mi? Maw 'Ms CENTERS FOR MEDICARE MEDICAID SERVICES DEPARTMENT OF HEALTH 8: HUMAN SERVICES Centers for Medicare 8: Medicaid Services Dallas Regional Of?ce 1301 Young Street, Room 827 Dallas, Texas 75202 DIVISION OF SURVEY AND CERTIFICATION, REGION VI January 18, 2019 Our Reference: CCN 371340, Complaint Intake 8, OK00052721 Douglas Swim, CEO Memorial Hospital of Texas County Authority 520 Medical Drive Guymon, OK 73942 Dear Mr. Swim: Section 1865 of the Social Security Act (the Act) and Centers for Medicare Medicaid Services (CMS) regulations provide that a provider entity accredited by a CMS-approved Medicare accreditation organization will be "deemed" to meet all of the applicable Medicare conditions and requirements. Section 1864 of the Act requires the State Agency to conduct a survey of a deemed hospital on a selective sampling basis, in response to a substantial allegation of noncompliance, or when CMS determines that a full survey is required after a substantial allegation survey identi?es substantial noncompliance. We have reviewed the reports of the October 9, 2018, and October 11, 2018, surveys conducted by the Oklahoma State Department of Health (OSDH) and found that your hospital was not in compliance with the following Medicare Conditions of Participation and EMTALA requirements: 42 CFR 485.618 Emergency Services 42 CFR 485.641 Periodic Evaluation QA Review 42 CFR 489.24(a) Medical Screening Exam 42 CFR Emergency Room Log We have determined that the de?ciencies substantially limit your hospital?s capacity to render adequate care and prevent it from being in compliance with all the applicable Medicare Conditions of Participation for hospitals. Hospitals must meet all provisions of Section 1861(0) of the Social Security Act, be in compliance with all of the applicable Medicare Conditions of Participation, and be free of hazard to patient health and safety in order to participate as providers of services in the Medicare program. The deemed status of your hospital was removed on January 18, 2019, as a result of the ?ndings of substantial noncompliance. The date on which the Medicare agreement of Memorial Hospital of Texas County Authority terminates is April 18, 2019. Termination can only be averted by correction of the de?ciencies, through submission of acceptable plans of correction and subsequent veri?cation of compliance by OSDH. A listing of de?ciencies for the October 9, 2018, and October 11, 2018, surveys are enclosed for your response. TT Page 2 Memorial Hospital of Texas County Authority The Form CMS-2567 with your dated and signed by your hospital?s authorized representative, must be submitted to Terri Cook, OSDH, via email at by January 28, 2019. This will ensure that the OSDH will be able to schedule a timely survey of your hospital to evaluate your compliance with the applicable Medicare Conditions of Participation and EMTALA requirements. The criteria for acceptable plans of correction are as follows: 1. The plan for correcting the speci?c de?ciency cited; The plan for improving the processes that lead to the de?ciency cited, including how the hospital is addressing improvements in its systems in order to prevent the likelihood of recurrence of the de?cient practice; The procedures for implementing the acceptable plans of correction for each de?ciency cited; A completion date for the implementation of the plans of correction for each de?ciency cited; The monitoring and tracking procedures that will be implemented to ensure that the plan of correction is effective and the speci?c de?ciency cited remain corrected and in compliance with regulatory requirements; and 6. The title of the person responsible for implementing the acceptable plan of correction. Copies of the Form including copies containing the hospital?s are releasable to the public in accordance with the provisions of Section 1864(such, the should not contain personal identi?ers, such as patient and staff names. However, it must be specific as to what corrective action the hospital will take to achieve compliance. A follow-up survey will be conducted at your hospital to verify compliance. If CMS determines that the reasons for termination remain, you will be informed in writing of the continuation of the termination process. You will again be asked to submit acceptable plans of correction and one ?nal revisit may be conducted before the termination date. A provider is not entitled to a hearing before termination, but only after termination actually takes place under Medicare regulations. The deemed status of Memorial Hospital of Texas County Authority will be restored when it is determined to be in substantial compliance with the applicable Medicare Conditions of Participation and the OSDH will discontinue its survey jurisdiction. You may contact Dodjie Guioa at 214-767-6179 or by email at if you have questions regarding this matter. Sincerely, Deer/m Karen Hillman, Manager Enforcement Branch Enclosure: cc: Accrediting Organization, OSDH PRINTED: 01/16/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVECES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 371340 3- WING 10/09/2018 NAME OF PROVIDER OR SUPPLIER . STREET ADDRESS, CITY. STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) .9 SUMMARY STATEMENT OF to PROVIDER's 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) 000 INITIAL COMMENTS 000 The Oklahoma State Department of Health conducted a Federal complaint survey at Memorial Hospitai Of Texas County in Guyman, Oklahoma on 09/27/18, 09/28/18, 10/08/18 and 10/09/18. The following Condition level de?ciencies were cited: ?485.618 Condition of Participation: Emergency Services ?485.641 Condition of Participation: Periodic Evaluation and Quality Assurance Review Standard level de?ciencies were also cited as a result of the survey. The following abbreviations may be found within this document: CEO Chief Executive Of?cer CNO Chief Nursing Of?cer COO Chief Operating Of?cer ED Emergency Department EMS Emergency Medical Service MSE Medical Screening Examination TPA Tissue Piasminogen Activator (clot~buster) 200 EMERGENCY SERVICES 200 485.618 The CAH provides emergency care necessary to meet the needs Of its inpatients and outpatients. This CONDITION is not met as evidenced by: Based on record review and interview, the hospital failed to provide appropriate emergency LABORATORY OR REPRESENTATIVES SIGNATURE TITLE (X6) DATE Any de?ciency statement ending with an asterisk denotes a de?ciency which the institution may be excused from correcting providing it is determined that other safeguards provide suf?cient 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 provrded. For nursing homes. the above ?ndings and plans of correction are disclosable 14 days following the date these documents are made available to the facrlity. lf de?ciencies are cited, an plan of correction is requisite to continued program FORM Prevrous Versrons Obsolete Event ID: SZP111 Facrlity ID HP2249 If continuation sheet Page 1 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/162019 FORM APPROVED OMB NO. 0938-0391 services and interventions to meet the emergency needs of patients according to current standards of practice as evidenced by: I. one (Patient #23) of three patients with possible stroke who arrived via EMS (Emergency Medical Services) and was sent to another hospital from the hospital?s ambulance bay due to no availability of Activase (TPA [Tissue Plasminogen Activator, also known as the "clot-buster'D, without physical evaluation, diagnostic imaging. laboratory studies, and nursing assessment. ll. two (Patient #3 and 5) of seven suicidal patients who presented to the emergency department (ED) and did not receive a mental health evaluation through an available contracted telemedicine service to determine the safety Of discharge to self or parent's custody for transfer to mental heaith faCIlity for further treatment. one (Patient of two patients who presented with a rattlesnake bite was not assessed prior to discharge to determine stability and current injury status, recommended observation. and anti-venom medication administration (due to unavailability) per hospital policy. IV. one (Patient #10) of two pediatric patients who presented to the ED on three different times with worsening complaints of fever, abdominal pain, and nausea/vomiting with no laboratory studies or diagnostic imaging ordered. These failed practIces had the likelihood to: STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 371340 1010912013 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (X4) ID 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) 200 Continued From page 1 200 FORM Prewous Obsolete Event ID SZP111 FaCIhty ID HP2249 If continuation sheet Page 2 of 42 PRINTED: 01/16/2019 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 BU COMPLETED . ILDING 371340 B. VMNG 1010912018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES to 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 CROSSREFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 200 Continued From page 2 200 I. cause injury, delay in care, and worsening of health condition due to lack of early intervention for one (Patient #23) of three patients who presented to the ED with possible stroke via EMS. ll. cause serious harm to two (Patient #3 and 5) patients who presented to the ED with suicide attempts and were transferred through a private vehicle to a mental health facility for further treatment without mental health evaluation and increased risk to patient safety for all suicidal patients who seek treatment in the ED. result in worsening of the health condition for one (Patient patient who presented to the ED with a rattlesnake bite and was not provided assessment, observation, and treatment per hospital policy and standards of practice. lV. result in worsening health condition and serious harm for one (Patient #10) pediatric patient who presented to the ED with repeated complaints of fever, abdominal pain. and nausea/vomiting with no evidence of laboratory or diagnostic studies ordered per Standards of practice. Findings: l. Stroke Patients A review of hospital policy titled "Emergency Medical Screening Examination and Stabilizing Treatment, dated 03/18/18" showed, the hospital campus included physical areas and structures adjacent to the hospital within 250 yards of the included availability of FORM PreVIous VerSIons Obsolete Event ID SZP111 FaCIlIty ID HP2249 if continuation sheet Page 3 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: VIEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER. 371340 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WNG (X3) DATE SURVEY COMPLETED 10/09/2018 NAME OF PROVIDER OR SUPPLIER MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY 520 MEDICAL DRIVE GUYMON, OK 73942 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) In PLAN OF CORRECTION I (x5) PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 200 Continued From page 3 equipment, supplies, and routine ancillary (support services such as laboratory, radiology, and pharmacy) services patient should be assessed upon arrival for prioritization and determine whether EMS was able to monitor patient's condition appropriately if an immediate medical screening examination (MSE) was not able to be performed. A review of hospital policy titled "Scope of Service/Plan of Care, dated 01/13/17" showed, patients who presented to the hospital's ED should receive an MSE that included all necessary labs, diagnostic testing, and services within the capabilities of the hospital in order to reach a diagnosis. A review of hospital document titled "Activase log 09/01/17 through 09/28/18" showed four patients (Patient 2, 25, and 26) had received Activase on the foliowing dates: 09/07/17, 10/08/17, 05/15/18, and 05/25/18. The hospital was not able to provide evidence of an order and receipt between the time period of 05/25/18 to 10/11/18 for the purchase of Activase to show the availability of the medication when Patient #23 arrived on 06/03/18. A review of an untitled hospital document showed the last purchase date for a package of two 100mg vials of Activase was on 09/07/17. Review of document titled "Fire Department EMS Incident Report, dated 06/03/18" showed, EMS crew were dispatched at 2:23 pm, to Patient #23's 200 FORM Prewous Obsolete Event ID: SZP111 ID HP2249 lf continuation sheet Page 4 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 residence and arrived on scene seven minutes later at 2:30 pm. At 2:36 pm, EMS crew noti?ed the hospital of positive stroke scale. EMS crew loaded the patient and departed the scene at 2:54 pm, arriving at hOSpital at 3:07 pm. EMS crew were noti?ed that hospital did not have Activase available. EMS crew noti?ed Staff that hospital had no Activase available and decision was made to transport patient Via air ambulance to next closest acute stroke ready hospital in Texas. Review of hospital document titled Log Incident with EMS, dated 06/03/18" showed the following: I called into ED for positive stroke scale to prepare for head 8 (ED physician) instructed nursing staff to notify EMS the hospital did not have Activase. EMS was noti?ed at the same time they arrived in the ED ambulance bay. *lncident was entered on 06/03/18 at 5:08 pm, by Staff (ED RN). *Incident was reviewed multiple times by Staff 1 (Manager of Quality/Risk Management) on I 06/14/18, 06/25/18, 06/27/18 and no analysis, interventions, or outcomes were documented. *Staff (peer review) noted on 06/28/18, Staff 8 (ED physician on duty on 06/03/18) reported he/she had been made aware of the event and was concerned. It was noted the patient was "in fact in the ED ambulance bay before EMS was alerted there was no Activase in the hospital". On 09/28/18 at 10:50 am, during a tour of the STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 371340 9- WNG 10/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) "3 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS 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) 200 Continued From page 4 200 FORM Prevmus VerSIons Obsolete Event ID SZP111 Factlity ID HP2249 If continuation sheet Page 5 of 42 PRINTED: 01/16/2019 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 COMPLETED 371340 B. WING 10/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE. ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (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 IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 200 Continued From page 5 200 pharmacy surveyors observed a box containing two 100mg vials OfActivase in the pharmacy. Staff was not able to identify when the Activase was purchased or determine how long the box of Activase had been available at the hospital. On 09/27/18 at 3.44 pm, Staff (EMS Director) stated, he/She was noti?ed by the EMS crew on arrival at the hospital there was no Activase available. Staff stated, the EMS crew were on scene approximately 23 minutes and the hospital had "ample time" to notify the EMS crew there was no Activase available. He/she stated. the patient remained in the ambulance and the physician dId not evaluate the patient. On 09/28/18 at 9:30 am, Staffl stated, his/her role included taking radio calls from EMS. Staffl stated, there had been a time when EMS arrived in the ambulance bay and EMS was told they needed to go someplace else because the hOSpitaI did not have something. Staff I reported, he/she was the one who noti?ed EMS the hospital did not have Activase on the day of the event. ll. Suicidal Patients A review of hospital policy titled "Emergency Medical Screening Examination and Stabilizing Treatment. dated 03/18/18" Showed emergency would be when a patient was a danger to him/herself or others who presented to the ED for a condition addressed through a pre-arranged community plan such as an MSE would be performed and treatment initiated prior to transfer FORM PreVIous VerSIons Obsolete Event ID: SZP111 FaCIlIty ID HP2249 If continuatIon sheet Page 6 Of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: VIEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY COMPLETED of patient pursuant to community plan. A review of hospital policy titled "Patient Awaiting Evaluation, dated 12/28/16" showed the patient should be evaluated and the need for evaluation determined. Review of a hospital document titled "Telemedicine Mental Health Access Agreement, dated 01/14/14" showed, a mental health facility would provide licensed mental health professionals to perform telemedicine mental health consultations for patients presenting to 'the hospital. Review of document titled "Managing Suicidal Patients in the Emergency Department, dated 02/16" from the Annuals of Emergency Medicine showed a suicide risk assessment helped to determine appropriate treatment for suicide patients percentage of patients with suicidal ideation or behaviors may be managed in the ED without a mental health evaluation and discharged home who tend to be the lowest risk are those with no suicide plan or intent, no prior attempts, mental illness, substance abuse, and/or agitation or irritability. Review of document titled "Suicide Assessment Five-step Evaluation and Triage for Mental Health Professionals, dated 2009" from the Suicide Prevention Resource Center showed determination of suicide risk level included four factors: risk factors, protective factors, suicide inquiry and interventions. High risk for suicide A. BUILDING 371340 8- 101091201 8 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY - GUYMON, OK 73942 (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 COMPLETJON TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE 200 Continued From page 6 200 FORM PreVIous VerSIonS Obsolete Event ID: SZP111 FaCIlrty lD HP2249 lf continuation sheet Page 7 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE VIEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 included an acute precipitating event, potentially lethal suicide attempt or persistent ideatIon with intent or rehearsal. These patients should be admitted unless there was a signi?cant change in suicide risk. Patients determined to be a moderate suicide risk usually have muttiple risk factors, and present with suicidal ideation and plan, but generally no Intent or behavior. Depending on the identi?ed risk factors, patients with moderate suicide risk may need to be admitted. Review of document titled "Caring for Adult Patients with Suicide Risk: A Consensus Guide for Emergency Departments? by the Suicide Prevention Resource Center showed after initial suicidal risk screening a more thorough secondary screening that provides disposition decisions for patients with suicide! ideations should be performed. The screen includes six questions that include thoughts of suicide, suicide intent, past suicide attempts, past mentai health issues or issues that affect ability to do things in life, substance abuse issues, and behaviorai issues. A mental health professional should be consulted in the ED if a patient answers "yes" to any of the questions for further evaluation, including a comprehensive suicide risk assessment. Patient #3 was a 17 year old female, who presented to the ED at 1:21 am, via EMS following ingestion of Fiuoxetine (Prozac) and Tyienol approximately three hours prior to arrival. Review of Patient medical record showed: *Suicide assessment identi?ed suicide ideation, STATEMENT OF DEFICIENCIES (x1) DERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 371340 B. WING 10I09I2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (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 LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 200 Continued From page 7 200 FORM OMS-2567632439) VerSIons Obsolete Event ID SZP111 FaCIlIty ID HP2249 lf continuation sheet Page 8 of 42 PRINTED: 01/16/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE VIEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A BUILDING COMPLETED 371340 3- WING 10I0912018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE. ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES so 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) 200 Continued From page 8 200 suicide attempt, feelings of hopelessness and despair and a depressed mood. *lnitial physician assessment performed at 1:45 am, noted overdose was patient's second attempt. Patient was lethargic but arousable. Physician's plan was to repeat Acetaminophen level at nine hours post ingestion and at 6:00 am. *lnitial labs at 1:30 am, showed critical Acetaminophen level at 32 uglmL (normal 13?30 uglmL). ALT (Alanine Aminotransferase [blood test to evaluate liver function]) 57 (normal 8?34 Acetaminophen level at 5:33 am, was 11 uglmL. *Medical Necessity for Air/Ground Transport was completed by physician stating a need for a higher level of care requiring a physician Specialist that was not available at the hospital. *Transfer Request/Consent was completed and signed by physician, and noted bene?ts of transfer to include Specialist availability to meet the needs of the patient and identifying the patient stable to transfer. *At approximately 6:00 am, there was a change of shift in ED physicians. *There was no re-assessment by the oncoming ED physician and no mental health consultation or evaluation obtained via telemedicine. *At 6:36 am, ED physician discharged patient to home in care Of foster parent with instructions "strongly recommend contact place where you had counseling earlier this year and talk with FORM PreVIous Versuons Obsolete Event ID: SZP11I FaCIlIty iD HP2249 If continuation sheet Page 9 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 them about how you are feeling, what is happening in your life." ED physician's ?nal diagnosis was anxiety disorder. Patient #5 was a 14 year old female, who presented tO the ED via private vehicle with reports Of ingesting ?a handful of Tylenol? approximately 30 minutes prior to arrival. Review of Patient #5'3 medical record showed: *Patient reported having family problems and not livmg with either parent. *DIagnosed with depression and ordered medication. *Patient reported "mom does not care enough to get medication for her'. Noted "some messed up things happened to her last summer but would not elaborate". *PhysiCIan noted patient was tearful and admitted to overdose by taking "2 handfuls of Tylenol". *Labs were ordered including 3 CBC (complete blood count [measures several components of the blood]), CMP (comprehensive metabolic panel [14 tests that provides information on metabolism, electrolyte and acidlbase balance, kidney/?ver function and blood glucose]), UDS (urine drug screen [test for the presence of illegal and prescription drugs]), urinalysis and Acetaminophen level. Initial Acetaminophen level was critical at 88 (low 13, high 30) and UDS was positive for amphetamines and methamphetamines. STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A BUILDING COMPLETED 371340 3- WING 10I09I2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) (D SUMMARY STATEMENT OF DEFICIENCIES In PLAN OF CORRECTION (x5) pREng (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) 200 Continued From page 9 200 FORM PreVIous VerSIons Obsolete Event ID: SZP111 ID HP2249 If contmuation sheet Page 10 of 42 .LJ. PRINTED: 01l16l2019 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 COMPLETED 371340 1010912018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVI 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) 200 Continued From page 10 200 *No assessment performed by ED physician. *No suicide assessment was performed by nursing staff at the time of triage or during the physical assessment. *No documentation in the patient's medical record DHS was noti?ed of the patient's suicide attempt by overdose. *There was no evidence the physician obtained a mental health evaluation Via telemedicine to determine the presence of an acute medical condition. *Patient was diagnosed with Acetaminophen overdose, was given contact information for two facilities to follow up with and discharged home with her mother. On 10/10/18 at 8:28 am, Staff (ED RN) stated, the hospital did have a telemedicine contract with a facility to perform mental health evaluations. Staff stated, the process was to contact the telemedicine site after a suicidal patient was "medically cleared". Staff stated, "a patient may be suicidal but the ED physician may decide the patient does not need a evaluation and discharge them". On 10110/18 at 9:08 am, Staff stated, staff asked the physician why the Patient #5 was being discharged home with her mother. Staff stated, the physician said ?the patient was an adolescent and her mother could take her." Staff FORM PreVIeus Obsolete Event ID: SZP111 FaCIlIty lD' HP2249 If continuatIon sheet Page 11 of 42 PRINTED: 01/16/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE VIEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCEES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER. A BUILDING COMPLETED 371340 3- WING 10/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY 52? MEDICAL DRIVE GUYMON, OK 73942 (x4) ID 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 CROSSREFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 200 Continued From page 11 200 stated, the patient did not have a mental health evaluation at the hospital prior to discharge. Staff stated that in his/her experience suicidal patients had received a mental health evaluation prior to discharge from the ED. On 10/10/18 at 11:59 am, Staff (Chief of Staff and Medical Director of the ED) stated, the hospital had issues in the ED regarding the quality of care provided to patients by ED physicians. Staff (3 stated, patients who presented to the hospital with suicidal ideation or suicide attempts should receive a mentai health evaluation. Staff stated the hospital had a telemedicine agreement for mental health services available for such consultatIons. Rattlesnake Bites Review of hospital policy titled "Snake Bite. dated 03/18/18" showed, treatment for known rattlesnake bItes Should include wound care, observation for four to six hours, and discharge home if there was no development of clinical signs. The policy fails to clearly identify the treatment and disposition of the patient when there were development of clinical signs and such as swelling, erythema, lab abnormalities, and other non-life threatening Policy failed to identify criteria of a ?wet? snake bite and when to initiate orders for management Of patients with wet snake bites. Review of hospital document titled "Emergency Department Orders for Snake-Bite Patients (Wet FORM Ver5Ions Obsolete Event ID: SZP111 Faculty ID HP2249 If continuation sheet Page 12 of 42 PRINTED: 01/16/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE 8: MEDICAID SERVICES OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: BUILDING COMPLETED 371340 3- 1010912018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE. ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 W) In 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) 200 Continued From page 12 200 Bite) Adult/Pediatric, undated" showed. labs should be obtained including CBC with platelet count, (PT prothrombin time a test that helps to detect and diagnose bleeding or clotting disorders, international normalized ratio a test that measures the time it takes the blood to clot). (partial thromboplastin time a test that assesses the body's ability to form blood clots), Fibrinogen. CMP, and urinalysis. Intravenous (IV) access Should be obtained and Normal Saline or Lactated RInger ?uid bolus administered. Mark with a permanent marker from the distal edge Of the fang to the leading edge of the swelling, and date and time it. Administer Crofab (antI-venom) immediately. Review of hospital document titled "Grievance Process Checklist and attachments, dated 04/1211 8" showed, a complaint was initiated by the quality/peer review personnel due to a concern regarding the care Patient #6 received in the ED. Findings showed, the standard Of care was not met for the care provided to Patient 6 for the treatment of the rattlesnake bite. Review Of hospital document titled "Continuous Quality improvement - Patient Complaints and Grievances, dated 04112/18" showed, the outcome of the quality review regarding Patient #6 was an ?extremely unexpected? practice that "could have (or did) contribute to patient injury". Medical record was forwarded for medical record by ESS (ED medical staf?ng group) for peer review. Review of untitled hospital document from Staff FORM PreVIous VerSI0ns Obsolete Event lD SZP111 FaCIlIty ID HP2249 If continuation sheet Page 13 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE VIEDICAID SERVICES PRINTED: 0111612019 FORM APPROVED OMB NO. 0938?0391 STATEMENT OF DEF ICIENCIES AND PLAN OF CORRECTION (x1) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER. 371 340 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (x3) DATE SURVEY COMPLETED 1 0109I201 8 NAME OF PROVIDER OR SUPPLIER MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY STREET ADDRESS, CITY, STATE, ZIP CODE 520 MEDICAL DRIVE GUYMON, OK 73942 (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) 0(5) COMPLETION DATE 200 Continued From page 13 regarding the review of Patient #6's medical treatment in the ED. His review noted there was no signi?cant change in the patient?s condition during the apprOXImately two hours she was in the ED. He noted the patient was sent to Amarillo the next morning by her primary care phy5ician for treatment with the anti?venom. His conclusion was two hours of observation with normal vital signs, normal labs and minimal edema met the "standard for reasonable care". Review of document titled "Envenomations: Initial Management of Common U.S. Snakebites, dated 06/2311 7" by the Academic Life of Emergency Medicine showed labs should include urinalysis, creatine kinase, ?brinogen, PTIINR, PTT, liver function tests, chemistry panel and complete cell count of envenomation include in?ammation such as pain, heat, and redness. Systemic signs may include hypotension, vomiting, coagulopathy (elevated PT, decreased ?brinogen, thrombocytopenia), diarrhea, or angioedema. Patients should be monitored for a minimum of 8 to 12 hours and repeat of labs prior to discharge even for those that Show no immediate signs of envenomation. Patient #6 was a 67 year old female, who arrived in the ED at 7:31 pm, via EMS with complaints of a rattlesnake bite one hour prior to arrival. Review of Patient #6's medical record showed: *Elevated vital signs: heart rate 117, respirations 22, and blood pressure 167/81 *Nursing assessment noted redness, bruising, tenderness, and warmth of the foot, snakebite marked. Patient denied pain. 200 FORM OMS-256710289) Previous Ver5ions Obsolete Event ID: Facility ID HP2249 If continuation sheet Page 14 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 CENTERS FOR MEDICARE MEDICAID SERVICES STATEMENT OF DEFICIENCIES (x1) AND PLAN OF CORRECTION IDENTIFICATION NUMBER. 371340 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. (X3) DATE SURVEY COMPLETED 10109I2018 NAME OF PROVIDER 0R SUPPLIER MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY STREET ADDRESS. CITY. STATE. ZIP CODE 520 MEDICAL DRIVE GUYMON, OK 73942 physician assessment noted one fang mark on dorsum right foot with minimal swelling. *At 7:53 pm, ice packs were provided and placed around the patient?s foot due to swelling. Assessment faited to identify the amount of swelling. *Patient stated she did not want pain medication at 8:03 pm. There was no documentation of an assessment of the patient's pain to determine if the patient had pain. *Labs were obtained including a CBC, CMP, and PTT. There were no abnormalities. *Triple antibiotic ointment was applied to the bite and the patient was discharged to home at 9:20 pm, approximately 1 hour and 50 minutes after admission. *Prior to discharge there was no evidence physician or nursing staff performed a re-assessment to determine the patient?s swelling. redness. bruising, warmth and tenderness to the foot remained stable and there was no increase. On 10/10/18 at 11:59 am, Staff (Chief of Staff and Medical Director of the ED) stated, he/she was aware the hospital did not have anti-venom at one time resulting in a patient being sent to another hospital. Staff stated, it was a concern the hospital did not have anti?venom. Staff stated, he/she was not aware what happened but he/she thought "they were going to make sure they were not short anymore." (x4) .0 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 DR LSC IDENTIFYING TAG CROSS-REFERENCED To THE APPROPRIATE DATE DEFICIENCY) 200 Continued From page 14 200 FORM PreVIous VersIons Obsolete Event ID: SZP111 ID HP2249 [f contInuatIon sheet Page 15 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938?0391 On 10/10/18 at 1:22 pm, Staff stated, he/she ?was furious? about Patient #6?s care in the ED because the hospital did have antI-venom and steroids but "they did not do anything for the patient". Staff stated the physician who performed the case review "did the same thing before". IV. Pediatric Patients A review of hospital poilcy, "Scope of Service/Plan of Care: Emergency Department?, revision date 01/13/17 showed the patient population served by the ED consisted of newborn, pediatric, adolescent, adult and geriatric patients requiring or seeking medical care. Support services included but were not limited to clinical laboratory studies and x?rays that were to be provided to the patient in a timely manner. A document, "Case Review Form" 05/09/18, showed the form was to be utilized as part of the peer-review process established by the hOSpitaI's medical staff bylaws. The conclusion of the review of Patient #10's medical care in the ED showed "there were several ?ndings in the history and physical examination that should have prompted a more thorough evaluation in the emergency department. Treatment did not meet standard Of care." The document also showed on 02/08/18, the patient was transferred from a primary care provider?s clinic to another facility and undenlvent surgery for pyloric stenosis. STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 371340 3- WNG 10/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY 52? MEDICAL DRIVE GUYMON, OK 73942 (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 IDENTIFYING INFORMATION) TAG CROSSREFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 200 Continued From page 15 200 FORM Previous VerSIons Obsolete Event ID: SZP111 Faculty ID HP2249 If continuation sheet Page 16 of 42 PRINTED: 01/16/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE 8v. VIEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 371340 3- WING 10,0912018 NAME. OF PROVIDER 0R SUPPLIER STREET ADDRESS, CITY. STATE. ZIP CODE 520 MEDICAL DRIVE ORAL OSP TA 0F TE AS CO NTYAUTHORITY MEM I I 73942 (x4) .9 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 0R LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 200 Continued From page 16 200 Patient #10 was a 27 day old infant, who was brought to the ED on three different occasions with complaints of vomiting, constipation and jaundice. Review of Patient #10's medical record showed the following: *Patient was in the emergency department on three occasions from 01/29/18 to 02/08/18 with complaints Of vomiting, constipation, jaundice (yellowing Of the yes caused by elevated liver enzymes, which is an indication of malabsorption of nutrients). *On 01/29/18 at 17 days Old, patient was brought to the ED by his/her mother with complaints of throwing up after feeding. The ED provider documented a normal physical exam. There was no evidence the ED physician ordered labs, diagnostic imaging, or provided medications prior to patient discharge. The patient's weight was documented in the nurse?s notes as 3.81 kg. *On 02/05/28 at 24 days old patient, was brought to the ED by his/her mother with reports of continued vomiting, yellow tinted eyes, ?jaundice tint to the skin," and blood in the urine. The ED provider documented "no mass, liver margin palpable". The ED provider did not address reports of blood in patient's urine. The patient's weight was documented in the nurse's notes as 3.45 kg. There was no evidence the ED physician ordered labs, diagnostic imaging, or provided medications prior to discharging patient home. *On 02/08/18 at 27 days Old patient, was brought to the by his/her mother with reports of continued vomiting and no bowel movement for ?ve days. The ED provider documented "normal physical exam". A glycerin suppository was administered. FORM Previous Versrons Obsolete Event ID: SZP111 Facalrty lD HP2249 If continuation sheet Page 17 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER: 371340 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 10/09/2018 NAME OF PROVIDER OR SUPPLIER MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY STREET ADDRESS. CITY, STATE, ZIP CODE 520 MEDICAL DRIVE GUYMON, OK 73942 (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 TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 200 330 Continued From page 17 The provider documented the patient?s weight at 3.45 kg, there was no documentation of weight in the nurse's notes. There was no evidence the ED physician ordered labs or diagnostic imaging and completed prior to patient being discharge home On 10/10/18 at 1:30 pm, Staff stated, ?we decided the contracted ED physician company should address these practices dealing with quality, we pulled records, we looked at census, we addressed concerns daily with them, there isn't documentation of those calls." Staff stated, in regards to Patient #10 "the lack of care from the doctors was identified?. Staff stated the provider "had to go through training on pyloric stenosis" (the facility was unable to provide documentation of training). On 10/10/18 at 11:59 am, Staff (Chief of Staff and Medical Director of the ED) stated, the hospital had issues in the ED regarding the quality of care provided to patients by ED physicians. Staff stated, he was aware the ED physicians had problems dealing with pediatric patients. Staff stated, another provider had noti?ed him of Patient #10 and he had agreed the standard of care in the ED had not been met. PERIODIC EVALUATION QA REVIEW 485.641 Periodic Evaluation and Quality Assurance Review 200 330 a FORM Prewous VerSIons Obsolete Event SZP111 aCIIlty ID HP2249 lf continuation sheet Page 18 of 42 I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 This CONDITION is not met as evidenced by: Based on record review and interview, the hospital failed to ensure that a functioning Quality Assessment and Performance Improvement (QAPI) program: i. was on-going and included executive and leadership roles and responsibilities for evaluating the quality of care prOVIded in the ED, identifying safety expectations using measurable indicators which identi?ed and reduced patient safety issues, medical errors and adverse outcomes through analyzing causes, implementing preventive actions plans, measuring outcomes for effectiveness and communioatmg lessons learned as evidenced by the lack of discussion in four of four "Super CommIttee" meetings from 09/06/17 to 06/27/18, three of three Medical Staff Committee meetings from 06/13/17 to 01/16/18, four of four Medical Executive Committee meetings from 04/04/17 to 01/23/18, three of three Board of Trustees (Governing Body) meetings from 01/24/18 to 08/08/18 and 16 Of 16 SpeCIal Board of Trustee Committee meetings from 02/15/17 to 08/08/18 for: (Refer to Tag (0?0336) a. one (Patient #23) occurrence reviewed 1/15/18 to 09/15/18 that showed the ED's failure to provide a physical evaluation, diagnostic imaging, laboratory studies, and nursing assessment to a possible stroke patient who arrived via EMS prior to sending the patient to another hospital in Texas due to having no availability of Activase. STATEMENT OF DEFICIENCIEs (x1) PROVI (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION NUMBER COMPLETED A. BUILDING 371340 B. 10/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMO N, OK 73942 (x4) ID 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 TO THE APPROPRIATE DATE DEFICIENCY) 330 Continued From page 18 330 FORM Prewous VerSIons Obsolete Event SZP111 ID HP2249 If continuation sheet Page 19 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY b. one (Patient occurrence reviewed 1/15/18 to 09/15/18 that showed the ED's failure to obtain a mental health evaluation and contacting DHS (Department of Human Services) prior to discharging a pediatric patient with suicide attempt and suicidal ideations for transfer to a facility through a private vehicle. c. one (Patient of two occurrences reviewed 1/15/18 to 09/15/18 that showed the ED's failure to follow hospital policy and standards of practice to include recommended observation, assessment prior to discharge, and the availability/administration of anti-venom. d. two (Patient #8 and 10) of two occurrences reviewed 1/15/18 to 09/15/18 that showed the ED's failure to evaluate, manage, and treat pediatric patients according to current standards of practice. II. was implemented and formulated risk reduction strategies to reduce patient safety, medical errors and adverse events identi?ed from occurrences and grievances were addressed through the QAPI program. (Refer to Tag C-0342) was implemented so that data was collected to demonstrate the effectiveness of corrective action(s) from risk reduction strategies for medical errors, patient safety, and adverse events. (Refer to Tag C-0343) These failed practices: a. had the likelihood for increased risk for worsening health conditions, delays in care, injury AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 371340 13- WING 10/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 52o MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (M) in 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) 330 Continued From page 19 330 FORM PreVIous VerSIons Obsolete Event ID: SZP111 aCIlIty ID If continuation sheet Page 20 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE VIEDICAID SERVICES PRINTED: 01l16l2019 FORM APPROVED OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER 37 1 340 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. (x3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY STREET ADDRESS, CITY, STATE, ZIP CODE 520 MEDICAL DRNE GUYMON, OK 73942 1010912018 (x4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE PREFIX TAG DEFICIENCY) (X5) COMPLETION DATE 330 336 Continued From page 20 to self or others, and adverse health outcomes related to the lack of Quality and Risk Management staff?s failure to investigate, and analyze occurrence reports, identify preventative action plans, and report ?ndings to a designated Quality Improvement Committee, the Medical Staff and Medical Executive Committees, and the Board of Trustees. b. resulted in de?cient occurrence reporting by the Quality/Risk Manager to the "Super Committee" and no evidence Of reporting to the Medical Staff and Medical Executive Committees and the Board of Trustees. Therefore, executive committees lacked suf?cient information to make informed decisions related to the provisions of quality and safe patient care. QUALITY ASSURANCE The CAH has an effective quality assurance program to evaluate the quality and appropriateness Of the diagnosis and treatment furnished in the CAH and of the treatment outcomes. The program requires that This STANDARD is not met as evidenced by: Based on record review and interview, the hospital failed to ensure a functioning Quality improvement Program was implemented that included executive and leadership roles and responsibilities for evaluating the quality Of care provided by the hospital, identifying safety expectations using measurable indicators which identi?ed and reduced patient safety issues, medical error and adverse outcomes through 330 336 FORM PreVIous VerSIons Obsolete Event ID: SZP111 ID HP2249 If continuation sheet Page 21 of 42 a DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 analyzing causes, implementing preventive actions plans, measuring outcomes for effectiveness and communicating lessons learned as evidenced by the lack of discussion in four of four "Super Committee" meetings from 09/06/17 to 06/27/18, three of three Medical Staff Committee meetings from 06/13/17 to 01/16/18, four of four Medical Executive Committee meetings from 04/04/17 to 01/23/18, three Of three Board of Trustees (Governing Body) meetings from 01/24/18 to 08/08/18 and 16 of 16 Special Board Of Trustee Committee meetings from 02/15/17 to 08/08/18 for: a. one (Patient #23) occurrence reviewed 1/15/18 to 09/15/18 that showed the ED's failure to provide a physical evaluation, diagnostic imaging, laboratory studies, and nursing assessment tO a possible stroke patient who arrived via EMS prior to sending the patient to another hOSpital in Texas due to having no availability of Activase. b. one (Patient occurrence reviewed 1/15/18 to 09/15/18 that showed the ED's failure to obtain a mental health evaluation and contacting DHS (Department of Human Services) prior to discharging a pediatric patient with suicide attempt and suicidal ideations for transfer tO a facility through private vehicle. c. one (Patient of two occurrences reviewed 1/15/18 to 09/15/18 that showed the ED's failure to follow hospital policy and standards of practice to include recommended observation, assessment prior to discharge, and the availability/administration of anti?venom. d. two (Patient #8 and 10) of two occurrences STATEMENT OF DEFICIENCIEs (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER. COMPLETED A. BUILDING 37134? 