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Based on review of governing body meeting minutes and hospital documents and interviews with hospital staff, the hospital does not ensure the organizational structure of the hospital is effective in providing quality health care in a safe environment. The governing body failed to monitor, evaluate and ensure the services of the hospital. Refer to Tag C-241 for details and findings.

Based on record review and interviews with hospital staff, the governing body does not ensure that policies governing the CAH"s total operation are implemented and ensure quality health care is provided in a safe environment.

Findings:


1. The governing body does not ensure that surgical procedures are performed in a safe manner. Refer to Tag 320

2. The governing body does not ensure a periodic evaluation of its total program is conducted at least once a year and includes a review of the following: a representative sample of both active and closed medical records; a review of the CAH's health care policies; and an evaluation of the utilization of services, if policies were followed and what changes if any were needed and has an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished. There was no evidence of the hospital monitored, collected data, or analyzed patient care. Refer to Tag 0330

3. The governing body did not ensure the hospital had developed an active ongoing infection control program that reviewed and evaluated practices in the hospital, with corrective actions taken when needed, to ensure a sanitary environment and avoid sources and transmission of infections for patients and personnel. Refer to Tag 278.

4. The governing body does not ensure that the hospital has an effective Quality Assurance/Performance Improvement (QA/PI) program to evaluate the quality and appropriateness of the diagnosis and treatment furnished. There was no evidence of the hospital collecting and analyzing data concerning the quality and appropriateness of all patient care furnished in the CAH. Refer to Tag 0336

Based on record review and interviews with hospital staff, the hospital does not ensure there is a system in place where drugs both scheduled and nonscheduled are reconciled daily to ensure patient safety through appropriate control and distribution of medications.

Findings:

1. Pharmacy personnel stated on 05/24/11 that medications obtained from the drug room are not always reconciled with the physicians' orders to ensure the medications have an appropriate order and for whom the medication was ordered and if any contraindications or allergies exist.

2. The pharmacist and the drug room tech stated on 05/24/11 that they do not get orders for drugs obtained from the drug room for emergency room patients so they cannot check to see if the medication is given with an appropriate order from a physician.

3. For scheduled drugs dispensed for use on the ambulance, the narcotic administration sheet is not reconciled with the ambulance run sheet to assure all records are accurate and in order.

4. Drug room personnel do not ensure that drugs dispensed for use on the ambulance are stored appropriately and are kept secure and at the proper storage temperature to prevent deterioration and unauthorized use.

5. Drug room personnel stated on 05/24/11 that they do not have an organized, regular system of identifying medication errors or adverse medication events.

Based on record review and interviews with staff, the hospital does not ensure that medication errors are evaluated to determine possible causitive factors and create systems to prevent their reoccurance.

Findings:

1. Review of Governing Body, Medical Staff and Pharmacy and Therapeutic committee meeting minutes for 2010 and 2011 did not have any review of medication errors or adverse drug events.

2. Hospital staff stated in an interview on 05/24/11 in the afternoon that they had not actively been identifying and documenting medication errors.

Based on review of the infection control documents, hospital meeting minutes, policies, procedures and personnel files, and interviews with staff, the hospital failed to develop and maintain an active on-going infection control program for ensuring a sanitary environment, and identifying and preventing infections and communicable diseases by designating a person qualified through training and/or experience as the infection control officer/practitioner (ICO).

Findings:

1. The list of Department Heads, provided to the surveyors on the afternoon of 05/23/2011, listed Staff L as the ICO, but the list of nursing personnel listed Staff M as the ICO.
a. Staff B told the surveyors on the morning of 05/24/2011 that Staff L was no longer the ICO and that it had recently been changed to Staff M. When asked, Staff B stated that Staff M did not have any training or experience in infection control.
b. Staff L stated on 05/24/2011 at 1340, that he had not received any ongoing training in infection control. He told the surveyors that he had only received basic training and that was before 2005.

2. The infection control manual did not contain an infection control plan for 2010 or 2011. The manual, with policies and procedures and the infection control plan had not been reviewed and updated to demonstrate it was based on current nationally recognized infection control guidelines. The manual had not been reviewed since 2005. The manual did not contain policies and procedures to describe how the infection control program would monitor to ensure infection control policies were followed.

