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Based on hospital document review, record review, personnel file review, observations and staff interviews, the hospital failed to ensure Emergency Services:

1. provided adequate, experienced, and trained nursing staff in the emergency department (ED);

2. were reviewed and included as part of the Performance Improvement and Quality Assessment program (Compliance); and

3. developed ED policies and procedures currently based on national standards of practice.

Findings:

1. On the afternoon of 06/26/14, surveyors reviewed the ED log.

A. 90% of the ED triage log documented patients were triaged incorrect. These findings upon review were discussed with hospital administration.

B. One personnel file (staff K) documented, "ESI Triage Course Post Test 73%. Worked all night." ESI Triage competency passing score was 80%.

Seven (K, W, X, Y, Z, AA, and BB) of seven personnel files reviewed for triage competencies.

C. The Quality Coordinator verified that Staff K did not pass the ESI Triage test yet was still triaging patients coming into the ED.

D. On the morning of 06/26/14, surveyors observed one (#12) of one open medical record. Staff W told surveyors, "I would have triaged this patient as a level 2 because the patient had an oxygen saturation of 74% and is in respiratory distress."

The medical record documented the patient was triaged as a level 4. (The facility uses a five level triage system. Level 1-resuscitation, 2-emergent, 3-urgent, 4-less urgent, 5-nonurgent.)

E. On the afternoon of 06/25/14, surveyors reviewed 17 (#3 through 11 and #13 through #20) of 17 closed medical records. All 17 medical records reviewed documented incorrect triage assignment.

2. Meeting minutes for Compliance, Medical Staff and Governing Body did not reflect services provided in the ED were reviewed, evaluated/analyzed with corrective action taken when indicated through the quality program. The Regional Quality Manager verified the findings at the time of review.

3. ED policies and procedures were not current.

A. On the afternoon of 06/25/14, surveyors asked the Hospital Administrator for all ED policies and procedures. The Hospital Administrator informed surveyors that the ED policies and procedures were being updated and worked on as they were outdated.

B. On the afternoon of 06/25/14, surveyors received a black binder from hospital administrative staff that contained ED policies and procedures titled, "Watonga Municipal Hospital." Surveyors observed "Watonga Municipal Hospital" policies and procedures were last reviewed and revised in 2009.

C. Administrative staff told surveyors that the hospital was purchased and changed its name July 1, 2012.

Based on document review and staff interview, the hospital did not ensure all patient care equipment was maintained in safe operating condition.

Findings:
On the morning of 06/25/2014, surveyors toured the facility with the Administrator.

A. Surveyors observed a portable HEPA filtration purification system on the medical floor. There was no documented evidence that indicated the portable HEPA filtration purification system was working properly and safe for patient use.

B. The Hospital Administrator told surveyors maintenance had been servicing the portable HEPA filtration system but had not be tested or inspected.

Based on document review, record review, policy and procedure review and staff interview, the hospital failed to:

1. Ensure that drug storage areas are administered according to accepted professional principles and hospital policy and procedures and all outdated, mislabeled or otherwise unusable drugs are unavailable for patient use. See Tag # 0276;

2. Ensure procedures for reporting, investigating, and analyzing medication errors are effective to reduce/prevent reoccurances. See Tag # 0277;

3. Develop and maintain an effective ongoing infection control program, directed by a qualified staff with training, that reviewed, analyzed and provided corrective actions to prevent and reduce spread of hospital acquired infections and communicable diseases. See Tag # 0278

4. Ensure patient care policies are reviewed annually by the group of professional personnel as required.

5. Ensure all services provided by contract or agreement are evaluated by the hospital's quality program.

6. Ensure nursing staff were trained and evaluated on competency to perform the essential functions of their jobs.

Based on observation, document review and staff interview, it was determined the hospital failed to ensure:

1. Current and accurate records are maintained of the receipt and disposition of all scheduled drugs in accordance with Federal and State laws.

2. The hospital does not ensure that the records are in order and all scheduled drugs are maintained and reconciled.

3. The drug room does not maintain records of scheduled drugs with sufficient detail to follow their flow from their entry into the hospital through dispensation and administration or wastage in a readily retrievable manner.

4. The pharmacist was involved in the review, investigation, analysis, action-planning, monitoring and trending of medication errors within the facility;

5. All drugs and biologicals were stored in accordance with accepted professional principles and practices; and

6. Pharmacy services department operated with current policies and procedures in accordance with professional principles and practices.

