HospitalInspections.org

Based on observation and interview, it was determined the hospital failed to ensure emergency supplies and equipment were readily available at all times in the emergency room. Findings:

On 07/24/13, the surveyors observed the surgery department and recovery area did not have an emergency crash cart. Staff I stated they moved the crash cart from the emergency room to surgery when cases were scheduled.

The surgery log for 2013 documented the crash cart was needed in the surgery/recovery area for up to four hours at a time.

Staff I was asked what would happen if the crash cart was needed in the ER when surgery/recovery was taking place. No reply was made.

Based on observation, record review and staff interview, it was determined the hospital failed to ensure:

a. the recovery area was adequately constructed, equipped and arranged to accommodate patients and was designed to ensure patient privacy. See Tag C-0221;

b. facilities, supplies and equipment were maintained for safety and quality. See Tag C-0222;

c. the premises was clean and orderly; See Tag C-0225;

d. temperature, humidity and ventilation was maintained within acceptable standards. See Tag C-0226; and

e. failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. See LSC survey K Tags.

Based on observation and staff interview, it was determined the hospital failed to ensure the recovery area was constructed, equipped and arranged to accommodate patients and was designed to ensure patient privacy. Findings:

On 07/24/13, a tour of the hospital's recovery area was conducted. The following observations were made:

An operating room was being used as a recovery room. The room held all the equipment needed in an operating room, including an anesthesia machine, anesthesia cart and various other items found in an operating room.

The room was not set up and constructed as a recovery room. Two sets of portable monitors and sets of other necessary equipment (all portable) for two patients was present. None of the recovery equipment was permanently installed and the room had not been modified as a "recovery room."

Two patient stretchers were found placed (within three feet of each other), side by side, in this recovery room. Staff I stated two patients were recovered at a time in this space.

The two recovery "bays" were not separated sufficiently to allow the ease of staff movement between the stretchers. The stretchers were crowded close together because of other equipment stored in the room.

The door to this room was propped open at all times.

The two recovery "bays" had no privacy curtain between them to protect each patient's privacy from the other, and had no curtain or other barrier, such as a screen, to guard the patients' privacy from people walking into the recovery area or walking by in the hallway.


The room was also being used to store various pieces of medical equipment. Old and unused equipment was stored around the perimeter of the room, including an old OR table, an obstetric delivery table, and an automated endoscope processor.

The room also held an infant warmer, a high-backed wheelchair, and a bedside commode.

The room was not equipped with a handwashing sink or a medication administration and preparation area as required by State Hospital Standards.

Based on observation, record review and staff interview, it was determined the hospital failed to ensure facilities, supplies and equipment were maintained for safety and quality. Findings:

On 07/24/13 and 07/25/13, a tour was conducted of the hospital. The following observations were made:

1. The ceiling in the sterile processing area was constructed with acoustic tiles. The tiles were old, yellowed and water stained. Some tiles were bowed and loose from the framework.

2. Floors throughout the surgery department were chipped and showed signs of dirt, grime and wax build-up.

3. Sprinkler heads throughout the department were rusted.

4. See also LSC survey Tags K-067 and K-147.

Based on observation and interview, it was determined the hospital failed to ensure the physical environment was uncluttered and that equipment and supplies were properly stored. The hospital also failed to ensure surfaces could be cleaned. Findings:

On 07/23, 07/24 and 07/25/13, the surveyors toured various areas of the hospital. The following observations were made:

1. The patient care unit hallways were cluttered with equipment and supplies.

2. The surgery department was cluttered with equipment from other departments and old equipment no longer in use. Supplies were stored in corridors.

3. The surgery department was unorganized and had a "haphazard" appearance. Sterile and non-sterile supplies were stored in their original shipping boxes that were grimy and dirty. These boxes were placed next to unpacked "clean" items. Sterile and non-sterile supplies were stored together.

4. Sinks in the surgery department were packed with items that had been washed and left there to dry, having never been put away.

5. The OR suite, the "recovery room", the decontamination room, the sterile processing room, the surgery corridors and storage closets and cabinets were cluttered and disorganized.

6. The cabinetry and closets in the surgery department were wood with a varnish finish that could not be cleaned and sanitized.

7. Floors throughout the surgery department were marred, chipped, discolored and dirty. The condition of the floors prevented adequate cleaning and decontamination.

8. Staff personal items, food and open beverage products were found in the sterile processing, operating room and recovery room.

9. See also LSC survey Tags K-147.

Staff I was asked about the condition of the surgery department. She stated the area had been in that condition so long that no one noticed it any more. She stated repairs had not been made because they were expecting to move into a new hospital sometime in the future. She stated there was not enough storage space anywhere in the hospital and the operating room was the only place some equipment could be stored.

Based on observation, record review and staff interview, it was determined the hospital failed to ensure temperature, humidity and ventilation was maintained within acceptable standards. Findings:

On 07/23, 07/24 and 07/25/13, a tour was conducted to the surgery department.

1. The surgery department was uncomfortably warm and there was no air movement in the area. Staff I stated the air conditioning was usually turned off when the surgery department was not in use.

2. There was no documentation temperature and humidity were monitored in the operating room and in sterile processing.

3. There was no documentation positive airflow was maintained to the operating room and the sterile processing room.

4. There was no documentation negative airflow was maintained to the decontamination and endoscopy procedure area.

5. See also LSC survey Tag K-067 and K-130.

See LSC survey Tags K-018, K-052, K-072, K-130.

