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Based on observation, review of policies and procedures, Governing Body Meeting Minutes, Levi Hospital Narrative Description and Scope of Services and interview, it was determined the facility did not meet the federal and state requirement related to the definition of an acute care hospital in that the facility did assure they maintained an operational acute care unit that was could provide care on an inpatient basis or to patients who presented to the Emergency Department for emergent care. The facility could not be assured its capability to provide services to the community as an acute care hospital. See A043 and A1100.

Based on observation and interview, it was determined the facility did not adhere to federal law in the operation of an acute care hospital according to 1861(b) and (e) of the Social Sercurity Act. The findings were:

A. The Social Sercurity Act (b) defines inpatient hospital as the ability to provide items and services furnished to an inpatient of a hopsital as:
1) "bed and board;"
2) "such nursing services and other related services, such use of hospital facilities, and such medical social services as are ordinarily furnished by the hospital for the care and treatment on inpatients, and such drugs, biologicals, supplies, appliances, and equipment, for use in the hospital, as are ordinarily furnished by such hospital for the care and treament of inpatients;" and
3) "such other diagnositc or therapeutic items or services, furnished by the hospital or by others under arrangements with them made by the hospital, as are ordinarily furnished to inpatients either by such hospital or by others under such arrangements."
B. The Social Sercurity Act (e) defines inpatient hospital as:
1) "is primarily engaged in providing, by or under the supervision of physicians, to inpatients (A) diagnostic services and therapeutic services for medical diagnosis, treatment and care of injured, disabled, or sick persons, or (B) rehabilitation services for the rehabilitation of injured, disabled, or sick persions;"
2) "Maintains clinical records on all patients;"
3) "has bylaws in effect with respect to its staff of physicians;"
4) "has a requirement that every patient with respect to whom payment may be made under this title must be under the care of a physician except that apatient receiving qualified psychologist serves (as defined in subsection (ii)) may be under the care of a clinical psychologist with respect to such services to the extent permitted under State law;"
5) "provides 24-hour nursing service rendered or supervised by a registered professional nurse, and has a licensed practical nurse or registered professional nurse on duty at all times...;"
6) "(A) has in effect a hospital utilization review plan which meets the requirements of subsection (k) and (B) has in place a discharge planning process that meets the requirements of subsection (ee);"
7) "inthe case of an institution in any State in which State or applicable local law provides for the licensing of hospitals, (A) is licensed pursuant to such law or (B) is approved, by the agency of such State or locality responsible for licensing hospitals, as meeting the standards established for such licensing;"
8) "has in effect an overall plan and budget that meets the requirements of subsection (Z);" and
9) "meets such other requirements as the Secretary finds necessary in the interest of the health and safety of individuals who are furnished services in the institution."
C. Based on observation, review of "Levi Hospital Narrative Description and Scope of Services" and interview, it was determined the facility did not provide inpatient acute care services and provided limited services to patients in the Emergency Department (ED) as follows:
1) Review of the "Levi Hospital Narrative Description and Scope of Services (Revised 06/2003, 08/2006, 12/2007)" stated, "...Levi Hospital does not operate an Emergency Department and provides limited emergency services based on its capability and capacity in compliance with EMTALA laws."
2) Review of the "Levi Hospital Narrative Description and Scope of Services (Revised 06/2003, 08/2006, 12/2007)" under "Exclusionary Criteria" stated, "The following criteria, if met, would prevent admission to Levi Hospital: 1) Medically unstable, including extensive and grossly infected wounds, active communicable disease, coma, acute head injuries, unstable cardiac conditions, end-stage renal failure, renal crisis, hypertensive crisis, acute and extensive CVA's and other medical conditions requiring immediate medical treatment in an inpatient setting ..." which limits the scope of services offered to patients presenting to the ED.
3) During a tour of the Acute Care Unit on the third floor on 11/16/11 with the Nurse Executive, there was no evidence of hospital beds or patient care equipment on the unit. Room 309 was utilized for storage and Room 308 was utilized as an office as stated by the Nurse Executive at the time of the tour.
4) The Nursing Station did not have evidence of patient care supplies, medications, patient care equipment, telephones, or office machines (i.e. facsimile) utilized for receiving laboratory or other test results.
5) A small room behind the Nursing Station contained an empty refrigerator and empty cabinets.
6) The Nurse Executive stated the unit had the capacity for six (6) potential patient care beds.
7) The Nurse Executive stated, "this unit was recently utilized for Hospice patients under contract."
8) Findings were confirmed with the Nurse Executive during the tour.
D. The facility was operating a 37 bed PPS (Prospective Payment System) Psychiatric Unit in which there 23 patients on current census without providing services to meet all the conditions of participation as a hospital.

