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Based on document review and interview, the survey hospital's written agreement for distant-site radiology services furnished to its inpatients failed to indicate the responsibility of the distant-site hospital's governing board to assure that all medical staff providing radiology services maintained their medical staff membership and privileging requirements in accordance with all Federal conditions of participation pertaining to the governing body requirements for medical providers furnishing the service. The survey hospital failed to document privileging of the radiologists associated with the distant-site facility providing radiology services including evidence of a medical staff recommendation based upon the decisions of the distant-site hospital or based upon a credential file review for each distant-site radiologist by the survey hospital.

Findings:

1. Review of the written agreement for radiology services between the survey hospital and the distant-site hospital failed to indicate the responsibility of the distant-site hospital ' s governing board to assure that all medical staff providing radiology services maintained their medical staff membership and privileging requirements in accordance with all Federal conditions of participation pertaining to the governing body requirements for medical providers furnishing the service.

2. During an interview on 4-01-14 at 1100 hours, administrator A1 confirmed that the agreement lacked the indicated provision.

3. On 3-30-14 at 1115 hours, staff A1 and A2 were requested to provide evidence of hospital privileging for the radiology service practitioners including a medical staff recommendation based upon a hospital-based credential review for each practitioner or based upon the decisions of the distant-site hospital.

4. During an interview on 4-01-14 at 1550 hours, staff A1 confirmed that the facility lacked evidence of hospital privileging for the distant-site radiology service practitioners.

Based on document review and interview, the facility failed to maintain a list of all contracted services, including the scope and nature of services provided for 5 of 25 contracted services.

Findings:

1. The list of contracted services failed to indicate a provider for biohazardous waste disposal, biomedical engineering, fire extinguisher service, fire alarm monitoring and maintenance, and emergency generator maintenance services.

2. Review of facility maintenance documentation indicated the following: biohazardous waste disposal by CS1, fire extinguisher service by CS2, fire panel monitoring and certification by CS3, and generator service by CS4.

3. During an interview on 3-31-14 at 1630 hours, staff A2 confirmed that the facility lacked a biomedical service provider.

4. During an interview on 4-01-14 at 1530 hours, administrator A1 confirmed that the list of contracted services lacked a provider for the indicated services.

Based on policy and procedure review, medical record review, and interview, the facility failed to ensure that the type of restraint was ordered when a restraint order was given, and failed to ensure the authentication of restraint and seclusion orders, as per facility policy, for 2 of 2 patients who had restraint orders (pts. #7 and #8).

Findings:
1. review of the policy and procedure "Physician Orders - Inpatient", policy number MD1110, last reviewed July 1, 2013, indicated:.
a. under "Procedure", it reads in section 2.0: "Authentication of physician or APN (advanced practice nurse) verbal orders 2.1 Ideally, each physician or APN should sign his/her own verbal orders within 48 hours of the time the order was given;..."

2. review of the policy and procedure "Original Order to Restrain or Seclude and One Hour Face-to-Face Evaluation", policy number FA0407, with a last review date of January 1, 2014, indicated:
a. the policy does not address that the type of restraint/restraints the provider may order must be stated in the order
b. the policy does not address a time frame for authentication of telephone or verbal orders for restraint or seclusion for patients
c. the forms attached to policy number FA0407 with the numbers FA0407 and FA0486 and FA0488 and a revised date of 01/01/14, lacks the type of physical restraint the provider is ordering

3. review of the policy and procedure "Restraint/Seclusion Initiation", policy number \POLDOC\FA0488, with a last review date of January 1, 2014, indicated:
a. under "Statement of Information:", it reads in section 3.: "Upon receiving orders for a restraint or seclusion, the date, time and type of restraint or seclusion is to be noted..."

