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Based on record review and interviews with hospital staff, the governing body failed to ensure that personnel providing services by contract are oriented and evaluated to ensure competence and meet the same requirements as employees of the hospital. This occurred in two (Staff M and U) of three contract staff personnel files reviewed.

Findings:

The hospital uses contracted personnel for the Nuclear Medicine and Sleep Study departments.

Review of the personnel file for Staff M did not contain documentation of the hospitals health requirements.

Review of the personnel files for Staff U did not contain documentation of hospital orientation and health requirement.

In the morning of 04/24/14 Staff D was asked for the health, files for Staff M and U. Staff D stated she did not keep health files for contracted personnel.

The above information was presented to the administrative staff during the exit interview, no further information was provided.

Based on policy and procedure review and staff interview, the hospital failed to ensure there was a comprehensive abuse policy that contained all the required components.

Findings:

On 04/23/14 the hospital's abuse policy was provided to the surveyors by. The hospital's abuse policy was reviewed.

The current policy did not contain all the required components for abuse protection such as:
a. when and how often staff would be trained to identify and report abuse;
b. how the hospital would protect the victim(s) during an investigation and;
c. measures the hospital would take to prevent abuse from occurring.

On the afternoon of 04/24/14, Staff K was asked if the hospital provided abuse training to the staff, Staff K stated no.

The findings were presented in the exit conference on the afternoon of 04/25/14 with the administrative staff. No further documentation was provided.

Based on hospital document review and interviews with hospital staff, the hospital failed to ensure evidence is maintained and demonstrated for CMS review to show:
a. Measurement, analysis and tracking of data used to assess processes of care, hospital service and operations with actions taken and results of the action.
b. The quality assessment and performance improvement (QAPI) involves all departments and services.

Findings:

1. Review of Governing Body, Medical Staff and Quality Assessment Performance Improvement meeting minutes for 2013 and 2014 did not have any evidence of analysis of data used for measurement of hospital processes, results of that analysis or actions taken, if any.

2. The meeting minutes did not show evidence contract services, including, but not limited to, nuclear medicine, magnetic resonance imaging, and sleep lab, are part of the QAPI program.

3. The above findings were reviewed and verified by Staff B and I.

4. The above findings were reviewed with administrative staff during the exit interview. No further information was provided.

Based on review of hospital documents and meeting minutes and interviews with staff, the hospital failed to ensure the medical staff enforced its bylaws concerning the infection control committee.

Findings:

1. The hospital's Medical Staff bylaws, Article X, Section 7, required a physician to Chair the infection control committee with the committee to be comprised of at least the Director of Nursing, Administrator, and representatives from other departments as needed. The bylaws documented the committee should meet monthly, but not less than ten (10) times per year.

2. Medical staff meetings did not demonstrate the infection control committee business, with review, analysis and plan of action, was conducted in the medical staff meetings.

3. Review of infection control committee documents submitted for the last year showed the infection control committee did not meet monthly - at least 10 times a year. According to the documents provided, the infection control committee met on 09/19/2013, 01/21/2014, and 02/18/2014. The "sign-in" sheets did not identify a physician present at the meetings. This finding was confirmed with Staff D at the time of review on 04/24/2014.

4. The above findings were reviewed with administrative staff during the exit conference on the afternoon of 04/24/2014. No further information was provided.

Based on medical record review and staff interview the hospital failed to ensure a registered nurse evaluated the care of each patient.

Findings:

Patient's #11 and 13 both had surgical procedures at the hospital. Review of the medical records for both patient's did not contain a pre-operative nursing assessment.

Patient #14 was a pediatric patient admitted to the hospital. Review of the medical record did not contain an initial pediatric assessment by the registered nurse.

Medical records #20 and 34 had documentation of hand held nebulizer respiratory treatment administered by the nursing staff, the records did not contain assessment and evaluations of the patient's conditions before and after the treatments, including vital signs, oxygen saturation, lung sounds and presence of a cough, with a description of any productive sputum or if the patient felt or had improved breathing after the treatment.


This was confirmed by Staff LL on 04/25/14 during medical record review.

Based on review of hospital documents, personnel files, medical records and interviews with hospital staff, the hospital failed to ensure nursing staff are adequately trained, oriented and have demonstrated skills competency for their assigned care areas and are competent to provide care to meet the needs of the patients. Review of one of seven nursing staff (L) who provided care in specialty areas and whose personnel files were reviewed did not have current job specific competencies.

Findings:

Staff L worked as the pharmacy room manager, Staff L did not have orientation and training to the drug room by the pharmacist.

The above information was confirmed by Staff B and K on the afternoon of 04/24/14.

Based on observation, document review and staff interview, the hospital failed to ensure nursing staff prepared and administered drugs and biologicals according to recognized standards of practice.

Findings:

On 04/25/14, the medical record for Patient # 12 was reviewed for physician's orders. The record documented a CRNA administered the anesthesia. The medical record did not contain any physician orders for the medications administered by the CRNA.