3. Upon entrance to the hospital on the morning of 05/23/2011, the surveyors requested all infection control data, including the infection control policies and procedures, plan, surveillance activities, infection control log and meeting minutes. Conversation with Staff L on the afternoon of 05/24/2011 revealed:
a. No meeting minutes were provided. Staff L stated on 05/24/2011 at 1345 that the infection control committee had not been active since the end of 2009 and there were no meetings since that time.
b. Staff L stated he only tracked reported infections that had cultures obtained and only logged the positive ones. He stated Staff M was doing the same thing since she started January 2011 and Staff M had been responsible for completing the log since December 2010. He stated the log information was not forwarded to quality improvement or medical staff for review and analysis.
c. Staff L told the surveyors that the infection control program did not contain any other monitoring/surveillance. He stated he had not conducted any monitoring to ensure infection control policies were enforced/followed, including handwashing surveillance and surgical services' practices.
d. Staff L stated the infection control program did not included employee health and monitoring staff for communicable diseases or immunization history.

4. The surveyors requested any data/surveillance Staff M had conducted since she had taken over infection control. The only documents provided were the infection control logs for December 2010 through April 2011. Another folder, labeled May 2011, contain one patient name. No other information was provided. The documents contain no evidence the documents had been reviewed, evaluated for appropriateness of treatment and if any identifiable trends had been established with plan of correction if trends/problems were identified. The documents contained no evidence employee health or monitoring of policies and procedures had occurred. Staff C stated she had provided all of Staff M's data.

5. Review of hospital documents did not show the infection control program had been reviewed, evaluated and revised to ensure the program included monitoring of the environment to provide a safe and sanitary environment; and provisions to identify, investigate, report, and prevent the spread of infections and communicable diseases among patients and the staff, including contract staff, physicians and allied health workers and volunteers. The meeting minutes provided did not demonstrate the hospital reviewed and analyzed infection control problems and infections to ensure a safe and sanitary environment. There was no evidence the data collected by Staff L and M had been reviewed and analyzed to ensure antibiotic therapy was appropriate. The last meeting minutes that infection control was mentioned was in 2009.

Based on document reviews and interviews, the hospital failed to assure that the nutritional needs of inpatients are met in accordance with recognized dietary practices.

Findings:

1. The hospital uses the services of a consultant dietitian. On 5/24/11 Staff A told surveyors there were no consulting dietitian reports for 2010-2011. The hospital failed to show oversight by a dietitian for patients requiring nutritional care.

2. A personnel file for the dietitian was not available for review. The hospital failed to provide a job description, orientation, evaluation and training to the facility for the dietitian.

3. These findings were reviewed in an exit conference on 5/24/2011. No further documentation was provided.

Based on review of hospital documents, review of personnel and interviews with the radiology department manager, the hospital failed to have documentation showing all the personnel operating the diagnostic x-ray equipment are qualified and trained.

Findings:

1. In an interview on the afternoon of 5/23/11 Staff E stated all of the employees in radiology were registered radiology technicians (ARRT). Radiology information and personnel files provided to surveyors did not indicate what types of procedures or equipment the employees were oriented, trained, and competent to utilize. Personnel files for employees identified as radiology technicians (E,H) did not have hospital orientation, or documented radiology training specific to the equipment utilized at the facility. Two of two radiology personnel (E,H) did not have competency or evaluation on use of the hospital's radiology equipment. On 5/24/2011 this finding was reviewed with administration and no further documents were provided.


2. On 5/24/11 surveyors were given Governing Body and Medical Staff Meeting Minutes. Review of minutes did not indicate there was any type of radiology department review. On 05/24/2011 this finding was reviewed with administration and no further documents were provided.

Based on review of medical records and an interview with hospital staff, the hospital failed to ensure nursing notes for respiratory therapy treatments were descriptive of the patient's pre-assessment and post-assessment of the patient's respiratory condition with evaluation of the patient's response to the respiratory treatment. This occurred in six of six medical records (Record #2, 8, 9, 11, 15, and 18) reviewed of patients who received respiratory hand held nebulizer treatments.

