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Based on review of personnel files, medical records, hospital documents, and interviews, the hospital failed to verify personnel were licensed, trained, and competent.

Findings:


1. On 4/5/12 surveyors reviewed personnel files. 1 of 3 (D,E,G) perioperative registered nurse personnel files reviewed for licensure verification did not contain current licensure verification.

2. Six of six (D,E,F,G,I,K) perioperative personnel did not have department specific orientation and training, current competency or evaluation relating to specific job responsibilities in the operating room.

3. Two of two (H, J) dietary personnel did not have department specific orientation and training. There was no competency and evaluation of dietary staff consistent with food handling, food sanitation, and clinical nutrition.

4. On 4/5/2012 surveyors reviewed radiology services with Staff J. None of the providers had documentation as being competent by the radiologist. There was no information provided indicating the staff had been evaluated for competency on current equipment.

Based on review of hospital documents, nursing policies and procedures, and interviews with staff the hospital failed to follow perioperative policies and procedures.

Findings:

1. On 4/4/2012 surveyors requested policy and procedure manuals surgery, anesthesia, and central sterile. Review of the surgery manual indicated policies had been reviewed and approved in 2012. The facility also provided the current Association of periOperative Registered Nurses (AORN) Standards and Recommended Practices as adopted into the surgical practice at the facility. According to the AORN policy "Fire Safety" D. Is an ESU (electrosurgical unit), laser, or fiber-optic cord being used? Actions-fiber optic light cord use: Place the light source in standby mode or turn it off when the cable is not in active use (e.g., used within 5 to 10 seconds). Inspect light cables before use and remove from service if broken light bundles are visible. Secure the working end (i.e., the end that is inserted into the body) of the telescope or cord on a moist towel or away from any drapes, sponges, or other flammable

AORN Standards and Recommended Practices also stipulates in "Safe Environment of Care, Recommendation IX.b.4. The ends of an active fiber-optic light cable should not come in contact with surgical drapes. Fiber-optic light cables provide an ignition source if they are disconnected from the working element or light source and allowed to contact drapes, sponges, or other fuel sources. IX.b.5. Light cables should be connected before activating the light source. IX.b.6. The light source should be placed into a stand-by mode when not in use to prevent ignition. Backing into the light source or turning the fiberoptic light cable toward the body may cause surgical attire to ignite. IX.c. Personnel should move any equipment that emits smoke at any time, whether in use or not to a safe area. IX.d.7. Gowns and drapes should not be exposed to ignition sources."

2. According to hospital documents, the patient chart, and personnel interviews, at the conclusion of a shoulder arthroscopy case, Staff F a certified surgical technician (CST) noticed a burn hole in the drapes and blanket covering Patient #1, Staff F then checked the patient and noted a small reddened area less than a centimeter in size with a pin point brownish center. Further documentation indicates Dr. N was notified and instructed the nurse to apply "Bacitracin and a Band-Aid". Discharge instructions stipulate "antibiotic ointment and Band-Aid R (right upper thigh burn). Keep clean and dry. In an interview with Staff D the circulator present during the case told surveyors the light handle of the arthroscopy equipment had been placed on the drape covering the patient and not on the backtable. Staff D also told surveyors Staff K was instructed to remove the equipment from use and send to be checked out. Documentation in the chart indicates the patient received a post discharge call on 1/3/12 and no concerns were voiced.

3. According to the policy entitled "Documentation of Intraoperative Nursing Care" page 8 "Discharge Assessment"1. The condition of the patient's skin on discharge is described. The drawing of the human form on the back of the first page of the record may be used to indicate the location of any change in the skin condition, i.e. abrasions, ecchymosis, lacerations, skin disorders, etc. There was no documentation of the "small reddened area" on the intraoperative documents.

4. The above findings were addressed in the exit conference 4/5/2012.

Based on review of the infection control documents, hospital meeting minutes, policies and procedures and personnel files, and interviews with staff, the hospital failed to develop an active ongoing infection control program that reviewed and evaluated practices in the hospital, with corrective actions taken when needed. The infection control program did not include immunization histories of staff (employed, contract,volunteer and medical staff) to ensure a sanitary environment and avoid sources and transmission of infections for patients and personnel.

