HospitalInspections.org

Based on document review and interview, the facility failed to credential a physician who provides telemedicine services to the facility from a remote location. This deficient practice increases the possibility that the subject provider is not qualified to perform specific services stipulated in the contract with the hospital. The findings are:

A. Review of radiology-related contract services revealed the existence of contracts with two vendors who performed cardiac stress tests and vascular ultrasounds respectively for hospital patients. Both cardiac stress test data and and vascular ultrasound computerized disks were sent to a separate out-of-state contractor where they were interpreted by a physician who held a valid New Mexico license. Results were then sent back to the hospital.

B. Review of a listing of credentialed physicians provided to the surveyor by the hospital revealed that the physician who interpreted the cardiac stress tests and vascular ultrasounds was not on the list.

C. On 09/14/12 at 10:25 am, during interview, the hospital Chief Executive Officer (CEO) verified that the physician who interpreted cardiac stress tests and vascular ultrasounds had not been credentialed by the hospital. When asked if the contract with the provider allowed for the hospital to accept the credentialing of the provider, the CEO stated that the contract did not have any verbiage regarding accepting the credentialing of the provider for the physician.

Based on observation and staff interview, the hospital failed to ensure that medications and medical supplies available for patient use were not expired. Medications and medical supplies were found to be past the manufacturer's recommended date for use. The hospital's failure to identify and dispose of outdated emergency medications and medical supplies resulted in the likelihood that emergency patients might be given the expired medications and medical supplies and have an unanticipated medical outcome. The findings are:

A. On 09/11/12 at 10:10 am, observation of the Emergency Department Exam Room #2, revealed the following:
1. One box of 6-0 Ethilon Nylon Suture, expiration date of 01/2012
2. One box of 2-0 Silk Reverse Cutting Suture 18", expiration date of 07/2012
3. One box of 3-0 18" Ethilon Nylon Suture, expiration date of 07/2012
4. Three 4-0 27" Chromic Gut Suture, expiration date of 01/2011
5. Three 22 gauge 1" angiocatheters, expiration date of 06/2012
6. One 20 gauge 1 1/4" angiocatheter, expiration date of 04/2011
7. One Female Speci-Cath Kit, expiration date of 03/2012
8. One Female Speci-Cath Kit, expiration date of 06/2011
9. One package of two sterile Rayon Swabs (to test for Chlamydia), expiration date of 04/2011
10. One package of two sterile Rayon Swabs, expiration date of 07/2011
11. Twelve Hemoccult test cards (sensitive test for enhanced detection of hidden blood in the stools), expiration date of 08/2012


B. On 09/11/12 at 10:50 am, observation of the Emergency Department Exam Room #1, revealed the following:
1. Four packages of 6 1/2 Sterile Latex Surgical Gloves, expiration date of 11/2011
2. One Skin Marking Pen, expiration date of 03/2012
3. Ten Hemoccult test cards (sensitive test for enhanced detection of hidden blood in the stools), expiration date of 08/2012
4. Three Albuterol Sulfate Inhalation (a bronchodilator, used to treat bronchospasms), expiration date of 08/2011
5. One Female Spec-Cath Kit, expiration date of 06/2011

C. On 09/11/12 at 11:15 am, observation of the Emergency Department refrigerator where medications are stored and ready for use, revealed the following:
1. Two Glycerin suppositories, adult size, expiration date of 11/2011
2. Three Budesonide Inhalation Suspension (a corticoidsteroid, used to treat asthma), expiration date of 07/2012
3. One green top Remel Micro Test MS Transport (for the transport of viruses, chlamydia, mycoplasma and ureaplasma), expiration date of 06/2010

D. On 09/11/12 at 11:45 am, observation of the Emergency Department Trauma Room #1, revealed the following:
1. Sixteen Hemoccult test cards (sensitive test for enhanced detection of hidden blood in the stools), expiration date of 08/2012
2. Eleven Hemoccult test cards (sensitive test for enhanced detection of hidden blood in the stools), expiration date of 10/2011
3. One box of 100 Sterile Carbon Steel Surgical Blades, expiration date of 07/2012
4. Four packages (pkgs) of 5-0 Silk Black Braided 18" Reverse Cutting Suture, expiration date of 07/2011
5. Eight pkgs of 4-0 27" Chromic Gut Suture, expiration date of 07/2011
6. One package of 4-0 27" Chromic Gut Suture, expiration date of 07/2012
7. Four pkgs of size 6 1/2 Sterile Latex Surgical Gloves, expiration date of 11/2011
8. Two pkgs of size 7 Sterile Latex Surgical Gloves, expiration date of 04/2012
9. Five Skin Marking Pens, expiration date of 03/2012
10. Five 24 gauge 3/4" angiocatheters, expiration date of 05/2012

E. On 09/11/12 at 1:20 pm, observation of the Emergency Department's Pediatric Resuscitation cart located in Trauma Room #1, which is available for servicing the entire spectrum of pediatric ages/sizes from the newly born to the adolescent, revealed the following:

1. Two pkgs of R2 Multifunction Electrodes (that are placed upon the infant/child in conjunction with the cardiac monitor), expiration date of 04/2011, found on top of the cart

Gray drawer designated to service newborn/small infants with weights of 3-5 kg .
1. One 8 french Enteral feeding tube, expiration date of 11/2010
2. One 24 gauge 3/4" angiocatheter, expiration date of 03/2012
3. One 24 gauge 3/4" angiocatheter, expiration date of 05/2012
4. One 22 gauge 1" angiocatheter, expiration date of 12/2011

Pink drawer designated to service infants with weights of 6-9 kg
1. One 8 french Enteral feeding tube, expiration date of 11/2010
2. Intravenous (IV) start kit, expiration date of 12/2010

Purple drawer designated to service toddlers with weights of 10-11 kg.
1. One 24 gauge 3/4" angiocatheter, expiration date of 03/2012
2. One 22 gauge 1" angiocatheter, expiration date of 12/2011
3. One IV start kit, expiration date of 12/2010

Yellow drawer designated to service a small child with a weight of 12-14 kg
1. Two 22 gauge 1" angiocatheter, expiration date of 01/2011

White drawer designated to service a child with a weight of 15-18 kg
1. One 18 gauge 1-1/4" angiocatheter, expiration date of 03/2011
2. Two 22 gauge 1" angiocatheters, expiration date of 01/2011
3. One 22 gauge 1" angiocatheter, expiration date of 06/2012
4. One IV start kit, expiration date of 12/2010

Blue drawer designated to service a child with a weight of 19-22 kg
1. One 22 gauge 1" angiocatheter, expiration date of 02/2012
2. One 22 gauge 1" angiocatheter, expiration date of 01/2011
3. One 20 gauge 1-1/4" angiocatheter, expiration date of 04/2011

Orange drawer designated to service a large child with a weight of 24-30 kg
1. One 20 gauge 1-1/4" angiocatheter, expiration date of 040/2011
2. One 18 gauge 1-1/4" angiocatheter, expiration date of 03/2011
3. One 22 gauge 1" angiocatheter, expiration date of 12/2011

Green drawer designated to service an adult with a weight of greater than or equal to 32 kg
1. One 18 gauge 1-1/4" angiocatheter, expiration date of 03/2011
2. One IV start kit, expiration date of 12/2010

F. On 09/11/12 at 1:50 pm, observation of the Emergency Department's Supply cabinet located in Trauma Room #1, revealed the following:
1. One bottle of Iodoform 2" Packing Strips, expiration date of 05/2011
2. One bottle of Iodoform 2" Packing Strips, expiration date of 08/2012
3. Three pkgs of Female Speci-Cath Kit, expiration date of 03/2012
4. Three 24 gauge 3/4" angiocatheters, expiration date of 03/2012
5. Ten 24 gauge 3/4" angiocatheters, expiration date of 05/2012
6. Four 16 gauge 1-1/4" angiocatheters, expiration date of 08/2012
7. Seventeen 16 gauge 1-1/4" angiocatheter's, expiration date of 04/2012
8. Nine 14 gauge 1-3/4" angiocatheters, expiration date of 03/2012

G. On 09/11/12 at 2:00 pm, during interview, the Director of Nursing confirmed the manufacturer's expiration dates of the medication and medical supplies.