Based on observation, interview and review of hospital documents, the governing body failed to provide the following:

1. That all practitioners providing patient care are qualified and have current appointments and licenses and privileges granted. See Tag C-0241

2. Policies and procedures were developed with advice from healthcare professionals and were based on recognized national standards and guidelines. See Tag C-0272;

3. Departmental policies and procedures included a description of services furnished directly and those furnished through agreement or arrangement. See Tag C-0273;

4. That non-licensed pharmacy personnel were trained, evaluated and had a job description. See Tag C-0276;

5. A developed and maintained active on-going infection control program. See Tag C-0278;

6. That dietary services policies and procedures were developed and implemented and that the consultant dietitian fulfilled minimum responsibilities for the hospital's nutritional services. See Tag C-0279;

7. That hospital polices for anesthesia, radiology, dietary, surgery and central sterile were reviewed at least annually. See Tag C-0280;

8. That personnel assigned to the Sleep Study Lab were qualified and trained, and the department had oversight by a manager.
See Tag C-0281;

9. That radiology services were supervised and performed according to accepted national standards. See Tag C-0283;

10. That a list of all services provided through arrangement, contract or agreement was maintained describing the nature and scope of the services. See Tag C-0291;

11. That nursing staff were trained and evaluated on competency to perform the essential functions of the job. See Tag C-0294; and

12. That a registered nurse assessed and evaluated the nursing care for each patient. See Tag C-0296.

13. That the recovery area was adequately constructed, equipped and arranged to accommodate patients and was designed to ensure patient privacy. See Tag C-0221;

14. That adequate facilities, supplies and equipment were maintained for safety and quality. See Tag C-0222;

15. That the premises was clean and orderly; See Tag C-0225;

16. That temperature, humidity and ventilation was maintained within acceptable standards. See Tag C-0226; and

17. That the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association are met. See LSC survey K Tags.

18. That surgical procedures, central sterile processes and contracted services providing patient care in the hospital are evaluated for quality and appropriateness of care provided. See C-0337

Based on record review and interviews with hospital staff, the governing body does not ensure that all practitioners providing patient care are qualified and have current appointments and licenses and privileges granted. Five of six physicians' and two of two allied health practitioners credential files reviewed were incomplete and did not have either evidence of current appointment to the medical staff, current licensure, or current privileges granted. The hospital could not provide one of one physician's credential file when it was requested for review or provide documentation the hospital had evaluated in the physician in accordance with established policies based on the individual practitioner's scope of clinical expertise and in accordance with Federal and State law.

Findings:

1. Five (O,P,R,T,U) of six physicians' and one (Q) of one physician assistant and one (S) of one nurse practitioner's credential files did not have evidence of current appointment by the governing body.

2. One (U) of one physician's credential file was not provided for review. The hospital could not locate the file. This physician performs endoscopy procedures once every two weeks.

3. Hospital Staff stated on 07/24/13 that the credential file for Physician (U) could not be located for review.

4. Three (N,R,U) of six physicians did not have evidence of current medical licensure.

Based on document review and staff interview, it was determined the hospital failed to:

a. ensure policies and procedures were developed with advice from healthcare professionals and were based on recognized national standards and guidelines. See Tag C-0272;

b. ensure departmental policies and procedures included a description of services furnished directly and those furnished through agreement or arrangement. See Tag C-0273;

c. ensure that non-licensed pharmacy personnel were trained, evaluated and had a job description. See Tag C-0276;

d. develop and maintain an active on-going infection control program. See Tag C-0278;

e. ensure dietary services policies and procedures were developed and implemented and that the consultant dietitian fulfilled minimum responsibilities for the hospital's nutritional services. See Tag C-0279;

f. ensure hospital polices for anesthesia, radiology, dietary, surgery and central sterile were reviewed at least annually. See Tag C-0280;

g. ensure personnel assigned to the Sleep Study Lab were qualified and trained, and the department had oversight by a manager.
See Tag C-0281;

h. ensure radiology services were supervised and performed according to accepted national standards. See Tag C-0283;

i. ensure a list of all services provided through arrangement, contract or agreement was maintained describing the nature and scope of the services. See Tag C-0291;

j. ensure nursing staff were trained and evaluated on competency to perform the essential functions of the job. See Tag C-0294; and

k. failed to ensure that a registered nurse assessed and evaluated the nursing care for each patient. See Tag C-0296.

Based on document review and staff interview, it was determined the hospital failed to ensure policies and procedures were developed with advice from healthcare professionals and were based on nationally recognized standards and guidelines.

Findings:

On 07/2313 and 07/24/13, various departmental policies and procedures were reviewed.

1. A dietary policy and procedure manual contained no policies and procedures. The hospital had no evidence dietary policies and procedures were developed with the oversight and approval of the dietitian.

2. The radiology policies and procedures had not been reviewed by anyone. Some policies were as old as 2002 and had no evidence they had been updated. There was no documentation the consultant radiologist had reviewed and approved the radiology department policies and procedures.

3. Anesthesia policies had not been reviewed and approved. Some policies were as old as 1991 and had no evidenced of updates and revisions. There was no evidence of policy development in collaboration with an anesthesia professional.

