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Based on record review and interviews with hospital staff, the hospital does not ensure that medical errors involving medication errors and adverse events are investigated and evaluated by clinical staff which include physicians and pharmacists as part of a ongoing Quality Improvement/Performance Improvement program. Hospital meeting minutes reviewed consisting of governing body, medical staff, and pharmacy and therapeutics meeting minutes for 2011 and 2012 stated that the hospital did not have any medication errors or adverse events. Hospital staff B stated on 05/10/12 in the afternoon that any medication errors or adverse events are documented on a incident report and given to staff B. There was no evidence of investigation, evaluation and action taken to identify causes and reduce the errors.

Based on review of policies and procedures and medical records and interviews with hospital staff, the hospital failed to ensure the registered nurse (RN) assessed, planned, supervised and reassessed/evaluated the nursing needs and care for each patient. Care/needs cannot be identified without complete baseline and ongoing assessments and evaluations. In one (Record #6) of four pediatric patient records reviewed, the RN did not perform complete assessments so that care needs could be identified; and the supervising RN did not oversee to ensure nursing care met the needs of the patient.

Findings:

1. Patient #6 presented to the emergency room (ER) on 02/17/2012 at 2140 with an oxygen saturation of 94% on room air. The patient was placed on oxygen while in the ER. The patient was admitted to the inpatient unit at 2340 with a diagnosis of RSV (respiratory synctial virus) pneumonia, pleurisy, and acute dyspnea. Staff K, the licensed practical nurse (LPN), took report from the ER nurse. The physician's admission orders did not contain an order for oxygen. Staff K noted the orders. Staff K performed the initial assessment. The assessment data recorded by Staff K showed the patient's oxygen saturation had again dropped to 94%. The assessment contained a co-signature by the RN on duty, Staff Q, but the record did not show Staff Q performed any assessment of the patient or questioned/voiced concern that Patient #6's saturation level was 94%. The record did not contain any documentation of contact with the physician until 0300 on 02/18/2012 when the patient's oxygen saturation dropped to 90%. The RN did not supervise the care provided to the patient.

2. The supervising RN did not ensure competency of nursing staff to meet the needs of the patients. The hospital admits and treats adult and pediatric patients. Review of Staff K's personnel files did not show competency training for pediatric patients. On the afternoon of 05/10/2012 Staff B, confirmed Staff K had not received pediatric training or age specific competency verification. Staff B stated that he did not think any staff had current pediatric competency training or verification.

Based on personnel record review and staff interview, it was determined the hospital failed to ensure clinical nursing staff were trained, oriented and had demonstrated skills competency for their assigned care areas. Findings:

On 05/09/12, two (AA and DD) of four registered nurses had no documentation of orientation to their job assignments and had no documentation of clinical skills competencies.

Registered Nurse DD was assigned to the ER and had no documentation of specialized training in emergency nursing or pediatrics.

One of one LPN (CC) assigned to work in PACU and in the pre-op area had no documentation of clinical skills competencies in these areas.

One of one nurse aide (Y) had no documentation of clinical skills competencies.

11 of 11 direct care staff files reviewed had no documentation of age-specific competencies.

The DON stated he was not aware documentation of orientation and skills competencies was not being done.

Based on record review and interviews with hospital staff, the hospital does not ensure that the medical record contains information describing the patients condition, progress and responses to treatment.

Findings:

1. Several records reviewed by surveyors did not have complete assessments by nursing personnel and/or did not have initial nursing assessments or post procedure assessments. Several records did not include nursing care provided throughout the perioperative period. There was no documentation of surgical prep, drape, safety equipment, cautery settings with ground pad placement, patient positioning, and time out. There was no documentation of surgical wounds or of the types of dressings applied in surgery. There was no documentation of devices implanted, such as cardiac pacemakers, to include name, type, serial numbers, etc.

There is no documentation of intravenous infusion amounts hung or infused, medication routes, dosage, and persons administering. Several patients did not have documentation of registered nurses assessing them within a twenty four hour period. There were no orders for care in the immediate postoperative (post anesthesia) phase.