10/09/2013 NAME OF PROVIDER OR SUPPLIER STREET CITY, STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 0(4) 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 LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 336 Continued From page 21 336 FORM PreVIous VerSIons Obsolete Event lD: SZP111 HP2249 If continuation sheet Page 22 of 42 I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE VIEDICAID SERVICES PRINTED: 0111612019 FORM APPROVED OMB NO. 0938-0391 reviewed 1115118 to 09115118 that showed the ED's failure to evaluate, manage and treat pediatric patients according to current standards of practice. These failed practices: I. resulted in the delayed care for two patients (Patient #6 and 23) worsening health conditions for two patient (Patient #6 and 10), the likelihood for increased risk of injury to self for one patient (Patient and adverse health outcomes for six patients (Patient 6, 7, 8, 10, and 23) related to the lack of Quality and Risk Management staff's failure to investigate, analyze occurrence reports, identify risk reduction strategies, implement corrective actIon plans, and report ?ndings to a designated Quality Improvement Committee, the Medical Staff and Medical Executive Committees and the Board of Trustees. ll. resulted in de?cient occurrence reportIng by the Quality/Risk Manager to the "Super Committee" and no evidence of reporting to the Medical Staff, and Medical Executive Committees and the Board Of Trustees. Therefore, executive committees lacked suf?cient information to make informed decisions related to the provisions of quality and safe patient care. Review of hospital policy titled "Quality Manual Plan), revised 04101118) showed the following: ?Goveming Body, Medical Staff, Hospital STATEMENT OF DEF ICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING (3 371340 3- 1010912013 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (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) 336 Continued From page 22 336 FORM Prevrous VerSIons Obsolete Event ID: SZP111 Faculty ID HP2249 If continuation sheet Page 23 of 42 LL DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE VIEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 Administrator/CEO (Chief Executive Of?cer, Nursing Executive/ONO (Chief Nursing Of?cer), Quality Representative and Departmental Directors were "responsible and accountable" for the Quality Management Program -Responsibilities included "development and implementation of an on-going program priorities for improved quality of care/treatment/services effectiveness of the program the use of risk~based thinking and process improvement approach." ?Goels included but were not limited to. improvement of "existing process and functions through a systematic quality patient care through objective care evaluation and other performance assessment activities." -Design of the program included root cause analysis for "near misses" and facilitate a "systematic examination" for opportunities for improvement should be made on a "minimum of a quarterly basis" to the committee" should include "signi?cant deviations from established standards of practice". -PACE (Plan, Act, Check and Enhance) should be used to ensure corrective and preventative actions were achieved (Refer to "Corrective and Preventative Action Policy?). On 10/10/18 at 1:22 pm, surveyors requested policy regarding performance improvement initiatives and variance/occurrence reporting, Staff stated the hospital did not have any policies in relation to these subjects. -"An unplanned event that did not result in injury, STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 371340 3- 10109I201 8 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY . GUYMON, OK 73942 (M) .D 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 TAG CROSSREPERENCED TO THE APPROPRIATE DATE 336 Continued From page 23 336 FORM PreVIous VerSIons Obsolete Event lD: SZP111 ID HP2249 if continuation sheet Page 24 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE VIEDICAID SERVICES PRINTED: 01/16/2019 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION 371340 FORM APPROVED OMB NO. 0938?0391 (X2) MULTIPLE CONSTRUCTION 0(3) DATE SURVEY A. BUILDING COMPLETED B. WING 10/09/2018 NAME OF PROVIDER OR SUPPLIER MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY STREET ADDRESS. CITY, STATE. ZIP CODE 520 MEDICAL DRIVE GUYMON, OK 73942 illness or damage but had the potential to do so? should be considered a "near miss event?. ?The organization must collect data, perform root cause analysis (RCA), preserve data (collect), formulate risk reduction strategies and collect data to demonstrate the effectiveness of the corrective l. Stroke A review of hospital policy titled "Emergency Medical Screening Examination and Stabilizing Treatment, dated 03/18/18" showed, the hospital campus included physical areas and structures adjacent to the hospital within 250 yards of the included availability of eqUIpment, supplies, and routine ancillary (support services such as laboratory. radiology and pharmacy) services patient should be assessed upon arrival for prioritization and determine whether EMS was able to monitor patient?s condition appropriately if an immediate MSE was not able to be performed. A review of hospital document titled "Activase log 09/01/17 through 09/28/18" showed four (Patient 2, 25, and 26) patients had received Activase on the following dates: 09/07/17, 10/08/17, 05/15/18 and 05/25/18. The hospital was not able to provide evidence of an order and receipt between the time period of 05/25/18 to 10/11/18 for the purchase of Activase to show the availability of the medication when Patient #23 arrived on 06/03/18. A review of an untitled hospital document showed the last purchase date for a package of two 100mg vials of Activase was on 09/07/17. (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PLAN OF CORRECTION (x5) (EACH MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG To THE APPROPRIATE DATE DEFICIENCY) 336 Continued From page 24 336 FORM Prewous VerSIons Obsolete Event ID. SZP111 ID HP2249 lf continuation sheet Page 25 of 42 PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES On 09/28/18 at 10:50 am, during a tour of the pharmacy surveyors observed a box containing two 100mg vials ofActivase in the pharmacy. Staff was not able to identify when the Activase was purchased or determine how long the box of Activase had been available at the hospital. Review of hospital occurrence titled Log incident with EMS, dated 06/03/18? was entered on 06/03/18 at 5:08 pm by StaffT (ED RN) and showed the following: called into ED for positive stroke scale to prepare for head (ED physician) instructed nursing staff to notify EMS the hospital did not have Activase. EMS was noti?ed at the same time they arrived in the ED ambulance bay. -Occurrence was reviewed by Staff (Manager Of Quality/Risk Management) on 06/04/18, 06/25/18, and 06/27/18 each time it was noted "Occurrence Report was viewed", there was no evidence the event was berng investigated, causes analyzed, or preventative actions implemented. ?Staff (peer review) reviewed the occurrence on 06/04/18, 06/07/18 at 10:25 am and 1:24 pm, 06/21/18, and 06/28/18, each time it was noted "Occurrence Report was vrewed", there was no evidence the event was being investigated, causes analyzed, or preventative actions implemented. ?Staff noted on 06/28/18, Staff 8 (ED physician on duty on 06/03/18) reported he/she had been made aware of the event and was concerned. it was noted the patient was "in fact in the ED ambulance bay before EMS was alerted there STATEMENT OF DEFICIENCIES (x1) PROV: (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 371340 3- WING 10109/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY 52? MEDICAL DRIVE GUYMON, OK 73942 (x4) ID 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 IDENTIFYING INFORMATION) TAG CROSSREFERENCED To THE APPROPRIATE DATE DEFICIENCY) 336 Continued From page 25 336 FORM Prevrous Versrons Obsolete Event ID SZP111 FaCIlIty ID HP2249 If continuation sheet Page 26 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE VIEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 was no Activase in the hospital" to Staff and Staff and asked for this to be addressed at the next Medical Executive committee in July". On 09/27/18 at 8:45 am, surveyors requested all Medical Staff and Medical Executive Committee meeting minutes for the past 12 months. There was no evidence provided to surveyors of any Medical Executive Committee meetings after 01/23/18. -on 07/18/18 at 1:41 pm, Staff entered in the occurrence ?i called and spoke with Staff (pharmacy) and we do currently have Activase". At 1:42 pm, Staff noted "Closing Remarks: hospital does have Activase in the building for patient needing Activase". The occurrence was then closed. -There was no evidence an RCA was initiated to determine why there was no Activase available at the hospital at the time of the patient's arrival, where the two vials of Activase came from the surveyors observed on 09/28/18 or why the patient did not receive initial triage, physician evaluation and prioritization. -There was no evidence Quality/Risk Management investigated, analyzed the causes through use of the RCA process, identi?ed process issues that could impact patient safety, assisted in implementation of risk reduction strategies, measured and collected data to determine effectiveness of corrective actions to reduce the risk of re-occurrence and communicated lessons learned to a designated Quality Committee, Medical Staff and Medical Executive Committee and the Board of Trustees. STATEMENT OF DEFICIENCIEs (x1) (x2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER COMPLETED A. BUILDING 371340 B. WING 10/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES Io 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) 336 Continued From page 28 336 FORM PreVIous VerSIons Obsolete Event ID SZP111 ID HP2249 lf continuation sheet Page 27 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 0111612019 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION A. BUILDING 371340 B. WING (x3) DATE SURVEY COMPLETED 1 0109l2018 NAME OF PROVIDER OR SUPPLIER MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY STREET ADDRESS. CITY, STATE, ZIP CODE 520 MEDICAL DRIVE GUYMON, OK 73942 4 ll. Suicide A review of hospital policy titled "Emergency Medical Screening Examination and Stabilizing Treatment, dated 03/18/18" showed emergency was determined when a patient was a danger to him/herself or others who presented to the ED for a condition addressed through a pre-arranged community plan such as an MSE would be performed and treatment initIated prior to transfer of the patient pursuant to the community plan. A review of hospital policy titled "Patient Awaiting Evaluation, dated 12128116" showed the patient should evaluated and the need for evaluation determined. Review of a hospital document titled "TelemedIcine Mental Health Access Agreement. dated 01114/14" showed a mental health facility would provide licensed mental health professionals to perform telemedicine mental health consultations for patients presenting to the hospital. Review of hospital occurrence report titled Log Incident: intention overdose was discharged wlo evaluation or consult" was entered on 09/04/18 by Staff (ED RN) and showed the following: -Staff (Peer Review) reviewed the occurrence on 09/06/18 and noted "minor (Patient discharged from ED with suicidal ideation and intentional overdose evaluation performed not contacted year old and (x4) "3 SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (x5) PREHX (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) 336 Continued From page 27 336 FORM Prevrous Versrons Obsolete Event ID: SZP111 ID HP2249 If contmuation sheet Page 28 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: VIEDICAID SERVICES PRINTED: FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING 371340 B. WING 1010912018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (x5) pREle (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY 0R LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 336 Continued From page 28 336 suicide attempt, positive drug use not living with parents states will take to hospital for consult but no transfer or contact for transfer made. Please comment on reason. transfer not made Of?cial from ED prior to discharge." -On 09114l18 Staff (ED RN) noted was not aware Tylenol was left in the room do not know the policies and procedures for a minor with an OD (overdose) could please orient me to those policies Review of an untitled hospital document dated 09106118 from Staff showed the occurrence was forwarded to the contracted ED medical group for physician review. Staff noted a 14 year Old patient was "seen in the ED with intentional overdose of Tylenol with suicidal ideation and methamphetamine abuse physician did not order a evaluation was not notI?ed of minor suicide attempt and positive drug use feel like the transfer should have been made by the ED physician, in the ED, prior to discharge of the patient." Review of hospital document titled Study Detail, dated 09/27/18" showed the event was sent to the ED contracted medical group for review. There was no evidence the hospital's peer review Committee reviewed and discussed the event to determine process issues or quality of care issues within the ED. On 10/10/18 at 1:22 pm, Staff stated quality reviewed the occurrence and determined education was needed. Staff stated education was provided to nursing staff regarding hospital FORM Previous VerSIons Obsolete Event ID: SZP111 ID HP2249 if contInuatIon Sheet Page 29 of 42 1..- a. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY policy for suicide patients. Staff stated there was not an investigative analysis tO determine any process issues and implementation of preventative actions to reduce the risk of re-occurrence for this type of occurrence. Ill. Pediatrics A review of hospital policy, "Scope of Service/Plan of Care: Emergency Department", revision date 01/13/17 showed the patient population served by the ED consisted of newborn, pediatric. adolescent, adult and geriatric patients requiring or seeking medical care. Support services inciuded but were not limited to clinical laboratory studies and x-rays that were to be provided to the patient in a timely manner. Review of hospital document titled "Occurrence Report Summary, dated 03/2211 8? showed Staff (Pediatrician) sent Patient #7 to the ED for further follow up treatment and ?was concerned with ED physician treatment". Staff Wsent Patient #7 to ED due to lethargy, fever and stomach pain present for several days. Staff requested work up by ED physician for possible appendicitis. CT scan and labs were ordered and completed. medication administered and patient was discharged. Staff called ED to Check on patient and was told patient was discharged. StaffW contacted parents and was told patient was taken to another acute care hospital for further treatment. Review of hospital document titled Study Detaii, dated 06120118" showed Patient #7?s medical chart was referred to ED contracted service for quality review by medical staff. Peer AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 371340 9- WNG 10109I2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE. ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (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 COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 336 Continued From page 29 336 FORM PreVIous Versrons Obsolete Event lD'. 11 ID HP2249 lf continuation sheet Page 30 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES PRINTED: 0111612019 FORM APPROVED OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES (X1) PROVI DERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY review ?ndings showed "advise period of observation instead of discharge from the There was no evidence from review of the incident ?le the patient?s medical record was reviewed by the ED contracted service. There was no evidence the hospital's peer review committee reviewed and discussed the event to determine process issues or quality of care issues within the ED. Review of Patient incident ?le showed no evidence the event was being investigated, causes analyzed, or preventative actions implemented by the hospital's program. Review of hospital document titled "Occurrence Report Summary, dated 09/09/18" showed one year Old infant (Patient 8) received from ED "in acute respiratory failure, grunting, oxygen saturations trouble breathing, received orders to transfer infant out, before leaving infant intubated." Review of hospital document titled Study Detail, dated 09l27/18? (identi?ed by Staff as the medical staff peer review report) showed no evidence of a review of Patient #8?s medical care and treatment in the ED. Comments noted "unstable infant not transferred from the There was no evidence the hospital's peer review committee reviewed and discussed the event to determine process issues or quality of care issues within the ED. Review of hospital document titled "Grievance Process Check List" showed Patient #8's medical record was sent out to the contracted ED service for review on 09/17/18. Review of Incident ?le by surveyors showed no evidence of case review by AND PLAN OF CORRECTION IDENTIFICATION NUMBER BUILDING COMPLETED 371340 B. WNG 1 0109I2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY 52? MEDICAL DRIVE GUYMON, OK 73942 (x4) .9 SUMMARY STATEMENT OF ID PLAN OF CORRECTION (x5) PREHX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR INFORMATION) TAG TO THE APPROPRIATE DATE DEFICIENCY) 336 Continued From page 30 336 FORM Prewous VerSIons Obsolete Event FaCIlIty lD HP2249 If contmuation sheet Page 31 of 42 PRINTED: 01/16/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE VIEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER BUILDING COMPLETED 371340 B. WING 10/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4, ID SUMMARY STATEMENT OF ID PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DAT DEFICIENCY) 336 Continued From page 31 336 the contracted ED medical provider. There was no evidence the event was being investigated, causes analyzed, or preventative actions implemented by the hospital's quality assurance and improvement program. A document, "Case Review Form? 05/09/18. Showed the form was to be utilized as part of the peer-review process established by the hospital's medical staff bylaws. The conclusion of the review Of Patient #10's medical care in the ED showed ?there were several ?ndings in the history and physical examination that should have prompted a more thorough evaluation in the emergency department. Treatment did not meet standard of care." The document also showed on 02/08/18, the patient was transferred from a primary care provider's clinic to another facility and underwent surgery for pyloric stenosis. Review of hospital document titled "Grievance Process Check List" showed Patient #10's medical record was to be reviewed at medical Staff peer review on 05/23/18. There was no evidence the hospital's peer review committee reviewed and discussed the event to determine process issues or quality Of care issues within the ED. There was no evidence the event was being investigated, causes analyzed, or preventative actions implemented by the hospital's QAPI program. On 10/10/18 at 1:22 pm, Staff stated tie/she did submit Patient #7's medical record to the contracted medicai service for review but does not know why he/she did not have a response from them. Staff stated "we left this in the contracted medical service's hands". Staff stated ?there should have been a peer review FORM Prewous VeTSIons Obsolete Event ID: SZP111 Fatality ID HP2249 If continuation sheet Page 32 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES 01/16l2019 FORM APPROVED OMB NO. 0938-0391 completed on Patient#10, I know it went to clinical care and the contracted medical service for review." IV. Snake Bite Review of hospital document titled "Grievance Process Check List" showed a complaint was initiated by the quality/peer review personnel due to a concern regardIng the care Patient #6 received in the ED. Findings showed the standard of care was not met for the care provided to Patient 6 for the treatment Of the rattlesnake bite. There was no evidence the event was investigated, causes analyzed, or preventative actions implemented by the hospital's QAPI program. Review of hospital document titled "Continuous Quality Improvement - Patient Complaints and Grievances, dated 04/12/18? showed the outcome Of the quality review regarding Patient #6 was an "extremely unexpected" practice that "could have (or did) contribute to patient injury". Medical record was forwarded for medIcal record by ESS (ED medical staf?ng group) for peer review. Review of untitled document (identi?ed as review of Patient #6'3 medIcal record by Staff of the contracted ED service) dated 04/24/18, showed "2 hour observation in the ED for a minimal snakebite with normal vital signs, labs and minimal edema that was not worsening, meets the standard for reasonable care." 0n 10l10/18 at 1:22 pm, Staff stated the ED contracted medical service was responsible for STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 371340 13- WING 10l091201 8 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) "3 SUMMARY STATEMENT OF DEFICIENCIES in 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) 336 Continued From page 32 336 FORM PreVIous VerSIons Obsolete Event ID: SZP111 ID HP2249 If continuation sheet Page 33 of 42 PRINTED: 011132019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE 8: VIEDICAID 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 371340 3- WING 10l091201 8 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) ID SUMMARY STATEMENT OF DEFICIENCIEs ID PLAN OF CORRECTION (x5) pREth (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) 336 Continued From page 33 336 I peer review of the ED medical staff. Staff I stated helshe or Staff would send the patient's 1 medical record to the ED contracted service and once completed they would send back a response. Staff stated the response would get ?led and any education or follow-up needed for the ED physicians would be provided by the ED I contracted providers. Staff stated the hospital I was responsible for addressing issues with their 1 staff. Staff stated the hospital did not have a quality committee, it has been combined into the ?Super Committee". Staff stated the ?Super Committee" had every hospital department represented and it would be inappropriate to analyze individual patient incidents with them present. Staff stated there was not a designated committee to discuss individual events in order to analyze causes, identIfy process issues and determine preventive actions to reduce the risk Of Ire-occurrence. Staff stated the quality improvement program had not implemented any type of investigative analysis or performance improvement efforts for the events discussed. On 10/10/18 at 11:59 am, Staff stated he/she "would have expected the quality and risk manager to have brought these items (events) to my attention, each time the hospital had changed owners then positions had changed I don't know who the quality/risk manager is." Staff stated issues involving the ED medical staff would be sent to the ED contracted medical service for review and then a representative would come to medlcal staff peer review to discuss their ?ndings. Staff stated helshe was not aware of any medical records being reviewed by medical staff peer review. FORM Previous Verstons Obsolete Event ID: SZP111 ID HP2249 If continuation sheet Page 34 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE VIEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER. 371 340 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. (x3) DATE SURVEY COMPLETED 10109I201 8 NAME OF PROVIDER OR SUPPLIER MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY STREET ADDRESS, CITY, STATE, ZIP CODE 520 MEDICAL DRIVE GUYMON, OK 73942 (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 336 (3342 Continued From page 34 On 10/11/18 at 10:30 am, Staff A (COO) stated he/she did not see a conclusion or action on the peer review forms. Staff A stated "It is obvious we are not closing the loop". Staff A stated helshe expected the peer review committee to be reviewing the medical cases to determine if the standard of care was met and if not what actions need to be taken on all cases including those involving the ED and ED physicians. Staff A stated he/she expected the quality program to be reviewing. investigating patient events (occurrences), and analyzing them to determine if hospital processes and procedures were being done. QUALITY ASSURANCE [The program requires that-] the CAH also takes appropriate remedial action to address de?ciencies found through the quality assurance program. This STANDARD is not met as evidenced by: Based on record review and interview, the hospital failed to ensure that a functioning QAPI program was implemented and risk reduction strategies formulated to address patient safety issues, medical errors and adverse events identi?ed from occurrences and grievances addressed through the QAPI program. These failed practices resulted in the delayed care for two patients (Patient #6 and 23). worsening health conditions for two patients (Patient #6 and 10), the likelihood for increased 336 C342 FORM PreVious Obsolete Event ID FaCIIity ID HP2249 if continuation sheet Page 35 of 42 A DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE VIEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 risk of injury to self for one patient (Patient and adverse health outcomes for six patients (Patient 6, 7, 8, 10, and 23), related to the lack of Quality and Risk Management staff's failure to investigate, analyze occurrence reports, identify risk reduction strategies, implement corrective action plans and report ?ndings to a designated Quality improvement Committee, Medical Staff and Medical Executive Committees and the Board of Trustees. Findings: Review Of hospital policy titled "Quality Manual Plan), revised 04/01/18) showed the following: -"The organization must collect data, perform root cause analysis (RCA), preserve data (collect), formulate risk reduction strategies and collect data to demonstrate the effectiveness of the corrective faulty process or system invariable permits or compounds the harm, and is the focus of improvement." Review of hospital document titled "Hospital Super Committee" meeting minutes from 09/06/17 to 06/27/18 showed no evidence of incident reporting for 09/06/17 and reporting of incidents, grievance, or cases sent to peer review for 03/29/18. On 06/27/18 meeting minutes showed the following: incidents (March 18, April 47, May 27), grievances (March 4, April 3, May 3), and cases sent to peer review (March 4, April 7, May 2). There was no evidence cases were STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 371340 B- WNG 10/09/201 8 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) ID 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 IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 342 Continued From page 35 342 FORM PreVIous VerSIons Obsolete Event ID SZP111 ID HP2249 If continuation sheet Page 36 of 42 PRINTED: (11/16/2019 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 COMPLETED 371340 B. WING 10/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) ID 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) 342 Continued From page 36 342 discussed to include the formulation of risk reduction strategies to address patient safety issues, medical errors and/or adverse events identi?ed from occurrences, grievances and cases sent to peer review. Review of hospital document titled "Medical Executive Committee" meetings minutes from 04/04/17 to 01/23/18 showed no evidence the quality program reported incidents or grievance data to the medicat executive committee. The meeting minutes failed to show evidence patient safety issues, medical errors and adverse events identi?ed from incidents, grievances and cases sent to peer review were discussed to include risk reduction strategies formulated by the medical executive committee. Review of hospital documents titled "Medical Staff Committee" meeting minutes from 06/13/17 to 01/16/18 showed no evidence the quality program reported incidents or grievance data to the medical staff committee. The meeting minutes failed to show evidence patient safety issues, medical errors and adverse events identi?ed from incidents, grievances and cases sent to peer review were discussed to include risk reduction strategles formulated by the medical staff committee. Review of hospital documents titled "Board of Trustees (Governing Body)" meeting minutes from 01/24/18 to 08/08/18 showed no evidence the quality program reported incidents or grievance data to the Governing Body. The meeting mmutes failed to Show evidence patient FORM PreVIous VeTSIons Obsolete Event ID SZP111 ID HP2249 If continuation sheet Page 37 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 01/16/2019 FORM APPROVED CENTERS FOR MEDICARE VIEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER. A BUILDING COMPLETED 371340 B. WING 10/0912018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) ID SUMMARY STATEMENT OF DEFICIENCIEs ID PROVIDERS 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) 342 Continued From page 37 342 safety issues, medical errors and adverse events identi?ed from incidents, grievances and cases sent to peer review were discussed to include risk reduction strategies and reported to the Governing Body. Review of hospital documents titled "Special Board of Trustee Committee" meeting minutes from 02/15/17 to 08/08/18 showed no evidence the quality program reported incidents or grievance data to the Governing Body. The meeting minutes failed to show evidence patIent safety issues, medical errors and adverse events identi?ed from incidents, grievances and cases sent to peer review were discussed to inciude risk reduction strategies and reported to the Governing Body. On 10/10/18 at 1:22 pm, Staff stated, he/she was responsible for evaluating all patient care services from a quality standpoint. Staff stated, he/she was not responsible for taking quality data including incidents and grievances to medical staff and Governing Body. Staff stated, the quaiity improvement program had not implemented any type of investigative analysis or performance improvement efforts for the events discussed. On 10/10/18 at 2:30 pm, Staff stated, he/she was responsible for taking quality indicator data to medical staff committee and the Governing Body. Staff stated, medical staff and Governing Body did not discuss individual incidents and grievances. FORM Prewous Obsolete Event ID: Faculty ID HP2249 If contInuation sheet Page 38 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE VIEDICAID SERVICES PRINTED: 01I1612019 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 371 340 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY A. BUILDING B. WING COMPLETED 1 010912018 NAME OF PROVIDER OR SUPPLIER MEMORIAL HOSPITAL OF TEXAS COUNTYAUTHORITY STREETADDRESS, CITY. STATE. ZIP CODE 520 MEDICAL DRIVE GUYMON, OK 73942 (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) 343 343 Continued From page 38 QUALITY ASSURANCE [The program requires that?] the CAH documents the outcome of ali remedial action. This STANDARD is not met as evidenced by: Based on record review and interviews, the hospital failed to ensure a functioning QAPI program was implemented so that data was collected to demonstrate the effectiveness of corrective action(s) from risk reduction strategies for medical errors, patient safety and adverse events. These failed practices resulted in the delayed care for two patients (Patient #6 and 23) worsening health conditions for two patients (Patient #6 and 10), the likelihood for increased risk of injury to self for one patient (Patient and adverse health outcomes for six patients (Patient 6, 7, 8, 10, and 23), related to the lack of Quality and Risk Management staff's failure to investigate, analyze occurrence reports, identify risk reduction strategies, implement corrective action plans and report ?ndings to a designated Quality Improvement Committee, Medical Staff and Medical Executive Committees and the Board of Trustees. Findings: Review of hospital policy titled "Quality Manual Plan), revised 04/01/18) showed the following: 343 343 FORM Prevaous VerSIons Obsolete Event SZP111 Facility ID HP2249 If continuation sheet Page 39 of 42 4. 44,. ?r DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE VIEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (x1) IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED - "The organization must collect data demonstrate the effectiveness of the corrective Review of hospital document titled ?Hospital Super Committee" meeting minutes from 09/06/17 to 06/27/18 showed no eVIdence the quality program was analyzing patient safety, medical errors and adverse patient events, determining preventative action plans, and collecting data to determine the effectiveness of the preventative action plans to ensure sustainability and decreased risk of re-occurrence. Review of hospital document titled "Medical Executive Committee" meetings minutes from 04/04/17 to 01/23/18 failed to show evidence the quality program presented to the medical executive committee patient safety, medical errors and adverse events identi?ed from incidents, grievances, and cases sent to peer review were analyzed, preventative action plans determined and data reported and trended to determine the effectiveness of the preventative action plans to ensure sustainability and decreased risk of re-occurrence. Review of hospitai documents titled "Medical Staff Committee" meeting minutes from 06/13/17 to 01/16/18 showed no evidence the quality program presented to the medical staff committee, patient safety, medical errors and adverse events identi?ed from incidents, grievances, and cases sent to peer review were analyzed, preventatIve action plans determined and data reported and A. 371340 8- WNG 1 0/09/201 8 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (x5) [31215le (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) 343 Continued From page 39 343 FORM PreVIous Obsolete Event ID: SZP111 ID HP2249 if continuatIon sheet Page 40 of 42 i A as DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE VIEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY trended to determine the effectiveness of the preventative action plans to ensure sustainability and decreased risk of re-occurrence. Review of hospital documents titled "Board of Trustees (Governing Body)" meeting minutes from 01/24/18 to 08/08/18 showed no evidence the quality program presented to the Governing Body, patient safety, medical errors and adverse events identi?ed from incidents, grievances, and cases sent to peer review were analyzed, preventative action plans determined and data reported and trended to determine the effectiveness of the preventative action pians to ensure sustainability and decreased risk of re-occurrence. Review of hospital documents titled "Special Board of Trustee Committee" meeting minutes from 02/15/17 to 08/08/18 showed no evidence the quality program presented to the Governing Body. patient safety. medical errors and adverse events identi?ed from incidents, grievances and cases sent to peer review were analyzed, preventative action plans determined and data reported and trended to determine the effectiveness of the preventative action plans to ensure sustainability and decreased risk of re-occurrence. On 10/10/18 at 1:22 pm, Staff stated, he/she was responsible for evaluating all patient care services from a quality standpoint. Staff stated he/she was not responsible for taking quality data including incidents and grievances to medical staff and Governing Body. Staff stated the AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 371340 10/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (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) 343 Continued From page 40 343 FORM Prevrous Versrons Obsolete Event ID: SZP111 Facility ID HP2249 If continuation sheet Page 41 of 42 PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE VIEDICAID SERVICES ELDL STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING - 37134? B- 10109I201s NAME OF PROVIDER OR SUPPLIER MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY STREET ADDRESS, CITY. STATE. ZIP CODE 520 MEDICAL DRIVE OK 73942 SUMMARY STATEMENT OF DEFICIENCIES (x4) ID 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) 343 Continued From page 41 343 quality improvement program had not implemented any type of investigative analysis or performance improvement efforts for the events discussed. On 10H 0/18 at 2:30 pm, Staff stated he/she was responSIble for taking quality indicator data to medical staff committee and the Governing Body. Staff stated medical staff and Governing Body did not discuss individual incidents and grievances. FORM PreVIous Ver5Ions Obsolete Event ID: SZP111 ID HP2249 If continuation sheet Page 42 of 42 Oktahoma State Department of Health a State SE Steam} February 13, 2019 Provider 371340 Event ID: SZP111 Complaint Douglas Swim, Administrator Memorial Hospital Of Texas County Authority 520 Medical Drive Guymon, OK 73942 Dear Mr. Swim: The Medical Facilities Division of the Oklahoma State Department of Health has received the "Provider's Plan of Correction" as required for the survey conducted on October 9, 2018. The Department finds this plan of correction to be an acceptable allegation of compliance. Please note: Condition Level Deficiencies require our department to conduct a follow-up survey in order to verify substantial compliance before a termination or recertification recommendation is made to CMS. if you have any questions, please feel free to call this office at 405-271?6576. Sincerely, (32.2 6mg, Terri Cook Administrative Programs Manager Facility Services Division Medical Facilities Service Oklahoma State Department of Health Board of Heat: Tom Hams Jew? as rmmyasmeg, MBA I ?nCcmEmunEmH-Eaam Rubens 3mm magmagr~rmma as 2 mm DES, MESA Mm: Kaishna, PRINTED: 01f16/2019 FORM APPROVED OMB NO. 09380391 DATE suavav COMPLETED 10/0912018 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES STATEMENT OF DEFICIENCIES (X1) AND PLAN OF CORRECTION EDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION A BUILDING . STREET ADDRESS, STATE, ZIP CODE 520 MEDICAL DRIVE GUYMON, OK 73942 371340 NAME OF PROVIDER OR SUPPLIER MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) .0 SUMMARY STATEMENT OF DEFICIENCIES to PREFIX TAG PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE TO THE APPROPRIATE DEFICIENCY) CONPLETION DATE 000 200 COMMENTS The Oklahoma State Department of Health conducted a Federal comptaint survey (0K00052658) at Memoriai Hospital of Texas County in Guyman, Oklahoma on 09127118, 09/28/18, 10/08/18 and 10109/1 8. The following Condition level deficiencies were cited: ?485.618 Condition of Participation: Emergency Services ?485.64?i Condition of Participation: Periodic Evaluation and Quality Assurance Review Standard Ieval deficiencies were aIso cited as a resuit of the survey. The foliowing abbreviations may be found within this document: CEO Chief Executive Of?cer CNO Chief Nursing Office:r COO Chief Operating Of?cer ED Emergency Department EMS Emergency Medical Service MSE Medical Screening Examination TPA Tissue Plasminogen Activator (clot?buster) EMERGENCY SERVICES 485618 The CAH provides emergency care necessary to meet the needs of its inpatients and outpatients. This is not met as evidenced by? Based on record review and interview. the hospital failed to provide appropriate emergency 000 200 See attached See attached 046) ME OR PROVIDERISU .- REPRESENTATIVES SIGNATURE TITLE a! - We IcIency a eme en as ens access a roiencyw ICI me I Ion may excuses mm on -cng prow-mgI Is -eermme a nlher safeguards pmvi. f?cieni protection to the patients . (See instructions.) Except for nursing homes. the ?ndings stated above are discloeable 90 days following the date of survey whether or not a ptan of correction is provided. For nursing homes? the above ?ndings and plans of correction are dI eiesabiede T, A -. . days {allowing the data these documents are made availebie to the facility. if deficiencies are cited, an approved plan of correction is requisite to sectioned. I program participation. Event ID FactiityiD: t-iP2249 Ifgg?ag?h??gge 1 orI42 FORM Previous Versions Obsolete DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES 01/1 612019 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY COMPLETED services and interventions to meet the emergency needs of patients according to current standards of practice as evidenced by: I. one (Patient #23) of three patients with possible stroke who arrived via EMS (Emergency Medical Services) and was sent to another hospital from the hospital's ambulance bay due to no availability of Activase (TPA [Tissue Plasminogen Activator, also known as the without physical evaluation, diagnostic imaging, laboratory studies, and nursing assessment. II. two (Patient #3 and 5) of seven suicidal patients who presented to the emergency department (ED) and did not receive a mental health evaluation through an available contracted telemedicine service to determine the safety of discharge to self or parent's custody for transfer to mental health facility for furthertreatment. one (Patient of two patients who presented with a rattlesnake bite was not assessed prior to discharge to determine stability and current injury status, recommended observation, and antI-venom medication admIniStration (due to unavailability) per hospital policy. IV. one (Patient#10) of two pediatric patients who presented to the ED on three different times with worsening complaints of fever. abdominal pain, and nausea/vomiting with no laboratory studies or diagnostic imaging ordered. These failed practices had the likelihood to. See attached A. BUILDING 371340 3- 10/09/2013 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 W) .0 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 0R LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 200 ContInued From page 1 200 FORM Prevuous VerSIons Obsolete Event ID: SZP111 Faculty ID HP2249 If continuation Sheet Page 2 of 42 JAN 218 Egg PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES STATEMENT OF DEFICIENCIES (X1) AND PLAN OF CORRECTION IDENTIFICATION (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY A BUILDING COMPLETED 371340 3? WING 10109I2018 NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 PROVIDER's PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TO THE APPROPRIATE DATE (x4) ?3 SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG DEFICIENCY) 200 Continued From page 2 cause injury, delay in care, and worsening of health condition due to lack of early intervention for one (Patient #23) of three patients who presented to the ED with possible stroke via EMS. ll. cause serious harm to two (Patient #3 and 5) . patients who presented to the ED with suicide attempts and were transferred through a private vehicle to a mental health facility for further treatment without mental health evaluation and increased risk to patient safety for all suicidal patients who seek treatment in the ED. Ill. result in worsening of the health condition for one (Patient patient who presented to the ED with a rattlesnake bite and was not provided assessment, observation, and treatment per hospital policy and standards of practice IV. result in worsening health condition and serious harm for one (Patient #10) pediatric patient who presented to the ED With repeated complaints of fever, abdominal pain, and nausea/vomiting WIth no evidence of laboratory or diagnostic studies ordered per standards of practice. Findings: I Stroke Patients A review of hospital policy titled "Emergency Medical Screening Examination and Stabilizing Treatment, dated 03/18/18" showed, the hospital campus included physical areas and structures adjacent to the hospital within 250 yards of the included availability of 200 See attached FORM reVIOus Versions Obsolete Event ID SZP11 1 FaCIiIty ID HP2249 if continuation sheet Page 3 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY equipment, supplies, and routine ancillary (support services such as laboratory, radiology, and pharmacy) services patient should be assessed upon arrival for prioritization and detenTiIne whether EMS was able to monitor patient's condition appropriately if an immediate medical screening examination (MSE) was not able to be performed. A review of hospital policy titled "Scope of Service/Plan of Care, dated 01/13/17" showed, patients who presented to the hospital's ED should receive an MSE that included all necessary labs, diagnostic testing, and services within the capabilities of the hospital in order to reach a diagnosis A review of hospital document titled "Activase log 09/01/17 through 09/28/18" showed four patients (Patient 2, 25, and 26) had received Activase on the following dates: 09/07/17, 10/08/17, 05/15/18, and 05/25/18. The hospital was not able to provide evidence of an order and receipt between the time period of 05/25/18 to 10/11/18 for the purchase Of Activase to show the availability of the medication when Patient #23 arrived on 06/03/18. A review of an untitled hospital document showed the last purchase date for a package of two 100mg vials of Activase was on 09/07/17. Review Of document titled "Fire Department EMS Incident Report, dated 06/0311 8" showed, EMS crew were dispatched at 2:23 pm, to Patient #23'5 See attached AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 371340 3- WING 1 0/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (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) 200 Continued From page 3 200 FORM PreVIous VerSIons Obsolete Event ID SZP111 ID HP2249 If continuation sheet Page 4 of 42 I . . DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED residence and arrived on scene seven minutes later at 2:30 pm. At 2:36 pm, EMS crew noti?ed the hospital of posmve stroke scale. EMS crew loaded the patient and departed the scene at 2:54 pm, arriving at hospital at 3:07 pm. EMS crew were noti?ed that hospital did not have Activase available. EMS crew noti?ed Staff that hospital had no Activase available and decision was made to transport patient via air ambulance to next closest acute stroke ready hospital in Texas . Review of hospital document titled Log Incident with EMS, dated 06/03/18" showed the following: called into ED for positive stroke scale to prepare for head 8 (ED physician) instructed nursing staff to notify EMS the hospital dId not have Activase. EMS was noti?ed at the same time they arrived in the ED ambulance bay. *lncident was entered on 06/03/18 at 5:08 pm, by Staff (ED RN). *Incident was reviewed multiple times by StaffF (Manager Of Quality/Risk Management) on 06/14/18, 06/25/18, 06/27/18 and no analysis, interventions, or outcomes were documented. *Staff (peer review) noted on 06/28/18, Staffs (ED physician on duty on 06/03/18) reported he/she had been made aware of the event and was concerned. it was noted the patient was "in fact in the ED ambulance bay before EMS was alerted there was no Activase in the hospital". On 09/28/18 at 10:50 am, during a tour of the See attached A. BUILDING 371340 B. WING 10/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (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 INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 200 Continued From page 4 200 FORM PreVIous VerSIons Obsolete Event ID: SZP111 FaCIlIty ID HP224Q if contInuatIon sheet Page 5 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 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 371340 3- WING 10/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 0R HOS I 0 XAS COUNTY HORITY 520 MEDICAL DRIVE MEM IAL TA TE AUT GUYMON, OK 73942 (x4) ?3 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS 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) 200 Continued From page 5 pharmacy surveyors observed a box containing two 100mg vials of Activase in the pharmacy. Staff was not able to identify when the Activase was purchased or determine how long the box of Activase had been available at the hospital. On 09/27/18 at 3:44 pm, Staff (EMS Director) stated, he/she was noti?ed by the EMS crew on arrival at the hospital there was no Activase available. Staff stated, the EMS crew were on scene approximately 23 minutes and the hospital had "ample time" to notify the EMS crew there was no Activase available. He/she stated, the patient remained in the ambulance and the physician dId not evaluate the patient. On 09/28/18 at 9:30 am, Staff I stated, his/her role included taking radio calls from EMS. Staffl stated, there had been a time when EMS arrived in the ambulance bay and EMS was told they needed to go someplace else because the hospital did not have something Staff reported, he/she was the one who noti?ed EMS the hospital did not have Activase on the day of the event. ll. Suicidal Patients A review of hospital policy titled "Emergency Medical Screening Examination and StabiIIZIng Treatment, dated 03/18/18" showed emergency would be when a patient was a danger to him/herself or others who presented to the ED for a condition addressed through a pre-arranged community plan such as an MSE would be performed and treatment initIated prior to transfer 200 See attached FORM OMS-256763239) Prewous Verssons Obsolete Event ID SZPT 11 FaCIlIty ID HP2249 If contIn uation sheet Page 6 of 42 4 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY of patient pursuant to community plan. A review Of hospital policy titled "Patient Awaiting Evaluation, dated 12/28/16" showed the patient should be evaluated and the need for evaluation determined. Review of a hospital document titled "Telemedicine Mental Health Access Agreement, dated 01l14/14? showed, a mental health facility would provide licensed mental health professionals to perform telemedicine mental health consultations for patients presenting to the hospital Review of document titled "Managing Suicidal Patients in the Emergency Department, dated 02/16" from the Annuals Of Emergency Medicine showed a risk assessment helped to determine appropriate treatment for suicide patients percentage of patients with suicidal ideation or behaviors may be managed in the ED without a mental health evaluation and discharged home who tend to be the lowest risk are those with no suicide plan or intent, no prior attempts, mental illness, substance abuse, and/or agitation orirritability. Review of document titled "Suicide Assessment Five-step Evaluation and Triage for Mental Health Professionals, dated 2009" from the Suicide Prevention Resource Center showed determination of suicide risk level included four factors: risk factors, protective factors, suicide inquiry and interventions. High risk for suicide See attached AND PLAN OF CORRECTION NUMBER A. BUILDING COMPLETED 371340 8- WING 1 01091201 8 NAME OF PROVIDER OR SUPPLIER STREET CITY, STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) ID SUMMARY STATEMENT OF Io PLAN OF CORRECTION (x5) pREij (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVEACTION SHOULD BE COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE DEFICIENCY) 200 Continued From page 6 200 FORM PreVious Ver5ions Obsolete Event ID SZP111 ID HP2249 If continuation sheet Page 7 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER. (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY COMPLETED included an acute precipitating event, potentially lethal suicide attempt or persistent ideation with intent or rehearsal. These patients should be admitted unless there was a signi?cant change in SUiCide risk. Patients determined to be a moderate suicide risk usually have multiple risk factors, and present with suicidal ideation and plan, but generally no intent or behavior. Depending on the identi?ed risk factors, patients with moderate suicide risk may need to be admitted. Review of document titled "Caring for Adult Patients with Suicide Risk: A Consensus Guide for Emergency Departments" by the Suicide Prevention Resource Center showed after initial suicidal risk screening a more thorough secondary screening that provides disposition decisions for patients with suicidal ideations should be performed. The screen