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At the time of the revisit this deficiency had not been corrected.

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.

Findings:

1. Hospital meeting minutes reviewed consisting of governing body, medical staff, and pharmacy and therapeutics meeting minutes in May and June of 2012 did not include any analysis and corrective action taken on medication errors or omissions. Documents provided to surveyors on the morning of June 25, 2012 included narcotic reconciliation errors. There was no information indicating what type of errors. A "y" was placed in a column on the document if the event had been reconciled. There was no analysis of what occurred and steps taken to investigate and analyze the incident. There was no documentation staff involved were aware of the incidents. There was no evidence of investigation, evaluation and action taken to identify causes and reduce the errors. There was no documentation this information was provided to Quality Assurance Committee, Medical Staff, or Governing Body.

2. Documents provided to surveyors did not include any type of education, training, or inservicing on medication errors or medication variances. There was no documentation since the initial survey indicating staff had been trained to identify medication errors and report them.


3. In an interview with Staff G on the afternoon of 6/25/2012 these findings were verified.

Based on record review and interviews with hospital staff, the hospital does not ensure that quality indicators tracked as part of the hospital's QAPI program identify opportunities for improvement and changes that will lead to improvement. Minutes from QAPI meetings, Pharmacy and Therapeutics, Infection Control did not include analysis and actions to be taken to improve performance. This finding was verified with Staff G on the afternoon of 6/25/2012.

At the time of the follow-up survey on 06/25/12, this deficiency had not been corrected.

Based on a review of personnel files, the hospital failed to ensure clinical nursing staff were trained, oriented and had demonstrated skills competency for their assigned care areas for four (Staff A, B, C and D) of four nursing staff records reviewed. Findings:

Staff A, B and C had no documentation of orientation to their assigned areas and had no documentation of skill competencies. There was no documentation of age-specific competencies for their assigned patient care areas.

Staff D had no documentation of orientation to all areas assigned to manage, including pre-op, intraoperative, post anesthesia care and sterile processing areas. There was no documentation of skill competencies (including age-specific competencies as applicable) in these areas.

The findings were presented an an exit conference with the CNO and the CEO. No other information was provided to the surveyors.

At the time of the revisit this deficiency had not been corrected.

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 history and physical prior to procedures, reports of treatments, documentation of care provided, medication administration, and vital signs monitoring.

Findings:


1. One of two surgical/procedure medical records reviewed did not have documentation of a current history and physical on the chart prior to the procedure.

2. Two of two surgical/procedure medical records reviewed had incomplete physician orders. None of the orders written by the physician(s) were dated and timed. On patient #1 orders for medications were written: Versed 2.5, Demerol 25, Propofol 20. There was no specified unit of measure (milliliters, milligrams, liters). There was no route of administration included in the orders. Orders for fluids did not have the amount of fluid to be hung or the amount of diluent fluid to be used to mix antibiotics. This finding was verified on the afternoon of 6/25/2012 with Staff G.

Patient #2 did not have dates and times on physician orders. There was no history and physical documented on the chart prior to the procedure. The physician's orders stipulated "see MAR (medication administration record) for orders". There were no orders written for the medications administered. The physician discharge orders did not include a date and time. There were no orders for the amount of fluids to be hung or the amount of diluent fluid to be used to mix antibiotics. This finding was verified on the afternoon of 6/25/2012 with Staff G.

3. The organ procurement log indicated Patient #3 had expired and the information had been called to the agency. Patient #3's medical record indicated the patient had transferred to another facility. The dictated discharge summary indicated the patient was transferred. There was no documentation the patient expired.

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

At the time of the revisit June 25, 2012 this deficiency had not been corrected.

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

Findings:
1. Contract radiology staff (MRI, Mobile Cardiac Imaging) did not have documentation of hospital radiology department orientation and skills competencies specific to the facility. Documents provided to surveyors on 6/25/12 indicate competency evaluations were performed by the contracted services supervisor and did not include the facilities infection control practices, emergency procedure practices specific to the facility, etc.

Documents provided to surveyors on the morning of 6/25/2012 indicated a contrast reaction occurred in the contract magnetic resonance imaging (MRI) suite. Documentation of the event stipulated the technologist telephoned for assistance. Another document indicated a contrast reaction occurred while a staff technologist injected contrast for computed tomography (CT). Documentation by the staff technologist indicated the patient was removed from the CT and taken to the emergency room. Review of both documents does not indicate either incident was analyzed and evaluated to ensure the incidents were handled to ensure prompt, safe care. The contrast reaction policy does not stipulate steps to be taken by the technologist to ensure the patient's are treated timely and safely. The policy indicates emergency medications are available in the radiology areas. There is no information in the policy indicating who can utilize the emergency medications. There is no documentation in any radiology personnel files indicating staff and contractors have been evaluated and are competent in caring for patient's during a contrast reaction.

2. There were no clinical performance evaluations specific to the facility for the contracted staff members.

At the time of a follow-up survey on 06/25/12, this deficiency had not been corrected. Findings:

A review of documents provided by hospital administration indicated the contract clinical dietitian had not provided evidence of:

~ dietary counseling for patients and caregivers
~ performance of nutritional assessments and evaluation of patient response to therapeutic diets
~ oversight and evaluation of kitchen sanitation and safe food handling practices
~ training and evaluation of the dietary manager to provide nutritional assessments and
~ development of quality assurance reports regarding nutrition and dietary services provided by the department.

The administrator and the chief nursing officer were made aware of the findings.

At the time of a follow-up survey conducted on 06/25/12, this deficiency had not been corrected. Findings:

The dietary manager's personnel file had no documentation of specialized training to perform nutritional assessments. There was no documentation of skills competencies to perform nutritional assessments as deemed by the clinical dietitian.

There was no documentation of job performance evaluations.

Based on review of personnel files and meeting minutes and interviews with hospital staff, the hospital failed to provide a qualified, trained individual to implement the infection control program.

Findings:

1. On 6/25/2012 surveyors were told Staff F was the infection control practitioner. Review of Staff F's personnel file did not contain evidence that Staff F had training or experience in infection control. The information provided did not contain documentation of training and experience on the principals and methods of infection control. Staff H told surveyors in an interview Staff F had been signed up as a member of APIC. There was no evidence Staff F had enrolled in any infection control education through APIC or any other entity.

2. Review of meeting minutes indicated the hospital had contracted with another facility to provide oversight of the infection control practitioner. There was no documentation provided at the time of survey indicating there had been any oversight or training provided to the infection control practitioner or hospital staff since the initial recertification survey. There was no evidence the contract individual had current certification in infection control. There was no evidence the facility verified the contracted infection control practitioner was qualified, trained, and competent to provide oversight of the hospital's infection control practitioner. There was no evidence the contracted practitioner had assisted the appointed infection control practitioner in developing appropriate policies, procedures, and surveillance methods specific to the facility.

3. These findings were reviewed with administrative staff during the exit conference on the afternoon of 6/25/2012.

Based on review of infection control data and meeting minutes containing infection control since the initial survey, 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. Infection control meeting minutes since the initial survey indicated the hospital had reviewed environmental cultures. No documentation provided to surveyors indicated the hospital monitored hand hygiene or surveilled for compliance. Hand hygiene information documented in the Infection control meeting minutes stipulated the facility would move away from the use of "anti-microbial soap to plain soap". There was no evidence the facility reviewed the current recommendations on hand hygiene from the Center's for Disease Control (CDC) or had used a nationally recognized infection control entity to determine changes to hand hygiene products or protocols.

2. Meeting minutes did not reflect the facility had completed an infection control risk assessment. This finding was confirmed with Staff G and H on the afternoon of 6/25/2012.

3. Meeting minutes indicated the facility had completed environmental cultures. In an interview with staff H on the afternoon of 6/25/2012 surveyors asked why environmental cultures were performed and if there had been an problem identified through surveillance. Staff B told surveyors there had been no problems but environmental cultures were performed to see if cleaning techniques were thorough. There was no documentation the facility observed staff cleaning and ensuring cleaners were utilized per manufacturers guidelines.

4. Meeting minutes did not reflect the infection control practitioner or the designee monitored surgical services aseptic techniques, surgical scrub, or cleaning/sterilization practices.

5. Review of meeting minutes since the initial recertification survey 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.

6. These findings were reviewed with administrative staff during the exit conference on the afternoon on 6/25/2012.

At the time of a follow-up survey conducted on 06/25/12, this deficiency remained.

The Director of Surgery had no documentation of orientation and skills competencies to all areas supervised including pre-operative, intraoperative, post anesthesia care and sterile processing.

There was no evidence of completion of any formalized continuing education in any of the peri-operative areas.

There was no evidence of collaboration with a mentor in surgical services.

At the time of a follow-up survey conducted on 06/25/12, this deficiency remained.

The personnel file for Staff E (a contract physical therapist), had no evidence of orientation and skills competencies for the physical therapy department. There was no job description found in the record.