The credential files for one CRNA (who administered drugs to Patient #12) did not contain evidence the CRNA had applied to the Oklahoma Board of Nursing for prescriptive authority to select, order, obtain and administer drugs without a physician's order. The files also did not contain the required two narcotic permits required if the CRNA has been granted prescriptive authority.

The above information was confirmed by Staff LL during medical record review.

Based on medical record review and interviews with hospital staff, the hospital did not ensure that all entries in the medical record were complete and contained the time they were signed or authenticated in electronic or written form by the person responsible for the services provided. This occurred in eight (#9 through 14, 23 and #30) thirty-five medical records reviewed.

Findings:

Medical records # 9 through 14 and #30 contained hand written operative reports. The operative reports did not contain the date or time they were authenticated by the physician or licensed practitioner.

The consult note for Patient #23 did not contain the date and time it was authenticated by the physician.

This was confirmed by Staff LL on 04/25/14 during medical record review.

The above information was presented to the administrative staff during the exit conference, no additional information was provided.

Based on record review and interviews with hospital staff, the hospital does not ensure current and accurate records are kept of the receipt and distribution of all scheduled drugs. The hospital does not ensure day-to-day accountability-of -use records are maintained that show the quantity of scheduled medication used and wasted in a clear and concise manner to so that the disposition of each drug may be readily determined.

Findings:

On the morning of 04/23/14 the surveyors toured the emergency department.

1. Bags of intravenous fluids had been removed from the overwrap and were hanging on a wall in one of the emergency department exam rooms. The hospital failed to require staff to follow the manufacturer's recommendation to only remove the overwrap immediately prior to use.

2. Review of the medical record for Patient #9 documented:

a. The total dose of Versed administered was 4 milligrams.

b. The RN documented on 03/06/14 at 0608, "Versed 2 mg administered IV(intravenous) per Dr's pre-op orders and per patient's high anxiety."

c. The CRNA documented two administrations of Versed 2 mg on 03/06/14 at 0632 and 0547.

3. Review of the pharmacy Narcotic Administration Record (NAR) for 03/27/14 documented Patient #33 received 50 mg of Demerol with no waste. The Medication Administration Record (MAR) in Patient #33's medical record, documented 25 mg of Demerol IVP (intravenous push ) given by the CRNA, but was documented by the RN in PACU .

Upon interview on 04/25/14 with Staff L, there was no indication that pharmacy staff had reconciled these NAR sheets to determine the correct disposition of these drugs.

The above information was confirmed by Staff B and LL on the afternoon of 04/25/14.

Based on review of hospital documents, meeting minutes, health files and infection control activity/surveillance reports, surveyor observations, and staff interviews, the hospital failed to ensure the infection control preventionist (ICP) developed and maintained a comprehensive ongoing infection control program that reviews hospital practices and infections/communicable diseases, analyzes data on these practices and infections, develops qualitative plans of actions to and provides follow-up to ensure corrective actions are appropriate, working and sustained ensuring a safe and sanitary environment.

Findings:

Meeting minutes containing Infection Control headings (infection control, quality assessment and performance improvement, medical staff, and governing body) were review for the time period of 2013 and 2014.

1. The infection control program did not have a physician on the committee as required by the Medical Staff bylaws. This was confirmed by Staff D, the staff identified as the ICP, on the afternoon of 04/23/2014.

2. The meeting minutes did not demonstrate review, analysis with plans of action when needed, and follow-up to ensure corrective actions implemented were effective. Infection control committee meeting agendas for 2014 contained documentation of problems and concerns, but no meeting minutes addressed these concerns. This findings were reviewed and verified with Staff D.

3. Deficient practices observed by the surveyors had not been identified by the infection control program. Observations include, but not limited to:
a. Intravenous (IV) fluid bags were removed from their protective covers.
b. Three of four carriers in the endoscopic suite had breaks in the protective cover and could no longer be disinfected.
c. There was a break in the wall surface behind the sink in the decontamination. The coating had been torn away, did not have a scrubable surface, and could no longer be cleaned and disinfected.
d. There was no hand sink available in the cleaning rooms.
e. During observation of the kitchen area on all three days of the survey, surveyors observed Staff H not wearing a hair covering in the food prep area.

4. Meeting minutes did not reflect staff immunization status and employee health were reviewed as part of the infection control program. Meeting minutes did not demonstrate analysis of employee, contract staff, physician and allied health immunizations, illness and infections to ensure infections and diseases were not transmitted between patients and staff. Personnel files (Staff N, P, R S, and BB) reviewed did not contain complete immunization histories as required. The yearly "fit testing" did not contain evidence a health assessment portion had been completed. These findings were reviewed and verified with Staff D on 04/24/2014 at 1350.

5. Laundry services were provided by contact services. Staff D told the surveyor on 04/24/2014 at 0900 that no one had visited the facility to ensure safe and sanitary infection control procedures were followed.