2. On 5/9/2012 surveyors reviewed outpatient procedure records. Some of the endoscopy patients had history and physicals documented in the medical record which were not updated prior to surgery. Physician orders were not present for medications, monitoring, and interventions provided throughout the perioperative stay.

3. There was no documentation provided to surveyors indicating the content of medical records was reviewed for completeness and accuracy. There was no documentation medical records were reviewed through the quality process. On 5/10/2012 Staff B told surveyors he did not know if medical records were reviewed for completion.

4. These findings were provided at the exit conference. No further documentation was provided.

Based on a review of medical records and interviews with hospital staff, the hospital failed the ensure the medical records were complete and contained all pertinent information such as complete nursing assessments, reports of treatments, documentation of care provided, medication administration, and vital signs monitoring.

Findings:


1. Five of five surgical/procedure medical records reviewed did not have documentation of the patient's status immediately post operative, during the recovery phase, and at discharge.

Patient #2's medical record indicated a pacemaker implantation was performed. There was no documentation of the patient's care during the preoperative, intraoperative, and immediate postoperative phases. Physician preoperative pacemaker orders in the record indicate the patient was to receive intravenous fluids (IVF) of normal saline (NS) , abx (antibiotics) sixty minutes prior, shave and prep chest. The preoperative orders were not noted. There was no documentation of care preoperatively, intraoperatively and postoperatively. The physician's dictated operative note indicated the patient received medications in the operating room of 500 ml of saline, 50,000 units of Polymixin B, and 50,000 units Bacitracin. There was no documentation by the physician or nursing of the time the medications were administered, the route of administration or who administered the medications. The procedure note also indicates the patient received divided doses of Fentanyl and hydralazine. There is no documentation of route of administration, time of administration, or who administered the medications. There was no documentation of the patient's condition throughout the perioperative phase. There was no documentation where the patient transferred and who had received report.

Pt #1's medical record indicated the patient had gastrointestinal bleeding with anemia. The patient had a endoscopy performed. Procedure documents indicate diprivan, demerol, and versed were given to the patient. There is no route of administration, dosing (milligrams, micrograms, milliliters) and name of the person administering. None of the postoperative orders were noted. There is no documentation in the chart the patient was assessed postoperatively by a registered nurse. At the time of transfer the licensed practical nurse transferred the care of the patient to another licensed practical nurse. There is no documentation a registered nurse assessed the patient until 24 hours after surgery.

Patient # 3's medical record indicated the patient had incision and drainage of abscess two times during hospitalization. There is no nursing documentation stipulating the patient status during the pre, intra, and postoperative phases. There is no documentation a registered nurse assessed or oversaw care of the patient during the perioperative phase. .


2. Five of five surgical/procedure medical records reviewed did not have post anesthesia care orders. There were no orders specific to the immediate postoperative care episode. There was no documentation indicating patients received care during the post-anesthesia phase.

3. Five of five surgical procedure medical records did not include the patient status at the time of discharge. There was no documentation the anesthesia provider or the physician assessed and cleared the patient for discharge. There was no discharge criteria developed, reviewed, approved, and implemented to provide for a safe discharge.

4. Several of the surgical/procedure patients did not have documentation a registered nurse assessed or cared for the patient during the immediate postoperative phase.

5. Several procedure records did not have documentation of the patient's condition at the time of transfer. There was no documentation where the patient transferred.

Based on record review and interviews with hospital staff, the hospital does not ensure the pharmacy drug room is administered in accordance with accepted professional principles. There is no evidence that the consultant pharmacist monitors the activities of the drug room and provides oversight of nonlicensed personnel.

Findings:

1. The hospital has both a licensed drug room and a licensed retail pharmacy within the hospital.

2. The drug room is staffed by two nonlicensed persons, one of which is called the Pharmacy Supervisor. There were no job descriptions, orientation, competencies or inservice training for these pharmacy staff.

3. There was no documentation in pharmacy records to show the pharmacist in charge (PIC) performed oversight to assure effective interventions and audit systems are implemented. See Tag 0494.

