DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
330235 A. BUILDING __________
B. WING ______________
08/24/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
AUBURN COMMUNITY HOSPITAL 17 LANSING STREET, AUBURN, NY, 13021
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
0000 Initial Comments
27051 The deficiencies cited below are a result of a Federal Title 18 Allegation Survey for complaint #NY00223389 conducted on 8/20/18 - 8/24/18 in accordance with 42 CFR part 482 Conditions of Participation (CoPs) for Hospitals. The CoP for Governing Body was not met. The Plan of Correction must relate to the care of all the patients and prevent such occurrences in the future. Intended completion dates (X5) and the mechanism(s) established to assure ongoing compliance must be included.
A0043 Governing Body
482.12
Corrected On: 11/13/2018
36617 Based on document review and interview, the Governing Body failed to maintain oversight to ensure that all patients were provided quality care. Numerous concerns related to a Physician's (Staff A) medical care and behavior were reported to Hospital Administration. The Hospital did not promptly investigate many of the concerns. Investigations that were completed were inadequate. Staff A's behavior was addressed in a cease and desist letter, however no monitoring plan was put in place to ensure compliance. Staff A was not credentialed per hospital process. These failures may have placed patients at risk for harm. Findings include: -- Review of 33 incident reports (dated 10/2017 through 7/2018) filed on Staff A, regarding his/her behavior and medical care, revealed many lacked adequate investigations. (Please see findings in Tag A049.) -- During interview of Staff B, Chief Executive Officer (CEO), on 8/23/18 at 10:30 am, a cease and desist letter, pertaining to Staff A's inappropriate behavior, was sent to him/her on 6/26/18. No monitoring was performed by the facility to ensure compliance. (Please see findings in Tag A050.) -- Review of Staff A's credentials file revealed a letter dated 12/19/17 that indicate he/she was appointed to the Department of Medicine. A proctoring plan was established that included retrospective chart reviews. The chart reviews were not completed. (Please see findings in Tag 046.)
A0046 Medical Staff - Appointments
482.12(a)(2)
Corrected On: 11/13/2018
27051 Based on document review and interview, the hospital failed to complete a physician's (Staff A) proctoring plan as indicated in his/her Credentials file. This may have led to adverse patient outcomes. Findings include: -- Review of Staff A's Credentials file revealed it contained a letter dated 12/19/17 that indicated Staff A was appointed to the hospital active medical staff. It further indicated a proctoring plan was set up to include a retrospective review of 10 medical records of Staff A by Staff H, Physician. -- During interview of Staff H on 8/22/18 1:00 pm, he/she indicated he/she did not have oversight of Staff A or review any of his medical records. -- During interview of Staff B, Chief Executive Officer, (CEO) on 8/23/18 at 10:30 am, he/she acknowledged, that when Staff A was appointed to Active Medical Staff, he/she should have had 10 medical record reviewed by Staff H.
A0049 Medical Staff - Accountability
482.12(a)(5)
Corrected On: 11/13/2018
27051 Based on document review and interview, the Board of Trustees (Governing Body) at the Hospital, did not ensure the Medical Staff was accountable for quality patient care provided by a physician (Staff A) during his/her employment from 10/2017 through 8/2018. This lack of accountability may have led to adverse patient outcomes. Findings include: -- Review of the hospital's incident reports data from 10/2017 through 7/2018 filed on Staff A revealed 33 incident reports were filed for that time period. Many of the incident reports involved behavior issues. However, some did involve medical care. For example, on 5/29/18 it was alleged that during a Code Blue (cardiac arrest resuscitation) Staff A insisted no one was allowed to talk, contrary to American Heart Association (AHA) guidelines that require closed-loop communications. Staff A told a registered nurse to shut up when he/she tried to verify a medication with another nurse prior to administration. Additionally, Staff A ordered a bigger dosage of medication than AHA guidelines indicate. The incident report also contained a statement at the bottom "I will file a complaint with HR (Human Resources) if Staff A is made aware of this complaint. He/she confronts us and makes the work environment uncomfortable when he/she has knowledge of a staff complaint." The investigation documentation by the Staff C, Chief Medical Officer (CMO), stated "This condition (statement at bottom of complaint) negates the validity of this complaint which is questionable at best." There was no documentation of any investigation into the issues identified. Other incident reports involving Staff A's medical care also lacked adequate investigations. -- During interview of Staff C on 8/21/18 at 8:55 am, he/she stated multiple incident reports had been filed regarding Staff A's behavior and medical care. Staff C investigated these concerns through discussions with Staff A. He/she did not feel that the issues rose to the level of being forwarded up to the Medical Executive Committee (MEC). -- During interview of Staff H, Physician on 8/22/18 at 1:00 pm, he/she went to Staff B, Chief Executive Officer (CEO), many times with concerns regarding the medical care being provided by Staff A. Concerns included for example, overuse of central lines and Staff A's ability to manage ventilator