Findings:

1. The scheduled drug ledgers had red pen marks that circled amounts of certain medications with amounts that did not match the count. The drug room supervisor said that the number of medications was entered in the wrong column but the pharmacist had accounted for the correct medication balance.

2. Surveyors did not see any documented evidence that the red circled amounts in the scheduled medication ledgers were the correct count by the pharmacist.

3. On the morning of 06/26/14, surveyors asked the drug room supervisor to explain the process of tracking narcotic wastes. The drug room supervisor told surveyors, that there was no way for pharmacy to track what narcotics are being wasted and that the Omni cell (automatic dispensing system) does not require that documentation.

On the afternoon of 06/26/14, the drug room supervisor demonstrated the use of the automatic dispensing system which did not require documentation of narcotic wastes. Hospital Administration was immediately notified.

The DON from another affiliate hospital, Regional Quality Manager, and the facility's Quality Coordinator verified that the automatic dispensing system did not require documentation of narcotic waste.

4. Medication error reports for October 2013 through June 2014 were reviewed. None of the error reports documented involvement/oversight by the pharmacist and had no documentation that the pharmacist was involved in the review, investigation, analysis, action-planning, monitoring and trending of medication errors.

On 06/26/14, the drug room supervisor was asked if the pharmacist was involved in the analysis of medication errors. The drug room supervisor stated, "I thought she was."

5. Surveyors toured the hospital on the morning of 06/25/14 with the Hospital Administrator, where the following observations were made:

In a room repurposed and now being used for the emergency department (ED) supply room there were:
12 bottles of Sterile Water 500 milliliters (mLs)
4 bottles of Sodium Chloride 500 mLs
10 bottles of infant formula
6 bags Normal Saline 1 liter (L)

In the ED there was:
1 Hibiclens 4 ounce bottle single use item being used for multiple patients, open and not dated.
1 Isopropyl Alcohol bottle 32 fluid ounces with a retail store's price tag affixed, opened, half used and not dated.
1 Antimicrobial skin cleaner 4 ounce spray bottle single patient use, opened, half used, and not dated.
2 Prefilled syringes Normal Saline 10mLs
2 Normal Saline 1 L bag

Surveyors asked staff Y what the Isopropyl Alcohol was used for and staff Y stated, "I don't know." Staff Y did indicate that single use items were used for multiple patients but did not know when the bottle was first opened and when it expires.

6. The drug room policies and procedures were not current and had not been reviewed and approved annually by the supervising pharmacist.

7. The findings were discussed with hospital administration at the exit interview. No further documentation was provided.

Based on document review, medical record review, and staff interviews, the hospital failed to ensure that medication errors and adverse drug events are evaluated to determine possible causative factors and create systems to prevent their reoccurrence.

Findings:

1. On the morning of 06/26/14, surveyors asked the drug room supervisor how the facility looked at medication errors. The drug room supervisor told surveyors that they randomly select charts and do audits or pull Omni Cell reports and look for discrepancies.

The drug room supervisor pulled a report from the Omni Cell and showed the surveyor that a provider ordered Morphine Sulfate 5 milligrams (MG) intravenous (IV) once and the medical record for that specific patient had documentation by the registered nurse who was caring for the patient administered Morphine Sulfate 8 MG IV. There was no evidence this medication error was analyzed and a plan of action developed to prevent their reoccurrence.

2. The drug room supervisor told surveyors on the afternoon of 06/26/14 that she reports all medications errors to the pharmacist and the director of nursing.

3. The Consultant Pharmacist's weekly reports did not have any review of medication errors and adverse drug events.

4. Review of Governing Body, Medical Staff, and Pharmacy and Therapeutic (P & T) committee meeting minutes for 2013 and 2014 did not have any review or evaluation of medication errors or adverse drug events. The documentation just gave numbers, no evaluation of the medication errors.

Based on infection control meeting minute review, infection control surveillance review, infection control policy and procedure review, and staff interview, the hospital failed to have an active surveillance program that includes specific measures for prevention, early detection, and investigation of infections and communicable diseases in the hospital.

Findings:

1. On the morning of 06/25/2014, surveyors requested and reviewed, infection control meeting minutes, infection control surveillance activity, and infection control policies and procedures.

2. There was no documentation the disinfectants that were used in the hospital were reviewed and approved by the infection control practitioner, the infection control committee, and medical staff.

3. On the morning of 06/25/2014, Staff T told surveyors that the disinfectants used in the hospital were the disinfectants used at the affiliated hospital and the disinfectants had not been approved for use at this hospital.