Based on observation, review of "Levi Hospital Narrative Description and Scope of Services" and interview, it was determined the facility did not provide inpatient services according to their licensed status as Surgery and General Medical Care Hospital. The findings were:

A. The Surgery and General Medical Care Hospital definition means "any facility limited to providing short-term inpatient surgical and general medical diagnostic care and treatment.
B. Based on observation, review of "Levi Hospital Narrative Description and Scope of Services" and interview, it was determined the facility did not provide inpatient services as follows:
1) Review of the "Levi Hospital Narrative Description and Scope of Services (Revised 06/2003, 08/2006, 12/2007)" stated, "...Levi Hospital does not operate an Emergency Department and provides limited emergency services based on its capability and capacity in compliance with EMTALA laws."
2) Review of the "Levi Hospital Narrative Description and Scope of Services (Revised 06/2003, 08/2006, 12/2007)" under "Exclusionary Criteria" stated, "The following criteria, if met, would prevent admission to Levi Hospital: 1) Medically unstable, including extensive and grossly infected wounds, active communicable disease, coma, acute head injuries, unstable cardiac conditions, end-stage renal failure, renal crisis, hypertensive crisis, acute and extensive CVA's and other medical conditions requiring immediate medical treatment in an inpatient setting ..." which limits the scope of services offered to patients presenting to the ED.
3) During a tour of the Acute Care Unit on the third floor on 11/16/11 with the Nurse Executive, there was no evidence of hospital beds or patient care equipment on the unit. Room 309 was utilized for storage and Room 308 was utilized as an office as stated by the Nurse Executive at the time of the tour.
4) The Nursing Station did not have evidence of patient care supplies, medications, patient care equipment, telephones, or office machines (i.e. facsimile) utilized for receiving laboratory or other test results.
5) A small room behind the Nursing Station contained an empty refrigerator and empty cabinets.
6) The Nurse Executive stated the unit had the capacity for six (6) potential patient care beds.
7) The Nurse Executive stated, "this unit was recently utilized for Hospice patients under contract."
8) Findings were confirmed with the Nurse Executive during the tour.
D. The facility was operating a 37 bed PPS (Prospective Payment System) Psychiatric Unit in which there 23 patients on current census without providing services to meet all the conditions of participation as a hospital.

Based on observations, review of policies and procedures, Governing Body Meeting Minutes, "Levi Hospital Narrative Description and Scope of Services" and interviews, it was determined the Governing Body did not fulfill their responsibility in that they did not assure the facility operated as an acute care hospital to provided services to patients on an ongoing basis; failed to assure the maintenance of an organized Emergency Department (ED) that could provide emergent care to patients who presented to the ED; failed to ensure Performance Improvement activities facility wide to evaluate data and implement corrective actions. The failed processes could not assure care was available or capable of being administered to patients who presented to the ED for emergent care or patients requiring care on an inpatient basis. The failed practice had the potential to affect all patients presented to the Emergency Department for emergent care, all patients admitted to the psychiatric unit and the 23 psychiatric patients on census. See A0020, A0263 and A1100.

Based on review of the Medical Staff Bylaws, Allied Health credential files, clinical record review and interview, it was determined the Governing Body did not ensure Medical staff was accountable to the Governing Body in that an Advanced Practice Nurse (APN) had not been credentialed or granted privileges to provided care for patients within the scope of an APN. The failed practice allowed an APN to deliver care without being credentialed to do so. The failed practice had the potential to affect all patients admitted to the facility. Findings follow:

A. Review of the Medical Staff Bylaws on 11/15/11 at 1430 revealed the credentialing process included application by the practitioner then reviewed by the Chief Executive Officer (CEO), Credentialing Committee, Medical Executive Committee (MEC). The MEC was then to submit recommendations for approval or denial to the Governing Body for final approval or denial of the application.
B. Review of APN #1's allied health credential file lacked evidence the MEC had made recommendations for approval, denial of, or any special limitations on staff appointment. There was no evidence of granted privileges by the Governing Body.
C. Review of clinical records on 11/17/11 at 1020 revealed APN #1 prescribed medications for four (#11, #12, #13 and #14) of five (#1, #11, #12, #13 and #14) patients and wrote progress notes as the practitioner for two (#1 and #12) of five (#1,#11, #12, #13 and #14) patients.
D. During an interview on 11/15/11 at 1545, APN #1 stated "I cover for Physician #1 on the weekends and sometimes I take a paid time off (PTO) day during the week and cover for him."
E. During an interview on 11/18/11 at 1015, the CEO confirmed one (#1) of two (#1 and #2) Advanced Practice Nurses were not credentialed per Medical Staff Bylaws.