includes SIX questions that include thoughts of suicide, suicide intent, past suicide attempts, past mental health issues or issues that affect ability to do things in life, substance abuse Issues, and behavioral issues A mental health professional should be consulted in the ED if a patient answers "yes" to any of the questions for further evaluation, including a comprehensive suicide risk assessment. Patient #3 was a 17 year old female. who presented to the ED at 1:21 am, via EMS following ingestion of Fluoxetine (Prozac) and Tylenol approximately three hours prior to arrival. Review of Patient #3's medical record showed: *Suicide assessment identi?ed suicide ideation, See attached A, 371340 WING 1 01091201 8 NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS, CITY. STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) ID 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 INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 200 Continued From page 7 200 FORM Prevnous Obsolete Event ID: SZP111 FaCIlity ID HP2249 If continuation sheet Page 8 of 42 F3 "s 'jngr JriIl? I) LUIJI PRINTED: 01/16/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES 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 COMPLETED 371340 . B. WING 1010912018 NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (M) (D SUMMARY STATEMENT OF DEFICIENCIES (D PROVIDERS PLAN OF CORRECTION (st 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) 200 Continued From page 8 200 suicide attempt, feelings of hopelessness and despair and a depressed mood *Initial physician assessment performed at 1:45 am, noted overdose was patient?s second attempt. Patient was lethargic but arousable. Physician?s plan was to repeat Acetaminophen level at nine hours post ingestion and at 6:00 am. *lnitial labs at 1:30 am, showed critical Acetaminophen level at 32 ug/mL (normal 13?30 ug/mL), ALT (Alanine Aminotransferase [blood test to evaluate liver functIonD 57 (normal 8-34 Acetaminophen level at 5:33 am, was 11 ug/mL. *MedIcal Necessity for Air/Ground Transport was completed by physician stating a need for a higher level of care requiring a physician specialist that was not available at the hospnai *Transfer Request/Consent was completed and signed by physician, and noted bene?ts of transfer to include speCIalist availability to meet the needs of the patient and identifying the patient stable to transfer *At approximately 6:00 am, there was a change of Shift in ED physicians *There was no re-assessment by the oncoming ED physician and no mental health consultation or evaluation obtained Via telemedicine. *At 6:36 am, ED physician discharged patient to home in care of foster parent with instructions "strongly recommend contact place where you had counseling earlier this year and talk with See attached FORM PreVIous VerSIonS Obsolete Event ID SZP111 Faculty lD if contInuatIon sheet Page 9 of 42 JAN 2 8 DEPARTMENT OF HEALTH AND HUMAN SERVICES . CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY them about how you are feeling, what is happening in your life." ED physician's final diagnose was anxiety disorder. Patient #5 was a 14 year old female, who presented to the ED via private vehicle with reports of ingesting "a handful of Tylenol" approximately 30 minutes prior to arrival. Review of Patient #5's medical record showed: *Patient reported having family problems and not living with either parent. *Diagnosed with depression and ordered medication. *Patient reported "mom does not care enough to get medication for her". Noted "some messed up things happened to her last summer but would not elaborate". *Physician noted patient was tearful and admitted to overdose by taking "2 handfuls of Tylenol". *Labs were ordered including a CBC (complete blood count [measures several components of the blood]), CMP (comprehensive metabolic panel [14 tests that prOVIdeS information on metabolism, electrolyte and acid/base balance, kidney/liver function and blood glucose]), UDS (urine drug screen [test for the presence of illegal and prescription drugs]), urinalysis and Acetaminophen level. Initial Acetaminophen level was critical at 88 (low 13, high 30) and UDS was positive for amphetamines and methamphetamines. See attached AND PLAN OF CORRECTION IDENTIFICATION NUMBER A BUILDING COMPLETED 371340 B. WING 10l09l2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) ID 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) 200 Continued From page 9 200 FORM OMS-2567 (02-99) PreVIous VerSIons Obsolete Event ID SZP111 ID HPQ249 if continuation sheet Page 10 of 42 VTI DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938?0391 *No assessment performed by ED physician. *No suicide assessment was performed by nursing staff at the time of triage or during the physical assessment. *No documentation in the patient's medical record DHS was noti?ed of the patient's suiCIde attempt by overdose *There was no evidence the phySIcian obtained a mental health evaluation via telemedicine to determIne the presence of an acute medIcal condition. *Patient was diagnosed with Acetaminophen overdose, was given contact information for two facilities to follow up with and discharged home with her mother. On 10/10/18 at 8 28 am, Staff (ED RN) stated, the hOSpital did have a telemedicine contract with a facility to perform mental health evaluations. Staff stated, the process was to contact the telemedicine site after a suicidal patient was ?medically Cleared". Staff stated, "a patient may be suicidal but the ED physician may decide the patient does not need a evaluation and discharge them". On 10/10/18 at 9:08 am, Staff stated, staff asked the physician why the Patient #5 was being discharged home with her mother. Staff stated, the physician said "the patient was an adolescent and her mother could take her." Staff See attached STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER COMPLETED A. BUILDING 371340 B. WING 10/09/201 8 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 001) .9 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 IDENTIFYING INFORMATION) TAG CROSSREFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 200 Continued From page 10 200 FORM PreVIous VeTSIons Obsolete Event ID: SZP111 ID HP2249 If continuation sheet Page 11 of 42 ?i lf?i rr-, JHIXJ 0 ?013 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938~0391 stated, the patient did not have a mental health evaluation at the hospital prior to discharge. Staff stated that in his/her experience suicidal patients had received a mental health evaluation prior to discharge from the ED. On 10/10/18 at 11:59 am, Staff (Chief of Staff and Medical Director Of the-ED) stated, the hospital had issues in the ED regarding the quality of care provided to patients by ED physicians. Staff stated, patients who presented to the hospital with ideation or suicide attempts should receive a mental health evaluation. Staff stated the hospital had a telemedicine agreement for mental health services available for such consultations. Rattlesnake Bites Review of hospital policy titled "Snake Bite, dated 03/18/18" showed, treatment for known rattlesnake bites should Include wound care, observation for four to six hours, and discharge home if there was no development of clinical signs. The policy fails to clearly identify the treatment and disposition of the patient when there were development of clinical signs and such as swelling, erythema, lab abnormalities, and other non-life threatening Policy failed to identify criteria of a "wet" snake bite and when to initiate orders for management of patIents with wet snake bites. Review of hospital document titled "Emergency Department Orders for Snake~Bite Patients (Wet See attached STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER- COMPLETED A. BUILDING 371340 8- WING 10109I2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY 0R LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 200 Continued From page 11 200 FORM Prewous VerSIons Obsolete Event SZPI11 Faculty ID HP224Q If continuation sheet Page 12 of 42 JAN 2 8 3mg; U5 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER: 371 340 (x2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY A BUILDING COMPLETED WING NAME OF PROVIDER OR SUPPLIER MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY STREET ADDRESS, CITY, STATE, ZIP CODE 520 MEDICAL DRIVE GUYMON, OK 73942 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION REGULATORY OR IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE DEFICIENCY) 200 Continued From page 12 200 Bite) Adult/Pediatric, undated? showed, labs should be obtained including CBC with platelet count, (PT prothrombin tIme a test that helps to detect and diagnose bleeding or clotting disorders, international normalized ratio a test that measures the time it takes the blood to Clot), (partial thromboplastin time a test that assesses the body's ability to form blood clots), Fibrinogen, CMP, and urinalysis. intravenous (IV) access should be Obtained and Normal Saline or Lactated Ringer ?uid bolus administered. Mark with a permanent marker from the distal edge of the fang to the leading edge of the swelling, and date and time it. Administer CrOfab (anti-venom) immediately Review of hospital document titled "Grievance Process Checklist and attachments, dated 04/12/18" showed, a complaint was initiated by the quality/peer review personnel due to a concern regarding the care Patient #6 received in the ED. Findings showed, the standard of care was not met for the care provided to Patient 6 for the treatment of the rattlesnake bite. Review of hospital document titled ?Continuous Quality Improvement - Patient Complaints and Grievances, dated 04/12/18" showed, the outcome of the quality review regarding Patient #6 was an "extremely unexpected" practice that "could have (or did) contribute to patient injury". Medical record was forwarded for medical record by ESS (ED medical staf?ng group) for peer review. Review of untitled hOSpitaI document from Staff See attached FORM Prevrous Versrons Obsolete Event 10: SZP111 Facility FD HP2249 If continuation sheet Page DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED. 01/1612019 FORM APPROVED OMB NO. 0938?0391 regarding the review of Patient #65 medical treatment in the ED. His review noted there was no signi?cant change in the patIent's condition during the approximately two hours she was In the ED. He noted the patient was sent to Amarillo the next morning by her primary care physician for treatment with the anti-venom. His conclusion was two hours of observation with normal vital signs, normal labs and minimal edema met the "standard for reasonable care". Review of document titled "Envenomations: Initial Management of Common U.S. Snakebites, dated 06/23/17" by the Academic Life of Emergency Medicine showed labs should include urinalysis, creatine kinase, ?brinogen, PTIINR, liver function tests, chemistry panel and complete cell count of envenomation include inflammation such as pain, heat, and redness. Systemic signs may include hypotension, vomiting, coagulopathy (elevated PT, decreased ?brinogen, thrombocytopenia), diarrhea, or angioedema. Patients should be monitored for a minimum of8 to 12 hours and repeat of labs prior to discharge even for those that show no immediate signs of envenomation. Patient #6 was a 67 year old female, who arrived in the ED at 7:31 pm, via EMS with complaints of a rattlesnake bite one hour mm to arrival. Review of Patient #6'5 medical record showed: *Elevated vital signs: heart rate 117, respirations 22, and blood pressure 167/81 *Nursing assessment noted redness, bruising, tenderness, and warmth of the foot, snakebite marked. Patient denied pain See attached STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER- COMPLETED A. BUILDING 371340 B. WING 1010912018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (X5) (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) 200 Continued From page 13 200 FORM PreVIous VerSIons Obsolete Event ID: SZP111 Faculty ID HP2249 f: I I if continuation sheet Page 14 of 42 8 25:33 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 0111612019 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1 PROVI (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY physician assessment noted one fang mark on dorsum right foot with minimal swelling. *At 7:53 pm, ice packs were provided and placed around the patient's foot due to swelling. Assessment failed to identIfy the amount of swelling. *Patient stated she did not want pain medication at 8:03 pm There was no documentation of an assessment of the patents pain to determine if the patient had pain. *Labs were obtained including a CBC, CMP, and PTT. There were no abnormalities. *Triple antibiotic ointment was applied to the bite and the patient was discharged to home at 9:20 pm, apprOXImately 1 hour and 50 minutes after admission. *Prior to discharge there was no evidence physician or nursing staff performed a re?assessment to determine the patIent's swelling, redness, bruising, warmth and tenderness to the foot remained stable and there was no increase. On 1OI1OI18 at 11:59 am, Staff (Chief of Staff and Medical Director of the ED) stated, he/she was aware the hospital did not have anti?venom at one time resulting in a patient being sent to another hospital. Staff stated, it was a concern the hospital did not have anti-venom. Staff stated, helshe was not aware what happened but he/she thought "they were going to make sure they were not short anymore." See attached AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 371340 WING 10I0912018 NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS. CITY. STATE. CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) In 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 LSG IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 200 Continued From page 14 200 FORM Prevrous Versrons Obsolete Event ID: SZP111 ID If continuation sheet Page 15 of 42 JAN :3 8 23,3 LL DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 On 10/10/18 at 1:22 pm, Staff stated, he/she "was furious" about Patient #6'5 care in the ED because the hospital did have anti?venom and stemIds but "they did not do anything for the patient". Staff stated the physician who performed the case review "did the same thing before". IV. Pediatric Patients A review of hospital policy, "Scope of Service/Plan of Care: Emergency Department?, revision date 01/13/17 showed the patient population served by the ED consisted of newborn, pediatric, adolescent, adult and geriatric patients requiring or seeking medical care Support services included but were not limited to clinical laboratory studies and x-rays that were to be provided to the patient in a timely manner. A document, "Case Review Form" 05/09/18, showed the form was to be utilized as part of the peer-review process established by the hospital?s medical staff bylaws. The conclusmn of the review of Patient #10's medical care in the ED showed "there were several ?ndings in the history and physical examination that should have prompted a more thorough evaluation in the emergency department. Treatment did not meet standard of care." The document also showed on 02/08/18, the patient was transferred from a primary care provider?s clinic to another facility and underwent surgery for pyloric stenosis. See attached STATEMENT OF OEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER COMPLETED A BUILDING 371340 B. WING 10/09/201 8 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (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 IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 200 Continued From page 15 200 FORM PreVIous Obsotete Event ID: SZP111 Faculty ID HP2249 If continuation sheet Page 16 of 42 (I . JAN {98 23:3 PRINTED: 01/16/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE 8: 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 371340 5? WFNG 10/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (X5) pREij (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVEACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 200 Continued From page 16 200 See attached Patient #10 was a 27 day Old infant, who was brought to the ED on three dIfferent occasions with complaints Of vomiting, constipation and jaundice. Review Of Patient#10's medical record showed the following: *Patient was in the emergency department on three occaSIonS from 01/29/18 to 02/08/18 with compiaInts of vomiting, constipation, Jaundice (yellowing of the yes caused by elevated liver enzymes, which Is an indication Of malabsorption of nutrients) *On 01/29/18 at 17 days Old, patient was brought to the ED by his/her mother with complaints Of throwing up after feeding The ED provider documented a normal physical exam. There was no evidence the ED physician ordered labs, diagnostic imaging, or provided medications prior to patient discharge. The patient's weight was documented in the nurse's notes as 3.81 kg. *On 02/05/28 at 24 days old patient, was brought to the ED by his/her mother with reports of continued vomiting, yellow tinted eyes, "jaundice tint to the skin," and blood in the urine. The ED provider documented "no mass, liver margin palpable". The ED provider did not address reports Of blood in patient's urine. The patient's weight was documented in the nurse?s notes as 3.45 kg. There was no evidence the ED physician ordered labs, diagnostic imaging, or provided medications prior to discharging patient home. *On 02/08/18 at 27 days old patient, was brought to the by his/her mother with reports of continued vomiting and no bowel movement for ?ve days. The ED provider documented "normal physical exam". A glycerin suppository was administered. FORM Prewous VerSIons Obsolete Event ID. SZP111 FacrlIty ID HP2249 If continuation sheet Page 17 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES 01/16/2019 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER: 371340 0(2) ULTIPLE CONSTRUCTION A. BUILDING B. WING (x3) DATE SURVEY COMPLETED 10l09l2018 NAME OF PROVIDER OR SUPPLIER MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY STREET ADDRESS, CITY, STATE, ZIP CODE 520 MEDICAL DRIVE GUYMON, OK 73942 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY 0R LSC IDENTIFYING INFORMATION) ID PREFIX TAG PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COM LETI ON DATE 200 330 Continued From page 17 The provider documented the patient?s weight at 3.45 kg, there was no documentation of weight in the nurse's notes. There was no evidence the ED physician ordered labs or diagnostic imaging and completed prior to patient being discharge home On at 1:30 pm, Staff stated, "we decided the contracted ED physician company shouid address these practices dealing with quality, we pulled records, we looked at census, we addressed concerns daily with them, there isn't documentation of those calls Staff stated, in regards to Patient #10 "the lack of care from the doctors was identi?ed". Staff stated the provider "had to go through training on pyloric stenosis" (the facility was unable to provide documentation of training). On 10/10/18 at 11:59 am, Staff (Chief of Staff and Medical Director of the ED) stated, the hospital had issues in the ED regarding the quality of care provided to patients by ED physicians. Staff stated, he was aware the ED physicians had problems dealing with pediatric patients. Staff stated, another provider had noti?ed him of Patient #10 and he had agreed the standard of care in the ED had not been met. PERIODIC EVALUATION QA REVIEW 485.641 Periodic Evaluation and Quality Assurance Review 200 330 See attached FORM Prevrous Versrons Obsolete Event ID SZP111 Faculty ID HP2249 If continuation sheet Page 18 of 42 PRINTED 01/16/2019 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 311340 B) 10/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATEI ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) (D SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (x5) PREHX (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) 330 Continued From page 18 330 See attached This CONDITION is not met as evidenced by: Based on record review and Interview, the hospital failed to ensure that a functioning Quality Assessment and Performance Improvement (QAPI) program: I. was on-going and included executive and leadership roles and responsibilities for evaluating the quality of care provided in the ED, identifying safety expectations using measurable indicators which identified and reduced patient safety Issues, medical errors and adverse outcomes through anaiyzing causes, implementing preventive actions plans, measuring outcomes for effectiveness and communicating lessons learned as evidenced by the lack of discussion in four of four ?Super Committee" meetings from 09/06/17 to 06/27/18, three of three Medical Staff Committee meetings from 06/13/17 to 01/16/18, four of four Medical Executive Committee meetings from 04/04/17 to 01/23/18, three of three Board of Trustees (Governing Body) meetings from 01/24/18 to 08/08/18 and 16 of 16 SpeCIal Board of Trustee Committee meetings from 02/15/17 to 08/08/18 for: (Refer to Tag (C-0336) a. one (Patient #23) occurrence reviewed 1 /1 5/ 18 to 09/15/18 that showed the ED's failure to provide a physical evaluation, diagnostic imaging, laboratory studies, and nursing assessment to a possible stroke patient who arrived via EMS prior to sending the patient to another hospital in Texas due to having no availability of Activase. FORM Previous Versions Obsolete Event ID. SZP111 ID If continuation sheet Page 19 of 42 A 13'} 3?11". we at; Ma I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER. 371340 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 10/09/2018 NAME OF PROVIDER OR SUPPLIER MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY STREET ADDRESS, CITY, STATE, ZIP CODE 520 MEDICAL DRIVE GUYMON, OK 73942 b. one (Patient occurrence reviewed 1/15/18 to 09/15/18 that showed the ED's failure to obtaIn a mental health evaluation and contactIng DHS (Department of Human Services) prior to discharging a pediatric patient with suicide attempt and suicidal ideations for transfer to a faCIlity through a private vehicle. C. one (Patient of two occurrences reviewed 1/15/18 to 09/15/18 that showed the ED's failure to follow hospital policy and standards of practice to include recommended observation, assessment prior to discharge, and the availability/administration of anti-venom. d. two (Patient #8 and 10) of two occurrences reviewed 1/15/18 to 09/15/18 that showed the ED's failure to evaluate, manage, and treat pediatric patients according to current standards of practice. II. was implemented and formulated risk reduction strategies to reduce patient safety, medical errors and adverse events identi?ed from occurrences and grievances were addressed through the QAPI program. (Refer to TagC-0342) was implemented so that data was collected to demonstrate the effectiveness of, correctIve action(s) from risk reduction strategies for medical errors. patient safety, and adverse events. (Refer to Tag 0?0343) These failed practIces: a. had the likelihood for increased risk for worsening health conditions, delays in care, injury See attached (x4) .9 SUMMARY STATEMENT OF DEFICIENCIES In PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE DEFICIENCY) 330 Continued From page 19 330 FORM CMS -2 567(02 ~99) PreVIous VersIons Obsotete Event SZP111 ID HP2249 lf contInuatIon sheet Page 20 of 42 Ill PRINTED: 01/16/2019 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 371340 8- WING 10I09I201 8 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 520 MEDICAL DRIVE GUYMON, OK 73942 (x4) .0 SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (x5) PREHX (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) MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY 330 Continued From page 20 330 to self or others, and adverse health outcomes related to the lack of Quality and Risk Management staff?s failure to investigate, and analyze occurrence reports, identify preventative action plans, and report ?ndings to a designated Quality Improvement Committee, the Medical Staff and Medical Executive Committees, and the Board of Trustees. See attached resulted in de?cient occurrence reporting by the Qualitleisk Manager to the "Super Committee? and no evidence of reporting to the Medical Staff and Medical Executive Committees and the Board of Trustees. Therefore, executive committees lacked suf?cient information to make informed decisions related to the prOVIsions of quality and safe patient care 336 QUALITY ASSURANCE 336 See attached 485.641(b) The CAH has an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes. The program requires that This STANDARD is not met as evidenced by: Based on record review and interview, the hospital failed to ensure a functioning Quality Improvement Program was implemented that included executive and leadership roles and responsibilities for evaluating the quality of care provided by the hospital, identifying safety expectations using measurable indicators which identi?ed and reduced patient safety issues, medical error and adverse outcomes through FORM PreVIous VerSIons Obsolete Event ID. 11 Facrlity ID HP2249 If continuation sheet Page 21 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY analyzing causes, implementing preventive actions plans, measuring outcomes for effectiveness and communicatlng lessons learned as evidenced by the lack of discussion in four of four "Super Committee" meetings from 09/06/17 to 06/27/18, three of three Medical Staff Committee meetings from 06/13/17 to 01/16/18, four of four Medical Executive Committee meetings from 04/04/17 to 01/23/18. three of three Board of Trustees (Governing Body) meetings from 01/24/18 to 08/08/18 and 16 of 16 Special Board of Trustee Committee meetings from 02/15/17 to 08/08/18 for' a. one (Patient #23) occurrence reVIewed 1/15/18 to 09/15/18 that showed the ED's failure to provide a physical evaluation, diagnostic imaging, laboratory studies, and assessment to a possible stroke patient who arrived via EMS prior to sending the patient to another hospital in Texas due to having no availability ofActivase. b. one (Patient occurrence reviewed 1/1 5/ 18 to 09/15/18 that showed the ED's failure to obtain a mental health evaluation and contactIng DHS (Department of Human Services) prior to discharging a pediatric patient with suicide attempt and suicidal ideations for transfer to a facility through private vehicle. 0. one (Patient of two occurrences reviewed 1/15/18 to 09/15/18 that showed the ED's failure to follow hospital policy and standards of practice to include recommended observation, assessment prior to discharge, and the availabillty/admlnistration of anti-venom. (1. two (Patient #8 and 10) of two occurrences See attached AND PLAN OF CORRECTION IDENTIFICATION NUMBER: BUILDING COMPLETED 371340 B. WING 1 0109/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY 520 MEDICAL DRIVE GUYMON, 0K73942 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (x5) FREHX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCES TO THE APPROPRIATE DATE DEFICIENCY) 336 Continued From page 21 336 FORM PreVIous VeTSIons Obsolete Event ID. SZP111 Faculty ID HP2249 :35; If continuation sheet Page 22 of 42 . I Lat DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 reviewed 1/1 5/ 18 to 09/15/18 that showed the ED's failure to evaluate, manage and treat pediatric patients according to current standards of practice These failed practices: I. resulted in the delayed care for two patients (Patient #6 and 23) worsening health conditions for two patient (Patient #6 and 10), the likelihood for increased risk of Injury to self for one patient (Patient and adverse health outcomes for six patients (PatIent 6, 7, 8, 10, and 23) related to the lack of Quality and Risk Management staff's failure to investigate, analyze occurrence reports, identify risk reduction strategies, implement corrective action plans, and report ?ndings to a designated Quality improvement Committee, the Medical Staff and Medical Executive Committees and the Board of Trustees. ll. resulted in de?cient occurrence reporting by the Quality/Risk Manager to the "Super Committee" and no evidence Of reporting to the Medical Staff and Medical Executive Committees and the Board of Trustees Therefore, executive committees lacked suf?cient information to make informed decisions related to the provisions of quality and safe patient care. Findings: Review of hospital policy titled "Quality Manual Plan), revised 04/01/18) showed the following: ?Governing Body, Medical Staff, Hospital See attached STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER COMPLETED A. BUILDING 371340 3- 10/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (X4) .0 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVEACTION SHOULD BE COMPLETION TAG REGULATORY 0R LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCE) TO THE APPROPRIATE DATE DEFICIENCY) 336 Continued From page 22 336 FORM Prewous VerSIons Obsolete Event 11 Faculty ID HP2249 If continuatlon sheet Page 23 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) AND PLAN OF CORRECTION IDENTIFICATION (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY COMPLETED Administrator/CEO (Chief Executive Of?cer, Nursing ExecutIve/CNO (Chief Nursing Of?cer), Quality Representative and Departmental Directors were "responsible and accountable" for the Quality Management Program -Responslbilities included "development and implementation of an on-going program ..addressing priorities for improved quality of care/treatment/services effectiveness of the program the use Ofrisk-based thinking and process improvementapproach." -Goals included but were not limited to: improvement of?existing process and functions through a systematic quaIIty patient care through Objective care evaluation and other performance assessment actiVItIes -Design of the program included root cause analysis for "near misses" and facilitate a "systematic examination" for opportunities for Improvement should be made on a "minimum of a quarterly basis" to the committee" should include "signi?cant deviations from established standards of practice". -PACE (Plan, Act, Check and Enhance) should be used to ensure corrective and preventative actions were achieved (Refer to "Corrective and Preventative Action Policy"). On 10/10/18 at 1:22 pm, surveyors requested policy regarding performance improvement initiatives and variance/occurrence reporting, Staff stated the hospital did not have any in relation to these subjects. -"An unplanned event that did not result in injury, See attached A. BUILDING 371340 9- 1 0/09/2018 NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (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 common TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE DEFICIENCY) 336 ContInued From page 23 336 FORM revmus Obsolete Event ID FaCIlIty ID HP224Q if continuation sheet Page 24 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 illness or damage but had the potential to do so" should be considered a "near miss event" "The organization must collect data, perform root cause analysis (RCA), preserve data (collect), formulate risk reduction strategies and collect data to demonstrate the effectiveness Of the corrective action(s) I. Stroke A review Of hospital policy titled "Emergency Medical Screening Examination and Stabilizing Treatment, dated 03/18/18" showed, the hospital campus included physical areas and structures adjacent to the hospital within 250 yards Of the included availability of equipment, supplies, and routine ancillary (support services such as laboratory, radiology and pharmacy) services patient should be assessed upon arrival for prioritization and determine whether EMS was able to monitor patient's condition appropriately if an immediate MSE was not able to be performed. A review Of hospital document titled "Activase log 09/01/17 through 09/28/18" showed four (Patient 2, 25, and 26) patients had received Activase on the dates: 09/07/17, 10/08/17, 05/15/18 and 05/25/18. The hospital was not able to provide evidence of an order and receipt between the time period Of 05/25/18 to 10/11/18 for the purchase of Activase to show the availability of the medication when Patient #23 arrived on 06/03/18. A review Of an untitled hospital document showed the last purchase date for a package Of two 100mg vials Of Activase was on 09/07/17. See attached STATEMENT OF DEFICIENCIEs (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER COMPLETED A. BUILDING 371 340 5- WING 1 0/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) Io SUMMARY STATEMENT OF DEFICIENCIES In PROVIDERS PLAN OF CORRECTION (st (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY 0R IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 336 Continued From page 24 336 FORM Prewous VerSIons Obsolete Event ID SZP111 Factilly ID HP2249 If continuation sheet Page 25 of 42 ?3 . L?Ul?l 41 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 On 09/28/18 at 10.50 am, during a tour of the pharmacy surveyors observed a box containing two 100mg vials of Activase in the pharmacy. Staff was not able to identify when the Activase was purchased or determine how long the box of Activase had been available at the hospital Review of hospital occurrence titled Log Incident with EMS, dated 06/03/18" was entered on 06/03/18 at 508 pm by Staff (ED RN) and showed the following: called into ED for positive stroke scale to prepare for head (ED physician) instructed nursing staff to notify EMS the hospital did not have Activase. EMS was noti?ed at the same time they arrived in the ED ambulance bay. Occurrence was reviewed by Staff (Manager of Quality/Risk Management) on 06/04/18,06/25/18, and 06/27/18 each tIme it was noted "Occurrence Report was viewed", there was no evidence the event was being investigated, causes analyzed, or preventative actions implemented. -Staff (peer review) reviewed the occurrence on 06/04/18, 06/07/18 at 10:25 am and 1:24 pm, 06/21/18, and 06/28/18, each time it was noted "Occurrence Report was viewed", there was no eVIdence the event was being investigated, causes analyzed, or preventative actions implemented -Staff noted on 06/28/18, Staff 8 (ED physician on duty on 06/03/18) reported he/she had been made aware of the event and was concerned. It was noted the patient was ?in fact in the ED ambulance bay before EMS was alerted there STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER. .COMPLETED A. BUILDING 371340 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 520 MEDICAL DRNE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY . GUYMON, OK 73942 (x4) ID 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 IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 336 ContInued From page 25 336 See attached FORM PreVIous Obsolete Event ID SZP111 ID HP2249 If continuatlon Sheet Page 26 of 42 ll DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (x1) IDENTIFICATION NUMBER. 371340 (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY A BUILDING COMPLETED 3' WING 10/09/2018 NAME OF PROVIDER OR SUPPLIER MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY STREET ADDRESS, CITY, STATE. ZIP CODE 520 MEDICAL DRIVE GUYMON, OK 73942 was no Activase in the hospital" to Staff and Staff and asked for this to be addressed at the next Medical Executive committee in July" On 09/27/18 at 8:45 am, surveyors requested all Medical Staff and Medical Executive Committee meeting minutes for the past 12 months. There was no evidence provided to surveyors of any Medical Executive Committee meetings after 01/23/18. -On 07/18/18 at 1:41 pm, Staff entered in the occurrence "l called and spoke with Staff (pharmacy) and we do currently have Activase". At 1:42 pm, Staff noted ?Closmg Remarks hospital does have Activase in the building for patient needing Activase". The occurrence was then closed. -There was no evidence an RCA was initiated to determine why there was no Activase available at the hospital at the time of the patient's arrival, where the two vials of Activase came from the surveyors Observed on 09/28/18 or why the patient did not receive initial triage, physician evaluation and prioritization. ?There was no evidence Quality/Risk Management investigated, analyzed the causes through use of the RCA process, identi?ed process issues that could impact patient safety, assisted in implementation of risk reduction strategies, measured and collected data to determine effectiveness of corrective actions to reduce the risk Of re?occurrence and communicated lessons learned to a designated Quality Committee, Medical Staff and Medical Executive Committee and the Board of Trustees. See attached (x4) ?3 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 TO THE APPROPRIATE DATE DEFICIENCY) 336 Continued From page 26 336 FORM PreVIous Obsolete Event ID SZP111 Faculty ID HP2249 11?; h} f) 6) ?continuation sheet Page 27 of 42 "With PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES Suicide A review of hospital policy titled "Emergency Medical Screening Examination and Stabilizing Treatment, dated 03/18/18" showed emergency was determined when a patient was a danger to him/herself or others who presented to the ED for a condition addressed through a pre-arranged community plan such as an MSE would be performed and treatment initiated prior to transfer of the patient pursuant to the community plan. A review of hospital policy titled "Patient Awaiting Evaluation, dated 12/28/16" showed the patient should evaluated and the need for evaluation determined. Review of a hospital document titled "Telemedicine Mental Health Access Agreement, dated 01/14/14" showed a mental health facility would provide licensed mental health profeSSIonals to perform telemedicine mental health consultations for patients presenting to the hospital. Review of hospital occurrence report titled Log Incident' intention overdose was discharged w/o evaluation or consult" was entered on 09/04/18 by Staff (ED RN) and showed the following: -Staff (Peer Review) reviewed the occurrence on 09/06/18 and noted "minor (Patient discharged from ED with suicidal ideation and intentional overdose evaluation performed not contacted year old and STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER. COMPLETED A. BUILDING a 371 340 B. WING 1 0/09/201 8 NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS, CITY. STATE, ZIP CODE I HOSPI A OF 5 CO NTY AU ITY 52? MEDICAL DRIVE EMOR AL XA OR GUYMON, OK 73942 (x4) .9 SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (x5) pREle (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE DATE DEFICIENCY) 336 Continued From page 27 336 See attached FORM PreVIous VerSIons Obsolete Event ID. SZP?itt ID HP2249 if continuation sheet Page 28 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 suicide attempt, positive drug use not living with parents states will take to hospital for consult but no transfer or contact for transfer made. Please comment on reason, transfer not made of?cial from ED prior to discharge." -On 09l14/18 Staff (ED RN) noted was not aware Tylenol was left in the room do not know the policies and procedures for a minor with an OD (overdose) someone could please orient me to those policies Review of an untitled hospital document dated 09/06/18 from Staff showed the occurrence was fonivarded to the contracted ED medical group for physician review. Staff noted a 14 year old patient was "seen in the ED with intentional overdose of Tylenol with suicidal ideation and methamphetamine abuse physician did not order a evaluation was not noti?ed of minor suicide attempt and positive drug use feel like the transfer should have been made by the ED physician, in the ED, prior to discharge of the patient." Review of hospital document titled Study Detaif, dated 09l27/18" showed the event was sent to the ED contracted medical group for review. There was no evidence the hospital's peer review committee reviewed and discussed the event to determine process issues or quality of care issues within the ED. On 10/10/18 at 1:22 pm, Staff stated quality reviewed the occurrence and determined education was needed. Staff stated education was prOVIded to nursing staff regarding hospital See attached STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER. COMPLETED A. BUILDING 371340 8- WING 10l0912018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE 336 Continued From page 28 336 FORM PreVIous VerSIons Obsolete Event ID SZP111 ID HP2249 If continuation sheet Page PRINTED: 0111612019 DEPARTMENT OF HEALTH AND HUMAN SERVICES 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 BUILDING COMPLETED 371340 3- WING 101091201 8 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) .0 SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (x5) pREng (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) 336 ContInued From page 29 336 See attached policy for suicide patients. Staff stated there was not an investigatIve analysis to determine any process Issues and implementation of preventative actions to reduce the risk of re?occurrence for this type of occurrence. Ill. Pediatrics A review of hospitai policy, "Scope of Service/Plan of Care: Emergency Department", reVIsion date 01/13?? showed the patient population served by the ED consisted of newborn, pediatric, adolescent, adult and geriatric patients requiring or seeking medical care. Support services included but were not limited to clinical laboratory studies and x?rays that were to be prOVIded to the patient in a timely manner. Review of hospital document titled ?Occurrence Report Summary, dated 03/22/18? showed Staff (Pediatrician) sent Patient #7 to the ED for further follow up treatment and "was concerned with ED physician treatment". Staff sent Patient #7 to ED due? to lethargy, fever and stomach pain present for several days. Staff requested work up by ED physician for possible appendicitis. CT scan and labs were ordered and completed, medication administered and patient was discharged. StaffW called ED to check on patient and was told patient was discharged Staff contacted parents and was told patient was taken to another acute care hospital for further treatment. Review of hospital document titled Study Detail, dated 06/20/18" showed Patient #7'5 medical chart was referred to ED contracted service for quality review by medical staff. Peer FORM PreVIous Verstons Obsolete Event ID: ID HP2249 If continuatlon sheet Page 30 of 42 If). Lir"\l\" i) 1.. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 review findings showed "advise period of observation Instead of discharge from the There was no evidence from review of the incident ?le the patient's medical record was reviewed by the ED contracted service. There was no evidence the hospital's peer review committee reviewed and discussed the event to determine process issues or quality of care issues within the ED. Review of Patent #7's incident ?le showed no evidence the event was being investigated, causes analyzed, or preventative actions implemented by the hospital?s QAPI program. Review of hospital document titled "Occurrence Report Summary, dated 09/09/18" showed one year Old infant (Patient 8) received from ED "in acute respiratory failure, grunting, oxygen saturations trouble breathing, received orders to transfer infant out, before leaving infant intubated." Review of hospital document titled Study Detail, dated 09/27/18" (identi?ed by Staff as the medical staff peer review report) showed no evidence of a review Of Patient #8's medical care and treatment In the ED. Comments noted ?unstable infant not transferred from the There was no evidence the hospital?s peer review committee reviewed and discussed the event to determine process issues or quality of care issues within the ED. Review of hospital document titled "Grievance Process Check List" showed Patient #B's medical record was sent out to the contracted ED service for review on 09/17/18 Review of incident ?ie by surveyors showed no evidence Of case review by See attached STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION Ixa) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A COMPLETED 371 340 B. WING 10I09I2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (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 IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 336 Continued From page 30 336 FORM -99) PreVIous VerSIons Obsolete Event SZP111 ID HP2249 if continuatIon sheet Page 31 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTIO (x3) DATE SURVEY the contracted ED medical provider. There was no evidence the event was being investigated, causes analyzed, or preventative actions implemented by the hospital's quality assurance and improvement program. A document, "Case Review Form" 05/09/18, showed the form was to be utilized as part of the peer-reVIew process established by the hospital?s medical staff bylaws. The conclusion of the review of Patient #10'5 medical care in the ED showed "there were several ?ndings in the history and physical examination that should have prompted a more thorough evaluation in the emergency department. Treatment did not meet standard of care." The document also showed on 02/08/18, the patient was transferred from a primary care provider's clinic to another facility and underwent surgery for pyloric stenosis. Review of hospital document titled "Grievance Process Check List" showed PatIent #10's medical record was to be reviewed at medical staff peer review on 05/23/18. There was no evidence the hospital's peer review committee reviewed and discussed the event to determine process issues or quality of care issues within the ED. There was no evidence the event was being investigated, causes analyzed, or preventative actions implemented by the hospital's QAPI program. On 10/10/18 at 1:22 pm, Staff stated he/she did submit Patient #7's medical record to the contracted medical service for review but does not know why he/she did not have a response from them. Staff stated "we left this in the contracted medical service's hands". Staff stated "there should have been a peer review See attached AND PLAN OF CORRECTION IDENTIFICATION BUILDING COMPLETED 371340 B. WING 10/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE MEMORI HOSPITAL OF TEXAS COUNTY AUTHORITY 520 MEDICAL DRIVE A GUYMON, OK 73942 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION 1 (X5) PREHX (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) 336 Continued From page 31 336 FORM Prevmus VerSIons Obsolete Event ID SZP111 FaCIIity ID HP2249 A ?vr A l1 4? If continuation sheet Page DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED 01/16/2019 FORM APPROVED OMB NO 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION 371340 (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY A BUILDING COMPLETED 8' 10/09/2018 NAME OF PROVIDER OR SUPPLIER MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY STREET ADDRESS, CITY. STATE, ZIP CODE 520 MEDICAL DRIVE GUYMON, OK 73942 completed on Patient #10, I know it went to clinical care and the contracted medical service for reVIew." IV. Snake Bite Review of hospital document titled "Grievance Process Check List" showed a complaint was initiated by the quality/peer review personnel due to a concern regarding the care Patient #6 received in the ED. Findings showed the standard of care was not met for the care provided to Patient 6 for the treatment of the rattlesnake bite. There was no evidence the event was investigated, causes analyzed, or preventative actions implemented by the hospital's QAPI program. Review Of hospital document titled "Continuous Quality Improvement - Patient Complaints and Grievances. dated 04/12/18" showed the outcome of the quality review regarding Patient #6 was an ?extremely unexpected" practice that "could have (or did) contribute to patient injury". Medical record was forwarded for medical record by ESS (ED medical staf?ng group) for peer review. Review of untitled document (identi?ed as review Of Patient #65 medical record by Staff of the contracted ED service) dated 04/24/18, showed "2 hour observation in the ED for a minimal snakebite with normal Vital signs, labs and minimal edema that was not worsening, meets the standard for reasonable care." On 10/10/18 at 1:22 pm, Staff stated the ED contracted medical service was responsible for (x4) ID 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) 336 Continued From page 32 336 See attached FORM PreVIous Ver3ions Obsolete Event ID SZP111 FaCIlity ID HP2249 If continuation sheet Page 33 of 42 4 i 4L DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES 01/16/2019 FORM APPROVED OMB NO. 0938?0391 peer review of the ED medical staff. Staff stated helshe or Staff would send the patient's medical record to the ED contracted service and once completed they would send back a response. Staff stated the response would get ?led and any education or follow-up needed for the ED physicians would be provided by the ED contracted providers. Staff stated the hospital was responsible for addressing issues with their staff. Staff stated the hospital did not have a quality committee, it has been combined into the "Super Committee". Staff stated the "Super Committee" had every hospital department represented and it would be inappropriate to analyze individual patient incidents with them present. Staff stated there was not a designated committee to discuss individual events in order to analyze causes, identify process issues and determIne preventive actions to reduce the risk of re-occurrence. Staff stated the quality improvement program had not implemented any type Of investigative analysis or performance improvement efforts for the events discussed. On 10/10/18 at 11:59 am, Staff stated he/she "would have expected the quality and risk manager to have brought these items (events) to my attention, each time the hospital had changed owners then positions had changed I don't know who the quality/risk manager is." Staff stated issues involving the ED medical staff would be sent to the ED contracted medicai service for review and then a representative would come to medical staff peer review to discuss their ?ndings. Staff stated he/she was not aware of any medical records being reVIewed by medical staff peer review. See attached STATEMENT OF DEFICIENCIES (x2) CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A BUILDING COMPLETED 371340 3- 10/09/2018 NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS. CITY, STATE. ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) .9 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL FREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE 336 Continued From page 33 336 FORM PreVIous VerSIons Obsolete Event lD SZP111 lD HP2249 If continuatIon sheet Page 34 of 42 It I) ?W'm i :71, I1 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938?0391 485.641 [The program requires that-?] the CAH also takes appropriate remedial action to address de?ciencies found through the qualIty assurance program. This STANDARD Is not met as evidenced by: Based on record review and interview, the hospital failed to ensure that a functioning QAPI program was implemented and risk reduction strategies formulated to address patient safety issues, medical errors and adverse events identi?ed from occurrences and grievances addressed through the program. These failed practices resulted in the delayed care for two patients (Patient#6 and 23), worsening health conditions for two patients (Patient #6 and 10), the likelihood for increased See attached STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A COMPLETED 371340 5- WING 10I0912018 NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (M) In SUMMARY STATEMENT OF DEFICIENCIES In PROVIDERS PLAN OF CORRECTION (x5) pREle (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY 0R LSC TAG TO THE APPROPRIATE DATE DEFICIENCY) 336 Continued From page 34 336 See attached On 10/11/18 at 10:30 am, Staff A (COO) stated helshe did not see a conclusion or action on the peer review forms. Staff A stated "It is obvious we are not closing the loop". Staff A stated he/she expected the peer review committee to be reviewing the medical cases to determine if the standard of care was met and if not what actions need to be taken on all cases includIng those involving the ED and ED physicians. Staff A stated he/she expected the quality program to be reviewing, investigating patient events (occurrences), and analyzing them to determine if hospital processes and procedures were being done 342 QUALITY ASSURANCE 342 FORM Prevnous VerSIorIs Obsoiete Event SZP111 FaCIlIty ID HP2249 JA "4 43 If continuation sheet Page rip LEE DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER. 371340 FORM APPROVED OMB NO. 0938?0391 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY A. BUILDING COMPLETED 5' WING 10/09/2013 NAME OF PROVIDER MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY STREET ADDRESS. CITY. STATE, ZIP CODE 520 MEDICAL DRIVE GUYMON, OK 73942 risk of Injury to self for one patient (Patient and adverse health outcomes for six patlents (Patient 6, 7, 8, 10, and 23), related to the lack of Quality and Risk Management staffs failure to investigate, analyze occurrence reports, identify risk reduction strategies, implement corrective action plans and report ?ndings to a designated Quality Improvement Committee, Medical Staff and Medical Executive Committees and the Board of Trustees. Findings: Review of hospital policy titled "Quallty Manual Plan), revised 04/01/18) showed the following. -"The organization must collect data, perform root cause analysis (RCA), preserve data (collect), formulate risk reduction strategies and collect data to demonstrate the effectiveness of the corrective faulty process or system invariable permits or compounds the harm, and is the focus of improvement Review of hospital document titled "Hospital Super Committee" meeting minutes from 09/06/17 to 06/27/18 showed no evidence of incident reporting for 09/06/17 and reporting of incidents, grievance, or cases sent to peer review for 03/29/18. On 06/27/18 meeting minutes showed the following: incidents (March 18, April 47, May grievances (March 4, April 3, May 3), and cases sent to peer review (March 4, April 7, May 2). There was no evidence caseswere See attach ed (x4) ID SUMMARY STATEMENT OF DEFICIENCIES lD- 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) 342 Continued From page 35 342 FORM PreVIous Obsolete Event in SZP111 ID HP2249 If continuation sheet Page L?l DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938-0391 discussed to include the formulation of risk reduction strategies to address patient safety issues, medicat errors and/or adverse events identi?ed from occurrences, grievances and cases sent to peer review. Review of hospital document titled "Medical Executive Committee" meetings minutes from 04/04/17 to 01/23/18 showed no evidence the quality program reported Incidents or grievance data to the medical executive committee. The meeting minutes failed to show evidence patient safety issues, medical errors and adverse events identi?ed from incidents, grievances and cases sent to peer review were discussed to include risk reduction strategies formulated by the medical executive com mittee. Review of hospital documents titled "Medical Staff Committee" meeting minutes from 06/13/17 to 01/16/18 showed no evidence the quality program reported incidents or grievance data to the medical staff committee. The meeting minutes failed to show evidence patient safety issues, medical errors and adverse events identi?ed from incidents, grievances and cases sent to peer review were discussed to include risk reduction strategies formulated by the medical staff committee. Review of hospital documents titled "Board of Trustees (Governing Body)" meeting minutes from 01/24/18 to 08/08/18 showed no evidence the quality program reported incidents or grievance data to the Governing Body. The meeting minutes failed to show evidence patient STATEMENT OF DEFICIENCIEs (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER- COMPLETED A. BUILDING 371340 3 10/09/2013 NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) .9 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 DEFICIENCY342 See attached FORM Prewous VerSIons Obsolete Event ID. SZP111 ID HP2249 If continuation sheet Page 37 of 42 {j 6. VA. 32? PRINTED: 01/16/2019 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE 8: 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 371340 3- WING 10/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) .3 SUMMARY STATEMENT OF DEFICIENCIES In PROVIDERS PLAN OF CORRECTION (x5) pREle (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 342 Continued From page 37 342 safety issues, medical errors and adverse events identi?ed from incidents, grievances and cases sent to peer review were discussed to include risk reduction strategies and reported to the Governing Body. See attached Review of hospital documents titled "Special Board of Trustee Committee" meetIng minutes from 02/15/17 to 08/08/18 showed no evidence the quality program reported incidents or grievance data to the Governing Body. The meetIng minutes failed to show evidence patient safety issues, medical errors and adverse events identi?ed from incidents, grievances and cases sent to peer review were discussed to include risk reduction Strategies and reported to the Governing Body. On 10/10/18 at 1:22 pm, Staff stated, he/she was responsible for evaluating all patient care services from a quality standpoint. Staff stated, he/She was not responsible for taking quality data including Incidents and grievances to medical staff and Governing Body. Staff stated, the quality improvement program had not implemented any type of investIgative analysis or performance improvement efforts for the events discussed. On 10/10/18 at 2:30 pm, Staff stated, he/she was responsible for taking qualIty indicator data to medical staff committee and the Governing Body. Staff stated, medical staff and Governing Body did not discuss individual incidents and grievances. FORM PreVIOus VeI'SIons Obsolete Event ID SZP111 FaCIlIty ID HP2249 [f contlnuation sheet Page 33 of 42 A. CL DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO 0938-0391 485.641 [The program requires that-?] the CAH documents the outcome Of all remedial action. This STANDARD is not met as evidenced by: Based on record review and interviews, the hospital failed to ensure a functioning QAPI program was implemented so that data was collected to demonstrate the effectiveness Of corrective action(s) from risk reduction strategies for medical errors, patient safety and adverse events. These failed practIces resulted In the delayed care for two patients (Patient #6 and 23) worsening health conditions for two patients (Patient #6 and 10), the likelihood for increased risk Of injury to self for one patient (Patient and adverse health outcomes.for six patients (Patient 6, 7, 8, 10, and 23), related to the lack Of Quality and Risk Management staff's failure to investigate, analyze occurrence reports, identify risk reduction strategies, implement corrective action plans and report ?ndings to a designated Quality Improvement Committee, Medical Staff and Medical Executive Committees and the Board of Trustees. Findings: ReVIew of hospital policy titled "Quality Manual Plan), revised 04i01l18) showed the followmg: STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A BUILDING COMPLETED 371340 9 1010912018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE EMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY 52? MEDICAL DRIVE GUYMON, OK 73942 (x4) .0 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) 343 ContInued From page 38 343 See attached 343 QUALITY ASSURANCE 343 FORM Prevrous VerSlonS Obsolete Event ID ID HP2249 lf continuatIon sheet Page 39 Of 42 . AL DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/1612019 FORM APPROVED OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER. 371340 (X2) MULTIPLE CONSTRUCTION A BUILDING B. WING (X3) DATE SURVEY COMPLETED 1 01091201 8 NAME OF PROVIDER OR SUPPLIER MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY STREET ADDRESS, CITY, STATE, ZIP CODE 520 MEDICAL DRIVE GUYMON, OK 73942 - "The organization must collect data demonstrate the effectiveness of the corrective Review of heapital document titled "Hospital Super Committee" meeting minutes from 09/06/17 to 06/27/18 showed no evidence the quality program was analyzing patIent safety, medical errors and adverse patient events, determining preventative action plans, and collecting data to determine the effectiveness of the preventative action plans to ensure and decreased risk of re-occurrence. Review of hospital document titled "Medical Executive Committee" meetings minutes from 04/04/17 to 01/23/ 18 failed to show evidence the quality program presented to the medical executive committee patient safety, medical errors and adverse events identi?ed from incidents, grievances, and cases sent to peer review were analyzed, preventative action plans determined and data reported and trended to determine the effectiveness of the preventative action plans to ensure sustainability and decreased risk of re-occurrence. Review of hospitai documents titled "Medical Staff Committee" meeting minutes from 06/13/17 to 01/16/18 showed no evidence the quality program presented to the medical staff committee, patient safety, medical errors and adverse events identi?ed from incidents, grievances, and cases sent to peer review were analyzed, preventative action plans determined and data reported and See attached (x4) .0 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 TAG TO THE APPROPRIATE DATE DEFICIENCY) 343 Continued From page 39 343 FORM Prewous VerSIons Obsolete Event ID SZP111 Faculty ID HP2249 If continuation sheet Page 40 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 01/16/2019 FORM APPROVED OMB NO. 0938?0391 trended to determine the effectiveness Of the preventative action plans to ensure sustainability and decreased risk of re-occurrence. Review of hospital documents titled "Board of Trustees (Governing Body)" meeting minutes from 01/24/18 to 08/08/18 showed no evidence the quality program presented to the Governing Body, patient safety, medical errors and adverse events identi?ed from incidents, grievances, and cases sent to peer review were analyzed, preventative action plans determined and data reported and trended to determine the effectiveness of the preventative action plans to ensure sustainability and decreased risk of re-occurrence Review of hospital documents titled "Special Board of Trustee Committee" meeting minutes from 02/15/17 to 08/08/18 showed no evidence the quality program presented to the Governing Body, patient safety, medical errors and adverse events identi?ed frOm incidents, grievances and cases sent to peer review were analyzed, preventative action plans determined and data reported and trended to determine the effectiveness of the preventative action plans to ensure sustainability and decreased risk of re?occurrence. On 10/10/18 at 1:22 pm, Staff stated, he/she was responsible for evaluating all patient care services from a quality standpoint. Staff stated he/she was not responsible for taking quality data including incidents and grievances to medical staff and Governing Body. Staff stated the STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 371340 B. WING 10/09/2018 NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS, CITY, CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 (x4) 10 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) 343 Continued From page 40 343 See attached FORM Previous VerSICns Obsolete Event lD' SZP111 FaCIIity ID HP2249 . 5 If continuation sheet Page 41 of 42 i Mir/3P"; gig) PRINTED: O1l16l2019 FORM APPROVED OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES quality improvement program had not implemented any type of investigative analysis or performance improvement efforts for the events discussed. On 10/10/18 at 2:30 pm, StaffC stated he/she was responsible for taking quality indicator data to medical staff committee and the Governing Body. Staff stated medical staff and Governing Body did not discuss individual incidents and grievances STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 371340 3- WING 1010912018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 520 MEDICAL DRIVE MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY GUYMON, OK 73942 pm In SUMMARY STATEMENT OF DEFICIENCIES In 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) 343 Continued From page 41 343 See attached FORM Prewous VerSIons Obsolete Event ID SZP111 Facility ID HP2249 l! continuation sheet Page 42 of 42 (X4) [0 Prefix (Tagil): FACILTY NAME Event iDtl: 5213111 000 Memorial Hospital of Texas County Facility HP2249 1. Describe your plan for correcting this deficiency? Our perspective is one of determination and resolve as we strive to actively and rapidly improve our documentation and processes to reflect the outstanding care we already provide. It was determined that the hospital needed much assistance in this endeavor, and we have thus hired a Utilization Review Consultant and a University Educator consultant. Both are on?board and working diligently, as described throughout this plan of correction. During a recent survey, it was discovered the QAPI program for the hospital was ineffective and in desperate need of a multi?faceted intervention. The Quality Risk Management Director at that time was immediately dismissed and the previous Quality Risk Management Director brought back in full?time to mentor the selected Quality Risk Management Director, in?training. The goal was to immediately refine, revive and re?deploy efficient and impactful quality programls) and initiatives across the entire facility. While the hospital is in the process of addressing the other issues identified during the survey, a strong and concerted effort is being placed on regaining a successful QAPI program and ensuring it is integrated across all departments as applicable as we know that can help build stronger mechanisms .of monitoring and control going forward. it should be noted the hospital is in the process of training a Quality Risk Management Director as noted above; in addition, the hospital is updating Education processes, and refining the Governing Board?s education and monitoring processes. As part of its corrective action planand Memorial Hospital of Texas County?s long?range plan to strengthen its quality program, the hospital has also purchased an electronic quality program (SQSS) designed to help hospitals to more effectively manage the large number of quality related activities important to ensure the safety and integrity of the patient care environment. This hospital, like many small hospitals, has historically struggled to manage the vast number of activities that are important in having a strong quality program because of the high number of activities that have to be managed by a smaller workforce. This tool is Specifically designed to increase capacity in these types of situations by having it supplement the workforce in scheduling, tracking, and recording activities. While there are a number of features in SQSS that the hospital will take advantage of, the primary piece currently being implemented will keep track of important quality activities that have to happen such as the number of quality control checks related to the CMS Conditions of Participation and patient safety. It alerts staff when they are due, collects the information about the completion of those activities, automatically notifies leadership when a task is not recorded as completed, automatically schedules periodic validation reviews by Team Leaders and quality professional to verify that activities are being completed properly, automatically generates important compliance reports for leadership and quality committee review and makes it faster and easier for leadership to put their hands on key information. 5055 has a series of hardwired checklists to reduce the risk that an important quality related activity could be over looked or drift without being identified. In SQSS, frontline personnel complete scheduled activities. 5055 then periodically schedules validation reviews by Team Leaders and quality professionals. It then also periodically schedules environmental surveillances by a team of quality professionals and leaders to provide for a type of checks and balances that can identify errors before they can evolve into ?a risk?that can cause harm. The monitoring of the activities and follow-up to any identified concerns will be part of the a r? regularly scheduled reports to the Quality Risk Management Director and included in the regularly scheduled QAPI reports to the Governing Board. 2. Describe the improvements to the processes that led to the cited deficiency? During the development of this corrective action plan, it has been identified that the Board, hospital leadership, as well as frontline staff lack foundational knowledge regarding regulatory requirements. The facility needs additional guidance from entry?level staff through the governing board. For this reason, staff training on $053 is already complete, and SQSS training for the governing board via face?to-face, one?on-one consultation with the Quality Risk Management Directors is underway. The orientation, competency validation, and annual required staff education is under scrutinous review and faces likely redesign. These processes will provide the staff the knowledge base to perform theirjob duties in a safe efficient environment, which supports the mission of the hospital and protects the patients and staff from harm. More importantly, the process will empower the Governing Board to assume a more engaged role in the quality initiatives of the facility. Additional specific outcomes include but are not limited to: 0 Strengthening the awareness of the legal responsibilities of the Board through education and engaging the Board. The Governing Board will be responsible for ensuring the facility is constructed, arranged, and maintained in a manner to ensure the safety of patients. 0 Strengthening the awareness and responsibilities of hospital leadership, management staff, and frontline staff for compliance with the Conditions of Participation, Oklahoma State Department of Health hospital standards and other regulatory agencies. 0 Strengthening the h05pital's internal standards by engaging the Team Leaders in their responsibility for QAPI activities, analyzing data collected, developing a process improvement and reporting the outcomes to the Quality Risk Management Director of the hospital and Board. 0 Strengthening the awareness of the frontline staff of current standards of practice through engaging the staff in the daily quaiity activities. 0 Strengthening the awareness and level of responsibility of the Medical Staff for the patient care environment, credentialing, and privileging responsibilities and engaging the Medical staff in quality activities. 0 Strengthen the level of responsibility for the annual review, revision and on?going development of policies and procedures for Emergency Services and Compliance/Education to ensure that patient care is delivered in a safe manner according to the current standards of practice for nationally recognized professional organizations. iJ 3. Describe your procedures for implementing the plan of correction for this deficiency? 0 Conduct Board education regarding responsibilities of the governing body, the Conditions of Participation, Infection Prevention and Control, Education as well as the Quality of Patient Care and Quality of Services provided. 0 Conduct leadership and management education regarding responsibilities for patient safety, quality of care and Conditions of Participation, Education as well as the Quality of Patient Care and Quality of Services provided. a The reporting structure and quality activities for Quality Risk Management Directors is being refined and re?deployed by the Quality Risk Management Director. - Refinement and Re?implementation of a hospital-wide electronic quality management system (SQSS) is underway. 4. Describe the monitoring procedures to ensure that the plan for correcting this deficiency is effective and remains corrected and/or in compliance with the regulatory requirements? what program will be put into place to monitor the continued effectiveness of the systemic changes. (This is part of your QAPI processes) Appropriate environmental surveillance is being implemented for the hospital through the use of an electronic quality management system (5055). The appropriate tasks are being assigned relating to the QAPI activities of each supervisor. This will ensure that a hospital-wide QAPI program is implemented and successful. This process is being conducted with the assistance of the Quality Risk Management Director, and the ln-training Quality Risk Management Director. The individual supervisors are delegated the responsibility of reporting compliance to the appropriate committee for the quality task. The individual supervisor will report to the Quality Risk Management Director. The Quality Risk Management Director will subsequently report to the Governing Board Ad Hoc Quality Risk Management Director. The Quality Risk Management Director role is assigned the responsibility of providing a administrative validation review for six months on behalf of the Quality Risk Management Director. This will ensure the continued occurrence of the surveillance monitoring and compliance with the requirement. The schedule for continued administrative validation reviews will be adjusted after six months or as deemed appropriate by the Quality Risk Management Director with the reviews to not be scheduled any less often than quarterly. The Quality Risk Management Director will monitor for compliance and follow through on any applicable corrective action plans for the six months of this corrective action plan. Continued monitoring by the Committee after the initial six?month window will occur quarterly as part of the regularly scheduled reports to the Committee unless the Committee deems a more frequent reporting schedule to be appropriate. 5. Provide the title of the person responsible for correcting this deficiency and ensuring compliance? The Governing Board, Administrator and Medical Staff, and the Quality Risk Management Director. . I mesa-52:23 I 6. Provide the date this deficiency corrective action/s will be completed? (Correction dates should be no more than 60 days from the survey exit date) Month/Day/Year: and ongoing Projected date of completion of construction is . 5" 9 JAN (ZULU (X4) ID Prefix (Tagil): FACILITY NAME 7 ., Event SZP111 200 Memorial Hospital of Texas County Facility ID: HP2249 INTRODUCTION AND BACKGROUND LEVEL IV CLASSIFICATION OF HOSPITAL EMERGENCY SERVICES DESIGNATION DISCUSSION An evaluation and assessment of Memorial Hospital of Texas County?s Stroke protocol initial and ongoing management practices has been completed. The apparent failure of services and interventions to meet the emergency needs of the acute stroke patient (according to current standards of practice) has been acknowledged by the clinical staff, hospital administration, Medical Staff, and Governing Board. The subsequent review also utilized the following current evidence-based practice and recommendations: *Review of 42 . *Review of Oklahoma State Statutes STROKE CENTER CLARIFICATION: A concise and detailed review of State Statutes is merited to clearly discern the facility's designation as a Level IV Stroke Center. General. The CAH shall provide emergency stabilization and treatment services commensurate with emergency medical needs of the community and CAH service area. All services shall be provided in accordance with acceptable standards of practice, compliant with applicable state and federal laws. MHTC strives for continuous compliance across all facets of our work in healthcare. Specific to the Emergency Department, MHTC has: 0 Reviewed and revised all Emergency Department (ED) policies as applicable 0 Developed and deployed a mutual agreement with EMS - Researched to incorporate evidence-based practice solutions - Deployed multi-faceted tracking solutions 0 lie-deployment of QAPI initiatives - Trained and Re?Trained staff at all levels - Involved Medical Staff and Governing Board for collaboration, consistency, and seamless communicationls) Organization and direction. The service shall be directed by personnel deemed qualified by the governing body and integrated with other services of the CAH. Although the service may function as a separate department, the CAH may also provide this service with staff from other areas who are trained in emergency services and who are available if needed in the emergency area. MHTC ED physician staff are credentialed, privileged and approved to work in the ED per Medical Staff By-Laws and as applicable Governing Board By-Laws as well. All ED staff receive preliminary and ongoing education with validation of proficiency at least annually. MHTC has also documented education and training, tracking of staff and provider education and training, validation of achieving minimum standards of care, verification of the utilization of evidence-based practice(s), and involvement of continuous quality metrics (QAPI). MHTC refers to QAPI as the Quality Oversight program for the hospital. The Quality and Risk Management (QRM) Director provides functional leadership for the QAPI Program (b1) Services shall be organized under the direction of a qualified member of the medical and professional staff. Nursing functions shall be the esponsibility of a registered nurse and shall be supervised by the Chief Clinical Of?cer. ED services are organized according to policy for MHTC. The nursing staff are trained consistently and are supervised via a team leader model of care delivery. (b2) There shall be written policies and procedures that establish protocols for emergency services provided. Policies shall also include written procedures for stabilization and transfer of patients whose treatment needs cannot be met at the CAH. If the CAH does not offer maternity tewices, emergency service policies shall include protocols for emergency deliveries. ED policy and procedure have been closely reviewed and crutinized and as an on?going protocol is further reviewed at least annually. Specific to this corrective action plan, MHTC has completely revised the CROFAB Venom Therapy policy and made major modifications to other policies as well. In addition, policy was updated according to the standard of care, best clinical care, and currently accepted evidence-based practice. Facilities, medications, equipment and supplies. Facilities, medications, equipment and supplies shall be provided to ensure prompt diagnosis land emergency medical treatment. Per findings of this survey and subsequent corrective action plan, MHTC will stock CroFab per policy and will, in the event of non-stock will place the ED on divert for suspected snake bites. (Additional detail is provided within this corrective action plan). I 'i?ilfi 1lPage JALQSLUM INTRODUCTION AND BA CKGROUNDLCONTINUE Facilities shall be separate and independent from operating, delivery, or inpatient rooms. The emergency services area shall be in close proximity to an exterior entrance of the CAH. ED is separate and independent from operating and inpatient rooms; the ED entrance (including an overhead awning for ambulance and emergency entrance) provides immediate access to the ED. (c2) Medications commonly used in life~saving procedures shall be provided. These shall include but not be limited to the following drugs and biologicals: analgesics, local anesthetics, antibiotics, serums and toxoids, cardiac glycosides, antihypertensives, diuretics, electrolytes, plasma expanders and replacement solutions. All medications necessary for ED provision of care are present and validated as up-to-date per policy. (CS) Equipment and supplies commonly used in ?fe-saving procedures shall be provided. These shall include but not be limited to: airways, endotracheal tubes, Iaryngoscope, ambu bag/valve/mask, obstetrics pack, tracheostomy set, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, lV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. ED equipment and supplies commonly used in life-saving procedures are provided and maintained per policy. (c4) The emergency service shall be equipped with a base station radio using medical frequencies VHF 155.340 or UHF Medical Channels 1 through 10 and/or compatible frequencies with emergency medical services operating in the area. Direct communications between the emergency service and the on-call physician or licensed independent practitioner and the on-call or on-site registered nurse shall be established as specified at OAC in collaboration with the Director of EMS services for Guymon, the ED radio communications processes have been validated and further, on-going validation are incorporated into staff education and training processes. We have deployed a policy and process for radio checks, including a process for how to handle radio check failure. Secondary communication processes have also been developed and deployed which includes cell phone communication between the charge nurse and/or administrator and the EMS Director of Texas County. Medical and nursing personnel. There shail be adequate medical and nursing personnel quali?ed in emergency care available at all times to meet the emergency service needs of the CAH. Medical and staff personnel are scheduled per policy which has been verified to be compliant with current law. (all) A physician or licensed independent practitioner shall be available at all times to directly communicate with CAH staff providing emergency care. The physician or licensed independent practitioner shall be able to be physically present at the CAH as specified by written facility policy. Medical and staff personnel are scheduled per policy which has been verified to be compliant with current law. (d2) A physician or licensed independent practitioner shall be on duty or on call at all times. This physician or practitioner shall be able to present at the CAH in a period of time not to exceed twenty (20) minutes. Medical and staff personnel are scheduled per policy which has been verified to be Icompliant with current law. (d3) A registered nurse shall be available at all times to assess, evaluate, and supervise the nursing care provided. If the CAH has no inpatients, the registered nurse may be available on an on-call basis if he or she can return to the CAH in a period of time not to exceed twenty (20) minutes when a patient presents to the emergency service. All emergency medical patients shall be evaluated on-site by a registered nurse unless the patient is evaluated on-site by a physician or licensed independent practitioner. Medical and staff personnel are scheduled per policy which has been verified to be compliant with current law. (d4) Adequate support staff shall be available on-site to meet the emergency service needs of the CAH. If the CAH has no inpatients and registered nursing services are provided on an on-call basis, the emergency service shall be staffed with at least an intermediate or paramedic level emergency medical technician. All CAH staff providing emergency services shall have current CPR certification. Medical and staff personnel are scheduled per policy which has been verified to be compliant with current law. Emergency medical records. ED records and documentation have been raised as a concern related to this survey and are addressed as a [component of this corrective action plan. First and foremost, MHTC has employed a consultant for Utilization Review, and 100% of all ED charts will be reviewed per a checklist/protocol that shall be developed in collaboration between the Governing Board, the Medical Staff, the Team Leaders/Interim Administrator, and the Utilization Review Consultant. We are in the process of reviewing our entire drug supply and dispensing process in the ED with cross-check of our current policy set to confirm validation and verificationZIPage INTRODUCTION AND BACKGROUND, CONTINUED (e1) Adequate medical records on every patient shall be kept. Each record shall contain the following as applicable: (e1A) Patient identification. (e13) Time and means of injury. (e1C) History of disease or injury. (e1D) Physical findings. (e1E) Laboratory and x-ray reports, if any. (e1F) Diagnosis and therapeutic orders. (e1G) Record of treatment including vital signs. (e1H) Disposition of the case. (ell) Signature of the registered nurse. (e11) Signature of the licensed independent practitioner, if applicable. (e1K) Signature of the physician, if applicable. (e1L) Documentation if the patient left against medical advice. (e12) Medical records for patients treated by the emergency service shall be organized and where appropriate integrated with inpatient records. A method of filing (hard copy or electronic) shall be maintained which assures prompt retrieval. (e1f) Drug and biologicals distribution and control. Drugs and biologicals in the emergency service shall be securely maintained and controlled by staff at all times. If the service does not have staff present at all times, all drugs and biologicals shall be secured in sealed or locked storage with devices placed to denote tampering. All Schedule II drugs shall be stored as specified by OAC All drugs and biologicals shall be administered and dispensed as required by state law. (elg) Patient examinations, treatments and transfers. Patient examinations, treatments and transfers shall be conducted in accordance with 42 U.S.C. (1395dd) and 42 U.S.C. (1395cc) and with the regulations at 42 CFR part 489.20 and 489.24. [Source: Added at 12 0k Reg 1555, eff 4-12-95 (emergency); Added at 12 0k Reg 2429, eff 6-26-95; Amended at 17 0k Reg 692, eff 12-16-99 (emergency); Amended at 17 0k Reg 2992, eff 7-13-00; Amended at 20 0k Reg 1664, eff 6-12-03] STROKE PATIENT FINDINGS: Stroke Finding 1: A review of hospital policy titled "Emergency Medical Screening Examination and Stabilizing Treatment, dated 03/18/18" showed the hospital campus included physical areas and structures adjacent to the hospital within 250 yards ofthe included availability of equipment, supplies, and routine ancillary (support services such as laboratory, radiology, and pharmacy) should be assessed upon arrival for prioritization and determine whether EMS was able to monitor patient's condition appropriately if an immediate medical screening examination (MSE) was not able to be performed. Stroke Finding 2: A review of hospital policy titled (Scope of Service/Plan of Care, dated 01/13/17? showed, patients who presented to the hospital's ED should receive an MSE that included all necessary labs, diagnostic testing, and services within the capabilities of the hospital in order to reach a diagnosis. Stroke Finding 3: A review of hospital document titled ?Activase log 09/01/17 through 09/28/18" showed four patients (Patient 2, 25, and 26) had received Activase on the following dates: 09/07/17, 10/08/17, 05/15/18, and 05/25/18. The hospital was not able to provide evidence of an order and receipt between the time period of 5/25/18 to 10/11/18 for the purchase of Activase to show the availability of the medication when Patient #23 arrived on 06/03/18. Stroke Finding 4: A review of an untitled hospital document showed that last purchase date for a package of two 100 mg vials of Activase was on 09/07/17. Stroke Finding 5: Review of document titled "Fire Department EMS Incident Report, dated 06/03/18" showed, MS crew were dispatched at 2:23 pm, to Patient #23?5 residence and arrived on scene seven minutes later at 2:30 pm. At 2:36 pm, EMS crew notified the hospital of positive stroke scale. EMS crew loaded the patient and departed the scene at 2:54 pm, arriving at hospital at 3:07 pm. EMS crew were notified that hospital did not have Activase available. EMS crew notified Staff that hospital had no Activase available and decision was made to transport patient via air ambulance to next closest acute stroke ready hospital in Texas. Stroke Finding 6: Review of hospital document titled Log incident with EMS, dated 06/03/18? showed the following: called into ED for positive stroke scale to prepare for head Staff (ED Physician) instructed nursing staff to notify EMS the hospital did not have Activase. EMS was notified at the same time they arrived in the ED ambulance bay. 0 Incident was entered on 06/03/18 at 5:08 pm, by Staff (ED RN) Incident was reviewed multiple times by Staff (Manager of quality/Risk management) on 06/14/18, 06/25/18, 06/27/18 and no analysis, interventions, or outcomes were documented. Staff (peer review) noted on 06/28/18, staff (ED physician on duty on 06/03/18) reported he/she had been made aware of the event and was concerned. It was noted the patient was ?in fact in the ED ambulance bay before EMS was alerted there was no Activase in the hospital". SUICIDE PATIENT FINDINGS: 3 Page Suicide Finding 1: A review of hospital policy titled ?Emergency Medical Screening Examination and Stabilizing Treatment, dated 03/18/18? INTRODUCTION AND BACKGROUND, CONTINUED emergency would be when a patient was a danger to him/herself or who presented to the ED for a condition addressed through a pre-arranged community plan such as and MSE would be performed and treatment initiated prior to transfer. Suicide Finding 2: A review of hospital policy titled ?Patient Awaiting Evaluation, dated 12/28/16 showed the patient should be evaluated and the need for evalutation determined. Suicide Finding 3: Review of a hospital document titled "Telemedicine Mental Health Access Agreement?, dated 01/14/14 showed, a mental health facility would provide licensed mental health professionals to perform telemedicine mental health consultations for patients presenting to the hospital. Suicide Finding 4: Review of document titled "Managing Suicidal Patients in the Emergency Department, dated 02/16" from the Annuals of Emergency Medicine showed a suicide risk assessment helped to determine appropriate treatment for suicide patients percentage of patients with suicidal ideation or behaviors may be managed in the ED without a mental health evaluation and discharged home who tend to be the lowest risk are those with no suicide plan or intent, no prior attempts, mental illness, substance abuse, and/or agitation or irritability. Suicide Finding 5: Review of document titled "Suicide Assessment Five?step Evaluation and Triage for Mental Health Professionals, dated 2009" from the Suicide PreventiOn Resource Center showed determination of suicide risk level included four factors: risk?factors, protective factors, suicide inquiry and interventions. High risk for suicide included an acute precipitating event, potentially lethal suicide attempt or persistent ideation with intent or rehearsal. These patients should be admitted unless there was a significant change in suicide risk. Patients determined to be a moderate suicide risk usually have multiple risk factors, and present with suicidal ideation and plan, but generally no intent or behavior. Depending on the identified risk factors, patients with moderate suicide risk may need to be admitted. Suicide Finding 6: Review of document titled "Caring for Adult Patients with Suicide Risk: A Consensus Guide for Emergency Departments" by the Suicide Prevention Resource Center showed after initial suicidal risk screening a more thorough secondary screening that provides disposition decisions for patients with suicidal ideations should be performed. The screen includes six questions that include thoughts of suicide, suicide intent, past suicide attempts, past mental health issues or issues that affect ability to do things in life, substance abuse issues, and behavioral issues. A mental health professional should be consulted in the ED if a patient answers ?yes? to any of the questions for further evaluation, including a comprehensive suicide risk assessment. Patient #3 was a 17 year-old female, who presented to the ED at 1:21 am, via EMS following ingestion of Fluoxetine (Prozac) and Tylenol approximately three hours prior to arrival. Review of Patient #3'5 medical record showed: - Suicide assessment identified suicide ideation, suicide attempt, feelings of hopelessness and despair and a depressed mood. 0 Initial physician assessment performed at 1:45 am, noted overdose was patient's seCOnd attempt. Patient was lethargic but arousable. Physician's plan was to repeat Acetaminophen level at nine hours post ingestion and at 6:00 am. 0 initial labs at 1:30 am, showed critical Acetaminophen level at 32 ug/mL (normal 13-30 ug/m L), ALT (Alanine Aminotransferase [blood test to evaluate liver function]) 57 (normal 8-34 Acetaminophen level at 5:33 am, was 11 ug/mL. 0 Medical Necessity for Air/Ground Transport was completed by physician stating a need for a higher level of care requiring a physician specialist that was not available at the hospital. 0 Transfer Request/Consent was completed and signed by physician, and noted benefits of transfer to include specialist availability to meet the needs of the patient and identifying the patient stable to transfer. 0 At approximately 6:00 am, there was a change of shift in ED physicians. There was no re-assessment by the oncoming ED physician and no mental health consultation or evaluation obtained via telemedicine. 0 At 6:36 am, ED physician discharged patient to home in care of foster parent with instructions "strongly recommend contact place where you had counseling earlier this year and talk with them about how you are feeling, what is happening in your life." 0 ED physician's final diagnosis was anxiety disorder. Patient #5 was a 14 year old female, who presented to the ED via private vehicle with reports of ingesting "a handful of Tylenol" approximately 30 minutes prior to arrival. Review of Patient #5'5 medical record showed: 0 Patient reported having family problems and not living with either parent. 0 Diagnosed with depression and ordered medication. 0 Patient reported ?mom does not care enough to get medication for her". 0 Noted "some messed up things happened to her last summer but would not elaborate?. 0 Physician noted patient was tearful and admitted to overdose by taking "2 handfuls of Tylenol". - Labs were ordered including 3 CBC (complete blood count (measures several components of the blood]), CMP (comprehensive metabolic panel [14 tests that provides information on metabolism, electrolyte and acid/base balance, kidney/liver function and blood glucose]), UDS (urine drug screen [test for the presence of illegal and prescription drugs]), urinalysis and Acetaminophen level. Initial 4 Page Acetaminophen level was critical at 88 (low 13, high 30) and U05 was positive for amphetamines and methamphetamines. .- . 0 No assessment performed by ED physician. INTRODUCTION AND BA CKGROUNDLCONTINUED - No suicide assessment was performed by nursing staff at the time of triage or during the physical assessment. 0 No documentation in the patient?s medical record DHS was notified of the patient's suicide attempt by overdose. 0 There was no evidence the physician obtained a mental health evaluation via telemedicine to determine the presence of an acute medical condition. 0 Patient was diagnosed with Acetaminophen overdose, was given contact information for two facilities to follow up with and discharged home with her mother. 0 On 10/10/18 at 8:28 am, Staff (ED RN) stated, the hospital did have a telemedicine contract with a facility to perform mental health evaluations. Staff stated, the process was to contact the telemedicine site after a suicidal patient was "medically cleared". Staff stated, "a patient may be suicidal but the ED physician may decide the patient does not need a evaluation and discharge them". 