4. There was no documentation that employee illnesses were reviewed and tracked. On the morning of 06/25/2014, Staff T told surveyors that employee illnesses were not reviewed and tracked.

5. There was no documentation of a current infection control plan for the hospital. On the morning of 06/25/2014, surveyors reviewed an infection control plan for the affiliated hospital. The infection control plan contained plans for ventilator patients and patients with central lines. The hospital does not care for patients on ventilators or patients with central lines. Staff T and Staff H told surveyors that this infection control plan is the only infection control plan the hospital had.

6. There was no documentation of environmental rounds to include all areas of the hospital such as dietary, radiology, lab, emergency department, and the medical surgical floor.

7. On the morning of 06/25/2014, Administrative staff told surveyors that laundry service is a contracted service. Staff H told surveyors that she had not observed laundry processes but planned to.

8. The infection control policies and procedures were last reviewed in 2009.

Based on hospital document review and staff interview, the hospital failed to ensure all contracted services and shared services comply with the Critical Access Hospital (CAH) conditions of participation.

Findings:

1. On the morning of 06/25/2014, surveyors requested a list of all contracted and shared service agreements to include what services were provided. A contracted service list was provided.

2. On the morning of 06/27/2014, Staff C told surveyors that the CAH does not evaluate all contracted and shared services.

Based on clinical record review, policy and procedure review, personnel file review, and staff interview, the hospital failed to provide:

1. written policies and procedures to ensure the integrity and security of electronic medical records and only view when necessary.

2. clinical records that were complete and documented all care provided and sufficient information in the clinical record in order to monitor the patient's condition and provide adequate care.

3. staff signatures on all clinical records and authentication of all entries made in the medical record.

4. failure to provide policies and procedures to guide the staff on the use and retrieval of electronic medical record system is down.

Findings:

1. Surveyors asked staff MM and staff NN (an employee at an affiliate hospital) how the hospital ensures clinical records are viewed only by those providing care. Staff MM did not know. Staff NN told surveyors they could call headquarters who then would run a report.

2a. Twenty (#1 through #20) of twenty records reviewed contained documentation by emergency department (ED) nurses of medical diagnoses as the patients' chief complaint.

2b. On the morning of 06/26/14, staff W told surveyors, "There is no option to free text the patient's chief complaint, there is only the option to pick a medical diagnosis. We nurses have to figure out what is the closest diagnosis to the chief complaint."

2c. On the morning of 06/26/14, staff Z told surveyors, "The medical record won't allow free texting, so I have to choose a medical diagnosis. This is the only option we have."
2d. Surveyors observed staff W attempting to free text a chief complaint into the electronic medical record under a current patient. The medical record did not accept free texting and only allowed the staff to choose a preloaded medical diagnosis.

2e. Surveyors reviewed 18 (#3 through #20) of 20 medical records, surveyors were unable to determine what care was provided to patients.

2f. There was no documented evidence of comprehensive nursing assessments in 18 (#3 through #20) of 20 records reviewed.

2g. A hospital document titled, "Patient Assessment and Reassessment Watonga Municipal Hospital Nursing Policy Manual" documented, "...all patients admitted to the facility will receive a complete head to toe assessment...The assessment of the care and/or treatment needs of the patient will be continuous throughout the patient's hospitalization..."

2h. There was no documented evidence of dietary assessments in 18 (#3 through #20) of 20 records reviewed.

2i. There was no documented evidence of patient responses to treatments and interventions in 18 (#3 through #20) of 20 records reviewed.

2j. There was no documented evidence of patient nursing assessments and reassessments completed in the ED and upon admission to the floor in 18 (#3 through #20) of 20 records reviewed.

2k. There was no documented evidence of notification to the provider in 18 (#3 through #20) of 20 records reviewed for patients with abnormal vital signs.

2l. There was no documented evidence of interventions done if there were abnormal values documented in 18 (#3 through #20) of 20 records reviewed.

2m. There was conflicting documentation in patient #12's medical record.

2n. These findings were verified by staff W, the Regional Quality Manager, and the Hospital Administrator.

3a. On the afternoon of 06/26/14, the facility was unable to provide surveyors with a list of authenticated user names, initials, and titles. Staff NN (HIM supervisor of an affiliate hospital) told surveyors there is not a list but one can be generated from headquarters.

3b. On the afternoon of 06/25/14, surveyors reviewed one (#12) of one open medical record. Staff W and the Regional Director of Quality were both unable to identify the authors of entries in the emergency department section of the patients medical record.