The facility failed to meet the Condition of Participation for this requirement. Refer to Tag C-0231.

The failure to comply with the 2000 Life Safety Code provisions has the potential for harm.








18749

Based on document request, observation, and interview, it was determined that the hospital failed to ensure that all essential mechanical, electrical and patient care equipment was maintained in safe operation condition. The failure to maintain essential air handling equipment in a safe operation condition resulted in the likelihood that patient safety could be compromised during a surgical procedure (C-222). The hospital failed to ensure that there was documentation of proper ventilation and temperature control in the Operating Suite. The failure to monitor the temperature and humidity in the operating room created the likelihood that a patient could have an adverse experience while undergoing surgery (C-226). The cumulative effect of these systemic practices resulted in the hospital's inability to ensure that the patient's medical needs could be met in a safe manner in the ORs.

Based on document request, observation, and interview, the hospital failed to ensure that all essential mechanical, electrical and patient care equipment was maintained in safe operation condition. The failure to maintain essential air handling equipment in a safe operation condition resulted in the likelihood that patient safety could be compromised during a surgical procedure. The findings are:

A. On 09/11/12 at 10:05 am, the Operating Suite was inspected. In operating room #209, the surveyor noted that the humidity gauge indicated that the humidity in the operating room was only 18%. Normal humidity for an operating room should be kept between 35 to 40%. Scrub Tech #1 was asked about the low humidity. She stated, "We have been having trouble with the humidity part of the air system for about six months. This problem has been turned over to the engineers." She also noted that the same problem with controlling the humidity affected the entire Operating Suite.

B. On 09/12/12 at 11:10 am, the Chief Executive Officer (CEO) was asked about the problem with the humidity in the operating suite. He stated that the air handling system in the new part of the hospital, where the Operating Suite was located, had a major problem with the humidity equipment and had been installed incorrectly by the contractor when the new part of the hospital was built three years earlier. He further stated that the hospital had hired a consultant firm from El Paso, TX, to evaluate the problem with the humidity equipment. The consultant report stated that the humidity equipment lines had been incorrectly installed, resulting in water beginning to run out of the air vents after about one hour of operation. The CEO said that the hospital had contracted with a air system firm out of Albuquerque, NM, but "they hadn't made it up here all summer to fix the problem."

C. On 09/13/12 at 2:25 pm, the Physical Plant manager was asked for the temperature and humidity logs for the Operating Suite. He stated, "We have not been keep temperature and humidity logs for the Operating Suite."

Based on document request and interview, the hospital failed to ensure that there was documentation of proper ventilation and temperature control in the Operating Suite. The failure to monitor the temperature and humidity in the operating room created the likelihood that a patient could have an adverse experience while undergoing surgery. The findings are:

A. On 09/10/12 at 3:00 pm, the hospital was given a Request for Information asking for "Temperature and humidity tracking logs for the past three months." On 09/11/12 at 11:00 am, when the Request for Information sheet was returned with documentation, next to the request for temperature and humidity logs was written, "No."

B. On 09/13/12 at 2:25 pm, the Physical Plant manager was asked for the temperature and humidity logs for the Operating Suite. He stated, "We have not been keeping temperature and humidity logs for the Operating Suite."

The Hospital must meet the applicable provisions of the National Fire Protection Association, 2000 Edition of the Life Safety Code.

Refer to the CMS-2567 for the Life Safety Code Survey conducted on September 11, 2012, for the following K-Tags:


1. K-0011: Fire Separation Walls
2. K-0018: Doors in Corridor Walls
3. K-0050: Fire Drills
4. K-0062: Maintenance of Automatic Sprinkler Systems
5. K-0066: Smoking
6. K-0069: Cooking Facilities
7. K-0077: Piped in Medical Gas Systems
8. K-0130: Powered Doors
9. K-0144: Emergency Generators
10. K-0154: Policies and Procedures - Sprinkler System
11. K-0155: Policies and Procedures - Fire Alarm System

Based on document request, document review, and interview, the Governing Body failed to ensure that the hospital was providing quality health care in a safe environment. The failure to have the required Quality Assurance program and an Infection Control program resulted in the likelihood that deficiencies affecting patient safety and medical errors could go undetected due to the lack of the above listed programs. The findings are:

Based on document request, document review, and interview, the hospital failed to have an effective quality assurance program. The hospital's quality assurance program failed to: (1) provide for ongoing monitoring and data collection, (2) provide problem prevention, identification and data analysis, (3) identification of corrective actions, (4) implementation of corrective actions, (5) evaluation of corrective actions, and (6) measures to improve quality on a continuous basis. The failure to have an effective ongoing quality assurance program created the likelihood that the hospital would be unaware of adverse patient events, medication errors, and issues of patient safety on a timely basis. (Refer to C 330)

Based on document reviews, observations, and interviews, the hospital failed to ensure: 1) to designate in writing the acting infection control officer; 2) that there was an active infection control surveillance program that is related to infections and communicable diseases, including those that are identified through employee health services; 3) that the active infection control surveillance program was both hospital wide and program specific and implemented correctly; and 4) that problems that are identified were reported to the medical staff, nursing, and administration, and were addressed in the hospital's quality assurance and in-service training programs. These deficient practices may result in the failure of the hospital to institute specific measures for prevention, early detection, control, education and investigation of infections and communicable diseases that provide a risk to patients, visitors and staff. (Refer to C 278)


Based on document request and interview, the hospital failed to ensure that all practitioners were correctly privileged before providing care to patients. The Governing Body failed to renew privileges for two Certified Registered Nurse Anesthetists (CRNA) on a timely basis resulting in one CRNA providing anesthesia to nine (9) patients between 06/12, when prior privileges expired, and 09/10/12. In addition, the Governing Body also failed to credential and privilege contract physicians providing telemedicine radiology services to the hospital. The failure to properly credential and privilege practitioners created the likelihood that a practitioner might perform procedures that they were not qualified to perform. The finding are:

A. On 09/13/12, the Administrative Assistant was asked to provide documentation that all the practitioners practicing in the hospital were properly credentialed and privileged. The documentation provided did not cover CRNA # 1 and CRNA #2. The Administrative Assistant was asked for the documentation for the two CRNA's. After checking, she stated at 10:20 am, " We do not have any documentation that these two CRNA's were reprivileged when their current privileges expired in 06/2012. The Board of Trustees never approved their privileges."