Based on review of records and interviews with hospital staff, the hospital does not ensure that current and accurate records are maintained of the receipt and disposition of all scheduled drugs in accordance with Federal and State laws. The drug room does not maintain records of scheduled drugs with sufficient detail to follow their flow from their entry into the hospital through dispensation and administration or wastage in a readily retrievable manner. The hospital does not ensure that the records are in order and all scheduled drugs are maintained and reconciled. Three ( #'s 23, 24, & 25 ) of three patient surgical records reviewed and compared to the Narcotic Administration Record (NAR) did not have doses administered and wasted that matched the intraoperative documentation of scheduled drugs by the Certified Registered Nurse Anesthetist (CRNA).

Findings:

1. Patient #23's intraoperative record documented that 400 micrograms (mcg) of Fentanyl was administered, but the NAR documented 250 mcg was administered.

2. Patient #24's intraoperative record documented Versed 3 milligrams (mg) administered, but the NAR documented 5 mg given. No wastage was documented on the NAR.

3. Patient #25"s intraoperative record had Propofol documented as given, but there was no amount documented just dashes.

4. NAR record 691373 did not document patient dose of Versed administered.

5. The NAR records are not retrieved and reconciled by pharmacy personnel from surgery in a timely manner. Records of drugs used in February 2012 were still in surgery and had not been reconciled by pharmacy personnel.

6. Staff P said that they did not reconcile the narcotic records to determine if the documentation of all drugs administered and wasted were correct. On 05/10/12 in the afternoon., the pharmacist stated that he did not reconcile the narcotic records

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 5/9/2012 surveyors reviewed radiology policies. Policies provided to surveyors indicated some radiology procedures were performed by contract staff. There were no personnel files stipulating these contract staff are licensed and/or registered, competent, oriented, and trained. There was no documentation contract staff had been oriented to the facility.

2. On the morning of 5/9/2012 surveyors were told on occasion non employee contract staff provided magnetic resonance imaging (MRI). There was no information provided to surveyors on the contract staff.

3. On the morning of 5/10/2012 surveyors reviewed two radiology personnel files. There were no current competencies reviewed and approved by the Radiologist and medical staff. There was no intravenous contrast competency as stated in policy. Equipment competencies were reviewed and evaluated by other radiology employees and were not current.

4. The above findings were reviewed with administration in the exit conference. No further documentation was provided.

Based on review of policies, and interviews with staff, the hospital failed to ensure a qualified radiologist supervises the radiology services. On the afternoon of 5/10/12 staff told surveyors the facility did not have a specified radiologist that supervised radiology services. There was no documentation provided a Radiologist oversaw the radiology department. These findings were discussed with administration at the exit conference 5/10/12.

Based on review of policies, personnel files, and interviews with staff the facility failed to designate competent, qualified radiology personnel.

Findings:
1. There were no current policies or documents reviewed and approved by the medical staff and chief radiologist identifying personnel competent to use the radiological equipment and administer procedures.
2. The facility did not have documentation stipulating staff were trained and competent in radiation safety for themselves and patients.
3. Two of two radiology staff (C,S)did not have departmental orientation and training. There were no current competencies reviewed and approved by the Radiologist and medical staff. There was no intravenous contrast competency as stated in policy. Equipment competencies were reviewed and evaluated by other radiology employees and were not current.

4. Contract radiology staff (MRI, Mobile Cardiac Imaging) did not have documentation of licensing, competency, orientation and training .

5. There were no clinical performance evaluations for the contracted staff members.

Based on clinical record review and staff interview, it was determined the facility failed to ensure a dietitian reviewed nutritional assessments and made recommendations for therapeutic diets for eight (#28, 29, 31, 32, 33, 34, 35, and #36) of eight patients who required a nutritional assessment and a therapeutic diet. Findings:

Clinical records for patients #28, 29, 31, 32, 33, 34, 35, and #36 were reviewed for nutritional assessments and consultation by the dietitian.

The hospital dietary manager had performed the nutritional assessments. There was no documentation the clinical dietitian had reviewed the nutritional assessments and made recommendations for therapeutic diets to meet the needs of the patients.

On 05/10/12, the CEO and DON stated they were not aware the dietitian had not been reviewing the nutritional assessments and providing recommendations to the dietary manager.