0 On 10/10/18 at 9:08 am, Staff (1 stated, staff asked the physician why the Patient #5 was being discharged home with her mother. Staff stated, the physician said "the patient was an adolescent and her mother could take her." Stafostated, the patient did not have a mental health evaluation at the hospital prior to discharge. Staff stated that in his/her experience suicidal patients had received a mental health evaluation prior to discharge from the ED. 0 On 10/10/18 at 11:59 am, Staff (Chief of Staff and Medical Director of the ED) stated, the hospital had issues in the ED regarding the quality of care provided to patients by ED physicians. Staff stated, patients who presented to the hospital with suicidal ideation or suicide attempts should receive a mental health evaluation. Staff stated the hospital had a telemedicine agreement for mental health services available for such consultations. PATIENT FINDINGS Snakebite Finding 1: Review of hospital policy titled ?Snake Bite, dated 03/ 18/18? showed, treatment for known rattlesnake bites should include wound care, observation for four to six hours, and discharge home if there was no development of clinical signs. The policy fails to clearly identify the treatment and disposition of the patient when there were development of clinical signs and such as swelling, erythema, lab abnormalities, and other non-life threatening Policy failed to identify criteria of a "wet" snake bite and when to initiate orders for management of patients with wet snake bites. Snakebite Finding 2: Review of hospital document titled ?Emergency Department Orders for Snake-Bite Patients (Wet Bite) Adult/Pediatric, undated? showed, labs should be obtained including CBC with platelet count, (PT prothrombin time a test that helps to detect and diagnose bleeding or clotting disorders, INR international normalized ratio a test that measures the time it takes the blood to clot), PTT (partial thromboplastin time a test that assesses the body's ability to form blood clots), Fibrinogen, CM P, and urinalysis. Intravenous (IV) access should be obtained and Normal Saline or Lactated Ringer fluid bolus administered. Mark with a permanent marker from the distal edge of the fang to the leading edge of the swelling, and date and time it. Administer Crofab (anti-venom) immediately. Snakebite Finding 3: Review of hospital document titled "Grievance Process Checklist and attachments, dated 04/12/18" showed, a complaint was initiated by the quality/peer review personnel due to a concern regarding the care Patient #6 received in the ED. Findings showed, the standard of care was not met for the care provided to Patient if 6 for the treatment of the rattlesnake bite. Snakebite Finding 4: Review of hospital document titled ?Continuous Quality Improvement Patient Complaints and Grievances, dated 04/12/18? showed, the outcome of the quality review regarding Patient #6 was an ?extremely unexpected" practice that "could have (or did) contribute to patient injury". Medical record was forwarded for medical record by ESS (ED Medical Staffing group) for peer review. Snakebite Finding 5: Review of untitledhospital document from Staff regarding the review of Patient #6'5 medical treatment in the ED. His review noted there was no significant change in the patient?s condition during the approximately two hours she was in the ED. He noted the patient was sent to Amarillo the next morning by her primary care physician for treatment with the anti-venom. His conclusion was two hours of observation with normal vital signs, normal labs and minimal edema met the "standard for reasonable care?. Snakebite Finding 6: Review of document titled "Envenomations: Initial Management of Common U.S. Snakebites, dated 06/23/17? by the Academic Life of Emergency Medicine showed labs should include urinalysis, creatine kinase, fibrinogen, PTT, liver function tests, chemistry panel and complete cell count of envenomation include inflammation such as pain, heat, and redness. Systemic signs may include hypotension, vomiting, coagulopathy (elevated PT, decreased fibrinogen, thrombocytopenia), diarrhea, or I I I: angioedema. Patients should be monitored for a minimum of 8 to 12 hours and repeat of labs prior to discharge even for those that show no INTRODUCTION AND BACKGROUND, CONTINUED immediate signs of envenomation. Snakebite Finding 7: Patient #5 was a 67 year old female, who arrived in the ED at 7:31 pm, via EMS with complaints of a rattlesnake bite one hour prior to arrival. Review of Patient #6'5 medical record showed: 0 Elevated vital signs: heart rate 117, respirations 22, and blood pressure 167/81 0 Nursing assessment noted redness, bruising, tenderness, and warmth of the foot, snakebite marked. Patient denied pain. 0 ED physician assessment noted one fang mark on dorsum right foot with minimal swelling. a At 7:53 pm, ice packs were provided and placed around the patient's foot due to swelling. 0 Assessment failed to identify the amount of swelling. 0 Patient stated she did not want pain medication at 8303 pm. There was no documentation of an assessment of the patient's pain to determine if the patient had pain. - Labs were obtained including a CBC, CMP, and There were no abnormalities. 0 Triple antibiotic ointment was applied to the bite and the patient was discharged to home at 9:20 pm, approximately 1 hour and 50 minutes after admission. 0 Prior to discharge there was no evidence physician or nursing staff performed a re-assessment to determine the patient's swelling, redness, bruising, warmth and tenderness to the foot remained stable and there was no increase. 0 On 10/10/18 at 11:59 am, Staff (Chief of Staff and Medical Director of the ED) stated, he/she was aware the hospital did not have anti? venom at one time resulting in a patient being sent to another hospital. Staff stated, it was a concern the hospital did not have anti- venom. Staff stated, he/she was not aware what happened but he/she thought "they were going to make sure they were not short anymore.? 0 On 10/10/18 at 1:22 pm, StaffC stated, he/she "was furious" about Patient #6?5 care in the ED because the hospital did have anti?venom and steroids but "they did not do anything for the patient". Staff stated the physician who performed the case review "did the same thing before". Pediatric Patient Findings Pediatric Finding 1: A review of hospital policy, "Scope of Service/Plan of Care: Emergency Department", revision date 01/13/17 showed the patient population served by the ED consisted of newborn, pediatric, adolescent, adult and geriatric patients requiring or seeking medical care. Support services included but were not limited to clinical laboratory studies and x-rays that were to be provided to the patient in a timely manner. A document, "Case Review Form? 05/09/18, showed the form was to be utilized as part of the peer?review process established by the hospital's Medical Staff bylaws. The conclusion of the review of Patient #10'5 medical care in the ED showed "there were several findings in the history and physical examination that should have prompted a more thorough evaluation in the emergency department. Treatment did not meet standard of care." The document also showed on 02/08/18, the patient was transferred from a primary care provider's clinic to another facility Land underwent surgery for pyloric stenosis. Patient #10 was a 27-day old infant, who was brought to the ED on three different occasions with complaints of vomiting, constipation and jaundice. Review of Patient #10'5 medical record showed the following: 0 Patient was in the emergency department on three occasions from 01/29/18 to 02/08/18 with complaints of vomiting, constipation, jaundice (yellowing of the yes caused by elevated liver enzymes, which is an indication of malabsorption of nutrients). - On 01/29/18 at 17 days old, patient was brought to the ED by his/her mother with complaints of throwing up after feeding. The EU provider documented a normal physical exam. There was no evidence the ED physician ordered labs, diagnostic imaging, or provided medications prior to patient discharge. The patient's weight was documented in the nurse?s notes as 3.81 kg. 0 On 02/05/28 at 24 days old patient, was brought to the ED by his/her mother with reports of continued vomiting, yellow tinted eyes, "jaundice tint to the skin," and blood in the urine. The ED provider documented "no mass, liver margin palpable". The ED provider did not address reports of blood in patient?s urine. The patient?s weight was documented in the nurse's notes as 3.45 kg. There was no evidence the ED physician ordered labs, diagnostic imaging, or provided medications prior to discharging patient home. a On 02/08/18 at 27 days old patient, was brought to the by his/her mother with reports of continued vomiting and no bowel movement for five days. The ED provider documented ?normal physical exam?. A glycerin suppository was administered. The provider documented GIPage the patient's weight at 3.45 kg, there was no documentation of weight in the nurse's notes. There was no evidence the ED physician INTRODUCTION AND BACKGROUND, CONCLUDED 0 ordered labs or diagnostic imaging and completed prior to patient being discharge home. a On 10/10/18 at 1:30 pm, Staff stated, ?we decided the contracted ED physician company should address these practices dealing with quality, we pulled records, we looked at census, we addressed concerns daily with them, there isn't documentation of those calls." Staff stated, in regards to Patient #10 "the lack of care from the doctors was identified". Staff stated the provider ?had to go through training on pyloric stenosis" (the facility was unable to provide documentation of training). 0 On 10/10/18 at 11:59 am, Staff (Chief of Staff and Medical Director of the ED) stated, the hospital had issues in the ED regarding the quality of care provided to patients by ED physicians. Staff stated he was aware the ED physicians had problems dealing with pediatric patients. Staff stated another provider had notified him of Patient #10 and he had agreed the standard of care in the ED had not been met(.033 7 Page 1. Describe your plan for correcting this deficiency? Stroke Findings 1, 2, 5: MHTC recognizes the imperative need for a policy and process detailing the appropriate Medical Screening Evaluation (MSE). Specifically, and per law, MHTC recognizes the following parameters as requirements to be included in appropriate Emergency Department documentation: 0 Patient identification 0 Time and means of injury I History of disease or injury 0 Physical findings 0 Medications, Allergies and Code Status 0 Laboratory and X-Ray reports, if any 0 Diagnosis and Therapeutic orders a Record of treatment including vital signs - Disposition of the case 0 Signature of the staff and provider 0 Documentation if the patient left against medical advice 0 Medical Records for patients treated by the emergency service, organized and where appropriate integrated with inpatient records, filed electronically. - Drug and biologicals distribution and control 0 Appropriate and efficient documentation of examinations, treatments and transfers of patients, in accordance with 42 CFR 489.20 and 489.24 Also implemented: - Utilization Review Consultant, who wili review 100% of all Emergency Department charts for a minimum period of six months. 0 Reviewed and updated 100% of ED Policies to confirm application and appropriateness of care. 0 Nursing Education Consultant, who will assist in the development and establishment ofa continuous and ongoing education plan for competency utilizing skills checklists, tests and hands-on learning tools. 0 Review and Collaborate with EMS Director to refine communications between Texas County EMS and MHTC ED: 0 Radio communications have already been reviewed, repaired and re?deployed as of the time of this corrective action plan, with meaningful and relevant initial training provided to all staff. This will serve as line of communication with EMS. 0 Telephone communications have also been reviewed, with no repair or modi?cation required. This will serve as of communication with EMS. 0 improve overali communications between EMS and MHTC ED. 0 Enter into transfer agreements for expeditious transfer as applicable for acute stroke patients to stroke centers able to provide a higher level of care. 0 Collaborate with EMS agencies, beginning with Guymon City EMS to develop inter?facility transfer protocols for stroke patients and will only use those EMS agencies that have a Department approved protocol for the inter-facility transfer of stroke patients. Policy established addressing staff education and process that a minimum standard shall be no more than 20 minutes from patient arrival to request for emergent transfer for acute stroke patients. 0 Policy established addressing staff education and process that a minimum standard shall be no more than 60 minutes for transfer of acute stroke patients as a total expected arrival-to-departure time no less than.65% of the time (reviewed quarterly), with accompanying comprehensive education plan. a Policy established addressing staff education and process that ALL RN staff and healthcare providers are able to recognize stroke patients and provide assessment as appropriate with documentation as described?in this corrective action plan. Plan will include F.A.S.T. protocol and National Institute of Health standards. . Policy established addressing staff education and process a written plan for transfer of patients to a Level, I, II, or Stroke Center. The written . plan shall establish medical conditions and circumstances to determine: 0 Which patients may be retained or referred for palliative or end-of?life care 0 Which patients shall require stabilizing treatment 0 Any ?suspected? acute stroke patient will be transferred per protocol 0 Which patients shall require transfer to a Level 1, ll, or Stroke Center Stroke Findings 3,4: MHTC stocks Activase as a standing drug utilized in the facility, but not as an intervention for Stroke Care; rather, as an intervention for Pulmonary Embolus and ST?Elevation Myocardial infarction Protocols related to the maintenance, purchase and control of Activase have been reviewed and updated, accompanied by significant education for nursing staff and pharmacy staff as wellLi Suicide Finding 1-6: MHTC recognizes the imperative need for a policy and process detailing the appropriate Medical Screening Evaluation (MSE). Specifically, and per law, MHTC recognizes the following parameters as requirements to be included in appropriate Emergency Department documentation: 0 Patient identification 0 Time and means of injury 0 History of disease or injury a Physical ?ndings 0 Medications, Allergies and Code Status 0 Laboratory and X?Ray reports, if any 0 Diagnosis and Therapeutic orders 0 Record of treatment including vital signs 0 Disposition of the case 0 Signature of the staff and provider 0 Documentation if the patient left against medical advice 0 Medical Records for patients treated by the emergency service, organized and where appropriate integrated with inpatient records, filed electronically. - Drug and biologicals distribution and control - Appropriate and efficient documentation of examinations, treatments and transfers of patients, in accordance with 42 CFR 489.20 and 489.24 Also implemented: - Utilization Review Consultant, who will review 100% of all Emergency Department charts for a minimum period of six months. 0 Reviewed and updated 100% of ED Policies to confirm application and appropriateness of care. 0 Nursing Education Consultant, who will assist in the development and establishment of a continuous and ongoing education plan for competency utilizing skills checklists, tests and hands-on learning tools. 0 Policy established addressing staff education and process that all ED patients age 10-24 will be screened for suicide risk using the ASQ screening toolkit developed by the National institute of Mental Health. I Policy established addressing staff education and process that all ED patients over the age of 24 will be screened for suicide risk using the PSS-3 tool developed by the Suicide Prevention Resource Center. 0 Policy established addressing staff education and process a written plan for telemedicine mental health consultation. The written plan shall establish risk levels and appropriate mental health consultation and intervention. 0 Policy established addressing staff education and process that all patients presenting with suicide attempt or ideation will receive telemedicine mental health evaluation. 0 We have utilized recommendations from the National institute of Mental Health and Suicide Prevention Resource Center to develOp and deploy our education and training. Suicide Finding 6: MHTC recognizes the imperative need for a policy and process detailing to the appropriate care and safety of suicidal patients through implementation of standardized screening and assessment of all patients presenting to the ED. lso implemented: 0 Policy established addressing staff education and process that all ED patients age 10-24 will be screened for suicide risk using the ASQ screening toolkit developed by the National Institute of Mental Health. 0 Policy established addressing staff education and process that all ED patients over the age of 24 will be screened for suicide risk using the PSS-3 tool developed by the Suicide Prevention Resource Center. 0 Policy established addressing staff education and process a written plan for telemedicine mental health consultation. The written plan shail establish risk levels and appropriate mental health consultation and intervention. 0 Policy established addressing staff education and process that all patients presenting with suicide attempt or ideation will receive telemedicine mental health evaluation. 0 Policy established addressing staff education and process that consultation of the American Academy of Poison Control will be utilized for all patients presenting with overdose of any substance, intentional or unintentional, to guide appropriate supportive care, diagnostic testing, and pharmacological intervention when applicable to minimize long term morbidity or mortality. a Policy established addressing staff education and process, (in accordance with Oklahoma State Statutes 340:2-3-33) that ensures proper DHS consultation for all mandatory reporting, including adolescent suicide attempt or ideation. - implementation of process for ED physicians to utilize Physician Handoff form for all Pediatric, Trauma, Stroke, or Chest pain patients present in the ED at the time of physician change of shift to ensure continuity, consistency, and congruency of plan of care between incoming and outgoing physicians. . Rattlesnake Bite Findings 1-7 3:3 Rat's i C. SIPage Snakebite Finding 1: MHTC has completed a review and revision of the snakebite policy and procedure utilizing the above referenced evidence? based practice references. The revised snakebite policy and procedure: Treatment and management of rattlesnake bites and common Unites States snakebites including the initial and ongoing management of snakebite wound care, patient observation time, appropriate release and discharge home process, clinical recognition and delineation of signs and differences between wet and dry snakebites, and the initiation of physician orders for wet and dry snakebites. 0 Has been vetted and approved by MHTC administration, MHTC Medical Staff and the Governing Board. 0 Staff education and training is nearing completion, utilizing: Relias computer-based training. 0 Review of current evidence?based practices as it relates to common United States snakebites, Emergency Department standup, briefings and updates. 0 Review of updated snakebite policy and procedure. 0 Relias training will be supplemented with face-to-face, inter-departmental training, which is on-going. 0 ED staff education is also complete as of 2/18/2019, with reinforcement training underway; expected completion prior to 3/18/2019, including poiiCy, process and forms. 0 As part of the QAPI activities for the department, the Emergency Department Team Leader will perform on-going, annual review of policies and procedures and current evidence-based practice in collaboration with the QRM Director. 0 Updates will be made accordingly per protocol through Medical Staff, Governing Board and QAPI. 0 Per current standard of 100% review of all ED charts, 100% of snakebite charts will also be reviewed, ensuring proper diagnosis and management practices are being meet in accordance to current recommended guidelines and standardof care. These charts will be monitored and reviewed by a utilization review consultant and enforced by MHTC administration, through a continuous quality improvement model of plan, do, check and act. 0 As a baseline, staff will audit prior to the utilization review consultant. The Emergency Department nursing staff is held reSponsible for completing their own concurrent chart audit. The Emergency Department nurse manager and the utilization review consultant will report compliance to the QRM Director and Quality Oversight Committee. The QRM Director shall report to the Medicai Staff and the Governing Board; any deficiencies will be addressed and changes in policy and procedure will be made according to standardized processes already in place here at MHTC. The hospital has purchased an electronic quality tool designed to help effectively manage, track, and monitor the large number of activities related to ensuring the safety and integrity of the patient care environment. The name of the tool is the Strategic Quality Support System (SQSS). This tool is an integral part of the long-range corrective action plan and continuous quality improvement plan for QAPI processes and program. This process is being conducted with the assistance of outside quality consultants. Snakebites are tracked and reviewed in this program. Snakebite Finding 2: Emergency Department Orders for Snake-Bite Patients (Wet Bite) Adult/Pediatric have been updated with current date and evidence-based practice and references. The orders have been vetted through Medical Staff, Governing Board, and QAPI. These orders reflect updated snake bite policy and procedures, approved by administration, Medical Staff, and Governing Board to include the following: Labs obtained will include, but are not limited to, CBC with platelet count, PTT, Fibrinogen, CMP, and urinalysis. 0 IV Access will be obtained in accordance with the aforementioned references. 0 The puncture site will be marked accordingly per aforementioned evidence-based references with date and time. Crofab will be administered per the manufacturer's recommendations and the revised policy and procedure including date and time of administration. 0 The process is currently being monitored by the administration team, facility Team Leaders, and the Quality Risk Management (QRM) Director. Snakebite Finding 3: If and when a complaint is initiated, the QRM Director maintains documentation in 3055 regarding all aspects of the grievance process. This includes reviews, Medical Staff committee review, Governing Board review, and closing the loop with feedback and communication to the patient and or patient representative including communicating the plan to improve quality of care and plan to meet the standard of care in accordance with the most up to date and current evidence-based practice. When reviewing the patient grievance process and the standard of care is found to not be met, review of the policy and procedure, protocol, physician orders, staff education and training, among others are to be reviewed and updated accordingly, utilizing the most current and up to date evidence-based practice and standards. This update to the policy and procedure, protocol, and any other clinical process is to be reviewed by med staff and the Governing Board and if agreed upon as clinically sound, implemented accordingly. Staff education and training is complete as of 2/18/19, the Relias computer~based training; follow-up education face-to-face and inter?departmental is on-going. Review of current evidence?based practices as it relates to common United States snakebites, Emergency Department standup briefings and updates, and review of updated snakebite policy and procedure. The Emergency Department nursing department preliminary education is complete, including policy, process and forms. As part of the QAPI activities for the department, the Emergency Department Team Leader will perform annual review of policies and procedures and current evidence-based practice in collaboration with the QAPI Manager. Updates will be made accordingly, as needed based on review, through MHTC protocol. 100% of snakebite charts will be reviewed, ensuring proper diagnosis and management practices are being meet in accordance to current recommended guidelines and standard of care. These charts will be monitored and reviewed by a utilization review consultant and enforced by MHTC administration. As a baseline, staff will audit prior to the utilization review consultant. The Emergency Department nursing staff is held responsible for completing their own concurrent chart audit. The Emergency Department nurse manager and the utilization review consultant will report compliance to the QRM Director and Quality Oversight Committeethhe QRM Director 10lPage 5 JAN 28 2323 l1". 1 shall report to the Medical Staff and the Governing Board; any deficiencies will be addressed and changes in policy and procedure will be made according to standardized processes already in place here at MHTC. The hospital has purchased an electronic quality tool designed to help effectively manage, track, and monitor the large number of activities related to ensuring the safety and integrity of the patient care environment. The name of ithe tool is the Strategic Quality Support System (SQSS). This tool is an integral part of the long-range corrective action plan and continuous quality improvement plan for MHTC's processes and program. This process is being conducted with the assistance of outside quality consultants. Snakebites are tracked and reviewed in this program Snakebite Finding 4: E53 physicians (ED Medical Staffing group) are no longer the Emergency Department staffing group for MHTC. Medestar physicians are currently staffing the Emergency Department for MHTC. In addition, the Oklahoma Office of Rural Health awarded a grant to conduct peer reviews and will be utilized for this service -- internally contracted physicians will not be utilized for peer chart review. Continuing Quality Improvement will be conducted by the Quality Risk Management Director, but all staff are accountable and empowered to participate in the quality improvement processes for MHTC. The Quality improvement process centers around on-going "Plan, Do, Check, Act" (PDCA) theory and includes but is not limited to revision of policy and procedure, staff education and training, physician education and training, contracted physician accountability, and staff empowerment and accountability. Follow-up with the patient to validate outcome of care and inform the patient of changes and improvements in continuous quality of care is also paramount; MHTC already has mechanisms in place whereby the ED staff make phone calls to patients. This phone call process is successful and monitored quantitatively. Moreover, as part of the activities for the department, the Emergency Department Team Leader performs annual review of policies and procedures and current evidence?based practice in collaboration with the Quality Risk Management Director. Updates will be made accordingly, as needed based on review, through MHTC protocol. Per current standard of 100% review of all ED charts, 100% of snakebite charts will also be reviewed, ensuring proper diagnosis and management practices are being meet in accordance to current recommended guidelines and standard of care. These charts will be monitored and reviewed by a utilization review consultant and enforced by MHTC administration, through a continuous quality improvement model of plan, do, check and act. As a baseline, staff will audit prior to the utilization review consultant. The Emergency Department nursing staff is held responsible for completing their own concurrent chart audit. The Emergency Department nurse manager and the utilization review consultant will report compliance to the QRM Director and Quality Oversight Committee. The QRM Director shall report to the Medical Staff and the Governing Board; any deficiencies will be addressed and changes in policy and procedure will be made according to standardized processes already in place here at MHTC. The hospital has purchased an electronic quality tool designed to help effectively manage, track, and monitor the large number of activities related to ensuring the safety and integrity of the patient care environment. The name of the tool is the Strategic Quality Support System (5055). This tool is an integral part of the long-range corrective action plan and continuous quality improvement plan for QAPJ processes and program. This process is being conducted with the assistance of outside quality consultants. Snakebites are tracked and reviewed in this program. ?nakebite Finding E85 physicians (ED Medical Staffing group) are no longer the Emergency Department staffing group for MHTC. Medestar physicians are currently staffing the Emergency Department for MHTC. in addition, the Oklahoma Office of Rural Health awarded a grant to conduct peer reviews and will be utilized for this service internally contracted physicians will not be utilized for peer chart review. Continuing Quality Improvement will be conducted by the Quality Risk Management Director, but all staff are accountable and empowered to participate in the quality improvement processes for MHTC. The Quality improvement process centers around on-going ?Plan, Do, Check, Act? (PDCA) theory and includes but is not limited to revision of policy and procedure, staff education and training, physician education and training, contracted physician accountability, and staff empowerment and accountability. Follow?up with the patient to validate outcome of care and inform the patient of changes and improvements in continuous quality of care is also paramount; MHTC already has mechanisms in place whereby the ED staff make phone calls to patients. This phone call process is successful and monitored quantitatively. Moreover, as part of the activities for the department, the Emergency Department Team Leader performs annual review of policies and procedures and current evidence~based practice in collaboration with the Quality Risk Management Director. Updates will be made accordingly, as needed based on review, through MHTC protocol. Per current standard of 100% review of all ED charts, 100% of snakebite charts will also be reviewed, ensuring proper diagnosis and management practices are being meet in accordance to current recommended guidelines and standard of care. These charts will be monitored and reviewed by a utilization review consultant and enforced by MHTC administration, through a continuous quality improvement model of plan, do, check and act. As a baseline, staff will audit prior to the utilization review consultant. The Emergency Department nursing staff is held responsible for completing their own concurrent chart audit. The Emergency Department nurse manager and the utilization review consultant will report compliance to the QRM Director and Quality Oversight Committee. The QRM Director shall report to the Medical Staff and the Governing Board; any deficiencies will be addressed and changes in policy and procedure will be made according to standardized processes already in place here at MHTC. The hospital has purchased an electronic quality tool designed to help effectively manage, track, and manitor the large number of activities related to ensuring the safety and integrity of the patient care environment. The name of the tool is the Strategic Quality Support System (SQSS). This tool is an integral part of . . iv. ,n11 Page i i i i the long-range corrective action plan and continuous quality improvement plan for MHTC's QAPI processes and program. This process is being conducted with the assistance of outside quality consultants. Snakebites are tracked and reviewed in this program. [Snakebite Finding 6: MHTC has completed a review and revision of the snakebite policy and procedure utilizing the above referenced evidence-based practice references. The revised snakebite policy and procedure: Emergency Department Orders for Snake-Bite Patients (Wet Bite) Adult/Pediatric have been updated with current date and evidence?based practice and references. The orders have been vetted through Medical Staff, Governing Board, and QAPI. These orders reflect updated snake bite policy and procedures, approved by administration, Medical Staff, and Governing Board to include the following: bnakebite Finding 7: MHTC has completed a review and revision of the snakebite policy and procedure utilizing the above referenced evidence-based practice references. The revised snakebite policy and procedure: Treatment and management of rattlesnake bites and common Unites States snakebites including the initial and ongoing management of snakebite Wound care, patient observation time, appropriate discharge home process, clinical recognition and delineation of signs and differences between wet and dry snakebites, and the initiation of physician orders for wet and dry snakebites. Has been vetted and approved by MHTC administration, MHTC Medical Staff and the Governing Board. Staff education and training is nearing completion, utilizing the Relies computer-based training, review of current evidence?based practices as it relates to common United States snakebites, Emergency Department standup briefings and updates, and review of updated snakebite policy and procedure. Relias training will be supplemented with face?to-faCe, inter-departmental training, which is ongoing. ED staff education is also complete, with reinforcement training underway; expected completion prior to March 18, 2019, including policy, process and forms. As part of the QAPI activities for the department, the Emergency Department Team Leader will perform on-going, annual review of policies and procedures and current evidence?based practice in collaboration with the QRM Director. Updates will be made accordingly per protocol through Medical Staff, Governing Board and QAPI. Per current standard of 100% review of all ED charts, 100% of snakebite charts will also be reviewed, ensuring proper diagnosis and management practices are being meet in accordance to current recommended guidelines and standard of care. These charts will be monitored and reviewed by a utilization review consultant and enforced by MHTC administration, through a continuous quality improvement model of plan, do, check and act. As a baseline, staff will audit prior to the utilization review consultant. The Emergency Department nursing staff conducts a concurrent chart audit. The Emergency Department nurse manager and the utilization review consultant will report compliance to the QRM Director and Quality Oversight Committee. The QRM Director shall report to the Medical Staff and the Governing Board. The hospital has purchased an electronic quality tool designed to help effectively manage, track, and monitor the large number of activities related to ensuring the safety and integrity of the patient care environment. The name of the tool is the Strategic Quality Support System (SQSS). This tool is an integral part of the long-range corrective action plan and continuous quality improvement plan for MHTC's QAPI processes and program. This process is being conducted with the assistance of outside quality consultants. Snakebites are tracked and reviewed in this program. Labs obtained will include, but are not limited to, CBC with platelet count, PTT, Fibrinogen, CMP, and urinalysis. lV Access will be obtained in accordance with the aforementioned references. The puncture site will be marked accordingly per aforementioned evidence-based references with date and time. Crofab will be administered per the manufacturer?s recommendations and the revised policy and procedure including date and time of administration. The process is currently being monitored by the administration team, facility Team Leaders, and the Quality Risk Management Director. a Treatment and management of rattlesnake bites and common Unites States snakebites including the initial and ongoing management of snakebite wound care, patient observation time, appropriate discharge home process, clinical recognition and delineation of signs and differences between wet and dry snakebites, and the initiation of physician orders for wet and dry snakebites. Has been vetted and approved by MHTC administration, MHTC Medical Staff and the Governing Board. Staff education and training is nearing completion, utilizing the Relias computer-based training, review of current evidence-based practices as it relates to common United States snakebites, Emergency Department standup briefings and updates, and review of updated snakebite policy and procedure. Relias training will be supplemented with face-to-face, inter-departmental training, which is on-going. ED staff education is also complete, with reinforcement training underway,- expected completion prior to March 18, 2019, including policy, process and forms. As part of the activities for the department, the Emergency Department Team Leader will perform on-going, annual review of policies and procedures and current evidence-based practice in collaboration with the QRM Director. Updates will be made accordingly per protocol through Medical Staff, Governing Board and Per current standard of 100% review of all ED charts, 100% of snakebite charts will also be reviewed, ensuring proper diagnosis and management practices are being meet in accordance to current recommended guidelines and standard of care. These charts will be monitored and reviewed by a utilization review consultant and enforced by MHTC administration, through a continuous quality improvement model of plan, do, check and act. .. 12:: JAN 138 Zuni w? "a i i . I As a baseline, staff will audit prior to the utilization review consultant. The Emergency Department nursing staffis held responsible for completing their own concurrent chart audit. The Emergency Department nurse manager and the utilization review consultant will report compliance to the QRM Director and Quality Oversight Committee. The QRM Director shall report to the Medical Staff and the Governing Board; any de?ciencies will be addressed and changes in policy and procedure will be made according to standardized processes already in place here at MHTC. The hospital has purchased an electronic quality tool designed to help effectively manage, track, and monitor the large number of activities related to ensuring the safety and integrity of the patient care environment. The name of the tool is the Strategic Quality Support System (5055). This tool is an integral part of the long~range corrective action plan and continuous quality improvement plan for MHTC's QAPI processes and program. This process is being conducted with the assistance of outside quality consultants. Snakebites are tracked and reviewed in this program. Emergency Department Orders for Snake-Bite Patients (Wet Bite) Adult/Pediatric have been updated with current date and evidence-based practice and references. The orders have been vetted through Medical Staff, Governing Board, and QAPI. These orders reflect updated snake bite policy and procedures, approved by administration, Medical Staff, and Governing Board to include the following: Labs obtained will include, but are not limited to, CBC with platelet count, PTT, Fibrlnogen, CM P, and urinalysis. 0 IV Access will be obtained in accordance with the aforementioned references. 0 The puncture site will be marked accordingly per aforementioned evidence-based references with date and time. Crofab will be administered per the manufacturer?s recommendations and the revised policy and procedure including date and time of administration. 0 The process is currently being monitored by the administration team, facility Team Leaders, and the Quality Risk Management Director. Critical communication between MHTC Pharmacy, Emergency Department staff, local providers, EMS director, and MHTC Chief of Staff addressing the on-hand availability of CroFab during snakebite season has already been established and will be reinforced on-going: 0 Goal of a minimum of six CroFab on hand for the initial dose and to start the recommended CroFab protocol, per manufacturer's recommendations. 0 MHTC is in collaboration with nearby facilities to develop a "share network? with CroFab. We will communicate and establish protocols with EMS addressing procedures if MHTC is short CroFab doses and there is a snakebite injury. This includes communication by radio to EMS identifying current shortfall of CroFab and timeline to be stocked and ready to accept snakebite patients. 0 if CroFab is unavailable establish a communication process with EMS to bypass MHTC. Staff education and training is complete via Relias for this topic, with reinforcement face-to-face and inter-departmental training currently underway. - Concurrent review is completed as it relates to common United States snakebites and CroFab, Emergency Department standup briefings and updates, and review of updated snakebite policy and procedure. 0 As part of the QAPI activities for the department, the Emergency Department Team Leader will perform on-going, annual review of policies and procedures and current evidence?based practice in collaboration with the QRM Director. 0 Updates will be made accordingly per protocol through Medical Staff, Governing Board and QAPI. Per current standard of 100% review of all ED charts, 100% of snakebite charts will also be reviewed, ensuring proper diagnosis and management practices are being meet in accordance to current recommended guidelines and standard of care. These charts will be monitored and reviewed by a utilization review consultant and enforced by MHTC administration, through a continuous quality improvement model of plan, do, check and act. 0 As a baseline, staff will audit prior to the utilization review consultant. The Emergency Department nursing staff is held responsible for completing their own concurrent chart audit. The Emergency Department nurse manager and the utilization review consultant will report compliance to the QRM Director and Quality Oversight Committee. The QRM Director shall report to the Medical Staff and the Governing Board; any deficiencies will be addressed and changes in policy and procedure will be made according to standardized processes already in place here at MHTC. The hospital has purchased an electronic quality tool designed to help effectively manage, track, and monitor the large number of activities related to ensuring the safety and integrity of the patient care environment. The name of the tool is the Strategic Quality Support System (5055). This tool is an integral part of the long-range corrective action plan and continuous quality improvement plan for MHTC's QAPI processes and program. This process is being conducted with the assistance of outside quality consultants. Snakebites are tracked and reviewed in this program. Pediatric Finding 1: MHTC recognizes the imperative need for a policy and process detailing the appropriate Medical Screening Evaluation (MSE). Speci?cally, and per law, MHTC recognizes the following parameters as requirements to be included in appropriate Emergency Department documentation: 0 Patient Identification 0 Time and means of injury a History of disease or injury 0 Physical findings 0 Medications, Allergies and Code Status 0 Laboratory and X-Ray reports, if any 0 Diagnosis and Therapeutic orders 1* r?r JAN 5:3 8 30k? 13 Page 0 Record of treatment including vital signs 0 Disposition of the case 0 Signature of the staff and provider 0 Documentation if the patient left against medical advice 0 Medical Records for patients treated by the emergency service, organized and where appropriate integrated with inpatient records, filed electronically. 0 Drug and biologicals distribution and control 0 Appropriate and efficient documentation of examinations, treatments and transfers of patients, in accordance with 42 CFR 489.20 and 489.24 Also implemented: - Utilization Review Consultant, who will review 100% of all Emergency Department charts for a minimum period of six months. 0 Reviewed and updated 100% of ED Policies to con?rm application and appropriateness of care. 0 Nursing Education Consultant, who will assist in the development and establishment of a continuous and ongoing education plan for competency utilizing skills checklists, tests and hands-on learning tools. 0 Policy established addressing ALL ED RN's shall be certified in Pediatric Advanced Life Support (PALS) and/or Emergency Nursing Pediatric Course (ENPC) within six months of hire. a Policy established addressing staff education and process that ALL RN staff and healthcare providers are to be trained in pediatric patient care and provide assessment as appropriate with documentation as described in this corrective action plan. a Policy established addressing staff education and process a written plan for transfer of patients to a higher level of care at a pediatric Intensive Care Unit or ED if appropriate. The written plan establishes medical conditions and circumstances to determine: 0 Which patients may be retained or referred to a higher level of care utilizing evidence based practice and acuity level worksheet. 0 Which patients shall require stabilizing treatment 2. Describe the improvements to the processes that led to the cited deficiency? Stroke Findings 1-6: MHTC is fully committed to process improvement. As mentioned in other segmentls) of this corrective action plan, there is significant human resources being placed toward success in this project and overall improvement of our hospital. We are committed to the health and well-being of our community. Here is a segment of our progress thus far, with far-reaching positive implications moving forward: 0 We have brought back our previous Quality Director as a mentor and consultant to the new-hire Quality and Risk Management Director for an indefinite period of time. 0 We have re-evaluated all ED policies and vetted them through our Medical Staff as well as our Governing Board. 0 We have hired a Utilization Review consultant who will work with us collaboratively to improve processes and will simultaneously audit 100% ofall ED charts for a minimum period of six months. a We have improved our staff insight into chart review through face-to-face and online education, to provide the Utilization Review Consultant with baseline reviews prior to the chart ever reaching Utilization Review. 0 We have established a TEAM LEADER model of care?delivery, allowing for a transparent chain?of-command and clear access to supervisors and resources for all levels of staff across all departments. 0 We have re-engaged our Governing Board to re?evaluate their processes and improve oversight to the facility overall. Suicide Findings 1-6: MHTC is fully committed to process improvement. As mentioned in other segment(s) of this corrective action plan, there are significant human resources being placed toward success in this project and overall improvement of our hospital. We are committed to the health and wen-being of our community. Here is a segment of our progress thus far, with far?reaching positive implications moving forward: 0 We have brought back our previous Quality Director as a mentor and consultant to the new?hire Quality and Risk Management Director for an indefinite period of time. . We have re?evaluated all ED policies and vetted them through our Medical Staff as well as our Governing Board. 0 We have hired a Utilization Review consultant who will work with us collaboratively to improve processes and will simultaneously audit 100% of all ED charts for a minimum period of six months. I We have improved our staff insight into chart review through face-to-face and online education, to provide the Utilization Review Consultant with baseline reviews prior to the chart ever reaching Utilization Review. a We have established 3 TEAM LEADER model of care-delivery, allowing for a transparent chain-of-command and clear access to supervisors and resources for all levels of staff across all departments. - 0 We have re-engaged our Governing Board to re?evaluate their processes and improve oversight to the facility overall. Snakebite Findings 1-7: Continuing Quality Improvement will be conducted by the Quality Risk Management Director, but all staff are accountable and empowered to participate in the quality improvement processes for MHTC. The Quality improvement process centers around on-going ?Plan, Do, Check, Act? (PDCA) 14 Page {41 1:1: wu w: ?New" CAD rm) :3 It} heory and includes but is not limited to revision of policy and procedure, staff education and training, physician education and training, contracted physician accountability, and staff empowerment and accountability. Follow-up with the patient to validate outcome of care and inform the patient of changes and improvements in continuous quality of care is also paramount; MHTC already has mechanisms in place whereby the ED staff make phone calls to patients. This phone call process is successful and monitored quantitatively. Moreover, as part of the activities for the department, the Emergency Department Team Leader performs annual review of policies and procedures and current evidence-based practice in collaboration with the Quality Risk Management Director. Updates will be made accordingly, as needed based on review, through MHTC protocol. Per current standard of 100% review of all ED charts, 100% of snakebite charts will also be reviewed, ensuring proper diagnosis and management practices are being meet in accordance to current recommended guidelines and standard of care. These-charts will be monitored and reviewed by a utilization review consultant and enforced by MHTC administration, through a continuous quality improvement model of plan, do, check and act. As a baseline, staff will audit prior to the utilization review consultant. The Emergency Departn'ient nursing staff is held responsible for completing their own concurrent chart audit. The Emergency Department nurse manager and the utilization review consultant will report compliance to the QRM Director and Quality Oversight Committee. The QRM Director shall report to the Medical Staff and the Governing Board; any deficiencies will be addressed and changes in policy and procedure will be made according to standardized processes already in place here at MHTC. The hospital has purchased an electronic quality tool designed to help effectively manage, track, and monitor the large number of activities related to ensuring the safety and integrity of the patient care environment. The name of the tool is the Strategic Quality Support System (SQSS). This tool is an integral part of the long-range corrective action plan and continuous quality improvement plan for QAPI processes and program. This process is being conducted with the assistance of outside quality consultants. Snakebites are tracked and reviewed in this program Pediatric Finding 1: Utilization Review Consultant, who will review 100% of all Emergency Department charts for a minimum period of six months. 0 Reviewed and updated 100% of ED Policies to confirm application and appropriateness of care. 0 Nursing Education Consultant, who will assist in the development and establishment of a continuous and ongoing education plan for competency utilizing skills checklists, tests and hands?on learning tools. 0 Policy established addressing ALL ED shali be certified in Pediatric Advanced Life Support (PALS) and/or Emergency Nursing Pediatric Course (ENPC) within six months of hire. 0 Policy established addressing staff education and process that ALL RN staff and healthcare providers are to be trained in pediatric patient care and provide assessment as appropriate with documentation as described in this corrective action plan. 0 Policy established addressing staff education and process a written plan for transfer of patients to a higher level of care at a pediatric Intensive Care Unit or ED if appropriate. The written plan shall establish medical conditions and circumstances to determine: 0 Which patients may be retained or referred to a higher level of care utilizing evidence based practice and acuity level worksheet. 0 Which patients shall require treatment 3. Describe your procedures for implementing the plan of correction for this deficiency. Stroke Findings 1, 2, S: MHTC recognizes the imperative need for an effective and efficient implementation process for the necessary corrective steps toward success. Regarding documentation and validation of documentation, policy and process related to the appropriate Medicai Screening Evaluation (MSE), MHTC recognizes legal requirements necessary to arrive at thorough, appropriate and adequate documentation for the Emergency Department in general and more specifically the acute stroke patient. MHTC shall educate and condone appropriate and efficient documentation of examinations, treatments and transfers of patients, in accordance with 42 CFR 489.20 and 489.24. in addition, MHTC shall: 0 Utilization Review Consultant, who will review 100% of all Emergency Department charts for a minimum period of six months. 0 Reviewed and updated 100% of ED Policies to confirm application and appropriateness of care. 0 Nursing Education Consultant, who will assist in the development and establishment of a continuous and ongoing education plan for competency utilizing skills checklists, tests and hands?on learning tools. - Collaborate with EMS Director for City of Guymon to refine communications between EMS and MHTC ED: 0 Radio communications have already been reviewed, repaired and re?deployed as of the time of this corrective action plan, with meaningful and relevant initial training provided to all staff. This will serve as PRIMARY iine of communication with EMS. 0 Telephone communications have also been reviewed, with no repair or modification required. This will serve as of communication with EMS. 0 Improve overall communications between EMS and MHTC ED. 0 Enter into transfer agreements for expeditious transfer as applicable for acute stroke patients to stroke centers able to provide a higher level of care. 0 Collaborate with EMS agencies, beginning with Guymon City EMS to develop inter-facility transfer protocols for stroke patients and will only use those EMS agencies that have a Department approved protocol for the inter- -facility transfer of stroke patients. Policy established addressing staff education and process that a minimum standard shall be no more than 20 minutes from patient arrival to request for emergent transfer for acute stroke patients .. - 15 Page (Una-sinus - Policy established addressing staff education and process that a minimum standard shall be no more than 60 minutes for transfer of acute stroke patients as a total expected arrival-to-departure time no less than 65% of the time (reviewed quarterly), with accompanying comprehensive education plan. 0 Policy established addressing staff education and process that ALL RN staff and healthcare providers are able to recognize stroke patients and provide assessment as appropriate with documentation as described in this corrective action plan. 0 Policy established addressing staff education and process a written plan for transfer of patients to a Level, I, II, or Stroke Center. The written plan shall establish medical?conditions and circumstances to determine: 0 Which patients may be retained or referred for palliative or end-of~life care 0 Which patients shall require stabilizing treatment 0 Any ?suspected? acute stroke patient will be transferred per protocol 0 Which patients shall require transfer to a Level I, ll, or Stroke Center Stroke Findings 3,4: MHTC has removed Activase as a standing drug utilized for Stroke care utilized in the facility. Protocols related to the maintenance, purchase and control of Activase have been reviewed and updated, accompanied by significant education for nursing staff and pharmacy staff as well. On-going education for these departments related to this critical life-saving medication are paramount to the success of the facility, even though MHTC will no longer be administering Activase to any acute stroke patient (in adherence to the Level iV designation as described previously in this corrective action document). Suicide Findings 1-6: MHTC recognizes the imperative need for an effective and efficient implementation process for the necessary corrective steps toward success. Regarding documentation and validation of documentation, policy and process related to the appropriate Medical Screening Evaluation (MSE), MHTC recognizes legal requirements necessary to arrive at thorough, appropriate and adequate documentation for the Emergency Department in general and more Specifically the suicidal patient. MHTC shall educate and condone appropriate and efficient documentation of examinations, treatments and transfers of patients, in accordance with 42 CFR 489.20 and 489.24. In addition, MHTC shall: 0 Utilization Review Consultant, who will review 100% of all Emergency Department charts for a minimum period of six months. 0 Reviewed and updated 100% of ED Policies to confirm application and appropriateness of care. a Nursing Education Consultant, who will assist in the development and establishment of a continuous and ongoing education plan for competency utilizing skills checklists, tests and hands?on learning tools. - Collaborate with Northwest Center for Behavioral Health to update and refine existing agreement between and MHTC ED. Snakebite Findings 1-7: Continuing Quality Improvement will be conducted bythe Quality Risk Management Director, but all staff are accountable and empowered to participate in the quality improvement processes for MHTC. The Quality improvement process centers around on-going ?Plan, Do, Check, Act" (PDCA) theory and includes but is not limited to revision of policy and procedure, staff education and training, physician education and training, contracted physician accountability, and staff empowerment and accountability. Follow-up with the patient to validate outcome of care and inform the patient of changes and improvements in continuous quality of care is also paramount; MHTC already has mechanisms in place whereby the ED staff make phone calls to patients. This phone call process is successful and monitored quantitatively. Moreover, as part of the activities for the department, the Emergency Department Team Leader performs annual review of policies and procedures and current evidence-based practice in collaboration with the Quality Risk Management Director. Updates will be made accordingly, as needed based on review, through MHTC protocol. Per current standard of 100% review of all ED charts, 100% of snakebite charts will also be reviewed, ensuring proper diagnosis and management practices are being meet in accordance to current recommended guidelines and standard of care. These charts will be monitored and reviewed by a utilization review consultant and enforced by MHTC administration, through a continuous quality improvement model of plan, do, check and act. its a baseline, staff will audit prior to the utilization review consultant. The Emergency Department nursing staff is held responsible for completing their own concurrent chart audit. The Emergency Department nurse manager and the utilization review consultant will report compliance to the QRM Director and Quality Oversight Committee. The QRM Director shall report to the Medical Staff and the Governing Board; any deficiencies will be ddressed and changes in policy and procedure will be made according to standardized processes already in place here at MHTC. The hospital has purchased an electronic quality tool designed to help effectively manage, track, and monitor the large number of activities related to ensuring the safety and integrity of the patient care environment The name of the tool is the Strategic Quality Support System (SQSS). This tool is an integral part of the long- range corrective action plan and continuous quality improvement plan for 5 processes and program. This process is being conducted with the assistance of outside quality consultants. Snakebites are tracked and reviewed In this program. Pediatric Finding 1: MHTC recognizes the imperative need for a policy and process detailing the appropriate Medical Screening Evaluation (MSE). Specifically, and per law, MHTC recognizes the following parameters as requirements to be included In appropriate Emergency Department documentation. 0 Patient identification I 0 Time and means of Injury Ii ii ?28 35,255 16 Page :u .1 I History of disease or injury Physical findings Medications, Allergies and Code Status Laboratory and X~Ray reports, if any Diagnosis and Therapeutic orders Record of treatment including vital signs Disposition of the case Signature of the staff and provider Documentation if the patient left against medical advice Medical Records for patients treated by the emergency service, organized and where appropriate integrated with inpatient records, filed electronically Drug and biologicais distribution and control 0 Appropriate and efficient documentation of examinations, treatments and transfers of patients, in accordance with 42 CFR 489.20 and 489.24 Also implemented: 0 Utilization Review Consultant, who will review 100% of all Emergency Department charts for a minimum period of six months. 0 Reviewed and updated 100% of ED Policies to confirm application and appropriateness of care. 0 Nursing Education Consultant, who will assist in the development and establishment of a continuous and ongoing education plan for competency utilizing skills checklists, tests and hands?on learning tools. a Policy established addressing ALL ED shall be certified in Pediatric Advanced Life Support (PALS) and/or Emergency Nursing Pediatric Course (ENPC within six months of hire). a Policy established addressing staff education and process that ALL RN staff and healthcare providers are to be trained in pediatric patient care and provide assessment as appropriate with documentation as described in this corrective action plan. 0 Policy established addressing staff education and process a written plan for transfer of patients to a higher level of care at a pediatric intensive Care Unit or ED if apprOpriate. The written plan shall establish medical conditions and circumstances to determine: 0 Which patients may be retained or referred to a higher level of care utilizing evidence based practice and acuity level worksheet. 0 Which patients shall require stabilizing treatment. 0 4. Describe themonitoring procedures to ensure that the plan for correcting this deficiency is effective and remains corrected and/or in compliance with the regulatory requirements? what program will be put into place to monitor the continued effectiveness of the systemic changes? (This is part of your QAPI processes) Monitoring processes will be transparent, thorough, secure, and efficient. They will include: 0 meetings with EMS to assure on-going transparent and effective communications between EMS and MHTC ED 0 Deployment of a communications log for the ED staff, to help pass along internal communications and relevant/timely information related to the department 0 Update of all ED policies 0 Re?education (through the online program RELIAS, as described in the QAPI segment of this corrective action plan) as well as on?going face- to-face education with ED staff across all shifts which will be mandatory and tracked via Nursing Education a On-going research to incorporate evidence-based practice solutions 0 Multi-faceted tracking solutions the incorporates Utilization Review Consultant, the Quality Oversight Committee, Medical Staff and Governing Board 0 Pie-deployment of QAPI initiatives 0 involve of Medical Staff and Governing Board for collaboration, consistency, and seamless communicationis) Continuing Quality improvement will be conducted by the Quality Risk Management Director, but all staff are accountable and empowered to participate in the quality improvement processes for MHTC. The Quality improvement process centers around on- going ?Plan Do, Check, Act? (PDCA) theory and includes but Is not limited to revision of policy and procedure staff education and training, physician education and training, contracted physician accountability, and staff empowerment and accountability. Follow~up with the patient to validate outcome of care and inform the patient of changes and improvements in continuous quality of care is also paramount; MHTC already has mechanisms in place whereby the ED staff make phone calls to patients. This phone call process is successful and monitored quantitatively. Moreover, as part of the activities for the department, the Emergency Department Team Leader performs annual review of policies and procedures and current evidence- based practice in collaboration with the Quality Risk Management Director, Updates wili be 5 17 Page 1: will i i g4" I [made accordingly, as needed based on review, through MHTC protocol. Per current standard 100% review of all ED charts, ensuring proper diagnosis and management practices are being met in accordance to current recommended guidelines and standard of care. These charts will be monitored and reviewed by a utilization review consultant and enforced by MHTC administration, through a continuous quality improvement model of plan, do, check and act. As a baseline, staff wiil audit prior to the utilization review consultant. The Emergency Department nursing staff is held responsible for completing their own concurrent chart audit. The Emergency Department nurse manager and the utilization review consultant will report compliance to the QRM Director and Quality Oversight Committee. The QRM Director shall report to the Medical Staff and the Governing Board; any de?ciencies will be addressed and changes in policy and procedure will be made according to standardized processes already in place here at MHTC. The hospital has purchased an electronic quality tool designed to help effectively manage, track, and monitor the large number of activities related to ensuring the safety and integrity of the patient care environment. The name of the tool is the Strategic Quality Support System (5055). This tool is an integral part of the long~range corrective action plan and continuous quality improvement plan for MHTC's QAPI processes and program. This process is being conducted with the assistance of outside quality consultants. 5. Provide the title of the person responsible for correcting this deficiency and ensuring complia nce? Quality and Risk Management Director Interim Hospital Administrator Hospital Administrative Team Leaders and Clinical Team Leaders Medical Staff Governing Board 6. Provide the date this deficiency corrective action/s will be completed? (Correction dates should be no more than 60 days from the survey exit date) March 13,2013 and on-going 7. Make sure you have signed and dated the first page of the CMS-2567 (Statement of Deficiencies). Use this tool for each tag listed on the CMS-2567. Additionally, write "See Attached" in the right-hand column for every tag cited on the CMS-2567. rm?- hill 2' E3 (Mill 18 Page (X4) ID Prefix (Tagll): FACILITY NAME Event SZP111 336 Memorial Hospital of Texas County Facility ID: HP2249 INTRODUCTION AND BACKGROUND Periodic Evaluation QA Review I During a recent survey, it was discovered the QAPI (MHTC refers to Quality Oversight) program for the hospital was ineffective and in desperate need of a multi-faceted intervention. The Quality and Risk Management (QRM) Director, functional leadership for the Program, at that time was immediately dismissed and the previous QRM Director brought back in full-time to mentor the selected QRM Director, in~training. The goal was to immediately refine, revive and re-deploy efficient and impactful quality program(s) and initiatives across the entire facility. While the hospital is in the process of addressing the other issues identified during the survey, a strong and concerted effort is being placed on regaining a successful Quality program and ensuring it is integrated across all departments as applicable as we know that can help build stronger mechanisms of monitoring and control going forward. it should also be noted the hospital is in the process of training a QRM Director as noted above; in addition, the hospital has deployed a Utilization Review Consultant, updating Education processes, and refining the Governing Board?s education and monitoring processes. As part of its corrective action plan and Memorial Hospital of Texas County?s long?range plan to strengthen its quality program, the hospital has also purchased an electronic quality program (50.55) designed to help hospitals to more effectively manage the large number of quality related activities important to ensure the safety and integrity of the patient care environment. This hospital, like many small hospitals, has historically struggled to manage the vast number of activities that are important in having a strong quality program because of the high number of activities that have to be managed by a smaller workforce. This tool is speci?cally designed to increase capacity in these types of situations by having it supplement the workforce in scheduling, tracking, and recording activities. While there are a number of features in SQSS that the hospital will take advantage of, the primary piece currently being implemented will keep track of important quality activities that have to happen such as the number of quality control checks related to the CMS Conditions of Participation and patient safety. it alerts staff when they are due, collects the information about the completion of those activities, automatically notifies leadership when a task is not recorded as completed, automatically schedules periodic validation reviews by managers and quality professional to verify that activities are being completed properly, automatically generates important compliance reports for leadership and quality committee review and makes it faster and easier for leadership to put their hands on key information. SQSS has a series of hardwired checklists to reduce the risk that an important quality related activity could be over looked or drift without being identified. In SQSS, frontline personnel complete scheduled activities. SQSS then periodically schedules validation reviews by managers and quality professionals. It lthen also periodically schedules environmental surveillances by a team of quality professionals and leaders to provide for a type of checks and balances that can identify errors before they can evolve into a risk that can cause harm. The monitoring of the activities and follow-up to any identified concerns will be part of the regularly scheduled reports to the Quality Oversight ommittee and included in the regularly scheduled QAPI reports to the Medical Staff and the Governing Board. Additional details regarding our QAPI efforts are detailed herein. 1. Describe your plan for correcting this deficiency? Stroke Findings 1, 2, 5: MHTC recognizes the imperative need for a policy and process related to the appropriate Medical Screening Evaluation (MSE). Specifically, and per law, MHTC recognizes the following parameters as requirements to be included in appropriate Emergency Department documentation: 0 Patient identification 0 Time and means of Injury 0 History of disease or injury 0 Physical ?ndings - Medications, Allergies and Code Status 0 Laboratory and XuRay reports, if any 0 Diagnosis and Therapeutic orders 0 Record of treatment including vital signs . . Disposition of the case . 0 Signature of the staff and provider fir-c: JAN 2 0.55;; ?Page . 0 Documentation if the patient left against medical advice 0 Medical Records for patients treated by the emergency service, organized and where appropriate integrated with inpatient records, filed electronically. I Drug and biologicals distribution and control 0 Appropriate and ef?cient documentation of examinations, treatments and transfers of patients, in accordance with 42 CFR 489.20 and 489.24 Also implemented: 0 Utilization Review Consultant, who will review 100% of ail Emergency Department charts for a minimum period of six months. 0 Reviewed and updated 100% of ED Policies to confirm application and appropriateness of care. 0 Nursing Education Consultant, who will assist in the development and establishment of a continuous and ongoing education plan for competency utilizing skills checklists, tests and hands-on learning tools. 0 Review and 0 Collaborate with EMS Director to refine communications between Texas County EMS and MHTC ED: 0 Radio communications have already been reviewed, repaired and re-deployed as of the time of this corrective action plan, with meaningful and relevant initial training provided to all staff. This will serve as PRIMARY line of communication with EMS. 0 Telephone communications have also been reviewed, with no repair or modification required. This will serve as of communication with EMS. 0 Improve overall communications between EMS and MHTC ED. 0 Enter into transfer agreements for expeditious transfer as applicable for acute stroke patients to stroke centers able to provide a higher level of care. 0 Collaborate with EMS agencres, beginning with Guymon City EMS to develop inter-facility transfer protocols for stroke patients and will only use those EMS agencies that have a Department approved protocol for the inter-facility transfer of stroke patients. .0 Policy established addressing staff education and process that a minimum standard shall be no more than 20 minutes from patient arrival to request for emergent transfer for acute stroke patients. a Policy established addressing staff education and process that a minimum standard shall be no more than 60 minutes for transfer of acute stroke patients as a total expected arrival-to?departure time no less than 65% of the time (reviewed quarterly), with accompanying comprehensive education plan. 0 Policy established addressing staff education and process that ALL RN staff and healthcare providers are abie to recognize stroke patients and provide assessment as appropriate with documentation as described in this corrective action plan. Plan will include F.A.S.T. protocol and National Institute of Health standards. - Policy established addressing staff education and process a written plan for transfer of patients to a Level, i, ll, or ill Stroke Center. The written plan shall establish medical conditions and circumstances to determine: 0 Which patients may be retained or referred for palliative or end-of-life care 0 Which patients shall require stabilizing treatment 0 -Any "suspected" acute stroke patient will be transferred per protocol 0 Which patients shall require transfer to a Level l, or ill Stroke Center Stroke Findings 3,4: MHTC stocks Activase as a standing drug utilized in the facility, but not as an intervention for Stroke Care,- rather, as an intervention for Pulmonary Embolus and ST?Elevation Myocardial Infarction (STEM Protocols related to the maintenance, purchase and control of Activase have been reviewed and updated, accompanied by significant education for nursing staff and pharmacy staff as well. Suicide Finding 1?6: MHTC recognizes the imperative need for a policy and process related to the appropriate Medical Screening Evaluation (MSE). Specifically, and per law, MHTC recognizes the following parameters as requirements to be included in appropriate Emergency Department documentation: 0 Patient identification 0 Time and means of Injury - History of disease or injury a Physical findings Medications, Allergies and Code Status 0 Laboratory and X-Ray reports, if any a Diagnosis and Therapeutic orders 0 Record of treatment including vital signs 0 Disposition of the case 0 Signature of the staff and provider 0 Documentation if the patient left against medical advice 0 Medical Records for patients treated by the emergency service, organized and where appropriate integrated with inpatient records, filed electronicallyDrug and biologicals distribution and control ZIPage g? 0 Appropriate and efficient documentation of examinations, treatments and transfers of patients, in accordance with 42 CFR 489.20 and 489.24 Also implemented: Utilization Review Consultant, who will review 100% of all Emergency Department charts for a minimum period of six months. Reviewed and updated 100% of ED Policies to con?rm application and appropriateness of care. Nursing Education Consultant, who will assist in the development and establishment ofa continuous and ongoing education plan for competency utilizing skills checklists, tests and hands-on learning toois. Policy established addressing staff education and process that all ED patients age 10-24 will be screened for suicide risk using the ASQ screening toolkit developed by the National institute of Mental Health. Policy established addressing staff education and process that all ED patients over the age of 24 will be screened for suicide risk using the P556 tool developed by the Suicide Prevention Resource Center. Policy established addressing staff education and process a written plan for telemedicine mental health consultation. The written plan shall establish risk levels and appropriate mental health consultation and intervention. Policy established addressing staff education and process that all patients presenting with suicide attempt or ideation will receive telemedicine mental health evaluation. We have utilized recommendations from the National Institute of Mental Health and Suicide Prevention Resource Center to develop and deploy our education and training. Suicide Finding 6: MHTC recognizes the imperative need for a policy and process related to the appropriate care and safety of suicidal patients through implementation of standardized screening and assessment of all patients presenting to the ED. Also implemented: Policy established addressing staff education and process that all ED patients age 10?24 will be screened for suicide risk using the ASQ screening toolkit developed by the National Institute of Mentai Health. Policy established addressing staff education and process that all ED patients over the age of 24 will be screened for suicide risk using the P553 tool developed by the Suicide Prevention Resource Center. Policy established addressing staff education and process a written plan for telemedicine mental health consultation. The written plan shall establish risk levels and appropriate mental health consultation and intervention. Policy established addressing staff education and process that all patients presenting with suicide attempt or ideation wiil receive telemedicine mental health evaluation. Policy established addressing staff education and process that consultation of the American Academy of Poison Control will be utilized for all patients presenting with overdose of any substance, intentional or unintentional, to guide appropriate supportive care, diagnostic testing, and pharmacological intervention when applicable to minimize long term morbidity or mortality. Policy established addressing staff education and process, (in accordance with Oklahoma State Statutes 340:2-3-33) that ensures proper DHS consultation for all mandatory reporting, including adolescent suicide attempt or ideation. implementation of process for ED physicians to utilize Physician Handoff form for all Pediatric, Trauma, Stroke, or Chest pain patients present in the ED at the time of physician change of shift to ensure continuity, consistency, and congruency of plan of care between incoming and outgoing physicians. Rattlesnake Bite Findings 1-7 Snakebite Finding 1: MHTC has completed a review and revision of the snakebite policy and procedure utilizing the above referenced evidence-based practice references. The revised snakebite policy and procedure: Treatment and management of rattlesnake bites and common Unites States snakebites including the initial and ongoing management of snakebite wound care, patient observation time, appropriate release and discharge home process, clinical recognition and delineation of signs and differences between wet and dry snakebites, and the initiation of physician orders for wet and dry snakebites. Has been vetted and approved by MHTC administration, MHTC Medical Staff and the Governing Board. Staff education and training is nearing completion, utilizing: Relias computer-based training. 0 Review of current evidence-based practices as it relates to common United States snakebites, Emergency Department standup, briefings and updates. 0 Review of updated snakebite policy and procedure. 0 Relias training will be supplemented with face-to-face, inter-departmentai training, which is on-going. ED staff education is also complete as of 2/18/2019, with reinforcement training underway; expected completion prior to 3/18/2019, including policy, process and forms. As part of the QAPE activities for the department, the Emergency Department Team Leader will perform on-going, annual review of policies and procedures and current evidence-based practice in collaboration with the QRM Director. Updates will be made accordingly per protocol through Medical Staff, Governing Board and QAPI. 2 1115' 1135?. 5? f? 5.3 . Jail?; ti dUiJ 3 Page 0 Per current standard of 100% review of all ED charts, 100% of snakebite charts will also be reviewed, ensuring proper diagnosis and management practices are being meet in accordance to current recommended guidelines and standard of care. These charts will be monitored and reviewed by a utilization review consultant and enforced by MHTC administration, through a continuous quality improvement model of plan, do, check and act. 0 As a baseline audit prior to the utilization review consultant, the Emergency Department nursing staff is held responsible for completing their own concurrent chart audit. The Emergency Department nurse manager and the utilization review consultant will report compliance to the QRM Director and Quality Oversight Committee. The QRM Director shall report to the Medical Staff and the Governing Board; any deficiencies will be addressed and changes in policy and procedure will be made according to standardized processes already in place here at MHTC. The hospital has purchased an electronic quality tool designed to help effectively manage, track, and monitor the large number of activities related to ensuring the safety and integrity of the patient care environment. The name of the tool is the Strategic Quality Support System (SQSS). This tool is an integral part of the long-range corrective action plan and continuous quality improvement plan for MHTC's QAPI processes and program. This process is being conducted with the assistance of outside quality consultants. Snakebites are tracked and reviewed in this program. Snakebite Finding 2: Emergency Department Orders for Snake?Bite Patients (Wet Bite) Adult/Pediatric have been updated with current date and evidence-based practice and references. The orders have been vetted through Medical Staff, Governing Board, and QAPI. These orders reflect updated snake bite policy and procedures, approved by administration, Medical Staff, and Governing Board to include the following: - Labs obtained will include but are not limited to, CBC with platelet count, PTT, Fibrinogen, CM P, and urinalysis. - IV Access will be obtained in accordance with the aforementioned references. 0 The puncture site will be marked accordingly per aforementioned evidence-based references with date and time. - Crofab will be administered per the manufacturer?s recommendations and the revised policy and procedure including date and time of administration. a The process is currently being monitored by the administration team, facility Team Leaders, and the Quality Risk Management (QRM) Director. Snakebite Finding 3: If and when a complaint is initiated, the QRM Director maintains documentation in 5055 regarding all aspects of the grievance process. This includes QAPI reviews, Medical Staff committee review, Governing Board review, and closing the loop with feedback and communication to the patient and or patient representative including communicating the plan to improve quality of care and plan to meet the standard of care in accordance with the most up to date and current evidence-based practice. When reviewing the patient grievance process and the standard of care is found to not be met, review of the policy and procedure, protocol, physician orders, staff education and training, among others are to be reviewed and updated accordingly, utilizing the most current and up to date evidence-based practice and standards. This update to the policy and procedure, protocol, and any other clinical process is to be reviewed by med staff and the Governing Board and if agreed upon as clinically sound, implemented accordingly. Staff education and training is complete as of 2/18/19, utilizing the Relias computer-based training; follow-up education face-touface and inter-departmental is on-going. Review of current evidence-based practices as it relates to common United States snakebites, Emergency Department standup briefings and updates, and review of updated snakebite policy and procedure. The Emergency Department nursing department preliminary education is complete, including policy, process and forms. As part of the QAPI activities for the department, the Emergency Department Team Leader will perform annual review of policies and procedures and current evidence-based practice in colfaboration with the QRM Director. Updates will be made accordingly, as needed based on review, through MHTC protocol. 100% of snakebite charts will be reviewed, ensuring proper diagnosis and management practices are being meet in accordance to current recommended guidelines and standard of care. These charts will be monitored and reviewed by a utilization review consultant and enforced by MHTC administration. As a baseline audit prior to the utilization review consultant, the Emergency Department nursing staff is held responsible for compieting their own concurrent chart audit. The Emergency Department nurse manager and the utilization review consultant will report compliance to the QRM Director and Quality Oversight Committee. The QRM Director shall report to the Medical Staff and the Governing Board; any deficiencies will be addressed and changes in policy and procedure will be made according to standardized processes already in place here at MHTC. The hospital has purchased an electronic quality tool designed to help effectively manage, track, and monitor the large number of activities related to ensuring the safety and integrity of the patient care environment. The name of the tool is the Strategic Quality Support System (5055). This tool is an integral part of the long-range corrective action plan and continuous quality improvement plan for MHTC's QAPI processes and program. This process is being conducted with the assistance of outside quality consultants. Snakebites are tracked and reviewed in this program Snakebite Finding 4: E55 physicians (ED Medical Staffing group) are no longer the Emergency Department staffing group for MHTC. Medestar physicians are currently staffing the Emergency Department for MHTC. In addition, the Oklahoma Office of Rural Health awarded a grant to conduct peer reviews and will be utilized for this service ~w internally contracted physicians will not be utilized for peer chart review. Continuing Quality improvement will be conducted by the Quality Risk Management Director, but all staff are accountable and empowered to participate in the quality improvement processes for MHTC. The Quality improvement process centers around on-going "Plan, Do, Check, Act" (PDCA) theory and includes but is not limited to revision of policy and procedure, staff education and training, physician education and training, contracted physician accountability, and staff empowerment. . ?pri '1 j?h priced 4 Page Follow-up with the patient to validate outcome of care and inform the patient of changes and improvements in continuous quality of care is also paramount; MHTC already has mechanisms in place whereby the ED staff make phone calls to patients. This phone call process is successful and monitored quantitatively. Moreover, as part of the QAPI activities for the department, the Emergency Department Team Leader performs annual review of policies and procedures and current evidence~based practice in collaboration with the Quality Risk Management Director. Updates will be made accordingly, as needed based on review, through MHTC protocol. Per current standard of 100% review of all ED charts, 100% of snakebite charts will also be reviewed, ensuring proper diagnosis and management practices are being meet in accordance to current recommended guidelines and standard of care. These charts will be monitored and reviewed by a utilization review consultant and enforced by MHTC administration, through a fontinuous quality improvement model of plan, do, check and act. As a baseline audit prior to the utilization review consultant, the Emergency Department nursing staff is held responsible for completing their own concurrent chart audit. The Emergency Department nurse manager and the utilization review consultant will report compliance to the QRM Director and Quality Oversight Committee. The QRM Director shall report to the Medical Staff and the Governing Board; any deficiencies will be addressed and hanges in policy and procedure will be made according to standardized processes already in place here at MHTC. The hospital has purchased an electronic quality tool designed to help effectively manage, track, and monitor the large number of activities related to ensuring the safety and integrity of the patient care environment. The name of the tool is the Strategic Quality Support System (50,55). This tool is an integral part of the long? range corrective action plan and continuous quality improvement plan for MHTC's QAPI processes and program. This process is being conducted with the assistance of outside quality consultants. Snakebites are tracked and reviewed in this program. Snakebite Finding 5: E55 physicians (ED Medical Staffing group) are no longer the Emergency Department staf?ng group for MHTC. Medestar physicians are currently staffing the Emergency Department for MHTC. In addition, the Oklahoma Office of Rural Health awarded a grant to conduct peer reviews and will be utilized for this service -- internally contracted physicians will not be utilized for peer chart review. Continuing Quality Improvement will be conducted by the Quality Risk Management Director, but all staff are accountable and empowered to participate in the quality improvement processes for MHTC. The Quality improvement process centers around on-going ?Plan, Do, Check, Act" (PDCA) theory and includes but is not limited to revision of policy and procedure, staff education?and training, physician education and training, contracted physician accountability, and staff empowerment. Follow-up with the patient to validate outcome of care and inform the patient of changes and improvements in continuous quality of care is Llso paramount; MHTC already has mechanisms in place whereby the ED staff make phone calls to patients. This phone call process is successful and monitored quantitatively. Moreover, as part of the QAPI activities for the department, the Emergency Department Team Leader performs annual review of policies and procedures and current evidence-based practice in collaboration with the Quality Risk Management Director. Updates will be made accordingly, as needed based on review, through MHTC protocol. Per current standard of 100% review of all ED charts, 100% of snakebite charts will also be reviewed, ensuring proper diagnosis and management practices are being meet in accordance to current recommended guidelines and standard of care. These charts will be monitored and reviewed by a utilization review consultant and enforced by MHTC administration, through a continuous quality improvement model of plan, do, check and act. As a baseline audit prior to the utilization review consultant, the Emergency Department nursing staff is held responsible for completing their own oncurrent chart audit. The Emergency Department nurse manager and the utilization review consultant will report compliance to the QRM Director and Quality Oversight Committee. The QRM Director shall report to the Medical Staff and the Governing Board; any deficiencies will be addressed and phanges in policy and procedure will be made according to standardized processes already in place here at MHTC. The hOSpital has purchased an electronic quality tool designed to help effectively manage, track, and monitor the large number of activities related to ensuring the safety and integrity of the patient care environment. The name of the too! is the Strategic Quality Support System (5055). This tool is an integral part of the long- range corrective action plan and continuous quality improvement plan for MHTC's QAPI processes and program. This process is being conducted with the assistance of outside quality consultants. Snakebites are tracked and reviewed in this program. Snakebite Finding 6: MHTC has completed a review and revision of the snakebite policy and procedure utilizing the above referenced evidence-based practice references. The revised snakebite policy and procedure: 0 Treatment and management of rattlesnake bites and common Unites States snakebites including the initial and ongoing management of snakebite wound care, patient observation time, appropriate discharge home process, clinicai recognition and delineation of signs and differences between wet and dry snakebites, and the initiation of physician orders for wet and dry snakebites. - Has been vetted and approved by MHTC administration, MHTC Medical Staff and the Governing Board. a Staff education and training is nearing completion, utilizing the Relias computer-based training, review of current evidence-based practices as it relates to common United States snakebites, Emergency Department standup briefings and updates, and review of updated snakebite policy and procedure. Relias training will be supplemented with face-to-face, inter-departmental training, which is can-going. - ED staff education is also complete, with reinforcement training underway; expected completion prior to March 18, 2019, including poiicy, process and forms. a As part of the QAPI activities for the department, the Emergency Department Team Leader will perform on- going, annual review of policies and procedures and current evidence- based practice in collaboration with the QRM Director 0 Updates will be made accordingly per protocol through Medical Staff, Governing Board and QAPI. JAN Iii; Slpage i Per current standard of 100% review of all ED charts, 100% of snakebite charts will also be reviewed, ensuring proper diagnosis and management practices are being meet in accordance to current recommended guidelines and standard of care. These charts will be monitored and reviewed by a utilization review censultant and enforced by MHTC administration, through a continuous quality improvement model of plan, do, check and act. As a baseline audit prior to the utilization review consultant, the Emergency Department nursing staff conducts a concurrent chart audit. The Emergency Department nurse manager and the utilization review consultant will report compliance to the QRM Director and Quality Oversight Committee. The QRM Director shall report to the Medical Staff and the Governing Board. The hospital has purchased an electronic quality tool designed to help effectively manage, track, and monitor the large number of activities related to ensuring the safety and integrity of the patient care environment. The name of the tool is the Strategic Quality Support System (5088). This tool is an integral part of the long-range corrective action plan and continuous quality improvement plan for MHTC's QAPI processes and program. This process is being conducted with the assistance of outside quality consultants. Snakebites are tracked and reviewed in this program. Emergency Department Orders for Snake?Bite Patients (Wet Bite) Adult/Pediatric have been updated with current date and evidence-based practice and references. The orders have been vetted through Medical Staff, Governing Board, and QAPI. These orders reflect updated snake bite policy and procedures, approved by administration, Medical Staff, and Governing Board to include the following: Labs obtained will include but are not limited to, CBC with platelet count, Fibrinogen, CMP, and urinalysis. IV Access will be obtained in accordance with the aforementioned references. The puncture site will be marked accordingly per aforementioned evidence-based references with date and time. Crofab will be administered per the manufacturer's recommendations and the revised policy and procedure including date and time of administration. The process is currently being monitored by the administration team, facility Team Leaders, and the Quality Risk Management Director. Snakebite Finding 7: MHTC has completed a review and revision of the snakebite policy and procedure utilizing the above referenced evidence-based practice references. The revised snakebite policy and procedure: Treatment and management of rattlesnake bites and common Unites States snakebites including the initial and ongoing management of snakebite wound care, patient observation time, appropriate discharge home process, clinical recognition and delineation of signs and differences between wet and dry snakebites, and the initiation of physician orders for wet and dry snakebites. Has been vetted and approved by MHTC administration, MHTC Medical Staff and the Governing Board. Staff education and training is nearing completion, utilizing the Relias computer-based training, review of current evidence-based practices as it relates to common United States snakebites, Emergency Department standup briefings and updates, and review of updated snakebite policy and procedure. Relias training will be supplemented with face-to-face, inter-departmental training, which is on-going. ED staff education is also complete, with reinforcement training underway; expected completion prior to March 18, 2019, including policy, process and forms. As part of the activities for the department, the Emergency Department Team Leader will perform on?going, annual review of policies and procedures and current evidence?based practice in collaboration with the QRM Director. Updates will be made accordingly per protocol through Medical Staff, Governing Board and Per current standard of 100% review of all ED charts, 100% of snakebite charts will also be reviewed, ensuring proper diagnosis and management practices are being meet in accordance to current recommended guidelines and standard of care. These charts will be monitored and reviewed by a utilization review consultant and enforced by MHTC administration, through a continuous quality improvement model of plan, do, check and act. As a baseline audit prior to the utilization review consultant, the Emergency Department nursing staff is held responsible for completing their own concurrent chart audit. The Emergency Department nurse manager and the utilization review consultant will report compliance to the QRM Director and Quality Oversight Committee. The QRM Director shall report to the Medical Staff and the Governing Board; any deficiencies will be addressed and changes in policy and procedure will be made according to standardized processes already in place here at MHTC. The hospitai has purchased an electronic quality tool designed to help effectively manage, track, and monitor the large number of activities related to ensuring the safety and integrity of the patient care environment. The name of the tool is the Strategic Quality Support System (SQSS). This tool is an integral part of the long?range corrective action plan and continuous quality improvement plan for MHTC's QAPI processes and program. This process is being conducted with the assistance of outside quality consultants. Snakebites are tracked and reviewed in this program. Emergency Department Orders for Snake-Bite Patients (Wet Bite) Adult/Pediatric have been updated with current date and evidence?based practice and references. The orders have been vetted through Medical Staff, Governing Board, and QAPI. These orders reflect updated snake bite policy and procedures, approved by administration, Medical Staff, and Governing Board to include the following: Labs obtained will include but are not limited to, CBC with platelet count, Fibrinogen, CMP, and urinalysis. lV Access will be obtained in accordance with the aforementioned references. The puncture site will be marked accordingly per aforementioned evidence-based references with date and time. Crofab will be administered per the manufacturer's recommendations and the revised policy and procedure includingdate and timeeof administration. . JAN 2 i) (?rst; 6 Page The process is currently being monitored by the administration team, facility Team Leaders, and the Quality Risk Management Director. Critical communication between MHTC Pharmacy, Emergency Department staff, local providers, EMS director, and MHTC Chief of Staff addressing the on?hand availability of CroFab during snakebite season has already been established and will be reinforced on-going: 0 Goal of a minimum of six CroFab on hand for the initial dose and to start the recommended CroFab protocol, per manufacturer?s recommendations. 