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At the time of the revisit on 11/16/11 this deficiency was not corrected.

Based on review of a list of hospital staff, personnel files and interviews with hospital staff, the hospital failed to maintain verification of current licensure and training for personnel working in the hospital.

Findings:

1. The facility provides radiology services through a contract. The facility did not verify radiology personnel had appropriate licensing and training to perform radiological procedures.

2. The facility provides clinical nutritional services through a contract relationship. According to State Department of Health regulations if a consultant dietitian is utilized the facility must employ a full time Certified Dietary Manager or a registered dietary technician. Staff G the dietary manager, does not have either training or certification. At the time of the revisit the facility did not have Staff G enrolled in the CDM or registered dietary technician program.

3. Respiratory treatments and respiratory care provided by the facility are administered by hospital nursing staff. The facility does not have a registered respiratory therapist overseeing the service. There is no documentation the nursing staff have been trained by a registered respiratory therapist. The facility failed to provide appropriate training for personnel administering respiratory therapy.

Based on review of hospital documents and records, and interviews with hospital staff, the governing body does not ensure that all services provided by the hospital are provided in a safe manner.

Findings:

1. The governing body failed to ensure quality care is provided by and/or in accordance with orders of a practitioner who has been granted privileges by the hospital. Refer to Tag - 0049

2. The governing body failed to ensure the hospital had an ongoing, hospital-wide, data-driven quality assessment and performance improvement ( QAPI) program that reviewed all services provided. Refer to Tag - 0267.

3. The governing body failed to ensure the hospital maintained an effective functioning grievance process and that all grievances were recognized, investigated, resolved and a written response was sent to the individual filing the grievance. Refer to Tag - 0118.

4. The governing body does not ensure that all services performed under contract are provided in a safe and effective manner. Refer to Tags A 0023, 0084, and 0619.

5. The governing body does not ensure that radiological services are provided in a safe manner by qualified personnel. Refer to Tags A 0536, 0545, 0546, 0553, 0554 and 0555.

6. The governing body failed to ensure dietary services were provided in a safe and effective manner to meet the needs of the patients. Refer to Tag - 0619

7. The governing body failed to provide respiratory services in accordance with acceptable standards of practice and Licensure requirements. Refer to Tag - 1151.

8. The governing body does not ensure that each patient's rights are protected and promoted. The governing body failed to ensure complete policies and procedures for restraints and seclusions were developed and enforced. Refer to Tag - 0175.

Based on review of hospital documents, medical records and interviews with hospital staff, the hospital's governing body failed to ensure quality care is provided by and/or in accordance with orders of a practitioner who has been granted privileges by the hospital.

Findings:

1. One of three patients transferred to another acute care facility's emergency department (Record #13), and whose medical record was reviewed, did not have orders to transfer the patient. According to the medical record, the physician (Staff K) was not contacted until after the patient left. The medical records did not contain evidence the hospital had called and received acceptance for transfer from the receiving hospital. This was reviewed with administrative staff on 11/15/2011.

2. Patient #12 - Admitted 09/15/2011 and discharge 09/23/2011, after the patient did not return from transfer to another hospital's ER.
a. The patient used a C-PAP (continuous positive air pressure). The hospital's admission exclusionary criteria stipulates patients requiring C-PAP will not be admitted unless medical review was provided. The medical record and meeting minutes did not reflect a medical review was conducted for this patient's admission.

b. The patient was transferred to another acute care hospital on 09/22/2011 in respiratory distress. Documentation on 09/22/2011 at 2030 recorded when the tech took the patient's oxygen saturation (Sat) rate, it was 74%. Staff tried to get the patient to wear his C-PAP and in the process, the patient's Sat dropped into the 60's. The attending physician (Staff K)was notified and he ordered the nurse to call another physician (Staff L). At 2100, the nurse call Staff L of the patient's Sat and that the patient's nails were blue. Staff L ordered the head of bed elevated, oxygen administration per nasal cannula, and Sats to be taken every 30 minutes. At 2200, staff was unable to arouse the patient, Sats were 84%, and the patient's pupils were dilated. At this time the physician ordered transfer of the patient to another acute care hospital. Neither physician presented to the hospital to examine the patient. Medical staff meeting minutes did not reflect a medical review of the quality of the medical care was conducted.

3. In two of two patient deaths that occurred in the hospital thus far in 2011, the medical record did not contain evidence a physician, credentialed by the hospital, was contacted until after cardiopulmonary resuscitation (CPR) had ended and emergency medical service (EMS) personnel had pronounced the patients dead.
a. Patient #8 - According to the medical record, on 03/24/2011 at 2025 CPR was started when the patient was found unresponsive. EMS was called and arrived at 2036. At that time, the EMS personnel called "time of death." According to the documentation, the physician was not contacted until after CPR had ceased. The nurse documented she attempted to call the physician at 2115 and left a message. At 2150, the physician called and report was given. The medical record did not contain an order for calling EMS, discontinuing CPR or release of body to the funeral home. The medical record does not demonstrate that a physician was involved in determining the medical care and needs for this patient during this time.

b. Patient #9 - According to the medical record, while taking his 1930 medications on 07/17/2011, the patient aspirated and started coughing. The patient Sat rate was taken and was 84% and "in a few more minutes tech said Sat dropped to 64." EMS was called and CPR was begun. The medical record documented CPR began at 2152 and EMS staff took over when they arrived at 2157. The medical record does not document why CPR was stopped, but the physician was not called until 2220. The EMS document recorded that they called their Medical Control physician and he told them if the patient had no pulse or respirations to cease efforts. They documented in their report that "efforts terminated at 2212." The medical record did not contain an order for calling EMS, discontinuing CPR or release of body to the funeral home - The last order entry was dated 07/12/2011. The medical record does not demonstrate that a physician, credentialed by the hospital, was involved in determining the medical care and needs for this patient during this time.

4. Although hospital staff conducted a "Critical Event Review" on Records #8 and #9, no physician was involved in the review. This was confirmed by Staff B on 11/15/2011. Medical staff meeting minutes did not reflect the medical staff had conducted a review of the quality of medical care provided of either patient or review of the medical supervision for the care provided.

