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State orders hospital to correct mistakes
Thelma Grimes/San Pedro Valley News-Sun
While the Arizona Department of Health Services (ADHS) has cleared Benson Hospital of one complaint, they are still under investigation for a separate case and have been ordered to correct a number of deficiencies or risk losing their Medicare license.
That information came as a result of a letter to the San Pedro Valley News-Sun from Benson Hospital Administrator Ron McKinnon. McKinnon was responding to a Dec. 24 story about the hospital's woes.
In the letter, McKinnon said the administration takes allegations very seriously. They are currently under investigation by the National Labor Relations Board and ADHS for various complaints filed by members of the nursing staff.
McKinnnon said the hospital has been cleared of an allegation filed by former employee Dawn Reece. Reece resigned due to a hostile work environment last year, but filed a complaint with ADHS, stating the hospital violated its own policy by hiring the lesser-qualified Theresa Vincifora as the director of nursing. Vincifora was appointed to the position in October despite her highest level of education being an associate's degree. Before October, the hospital required someone with a bachelor's degree, and preferred someone with a master's.
McKinnon quoted Connie Belden of ADHS, who said there was not enough evidence to substantiate Reece's complaint.
However, McKinnon didn't mention that there is another ADHS investigation ongoing. Laura Oxley, spokeswoman for ADHS, said details of the ongoing investigation could not be disclosed until a decision is made.
Oxley further confirmed that the hospital has come under scrutiny after an onsite visit was conducted in November that revealed several deficiencies regarding the improper administration of medication, improper treatment of younger patients and a failure to update hospital bylaws and regulations.
"The department requires immediate correction of any deficiency that presents a threat to the health or safety of a client, resident, patient or agency personnel, and urges correction of all deficiencies at the earliest possible date," Belden said in a Dec. 22 letter to McKinnon.
Mary Wiley, assistant director of the Division of Licensing Services, also wrote McKinnon a letter, stating that as a Medicare provider, Benson Hospital must comply with the Social Security Act and the Conditions of Participation established by the Secretary of Health and Human Services.
"A Medicare re-certification survey of your facility was completed on Nov. 21," Wiley said. "After careful review, we have determined that the findings of the survey reflect that Benson Hospital was not in compliance with the conditions required for participation in the Medicare program. Accordingly, we are initiating action that may lead to the termination of Benson Hospital participation in the Medicare program within 90 days from the date of the resurvey."
Based on her visit, Belden said the hospital is not complying with the state's quality management code.
"Based on review of facility documents, clinical records, the Critical Access Hospital's policies and procedures and staff interviews, the department has determined the hospital's review of medication errors was not evaluated with accurate data collection, and without input from the pharmacy department," Belden said.
ADHS reviewed medication error reports between Jan. 2008 and Oct. 2008. The types of errors reported included the wrong dosage of medication in 15 of 86 cases, expired drugs were used in 5 of 86 cases, proper medications were not stocked in six cases, the wrong medication was stocked in four cases and medication was not given as needed in four cases due to the pharmacy's discontinuing the order.
Belden said medication errors ranged from 3 to 18 per month, with a nursing response to the mistakes being entered on the report, but no pharmacy report was attached to 60 of the 86 cases.
In an interview, the hospital's performance improvement coordinator admitted that the quarterly reports being presented to the medical staff and governing board had incorrect data, Belden said.
While the board was hearing reports of medication errors being as low as .2 percent, Belden showed that the 22-bed facility that houses between three and eight patients a day has a higher percentage of medication errors than what is being reported.
Hospital administration blamed the incorrect data on "an electronic problem in gathering the correct data."
On Nov. 20 new calculations were configured, showing the hospital ranged between .2 percent in medication errors a month to as much as 2 percent between Nov. 2007 and Oct. 2008.
When Vincifora was interviewed on Nov. 18, the new director of nursing admitted the percentage numbers provided in the data were lower, considering the number of medication error reports she reviews each month. Vincifora went on to blame the problem on the pharmacy department, which she told Belden does not provide any feedback to the nursing department.
Further, Vincifora told Belden that she was unaware of any of the medication errors harming patients.
"Multiple occurrence reports related to medication errors were reviewed," Belden said. "Nursing recommendations to prevent reoccurrence were noted on the reports. There were no notes from the pharmacy department. Two clinic records (Patient No. 16 and No. 17) were reviewed. The medication error to patient N o. 16 involved missed doses, but no patient reaction occurred. Patient No. 17 was administered a pneumovax injection that resulted in an inflammatory reaction. The documentation revealed the nurse might have incorrectly administered the injection.