Based on observations, review of policies and procedures, "Levi Hospital Narrative Description and Scope of Services" and interview, it was determined the Governing Body did not fulfill their responsibility in that they failed to ensure oversight of the Emergency Department (ED) to assure services could be provided to patients who presented to the ED. The facility could not assure emergent care was available or capable of being administered to patients who presented to the ED. The failed practice had the potential to affect all patients presented to the Emergency Department for emergent care and all patients admitted to the facility. Findings follow:

A. Review of the "Levi Hospital Narrative Description and Scope of Services (Revised 06/2003, 08/2006, 12/2007" revealed the hospital did not participate in surgery, organ procurement, electroconvulsive therapy or invasive medical procedures. The hospital provided only limited services in the Emergency Department based on its capability and capacity in compliance with EMTALA laws. The "Exclusionary Criteria" stated, "The following criteria, if met, would prevent admission to Levi Hospital: 1) Medically unstable, including extensive and grossly infected wounds, active communicable disease, coma, acute head injuries, unstable cardiac conditions, end-stage renal failure, renal crisis, hypertensive crisis, acute and extensive CVA' s and other medical conditions requiring immediate medical treatment in an inpatient setting ..."
B. During a tour of the ED on 11/16/11 at 0905 with the Nurse Executive, equipment and supplies consisted of a padded wooden structure, desk, three chairs, and a sterile pack for infant delivery. Inspection of the sterile pack for infant delivery revealed a hole in the outside covering, which compromised the integrity and had the potential to spread infection..
C. Review of policies and procedures revealed there was no evidence of developed policies and procedures to guide the standards of practice for the ED.
D. In an interview with the Nurse Executive on 11/16/11 at 1500, the above were confirmed.

Based on review of the facility's grievance log, "Patient Rights" policy and interview, the facility failed to assure written notification was sent to grievance complainants informing them of the facility's decision which included the name of the hospital contact person, the steps taken on behalf of the complainant to investigate a grievance, the results of the grievance process and the date of completion. The failed practice did not assure the complainant was informed of the grievance investigation, whom to contact to discuss the investigation, the results of the investigation or the date of completion and had the potential to affect all patients or their representatives who filed grievances with the facility. Findings follow:

A. Review of the facility's "Patient Rights" policy revealed it did not describe how a grievance would be investigated, how a complainant would be notified of the results, did not include a contact person, an expected time frame with which to investigate or the date of completion.
B. Review of the facility's grievance log revealed a list of patient names and dates, but no indication of complaint follow-up or resolution.
C. Interview with the Nurse Executive on 11/17/11 at 1530 verified the findings.

Based on observation and interview, the facility failed to assure patients' rights to personal privacy in that patients seen in the Emergency Department (ED) were not protected visually from other patients and visitors. The failed practice did not assure patients received care in a private setting and had the potential to affect all patients presenting to the ED. Findings follow:

During a tour of the ED on 11/16/11 at 0845, the Nurse Executive escorted the survey team to the Admissions Entrance of the facility and stated that was where patients presented for emergent care and patients not requiring psychiatric care were evaluated in this location and transferred to another facility if a "higher level of care" was indicated. The Admissions Entrance was a hallway with clear sliding glass doors and windows into an office utilized by registration personnel. The area did not assure privacy for patients or visitors.