5. Patient #1's medical record included physician orders for dietary consult. Patient #1 had a history of recent weight loss, dysphagia, gastroesophageal reflux disease, prostate cancer, and depression. An order was written for a dietary consult. A dietary consult was completed with recommendations to change the diet and offer health shakes in the afternoon and at bed time. The physician did not address the consult in any of the progress notes or discharge summary. There were no orders written to implement the plan. There was no documentation why the physician did not implement the recommendations.

Based on record review and interviews with hospital staff, the governing body does not ensure that all services performed under contract are provided in a safe and effective manner. Services provided to the hospital by contract are not monitored and evaluated by the hospital's quality assessment and performance improvement (QAPI) program to ensure that they are provided in a safe and effective manner.

1. According to the organizational chart reviewed on 11/14/11 the Food Services Department reports to the Plant Operations Manager. The Dietitian and Dietary manager reports to nursing. Staff E told surveyors Staff G was Food Services Director. In an interview on 11/15/11 Staff E told surveyors she reported to Staff A. Staff E also stated she was not aware she was reporting to Staff C. Staff E told surveyors Food services was to report to the Plant Operations Manager. On the afternoon of 11/15/11 Staff A told surveyors Staff E reported to Staff C. Job descriptions, evaluations, for the department do not indicate what responsibilities the Plant Operations Manager will oversee. The Director of Plant Operations does not have education, training, and experience to evaluate clinical dietetics.

2. According to Staff A and B radiology is provided through a mobile x-ray company. There is no documentation the x-ray personnel are licensed, oriented, trained and competent. There is no documentation the hospital evaluates the x-ray service or outcomes.

3. According to Staff A and B respiratory therapy is provided by nursing staff. There is no documentation the facility contracts with a respiratory therapist to provide departmental oversight and training. There is no documentation the facility reviews the respiratory services or outcomes.

Based on review of hospital documents, surveyor observations and interviews with staff, the hospital failed to ensure patients/patients' representatives are informed how to file a grievance with the State agency. The hospital's grievance policy and patient admission handout did not include contain the correct information on how to access the State agency to file a complaint. The policy and the handout did not have correct telephone number and agency designation as required. This finding was reviewed and verified by administrative staff on 11/15/2011.

Based on review of hospital policies and procedures and medical records and interviews with hospital staff, the hospital failed to develop complete policies to determine the interval and method of documentation and enforce policies for one to one review of the restraints and/or seclusions.

Findings:

1. The hospital's policy and procedure, entitled Behavior Management - Personal Restraint, with a review of 05/2010, did not specify:
a. How and how often patients would be monitored
b. Where the monitoring would be documented.

2. The hospital's policy and procedure, entitled Behavior Management - Medication, with a review of 05/2010, did not specify:
a. That chemical restraints/medication will not be ordered as a "PRN" (as needed/standing order)
b. How and how often patients would be monitored
c. Where the monitoring would be documented.

3. For one of two patient's restrained/secluded (Patient #11)and whose medical record was reviewed, the hospital did not follow its policy. The hospital's policy for one hour evaluation stipulated the evaluation would not be performed by anyone involved with the restraint and/or seclusion. The one hour evaluation for Patient #11's seclusion on 10/29/2011 was performed by the nurse involved with the restraint. This finding was reviewed and verified with Staff C on the afternoon of 11/15/2011.

4. Above findings were reviewed and verified with administrative staff on the afternoon of 11/15/2011.

At the time of the revisit on 11/14/11 this deficiency had not been corrected.

Based on review of hospital documents and meeting minutes and interviews with hospital staff, the hospital failed to track and analyze quality indicators hospital-wide to improve patient care. The Quality program failed to include dietary indicators addressing clinical outcomes, organ procurement, radiology, and respiratory care services.

Findings:

1. Dietary indicators addressed in the hospital's Quality Management program did not address nutritional outcomes. Indicators addressed are "nutritional consults completed within three days, and patient nutritional consult log completion". The facility does not have indicators developed to determine if the nutritional services are meeting the needs of the patients.

2. Organ procurement, respiratory therapy and radiology services were not addressed in the Quality Management program.


3. This finding was reviewed and verified with hospital administration on the afternoon of 11/15/2011.

Based on review of medical records,and interviews with hospital staff, the hospital failed to ensure the registered nurse (RN) supervised the nursing care for each patient. The supervisory nurse failed to ensure physicians' orders and hospital policies were followed. This occurred in nine of 17 patient charts (Patients 1, 2, 3, 4, 5,6,7,16,17)

Findings:

1. According to the hospital policy Nursing Assessment/Reassessments, a continuous evaluation of patient needs and nursing interventions to meet those needs with appropriate documentation in the Nurse's Notes is the expectation for all nursing staff. Further in the policy, it stipulates. physical limitations/restrictions will be identified by patient and/or nurse and reported to the attending physician for patient specific orders. The policy also stipulates all staff members are expected to report and document any signs of change in the patient's condition to the RN: changes in vital signs, changes in level of consciousness, changes in behavior, changes in physical abilities, suspected side effects of medications. The RN is responsible to document and report the observed changes to the attending physician or physician on-call.

2. Patient #3 was admitted with a history of diabetes, hyperlipidemia, hypertension, status post myocardial infarction, mental disability possible dementia, and increasing agitation. The physician documented Pt #3 was increasingly unable to perform self care and was being assessed for placement in a nursing home. The physician ordered a regular diet without concentrated sweets and no additional salt. The patient's blood sugar on admission was 224. The nursing assessment did not indicate the patient was a diabetic. Scoring on the form did not indicate the need for a dietary consult. The physician did not order a dietary consult throughout the stay. The patient's blood sugars ranged from 300 mg/dcl to 500 mg/dcl and she was placed on a sliding scale as well as oral agents to control her blood sugar. The dietitian was not consulted although the physician documented the patient had "poor glucose control" and increased the patient to a "moderate dose regimen". The patient did not receive a dietary consult because the nursing assessment -nutritional assessment was not completed and the scoring did not reflect the patient condition.

Patient #1's medical record included physician orders for dietary consult. Patient #1 had a history of recent weight loss, dysphagia, gastroesophageal reflux disease, prostate cancer, and depression. An order was written for a dietary consult. A dietary consult was completed with recommendations to change the diet and offer health shakes in the afternoon and at bed time. The physician did not address the consult in any of the progress notes or discharge summary. There were no orders written to implement the plan. There was no documentation why the physician did not implement the recommendations. The patient did not receive additional supplements as recommended.