patients. -- During interview of Staff I, Physician, on 8/31/18 at 9:10 am, he/she had emailed the CMO on 2/23/18 about concerns pertaining to the medical care provided by Staff A. Review of the email revealed Staff I had identified two specific cases involving patients that he/she had grave concerns about the care provided. Staff I indicated Staff A "endangered patient care by refusing to follow protocol, consider the opinions of consultants, or transfer patients when required." Staff I indicated there were a number of near misses with patient's care that required his/her intervention. The CMO emailed Staff I indicating, he/she would look into the concerns and notify Staff I of the findings. After receiving no response from the CMO, he/she emailed Staff D, President of the Medical Staff, on 5/29/18 with the same concerns asking him/her to investigate and take corrective actions. Review of the email revealed Staff I identified the same two cases and his/her concerns about the care provided. Staff I asked Staff D to investigate the conduct, professionalism and behavior of Staff A. Staff I also indicated that numerous other physicians and staff members had raised concerns about Staff A's professionalism. No response was received from Staff D. Staff I again emailed Staff B and Staff D on 8/15/18 with additional concerns pertaining to the medical care and behavior of Staff A. Review of the email sent to Staff B indicated, Staff A had continued with inappropriate behavior and multiple complaints had been generated by the staff. Staff I also indicated concerns pertaining documentation by Staff A. Staff B stated he/she would have the Quality Department look into it. Review of the email sent to Staff D indicated, there were a number of additional complaints generated by nursing staff and concerns about Staff A's documentation in the medical record. Staff I was not aware of any investigation being initiated. -- During interview of Staff D on 8/20/18 at 10:15 am, he/she stated that no physicians had come to him/her with concerns regarding another physician. Staff D stated he/she reads all incident reports and sends out for external review any concerns regarding medical care if needed. He/she stated there have been no concerns raised regarding the quality of care provided by Staff A. -- During interview of Staff B on 8/23/18 at 11:20 am, he/she reported that three providers came to him/her directly with concerns regarding the medical care and inappropriate behaviors exhibited by Staff A. Staff B acted on these concerns by putting together a "Steering Committee" also referred to as a Medical Directors Meeting, headed up by Staff C, that meets weekly to discuss medical issues. The meeting minutes (dated 12/2017 through 8/2018) lacked any documentation regarding concerns about Staff A's medical care. When asked if the CMO, a pathologist, was qualified to review medical care issues related to care provided by an intensivist, he respond that yes the CMO is qualified and also the Assistant Chief Medical Officer is an Obstetrician / Gynecologist (OB/GYN). -- Review of the hospital's MEC meeting minutes, dated 11/2017 through 8/2018, and Board of Trustees meeting minutes, dated 8/2017 through 8/2018, revealed there was no documenation that quality of care issues regarding Staff A were discussed.
A0050 Medical Staff - Selection Criteria
482.12(a)(6)
Corrected On: 11/13/2018
36617 Based on document review and interview, the hospital failed to monitor a physician's behavior (Staff A) after numerous complaints and a cease and desist letter to the physician. This could lead to unsafe patient care. Findings include: -- Review of documents revealed Staff A was hired as a locum tenens (temporary physician staff) prior to 10/30/17 when he/she then became a hospital employee. -- Review of meeting minutes from Medical Executive Committee, Credentials Report section, dated 11/21/17, contained the following statement, "Appointments to Staff: Staff A, Department of Medicine, Active Staff." -- Review of incident report data from October 2017 indicated, there was one incident reported involving Staff A. In 4/2018 there were 12 incidents involving Staff A and in 5/2018, 13 incidents. -- Review of the incident reports revealed, a variety of issues were documented (See findings in Tag 0049 for specific medical care issues). For example, on 4/19/18, it was alleged that Staff A was rude to a staff member. On 5/4/18, Staff A was accused of calling a staff member a derogatory name two times. On 5/21/18, Staff A, made derogatory comments about another physician to a staff member. On 5/21/18, Staff A made inappropriate sexual comments to a staff member. -- Review of a letter to Staff A, dated 6/26/18, stated "pursuant to our discussion on 6/14/18 .... the Hospital has received substantiated complaints regarding your conduct and professionalism in the work place and therefore the Hospital hereby requests that you cease such behavior effective immediately. The following summarizes the complaints which have been brought to our attention ... frequent, inappropriate name calling, unprofessional interactions, verbal abuse towards other employees, ... use of profanity and insults, disruptive behavior ... in front of patients and their loved ones ... inability to control your behaviors, reactions, and emotions, ... and sexual harassment ... Our expectation is that this behavior will cease immediately." -- During interview of Staff B, Chief Executive Officer (CEO) on 8/23/18 at 10:30 am, when asked, he/she verified no monitoring plan had been put in place to determine if the letter was effective in stopping the behaviors.