Findings:

1. The hospital's respiratory policies and procedures did not specify what documentation, of the patient status before and after treatments, was required for nebulizer treatments.

2. The hospital's respiratory form contained treatment headings only contained pre-treatment and post-treatment headings for the patient's pulse. The heading for respirations documented it was prior to treatment. The headings labeled for oxygen saturation, cough, and breath sounds did not specify if they were for pre and post-treatment documentation or only for one. Without complete pre-treatment and post-treatment evaluations/assessments of the patient respiratory condition, you cannot evaluate the patient's response to the treatment -if the patient's respiratory status improved, stayed the same, or diminished.

3. Documentation of respiratory treatments in the six medical records (Record #2, 8, 9, 11, 15, and 18) did not contain complete pre-treatment and post-treatment evaluations/assessments of the patient respiratory condition and evaluation of the patient's respiratory response to the treatment. Nursing notes and respiratory treatment notes were reviewed.

4. These findings were reviewed and verified with Staff B on the morning of 05/24/2011 and again at the exit conference with administrative staff on the afternoon of 05/24/2011.

Based on record review and interviews with hospital staff, the governing body does not ensure that policies governing the CAH"s total operation are implemented, that medical staff providing patient care are evaluated and appointed by the governing body and does not ensure quality health care is provided in a safe environment.

Findings:

1. On 5/23/2011 surveyors requested surgical and procedure logs. On 5/23/11 only a surgery log was provided. On the morning of 5/23/11 Staff A was asked if the facility performed any type of endoscopy work. Surveyors were told "no". On the afternoon of 5/24/11, a surveyor observed documentation in the medication logs where medications were being checked out to "procedures". On the afternoon of 5/24/11, surveyors were told by Staff B and administration that endoscopy procedures were being performed at the facility by physician's R and S. Surveyors were told these physicians were contract. There was no documentation physicians R and S were credentialed and privileged. Physicians R and S were not listed on the medical staff roster.

2. On 5/23/2011 surveyors reviewed the surgical log. Staff BN and O were listed as surgical assistants. Staff N and O were not employees of the facility. There was no documentation Staff N was authorized by the Governing Body and Medical Staff to perform procedures or work in the operating room. There was no documentation Staff N and O had been oriented, trained, evaluated, and were competent to provide care to surgical patients.

3. On 5/24/2011 surveyors reviewed the infection control log, policies and procedures. There was no surveillance of surgical services documented. Staff L told surveyors the infection control committee was not functioning. The governing body did not ensure the hospital had developed an active ongoing infection control program that reviewed and evaluated practices in the hospital, with corrective actions taken when needed, to ensure a sanitary environment and avoid sources and transmission of infections for patients and personnel.


4. On 5/24/2011 surveyors reviewed two personnel files selected from staff currently working in the surgical area and the Post Anesthesia Care Unit (PACU). Two of two competency forms (Staff G, T) were not signed by a preceptor. Two of two personnel files did not have current competency, evaluation or training.

5. On 5/24/11 surveyors reviewed Governing Body Meeting Minutes and Medical Staff Meeting Minutes, There was no review of surgical services where quality of care, incidents related to surgery, or surgical infection control practices were reviewed.

6. The policies and procedures for the operating room have not been reviewed or approved on a yearly basis. The above findings were reviewed with administration at the exit conference. No further documentation was provided.

Based on record review and interviews with hospital staff, 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 following: a representative sample of both active and closed medical records; a review of the CAH's health care policies; and an evaluation of the utilization of services, if policies were followed and what changes if any were needed and has an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished.
Finding: There was no evidence of the hospital conducting ongoing monitoring and data collection and analysis of patient care.
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Based on record review and interviews with hospital staff, 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 following: a representative sample of both active and closed medical records; a review of the CAH's health care policies; and an evaluation of the utilization of services, if policies were followed and what changes if any were needed.