Patient #17's medical record indicates the 93 year old had a history alzheimer's, gout, seizure disorder, gastrointestinal problems, increasing dementia. The patient received a nutritional consult and supplements were ordered. The order was to provide supplements if the patient did not eat at least a certain percentage of the meal. Multiple instances staff documented the patient's meal intake amounts were below the amount the dietitian wanted. No supplements were provided to the patient.

Patient #16's medical record indicated the 55 year old male was admitted for behavioral disturbances. On admission the patient's blood glucose level was 297, Hemoglobin A1C 11.5 and finger stick blood sugars (FSBS) ranged in 400-500 range. The patient did not have a complete nursing assessment. The patient did not receive a dietary consult. There was no documentation by the physician indicating why a consult was ot ordered. During the patient's stay nursing staff did not document a physical assessment.

Patient #5's medical record indicates on admission the patient had a history of multiple sclerosis, hypertension, seizure disorder, pressure ulcer, and was becoming increasingly aggressive. The patient was described on admission by the physician as "frail, thin, caucasian man". No dietary consult was ordered on admission. On the nursing assessment the patient was listed as having "no teeth". The nutritional assessment did not include any check marks in the "trouble with chewing or swallowing" information. On the third day of admission a dietary consult was ordered. The dietitian recommended changes to the diet including "Medpass or Resource 2.0 if eats less than 50% of meal. Also, give 4 ounces of Med Pass at 1000, 1500, and at bedtime (HS). The order for MedPass at 1000, 1500, and HS was not started until the next day. On multiple opportunities to provide the 4 ounces of MedPass the patient did not receive the supplement. Later in the stay nursing staff changed the 4ounce MedPass order to PRN (as needed) . There was no order to change to PRN documented in the chart. During the patient stay nursing staff did not offer the supplement if the patient at less than 50% of a meal. There was no documentation why nursing staff did not provide the supplement.

Patient #2 -according to the history and physical -had a history of irritable bowel syndrome and had diarrhea related to the diagnosis. Physician dictation stipulated "restrict diet". There was no documentation on the nursing assessment or daily flowsheet the staff restricted the patient's diet. There was no documentation the staff identified the irritable bowel syndrome. The nutritional screen did not indicate the patient had any nutritional problems. The nursing staff did not do any physical assessments after the initial nursing assessment.

Patient #4-the patient's history and physical indicated the patient "hardly ever ate". The nursing assessment did not include a complete nutritional screen. There were no nursing physical assessments documented after the initial nursing assessment.

Patient #6- the patient's history and physical indicated the patient had a history of gastroesophageal reflux disease (GERD). Documentation further in the chart indicated the patient was on a "no concentrated sweets" diet. There was no documentation indicating why the patient was on the diet. The nutritional screen did not indicate the patient had any dietary issues including GERD. Daily physical assessments were not completed by nursing after the initial physical assessment on admission.

Patient #7-the patient's history and physical stipulate the patient was diabetic. There was no documentation in the nursing assessment indicating the patient was a diabetic. There were no physical assessments by nursing staff after the initial admitting nursing assessment. There was no nutritional screen. There was no dietary consult. There was no indication the patient was provided a "no concentrated sweet" diet. Daily physical assessments were not completed by nursing after the initial physical assessment on admission.

3. This information was provided at the exit interview on 11/15/11. No further documentation was provided.

Based on review of policies, interviews with staff, and review of medical records the faiclity failed to provide radiological services in a safe manner. Staff A told surveyors xray services were provided through a contract with a mobile xray company. The facility did not have radiology policies and procedures. There was no evidence the personnel operating the equipment were competent, oriented, and trained. There was no evidence the equipment used was safe and routinely inspected.

Based on review of policy and procedure and interviews with staff the facility failed to ensure radiology exams were provided in a safe manner. The facility provides radiology services through a mobile xray contract. The facility does not have policies and procedures establishing appropriate shielding of patients and staff during examinations. The facility did not have radiology policies and procedures.

Based on interviews with staff and document review the facility failed to ensure the xray equipment utilized in the facility was periodically inspected and licensed. On 11/15/11 Staff A told surveyors the xray equipment utilized in the facility was provided through a contract. The facility did not have documentation of current inspection, tube license, or physicist report.

Based on policy and procedure, interviews, and review of personnel files the facility does not ensure personnel providing radiology services are appropriately trained and competent to provide services to patients.

Findings:

1. On the morning of 11/15/2011 surveyors were told diagnostic radiology services were provided to the hospital through a contract.

2. Surveyors requested personnel records for contracted services. None were provided. The hospital did not have a list of personnel qualified to run the equipment or provide services to patients. The hospital failed to ensure the contract personnel providing services to patients were appropriately trained, competent, and qualified to provide radiology services to patients.

Based on review of policies, and interviews with staff, the hospital failed to ensure a qualified radiologist supervises the radiology services, only personnel designated as qualified by the medical staff used the radiologic equipment and administered procedures; and all personnel regularly exposed to radiation are checked for radiation exposure periodically.

Findings:

1. On the morning of11/15/11, Staff A told surveyors the facility had a contract with a mobile x-ray company and the xrays are read via a digital pacs system.

2. Review of hospital documents did not indicate a radiologist oversaw the radiology services.

3. There were no radiology policies developed, reviewed, and approved by the medical staff.

4. The facility did not have any documents indicating personnel were licensed, trained, oriented to facility or qualified to operate the xray equipment. There were no documents indicating the personnel were monitored for radiation exposure.

5. These findings were confirmed with Staff A 11/15/11.

Based on review of hospital documents, review of personnel files and interviews with administration, the hospital failed to have documentation showing personnel operating the imaging equipment are qualified and trained. There was no documentation the medical staff or the radiologist had developed, reviewed, and approved criteria designating personnel competent to perform all radiology procedures.

Based on review of policy and procedure, medical records, and interviews with staff, the hospital failed to maintain records for all radiology procedures performed.

Findings:

1. On 11/15/2011 surveyors requested radiology policies. According to Staff A and B, radiology services are provided under contract. The facility did not have policies and procedures reviewed and approved through the medical staff on how x-ray films will be stored and retrieved.

