic visit. She reported that "Dr looked at pt'S eyes and said he was OK and that he has FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 31 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER: 430084 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (x3) DATE SURVEY COMPLETED 11I1912015 NAME OF PROVIDER OR SUPPLIER PHS INDIAN HOSPITAL AT ROSEBUD STREET ADDRESS, CITY, STATE. ZIP CODE 400 SOLDIER CREEK ROAD ROSEBUD, SD 57570 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) iD PREFIX TAG PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETION CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A431 A441 Continued From page 36 such as critical care sheets, and electrocardiograms that were noted as completed during the care of the patients. Findings include: See the following for details: A0441 Standard: Protecting Patient Records. The hospital failed to ensure confidentiality of patient records by not requiring a form of identification was provided when patients picked up requested copies of medical records. A0449 Standard: Content of Record. The hospital failed to ensure that patient medical records contained all forms of documentation of the services such as written documents, computerized electronic information, radiology fiIm and scans, laboratory reports, and other forms of information regarding the condition of a patient, provided to patients that were seen both as inpatients and patients seen in the emergency department. The hospital failed to ensure patient medical records were complete by containing pertinent information such as critical care sheets, and electrocardiograms that were noted as completed during the care of the patients. PROTECTING PATIENT RECORDS The hospital must have a procedure for ensuring the confidentiality of patient records. Information from or copies of records may be released only to authorized individuals, and the hospital must ensure that unauthorized individuals cannot gain access to or alter patient records. Original medical records must be released by the hospital only in accordance with Federal or State Iaws, court orders, or subpoenas. A431 A441 FORM Previous Versions ObsoIete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 37 of 82 PRINTED: 01/20/2016 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 430084 3- 1111912015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD ROSEBUD, SD 57570 PHS INDIAN HOSPITAL AT ROSEBUD (x4) ID SUMMARY STATEMENT OF DEFECIENCIES ID PROVIDERS PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL pREIrlx (EACH CORRECTIVE ACTEON SHOULD BE COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE . DEFICIENCY) A441 Continued From page 37 A441 This STANDARD is not met as evidenced by: - Based on patient, family and staff interviews, review of the medical record request form, and review of policy and procedure, the hospital failed to ensure that requests for release of medical records included identification of the person requesting the information and the person to whom the copy of the medical record was given. Additionally, the hospital faiied to ensure that patient's medical record information was only released by patient consent or authorized disclosure in accordance with FederaI or State laws, court orders, or subpoenas. Findings include: 1. interview on 11/18/15 at 9:50 AM, Employee (Z) revealed when an individual completed a form for release of medical records, she obtained the information requested, and when the individual returned to pick up the copy of the medical record, Employee (Z) would give it to them and confirmed there was no request for the individual toprovide identification. When Employee (2) was asked why no identification was requested, she stated she "had been therefor 30 years and knew almost everyone. The only time identification may be requested is if someone else is picking up the medical record for the person who had requested the information." 2. Review of the form "Authorization For Use or Disclosure of Protected Health information" revealed at the following statement at the bottom of the form; "This information is to be released for the purpose stated above and may not be used by the recipient for any other purpose. Any person who knowingly and wiIIfully request or FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 38 of 82 PRINTED: 01/20/201 DEPARTMENT OF HEALTH AND HUMAN SERVICES 6 FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938~0391 STATEMENT OF DEFICIENCIES (x1) (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 430084 3- WING . 11/1 9/2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 400 SOLDIER CREEK ROAD ROSEBUD, SD 57570 PHS INDIAN HOSPITAL AT ROSEBUD (x4) ID 4 SUMMARY STATEMENT OF ID PLAN OF CORRECTION (X5) pREFix (EACH MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE A441 Continued From page 38 A441 Obtains any record concerning an individual from a Federal agency under false pretenses shall be guilty of a misdemeanor." The following section had a Space titled next to that section is a section that had a Space for NAME (Last, First, MI), RECORD NUMBER, ADDRESS, and DATE OF BIRTH. 3. Review of the facility policy titled "Release of Information", Revised Date 9-2013, Reviewed Date 10/2015 stated: "Policy: The release of medical information may be made to an authorized agency or individual as identified. Purpose: To assure the privacy and confidentiality of patient information. Procedure: A. Receipt: 1. All requests for medical information will be directed to the Medical Records Department. 2. All requests will be date stamped as to the date received in the Release of Information Office. 3. The release information will be considered valid when the following elements are met. Addressed to the Rosebud Comprehensive Health Care Facility. Patient is identified by: name and either by, date of birth, social security number. Identification of individual or facility to whom the records will be disclosed to Note: signature will be compared with signature on file. If validity is questionable, patient will be contacted. FORM Previous Versions Obsolete Event ID: N03E11 Facility lD: 430084 If continuation sheet Page 39 of 82 PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 430084 8- WING 11I19I201 5 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD . ROSEBUD, SD 57570 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (x5) pREFix (EACH MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A441 Continued From page 39 A441 Specific information requested shall be indicated all outpatient visits of 1997). B. Search and Preparation of Document (5): The patient registration system will be utilized to search for the patient &the health record. 