Center submits corrective action plan
Medical Center sent a corrective
action plan on Sept. 14 to the federal Centers for Medicare and
Medicaid Services (CMS), responding to deficiencies cited in a
comprehensive nine-day survey earlier in the summer.
the 23 CMS conditions for participation as a Medicare provider,
the Medical Center was found not in compliance with one
physical environment because of several life safety violations.
Among them were eight fire doors that did not close fully, a shaft
that was not sealed, several missing exit lights and sprinkler
heads, and two outside smoking areas that did not have sprinklers
installed. All have been corrected and certified as satisfactory
by the state fire marshal.
survey findings related to two of the 77 CMS standards (subsets
of the conditions) and 13 of the 297 elements within the standards.
were corrected while the reviewers were here, other changes have
been made since then, and the remaining few will be completed
by the end of the year, said Leonard W. Sandridge, executive
vice president and chief operating officer. He noted that many
of the problems involved incomplete records or policies and review
processes that were not specific enough.
Medication rooms in two units were unlocked during the day. Locks
are now in place and used.
There were no written guidelines for cleaning and maintenance
of the lithotriper equipment and insufficient oversight of its
Emergency Department medical records of some prior patients were
incomplete. In one case, an incorrect initial assessment was noted
on the chart.
In nine cases, resident physicians performed a surgical procedure
without the supervision of an attending physician, contrary to
hospital policy. The policy has been revised to make clear that
this should occur only in life-threatening or other urgent situations.
In several units, quality assurance reports were not handled within
the required 72 hours or follow-up to problems was not documented.
In another area, a medication error was reported promptly to the
quality assurance program, but not until later to the pharmacy.
A patient did not receive a written response to his complaint,
although the resolution had been discussed with him.
In two medical records, there was no evidence that the patients
had been informed of the side-effects of their medications.
Equipment was observed in the hallways or stored in inappropriate