Based on clinical record review, personnel file review and staff interview, it was determined the hospital failed to ensure dietary staff were trained and had demonstrated skills competencies to perform their duties. Findings:

Clinical records for patients #28, 29, 31, 32, 33, 34, 35, and #36 had documentation the dietary manager had completed nutritional assessments.

The dietary manager's personnel file had no documentation of specialized training to perform nutritional assessments.

There was no documentation of certification as a dietary manager.

The dietary manager had no documentation of skills competencies and job performance evaluations.

One of one dietary aide had no documentation in the personnel file of skills competencies.

Based on review of personnel files and meeting minutes and interviews with hospital staff, the hospital failed to designate/appoint an appropriate infection control professional.

Findings:

1. Staff B told the surveyors on 05/09/2012 that about September 2011, Staff I was the infection control officer.

2. Review of Quality, medical staff and governing body meeting minutes did not reflect Staff I had been designated/appointed as the infection control professional.

3. Review of Staff I's personnel file did not contain evidence that Staff I had been designated an the infection control professional. there was no job description for the infection control professional, no performance evaluation, or documentation of appointment. The information provided did not contain documentation of training and experience on the principals and methods of infection control.

4. Staff B confirmed on 05/10/2012 at 1500 that he did not have any documentation of infection control training for Staff I.

5. The policy, entitled Infection Control Practitioner Duties, did not have an approval or review date listed on the policy. there was no documentation that the Infection Control Practitioner conducted "routine surveillance of hospital infections to determine a baseline of nosocomial infections" and "investigated any infection that exceeds the baseline or is unusual. Review of the infection control log showed that hospital infections were recorded and reviewed for possible nosocomial infections/hospital acquired infections (HAI) by another staff member, Staff J. Staff B told the surveyors that Staff J was the Quality person and not infection control. He stated this person, Staff J, has not attended infection control training.

6. These findings were reviewed with administrative staff during the exit conference on the afternoon of 05/10/2012.

Based on review of infection control data and meeting minutes containing infection control for the past twelve months, and hospital documents, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner developed and maintained a comprehensive system for reporting, analyzing and controlling infections and communicable diseases among patients and staff and ensuring a sanitary environment.

Findings:

1. The hospital's infection control Policy Statement documented, "A detailed, written procedure will be developed, reviewed and updated periodically for each department in this health care facility regarding the risk of infection to patients and personnel." Review of documents provided did not contain evidence the hospital has conducted a hospital-wide risk assessment to identify the types of patients and organisms serviced at the facility. The Infection Control Manual presented to he surveyors for review on the morning of 05/10/2012, contained several documents - Policy Statement, Mission Statement, Program Goals, and Infection Control Committee. None of these documents described what or how often different departments/areas would be monitored.

2. Active surveillance - The document, Infection Control Committee, says the committee will "evaluate, revise as necessary, and approve the type and scope of surveillance activities utilized at least annually." The only surveillance/active monitoring described was the infection control log for possible hospital acquired infections. The document, Mission Statement recorded the Infection Control Program is to provide "an ongoing review and assessment of aseptic, isolation and sanitation techniques."

a. Aseptic techniques - With the exception of monitoring for infections, no monitoring of hospital aseptic techniques occur.
i. The infection control practitioner did not conduct active monitoring/surveillance to ensure adequate and appropriate hand hygiene is carried out throughout the hospital, in all departments. The only evidence of hand hygiene was a policy on handwashing and an inservice handout with signatures, noted in the November 10, 2011 meeting minutes. The hospital does not have a policy on using hand sanitizers - the percentage of alcohol needed to be effective; when appropriate to use; how much to use; and at what frequency hands need to be washed instead of using the sanitizer.
ii. Each department had policies concerning aseptic practices. The infection control practitioner did not conduct active monitoring/surveillance to ensure staff followed aseptic policies and procedures in each department.

b. Isolation techniques and practices - With the exception of the mention in the April 6, 2012 meeting minutes that no order was needed to initiate isolation precautions if warranted and a possibility of changing out the isolation carts in the hall to ones that hung on the door, no active surveillance occurred as to whether the carts were stocked appropriately or if staff followed established policies and practices for the different types of isolation.