B. On 09/14/12 at 9:10 am, the Chief Executive Officer (CEO) was asked to provide a list of any surgical cases that either CRNA #1 or CRNA #2 had provided anesthesia. At 9:40 am the CEO stated, " CRNA #1 has not provided any anesthesia since 06/2012, but CRNA #2 has provided anesthesia for nine cases in the past three and a half months."

C. On 09/14/12 at 9:40 am, the CEO was asked to provide documentation that the contract radiologist performing telemedicine through remote reading of radiology tests had been credentialed and privileged by the Governing Body. At 10:10 am, the CEO stated, "I have determined that the hospital has not verified the credentials of the contract physicians nor have we approved their privileges."

Based on staff interview, the hospital failed to disclose the name and address of the Chief Executive Officer (CEO) to the State Agency. This failed practice could lead to the patients and their representative not knowing who was in charge of the hospital. The finding are:

A. On 09/11/12 at 10:45 am, during an interview, the CEO was asked if the hospital had sent the State Agency his name and address. He stated he did not know if this had been done and would look for proof that it had been done.

B. On 09/12/12 at 4:45 pm, during an interview, the CEO confirmed that he could not find any documentation that the State Agency had been sent the name and address of the CEO.

Based on staff interview, the hospital failed to disclose the name and address of the Medical Director to the State Agency. This failed practice could lead to the patients and their representative not knowing who was in charge of the medical staff in the hospital. The finding are:

A. On 09/11/12 at 10:45 am, during an interview, the Chief Executive Officer was asked if the hospital had sent the name and address of the hospital's medical director. He stated he did not know if this had been done and would look for proof that it had been done.

B. On 09/12/12 at 4:45 pm, during an interview, the CEO confirmed that he could not find any documentation that the State Agency had been sent the name and address of the medical director.

Based on document request and interview, the hospital failed to have sufficient staff to provide services essential to the operation of the hospital. The hospital did not have staff hired to run the quality assurance and infection control programs. The lack of dedicated staff to managed these two essential programs resulted in the likelihood that issues involving patient safety and medical errors could occur without the knowledge of the hospital. The findings are:

A. On 09/13/12 at 10:15 am, during interview, the Chief Executive Officer (CEO) and the Director of Nursing(DON)/acting infection control practitioner confirmed that the DON/acting infection control practitioner had not been designated in writing and had the responsibility for the infection control program. The CEO and DON/acting infection control practitioner also confirmed that there really was not a formal Infection Control program and further stated that the hospital had not had an official infection control officer since 2009. The CEO was asked the reason why the hospital had not hired an infection control officer for the last three years. He stated that the Medical Staff felt that the DON was able to handle the infection control responsibilities. The DON/acting infection control practitioner was asked if she had any specific training regarding infection control. She stated that she did not had any formal education, training, experience or certification training from a recognized infection control association.

B. On 09/13/12 at 10:15 am the CEO and DON were ask why the hospital had not made any effort to hire a quality assurance program manager. The CEO stated that "the QA and IC had been done by the same person that left in 06/09 and that the DON was assigned these jobs on an acting basis. No effort has been made to fill these positions." The CEO further stated that "the DON will be formally designated to do both jobs at next Board of Trustees meeting on 09/24/12."

C. It should be noted that the DON has been assigned to do these job on an acting basis since 06/09 and the result is that the hospital has neither a viable quality assurance program (See C-330) nor an infection control program.

Based on document reviews, observations, and interviews, the hospital failed to ensure: 1) to designate in writing the acting infection control officer; 2) that there was an active infection control surveillance program that was related to infections and communicable diseases, including those that were identified through employee health services; 3) that the active infection control surveillance program was both hospital wide and program specific and implemented correctly; and 4) that problems that were identified were reported to the medical staff, nursing, and administration, and addressed in the hospital's quality assurance and in-service training programs. These deficient practices could result in the likelihood that the absence of these specific measures for prevention, early detection, control, education and investigation of infections and communicable diseases increase the infection risk to patients, visitors and staff. The findings are:

A. On 09/13/12 at 10:15 am, during interview, the Chief Executive Officer (CEO) and the Director of Nursing(DON)/acting infection control practitioner confirmed that the DON/acting infection control practitioner had not been designated in writing and has the responsibility for the infection control program. The CEO and DON/acting infection control practitioner also confirmed that there really was not a formal Infection Control program and further stated that the hospital has not had an official infection control officer since 2009. The CEO was asked the reason why the hospital had not hired an infection control officer for the last three years. He stated that the Medical Staff felt that the DON was able to handle the infection control responsibilities. The DON/acting infection control practitioner was asked if she had had any specific training regarding infection control, she stated that she has not had any formal education, training, experience or certification training from a recognized infection control association.

B. Review of the hospital's infection control policies and procedures (P&P) were last reviewed and approved 04/11/11 by the Department Director and the Chief of Medical Staff. On 09/12/12 at 3:00 pm, during interview, the DON/acting infection control practitioner was asked if the P&P's were to be approved on a yearly basis. She replied, "Yes and they [the P&P's] should have been approved by the medical staff in April of this year."

C. On 09/12/12 at 3:00 pm, during interview, the DON/acting infection control practitioner stated that she stopped by the laboratory on a daily basis to inquire about Microbiology lab results of inpatients and outpatients. When asked what specific infections she was tracking and keeping a log for, she replied, "Nosocomial infections and reports this information to the Medical Staff General Session."

D. On 09/13/12 at 8:15 am, during interview, the laboratory manager stated that he does not report infection control related information to the DON/acting infection control practitioner. He stated that the DON/acting infection control practitioner came into the lab about once per month and reviewed the microbiology log.
1. The laboratory manager stated that he does not track contaminated blood cultures nor does the laboratory identify the contaminated blood cultures. If there is a possible contaminated blood culture, the lab manager leaves that decision to the provider.
2. On 09/13/12 at 10:45 am, during interview, the DON/acting infection control practitioner stated that she did not look at blood culture contamination rates.
3. On 09/13/12 at 10:45 am, during interview, the CEO stated that the tracking of the contaminated blood cultures was not a quality assurance activity for the laboratory.

E. On 09/11 through 09/13/12, during observations throughout the hospital, which included the emergency department, nursing station crash carts, sterile processing room and operating room, the hospital failed to ensure that medications and medical supplies readily available for patient use were not expired. Medications and medical supplies were found to be past the manufacturer's recommended date for use on the emergency crash cart. (Refer to C297)
1. On 09/13/12 at 8:30 am, during observation, in the public/staff restroom across from the pharmacy, the automatic foaming soap dispenser was not functioning properly and there were no towels to dry wet hands.
2. On 09/13/12 at 8:35 am, during interview, the pharmacist confirmed that sometimes the automatic foam soap dispenser does not always work properly.
3. On 09/13/12 at 2:45 pm, during observation, in the same restroom, the automatic foaming soap dispenser was not functioning.
4. On 09/14/12 at 9:45 am, during observation, the top of the heating/air conditioner and vents located in the conference room were dirty with dust.