Findings:

1. The hospital policy for health screening, provided to the surveyors on 04/04/2012, had a heading for another facility and "health system". Staff B, C and EE told the surveyors that many of the policies for the hospital were adopted from the corporate/health system level. The two policies concerning employee health showed approval dated of 01/07/2003 and 09/19/2011. A notation of the bottom of the second policy, approval date 09/19/2011, said it replaced the 2003 document/policy. This policy required personnel documentation of immunity to Rubella, Rubeola, Mumps and Varicella or that vaccines would be provided. It also stipulated that Hepatitis B vaccine would be offered. The policy stipulated that tuberculosis (TB) skin tests would be required at a minimum of once a year with an exception for those who tested positive. Staff B and C told the surveyors on 04/05/2012 that influenza vaccines were also offered yearly.

2. Review of the meeting minutes containing infection control did not contain review/evaluation of staff immunization histories. Staff C stated on the morning of 04/05/2012 that she did not get the immunization history information. She stated that another nurse gave the annual TB skin tests, but another hospital in the health system kept all the immunization histories; she did not get a report; and immunization practices were not a part of the infection control program.

3. Fourteen personnel files, which included three agency staff, were requested for review of health and immunization records. Two agency personnel records were not obtained (Staff BB and CC). Staff stated they did not routinely maintain files on the agency staff. Twelve of twelve of twelve personnel files reviewed for health information (Staff C, P, R, S, T, U, V, W, Y, Z, and AA) did not contain documentation of complete immunization histories as specified in the Oklahoma State Licensure Hospital Standards Chapter 667 and per hospital policy. When asked, staff stated they did not obtain the personnel files from the other/designated health system hospital and what they provided was all the hospital had current access/capability to review/provide. Many of the physician credential and health files did not contain complete immunization histories.

4. Findings were reviewed with administrative staff on the afternoon of 04/05/2012. No additional data was provided.

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. On the afternoon of 4/5/12 Staff L told the surveyors that Staff H did all of the nutritional consults on patients. Staff L did not know a specific time frame for completion. Staff L demonstrated the computerized nursing intake information pertaining to dietary. Staff L did not know how the nutritional screen component was scored to trigger a dietary consult. Staff L told surveyors the nurses usually call dietary if there are dietary problems There was no policy for the nutritional assessment or nutritional screen for the inpatient unit. A nutritional assessment policy was provided for the swing-bed patients. The policy provided did not match the process described by Staff L.

2. On the afternoon of 4/5/2012 in a phone interview with Staff H, Staff H told surveyors when a patient required a nutritional assessments she completed those. Staff H told surveyors she was usually notified by the nurses if patients needed nutritional consults. Staff H told surveyors she did not have a current policy regarding nutritional assessments of inpatients. Staff H also told surveyors the policies in place did not reflect the process with the computerized system.

3. Dietary and nursing policies did not include a policy and procedure for nutritional screens/nutritional consults. There are no current dietary policies and procedures.

4. There is no current Oklahoma Dietary Manual reviewed and approved through Medical Staff and Governance.

5. Review of Quality Assurance Performance Improvement 2011 data did not include clinical nutritional services.

6. The above findings were reviewed with the administrative team at the exit conference on 2/22/12. No further documentation was provided.

Based on review of hospital documents, review of personnel files and interviews with the radiology department manager, the hospital failed to have documentation showing all the personnel operating the diagnostic radiology equipment are qualified and trained, and the radiology department has oversight by the Radiologist, Medical Staff, and Governing Body.

Findings:

1. In an interview on the morning of 4/5/12 Staff A told surveyors some of the radiology services were contract but most were provided by employees. There was no documentation the personnel providing the services were oriented, trained, and competent.

2. Personnel files (M) provided to surveyors did not include competencies reviewed and approved through the radiologist and medical staff. This finding was confirmed with Staff on the afternoon of 4/5/2012.

3. The above findings were reviewed with administration at the exit conference. No further documentation was provided.

Based on record review an interviews with hospital staff, the hospital does not ensure that a periodic evaluation of the hospital's total program is conducted. An evaluation that includes information collected on the hospital's total program is not summarized, analyzed and all required elements are not included in the evaluation at least annually.