4. Central sterile policies and procedures had not been reviewed and approved. Some policies were as old as 2004. None of the policies had evidence they were based on national standards and guidelines.

5. Surgery policies and procedures were signed in 2012 as being reviewed by the chief of staff and the CEO. None of the policies had evidence they were based on national standards or guidelines.

On 07/23/13, the DON was asked about the above departmental policy and procedure manuals. She stated she was not familiar with the manuals and did not know what was in them.

On 07/24/13, the CEO stated the hospital did not review policy and procedure manuals on a regular basis.

Based on policy and procedure review and staff interview, it was determined the hospital failed to ensure departmental policies and procedures included a description of services furnished directly and those furnished through agreement or arrangement. Findings:

On 07/23/13 and 07/24/13, various departmental policy and procedure manuals were reviewed. None of the departmental manuals contained this information.

It could not be determined through the department manuals what services were provided by the hospital and what services were provided elsewhere.

The CEO and the DON confirmed this finding.

Based on record review and interviews with hospital staff, the hospital does not ensure that non-licensed pharmacy personnel are trained, evaluated and have a job description. Staff I did not have a job description defining her job duties in the hospital's drug room. Staff I did not have any competencies or evaluations by the Consultant Pharmacist for the duties performed in the drug room. This was verified by the hosptial Chief Executive Officer on 07/24/13.

Based on review of hospital documents and meeting minutes and interviews with staff, the hospital failed to:

a. Develop and maintain an active on-going infection control/infection prevention (IP) program for ensuring a sanitary environment, and identifying and preventing infections and communicable diseases among patients and staff; and

b. Analyze IP surveillance data and concerns, develop corrective actions when needed and conduct follow-up to ensure corrective actions are appropriate and sustained to ensure a sanitary environment and avoid sources and transmission of infections for patients and personnel.

Findings:

Plan/Program:

1. The hospital has not conducted a hospital-wide IP risk assessment to identify the types of patients, risks/concerns, organisms, and diseases prevalent in the community and hospital.

2. The hospital has not conducted a tuberculosis risk assessment.

3. These findings were confirmed with administrative staff on the afternoon of 07/23/13.

Surveillance:

The current IP Plan provided to the surveyors on 07/23/13 documented the program monitoring would include all department/areas of the organization/hospital.

1. The IP manual contained IP policies and procedures for all departments. The infection control program has not monitored to ensure the policies were followed.

2. Documents provided and meeting minutes did not demonstrate that, other than positive cultures of patients, the IP program monitored and evaluated infections of patients and staff to ensure infections and communicable diseases were not transmitted between staff and between patients and staff.

3. The Centers for Disease Control (CDC) and the Association for Professionals in Infection Control and Epidemiology (APIC) have identified hand hygiene as the first avenue/most important tool in the prevention of spread of organisms and diseases. The infection control program does not monitor hand hygiene practices throughout the hospital and does not have a tool for monitoring. This was confirmed with Staff B on the afternoon of 07/23/13.

4. Surgical services and central sterile processing is not monitored, including, but not limited to, use of disinfectants and sterilizing and high level disinfection practices. Instrument sterilization was being performed by another hospital. The hospital did not monitor and review the other hospital's sterilization practices for quality. (Refer to Tag C-320 for details.)

5. There is no monitoring of endoscopes to ensure cleaning and disinfecting are completed appropriately. Although the IP manual contained a policy for cleaning and disinfecting the scope, the surgery manual did not contain policies and procedures. Surveyors observed that endoscopes were not cleaned, disinfected and maintained according to recognized standards. (Refer to Tag C-320 for details.)

6. Isolation is not monitored to ensure:
a. Patient are placed in appropriate isolation according to current CDC guidelines,
b. Isolation carts are stocked appropriately,
c. Staff, physicians, volunteers, and visitor follow appropriate isolation requirements,
d. Appropriate disinfection of the room occurs.

7. No monitoring of disinfectant applications throughout the hospital departments and locations to ensure they are applied and remain "wet" contact time according to the manufacturers guidelines.


Policies and Procedures:

1. The infection control manual did not contain a policy and procedure for respiratory isolation masks, N-95 respirators, with:
a. Detail on how this was to be accomplished and by whom; and
b. How frequent the staff need fit testing of masks, based on current standards of practice.

2. The infection control program does not have policies and procedures on how patients and staff with potential or confirmed influenza will be medically managed, including:
a. Screening,
b. Any required tests to confirm infection,
c. Any particular requirements according to current CDC guidelines
d. Procedure for reporting reportable infections and diseases to the proper authorities, with delineation of responsibilities.

3. Policies on disinfectant approval and list of approved disinfectants with what area used and application requirements, including:
a. mixture
b. wet time contact with surface to be effective
c. what organisms the disinfectants kill.


Observations:

1. The hospital does surgical procedures of endoscopy. The most prevalent organism for colonoscopy procedures is Clostridium difficile (C-diff). Staff stated they did not have any product to clean between cases or for terminal cleaning.

2. Staff processed dirty scopes in the same room that endoscopes were being performed.

3. Personnel file review did not contain evidence of inservice provided to teach staff or that the following had been accomplished:
a. Appropriate hand hygiene compliance and techniques;
b. Isolation and personal protective equipment;
c. Bloodborne pathogens;
d. Appropriate disinfectant applications;
e. Respiratory isolation mask, N-95, fit testing or health questionnaire.

