HospitalInspections.org

Based on review of hospital documents, nursing policies and procedures, and interviews with staff the hospital failed to have current written policies and procedures.

Findings:

1. On 8/24/2010 surveyors requested policy and procedure manuals for nursing, obstetrics, surgery, radiology, swing bed, and pharmacy. Review of the surgery manual did not indicate policies had been reviewed in five years. Review of the radiology manual did not show policies had been reviewed and approved for several years.
a. On 8/25/2010 surveyors toured the surgery department and spoke with Staff L. Staff L stated the surgery policies were not up to date and was on "the list of things to do". Staff L also stated they had not been updated in at least four years. Review and approval dates on the policies were 2005. This finding was confirmed with administration and no further documentation was provided.

b. On 8/24/2010 surveyors were provided with multiple radiology manuals. Many of the policies in the manual were approved five to ten years earlier without revision or review since. A nuclear medicine policy and procedure manual was provided to surveyors. The policies in the manual did not have any review and approval by the hospital medical staff or the governing body. The header on the policies stipulated "Oklahoma Cardiovascular Associates". This finding was reviewed in the exit conference with the administrator and no further documentation was provided.

Based on observation and staff interviews, the hospital failed to ensure that the preoperative and post anesthesia (Preop/PACU) drugs are checked consistently for outdated drugs. The cabinet and the refrigerator in the preoperative and post anesthesia area contained outdated drugs at the time of the survey/tour.

Findings:

1. On 8/25/2010 in the afternoon surveyors toured the surgery department. In the cabinet above the medication storage( Preop/PACU) area Epinephrine 1:1000 30cc vial was found to be opened and unlabeled. Also, in the refrigerator at the medication storage area Novolin R was found opened and unlabeled, the box the vial was in had a label from February. Surveyors also found crackers in the refrigerator labeled for medications. These findings were verified with Staff L who stated these drugs should not have been there.

Based on review of the infection control documents, hospital meeting minutes, policies and procedures and personnel files, and interviews with staff, the hospital failed to develop an active infection control program for identifying and preventing infections and communicable diseases by designating a person qualified through training and/or experience as the infection control officer (ICO).

Findings:

1. The personnel file, for the person identified as the ICO, did not contain evidence the individual had training or experience in infection control. On the morning of 08/25/2010 Staff C stated she did not have any previous experience in infection control and had not received any infection control training on setting up an infection control program with active surveillance and analysis of data.

2. The hospital's infection control plan appropriately required surveillance, monitoring and evaluation of all aseptic, isolation and sanitation procedures, including sterilization and disinfection practices, with reporting and analysis of findings.

3. Review of meeting minutes for infection control, medical staff and quality did not contain data from active surveillance of staff. On the morning of 08/25/2010, Staff C and D stated surveillance/observation activities of staff to ensure policies and procedures were followed had not been part of the infection control reporting. Staff C and stated she had not inserviced employees on proper handwashing/hand cleansing techniques or performed any hand sanitation surveillance.

Based on review of hospital documents, review of personnel and interviews with the radiology department manager, the hospital failed to have documentation showing all the personnel operating the diagnostic x-ray equipment and nuclear medicine services are qualified and trained.

Findings:

1. In an interview on the afternoon of 8/24/2010 Staff Q told surveyors modality specific Association of Registered Radiology Technicians (ARRT) supervised computed tomography (CT) and magnetic resonance imaging (MRI) scans but that some personnel performing these tests were not "modality certified". Staff Q could not provide documentation the ARRT's that were not modality certified had been deemed competent by the medical staff or the radiologist. On 8/25/2010 this finding was reviewed with administration and no further documents were provided.


2. On 8/24/2010 surveyors were given a manual with nuclear medicine policies and procedures. The headers on the information stipulated "Oklahoma Cardiovascular Associates". There was no documentation the nuclear medicine technician had been oriented or trained to the specific facility. There was no documentation the policies and procedures had been reviewed and approved by the medical staff or governing body. This information was confirmed with StaffQ and administration on 8/25/2010 and no further documents were provided.

Based on review of hospital documents and interviews with hospital staff, the hospital does not assure nursing staff are adequately trained to meet the needs of the patients. Five of five nursing personnel (Staff B,F,L,M,S) did not have departmental orientation, competency, and evaluation for the specialized areas where they worked.