"Education was provided to the nurse and the patient was given an antibiotic," the report further states.
Belden said further investigation revealed that a pharmacy technician was not consulted or on hand for any meetings between January and October of 2008, meaning in 60 of 86 cases, where there were medication errors, the hospital administration did not get advice from an actual pharmacist.
McKinnon was interviewed Nov. 20 and he acknowledged that "the pharmacist had not been participating in meetings and would not communicate with the nursing department regarding medication errors."
A new pharmacist is now in place, and Belden interviewed him Nov. 19. He said he had been made aware of the problems.
Besides problems with administering medication, Belden also found that the hospital is not complying with medical staff bylaws and medical staff regulations regarding young patients.
In her investigation, Belden found problems with how hospital staff is treating pediatric patients in the emergency room and hospital.
In her report, Belden said a patient under age 5 was admitted in March of last year, and another under 10 was admitted on May 16. Belden said reports from the two cases state that hospital staff was given general hospital orders to treat the patients.
However, after conducting interviews, staff members admitted to Belden that the standing hospital orders are for treating only adult patients.
"A physician hospitalist stated, during an interview on Nov. 19, that the standing orders approved by the medical staff were intended for adult patients and the hospital had no standing orders for pediatric patients," Belden said in the deficiency report. "The hospitalist reviewed the standing orders in (the 5-year-old's case), and acknowledged the orders were for adult patients only and should not have been ordered for a pediatric patient."
The third deficiency outlined by Belden is that hospital administration is not reviewing medical staff bylaws and medical staff regulation every 36 months as required.
Belden said there was no date or signature on the bylaws to show when they were last updated. The regulations and bylaws are supposed to be updated and reviewed by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) on a tri-annual basis.
Benson Hospital has not been accredited by JCAHO in five years.
Belden ordered the hospital to create a plan that would correct all deficiencies on a temporary and permanent basis, the date the correction will be completed, designate someone to be responsible for overseeing the required corrections and a monitoring system to prevent such problems from happening in the future.
Besides problems with licensing and ADHS, Benson Hospital is also under investigation by the National Labor Relations Board (NLRB).
Current and former members of the nursing staff have filed several complaints. Three complaints were filed over the last year, and two of those are under investigation.
Complaints filed on Oct. 24 and Dec. 3 claim Benson Hospital administration has engaged in unfair labor practices.
While the Arizona Department of Health Services (ADHS) has cleared Benson Hospital of one complaint, they are still under investigation for a separate case and have been ordered to correct a number of deficiencies or risk losing their Medicare license.
That information came as a result of a letter to the San Pedro Valley News-Sun from Benson Hospital Administrator Ron McKinnon. McKinnon was responding to a Dec. 24 story about the hospital's woes.
In the letter, McKinnon said the administration takes allegations very seriously. They are currently under investigation by the National Labor Relations Board and ADHS for various complaints filed by members of the nursing staff.
McKinnnon said the hospital has been cleared of an allegation filed by former employee Dawn Reece. Reece resigned due to a hostile work environment last year, but filed a complaint with ADHS, stating the hospital violated its own policy by hiring the lesser-qualified Theresa Vincifora as the director of nursing. Vincifora was appointed to the position in October despite her highest level of education being an associate's degree. Before October, the hospital required someone with a bachelor's degree, and preferred someone with a master's.
McKinnon quoted Connie Belden of ADHS, who said there was not enough evidence to substantiate Reece's complaint.
However, McKinnon didn't mention that there is another ADHS investigation ongoing. Laura Oxley, spokeswoman for ADHS, said details of the ongoing investigation could not be disclosed until a decision is made.
Oxley further confirmed that the hospital has come under scrutiny after an onsite visit was conducted in November that revealed several deficiencies regarding the improper administration of medication, improper treatment of younger patients and a failure to update hospital bylaws and regulations.
"The department requires immediate correction of any deficiency that presents a threat to the health or safety of a client, resident, patient or agency personnel, and urges correction of all deficiencies at the earliest possible date," Belden said in a Dec. 22 letter to McKinnon.
Mary Wiley, assistant director of the Division of Licensing Services, also wrote McKinnon a letter, stating that as a Medicare provider, Benson Hospital must comply with the Social Security Act and the Conditions of Participation established by the Secretary of Health and Human Services.
"A Medicare re-certification survey of your facility was completed on Nov. 21," Wiley said. "After careful review, we have determined that the findings of the survey reflect that Benson Hospital was not in compliance with the conditions required for participation in the Medicare program. Accordingly, we are initiating action that may lead to the termination of Benson Hospital participation in the Medicare program within 90 days from the date of the resurvey."