Meeting Minutes:

On the morning of 07/23/13, Staff B told the surveyors that IP meeting minutes were part of the Super Committee Meeting. The surveyors reviewed the Super Committee Meeting minutes for 2013.

1. The meeting minutes did not contain review, evaluation and analysis of infections to ensure infections and communicable diseases were not transmitted between staff and between patients and staff.

2. The meeting minutes did not contain evidence physicians and staff (employee, volunteer and contract) immunizations were part of the IP process with review of deficiencies and plans of actions to correct and sustain corrective measures. Example: Staff X, the contracted sleep study/lab director did not have a health file of immunizations.

3. The meeting minutes did not demonstrate surgical services- central supply and endoscopy- were monitored, reviewed and analyzed with corrective actions taken and follow-up to ensure compliance with accepted standards of practice.

4. Concerns/items reported in one meeting minutes were not followed to ensure corrective actions were taken and sustained. Example: need for flu immunizations and tuberculin testing tracking.

5. The meeting minutes did not contain surveillance/monitoring to ensure IP policies and procedures are followed. Staff B stated on the afternoon of 07/23/13 that this surveillance was not performed.

6. The meeting minutes did not contain evidence disinfectants used in the hospital had been reviewed for appropriateness and approved for use. The surveyors observed Virex TB and Clorox Disinfectant Wipes available for use in the radiology department. Staff B and G confirmed this had not been performed.

Based on policy and procedure review and staff interview, it was determined the hospital failed to ensure dietary services policies and procedures were developed and implemented and that the consultant dietitian fulfilled minimum responsibilities for the hospital's nutritional services. Findings:

On 07/23/13 and 07/24/13, hospital management staff were asked to provide dietary services policies and procedures. A binder was provided that had no policies and procedures in it.

The dietary manager stated the hospital followed the current State dietary manual. There were no hospital policies that were specific to issues such as the frequency of meals served, the system for ordering diets and patient tray delivery, non-routine dietary issues such as diet changes, early/late trays, nutritional supplements, kitchen sanitation, etc.

There was no documentation the food and nutrition services were included in the QAPI program.

The dietary department had documentation the consultant licensed dietitian visited the hospital once a month. There was no policy and procedure that addressed how the dietitian was consulted in between onsite visits.

The last documented dietitian visit was on 04/30/13. Each month the hand-written report from the dietitian documented the same information: "... Monitored nutritional status of in-patients... sanitation check... consulted [with] charge nurses..."

The monthly report had no specifics about findings and recommendations or actions taken.

There was no documentation the dietitian reviewed, revised or provided consultation with the dietary manager on policy and procedure development. There was no documentation of any recent departmental inservices for staff.

There was no documentation the dietitian monitored any QAPI indicators or participated in the QAPI process.

Based on record review and interviews with hospital staff, the hospital does not ensure that hospital polices are reviewed at least annually as required for a critical access hospital. Anesthesia, radiology, dietary, surgery, central sterile had not been reviewed withing the last year. Hospital staff verified that the policies had not been reviewed.

Based on review of hospital documents, review of personnel files and interviews, the hospital failed to have documentation showing all the personnel assigned to the outpatient department (Sleep Study Lab) are qualified and trained, and the department has oversight by a manager.

Findings:

On 7/24/13 in the afternoon, Staff B stated the facility provided sleep study lab services by Staff X and hospital employee, Staff J.

There was no evidence, in the personnel file, that Staff J was oriented, trained and competent as a sleep lab technologist. This was confirmed by Staff B on the afternoon of 7/24/13.

On 7/24/13, the hospital failed to develop and implement sleep study policy and procedures to direct staff. The surveyors asked Staff B for the policies and procedures for the sleep study lab. None was provided.

Review of the Governing Body meeting minutes showed no evidence that a manager had been assigned to the sleep study lab.

Based on record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure radiology services were supervised and performed according to accepted national standards.

On 07/23/13, the radiology policies and procedures were reviewed. The policies had not been reviewed, updated and approved by the appointed chief of radiology. The policies had no documentation they were developed based on accepted standards of practice.

There was no departmental description of all radiology procedures performed by the hospital. There was no description to designate which radiology tests must be interpreted by a radiologist.

The manual had a computerized tomography policy last updated in 2002. Other policies were outdated.

Staff competencies were last evaluated in 2008.

A dosimetry report, dated 01//25/13, had no documentation of the results of the evaluation. There was no conclusion to the physicist's findings.

The CEO stated departmental policies were not reviewed on a regular basis and that there was no documentation of the chief of radiology's scope of responsibility for the hospital's radiology department.

Based on record review and interviews with hospital staff, the hospital failed to ensure that a list of all services provided through arrangements, contracts or agreements is maintained describing the nature and scope of the services. Sleep Study Lab was not included on the list of contracted services.

Findings:

1. On the afternoon of 7/24/13, both Staff B and G stated the sleep study lab is a contracted service provided by Staff X.

2. The contractor list provided by the facility on 7/23/13, did not list a contractor for the Sleep Study Lab.

2. On the afternoon of 7/24/13, surveyors asked, Staff G was asked for the written contract with Staff X. No contract was provided. Staff G stated she was unable to locate the written contract.

Based on record review and staff interview, it was determined the hospital failed to ensure nursing staff were trained and evaluated on competency to perform the essential functions of their jobs. This occurred for six of six licensed nursing personnel (Staff A, B, C, D, M and W) whose personnel files were reviewed.