4. review of patient medical records indicated:
a. pt. #7 had:
A. a telephone order written at 4:15 AM on 1/19/14 that read: "Seclude/Restraint for violent agitated behavior..."
B. a form FA0488, that had "Restrain: Seclusion: and Chemical restraint" checked, but lacked specificity of the type of restraint ordered
b. pt. #8 had:
A. a telephone order at 1418 hours on 8/18/13 for "...4 [hour] Seclusion et (and) restraint"
B. a telephone order on 8/2/13 at 1614 hours to "Restrain et Seclude...for up to 4 hrs..."
C. had forms FA0488 that had "Restrain: Seclusion: and Chemical restraint" checked, but lacked specificity of the type of restraint ordered

5. interview with staff member #51, the director of nursing, at 3:10 PM on 3/31/14 and at 2:07 PM on 4/4/14, per phone, indicated:
a. the facility utilizes two types of restraint: a "come along" velcro restraint used on the upper body, and "velcro 4 point" restraints
b. the orders given, and the forms listed in 3 above, do not specify which type of restraint the practitioner is ordering
c. physicians were unaware that there was a policy specifying authentication of verbal and telephone orders within 48 hours

Based on document review and interview, the professional staff bylaws failed to assure that the
individual responsible for the organization and conduct of the credentialed professional staff was a doctor of medicine or osteopathy, dental medicine or dental surgery, or a doctor of podiatric medicine.

Findings:

1. The Professional Staff Bylaws (approved 2-14) indicated that the Chairperson of the PSO [A10] signed the Bylaws as the representative of the PSO and indicated that "...The chairperson shall be responsible to the Chief Clinical Officer ..." rather than the Chief Medical Officer [CMO].

2. During an interview on 4-01-14 at 1535 hours, compliance officer A8 confirmed that the bylaws failed to assure that the PSO chairperson was accountable to the CMO.

Based on document review and interview, the facility failed to assure that professional staff completed documentation of an update (including any changes in patient condition) within 24 hours of admission for all History and Physical (H&P) examinations completed within the authorized period prior to admission by the qualified licensed professional.

Findings:

1. The Professional Staff Bylaws (approved 2-14) indicated the following: "Medical Records Requirements [page 24] All PSO members will abide by the policies and procedures of the Center in regard to the documentation of treatment."

2. The policy/procedure History and Physical Examinations - Inpatient (approved 1-14) failed to indicate a requirement for documenting an H&P update by the qualified professional staff within 24 hours of the patient ' s arrival to the facility.

3. During an interview on 4-01-14 at 1335 hours, staff A8 confirmed that the professional staff policy/procedure lacked the indicated provision.

Based on policy and procedure review, medical record review, and interview, the nursing staff failed to implement orders for CIWA (clinical institute withdrawal assessment) scale protocol at the time of admission orders for one patient (pt. #5).

Findings:
1. review of the policy and procedure "CIWA Evaluation Form", policy number FA0414, with a last review date of July 1, 2013, indicated:
a. under "Procedure", it reads in section 4.0, "If the physician deems detoxification is needed, CIWA protocol will be ordered. The nursing staff will complete CIWA orders and protocol."

2. review of medical records indicated:
a. pt. #5 had :
A. orders on admission 2/2/14 at 6:20 PM for CIWA every 4 hours "while awake"
B. nursing noted that the patient arrived to the unit "...in wheelchair..."at 7:00 PM; that the patient was "...on phone with friend..." at 7:35 PM; and that the nursing admission assessment was completed at 8:00 PM
C. documentation on the "Psychiatric Close Observation Record" form indicating the patient was in their room with staff from 7:45 PM to 8:45 PM; in the "Dining/Activity Room" with peers from 9:00 PM to 9:45 PM and then in their room "Quiet" from 9:45 PM to 10:45 PM; and noted as "sleeping" beginning at 10:45 PM
D. the first CIWA assessment done on 2/3/14 at 6:25 AM when the patient scored at 15

3. interview with staff member #51, the director of nursing, at 4:50 PM on 3/31/14 and 8:30 AM and 11:30 AM on 4/1/14, indicated:
a. "it takes a long time to do an admission assessment" so that nursing may not have had time to do the CIWA the evening of admission for pt. #5
b. nursing doesn't have to do a CIWA assessment "while a patient is in bed, or sleeping, nursing can determine when they want to complete an assessment"
c. with the physician order at 6:20 PM for CIWA protocol, it appears that nursing had time to begin the CIWA assessment at some time between 7 PM, when the patient arrived on the unit, and 10:45 PM when the patient was first noted as sleeping--waiting until 6:25 AM, when the patient scored high--15, was not following/implementing physician orders for a detoxing patient who was at risk

Based on policy and procedure review, document review, medical record review, and interview, the facility failed to ensure the timing and/or completion of medical records by staff for 6 of 8 patients (pts. #1 through #5 and #8).