2. The medical records is then retrieved from the permanent file area and reviewed for the requested information. 5. Photocopying of the record shall be performed by: Photocopy ONLY the information that has been requested. A copy of the original consent form will be made to be returned with the requestor. Assure photocopied documents are clear as possible no smudges, etc). 6. Arrange the photocopied records in order Ambulatory records, Lab, Radiology, etc) 7. Photocopied records will be placed in a sealed secure envelope. The envelope will be labeled CONFIDENTIAL. PRIORITIES AND TIME FRAMES: The following priorities and time frames shali apply to release Of medicai information requests. Emergency request involving immediate emergency care of patient/customer: Process immediately. All other requests: within 10 workdays or soonen ACCOUNTING OF DISCLOSURE: 1. Staff will stamp the originai consent with the date of when it was received. 2. All request will be entered into the Release FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 40 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938-0391 STATEMENT (X1) of Information program within RPMS (Resource and Patient Management System) and tracked until completed. - 3. All original written authorization and [or consent forms will be permanently filed in the patient record." 4. During an interview on 11/18/15 at 2:00 PM the Clinical Director revealed he had become aware of the policy and procedure for releasing copies of medical records to patients and that the procedure "was not right" and needed to be changed. There was nothing in the policy and procedure'that stated that the person requesting the release of their medical record information needed to provide any type of identification when picking up their copy of the medical record. 5. On 11/17/15 a patient came into the hospital to file a grievance lcomplaint which involved unauthorized release of medical information. At 10:45 AM the complainant and family then asked to speak to the survey team to file concerns. 1) The patient reported he had been seen in the ED and ED staff had called the police and released medical information concerning patient lab reports without the patient's consent. 2) The ED record had a "yes" where it asked if consent was given to treat. 3) The hospital release the copy of the patient medical record without checking the patient's identification before give out the record. 1) The patient presented an email from the police department. The email was entitled, "Incident Report Rosebud Police Department Sgt. It stated, few hours later I was advised by emergency room staff that (patient (x2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION NUMBER: A BUILDING COMPLETED 430084 3- WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE. ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 (x4) :0 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (x5) (EACH DEFTCIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A441 Continued From page 40 A441 FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 41 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938~0391 STATEMENT OF DEFICIENCIES (Xi) AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 430084 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (x3) DATE SURVEY COMPLETED 11I19I2015 NAME OF PROVIDER OR SUPPLIER PHS INDIAN HOSPITAL AT ROSEBUD 400 SOLDIER CREEK ROAD ROSEBUD, SD 57570 STREET ADDRESS, CITY, STATE, ZIP CODE (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PLAN OF CORRECTION (x5) PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG TO THE APPROPRIATE DATE DEFICIENCY) A441 Continued From page 41 was only one that registered alcohol from lab results. was advised by staff that called the police department that (patient name?) blood alcohol was over 300. I advised that once the (person/gender) was done with medical attention he/she would be transported to the Rosebud jail for 2) Review of patient #223 ED record identified concerns with lack of monitoring and signed consent. The patient was brought into the Ed by ambulance on 11/7/15 at 5:35 PM. The ED record noted the patient had been involved in a MVA (motor vehicle accident). "Patient odorous of ETOH, garbled speech, poor historian and uncooperative. Patient was reported to have loss of consciousness at scene. Patient alert upon arrival hollering and attempting to take straps off backboard and head support C-Collar." The section "ls consent to treat been signed" was marked as However, further review found no signed consent. A "Critical Care Flow Sheet" was initiated on this patient. However, the record was incomplete. The flow sheet showed one full set of vital signs at 1735 (5:35 PM) and then a partial set at 1810 (6:10 PM)There were no other vital signs documented and the patient was released on 11/8/15 at 1:40 AM. There was no indication in the medical record that when the patient was brought into the ED the patient was on a "Police Hold" or in "Poiice Custody". The discharge note showed the patient was released on 11/8/15 at 1:40 AM. The note stated, notified that patient was medically cleared for release to adult corrections. Pt. driver A441 FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 42 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 430084 3- WENG 11/19/201 5 NAME OF PROVIDER OR SUPPLIER PHS INDIAN HOSPITAL AT ROSEBUD STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD ROSEBUD, SD 57570 (x4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE A441 A 449 Continued From page 42 of a 2 car motor vehicle accident. Pt. out of ER with RPD Officer 3) Interview on 11/18/15 at 9:50 AM, Employee (2) revealed when an individual completed a form for release of medical records, she obtained the information requested, and when the individual returned to pick up the copy of the medical record, Employee (Z) would give it to them and confirmed there was no request for the individual to provide identification. (See details cited in example 1.) 