2. On 11/15/2011 this finding was reviewed with Staff A. No further documentation was provided.

Based on review of policy and procedure and interviews with staff the facility failed to have a process to maintain films and scans. On 11/15/2011 Staff A told surveyors images from the contracted x-ray service were digital and the facility only received a report of findings from the radiologist. The facility did not have a policy or process for storage and retrieval of films from the contracted x-ray service. There was no documentation the x-ray service maintained records for a minimum of five years.

At the time of the revisit on 11/15/11 this Condition was not in compliance

Based on record review and interviews with hospital staff the hospital does not ensure there is a organized dietary service with oversight by a registered dietitian. The hospital did not have evidence that a dietitian was providing oversight or services with regularly scheduled visits and oversight of clinical nutritional services. The facility failed to meet the nutritional needs of the patient.

Findings:

1. Nine of nine (1,2,3,4,5,6,7,16,17) patients had nutritional conditions requiring nutritional intervention which the facility did not act on. The hospital staff did not identify these conditions. Two of the nine patients had a nutritional consult without recommendations by the dietitian being implemented. Seven of the nine patients had conditions requiring nutritional consult and intervention. The facility failed to train staff, implement policies, and oversee processes to ensure patients nutritional needs are met.

2. No dietitian reports were provided during the survey to show the dietitian was actively supervising dietary services at the hospital. In an interview at on 11/14/11 Staff B told surveyors the consultant had not provided a monthly report but the report would be available on 11/15/11. No report was provided on 11/15/11. In an interview with Staff E on 11/15/11 Staff E told surveyors she was responsible for providing dietary consults. There was no evidence Staff E provided oversight to dietary/clinical staff ensuring compliance with dietetic policies effecting patient treatment. During the interview Staff E was asked about processes relating to "revised" dietary policies. Staff E was not aware of specific duties listed in policies as a requirement of the "dietary supervisor". Staff E told surveyors she thought she was responsible for the dietary consults but thought the plant operations manager would provide the department management. Staff E also told surveyors Staff F was providing consultant dietitian services but was not sure of all of Staff F's responsibilities. Surveyors were provided an organizational chart on 11/14/11. The organizational chart indicates the dietitian reports to nursing. The dietary manager reports to the dietitian. The Food Services Department reports to the plant operations manager. Job descriptions for the dietitians and the dietary manager do not match the reporting structure in the organizational chart.

2. On 11/14/11 surveyors were provided two dietitian contracts (Staff E and Staff F). Staff B told surveyors Staff E was the consultant dietitian. Staff E's contract was provided showing that the hospital had a contract with a dietitian to provide services as the manager for the dietary department of the hospital for a ten to twelve hours per month. The contract stipulates the dietitian will consult in menu planning, food production and service, and therapeutic diet orders. The contract further stipulates the dietitian will provide a monthly personnel inservice education, perform monthly written reports summarizing consulting dietitian's activities and evaluation of the food service. Staff F's contract was for consulting on menu planning, food production and service, therapeutic diet orders, and evaluation of the food service. There were no monthly reports indicating the dietitians oversaw all required elements of the dietary program.

3. A list of personnel was provided to surveyors 11/15/11. Staff C was listed as the dietary manager. Staff C is not a certified dietary manager (CDM) or dietary technician as required when the dietitian is a consultant. There was no documentation in the file indicating Staff C enrolled in CDM training.

5. Meeting minutes reviewed for 2011 did not document that a dietitian was attending or providing reports in any of the hospital's meetings such as medical staff, committee of the whole or governing board.

6. Dietary policies and procedures were provided to surveyors 11/14/11. The policies and procedures had a revision date of 10/11. The departmental policies did not have policies regarding potioning. The process for nutritional assessment and nutritional screen did not match the nursing policies regarding assessment and screening. Processes for cleaning and sanitizing the department and equipment did not identify cleaners and sanitizer appropriate for use and instructions for use. There was no evidence the Infection Control processes had been integrated into the departmental policies. Departmental policies regarding hand washing, incident reporting, and complaints do not match hospital policies. Two of the policies indicate the Dietary department and the Dietary manager are responsible for documenting intake and problems with diet. Staff C and E were not aware of these policies.

7. Staff G provided surveyors copies of dietary/kitchen inspection reports on 11/15/11. There was no documentation the inspection reports had been reviewed or acted on in any committee meetings or governance. Staff E was not aware of the inspection reports when asked during and interview on 11/15/11.

Based on review of medical records, policies and procedures, dietary consultation reports, and interviews with staff, the facility failed to ensure dietary services were provided in an organized manner and problems identified in dietary were included quality assurance performance improvement activities (QAPI).

Findings:

1. In an interview with Staff E surveyors were told the dietary department reviewed nutritional consult timeliness. Staff E stated the facility did not check ensure the nutritional consult recommendations were followed up and implemented. 11/14/2011 Surveyors requested the consultant dieitian's report for the prior month. Staff B told surveyors the report would be available 11/15/11. The consultant dieitian's report was not available 11/15/11. Staff G provided surveyors copies of inspection reports on 11/15/11. There was no documentation the inspection reports had been reviewed or acted on in any committee meetings or governance.

2. Nine of nine patients (1,2,3, 4,5,6,7,16,17) reviewed for dietary concerns did not have appropriate nutritional intervention implemented. There was no documentation patient's receiving dietary consults had nutritional plans implemented and evaluated. See 0628 and 0630

3. No dietitian reports were provided during the survey to show the dietitian was actively supervising dietary services at the hospital. In an interview at on 11/14/11 Staff B told surveyors the consultant had not provided a monthly report but the report would be available on 11/15/11. No report was provided on 11/15/11. In an interview with Staff E on 11/15/11 Staff E told surveyors she was responsible for providing dietary consults. There was no evidence Staff E provided oversight to dietary/clinical staff ensuring compliance with dietetic policies effecting patient treatment. During the interview Staff E was asked about processes relating to "revised" dietary policies. Staff E was not aware of specific duties listed in policies as a requirement of the "dietary supervisor". Staff E told surveyors she thought she was responsible for the dietary consults but thought the plant operations manager would provide the department management. Staff E also told surveyors Staff F was providing consultant dietitian services but was not sure of all of Staff F's responsibilities. Surveyors were provided an organizational chart on 11/14/11. The organizational chart indicates the dietitian reports to nursing. The dietary manager reports to the dietitian. The Food Services Department reports to the plant operations manager. Job descriptions for the dietitians and the dietary manager do not match the reporting structure in the organizational chart.