Findings:

1. The hospital takes care of all age patients in the emergency room and/or as inpatients. The personnel files for Staff A, B, C, D, M and W did not contain evidence of training, testing and/or age-specific competency verification.

2. Staff B told the surveyors that licensed nursing staff administered respiratory treatments of oxygen administration, nebulizer treatments, and pulse oxygenation. (This also was confirmed by medical record review of Records #14, 16 and 17.) Staff A, B, C, D, M and W did not have evidence of respiratory training and competency verification by the respiratory therapist.

3. The personnel files Staff A, B and C did not contain skills competency verification. This was discussed with Staff B and G on the afternoon of 07/23/13, but no further documentation/verification of skill competency was provided.

Based on record review and staff interview, the facility failed to ensure that a registered nurse assessed and evaluated the nursing care for each patient. This occurred in one of one (Patient #16) medical record reviewed of a patient designated as Respite Care.


Findings:

The hospital has defined respite care as ..."Respite Care is temporary or long-term, supervised, extended care in the hospital setting. Respite patients are not regular admitted patients and are on a private pay basis only..."

1. State Hospital Licensure Standard, Chapter 667, Subchapter 39-9, states " A registered nurse shall assess, plan, supervise, and evaluate the nursing care for each patient. "

2. Review of Patient #16 medical record did not contain an initial assessment, " Shift Assessment" or any on-going assessments.

3. On 7/24/13 at 11:00 am, Staff A stated no nursing assessments are completed on respite care patients.

4. A policy titled, "Respite Care", documented,

"...Since respite care patients are not acute care patients, their physician will not be seeing the Respite patients routinely..." ..."Nursing services offered include daily monitoring of vital signs (blood pressure, temperature, pulse, respirations)..." ..."ACUTE CARE PATIENTS WILL TAKE PRIORITY TO RESPITE CARE PATIENTS..."

Based on record review and staff interview, it was determined the hospital failed to ensure the clinical record correctly identified the author of every medical record entry, was maintained for every patient receiving care and was legible and complete. See Tag C-0302.

The hospital also failed to ensure enough information was documented to monitor the patient's condition and to provide appropriate care. See Tag C-0306.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure medical records were legible and complete for two (#15 and #18) of two surgical patient records reviewed.

Findings:

On 07/23/13 and 07/24/13, clinical records were reviewed for two surgery patients.

1. The record for patient #18 had the following deficiencies:

~The surgical checklist was signed by the OR nurse only and not co-signed by the pre-op nurse.
~The pre-op record did not document how much IV fluid was started on the patient.
~Pre-op, intra-op and post-op orders were signed as noted by the nurse in the recovery period.
~The physician's orders documented,"... Tetracaine 1% sucker..." There was no documentation of a complete order to include when this medication should be administered. There was no documentation it was administered.
~The surgical "time out" form did not identify who initiated the time out. The initials "JW" were documented, but the initials were not identified by a full signature.
~The surgical time out did not identify all the staff who should have participated in the time out to include the physician, the nurse providing sedation and the OR tech.
~The sedation record was missing the following :
no ASA designation
No documentation of patient positioning for the procedure
No documentation of who administered medications
No physician's orders for the medications administered
No documentation of how the patient tolerated the procedure
No documentation of where sedation was provided, i.e., OR room number or other location
No documentation of the rate oxygen was administered
No documentation the type of procedure was verified before the start of the case
An Aldrete score was documented as "7" but there was no documentation of how that number was determined.
~The intra-operative record had no documentation of the number of the scopes used on the patient and no documentaton of who administered conscious sedation and who performed the CLO-test. The intra-operative did not document the patient's position for both procedures (EGD and colonoscopy) and did not document safety measures provided. There was no documentation of special padding and protection of bony prominences.
~The recovery record was a copy and many parts were not readable.
~There was no documentation of a nursing assessment upon arrival to the recovery area.
~There was no date and time documented on the recovery record.
~There was no documentation of post-operative follow-up.
~There was no documentation of the time the patient was discharged from recovery.

2. The clinical record for patient #15 had the following deficiencies:

~Combination physician's orders for pre, intra, and post-op were first noted by a nurse in the recovery room. The physician did not sign the orders.
~The pre-op form did not document how much IV fluid was started and did not document the time the patient went to the OR.
~The surgical checklist had no OR nurse signature. The pre-op nurse was identified by initials only and had no full signature for identification.
~The sedation record had no:
ASA determination
pre-op diagnosis
time noted when the patient left the OR
rate of oxygen administration
IV site documented
patient position documented
signature of who administered medications
~The sedation record documented an Aldrete score of "9" but there was no documentation of how this number was determined.
~The intra-op form had no documentation of the number of the scope used, no documentation of the time the procedure was completed and no time the patient left the OR. There was no documentation of patient position during the procedure.
~The recovery record was a bad copy that was partly illegible.
~Vital signs were documented by someone with different handwriting than the author identified on the record. The DON stated the vital signs were recorded by a tech "on the floor." There was no identification of who took the vital signs and who documented the vital signs.
~There was no documentation the criteria for discharge was met.

