Hospital cited by second agency

By Marlena Hartz: CNJ staff writer

Spurred by complaints, three independent organizations have inspected Plains Regional Medical Center since January, officials confirmed this week. Two of those agencies have cited the hospital for being out of compliance with their standards. The third determined the complaint was unsubstantiated.

PRMC officials and inspection agencies have said inspections are routinely conducted at hospitals, and complaints about hospitals are common.

“Hospitals are heavily regulated, which is appropriate,” said Todd Sandman, a spokesperson from PRMC’s parent company, Presbyterian Healthcare Services.

“No one cares more about patient safety than the people who work in the hospital,” Sandman said. “Hospitals provide funds to oversight bodies. That in itself tells you the role our hospitals think oversight plays.

“It is critical,” he said.

Oversight agencies generally grant hospitals at least 45 to 60 days to fix problems, officials said.

Hospital administrator Brian Bentley resigned shortly after the rash of inspections began. He has declined to answer questions about why he resigned. PRMC officials will not comment either.

Here’s a summary of inspections conducted at PRMC since January:

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The agency that last fall granted the hospital accreditation, the Joint Commission on Accreditation of Healthcare Organizations, conducted an inspection of the hospital after receiving a complaint about the hospital in early January. The inspection occurred Jan. 26, said Joint Commission spokesperson Mark Forstneger.

“The complaint involved infection control, medication management and management of environment care issues,” Forstneger said.
Forstneger said environmental care issues can include problems with hazardous waste disposal, emergency management plans or the safety of the hospital building itself. He would not elaborate on the environmental care issues or other areas the Commission defined as deficient at PRMC.

In keeping with Commission procedures, the source of complaint is kept confidential, Forstneger said.

When accreditation officials inspected PRMC, the hospital was found to be out of compliance with Joint Commission standards, he said. As a result, the Commission set five preliminary requirements for the hospital:

• Provide patients with comparable needs the same standard of care, treatment and services throughout the hospital.

• Improve the safety of using medications.

• Properly and safely store medications.

• Perform initial assessments as defined by the hospital (i.e., hospital must follow the set standards for obtaining information about each individual seeking entry into the hospital for service, and matching patient needs with the appropriate setting, care level and intervention).

• Manage fire safety risks.

The hospital must decide to set a plan of corrective action or appeal the findings by this week, Forstneger said. If a hospital accredited by the Commission has been deemed a serious health risk to patients, the Commission will immediately place that hospital in preliminary denial of accreditation, which is almost unheard of, Forstneger said. Should that occur, however, information would be posted online at www.joint commission.org.

PRMC’s accreditation with the organization is still valid, Forstneger said.
To determine whether a health care provider is following standards, the Commission examines patient records and interviews employees, Forstneger said.

While he didn’t have concrete figures for the number of inspections the Commission conducts as a result of complaints each year, Forstneger said, “The Joint Commission receives thousands of complaints a year.”

The Commission accredits about 96 percent of all hospital beds in the nation, he said, and accredited approximately 4,500 hospitals in 2004. Of hospitals that underwent routine inspections in 2004, 87 percent had to correct medical standards to comply with the Commission, Forstneger said.

“The Commission provides the gold seal of approval for hospitals. They are recognized across the world as providing an effective framework for helping hospitals improve the quality of care they provide,” he said.

The accreditation organization also inspected PRMC’s laboratory services Feb. 22-24, he said. That inspection was not spurred by a complaint, he said, and was routine. The findings of the lab inspection are pending, he said.

The Commission recently beefed up its standards by requiring all future surveys of health care providers to be unannounced, Forstneger said.

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Centers for Medicare and Medicaid also found PRMC was out of compliance with its medical standards during a Feb. 6 inspection conducted by the officials from the New Mexico Department of Health.
Neither federal nor PRMC officials would release those findings.

The federal agency will conduct a more comprehensive survey of the hospital in the near future, officials have said. The hospital already has received feedback from the agency about deficient areas and is addressing the problems, PRMC officials previously told the Clovis News Journal.

PRMC’s dealings with CMS and the Joint Commission “go hand in hand,” Sandman said.

Sandman said Medicaid and Medicare standards are very similar to JCAHO standards.

“These things really mirror each other,” Sandman said. “Once we satisfy CMS, we believe we will satisfy JCAHO as well.”

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The state branch of the Occupational Safety and Health Administration, a federal Department of Labor organization formed to ensure the safety of workers in the workplace, received a complaint about the hospital that alleged federal procedures for handling blood were not being followed.

The allegations were unsubstantiated during a Feb. 27 inspection, according to OSHA documents, and no citations were issued.

“The inspection was generated by a referral which alleged that the Bloodborne Pathogen Program for Plains Regional Medical Center … is inadequate, and employees are exposed to blood pathogens without training and personal protective equipment. Also alleged is that housekeeping is inadequate, exposing employees to trip hazards and disease hazards,” the OSHA inspection report reads.

Bloodborne pathogens can include Hepatitis B, Hepatitis C and HIV/AIDS, according to the OSHA Web site, www.osha.gov.

A representative from the New Mexico OSHA bureau “did not identify any conditions to which PRMC employees were exposed which were in violation of health standards or regulations on the day of the inspection,” according to a letter sent by an OSHA compliance officer.