3c. On the afternoon of 06/25/14, surveyors reviewed patient #12's medical record. The medical record documented, "74% oxygen saturation" without evidence of the author.

4a. Staff MM, a health information technician told surveyors on the afternoon of 06/26/14, there are not medical records policies and procedures for the facility where she is an employee but can access an affiliate hospital's medical records policies and procedures.

4b. On the afternoon of 062614, the Hospital Administrator told surveyors that there is no medical records supervisor/manager at their facility, they use staff NN an employee at an affiliate hospital.

4c. On the afternoon of 06/26/14, surveyors requested medical records policies and procedures that help guide staff when the electronic medical record is down. None was provided.

5. The above findings were verified with the administrative staff at the time of review and at the exit conference. No other documentation was provided.

Based on record review and interviews with hospital staff, the hospital does not ensure that the hospital performs a periodic evaluation and quality assurance review as required with the Critical Access Hospital (CAH) conditions of participation. The hospital has not conducted an annual periodic evaluation and does not have an effective and ongoing quality assurance program.

Findings:

1. The hospital does not ensure that a yearly periodic evaluation was conducted which included a representative sample of active and closed medical records.

2. The hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes a review of the CAH's health care policies. See Tag # 0334.

3. The hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes an evaluation of the utilization of services, if policies were followed and what changes if any were needed.

4. The hospital does not have an effective Quality Assurance Performance Improvement (QAPI) program to evaluate the quality and appropriateness of the diagnosis and treatment furnished. See Tag # 0336.

5. The hospital does not have an effective quality assurance program implemented to evaluate nosocomial infections and medication therapy.

6. The hospital does not have a functioning QAPI system is implemented so that remedial action can address deficiencies found through the QAPI program.
See Tag # 0343.

Based on record review and staff interviews, the hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes a review of the CAH's health care policies.

Findings:

1. Governing Body and Medical Staff meeting minutes for 2013 and 2014 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

2. Review of all selected hospital services had no documentation of yearly review as required. All hospital department policy and procedure manuals (except Radiology and Dietary) were not current and were being revised and updated.

3. On the afternoon of 06/27/14, findings were verified by the Hospital Administrator.

Based on record review and staff interview, the hospital does not ensure that the hospital has an effective Quality Assurance Performance Improvement (QAPI) program to evaluate the quality and appropriateness of the diagnosis and treatment furnished. There was no evidence of the hospital conducting a collection and analysis of data concerning the quality and appropriateness of all patient care furnished in the CAH.

Findings:

1. Governing Body and Medical Staff meeting minutes for 2013 and 2014 did not contain evidence of any analysis of data presented to identify problems, evaluate situations, and take corrective actions.

2. The hospital provided a QAPI plan for the hospital for review but the quality data provided to surveyors did not include any analysis, surveillance, and performance improvement based on findings.

3. Hospital staff verified on 6/27/2014 in the afternoon that the hospital's QAPI program is receiving data but not analyzing, evaluating, or taking corrective actions from the data.

Based on record review and staff interviews, the hospital failed to ensure that a functioning quality assessment and performance improvement (QAPI) system was implemented so that remedial action can address deficiencies found through the QAPI program.

Findings:

1. Review of Governing Body and Medical Staff meeting minutes for 2013 and 2014 and interviews with hospital staff during the survey did not have evidence the hospital had a functioning QAPI program that identified deficiencies and implements remedial action.

2. There was no evidence medication errors identified by the Consultant Pharmacist were analyzed and a plan of action instituted through a functioning QAPI program.

3. There was no evidence that deficient nursing practices identified and reviewed by the director of nursing were addressed through the QAPI program.

4. There was no evidence that the hospital had an infection control program specific to their facility's needs identified by the infection control practitioner and addressed through the QAPI program.

5. There was no evidence that the hospital had identified and addressed nursing that documented medical diagnoses for patients that presented to the emergency department through the QAPI program.

Based on staff interview and review of personnel files, the hospital failed to have a system in place that prevents mistreatment, neglect and abuse of residents. This occurred in 16 of 18
( A, B, C, D, E, F, G, H, I, J, K, L, O, P, Q, R, S, & T ) personnel files reviewed.

Findings:

1. On the morning of 06/26/2014, surveyors reviewed 18 personnel files. Sixteen of eighteen personnel files reviewed (A, B, C, D, E, F, G, H, I, J, K, L, O, P, Q, R, S, & T) did not contain nurse aide registry checks.

2. On the morning of 06/26/2014, Staff S told surveyors that the hospital does not conduct nurse aide registry checks on all staff.