F. On 09/13/12 at 10:30 am, during interview, the CEO and DON/acting infection control practitioner stated that the hospital does not have an Infection Control (IC) Committee, but that the Medical Staff General Session acts as the IC committee.
1. Review of the Medical Staff General Session Meeting minutes from 10/12/10 through 06/12/12 revealed the following:
a. "No nosocomial infections" reported for the 2nd quarter on 10/11/10.
b. "No nosocomial infections" reported for the 3rd quarter on 11/09/10.
c. There was "No General session of Medical Staff Meeting" on 12/2010.
d. There was "No General session of Medical Staff Meeting" on 01/2011.
e. There was "No General session of Medical Staff Meeting" on 02/2011.
f. "2011 data tracking is being done..." indicated on 03/08/11.
g. "No report" reported on 04/12/11.
h. "No report" reported on 05/10/11.
i. "No report" reported on 06/14/11.
j. There was "No General session of Medical Staff Meeting" on 07/12/11.
k. "Absent" at the 08/11/11 meeting.
l. "Absent" at the 09/13/11 meeting.
m. "The quarterly meeting will be next month," indicated on 10/11/11.
n. "Handouts passed out on the tracking of nosocomial infections," indicated at the 11/08/11 meeting.
o. "Handouts passed out on the tracking of nosocomial infections," indicated at the 12/13/11 meeting.
p. "No report this month," indicated on 01/10/12.
q. "No report this month," indicated on 06/12/12.

Based on record review and staff interview, the hospital failed to ensure that patients' medical records at the hospital's outpatient clinic were available and accessible in the hospital's medical record system for 18 of 18 sampled patient records (#1 through #18). This failed practice could lead to a patient's doctor not being aware of all of the treatments that the patient has received at the outpatient clinic. The findings are:

A. Review of the clinical record for Patient #1 through #18 revealed only services provided within the physical hospital. No outpatient clinic notes were found.

B. On 09/12/12 at 10:00 am, during an interview, the medical record staff confirmed that the clinic records were not not part of the hospital medical record.

Based on observation, document review and interview, the hospital failed to ensure that the hospital's laboratory was in compliance with the CLIA regulation. The failure to be in compliance with the CLIA regulations resulted in the likelihood that laboratory services and tests could be invalid or in error resulting in an adverse outcome for the patient. The findings are:

A. During the period 09/10/12 through 09/14/12, while the full review survey was being done by the health team, the hospital laboratory was being inspected by the State Agency CLIA surveyor.

B. On 09/14/12 at 10:00 am, the CLIA surveyor was interviewed. She stated that the laboratory was not in compliance with the CLIA regulations and would be so cited in her CLIA statement of deficiencies.

Based on observation, staff interview and facility policy, the hospital failed to ensure that medications and medical supplies available for patient use were not expired. Medications and medical supplies were found to be past the manufacturer's recommended date for use on the emergency crash cart. This deficient practice had the potential exposing all patients to expired emergency medications and medical supplies which might not have the desired effect on the patients. The findings are:

A. On 09/12/12 at 2:45 pm, during observation of the emergency crash cart located at the nurses station, revealed the following:
1. Three packages of R2 Multifunction Electrodes (that are placed upon the infant/child in conjunction with the cardiac monitor), expiration date of 05/2009, found on top of the cart.
2. Ten Red Dot Neonatal ECG Radiolucent Monitoring Electrodes, expiration date of 08/2011
3. Three Provent Arterial Blood Sampling Kits, expiration date of 06/2012
4. One Povidine Iodine Swab Sticks, expiration date of 09/2008
5. One Povidine Iodine Swab Sticks, expiration date of 05/2008
6. One 14 gauge (g) 1-3/4" intravenous (IV) angiocatheter, expiration date of 04/2010
7. One 14 g 1-3/4" IV angiocatheter, expiration date of 06/2005
8. One 18 g 1-1/4" IV angiocatheter, expiration date of 08/2010
9. One 20 g 1-1/4" IV angiocatheter, expiration date of 07/2012
10. One 20 g 1-1/4" IV angiocatheter, expiration date of 03/2011
11. One 22 g 1" IV angiocatheter, expiration date of 09/2009
12. One 22 g 1" IV angiocatheter, expiration date of 01/2010
13. Two 24 g 3/4" IV angiocatheter, expiration date of 03/2010
14. Two 16 g 1-1/4" IV angiocatheter, expiration date of 04/2009
15. Three 19 g 3/4" IV angiocatheter, expiration date of 01/2009
16. One vial 1 ml of Narcan (an antidote to opoid-induced respiratory depression), expiration date of 06/2012
17. Two packages of R2 Multifunction Electrodes, expiration date of 05/2009
18. Two packages of R2 Multifunction Electrodes, expiration date of 10/2010
19. Two packages of R2 Multifunction Electrodes, expiration date of 02/2011
20. Twenty-five packages of infant electrodes, expiration date of 09/2004
21. One Laryngeal Mask Airway (LMA)( an alternative airway device used for anesthesia and airway support), expiration date of 10/2011
22. One Adult Carbon Dioxide (CO 2) Detector (used to confirm tracheal intubation is in the lungs), expiration date of 07/2012
23. One Pediatric CO 2 Detector, expiration date of 08/2012
24. One 8.0 Nasopharyngeal Airway, expiration date of 04/2010
25. One Impedance Threshold Device (An inspiratory valve used in cardiopulmonary resuscitation (CPR) to decrease intrathoracic pressure and improve venous return to the heart), expiration date of 10/2011
26. One Impedance Threshold Device, expiration date of 02/2012
27. One Sterile Triple Lumen Central Venous Catheter tray, expiration date of 04/2012
28. One Central Venous Pressure Monitor, expiration date of 03/2009
29. One 6 french Catheter Drainage Tray Safe-T Centesis, expiration date of 03/2012
30. Two Dopamine (a Vasopressor, used to improve perfusion to vital organs) 250 ml bags, expiration date of 06/2012
31. One 1000 ml bag of D5 solution, expiration date of 05/2012

B. On 09/12/12 at 3:15 pm, during interview, the Director of Nursing confirmed the manufacturer's expiration dates of the emergency medications and medical supplies.

C. Review of the facility policy titled "Crash Cart" revised on 01/05/11, revealed the following: "...Check the stock sheet, and restock after each code, or of [sic] the cart has been opened. Pharmacy will check the Crash Cart for outdates on the medications monthly."