Based on her visit, Belden said the hospital is not complying with the state's quality management code.
"Based on review of facility documents, clinical records, the Critical Access Hospital's policies and procedures and staff interviews, the department has determined the hospital's review of medication errors was not evaluated with accurate data collection, and without input from the pharmacy department," Belden said.
ADHS reviewed medication error reports between Jan. 2008 and Oct. 2008. The types of errors reported included the wrong dosage of medication in 15 of 86 cases, expired drugs were used in 5 of 86 cases, proper medications were not stocked in six cases, the wrong medication was stocked in four cases and medication was not given as needed in four cases due to the pharmacy's discontinuing the order.
Belden said medication errors ranged from 3 to 18 per month, with a nursing response to the mistakes being entered on the report, but no pharmacy report was attached to 60 of the 86 cases.
In an interview, the hospital's performance improvement coordinator admitted that the quarterly reports being presented to the medical staff and governing board had incorrect data, Belden said.
While the board was hearing reports of medication errors being as low as .2 percent, Belden showed that the 22-bed facility that houses between three and eight patients a day has a higher percentage of medication errors than what is being reported.
Hospital administration blamed the incorrect data on "an electronic problem in gathering the correct data."
On Nov. 20 new calculations were configured, showing the hospital ranged between .2 percent in medication errors a month to as much as 2 percent between Nov. 2007 and Oct. 2008.
When Vincifora was interviewed on Nov. 18, the new director of nursing admitted the percentage numbers provided in the data were lower, considering the number of medication error reports she reviews each month. Vincifora went on to blame the problem on the pharmacy department, which she told Belden does not provide any feedback to the nursing department.
Further, Vincifora told Belden that she was unaware of any of the medication errors harming patients.
"Multiple occurrence reports related to medication errors were reviewed," Belden said. "Nursing recommendations to prevent reoccurrence were noted on the reports. There were no notes from the pharmacy department. Two clinic records (Patient No. 16 and No. 17) were reviewed. The medication error to patient N o. 16 involved missed doses, but no patient reaction occurred. Patient No. 17 was administered a pneumovax injection that resulted in an inflammatory reaction. The documentation revealed the nurse might have incorrectly administered the injection.
"Education was provided to the nurse and the patient was given an antibiotic," the report further states.
Belden said further investigation revealed that a pharmacy technician was not consulted or on hand for any meetings between January and October of 2008, meaning in 60 of 86 cases, where there were medication errors, the hospital administration did not get advice from an actual pharmacist.
McKinnon was interviewed Nov. 20 and he acknowledged that "the pharmacist had not been participating in meetings and would not communicate with the nursing department regarding medication errors."
A new pharmacist is now in place, and Belden interviewed him Nov. 19. He said he had been made aware of the problems.
Besides problems with administering medication, Belden also found that the hospital is not complying with medical staff bylaws and medical staff regulations regarding young patients.
In her investigation, Belden found problems with how hospital staff is treating pediatric patients in the emergency room and hospital.
In her report, Belden said a patient under age 5 was admitted in March of last year, and another under 10 was admitted on May 16. Belden said reports from the two cases state that hospital staff was given general hospital orders to treat the patients.
However, after conducting interviews, staff members admitted to Belden that the standing hospital orders are for treating only adult patients.
"A physician hospitalist stated, during an interview on Nov. 19, that the standing orders approved by the medical staff were intended for adult patients and the hospital had no standing orders for pediatric patients," Belden said in the deficiency report. "The hospitalist reviewed the standing orders in (the 5-year-old's case), and acknowledged the orders were for adult patients only and should not have been ordered for a pediatric patient."
The third deficiency outlined by Belden is that hospital administration is not reviewing medical staff bylaws and medical staff regulation every 36 months as required.
Belden said there was no date or signature on the bylaws to show when they were last updated. The regulations and bylaws are supposed to be updated and reviewed by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) on a tri-annual basis.
Benson Hospital has not been accredited by JCAHO in five years.
Belden ordered the hospital to create a plan that would correct all deficiencies on a temporary and permanent basis, the date the correction will be completed, designate someone to be responsible for overseeing the required corrections and a monitoring system to prevent such problems from happening in the future.
Besides problems with licensing and ADHS, Benson Hospital is also under investigation by the National Labor Relations Board (NLRB).
Current and former members of the nursing staff have filed several complaints. Three complaints were filed over the last year, and two of those are under investigation.
Complaints filed on Oct. 24 and Dec. 3 claim Benson Hospital administration has engaged in unfair labor practices.