The DON was shown the findings in the clinical records. No comment was made.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure the clinical records contained all the information necessary to monitor the patient's condition for three (#15, 16 and #18) of three clinical records reviewed. Findings:

On 07/23/13 and 07/24/13, clinical records were reviewed for two surgery patients.

1. The record for patient #18 had the following deficiencies:

~The surgical checklist was signed by the OR nurse only and not co-signed by the pre-op nurse.
~The pre-op record did not document how much IV fluid was started on the patient.
~Pre-op, intra-op and post-op orders were signed as noted by the nurse in the recovery period.
~The physician's orders documented,"... Tetracaine 1% sucker..." There was no documentation of a complete order to include when this medication should be administered. There was no documentation it was administered.
~The surgical "time out" form did not identify who initiated the time out. The initials "JW" were documented, but the initials were not identified by a full signature.
~The surgical time out did not identify all the staff who should have participated in the time out to include the physician, the nurse providing sedation and the OR tech.
~The sedation record was missing the following :
no ASA designation
No documentation of patient positioning for the procedure
No documentation of who administered medications
No physician's orders for the medications administered
No documentation of how the patient tolerated the procedure
No documentation of where sedation was provided, i.e., OR room number or other location
No documentation of the rate oxygen was administered
No documentation the type of procedure was verified before the start of the case
An Aldrete score was documented as "7" but there was no documentation of how that number was determined.
~The intra-operative record had no documentation of the number of the scopes used on the patient and no documentation of who administered conscious sedation and who performed the CLO-test. The intra-operative did not document the patient's position for both procedures (EGD and colonoscopy) and did not document safety measures provided. There was no documentation of special padding and protection of bony prominences.
~The recovery record was a copy and many parts were not readable.
~There was no documentation of a nursing assessment upon arrival to the recovery area.
~There was no date and time documented on the recovery record.
~There was no documentation of post-operative follow-up.
~There was no documentation of the time the patient was discharged from recovery.

2. The clinical record for patient #15 had the following deficiencies:

~Combination physician's orders for pre, intra, and post-op were first noted by a nurse in the recovery room. The physician did not sign the orders.
~The pre-op form did not document how much IV fluid was started and did not document the time the patient went to the OR.
~The surgical checklist had no OR nurse signature. The pre-op nurse was identified by initials only and had no full signature for identification.
~The sedation record had no:
ASA determination
pre-op diagnosis
time noted when the patient left the OR
rate of oxygen administration
IV site documented
patient position documented
signature of who administered medications
~The sedation record documented an Aldrete score of "9" but there was no documentation of how this number was determined.
~The intra-op form had no documentation of the number of the scope used, no documentation of the time the procedure was completed and no time the patient left the OR. There was no documentation of patient position during the procedure.
~The recovery record was a bad copy that was partly illegible. There was no documentation the criteria for discharge was met.

The DON was shown the findings in the clinical records. No comment was made.

3. State Hospital Licensure Standard, Chapter 667, Subchapter 39-9, documented "...A registered nurse shall assess, plan, supervise and evaluate the nursing care for each patient..."

A hospital policy, titled, "Respite Care," documented, "... Since respite care patients are not acute care patients, their physician will not be seeing the respite patients routinely... Nursing services offered include daily monitoring of vital signs (blood pressure, temperature, pulse, respirations) ... ACUTE CARE PATIENTS WILL TAKE PRIORITY TO RESPITE CARE PATIENTS..."

On 7/24/13, the surveyors were told that patient #16 was admitted as a respite care patient. The patient had been in the hospital off and on during 2013 as an acute care patient and as a respite patient.

When the patient was classified as a respite patient, she was not admitted and cared for as an acute care patient.

The clinical record had no documentation of admitting orders by the physician. There was no documentation of an admission history and physical examination.

There was no documentation of an initial comprehensive nursing assessment.

The record had no nursing care plan, no physician progress notes, no on-going physician orders, and no on-going assessment and evaluation by the nursing staff or the physician.

At 11:00 a.m., staff A stated respite care patients did not have the same documentation requirements as acute care or swing bed patients.

Based on observation, document review, policy and procedure review and staff interview, it was determined the hospital failed to ensure surgical procedures were performed in a manner that conformed to national standards of practice as evidenced by failure to:

a. define the scope of surgical services;
b. provide supervision of surgical services by an experienced registered nurse;
c. develop and implement surgical policies and procedures based on recognized national standards;
d. maintain an operating room register that included all the required elements;
e. conform to standards of practice for peri-operative care and the high level disinfection of endoscopes;
f. clean between surgical cases and perform terminal cleaning of the surgical area; and
g. failed to provide emergency supplies and equipment dedicated to the operating room and recovery areas.

The hospital also failed to:

i. make available a current roster of each practitioner's surgical privileges to be located in the surgery department and also where scheduling of cases is performed. See Tag C-0321; and

j. failed to provide acceptable pre-anesthesia and post-anesthesia evaluations. See Tag C-0322.

Findings:

1. On 07/23/13 and 07/24/13, the surveyors conducted a survey of the hospital's surgical services. The administrative staff were asked to provide policies and procedures and other documents related to the provision of surgical services.

There was no documentation of a written scope of surgical services currently provided by the hospital.

2. The DON stated she was responsible for supervision of surgical services. The hospital had no documentation the DON had formal training or experience in peri-operative care and no documentation of specialized certification.

The DON stated her only training and experience was "on the job" at this hospital. The hospital had no job description and no defined qualifications for a manager/director of surgical services. There was no documentation of skills competencies required for this position.