D. On 09/13/12 at 1:30 pm, inspection of the sterile processing room, revealed the following:
1. Two boxes that contained 25 each of Kendall Skin Markers, expiration date of 03/2012
2. Two boxes that contained 25 each of Kendall Skin Markers, expiration date of 11/2010
3. Twenty-nine Vacutainer serum blood collection tubes, expiration date of 07/2008
4. One box of blood collection tubes, expiration date of 01/2011
5. Eleven American Sterilizer Biological/Integrator Challenge Pack, expiration date of 01/2011
6. Two boxes of 100 Sterile Carbon Surgical Blades, expiration date of 08/2012
7. One box (60 strips) Cidex Solution test strips, expiration date of 06/2012
8. One bottle of Lidocaine HCL 10 mg/ml, expiration date of 01/2011
9. Three Central Venous Catheter trays, expiration date of 04/2012
10. Three Letra Plume-away, expiration date of 01/2010
11. Twelve blood collection tubes, expiration date of 07/2011
12. Nine standard Yankauer Suction sets, expiration date of
07/2012
The following items were observed in the operating room suites:
1. Two Gauze Sponges size 8 x 4, expiration date of 02/2012
2. Four Gold 3500 Resting ECG Electrodes, expiration date of
11/2011
3. Three R2 Multifunction Electrodes, expiration date of
02/2011
4. Two R2 Multifunction Electrodes, expiration date of
10/2010
5. One R2 Pediatric Electrodes, expiration date of
05/2010
6. One Pediatric Cap CO 2 Detector, expiration date of
10/2009
7. One Easy Cap CO 2 Detector, expiration date of
10/2009
8. One Suction Connection Tubing, expiration date of
01/2006
9. One Suction Connection Tubing, expiration date of
09/2008
10. One Suction Connection Tubing, expiration date of
09/2010
11. One Suction Connection Tubing, expiration date of
12/2011
12. One Bard Foley Catheterization Tray, expiration date of
04/2011
13. One Bard Foley Catheterization Tray, expiration date of
02/2012
14. One Nasopharyngeal Airway, expiration date of
09/2001
15. Two Nasopharyngeal Airway, expiration date of
04/2010
16. One Nasopharyngeal Airway, expiration date of 06/2007
17. One Nasopharyngeal Airway, expiration date of 01/2011
18. One Laryngeal Mask Airway (LMA) size 5, expiration date of 11/2011
19. One LMA size 5, expiration date of 05/2012
20. One LMA size 4, expiration date of 10/2011
21. One LMA size 4, expiration date of 12/2011
22. One Central Venous Catheter Tray, expiration date of 11/2009
23. One 100 ml bottle Lidocaine Oral, expiration date of 02/2012

E. On 09/13/12 at 3:00 pm, during interview, the Scrub Tech confirmed the manufacturer's expiration dates of the operating room medications and medical supplies.

Based on record review, staff interview, facility medical bylaws and policy and procedures, the hospital failed to ensure that all patient medical record entries, including physician telephone/verbal order countersignature entries were dated and progress notes were either timed and legible for 3 of 18 sampled patients (#2, 6 and 17). This deficient practice had the potential to affect (1) early identification of medical issues, (2) correction of verbal orders and (3) making assessments of the patient's condition, (4) decisions on the provision of care to the patient and (5) planning the patient's care. The findings are:

A. Review of Patient #2, 6 and 17's medical records revealed physician telephone/verbal order countersignature entries were not dated and the physician's writing in the progress notes was illegible.

B. On 09/13/12 at 3:15 pm, during interview, Staff #1 (a Registered Nurse) was asked to read the physician progress notes for Patient #2. Staff #1 was unable to read them, he was only able to pick out a few words.

C. On 09/13/12 at 2:00 pm, during interview, the Assistant in the Medical Records Department was asked who the physician was for Patient #17. She identified the attending physician. She reviewed specifically the physician orders and progress notes of this patient. She stated that the illegibility issue was discussed at the Medical Staff meeting. When the Assistant Medical Records staff member was asked if the physicians are required to date their signatures when they co-sign verbal and telephone orders, she replied, "Yes."

D. On 09/14/12 at 10:45 am, during interview, the Medical Records Supervisor confirmed that the facility had a few physicians whose writing is illegible.

E. Review of the Medical Staff General Session meeting minutes under Medical Records indicated the following:
1. The meeting held on 06/14/11 revealed the following: "It was brought to the doctors attention on how medical records will be monitoring the date, time, initial and signature on all orders. July 1, 2011 is the starting date for the monitoring."
2. The meeting held on 11/08/11 revealed that the date and time on physician standing orders and standing admit orders were not being done. The "Rules and Regulations of the Medical Staff" require that the date and time be entered on all physician orders.
3. The meeting held on 12/13/11 revealed that the "standing orders are the ones not getting a date and time on them..."

F. Review of the "Rules and Regulations of the Medical Staff" last approved by the Medical Staff on 03/14/06 and last approved by the Board of Directors on 03/21/06, revealed the following:
"...Pre-printed orders shall be reviewed every year and formulated by conference between the medical staff and nursing staff. These orders shall be signed by the attending practitioner...Orders dictated over the telephone shall be signed by the person to whom dictated, with the name of the practitioner per his or her, own name. At his/her next visit, as soon as practically possible, the attending practitioner shall sign such orders. All orders shall be signed within one month."

Based on observation and interview, the hospital failed to ensure that sterilized materials were handled and stored in a manner that ensures sterility, e.g., in a moisture and dust controlled environment. This failure to correctly store sterilized materials in a safe manner resulted in the likelihood that sterilized materials could become contaminated, increasing the possibility of infection following surgery. The findings are:

A. On 09/11/12 at 10:05 am, the operating suite, consisting of an operating room, a procedure room, a recovery bay, sterile processing room and storage areas, was inspected. In the sterile processing room there was a storage area that was approximately 8' by 8'. This storage area had shelving on three walls and a large opening into the sterile processing area. There was no door on this storage area. Packages of sterile instruments were placed on the shelving, leaving them exposed to dust and inappropriate humidity. Scrub Tech #1 was asked why the sterile instrument packages were stored in the open and she replied, "We don't have any other place to store them."

B. During the inspection at 10:05 am, there was a large metal shelf across from Operating Room #209 that had three shelves; these shelves were filled with additional sterile instrument packages. Surgical Tech #1 acknowledged that none of these sterile instrument packages were protected from dust and traffic.


Based on document review and interview, the hospital, medical staff and governing body failed to ensure that all practitioners administering anesthesia had been granted clinical privileges by the medical staff and governing body. Two Certified Registered Nurse Anesthetists (CRNAs) were not privileged to provide anesthesia, but one of the two had provided anesthesia in nine (9) cases since 06/2012, although he was not privileged. The failure to prevent non-privileged practitioners from providing anesthesia resulted in the likelihood that there could be an adverse patient outcome. (Refer to C-321.)


Based on interview, the hospital failed to ensure that the Cidex disinfection solution was being checked with non-expired Cidex test strips. This failure to ensure that the Cidex test strips were viable resulted in the likelihood that instruments disinfected in the Cidex solution since 06/2012 might not be truly disinfected because the Cidex solution had lost its required level of disinfection strength. The finding are:

A. On 09/13/12 at 2:00 pm, an inspection of surgical supplies in a cabinet in the room where a large container of Cidex was kept, found that the open vial of Cidex test strips had an expiration date of 06/12.

B. On 09/13/12 at 2:00 pm, Scrub Tech #1 was asked if she had been checking the Cidex solution with these strips since 06/2012. She stated that she had been using the vial of Cidex test strips that were expired.

Based on observation and interview, the hospital failed to ensure that all drugs, medications and surgical supplies were not expired. An inspection of the Operating Suite found excessive volumes of expired drugs, medications and surgical supplies. The presence of expired drugs, medications and surgical supplies readily available in all areas of the Operating suite could result in a surgical team member might use the expired drugs, medications and surgical supplies in a surgical procedure, not realizing that they were expired. The findings are:

A. On 09/11/12 at 10:30 am, two bottles of furosemide that were expired by 06/12 were available for use in the OR emergency cart.

B. On 09/11/12 at 10:45 am, the surveyor inspected the Anesthesia Work room. The following list of expired drugs and medications were identified:

3 containers of Lidocain Viscous, expired 8/12
3 bottles (240 ml) of Suprane expired 4/12, 5/12 and 10/11, respectively.
11 vials of Bacterostatic Sodium Chloride, expired 3/12
3 boxes of (5 doses per box) of Lidocaine HCL 1%, expired 7/12
27 vials of Oxytocin, expired 1/12
3 vials Heparin NA 1000 USP, expired 1/12
10 vials of Amidate 20 mg., expired 12/11
6 vials of Succinylcholine, expired 3/12

B. On 09/11/12, CRNA #3 was present when expired drugs were found in the Anesthesia Work room. He verified that all of the above listed drugs were expired.

C. On 09/13/12, because of the significant amounts of expired drugs, medications and supplies that were found all over the hospital, an inspection of all storage of drugs, medications and surgical supplies was done. The following drugs, medications and surgical supplies were found to be expired:

1. On 09/13/12 at 1:30 pm, during inspection of the sterile processing room, the following drugs, medications and surgical supplies were found to be expired:
a. Two boxes that contained 25 each of Kendall Skin Markers, expiration date of 03/2012
b. Two boxes that contained 25 each of Kendall Skin Markers, expiration date of 11/2010
c. Twenty nine Vacutainer serum blood collection tubes, expiration date of 07/2008
d. One box of blood collection tubes, expiration date of 01/2011
e. Eleven American Sterilizer Biological/Integrator Challenge Pack, expiration date of 01/2011
f. Two boxes of 100 Sterile Carbon Surgical Blades, expiration date of 08/2012
g. One box (60 strips) Cidex Solution test strips, expiration date of 06/2012
h. One bottle of Lidocaine HCL 10 mg/ml, expiration date of 01/2011
i. Three Central Venous Catheter trays, expiration date of 04/2012
j. Three Letra Plume-away, expiration date of 01/2010
k. Twelve blood collection tubes, expiration date of 07/2011
l. Nine standard Yankauer Suction sets, expiration date of
07/2012
2. The following items were observed in the operating room suites:
a. Two Gauze Sponges size 8 x 4, expiration date of 02/2012
b. Four Gold 3500 Resting ECG Electrodes, expiration date of
11/2011
c. Three R2 Multifunction Electrodes, expiration date of
02/2011
d. Two R2 Multifunction Electrodes, expiration date of
10/2010
e. One R2 Pediatric Electrodes, expiration date of
05/2010
f. One Pediatric Cap CO 2 Detector, expiration date of
10/2009
g. One Easy Cap CO 2 Detector, expiration date of
10/2009
h. One Suction Connection Tubing, expiration date of
01/2006
i. One Suction Connection Tubing, expiration date of
09/2008
j. One Suction Connection Tubing, expiration date of
09/2010
k. One Suction Connection Tubing, expiration date of
12/2011
l. One Bard Foley Catheterization Tray, expiration date of
04/2011
m. One Bard Foley Catheterization Tray, expiration date of
02/2012
n. One Nasopharyngeal Airway, expiration date of
09/2001
o. Two Nasopharyngeal Airway, expiration date of
04/2010
p. One Nasopharyngeal Airway, expiration date of 06/2007
q. One Nasopharyngeal Airway, expiration date of 01/2011
r. One Laryngeal Mask Airway (LMA) size 5, expiration date of 11/2011
s. One LMA size 5, expiration date of 05/2012
t. One LMA size 4, expiration date of 10/2011
u. One LMA size 4, expiration date of 12/2011
v. One Central Venous Catheter Tray, expiration date of 11/2009
w. One 100 ml bottle Lidocaine Oral, expiration date of 02/2012

D. On 09/13/12 at 3:00 pm, during interview, the Scrub Tech confirmed the manufacturer's expiration dates of the operating room medications and medical supplies.

Based on document review and interview, the hospital, medical staff and governing body failed to ensure that all practitioners administering anesthesia had been granted clinical privileges by the medical staff and governing body. Two Certified Registered Nurse Anesthetists (CRNAs) were not privileged to provide anesthesia but one of the two had provided anesthesia in nine (9) cases since 06/2012, although he was not privileged. The failure to prevent non-privileged practitioners from providing anesthesia resulted in the likelihood that there could be an adverse patient outcome. The findings are:

A. On 09/13/12 at 3:35 pm, the Administrative Assistant was asked if all the CRNAs practicing at the hospital had approved privileges. She stated that her records indicated that CRNA #1 and CRNA #2 were practicing at the hospital, but that she was unable to find any documentation to show that their requests for privileges had been reviewed and approved by the Medical Staff. In addition, she stated that there was no record that the Governing Body had ever approved privileges for these two CRNAs.

B. On 09/14/12 at 9:45 am, the Chief Executive Officer (CEO) stated, "CRNA #1 has not performed any procedures here since 06/2012, but CRNA #2 has provided anesthesia in nine (9) cases since 06/2012."

Based on document request, document review, and interview, the hospital failed to ensure that an effective quality assurance program existed to evaluate the quality and appropriateness of the diagnosis and treatment furnished. The hospital's failure to evaluate all patient care services and other services resulted in the likelihood that patient health and safety could be compromised. The findings are:

Based on document request, document review and interview, the hospital failed to have an effective quality assurance program. The hospital's quality assurance program failed to: (1) provide for ongoing monitoring and data collection; (2) provide problem prevention, identification and data analysis; (3) identification of corrective actions; (4) implementation of corrective actions; (5) evaluation of corrective actions; and (6) measures to improve quality on a continuous basis. The failure to have an effective ongoing quality assurance program created the likelihood that the hospital would be unaware of adverse patient events, medication errors, and issues of patient safety on a timely basis. (Refer to C-336.)


Based on document request, document review and interview, the hospital failed to ensure that all patient care services and other services affecting patient health and safety were evaluated for the quality and appropriateness of the diagnosis and treatment furnished by the hospital and of treatment outcomes. The hospital also failed to ensure that the quality assurance data was provided to the Medical Staff and Governing Body. The failure to evaluate diagnosis and treatment furnished by the hospital and of treatment outcomes resulted in the likelihood that significant issues affecting patient health and safety would not be identified by the hospital and the quality assurance program and not communicated to the Medical Staff or Governing Body. (Refer to C-337.)


Based on document request, document review and interview, the hospital failed to ensure that the quality and appropriateness of the diagnosis and treatment furnished by nurse practitioners and clinical nurse specialists were evaluated by a member of the hospital staff who was a doctor of medicine or osteopathy, or by another doctor of medicine or osteopathy under contract with the hospital. The failure to evaluate the quality and appropriateness of the diagnosis and treatment furnished by nurse practitioners and clinical nurse specialists resulted in the likelihood that the hospital, the quality assurance program, the Medical Staff and Governing Body would not be aware of problems or issues with the quality and appropriateness of the diagnosis and treatment furnished by nurse practitioners and clinical nurse specialists. (Refer to C-339.)


Based on document request, document review and interview, the hospital failed to ensure that it had an arrangement with an outside entity to review the appropriateness of the diagnosis and treatment furnished by doctors of medicine and osteopathy. This failure resulted in the likelihood that physicians could make medical errors that went unrecognized by the hospital, putting the patients at risk. (Refer to C-340.)


Based on document request and interview, the hospital failed to ensure that appropriate remedial action had been taken to address deficiencies identified through the quality assurance program. This failure to have a quality assurance program that was collecting data, analyzing the data and identifying deficiencies resulted in the likelihood that deficient practices could affect patient safety and medical errors without the hospital being aware of the deficiencies. (Refer to C-342.)