Findings:

1. On the afternoon of 8/24/2010 surveyors were provided five registered nurse personnel files (Staff B,F,L,M,S) .Five of five files did not have specialty orientation, current competencies, or evaluations. This finding was confirmed with Staff B who indicated there were no documents supporting staff had been oriented to specialty areas such as obstetrics, surgery, post anesthesia recovery, newborn nursery, or surgical services.

2. On the morning of 8/25/2010, Staff B told surveyors registered nursing staff performed conscious sedation. Five of five (B,F,L, M,S) did not have conscious sedation training in their personnel files. The personnel files reviewed included a staff member (Staff M) who had delivered conscious sedation on 4/2/2010.

3. On the afternoon of 8/24/2010, Staff B told surveyors nursing personnel administered blood and blood products. Staff B stated there had not been any blood administration training or competencies provided to staff in several years. Five of five nursing personnel files (Staff B,F,L,M,S ) reviewed did not have current blood administration training or competencies.

4. On the morning of 8/25/2010, a surveyor toured the obstretics and newborn nursery area. Staff M was listed as on duty and providing care for a obstetric patient. Staff M's personnel file did not have any specialty orientation or training documented for obstetrics. This finding was reviewed with Staff B and administration at the exit conference.

5. Staff A, B and G told the surveyors on the afternoon of 08/24/2010 and the morning of 08/25/2010 that nursing staff administered respiratory treatments when the respiratory therapist was not available. On 08/25/2010 at 1120, the respiratory therapist stated he had not trained/conducted competency education in respiratory for nursing staff "in some time".

6. On the afternoon of 8/25/2010, the above findings were reviewed with the administration and no further documentation was provided.

Based on review of medical records, respiratory policies and procedures and personnel files and an interview with the respiratory therapist, the hospital failed to ensure notes for respiratory therapy treatments were descriptive of the patient's pre-assessment and post-assessment of the patient's respiratory condition with evaluation of the patient's response to the respiratory treatment. This occurred in one of one medical record reviewed, of patients receiving respiratory therapy treatments (Records #7).

Findings:

1. Record #7, reviewed on 08/25/2010 at 1100 - The patient was admitted on 08/23/2010 at 1000 and the physician's admission orders included hand held nebulizer treatments every six (6) hours. The medication administration record (MAR) recorded the patient received nebulizer treatments at 1200 and 1800 on 08/23/2010; 2400, 0600, 1200 and 1800 on 08/24/2010 and at 2400 and 0600 on 08/25/2010.

2. Staff A, B and G told the surveyors on the afternoon of 08/24/2010 and the morning of 08/25/2010 that nursing staff administered respiratory treatments when the respiratory therapist was not available.

3. On 08/25/2010 at 1120, Staff G stated nursing staff did not chart on the respiratory form. He showed the surveyor the respiratory form where he charted. According to the form, Staff G provided the 1200 respiratory therapy treatments for Patient #7 on 08/23/2010 and 08/24/2010. The form did not contain a pre-assessment, post-assessment or evaluation of the patient's response to the respiratory treatment. Staff G offered no explanation as to why this was not charted.

4. Staff H stated nursing only charted on the MAR when respiratory treatments were performed by nursing staff. She stated she did not perform any assessment of the patient's respiratory system or how the patient responded to the treatment.

Based on record review and interviews with hospital staff, the hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes a review of the CAH's health care policies. The annual periodic evaluation presented for review for the hospital did not include a review of the CAH's health care policies. The only data presented for review representing the hospital's periodic evaluation was statistical data. This was verified by hospital staff A on 08/25/10 in the afternoon.

Based on record review and interviews with hospital staff, the hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and has evaluated the utilization of services, that policies were followed and if any changes are needed. The only data presented for review representing the hospital's periodic evaluation was statistical data. No conclusions or evaluation of services were documented. This was verified by hospital staff A on 08/25/10 in the afternoon.

Based on a review of policies and procedures and staff interview, the hospital failed to ensure the swing bed policies included a policy and procedure addressing mistreatment, neglect and abuse and misappropriation of property of swing bed patients.

Findings:

1. At the time of review on the morning of 08/25/2010, the hospital did not have a policy addressing mistreatment, neglect and abuse and misappropriation of property of swing bed patients. This was confirmed with the Chief Executive officer at the time.

2. The policy and procedure developed while the surveyors were at the facility did not address:
a. How the hospital would protect the patient and staff while the allegation was being investigated.
b. How the hospital would educate staff on recognizing abuse and neglect and the hospital's policy on the procedure to follow if a staff member received an allegation or witnessed abuse, neglect or misappropriation of patient property.