3. Policies and procedures related to surgery, anesthesia services, post anesthesia care and central sterile processing were outdated, many were not applicable, and many were not in line with current standards of practice. None of the policies and procedures had evidence they were developed based on a nationally recognized source.

The surgery emergency operations plan was dated 2008.

The conscious sedation policy was dated 2005 and information contained within the policy was based on sources much older. None of the nurses who provided conscious sedation had documentation of training, experience and skills competency to provide this levelof care. The DON said the documentation to show evidence of training and competency was lost.

A policy, titled, "Post Anesthesia Nursing Practice Standards," was dated 1991.

A malignant hyperthermia policy was dated 1997 and did not include current guidelines and information.

An endoscope cleaning process policy was dated 2004.

Many policies were missing, including:

~aseptic practices and surveillance
~identification of infected versus non-infected cases
~housekeeping requirements and procedures
~pre-operative work-up and history and physical examination requirements
~informed consents
~clinical procedures and protocols
~OR safety practices, i.e., alcohol prep, use of electrocautery, etc.
~patient identification
~surgical staff job duties and job descriptions
~OR attire
~flash sterilization
~surgery scheduling
~unique pre-op/OR/recovery personnel policies
~resuscitative techniques (Code Blue policies) and special OR procedures related to resuscitation
~special requirements for surgical "Do Not Resuscitate" status
~care and processing of surgical specimens
~use of reversal agents and special patient recovery requirements

On 07/23/13 and 07/24/13, the DON was asked about specifics within the surgery, anesthesia and central sterile processing policies and procedures. She stated she was not familiar with the policies in those manuals and could not answer any questions.

4. The operating room register did not include the patient's pre and post operative diagnosis and the patient's age. The policy regarding the operating room register was written in 2003 and updated in 2010, but did not require documentation of all the CMS elements.

5. Staff assigned to work in surgery stated endoscopes were cleaned in the procedure room while procedures were in progress. The staff did not clean the scopes in the surgery department decontamination room.

Staff I stated she worked as an OR tech assisting the physician during procedures and also carried out scope cleaning and disinfection between cases. She stated the scopes were cleaned by hand. Staff stated one tub was filled with cidex for disinfection and one tub was filled with water for rinsing. The staff did not say the scopes were first cleaned with an enzymatic cleaner, rinsed and hard dried prior to disinfection with cidex.

In addition to the deficient practice of cleaning/disinfecting scopes in a clean/aseptic environment, the patients and staff were exposed to environmental contamination and potentially to the cidex vapors.

There was no documentation the cidex solution was checked for adequate concentration levels between cases. There was no documentation of scope disinfection (exposure) time for each case. The cidex bottle was not dated when it was opened.

There was no policy and procedure that described this process. Staff I stated the physician told the staff to set up the scope cleaning process in this manner and that it was "OK."

There were no department records of disinfection by scope number and patient ID. There was no documentation of who processed the scopes. None of the clinical records reviewed had this documentation.

The staff stated scope procedures were performed one day a week, twice a month. The operating room registered documented procedures may only be done once a month. Staff I stated when the scopes were cleaned at the end of the day, they were hung in a closet. She stated the scopes were not reprocessed after a period of non-use. She stated there was no policy related to this.

2013 AORN Standards recommend that flexible endoscopes should be reprocessed before use if unused for more than five days.

The hospital had two EGD scopes and two colonoscopes available for use. On 07/23/13, the OR register documented the following procedures had been performed, including procedure times:

July 17, 2013 Start time 7:13 a.m. EGD and Colonoscopy
End time 7:27 a.m.
Total surgery time: 14 minutes

Start time 7:43 a.m. EGD
End time 7:45 a.m.
Total surgery time: 2 minutes

Start time 8:06 a.m. Colonoscopy
End time 8:11 a.m.
Total surgery time: 5 minutes

Start time 8:30 a.m. EGD
End time 8:44 a.m.
Total surgery time: 14 minutes

This indicated one team performed five separate procedures, and concurrently processed the endoscopes, in one hour and thirty one minutes. Staff I stated a single team had performed as many as seven procedures in an hour and a half.

A further review of the operating room log documented the following:

On 06/19/13, an EGD and colonoscopy was performed on a patient in five minutes total surgery time.

On 05/22/13 the following procedures were performed in the following order:

Colonoscopy with biopsy: 15 minutes
EGD: no times listed
Colonoscopy: 46 minutes
EGD/Colonoscopy: 14 minutes
Colonoscopy: 8 minutes
EGD/Colonoscopy: 15 minutes
EGD: 6 minutes

This indicated 9 surgical procedures were performed by one team in three hours and six minutes.

On 05/08/13, a colonoscopy was performed in five minutes.

On 04/24/13, an EGD and colonoscopy was performed in 35 minutes.

On 04/10/13, two colonoscopies and one EGD was performed in under an hour.

On 03/27/13, two colonoscopies were performed in 38 minutes.

On 03/13/13, two EGDs and one colonoscopy were done in 48 minutes.

On 02/13/13, two EGDs and two colonoscopies were done in 53 minutes.

6. Staff I stated there was no procedure room cleaning between cases and the surgery department was not terminally cleaned at the end of the day. No cleaning logs were available. She stated she was the person responsible for cleaning the surgery department. She stated there was no schedule for deep cleaning the entire department.