Based on document request and interview, the hospital failed to ensure that the outcome of all remedial actions was documented. This failure to document the outcome of remedial actions resulted in the likelihood that identified remedial actions would not be tracked to ensure that action had been taken and that monitoring would be done. (Refer to C-343.)

Based on document request, document review and interview, the hospital failed to have an effective quality assurance program. The hospital's quality assurance program failed to: (1) provide for ongoing monitoring and data collection; (2) provide problem prevention, identification and data analysis; (3) identification of corrective actions; (4) implementation of corrective actions; (5) evaluation of corrective actions; and (6) measures to improve quality on a continuous basis. The failure to have an effective ongoing quality assurance program created the likelihood that the hospital would be unaware of adverse patient events, medication errors, and issues of patient safety on a timely basis. The findings are:

A. On 09/10/12 at 3:00 pm, the hospital was given a request for information asking for evidence that all patient care services and other services affecting patient health and safety had been evaluated. The hospital submitted a note book containing two Board Quality Reports 2012. These reports identified data for nursing, emergency services, infection control, patient safety and deaths reported to donor services. No data was provided for the following hospital services:

Respiratory
Rehabilitation
Laboratory
Pharmacy
Radiology
Nuclear Medicine
Food & Dietary
Physical Plant
Outpatient
Anesthesia

B. On 09/13/12 at 10:20 am, the Chief Executive Officer (CEO) and Director of Nursing (DON) were interviewed concerning the scope of the quality assurance program. They were asked, "Does your quality assurance program evaluate all patient care services and other services affecting patient health and safety?" The CEO stated, "Our program is incomplete." No other data for the services listed above was provided by the hospital prior to the exit.

C. On 09/13/12 at 10:20 am, the CEO and DON were interviewed concerning the extent of the quality assurance program. They were asked, "Can the hospital provide evidence that the hospital has taken appropriate remedial action to address deficiencies found through the quality assurance program?" The CEO stated, "Other than peer review, we have an incomplete program."

Based on document request, document review and interview, the hospital failed to ensure that all patient care services and other services affecting patient health and safety were evaluated for the quality and appropriateness of the diagnosis and treatment furnished by the hospital and of treatment outcomes. The hospital also failed to ensure that the quality assurance data was provided to the Medical Staff and Governing Body. The failure to evaluate diagnosis and treatment furnished by the hospital and of treatment outcomes resulted in the likelihood that significant issues affecting patient health and safety would not be identified by the hospital and the quality assurance program and not communicated to the Medical Staff or Governing Body. The findings are:

A. On 09/13/12 at 10:20 am, the Chief Executive Officer (CEO) and Director of Nursing (DON) were interviewed concerning the scope of the quality assurance program. They were asked, " Does your quality assurance program evaluate all patient care services and other services affecting patient health and safety?" The CEO stated, " Our program is incomplete." No other data for the services listed below was provided by the hospital prior to the exit.

Respiratory
Rehabilitation
Laboratory
Pharmacy
Radiology
Nuclear Medicine
Food & Dietary
Physical Plant
Outpatient
Anesthesia


B. On 09/13/12 at 10:20 am, the CEO and DON were interviewed concerning the evaluation by the quality assurance program. They were asked, "Can the hospital prove through documentation that quality assurance data was provided to the Medical Staff and Governing Body?" The CEO replied, "Only parts of it."

C. On 09/12/12 at 10:45 am the minutes of the hospital's Board of Trustees for the period between 02/2012 and 07/2012 were reviewed. During this six (6) month period there was no mention of quality assurance issues. In June 2012 the hospital's Board of Trustees did receive the Annual Critical Access Hospital Evaluation. This report met the requirement for Periodic Evaluation, but the Periodic Evaluation is not an ongoing process month-by-month to collect quality assurance data.

Based on document request, document review and interview, the hospital failed to ensure that the quality and appropriateness of the diagnosis and treatment furnished by nurse practitioners and clinical nurse specialists were evaluated by a member of the hospital staff who was a doctor of medicine or osteopathy, or by another doctor of medicine or osteopathy under contract with the hospital. The failure to evaluate the quality and appropriateness of the diagnosis and treatment furnished by nurse practitioners and clinical nurse specialists resulted in the likelihood that the hospital, the quality assurance program, the Medical Staff and Governing Body would not be aware of problems or issues with the quality and appropriateness of the diagnosis and treatment furnished by nurse practitioners and clinical nurse specialists. The findings are:

A. On 09/13/12 at 10:20 am, the Chief Executive Officer (CEO) and Director of Nursing (DON) were interviewed concerning the evaluation process of the quality assurance program. They were asked, "Can the hospital demonstrate through documentation that a doctor of medicine or osteopathy evaluated the quality of care provided by mid-level practitioners?" The CEO stated, "Only when we have an exceptional event. It is not done on a regular basis."

B. A review of six (6) months of Board of Trustee's meetings did not find that the evaluation of mid-level practitioners had been presented to the Board during that time period.

C. On 09/10/12 at 3:00 pm, the hospital was given a Request for Information on Periodic Evaluation and Quality Assurance Review. Question # 4 requested that the hospital provide "documentation that in the past year a member of the medical staff has evaluated the quality and appropriateness of the diagnosis and treatment furnished by nurse practitioners, clinical nurse specialists and physician assistants." By the time of the survey exit on 09/14/12 at 11:30 am, no evidence had been provided to demonstrate that such evaluation was being done.

Based on document request, document review and interview, the hospital failed to ensure that it had an arrangement with an outside entity to review the appropriateness of the diagnosis and treatment furnished by doctors of medicine and osteopathy. This failure resulted in the likelihood that physicians could make medical errors that went unrecognized by the hospital, putting the patients at risk. The findings are:

A. On 09/10/12 at 3:00 pm, the hospital was given a Request for Information that asked the hospital to provide "documentation that in the past year an evaluation of the quality and appropriateness of the diagnosis and treatment furnished by the hospital's medical staff have been done by an outside entity that is qualified to do such an evaluation." By the time of the survey exit on 09/14/12 at 10:30 am, no documentation had been provided.

B. On 09/13/12 at 10:20 the Chief Executive Officer (CEO) and Director of Nursing (DON) were interviewed concerning the evaluation aspect of the quality assurance program. They were asked, "Can you prove through documentation that as part of your quality assurance, the hospital has an arrangement with an outside entity to review the appropriateness of the diagnosis and treatment provided by each medical doctor and doctor of osteopathy providing services to the hospital's patients, including medical doctors and doctors of osteopathy providing telemedicine services?" The CEO stated, "No."

Based on document request and interview, the hospital failed to ensure that appropriate remedial action had been taken to address deficiencies identified through the quality assurance program. This failure to have a quality assurance program that was collecting data, analyzing the data, and identifying deficiencies resulted in the likelihood that deficient practices could affect patient safety and medical errors without the hospital being aware of the deficiencies. The findings are:

A. On 09/13/12 at 10:20 am, the Chief Executive Officer (CEO) and Director of Nursing (DON) were interviewed concerning the operation of the quality assurance program. They were asked, "Does the hospital have evidence that it has taken appropriate remedial action to address deficiencies found through the quality assurance program?" The CEO responded, "We have an incomplete program."

B. On 09/10/12 at 3:00 pm, the hospital was given a Request for Information asking for "documentation of proper remedial action that has been taken by the hospital to correct deficiencies identified in the quality assurance program." By the time of the exit on 09/14/12 at 11:30 am, the hospital was only able to provide documentation that covered a small part of the data that was required to be collected and evaluated by the Quality Assurance program.

