Calhoun Liberty Hospital

Calhoun Liberty Hospital Releases Corrective Action Plan

Today, Calhoun Liberty Hospital released the corrective action plan as required by the Agency for Health Care Administration (AHCA) in advance of the February 19 deadline. The plan was submitted to the agency yesterday to ensure time for delivery and review.

Hospital CEO Ruth Attaway also released the following statement:

“This is a thorough plan that details how our hospital will move forward to implement the corrective actions by March 1, meeting the state’s deadlines and continuing to serve our community. We are extremely grateful to the members of the medical community who have supported us and are helping us meet these requirements, including the Florida State University College of Medicine and Tallahassee Memorial Hospital.

“Our hospital is providing critical health care services for more than 20,000 residents, and closing our doors is not an option.”

The details of the plan match the deficiencies identified by AHCA and are detailed below.

H020 – Failure to provide the appropriate assessment/reassessment

The hospital has procedures in place to ensure periodic reassessments of the patient are conducted based on changes in the patient’s condition. Training will be scheduled to review this policy and procedures with remaining staff before 3/1/2016.  All newly employed clinical staff will be required to review policy and procedures prior to patient care.

The hospital has care protocols based on the patient’s identified complaint. Staff will be educated on protocols and all new staff members will be required to review protocols prior to patient care.

H043 – Failure to provide an appropriate medical screening exam (MSE)

Emergency services personnel are available 24/7 in the emergency department. All registration staff have been instructed on the necessity of a MSE as of 2/11/2016. Triage staff were instructed on the necessity of a MSE and regarding proper documentation when a patient refuses a MSE on 2/6/2016. All ER staff have been trained regarding the need for a repeat MSE when a patient voices a new complaint as of 2/6/2016. Documentation audits have been put into place for ER records since 1/8/2016. The hospital is coordinating with Tallahassee Memorial Hospital to provide a physician certified in emergency medicine to provide training on the requirement for all patients presenting to the emergency department on the following:

–       How to conduct an appropriate medical screening;

–       Recognition and proper management of patient emergency medical conditions;

–       Requirements for patient stabilization prior to transfer or discharge;

–       Patient transfer requirements;

–       How to recognize violations of Florida Statute 395.1041; and

–       Evaluation of the hospital internal incident reporting system with a focus on grievances relating to the emergency department services.

This training will be completed prior to March 1, 2016.

The hospital will engage the services of a physician certified in emergency medicine to conduct a semiannual audit of emergency department records to include assessment of compliance with Chapter 395.1041, FS. The initial audits will be conducted by 3/1/2016 and every six months thereafter. Audits will be conducted on 10 percent of all patients listed on the ER log.

H049 – Failure to follow Emergency Department policy and procedures

The hospital maintains written policies and procedures specifying the scope and conduct of emergency services to be rendered to patients. The policies are reviewed and approved annually, revised as necessary, and dated to indicate time of the last review. An updated organization-wide policy was implemented on 2/1/2016. The Hospital will require all current staff to review the ER Policy and Procedure manual before 3/1/2016. All newly employed clinical staff will review the policy prior to patient contact. The hospital has hired a new Compliance Officer and an ER Nurse Manager to monitor enforcement of policies and procedures in the ER.

H119 – Failure to provide necessary nursing services

The hospital maintains written policies and procedures specifying the scope and conduct of patient care provided by the nursing staff. The policies are reviewed and approved annually, revised as necessary, and dated to indicate time of the last review. The Hospital will require all current staff to review the Patient Care Policies and Procedure manual prior to 3/1/2016. All newly hired clinical staff will be required to review policy and procedure manual prior to patient contact. The hospital has hired a new Compliance Officer and is providing a Nurse Manager for each nursing department to monitor enforcement of policies and procedures by the nursing staff.

H0120 – Failure to document patient status upon discharge

The hospital maintains written policies and procedures that specify documentation required on discharge. There is documentation that Patient #10 refused discharge vital signs. Current staff have been educated on documenting a complete set of vital signs as of 2/6/2016 and ER charts are being reviewed for evidence of this documentation.

H0204 – Failure to immediately address issues with emergency access

The Quality improvement committee will meet on 2/16/2016. Guidelines will be discussed regarding when meetings will need to be called beyond the scheduled quarterly meetings. The quality improvement committee will immediately address any future identified issues with emergency access.

H0219 – Failure to report incident to Risk Manager and to initiate investigation

The CEO was educated on reportable issues on 2/10/2016. The CEO and the Board will be educated on ensuring compliance with applicable laws on 2/22/2016 at the scheduled Board meeting. Department Heads were educated on reporting compliance on 2/16/16.