c. Maintenance of a clean and sanitary environment -
i. The infection control program has not reviewed the disinfectants used in the hospital to verify they are effective on the different types of organisms that might be present in the hospital. Three different disinfectants were noted as used in the hospital. One product, Sani-Shield, is not registered with the EPA (Environmental Protective Agency). Staff B, L, M or N could not produce written manufacture guidelines or tell the surveyors what organisms the product Triad, used throughout the hospital by housekeeping, was effective against. The third product, Sani-Cloth, is not effective against C-difficile. The hospital provides colonoscope procedures and the most prevalent organism is C-difficile.
ii. The infection control program has not monitored surgical practices to ensure appropriate cleaning and sterilization of instruments and equipment has occurred. Staff L and M stated no one has monitored cleaning and sterilization practices. On the afternoon of 05/10/2012, Staff L stated she did not know much about cleaning and sterilizing the instruments. On the afternoon of 05/10/2012, Staff M reported she did not document checking the sterilizer log or provide any documentation to anyone about sterilization practices. Staff M stated she only ran a Bowie-dick/Dart test on the autoclave once a week. Standard of practice, according to AORN (Association of Operating Room Nurses), APIC (Association of Professionals in Infection Control) and AAMI (Association for the Advancement of Medical Instrumentation) a Bowie-dick or Dart test needs to be completed as the first load of each surgery day to ensure the autoclave is functioning properly.
iii. The chairs in the step-down/Phase II recovery room have cloth seats with noticeable stains. Cloth chairs cannot be sanitized/disinfected between each use.

3. Review of meeting minutes for the past twelve months did not demonstrate the hospital had an ongoing infection control program that reviewed and analyzed infection control practices and concerns throughout the hospital with corrective action taken when indicated and follow-up to ensure the action taken was effective. The meeting minutes did not reflect an ongoing active monitoring for compliance with all policies , procedures, protocols and other infection control program requirements, including reviewing for possible transmission of infections and illness between patients and staff.

4. Nine of 15 employee health files reviewed had no documentation of annual TB skin testing or a TB symptom questionnaire, if the employee had a previously positive TB skin test.

5. These findings were reviewed with administrative staff during the exit conference on the afternoon on 05/10/2012.

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 and integrate this program in the the quality performance improvement (QAPI) program. Seven (Patients #14, 15, 16, 17, 19, 21, and 22) of fifty-nine patient deaths in 2011, five of which occurred in the emergency room, were not reported to the OPO.

Findings:

1. Upon arrival at the hospital on 05/09/2012 at 0930, the surveyors requested the list of items, including the activity report from the OPO. The information provided on 05/10/2012 and had documentation that it was received at the hospital on 05/06/2012. This was confirmed with Staff B at the time.

2. On the afternoon of 05/10/2012, Staff B told the surveyors that OPO activity was not reported through quality and no one checked to ensure all deaths were reported as required.

Based on clinical record review, review of policy and procedure, and staff interview, it was determined the hospital failed to ensure surgical services were provided according to acceptable standards of practice. Findings:

1. The hospital did not have current and comprehensive policies and procedures to govern and guide preoperative, intraoperative and postoperative patient care and services. See Tag 0951.

2. The hospital did not have adequate supervision of the preoperative, intraoperative and postoperative care areas by an experienced and adequately trained registered nurse. See Tag 0942.

3. The hospital did not have documentation all perioperative staff were trained and oriented in their service areas and had demonstrated skills competencies to perform their job duties.

Personnel files for the preoperative nurses, PACU nurses, surgical technologist, sterile processing technician and OR aide had no documentation of orientation to their service areas, no evidence of specialized training relevant to their current job duties, no documentation of skills competencies and no evidence of periodic performance evaluations.

There was no documentation any of the surgery personnel who performed sterile processing of surgical instruments and equipment had specialized training to do so.

Based on record review and staff interview, it was determined the hospital failed to ensure surgical services were supervised by an experienced registered nurse.

On 05/10/12, the operating room supervisor was asked about her surgical nursing training and experience. She stated she had worked as an "occasional" circulating nurse for the past year. She stated she learned circulating "on the job" and got most of her information about the OR from the surgery policy and procedure manual.

