Medical Center submits corrective action plan

Staff Report

The 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.

Of 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.

Other survey findings related to two of the 77 CMS standards (subsets of the conditions) and 13 of the 297 elements within the standards.

“Many 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.

Among the findings:

• 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 use.

• 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 areas.