482.24(c) CONTENT OF RECORD The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient's progress and response to medications and services. This STANDARD is not met as evidenced by: Based on review of medical records and staff interviews the hospital failed to ensure medical records were complete and contained information/documentation regarding evaluations, interventions and patient care provided. The hospital also failed to ensure patient medical record information which was scanned into computerized medical records/EHR (electronic health record) was accessible and available to the physicians and other care providers to use in making decisions on the provision of care to the patients seen both in in the emergency department and inpatients. Findings included: A441 A 449 FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430034 If continuation sheet Page 43 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER: 430084 (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED B. WING 11/19/2015 NAME OF PROVIDER OR SUPPLIER PHS INDIAN HOSPITAL AT ROSEBUD STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD ROSEBUD, SD 57570 (X4) ID PREHX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR-LSC IDENTIFYING INFORMATION) ID PREFIX TAG PLAN OF CORRECTION (EACH CORRECTIVE ACTEON SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE A 449 A 700 A 724 Continued From page 47 11/19/15 at 10:15 AM ED cases were reviewed. The Provider expressed concerns with the EHR system and lack of access to records or reports that were supposed to be scanned into the EHR that could affect both Ed and inpatients. Interview with Staff (K) (Inpatient Supervisor Nurse and CAC) was brought into the conversion. Staff (K) reported that they did have three computers set up that had the ability to view scanned documents. Provider (I) reported, "Then that is part of the problem because I did not know that or where those computers are." Staff (K) stated, "Then I think that is a training issue that we need to address and ensure everyone knows how to access and use the system." SEE Details A1100 482.41 PHYSICAL ENVIRONMENT The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This CONDITION is not met as evidenced by: Based on observation and interview, the facility failed to comply with the 2000 NFPA 101 Life Safety Code as required. FACILITIES, SUPPLIES, EQUIPMENT MAENTENANCE Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This STANDARD is not met as evidenced by: Based on observation, document review and staff interview the hospital failed to ensure the equipment was maintained and repaired for the Surgical Department steam autoclaves and A 449 A 700 A 724 FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 48 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF (x1) (x2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 430084 3- 11I1 912015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD - ROSEBUD, SD 57570 (x4) ED SUMMARY STATEMENT OF DEFICIENCIES lD PROVIDERS PLAN OF CORRECTION (x5) PREFEX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A 724 Continued From page 48 A 724 washer, the Outpatient Department vinyl covered exam tables, the Outpatient Dental Department steam autoclaves and washer/sterilizers, Dietary Department cook range hood and dish machine and the Emergency Room (ER) bay oxygen leak, that would not provide patients with an acceptable level of safety and quality of care. Findings include: 1. Review of the hospital's policies and procedures revealed a document titled, "Aberdeen Area Indian Health Service Circular 05?03 Medical Device Selection and Acquisition." The purpose is to ensure that all medical/dental device/equipment purchases made within the Aberdeen Area are safe to operate, compatible with existing systems, meet the needs of the medical care staff, installation issues are provided for, after purchase support is available and technology needs are met while maintaining fiscal integrity. The policy directed the Clinical Engineer as the person responsible for purchase requests. 2. The tour of the surgical department on 11/18/15 at 10:15 AM found issues with maintenance of equipment. The issues included: 1) The "Steris AutoClave" sterilizers between OR (operating room) Aand was not working. The OR supervisor reported the machine had not run properly for over the past ten months. A log form was provided which showed the tracking of the machine had not been in use for ten months. She reported that she had been told it required a special steam trap in the ceiling and had caused leaking in the roof . 2) The blanket warmer between OR room A FORM Previous Versions Obsolete Event tD: N03E11 Facility ID: 430084 if continuation sheet Page 49 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES . PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938-0391 and was not working nor maintaining proper temperatures. Staff reported that they were unable to provide warm blankets to new born's and/or surgical patients in the OR. 3) The main washer/disinfector in central supply had not been working for six months and was just recently fixed. However, the delay in repairs concerned staff, who had to wash all surgical instruments by hand. 4) The Endo System 1E processor was not working. The facility had one other Endo System processor which was working. The Endo System 1E processor which was not working had been out Of service for ten months, which was verified by a log tracking sheet. The RM SYSTEM 1 CR8 Monitor Of Proper Sterilization Technique" form showed that the system had not been working since 11/13/14. A commented noted on the form dated 3/2/15 stated, "I'm working on it." The OR supervisor reported that if current Endo processor stopped working OR case needing an endoscope would be canceled. The OR Supervisor provided Reports forms from July 2015 through October 2015 which confirmed the maintenance of equipment as described above had been an on gOing problem. 