Based on observation and interview, the facility failed to assure patients received care in a safe environment which was free from contamination, had emergency equipment/supplies available, or had staff available for patient care or trained in emergency management. The failed practice did not assure supplies and/or equipment was available for patient use, that staff was trained in emergency management and did not prevent the spread of infection. Findings follow:

A. During a tour of the Emergency Department (ED), on 11/16/11 at 0845 a padded wooden structure was utilized as a patient bed. The wooden structure was not sealed with a covering so that it could be cleaned and disinfected between patients or to assure splintering did not cause injury to patients.
B. During a tour of ED on 11/16/11 at 0845, there was no evidence of a phone in the Department.
C. Shelving in cabinets utilized for supplies in the ED was constructed of wood which was not sealed with a covering to assure cleaning and disinfection.
D. The emergency cart (crash cart) was located on the fourth floor of the facility which was not easily accessible to patients who presented to the ED.
E. Findings were confirmed with the Nurse Executive at the time of the tour.
F. There was no documented evidence of staff training or orientation specific to the ED and was verified by the Nurse Executive on 11/18/11 at 1020.

Based review of the facility's "Patient Rights" policy and interview, the facility failed to assure the policy included a process for assuring patients were protected from abuse by a staff member, other patient, or visitor or how to report suspected abuse and what actions to take when a suspected abuse report is received. The failed practice did not assure there was a system in place to protect patients from abuse, neglect or harassment from others and had the potential to affect all patients admitted to the facility. Findings follow:

A. Review of the facility's policies and procedures revealed no evidence of policies and procedure for investigating allegations of abuse and neglect including methods to protect patients from abuse during investigations of allegations, did not identify how the facility substantiated allegations of abuse and neglect, did not identify appropriate actions the facility would take, and did not identify what actions a staff members would take if they witnessed abuse and neglect.
B. Findings were confirmed during an interview with the Nurse Executive on 11/17/11 at 1530.

Based on review of the Performance Improvement Committee Meeting Minutes for four of four quarters (fourth 2010 to third 2011) and interview, it was determined for two (second and third) of four quarters the contracted service for respiratory care was not integrated into the quality assessment/process improvement process and data collected was not analyzed to track and trend outcomes to develop a corrective action; there was no evidence Performance Improvement Committee met for two (fourth 2010 and first 2011) of four quarters. The failed practices did not ensure the Performance Improvement Committee had an ongoing process to focus on indicators to ensure the improvement of care delivered to patients. The failed practice had the potential to affect any patient who received respiratory care and all patients admitted to the facility. The findings were:

A. Review of the Performance Improvement (PI) Committee Meeting Minutes for two of two (second and third 2011) in which data was collected and interview revealed the facility failed to analyze data collected to assess opportunities for improvement for Nursing Services and Discharge Planning. See A0265.
B. Review of the Performance Improvement (PI) Committee Meeting Minutes for two of two (second and third 2011)quarters, Respiratory Therapy Contract Agreement, Performance Improvement Plan Section IV.B, and interview revealed the Process Improvement Committed failed to assure Emergency Services, Patient Grievances and Respiratory Therapy was integrated into the Quality Assessment/PI activities. See A0267.

Based on review of the Performance Improvement (PI) Committee Meeting Minutes for four (fourth 2010 and first to third 2011) quarters and interview, it was determined the Process Improvement Committee failed to assure for two of two (second and third 2011) quarters the data collected was analyzed to assess opportunities for improvement for Nursing Services, Discharge Planning and Patient Grievances; there was no evidence the Process Improvement Committee met for two of two (fourth 2010 and first 2011) quarters to provide an ongoing program; there was no evidence the Respiratory Therapy Department was integrated into the Quality Assurance/Process Improvement (QA/PI) activities. The failed practice did not assure PI activities were evaluated for revision or improvement in patient outcomes and had the potential to affect all patients admitted to the facility. Findings follow:

A. Review of PI Committee Meeting Minutes for second and third quarter 2011 revealed evidence of data collection for Discharge Planning and Nursing Services but there was the data was analyzed to determine opportunities for improvement and education; there was no evidence respiratory therapy was integrated in QA/PI activities.
B. During an interview with the Nurse Executive on 11/17/11 at 0925 regarding the QA/PI activities for Nursing Services, she stated, "This is all my psych (psychiatric) unit PI, the rest comes from Medical Records or other departments. "
C. On 11/17/11 at 0945, the Process Improvement Committee Meetings for the fourth quarter 2010 and first quarter 2011 were requested from the Nurse Executive but were not presented by the time of exit on 11/18/11.
D. On 11/17/11 at 1045, the Nurse Executive confirmed the Respiratory Therapy Department was integrated in QA/PI activities.