Findings:
1. review of the policy and procedure "Chart Document - Inpatient", policy number CR1115, with a last date reviewed of July 1, 2013, indicated:
a. under "Policy Statement", it reads: "A complete, concise and accurate medical record for Inpatient will be maintained on each patient for services provided by patient care personnel."
b. under "Procedure", it reads in section 4.0: "...4.3 All entries should be neat, legible, accurate, concise and written in black ink..."

2. review of the policy and procedure "Inpatient Nursing Assessment", policy number \POLDOC\CR1140, with a last review date of July 1, 2012, indicated:
a. under "Guidelines for use of Nursing Assessment Record", it reads in section 8.0: "After the nursing assessment is taken at admission, vitals will be taken every shift for three days or more often as indicated and weekly thereafter..."

3. review of the policy and procedure "Graphic Record Form - IP", policy number FA0423, with a last review date of July 1, 2012, indicated:
a. under "Policy Statement", it reads: "This form is utilized each shift to record temperature, pulse, blood pressure, height, and weight. Vitals are taken one (1) time per shift for the first 3 days after admission."

4. review of the document titled "Nursing Assessment Form", an attachment to the policy FA0418, with a last revised date of 07/01/04, indicated:
a. at the top of the page, the "Instructions" read: "Place your initials and time in the appropriate box...A nursing assessment shall be completed one time each 8 hour shift by the RN (registered nurse) or designated LPN (licensed practical nurse)."

5. review of medical records indicated:
a. pt. #1 was admitted on 2/28/14 and lacked:
A. a third set of vital signs on the evening/night shift the day of admission, 2/28/14 (had 11 AM and 5 PM vital signs, but lacked later shift vitals)
B. on the Nursing Assessment Form: the time of assessment for the 2300 to 0700 assessment on 3/22/14; the 1500 to 2300 shift on 3/23/14; and the 2300 to 0700 and 0700 to 1500 shifts on 3/30/14
b. pt. #2 was admitted on 3/22/14 and lacked:
A. a date of authentication of physician orders written 3/26/14 at 9:30 AM
B. on the Nursing Assessment Form: the time of assessment for the 0700 to 1500 shift and the 1500 to 2300 shift on 3/24/14; the 0700 to 1500 shift on 3/26/14 and 3/27/14; the 2300 to 0700 shift on 3/28/14; and the 0700 to 1500 shift on 3/29/14
c. pt. #3 was admitted on 3/28/14 and lacked:
A. on the Nursing Assessment Form: the time of assessment for the 2300 to 0700 and 1500 to 2300 shifts on 3/30/14
d. pt. #4 was admitted on 3/27/14 and lacked:
A. on the Nursing Assessment Form: the time of assessment for the 2300 to 0700 and the 0700 to 1500 shifts on 3/29/14 and the 2300 to 0700 shift on 3/30/14
e. pt. #5 was admitted on 2/2/14 and lacked:
A. a third set of vital signs on 2/3/14 (vitals at Midnight and 9 PM only)
B. on the Nursing Assessment Form: the time of assessment for all three shifts on 2/7/14; 2/8/14; 2/9/14; and 2/10/14
f. pt. #8 was admitted on 8/17/13 and lacked:
A. on the Nursing Assessment Form: the time of assessment for all three shifts on 8/18/13; 8/19/13; and 8/20/13

6. interview with staff member #51, the director of nursing, at 3:10 PM on 3/31/14, indicated:
a. nursing staff were unaware that the "time" needed to be documented with each shift assessment and thought it was OK to just put it in the correct shift area, such as 0700 to 1500
b. without putting the specific time of assessment on the Nursing Assessment Form, it is not clear exactly when the assessment was performed and does not follow the instructions at the top of the form

Based on document review, observation and interview, the facility failed to maintain its equipment and supplies for 1 medical device and 1 floor maintenance equipment observed on a tour of the facility.