H0408 – Failure to evaluate patient care services after receiving a complaint

The Governing Board implemented a system for monitoring compliance with 395.0197, FS in February 2016. This monitoring includes identification and timely analysis of patient grievances that relate to patient care and the quality of medical services.

The hospital’s LRM reviews all patient grievances on a daily basis M-F and as notified by staff after hours. The LRM performs follow up analysis as needed.

To address timely reporting of adverse incidents to the risk manager or designee, a new, more user friendly incident reporting form was developed and all staff have been or will be instructed in its use by 3/1/2016.

The LRM has in-serviced all department heads (2/16/2016); the ER staff (2/6/2015); and the C.N.A staff (2/11/2016), and has scheduled an in-service with the nursing floor staff on 2/18/2016 on mandatory reporting by staff of violations of 395.1041, FS to the risk manager or the designee.

The registration team leader is reviewing the ER log book daily to ensure that all patients presenting to the ER are seen appropriately. Any patient found to have presented and not been seen for any reason generates an incident report for analysis by the LRM. The new Risk Manager began a log of patient grievances on 2/1/2016. Any reports received between January 1, 2016 through February 1, 2016 were logged as well. This log will be maintained by Risk Manager and in her absence, the Risk Manager Designee.

H410 – Failure to implement incident reporting system

The hospital has implemented an incident reporting system, and all department heads, as well as the Administrator, have been trained on the use of the incident reporting system. The investigation into patient #10 was initiated immediately by the hospital’s former Director of Nursing, who is an LRM. Statements were collected and the chart was reviewed. AHCA surveyors reviewed those statements and the progress of the investigation during their site visit. Audio and video information was not available at the time of the AHCA site visit. The hospital currently employees three Licensed Risk Managers, and the Administrator serves as the RM designee.

H416 – Failure to submit an adverse incident report

AHCA required reporting, pursuant to 395.0197 (6) and (7) will be submitted in a timely manner. This incident report was prepared for submission in a timely manner but after discussion with AHCA surveyor on site and review of the requirements, it was decided that this incident did not meet reporting requirements.

Patient #10 died of a Pulmonary Embolism, which was not associated with medical intervention nor was it a condition that health care personnel could exercise control over. AHCA was in the building prior to the reporting deadline and the necessity to report was discussed with AHCA surveyor on site; it was determined this incident did not meet the reporting requirements. Audio and video evidence were not available at the time of the site visit.

Additional Correction Actions and Plans

Measures have been put into place to ensure the deficient practice will not recur.

–      The Assistant Administrator/Chief Nursing Officer will maintain records of the in-service, preservice and training activities. The Compliance Officer will maintain records of ongoing monitoring activities. A summary of these records will be reviewed with the Board at the regularly scheduled meetings and will be available for review by AHCA staff upon request. Any patient found to have been affected by deficient practice will be followed up with by the LRM and the incident reported to the appropriate regulatory agency in a timely manner.

–      All patients presenting to the ER have the potential to be affected. Registration clerks are typically the first point of contact for these patients and all registration clerks have received training from the LRM on EMTALA on 2/10/16 and 2/11/16. ER and EMS staff received mandatory training on EMTALA from the LRM on 2/5/16.

–     A physician certified in emergency medicine will be engaged to provide training to all licensed healthcare staff on EMTALA and Chapter 395.1041 FS. requirements.

–      The Compliance Officer will make attempts to contact patients who leave the ER under the following statuses: Against Medical Advice (AMA), elopement or Leaving without Being Seen (LWBS) to investigate for any EMTALA violations.

–     There has been a restructuring of leadership staff in the hospital to divide the supervision and enforcement of policy and procedure by department, allowing more time for oversight in each area. A staff development program is being planned to provide education to staff on a routine basis.

–     Training and education will be provided to existing staff and all new staff on policies and procedures as well as regulatory requirements relating to risk management and EMTALA.

–     Monthly nursing staff meetings have been implemented with reminders of EMTALA and a review of ER patient audit findings as well as any other identified topic. This will continue for six months, and we will then evaluate the effectiveness.

–      An ER Nurse Manager has been hired and is responsible for oversight of staff in the ER to ensure compliance with policies and procedures.

–     The hospital will monitor corrective action by checking the ER log against patient charts on a regular basis to ensure that all patients receive an appropriate medical screening exams or have documented refusals. A new Compliance Officer and Licensed Risk Manager will review all complaints, grievances and incident reports.