Findings:

1. The data collected quarterly does not include review of all hospital policies.

2. All data which is collected quarterly is not summarized, reviewed and analyzed annually to determine the best use of hospital services.

3. Hospital staff (A) on 04/05/12 in the afternoon stated that the information collected quarterly had not been reviewed on an annual basis as part of a total program evaluation.

Based on record review and interviews with hospital staff, the hospital does not ensure that a review of the CAH's health care polices are reviewed once a year as part of the hospital total program evaluation.

Findings:

1. Policies for swing bed, physical therapy, surgery and dietary had not been reviewed at least once a year.

2. Review of the hospital's policies was not included in the hospital's quarterly review and included as part of an evaluation of the hospital's total program.

3. Hospital Staff (A) verified on 04/05/12 in the afternoon that all policies had not been reviewed.

Based on record review and interviews with hospital staff, the hospital had not conducted an annual total program evaluation that determines whether the utilization of hospital services are appropriate, policies are followed and if any changes are needed. Hospital Staff (A) verified on 04/05/12 that this evaluation of the hospital's total program had not been conducted.

Based on review of hospital documents for 2011 and 2012 and interviews with hospital staff, the hospital does not ensure that medication errors identified are evaluated, analyzed and action taken to improve the care and safety of patients. Errors were identified but were not analyzed to determine why they were occurring and a plan of action implemented to reduce the errors.

Findings:

1. Staff (DD) verified on 04/05/12 in the afternoon medication errors are documented and reported through a committee that includes Pharmacy and Therapeutics, Infection Control, and Safety.

2. There was no evidence in Governing body, Medical staff, Performance Improvement or Pharmacy and Therapeutics committee meetings that the errors were analyzed to determine whether it was a personnel or system problem. The only documentation consisted of numbers of errors. It did not include evaluation of possible causes.

Based on review of the hospital's swing bed policies and procedures, personnel files, and medical records, and interviews with hospital staff, the hospital failed to provide an ongoing activity program that:
1. Is directed by a qualified staff member;
2. Develops an individualized comprehensive activity assessment of the individual physical and psychological needs and interests assessments of each patient; and
3. Provides individual, group and/or bedside activities based on the patient's assessment.

This occurred for five of five swingbed patients (Records #7, 8,9, 10 and 11) whose medical records were reviewed.

Findings:

1. On the morning of 04/05/2012, Staff EE identified Staff P, the speech therapist, as the Swingbed Activities Program Coordinator/Director.

2. Review of Staff P's personnel file did not demonstrate the individual had training to qualify as the swingbed activity director/coordinator. On 04/05/2012 at 1425, Staff P stated she was not the hospital's Swingbed Activities Program Coordinator. She stated that she and the social worker had tried to fill out the form and she used it to determine whether the patient needed speech therapy. Staff B and Staff P stated at that time that the hospital did not have a Swingbed Activities Program Director.

3. On 04/05/2012/2011, one surveyor reviewed Records #7, 8, 9, and 10 with Staff L. The form, Activity Program Assessment, a single one-sided handwritten sheet, was available for review for current patient medical records #8, 9, and 10 in handwritten form, and as scanned images into the computerized medical record for Records #7 and 11. The forms were signed as completed by Staff P and/or the social worker. The forms were not completed and did not contain a plan for providing activities to/for the individual based on the patients interests and the physical, mental and psychosocial needs of each patient being considered. The medical record did not demonstrate individual, group, and/or bedside activities had been provided or offered every day for the patients during their swingbed hospitalization.

4. The hospital had appropriate policies. The hospital's swingbed policies, with a revision/review date of October 2007, stipulated that an activity assessment by a qualified staff would address each patients, life style, interests, hobbies, social involvement, functional limitation, emotional stability and religion/spirituality; be documented in the medical record; and a plan would be part of the patient's "overall Plan of Care." The policies addressed activities would be developed for individual, group and/or bedside participation with development of an overall Activities Calendar.

5. Staff B, L, P and EE told the surveyors that the hospital did not have an Activities Calendar.

6. The findings were discussed with administrative staff on the afternoon of 04/05/2012. No additional information was provided for review.