Findings:

1. During a tour of the facility on 3-31-14 at 1510 hours, the following condition was observed: a Welch Allyn AED 10 (automatic external defibrillator) without evidence of preventive maintenance. Staff A4 was requested to provide evidence of periodic maintenance and testing and none was provided prior to exit.

2. Documentation provided on request indicated that AED product manufacturing by Welch Allyn was discontinued in 2009 and indicated that effective 3-31-14 that the device would no longer be supported by the manufacturer.

3. During an interview on 3-31-14 at 1630 hours, staff A4 confirmed that the facility lacked a biomedical service provider and confirmed that no documentation of preventive maintenance for the AED was available.

4. During a tour of the facility on 3-31-14 at 1537 hours, the following condition was observed in an environmental services storage room: a broken ground pin on the male power cord connector for a 170 rpm Viper 20" floor scrubber.

5. During an interview on 3-31-14 at 1540 hours, staff A1 confirmed that the equipment had not been maintained to an acceptable level of safety.

Based on policy and procedure review, personnel file review, and interview, the infection control committee failed to ensure the continuing education of the infection preventionist related to infection control practices, and based on observation and interview, the infection control committee failed to ensure the cleanliness of the staff pantry area and refrigerators in the central supply room #304.
Findings:
1. Review of the policy and procedure RMO 140, " Infection Control Monitoring and Education " , with a last review date of July 1, 2013, indicated:
a. Under " Procedure " , in section 4.0 " The Responsibilities of the Risk Management and Environment Safety Subcommittee for Infection Control Activities " , it reads: " 4.1 Specific member responsibilities for Infection Control: .1 Bring clinical, administrative, or epidemiological expertise to the committee; ... "
2. Review of the education documentation for the infection preventionist (staff member #51), indicated the only education, related to infection control, for 2013 was one hour for hand hygiene as presented by the WHO (world health organization)-no documentation was found for 2012
3. Interview with staff member #51 confirmed that:
a. there was no other continuing education received, related to infection prevention practices, for this infection preventionist in 2012 or 2013
b. it cannot be determined what epidemiological expertise staff member #51 possesses to act as the infection control preventionist for the facility
4. While on tour of the facility in the company of staff member #51, the infection preventionist and director of nursing, it was observed:
a. at 1:00 PM on 4/1/14, in the staff break room, it was observed that were:
A. crumbs at the back of the freezer shelf and under the left vegetable drawer of
the refrigerator and the bottom shelf of the refrigerator was sticky as was the lip of glass on top of the vegetable drawer
B. the two drawers under the coffee maker had spilled coffee stains and coffee grounds spilled and loose in the drawer
C. the drawer under the microwave had crumbs present in the back left corner area
D. the microwave was dirty with spattered food throughout
b. at 3:05 PM on 4/1/14, it was observed in the small pantry refrigerator on the patient unit that there was spilled/dried liquid on the shelf and door
c. at 3:10 PM on 4/1/14, it was observed in the storage room/Central Supply Room #304 on the North wing:
A. the left refrigerator had debris on the lower shelf of the door and the right refrigerator had dribbles of dried liquids on the lower door shelf

5. interview with staff member #51 at 1:00 PM and 3:30 PM on 4/1/14 indicated:
a. the areas listed in 4 above were unclean as described
b. housekeeping staff used to clean the refrigerators, but only wash the exteriors now--it is unclear why this practice was discontinued
c. nursing staff are to clean the interiors of the refrigerators but staffing has been short lately
d. there is no policy related to how often to clean the refrigerators and exactly who has this responsibility
e. a form titled "Unit Routines:" was provided and staff member #51 indicatd that MHTs (mental health technicians), as part of routine duties, are to: "...45. Clean & organize break room - including fridge..."--it is unclear how often this is to occur