3. The follow up interviews with Biomed and maintenance staff from the AO (Area Office) confirmed ongoing issues with getting timely repairs and maintenance of the facility's equipment. Staff (B) (Clinical Engineer Biomed contracted STATEMENT OF DEFICIENCIES (XI) (x2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 430084 B. WING 11/1 9/2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 W) .9 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A 724 Continued From page 49 A 724 FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 50 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938-0391 from Pierre) reported contracted staff was provided to help the due to a number of vacant positions in Maintenance Department. The organizational chart was provided, by the Acting CEO, which showed that under the Supervisor General Engineer position was "Vacant", as well as five other positions under "Maintenance". Staff (G) (Clinical Engineer Biomed) provided work orders of equipment which showed delay in repairs. The examples of ongoing repair delays inciuded: washer/disinfector in surgery from 7/15/14 to 3/23/15 and warming cabinet in the OR. The work order was requested on 1/30/15 and not completed until 9/15/15. Staff (G) also reported that there had been issues with electronic work orders which may have been deleted. 4. Review of the April 16 2015 "Medical Staff" meeting minutes identified on going problems with surgical and dental equipment. The minutes from 4/16/15 included: "Surgical Review Dr. talked with (name operating room supervisor about some of the concerns in the OR. The sterilizer between A has not been working for over a year. They are being told they have one that works, but if it breaks down, the OR will have to Shut down. The washer disinfector has been down for three weeks, so they have been washing by hand. Only one OR table works so they have been moving the table between one OR to the other. Dental Review - The (namem) company came to do some repairs in the clinic. Dental's digital x?ray machine has been. sitting in boxes for two years uninstailed due to no wiring. Area put a hold on STATEMENT OF DEFICIENCIES (X1) (x2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 430084 B. WING 11I1 9/201 5 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 (x4) SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE DEFICIENCY) A 724 Continued Frorn page 50 A 724 FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430034 If continuation sheet Page 51 of 82 ED: 1/20/2 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINT 0 6 FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: BUKDING COMPLETED 430084 3- 1111912015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (X5) PREHX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE - TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE DEFICIENCY) A 724 Continued From page 51 A 724 because the hospital was going wireless. The area under follow? up date was not marked for - either of these reviews and the issues were still present at the time Of the survey 11/19/15." 5. Observation on 11/16/15 at 10:50 AM revealed the outpatient clinic departments that included Family Practice, Pediatric, Diabetic and Elderly exam room #2628, had torn/missing Vinyl from the corner Of the exam table, which exposed the foam base of the table where the patient would sit or lay down for examination. The missing corner pieces Of Vinyl rendered the exam table non-cleanable. Further Observation at the same time revealed the Vinyl covers on exam tables were torn at the corner edges, where a patient would Sit for an exam leaving the table non-cleanable in Exam Room #2627, #2611, #2613, and #2606. An interview with the Outpatient Clinic Supervisor on 11/16/15 at 11 :00 AM, verified the exam table corners were torn and the department had ordered new tables. An interview with Maintenance Staff (F) on 11/17/15 at 3:00 PM, verified they were unaware Of a work order to repair the exam tables in the Outpatient Clinic. 6. Observation of the dietary department on 11/16/15 with the Supervisory Dietitian identified the following issues: 1) The cleaning Of stove hood and vent was last cleaned on dated 2/28/11. However, the Supervisory Dietitian stated that it was to be clean annually. FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 52 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938-0391 2) The kitchen had a new automatic chemical dispenser recently installed on the dish machine. The Supervisory Dietitian stated that he did not know how to test or check the level of chemical being used in the dish machine, to ensure proper amount of chemical was being dispensed. The Supervisory Dietitian reported he was not given testing strips and did not know how to test chemical concentration of the machine. He later reported that the chemical representative was contacted and inform him that the machine had a sensor and display to check detergent level. He then checked the machine and found it to be reading at 306 to 310 PPM (part per million) even though the machine was set at 300 PPM. The chemical representative was not aware of a toxic level or PPM that should not be exceeded and would be calling back with more information. The Supervisory Dietitian reported he would not use the machine until they were notified of proper chemical concentration. 7. Review of the Emergency Committee meeting minutes from May, 2015 to September, 2015 revealed "oxygen leak in the trauma room gases tower". At the time of the survey, it was verified as an ongoing problem. Additionally, the September, 2015 meeting notes identified the following needs new equipment for patient care as requested at the beginning of the fiscal year. Emergency equipment, blood pressure and stretchers among others. Needs resubmitted in last equipment meeting 04/15/15." STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED . A. BUILDING 430084 3- WING 1111912015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, so 57570 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A 724 Continued From page 52 A 724 FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 53 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8; MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED. OMB NO. 0938-0391 The infection control officer or officers must develop a system for identifying, reporting, investigating, and controliing infections and communicable diseases of patients and personnel. This STANDARD is not met as evidenced by: Based on observations, record review and staff interviews, it was determined that the Hospital failed to ensure that there was an active infection control program that monitored, investigated, controlled, and/or prevented or decreased the opportunities for the spread of infections. Findings included: 1. Review of patient #34's ED (Emergency Department) record identified concerns with care and care of a patient with clinical history of untreated TB (tuberculosis). The patient was brought into the ED on 3/27/15 by ambulance at 9:09 AM and was transferred out at 2:25 PM. The record stated, "The patient had been found outside and was agitated and combative". The patient was diagnosed with hypothermia, sepsis, and severe metabolic acidosis. A portable X-ray revealed, "Right lower lobe infiltrate." The reason for portable exam stated, "Hx (history) of untreated The clinical record did not contain a "Critical Care Flow Sheet" for this patient who was triaged at level two nor did the record show any infection control measures put in place for a patient with untreated TB. There was no documentation in the transfer record to inform the accepting facility that the patient they were getting had a history Of untreated TB. STATEMENT OF DEFICEENCIES (x1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING . 430034 3? 1111912015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CJTY. STATE, ZIP CODE 400 SOLDIER CREEK ROAD PHS HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (X5) (EACH MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYENG INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A 749 Continued From page 53 A 749 A 749 INFECTION CONTROL PROGRAM A 749 FORM Previous Versions Obsolete Event lD: Facility ID: 430084 If continuation sheet Page 54 of 82 PRINT 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES ED 01/20/20 6 FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 430034 3- 11/19/2015 NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PHS INDIAN HOSPITAL AT ROSEBUD 400 SOLDIER CREEK ROAD ROSEBUD, SD 57570 (x4) 19 SUMMARY STATEMENT OF DEFICIENCIES In PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE .PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE DEFICIENCY) A 749 Continued From page 54 A 749 Interview with the EC (Infection Control) Nurse on 11/19/15 at 2:45 PM was asked if she was aware of the patient with untreated TB seen in the ED. The infection control log was Check however the patient was not found in the log. She reported she was not aware of the case and that she would expect to see documentation of PPE and infection control precautions being used which was not found. She also reported the isolation room is actual part of Outpatient Department is not used for ED patients. However, another staff member had reported the patients needing isolation in the ED would be put in a separate room in the outpatient department. 2. Review of the Infection Control reports, written by the IC nurse for three months; 8/14/2015, 9/8/2015 and 10/5/15 identified ongoing concerns. The repeated concern stated, "Non-compliance with (name of accrediting organization) Plan of Correction (P00) in the Emergency Department regarding the separation of Clean/dirty equipment and storage of equipment in trauma room continues to be a concern. states we will provide separation of Clean and dirty, but we have not complied. Spoke with unit supervisor and head of maintenance with solutions still pending. This is an ongoing issue until renovations completed in There was no follow up actions documented or temporary steps noted by infection control to mitigate risks and prevention cross contamination in the ED. Additionally, the IC reports did not address the ongoing problems with maintenance of surgical FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 55 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY and dental sterilizers lautoclaves or surgical washer/disinfector. The potential for improper cleaning and inadequate sterilization of surgical instruments has a potential risk for device related infections. Interview with the IC (infection Control) Nurse on 11/19/15 at 2:45 PM confirmed she was not aware of those ongoing equipment issues. The tour of the surgical department on 11/18/15 at 10:15 AM confirmed ongoing issues with the maintenance of equipment. 3. Review of the Infection Control Log from 4/6/15 to 11/13/15 identified the facility cared for a high population Of patients having infections. This included a high number of MRDO (multiple drug resistant organism) infections. The concern was ensuring isolation procedure were followed when indicated and that patient and caregivers were educated about their infections when being seen in the ED and outpatient clinic. The log showed: -A patient being admitted to the facility on 1112/15 with MRSA (methicillin resistant staphylococcus auerus) infection of the right index finger. However, no documentation or infection control measures were put in piece. -Oct. 2015 showed four patients seen in the ED and five in the Outpatient Department with MRSA infections. However, there was no indication of the facility was educating patients, visitors, caregivers, and staff, as appropriate, about infections and communicable diseases and methods to reduce transmission in the hospital and in the community. As it was identified in the facility's policy and procedure, "Participation in an? organizational proactive education program, in an effort to reduce and control infection and [or A. BUILDING COMPLETED 430084 3- 1111912015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 (x4) .9 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (X5) PREHX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE DEFICIENCY) A 749 Continued From page 55 A 749 FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 56 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 430084 8- WING 11/19/2015 NAME OF PROVIDER OR SUPPLIER PHS HOSPITAL AT ROSEBUD STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD ROSEBUD, SD 57570 SUMMARY STATEMENT OF DEFICIENCIES 4. Review of the policy and procedure for infection control provided on 11/16/15 at 10:12 AM included following: The goal of Rosebud Comprehensive Health Care Facility is to establish a comprehensive infection Control Program, to ensure that the organization has a functioning coordinated process in place, to reduce the risks of endemic HAIS (Hospital Acquired Infections) in patients and healthcare workers and to optimize use of resources through a strong preventive "Participation in an organizational proactive education program, in an effort to reduce and control infection and/or "Infection Control Plan FY2014-15 What: To improve reporting of infections (surveillance) the Rosebud Health Care Facility. Why: Prompt reporting of infections ensures quick response in order for control Of Potential transmission and subsequent outbreaks of infections. Who: Patients, visitors and staff are ultimately benefited by prompt control of Infectious Diseases within our hospital. Where: Infection Control Person will monitor reporting and progress will be reported Appropriately. (x4) ID ID PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCES TO THE APPROPRIATE DATE DEFICIENCY) A 749 Continued From page 56 A 749 FORM Previous Versions Obsoiete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 57 of 82 PRINTED: 01/20/2016 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 430084 3- 11/19/2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, STATE. ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION X5 I I (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE DEFICIENCY) A 749 Continued From page 57 A 749 Implementation of surveillance monitors: a) infection control log - started 9/11/09 and wit! continue to maintain. b) IV and foley-monitor for PI. Ongoing since 10/09 and continue to maintain. 0) IC environmental rounds cover areas of Health Care Facility-this will include, but not limited to use of gloves, proper use of cleaning products, cleanliness of area, proper use of PPE outdates on medications and supplies. These rounds are conducted quarterly, with random checks as needed. d) Continue to provide orientation to new staff, volunteers, and students. e) Provide annual BBP (blood borne pathogen), TB (tuberculosis), and hand hygiene training. f) Provide and maintain employee health records. Ensuring staff are up to date on required/recommended immunizations. Provide staff with fit testing for respirator masks (N95) . 9) Continue to report to SD Department of Health the required reportable diseases. h) Will keep up to date on Infection Control issues and update staff as needed." A1077 482.54(a) INTEGRATION OF OUTPATIENT A1077 SERVICES Outpatient services must be appropriately organized and integrated with inpatient services. This STANDARD is not met as evidenced by: Based on document review and staff interview, the hospital failed to ensure the outpatient services were appropriately integrated with the inpatient services which included outpatient policies and procedures for one patient (Patient #50) that voiced a complaint related to the inability to make appointments for outpatient FORM Previous Versions Obsolete Event ID: NO3E11 ID: 430084 If continuation Sheet Page 53 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES 01/20/2016 FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938?0391 STATEMENT OF (x1) (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A COMPLETED 430084 B. WING 11I1 9l2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSSREFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A1077 Continued From page 58 A1077 Clinics and long wait times for a walk in appointment at the outpatient Clinics. Findings include: 1. Review of the outpatient Clinic titled "Frequency of Diagnoses Report, 2015" on 11/19/15 at 2:00 PM revealed the hospital offered patient care in the following outpatient clinics; The Women's Health (obstetrics and gynecology Dental, Behavioral Health, Family Practice, Pediatrics, Diabetic and Elderly Clinics. Review of the hospital's patient data for the month of August data included 1551 patients visits, September data included 1106 patient visits and October had 1084 patient visits. 2. Atelephone interview with Patient #50 on 11/19/15 at 10:30 AM regarding a complaint that concerned their inability to get an appointment to see a provider in an prompt manner, be able to have a walk in appointment scheduled and usually ended up waiting three to four hours to see a provider and get their medications. Patient #50 also added that they started calling the Clinic on Monday, 11/16/15 at 7:58 AM and when the clinic answered the phone about 8:10 AM the appointments were already filled. 3. An interview with Outpatient Patient Supervisor (H) on 11l19/15 at 3:00 PM concerning Patient#50's compiaint, confirmed the hospital lacked policies and procedures for the outpatient clinics and did not have a procedure regarding patient scheduling, triage Of patient health care concerns/needs, and provider/staff availability in the clinics. Staff (H) verified the Clinics lacked appropriate provider (Medical staff) staffing for the volume of patient health care needs. FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 59 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED - OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER: 430084 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (x3) DATE SURVEY COMPLETED 11I19I2015 NAME OF PROVIDER OR SUPPLIER PHS INDIAN HOSPITAL AT ROSEBUD STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD ROSEBUD, SD 57570 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE (X5) COMPLETION DATE A1077 A1100 Continued From page 59 4. During an interview with a Provider on 11/19/15 at 10:15 AM, concerns were expressed with the Outpatient Department over the volume Of patients being seen and the lack of staff. The Provider stated, know we are short a couple of Providers and have three or four nursing positions open. I know they are trying to get as many patients seen as possible but at some point you have to stop and be able to ensure the quality of care that is being provided." 5. Review of the the current organizational chart for the Outpatient Department showed there were four (4 of 9) clinical nurse positions "Vacant". Additionally, three Medical Officer positions and one Physician Assistant position (4 of 11 providers) were listed as being "Vacant". 