0 MHTC is in collaboration with nearby facilities to develop a ?share network" with CroFab. We will communicate and establish protocols with EMS addressing procedures if MHTC is short CroFab doses and there is a snakebite injury. This includes communication by radio to EMS identifying current shortfall of CroFab and timeline to be stocked and ready to accept snakebite patients. a If CroFab is unavailable establish a communication process with EMS to bypass MHTC. Staff education and training is complete via Relias for this topic, with reinforcement face?to?face and inter-departmental training currently underway. Concurrent review is completed as it relates to common United States snakebites and CroFab, Emergency Department standup briefings and updates, and review of updated snakebite policy and procedure. 0 As part of the QAPI activities for the department, the Emergency Department Team Leader will perform on-going, annual review of policies and procedures and current evidence-based practice in collaboration with the QRM Director. 0 Updates will be made accordingly per protocol through Medical Staff, Governing Board and - Per current standard of 100% review of all ED charts, 100% of snakebite charts will also be reviewed, ensuring proper diagnosis and management practices are being meet in accordance to current recommended guidelines and standard of care. These charts will be monitored and reviewed by a utilization review consultant and enforced by MHTC administration, through a continuous quality improvement model of plan, do, check and act. 0 As a baseline audit prior to the utilization review consultant, the Emergency Department nursing staff is held responsible for completing their own concurrent chart audit. The Emergency Department nurse manager and the utilization review consultant will report compliance to the QRM Director and Quality Oversight Committee. The QRM Director shall report to the Medical Staff and the Governing Board; any deficiencies will be addressed and changes in policy and procedure will be made according to standardized processes already in place here at MHTC. The hospital has purchased an electronic quality tool designed to help effectively manage, track, and monitor the large number of activities related to ensuring the safety and integrity of the patient care environment. The name of the tool is the Strategic Quality Support System (SQSS). This tool is an integral part of the long?range corrective action plan and continuous quality improvement plan for processes and program. This process is being conducted with the assistance of outside quality consultants. Snakebites are tracked and reviewed in this program. Pediatric Finding 1: MHTC recognizes the imperative need for a policy and process related to the appropriate Medical Screening Evaluation (MSE). Specifically, and per law, MHTC recognizes the following parameters as requirements to be included in appropriate Emergency Department documentation: 0 Patient Identification a Time and means of Injury 0 History of disease or injury 0 Physical findings - Medications, Allergies and Code Status 0 Laboratory and X-Ray reports, if any 0 Diagnosis and Therapeutic orders 0 Record of treatment including vital signs - Disposition of the case 0 Signature of the staff and provider 0 Documentation if the patient left against medical advice 0 Medical Records for patients treated by the emergency service, organized and where appropriate integrated with inpatient records, filed electronically. 0 Drug and biologicals distribution and control 0 Appropriate and efficient documentation of examinations, treatments and transfers of patients, in accordance with 42 CFR 489.20 and 489.24 Also implemented: 0 Utilization Review Consultant, who will review 100% of all Emergency Department charts for a minimum period of six months. 0 Reviewed and updated 100% of ED Policies to confirm application and appropriateness of care. 0 Nursing Education Consultant, who will assist in the development and establishment of a continuous and ongoing education plan for competency utilizing skills checklists, tests and hands-on learning tools. 0 Policy established addressing ALL ED shall be certified in Pediatric Advanced Life Support (PALS) and/or Emergency Nursing Pediatric Course (EN PC) within six months of hire. 0 Policy established addressing staff education and process that ALL RN staff and healthcare providers are to be trained In pediatric patient care and provide assessment as appropriate with documentation as described in this corrective action plan. 3 a Policy established addressing staff education and process a written plan for transfer of patients to a higher level of-care'ata pediatric Intensive nr i .. :6 7 Page i V. Care Unit or ED if appropriate. The written plan establishes medical conditions and circumstances to determine: 0 Which patients may be retained or referred to a higher level of care utilizing evidenceubased practice and acuity level worksheet. 0 Which patients shall require stabilizing treatment 2. Describe the improvements to the processes that led to the cited deficiency? Stroke Findings 1-6: MHTC is fully committed to process improvement. As mentioned in other segmentls) of this corrective action plan, there is significant human resources being placed toward success in this project and overall improvement of our hospital. We are committed to the health and well-being of our community. Here is a segment of our progress thus far, with far-reaching positive implications moving forward: 0 We have brought back our previous Quality Director as a mentor and consultant to the neW?hire Quality and Risk Management Director for an indefir'iite period of time. 0 We have re-evaluated all ED policies and vetted them through our Medical Staff as well as our Governing Board. 0 We have hired a Utilization Review consultant who will work with us collaboratively to improve processes and will simultaneously audit 100% of all ED charts for a minimum period of six months. 0 We have improved our staff insight into chart review through face-to-face and online education, to provide the Utilization Review Consultant with baseline reviews prior to the chart ever reaching Utilization Review. 0 We have established 3 TEAM LEADER model of care-delivery, allowing for a transparent chain-of?command and clear access to supervisors and resources for all levels of staff across all departments. 0 We have re-engaged our Governing Board to reevaluate their processes and improve oversight to the facility overall. Suicide Findings 1-6: MHTC is fully committed to process improvement. As mentioned in other segmentls) of this corrective action plan, there are significant human resources being placed toward success in this project and overall improvement of our hospital. We are committed to the health and well-being of our community. Here is a segment of our progress thus far, with far-reaching positive implications moving forward: 0 We have brought back our previous Quality Director as a mentor and consultant to the new-hire Quality and Risk Management Director for an indefinite period of time. 0 We have re?evaluated all ED policies and vetted them through our Medical Staff as well as our Governing Board. 0 We have hired a Utilization Review consultant who will work with us collaboratively to improve processes and will simultaneously audit 100% of all ED charts for a minimum period of six months. 0 We have improved our staffinsight into chart review through face-to-face and online education, to provide the Utilization Review Consultant with baseline reviews prior to the chart ever reaching Utilization Review. 0 We have established a TEAM LEADER model of care-delivery, allowing for a tranSparent chain-of-command and clear access to supervisors and resources for all levels of staff across all departments. 0 We have re-engaged our Governing Board to re?evaluate their processes and improve oversight to the facility overall. Snakebite Findings 1-7: Continuing Quality improvement will be conducted by the Quality Risk Management Director, but all staff are accountable and empowered to participate in the quality improvement processes for MHTC. The Quality improvement process centers around on-going "Plan, Do, Check, Act" (PDCA) theory and includes but is not limited to revision of policy and procedure, staff education and training, physician education and training, contracted physician accountability, and staff empowerment and acc0untability. Follow-up with the patient to validate outcome of care and inform the patient of changes and improvements in MHTC's continuous quality of care is lso paramount; MHTC already has mechanisms in place whereby the ED staff make phone calls to patients. This phone call process is successful and monitored quantitatively. Moreover, as part of the activities for the department, the Emergency Department Team Leader performs annual review of policies and procedures and current evidence-based practicejn collaboration with the Quality Risk Management Director. Updates will be made accordingly, as needed 'based on review, through MHTC protocol. Per current standard of 100% review of all ED charts, 100% of snakebite charts ill also be reviewed, ensuring proper diagnosis and management practices are being meet in accordance to current recommended guidelines and standard of care. These charts will be monitored and reviewed by a utilization review consultant and enforced by MHTC administration, through a continuous quality improvement model of plan, do, check and act. As a baseline audit prior to the utilization review consultant, the Emergency Department nursing staff is held responsible for completing their own concurrent chart audit. The Emergency Department nurse manager and the utilization review consultant will report compliance to the QRM Director nd Quality Oversight Committee. The QRM Director shall report to the Medical Staff and the Governing Board; any deficiencies will be addressed and hanges in policy and procedure will be made according to standardized processes already in place here at MHTC. Th?ospitalhas?purcha?sed an 4 ?at .. SIPage electronic quality tool designed to help effectively manage, track, and monitor the large number of activities related to ensuring the safety and integrity of the patient care environment. The name of the tool is the Strategic Quality Support System (SQSS). This tool is an integral part of the long- range corrective action plan and continuous quality improvement plan for MHTC's processes and program. This process is being conducted with the assistance of outside quality consultants. Snakebites are tracked and reviewed in this program Pediatric Finding 1: Utilization Review Consultant, who will review 100% of all Emergency Department charts for a minimum period of six months. 0 Reviewed and updated 100% of ED Policies to con?rm application and appropriateness of care. a Nursing Education Consultant, who will assist in the development and establishment of a continuous and ongoing education plan for competency utilizing skills checklists, tests and hands-on learning tools. 0 Policy established addressing ALL ED shall be certified in Pediatric Advanced Life Support (PALS) and/or Emergency Nursing Pediatric Course (ENPC). 0 Policy established addressing staff education and process that ALL RN staff and healthcare providers are to be trained in pediatric patient care and provide assessment as appropriate with documentation as described in this corrective action plan. 0 Policy established addressing staff education and process a written plan for transfer of patients to a higher level of care at a pediatric intensive Care Unit or ED if appropriate. The written plan shall establish medical conditions and circumstances to determine: 0 Which patients may be retained or referred to a higher level of care utilizing evidence-based practice and acuity level worksheet. 0 Which patients shall require stabilizing treatment 3. Describe your procedures for implementing the plan of correction for this deficiency. Stroke Findings 1, 2, 5: MHTC recognizes the imperative need for an effective and efficient implementation process for the necessary corrective steps toward success. Regarding documentation and validation of documentation, policy and process related to the appropriate Medical Screening Evaluation (MSE), MHTC recognizes legal requirements necessary to arrive at thorough, appropriate and adequate documentation for the Emergency Department in general and more specifically the acute stroke patient. MHTC shall educate and condone appropriate and efficient documentation of examinations, treatments and transfers of patients, in accordance with 42 CFR 489.20 and 489.24. In addition, MHTC shall: - Utilization Review Consultant, who will review 100% of all Emergency Department charts for a minimum period of six months. 0 Reviewed and updated 100% of ED Policies to confirm application and appropriateness of care. 0 Nursing Education Consultant, who will assist in the development and establishment ofa continuous and ongoing education plan for competency utilizing skills checklists, tests and hands-on learning tools. 0 Collaborate with EMS Director for City of Guymon to refine communications between EMS and MHTC ED: 0 Radio communications have already been reviewed, repaired and re-deployed as of the time of this corrective action plan, with meaningful and relevant initial training provided to all staff. This will serve as PRIMARY line of communication with EMS. 0 Telephone communications have also been reviewed, with no repair or modification required. This will serve as SECONDARY line of communication with EMS. 0 improve overall communications between EMS and MHTC ED. 0 Enter into transfer agreements for expeditious transfer as applicable for acute stroke patients to stroke centers able to provide a higher level of care. 0 Collaborate with EMS agencies, beginning with Guymon City EMS to develop inter-facility transfer protocols for stroke patients and will only use those EMS agencies that have a Department approved protocol for the inter?facility transfer of stroke patients. 0 Policy established addressing staff education and process that a minimum standard shall be no more than 20 minutes from patient arrival to request for emergent transfer for acute stroke patients. 0 Policy established addressing staff education and process that a minimum standard shall be no more than 60 minutes for transfer of acute stroke patients as a total expected arrival-to?departure time no less than 65% of the time (reviewed quarterly), with accompanying comprehensive education plan. 0 Policy established addressing staff education and process that ALL RN staff and healthcare providers are able to recognize stroke patients and provide assessment as appropriate with documentation as described in this corrective action plan. 0 Policy established addressing staff education and process a written plan for transfer of patients to a Level, I, II, or Ill Stroke Center. The written plan shall establish medical conditions and circumstances to determine: 0 Which patients may be retained or referred for palliative or end-of-life care 0 Which patients shall require stabilizing treatment 0 Any ?suspected" acute stroke patient will be transferred per protocol 0 Which patients shall require transfer to a Level l, ll, or ill Stroke Center Stroke Findings 3,4: MHTC has removed Activase as a standing drug for Stroke care utilized in the facility. Protocols related to the maintenance, purchase and control of Activase have been reviewed and updated, accompanied by significant education for nursing staff and pharmacy staff as well. On?going education for these departments related to this critical life-saving medication are paramount to the success of the facility, even though MHTC will no longer be administering Activase to any acute stroke patient (in adherence to the Level IV designation as described previously in the C200 corrective action SIPase JAi~i282~w document). Suicide Findings 1-6: MHTC recognizes the imperative need for an effective and efficient implementation process for the necessary corrective steps toward success. Regarding documentation and validation of documentation, policy and process related to the appropriate Medical Screening Evaluation (MSE), MHTC recognizes legal requirements necessary to arrive at thorough, appropriate and adequate documentation for the Emergency Department in general and more specifically the suicidal patient. MHTC shall educate and condone appropriate and efficient documentation of examinations, treatments and transfers of patients, in accordance with 42 CFR 489.20 and 489.24. in addition, MHTC shall: 0 Utilization Review Consultant, who will review 100% of all Emergency Department charts for a minimum period of six months. 0 Reviewed and updated 100% of ED Policies to confirm application and appropriateness of care. 0 Nursing Education Consultant, who will assist in the development and establishment of a continuous and ongoing education plan for competency utilizing skills checklists, tests and hands-on learning tools. 0 Collaborate with Northwest Center for Behavioral Health to update and refine existing agreement between and MHTC ED. Snakebite Findings 1-7: Continuing Quality improvement will be conducted by the Quality Risk Management Director, but all staff are accountable and empowered to participate in the quality improvement processes for MHTC. The Quality improvement process centers around on-going ?Plan, Do, Check, Act" (PDCA) theory and includes but is not limited to revision of policy and procedure, staff education and training, physician education and training, contracted physician accountability, and staff empowerment and accountability. Follow?up with the patient to validate outcome of care and inform the patient of changes and improvements in continuous quality of care is also paramount; MHTC already has mechanisms in place whereby the ED staff make phone calls to patients. This phone call process is successful and monitored quantitatively. Moreover, as part of the QAPI activities for the department, the Emergency Department Team Leader performs annual review of policies and procedures and current evidence-based practice in collaboration with the Quality Risk Management Director. Updates will be made accordingly, as needed based on review, through MHTC protocol. Per current standard of 100% review of all ED charts, 100% of snakebite charts will also be reviewed, ensuring proper diagnosis and management practices are being meet in accordance to current recommended guidelines and standard of care. These charts will be monitored and reviewed by a utilization review consuitant and enforced by MHTC administration, through a continuous quality improvement model of plan, do, check and act. As a baseline audit prior to the utilization review consultant, the Emergency Department nursing staff is held responsible for completing their own concurrent chart audit. The Emergency Department nurse manager and the utilization review consultant will report compliance to the QRM Director and Quality Oversight Committee. The QRM Director shall report to the Medical Staff and the Governing Board; any deficiencies will be addressed and changes in policy and procedure will be made according to standardized processes already in place here at MHTC. The hospital has purchased an electronic quality tool designed to help effectively manage, track, and monitor the large number of activities related to ensuring the safety and integrity of the patient care environment. The name of the tool is the Strategic Quality Support System (SQSS). This tool is an integral part of the long?range corrective action plan and continuous quality improvement plan for MHTC's QAPI processes and program. This process is being conducted with the assistance of outside quality consultants. Snakebites are tracked and reviewed in this program. Pediatric Finding 1: MHTC recognizes the imperative need for a policy and process related to the appropriate Medical Screening Evaluation (MSE). Specifically, and per law, MHTC recognizes the following parameters as requirements to be included in appropriate Emergency Department documentation: 0 Patientldentification Time and means of Injury History of disease or injury Physical findings Medications, Allergies and Code Status Laboratory and X?Ray reports, if any Diagnosis and Therapeutic orders Record of treatment including vital signs Disposition of the case Signature of the staff and provider Documentation if the patient left against medical advice Medical Records for patients treated by the emergency service, organized and where appropriate integrated with inpatient records, filed electronically Drug and biologicals distribution and control 0 Appropriate and ef?cient documentation of examinations, treatments and transfers of patients, in accordance with 42 CFR 489.20 and 489.24 . Also implemented: ?7 AM Ct inn .s {.qu 10 Page a 443 min?.? Utilization Review Consultant, who will review 100% of all Emergency Department charts for a minimum period of six months. 0 Reviewed and updated 100% of ED Policies to con?rm application and appropriateness of care. 0 Nursing Education Consultant, who will assist in the development and establishment of a continuous and ongoing education plan for competency utilizing skills checklists, tests and hands-on learning tools. 0 Policy established addressing ALL ED shall be certified in Pediatric Advanced Life Support (PALS) and/or Emergency Nursing Pediatric Course (ENPC). 0 Policy established addressing staff education and process that ALL RN staff and healthcare providers are to be trained in pediatric patient care and provide assessment as appropriate with documentationas described in this corrective action plan. 0 Policy established addressing staff education and process a written plan for transfer of patients to a higher level of care at a pediatric Intensive Care Unit or ED if appropriate. The written plan shall establish medical conditions and circumstances to determine: 0 Which patients may be retained or referred to a higher level of care utilizing evidence-based practice and acuity level worksheet. 0 Which patients shall require stabilizing treatment. 4. Describe the monitoring procedures to ensure that the plan for correcting this deficiency is effective and remains corrected and/or in compliance with the regulatory requirements? what program will be put into place to monitor the continued effectiveness of the systemic changes? (This is part of your QAPI processes) Monitoring processes will be transparent, thorough, secure, and efficient. They will include: 0 meetings with EMS to assure on-going transparent and effective communications between EMS and MHTC ED 0 Deployment of a communications log for the ED staff, to help pass along internal communications and relevant/timely information related to the department 0 Update of all ED policies 0 Re-education (through the online program RELIAS, as described in the QAPI segment of this corrective action plan) as well as on-going face- to?face education with ED staff across all shifts which will be mandatory and tracked via Nursing Education - On-going research to incorporate evidence?based practice solutions 0 Multi-faceted tracking solutions the incorporates Utilization Review Consultant, the Quality Oversight Committee, Medical Staff and Governing Board Rea?deployment of QAPI initiatives Involve of Medical Staff and Governing Board for collaboration, consistency, and seamless communication(s) Continuing Quality Improvement will be conducted by the Quality Risk Management Director, but all staff are accountable and empowered to participate in the quality improvement processes for MHTC. The Quality improvement process centers around on-going "Plan, Do, Check, Act" (PDCA) theory and includes but is not limited to revision of policy and procedure, staff education and training, physician education and training, contracted physician accountability, and staff empowerment and accountability. Follow?up with the patient to validate outcome of care and inform the patient of changes and improvements in continuous quality of care is also paramount; MHTC already has mechanisms in place whereby the ED staff make phone calls to patients. This phone call process is successful and monitored quantitatively. Moreover, as part of the QAPI activities for the department, the Emergency Department Team Leader performs annual review of policies and procedures and current evidence?based practice in collaboration with the Quality Risk Management Director. Updates will be made accordingly, as needed based on review, through MHTC protocol. Per current standard of 100% review of all ED charts, MHTC ensures proper diagnosis and management practices are being meet in accordance to current recommended guidelines and standard of care. These charts will be monitored and reviewed by a utilization review consultant and enforced by MHTC administration, through a continuous quality improvement model of plan, do, check and act. As a baseline audit prior to the utilization review consultant, the Emergency Department nursing staff is held responsible for completing their own concurrent chart audit. The Emergency Department nurse manager and the utilization review consultant will report compliance to the QRM Director nd Quality Oversight Committee. The QRM Director shall report to the Medical Staff and the Governing Board; any deficiencies will be addressed and changes in poliCy and procedure will be made according to standardized processes already in place here at MHTC. The hospital has purchased an lectronic quality tool designed to help effectively manage, track, and monitor the large number of activities related to ensuring the safety and integrity of the patient care environment. The name of the tool is the Strategic Quality Support System (5055). This tool is an integral part of the long-range corrective action plan and continuous quality improvement plan for MHTC's QAPI processes and program. This process is being conducted with the assistance of outside quality consultantscurd 11 Page 5. Provide the title of the person responsible for correcting this deficiency and ensuring compliance? Quality and Risk Management Director Interim Hospital Administrator Hospital Administrative Team Leaders and Clinical Team Leaders Medical Staff Governing Board 6. Provide the date this deficiency corrective action/s will be completed? (Correction dates should be no more than 60 days from the survey exit date) March 18,2018 and on-going 7. Make sure you have signed and dated the first page of the CMS-2567 (Statement of Deficiencies). Use this tool for each tag listed on the CMS-2567. Additionally, write "See Attached" in the right-hand column for every tag cited on the CMS-2567. JAN 38 933235 12 Page (x4) ID Prefix (tagii): FACILTY NAME Event 342 Memorial Hospital of Texas County Facility HP2249 Review of hospital policy titled "Quality Manual Plan), revised 04/01/18) showed the following: The organization must collect data, perform root cause analysis (RCA), preserve data (collect), formulate risk reduction strategies and collect data to demonstrate the effectiveness of the corrective action(s). faulty process or system invariable permits or compounds the harm, and is the focus of improvement. Review of hospital document titled "Hospital Super Committee" meeting minutes from 09/06/17 to 06/27/18 showed no evidence of incident reporting for 09/06/17 and reporting of incidents, grievance, or cases sent to peer review for 03/29/18. On 06/27/18 meeting minutes showed the following: incidents (March 18, April 47, May 27), grievances (March 4, April 3, May 3), and cases sent to peer review (March 4, April 7, May 2). There was no evidence cases were discussed to include the formulation of risk reduction strategies to address patient safety issues, medical errors and/or adverse events identified from occurrences, grievances and cases sent to peer review. Review of hospital document titled "Medical Executive Committee" meetings minutes from 04/04/17 to 01/23/18 showed no evidence the quality program reported incidents or grievance data to the medical executive committee. The meeting minutes failed to show evidence patient safety issues, medical errors and adverse events identified from incidents, grievances and cases sent to peer review were discussed to include risk reduction strategies formulated by the medical executive committee. Review of hospital documents titled "Medical Staff Committee" meeting minutes from 06/13/17 to 01/16/18 showed no evidence the quality program reported incidents or grievance data to the medical staff committee. The meeting minutes failed to show evidence patient safety issues, medical errors and adverse events identified from incidents, grievances and cases sent to peer review were discussed to include risk reduction strategies formulated by the medical staff committee. Review of hospital documents titled ?Board of Trustees (Governing Body)" meeting minutes from 01/24/18 to 08/08/18 showed no evidence the quality program reported incidents or grievance data to the Governing Body. The meeting minutes failed to show evidence patient safety issues, medical errors and adverse events identified from incidents, grievances and cases sent to peer review were discussed to include risk reduction strategies and reported to the Governing Body. Review of hospital documents titled "Special Board of Trustee Committee" meeting minutes from 02/15/17 to 08/08/18 showed no evidence the quality program reported incidents or grievance data to the Governing Body. The meeting minutes failed to show evidence patient safety issues, medical errors and adverse events identified from incidents, grievances and cases sent to peer review were discussed to ?Page JAN 5:35 Luig include risk reduction strategies and reported to the Governing Body. On 10/10/18 at 1:22 pm, Staff stated, he/she was responsible for evaluating all patient care services from a quality standpoint. Staff stated, he/she was not responsible for taking quality data including incidents and grievances to medical staff and Governing Body. Staff stated, the quality improvement program had not implemented any type of investigative analysis or performance improvement efforts for the events discussed. On 10/10/18 at 2:30 pm, Staff stated, he/she was responsible for taking quality indicator data to medical staff committee and the Governing Body. Staff stated, medical staff and Governing Body did not discuss individual incidents and grievances. 1. Describe your plan for correcting this deficiency? it was discovered the QAPI program for the hospital was ineffective and in desperate need of a multi-faceted intervention. The Quality Risk Management Director at that time was immediately dismissed and the previous Quality Risk Management Director brought back in full-time to mentor the selected Quality Risk Management Director, in-training. The goal was to immediately refine, revive and re?deploy efficient and impactful quality program(s) and initiatives across the entire facility. While the hospital is in the process of addressing the other issues identified during the survey, a strong and concerted effort is being placed on regaining a successful program and ensuring it is integrated across all departments as applicable, as we know that can help build stronger mechanisms of monitoring and control going forward. It should be noted the hospital is in the process of training a Quality Risk Management Director as noted above; in addition, the hospital is updating Education processes, and refining the Governing Board?s education and monitoring processes as well as engaging the Medical Board in a more accountable role of both participation and oversight. As part of its corrective action plan and Memorial Hospital of Texas County?s long-range plan to strengthen its quality program. The hospital has also purchased an electronic quality program (5055) designed to help hospitals to more effectively manage the large number of quality related activities important to ensure the safety and integrity of the patient care environment. This hospital, like many small hospitals, has historically struggled to manage the vast number of activities that are important in having a strong quality program because of the high number of activities that have to be managed by a smaller workforce. This tool is specifically designed to increase capacity in these types of situations by having it supplement the workforce in scheduling, tracking, and recording activities. While there are a number of features in SQSS that the hospital will take advantage of, the primary piece currently being implemented will keep track of important quality activities that have to happen such as the number of quality control checks related to the CMS Conditions of Participation and patient safety. It alerts staff when they are due, collects the information about the completion of those activities, automatically notifies leadership when a task is not recorded as completed, automatically schedules periodic validation reviews by Team Leaders and quality professional to verify that activities are being completed properly, automatically generates important compliance reports for leadership and quality committee review and makes it faster and easier for leadership to put their hands on key information. SQSS has a series of hardwired checklists to reduce the risk that an important quality related activity could be over looked or drift without being identified. In 5055, frontline personnejlcompl?te scheduled?? 2 Page slit-i 2 8 25.3539 i activities. SQSS then periodically schedules validation reviews by Team Leaders and quality professionals. It then also periodically schedules environmental surveillances by a team of quality professionals and leaders to provide for a type of checks and balances that can identify errors before they can evolve into a risk that can cause harm. The monitoring of the activities and follow-up to anyidentified concerns will be part of the regularly scheduled reports to the Quality Risk Management Director and included in the regularly scheduled reports to the Governing Board. 2. Describe the improvements to the processes that led to the cited deficiency? During the development of this corrective action plan, it has been identified that the Board, hOSpital leadership, as well as frontline staff lack foundational knowledge regarding regulatory requirements. The facility needs additional guidance from entry?level staff through the governing board. For this reason, staff training on SQSS is already complete, and SQSS training for the governing board via face-to-face, one-on?one consultation with the Quality Risk Management Directors is underway. The orientation, competency validation, and annual required staff education is under scrutinous review and faces likely redesign. These processes will provide the staff the knowledge base to perform theirjob duties in a safe, efficient environment, which supports the mission of the hospital and protects the patients and staff from harm. More importantly, the process will empower the Governing Board to assume a more engaged role in the quality initiatives of the facility. Additional specific outcomes include but are not limited to: 0 Strengthening the awareness of the legal responsibilities of the Board through education and engaging the Board. The Governing Board will be responsible for ensuring the facility is constructed, arranged, and maintained in a manner to ensure the safety of patients. 0 Strengthening the awareness and responsibilities of hospital leadership, management staff, and frontline staff for compliance with the Conditions of Participation, Oklahoma State Department of Health hospital standards and other regulatory agencies. 0 Strengthening the hospital?s internal standards by engaging the Team Leaders in their responsibility for QAPI activities, analyzing data collected, developing a process improvement and reporting the outcomes to the Quality Risk Management Director of the hospital and Board. 0 Strengthening the awareness of the frontline staff of current standards of practice through engaging the staff in the daily quality activities. - Strengthening the awareness and level of responsibility ofthe Medical Staff for the patient care environment, credentialing, and privileging responsibilities and engaging the Medical staff in quality activities. 0 Strengthen the level of responsibility for the annual review, revision and ongoing development of policies and procedures for Emergency Services and Compliance/Education to ensure that patient care is delivered in a safe manner according to the current standards of practice for nationally recognized professional organizations. A ll: 5? JAN t; cum 3 Page 3. Describe your procedures for implementing the plan of correction for this deficiency? 0 Conduct Board education regarding responsibilities of the governing body, the Conditions of Participation, Infection Prevention and Control, Education as well as the Quality of Patient Care and Quality of Services provided. 0 Conduct leadership and management education regarding responsibilities for patient safety, quality of care and Conditions of Participation, and Education as well as the Quality of Patient Care and Quality of Services provided. 0 The reporting structure and quality activities for Quality Risk Management Directors is being refined and re?deployed by the Quality Risk Management Director. 0 Refinement and Re-implementation of a hospital?wide electronic quality management system (SQSS) is underway. MHTC recognizes the imperative need for an effective and efficient implementation process for the necessary corrective steps toward success. Regarding documentation and validation of documentation, policy and process related to the appropriate Quality Plan, MHTC recognizes the imperative and fundamental nature with which a hospital must operate built upon QUALITY. MHTC shall educate and condone appropriate and efficient documentation of the execution of the quality plan, an overview of which has been attached here for reference. in addition, MHTC shall: i 0 We have brought back our previous Quality Director as a mentor and consultant to the new-hire Quality and Risk Management Director for an indefinite period of time. (as of 1/1/19) 0 We have formulated an entirely new Quality Plan, an overview of which is attached here, following CMS guidelines. 0 We have re-evaluated all ED policies and vetted them through our Medical Staff as well as our Governing Board. (as of 2/18/19) 0 We have hired a Utilization Review consultant who will work with us collaboratively to improve processes and will simultaneously audit charts for a minimum period of six months; this will greatly improve quality metrics and initiatives. (2/18/19) 0 We have improved our staff insight into chart review through face-to?face and online education, to provide the Utilization Review Consultant with baseline reviews prior to the chart ever reaching Utilization Review. 0 We have established a TEAM LEADER model of care?delivery, allowing for a transparent chain-of- command and clear access to supervisors and resources for ail levels of staff across all departments. (1/16/19) . We have re-engaged our Governing Board to re?evaluate their processes and improve oversight to the facility overall. (12/10/18) 4 Page 4. Describe the monitoring procedures to ensure that the plan for correcting this deficiency is effective and remains corrected and/or in compliance with the regulatory requirements? what program will be put into place to monitor the continued effectiveness of the systemic changes. (This is part of your QAPI processes) Appropriate environmental surveillance is being implemented for the hospital through the use of an electronic quality management system (SQSS). The appropriate tasks are being assigned relating to the QAPI activities of each supervisor. This will ensure that a hospital-wide QAPI program is implemented and successful. This process is being conducted with the assistance of the Quality Risk Management Director, and the ln?training Quality Risk Management Director. The individual supervisors are delegated the responsibility of reporting compliance to the appropriate committee for the quality task. The individual supervisor will report to the Quality Risk Management Director. The Quality Risk Management Director will subsequently report to the Governing Board Ad Hoc Quality Risk Management Director. The Quality Risk Management Director role is assigned the responsibility of providing a administrative validation review for six months on behalf of the Quality Risk Management Director. This will ensure the continued occurrence of the surveillance monitoring and compliance with the requirement. The schedule for continued administrative validation reviews will be adjusted after six months or as deemed appropriate by the Quality Risk Management Director with the reviews to not be scheduled any less often than quarterly. The Quality Risk Management Director will monitor for compliance and follow through on any applicable corrective action plans for the six months of this corrective action plan. Continued monitoring by the Committee after the initial six-month window will occur quarterly as part of the regularly . scheduled reports to the Committee unless the Committee deems a more frequent reporting schedule to be appropriate. Monitoring processes will be transparent, thorough, secure, and efficient. They will include: 0 meetings with Quality Oversight Committee (Super Committee) to ensure cross-talk and communication amongst all departments regarding quality. This now also includes incident reporting from across all departments. 0 Weekly quality meeting with the leadership staff. . Update of all ED policies to ensure quality effectiveness; all hospital policies have undergone review and consideration. 0 Re-education (through the online program RELIAS, as described in the segment of this corrective action plan) as well as on?going faceato?face education with staff across all shifts which will be mandatory and tracked via Nursing Education. (MHTC refers to QAPI as the Quality Oversight program for the hospital. The Quality and Risk Management (QRM) Director provides functional leadership for the QAPI Program). a On-going research to incorporate evidence?based practice solutions . Multi?faceted tracking solutions the incorporates Utilization Review Consultant, the Quality Oversight Committee, Medical Staff and Governing Board 0 Re-deployment of initiatives - Involve of Medical Staff and Governing Board for collaboration, consistency, and seamless communication(s) Slpagg . Continuing Quality Improvement will be conducted by the Quality Risk Management Director, but all staff are accountable and empowered to participate in the quality improvement processes for MHTC. The Quality improvement process centers around on?going ?Plan, Do, Check, Act? (PDCA) theory and includes but is not limited to revision of policy and procedure, staff education and training, physician education and training, contracted physician accountability, and staff empowerment and accountability. Continuous quality improvement is paramount to MHTC. As a baseline audit prior to the utilization review consultant, the Emergency Department nursing staff is held responsible for completing their own concurrent chart audit. The Emergency Department nurse manager and the utilization review consultant will report compliance to the QRM Director and QAPI Committee. The QRM Director shall report to the Medical Staff and the Governing Board; any deficiencies will be addressed and changes in policy and procedure will be made according to standardized processes already in place here at MHTC. The hospital has purchased an electronic quality tool designed to help effectively manage, track, and monitor the large number of activities related to ensuring the safety and integrity of the patient care environment. The name of the tool is the Strategic Quality Support System (5055). This tool is an integral part of the long-range corrective action plan and continuous quality improvement plan for MHTC's QAPI processes and program. This process is being conducted with the assistance of outside quality consultants. We have attached a generalized overview of our Quality Plan for additional commentary regarding this corrective action response: MHTC QUALITY PLAN Purpose: Ensure that MHTC maintains an organization-wide Quality Assurance/Performance Improvement Program. Scope: Organization-wide (hospital and clinic) This, Quality Manual documents a quality system that demonstrates our ability to provide services that meet customer needs and regulatory requirements. This manual will serve to represent the scope of our quality system to encompass the leadership, planning and the provision of care, management to include all clinical non?clinical support functions as well as our means of monitoring the effectiveness ofthe quality system in the delivery of services to our patients as our primary customer. The organization defines quality as "doing the right thing, at the right time, for the right peOple." Exclusion: The exclusion of ISO Design and development shall be noted. The rationale for excluding this section of the standard is such that ?exercising professional judgement, skill and expertise? are not considered to be design and development as a means of meeting customer requirements and a part of our quality system. Policy: The organization maintains an organization-wide Quality Management System (QMS) that reflects ongoing implementation, improvement and maintenance utilizing the organization?s quality management goals. Goals: . 1.) Ensure the provision of high-quality patient care through objective care evaluation and other BIPage performance assessment activities. . 2. Ensure coordination and integration of all performance assessment activities by establishing a group (Quality Oversight Committee) as a focal point through which information of performance activities that impact on patient care will be exchanged and monitored. 3.) Maintain a comprehensive, effective system for monitoring and evaluating the quality of patient care and services provided in a cost-effective manner in a continuum of improving organizational performance. 4.) Organizational leaders set expectations and develop plans to manage processes that assess, improve and monitor the quality of governance, management, clinical, non?clinical and support activities. 5.) Establish continuous improvement in patient care performance, minimizing liability and promoting appropriate utilization of patient care resources. 6.) Provide improvement of existing processes and functions through a systematic approach. 7.) Identification of the processes needed for operations, provision of patient care services through various processes, and their application throughout the organization. 