4. On 11/14/11 surveyors were provided two dietitian contracts (Staff E and Staff F). Staff B told surveyors Staff E was the consultant dietitian. Staff E's contract was provided showing that the hospital had a contract with a dietitian to provide services as the manager for the dietary department of the hospital for a ten to twelve hours per month. The contract stipulates the dietitian will consult in menu planning, food production and service, and therapeutic diet orders. The contract further stipulates the dietitian will provide a monthly personnel inservice education, perform monthly written reports summarizing consulting dietitian's activities and evaluation of the food service. Staff F's contract was for consulting on menu planning, food production and service, therapeutic diet orders, and evaluation of the food service. There were no monthly reports indicating the dietitians oversaw all required elements of the dietary program.

5. Dietary policies and procedures were provided to surveyors 11/14/11. The policies and procedures had a revision date of 10/11. The departmental policies did not have policies regarding potioning. The process for nutritional assessment and nutritional screen did not match the nursing policies regarding assessment and screening. Processes for cleaning and sanitizing the department and equipment did not identify cleaners and sanitizer appropriate for use and instructions for use. There was no evidence the Infection Control processes had been integrated into the departmental policies. Departmental policies regarding hand washing, incident reporting, and complaints do not match hospital policies. Two of the policies indicate the Dietary department and the Dietary manager are responsible for documenting intake and problems with diet. Staff C and E were not aware of these policies.

6. Patient #1's medical record included physician orders for dietary consult. Patient #1 had a history of recent weight loss, dysphagia, gastroesophageal reflux disease, prostate cancer, and depression. An order was written for a dietary consult. A dietary consult was completed with recommendations to change the diet and offer health shakes in the afternoon and at bed time. The physician did not address the consult in any of the progress notes or discharge summary. There were no orders written to implement the plan. There was no documentation why the physician did not implement the recommendations. The patient did not receive additional supplements as recommended.

Patient # 3's medical record indicates the patient was admitted with a history of diabetes, hyperlipidemia, hypertension, status post myocardial infarction, mental disabilities potential dementia, and increasing agitation. The patient was admitted for testing, change in drug regimine, and potential placement in a nursing home due to being unable to care for self at home. Admitting orders did not include a dietary consult . The nursing assessment did not include a full nutritional assessment and "diabetic" was not listed by nursing in the nutrtional section. The patients blood sugar on admission was 224. The patient's urinalysis on admission included "large amount of glucose" and was positive for nitrites. The physician ordered fingerstick blood sugars (FSBS) twice a day (BID). The patient's diet order was "regular diet with no concentrated sweets and no additional salt". The patient had been on oral medication for blood sugar control prior to hospitalization and admitting orders continued the oral medications for blood sugar control. Ten days after admission the patient was placed on a sliding scale insulin program. Five days later the physician changed the fingerstick blood sugar orders to "before meals and at bed time (FSBS AC and HS). The physician documented the patient had "poor glucose control" five days later. During the patient's stay FSBS ranged from 300-525 mg/dcl. 25 of the 26 days the patient was hospitalized nursing did not assess and address the elevated blood sugar in the daily nursing flowsheet. Nursing assessments throughout the stay did not include documentation regarding the patient's diabetic condition. The dietitian did not see the patient. Nursing did not include all the patient's medical problems in the nutritional assessment so a consult would be triggered. The physician did not order a dietary consult and there was no documentation by the physician why dietary was not consulted.

Patient #4's medical record indicates on admission the patient had a history of multiple sclerosis, hypertension, seizure disorder, pressure ulcer, and was becoming increasingly aggressive. The patient was described on admission by the physician as "frail, thin, caucasian man". No dietary consult was ordered on admission. On the nursing assessment the patient was listed as having "no teeth". The nutritional assessment did not include any check marks in the "trouble with chewing or swallowing" information. On the third day of admission a dietary consult was ordered. The dietitian recommended changes to the diet including "Medpass or Resource 2.0 if eats less than 50% of meal. Also, give 4 ounces of Med Pass at 1000, 1500, and at bedtime (HS). The order for MedPass at 1000, 1500, and HS was not started until the next day. On multiple opportunities to provide the 4 ounces of MedPass the patient did not receive the supplement. Later in the stay nursing staff changed the 4ounce MedPass order to PRN (as needed) . There was no order to change to PRN documented in the chart. During the patient stay nursing staff did not offer the supplement if the patient at less than 50% of a meal. There was no documentation why nursing staff did not provide the supplement.

Patient #17's medical record indicates the 93 year old had a history alzheimer's, gout, seizure disorder, gastrointestinal problems, increasing dementia. The patient received a nutritional consult and supplements were ordered. The order was to provide supplements if the patient did not eat at least a certain percentage of the meal. Multiple instances staff documented the patient's meal intake amounts were below the amount the dietitian wanted. No supplements were provided to the patient.

Patient #16's medical record indicated the 55 year old male was admitted for behavioral disturbances. On admission the patient's blood glucose level was 297, Hemoglobin A1C 11.5 and finger stick blood sugars (FSBS) ranged in 400-500 range. The patient did not have a complete nursing assessment. The patient did not receive a dietary consult. There was no documentation by the physician regarding the lack of blood sugar control.

Patient #2 -according to the history and physical -had a history of irritable bowel syndrome and had diarrhea related to the diagnosis. Physician dictation stipulated "restrict diet". There was no documentation on the nursing assessment or daily flowsheet the staff restricted the patient's diet. There was no documentation the staff identified the irritable bowel syndrome. The nutritional screen did not indicate the patient had any nutritional problems. The nursing staff did not do any physical assessments after the initial nursing assessment.

Patient #4-the patient's history and physical indicated the patient "hardly ever ate". The nursing assessment did not include a complete nutritional screen. There were no nursing physical assessments documented after the initial nursing assessment.

