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Based on staff interview and review of medical records, CAH policies, and credentials files, it was determined the CAH's governing body failed to ensure systems vital to the operation of the CAH had been developed, implemented, and monitored. This resulted in a lack of guidance and oversight of the CAH's operation. Findings include:

1. The governing body did not ensure medical services would be provided to Swing bed patients in accordance with the CAH's policy.

The policy "SWING BEDS," not dated, stated "The patient will be visited by a medical provider at least twice weekly while in skilled swing bed status, and at least once a month, or as condition necessitates, while in unskilled swing bed status." This policy had not been followed. The plan to provide routine medical supervision of swing bed patients had not been implemented.

Patient #1's medical record documented a 92 year old female who was admitted to the CAH as a swing bed patient on 5/21/10. She was currently a patient as of 3/30/11. Her primary diagnosis was breast cancer with metastasis. The medical record did not specify if Patient #1 was in skilled or unskilled swing bed status. Her history and physical examination was performed by the PA on 5/21/11. A physician documented a general examination of Patient #1 on 5/25/11, 8/04/11, and 10/04/10. The record documented she was seen again on 3/06/10 and 3/08/10 by a PA because of complaints of ear pain. No other examinations were documented. No general examinations were documented over a 5 month period, from 10/04/10 through 3/29/11.

The Chief of Staff was interviewed on 3/29/11 at 4:05 PM. He stated, if the nurses asked a practitioner to see Patient #1 for a medical problem, she would be seen promply. However, he said there was no plan to see Patient #1 on a routine basis

The hospital did not implement a system to ensure swing bed patients were examined by a practitioner on a routine basis.

2. The CAH failed to ensure systems to identify and investigate infections had been clearly defined and implemented. Refer to C278 as it relates to the lack of a comprehensive program to identify and investigate infections.

3. The CAH failed to ensure practitioners who performed surgical procedures had been granted privileges by the hospital board for those procedures. Refer to C321 as it relates to the lack of complete privileges granted to practitioners.

4. The CAH failed to ensure a comprehensive quality assurance program had been developed and implemented. Refer to C330 as it relates to the lack of a program to measure the CAH's performance.

The governing body did not ensure critical systems had been developed and implemented.

Based on staff interview and review of policies, it was determined the CAH failed to ensure systems to identify and investigate infections had been clearly defined and implemented. This resulted in a lack of guidance to staff directing them as to how to control infections. Findings include:

The "INFECTION CONTROL PLAN," not dated, did not specify a committee or other group who was responsible for controlling infections at the CAH. The plan did not specify a method for surveillance of infections. Also, the plan did not include a definition of nosocomial or hospital acquired infections.

The IC Officer was interviewed on 3/31/11 beginning at 12:55 PM. She stated the CAH did not have an IC committee or other designated group to provide guidance for the IC program. She stated the Medical Staff reviewed IC data but she said they did not provide policy direction for staff. She stated no group approved things like procedures to clean surfaces and equipment or procedures to maintain a sanitary environment. She stated she and another Registered Nurse provided surveillance activities for the CAH but she said an official procedure for surveillance of infections had not been developed. Finally, she stated the hospital had not adopted an official definition of nosocomial (hospital acquired) infections.

The hospital had not developed a complete IC program.

Based on staff interview and review of medical records and credentials files, it was determined the CAH failed to ensure 3 of 5 practitioners (Staff A, B, and C), who performed surgical procedures, had been granted privileges by the hospital board for those procedures. This prevented the CAH from ensuring the practitioners were qualified to perform those procedures. Findings include:

1. The CAH allowed Practitioner A to perform colonoscopies without current privileges.

Medical records documented Patient #12, a 60 year old male, had a colonoscopy performed by Staff A on 11/15/10. Medical records documented Patient #13, a 66 year old male, had a colonoscopy performed by Staff A on 12/21/10. Medical records also documented Patient #14, a 58 year old female, had a colonoscopy with polypectomy performed by Staff A on 12/16/10.

Staff A's privilege list, approved by the hospital board on 2/17/10, did not include colonoscopy in his list of privileges. Hospital board meeting minutes, dated 8/09/06, stated Staff A was granted temporary privileges at that time for "endoscopy procedures." A specific list of those procedures was not included. No privileges to perform endoscopic procedures were granted to Staff A when he was reappointed to the Medical Staff in 2008 and 2010.

