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At the time of the revisit 9/19/2011, this deficiency was not corrected.

Based on review of personnel files and interviews with hospital staff, the hospital failed to ensure the Director of Nursing (DON), or designee, provided orientation and evaluation of agency or contracted personnel.

Findings:

1. On 9/19/2011 surveyors requested a registered nurses file, Staff R, who contracted with the hospital to provide peripherally inserted central line catheters (PICC) lines. There was no evidence that staff R nurse's competencies had been evaluated by the facility.

2. On 9/19/2011 surveyors requested Staff G and H personnel files. Staff A told surveyors Staff G and H worked for a physician and assisted the physician in ophthalmic cases performed at the facility. The facility did not have qualification, competencies, orientation to the facility or any facility evaluations.

The above findings were reviewed with the administrative team at the exit conference the afternoon of 9/19/2011. No further documentation was provided.

Based on record review and interviews with hospital staff, the hospital does not ensure a practitioner authorized to write orders by hospital policy and in accordance with State law and who is responsible for the care of the patient as specified under CFR 482.12(c) is writing orders for patients. Three (#'s 6, 12 & 13) of five patient records which had telephone/verbal orders, progress notes and history and physicals written by a fourth year medical student who was not authorized to write orders without supervision by the ordering physician. There was no documentation in Patient # 12's record that the patient was ever seen by the admitting physician during the patient's stay. The patient was admitted on 09/07/11 and discharged on 09/10/11.

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

Based on medical record review, interviews with staff, and policy review the facility failed to provide nutritional assessments by a qualified dietitian when ordered.

Findings:

1. Patient #6's medical record included physician orders for a consult by the dietitian. There was no documentation in the chart the dietitian had performed a dietary consult.

2. According to the hospital's policy on nutritional screen, all patients with multiple comorbidities will have a nutrition assessment triggered through the nutritional screen. Two (6,12) of three medical records reviewed for screens and assessments did not have a nutritional screen and/or assessment. This finding was reviewed with Staff A, Staff B, and Staff I on the afternoon of 9/19/2011.

These findings were reviewed in the exit interview. No further information was provided.

At the time of the revisit on 09/19/2011, this deficiency was not corrected.

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Based on staff interviews and record review, the facility failed to ensure that surgical services maintained standards of safe patient care.

Findings:

1. The policy developed for "flash"/immediate use sterilization did not specify:
a. The process would only be used in case of emergency, as in a dropped instrument or unexpected need of a specialty instrument.

b. The process would not be used for convenience or routine sterilization because the facility did not have enough instrument sets.


2. Since the survey on 08/03/2011, the surgical services department continued the process of "flash"/immediate use sterilization for finger sets, tonsils and adenoids, and bilateral myringotomies. The surgical services department failed to limit the use of "flashed"/immediate use instruments or explore other options so that instruments could be properly sterilized until ordered instrument sets could be obtained.