Patient #6- the patient's history and physical indicated the patient had a history of gastroesophageal reflux disease (GERD). Documentation further in the chart indicated the patient was on a "no concentrated sweets" diet. There was no documentation indicating why the patient was on the diet. The nutritional screen did not indicate the patient had any dietary issues including GERD.

Patient #7-the patient's history and physical stipulate the patient was diabetic. There was no documentation in the nursing assessment indicating the patient was a diabetic. There were no physical assessments by nursing staff after the initial admitting nursing assessment. There was no nutritional screen. There was no dietary consult. There was no indication the patient was provided a "no concentrated sweet" diet.

The hospital failed to identify nutritional needs and implement processes to provide for adequate nutritional care.

Based on review of policies, personnel files, and interviews, the hospital failed to provide adequate training and oversight to dietary and nursing personnel.

Findings:
1. On 11/15/11 surveyors were told by Staff B the nursing staff and dietary had been re-trained regarding nutritional assessments, consults, and dietary documentation. Review of medical records selected for dietary concerns indicate nine of nine (1,2,3,4,5, 6, 7,16,17) medical records reviewed did not have nutritional consults implemented, nutritional assessments completed, or consult orders followed as directed. The facility failed to train and oversee dietary and nursing staff on clinical nutritional services.

2. On 11/15/11 Staff B told surveyors Staff G was the dietary manager. Staff B also stated the dietitian was a contracted position. Review of Staff G's personnel file indicates Staff G is not a Certified Dietary Manager (CDM) or Registered Dietary Technician. Staff G did not have any documentation she was enrolled in coursework to complete CDM coursework. .

3. On 11/15/11 surveyors reviewed Staff O's personnel file. Staff O, a newly hired dietary employee did not have orientation and training to the facility. Documentation in the personnel file indicated she had read and reviewed dietary policies. There were no documents in Staff O file indicating the dietitian had reviewed Staff O's skills.

At the time of the revisit on 11/16/2011 this deficiency had not been corrected.

Based on a review of policies and procedures, medical records, and staff interviews, the hospital failed to ensure the menus were meeting the needs of the patients.

Findings:

1. According to the Nutritional Assessment -Department of Nursing policy a brief assessment of each patient's nutritional status will be done as part of the admission nursing assessment. No further nutritional assessment is required if nutritional problems are not identified. The policy does not match the form used to document the nutritional assessment completed by nursing. The policy does not provide the process for staff to follow to initiate a nutritional consult when utilizing the nutritional assessment scoring provided on the form. Some conditions listed on the form do not have scoring provided but are conditions that would contribute to the need for a dietitian's consult. The form does not address how to score these conditions.

Patient #3 was admitted with a history of diabetes, hyperlipidemia, hypertension, status post myocardial infarction, mental disability possible dementia, and increasing agitation. The physician documented Pt #3 was increasingly unable to perform self care and was being assessed for placement in a nursing home. The physician ordered a regular diet without concentrated sweets and no additional salt. The patient's blood sugar on admission was 224. The nursing assessment did not indicate the patient was a diabetic. Scoring on the form did not indicate the need for a dietary consult. The physician did not order a dietary consult throughout the stay. The patient's blood sugars ranged from 300 mg/dcl to 500 mg/dcl and she was placed on a sliding scale as well as oral agents to control her blood sugar. The dietitian was not consulted although the physician documented the patient had "poor glucose control" and increased the patient to a "moderate dose regimen". The nutritional assessment component of the initial nursing assessment was not complete. The patient did not receive a dietary consult.

Patient #1's medical record included physician orders for dietary consult. Patient #1 had a history of recent weight loss, dysphagia, gastroesophageal reflux disease, prostate cancer, and depression. An order was written for a dietary consult. A dietary consult was completed with recommendations to change the diet and offer health shakes in the afternoon and at bed time. The physician did not address the consult in any of the progress notes or discharge summary. There were no orders written to implement the plan. There was no documentation why the physician did not implement the recommendations. The patient did not receive additional supplements as recommended.

Patient #17's medical record indicates the 93 year old had a history alzheimer's, gout, seizure disorder, gastrointestinal problems, increasing dementia. The patient received a nutritional consult and supplements were ordered. The order was to provide supplements if the patient did not eat at least a certain percentage of the meal. Multiple instances staff documented the patient's meal intake amounts were below the amount the dietitian wanted. No supplements were provided to the patient.

Patient #16's medical record indicated the 55 year old male was admitted for behavioral disturbances. On admission the patient's blood glucose level was 297, Hemoglobin A1C 11.5 and finger stick blood sugars (FSBS) ranged in 400-500 range. The patient did not have a complete nursing assessment. The patient did not receive a dietary consult. There was no documentation by the physician regarding the lack of blood sugar control.

Patient #5's medical record indicates on admission the patient had a history of multiple sclerosis, hypertension, seizure disorder, pressure ulcer, and was becoming increasingly aggressive. The patient was described on admission by the physician as "frail, thin, caucasian man". No dietary consult was ordered on admission. On the nursing assessment the patient was listed as having "no teeth". The nutritional assessment did not include any check marks in the "trouble with chewing or swallowing" information. On the third day of admission a dietary consult was ordered. The dietitian recommended changes to the diet including "Medpass or Resource 2.0 if eats less than 50% of meal. Also, give 4 ounces of Med Pass at 1000, 1500, and at bedtime (HS). The order for MedPass at 1000, 1500, and HS was not started until the next day. On multiple opportunities to provide the 4 ounces of MedPass the patient did not receive the supplement. Later in the stay nursing staff changed the 4 ounce MedPass order to PRN (as needed) . There was no order to change to PRN documented in the chart. During the patient stay nursing staff did not offer the supplement if the patient at less than 50% of a meal. There was no documentation why nursing staff did not provide the supplement.

Patient #2 -according to the history and physical -had a history of irritable bowel syndrome and had diarrhea related to the diagnosis. Physician dictation stipulated "restrict diet". There was no documentation on the nursing assessment or daily flowsheet the staff restricted the patient's diet. There was no documentation the staff identified the irritable bowel syndrome. The nutritional screen did not indicate the patient had any nutritional problems. The nursing staff did not do any physical assessments after the initial nursing assessment.

Patient #4-the patient's history and physical indicated the patient "hardly ever ate". The nursing assessment did not include a complete nutritional screen. There were no nursing physical assessments documented after the initial nursing assessment.