Based on review of the Performance Improvement (PI) Committee Meeting Minutes for four quarters (fourth 2010 and first to third 2011), Respiratory Therapy Contract Agreement, Performance Improvement Plan Section IV.B and interview, the facility failed to assure Quality Assurance/ Performance Improvement (QA/PI) activities were conducted for Emergency Services, Patient Grievances and Respiratory Therapy. The Process Improvement Committee did not assure there was an ongoing program to analyze data to identify opportunities for change or improvements, and implement actions to correct areas of improvement and had the potential to affect all patients admitted to the facility. The findings were:

A. Review of the Respiratory Therapy Contract Agreement on 11/15/11 at 1000 revealed "A Quality Assurance program for the department will be established under guidance of the Hospital's Quality Assurance Director."
B. Review of the facility Performance Improvement Plan Section IV.B, "Hospital Staff Review Functions" revealed a list of departments included in the Performance Improvement Plan which included Respiratory Therapy.
C. Review of Performance Improvement Committee Meeting Minutes for the second and third quarters of 2011 revealed no evidence QA/PI activities for Respiratory Services were integrated into the facility wide Performance Improvement Activities. In an interview on 11/17/11 at 1045 the Nurse Executive verified the Respiratory Therapy Service was not integrated into the facility wide Performance Improvement program.
D. Review of the PI Committee Meeting Minutes for second and third quarters 2011 revealed no evidence that QA/PI activities were discussed for Emergency Services. Findings were verified with the Nurse Executive on 11/17/11 at 0925.
E. Review of PI Committee Meeting Minutes for second and third quarter 2011 revealed no evidence that QA/PI for Patient Grievances was discussed. Findings were verified with the Nurse Executive on 11-17-11 at 0925.
F. On 11/17/11 at 0945, the Process Improvement Committee for the fourth quarter 2010 and first quarter 2011 were requested from the Nurse Executive but were not presented by the time of exit on 11/18/11.

Based on observation and interview it was determined the physical condition in patient rooms and bathrooms was not maintained to ensure the health and safety of patients due to unclean bathrooms, missing locks on air-conditioning unit controls, and stained/wet ceiling tiles. The failed practice had to the potential to affect all patients admitted to the facility. The facility had a census of 23 patients on 11/15/11. The findings follow:

A. On a tour of the facility on 11/16/11 at 1250 with the Director of Plant Operations/Maintenance the following conditions were observed:
1) In Patient Room 502, the paint around the window frame was cracked. There was mildew in the in the corners of the shower floor.
2) In Patient Room 509, the security cover over the air conditioning unit was pulled away from the wall. A glue residue was on the floor at the threshold to the bathroom.
3) In Patient Room 507, there was grime and mildew in the corners of the shower floor.
4) In Patient Room 411, the paint on the exterior wall was cracked and peeling from water damage. There was mildew and grime in the corners of the shower floor.
5) In Patient Room 412, there was mildew and grime in the corners of the shower floor. There were three wet and stained ceiling tiles located by the window. The locking mechanism on the air conditioning unit controls was missing. This room was located on a psychiatric unit.6) In Patient Room 408, located on a psychiatric unit, the locking mechanism on the air conditioning unit controls was missing. Mildew was observed in the corners of the shower floor.
7) In Patient Room 403, located on a psychiatric unit, the locking mechanism on the air conditioning unit controls was missing. Mildew was observed in the corners of the shower floor.
8) In Patient Room 402 the lens cover on the night light was loose. There was mildew in the corners of the shower floor.

B. The Director of Plant Operations/Maintenance verified the above items in an interview conducted on 11/16/11 at 1445.

Based on observation and interview it was determined the facility did not meet Life Safety Code requirements related to maintaining the half hour fire resistance rating of corridor walls, the use of roller latches on patient room doors, and the fire protection of a room used to store flammable materials.

Failure to maintain the fire resistance rating has the potential to affect the health and safety of all patients due to the potential of fire and smoke transfer between the corridor and patient rooms. The facility had a census of 23 patients on 11/15/11.

The use of roller latches on patient room doors had the potential to affect the health and safety of patients due to the potential failure of the roller latches to maintain the doors in the closed position in a fire and smoke event.

The failure to provide fire protection in rooms used to store flammable materials had the potential to affect the health and safety of patients due to the spread of fire and smoke to patient rooms.

See CMS 2567, Tag K17, K18, and K29.