Based on policy and procedure review, personnel file review, and interview, the infection control committee failed to implement its policy and procedure related to the immunization status of 4 of 6 nursing and technician staff members (staff N2, N3, N4 and N6).
Findings:
1. Review of the policy \POLDOC\FA0448, " Immunization Record -IP (inpatient) " , with a last review date of July 1, 2013, indicated:
a. Under " Summary " , on page one, it reads: " To meet necessary state and federal mandates, all inpatient staff that provide direct care must provide documentation of immunizations for, or antibodies to, MMR (measles, mumps, rubella) and Varicella (Chicken Pox), by having the attached form completed on their behalf, or by submitting a copy of an official State Immunization Form which indicates immunization. "
b. Under " Statement of Information " , it reads: " ...2.0 NEC (Northeastern Center) Inpatient Services employees shall secure evidence from their general practitioner that they have either had the required immunizations, a titer test indicating immunization, have had the inquired about disease, or have secured the official State Immunization form as evidence of immunization ... "
2. Review of personnel files indicated:
a. Staff member N2 was a RN (registered nurse) hired 1/10/12 who lacked any information or documentation in the file regarding immunization status related to Rubella, Rubeola, and Varicella
b. Staff member N3 was a RN hired 1/10/12 who had documentation of an equivocal Rubeola result (0.9 with 0.9 to 1.0 being " equivocal " per the lab document)-no follow up was noted
c. Staff member N4 was a MHT (mental health tech) who was hired 10/9/12 and lacked any documentation of Varicella immunity
d. Staff member N6 was a MHT hired 6/11/13 who lacked any documentation in the file related to the immunity of Rubella, Rubeola, or Varicella
e. Staff member N1 was hired 10/11/11 and had a last TB (tuberculosis) test done 1/18/13
f. N3 was hired 1/10/12 and had no TB test documentation in the file
g. N4 was hired 10/9/12 with a last TB of 10/12
3. Interview with staff members #51, the infection control practitioner, and # 56, the human resources director, at 11:00 AM on 4/1/14, indicated:
a. The personnel files are lacking immunization documentation as listed in 2. Above
b. There was no follow up to the equivocal Rubeola result for staff member N3, making it unknown whether this staff member has immunity to the disease, or not
c. All three employees (N1, N3, and N4) have lapsed TB tests or no documentation in their files as stated above
(Note: a policy related to TB testing was requested on 4/4/14 at 2:07 PM by phone call and on 4/7/14 at 11:19 AM by e-mail, with no receipt of the policy at this time

Based on policy and procedure review, document review, and interview, the infection control committee failed to ensure medical staff involvement in the infection control committee, which is part of the risk management committee at this facility.

Findings:
1. review of the policy and procedure "Continuous Quality Improvement Program-Inpatient Services", policy number QI1125, with a last review date of July 1, 2009, indicated:
a. on page 2 under "Procedures", in item 6.0., it reads: "Staff composition on Risk Management/Infection Control Committee shall include the Risk Management Nurse as chair, Chief Operating Officer, Hospital Administrator, Hospital Nurse, Hospital Mental Health Technician, Hospital Janitor, Hospital Maintenance, and Quality Improvement Coordinator..."

2. review of Risk Management committee meetings for: 10/2012, 11/2012, 5/1/13, 6/27/13, 10/4/13, 11/22/13, and 2/6/14 indicated that:
a. a physician was only listed as "present" at the 5/1/13 meeting
b. the meeting minutes of 6/27/13 indicated the physician was "absent"

3. interview with staff members # 51, the infection preventionist, and #56, the human resources director, at 12:35 PM on 4/1/14 indicated:
a. the committee composition lacks the inclusion of a medical staff member
b. it cannot be determined that there is physician involvement in the infection control program and committee processes without medical staff member attendance at the committee meetings
c. it was stated that the physician attends QI (quality improvement) meetings pertinent to infection control issues and practices, but review of the QI committee meeting minutes of 8/23/13; 10/18/13; 11/15/13; 1/24/14 and 2/28/14 also lacked indication that a physician was present at these meetings