Highlights of PRMC report

The following is a summary of deficiencies cited in the report:
• Infection control
A tour of the operating room revealed waste from a recent surgery had been placed in the regular trash rather than the bin for infectious waste.
Infectious waste in New Mexico — which can include organs, blood, used needles or any substance that has a risk of transmitting disease to humans — must be rendered non-infectious before disposal, in accordance with the law. That can be done in a number of ways, including incineration or heat sterilization, according to the New Mexico Environment Department Web site. A company based in Roswell disposes of infectious waste for the hospital. However, regular trash is sent to the Clovis landfill.
In response to the findings, infectious waste is now placed in clear bags, according to PRMC officials.

• Restraint for acute medical and surgical care
To administer sedatives lawfully, a person must complete a training program. Registered nurses who did not complete the training program issued sedatives to patients, the report showed.
Also, the hospital failed to properly document instances where restraints were used on patients and failed to show why the restraints were needed, the report said.
Since the inspection, all nurses have been trained to issue sedatives and staff has been instructed to provide detailed documentation of events that led to the use of restraints, according to PRMC spokesperson Tayloria Grant.

• Medical staff accountability
In one randomly selected patient’s records, inspectors found a surgeon could not be found following a surgery. The surgeon had not written transfer orders for the patient. The patient waited about two hours to be transferred. No actions against the surgeon in response to this incident were taken, the report said.

• Discharge planning
“The hospital failed to implement a discharge planning process for all patients,” the report said.

• Criteria for discharge evaluations
“The hospital did not have a process in place to assess all patients who were likely to suffer adverse health consequences,” the report said. One hospital social worker told inspectors “due to time constraints and the number of patients, there was no way everyone could be seen,” the report said.

• Governing body
“All hospitals must have an effective governing body legally responsible for the conduct of the hospital as an institution.
“The governing body of PRMC failed to assure that all departments in the hospital operated in compliance with the conditions of participation, including contracted services,” the report said.
The governing body at PRMC is its board of trustees and ultimately the Presbyterian Healthcare Services Board of Trustees.

• Contracted services
“The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts.
“The hospital failed to assure that contracted services were reviewed to assure compliance with quality standards.
“The chief executive officer (Brian Bentley) stated that he was not aware the governing body was ever responsible for assessing the quality of contract services,” the report said.
A range of services at PRMC are contracted, including anesthesia and radiology, Presbyterian Healthcare Services Presbyterian spokesperson Todd Sandman said.

• Quality Assurance Performance Improvement process (QAPI)
“The hospital failed to assure that the quality assurance performance improvement program included data collection and assessment from all the hospital departments and services; failed to assure the performance improvement initiatives focused on indicators to improve health outcomes and reduce medical errors; and failed to take action when made aware of substandard performance.”
PRMC had no statistical data or performance improvement projects in anesthesia, pharmacy and infection control, the report said. Instead, PRMC medical staff and infection control reviewed anesthesia, interviews with staff indicated. A pharmacy and therapeutics committee reviewed pharmacy activities.
Adverse patient outcomes were not reported to the QAPI, and instead, were dealt with by the PRMC risk management office.

• QAPI program scope
When notes from the QAPI committee at PRMC were reviewed, there was no record of discussion of adverse patient outcome, “nor any reporting or trending regarding adverse patient outcomes,” the report said.

• QAPI health outcomes
Statistical data and improvement projects from anesthesia, pharmacy and infection control were absent.

• QAPI medical errors
The QAPI group did not sufficiently collect data to identify and mitigate medical errors, the report said.

• Leadership responsibilities
Only medical staff, and not the QAPI committee, received data collection and surveillance information.

• Executive responsibilities
Those in charge for performance improvement at the hospital confirmed that they did not follow QAPI standard operations, the report said.