Based on observation, review of Infection Control Committee Meetings Minutes and interview, it was determined the Infection Control Officer failed to ensure processes were in place to monitor and evaluate housekeeping to assure a clean and sanitary environment was maintained. Failure to assure a clean and sanitary environment allowed for the spread of infections and communicable diseases among patients and staff. The failed practice had the potential to affect all 23 psychiatric patients on census on 11/15/11, all patients admitted to the facility, visitors and staff. Findings follow:

A. Tour of the Emergency Department was conducted with Nurse Executive on 11/16/11 from 0855-0945. The following was observed and verified at the time of observation by the Nurse Executive.
1) A padded wooden structure that contained splits in the wooden surfaces covered with linen and a pillow. The wooden structure was not sealed with a covering to aide in cleaning, disinfecting and preventing splintering. Wood cannot be cleaned or disinfected due to its porous nature to prevent the spread of infection. In an interview at 0910, the Nurse Executive identified the wooden padded structure as a stretcher.
2) Shelving of the cabinetry was non sealed plywood utilized for patient supplies. Wood cannot be cleaned or disinfected due to its porous nature to prevent the spread of infection.
3) Soiled porous cloth chair which cannot easily be cleansed or disinfected to prevent the spread of infection.
4) Desk contained rust on legs. Due to the porous nature of rust it cannot be cleaned or disinfected.
5) Over bed lighting contained an accumulation of dust.
6) The floor was stained with an unknown dark substance.
7) The patient bathroom contained an open bar of soap, porous fabric shower curtain and a platform utilized at the base of the toilet contained stains of an unknown origin.
8) An unlocked room adjacent to the patient ' s bathroom revealed used personal items to include lotion, shampoo, coffee and a fan with an accumulation of dust was accessible to psychiatric patients. In an interview on 11/16/11 at 0900, the Nurse Executive identified the room as an area utilized by staff as a sleeping area and the supplies belong to staff.
B. Observation of the Physical Therapy corridor on 11/16/11 at 0950 revealed:
1) Five porous cloth chairs which did not allow easy cleaning and disinfection and increased the potential to spread infections and communicable diseases.
2) The Nurse Executive verified the above item at the time of observation.
C. Tour of the fourth floor on 11/16/11 at 0955 with the Nurse Executive, the following was observed and confirmed by the Nurse Executive at the time of the observation.
1) The Quiet Room revealed a restraint bed with an accumulation of an unknown substance under the padding.
2) Observation of the exterior surface of the nursing station revealed multiple areas of exposed wood where the Formica was removed or chipped which does not allow for disinfection and cleansing due to non sealed wood porous nature.
3) Observation of patient Room #402 show contained mildew in the corners of the shower floor.
4) Observation of patient Room #403 included an accumulation of grime and dirt. Mildew was observed in the corners of the shower.
5) Observation of patient Room #408 security covering over the air condition unit contained an accumulation of dust. The show contained mildew in the corners of the shower floor.
6) Patient Room 411, the paint on the exterior wall was cracked and peeling from water damage. Mildew and grime was observed in the corners of the shower floor.
7) Patient Room 412 corners of the shower floor contained mildew and grime. Three wet and stained ceiling tiles were observed by the window.
D. Tour of the fifth floor on 11/16/11 at 1030 with the Nurse Executive, the following was observed and confirmed by the Nurse Executive at the time of the observation.
1) In Patient Room 502, the paint around the window frame was cracked. There was mildew in the in the corners of the shower floor.
2) In Patient Room 507, there was grime and mildew in the corners of the shower floor.
3) In Patient Room 509, the security cover over the air conditioning unit was pulled away from the wall and contained a dark residue and an accumulation of dust. A glue residue was observed on the floor at the threshold to the bathroom.
4) A clean storage room contained an ice machine stained with an unknown substance with an attached cleaning schedule which revealed last cleaning dated 12/15/11.
5) The clean storage room also contained the storage of a bedside toilet and a patient shower chair. Unable to determine if the bedside toilet and patient shower chair were stored as clean equipment as there was no method of identification.
E. Review of the Infection Control Performance Improvement Summaries from September 2010 to September 2011 revealed monthly sanitation walking rounds for safety and cleanliness with a total of 30 rooms per month monitored and 30 rooms compliant each month for the past 12 months.
F. In an interview with Infection Control Coordinator on 11/16/11 at 1400, the environmental tour findings were shared. The Infection Control Coordinator stated "I don't look at all that, but now I will."