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Reader Comments
The following are comments from the readers. In no way do they represent the view of bensonnews-sun.com.
Reb wrote on Jan 17, 2009 12:35 AM:
" not in compliance is not good for the patients or the morale of the staff. its relevant as far as the medication errors go, because where there was harm or not, there were still errors, so the statement of there was no harm done is wrong. knowledge of a dose misadministered or not given can still cause a patient mental distress. it is a given that the staff tries their best, but administration knowing they were not in compliance concerning bylaws and policy, there is no excuse for that. that is what administration is for, to guide and direct and to ensure that all the paperwork for the hospital is in order and that local patients will not lose out because the facility isn't in compliance with state and federal guidelines to ensure available care for medicare and pediatric patients as well as adult patients and patients with regular insurance. "
Anonymous Too wrote on Jan 17, 2009 7:21 PM:
" “Anonymous” is absolutely correct when he/she stated that improvements and measures to ensure the best quality of care possible at Benson Hospital is a CONTINUOUS undertaking by all hospital staff.
Why has this information not ever reported in the “back and forth articles”?
I also agree with “Anonymous” that hospital staff (past and present) have personal issues with hospital administration (especially with Theresa Vincifora).
Where is the unprejudiced press? Let’s hear from both sides, okay?
JCAHO (The Joint Commission on the Accreditation of Healthcare Organizations) is an organization that certifies (accredits) hospital organizations. Benson Hospital has maintained JCAHO accreditation for decades until they became a Critical Access Hospital (CAH).
Why has this information not ever reported in the “back and forth articles”?
AzDHS (The Arizona Department of Health Services) per Centers for Medicare & Medicaid Services Standards (CMS) now certifies the hospital on a regular basis. The Hospital is STILL certified (accredited) per CMS.
Why has this information not ever reported in the “back and forth articles”? "
Why has this information not ever reported in the “back and forth articles”?
I also agree with “Anonymous” that hospital staff (past and present) have personal issues with hospital administration (especially with Theresa Vincifora).
Where is the unprejudiced press? Let’s hear from both sides, okay?
JCAHO (The Joint Commission on the Accreditation of Healthcare Organizations) is an organization that certifies (accredits) hospital organizations. Benson Hospital has maintained JCAHO accreditation for decades until they became a Critical Access Hospital (CAH).
Why has this information not ever reported in the “back and forth articles”?
AzDHS (The Arizona Department of Health Services) per Centers for Medicare & Medicaid Services Standards (CMS) now certifies the hospital on a regular basis. The Hospital is STILL certified (accredited) per CMS.
Why has this information not ever reported in the “back and forth articles”? "
Ex-Employee wrote on Jan 20, 2009 2:59 PM:
" I used to work there in 2005/2006. I have seen this type of medication errors mentioned in the article made by floor nurses. I have also seen the hostile workplace that was mentioned. The lawyer I talked to said if this was any other state that I would have a case with all of the documentation that I had. However in the great state of Arizona it is necessary to prove intent. Good luck to anyone who is pursuing a lawsuit in order to improve a hostile and sometimes dangerous work environment. "
Been there too. wrote on Jan 20, 2009 9:11 PM:
" The administration at Benson Hospital needs to step down. There were numerous nurse complaints that we did not have the drugs, supplies or support to do our jobs effectively. To compare Vincifora to former DONS Carter and Lewis is ludicrous. She is not even in their league. The public needs to call for an accounting of the administrations practices to preserve our hospital. Many people with serious health problems can only live in this rural area because of the availbiliy of an ambulance and hospital services. The entire San Pedro Valley is taxed for this and Ron McKinnon and Denice Huerto owes the public an explanation of their acts. "
Why are you surprised wrote on Jan 20, 2009 9:46 PM:
" To Ex-Employee
Get a new lawyer.
Why is everyone so surprised at the press bing so one sided and biased. This is what they always do.
Maybe now that it is happening to some of you, you will take a new look at what was reported about Kathy Suagee and Diane Tipton. You need to remember this investigative reporter and news paper never investigated the facts concerning Fenn or Ann Roberts. They just took sides and reported it that way..
This community needs to rethink their pledge of allegiance. "
Get a new lawyer.
Why is everyone so surprised at the press bing so one sided and biased. This is what they always do.
Maybe now that it is happening to some of you, you will take a new look at what was reported about Kathy Suagee and Diane Tipton. You need to remember this investigative reporter and news paper never investigated the facts concerning Fenn or Ann Roberts. They just took sides and reported it that way..
This community needs to rethink their pledge of allegiance. "
Anonymous wrote on Jan 15, 2009 4:55 PM: