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Based on review of hospital policy, meeting minutes, and interviews with personnel. The hospital failed to correctly identify grievances. The hospital does not ensure all grievances are reviewed by the Governing Body or a Committee appointed by the Governing body. There is no documentation the hospital ensures grievance data is used to improve patient care.

Findings:

1. On 7/30/2012 surveyors reviewed the facility grievance policy. The policy does not correctly define a grievance with all the required elements. There is no formalized process where all grievances are reviewed through the governing body or a committee appointed by the governing body.

2. On 7/30/2012 surveyors reviewed four grievances (#23,24,25,26). Two grievances did not have letters (24, 26) Two grievances included letters (23,25). Both letters did not include steps taken to investigate the grievance and steps taken on behalf of the patient. There was no documentation any of the grievances were investigated for all of the allegations.

3. On 7/31/12 surveyors reviewed incident report logs from 2011-2012. Incident reports included documentation patient #27 complained about care to a staff member. The incident report included statements from the patient such as "I just can't trust her ability"; "I'm a fraid to go to sleep with her caring form me". There was no documentation this complaint was handled as a grievance.

4. The hospital does not ensure grievance data is incorporated in the hospital's Quality Assessment and Performance Improvement (QAPI) Program with analysis of the data and implementation of processes to improve patient care:
There was no evidence that grievance and complaint data was reviewed, trended and analyzed with implementation of corrective and/or process changes to improve patient care.

5. There was no evidence the Governing Body reviewed, trended, and analyzed incident, grievance, and complaint data.

6. This information was provided to administration at the exit conference. No further information was provided.

Based on review of records and interviews with staff, the hospital does not ensure that all patient grievances are reviewed, resolved, and a written response sent in the hospital's grievance process. Five of five (23,24,25,26,27) grievances/ complaints reviewed met the definition of a grievance but did not have all required documentation or elements.

Findings:

1. Grievances #24 and 26 (which required investigation and follow up) did not have evidence of a letter being sent to the complainant.

2. Grievance #23 was listed and investigated as a grievance. A response letter was sent. The letter did not stipulate what was done on behalf of the patient to resolve the grievance and the steps taken to investigate the grievance.

4. Grievance #25 was submitted by a relative of a patient. The grievance detailed multiple issues with patient care, delay in transfer, and unresponsive staff. There was a letter sent to the complainant indicating the facility had failed to "meet expectation". There was no documentation the facility was investigating the allegations and would follow up with the complainant.

5. Patient #27 complained to staff about a nurse caring for the patient. The patient told staff she was afraid to got to sleep if the nurse cared for her. Patient #27 stated she did not believe the nurse was capable of caring for her. No grievance or complaint process was initiated. The incident required investigation and staff being removed from the care of the patient.

6. On 7/31/2012 surveyors reviewed facility staff training on patient rights, grievances, and complaints. The documentation did not include a definition of complaints or grievances with all the required elements. There was no review of the facility grievance process.

7. On 8/1/2012 the above findings were shared with administration. There was no further documentation.

Based on review of the hospital's grievance/complaint policy, grievance log and four grievances and interviews with hospital staff, the hospital failed to develop a policy with all the required elements, provide a timely written notice to the complainant with the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This occurred for four of four grievances and one incident. These findings were reviewed on the afternoon of 08/01/2012 with administration. No further information was provided.

Based on record review and interviews with hospital staff, the hospital does not ensure that patients receive care in a safe setting. The hospital failed to review, analyze, and trend incidents, grievances, and complaints in order to develop plans to improve patient safety and clinical performance.

Findings:

1. Review of Quality Assurance and Performance Improvement Committee Meeting minutes for 2011/ 2012, Governing Body Meeting Minutes, and Medical Staff Meeting Minutes did not include analysis of incidents, grievances, and complaints to identify patterns which might impair patient safety. There was no analysis to develop plans of correction to improve patient safety.

2. Review of Pharmacy and Therapeutics meeting minutes indicated there were no adverse medication events for 2011/2012. Review of risk management information indicated there were multiple medication incidents during this period of time. None of the errors were analyzed for trends or patterns. None of the medication incidents were reviewed by the pharmacist.

3. Surveyors reviewed personnel files on 8/1/2012. There was no documentation the employees were educated on the current grievance policy/process. There was no documentation the employees were educated on incident reporting and medication error reporting.

4. This finding was discussed at the exit conference. No further documentation was provided.

Based on review of Governing Body, Medical Staff and Quality Assessment/Performance Improvement meeting minutes and incident reports for 2011 and 2012 , the hospital does not ensure that medication errors identified are analyzed and opportunities for the reduction of the errors are evaluated and a plan of action initiated. Incident reports are initiated documenting medication errors, but there is no evidence in meeting minutes that they are analyzed to determine causes and implement actions to reduce their occurrence.

Based on review of medical records, interviews with staff, and review of policy the facility failed to ensure medical orders were dated, timed, and authenticated by a practitioner authorized to write orders for care.

1. Durng the review of electronic medical records surveyors found orders for medications and treatments where the ordering practitioner was identified with an identification number (ID). The hospital did not have documentation stipulating the identification numbers had been assigned to each pracitioner. The hospital could not provide documentation of the numbers assigned to each practitioners..

2. At the time of the review of electronic medical records surveyors were told some of the documents were scanned. Multiple records had scanned physician order sheets. These sheets included verbal orders. The verbal orders did not include pracitioner signature for authentication. There was no processes established for scanned documents to be reviewed and authenticated by the ordering pracitioner.

3. There were no policies and procedures reviewed, approved, and implemented stipulating authentication of orders through the electronic medical record system. There were no policies and procedures indicating what documents would be scanned and how verbal orders would authenticated by the ordering practitioner.

4. The above findings were reviewed with administration at the time of the exit. No further documentation was provided.

Based on record review and interviews with hospital staff, the hospital does not ensure medical records services are provided in a organized and structured manner. The facility failed to maintain a medical record for every patient evaluated or treated in the hospital.

Findings:
1. On July 30, 2012 surveyors accessed patient records through the facilities electronic medical record. During the review several problems were noted. Surveyors then requested a paper copy of a medical record. Similar problems occurred when reviewing the paper copy record. For example:

2. Documentation of patient care did not flow chronologically. Surveyors were not able to determine responses to medication and treatments. Patient #14 had orders for a patient controlled analgesia (PCA) pump. There was no documentation of the amount of medication the patient received throughout the entire stay There was no documentation on several days the total intravenous fluids the patient received

3. Surveyors were unable to find physical therapy, recreational therapy, and respiratory therapy treatments and responses when ordered on patients.

4. Documentation of intravenous fluid totals did not always flow from into the intake and output graph. Several medical records did not have the amount of intravenous fluids infused. This finding was verified with Staff C.

5. Some patient's had orders in their records where the ordering practitioner was identified with an identification number (ID). The hospital could not provide documentation who the ordering practitioner was.

6. All of the records reviewed included areas where patient information populated inappropriately for example:

Patient #17's record, a 25 year old male admitted for surgery, included a partial nursing assessment in the "maternal child section." The record indicated an order for PCA pump. There was no documentation of two registered nurses on initiation/discontinuation of the PCA as required by hospital policy. There was no documentation indicating the amount of medication the patient received per shift and responses to treatment.

Patient #14' s record, a 76 year old male admitted for surgery, included a partial nursing assessment in the "maternal child section. Several verbal orders did not have authentication by the ordering practitioner. The record indicated an order for PCA pump. There was no documentation of two registered nurses on initiation/discontinuation of the PCA as required by hospital policy. There was no documentation of pain assessment.

Patient #16's record , admitted for cholecystitis and removal of gallbladder, did not include a discharge summary. There was no documentation of intravenous fluids administered on the first day postoperatively.

Patient #18's record, admitted for a patella fracture and open reduction internal fixation did not include a history and physical prior to surgery. Orders included physical therapy. Physical therapy documentation was not found in the record.

Patient#18's record, a male patient admitted for gallbladder removal surgery, included nursing assessments found only under the "maternal care" report file. The record included Staff ID's and Generic ID's of providers that could not be identified.

7. On 7/31/2012 Surveyor requested a paper medical record for review. The paper copy did not have any chronologic order. Treatments were not documented in components of the record labeled for the documentation. A category entitled "Respiratory therapy" included pain assessments performed by registered nurses. The respiratory treatment documentation was not found. Responses to medications and treatments could not be found. Categories of caregivers which did not exist at the hospital displayed on the paper chart. Intravenous fluid total volume infused was not recorded. Some orders for medications and treatments did not print. Staff assisting the surveyors stated there had been problems with the electronic system and the care giving personnel worked through them when the problems were found.


8. On August 1, 2012 surveyors requested Medical Records policy and procedure. Staff B told surveyors there were no policies and procedures which included electronic medical records. There were no policies and procedures developed, reviewed, approved and implemented stipulating all required elements for inpatient and outpatient medical records. There were no policies and procedures developed, reviewed, approved and implemented indicating how to access a complete medical record for inpatients and outpatients. There were no policies indicating what documents comprised a complete outpatient record or a complete inpatient record. There were no policies on documentation standards including processes used to document in the electronic record. There were no policies indicating integration of paper medical records into the electronic medical record. The policy and procedures did not reflect the current medical records practice. There were no policies addressing use of the electronic documentation system and how the clinicians accessed particular documents.

9. On 7/30 and 7/31/2012 surveyors reviewed Quality Council, Governing Body, and Medical Staff Meeting minutes. There was no documentation indicating medical records were reviewed and assessed for accuracy and completion.

10. There was no documentation indicating the Governing Body or Quality Council were aware of problems with the implementation of electronic medical record system.

Based on interviews with staff, review of medical records and review of policy and procedure the facility failed to implement a medical records system which allows timely access to pertinent patient information.

Findings:

1. On 7/30/2012 surveyors requested access to electronic records. During the reviews the surveyors encountered multiple difficulties assessing the content of the record for completeness and accuracy. Surveyors repeatedly reviewed nursing assessments in categories that did not match the patient's condition. For example the record of a 25 year old male admitted for abdominal surgery included nursing assessments in a category "maternal/child" assessment. This occurred in all medical records, male and female. Surveyors were unable to determine responses to treatments and medications. Surveyor requested a paper medical record for review. The paper copy did not have any chronologic order. Treatments were not documented in components of the record labeled for the documentation. A category entitled "Respiratory therapy" included pain assessments performed by registered nurses. The respiratory treatment documentation was not found. Responses to medications and treatments could not be found. Categories of caregivers which did not exist at the hospital displayed on the paper chart. Intravenous fluid total volume infused was not recorded. Some orders for medications and treatments did not print. Staff assisting the surveyors stated there had been problems with the electronic system and the care giving personnel worked through them when the problems were found.

2. On 7/30/2012 surveyors were told medical records are electronic and paper. There are no processes reviewed, approved, and implemented integrating the hard copy documents into the electronic documentation. There are no policies and procedures regarding the electronic medical record . This finding was verified with Staff B on 8/1/2012.

3. There are no policies and procedures stipulating when a chart is considered complete in the electronic medical record. Multiple charts reviewed electronically and hard copy were not complete or accurate. There was no documentation medical records were reviewed for timely completion and accuracy.

4. On 7/31/2012 surveyors were told problems with the system and documentation are identified during use of the system and not prior to go live. Staff C told surveyors the "super user" for the facility had recently been hired into a corporate position. Staff C told surveyors personnel at the facility had become more proficient using the system. There was no documentation the facility had appropriate support for the information technology problems occurring.

5. On 7/30 and 7/31/2012 surveyors reviewed Quality Council, Governing Body, and Medical Staff Meeting minutes. There was no documentation medical records were reviewed and assessed for accuracy and completion. There was no documentation the problems identified during implementation continuing through the survey had been formally identified and addressed through Governing Body, Medical Staff, or Quality Council.

Based on interviews with staff, review of medical records and review of policy and procedure the facility failed to implement a medical records system which allows timely access to accurate and complete patient information.

Findings:

1. On 7/30/12 surveyors requested access to electronic records. During the reviews the surveyors encountered multiple difficulties finding treatments, responses to treatments, orders for care performed, vital sign monitoring, nursing assessments, nursing narrative, physical therapy, recreation therapy documentation. These findings were confirmed with staff on 8/1/2012.

2. On 7/30/12 surveyors were told medical records are electronic and paper. Staff told surveyors there were no policies and procedures for electronic documentation. Policies and procedures for medical records services do not stipulate what documents are electronic and what documents are paper to be scanned. There are no processes reviewed, approved, and implemented integrating the hard copy documents into the electronic documentation. There are no policies and procedures reviewed, approved and implemented stipulating use of and documenting in the electronic medical record.

3. There are no policies and procedures stipulating when a chart is considered complete in the electronic medical record. Multiple charts reviewed electronically and hard copy were not complete. There was no documentation medical records were reviewed for completion and accuracy.

4. During a record review surveyors found orders placed under a staff ID which had only numbers. There was no documentation indicating what person was utilizing this identification number. The hospital could not verify the originator of the order.

5. Surveyors also found entries made in the chart which included names but no professional titles. There was no information in the chart to determine if the appropriate level practitioner was ordering.

6. Patient #8, admission 06/19-22/2012 - The physician's admission orders included an order for PT and OT evaluation. Treatment was not provided as ordered.
a. The record did not contain evidence an OT evaluation had been completed. This was confirmed with Staff B and C on 07/31/2012 and with the corporate computer staff on 08/01/2012.
b. A PT evaluation was performed on 09/19/2012 at 0920. In the evaluation, the PT documented plan to visit the patient daily for one week. in addition to the evaluation, PT saw the patient: 06/19/2012 at 1327; 06/20/2012 at 1030 and 1626; 06/21/2012 at 1040 and 1533; and 06/22/2012 at 0909. The medical record did not contain additional orders for PT and the PT plan was not signed by the physician. This finding was confirmed with Staff B and C on 07/31/2012 and with the corporate computer staff on 08/01/2012.

7. Patient #9, admission 05/18-24/2012 - PT treatment was not provided as ordered. The physician's order on 05/22/2012 ordered PT to treat the patient daily for generalized weakness. PT provided treatments twice a day on 05/22 and 23/2012. This finding was confirmed with Staff B and C on 07/31/2012 and with the corporate computer staff on 08/01/2012.

Based on review of medical records and interviews with staff the hospital failed to ensure unauthorized individuals had access to electronic medical records.

Findings:

1. Some patient's had orders in their records where the ordering practitioner was identified with an identification number (ID). The hospital could not provide documentation who the ordering practitioner was. The facility could not identify the practitioner who had access to the chart and entered orders.


2. On 8/1/2012 the Staff B told surveyors the facility did not have policies and procedures stipulating documentation and use of the electronic medical record. There was no process or policy indicating what practitioners had permission to document in different areas of the medical record. There was no policy and procedure indicating what personnel could enter physician orders and how and when orders were verified by the ordering practitioner.

3. Review of Governing Body Meeting Minutes 2011-2012, Quality Meeting Minutes 2011 2012 did not include documentation Medical Records policies and procedures had been revised, reviewed, and implemented to insure records were accessed only by practitioners caring for the patient.

Based on clinical record review, policy and procedure review and staff interview, the hospital failed to ensure the clinical record documentation adequately reflected the care and services provided to the patients.

Findings:


1. Patient #17's record (a 25 year old male hospitalized for abdominal surgery) partial nursing assessment was found in a category titled "maternal/child". Also in a category entitled "respiratory" nursing documentation included pain levels and registered nursing documentation but did not include respiratory therapy documentation. No respiratory orders were indicated for the patient.

2. Patient #14' s record, a 76 year old male admitted for surgery, included a partial nursing assessment in the "maternal child section. The patient had orders for a patient controlled analgesia (PCA) pump. There was no documentation of the amount of medication the patient received throughout the entire stay. There was no documentation on several days the total intravenous fluids the patient received. Also in a category entitled "respiratory" nursing documentation included pain levels and registered nursing documentation but did not include respiratory therapy documentation. No respiratory orders were indicated for the patient.


3. Swingbed Patients #8 and 9 did not have comprehensive activity assessments documenting the patients interests and physical, mental and psychosocial needs. This was confirmed with Staff B on 07/31/2012 at 1515 and with Staff J and the corporate computer staff at the time of their chart review on 08/01/2012 through another computer view (Portal).

4. Patient #8, swingbed admission 06/19 through 22/2012, and Patient #9, swingbed admission 05/18 through 24/2012 - The electronic medical record, through the view supplied for the surveyors to utilize (HPF), did not contain evidence activities were provided to the swingbed patients. This finding was confirmed with Staff B on 07/31/2012 at 1515.

a. On 08/01/2012, the corporate computer staff only found activity entry for Patient #8 for 06/20/2012 at 1325. The entry documented the patient refused puzzles and stated they "just" wanted to read.

b. On 08/01/2012, the corporate computer staff only found activity entries for Patient #9 for 05/21/2012 at 1324 and 05/23/12. Both times the patient refused offered activities.

5. Some patient's had orders in their records where the ordering practitioner was identified with an identification number (ID). The hospital could not provide documentation who the ordering practitioner was.

6. Patient record's 14, 15, 16, 17, 18, 19, 21 included a caregiver category entitled "ortho tech". Staff B and C told surveyors the facility did not have "ortho tech" employees. Within the "orthotech" fields care information was documented such as "call light within reach".

7. Patient's receiving fluids intravenously did not have documentation of the amount of fluids received. Staff C told surveyors the electronic documentation component would not input the amount hung or the amount delivered unless the caregiver scanned the intravenous fluid prior to administering the fluid to the patient.

8. Patient's 14, 17, and 18 had orders for patient controlled analgesia (PCA). There was no documentation reflecting how much medication the patient received during the shift and the responses to the pain medication. There was no documentation the PCA pump was checked by two registered nurses during set up or breakdown. There was no documentation of wastage.

Based on review of medical records, interviews with staff, review of meeting minutes, and hospital documents the facility failed to provide a medical record containing all the required elements.

Findings:

1. On 7/31/12 surveyors reviewed three procedure charts. Three of three medical records reviewed for vital sign documentation in the post anesthesia phase did not have documentation of vital signs as ordered by the anesthesia provider, post procedure. This finding was reviewed with Staff C. Staff C indicated the graphics containing vital signs did not always populate in the patient record. .

2. Several medical records reviewed included orders for intake and output. None of the records reviewed consistently included intravenous fluid administration totals. On 7/31/12 Staff C told surveyors if the fluids were hung without scanning them into the electronic system the fluid administered would not be included in the total amount of fluids infused. Staff C said the facility was working on correcting this problem. .

3. Patients # 14, 17 & 30's records did not have documentation of two signatures one being a Registered Nurse (RN)as required by the hospital's policies when initiating and resetting the PCA pump.

4. Patients # 14, 17 & 30's records did not document the pump setting, reservoir volume, drug concentration, continuous rate, doses given and doses attempted every shift as required by the hospital's policies for PCA.

5. Patients # 14, 17 & 30's records did not document the remaining reservoirs remaining after the PCA was discontinued and disposed of by the nursing staff.

6. The narcotic administration record (NAR) for the Morphine PCA for Patient #30 did not document time each PCA was initiated or any wastage. The NAR which was for May 2012 was not immediately available for surveyor review.

7. Three of three surgical procedure patients #14, 17, 19, 20 included nursing assessments populating in a category labeled as maternal/child assessment. Pt's #14, 17, and 20 were all male patients who had surgical procedures.

8. There was no documentation provided to surveyors that medical records were reviewed for accuracy and completion.

9. The above findings were reviewed at the exit conference 8/1/2012. No further documentation was provided.

Based on record review and interviews with hospital staff, the hospital does not ensure that scheduled drugs are tracked from point of entry into the hospital to the point of departure either through administration to the patient, destruction or return to the manaufacturer. Physician Controlled Analgesia (PCA) administered to patients is not tracked as required by Federal and State law and the hospital's policies and procedures. Three (#'s 14, 17 & 30)of three patient records reviewed with PCA administered did not have complete documentation of doses given, attempted and any wastage every shift.

Findings:

1. Patients # 14, 17 & 30's records did not have documentation of two signatures one being a Registered Nurse (RN)as required by the hospital's policies when initiating and resetting the PCA pump.

2. Patients # 14, 17 & 30's records did not document the pump setting, reservoir volume, drug concentration, continuous rate, doses given and doses attempted every shift as required by the hospital's policies for PCA.

3. Patients # 14, 17 & 30's records did not document the remaining reservoirs remaining after the PCA was discontinued and disposed of by the nursing staff.

4. The narcotic administration record (NAR) for the Morphine PCA for Patient #30 did not document time each PCA was initiated or any wastage. The NAR which was for May 2012 was not immediately available for surveyor review.

Based on review of infection control data, surveillance activities, and meeting minutes, and hospital documents, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner (ICP) 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 surveyors reviewed meeting minutes and surveillance activities provided for 2011 and 2012 containing Infection Control.

2. Meeting minutes containing infection control, did not reflect the program contained review and analysis with plans of action and follow-up of monitoring:
a. While Employee Health did track employee illness, it did not analyze the data to ensure transmissions between staff and patients did not occur;
b. Infections and communicable diseases - The modes of possible transmission between individuals (patients and staff) with analysis of measures taken to contain and prevent transmission and whether they were effective.
c. Except for handwashing, monitoring in all areas of the hospital to ensure that staff followed established policies and procedures and standards of practice to prevent and control infections and maintain a sanitary environment.
d. Concerns/problems identified in one meeting were not reported in the next meeting with an analysis of corrective actions to determine needed further follow-up or change.

3. Monitoring activities, provided for review, did not include active surveillance of the practices, to ensure staff adhered to the policies to avoid possible transmission of infections throughout the hospital, including the proper application of disinfectants.
a. The ICP has not monitored the application of disinfectants to ensure they were applied according to the manufacture's guidelines in all department of the hospital.
b. Surgical staff were routinely using a specialized shorten cycle container to sterilize eye instruments. The ICP has not monitored to ensure this is a recommended sterilization process for the instruments.
c. The infection control plan documented a plan to monitor gown/glove compliance in isolation rooms. This activity has not occurred.

4. These findings were reviewed with Staff D at the time of review on 07/30/2012, and with hospital administrative staff during the exit conference on the afternoon of 08/01/2012.

Based on surveyors observations, review of facility documents and interviews with facility staff, the facility failed to provide surgical services in accordance with acceptable standards of practice.

Findings:
1. The hospital policy "Flash sterilization" indicates A. Flash sterilization may be used for the immediate need of an individual item or set. Items processed by means of this cycle must always be used immediately since sterility assurance cannot be maintained. B. Flash sterilization should be avoided whenever possible and may be utilized in the following instances: 1. Emergency situations when no replacement instruments are available; and 4. Special items or trays supplied by vendors must be made available to the hospital prior to the day of surgery or with sufficient lead time, at least 24 hours, for processing through standard sterilization methods.

The Centers for Disease Control and Prevention (CDC -- from Infection Control and Hospital Epidemiology, "Guideline for Prevention of Surgical Site Infection", April 1999, page 261; and from Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, page 61) and the Association of Operating Room Nurses (AORN -- Perioperative Standards and Recommended Practices, pages 578 through 581, 2008 edition) do not recommend the use of "flash" sterilization for the routine sterilization of instruments, reasons of convenience or as an alternative to purchasing additional instrument sets or to save time. "Flash" sterilization, according to current CDC guidelines, should be limited to the purpose of sterilizing a surgical instrument in an emergency, such as when a needed instrument has been dropped or otherwise become contaminated.

On the morning of 7/30/2012, staff told the surveyors that the facility routinely performed multiple eye surgeries. Staff E told surveyors the facility utilized a "Riley Pack" with a sterilization exposure time of 4 minutes and no dry time. Staff E also told surveyors the facility would use the shortened cycle the morning of the scheduled eye cases because the physician brought the eye sets in the morning of the scheduled cases. Staff E stated the reason for routine use of shortened sterilization was the lack of the time to perform terminal sterilization prior to the start of cases and lack of time between cases. Staff E also told surveyors after the 4 minute cycle the flash pack would have condensate in the bottom of the tray. Staff E told surveyors the 4 minute flash was not a full sterilization cycle but a shortened sterilization cycle. The staff failed to follow nationally recognized guidelines and hospital policy.


2. According to the policy Terminal Cleaning -"surgical procedure rooms and scrub /utility areas should be terminally cleaned daily". The Operating Room Policies did not address terminal cleaning after "infected" cases. There was no documentation staff were trained to "terminally clean" the operating rooms after infected cases.

3. According to the policy "Infection Control Mechanisms-surgical wound classification" non traumatic, no inflammation encountered, no break in technique, respiratory, alimentary and genitourinary tracts not entered is considered a Class-I procedure examples:arthroscopic examination, exploratory laparotomy, orthopedic reconstructive procedures, tubal plasty, vascular surgery. Class II clean/contaminated cases included respiratory, alimentary and genitourinary without significant spillage, minor break in technique, use of mechanical drainage or reopening of wounds. Example appendectomy, bowel resection, cesarean section myringotomy, oral surgery. Class IV-Dirty Pus encountered, traumatic wound from a dirty site or traumatic wound that is over six (6) hours. Class III Contaminated Major break in technique, gross spillage from gastrointestinal tract entrance interacts in presence of inflammation, entrance into genitourinary or biliary tracts in the presence of infected urine or bile or a traumatic wound under six hours. Burn debridement, closure of colostomy, diverticulectomy, injury under 6 hours, rectal vaginal procedures; Class IV Dirty Pus encountered, traumatic wound from a dirty site or a traumatic wound that is over six (6) hours Drainage of intra-abdominal abscess, gunshot wound, injury over six hours.

On 7/31/2012 surveyors reviewed operating room log and medical record for wound classification. Five of five orthopedic procedures were classified as Class II although all cases should have been documented as Class I. Three of three laparoscopic procedures were classified incorrectly.

4. The above findings were discussed at the exit conference. No further documentation was provided.

Based on review of medical records and interviews with staff, the hospital failed to ensure rehabilitative, physical therapy (PT) and occupational therapy (OT), services were provided as ordered for two of two (Patients # 8 and 9) patients, who had orders for rehabilitative services and whose medical records were reviewed.

Findings:

1. Prior to the end of April 2012, medical record documents were handwritten. Since that time, the hospital, including rehabilitation services, has used an electronic medical record. Physician orders are a combined product of handwritten and computerized entry.

2. Patient #8, admission 06/19-22/2012 - The physician's admission orders included an order for PT and OT evaluation. Treatment was not provided as ordered.
a. The record did not contain evidence an OT evaluation had been completed. This was confirmed with Staff B and C on 07/31/2012 and with the corporate computer staff on 08/01/2012.
b. A PT evaluation was performed on 09/19/2012 at 0920. In the evaluation, the PT documented plan to visit the patient daily for one week. in addition to the evaluation, PT saw the patient: 06/19/2012 at 1327; 06/20/2012 at 1030 and 1626; 06/21/2012 at 1040 and 1533; and 06/22/2012 at 0909. The medical record did not contain additional orders for PT and the PT plan was not signed by the physician. This finding was confirmed with Staff B and C on 07/31/2012 and with the corporate computer staff on 08/01/2012.

3. Patient #9, admission 05/18-24/2012 - PT treatment was not provided as ordered. The physician's order on 05/22/2012 ordered PT to treat the patient daily for generalized weakness. PT provided treatments twice a day on 05/22 and 23/2012. This finding was confirmed with Staff B and C on 07/31/2012 and with the corporate computer staff on 08/01/2012.

Based on review of medical records and personnel files and interviews with hospital staff, the hospital failed to provide ongoing activities to swingbed patients that were based on a comprehensive assessment performed by a qualified activity coordinator/professional. This occurred in two of two (Patients #8 and 9) swingbed patients, whose medical records were reviewed.

Findings:

1. Administrative staff identified Staff J as the swingbed activities coordinator on 07/31/2012.

2. Review of Staff J's personnel file did not contain a job description for swingbed activities coordinator. Staff J's personnel file did not contain evidence Staff J was a recreation specialist, licensed or registered recreation therapist, occupational therapist or occupational therapy assistant and/or had completed the course approved by the State. This finding was reviewed and confirmed with Staff B and with Staff J on the afternoon of 08/01/2012.

3. Swingbed Patients #8 and 9 did not have comprehensive activity assessments documenting the patients interests and physical, mental and psychosocial needs. This was confirmed with Staff B on 07/31/2012 at 1515 and with Staff J and the corporate computer staff at the time of their chart review on 08/01/2012 through another computer view (Portal).

4. Patient #8, swingbed admission 06/19 through 22/2012, and Patient #9, swingbed admission 05/18 through 24/2012 - The electronic medical record, through the view supplied for the surveyors to utilize (HPF), did not contain evidence activities were provided to the swingbed patients. This finding was confirmed with Staff B on 07/31/2012 at 1515.
a. On 08/01/2012, the corporate computer staff only found activity entry for Patient #8 for 06/20/2012 at 1325. The entry documented the patient refused puzzles and stated they "just" wanted to read.
b. On 08/01/2012, the corporate computer staff only found activity entries for Patient #9 for 05/21/2012 at 1324 and 05/23/12. Both times the patient refused offered activities.

Based on review of medical records and interviews with staff the hospital failed to ensure unauthorized individuals had access to electronic medical records.

Findings:

1. Some patient's had orders in their records where the ordering practitioner was identified with an identification number (ID). The hospital could not provide documentation who the ordering practitioner was. The facility could not identify the practitioner who had access to the chart and entered orders.


2. On 8/1/2012 the Staff B told surveyors the facility did not have policies and procedures stipulating documentation and use of the electronic medical record. There was no process or policy indicating what practitioners had permission to document in different areas of the medical record. There was no policy and procedure indicating what personnel could enter physician orders and how and when orders were verified by the ordering practitioner.

3. Review of Governing Body Meeting Minutes 2011-2012, Quality Meeting Minutes 2011 2012 did not include documentation Medical Records policies and procedures had been revised, reviewed, and implemented to insure records were accessed only by practitioners caring for the patient.