Based on document request and interview, the hospital failed to ensure that the outcome of all remedial actions were documented. This failure to document the outcome of remedial actions resulted in the likelihood that identified remedial actions would not be tracked to ensure that action had been taken and that monitoring would be done. The findings are:

A. On 09/13/12 at 10:20 am, the Chief Executive Officer (CEO) and Director of Nursing (DON) were interviewed concerning the operation of the quality assurance program. They were asked, "Does the hospital have evidence that it has taken appropriate remedial action to address deficiencies found through the quality assurance program?" The CEO responded, "We have an incomplete program."

B. On 09/10/12 at 3:00 pm, the hospital was given a Request for Information asking for "documentation of proper remedial action that has been taken by the hospital to correct deficiencies identified in the quality assurance program." By the time of the exit on 09/14/12 at 11:30 am, the hospital was only able to provide documentation that covered a small part of the data that was required to be collected and evaluated by the Quality Assurance program.

Based on observation, clinical record review, and interview, it was determined that the hospital failed to ensure that the patient or their representative was notified in advance regarding the changes in the care and treatment of the patient (C-365); ensure the physician documented the reason that the patient was to be discharged (C-376 and C-379); and notify the patient and their representative in writing before discharging the patient (C-377) for 1 of 2 sampled swing-bed patients (#15). The hospital further failed to have a ongoing activities program for 2 of 2 sampled swing-bed patients (# 15 and 16) (C-385). The hospital failed to conduct a comprehensive assessment that contained customary routines, nutritional status, and activity pursuits for 2 of 2 sampled swing-bed patients (#15 and 16) (C-388). The hospital failed to ensure the patients or their representatives participated in the creation of the care plan for 2 of 2 sampled swing-bed patients ((#15 and 16) (C-396). The cumulative effect of these systemic practices resulted in the hospital's inability to ensure that the swing-bed patients nursing and mental well-being would be met.

Based on clinical record review and interview, the hospital failed to ensure the patient or their representative was notified in advance regarding the changes in the care and treatment of the patient for 1 of 2 sampled swing-bed patients (#15). This failed practice could lead to patients refusing care because they were not expecting the change to their care. The findings are:

A. On 09/11/12 at 3:15 pm, the Power of Attorney (POA) for Patient #15 stated that she was not told that her mother was going to be discharged on 09/06/12. She found out when she arrived to see her mother on that day.

B. Review of Patient #15's clinical record revealed a handwritten physician's order for discharge to a nursing facility on that day. Further review of the clinical record revealed no documentation that this was discussed with either the patient or the POA was found.

C. On 09/13/12 at 11:30 am, during an interview, the Director of Nursing also could not find any documentation that the patient or their representative was given prior notice regarding the discharge from the hospital.

Based on clinical record review and staff interview, the hospital failed to ensure the physician documented the reason that the patient was to be discharged in their clinical record for one of two sampled swing-bed patients (#15). This failed practice could lead to the patient being discharged before they are medically ready to be discharged. The findings are:

A. Review of the physician's handwritten, untimed orders for 09/06/12 read, "May discharge to LTC (a nursing home) today." Further review of the physician's order and progress notes revealed no documentation for the rationale for discharge.

B. On 09/13/12 at 10:45 am, the Director of Nursing confirmed that the physician did not write a reason for the discharge.

Based on clinical record review and interview. the hospital failed to notify the patient and their representative in writing before discharging the patient for 1 of 2 sampled swing-bed patients (#15). This failed practice could lead to patient and their representative not to be prepared for the discharge and have that patient a safe place to stay. The findings are:

A. Review of the Patient #15's clinical record revealed no documentation that the patient or their representative were told when the patient would be ready for discharge.

B. On 09/11/12 at 3:15 pm, during an interview, Patient #15's daughter and Power of Attorney stated she was not given a written notice of discharge prior to the discharge. She had to ask for the discharge orders after the doctor had written them.

C. On 09/13/12 at 10:45 am, during an interview, the Director of Nursing stated that she could not find any documentation that the patient or the daughter had been given a written notice of discharge prior to the doctor witting the discharge order.

Based on clinical record review and staff interview, the hospital failed to ensure the physician documented the reason that the patient was to be discharged on a written notice of discharge for one of two sampled swing-bed patients (#15). This failed practice could lead to the patient being discharged before the patient is medically ready to be discharged. The findings are:

A. Review of the physician's handwritten, untimed orders for 09/06/12 read, "May discharge to LTC (a nursing home) today." Further review of the physician's order and progress notes revealed no documentation for the rationale for discharge.

B. On 09/13/12 at 10:45 am, the Director of Nursing confirmed that the physician did not write a reason for the discharge.

Based on observation, clinical record review, and interview, the hospital failed to have an ongoing activities program for 2 of 2 sampled swing-bed patients (# 15 and 16). This failed practice could lead to patients having a decline in emotional and physical well-being. The findings are:

A. On 09/11/12 between 9:00 am and 11:45 am and 1:00 pm and 4:00 pm, no activities were observed to be done or offered to either Patient #15 or Patient #16.

B. On 09/12/12 between 9:00 am and 11:45 am and 1:00 pm and 4:00 pm, no activities were observed to be provided or offered to either Patient #15 or Patient #16.

C. Review of the clinical records revealed the following information:
1. Patient #15 was admitted to the swing-bed on 08/29/12. She was lethargic, but fully orientated.
2. Patient #16 was admitted to the swing-bed on 08/28/12. She was alert and fully orientated.
3. No documentation that ongoing activities were offered or done with the patients during their stay in the swing-beds for both patients.

D. On 09/11/12 at 3:00 pm, during an interview, Patient #16 stated that she had not been offered any activities, but she watches television and occasionally does therapy.

E. On 09/11/12 at 3:15 pm, during an interview, the Power of Attorney for Patient #15 stated that she had not been offered any activities, but she watches television and occasionally does therapy.

F. On 09/13/12 at 10:20 am, during an interview, the occupational therapy assistant that is in charge of the activities for the swing-bed stated that she did not know that the activities needed to be ongoing and that there needed to be documentation to show what the patients did during the day.

Based on clinical record review and staff interview, the hospital failed to conduct a comprehensive assessment that contained customary routines, nutritional status, and activity pursuits for 2 of 2 sampled swing-bed patients (#15 and 16). This failed practice could result in the patient not receiving the necessary services to fully gain optimum health. The findings are:

A. Review of Patient #15's and 16's Resident-Data Collection revealed no information about customary routines, nutritional status, and activity pursuits.

B. On 09/13/12 at 10:45 am, during an interview, the Director of Nursing confirmed that neither assessment had information about customary routines, nutritional status, and activity pursuits.

Based on interview, the hospital failed to ensure the patients or their representatives participated in the development of the care plan for 2 of 2 sampled swing-bed patients ((#15 and 16). This failed practice could result in the patients not receiving all of the services necessary for their health to improve. The findings are:

A. On 09/11/12 at 3:00 pm, during an interview, Patient #16 stated that she did not participate in the development of her care plan when she was asked about this.

B. On 09/11/12 at 3:15 pm, during an interview, Patient #15's Power of Attorney stated she was not asked to participate in the development of her mother's care plan.