8.) Ensure communication and reporting quality management information among the organization?s staff, administration, department heads, medical staff and Governing Body. 9.) Accomplish peer review if needed in a setting where persons of the same discipline review the caregiver?s performance. The Quality Manual Plan) is supported by the following documented policies/procedure: Preventative and Corrective Action Control of Records Nonconforming Products Internal Audit Document Control Objectives: The organization?s senior leadership ensures that quality objectives, including those needed to meet requirements, are established at relevant functions and levels. Our quality objectives for the organization are: A. Quality improvement and patient safety, including the reduction of medical errors. B. Address internal and external opportunities and risk to guide quality improvement and minimize and prevent undesirable effects. C. Provide patient safety considerations that are appropriately incorporated in hospital programs and that the hospital environment is safe. D. Improve services and patient care to enhance patient satisfaction. E. Patient care, treatment and/or services consistent with recognized professional standards F. Delivery of care, treatment and/or services provided within the available resources. G. Review of patient care in Quality Oversight Committee meetings, where representatives of each discipline involved in the care are present. (Review of charts from all patient care areas and then reported during the meeting utilizing the Quality Formula.) H. Assess individual competence and performance. I. Determination that current processes meet criteria to ensure that both the operation and management of these processes are effective during the Quality Oversight Committee meeting in the final quarter each year as well as ongoing as needed. J. Assurance of the availability of resources and information necessary to support the operation and monitoring the organization? 5 processes. a. t} f_ i 7)Page K. Monitoring, measurement and analysis of the organizations processes to ensure implementation of actions necessary to achieve planned results and continual improvement. Encourage the coordination of work and collaboration among departments and professional groups by organizing performance improvement activities around the flow of patient care, in which the interrelated processes are often cross disciplinary and cross?departmental. QMS manages these processes in accordance with the requirements of all applicable standards. QMS ensures management of any processes that affect the provision of services conformity with requirements that are out?sourced or provided through a contracted entity. These processes needed for the Quality Management System include processes for management activities, provision of resources, service realization and measurement. Leadership Responsibilities: A. Governing Body Medical Staff Hospital Administrator/COO Quality Director Nursing Executive/CCO Department Team Leaders/Managers Responsibilities include: A. Assuring development and implementation of an ongoing program Addressing priorities for improved quality of care, treatment and services Establishment of clear expectations for safety Assuring effectiveness of the program. Allocating adequate resources for measuring, assessing, improving and sustaining the organizations performance and reducing risk to the patients. Communicating importance of quality management through encouraging involvement and providing direction and support to achieve effective quality management. G. Promoting the use of risk-based thinking and process improvement approach in quality management. H. Determining the number of distinct improvement projects conducted annually. Design of the Program: Specific focal areas of the QAPI program are: A. Quality Assessment 8. Performance Improvement C. Risk Management events (including, but not limited to, sentinel events and near-misses) D. Root?Cause-Analysis studies. The Program is designed to: iThe following group of individuals is responsible and accountable for the Quality Management System Program: JAN. .58 8 Page I A. include each organized service B. Establish a link between Quality Assessment and Performance Improvement C. The number and scope of distinct improvement projects conducted annually shall be consistent with the scepe and complexity of the services, operations and available resources. D. Conduct root?cause-analysis (trajectory) studies as necessary for high risk/high volume/problem prone situations that are interdisciplinary and/or organization wide in perspective but are not captured in the portions of the program. E. Facilitate the organization?s systematic examination of opportunities to improve ca re, treatment and services. F. Establish a systematic mechanism to quantify improvements in care, treatment and services. Where sample sizes are applicable, the followingQuaiity Formula is utilized: A. 1?30 cases/events=100% of data collection. B. 31-599 cases/events=10% of data collection. C. 600 cases and more=5% of data collection. Procedures: Quality Assessment: Hospital and Clinic Performance Indicator?Monitors: The performance indicators reflect situations that are: high risk and/or high volume and/or problem prone. To the extent possible, performance indicators are stated in a positive manner. The Director reserves the right to assign performance indicators. Threshold for Evaluation: A Threshold for Evaluation (TFE) is established for each performance indicator. Usually, will range from 90% to 100%. Once a TFE has been established, it cannot be lowered without approval from the Super Committee. The Director reserves the right to establish Data Collection: On a basis, data are collected for each performance indicator according to a prescribed formula for sample sizes and recorded into the QI Calendar in 5055. Determination of Whether the TFE is Met/Exceeded: On a basis, the percent compliance of collected data is calculated and compared with the pre? established TFE. if the TFE is met/exceeded data collection continues for the subsequent month(s) for the duration of the quarter. If the TFE is met/exceeded for the entire quarter, the performance indicators are studied for another quarter or discontinued if the performance indicators have met/exceeded the TFE for a :2nd consecutive quarter unless the performance indicator is a required reporting measure per reghlation. If the TFE is NOT met, the Department Manager/Committee Chair/Contractor is responsible for implementing corrective action(s in an attempt to achieve compliance for the remainder of the quarter lf performance indicators are NOT met for 2 consecutive months, the measure will be forwarded to the Super Committee for review and a written corrective action statement will be developed for each performance Typically, 3?5 performance indicators (monitors) are established for each Elli r; raw-r;- vm'i 6 dual 9 Page indicator that is not meeting the established TFE. Corrective Action Statements: Each corrective action statement must contain three components: Who, will do What, by When? Reporting: Reports are compiled and presented to the Quality Oversight Committee, Medical Staff and Governing Body. Reporting to the Quality Oversight Committee Committee and sub-committees) shall be completed at least quarterly for the following departments: A. Quality/Risk Management B. Plant Ops (Safety, Life?Safety, Security, Hazardous Materials Management, Emergency Preparedness, Biomedical Services) Pharmacy Nursing Human Resources Infection Control/Employee Health House?keeping Emergency Department Ancillary Departments (RT, Lab, ?ray, The OJRM Director reserves the right to review department/committee meetings to determine feedback from department/committee staff regarding Quality Assessment Performance Improvement proceeding. ?re?irnpn Quality Assessment: Medical Staffand Allied Health Professionals Performance Indicators (Monitors): Performance indicators are selected from regulatory requirements, physician?s privilege list and community A. Use of blood and blood products B. Prescribing of medications: Prescribing patterns, trends, errors and appropriateness of prescribing for Drug Use Evaluations. Operative and invasive procedures: appropriateness and outcomes. Moderate Sedation Outcomes. Appropriateness of care for non?invasive procedures/interventions. Utilization data Significant deviations from established standards of practice. Timely and legible completion of patients? medical records. Any variant should be analyzed for statistical significance. Screening: On a bi-annual basis, a non-physician screens medical records to identify evidence of compliance with the performance indicators. standards for Ongoing Periodic Performance Evaluations (OPPE) on reappointment including but is not limited to: no?: 10lPage 1 Ail aurora Peer Review: In the event the screener cannot readily identify compliance with the performance indicators, the medical record is forwarded to peer review. The peer review committee makes the determination whether the standard of medical care was met. The determination is quantified according to a classification system utilizing the Quality Review Form. Profiling: On at least a quarterly basis, data is compiled to reflect volume statistics and performance indicators applicable to each provider and, if assigned by the peer review committee, the most severe deviation from the standard of care. Profiling reports are reported exclusively to the medical executive committee at the time of physician reappointment. Corrective Action: Corrective actions are carried out at the discretion of the Chief of Staff. Examples of corrective actions include, but are not limited to: individual counseling, individual or group education sessions. Reporting: Written reports are reported at least quarterly to the Medical Staff and Governing Board Meeting. Individual profiles accompany credential files at the time of reappointment and are reported exclusively to the medical executive committee. Evaluation of the Quality Management System The Quality Oversight Committee Committee) evaluates the organization?s Quality Management System at least annually to ensure continuing suitability, effectiveness, and alignment with the strategic direction of the organization. goals are reviewed at least annually and revised and/or formulated if necessary based on the findings from the annual evaluation as well as identified opportunities for improvement and applicable trends in the health care arena. Confidentiality Proceedings of the program are confidential and are managed in a confidential manner. in Process Improvement When a nonconformity or need for process improvement is identified, the organization will utilize the PACE (Plan, Act, Check and Enhance) cycle to ensure performance improvement and/or corrective and preventative is achieved. ?lgg: Team members will review and analyze the nonconformity and determine steps to take to ensure immediate corrective and preventative action to reduce the possibility of recurring nonconformance. A task list that determines who, will do what, by when is helpful during this stage. Act: Perform actions to implement process improvement plan as detailed during planning stage. During the action stage, applicable department managers, committee members and/or medical staff will develop and adopt if needed performance indicators to verify and maintain ongoing performance improvement. 191?) CD c: ~l 11 Page Check: After timelines are reached, team members will collect and analyze data regarding performance indicators and/or criteria to determine if compliance and process improvement has been achieved. Enhance: Based on the analysis of data, the process improvement and/or corrective action plan is enhanced by: 0 If compliance meeting the established TFE (or other criteria) was achieved, implement steps to ensure process/procedure changes are the new standard. 0 If some improvement was achieved but not to full compliance meeting the TFE (or other criteria), team members will ?enhance? the corrective and preventative action plan to continue process improvement. . If no improvement occurred, team members will return to planning stage and reevaluate the actions needed to achieve process improvement. Sentinel Events A sentinel event is an unexpected occurrence involving the death or serious physical or injury, or the risk thereof. 0 ?Serious injury? specifically includes loss of limb or function. 0 ?Or the risk thereof? includes any process variation for which a recurrence would carry a significant change of a serious adverse outcome. Such events are called ?sentinel? because they signal the need for immediate investigation and response. ?Sentinel event? and ?medical error? are not synonymous. - Sentinel events do NOT always occur because of an error. 0 Some errors do NOT result In a sentinel event the organization must: A. Collect data B. Perform root-cause-analysis and preserve data C. Formulate risk reduction strategy and preserve data demonstrating the effectiveness of the corrective action(s). Although human error is commonly an initiating event, a faulty process or system invariably permits or compounds the harm, and is the focus of improvement. Examples of Sentinel Events: 0 Suicide 0 Medication Error . Restraint death 0 Treatment Delay - Unintended retention of foreign body 0 Patient Abduction 0 Procedural complication Elopement death 0 Transfusion death 12 Page 0 Wrong site surgery - Assault/rape/homicide 0 Fall related death - Unanticipated death offull-term infant Near Miss Events A Near Miss Event is an unplanned event that did not result in injury, illness or damage but had the potential to do so. Such events are called ?near miss? because only a fortunate break in the chain of events prevented an injury, fatality or damage. ?Near Miss? is also referred to as a "close call?. In the event of a Near Miss the organization must: A. Collect data B. Perform root?cause-analysis and preserve data. C. Formulate a risk reduction strategy and preserve data demonstrating the effectiveness of the corrective action(s). Although human error is commonly an initiating event, a faulty process or system invariably permits or compounds the harm, and is the focus of improvement. ADMINISTRATIVE APPROVAL of the plan was vetted through the Chief of Staff/Medical Staff as well as the Governing Board. 5. Provide the title of the person responsible for correcting this deficiency and ensuring compliance? The Governing Board, Administrator and Medical Staff, and the Quality Risk Management Director. Jaw 5? <1 liar: at: LIJSJ 13 Page 6. Provide the date this deficiency corrective action/s will be completed? (Correction dates should be no more than 60 days from the survey exit date) 1/28/2019 141Page emiv ml}: (X4) ID Prefix FACILTY NAME Event 343 Memorial Hospital of Texas County Facility HP2249 Review of hospital policy titled "Quality Manual Plan), revised 04/01/18) showed the following: "The organization must collect data demonstrate the effectiveness of the corrective Review of hospital document titled "Hospital Super Committee" meeting minutes from 09/06/17 to 06/27/18 showed no evidence the quality program was analyzing patient safety, medical errors and adverse patient events, determining preventative action plans, and collecting data to determine the effectiveness of the preventative action plans to ensure sustainability and decreased risk of re?occurrence. Review of hospital document titled ?M'edical Exchtive Committee" meetings minutes from 04/04/17'to 01/23/18 failed to show evidence the quality program presented to the medical executive committee patient safety, medical errors and adverse events identified from incidents, grievances, and cases sent to peer review were analyzed, preventative action plans determined and data reported and trended to determine the effectiveness of the preventative action plans to ensure sustainability and decreased risk of re-occurrence. Review of hospital documents titled "Medical Staff Committee" meeting minutes from 06/13/17 to 01/16/18 showed no evidence the quality program presented to the medical staff committee, patient safety, medical errors and adverse events identified from incidents, grievances, and cases sent to peer review were analyzed, preventative action plans determined and data reported and trended to determine the effectiveness of the preventative action plans to ensure sustainability and decreased risk of re- occurrence. Review of hospital documents titled "Board of Trustees (Governing Body)" meeting minutes from 01/24/18 to 08/08/18 showed no evidence the quality program presented to the Governing Body, patient safety, medical errors and adverse events identified from incidents, grievances, and cases sent to peer review were analyzed, preventative action plans determined and data reported and trended to determine the effectiveness of the preventative action plans to ensure sustainability and decreased risk of re-occurrence. Review of hospital documents titled "Special Board of Trustee Committee? meeting minutes from 02/15/17 to 08/08/18 showed no evidence the quality program presented to the Governing Body, patient safety, medical errors and adverse events identified from incidents, grievances and cases sent to peer review were analyzed, preventative action plans determined and data reported and trended to determine the effectiveness of the preventative action plans to ensure sustainability and decreased risk of re-occurrence255-1 1 Page On 10/10/18 at 1:22 pm, Staff stated, he/she was responsible for evaluating all patient care services from a quality standpoint. Staff stated he/she was not responsible for taking quality data including incidents and grievances to medical staff and Governing Body. Staff stated the quality improvement program had not implemented any type of investigative analysis or performance improvement efforts for the events discussed. On 10/10/18 at 2:30 pm, Staff stated he/she was responsible for taking quality indicator data to medical staff committee and the Governing Body. Staff stated medical staff and Governing Body did not discuss individual incidents and grievances. 1. Describe your plan for correcting this deficiency? It was discovered the QAPI program for the hospital was ineffective and in desperate need of a multi?faceted intervention. The Quality Risk Management Director at that time was immediately dismissed and the previous Quality Risk Management Director brought back in full?time to mentor the selected Quality Risk Management Director, in-training. The goal was to immediately refine, revive and re?deploy efficient and impactful quality program(s) and initiatives across the entire facility. While the hospital is in the process of addressing the other issues identified during the survey, a ?strong and concerted effort is being placed on regaining a successful QAPI program and ensuring it is integrated across all departments as applicable as we know that can help build stronger mechanisms of monitoring and control going forward. It should be noted the hospital is in the process of training a Quality Risk Management Director as noted above; in addition, the hospital is updating Education processes, and refining the Governing Board?s education and monitoring processes as well as engaging the Medical Board in a more accountable role of both participation and oversight. As part of its corrective action plan and Memorial Hospital of Texas County?s long?range plan to strengthen its quality program, the hospital has also purchased an electronic quality program (SQSS) designed to help hospitals to more effectively manage the large number of quality related activities important to ensure the safety and integrity of the patient care environment. This hospital, like many small hospitals, has historically struggled to manage the vast number of activities that are important in having a strong quality program because of the high number of activities that have to be managed by a smaller workforce. This tool is specifically designed to increase capacity in these types of situations by having it supplement the workforce in scheduling, tracking, and recording activities. While there are a number of features in 5055 that the hospital will take advantage of, the primary piece currently being implemented will keep track of important quality activities that have to happen such as the number of quality control checks related to the CMS Conditions of Participation and patient safety. It alerts staff when they are due, collects the information about the completion of those activities, automatically notifies leadership when a task is not recorded as completed, automatically schedules periodic validation reviews by Team Leaders and quality professional to verify that activities are being completed properly, automatically generates important compliance reports for leadership and quality committee review and makes it faster and easier for leadership to put their hands on key information. 5055 has a series of hardwired checklists to reduce the risk that an important quality related activity could be over looked or drift without being identified. In SQSS, frontline personnel complete ZlPage 1" J: J?al 3 0 Cut: scheduled activities. SQSS then periodically schedules validation reviews by Team Leaders and quality professionals. It then also periodically schedules environmental surveillances by a team of quality professionals and leaders to provide for a type of checks and balances that can identify errors before they can evolve into a risk that can cause harm. The monitoring of the activities and follow?up to any identified concerns will be part of the regularly scheduled reports to the Quality Risk Management Director and included in the regularly scheduled QAPI reports to the Governing Board. 2. Describe the improvements to the processes that led to the cited deficiency? During the development of this corrective action plan, it has been identified that the Governing Board, hospital leadership, as well as frontline staff lack foundational knowledge regarding regulatory requirements. The facility needs additional guidance from entry?level staff through the governing board. For this reason, staff training on SQSS is already complete, and SQSS training for the governing board via face-to-face, one? on?one consultation with the Quality Risk Management Directors is underway. The orientation, competency validation, and annual required staff education is under scrutinous review and faces likely redesign. These processes will provide the staff the knowledge base to perform theirjob duties in a safe efficient environment, which supports the mission of the hospital and protects the patients and staff from harm. More importantly, the process will empower the Governing Board to assume a more engaged role in the quality initiatives of the facility. Additional specific outcomes include but are not limited to: 0 Strengthening the awareness of the legal responsibilities of the Board through education and engaging the Board. The Governing Board will be responsible for ensuring the facility is constructed, arranged, and maintained in a manner to ensure the safety of patients. 0 Strengthening the awareness and responsibilities of hospital leadership, management staff, and frontline staff for compiiance with the Conditions of Participation, Oklahoma State Department of Health hospital standards and other regulatory agencies. 0 Strengthening the hospital's internal standards by engaging the Team Leaders in their responsibility for activities, analyzing data collected, developing a process improvement and reporting the outcomes to the Quality Risk Management Director of the hospital and Board. 0 Strengthening the awareness of the frontline staff of current standards of practice through engaging the staff in the daily quality activities. 0 Strengthening the awareness and level of responsibility of the Medical Staff for the patient care environment, credentialing, and privileging responsibilities and engaging the Medical staff in quality activities. 0 Strengthen the level of responsibility for the annual review, revision and on?going development of policies and procedures for Emergency Services and Compliance/Education to ensure that patient care is delivered in a safe manner according to the current standards of practice for nationally recognized professional organizations. :ier Lhigocud 3 Page 3. Describe your procedures for implementing the plan of correction for this deficiency? Conduct Board education regarding responsibilities of the governing body, the Conditions of Participation, Infection Prevention and Control, Education as well as the Quality of Patient Care and Quality of Services provided. Conduct leadership and management education regarding responsibilities for patient safety, quality of care and Conditions of Participation, Education as well as the Quality of Patient Care and Quality of Services provided. The reporting structure and quality activities for Quality Risk Management Directors is being refined and re-deployed by the Quality Risk Management Director. Refinement and Re?implementation of a hospital?wide electronic quality management system (SQSS) is underway. MHTC recognizes the imperative need for an effective and efficient implementation process for the necessary corrective steps toward success. Regarding documentation and validation of documentation, policy and process related to the appropriate Quality Plan, MHTC recognizes the imperative and fundamental nature with which a hospital must operate built upon QUALITY. MHTC shall educate and condone appropriate and efficient documentation of the execution of the quality plan, an overview of which has been attached here for reference. In addition, MHTC shall: We have brought back our previous Quality Director as a mentor and consultant to the new?hire Quality and Risk Management Director for an indefinite period of time. (as of 1/1/19) We have formulated an entirely new Quality Plan, an overview of which is attached here, following CMS guidelines. We have re-evaluated all ED policies and vetted them through our Medical Staff as well as our Governing Board. (as of 2/18/19) We have hired a Utilization Review consultant who will work with us collaboratively to improve processes and will simultaneously audit charts for a minimum period of six months; this will greatly improve quality metrics and initiatives. (2/18/19) We have improved our staff insight into chart review through face?to-face and online education, to provide the Utilization Review Consultant with baseline reviews prior to the chart ever reaching Utilization Review. We have established 3 TEAM LEADER model of care?delivery, allowing for a transparent chain-of- command and clear access to supervisors and resources for all levels of staff across all departments. (1/16/19) We have re-engaged our Governing Board to re?evaluate their processes and improve oversight to the facility overall. (12/10/18) 5h) I 1-- D. Cf?) r3 .) k. UJ 4 Page I 4. Describe the monitoring procedures to ensure that the plan for correcting this deficiency is effective and remains corrected and/or in compliance with the regulatory requirements? what program will be put into place to monitor the continued effectiveness of the systemic changes. (This is part of your QAPI processes) Appropriate environmental s'urveillance is being implemented for the hospital through the use of an electronic quality management system (SQSS). The appropriate tasks are being assigned relating to the QAPI activities of each supervisor. This will ensure that a hospital?wide QAPI program is implemented and successful. This process is being conducted with the assistance of the Quality Risk Management Director, and the ln-training Quality Risk Management Director. The individual supervisors are delegated the responsibility of reporting compliance to the appropriate committee for the quality task. The individual supervisor will report to the Quality Risk Management Director. The Quality Risk Management Director will subsequently report to the Governing Board Ad Hoc Quality Risk Management Director. The Quality Risk Management Director role is assigned the responsibility of providing a administrative validation review for six months on behalf of the Quality Risk Management Director. This will ensure the continued occurrence of the surveillance monitoring and compliance with the requirement. The schedule for continued administrative validation reviews will be adjusted after six months or as deemed appropriate by the Quality Risk Management Director with the reviews to not be scheduled any less often than quarterly. The Quality Risk Management Director will monitor for compliance and follow through on any applicable corrective action plans for the six months of this corrective action plan. Continued monitoring by the Committee after the initial six-month window will occur quarterly as part of the regularly scheduled reports to the Committee unless the Committee deems a more frequent reporting schedule to be appropriate. Monitoring processes will be transparent, thorough, secure, and efficient. They will include: 0 meetings with Quality Oversight Committee (Super Committee) to ensure cross?talk and communication amongst all departments regarding quality. This now also includes incident reporting from across all departments. 0 Weekly quality meeting with the leadership staff. 0 Update of all ED policies to ensure quality effectiveness; all hospital policies have undergone review and consideration. 0 Re?education (through the online program RELIAS, as described in the QAPI segment of this corrective action plan) as well as on?going face?to-face education with staff across all shifts which will be mandatory and tracked via Nursing Education. (MHTC refers to QAPI as the Quality Oversight program for the hospital. The Quality and Risk Management (QRM) Director provides functional leadership for the QAPI Program). 0 On~going research to incorporate evidence-based practice solutions - Multi?faceted tracking solutions the incorporates Utilization Review Consultant, the Quality Oversight Committee, Medical Staff and Governing Board 0 Re?deployment of QAPI initiatives 0 Involve Medical Staff and Governing Board for collaboration, consistency, and seamless communication(s) SIPage Continuing Quality Improvement wiil be conducted by the Quality Risk Management Director, but all staff are accountable and empowered to participate in the quality improvement processes for MHTC. The Quality improvement process centers around on?going ?Plan, Do, Check, Act? (PDCA) theory and includes but is not limited to revision of policy and procedure, staff education and training, physician education and training, contracted physician accountability, and staff empowerment and accountability. Continuous quality improvement is paramount to MHTC. As a baseline audit prior to the utilization review consultant, the Emergency Department nursing staff is .held responsible for completing their own concurrent chart audit. The Emergency Department nurse manager and the utilization review consultant will report compliance to the QRM Director and QAPI Committee. The QRM Director shall report to the Medical Staff and the Governing Board; any deficiencies will be addressed and changes in policy and procedure will be made according to standardized processes already in place here at MHTC. The hospital has purchased an electronic quality tool designed to help effectively manage, track, and monitor the large number of activities related to ensuring the safety and integrity of the patient care environment. The name of the tool is the Strategic Quality Support System (SQSS). This tool is an integral part of the long-range corrective action plan and continuous quality improvement plan for QAPI processes and program. This process is being conducted with the assistance of outside quality consultants. We have attached a generalized overview of our Quality Plan for additional commentary regarding this corrective action response: MHTC QUALITY PLAN Purpose: Ensure that MHTC maintains an organization?wide Quality Assurance/Performance Improvement Program. Scope: Organization?wide (hospital and clinic) This Quality Manual documents a quality system that demonstrates our ability to provide services that meet customer needs and regulatory requirements. This manual will serve to represent the scope of our quality system to encompass the leadership, planning and the provision of care, management to include all clinical non?clinical support functions as well as our means of monitoring the effectiveness of the quality system in the delivery of services to our patients as our primary customer. The organization defines quality as ?doing the right thing, at the right time, for the right people." Exclusion: The exclusion of ISO Design and development shall be noted. The rationale for excluding this section of the standard is such that ?exercising professional judgement, skill and expertise? are not considered to be design and development as a means of meeting customer requirements and a part of our quality system. Policy: The organization maintains an organization-wide Quality Management System (QMS) that reflects ongoing implementation, improvement and maintenance utilizing the organization?s quality management goals. Goals: ?Page 1.) Ensure the provision of high-quality patient care through objective care evaluation and other performance assessment activities. 2.) Ensure coordination and integration of all performance assessment activities by establishing a group (Quality Oversight Committee) as a focal point through which information of performance activities that impact on patient care will be exchanged and monitored. 3.) Maintain a comprehensive, effective system for monitoring and evaluating the quality of patient care and services provided in a cost-effective manner in a continuum of improving organizational performance. 4.) Organizational leaders set expectations and develop plans to manage processes that assess, improve and monitor the quality of governance, management, clinical, non-clinical and support activities. 5.) Establish continuous improvement in patient care performance, minimizing liability and promoting appropriate utilization of patient care resources. 6.) Provide improvement of existing processes and functions through a systematic approach. 7.) Identification of the processes needed for operations, provision of patient ca re services through various processes, and their application throughout the organization. 8.) Ensure communication and reporting quality management information among the organization?s staff, administration, department heads, medical staff andGoverning Body. 9.) Accomplish peer review if needed in a setting where persons of the same discipline review the caregiver?s performance. The Quality Manual Plan) is supported by the following documented policies/procedure: Preventative and Corrective Action Control of Records Nonconforming Products Internal Audit Document Control Objectives: The organization?s senior leadership ensures that quality objectives, including those needed to meet requirements, are established at relevant functions and levels. Our quality objectives for the organization are: A. Quality improvement and patient safety, including the reduction of medical errors. B. Address internal and external opportunities and risk to guide quality improvement and minimize and prevent undesirable effects. C. Provide patient safety considerations that are apprOpriately incorporated in hospital programs and that the hospital environment is safe. Improve services and patient ca re to enhance patient satisfaction. Patient care, treatment and/or services consistent with recognized professional standards Delivery of care, treatment and/or services provided within the available resources. Review of patient care in Quality Oversight Committee meetings, where representatives of each discipline involved in the care are present. (Review of charts from all patient care areas and then reported during the meeting utilizing the Quality Formula.) H. Assess individual competence and performance. QWWU .1. mm 14 a adj-i -- 2 8 2633 Fmath< .u - 7 Page l. Determination that current processes meet criteria to ensure that both the operation and management of these processes are effective during the Quality Oversight Committee meeting in the final quarter each year as well as ongoing as needed. J. Assurance of the availability of resources and information necessary to support the operation and monitoring the organization?s processes. K. Monitoring, measurement and analysis of the organizations processes to ensure implementation of actions necessary to achieve planned results and continual improvement. Encourage the coordination of work and collaboration among departments and professional groups by organizing performance improvement activities around the flow of patient care, in which the interrelated processes are often cross disciplinary and cross-departmental. QMS manages these processes in accordance with the requirements of all applicable standards. QMS ensures management of any processes that affect the provision of services conformity with requirements that are out-sourced or provided through a contracted entity. These processes needed for the Quality Management System include processes for management activities, provision of resources, service realization and measurement. Leadership Responsibilities: A. Governing Body Medical Staff Hospital Administrator/COO Quality Director Nursing Executive/CCO Department Team Leaders/Managers TWUOFD Responsibilities include: A. Assuring development and implementation of an ongoing program B. Addressing priorities for improved quality of care, treatment and services C. Establishment of clear expectations for safety D. Assuring effectiveness of the program. E. Allocating adequate resources for measuring, assessing, improving and sustaining the organizations performance and reducing risk to the patients. F. Communicating importance of quality management through encouraging involvement and providing direction and support to achieve effective quality management. G. Promoting the use of risk?based thinking and process improvement approach in quality management. H. Determining the number of distinct improvement projects conducted annually. Design of the Program: Specific focal areas of the QAPI program are: A. QualityAssessment B. Performancelmprovement . The following group of individuals is responsible and accountable for the Quality Management System Program: mu :28 2mg 8 Page C. Risk Management events (including, but not limited to, sentinel events and near-misses) D. Root-Cause?Analysis studies. The Program is designed to: A. include each organized service B. Establish a link between Quality Assessment and Performance Improvement C. The number and scope of distinct improvement projects conducted annually shall be consistent with the scope and complexity of the services, operations and available resources. D. Conduct root-cause?analysis (trajectory) studies as necessary for high risk/high volume/problem prone situations that are interdisciplinary and/or organization wide in perspective but are not captured in the portions of the program. E. Facilitate the organization's systematic examination of opportunities to improve ca re, treatment and services. F. Establish a systematic mechanism to quantify improvements in care, treatment and services. Where sample sizes are applicable, the following Quality Formula is utilized: A. 1?30 cases/events=100% of data collection. B. 31-599 cases/events=10% of data collection. C. 600 cases and more=5% of data collection. Procedures: Quality Assessment: Hospital and Clinic Performance Indicatoeronitors: Typically, 3?5 performance indicators (monitors) are established for each The performance indicators reflect situations that are: high risk and/or high volume and/0r problem prone. To the extent possible, performance indicators are stated in a positive manner. The Quality Risk Manager Director reserves the right to assign performance indicators. Threshold for Evaluation: A Threshold for Evaluation (TFE) is established for each performance indicator. Usually, will range from 90% to 100%. Once a TFE has been established, it cannot be lowered without approval from the Super Committee. The Director reserves the right to establish Data Collection: On a basis, data are collected for each performance indicator according to a prescribed formula for sample sizes and recorded into the Ql Calendar in SQSS. Determination of Whether the TFE is Met/Exceeded: On a basis, the percent compliance of collected data is calculated and compared with the pre- established TFE. If the TFE is met/exceeded data collection continues for the subsequent month(s) for the duration of the quarter. 7, . SIPage i If the TFE is met/exceeded for the entire quarter, the performance indicators are studied for another quarter or discontinued if the performance indicators have met/exceeded the TFE for a 2nd consecutive quarter unless the performance indicator is a required reporting measure per regulation. If the TFE is NOT met, the Department Manager/Committee Chair/Contractor is responsible for implementing corrective action(s) in an attempt to achieve compliance for the remainder of the quarter. If performance indicators are NOT met for 2 consecutive months, the measure will be forwarded to the Super Committee for review and a written corrective action statement will be developed for each performance indicator that is not meeting the established TFE. Corrective Action Statements: Each corrective action statement must contain three components: Who, will do What, by When? Reporting: Reports are compiled and presented to the Quality Oversight Committee, Medical Staff and Governing Body. Reporting to the Quality Oversight Committee Committee and sub-committees) shall be completed at least quarterly for the following departments: A. Quality/Risk Management B. Plant Ops (Safety, Life?Safety, Security, Hazardous Materials Management, Emergency Preparedness, Biomedical Services) Pharmacy Nursing Human Resources Infection Control/Employee Health House?keeping Emergency Department Ancillary Departments (RT, Lab, X- ray, The Director reserves the right to review department/committee meetings to determine feedback from department/committee staff regarding Quality Assessment Performance Improvement proceeding. Quality Assessment: Medical Staff and Allied Health Professionals Performance Indicators (Monitors): Performance indicators are selected from regulatory requirements, physician?s privilege list and community standards for Ongoing Periodic Performance Evaluations (OPPE) on reappointment including but is not limited to: A. Use of blood and blood products B. Prescribing of medications: Prescribing patterns, trends, errors and appropriateness of prescribing for Drug Use Evaluations. C. Operative and invasive procedures: appropriateness and outcomes. D. Moderate Sedation Outcomes. 10 Page E. Appropriateness of care for non-invasive procedures/interventions. F. Utilization data G. Significant deviations from established standards of practice. H. Timely and legible completion of patients? medical records. I. Any variant should be analyzed for statistical significance. Screening: On a bi?annual basis, a non?physician screens medical records to identify evidence of compliance with the performance indicators. Peer Review: In the event the screener cannot readily identify compliance with the performance indicators, the medical record is forwarded to peer review. The peer review committee makes the determination whether the standard of medical care was met. The determination is quantified according to a classification system utilizing the Quality Review Form. Profiling: On at least a quarterly basis, data is compiled to reflect volume statistics and performance indicators applicable to each provider and, if assigned by the peer review committee, the most severe deviation from the standard of care. Profiling reports are reported exclusively to the medical executive committee at the time of physician reappointment. Corrective Action: Corrective actions are carried out at the discretion of the Chief of Staff. Examples of corrective actions include, but are not limited to: individual counseling, individual or group education sessions. Reporting: Written reports are reported at least quarterly to the Medical Staff and Governing Board Meeting. Individual profiles accompany credential files at the time of reappointment and are reported exclusively to the medical executive committee. Evaluation of the Quality Management System The Quality Oversight Committee Committee) evaluates the organization?s Quality Management System at least annually to ensure continuing suitability, effectiveness, and alignment with the strategic direction of the organization. goals are reviewed at least annually and revised and/or formulated if necessary based on the findings from the annual evaluation as well as identified opportunities for improvement and applicable trends in the health care arena. Confidentiality Proceedings of the QAPI program are confidential and are managed in a confidential manner. in Process Improvement When a nonconformity or need for process improvement is identified, theiqrganizationWill utilize the PACE (Plan, Act, Check and Enhance) cycle to ensure performance improvement and/or corrective and preventative is achieved. Mi Team members will review and analyze the nonconformity and determine steps to take to ensure immediate corrective and preventative action to reduce the possibility of recurring nonconformance. A task list that determines who, will do what, by when is helpful during this stage. Act: Perform actions to implement process improvement plan as detailed during planning stage. During the action stage, applicable department managers, committee members and/or medical staff will develop and adopt if needed performance indicators to verify and maintain ongoing performance improvement. Check: After timelines are reached, team members will collect and analyze data regarding performance indicators and/or criteria to determine if compliance and process improvement has been achieved. Enhance: Based on the analysis of data, the process improvement and/or corrective action plan is enhanced by: 0 If compliance meeting the established TFE (or other criteria) was achieved, implement steps to ensure process/procedure changes are the new standard. 0 If some improvement was achieved but not to full compliance meeting the TFE (or other criteria), team members will ?enhance? the corrective and preventative action plan to continue process improvement. 0 If no improvement occurred, team members will return to planning stage and reevaluate the actions needed to achieve process improvement. Sentinel Events A sentinel event is an unexpected occurrence involving the death or serious physical or injury, or the risk thereof. 0 ?Serious injury? specifically includes loss of limb or function. 0 ?Or the risk thereof? includes any process variation for which a recurrence would carry a significant change of a serious adverse outcome. Such events are called ?sentinel? because they signal the need for immediate investigation and response. ?Sentinel event? and ?medical error? are not synonymous. Sentinel events do NOT always occur because of an error. 0 Some errors do NOT result In a sentinel event the organization must: A. Collect data B. Perform root-cause?analysis and preserve data C. Formulate risk reduction strategy and preserve data demonstrating the effectiveness of the corrective action(s). Although human error is commonly an initiating event, a faulty process or system invariably permits or compounds the harm, and is the focus of improvement. . m- up. 12 Page L. 333 (at) i? Examples of Sentinel Events: 0 Suicide 0 Medication Error 0 Restraint death 0 Treatment Delay 0 Unintended retention of foreign body 0 Patient Abduction 0 Procedural complication Elopement death 0 Transfusion death 0 Wrong site surgery 0 Assault/rape/homicide - Fall related death 0 Unanticipated death of full-term infant Near Miss Events A Near Miss Event is an unplanned event that did not result in injury, illness or damage but had the potential to do 50. Such events are called ?near miss? because only a fortunate break in the chain of events prevented an injury, fatality or damage. ?Near Miss? is also referred to as a ?close call". In the event of a Near Miss the organization must: A. Collect data B. Perform root-cause-analysis and preserve data. C. Formulate a risk reduction strategy and preserve data demonstrating the effectiveness of the corrective action(s). Although human error is commonly an initiating event a faulty process or system invariably permits or compounds the harm, and' Is the focus of improvement. ADMINISTRATIVE APPROVAL of the plan was vetted through the Chief of Staff/Medical Staff as well as the Governing Board. 5. Provide the title of the person responsible for correcting this deficiency and ensuring compliance? The Governing Board, Administrator and Medical Staff, and the Quality Risk Management Director. 6. Provide the date this deficiency corrective action/s will be completed? (Correction?d?tes should be no? 5? JAN 28-235? 13 Page can. 14 Page Month/Day/Year: and ongoing Projected date of completion of construction is If . .u um? var? v. mam -