482.55 EMERGENCY SERVICES The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This CONDITION is not met as evidenced by: Based on staff interviews and review of medical records and hospital policies, it was determined the hospital failed to meet the Condition of Participation (COP) for Emergency Services when they failed to ensure the patients evaluated and treated in the emergency department (ED) were provided appropriate, timely, and safe medical care based on acceptable standards of practice. This failure represented a failure to provide appropriate emergency care for four patients #39, #42, and #47) who presented with cardiac events, preterm labor and delivery, or trauma after a motor vehicle accident and A1077 A1100 FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430034 If continuation sheet Page 60 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 430084 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY A. BUILDING COMPLETED B. WING 11/19/2015 NAME OF PROVIDER OR SUPPLIER PHS INDIAN HOSPITAL AT ROSEBUD STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD ROSEBUD, SD 57570 (x4) 10 PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR IDENTIFYING INFORMATION) :0 PLAN OF CORRECTION (X5) PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A1100 Director, and the Area Office Nurse Consultant Continued From page 60 constituted an Immediate Jeopardy (IJ) situation. The Deputy CEO, the Area Office Clinical were notified of the immediate jeopardy on 11/19/15 at2z10 PM. The immediate jeopardy situation was not abated prior to the surveyors exiting the Hospital. The administrative staff provided a draft plan, which they indicated needed to be approved by the Area Office in the morning. evidence of the actions taken to abate the Immediate Jeopardy. The findings included: 1. The ED failed to ensure that patients received adequate medical screening examinations (MSE). 2. The ED failed to ensure that patients were stabilized when they presented with emergency medical conditions (EMC). 3. The ED failed to ensure that patients who required a higher level of care were transferred without a delay. 4. The Governing Body and the Medical Staff failed to provide effective oversight to ensure safe, appropriate emergency services were given to the patients who presented at the ED with an EMC. 5. The Governing Body failed to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program which evaluated the care provided in the ED and used the findings to make improvements in the quality of care for patients seen in the ED. A1100 FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 if continuation sheet Page 61 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938-0391 - STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. 430084 3- 11/19/2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 (x4) .0 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (x5) PREHX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A1100 Continued From page 61 A1100 6. The Governing Body failed to ensure that the patients' medical records were complete. The surveyors found that numerous parts of the electronic health records (EHR) were missing. It was not possible to determine that appropriate emergency care was provided with the lack of charting, including vital Signs, critical care flow sheets, EKG monitor strips, fetal heart tone monitoring strips, medication documentation, and orders. Each EHR was reviewed by the Area Office Clinical Director, who verified the incompleteness of each records. PATIENTS WHO WERE IDENTIFIED AS BEING AT RISK FOR IMMEDIATE JEOPARDY 1. Review of the ED log revealed that patient #37 presented to the ED on 4/23/15 at 7:17 PM with "chest pain". The nursing assessment - triage indicated "Patient put on monitor. Shows SVT type 160 Stat EKG shows Afib. Patient has no history. Please see critical care for all care. Dr. __(name) notified." At 7:20 PM, the patient?s blood pressure was pulse (P) 180, respirations (R) 24, pain 8 (8 out of 10), and 02 saturation 98%. The pain was described as "pain through to back". The patient was assigned an Of 2. The patient's MSE was noted to have been done at 8:15 PM. The chief complaint is listed as palpitaiton, dizziness and sob since last weekend. Pt previously healthy without ?hx of diabetes mellitus, hypertension or dyslipidemia. The Review of the Systems by the provider revealed that the patient denied chest and denied shortness of diagnoses were atrial fibriitation, and anxiety. The physician's plan was to transfer the patient to a FORM OMS-256763299) Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 62 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 430084 (x2) MULTIPLE CONSTRUCTION AEBUILDING B. WING (X3) DATE SURVEY COMPLETED 11/19/2015 NAME OF PROVIDER OR SUPPLIER PHS INDIAN HOSPITAL AT ROSEBUD 400 SOLDIER CREEK ROAD ROSEBUD, SD 57570 STREET ADDRESS, CITY, STATE, ZIP CODE (x4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PLAN OF CORRECTION (x5) PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG CROSS-REFERENCE.) TO THE APPROPRIATE DATE DEFICIENCY) A1100 Continued From page 62 hospital in Sioux Falls with a time of 8:42 PM. The change in plans to Rapid City noted a time of 9:16 PM. The patient left the Hospital at 11:55 PM. At 8:42 PM, the medication orders were "diltiazem 25 mg iv now, then 20 mg after 30 min. iv drip diituiazen 15 mg/hr." Review of the patient's Order Summary revealed the following: 4123115 8:43 PM - Diltiazem 5 mg/ml inj; Inject five (5) mg inj. IVP PSIV now 4/23/15 8:43 PM - Lorazepam 0.5 mg tab 0.5mg; Take two (2) tablets by mouth now 4123115 8:44 PM - Diltiazem 5 mg/ml inj; Inject five (5) mg inj. IVP PSIV now 4123/15 - Diltiazem 5 mg/ml inj; Inject five (5) mg inj. IVP PSIV now 4123115 8:45 PM - Nitroglycerin 0.4 mg tab, sublingingual 0.4 mg dissolve one (1) under the tongue now . 4123115 8:46 PM - Aspirin 81 mg Chew UD tab, chewable 81 mg; Chew three (3) tablets by mouth now 4123/15 8:52 PM - Diltiazem 5 mg/ml inj; Inject 20 mg. PSIV now 4123115 8:52 PM - Diltiazem 5 mg/ml inj; Inject 10 mg. PSIV now 4123115 8:53 PM Diltiazem 5 mg/ml inj; Inject 15 mg/HR drip PSIV now 4123115 9:17 PM - Heparin inj. soln inject 5000 units intravenous subcutaneous 4123115 9:18 PM Heparin inj soln inject 1000 units intravenous subcutaneous 4123115 10:36 PM - Lorazepam 2mg/ml inject 1 mg PSIV now 4123/15 10:46 PM - Lorazepam 2mg/ml inject 1 A1100 FORM Previous Versions Obsolete Event ID: NO3E11 Facility ID: 430084 if continuation sheet Page 63 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY mg PSIV now 4/23/15 10:46 PM - Discontinue Lorazepam 0.5 mg UD tab 0.5 mg. Take two tablets by mouth. Review of the patient's Critical Care Flow Sheets revealed that there are numerous write-overs, making it difficult to read what was actually written. The medication Charting appears to be different than the orders for medication. The accuracy of the documentation was questionable. An addendum was added at 9:16 PM noting that the patient was being transferred to a Rapid City hosp?aL An addendum was written at 11:56 PM to clarify what and how much medication was given. Another addendum was written on 4/24/15 at 6:09 AM in which the doses of heparin were discussed. Family interview revealed that the patient was admitted to the Rapid City hospital and required cardiac surgery. When the family member was asked about the Sioux Falls hospital, she that she was told that the?hospital refused the transfer. The family member verified with the Sioux Falls hospital that it had not refused the transfer and was not even asked to accept the transfer. but to provide consultation. 