The files for Staff I had no documentation of formal training and experience as an OR technician, in sterile processing or endoscope processing. There was no documentation of skills competencies and job specific evaluations. The file contained no job descriptions.

7. Staff I was asked if the surger and/or recovery departments had an emergency crash cart. She stated, "No." She stated the staff "borrowed" the crash cart from the emergency room for use in the OR/recovery when procedures were being done. The OR and recovery areas did not have dedicated emergency equipment.

There was no evidence the medical staff had not determined what emergency equipment must be available in these areas.

Based on document review and staff interview, it was determined the hospital failed to maintain a current roster with each practitioner's specific surgical privileges available to the surgery department and in the area where surgeries are scheduled.

Findings:

On 07/23/13, the DON was asked to provide this information. None was provided.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure a qualified practitioner provided a comprehensive pre- and post anesthesia evaluation.

Findings:

On 07/24/13, anesthesia policies and procedures were reviewed. The anesthesia policies had not been updated and approved.

There was no documentation of the scope of anesthesia services provided by the hospital. There was no policy that addressed pre and post anesthesia evaluations. There was no documentation the hospital no longer provided general anesthesia services.

Clinical records for three endoscopy patients were reviewed. One record indicated an American Society of Anesthesiologist's (ASA) score was documented by the physician prior to the procedure. Two records had no documentation of an ASA score.

The records had no documentation by the physician of the type of anesthesia/sedation planned, any potential problems identified, and the patient's condition prior to induction.

The hospital medical staff had not delegated who could perform a post-anesthesia assessment and what should be included in the assessment.

The clinical records indicated patients were assessed post anesthesia by nursing staff only. The records had no documentation of the presence or absence of post-anesthesia recovery complications. One patient required the administration of a reversal agent. There was no documentation as to why this medication was given.

Based on review of hospital documents and interviews with hospital staff, the hospital does not ensure policies and procedures are evaluated, reviewed and revised annually as part of the annual program evaluation. The annual program evaluation presented for review did not have evidence of the review of the hospital's policies and procedures. Governing body, medical staff and quality assurance/performance improvement (QA/PI) meeting minutes reviewed did not have evidence of policy and procedure review. Hospital staff verified that the performance evaluation did not include any review, evaluation or revision of the policies and procedures.

Based on governing body, medical staff and QA/PI meeting minutes and interviews with hospital staff, the hospital does not ensure the program evaluation is used to determine whether the utilization of services was appropriate, policies were followed or whether changes are needed. The program evaluation presented for review only had data and statistics. There was no evaluation of the services the hospital provides and whether additional services might be needed.

Based on record review and interviews with hospital staff, the hospital does not ensure surgical procedures, central sterile processes and contracted services providing patient care in the hospital are evaluated for quality and appropriateness of care provided.

Findings:

1. Endoscopy procedures performed in the hospital were not evaluated by the QA/PI process to assure quality of care in high risk low volumn procedures. Endoscopy procedures are provided in the hospital by a physician one day every two weeks. See Tag C 0320.

2. Sleep study procedures provided to patients in the hospital were not evaluated by the QA/PI program to evaluate quality of care. Personnel providing sleep study monitoring did not have evidence of orientation, evaluation of competency or a current immunization history.

3. The QA/PI program did not include a infection control/infection prevention program that evaluates an active on-going infection control/infection prevention (IP) program for ensuring a sanitary environment, and identifying and preventing infections and communicable diseases among patients and staff. See Tag C 0278.

4. There was no evidence physician's providing surgical care were evaluated by the hospital for competency and current licensure. The hospital was unable to provide a credential file for the physician providing surgical care to patients. This was verified by hospital staff.

Based on clinical record review, document review and staff interview, it was determined the hospital failed to ensure swing bed patients were given a written copy of swing bed resident ' s rights. Findings:

On 07/24/13, three clinical records were reviewed (#1, 4, and #8) for swing bed patients. There was no evidence the patients received notification of written swing bed resident ' s rights.
A document, titled, " Prague Community Hospital Swing Bed Program " failed to include written swing bed resident ' s rights.
At 11:40 a.m., staff B was asked if the hospital provided written resident rights for swing bed patients. She stated the hospital did not provide written resident rights but verbally informed patients of their rights.

Based on clinical record review, document review, and staff interview, the hospital failed to provide swing bed patients with a list of items and services that might not be covered and may be charged, and the amount of those charges. Findings:
On 07/24/13, three clinical records were reviewed (#1, 4, and #8) for swing bed patients. None of the clinical records included documentation the patients were given notification of items and services that may be charged to them.
A hospital document, titled, " Prague Community Hospital Swing Bed Program " failed to include a list of items and services that may be charged to the patient.
At 11:40 a.m., staff B was asked if the hospital provided swing bed patients with a list of items and services that the facility may charge to them. She stated the hospital did not provide a list of items and services with charges in writing.

Based on clinical record review and document review, there was no evidence the contracted social service worker had assessed the needs of the residents. Findings:
On the afternoon of 07/23/13, the hospital administrative staff provided an expired medical social services contract.
On the morning of 07/24/13, a current medical social services contract was provided.
Clinical records for three swing bed patients (#1, 4, and #8) had no documentation of medical social service assessment, interventions, and discharge planning documented by the contracted social worker.