The Director of Medical Records, who also maintained the practitioner credentials files, was interviewed on 3/29/11 at 3:10 PM. She confirmed privileges for colonoscopy had not been granted to Staff A.

Staff A performed colonoscopies without privileges.

2. Patient #11's medical record documented a 53 year old female who had a sacroiliac joint injection, a pain procedure, on 3/19/11. This was performed by Staff B.

Staff B's privilege list, approved by the hospital board on 2/17/10, did not include sacroiliac joint injections in his list of privileges.

The Director of Medical Records was interviewed on 3/29/11 at 3:10 PM. She confirmed privileges for sacroiliac joint injections had not been granted to Staff B.

Staff B performed a sacroiliac joint injection without privileges.

3. Patient #1's medical record documented a 92 year old female who had the toe nail removed from the big toe of her left foot on 12/29/10. This was performed by Staff C.

Staff C's privilege list, approved by the hospital board on 9/15/10, did not include toe nail removal in his list of privileges.

The Director of Medical Records was interviewed on 3/29/11 at 3:10 PM. She confirmed privileges for toe nail removal had not been granted to Staff C.

Staff C performed performed a toenail removal without privileges.

Based on staff interview and review of hospital policies, administrative documents, and governing body meeting minutes, it was determined the CAH failed to ensure a periodic evaluation and quality assurance program had been developed and implemented. This resulted in the inability of the CAH to identify and correct care related issues. Findings include:

1. Refer to C331 as it relates to the failure of the CAH to ensure a periodic evaluation of its total program was carried out.

2. Refer to C332 as it relates to the failure of the CAH to ensure a periodic evaluation of its total program, including the utilization of CAH services, was carried out.

3. Refer to C333 as it relates to the failure of the CAH to ensure a periodic evaluation of its total program, including a sample of both active and closed clinical records, was carried out.

4. Refer to C334 as it relates to the failure of the CAH to ensure a periodic evaluation of its total program, including the CAH's health care policies, was carried out.

5. Refer to C336 as it relates to the failure of the CAH to ensure an effective quality assurance program had been developed and implemented.

6. Refer to C337 as it relates to the failure of the CAH to ensure an effective quality assurance program to evaluate the quality and appropriateness of treatment furnished in the CAH, including all patient care services and other services affecting patient health and safety, were evaluated.

The cumulative effect of these negative systemic practices resulted in the inability of the CAH to evaluate the care provided.

Based on staff interview and review of CAH policies and Governing Body Meeting minutes, it was determined the CAH failed to ensure a periodic evaluation of its total program was carried out. This prevented the CAH from assessing its programs and services in order to make improvements. Findings include:

An evaluation of the CAH's total program was not documented in Governing Body Meeting minutes between 4/01/10 and 3/30/11.

The DON was interviewed on 3/31/11 at 12:55 PM. She stated she was responsible for the quality assurance program at the CAH. She stated an evaluation of the CAH's total program had not been completed in the past year. She also said a policy outlining how such an evaluation would be performed, including what items would be measured, had not been developed.

The CAH did not conduct an evaluation of its total program.

Based on staff interview and review of CAH policies and administrative documents, it was determined the CAH failed to ensure a periodic evaluation of its total program, including the utilization of CAH services, was carried out. This prevented the CAH from assessing its programs and services in order to make improvements. Findings include:

An evaluation of the CAH's total program, including the utilization of CAH services, was not documented between 4/01/10 and 3/30/11.

The DON was interviewed on 3/31/11 at 12:55 PM. She stated she was responsible for the quality assurance program at the CAH. She stated an evaluation of the CAH's total program, including the utilization of CAH services, had not been completed in the past year. She also said a policy outlining how such an evaluation would be performed, including a method to evaluate the utilization of CAH services, had not been developed.

The CAH did not conduct an evaluation of its total program, including the utilization of CAH services.

Based on staff interview and review of CAH policies and administrative documents, it was determined the CAH failed to ensure a periodic evaluation of its total program, including a sample of both active and closed clinical records, was carried out. This prevented the CAH from assessing its programs and services in order to make improvements. Findings include:

An evaluation of the CAH's total program, including a sample of both active and closed clinical records, was not documented between 4/01/10 and 3/30/11.