2. Review of patient #47's two ED visits on 7/22/15 evidenced that the patient was 34 weeks pregnant (G2 P1). The chief complaint of the patient for the 10:46 AM ED visit was "uterine pains. Pain started around 5?6 am this morning. She states they come every 5 mins. Slight contractions". The patient rated her pain at 8 (8 AND PLAN OF CORRECTION NUMBER: A. BUILDING COMPLETED 430084 3- WING 11/191201 5 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE, er CODE 400 SOLDIER CREEK ROAD PHS ENDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 (x4) ID SUMMARY STATEMENT OF DEFICIENCIEs ID PROVIDERS PLAN OF CORRECTION (x5) pRme (EACH DEFICIENCY MUST BE PRECEDED BY FULL RREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A1100 Continued From page 63 A1100 FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 64 Of 82 - DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 430084 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 11I19l2015 NAME OF PROVIDER OR SUPPLIER PHS INDIAN HOSPITAL AT ROSEBUD STREET ADDRESS. CITY, STATE. ZIP CODE 400 SOLDIER CREEK ROAD ROSEBUD, SD 57570 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PLAN OF CORRECTION PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) (X5) A1100 Continued From page 74 - Medical history - Tetanus status - Immunization status for patients 18 years and younger - Last menstrual period for all women of child-bearing age - Weight of all patients (Height to be obtained yearly, with patient in socking feet) - Vital signs which includes-Temperature - Heart rate - Respiratory Rate - Blood pressure - Pain Level - 02 saturation, if applicable - Nursing observations - Glasgow coma scale, if applicable - Trauma score, if applicable - Signature of Triage RN Ail patient information is documented in the patient's medical record on the Emergency Room PCC form. Emergency Severity lndex(ESl): - Resuscitative (ESI l) immediate care, life-threatening conditions that requires lifesaving interventions: -Acute chest pain with Airway and breathing difficulty -Anaphylaxis -Cardiac arrest - rregular pulse with Multiple trauma -Open chest/abdominal wound Poisoning with neurologic changes Profound shock Respiratory arrest Seizure Severe head trauma Uncontrolled hemorrhage - Emergency (ESI 2) - major injury or illness but A1100 FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 If continuation sheet Page 75 of 82 RINTED: 01/ 0/ DEPARTMENT OF HEALTH AND HUMAN SERVICES 2 2 6 FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938?0391 STATEMENT OF DEFICIENCEES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. COMPLETED 430084 3- 1111912015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4oo SOLDIER CREEK ROAD HS INDIAN OSPITAL AT OSEBUD ROSEBUD, so 57570 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (x5) pREle (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A1100 Continued From page 75 A1100 stable; treatment and reassessment should occur within five (5) to 15 minutes: 'Active Iabor Acute asthma attack Aggressive patient IA with neurologic deficit -Drug overdose -Eye injury with loss of vision -Major burn -Major fractures Pregnant patient with active bleeding Severe headache Sexual assault Suicidal/homicidal behavior -TesticuIar pain - Urgent (Level 3) - treatment and reassessment should occur in 15-45 minutes: Abdominal pain Alcohol/drug intox ication Bleeding, patient is stable -Closed fracture -Drug ingestion - injury (no vision loss) - Laceration - Minor chest pain - Non?cardiac chest pain - Renal calculi - Urinary retention Semi-?Urgent (ESI 4) - treatment and reassessment should occur in one to two 1-2) hours: Abscess Constipation Cystitis -Earache -Minor bites Minor burn FORM Previous Versions Obsolete Event ID: N03E11 Facility ID: 430084 if continuation sheet Page 76 of 82 PRINTED: 01/20/2016 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 430084 3- WING 11I19I2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE, ZIP CODE PHS INDIAN HOSPITAL AT ROSEBUD 40? SOLDIER CREEK ROAD ROSEBUD, SD 57570 (X4) ID SUMMARY STATEMENT OF DEFECIENCIES ID PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY 0R LSC IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE DEFICIENCY) A1103 Continued From page 80 A1103 Dr (HH) noted that the "Pt. was transferred to (hospital in Sioux Falls)". A1112 EMERGENCY A1112 SERVICES PERSONNEL There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. This STANDARD is not met as evidenced by: Based on record review and staff interview, it was determined that the Emergency Department failed to have adequate, qualified medical and nursing personnel to meet the needs of the patients who presented to the ED. The findings included: Review of the the current organizational chart for the Emergency Room showed vacancies for the Supervisor Medical Officer as well as another Medical Officer and two Physician Assistant positions. The vacancies listed for nursing showed three clinical nurse positions as "Vacant". On 11/16/15, in an interview with the Acting CEO, she revealed that the Acting Clinical Director was currently also covering the ED Supervisor Medical Officer position. Review of the number of emergency cases for each of the last six months, as provided by the ED Nursing Supervisor, showed the volume of patients being seen in ED: FORM Previous Versions Obsolete Event ID: NO3E11 Facility ID: 430084 If continuation sheet Page 81 of 82 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/20/2016 FORM APPROVED OMB NO. 0938-0391 May, 2015 1052, June, 2015 1037, July. 2015 1042, August, 2015 1082, September, 2015 1194, October, 2015 1188. On 11/17/15 in an interview with the ED Nursing Supervisor, she confirmed issues with coverage for providers and nursing staff. STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION NUMBER: COMPLETED A. BUILDING 430034 3- 1111912015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, so 57570 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING TAG TO THE APPROPRIATE DATE DEFICIENCY) A1112 Continued From page 81 A1112 FORM Previous Versions Obsolete Event ID: NO3E11 Facility ID: 430084 If continuation sheet Page 82 of 82