Based on review of hospital documents and meeting minutes, and infection control policies and procedures, and interviews with hospital staff, the hospital's leadership failed to ensure infection control activities, issues, and problems, were followed through quality assessment and performance improvement (QAPI) committee to assure:

1. Concerns/problems were monitored throughout the hospital, reviewed and analyzed;

2. Corrective actions were taken to prevent, identify and manage infections and communicable diseases with measures that resulted in improvement on an ongoing basis; and

3. Corrective actions were followed to ensure improvement resulted and alternative solutions/actions were not needed.

Findings:

1. Hospital meeting minutes for 2013 were reviewed. The meeting minutes provided to the surveyors during the on-site survey (infection control, quality assessment and performance improvement, medical staff, and governing body) did not contain evidence/demonstrate the hospital leadership:
a. Reviewed and analyzed infection control data or lack thereof;
b. Ensured that all departments/units of the hospital were included and monitored through the infection control/prevention program;
c. Developed corrective plans of action to reduce and/or prevent transmission of organisms and improve patient care, ensure a safe and sanitary environment, and prevent or decrease infections and communicable diseases; and
d. Provide follow-up/monitoring to ensure corrective actions taken were effective and sustainable.

2. The same hospital minutes did not contain analysis of employee, contract staff, physician and allied health immunizations, illness and infections to ensure infections and diseases were not transmitted between patients and staff.

3. Meeting minutes did not reflect the hospital's leadership has provided oversite of the infection control program to ensure a safe environment. The meeting minutes did not demonstrate the hospital's leadership ensured surveillance/monitoring of all areas was performed to ensure current standards of practice in infection control were followed. The infection control portion of the meeting minutes did not demonstrate issues observed by the surveyors were identified, analyzed and corrective actions taken with follow-up to ensure compliance.

4. The Medical Staff bylaws required a physician to Chair the committee and the committee to meet monthly - at least 10 times per year. The hospital's leadership did not ensure this occurred.

Based on document review and staff interview, the hospital failed to ensure there was a registered nurse circulator solely dedicated to care for patients during surgical procedures.

Findings:

The hospitals Moderate Sedation policy was reviewed. The policy, states, "...The RN monitoring the patient receiving conscious sedation should have no other responsibilities that would require leaving the patient unattended or would compromise continuos monitoring during the procedure..."

In an interview with Staff LL on 04/25/14 she stated, during surgical procedures performed by Dr. Lackey the nurse assigned as the circulator, also provided the conscious sedation. She stated there was not another qualified registered nurse in the room to fulfill the circulator duties.

These findings were reviewed with administrative staff during the exit interview.

Based on clinical record review and staff interview,the hospital failed to ensure a medical history and physical (H&P) examination was completed prior to surgery or anesthesia for two of seven records reviewed.

Findings:

Clinical records were reviewed for seven patients who had surgical procedures.

1. Patient #8 had a surgical procedure on 03/01/14, the H&P was completed on 02/15/14.

2. Patients # 10 had a surgical procedure on 04/2/14, the H&P was completed on 11/16/13.

3. The above information was confirmed by Staff LL on 04/25/14 during medical record review.

Based on record review and staff interview,the hospital failed to ensure properly executed informed consents were provided prior to surgery. This occurred in six of seven (#9 through 14) surgical records reviewed.

Findings:

Medical records for Patient's # 10 through 14 did not contain the date and time the physician signed the consent.

Medical record for patient # 9 did not contain the time the patient signed the consent.
The above information was confirmed by Staff LL on 04/25/14 during medical record review.

Based on document review, policy and procedure review and staff interview, the hospital failed to have policies and procedures that governed outpatient services and the integration with inpatient services.

Findings:

On 04/24/14, Staff A stated the Nuclear Medicine, Magnetic Resonance Imaging (MRI) and Sleep Study are offered at the hospital on a contracted basis.

The policies and procedures provided by the hospital staff had not been approved by the medical staff and the department managers.

This was confirmed by Staff B on 04/25/14.

Based on personnel record review and staff interview, the hospital failed to ensure individuals who had been convicted of abusing, neglecting, or mistreating individuals in a health care setting were not employed.

Findings:

Review of the personnel files for Staff J, who had patient contact, did not contain evidence of a state nurse aide registry check.

On 04/24/14 in the afternoon, Staff MM was asked if the hospital had completed State nurse aide registry checks on staff members that provide patient care and/or had patient contact, Staff MM stated no.

Based on review of medical records and interviews with hospital staff, the hospital failed to provide ongoing activities to swingbed patients that were based on a comprehensive assessment performed by a qualified activity coordinator/professional. This occurred in three of four (Patients #21, 24 and 25 ) swingbed patients, whose medical records were reviewed.

Findings:

Swingbed Patient #21 did not have a comprehensive activity assessment documenting the patients interests and physical, mental and psychosocial needs.

Patient #24, swingbed admission 02/12 through 26/2014 and Patient #25, swingbed admission 02/28 through 03/19/2014- These patients did not have a comprehensive activity assessment documenting the patients interests and physical, mental and psychosocial needs. Both medical records did not contain evidence activities were provided to the swingbed patients.

The above information was confirmed with Staff LL on 04/25/2014 during chart review.