The DON was interviewed on 3/31/11 at 12:55 PM. She stated she was responsible for the quality assurance program at the CAH. She stated an evaluation of the CAH's total program, including a sample of both active and closed clinical records, had not been completed in the past year. She also said a policy outlining how such an evaluation would be performed, including a method to review both active and closed clinical records, had not been developed.

The CAH did not conduct an evaluation of its total program, including a sample of both active and closed clinical records.

Based on staff interview and review of CAH policies and administrative documents, it was determined the CAH failed to ensure a periodic evaluation of its total program, including the CAH's health care policies, was carried out. This prevented the CAH from assessing its programs and services in order to make improvements. Findings include:

An evaluation of the CAH's total program, including the CAH's health care policies, was not documented between 4/01/10 and 3/30/11.

The DON was interviewed on 3/31/11 at 12:55 PM. She stated she was responsible for the quality assurance program at the CAH. She stated an evaluation of the CAH's total program, including the CAH's health care policies, had not been completed in the past year. She also said a policy outlining how such an evaluation would be performed, including a method to review the CAH's health care policies, had not been developed.

The CAH did not conduct an evaluation of its total program, including the CAH's health care policies.

Based on staff interview and review of CAH policies and administrative documents, it was determined the CAH failed to ensure a quality assurance program to evaluate the quality and appropriateness of treatment furnished in the CAH had been developed and implemented. This prevented the CAH from assessing its services in order to make improvements. Findings include:

Evidence of a quality assurance program to evaluate the quality and appropriateness of treatment furnished in the CAH was not documented between 4/01/10 and 3/30/11.

The DON was interviewed on 3/31/11 at 12:55 PM. She stated she was responsible for the quality assurance program at the CAH. She stated a quality assurance program to evaluate the quality and appropriateness of treatment furnished in the CAH had not been conducted in the past year. She also said a policy outlining a quality assurance program had not been developed.

The CAH did not develop and implement a quality assurance program.

Based on staff interview and review of CAH policies and administrative documents, it was determined the CAH failed to ensure an effective quality assurance program to evaluate the quality and appropriateness of treatment furnished in the CAH, including all patient care services and other services affecting patient health and safety, were evaluated. This prevented the CAH from assessing its services in order to make improvements. Findings include:

Evidence of a quality assurance program, including quality indicators to assess all patient care services and other services affecting patient health and safety, was not documented between 4/01/10 and 3/30/11.

The DON was interviewed on 3/31/11 at 12:55 PM. She stated she was responsible for the quality assurance program at the CAH. She stated a quality assurance program, including quality indicators to assess all patient care services and other services affecting patient health and safety, had not been developed and implemented in the past year. She also said a policy outlining how such a quality assurance program would be implemented had not been developed.

The CAH did not develop a quality assurance program, including quality indicators to assess all patient care services and other services affecting patient health and safety.

Based on staff interview and review of medical records, it was determined the CAH failed to ensure a program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being for 1 of 1 current swing bed patient (#1). This resulted in a lack of direction to staff to assist them to provide activities. Findings include:

The CAH had 1 swing bed patient in residence during the survey. Patient #1's medical record documented a 92 year old female who was admitted to the CAH as a swing bed patient on 5/21/10 and was currently a patient as of 3/30/11. Her primary diagnosis was breast cancer with metastasis. An activities assessment and a plan for activities was not documented in her medical record.

The DON, who also served as the Activities Director, was interviewed on 3/29/11 at 1:10 PM. She reviewed the medical record. She confirmed an activities assessment had not been conducted and a plan for activities had not been developed.

The CAH did not provide an activities program for Patient #1.

Based on staff interview and review of medical records, it was determined the CAH failed to ensure assessments of psychosocial well-being and activity pursuit had been conducted for 1 of 1 current swing bed patient (#1). This prevented the staff from developing a plan to address psychosocial and activity needs. Findings include:

The CAH had 1 swing bed patient in residence during the survey. Patient #1's medical record documented a 92 year old female who was admitted to the CAH as a swing bed patient on 5/21/10 and was currently a patient as of 3/30/11. Her primary diagnosis was breast cancer with metastasis. A psychosocial assessment and an activities assessment were not documented in her medical record. In addition, her plan of care, dated 5/22/10, did not include plans to address activities or psychosocial areas of care.

The DON was interviewed on 3/29/11 at 1:10 PM. She reviewed the medical record. She confirmed a psychosocial and activities assessment had not been conducted.

The CAH did not provide complete assessments for Patient #1.