Local hospital warned of lapses

In late July, the Centers for Medicare and Medicaid Services conducted an inspection at MountainView Hospital, where surveyors observed blood spots on a floor, unsecured medical records, illegible physician notes and breaches in infection control policy and procedures.

As a result, the hospital received a letter from CMS warning it could be decertified if management didn't correct those deficiencies within 90 days. If decertified, the hospital would lose its Medicare contract.

None of the deficiencies led to any harm to patients, according to the survey report, but they still warranted a letter from CMS and a plan of correction.

"The cumulative effect of these systematic practices resulted in the facility's failure to provide acceptable standard infection control services to its patients," the report reads.

William Wagnon, Mountain-View's chief executive officer, said the inspection was random and followed a survey by the Joint Commission -- the nation's premier evaluator and accrediting agency of hospitals and other medical care facilities and programs -- in which the hospital received a Gold Seal of Approval.

He said the hospital submitted a plan of correction to CMS on Sept. 24 and is waiting to hear the results.

Most of the corrections involved reviewing policies and procedures with the hospital's medical staff, implementing new procedures and putting better monitoring in place.

Wagnon said the public shouldn't take the CMS report to mean that inadequate health care is being provided at MountainView.

"What we want the public to know is that this was a random inspection and, due to heightened sensitivity, this survey has given us opportunities to improve," he said. "These were isolated incidents, and we have made improvements, organizationally, hospital-wide."

The survey, which took place July 22-25, was based on observations and interviews with patient staff as well as a review of 45 patient charts. The survey found that MountainView failed to:

•Implement and follow policies to control infections;

•Ensure that a safe and sanitary environment was provided to protect the health and safety of patients;

•Have a consistent and comprehensive system for identifying, reporting, investigating and controlling infections and communicable diseases in patients and staff.

Specifically, the hospital didn't provide proof of a Quality Assessment and Performance Improvement Program for its rehabilitation department, nor did it have a system in place to monitor infection control for outpatients who had undergone an endoscopy or a cardiac catheterization procedure at the facility.

During the survey, some of the medical staff were observed not properly cleaning their hands, leaving trash on an operating room floor and failing to clean blood drops from the floor after procedures.

Surveyors also observed medical staff taking a medication cart from an isolation room -- used for patients with infections that can be spread by air such as tuberculosis or chickenpox -- into a neighboring room without cleaning it.

In other instances, the surveyors noticed that some medical records were in an area where they could be accessed by unauthorized individuals.

In addition, in two of the 45 patient records reviewed, CMS found that physician handwriting was not legible.

For example, on both patients' records "the physician's signature was totally illegible and appeared to resemble an 'x' on both the progress notes and the physician's orders,'" the report said.

According to the hospital's plan of correction, the medical staff has been reminded of its handwriting policies and other policies to avoid other deficiencies documented by CMS.

"Extensive education has been undertaken with the hospital staff as well as the medical staff," Wagnon wrote in a letter to CMS.

Contact reporter Annette Wells at awells@reviewjournal.com or 702-383-0283.