Findings:

1. Interviews with hospital personnel on the afternoon of 05/24/11 stated that the hospital had not conducted an evaluation of its total program at least annually which included a review of active and closed records, hospital policies and procedures and evaluation of the services provided and if changes were needed.

2. Governing Body and Medical Staff meeting minutes for 2010 and 2011 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

Based on record review and interview with hospital staff, the hospital does not ensure a yearly program evaluation reviewing the utilization of CAH services, including the number of patients served and the volume of services is conducted.

Findings:

1. Interviews with hospital personnel on the afternoon of 05/24/11 stated that the hospital had not conducted an evaluation of its total program at least annually which included a review of the utilization of CAH services, including the number of patients served and the volumn of services is conducted.


2. Governing Body and Medical Staff meeting minutes for 2010 and 2011 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

Based on record review and interviews with hospital staff, the hospital does not ensure that a yearly periodic evaluation was conducted which included a representative sample of active and closed medical records.

Findings:

1. Governing Body and Medical Staff meeting minutes for 2010 and 2011 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

2. Interviews with hospital personnel on the afternoon of 05/24/11 stated that the hospital had not conducted an evaluation of its total program at least annually which included a review of a representative sample of active and closed medical records.

Based on record review and interviews with hospital staff, 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 2010 and 2011 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

2. Review of selected hospital policies did not document a yearly review as required. The following policies had the following review dates Radiology 2009, Infection Control 2005, Emergency Services 2000, 2001, 2004 and Respiratory 2000 and 2001.

3. Hospital personnel stated in the afternoon of 05/24/11 that they did not have any other documentation of policy review.

Based on record review and interviews with hospital staff, 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.

Findings:

1. Governing Body and Medical Staff meeting minutes for 2010 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program to determine if services were effectively utilized, policies were followed and if changes were needed.

2. Hospital staff stated on the afternoon of 05/24/11 that they had not conducted a periodic evaluation that included all the requirements.

Based on record review and interviews with hospital staff, the hospital does not ensure that the hospital has an effective Quality Assurance/Performance Improvement (QA/PI) 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 did not contain evidence of any analysis of data presented to identify problems, evaluate situations, and take corrective actions.

2. The hospital could not provide for review a QA/PI plan for the hospital.

3. There was no evidence of reviews of nosocomial infections and medication therapy in the medical staff meeting minutes. There were no infection control meeting minutes for review.

4. Hospital staff verified on 05/24/11 in the afternoon that the hospital does not have a functioning QA/PI program.

Based on record review and interviews with hospital staff, the hospital does not ensure that an effective quality assurance program is implemented and evaluates the quality and appropriateness of the diagnosis and treatment of patients in the hospital through a functioning QA/PI program. All patient care services and other services affecting patient health and safety are not evaluated and the hospital does not collect and analyze data concerning the quality and appropriateness of all patient care furnished in the CAH.

Findings:

1. The hospital stated on 05/24/11 in the afternoon that they do not have a functioning QA/PI program.

2. Medical staff meeting minutes for 2010 and 2011 did not have any review of deaths, surgical services, or blood usage by the hospital's medical staff.

Based on review of infection control documents, hospital meeting minutes, policies and procedures and personnel files, and interviews with staff, the hospital does not ensure that an effective quality assurance program is implemented and nosocomial infections and medication therapy are evaluated. The hospital failed to develop an active on-going infection control program for ensuring a sanitary environment, and identifying and preventing infections and communicable diseases by designating a person qualified through training and/or experience as the infection control officer (ICO).

Based on record review and interviews with hospital staff, the hospital does not insure that a functioning QA/PI system is implemented so that remedial action can address deficiencies found through the QA/PI program. Review of Governing Body and Medical Staff meeting minutes for 2010 and 2011 and interviews with hospital staff during the survey did not have evidence the hospital has a functioning QA/PI program.

Based on record review and interviews with hospital staff the hospital does not ensure that a functioning QA/PI program is implemented in the hospital. The hospital has not documented any remedial action because the QA/PI program has not been active. This was verified by hospital staff on 05/24/11 and by review of Governing Body and Medical Staff meeting minutes for 2010 and 2011.