Based on observation, interview and review of "Levi Hospital Narrative Description and Scope of Services (Revised 06/2003, 08/2006, 12/2007)" the facility failed to assure emergency services were available to meet the needs of patients in that the scope of services was limited, policies and procedures were not developed to establish facility standards of practice, equipment and supplies were not available for the emergent care of each patient who presented to the Emergency Department (ED) and the ED was not integrated into the Quality Assessment/Performance Improvement (QA/PI) process. The failure compromised the health and safety of each patient who presented to the ED for care or services. Findings follow:

A. Review of the "Levi Hospital Narrative Description and Scope of Services (Revised 06/2003, 08/2006, 12/2007)" stated, "...Levi Hospital does not operate an Emergency Department and provides limited emergency services based on its capability and capacity in compliance with EMTALA laws."
B. Review of the "Levi Hospital Narrative Description and Scope of Services (Revised 06/2003, 08/2006, 12/2007)" under "Exclusionary Criteria" stated, "The following criteria, if met, would prevent admission to Levi Hospital: 1) Medically unstable, including extensive and grossly infected wounds, active communicable disease, coma, acute head injuries, unstable cardiac conditions, end-stage renal failure, renal crisis, hypertensive crisis, acute and extensive CVA's and other medical conditions requiring immediate medical treatment in an inpatient setting ..." which limits the scope of services offered to patients presenting to the ED.
C. Based on observation and interview, the facility failed to assure emergency services were integrated with other departments of the hospital as evidenced by the unavailability of equipment, personnel and resources for emergent care. See A1103.
D. Based on observation and interview, the facility failed to assure adequate medical and nursing personnel qualified in emergency care were available in the Emergency Department. See A1110.

Based on observation and interview, the facility failed to assure emergency services were integrated with other departments of the hospital as evidenced by the unavailability of equipment, personnel and resources for emergent care. The failed practice did not make available resources to assess and render care for emergency patients and had the potential to affect all patients presenting to the Emergency Department (ED) of the facility. Findings follow:
A. During a tour of the ED on 11/16/11 at 0905 with the Nurse Executive, equipment and supplies consisted of a padded wooden structure, desk, three chairs, and a sterile pack for infant delivery.
B. Inspection of the sterile pack for infant delivery revealed a hole in the outside covering, which compromised the integrity and had the potential to spread infection..
C. The Nurse Executive confirmed that a crash cart was located on the fourth floor of the facility, therefore not easily accessible in the event a patient presented in need of emergent care.
D. The Nurse Executive stated that patients other than those presenting for psychiatric screening were transferred to a facility for a higher level of care.
E. The Nurse Executive stated that a list of poison antidotes was located on the fourth floor.
F. The Nurse Executive stated that in the event that the crash cart was needed, CPR (cardio-pulmonary resuscitation) would be instituted and 911 called.
G. The above findings were confirmed with the Nurse Executive at the time of the tour.
H. On 11/18/11 at 0930 an interview was conducted with the Materials Managers who confirmed that there was not an inventory of supplies and equipment for the Emergency Department or that it was checked each shift.

Based on review of policies and procedures and interview, the facility failed to assure policies and procedures specific to emergency services were established and were a continuing responsibility of the medical staff. The failed practice did not assure patient care was administered according to policy and did not assure the medical staff had ongoing/continuing assessment of the care provided in the emergency department based on ongoing monitoring being conducted and had the potential to affect all patients presenting to the facility for emergent care. Findings follow:

Review of the facility's policies and procedures revealed there was no evidence of policies and procedures related to Emergency Services or Emergency Department. Findings were confirmed with the Nurse Executive on 11/17/11 at 0925.

Based on observation and interview, the facility failed to staff the Emergency Department (ED) with medical and nursing personnel 24 hours a day/7 days a week to assure patients ' needs were met who at any time could present to the ED. The failed practice did not assure emergent care could be administered and had the potential to affect all patients presenting to the facility for emergent care. Findings follow:
A. During a tour of the ED on 11/16/11 at 0905 the Nurse Executive unlocked the door to the Emergency Room and turned on the lights. No other staff was present in the Room/Department.
B. On 11/18/11 at 1020, the Nurse Executive confirmed that there was no specific staff orientation to the Emergency Room/Department, only general orientation.
C. On 11/18/11 at 1020, the Nurse Executive confirmed that there was no specific staff training for the Emergency Room/Department.
D. On 11/18/11 at 1020, the Nurse Executive confirmed that there were no specific assigned duties of nursing personnel for the Emergency Room/Department and that the nurses came down from the fourth floor if needed.