Patient #6- the patient's history and physical indicated the patient had a history of gastroesophageal reflux disease (GERD). Documentation further in the chart indicated the patient was on a "no concentrated sweets" diet. There was no documentation indicating why the patient was on the diet. The nutritional screen did not indicate the patient had any dietary issues including GERD.

Patient #7-the patient's history and physical stipulate the patient was diabetic. There was no documentation in the nursing assessment indicating the patient was a diabetic. There were no physical assessments by nursing staff after the initial admitting nursing assessment. There was no nutritional screen. There was no dietary consult. There was no indication the patient was provided a "no concentrated sweet" diet.


2. According to the Staff G and Staff C the dietary consults are reviewed by the Dietary Manager to ensure the consult occurs within three days of the order. There is no documentation the dietary department or nursing reviews consults in order to determine if the dietitians recommendations are being followed and implemented.

3. These findings were presented to administration on 11/15/11. No further documentation was provided.

Based on a review of policies and procedures, medical records, and staff interviews, the hospital failed to ensure the menus were meeting the needs of the patients.

Findings:

1. According to the Nutritional Assessment -Department of Nursing policy a brief assessment of each patient's nutritional status will be done as part of the admission nursing assessment. No further nutritional assessment is required if nutritional problems are not identified. The policy does not match the form used to document the nutritional assessment completed by nursing. The policy does not provide the process for staff to follow to initiate a nutritional consult when utilizing the nutritional assessment scoring provided on the form. Some conditions listed on the form do not have scoring provided but are conditions that would contribute to the need for a dietitian's consult. The form does not address how to score these conditions.

Patient #3 was admitted with a history of diabetes, hyperlipidemia, hypertension, status post myocardial infarction, mental disability possible dementia, and increasing agitation. The physician documented Pt #3 was increasingly unable to perform self care and was being assessed for placement in a nursing home. The physician ordered a regular diet without concentrated sweets and no additional salt. The patient's blood sugar on admission was 224. The nursing assessment did not indicate the patient was a diabetic. Scoring on the form did not indicate the need for a dietary consult. The physician did not order a dietary consult throughout the stay. The patient's blood sugars ranged from 300 mg/dcl to 500 mg/dcl and she was placed on a sliding scale as well as oral agents to control her blood sugar. The dietitian was not consulted although the physician documented the patient had "poor glucose control" and increased the patient to a "moderate dose regimen". The patient did not receive a dietary consult because the nursing assessment -nutritional assessment was not completed and the scoring did not reflect the patient condition. The nursing staff did not perform/document a daily physical assessment on the patient. There was no information

Patient #1's medical record included physician orders for dietary consult. Patient #1 had a history of recent weight loss, dysphagia, gastroesophageal reflux disease, prostate cancer, and depression. An order was written for a dietary consult. A dietary consult was completed with recommendations to change the diet and offer health shakes in the afternoon and at bed time. The physician did not address the consult in any of the progress notes or discharge summary. There were no orders written to implement the plan. There was no documentation why the physician did not implement the recommendations. There was no documentation of nursing notifying the attending physician of the dietitian's recommendations. There was no documentation a daily physical assessment was completed by nursing. The patient did not receive additional supplements as recommended.

Patient #17's medical record indicates the 93 year old had a history alzheimer's, gout, seizure disorder, gastrointestinal problems, increasing dementia. The patient received a nutritional consult and supplements were ordered. The order was to provide supplements if the patient did not eat at least a certain percentage of the meal. Multiple instances staff documented the patient's meal intake amounts which should have triggered the staff providing supplements as ordered. No supplements were provided to the patient. There was no documentation why nursing did not provide supplements as ordered.

Patient #16's medical record indicated the 55 year old male was admitted for behavioral disturbances. On admission the patient's blood glucose level was 297, Hemoglobin A1C 11.5 and finger stick blood sugars (FSBS) ranged in 400-500 range. The patient did not have a complete initial nursing assessment. The patient did not receive a dietary consult. There was no documentation by the physician regarding the lack of blood sugar control. There was no documentation the nurses assigned to care for the patient did a complete physical assessment and provided information to the physician which would improve the nutritional status of the patient.

Patient #5's medical record indicates on admission the patient had a history of multiple sclerosis, hypertension, seizure disorder, pressure ulcer, and was becoming increasingly aggressive. The patient was described on admission by the physician as "frail, thin, caucasian man". No dietary consult was ordered on admission. On the nursing assessment the patient was listed as having "no teeth". The nutritional assessment did not include any check marks in the "trouble with chewing or swallowing" information. On the third day of admission a dietary consult was ordered. The dietitian recommended changes to the diet including "Medpass or Resource 2.0 if eats less than 50% of meal. Also, give 4 ounces of Med Pass at 1000, 1500, and at bedtime (HS). The order for MedPass at 1000, 1500, and HS was not started until the next day. On multiple opportunities to provide the 4 ounces of MedPass the patient did not receive the supplement. Later in the stay nursing staff changed the 4ounce MedPass order to PRN (as needed) . There was no order to change to PRN documented in the chart. During the patient stay nursing staff did not offer the supplement if the patient at less than 50% of a meal. There was no documentation why nursing staff did not provide the supplement.



2. According to the Staff G and Staff C the dietary consults are reviewed by the Dietary Manager to ensure the consult occurs within three days of the order. There is no documentation the dietary department or nursing reviews consults in order to determine if the dietitians recommendations are being followed and implemented. There is no documentation by the dietitian or dietary staff (after the initial consult) the patient receives diet as ordered, supplements ordered, or nutritional intake is adequate for conditions identified on the initial nursing assessment.

3. These findings were presented to admninistration on 11/15/11. No further documentation was provided.

Based on review of the hospital's death list, the contract with the OPO (organ procurement organization - LifeShare of Oklahoma), and medical records and interviews with hospital staff, the hospital failed to develop and implement written protocols to ensure all deaths were reported to the OPO. This occurred in two (2) of two (2) patient deaths (Patients #8 and 9) that occurred in the hospital thus far in 2011. The hospital failed to integrate this program in the the quality performance improvement (QAPI) program.