She stated she believed the policy and procedure manual was outdated, but it was the only hospital reference material available.

She stated she had no formal training or orientation as a circulator.

She was asked how long she had been the OR supervisor. She stated she had been acting as the OR supervisor for a month. She stated she had no experience or training as an OR supervisor.

There was no documentation of OR orientation, specialized training or skills competency in the OR supervisor's personnel file.

Based on record review and staff interview, it was determined the hospital failed to update and fully develop the surgery department policies and procedures to reflect current standards of practice. Findings:

On 05/09/12, the hospital's surgery policies and procedures were reviewed. The following deficiencies were noted:

1. There was no policy that addressed pre-operative protocols and practices including pre-operative comprehensive nursing assessment, antibiotic usage, prevention of venous stasis and surgical site identification.

2. A policy addressing informed consent was outdated and did not reflect current facility practices and requirements.

3. All surgical procedures performed in the OR did not have corresponding policies and procedures, such as pacemaker insertion and laparoscopic surgeries.

4. There were no updated OR safety policies that addressed:

a. safe patient handling, movement, positioning and pressure point padding

b. use of the electrocautery device and grounding pad placement

c. hazard identification and emergency procedures in the operating room

d. prevention of hypothermia and

e. surgical fire prevention.

5. There was no policy that addressed implantable devices and the protocols associated with them.

6. There were no policies that addressed perioperative department orientation for preoperative nurses, CRNAs, OR nurses, PACU nurses, surgical technologists, sterile processing technicians and OR aides.

7. There were no policies addressing current job descriptions and skills competencies for all perioperative staff.

8. There were no policies that addressed current surgical skin preparation practices.

9. There was no policy that addressed current standards of practice for perioperative nursing documentation.

10. There were no policies addressing handling, care and processing of surgical specimens.

The DON and the OR manager stated they were aware the surgery policies, procedures and protocols were outdated and incomplete.

Based on review of medical records, hospital documents, and personnel interviews the facility failed to provide immediate postoperative care according to acceptable standards of practice.

Findings:

1. There are no policies and procedures written, reviewed, approved, and implemented governing the care provided during the use of anesthesia and recovery room phase.

2. Five of five (1,2, 3, 30, 37) surgical/procedure medical records reviewed did not have documentation of the patient's status immediately post operative, during the recovery phase, and at discharge.

3. Five of five (1,2,3,30,37) surgical/procedure medical records reviewed did not have post anesthesia care orders. There were no orders specific to the immediate postoperative care episode. Documentation indicated patients received oxygen, medications, and frequent monitoring of vital signs. The orders did not reflect the type of care provided to the post surgical patients.

4. Five of five (1,2,3,30,37) surgical procedure medical records did not include the patient status at the time of discharge. There was no documentation the anesthesia provider or the physician assessed and cleared the patient for discharge. There was no discharge criteria developed, reviewed, approved, and implemented to provide for a safe discharge.

5. Several of the surgical/procedure patients did not have documentation a registered nurse assessed or cared for the patient during the immediate postoperative phase.

6. These findings were reviewed with the administration on 5/10/2012. No further documentation was provided.

Based on review of clinical records and personnel files and interview with staff, it was determined the hospital failed to ensure occupational therapy staff were credentialed and qualified to provide occupational therapy services. Findings:

Patient #26 was admitted to the hospital on 04/12/12 with orders for occupational therapy. The clinical record documented the patient received occupational therapy services provided by staff "R".

The hospital was asked to provide evidence staff "R", an occupational therapist, was credentialed and qualified to provide occupational therapy.

On 05/10/12, the CEO stated the hospital had not credentialed the occupational therapist and there was no documentation of competency to provide occupational therapy services.

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

Personnel files for 15 staff and/or contract employees were reviewed. Nine of 15 employee records had no documentation of criminal background checks.

Ten of ten employees who required a state nurse aide registry check had no documentation this had been done before the employees were hired.

On 05/10/12 the CEO stated she was not aware criminal background checks had not been done for all staff and was not aware of the requirement to check the nurse aide registry.