Findings:

1. On the morning of 11/14/2011, the surveyors requested the list of deaths that occurred in the hospital, the hospital's contract with the OPO and the OPO activity reports for 2011. Staff B gave the surveyors the list of the two patients who had died in the hospital. No OPO activity reports were provided. Staff B, on the afternoon of 11/14/2011, told the surveyors that the patient deaths had not been reported to the OPO and the hospital was unaware of the responsibility to report patient deaths to the OPO.

2. Although the hospital had a contract with the OPO that stipulated all deaths/imminent deaths were to be call to the OPO, telephone number included, the hospital failed to develop and implement written policies/protocols to ensure they were reported and to include this as part of the QAPI program.

3. These findings were verified with Staff A and B on the afternoon of 11/2011. They stated that no one checked to ensure all deaths/imminent deaths were called to the OPO and the OPO program/policies were not a part of the QAPI program.

Based on review of hospital documents, personnel files, and medical records, and interviews with hospital staff, the hospital failed to provide respiratory services in accordance with acceptable standards of practice and Licensure requirements.

Findings:

1. The surveyors requested to review the hospital's respiratory policies. None was provided. Staff A and B told the surveyors on 11/14/2011 that the hospital did not have respiratory policies or a respiratory department. (Refer to Tag #1160).

2. The hospital provides respiratory services. Patients use oxygen concentrators, hand held nebulizers and C-PAP (continuous positive airway pressure). This finding was confirmed with Staff A, B, and C on the afternoon of 11/14/2011.

3. The hospital failed to appoint/designate a physician, with knowledge, experience and capabilities to supervise and administer the service properly, to be the director of respiratory care services for the hospital. (Refer to Tag #1153.)

4. The hospital failed to ensure respiratory services were supervised by a respiratory therapist and provided by trained and competent staff. (Refer to Tag #1154).

5. Review of meeting minutes did not demonstrate respiratory services provided at the hospital were integrated and reviewed in the quality assessment and performance improvement and infection control programs.

The hospital's admission exclusionary criteria stipulates patients requiring C-PAP will not be admitted unless medical review was provided. Patient #12 used a C-PAP. The medical record and meeting minutes did not reflect a medical review was conducted for this patient's admission. The patient was transferred to another acute care facility on 09/23/2011 in respiratory distress.

Based on review of hospital documents and medical records, and interviews with hospital staff, the hospital failed to develop an organized respiratory service.

Findings:

1. The surveyors requested to review the hospital's respiratory policies. None was provided. Staff A and B told the surveyors on 11/14/2011 that the hospital did not have respiratory policies or a respiratory department.

2. The hospital provides respiratory services. Patients use oxygen concentrators, hand held nebulizers and C-PAP (continuous positive airway pressure). This finding was confirmed with Staff A, B, and C on the afternoon of 11/14/2011.

Based on review of hospital documents, personnel files, and medical records, and interviews with hospital staff, the hospital failed to appoint/designate a physician, with knowledge, experience and capabilities to supervise and administer the service properly, to be the director of respiratory care services for the hospital.

Findings:

1. Review of the hospital's organizational chart and meeting minutes did not show that a physician had been designated as director for respiratory services On the afternoon of 11/14/2011, Staff A confirmed this finding.

2. The surveyors requested to review the hospital's respiratory policies. None was provided. Staff A and B told the surveyors on 11/14/2011 that the hospital did not have respiratory policies or a respiratory department.

3. Review of patient records and interviews with Staff B, C and D on the 11/14 and 11/15/2011, demonstrated the hospital provided respiratory services of oxygen, C-PAP (continuous positive airway pressure) and hand held nebulizer. (Patient #12 had both oxygen and C-PAP).

Based on review of hospital documents and personnel files and interviews with hospital staff, the hospital failed to ensure respiratory services were supervised and provided by qualified staff.

Findings:

1. The hospital provides respiratory services of oxygen, hand held nebulizers and C-PAP (continuous positive airway pressure). This was finding confirmed with Staff B and C on the afternoon of 11/14/2011.

2. Review of the hospital's organizational chart, contracts and employee list did not show respiratory services. This finding was confirmed with Staff A on the afternoon of 11/14/2011.

3. State Licensure Hospital Standards, Subchapter 23-6(a) requires that "respiratory therapy services, including equipment, shall be supervised by a licensed respiratory therapist. Staff A confirmed on 11/14/2011 that the hospital did not employee a respiratory therapist and did not have a contract with a respiratory therapist to provide supervision and training to staff providing respiratory services.

4. Staff C told the surveyors that nursing personnel provided the hospital's respiratory services, but stated a respiratory therapist had not provided training.

Based on review of hospital documents and interviews with staff, the hospital's medical staff failed to develop and enforce policies for respiratory services.

Findings:

1. The hospital provides respiratory services of oxygen, hand held nebulizers and C-PAP (continuous positive airway pressure). This was finding confirmed with Staff B and C on the afternoon of 11/14/2011.

2. The hospital's medical staff has not defined the scope of respiratory services that will be offered to patients.

3. On 11/14/2011 Staff A and B told the surveyors that respiratory policies had not been developed.
The hospital did not have respiratory policies, including :
a. Scope of services;
b. Equipment assemble, operation, cleaning, and preventive maintenance;
c. Safety practices, including infection control measures for equipment and supplies;
d. Documentation required pre and post treatments, including oxygen saturation, vital signs, lung sounds, and presence with description of any cough or sputum;
e. Procedures to follow in the advent of adverse reactions to treatments or interventions;
f. Aerosol, humidification and therapeutic gas administrations/treatments; and
g. Storage, access, control and administration of medications and medications errors.

Based on review of hospital documents, personnel files and interview with staff, the hospital failed to ensure that respiratory services/procedures were administered by trained staff with each respiratory therapy procedure performed by each employee designated in writing, including the amount of supervision required when performing each procedure. Four of four licensed nursing personnel (Staff C, D, H and I), whose personnel files were reviewed, did not have documented training and competencies.

Findings:

1. The hospital provides respiratory services of oxygen, hand held nebulizers and C-PAP (continuous positive airway pressure). This was finding confirmed with Staff B and C on the afternoon of 11/14/2011.

2. Staff A, B and C told the surveyors that the hospital did not have a respiratory therapist to provide the respiratory services; services were provided by nursing staff.